Successful resuscitation of a verapamil intoxicated child with a dextrose-insulin infusion

Objective: To report the use of dextrose-insulin infusion in the successful resuscitation of an adolescent following an overdose of sustained-release verapamil that was refractory to traditional medical management. Case summary: A 13-year-old female with depression and post-traumatic stress disorder ingested 25-30 120-mg tablets (120-140 mg/kg) of sustained-release verapamil in a suicide attempt. Gastric lavage was performed, and activated charcoal and sorbitol were given for gastric decontamination. She developed atrial-ventricular (A-V) dissociation, bradycardia, hypotension and somnolence. Initial interventions included endotracheal intubation for airway protection, fluid resuscitation, high-dose intravenous calcium chloride, and glucagon. Hypotension and A-V block continued despite the addition of dopamine, epinephrine, and norepinephrine infusions. Normal sinus rhythm and hemodynamic stability occurred only after an infusion of regular insulin (0.1 U/kg/hr) and dextrose (0.5 g/kg/hr) was started. She was weaned from vasopressor infusions over the next 48 hours and she was successfully extubated. Follow-up cardiac evaluation was normal. Conclusion: In this report, insulin euglycemia adjunctive therapy was used for the successful resuscitation of a severe verapamil intoxication that was refractory to standard therapies.