Beta-blocker toxicity: Difference between revisions
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== Management ==
== Management ==
 
*Consider charcoal if present within 2 hr of ingestion  
#Consider charcoal if present within 2 hr of ingestion  
*Bradycardia (symptomatic)  
#Bradycardia (symptomatic)  
**Atropine 0.5-1mg q3-5min up to 0.04mg/kg  
##Atropine 0.5-1mg q3-5min up to 0.04mg/kg  
*Hypotension  
#Hypotension  
**IV fluids  
##IV fluids  
*Hypoglycemia  
#Hypoglycemia  
**Adult - D50  
##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 <ref>Kerns W. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-331. (Review)</ref> <ref>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</ref>
*Adult: 5mg IV bolus over one minute <ref>Kerns W. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-331. (Review)</ref> <ref>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</ref>
#Ped: 50mcg/kg  
*Ped: 50mcg/kg  
#Rebolus if no response after 10min  
*Rebolus if no response after 10min  
#Effects persist for 10-15 min
*Effects persist for 10-15 min
#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<ref>High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning.  Engebretsen KM et al.  Clin Toxicol 2011;49:277-283</ref>
*Augments myocardial contraction<ref>High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning.  Engebretsen KM et al.  Clin Toxicol 2011;49:277-283</ref>
#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 to be added as adjunctive therapy to all other therapies.  Toxcity can also be manage vasopressors alone <ref>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</ref>
*Consider to be added as adjunctive therapy to all other therapies.  Toxcity can also be manage vasopressors alone <ref>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</ref>
#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


===Intralipid Therapy===
===Intralipid Therapy===
''Draw all labs prior to infusion.  Support as an antidote comes from animal studies and case reports''
''Draw all labs prior to infusion.  Support as an antidote comes from animal studies and case reports''
#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>
*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>
#Bolus could be repeated 1-2 times if persistent systole
*Bolus could be repeated 1-2 times if persistent systole
# Infusion of 0.25 mL/kg/min for 30-60 minutes
* Infusion of 0.25 mL/kg/min for 30-60 minutes
#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)
*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
**Infusion rate could be increased if the BP declines
===Hemodialysis===  
===Hemodialysis===  
#Only effective for Nadolol, sotalol, and atenolol
*Only effective for Nadolol, sotalol, and atenolol


==Disposition==
==Disposition==

Revision as of 18:16, 8 March 2015

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
  2. Glucose
  3. Chemistry
    • Creatinine (esp with atenolol)

Differential Diagnosis

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

Management

  • Consider charcoal if present within 2 hr of ingestion
  • Bradycardia (symptomatic)
    • Atropine 0.5-1mg q3-5min up to 0.04mg/kg
  • Hypotension
    • IV fluids
  • 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 n/v)
  • 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

High dose insulin and glucose

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

Vasopressors

  • Consider to be added as adjunctive therapy to all other therapies. Toxcity can also be manage 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

  • IV 20% Intralipid at 1.5 mL/kg Bolus[5]
  • Bolus could be repeated 1-2 times if persistent systole
  • Infusion of 0.25 mL/kg/min for 30-60 minutes
  • 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

  • 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. ↑ 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. ↑ Cave, G. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. 2009. 16(9)815–824
  1. http://www.lipidrescue.org/
  2. EB Medicine May/Jun 2014 Vol 4, No 3
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