DDX

Consider in “low and slow” overdoses

BB OD tends to be more somnolent/altered at presentation

CCB – tends to late CNS depression, “looks good” even when actually very sick

BB – Euglycemic or hypoglycemic (BB decreases glycolysis and gluconeogenesis)

CCB – Hyperglycemic d/t impaired insulin release, pancreatitis

Propranolol and Acebutalol – Na+ channel blocking activity – high seizure risk (careful w/ AC administration) and tend to get very sick

Sotalol – K+ channel blockade – Long QTc + bradycardia – Torsades risk

Treatment

-Decontamination – Consider lavage, charcoal, WBI

-AC probably good for recent ingestion

-Can prophylactically intubate for anticipated course or to do lavage but then you lose m/s as a marker for titrating therapy, judging severity of shock state etc.

-IVF bolus

-Atropine trial (unlikely to help)

-Calcium – empiric 1 g CaGluc q 15 min x 4-6 g then target ~ 1.5 x upper limit normal following ionized Ca++

-Pacing – can try but unlikely to help globally poisoned heart

-Glucagon for BB OD – Bypasses blocked B-receptor for direct G-protein activiation

-5-10 mg IV bolus

-T1/2 3-5 min

-Consider gtt

-Pressors – No data to guide initial choice – Norepi probably 1st line

Electrolytes -Don’t forget to check/replace K+, Mg++, phos

-HDI – Used in BB or CCB OD if needing anything more than very low doses of pressor

-1u/kg (i.e. 100 unit) bolus given w/ 1-2 amps D50

-1 – 10 u/kg/hr gtt – start at low end then double dose q 10 min titrating for response

-Check k+ q 30 min; check glucose q 10-15 min when starting

-Goal glucose 100-250: if 100-150-> give 2 amps; if 150-200->give 1 amp

-CCB OD tends to rarely get hypoglycemic even on HDI

-Can carefully space out labs once trajectory/stability established

– Special Considerations

– Dihydropyridine CCB (e.g. amlodipine) cause profound vasoplegia – guide pressor choice based on bedside echo – if adequate systolic function but still hypotensive unlikely to benefit from ECMO, consider vasopressin, phenylephrine, methylene blue (NO scavenger)

–Salvage – Consider if requiring 3 pressors

-Intralipid – can use to try to temporize but probably not very useful

-ECMO – the real salvage, limited efficacy if adequate cardiac output but still hypotensive

– Methylene blue – NO scavenger increases SVR

-Dialyzable BB:

Sotalol

Atenolol

Timolol

Acebutalol

Nadalol