High dose insulin with dextrose supplementation is indicated for patients with calcium channel blocker and beta blocker overdose and signs of cardiac toxicity.

Mechanisms are not completely elucidated, but mostly related to the stimulation of PI3K.

Evidence comes from animal models and 20 years of successful use in humans.

Highly concentrated forms of insulin and dextrose via central line.

Coordinate with toxicology, pharmacy, and nursing to avoid dosing errors.

Takes 30 minutes to see effect, temporize with traditional vasopressors (norepinephrine, vasopressin).

Titrate to end organ perfusion as MAP may not change significantly.

Disposition to ICU.

Back up plans for mechanical support such as venous-arterial ECMO such be considered early for refractory patients.

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