This handout is for cardiogenic shock — beta-blocker overdose (hie-first toxicologic cs). Your care team identified this based on: intentional β-blocker ingestion + bradycardia + hypotension — bb od with shock physiology; hie pathway.
Other reasons your team may use this plan: altered mental status / seizure with known β-blocker exposure — suspect propranolol (lipophilic, bbb penetrant); ecg bradycardia + av block ± qrs widening (propranolol na-channel effect) post-bb ingestion → bicarbonate + hie pathway; concurrent bb + ccb ingestion — synergistic toxicity; severe cs requires hie + calcium + glucagon + early mcs planning.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| insulin regular | 1 U/kg IV bolus → 0.5–2 U/kg/h continuous infusion (HIE) | IV | continuous; titrate up if persistent hypotension, no upper limit set in OD literature beyond 10 U/kg/h has been reported | Engebretsen 2011 PMID 21626672 — HIE > standard pressors in BB/CCB OD; restores myocyte glucose oxidation and provides direct positive inotropy independent of β-receptor signalling; FIRST-LINE in toxicologic CS |
| glucagon | 5–10 mg IV bolus → 5–10 mg/h continuous infusion | IV | continuous | AACT 2017 PMID 29022414 — bypasses β-receptor and stimulates myocardial cAMP via glucagon receptor; pre-treat with anti-emetic (ondansetron 8 mg IV) — vomiting universal at therapeutic dose; tachyphylaxis common after 24 h |
| calcium gluconate | 3 g IV q5 min × max ~12 g (then titrate to ionized Ca >2.0) | IV | q5 min initial then q4–6 h titrate | Augments intracellular Ca; especially helpful for concurrent CCB co-ingestion (synergistic toxicity); calcium chloride 10% 1 g via central line is alternative — 3× more elemental Ca per gram |
| sodium bicarbonate | 1–2 mEq/kg IV bolus then infusion to keep arterial pH 7.50–7.55 | IV | bolus + continuous infusion | Treats propranolol Na-channel blockade (membrane-stabilising effect — analogous to TCA OD); bolus repeat q5 min until QRS narrows; continuous infusion to maintain alkalemia (target pH 7.50–7.55) |
| intralipid 20% | 1.5 mL/kg IV bolus over 1 min → 0.25 mL/kg/min infusion × 30–60 min (max ~10 mL/kg total) | IV | bolus may repeat × 2 q5 min then continuous | Levine 2014 PMID 25498415 — lipid sink for lipophilic agents (propranolol most lipophilic; metoprolol intermediate; atenolol/nadolol hydrophilic — limited value for hydrophilic BBs); rescue therapy in shock or arrest |
| norepinephrine | 0.05–0.5 µg/kg/min IV titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — first-line vasopressor in generic CS; in BB OD often inadequate alone (β blockade) — combine with HIE; doses required often supraphysiologic |
| epinephrine | 0.05–0.5 µg/kg/min IV titrate | IV | continuous | Adjunct when NE alone fails; partial β-receptor override at high doses; AVOID as monotherapy without HIE — receptor blockade defeats standard ACLS dosing |
| isoproterenol | 2–10 µg/min IV titrate to HR 60–80 | IV | continuous | β-1 chronotropic bridge during pacing capture-failure (common in severe BB OD due to receptor blockade); transvenous pacing remains preferred definitive bridge to HIE recovery |
| atropine | 0.5–1 mg IV q3–5 min × max 3 mg | IV | q3–5 min | AHA 2020 ACLS bradycardia algorithm; usually inadequate in severe BB OD (receptor blockade defeats vagolysis); transient bridge to HIE / pacing |
| magnesium sulfate | 2 g IV bolus then 2 g/h infusion | IV | continuous if torsades | AHA 2020 ACLS — first-line for torsades regardless of serum Mg; SOTALOL OD specifically prone to QT prolongation + torsades (class III effect); combine with overdrive pacing if bradycardia-dependent |
| ondansetron | 8 mg IV before glucagon bolus | IV | q8 h while on glucagon infusion | Pre-treatment for glucagon-induced vomiting (universal at 5–10 mg dose); aspiration risk in obtunded patient |
| activated charcoal | 1 g/kg PO/NG if airway protected, ingestion <1 h (<2 h for sustained-release) | PO/NG | one-time | GI decontamination per AACT/EAPCCT — limited evidence; AVOID if ileus / obtundation without intubation |
Plan: BB overdose with CS — HIE-first toxicologic pillars (insulin-euglycemia + glucagon + calcium + bicarbonate + lipid emulsion); pressors as adjuncts; VA-ECMO if refractory
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Psychiatric inpatient admission post-medical clearance for intentional OD (mandatory safety planning); Toxicology + Cardiology follow-up at 1–4 wks; outpatient SSRI / mood stabilizer review with psychiatry; medic-alert documentation for severe BB-sensitivity if therapeutic re-introduction needed; family education on lethal-means counseling
Guideline: AACT 2017 BB Toxicity Expert Consensus (PMID 29022414); Engebretsen 2011 HIE in BB/CCB OD (PMID 21626672); SCAI 2022 CS staging (Naidu PMID 35718438); ACMT HIE position statement; AHA 2020 ACLS