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tox.beta-blocker-overdose.core.v1PRODUCTION
tox.beta-blocker-overdose.core.v1

Beta-blocker overdose

toxicologyacuteadultpediatric
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12/12 authored

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

Current phase

Frame

Detailed

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)

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BB poisoning scenario framed; agent class and formulation noted

Patient inputs (12)

Pediatric "one-pill-can-kill" risk (sotalol/propranolol); weight-based HIET / glucagon dosing (AACT/ACMT 2023)

HIET (1 U/kg bolus then 0.5–1 U/kg/h), glucagon, lipid emulsion all weight-based (Engebretsen 2011)

Lipophilic propranolol (Na-channel/CNS/seizure, lipid-emulsion candidate) vs sotalol (QT/torsades) vs sustained-release (delayed peak, WBI) drives the plan (Kerns 2007)

Time-to-peak and sustained-release kinetics dictate decontamination window and observation duration (AACT/ACMT 2023)

CCB / digoxin / TCA / clonidine co-ingestion changes the toxidrome and antidote (critical-care tox review 2024)

HYPOglycemia favors BB over CCB (which causes HYPERglycemia) — the pivotal discriminator; also guides HIET dextrose (Engebretsen 2011)

HIET drives intracellular K shift → must co-monitor and replace (AACT/ACMT 2023)

PR/QRS widening (propranolol Na-channel), QT prolongation / torsades (sotalol), brady-arrhythmia / heart block (AACT/ACMT 2023)

Bradycardia is the cardinal sign; refractory bradycardia escalates the ladder (AACT/ACMT 2023)

Hypotension / cardiogenic shock drives HIET, vasopressors, mechanical support (Engebretsen 2011)

CNS depression / coma — lipophilic propranolol; airway protection (Kerns 2007)

Tissue hypoperfusion marker; clearance tracks response to HIET / pressors (critical-care tox review 2024)

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningcardiogenic_shock_refractory_to_fluids_atropine
    Persistent shock despite crystalloid + atropine (AACT/ACMT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpropranolol_na_channel_cns_toxicity
    Propranolol ingestion with QRS >120 ms, seizures, or coma (Kerns 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsotalol_qt_prolongation_torsades
    Sotalol ingestion with prolonged QT and/or torsades de pointes (Kerns 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_arrest_or_collapse
    Cardiac arrest or peri-arrest refractory to HIET + pressors + glucagon (critical-care tox review 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_bradycardia_hypotension
    HR <50 with SBP <90 / hypoperfusion in suspected BB ingestion (critical-care tox review 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresustained_release_or_massive_ingestion
    Sustained/extended-release formulation or massive ingestion (delayed, prolonged toxicity) (AACT/ACMT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RED_FLAGSrequiredDrives severity classification
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Recommended regimen

Beta-blocker overdose — stepwise resuscitation ladder (fluids/atropine → HIET → vasopressors → glucagon → lipid emulsion → mechanical support)
axis: bb_overdose_resuscitation_ladderstep 1 - Step 1 — Crystalloid + atropine + decontamination
Selected step "Step 1 — Crystalloid + atropine + decontamination" — Symptomatic bradycardia / hypotension at presentation; airway-protected and early ingestion for charcoal; sustained-release for WBI
  • normal saline (isotonic crystalloid)
    first line
    crystalloid
    10–20 mL/kg IV bolus (cautious — repeat to perfusion, avoid pulmonary edema in BB-induced cardiogenic shock) • IV • bolus, reassess
    triggers: hypotension, volume_responsive
    First-line volume support; limited efficacy in pump failure — escalate early rather than over-resuscitate (AACT/ACMT 2023)
    rxcui 9863
  • atropine
    first line
    antimuscarinic
    0.5–1 mg IV (peds 0.02 mg/kg, min 0.1 mg) q3–5 min, max 3 mg • IV • q3–5 min PRN
    triggers: symptomatic_bradycardia
    Temporizing for vagally-mediated bradycardia; frequently inadequate alone in significant BB poisoning — do not delay HIET/pressors (critical-care tox review 2024)
    rxcui 1223
  • activated charcoal
    add on
    GI_decontaminant
    1 g/kg PO/NG (max 50 g) • PO/NG • single dose
    triggers: airway_protected, ingestion_within_1_2h, no_ileus
    Only if early and airway protected — caution with declining mental status (lipophilic propranolol) (AACT/ACMT 2023)
    rxcui 272
  • whole-bowel irrigation (polyethylene glycol)
    add on
    GI_decontamination_procedure
    PEG-ELS 1–2 L/h (peds 25 mL/kg/h) until rectal effluent clear • PO/NG • continuous
    triggers: sustained_release_formulation, large_ingestion, airway_protected
    Sustained/extended-release BB — reduces ongoing absorption; protect airway and exclude ileus first (AACT/ACMT 2023)

ed playbook — drug actions (7)

