From the Guidelines
Norepinephrine is the preferred vasopressor for managing beta blocker overdose, and it should be administered for hypotension due to β-blocker poisoning, as recommended by the 2023 American Heart Association guidelines 1.
Treatment Approach
The treatment approach for beta blocker overdose with norepinephrine involves:
- Starting norepinephrine at 0.1-0.5 mcg/kg/min IV and titrating to maintain adequate blood pressure (typically systolic BP >90 mmHg), with doses potentially exceeding 1 mcg/kg/min in severe cases.
- Using norepinephrine to stimulate alpha-1 receptors to cause vasoconstriction and beta-1 receptors to increase cardiac contractility, directly counteracting the hypotension and bradycardia caused by beta blockers.
Additional Treatments
Additional treatments for beta blocker overdose include:
- High-dose insulin therapy (1 unit/kg bolus followed by 1-10 units/kg/hr infusion), as recommended by the 2023 American Heart Association guidelines 1.
- Glucagon (5-10 mg IV bolus followed by 1-5 mg/hr infusion), which may be reasonable to use for bradycardia or hypotension due to β-blocker poisoning, according to the 2023 American Heart Association guidelines 1.
Monitoring and Weaning
- Blood glucose monitoring is essential during treatment with high-dose insulin therapy.
- Vasopressor therapy should be gradually weaned as the patient stabilizes and the beta blocker is metabolized and eliminated.
Ineffective Treatments
- Atropine and cardiac pacing are often ineffective in severe overdoses, and their use may be reasonable but with limited benefit, as stated in the 2023 American Heart Association guidelines 1.
From the Research
Treatment for Beta Blocker Overdose
The treatment for beta blocker overdose involves various modalities, including:
- Gastric decontamination with activated charcoal or gastric lavage 2
- Administration of catecholamines, inotropes, and vasopressors, such as norepinephrine, to improve haemodynamics 3
- Use of atropine to improve heart rate and blood pressure 2, 3
- High-dose insulin euglycaemic therapy to improve haemodynamics and provide a mortality benefit 3
- Glucagon therapy to increase heart rate and myocardial contractility, and improve atrioventricular conduction 4
- Intravenous lipid emulsion therapy, although its effectiveness is variable 5, 3
- Veno-arterial extracorporeal membrane oxygenation (ECMO) for severe cardiogenic shock or cardiac arrest 3, 6
Role of Norepinephrine in Treatment
Norepinephrine is used as a vasopressor to improve haemodynamics in beta blocker overdose 5, 3. It is often used in conjunction with other treatments, such as high-dose insulin euglycaemic therapy and glucagon. The use of norepinephrine has been reported to provide a survival benefit and improve haemodynamics in patients with beta blocker overdose 3.
Other Considerations
The treatment of beta blocker overdose should be individualized based on the severity of the overdose and the patient's clinical presentation. A graduated response to cardiovascular instability is recommended, starting with intravenous fluids and progressing to catecholamines, inotropes, and vasopressors as needed 3. Advanced treatments, such as ECMO, may be indicated in severe cases 3, 6.