What is the management for a patient over 60 with atrial flutter on apixaban (anticoagulant) who presents with hypotension due to incorrect dosage of bisoprolol (beta blocker), 10mg instead of 2.5mg?

Management of Beta-Blocker Overdose with Hypotension in Atrial Flutter

Immediately discontinue bisoprolol and initiate supportive hemodynamic management with intravenous fluids, and if hypotension persists despite fluid resuscitation, administer intravenous glucagon as the antidote of choice for beta-blocker toxicity, followed by vasopressor support (norepinephrine or dopamine) if needed. 1

Immediate Actions

Discontinue the Offending Agent

• Stop bisoprolol immediately - the patient has received 10 mg instead of the intended 2.5 mg, representing a 4-fold overdose 2, 3
• Bisoprolol has a half-life of 9-12 hours, so effects will persist for 24-48 hours even after discontinuation 2

Hemodynamic Stabilization

• Initiate intravenous fluid resuscitation as first-line treatment for beta-blocker-induced hypotension 1
• Continuous cardiac monitoring is essential to assess for bradycardia and heart rate response 2
• Monitor blood pressure continuously during acute management 2

Pharmacological Antidote Therapy

Glucagon Administration

• Glucagon is the primary antidote for beta-blocker toxicity - it works through non-adrenergic mechanisms to increase cardiac contractility and heart rate 1
• Administer as an initial bolus followed by continuous infusion if hypotension persists despite fluid resuscitation 1

Vasopressor Support

• If hypotension persists despite fluids and glucagon, initiate norepinephrine or dopamine for vasopressor support 1
• These agents provide both inotropic and vasopressor effects to counteract beta-blockade 1

Rate Control Considerations for Atrial Flutter

Temporary Cessation of Rate Control

• While bisoprolol is held, the ventricular rate in atrial flutter may increase significantly 2
• Monitor heart rate closely - typical atrial flutter has an atrial rate of 250-350 bpm, and without AV nodal blockade, ventricular rates can approach 150 bpm with 2:1 conduction 2

Alternative Rate Control Once Stabilized

• After hemodynamic stabilization, if rate control is still needed and hypotension has resolved, consider intravenous diltiazem or metoprolol at reduced doses with careful blood pressure monitoring 2
• Diltiazem 0.25 mg/kg IV over 2 minutes can be used for acute rate control, but avoid in the setting of ongoing hypotension 2, 4
• Once blood pressure normalizes, restart bisoprolol at the correct dose of 2.5 mg daily 2, 3

Anticoagulation Management

Continue Apixaban

• Do not interrupt apixaban - the patient remains at thromboembolic risk from atrial flutter 2, 5
• Standard dosing is 5 mg twice daily, or 2.5 mg twice daily if the patient meets dose-reduction criteria (age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL - at least 2 of 3 criteria) 2, 5
• Apixaban does not require dose adjustment for beta-blocker overdose or hypotension 5

Monitoring Parameters

Vital Signs

• Continuous blood pressure and heart rate monitoring for at least 24 hours given bisoprolol's 9-12 hour half-life 2, 3
• Assess for rebound tachycardia as beta-blockade wears off 6

Cardiac Assessment

• Serial 12-lead ECGs to monitor for conduction abnormalities and assess ventricular rate control 2
• Consider continuous telemetry monitoring until hemodynamically stable 2

End-Organ Perfusion

• Monitor urine output, mental status, and lactate levels to assess adequacy of tissue perfusion 1
• Assess for signs of cardiogenic shock (cool extremities, altered mentation, oliguria) 1

Common Pitfalls to Avoid

• Do not use additional AV nodal blocking agents (calcium channel blockers, digoxin, or additional beta-blockers) until hypotension fully resolves 2, 4
• Avoid atropine as primary therapy - it is generally ineffective for beta-blocker-induced bradycardia and hypotension; glucagon is superior 1
• Do not discontinue anticoagulation - thromboembolic risk persists regardless of hemodynamic status 2
• Do not assume hypotension is solely from beta-blocker overdose - evaluate for other causes including bleeding (especially given anticoagulation), sepsis, or acute coronary syndrome 1, 7

Disposition and Follow-Up

• Admit for observation given significant overdose and need for continuous monitoring 1
• Once hemodynamically stable for 24 hours and bisoprolol effects have waned, restart at correct dose of 2.5 mg daily 2, 3
• Educate patient and caregivers about correct medication dosing to prevent recurrence 3
• Ensure appropriate medication reconciliation and consider pharmacy consultation 3