Beta-blocker toxicity - Revision history

Danbot: Add MedicationDose SMW annotations (6 entries: atropine, glucagon, calcium chloride, insulin, intralipid); dosing verified

2026-03-20T16:31:42Z

Add MedicationDose SMW annotations (6 entries: atropine, glucagon, calcium chloride, insulin, intralipid); dosing verified

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 *Observe all others for ~ 6hr
 ==See Also==
 *[[Beta blockers]]

Blsimpso at 01:50, 1 July 2021

2021-07-01T01:50:31Z

← Older revision		Revision as of 01:50, 1 July 2021
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	==See Also==		==See Also==
	*[[Beta blockers]]		*[[Beta blockers]]

			==External Links==
			*[https://www.nuemblog.com/blog/beta-blocker-overdose NUEM - Beta-Blocker Toxicity]
			*[https://emcrit.org/ibcc/ccb/ EMCrit - Calcium Channel Blocker (CCB) & Beta Blocker (BBl) Overdose]

	==References==		==References==

Elcatracho: /* Clinical Features */

2021-02-20T20:20:59Z

Clinical Features

← Older revision		Revision as of 20:20, 20 February 2021
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	**Brugada pattern of EKG with propanolol overdose		**Brugada pattern of EKG with propanolol overdose
	**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]		**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]
	**~~Propanolol~~ has sodium channel blockade activity leading to [[wide QRS]]<ref>Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol. 1996;34(3):273-278. doi:10.3109/15563659609013789</ref>		**Propranolol has sodium channel blockade activity leading to [[wide QRS]]<ref>Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol. 1996;34(3):273-278. doi:10.3109/15563659609013789</ref>

	==Differential Diagnosis==		==Differential Diagnosis==

Josgood: /* Clinical Features */

2021-01-06T04:53:24Z

Clinical Features

← Older revision		Revision as of 04:53, 6 January 2021
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	==Clinical Features==		==Clinical Features==
	*Effects will typically be seen within 6 hours if ingestion with the exception of sotalol which can have a delayed and prolonged toxicity		*Effects will typically be seen within 6 hours of ingestion with the exception of sotalol which can have a delayed and prolonged toxicity
	*Cardiac		*Cardiac
	**[[Bradycardia]]		**[[Bradycardia]]

Elcatracho: /* Clinical Features */

2020-12-10T19:15:58Z

Clinical Features

← Older revision		Revision as of 19:15, 10 December 2020
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	**Brugada pattern of EKG with propanolol overdose		**Brugada pattern of EKG with propanolol overdose
	**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]		**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]
	**Propanolol has sodium channel blockade activity leading to wide QRS<ref>Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol. 1996;34(3):273-278. doi:10.3109/15563659609013789</ref>		**Propanolol has sodium channel blockade activity leading to [[wide QRS]]<ref>Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol. 1996;34(3):273-278. doi:10.3109/15563659609013789</ref>

	==Differential Diagnosis==		==Differential Diagnosis==

Elcatracho: /* Evaluation */

2020-12-10T19:14:50Z

Evaluation

← Older revision		Revision as of 19:14, 10 December 2020
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	**PR prolongation		**PR prolongation
	**[[Bradycardia]]		**[[Bradycardia]]
	**[[QT Prolongation]] (with sotalol) <ref>Link MS, Foote CB, Sloan SB, Homoud MK, Wang PJ, Estes NA 3rd. Torsade de pointes and prolonged QT interval from surreptitious use of sotalol: use of drug levels in diagnosis. Chest. 1997;112(2):556-557. doi:10.1378/chest.112.2.556</ref>		**[[QT Prolongation]] with sotalol<ref>Link MS, Foote CB, Sloan SB, Homoud MK, Wang PJ, Estes NA 3rd. Torsade de pointes and prolonged QT interval from surreptitious use of sotalol: use of drug levels in diagnosis. Chest. 1997;112(2):556-557. doi:10.1378/chest.112.2.556</ref>
			**[[Wide QRS]] with propanolol
	**Any bradydysrhythmia		**Any bradydysrhythmia
	**Obtain multiple ECGs over time to monitor any changes		**Obtain multiple ECGs over time to monitor any changes

