Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Peak toxicity can be delayed by several hours. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. CCBs can also produce vasodilatory shock. Significant myocardial depression, bradycardia and hypotension result in both cases. Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles.
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