From the Guidelines
Propranolol overdose is a life-threatening medical emergency that requires immediate attention, and treatment should prioritize supportive care, including gastric decontamination, intravenous fluids, atropine, vasopressors, and glucagon, as outlined in the most recent guidelines 1.
Key Considerations
- The management of propranolol overdose involves addressing the drug's effects on the cardiovascular system, including bradycardia, hypotension, and potential cardiac arrest.
- According to the 2023 American Heart Association guidelines, treatment modalities for beta-blocker poisoning, such as propranolol overdose, include atropine, glucagon, calcium, vasopressors, high-dose insulin, and in severe cases, extracorporeal membrane oxygenation (ECMO) 1.
- The use of extracorporeal treatments (ECTR) like ECMO may be considered in refractory cases, although the evidence is based on case reports and series, and there is a risk of serious complications associated with catheterization and ECTR itself 1.
Treatment Approach
- Initial management should focus on supportive care, including gastric decontamination with activated charcoal if the ingestion was recent, followed by administration of intravenous fluids, atropine for bradycardia, and vasopressors for hypotension.
- Glucagon is recommended as a specific antidote to counteract beta-blocker effects, with an initial bolus of 5-10 mg IV followed by an infusion of 1-5 mg/hour.
- In severe cases, consideration may be given to high-dose insulin therapy, intravenous lipid emulsion, or ECMO, taking into account the potential risks and benefits, including the complications associated with ECTR 1.
Important Considerations for Morbidity, Mortality, and Quality of Life
- The primary goal in managing propranolol overdose is to prevent morbidity and mortality by promptly addressing the drug's toxic effects on the cardiovascular system and other body systems.
- Given the potential for severe cardiovascular collapse, QRS prolongation, and ventricular dysrhythmias due to propranolol's sodium channel blocking and membrane-stabilizing effects, close monitoring and aggressive management are crucial.
- The choice of treatment should be guided by the most recent and highest quality evidence, with consideration of the patient's specific clinical presentation and the potential risks and benefits of each treatment modality 1.
From the FDA Drug Label
OVERDOSAGE Propranolol is not significantly dialyzable. In the event of overdosage or exaggerated response, the following measures should be employed: General: If ingestion is, or may have been recent, evacuate gastric contents, taking care to prevent pulmonary aspiration Supportive Therapy: Hypotension and bradycardia have been reported following propranolol overdose and should be treated appropriately. The effects of a Propranolol overdose include:
- Hypotension
- Bradycardia These effects should be treated with:
- Glucagon for hypotension or depressed myocardial function
- Atropine or isoproterenol for bradycardia
- Isoproterenol and aminophylline may be used for bronchospasm 2
From the Research
Effects of Propranolol Overdose
The effects of a propranolol overdose can be severe and life-threatening. Some of the possible effects include:
- Seizures and loss of consciousness 3
- Cardiac shock, including bradycardia, hypotension, and cardiac arrest 4, 3, 5
- Electromechanical dissociation 6
- Decreased systemic vascular resistance 4
- Sodium channel blockade 5
- Profound myocardial depression 4
Treatment and Management
Treatment for propranolol overdose may involve the use of various medications, including:
- Calcium chloride, which has been shown to produce a dramatic restoration of blood pressure and narrowing of QRS complexes 6
- Glucagon, which may help reverse the effects of propranolol overdose 7
- Inotropes, such as epinephrine and high-dose insulin, which may be used to support cardiac function 5
- Bicarbonate, which may be used to treat acidosis 6
Dose Thresholds for Severe Toxicity
Research suggests that the dose threshold for severe toxicity in isolated propranolol overdose may be around 2,000 mg 5. However, severe toxicity can occur at lower doses, especially in cases of co-ingestion with other substances 5. The outcome of propranolol overdose is usually favorable with good supportive care, even in cases of severe toxicity 5.