Elcatracho: /* Clinical Features */

2020-12-10T19:13:40Z

Clinical Features

← Older revision		Revision as of 19:13, 10 December 2020
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	**Brugada pattern of EKG with propanolol overdose		**Brugada pattern of EKG with propanolol overdose
	**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]		**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]
			**Propanolol has sodium channel blockade activity leading to wide QRS<ref>Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol. 1996;34(3):273-278. doi:10.3109/15563659609013789</ref>

	==Differential Diagnosis==		==Differential Diagnosis==

Elcatracho: /* Evaluation */

2020-12-10T19:06:47Z

Evaluation

← Older revision		Revision as of 19:06, 10 December 2020
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	**PR prolongation		**PR prolongation
	**[[Bradycardia]]		**[[Bradycardia]]
	**[[QT Prolongation]]		**[[QT Prolongation]] (with sotalol) <ref>Link MS, Foote CB, Sloan SB, Homoud MK, Wang PJ, Estes NA 3rd. Torsade de pointes and prolonged QT interval from surreptitious use of sotalol: use of drug levels in diagnosis. Chest. 1997;112(2):556-557. doi:10.1378/chest.112.2.556</ref>
	**Any bradydysrhythmia		**Any bradydysrhythmia
	**Obtain multiple ECGs over time to monitor any changes		**Obtain multiple ECGs over time to monitor any changes

Mtjordan91: /* Background */

2019-11-20T19:28:16Z

Background

← Older revision		Revision as of 19:28, 20 November 2019
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	==Background==		==Background==
	*Coingestion with [[Calcium Channel Blockers]], [[Tricyclic Antidepressants]], and [[Antipsychotics]] increases mortality		*Coingestion with [[Calcium Channel Blockers]], [[Tricyclic Antidepressants]], and [[Antipsychotics]] increases mortality
	*Agents with membrane-stabilizing activity are especially lethal as they [[QT prolongation\|prolong QT]], leading to dysrhythmias		*Agents with membrane-stabilizing activity (e.g. sodium channel blockade) are especially lethal as they [[QT prolongation\|prolong QT]], leading to dysrhythmias
	**[[Propranolol]]		**[[Propranolol]]
	**[[Sotalol]]		**[[Sotalol]]
	*[[Propranolol]] is particularly CNS toxic, as it is highly lipophilic and passes blood brain barrier freely, causing seizures and comatose state<ref>NIH. PROPRANOLOL HYDROCHLORIDE. https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3176</ref>		*[[Propranolol]] is particularly CNS toxic, as it is highly lipophilic and passes blood brain barrier freely, causing seizures and comatose state<ref>NIH. PROPRANOLOL HYDROCHLORIDE. https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+3176</ref>
			*At toxic levels, beta-blockers will inhibit both beta-1 and beta-2 activity regardless for their affinity for specific receptors at therapeutic levels

	==Clinical Features==		==Clinical Features==
			*Effects will typically be seen within 6 hours if ingestion with the exception of sotalol which can have a delayed and prolonged toxicity
	*Cardiac		*Cardiac
	**[[Bradycardia]]		**[[Bradycardia]]
			***Most common presenting sign
	**[[Hypotension]]		**[[Hypotension]]
	**[[Ventricular dysrhythmias]]		**[[Ventricular dysrhythmias]]
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	**Bronchospasm (uncommon)		**Bronchospasm (uncommon)
	**[[Hypothermia]]		**[[Hypothermia]]
			**Brugada pattern of EKG with propanolol overdose
			**Sotalol has type III anti-arrhythmic that can lead to prolonged QT causing [[torsade de pointes]] and possibly [[ventricular fibrillation]]

	==Differential Diagnosis==		==Differential Diagnosis==
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	**[[QT Prolongation]]		**[[QT Prolongation]]
	**Any bradydysrhythmia		**Any bradydysrhythmia
			**Obtain multiple ECGs over time to monitor any changes
	*Glucose		*Glucose
	*Chemistry		*Chemistry
	**Creatinine (esp with atenolol)		**Creatinine (esp with atenolol)
			*Continuous cardiac monitoring
			*Respiratory rate
			**Propranolol can induce central apnea

