What is the appropriate treatment for beta‑blocker overdose?

Treatment of Beta-Blocker Overdose

For life-threatening beta-blocker overdose with hypotension, initiate vasopressors immediately, then add high-dose insulin therapy (Class I recommendation). 1

Initial Management Algorithm

Supportive Care Foundation

• Monitor and treat hypoglycemia with supplemental dextrose as standard care, as beta-blocker poisoning can cause hypoglycemia 1
• Establish continuous cardiac monitoring and hemodynamic support
• Consider activated charcoal for GI decontamination in select early presentations 2

First-Line Pharmacologic Therapy

For hypotension (Class I recommendations):

1. Vasopressors - Start immediately as they are readily available and act quickly 1
2. High-dose insulin - Administer for hypotension refractory to vasopressors OR in conjunction with vasopressor therapy 1
   • High-dose insulin improves inotropy in cardiogenic shock
   • Associated with lower rates of vasoconstrictive complications compared to vasopressor-only therapy 1

For bradycardia or hypotension (Class IIa recommendation):

• Glucagon bolus followed by continuous infusion - Increases contractility and improves hemodynamics 1

Second-Line Therapies

For beta-blocker-induced bradycardia (Class IIb recommendations):

• Atropine may be reasonable 1
• Electrical pacing may be reasonable 1

Agent-Specific Considerations

For atenolol or sotalol poisoning specifically:

• Hemodialysis may be reasonable for life-threatening toxicity (Class IIb) 1
• The EXTRIP workgroup suggests hemodialysis for patients with impaired kidney function experiencing refractory bradycardia and hypotension from atenolol or sotalol 3
• For sotalol specifically: monitor for QT prolongation and torsades de pointes; hemodialysis can be life-saving even in patients with normal renal function 4

For propranolol overdose:

• Expect potential CNS manifestations (delirium, coma, seizures) and sodium channel blockade effects causing ventricular dysrhythmias 2
• Propranolol is NOT dialyzable due to high lipophilicity 3

Refractory Cases

For cardiogenic shock refractory to pharmacological interventions (Class IIa recommendation):

• VA-ECMO is reasonable and may be life-saving 1, 5
• Consider early consultation for ECMO in patients not responding to maximal medical therapy

What NOT to Use

Intravenous lipid emulsion (ILE) therapy:

• NOT recommended (Class III: No Benefit) - not likely to be beneficial for life-threatening beta-blocker poisoning 1

Critical Pitfalls to Avoid

1. Don't delay vasopressors - They should be the initial therapy for beta-blocker-induced hypotension given immediate availability 1

2. Don't use high-dose insulin alone - It should be given refractory to OR in conjunction with vasopressors, not as monotherapy 1

3. Don't assume all beta-blockers are dialyzable - Only atenolol and sotalol benefit from hemodialysis; propranolol is non-dialyzable 3

4. Don't overlook agent-specific toxicity - Sotalol causes QT prolongation and torsades de pointes requiring specific monitoring and management 4, 2

5. Don't wait too long for ECMO - In refractory cardiogenic shock despite maximal therapy, early ECMO consultation improves outcomes 1, 5

Disposition

All patients with beta-blocker overdose causing hemodynamic instability require ICU admission for close hemodynamic monitoring 2. Cardiovascular symptoms typically appear within 2 hours of ingestion for immediate-release formulations, 8 hours for sustained-release, and 12 hours for sotalol 3.