EMedHome's Clinical Pearl
ACE inhibitor toxicity can result in severe bradycardia and profound hypotension. (Am J Emerg Med. 2019;37:1217; J Hum Hypertens. 1995;9:711; Ann Emerg Med. 1991;20:1125.)
Consider naloxone to treat ACEI poisoning, especially in cases of severe hypotension in which aggressive administration of IV fluids would be a concern. Using naloxone in this setting may also avoid the need to employ vasopressive support and pacing.
Several distinct families of endogenous opioids have been identified, with the most well-characterized being endorphins, enkephalins, and dynorphins. Enkephalins have direct effects on blood pressure, heart rate, and the baroreceptor reflex.
ACE inhibitors inhibit the metabolism of enkephalins, potentiating their opioid effect, which includes lowering blood pressure. Administering naloxone has been shown to increase blood pressure in ACE inhibitor overdoses. (Maryland Poison Center, toxtidbits. January 2012. http://bit.ly/32BCzm9.)
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