Beta-blocker toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Coingestion with CCB, cyclics, and neuroleptics increases mortality | |||
*Agents with membrane-stabilizing activity are esp lethal | |||
**Prolongs QT > dysrhythmias | |||
***Propranolol | |||
***Sotalol | |||
==Diagnosis== | ==Diagnosis== | ||
Clinical Manifestations | |||
*Cardiac | |||
**Bradycardia | |||
**Hypotension | |||
**Ventricular dysrhythmias | |||
*CNS | |||
**Mental status change | |||
***Delirium, coma | |||
**Seizure | |||
*Other | |||
**Hypoglycemia | |||
**Bronchospasm | |||
==Work-Up== | ==Work-Up== | ||
*ECG | |||
**PR prolongation | |||
**Bradycardia | |||
**QT prolongation | |||
**Any bradydysrhythmia | |||
*Glucose | |||
*Chemistry | |||
==DDx== | ==DDx== | ||
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**SLUDGE | **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 (in order): | |||
*Glucagon | |||
**Adult: 5mg IV bolus over one minute | |||
**Ped: 50mcg/kg | |||
*Consider concurrent administration of ondansetron (causes n/v) | |||
**Rebolus if no response after 10min | |||
**If effective start infusion at | |||
***Adult: 2-5mg/hr | |||
***Ped: 70mcg/kg/hr | |||
*Calcium | |||
**Adult: 30mL of 10% soln | |||
**Ped: 60mg/kg/dose (max 3g) | |||
*Vasopressors | |||
**Consider if all of above has failed | |||
**Epinephrine | |||
***Adult: Start 1 mcg/min and titrate to MAP=60 | |||
***Ped: Start 0.1mcg/kg/min | |||
*High dose insulin and glucose | |||
*Hemodialysis | |||
**Only effective for atenolol, sotalol | |||
** | |||
* | |||
==Disposition== | ==Disposition== | ||
*Admit all symptomatic patients | |||
*Admit all sotalol ingestions (long half-life) | |||
*Observe all others for ~ 6hr | |||
==See Also== | ==See Also== | ||
==Source== | ==Source== | ||
Rosen's | |||
[[Category:Tox]] | [[Category:Tox]] | ||
Revision as of 18:34, 23 March 2011
Background
- Coingestion with CCB, cyclics, and neuroleptics increases mortality
- Agents with membrane-stabilizing activity are esp lethal
- Prolongs QT > dysrhythmias
- Propranolol
- Sotalol
- Prolongs QT > dysrhythmias
Diagnosis
Clinical Manifestations
- Cardiac
- Bradycardia
- Hypotension
- Ventricular dysrhythmias
- CNS
- Mental status change
- Delirium, coma
- Seizure
- Mental status change
- Other
- Hypoglycemia
- Bronchospasm
Work-Up
- ECG
- PR prolongation
- Bradycardia
- QT prolongation
- Any bradydysrhythmia
- Glucose
- Chemistry
DDx
- 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 (in order):
- Glucagon
- Adult: 5mg IV bolus over one minute
- Ped: 50mcg/kg
- Consider concurrent administration of ondansetron (causes n/v)
- Rebolus if no response after 10min
- If effective start infusion at
- Adult: 2-5mg/hr
- Ped: 70mcg/kg/hr
- Calcium
- Adult: 30mL of 10% soln
- Ped: 60mg/kg/dose (max 3g)
- Vasopressors
- Consider if all of above has failed
- Epinephrine
- Adult: Start 1 mcg/min and titrate to MAP=60
- Ped: Start 0.1mcg/kg/min
- High dose insulin and glucose
- Hemodialysis
- 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