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cardio.cardiogenic-shock.bb-overdose.v1PRODUCTION
cardio.cardiogenic-shock.bb-overdose.v1

Cardiogenic shock — Beta-blocker overdose (HIE-first toxicologic CS)

cardiologyacuteadult
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Recognize BB OD as toxicologic CS — receptor blockade defeats standard ACLS; HIE + glucagon + calcium + lipid emulsion + bicarbonate are the pillars; standard epinephrine alone often inadequate

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BB OD with shock physiology confirmed

Patient inputs (14)

Pediatric BB OD (single-tablet ingestion of long-acting propranolol) catastrophic; geriatric polypharmacy compounds toxicity

Hypothermia common in severe BB OD; warm to ≥36°C before pronouncement of refractoriness

eGFR for water-soluble BB clearance (atenolol/nadolol — hemodialysis option) + supportive drug dosing

Identify specific BB (propranolol most dangerous — lipophilic + Na-channel effect; sotalol → torsades); dose in mg/kg; coingestants (CCB synergistic)

Concurrent CCB / TCA / opioid / EtOH; CCB co-ingestion is the highest-mortality phenotype

BB OD impairs glycogenolysis → hypoglycemia (esp pediatric); during HIE, target euglycemia 100–250 mg/dL with D10W titration

Insulin shifts K intracellularly during HIE — replace aggressively (K target ≥4.0); hourly during HIE infusion

Differentiate primary toxic CS from ischemia-precipitated arrhythmia / shock

Bradycardia + AV block (1st/2nd/3rd-degree); QRS widening with propranolol (Na-channel block — bicarbonate response); QT prolongation with sotalol (class III)

Confirms reduced contractility; rules out structural / ischemic mimics; serial echo to track HIE inotropic recovery

SCAI 2022 baseline + vasopressor titration; persistent SBP <90 despite HIE → MCS escalation

Bradycardia (HR <60) + AV block hallmark; may be capture-failure on transvenous pacing due to receptor blockade

SCAI 2022 staging + perfusion marker; CardShock prognostication (Harjola PMID 26333869)

HIE dosing weight-based (insulin 1 U/kg bolus → 0.5–2 U/kg/h); calcium gluconate 3 g per dose; lipid emulsion 1.5 mL/kg bolus

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningrefractory_bradycardia_despite_glucagon_atropine_in_bb_od
    Symptomatic bradycardia (HR <40 + hypotension or AMS) despite glucagon + atropine + isoproterenol bridge in BB OD — start HIE if not already running + transvenous pacing (capture often poor) + early MCS planning
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpropranolol_qrs_widening_above_120_in_bb_od
    Propranolol OD with QRS widening >120 ms — Na-channel (membrane-stabilising) effect; analogous to TCA OD; maximize bicarbonate + lipid emulsion; pre-arrest harbinger
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglipid_emulsion_failure_in_severe_bb_od
    Refractory shock / pre-arrest despite HIE + glucagon + calcium + bicarbonate + lipid emulsion in severe lipophilic BB OD (esp propranolol) — emergent VA-ECMO bridge
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuicide_attempt_with_concurrent_ccb_co_ingestion
    Intentional BB OD with concurrent CCB ingestion — highest mortality phenotype; synergistic toxicity (combined β + Ca-channel blockade); prophylactic VA-ECMO team activation; psych safety planning post medical clearance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsotalol_overdose_with_qtc_above_500_torsades
    Sotalol OD with QTc >500 ms ± polymorphic VT — class III effect; Mg + overdrive pacing + emergent hemodialysis (sotalol is dialyzable; low Vd)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

