Beta Blocker Toxicity
Considerations
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Emergency situation (PALS, ACLS algorithms), full stomach
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Multidisciplinary care: toxicology, CCU, ICU, nephrology for dialysis
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Multisystem effects:
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Cardiovascular: bradycardia, arrhythmias, hypotension, cardiac arrest
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Respiratory: bronchospasm
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Metabolic: hypoglycemia, hyperkalemia
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CNS: stupor, coma, seizures
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Comorbid disease (CAD, CHF, atrial fibrillation, dysrhythmias, HOCM)
Treatment
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Airway/ventilation/oxygenation
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Follow ACLS/PALS algorithms + consult toxicology/CCU/ICU
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Consider gastric decontamination with activated charcoal if within 2 hours of ingestion
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Bradycardia: atropine, pacing if needed
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Hypotension:
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Fluid therapy
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Glucagon: 5-10mg IV bolus then 2-5mg/hr infusion (PALS 50-150 mcg/kg)
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High dose insulin: 1 U/kg/hr insulin + 1g/kg/hr glucose
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Replace K+ if < 2.5
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Vasopressors (high doses may be required)
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Epinephrine 50-100 mcg/min
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Calcium chloride 1 g IV boluses
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Arrhythmia/wide QRS:
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Cardiovert
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Bicarbonate: 1-2 meq/kg IV boluses with maintenance infusion if needed
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Magnesium 2g boluses
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Avoid other antidysrhythmic drugs such as class Ia & Ic
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Advanced therapies:
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Dialysis: only for atenolol, nadolol, sotalol
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Intralipid
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ECMO
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IABP
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Ventricular assist device (VAD)
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Hypoglycemia: D50W
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Seizures: benzodiazepines
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Special considerations:
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Propanolol causes sodium channel blockade with QRS widening (treat with NaHCO3)
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Sotalol causes potassium efflux blockade with long QT (monitor for Torsades)
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