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Beta Blocker Poisoning

Beta Blocker Toxicity


Presentation

  • 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]
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]
Rales
  • .  Lungs: Scattered rhonchi and end-expiratory wheezes bilaterally, with no rales.  All other physical examination results were normal however the patient got worse during the physical exam and condition deterioratedSource: Heitz, Cory.[slideshare.net]
Nausea
  • 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]
  • 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]
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]
  • We report a case with an uneventful intraoperative period but profound bradycardia and hypotension postoperatively, only relieved with high-dose insulin therapy.[ijccm.org]
  • If the patient is hypotensive, administer 20 mL/kg of isotonic intravenous fluids and place the patient in the Trendelenburg position.[emedicine.medscape.com]
Neck Pain
  • He denies headache, neck pain, visual changes, abdominal pain, fevers, rashes, or change in his bowel movements.Source: Heitz, Cory. "BETA BLOCKER OVERDOSE." Emergency Medicine Education Online.[slideshare.net]
Seizure
  • 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]
  • 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]
  • Treatments (Con’t)Supportive Treatments Benzodiazepines for Seizures![slideshare.net]
  • Seizures are more commonly observed in drugs with MSA. Beta-blockers with MSA are associated with the largest proportion of fatalities.[emedicine.medscape.com]
Akathisia
  • 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]

Workup

  • 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]
Insulin Decreased
  • This lack of circulating insulin decreases cardiac carbohydrate metabolism by preventing glucose uptake and use by cardiac muscle. 13 This results in a lack of fuel for aerobic energy production, causing a shift to fatty acid oxidation within the cells[slideplayer.com]
Narrow QRS Complex
  • Narrow QRS complexes No visible P waves Example 3 Complete heart block: Sinus rhythm – P waves occur at a rate of around 90 bpm. 3rd degree AV block – there is no relationship between the P waves and QRS complexes.[lifeinthefastlane.com]

Treatment

  • 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]

Prognosis

  • 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]

Etiology

  • 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]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • 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]
  • 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]

Prevention

  • The protective effects of ISA do not completely prevent cardiovascular toxicity following overdose.[slideplayer.com]
  • Beta-blockers bind to these receptors and prevent this downstream effect, eventually lowering the calcium uptake into the myocyte.[nuemblog.com]
  •  chest radiography to prevent cardiac failure serum electrolytes to prevent potassium buildup Treat seizures with benzodiazepines, if they are not working, then treat with barbiturates Make sure activated charcoal is given Source: "Beta-Adrenergic[slideshare.net]

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