BB overdose with CS — HIE-first toxicologic pillars (insulin-euglycemia + glucagon + calcium + bicarbonate + lipid emulsion); pressors as adjuncts; VA-ECMO if refractory
axis: bb_overdose_phenotype
Selected axis "BB overdose with CS — HIE-first toxicologic pillars (insulin-euglycemia + glucagon + calcium + bicarbonate + lipid emulsion); pressors as adjuncts; VA-ECMO if refractory" by default fallback (first axis)
  • insulin regular
    first line
    insulin_short_acting_for_hie
    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
    triggers: bb_overdose_with_shock, ccb_overdose_with_shock, concurrent_bb_ccb_overdose
    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
    rxcui 253182
  • glucagon
    first line
    glucagon_receptor_agonist
    5–10 mg IV bolus → 5–10 mg/h continuous infusion • IV • continuous
    triggers: bb_overdose_with_bradycardia_hypotension
    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
    rxcui 4832
  • calcium gluconate
    first line
    electrolyte_calcium_salt
    3 g IV q5 min × max ~12 g (then titrate to ionized Ca >2.0) • IV • q5 min initial then q4–6 h titrate
    triggers: bb_overdose_with_shock, concurrent_ccb_co_ingestion, qrs_widening
    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
    rxcui 1908
  • sodium bicarbonate
    first line
    alkalinizing_agent
    1–2 mEq/kg IV bolus then infusion to keep arterial pH 7.50–7.55 • IV • bolus + continuous infusion
    triggers: propranolol_overdose_with_qrs_widening, qrs_above_120_post_bb_od
    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)
    rxcui 36676
  • intralipid 20%
    rescue
    lipid_emulsion_for_lipophilic_od
    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
    triggers: severe_propranolol_overdose_refractory_to_hie, severe_lipophilic_bb_od_with_shock_or_arrest
    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
    rxcui 9949
  • norepinephrine
    second line
    vasopressor_alpha_beta
    0.05–0.5 µg/kg/min IV titrate MAP ≥65 • IV • continuous
    triggers: cs_overlay_on_bb_od_persistent_after_hie
    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
    rxcui 7512
  • epinephrine
    second line
    sympathomimetic_alpha_beta
    0.05–0.5 µg/kg/min IV titrate • IV • continuous
    triggers: ne_inadequate_for_map_in_bb_od, symptomatic_bradycardia_unresponsive_to_atropine
    Adjunct when NE alone fails; partial β-receptor override at high doses; AVOID as monotherapy without HIE — receptor blockade defeats standard ACLS dosing
    rxcui 3992
  • isoproterenol
    rescue
    beta1_agonist
    2–10 µg/min IV titrate to HR 60–80 • IV • continuous
    triggers: symptomatic_bradycardia_with_pacing_capture_failure_in_bb_od
    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
    rxcui 6054
  • atropine
    second line
    antimuscarinic
    0.5–1 mg IV q3–5 min × max 3 mg • IV • q3–5 min
    triggers: symptomatic_bradycardia_in_bb_od
    AHA 2020 ACLS bradycardia algorithm; usually inadequate in severe BB OD (receptor blockade defeats vagolysis); transient bridge to HIE / pacing
    rxcui 1223
  • magnesium sulfate
    rescue
    electrolyte
    2 g IV bolus then 2 g/h infusion • IV • continuous if torsades
    triggers: sotalol_induced_torsades, qtc_above_500_with_polymorphic_vt
    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
    rxcui 6585
  • ondansetron
    add on
    antiemetic_5ht3
    8 mg IV before glucagon bolus • IV • q8 h while on glucagon infusion
    triggers: glucagon_infusion
    Pre-treatment for glucagon-induced vomiting (universal at 5–10 mg dose); aspiration risk in obtunded patient
    rxcui 26225
  • activated charcoal
    add on
    gi_decontamination
    1 g/kg PO/NG if airway protected, ingestion <1 h (<2 h for sustained-release) • PO/NG • one-time
    triggers: recent_bb_ingestion_within_1_to_2_hours_with_protected_airway
    GI decontamination per AACT/EAPCCT — limited evidence; AVOID if ileus / obtundation without intubation
    rxcui 272

outpatient playbook — drug actions (2)

