AW Antidote/1

¿“«–æ‘…®“°¬“µâ“π·§≈‡´’¬¡
(CALCIUM CHANNEL BLOCKERS POISONING)
ºŸâ™à«¬»“ µ√“®“√¬å𓬷æ∑¬å ÿ™—¬ ÿ‡∑æ“√—°…å
“¢“æ‘…«‘∑¬“ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å
®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
ºŸâªÉ«¬À≠‘߉∑¬§Ÿà Õ“¬ÿ 25 ªï Õ“™’æ°àÕ √â“ß
Õ“°“√ ”§—≠: °‘𬓠verapamil (40 mg) 25 ‡¡Á¥ 30 π“∑’°àÕπ¡“‚√ß欓∫“≈
ª√–«—µª‘ ®í ®ÿ∫π— : 2 —ª¥“Àå°Õà π‰¥â√∫— °“√«‘π®‘ ©—¬·¬°‚√§√–À«à“ß verapamil sensitive ventricular tachycardia °—∫ WolffeParkinson-White syndrome √Õµ√«®«‘π‘®©—¬‡æ‘Ë¡‡µ‘¡ ·æ∑¬å„Àâ°“√√—°…“¥â«¬ verapamil (40 mg)
ºŸâªÉ«¬¡’ªí≠À“∑“ß∫â“π ®÷ß°‘𬓠verapamil ª√–¡“≥ 25 ‡¡Á¥ ‡¡◊ËÕ30 π“∑’°àÕπ¡“‚√ß欓∫“≈
À≈—ß°‘π√Ÿâ ÷°µ—«¥’ „® —Ëπ‡≈Á°πâÕ¬ ‰¡à¡’Àπâ“¡◊¥
ª√–«—µ‘Õ¥’µ: ‡ªìπ ventricular tachycardia ¡“ 3 ªï
µ√«®√à“ß°“¬: BT 37 C, PR 125 --> 72 /min, RR 20/min, BP 80/50 --> 100/70 mmHg
Good consciousness, others within normal limits
º≈°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√:
Hb 12.3 gm%, Hct 38%, WBC3 10,580/10 cells/mm3 (N 47%, L 42%), platelet 340,000/103cells/mm3
BUN/Cr 150/8 mg%, plasma glucose 125 mg%, Na+ 138, K+ 4.2, Cl- 102, HCO3- 19 mEq/L
EKG ·√°√—∫∑’ËÀâÕß©ÿ°‡©‘π‡ªìπ wide QRS complex tachycardia rate ª√–¡“≥ 120-130 /min
‰¥â√°— …“¥â«¬°“√≈â“ß∑âÕß „Àâºß∂à“π°—¡¡—πµå 45 °√—¡ „Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ·≈–√—∫‡¢â“ÀÕºŸªâ «É ¬Àπ—°
µàÕ¡“æ∫ EKG ‡ªìπ sinus arrest with accelerated junctional rhythm ·≈–¡’ delta wave ‰¥â„Àâ 10% calcium gluconate
10 ¡≈. EKG ‡ª≈’ˬπ‡ªìπ normal sinus rhythm µàÕ¡“‡°‘¥ junctional rhythm Õ’°·≈–‡ª≈’ˬπ‡ªìπ normal sinus rhythm
°≈—∫‰ª°≈—∫¡“‡ªìπ‡«≈“ª√–¡“≥ 24 ™—Ë«‚¡ß ·µàºŸâªÉ«¬√Ÿâ ÷°µ—«¥’·≈– —≠≠“≥™’懪ìπª°µ‘‚¥¬µ≈Õ¥ ®÷߬⓬‰ªÀÕ
ºŸâªÉ«¬ª°µ‘ ·≈–‰¥â√—∫°“√µ√«®‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ«‘π‘®©—¬ Wolffe-Parkinson-White syndrome
ºŸâªÉ«¬√“¬π’È¡’ª√–«—µ‘·≈–Õ“°“√· ¥ß™—¥‡®π«à“‡ªìπæ‘…®“° verapamil ´÷Ë߇ªì𬓄π°≈ÿà¡ calcium channel
blockers ‚¥¬¡’ mild transient hypotension ·≈– junctional rhythm ‰¥â√—∫°“√¥Ÿ·≈√—°…“‚¥¬°“√≈â“ß∑âÕß „Àâºß
∂à“π°—¡¡—πµå °“√‡ΩÑ“¥Ÿ„πÀÕºŸâªÉ«¬Àπ—°·≈–„Àâ°“√√—°…“µ“¡Õ“°“√ ºŸâªÉ«¬µÕ∫ πÕßµàÕ°“√√—°…“¥’ ·≈–‰¥â„Àâ
·§≈‡´’¬¡ ‡æ◊ËÕ√—°…“¿“«– sinus arrest ´÷Ë߉¡à “¡“√∂ √ÿª‰¥â«à“¡’°“√µÕ∫ πÕ߇æ√“–‡ª≈’ˬπ‡ªìπ normal sinus
rhythm ‰¥â·¡â‰¡à‰¥â√—∫·§≈‡´’¬¡
¬“µâ“πæ‘… Ò
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Calcium channel blockers (CCBs) ‡ªìπ¬“∑’Ë„™â„π°“√√—°…“‚√§¢ÕßÀ—«„®·≈–À≈Õ¥‡≈◊Õ¥ ‚¥¬„™â
‡ªìπ¬“¢¬“¬À≈Õ¥‡≈◊Õ¥À—«„® §«∫§ÿ¡§«“¡¥—π‚≈À‘µ Ÿß ·≈–√—°…“À—«„®‡µâπº‘¥®—ßÀ«– „™â°—πÕ¬à“ß·æ√àÀ≈“¬
