Beta-blocker toxicity: Difference between revisions

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##SLUDGE
##SLUDGE


==Management==
== Management ==
#Consider charcoal if present within 2 hr of ingestion
 
#Bradycardia (symptomatic)
#Consider charcoal if present within 2 hr of ingestion  
## Atropine 0.5-1mg q3-5min up to 0.04mg/kg
#Bradycardia (symptomatic)  
#Hypotension
##Atropine 0.5-1mg q3-5min up to 0.04mg/kg  
##IV fluids
#Hypotension  
#Hypoglycemia
##IV fluids  
##Adult - D50
#Hypoglycemia  
##Adult - D50  
##Ped - 2.5mL/kg of D10
##Ped - 2.5mL/kg of D10


If IV fluid and atropine are not sufficient then consider:
If IV fluid and atropine are not sufficient then consider:  
 
#Glucagon  
#Glucagon  
##Half-life is 20min
##Half-life is 20min  
##Consider concurrent administration of ondansetron (causes n/v)
##Consider concurrent administration of ondansetron (causes n/v)  
##Adult: 5mg IV bolus over one minute
##Adult: 5mg IV bolus over one minute  
##Ped: 50mcg/kg
##Ped: 50mcg/kg  
##Rebolus if no response after 10min
##Rebolus if no response after 10min  
##If effective start infusion at:
##If effective start infusion at:  
###Adult: 2-5mg/hr
###Adult: 2-5mg/hr  
###Ped: 70mcg/kg/hr
###Ped: 70mcg/kg/hr  
#High dose insulin and glucose
#High dose insulin and glucose  
##Augments myocardial contraction
##Augments myocardial contraction  
#Vasopressors
##Regular Insulin 1 Unit/kg IV Bolus
##Consider if all of above has failed
##Regular insulin 1Unit/kg/hr Drip
##Epinephrine
##D50W drip at 0.1-0.2gram/kg/hr 
###Adult: Start 1 mcg/min and titrate to MAP=60
#Vasopressors  
###Ped: Start 0.1mcg/kg/min
##Consider if all of above has failed  
#Hemodialysis
##Epinephrine  
###Adult: Start 1 mcg/min and titrate to MAP=60  
###Ped: Start 0.1mcg/kg/min  
#Hemodialysis  
##Only effective for atenolol, sotalol
##Only effective for atenolol, sotalol


Revision as of 14:36, 18 March 2012

Background

  • Coingestion with CCB, cyclics, and neuroleptics increases mortality
  • Agents with membrane-stabilizing activity are esp lethal
    • Prolongs QT > dysrhythmias
      • Propranolol
      • Sotalol

Diagnosis

  • Cardiac
    • Bradycardia
    • Hypotension
    • Ventricular dysrhythmias
  • CNS
    • Mental status change
      • Delirium, coma
    • Seizure (esp w/ propranolol)
  • Other
    • Hypoglycemia (uncommon in adults)
    • Bronchospasm (uncommon)

Work-Up

  1. ECG
    1. PR prolongation
    2. Bradycardia
    3. QT prolongation
    4. Any bradydysrhythmia
  2. Glucose
  3. Chemistry

DDx

  1. Calcium-channel blockers
    1. Unlikely to cause CNS changes
    2. Hyperglycemia is more common
  2. Digoxin
    1. Nausea/vomiting is more common
  3. Clonidine
    1. Miosis, somnolence
  4. Cholinergic agents
    1. SLUDGE

Management

  1. Consider charcoal if present within 2 hr of ingestion
  2. Bradycardia (symptomatic)
    1. Atropine 0.5-1mg q3-5min up to 0.04mg/kg
  3. Hypotension
    1. IV fluids
  4. Hypoglycemia
    1. Adult - D50
    2. Ped - 2.5mL/kg of D10

If IV fluid and atropine are not sufficient then consider:

  1. Glucagon
    1. Half-life is 20min
    2. Consider concurrent administration of ondansetron (causes n/v)
    3. Adult: 5mg IV bolus over one minute
    4. Ped: 50mcg/kg
    5. Rebolus if no response after 10min
    6. If effective start infusion at:
      1. Adult: 2-5mg/hr
      2. Ped: 70mcg/kg/hr
  2. High dose insulin and glucose
    1. Augments myocardial contraction
    2. Regular Insulin 1 Unit/kg IV Bolus
    3. Regular insulin 1Unit/kg/hr Drip
    4. D50W drip at 0.1-0.2gram/kg/hr 
  3. Vasopressors
    1. Consider if all of above has failed
    2. Epinephrine
      1. Adult: Start 1 mcg/min and titrate to MAP=60
      2. Ped: Start 0.1mcg/kg/min
  4. Hemodialysis
    1. Only effective for atenolol, sotalol

Disposition

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

See Also

Source

Rosen's

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