Beta Blocker Toxicity 

 

 

Considerations

 

  • Emergency situation (PALS, ACLS algorithms), full stomach

  • Multidisciplinary care: toxicology, CCU, ICU, nephrology for dialysis

  • Multisystem effects:

    • Cardiovascular: bradycardia, arrhythmias, hypotension, cardiac arrest

    • Respiratory: bronchospasm

    • Metabolic: hypoglycemia, hyperkalemia

    • CNS: stupor, coma, seizures

  • Comorbid disease (CAD, CHF, atrial fibrillation, dysrhythmias, HOCM)

 

 

Treatment 

 

  • Airway/ventilation/oxygenation 

  • Follow ACLS/PALS algorithms + consult toxicology/CCU/ICU

  • Consider gastric decontamination with activated charcoal if within 2 hours of ingestion 

  • Bradycardia: atropine, pacing if needed 

  • Hypotension:

    • Fluid therapy 

    • Glucagon: 5-10mg IV bolus then 2-5mg/hr infusion (PALS 50-150 mcg/kg)

    • High dose insulin: 1 U/kg/hr insulin + 1g/kg/hr glucose

      • Replace K+ if < 2.5

    • Vasopressors (high doses may be required)

      • Epinephrine 50-100 mcg/min

    • Calcium chloride 1 g IV boluses

  • Arrhythmia/wide QRS:

    • Cardiovert

    • Bicarbonate: 1-2 meq/kg IV boluses with maintenance infusion if needed 

    • Magnesium 2g boluses 

    • Avoid other antidysrhythmic drugs such as class Ia & Ic

  • Advanced therapies:

    • Dialysis: only for atenolol, nadolol, sotalol

    • Intralipid

    • ECMO

    • IABP

    • Ventricular assist device (VAD)

  • Hypoglycemia: D50W 

  • Seizures: benzodiazepines 

  • Special considerations:

    • Propanolol causes sodium channel blockade with QRS widening (treat with NaHCO3)

    • Sotalol causes potassium efflux blockade with long QT (monitor for Torsades)