What is the treatment for caffeine overdose causing tachycardia?

Treatment of Caffeine Overdose Causing Tachycardia

For caffeine overdose causing tachycardia, administer activated charcoal if within 1-2 hours of ingestion, treat symptomatic tachycardia with beta-blockers (particularly esmolol), correct hypokalemia aggressively, and consider hemodialysis for severe cases with refractory arrhythmias or serum caffeine levels >100 mg/L. 1, 2, 3

Immediate Management

Activated Charcoal Administration

• Administer activated charcoal within 1-2 hours post-ingestion to prevent further caffeine absorption 1, 4
• This is the first-line intervention if the patient presents early and can protect their airway 5

Cardiovascular Stabilization

• Beta-adrenergic blockade is the cornerstone of tachycardia management in caffeine toxicity 2
• Esmolol infusion is preferred due to its short half-life and titratable nature, allowing rapid adjustment if hypotension develops 2
• Oral metoprolol can be used for transition to outpatient management once stabilized 2

Electrolyte Correction

• Aggressively replace potassium early - caffeine overdose commonly causes profound hypokalemia (levels as low as 2.3 mmol/L) which contributes to ventricular arrhythmias 6, 5
• Monitor potassium levels closely, as resuscitation medications (epinephrine, bicarbonate) can further decrease potassium 6
• Hyponatremia may also occur and requires correction 6

Management of Refractory Arrhythmias

Ventricular Tachycardia/Fibrillation

• Immediate defibrillation for pulseless VT/VF - caffeine-induced arrhythmias may require multiple shocks 2, 5
• Amiodarone is the preferred antiarrhythmic: administer 300 mg IV bolus for counter-shock-resistant VF 6, 2
• Lidocaine can be used as an alternative antiarrhythmic agent 2
• Magnesium supplementation may help stabilize cardiac rhythm 5

Vasopressor Considerations

• Use epinephrine cautiously - it can worsen hypokalemia through beta-receptor stimulation 6
• Consider vasopressin as an alternative vasopressor without beta-adrenergic effects 6

Advanced Interventions

Hemodialysis Indications

• Consider hemodialysis for:
  • Serum caffeine levels >100-150 mg/L 2, 3
  • Refractory ventricular arrhythmias despite medical management 2, 5
  • Potentially lethal ingested doses (>5-10 g) 3
  • Profound metabolic acidosis 5
• Hemodialysis effectively eliminates caffeine and is associated with better survival rates even after severe intoxication 3
• Initiate once the patient is hemodynamically stable enough to tolerate the procedure 2

Seizure Management

• Treat convulsions with benzodiazepines (diazepam or pentobarbital) 1
• Seizures are associated with worse outcomes and require aggressive management 3

Monitoring and Supportive Care

Laboratory Monitoring

• Serum caffeine levels (serious toxicity occurs at >50 mg/L; fatal levels typically >100-240 mg/L) 1, 2
• Serial potassium, sodium, and magnesium levels 6, 5
• Arterial blood gas for metabolic acidosis (pH can drop to 6.47) 6
• Lactate levels (can reach 33 mmol/l in severe cases) 6
• Monitor for rhabdomyolysis with creatine kinase levels 4

Cardiac Monitoring

• Continuous telemetry for tachydysrhythmias 4
• Serial ECGs to assess for wide-complex tachycardia 6
• Prepare for multiple episodes of VT/VF requiring repeated defibrillation (up to 23 episodes reported) 2

Critical Pitfalls to Avoid

• Do not delay activated charcoal if within the appropriate timeframe - this is the most effective way to prevent absorption 4, 5
• Do not underestimate hypokalemia - it is a major contributor to fatal arrhythmias and must be corrected aggressively before it worsens with resuscitation medications 6
• Do not hesitate to initiate hemodialysis in severe cases - waiting too long increases mortality risk 3
• Recognize that doses as low as 5 g can be lethal (80-100 mg/kg), making early aggressive intervention critical 4, 3
• Be prepared for prolonged resuscitation - patients may require multiple defibrillations and extended ICU stays but can achieve full neurological recovery 2, 5