  1. 1. continue psych regimen per psychiatry
    per psychiatry • PO • per regimen
    trigger: Underlying psych diagnosis
    Long-term mood stabilization + suicide prevention
  2. 2. lifelong avoidance of BB unless cardiology shared decision + means restriction
    patient + family education + medic-alert • n/a • lifelong
    trigger: Intentional BB OD history
    Lethal-means counseling; consider non-BB alternative for cardiac indications

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Intentional β-blocker ingestion + bradycardia + hypotension — BB OD with shock physiology; HIE pathway; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — Beta-blocker overdose (HIE-first toxicologic CS)** (cardio.cardiogenic-shock.bb-overdose.v1).
Scope: Recognize BB OD as toxicologic CS — receptor blockade defeats standard ACLS; HIE + glucagon + calcium + lipid emulsion + bicarbonate are the pillars; standard epinephrine alone often inadequate

No severity triggers fired against current inputs.

Plan

Regimen axis: **BB overdose with CS — HIE-first toxicologic pillars (insulin-euglycemia + glucagon + calcium + bicarbonate + lipid emulsion); pressors as adjuncts; VA-ECMO if refractory**.
1. 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 (insulin_short_acting_for_hie, first line) — 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
2. glucagon 5–10 mg IV bolus → 5–10 mg/h continuous infusion IV continuous (glucagon_receptor_agonist, first line) — 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
3. 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 (electrolyte_calcium_salt, first line) — 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
4. sodium bicarbonate 1–2 mEq/kg IV bolus then infusion to keep arterial pH 7.50–7.55 IV bolus + continuous infusion (alkalinizing_agent, first line) — 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)
5. 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 (lipid_emulsion_for_lipophilic_od, rescue) — 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
6. norepinephrine 0.05–0.5 µg/kg/min IV titrate MAP ≥65 IV continuous (vasopressor_alpha_beta, second line) — 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
7. epinephrine 0.05–0.5 µg/kg/min IV titrate IV continuous (sympathomimetic_alpha_beta, second line) — Adjunct when NE alone fails; partial β-receptor override at high doses; AVOID as monotherapy without HIE — receptor blockade defeats standard ACLS dosing
8. isoproterenol 2–10 µg/min IV titrate to HR 60–80 IV continuous (beta1_agonist, rescue) — 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
9. atropine 0.5–1 mg IV q3–5 min × max 3 mg IV q3–5 min (antimuscarinic, second line) — AHA 2020 ACLS bradycardia algorithm; usually inadequate in severe BB OD (receptor blockade defeats vagolysis); transient bridge to HIE / pacing
10. magnesium sulfate 2 g IV bolus then 2 g/h infusion IV continuous if torsades (electrolyte, rescue) — 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
11. ondansetron 8 mg IV before glucagon bolus IV q8 h while on glucagon infusion (antiemetic_5ht3, add on) — Pre-treatment for glucagon-induced vomiting (universal at 5–10 mg dose); aspiration risk in obtunded patient
12. activated charcoal 1 g/kg PO/NG if airway protected, ingestion <1 h (<2 h for sustained-release) PO/NG one-time (gi_decontamination, add on) — GI decontamination per AACT/EAPCCT — limited evidence; AVOID if ileus / obtundation without intubation

Setting playbook (outpatient) — Long-term psychiatric + cardiology follow-up; safety plan maintenance; medication reconciliation (avoid BB re-exposure if intentional OD); annual ECG + echo if conduction or contractile recovery incomplete; family / community lethal-means counseling
13. continue psych regimen per psychiatry per psychiatry PO per regimen — Underlying psych diagnosis (Long-term mood stabilization + suicide prevention)
14. lifelong avoidance of BB unless cardiology shared decision + means restriction patient + family education + medic-alert n/a lifelong — Intentional BB OD history (Lethal-means counseling; consider non-BB alternative for cardiac indications)

Non-pharmacologic actions:
- Quarterly psych follow-up; annual / biannual cardiology
- Continued lethal-means counseling + medication storage education
- Crisis hotline (988) + safety plan reinforcement at every visit
- Family education on warning signs

