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Beta-Blocker Toxicity

Beta-Blockers Toxicity


Presentation

  • Both patients presented with profound bradycardia and cardiogenic shock. The effectiveness of intravenous glucagon administration is demonstrated in the first case.[ncbi.nlm.nih.gov]
  • An overdose of the beta-blocking agent metoprolol is presented in which the patient remained asymptomatic despite blood levels that were more than 25 times that reported to be the upper limit of therapeutic.[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]
  • Presents a multi-disciplinary and international approach to critical renal care for a thorough and integrated presentation of how to care for critically ill patients with renal disease or complications.[books.google.de]
  • Each patient received an ECG on presentation and a structured follow-up.[ncbi.nlm.nih.gov]
Camping
  • When the beta receptor is stimulated, cAMP is increased and calcium influx (via L-type calcium channels) also increases.[ww2.mc.vanderbilt.edu]
  • Blockade of beta-receptors results in decreased production of intracellular cyclic adenosine monophosphate (cAMP) with a resultant blunting of multiple metabolic and cardiovascular effects of circulating catecholamines.[emedicine.medscape.com]
  • Phosphodiesterase Inhibitors (PDEIs) – Milrinone and other PDEIs increase inotropy activating intracellular cAMP independent of adrenergic receptors. The increase in cAMP can also cause vasodilation, however, which can worsen hypotension.[sinaiem.org]
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]
Sepsis
  • Significant updating of following topics - acute coronary syndrome management, trauma, sepsis management, imaging, arrhythmias. Expansion of administration section - especially patient safety. Changes to drug overdose sections in toxicology section.[books.google.de]
Hypotension
  • Sotalol overdoses, in addition to bradycardia and hypotension, can cause torsade de pointes.[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]
  • If a patient is bradycardic and hypotensive consider a beta-blocker or calcium blocker overdose.[calsprogram.org]
Seizure
  • 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]
  • 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]
  • Seizures are more commonly observed in drugs with MSA. Beta-blockers with MSA are associated with the largest proportion of fatalities.[emedicine.medscape.com]
  • Propranolol toxicity is associated with QRS widening and a positive R’ wave in aVR (signs of sodium channel blockade ), which portend the onset of coma, seizures, hypotension and ventricular arrhythmias.[lifeinthefastlane.com]
  • If the patient does not respond to these measures, the following interventions may be considered: Inotropes and chronotropes Glucagon Gastric decontamination Benzodiazepines (in patients with seizures) Hemodialysis Cardiac pacing/cardiopulmonary resuscitation[emedicine.medscape.com]

Workup

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]
First-Degree Atrioventricular Block
  • The development of bradycardia and first degree atrioventricular block during observation appeared to predict toxicity in this patient who suddenly developed hypotension 6 h postingestion.[ncbi.nlm.nih.gov]
  • atrioventricular block, and even sinus tachycardia. [1] Differential [ edit ] It may not be possible to tell the difference between beta blocker toxicity and calcium channel blocker overdose based on signs and symptoms. [1] Management [ edit ] The medical[en.wikipedia.org]
T Wave Inversion
  • ECG was normal with a sinus rhythm and nonspecific t wave inversion in lead III.[ijccm.org]

Treatment

  • A review of the medical literature indicates that the optimal treatment for acute beta-blocker toxicity is intravenous glucagon. Calcium administration should also be considered.[ncbi.nlm.nih.gov]
  • 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]
  • This article provides a detailed review of the pharmacology, pathophysiology, clinical presentation and treatment strategies for CCB and BB overdoses.[ncbi.nlm.nih.gov]

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]
  • ] 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]
  • This article provides a detailed review of the pharmacology, pathophysiology, clinical presentation and treatment strategies for CCB and BB overdoses.[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]
  • 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

  • Beta-blockers bind to these receptors and prevent this downstream effect, eventually lowering the calcium uptake into the myocyte.[nuemblog.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]
  • Beta blockers prevent remodeling of the heart after an ischemic event by reducing the effects of catecholamines on cardiac tissue.[ncbi.nlm.nih.gov]

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