In overdose, beta-blockers and CCBs have similar presentation and treatment overlaps and are often refractory to standard resuscitation measures. [ncbi.nlm.nih.gov]

A comprehensive textbook of adult emergency medicine for trainee doctors - covers all the problems likely to present to a trainee in the emergency department. [books.google.de]

• Hypothermia

  Signs and Symptoms: Bradycardia: Hypotension: Seizures: EKG changes: Sinus or nodal bradycardia First-degree AV block QRS prolongation (slight) QT Prolongation Hypothermia, hypoglycemia can occur but are less common. [calsprogram.org]

  His urine output reduced, and he developed hypothermia. Cardiac evaluation by a senior cardiologist with bedside ECHO and enzymes ruled out any cardiac pathology. [ijccm.org]

  Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution". [en.wikipedia.org]

  Differential Diagnosis of Low and Slow Non-toxicological causes: MI with cardiogenic shock Hyperkalemia Myxedema coma Spinal cord injury Hypothermia Toxicological causes: Calcium channel blockers Beta-blockers Digoxin Opiates Alpha-2 antagonists (e.g. [emergencymedicinecases.com]

• Collapse

  […] associated with prolonged QT interval can be treated with Mg and lidocaine; correct hypokalaemia and hypocalaemia Elimination GI decontamination life saving measures take precedence induced emesis contraindicated because of risk of sudden cardiovascular collapse [aic.cuhk.edu.hk]

  Ultrasonography (USG) revealed completely collapsed inferior vena cava (IVC) which was treated with 2 L of crystalloid administered cautiously over 1 h without any significant improvement. [ijccm.org]

  In overdose, metoprolol can cause direct myocardial depression leading to bradycardia, hypotension, and potential cardiovascular collapse but there are presently no clear treatment guidelines for beta-blocker overdose. [empr.com]

  Ketamine may be more hemodynamically stable than other induction agents (although any agent can result in hemodynamic collapse due to loss of sympathetic tone). I would use a slightly lower dose than normal, starting at 0.5mg/kg. [first10em.com]

  Boyer and Shannon reported 2 cases of CCB overdose were treated with insulin at 0.5 U/kg/hr which rapidly reversed the cardiovascular collapse [11]. [casereports.in]

• Unconsciousness

  Case Study 2 EMS was called after a 4 year old female child was found unconscious by her mother Child’s mother says the child accidently ingested her husband’s blood pressure medication and she does not know how many the child took Source: Rahm, Stephen [slideshare.net]

  Relevant Paper(s) Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses Dolcourt et al, 2008 USA 52 yr old male with overdose of atenolol and verapamil, presented unconscious with HR 49, SBP 40, anuric [bestbets.org]

• Respiratory Distress

  Beta Blocker Overdose can be life-threatening, due to possible dangerous drop in blood pressure and respiratory distress The prognosis is dependent on the dosage of beta blocker taken, the time between overdose and treatment, severity of the symptoms, [dovemed.com]

  You completes a primary survey Airway Patent and self-maintained Breathing Respiratory rate: 18 Oxygen saturations: 97% on air Chest sounds: clear No obvious respiratory distress Circulation Absent radial pulse Palpable central pulse Heart rate: 33 Blood [medicnow.com]

• Dyspnea

  He has had mild dyspnea on exertion, a persistent dry cough, and mild nausea. He denies vomiting, diaphoresis, and hemoptysis. He has had a decreased appetite for one week. [slideshare.net]

• Nausea

  Side effects: Anticholinergic effects = 1) CNS effects, 2) GI – decreased saliva, nausea, vomiting, ileus, 3) GU – urinary retention, 4) CV – tachycardia (obviously) and arrhythmias, 5) Eyes – blurry vision 2. [errolozdalga.com]

  Glucagon-treated patients should be monitored for side effects of nausea, vomiting, hypokalemia, and hyperglycemia. The high cost and limited availability of glucagon may be the only factors precluding its future clinical acceptance. [ncbi.nlm.nih.gov]