AVOID / contraindication checks:
- Hie_requires_glucose_monitoring_q1h_and_aggressive_K_replacement (insulin shifts K intracellularly; D10W titration to maintain euglycemia 100–250)
- Glucagon_pre_treat_with_antiemetic (vomiting universal at therapeutic dose; aspiration risk)
- Lipid_emulsion_LIMITED_value_for_hydrophilic_BBs_atenolol_nadolol (use HIE + hemodialysis instead)
- Standard_epinephrine_alone_OFTEN_inadequate_in_bb_od (combine with HIE; β receptor blockade defeats ACLS dosing)
- Phenylephrine_pure_alpha_LESS_effective_in_bb_od (does not address inotropic / chronotropic failure)
- Transvenous_pacing_capture_failure_common (bridge with isoproterenol + epinephrine + HIE during attempt)
- Concurrent_ccb_co_ingestion_HIGHEST_mortality_phenotype (early MCS / VA ECMO planning)
- Hemodialysis_only_for_water_soluble_agents (atenolol, nadolol, sotalol — low Vd, dialyzable; propranolol, metoprolol NOT dialyzable)

Monitoring

Regimen monitoring:
- continuous telemetry with qrs qt q4-6h during hie
- arterial line continuous BP
- central line for pressors + calcium chloride
- glucose q1h during hie target 100-250
- potassium q1h during hie replace to above 4.0
- magnesium q4-6h replace to above 2.0
- lactate q2-4h until normalised
- UOP hourly
- serial echo q12-24h to track inotropic recovery
- temperature q1h maintain above 36c (hypothermia common in severe OD)
- serum drug level if assay available esp sotalol (dialyzability)

Setting (outpatient) monitoring:
- Psych quarterly
- Cardiology q3–6 mo year 1; annual thereafter
- Annual ECG + echo if residual abnormality

Follow-up plan: 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
- Close-out criterion: Psych admission + safety plan + outpatient cardiology + toxicology follow-up scheduled

Monitoring phase: Continuous telemetry; A-line; central line; serial ECG q4–6 h (track QRS, QT, conduction); glucose q1h during HIE (D10W titration; target 100–250); K hourly (insulin shifts intracellularly — replace aggressively to ≥4.0); Mg q4–6 h; lactate q2–4 h until clearing; UOP hourly; serial echo q12–24 h to track inotropic recovery

Disposition

Current setting: outpatient — Long-term psychiatric + cardiology follow-up; safety plan maintenance; medication reconciliation (avoid BB re-exposure if intentional OD); annual ECG + echo if conduction or contractile recovery incomplete; family / community lethal-means counseling

Disposition criteria:
- Stable on long-term outpatient regimen with engaged psych + cardiology follow-up; lifelong follow-up

Escalation triggers (move to higher acuity):
- Recurrent suicidal ideation → ED + involuntary hold
- Inadvertent BB exposure → ED
- Progressive conduction / contractile disease → cardiology + EP

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Symptomatic bradycardia (HR <40 + hypotension or AMS) despite glucagon + atropine + isoproterenol bridge in BB OD — start HIE if not already running + transvenous pacing (capture often poor) + early MCS planning
- [LIFE_THREATENING] Propranolol OD with QRS widening >120 ms — Na-channel (membrane-stabilising) effect; analogous to TCA OD; maximize bicarbonate + lipid emulsion; pre-arrest harbinger
- [LIFE_THREATENING] Refractory shock / pre-arrest despite HIE + glucagon + calcium + bicarbonate + lipid emulsion in severe lipophilic BB OD (esp propranolol) — emergent VA-ECMO bridge

Citations

- 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 [PMID:29022414](https://pubmed.ncbi.nlm.nih.gov/29022414/)
- Cited evidence (PMID 21626672) [PMID:21626672](https://pubmed.ncbi.nlm.nih.gov/21626672/)
- Cited evidence (PMID 25498415) [PMID:25498415](https://pubmed.ncbi.nlm.nih.gov/25498415/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:29022414
  • Cited evidence (PMID 21626672) — PMID:21626672
  • Cited evidence (PMID 25498415) — PMID:25498415
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234