	==Management==		==Management==
			#Adress airway, breathing, and circulation
	#Consider [[activated charcoal]] if present within 2 hr of ingestion		#Consider [[activated charcoal]] if present within 2 hr of ingestion
	#[[Symptomatic bradycardia]]		#[[Symptomatic bradycardia]]
	#*[[Atropine]] 0.5-1mg q3-5min up to ~~0.04mg/kg~~		#*[[Atropine]] 0.5-1mg q3-5min up to 3mg
	#*Avoid atropine in wide-complex bradycardia and consider chronotropes such as [[epinephrine]], [[dobutamine]], [[dopamine]], [[isoproterenol]]		#*Avoid atropine in wide-complex bradycardia and consider chronotropes such as [[epinephrine]], [[dobutamine]], [[dopamine]], [[isoproterenol]]
	#*Consider [[transcutaneous pacing\|transcutaneous]] vs [[transvenous pacing]]		#*Consider [[transcutaneous pacing\|transcutaneous]] vs [[transvenous pacing]]
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	===[[Glucagon]]===		===[[Glucagon]]===
	*Half-life is 20 min		*Acts independently of Beta-adrenergic receptors in cardiac tissue
			*Half-life is 20 min, thus, if effective, need to start drip quickly after bolus
	*Adult: 5 mg 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: 5 mg 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
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	**Adult: 2-5 mg/hr		**Adult: 2-5 mg/hr
	**Ped: 70 mcg/kg/hr		**Ped: 70 mcg/kg/hr
			**Tachyphylaxis occurs quickly with glucagon so frequent monitoring of heart rate and blood pressure is necessary as the drip might need to be uptitrated
	*Routine treatment with glucagon is not suggested as a sole antidote<ref>Graudins A et al. Calcium channel antagonist and beta‐blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016 Mar; 81(3): 453–461.</ref>		*Routine treatment with glucagon is not suggested as a sole antidote<ref>Graudins A et al. Calcium channel antagonist and beta‐blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016 Mar; 81(3): 453–461.</ref>
	**Continuous drip is usually limited by insufficient quantities from pharmacy		**Continuous drip is usually limited by insufficient quantities from pharmacy
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	===Calcium===		===Calcium===
			*Beta-antagonism decreases intracellular calcium leading to smooth muscle relaxation; supplementation may reverse hypotension by increasing intracellular calcium levels
	*[[Calcium gluconate]] 3g (30-60mL of 10% soln)		*[[Calcium gluconate]] 3g (30-60mL of 10% soln)
	*[[Calcium chloride]] 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)		*[[Calcium chloride]] 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)
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	**Give Calcium 1g Q5min to titrate to BP effect		**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		**If effect in BP is seen can give as a drip at 10-50mg/kg/hr
			*Aim for calcium level of 14mg/dL and measure at least 30 minutes after administration

	===[[High dose insulin therapy\| High-dose insulin and glucose]]===		===[[High dose insulin therapy\| High-dose insulin and glucose]]===
	*Takes 30-60 min for effect		*Takes 30-60 min for effect
	*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 leading to increased cardiac output<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 0.5 gram/kg dextrose		*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		*Regular insulin 1 Unit/kg/hr Drip, titrate infusion until hypotension is corrected or max 10u/kg/hr
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	**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

			===Bicarbonate===
			*Bolus if QRS is wide
			**Sodium channel blockade from propranolol

			===[[QT Prolongation]]===
			*Magnesium if QT is prolonged
			**Sotalol known to prolong QT

	===[[Intralipid\|Intralipid Therapy]]===		===[[Intralipid\|Intralipid Therapy]]===

ClaireLewis at 00:27, 2 September 2019

2019-09-02T00:27:49Z

← Older revision		Revision as of 00:27, 2 September 2019
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	**[[Bradycardia]]		**[[Bradycardia]]
	**[[Hypotension]]		**[[Hypotension]]
	**Ventricular dysrhythmias		**[[Ventricular dysrhythmias]]
	*CNS		*CNS
	**Mental status ~~change~~		**[[Mental status changes]]
	***Delirium, coma		***Delirium, coma
	**[[Seizure]] (esp with [[propranolol]])		**[[Seizure]] (esp with [[propranolol]])
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	===Calcium===		===Calcium===
	*Calcium gluconate 3g (30-60mL of 10% soln)		*[[Calcium gluconate]] 3g (30-60mL of 10% soln)
	*Calcium chloride 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)		*[[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]		**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		**Give Calcium 1g Q5min to titrate to BP effect
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	**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]]

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

	===Sedation===		===Sedation===
	*Consider [[ketamine]] as post-intubation sedation for hemodynamics		*Consider [[ketamine]] as post-intubation sedation for hemodynamics