  […] channel blocker toxicity Other names Calcium channel blocker poisoning, calcium channel blocker overdose A 20% lipid emulsion commonly used for calcium channel blocker toxicity Specialty Emergency medicine Symptoms Slow heart rate, low blood pressure, nausea [en.wikipedia.org]

  Consider pretreating with an antiemetic as nausea can be a side effect. Monitor the potassium levels frequently due to the potassium shift caused by the glucagon. [calsprogram.org]

• Hypotension

  The common feature of beta-blocker toxicity is excessive blockade of the beta-receptors resulting in bradycardia and hypotension. [ncbi.nlm.nih.gov]

  Glucagon administration is indicated for hypotension, bradycardia or conduction impairment. It may also be effective in treating hypotension in calcium channel blocker and other overdoses with cardiac toxicity. [ww2.mc.vanderbilt.edu]

  Clinical features usually present within 4 h of ingestion, can be delayed for 6-12 hours for sustained released formulation Cardiovascular hypotension, bradycardia & heart block congestive cardiac failure ECG - bradycardia, 1st AV block, intraventricular [aic.cuhk.edu.hk]

  We report a case with an uneventful intraoperative period but profound bradycardia and hypotension postoperatively, only relieved with high-dose insulin therapy. [ijccm.org]

• Seizure

  […] blockers with high lipid solubility cause more adverse CNS effects, and a higher volume of distribution makes extracorpeal removal less effective (eg Carvedilol, propanolol) � blockers with membrane stabilizing activity associates with higher risk of seizure [aic.cuhk.edu.hk]

  A depressed level of consciousness and seizures may occur as a result of cellular hypoxia from poor cardiac output, a direct CNS effect caused by sodium channel blocking, or even hypoglycemia. [calsprogram.org]

  Some opioids can cause seizures (i.e., meperidine). Opioids may also cause hypoperfusion, which can lead to seizures. [emergencymedicinecases.com]

  Hyperkalaemia and hypo or hyperglycaemia can also be seen. 2 Seizures and coma occur in severe propranolol poisoning due to its ability to cross the blood brain barrier. [emergpa.net]

  Treatments (Con’t)Supportive Treatments Benzodiazepines for Seizures! [slideshare.net]

• Tremor

  Propranolol, a nonselective β blocker, is the first-line drug in the management of essential tremor, portal hypertension, migraine prophylaxis, and thyroid storm. [amboss.com]

  In addition to cardiovascular disorders, beta blockers are also used in the management of anxiety, migraine headache, glaucoma, tremor, hyperthyroidism, and various other disorders. [ncbi.nlm.nih.gov]

  Furthermore they are used to treat migraine, hyperthyroidism and benign tremor. They are uncommonly taken in overdose and can lead to significant morbidity. Toxicokinetics: The kinetics of beta blockers depend on their lipophilicity 1. [emergpa.net]

  […] antagonists (beta-blockers) (BBs) are commonly used for treatment of hypertension, coronary artery disease, and tachydysrhythmias. β-adrenergic antagonists has also been used to treat congestive heart failure, glaucoma, migraine headaches, benign essential tremor [calpoison.org]

  FDA Approved Indications Hypertension Pediatric hypertensive emergency Angina pectoris Cardiac arrhythmias/tachycardias MI CHF Pheochromocytoma Migraine prevention Hypertrophic subaortic stenosis Parkinsonian tremors Akathisia Bleeding in [slideshare.net]

• Irritability

  (Go to Episode 86 Emergency Management of Hyperkalemia for ECG examples) Classic digoxin toxicity ECG findings are a result of myocardial irritability or blockade at the AV node and include: Myocardial irritability: Slow atrial fibrillation Bidirectional [emergencymedicinecases.com]

Case Study 3 (Con’t)After initial treatment After lab work Since the patient was getting  Dopamine infusion was titrated up to 20 μg/kg/minute worse, a complete blood and toxicology workup was  simultaneous infusion of norepinephrine was added to try [slideshare.net]

• Torsades De Pointes

  This patient is at significant risk of Torsades de Pointes. Example 5 This ECG demonstrates some of the key features of propranolol overdose : 1st degree AV block. [lifeinthefastlane.com]

