CLINICAL MANIFESTATIONS Sx within 6 hours of Ingestion Hypotension Bradycardia SHOCK Arrythmias Neuro: sz, delirium, coma Bronchospasm Hypoglycemia
WORKUP: Get good ingestion history H&P LABS: BB screen/levels Glucose Chemistries Other ingestion labs (APAP, ASA, etc) STUDIES: EKG CXR
TREATMENT: THE BASICS 1.ABCs!!!! 2.Hypotension IVF, Pressors (more on this in a minute) 3.Bradycardia Atropine 0.5-1mg Q3-5min 4.Hypoglycemia D50 5.Seizures Benzos
TREATMENT: BEYOND THE BASICS GLUCAGON Activates adenylyl cyclase increased CAMP increased Ca available for muscle contraction 5mg IV x1, MR x1 to assess for VS improvement If successful, start a 2-5mg/hr gtt SE: Vomiting NO GOOD DATA IN PEOPLE (just some in animals) CALCIUM CaCl 1g IVP (max: 3g) OR CaGlc 1g IV (max: 3g) Increase inotropy DATA: Case reports only
TREATMENT: BEYOND THE BASICS II PRESSORS: Stimulate receptors to increase CAMP inotropy No good data, but recommended if necessary to maintain MAPs Competitive Inhibition PDE INHIBITORS: Milrinone, Inamrinone Inhibit CAMP breakdown by PDE Data: isolated case reports only (although our patient did well!!) SE: GI, Hypotension, Arrythmias
TREATMENT: BEYOND THE BASICS III HDIDK (high dose insulin w/ dextrose and K): Last line of defense at this point as data is preliminary (some good data with CaChB overdose) BBs inhibit pancreatic insulin release less glucose available in muscle cells for energy extraction Correct hypoglycemia first!!! MISCELLANEOUS: Charcoal Bicarb, Mg IABP CVVHD
REFERENCES: UpToDate- Beta Blocker Poisoning, Thyroid Storm, Beta Blockers in Management of Hyperthyroidism Shepherd et, al. “Treatment of poisoning caused by B- adrenergic and calcium-channel blockers”. Am J Health Syst. Pharm- Vol 63. Oct 1 2006. Bailey B. Glucagon in beta blocker and calcium channel blocker overdoses: a systematic review. Journal of Clinical Toxicology. 2003; 41 (5); 595-602. Leppikangas, et al. Levosimendan as a rescue drug in experimental propanolol-induced myocardial depression: a randomized study. Ann Emerg Med. 2009 Dec; 54(6): 811-817.