Beta-blocker toxicity: Difference between revisions

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===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<ref>Rothschild L, Bern S, Oswald, et al. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma Resusc Emerg Med. 2010; 18:51.</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>
*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>

Revision as of 01:16, 9 September 2015

Background

Clinical Features

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

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

Diagnostic Evaluation

  • ECG
  • Glucose
  • Chemistry
    • Creatinine (esp with atenolol)

Management

  1. Consider activated charcoal if present within 2 hr of ingestion
  2. Symptomatic bradycardia
    • Atropine 0.5-1mg q3-5min up to 0.04mg/kg
  3. Hypotension
    • IV fluids
  4. 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[5]

  • IV 20% Intralipid at 1.5 mL/kg Bolus[6]
    • Bolus could be repeated 1-2 times if persistent asystole
    • Followed by infusion of 0.25 mL/kg/min for 30-60 minutes or until hemodynamic stability achieved
  • 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

References

  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. ↑ Rothschild L, Bern S, Oswald, et al. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma Resusc Emerg Med. 2010; 18:51.
  6. ↑ Cave, G. Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review. 2009. 16(9)815–824
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