  Sinus bradycardia ± 1 st degree AV block and interventricular conduction delay are most common dysrhythmia. 2 QRS widening can occur in propranolol toxicity, while QT prolongation and possibly Torsades de Pointes can occur in sotalol poisoning. [emergpa.net]

  Sotalol overdoses, in addition to bradycardia and hypotension, can cause torsade de pointes. [ncbi.nlm.nih.gov]

  Class III agents prolong the action potential duration and the effective refractory period of AV and atrioventricular myocytes, which can lengthen the QT-interval duration and result in polymorphic ventricular tachycardia (ie, torsade de pointes ). [emedicine.medscape.com]

Cases refractory to fluids, atropine, and glucagon should be considered candidates for high-dose insulin, euglycemia (HIE) treatment. [ncbi.nlm.nih.gov]

If you are not familiar with the use of high-dose insulin for the treatment of beta blocker toxicity we suggest you first consult your poison control center before beginning treatment. [calsprogram.org]

Within an hour of treatment with this regime BP improved to 100/60 mmHg. [ijccm.org]

Beta Blocker Overdose can be life-threatening, due to possible dangerous drop in blood pressure and respiratory distress The prognosis is dependent on the dosage of beta blocker taken, the time between overdose and treatment, severity of the symptoms, [dovemed.com]

[…] blockers either by accident or on purpose [3] Differential diagnosis Beta blocker toxicity [1] Treatment Activated charcoal, whole bowel irrigation, intravenous fluids, calcium gluconate, glucagon, high dose insulin, vasopressors, lipid emulsion [1] [2] Prognosis [en.wikipedia.org]

They are recommended for the treatment of congestive heart failure by American College of Cardiology Foundation/American Heart Association Task Force. [1] [2] Etiology The etiology of beta-blocker overdose is closely related to the epidemiology of depression [ncbi.nlm.nih.gov]

Addresses the full range of renal problems, from epidemiology to monitoring and diagnostic procedures to pathophysiology of organ systems in relation to kidney failure. [books.google.de]

Two-thirds of these patients overdosed on someone else’s medication or were using beta blockers for noncardiac indications (e.g., migraine, tremor, thyrotoxicosis). [3] [4] [5] Epidemiology In 2015, According to American Association of Poison Control [ncbi.nlm.nih.gov]

Answer: Beta-Blocker Toxicity 1-4 Epidemiology: In 2015, U.S. poison centers received > 40,000 calls regarding beta-blocker exposures. [emdocs.net]

] There is tentative clinical evidence and good theoretical evidence of the benefit of lipid emulsion in severe overdoses of CCBs. [13] Methylene blue may also be used for those with low blood pressure that does not respond to other treatments. [11] Epidemiology [en.wikipedia.org]

Several ECG differences in acebutolol intoxication might reflect unique pathophysiologic processes relative to other beta-blockers. [ncbi.nlm.nih.gov]

Pharmacology, pathophysiology and management of calcium channel blocker and β -blocker toxicity. Toxicological Reviews. 2004;23(4):223–238. doi: 10.2165/00139709-200423040-00003. Olson, Kent Russell. Poisoning & Drug Overdose. [ww2.mc.vanderbilt.edu]

Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker toxicity. Toxicol Rev. 2004; 23(4):223-38. Doepker B, Healy W, Cortez, E and Adkins, E. [osuemed.wordpress.com]

Addresses the full range of renal problems, from epidemiology to monitoring and diagnostic procedures to pathophysiology of organ systems in relation to kidney failure. [books.google.de]

The protective effects of ISA do not completely prevent cardiovascular toxicity following overdose. [slideplayer.com]

References: [7] [8] [9] [10] [11] [6] Side effects General side effects Beta blocker withdrawal Caused by sudden termination of β blockers Clinical features : : tachycardia, tachyarrhythmia, hypertension, acute coronary syndrome, sudden cardiac death Prevention [amboss.com]

They may actually present with reflex tachycardia How to tell CCB OD from B-Blocker CCBs do not cause AMS CCBs block receptor in B-Islet cells, preventing insulin release, so can see hyperglycemia as opposed to the normal-low sugar in B-Blockers Presentation [emcrit.org]