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Beta-blocker toxicity

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Updated 2023 AHA guidelines for the management of beta-blocker toxicity.

Background

Overview

Definition
Beta-blocker toxicity refers to an overdose or excessive exposure to β-blocker medications.
1
Pathophysiology
The pathophysiology of β-blocker toxicity involves the excessive blockade of β-adrenergic receptors. This blockade leads to a decrease in HR and myocardial workload.
2
Epidemiology
The incidence of β-blocker toxicity is estimated at 5.1% among hospitalized patients with acute poisoning.
3
Disease course
Clinically, patients with β-blocker toxicity often present with bradycardia, hypotension, and varying degrees of AV block. In severe cases, patients may experience life-threatening cardiogenic shock refractory to pharmacological interventions.
4
Prognosis and risk of recurrence
The prognosis of β-blocker toxicity can range from mild to severe toxicity, depending on the amount of β-blocker ingested and the time elapsed before treatment.
4

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of beta-blocker toxicity are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2023), the American Heart Association (AHA/HRS/ACC 2019), and the American Association of Poison Control Centers (AAPCC/AACT/ACMT 2005). ...
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Diagnostic investigations

Initial assessment: as per AACT/AAPCC/ACMT 2005 guidelines, elicit history to determine the precise ingested dose of a β-blocker, the presence of coingestants and comorbidities in patients without evidence of self-harm.
B
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Medical management

Admission to emergency department: as per AACT/AAPCC/ACMT 2005 guidelines, refer patients with stated or suspected self-harm or victims of a potentially malicious administration of β-blocker to an emergency department immediately, guided by local poison center procedures, regardless of the dose reported.
B
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Inpatient care

Inpatient monitoring
As per AACT/AAPCC/ACMT 2005 guidelines:
Monitor asymptomatic patients referred to healthcare facilities for the following durations after ingestion:
6 hours for an immediate-release product other than sotalol
8 hours for a sustained-release product
12 hours for sotalol
B
Do not obtain routine 24-hour inpatient monitoring in asymptomatic patients unintentionally ingested a sustained-release product.
D

Therapeutic procedures

Temporary cardiac pacing: as per AHA 2023 guidelines, consider attempting electrical pacing in patients with β-blocker-induced bradycardia.
C

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Follow-up and surveillance

Outcome assessment: as per AACT/AAPCC/ACMT 2005 guidelines, obtain follow-up calls depending on the specific circumstances to determine outcome at appropriate intervals for up to 12-24 hours based on the judgment of the poison center staff.
B