Beta-blocker toxicity: Difference between revisions
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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  
##Regular Insulin 1 Unit/kg IV Bolus accompanied by 0.5g/kg dextrose
#Regular Insulin 1 Unit/kg IV Bolus accompanied by 0.5g/kg dextrose
##Regular insulin 1Unit/kg/hr Drip  
#Regular insulin 1Unit/kg/hr Drip  
##D50W drip at 0.1-0.2gram/kg/hr   
#D50W drip at 0.1-0.2gram/kg/hr   
#Vasopressors  
===Vasopressors===
##Consider if all of above has failed  
#Consider if all of above has failed  
##Epinephrine  
#Epinephrine  
###Adult: Start 1 mcg/min and titrate to MAP=60  
##Adult: Start 1 mcg/min and titrate to MAP=60  
###Ped: Start 0.1mcg/kg/min  
##Ped: Start 0.1mcg/kg/min  
#Fat Emulsion Therapy - "Intra-lipid"
===Intralipid Therapy===
##IV 20% Intralipid at 1.5 mL/kg Bolus
''Draw all labs prior to infusion.  Support as an antidote comes from animal studies and case reports''
###Bolus could be repeated 1-2 times if persistent asystole
#IV 20% Intralipid at 1.5 mL/kg Bolus<ref>Cave, G. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. 2009.  16(9)815–824</ref>
##if responsive to bolus initiate infusion at 0.25 mL/kg/min for 1hr then R/A
#Bolus could be repeated 1-2 times if persistent systole
###Infusion rate could be increased if the BP declines
# Infusion of 0.25 mL/kg/min for 30-60 minutes
#Hemodialysis  
#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)
##Only effective for Nadolol, sotalol, and atenolol
##Infusion rate could be increased if the BP declines
===Hemodialysis===
#Only effective for Nadolol, sotalol, and atenolol


==Disposition==
==Disposition==

Revision as of 14:35, 24 July 2014

Background

Diagnosis

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

Work-Up

  1. ECG
    1. PR prolongation
    2. Bradycardia
    3. QT Prolongation
    4. Any bradydysrhythmia
  2. Glucose
  3. Chemistry
    1. Creatinine (esp with atenolol)

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:

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

High dose insulin and glucose

  1. Augments myocardial contraction
  2. Regular Insulin 1 Unit/kg IV Bolus accompanied by 0.5g/kg dextrose
  3. Regular insulin 1Unit/kg/hr Drip
  4. D50W drip at 0.1-0.2gram/kg/hr 

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

Intralipid Therapy

Draw all labs prior to infusion. Support as an antidote comes from animal studies and case reports

  1. IV 20% Intralipid at 1.5 mL/kg Bolus[1]
  2. Bolus could be repeated 1-2 times if persistent systole
  3. Infusion of 0.25 mL/kg/min for 30-60 minutes
  4. 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)
    1. Infusion rate could be increased if the BP declines

Hemodialysis

  1. Only effective for Nadolol, sotalol, and atenolol

Disposition

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

See Also

Source

  1. Rosen's
  2. http://emedicine.medscape.com/article/813342-overview
  3. http://www.lipidrescue.org/
  4. EB Medicine May/Jun 2014 Vol 4, No 3
  1. ↑ Cave, G. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. 2009. 16(9)815–824
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