What is the management for beta blocker overdose?

Management of Beta-Blocker Overdose

For beta-blocker overdose, high-dose insulin therapy should be administered for hypotension refractory to or in conjunction with vasopressor therapy as the primary treatment. 1

Initial Assessment and Stabilization

• Assess for bradycardia, hypotension, altered mental status, and hypoglycemia
• Secure airway, breathing, and circulation
• Obtain ECG, continuous cardiac monitoring, blood glucose levels
• Consider activated charcoal for recent ingestions (within 1-2 hours) if airway is protected

Treatment Algorithm

First-Line Therapies:

1. Vasopressors (Class 1, C-LD) 1

   • Begin immediately for hypotension
   • Options include epinephrine, norepinephrine, dopamine
   • Titrate to maintain adequate perfusion

2. High-Dose Insulin Euglycemic Therapy (HIET) (Class 1, B-NR) 1

   • Bolus: 1 U/kg IV
   • Infusion: 1 U/kg/hour, titrated to clinical effect
   • Monitor glucose every 15-30 minutes initially
   • Administer dextrose to maintain euglycemia
   • Monitor potassium levels and replace as needed

Second-Line Therapies:

1. Glucagon (Class 2a, C-LD) 1

   • Bolus: 5-10 mg IV over 3-5 minutes
   • Follow with continuous infusion: 1-5 mg/hour
   • Caution: may cause vomiting (protect airway)

2. Atropine (Class 2b, C-LD) 1

   • 0.5-1 mg IV for symptomatic bradycardia
   • May repeat to maximum of 3 mg
   • Often has limited efficacy in beta-blocker overdose

3. Calcium (Class 2b, C-LD) 1

   • Calcium chloride 10% 10-20 mL IV or calcium gluconate 10% 30-60 mL IV
   • May repeat every 10-20 minutes for 3-4 doses if beneficial

Refractory Cases:

1. Extracorporeal Life Support (Class 2a, C-LD) 1

   • Consider VA-ECMO for life-threatening poisoning with cardiogenic shock refractory to pharmacological interventions
   • Early consultation with ECMO team is recommended

2. Cardiac Pacing (Class 2b, C-LD) 1

   • Consider for persistent symptomatic bradycardia unresponsive to medical therapy
   • May have limited efficacy due to myocardial depression

3. Hemodialysis (Class 2b, C-LD) 1

   • Consider for life-threatening atenolol or sotalol poisoning
   • Most effective for water-soluble beta-blockers with low protein binding

Important Considerations

• Intravenous Lipid Emulsion Therapy is NOT recommended (Class 3: No Benefit, C-LD) for beta-blocker overdose 1, 2

• Specific Beta-Blocker Properties may influence management:

  • Lipophilic agents (propranolol, metoprolol): longer duration of toxicity
  • Water-soluble agents (atenolol, sotalol): potentially amenable to hemodialysis
  • Agents with membrane-stabilizing effects (propranolol): may cause QRS widening and seizures

• Monitoring Parameters:

  • Continuous cardiac monitoring
  • Frequent blood pressure measurements
  • Serial ECGs
  • Blood glucose and potassium levels
  • Lactate levels to assess tissue perfusion

Evidence Quality and Limitations

The evidence supporting these recommendations comes primarily from case reports, case series, and animal studies 3. The 2023 American Heart Association guidelines provide the most current evidence-based recommendations 1, with high-dose insulin and vasopressors having the strongest evidence for improving outcomes in beta-blocker overdose.

While multiple therapies are often administered simultaneously in clinical practice, making it difficult to determine the individual contribution of each intervention 3, the evidence suggests a graduated response to cardiovascular instability is most effective, with early implementation of high-dose insulin therapy showing particular promise for improving survival 1, 3.

Human is: