Beta-Blocker Toxicity

Prioritize airway, breathing, and circulation in any suspected beta-blocker poisoning. The immediately dangerous phenotype is bradycardia with hypotension or shock; serial blood-pressure measurements and continuous cardiac monitoring are indicated after exposures capable of cardiovascular toxicity. BMJ+1BMJToxidromes and a general approach to poisoningScienceDirectManagement of Beta-Adrenergic Blocker Poisoning - ScienceDirect

Obtain a 12-lead ECG after intentional ingestion or exposure to a poison capable of dysrhythmia. Specifically assess rhythm and conduction intervals: QRS prolongation indicates sodium-channel blockade and is associated with dysrhythmia, seizures, and fatality. Propranolol toxicity can present with altered mentation, seizures, and ventricular dysrhythmias because of sodium-channel blockade. BMJ+1BMJToxidromes and a general approach to poisoningScienceDirectPearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity - ScienceDirect

Measure bedside glucose immediately in altered sensorium or seizure. Treat documented hypoglycemia with oral glucose when safe or dextrose-containing intravenous fluids when enteral treatment is unsafe. Glucose abnormalities may also help distinguish beta-blocker toxicity from calcium-channel blocker toxicity, although neither routine laboratory testing nor a single metabolic pattern confirms either diagnosis. BMJ+2BMJToxidromes and a general approach to poisoningjaccBRASH Syndrome Following Coronary Angiography - JACCScienceDirectPearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity - ScienceDirect

Obtain serum electrolytes and renal function in suspected clinically important poisoning, and measure lactate when shock or end-organ hypoperfusion is suspected. Renal function and lactate do not establish the diagnosis of beta-blocker toxicity, but they define organ injury and perfusion deficit that should drive ICU-level monitoring and escalation. BMJ+1BMJToxidromes and a general approach to poisoningScienceDirectPearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity - ScienceDirect

In intentional or potentially toxic exposure, obtain quantitative acetaminophen and salicylate concentrations; add a digoxin concentration when digoxin coingestion is plausible. Obtain pregnancy testing when appropriate because it changes imaging, medication, and disposition decisions. BMJ+1BMJToxidromes and a general approach to poisoningScienceDirectPearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity - ScienceDirect

Use targeted studies for alternate toxidromes: blood gas for pH and serum lactate in severe poisoning; serum osmolality when toxic alcohol exposure is suspected; and co-oximetry when carbon monoxide exposure or methemoglobinemia is possible. These tests are phenotype-directed rather than routine confirmation studies for beta-blocker exposure. BMJBMJToxidromes and a general approach to poisoning

Provide immediate supportive resuscitation for hypotension, bradycardia, or shock. If hemodynamic compromise persists after IV fluids and atropine, use glucagon as a beta-blocker-directed antidotal therapy; refractory cases should progress promptly to high-dose insulin euglycemia treatment rather than repeated ineffective temporizing measures. ScienceDirect+1ScienceDirectManagement of Beta-Adrenergic Blocker Poisoning - ScienceDirectPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Glucagon has a physiologic rationale in impending or actual shock from beta-blocker overdose, but its optimal dose and clinical efficacy are uncertain. Anticipate vomiting and hyperglycemia; hypocalcemia has also been reported. In a controlled physiologic study, glucagon doses as high as 50 micrograms/kg produced hemodynamic effects, with nausea lasting less than 30 minutes when present. AHA Journals+2AHA JournalsHigh‐Dose Glucagon Has Hemodynamic Effects Regardless of ...acep[PDF] T H E 2 0 1 7 L L S A L IT E R A T U R E R E V IE W - ACEPPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Give IV calcium as an adjunct for hypotension after beta-blocker overdose, particularly when calcium-channel blocker coingestion is possible. Calcium chloride 1-5 g IV, or an equivalent calcium gluconate dose, may be followed by an infusion; calcium is not a substitute for escalation to high-dose insulin when shock persists. acep+1acep[PDF] T H E 2 0 1 7 L L S A L IT E R A T U R E R E V IE W - ACEPPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Use vasopressors as supportive therapy when perfusion remains inadequate, recognizing that the inotropic response to high-dose insulin may be delayed 15-60 minutes. Vasopressor selection should follow the dominant bedside hemodynamic abnormality rather than a fixed toxicology protocol. PubMedPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

For beta-blocker toxicity with shock refractory to fluids, atropine, and glucagon, administer regular insulin 1 U/kg IV bolus followed by a continuous infusion of 1-10 U/kg/h. Earlier protocols used a 0.5 U/kg bolus followed by 0.5-1 U/kg/h, but published treatment recommendations increased to the 1 U/kg bolus and 1-10 U/kg/h regimen. PubMed+1PubMedHigh-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning - PubMedPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Administer 0.5 g/kg IV dextrose with the insulin bolus unless glucose exceeds 400 mg/dL, then continue dextrose support to maintain glucose 100-200 mg/dL. Initiate a 10% dextrose infusion and give 50% dextrose IV boluses as needed. PubMedPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Measure glucose and potassium before insulin. Check glucose every 30 minutes initially for up to 4 hours; high-dose insulin can cause profound hypoglycemia and hypokalemia, which may worsen cardiotoxicity. Titrate insulin to hemodynamic response while maintaining euglycemia and correcting clinically important electrolyte abnormalities. PubMedPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Do not judge high-dose insulin failure in the first several minutes: its inotropic effect may be delayed 15-60 minutes, and vasopressors may be needed during that interval. Experimental models and accumulated case experience support high-dose insulin in severe beta-blocker and calcium-channel blocker poisoning, but controlled human trial evidence remains limited. PubMed+1PubMedHigh-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning - PubMedPubMedBeta-Blocker Toxicity - StatPearls - NCBI Bookshelf

Admit patients requiring continuous cardiac monitoring, serial ECGs, vasopressors, glucagon, calcium infusion, or high-dose insulin to a monitored critical-care setting. Serial ECGs are particularly important after exposure to cardiotoxins because conduction delay and dysrhythmia can evolve after the initial assessment. BMJBMJToxidromes and a general approach to poisoning

When shock persists despite fluids, atropine, glucagon, calcium, vasopressors, and high-dose insulin, obtain urgent multidisciplinary critical-care and toxicology support for advanced circulatory support. Extracorporeal life support is described as an escalation therapy in severe cardioactive poisoning literature, particularly for calcium-channel blocker poisoning; its use in a beta-blocker or mixed overdose should be individualized to reversible toxic cardiogenic shock and local capability. ScienceDirect+1ScienceDirectHigh dose insulin for beta-blocker and calcium channel-blocker poisoningacep[PDF] T H E 2 0 1 7 L L S A L IT E R A T U R E R E V IE W - ACEP

Treat concomitant poisonings in parallel. Acetaminophen, salicylate, and digoxin measurements are specifically useful in intentional ingestion or suspected coingestion, and calcium-channel blocker coingestion should be suspected when hyperglycemia, metabolic acidosis, and profound shock accompany bradycardia or conduction delay. BMJ+2BMJToxidromes and a general approach to poisoningNEJMTreatment of Calcium-Channel–Blocker Intoxication with Insulin Infusion | New England Journal of MedicineScienceDirectPearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity - ScienceDirect