Refractory Shock from Amlodipine Overdose Overcomed with Hyperinsulinemia

Area of Science:

• Cardiology
• Toxicology
• Emergency Medicine

Background:

• Calcium channel blocker (CCB) intoxication carries a high mortality rate, often leading to refractory shock.
• Amlodipine, a long-acting dihydropyridine CCB, overdose can cause severe vasodilation and hypotension.
• The COVID-19 pandemic has been linked to increased anxiety disorders and suicide attempts.

Observation:

• A 72-year-old woman presented with amlodipine overdose and severe hypotension (72/55 mmHg) unresponsive to standard resuscitation.
• The patient developed acute pulmonary edema and required mechanical ventilation.
• Initial treatments including fluids, vasopressors, and calcium chloride were insufficient.

Findings:

• High-dose insulin infusion (up to 10 units/kg/hr) with dextrose was initiated to achieve euglycemic hyperinsulinemia.
• Hemodynamic status significantly improved within 30 minutes, with systolic blood pressure rising to 95 mmHg.
• Insulin's effects were dose-dependent, leading to improved blood pressure and resolution of pulmonary edema after furosemide administration.

Implications:

• High-dose insulin infusion may act as an inotropic and vasotropic agent in CCB toxicity.
• This treatment potentially alters myocardial metabolism and augments insulin secretion/uptake.
• Euglycemic hyperinsulinemia presents a promising therapeutic option for managing severe calcium channel blocker overdoses.