What is the approach to beta (β) blocker overdose, including presentation and treatment?

From the Guidelines

Beta blocker overdose requires prompt recognition and aggressive management, with the cornerstone of treatment being glucagon administration, as it bypasses beta receptors to increase cardiac contractility, and high-dose insulin therapy for cardiogenic shock, as recommended by the 2023 American Heart Association guidelines 1. Patients typically present with bradycardia, hypotension, altered mental status, seizures, hypoglycemia, bronchospasm, and in severe cases, cardiogenic shock or cardiac arrest. Initial treatment includes:

• Standard resuscitation measures (ABCs)
• Activated charcoal if within 1-2 hours of ingestion
• Continuous cardiac monitoring First-line pharmacologic therapy includes:
• Atropine (0.5-1mg IV every 3-5 minutes, maximum 3mg) for bradycardia, though its effectiveness is often limited
• Glucagon, administered as a 5-10mg IV bolus followed by an infusion of 1-5mg/hour For persistent hypotension, IV fluids and vasopressors like epinephrine (2-10 mcg/min) or norepinephrine (0.1-1 mcg/kg/min) should be used, as supported by the 2023 American Heart Association guidelines 1. High-dose insulin therapy (1 unit/kg bolus followed by 0.5-1 unit/kg/hour infusion) with glucose supplementation is effective for cardiogenic shock by improving cardiac contractility and peripheral vasodilation, as recommended by the guidelines 1. In refractory cases, hemodialysis is useful for water-soluble agents like atenolol, and extracorporeal membrane oxygenation may be necessary in life-threatening cases unresponsive to other interventions, as suggested by the guidelines 1. It is essential to note that lipid emulsion therapy is not likely to be beneficial for life-threatening β-blocker poisoning, according to the 2023 American Heart Association guidelines 1.

Key considerations in the management of beta blocker overdose include:

• Prompt recognition and aggressive management
• Administration of glucagon and high-dose insulin therapy
• Use of vasopressors and IV fluids for hypotension
• Consideration of hemodialysis and extracorporeal membrane oxygenation in refractory cases
• Avoidance of lipid emulsion therapy, as it is not likely to be beneficial, as stated in the guidelines 1.

Overall, the management of beta blocker overdose requires a comprehensive approach, with a focus on supportive care, pharmacologic therapy, and consideration of advanced interventions, as recommended by the 2023 American Heart Association guidelines 1.

From the Research

Approach to Beta Blocker Overdose

The approach to beta blocker overdose involves a comprehensive management plan, including presentation and treatment. The presentation of beta blocker overdose can vary, but common symptoms include:

• Hypotension
• Bradycardia
• Heart failure
• Impaired atrioventricular conduction
• Bronchospasm
• Seizures

Treatment of Beta Blocker Overdose

The treatment of beta blocker overdose includes:

• Gastric decontamination with activated charcoal or gastric lavage 2
• Administration of catecholamines, inotropes, and vasopressors to improve haemodynamics 2
• Use of atropine to improve heart rate and blood pressure 2, 3
• Administration of calcium to improve haemodynamics 2, 3, 4
• High-dose insulin euglycaemic therapy to improve haemodynamics and reduce mortality 2, 4
• Use of glucagon to increase heart rate and myocardial contractility 2, 5, 4
• Consideration of veno-arterial extracorporeal membrane oxygenation in severe cases 2
• Use of temporary pacing to prevent arrhythmias in sotalol toxicity 2

Specific Treatment Options

• Glucagon: 50 micrograms/kg iv loading dose, followed by a continuous infusion of 1-15 mg/h, titrated to patient response 5
• High-dose insulin euglycaemic therapy: bolus then continuous infusion, with maintenance dosing ranging from 1 to 10 units/kg/h of insulin 2
• Calcium: intravenous calcium salts to reverse hypotension and bradycardia 3, 4
• Catecholamines: use of catecholamines, such as epinephrine, to improve haemodynamics 2, 4

Important Considerations

• The treatment of beta blocker overdose often requires a combination of therapies, and the choice of treatment should be individualized based on the patient's specific symptoms and response to treatment 2, 4
• The use of high-dose insulin euglycaemic therapy and glucagon may be associated with adverse effects, such as hypoglycaemia and hypokalemia 2, 5
• The treatment of beta blocker overdose should be guided by the patient's clinical response, and adjustments to treatment should be made as needed 2, 4