·µà “¡“√∂∑”„À⇰‘¥§«“¡‡ªìπæ‘…∑’Ë√ÿπ·√߉¥â ∂â“√—∫ª√–∑“π‡ªìπ®”π«π¡“°
CCBs ·∫àßµ“¡‚§√ß √â“ßÕÕ°‡ªìπ 3 °≈ÿà¡ §◊Õ
❍ °≈ÿà¡ phenylalkylamines ‰¥â·°à verapamil
❍ °≈ÿà¡ dihydropyridines ‰¥â·°à nifedipine
❍ °≈ÿà¡ benzothiazines ‰¥â·°à diltiazem
πÕ°®“°π’Ȭ—ß¡’ CCBs ∑’ËÕ“®‡√’¬°‡ªìπ second generation ∑’ËÕÕ°ƒ∑∏‘Ï selective µàÕ°≈â“¡‡π◊ÈÕ‡√’¬∫¢Õß
À≈Õ¥‡≈◊Õ¥¡“°°«à“°≈â“¡‡π◊ÕÈ À—«„® CCBs ‡À≈à“π’¡È °— „™â‡ªìπ¬“√—°…“§«“¡¥—π‚≈À‘µ Ÿß ‰¥â·°à amlodipine, nicardipine,
nitrendipine œ≈œ ´÷ËßÕ¬Ÿà„π°≈ÿà¡ dihydropyridines „πºŸâªÉ«¬∑ÿ°√“¬∑’Ë¡’§«“¡¥—π‚≈À‘µµË” æ∫«à“ºŸâªÉ«¬ à«π„À≠à
µÕ∫ πÕ߉¥â¥’ ·µà ”À√—∫°“√„Àâ·§≈‡´’¬¡√—°…“¿“«–À—«„®‡µâπº‘¥ª°µ‘ ¡’°“√µÕ∫ πÕß·µ°µà“ß°—πÕÕ°‰ª„π
ºŸâªÉ«¬·µà≈–√“¬ ®÷ßæ‘®“√≥“‡ªìπ√“¬Ê‰ª
°“√„Àâ·§≈‡´’¬¡®–‡ªìπ 10% calcium chloride (13.6 mEq/L) 10 ¡≈. À√◊Õ 10% calcium gluconate
(4 mEq/L) 30 ¡≈. „Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”™â“Ê ¿“¬„π 5 π“∑’ “¡“√∂„Àâ´È”‰¥â∑ÿ° 10-20 π“∑’∂⓺ŸâªÉ«¬¬—߉¡à¥’¢÷Èπ
„π°√≥’∑’Ë„Àâ·§≈‡´’¬¡À≈“¬Ê §√—Èß µâÕßµ√«®«—¥√–¥—∫·§≈‡´’¬¡„π‡≈◊Õ¥‡æ√“–Õ“®¡’¿“«– hypercalcemia ‰¥â
°“√√—°…“Õ◊ËπÊ ∑’ËÕ“®‰¥âª√–‚¬™π剥ⷰà glucagon ‚¥¬„Àâ¢π“¥ 3-10 ¡°. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑—π∑’
·≈–„Àâ„πª√‘¡“≥ 1-5 ¡°/™¡. ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”´÷Ëß¡’√“¬ß“π “¡“√∂√—°…“¿“«– myocardial depression ®“°
°“√‡ªìπæ‘…¢Õß verapamil, nifedipine ·≈– diltiazem ‰¥â ‚¥¬ —ππ‘…∞“π«à“ glucagon ®–®—∫°—∫ catecholamineindependent receptor ·≈–°√–µÿâπ adenyl cyclase „Àâ √â“ß intracellular cAMP ‡æ‘Ë¡¢÷Èπ ∑”„Àâ¡’ calcium flux
‡¢â“‡´≈≈å‚¥¬‰¡àºà“π∑“ß calcium channel
πÕ°®“°π’¡È √’ “¬ß“π°“√„Àâ 4-aminopyridine ‡æ◊ÕË √—°…“¿“«–‡ªìπæ‘…®“° verapamil ‚¥¬∑’Ë 4-amino-pyridine
¡’ƒ∑∏‘χæ‘Ë¡ calcium influx ·≈–≈¥ potassium influx
‡Õ° “√ª√–°Õ∫°“√‡√’¬∫‡√’¬ß
1. Pearigen PD, Benowitz NL. Poisoning due to calcium antagonists: Experience with verapmil, diltiazem and
nifedipine. Drug Saf 1991;6:408-30.
2. Ramoska EA, Spiller HA, Winter M, Borys D. A 0ne-year evaluation of calcium channel blokcer overdose:
Toxicity and treatment. Ann Emerg Med 1993;22:196-200.
3. Kenny J. Treating overdose with calcium channel blockers. Br Med J 1994;308:992-3.
4. Spiller HA, Meyers A, Ziemba T, Riley M. Delayed onset of cardiac arrhythmias from sustained release
verapamil. Ann Emerg Med 1991;20:201-3.
5. Morris DL, Goldschlager N. Calcium infusion for reversal of adverse effects of intravenous verapamil. JAMA
1983;249:3212-3.
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