Beta-blocker toxicity

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Background

Clinical Features

Differential Diagnosis

Symptomatic bradycardia

Evaluation

Management

  1. Consider activated charcoal if present within 2 hr of ingestion
  2. Symptomatic bradycardia
  3. Hypotension
    • IV fluids
  4. Hypoglycemia
    • Adult - D50
    • Ped - 2.5mL/kg of D10
If IV fluid and atropine are not sufficient then consider

Glucagon

  • Half-life is 20min
  • Consider concurrent administration of ondansetron (causes nausea and vomiting)
  • Adult: 5mg IV bolus over one minute [1] [2]
  • Ped: 50mcg/kg
  • Rebolus if no response after 10min
  • Effects persist for 10-15 min
  • If effective start infusion at:
    • Adult: 2-5mg/hr
    • Ped: 70mcg/kg/hr

Calcium

  • Calcium gluconate 3g (30-60mL of 10% soln)
  • Calcium chloride 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)
    • Preferred over calcium gluconate because it provides triple the amount of calcium on a weight-to-weight basis [2]
    • Give Calcium 1g Q5min to titrate to BP effect
    • If effect in BP is seen can give as a drip at 10-50mg/kg/hr

High-dose insulin and glucose

  • Takes 30-60min for effect
  • Augments myocardial contraction[3]
  • Regular Insulin 1 Unit/kg IV Bolus accompanied by 0.5 gram/kg dextrose
  • Regular insulin 1 Unit/kg/hr Drip, titrate infusion until hypotension is corrected or max 10u/kg/hr
  • D50W drip at 0.1-0.2 gram/kg/hr
  • Initial glucose checks q15 minutes until blood sugar stability established
  • Replace potassium and magnesium if necessary

Vasopressors

  • Consider to be added as adjunctive therapy to all other therapies
  • Toxicity can also be managed with vasopressors alone[4]
  • Epinephrine
    • Adult: Start 1 mcg/min and titrate to MAP=60
    • Ped: Start 0.1mcg/kg/min

Intralipid Therapy

Draw all labs prior to infusion

  • Support as an antidote comes from animal studies and case reports[5]
  • IV 20% Intralipid at 1.5 mL/kg Bolus[6]
    • Bolus could be repeated 1-2 times if persistent asystole
    • Followed by infusion of 0.25 mL/kg/min for 30-60 minutes or until hemodynamic stability achieved
  • if responsive to bolus initiate infusion at 0.25 mL/kg/min for 1hr (e.g. about 600 mL over 30 minutes in a 70kg adult)
    • Infusion rate could be increased if the BP declines

Hemodialysis

ECMO

  • Consider VA ECMO for refractory cases
  • Note that if ECMO is chosen, intralipids are avoided due to potential of clotting of the ECMO circuits

Sedation

  • Consider ketamine as post-intubation sedation for hemodynamics

Disposition

  • Admit all symptomatic patients
  • Admit all sotalol ingestions (long half-life)
  • Observe all others for ~ 6hr

See Also

References

  1. ↑ Kerns W. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-331. (Review)
  2. ↑ Bailey B (2003). Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. Journal of toxicology. Clinical toxicology, 41 (5), 595-602 PMID: 14514004
  3. ↑ High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Engebretsen KM et al. Clin Toxicol 2011;49:277-283
  4. ↑ Levine M et al. Critical Care Management of Verapamil and Diltiazem Overdose with a Focus on Vasopressors: A 25-Year Experience at a Single Center. Ann Emerg Med 2013 May 1
  5. ↑ Rothschild L, Bern S, Oswald, et al. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma Resusc Emerg Med. 2010; 18:51.
  6. ↑ Cave, G. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. 2009. 16(9)815–824
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