12-phase flow (12)

1. 1FRAME
   Frame as an adult/pediatric acute BB poisoning: bradycardia + hypotension + hypoglycemia, with agent-specific overlays (propranolol Na-channel/CNS/seizure; sotalol QT/torsades; sustained-release delayed) (AACT/ACMT 2023)
   inputs: agent_and_formulation, coingestants
   advance: BB poisoning scenario framed; agent class and formulation noted
2. 2ENTRY
   Recognize entry trigger: stated/suspected ingestion, unexplained bradycardia-hypotension, hypoglycemia-with-bradycardia, or AMS/seizure with bradycardia (Kerns 2007)
   inputs: age
   advance: Trigger captured + demographics recorded
3. 3CONTEXT
   Capture agent/formulation, dose/time, weight, age, coingestants (CCB, digoxin, TCA, clonidine), intent (deliberate vs accidental pediatric) (AACT/ACMT 2023)
   inputs: age, weight_kg, agent_and_formulation, time_and_dose_of_ingestion, coingestants
   advance: Agent, dose, timing, weight and coingestants documented
4. 4RED_FLAGS
   Screen for life-threats: HR <40 / symptomatic bradycardia, SBP <90 / cardiogenic shock, GCS depression / seizure, wide QRS (propranolol), prolonged QT with torsades (sotalol), cardiac arrest (critical-care tox review 2024)
   inputs: hr, sbp, gcs
   actions: calc.news2, workup.bradycardia
   advance: Red flags screened; resuscitation + ICU activated if any present
5. 5INITIAL_WORKUP
   Bedside glucose (HYPOglycemia = BB pattern), 12-lead ECG (PR/QRS/QT), BMP + K + Mg, lactate, ABG/VBG, acetaminophen + salicylate + tox screen, troponin; continuous telemetry (Engebretsen 2011)
   inputs: glucose, potassium, ecg, lactate
   actions: workup.bb_ccb_overdose, panel.glucose_a1c, panel.metabolic, panel.cardiac
   advance: Glucose, ECG, electrolytes, lactate and tox screen returned
6. 6BRANCHING_WORKUP
   Branch by agent: propranolol → wide-complex / seizure pathway + lipid-emulsion candidacy; sotalol → QT / torsades surveillance + Mg/isoproterenol/overdrive pacing; sustained-release → prolonged observation + whole-bowel irrigation; refractory shock → echo + mechanical-support evaluation (Kerns 2007)
   inputs: agent_and_formulation, ecg
   actions: workup.wide_complex_tach, workup.brady_heart_block, panel.tox_screen
   advance: Agent-specific pathway selected; SR/QT/Na-channel branches activated as applicable
7. 7DIFFERENTIAL
   Differentiate from CCB toxicity (glucose direction: BB → hypoglycemia, CCB → hyperglycemia; both bradycardic-hypotensive), digoxin toxicity, clonidine/imidazoline, cholinergic/organophosphate, TCA, hyperkalemia, MI/intrinsic conduction disease, hypothyroid/myxedema (critical-care tox review 2024)
   inputs: glucose, coingestants
   actions: workup.cardiogenic_shock
   advance: BB toxicity confirmed as principal driver; mimics excluded
8. 8RISK_STRATIFICATION
   Stratify severity: isolated mild bradycardia vs cardiogenic shock vs Na-channel/CNS toxicity vs sotalol torsades vs arrest; massive ingestion, sustained-release, propranolol and sotalol are high-risk markers requiring ICU (AACT/ACMT 2023)
   inputs: hr, sbp, gcs
   actions: calc.qsofa, calc.news2
   advance: Severity tier assigned; ICU vs monitored-bed disposition decided
9. 9TREATMENT
   Ladder: IV crystalloid + atropine 0.5–1 mg (peds 0.02 mg/kg) → HIET (regular insulin 1 U/kg IV bolus + D50, then 0.5–1 U/kg/h titrated to 10 U/kg/h with dextrose + glucose/K monitoring) → norepinephrine/epinephrine for shock → glucagon 3–10 mg IV bolus (peds 50 mcg/kg) then 3–5 mg/h infusion → IV lipid emulsion 1.5 mL/kg bolus then 0.25 mL/kg/min for lipophilic agents (propranolol) → transvenous pacing / VA-ECMO if refractory; sotalol torsades → IV magnesium + isoproterenol/overdrive pacing ± lidocaine; sustained-release → whole-bowel irrigation; activated charcoal if airway-protected and early (Engebretsen 2011; Kerns 2007)
   inputs: hr, sbp, glucose, weight_kg, agent_and_formulation
   advance: Stepwise ladder initiated and titrated to perfusion endpoints
10. 10DISPOSITION
    ICU for any hemodynamic instability, HIET, vasopressors, sustained-release, propranolol or sotalol ingestion; monitored bed with prolonged observation for asymptomatic sustained-release; psychiatry for deliberate self-harm; poison-center co-management (AACT/ACMT 2023)
    advance: Disposition assigned with poison-center and (if deliberate) psychiatry engaged
11. 11MONITORING
    Continuous telemetry + ECG (QRS/QT), q1h vitals, q30–60 min glucose during HIET, q1–2h potassium, lactate clearance, urine output / fluid balance during HIET, neuro checks for propranolol CNS toxicity (Engebretsen 2011)
    inputs: hr, sbp, glucose, potassium
    actions: workup.hypoglycemia, panel.metabolic, panel.cardiac
    advance: Hemodynamics stable, HIET weaning, glucose/K normalized, QRS/QT resolved
12. 12FOLLOWUP
    Observation period satisfied (≥6 h immediate-release with normal ECG; ≥24 h for sustained-release / sotalol / propranolol); psychiatric evaluation and safety plan if intentional; poison-prevention counseling for pediatric exploratory ingestion; medication-reconciliation and safe-storage education (AACT/ACMT 2023)
    actions: workup.delirium
    advance: Safe-discharge criteria met + psych / prevention follow-up arranged