Abstract
BACKGROUND: Calcium channel blocker (CCB) overdose can present as vasoplegic or cardiogenic shock, but current guidance does not operationalize bedside echocardiography to direct therapy. OBJECTIVES: We propose an echocardiography-centered, phenotype-driven flowchart to standardize decisions. METHODS: Our proposed algorithm (1) prioritizes standard airway, breathing and circulatory management and an initial mean arterial blood pressure (MAP) target ≥ 65 mmHg, with higher targets (for example, 75–80 mmHg) considered in selected patients such as those with chronic hypertension; (2) embeds immediate point-of-care echocardiography (POCUS) to classify preserved/hyperdynamic LV function (vasoplegia; typical of dihydropyridines) versus reduced EF/poor contractility with bradycardia (cardiogenic shock; typical of non-dihydropyridines); and (3) links each phenotype to distinct treatment pathways. RESULTS: The vasoplegia branch prioritizes norepinephrine with or without vasopressin, empiric IV calcium (bolus ± infusion) with ionized calcium monitoring, and a trial of methylene blue when refractory, with VV-ECMO considered for severe noncardiogenic pulmonary edema. The cardiogenic branch emphasizes calcium, epinephrine/inotropic support, high-dose insulin (HDI) for myocardial depression, pacing for unstable bradycardia, and early VA-ECMO when conventional measures fail. Reassessment loops with serial echo and explicit escalation/de-escalation triggers are defined; lipid emulsion is positioned as a salvage therapy. We also outline potential harms of misclassification (e.g., HDI potentially worsening isolated vasoplegia). CONCLUSION: An echo-guided framework may reduce time-to-effective therapy and iatrogenesis and offers a standardizable bedside pathway. This proposal requires prospective validation and local adaptation of thresholds and sequencing. Unlike existing CCB overdose protocols, this flowchart operationalizes immediate point-of-care echocardiographic phenotyping to separate vasoplegic from cardiogenic shock and links each phenotype to explicit escalation, reassessment, and de-escalation triggers.