What is the treatment for a beta blocker overdose?

Treatment for Beta Blocker Overdose

For beta blocker overdose, high-dose insulin with glucose and IV glucagon are the most reasonable first-line treatments for patients in refractory shock, followed by calcium administration and ECMO for refractory cases. 1

Initial Management

• Establish cardiac monitoring, secure airway if needed, and obtain IV access as part of standard resuscitation following BLS and ACLS algorithms 2
• Beta blocker overdose presents with life-threatening hypotension and/or bradycardia that may be refractory to standard treatments such as vasopressor infusions 1
• Do not induce emesis; consider oral activated charcoal if available and no contraindications exist, but do not delay transportation to administer charcoal 3

First-Line Therapies for Refractory Shock

High-Dose Insulin with Glucose (Class 2a, LOE C-LD)

• Administration of high-dose insulin with glucose is reasonable in patients with beta blocker overdose who are in refractory shock 1
• Typical dosing: 1 U/kg regular insulin as IV bolus, followed by continuous infusion of 1 U/kg per hour titrated to clinical effect 1
• Administer dextrose and potassium infusions concurrently to prevent hypoglycemia and hypokalemia 1, 4
• Animal studies, case reports, and case series have reported increased heart rate and improved hemodynamics after high-dose insulin administration 1

IV Glucagon (Class 2a, LOE C-LD)

• Administration of IV glucagon is reasonable in patients with beta blocker overdose who are in refractory shock 1
• Several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration 1, 5
• Glucagon increases heart rate and myocardial contractility by bypassing the beta-adrenergic receptor site 5
• Typical dosing: 50 μg/kg IV loading dose, followed by continuous infusion of 1-15 mg/hour, titrated to patient response 5
• Monitor for side effects including nausea, vomiting, hypokalemia, and hyperglycemia 4, 5

Second-Line Therapies

Calcium Administration (Class 2b, LOE C-LD)

• Administration of calcium may be considered in patients with beta blocker overdose who are in refractory shock 1
• Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in beta blocker toxicity 1
• Recommended dose: 0.3 mEq/kg of calcium (0.6 mL/kg of 10% calcium gluconate or 0.2 mL/kg of 10% calcium chloride) IV over 5-10 minutes 2

Vasopressor Support

• Norepinephrine is recommended to increase blood pressure in vasoplegic shock 2
• Epinephrine can be used to increase contractility and heart rate 2, 6
• Dobutamine can be considered in the presence of confirmed myocardial dysfunction 2

Rescue Therapy for Refractory Cases

ECMO (Class 2b, LOE C-LD)

• ECMO might be considered in patients with beta blocker overdose who are in shock refractory to pharmacological therapy 1
• Case reports and at least one retrospective observational study have documented survival after ECMO in patients with refractory shock from beta blocker overdose 1, 7
• A recent consensus statement supports the use of ECMO for refractory shock from reversible causes such as drug toxicity 1

Monitoring Parameters

• Continuous cardiac monitoring for arrhythmias and conduction abnormalities 2
• Frequent blood pressure measurements and serial ECGs to assess for QRS prolongation and conduction abnormalities 2
• Frequent monitoring of serum glucose, potassium, and calcium levels, especially when using high-dose insulin therapy 2, 4
• Assessment of cardiac function via echocardiography when available 2

Special Considerations

• Abrupt withdrawal of beta blocker therapy can lead to clinical deterioration and should be avoided in patients on chronic therapy 1
• Consultation with a medical toxicologist or specialist is recommended when managing treatment-refractory hypotension 2
• Patients with stated or suspected self-harm should be referred to an emergency department immediately regardless of the dose reported 3
• Asymptomatic patients who ingested more than the referral dose should be monitored for at least 6-8 hours for immediate-release preparations and 12 hours for sotalol or sustained-release preparations 3