  1. 1. normal saline bolus
    10–20 mL/kg IV (cautious, reassess) • IV • bolus
    trigger: Hypotension
    Volume support; limited in pump failure (AACT/ACMT 2023)
  2. 2. atropine
    0.5–1 mg IV (peds 0.02 mg/kg) q3–5 min, max 3 mg • IV • q3–5 min PRN
    trigger: Symptomatic bradycardia
    Temporizing only — do not delay HIET (critical-care tox review 2024)
  3. 3. regular insulin (HIET) + D50
    Insulin 1 U/kg IV bolus + D50 if glucose <250, then 0.5–1 U/kg/h titrated • IV • bolus then infusion
    trigger: Shock refractory to fluids/atropine
    Early inotrope of choice in toxin cardiogenic shock (Engebretsen 2011)
  4. 4. norepinephrine / epinephrine
    NE 0.05–0.5 mcg/kg/min; epi 0.05–1 mcg/kg/min, titrate MAP ≥65 • IV • continuous
    trigger: Persistent shock
    Pressor support while HIET takes effect (critical-care tox review 2024)
  5. 5. glucagon
    3–10 mg IV bolus (peds 50 mcg/kg) then 3–5 mg/h • IV • bolus then infusion
    trigger: Refractory bradycardia/hypotension
    cAMP inotrope adjunct; pretreat antiemetic (AACT/ACMT 2023)
  6. 6. magnesium sulfate
    2 g IV over 1–2 min then infusion • IV • bolus then infusion
    trigger: Sotalol QT prolongation / torsades
    First-line for sotalol TdP (Kerns 2007)
  7. 7. sodium bicarbonate
    1–2 mEq/kg IV bolus, repeat to QRS narrowing • IV • repeat PRN
    trigger: Propranolol wide QRS (>120 ms)
    Reverses Na-channel membrane-stabilizing effect (Kerns 2007)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Reported / suspected beta-blocker ingestion or polypharmacy overdose (AACT/ACMT 2023); Bradycardia + hypotension without obvious cardiac cause (critical-care tox review 2024); Hypoglycemia with bradycardia/hypotension — BB pattern (Engebretsen 2011).

Objective

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

Assessment

**Beta-blocker overdose** (tox.beta-blocker-overdose.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Beta-blocker overdose — stepwise resuscitation ladder (fluids/atropine → HIET → vasopressors → glucagon → lipid emulsion → mechanical support)** — step "Step 1 — Crystalloid + atropine + decontamination".
1. normal saline (isotonic crystalloid) 10–20 mL/kg IV bolus (cautious — repeat to perfusion, avoid pulmonary edema in BB-induced cardiogenic shock) IV bolus, reassess (crystalloid, first line) — First-line volume support; limited efficacy in pump failure — escalate early rather than over-resuscitate (AACT/ACMT 2023)
2. atropine 0.5–1 mg IV (peds 0.02 mg/kg, min 0.1 mg) q3–5 min, max 3 mg IV q3–5 min PRN (antimuscarinic, first line) — Temporizing for vagally-mediated bradycardia; frequently inadequate alone in significant BB poisoning — do not delay HIET/pressors (critical-care tox review 2024)
3. activated charcoal 1 g/kg PO/NG (max 50 g) PO/NG single dose (GI_decontaminant, add on) — Only if early and airway protected — caution with declining mental status (lipophilic propranolol) (AACT/ACMT 2023)
4. whole-bowel irrigation (polyethylene glycol) PEG-ELS 1–2 L/h (peds 25 mL/kg/h) until rectal effluent clear PO/NG continuous (GI_decontamination_procedure, add on) — Sustained/extended-release BB — reduces ongoing absorption; protect airway and exclude ileus first (AACT/ACMT 2023)

Setting playbook (ed) — Resuscitate bradycardia/hypotension, confirm the BB toxidrome (HYPOglycemia distinguishes from CCB), start the ladder early (do not over-rely on atropine), and escalate to ICU (AACT/ACMT 2023)
5. normal saline bolus 10–20 mL/kg IV (cautious, reassess) IV bolus — Hypotension (Volume support; limited in pump failure (AACT/ACMT 2023))
6. atropine 0.5–1 mg IV (peds 0.02 mg/kg) q3–5 min, max 3 mg IV q3–5 min PRN — Symptomatic bradycardia (Temporizing only — do not delay HIET (critical-care tox review 2024))
7. regular insulin (HIET) + D50 Insulin 1 U/kg IV bolus + D50 if glucose <250, then 0.5–1 U/kg/h titrated IV bolus then infusion — Shock refractory to fluids/atropine (Early inotrope of choice in toxin cardiogenic shock (Engebretsen 2011))
8. norepinephrine / epinephrine NE 0.05–0.5 mcg/kg/min; epi 0.05–1 mcg/kg/min, titrate MAP ≥65 IV continuous — Persistent shock (Pressor support while HIET takes effect (critical-care tox review 2024))
9. glucagon 3–10 mg IV bolus (peds 50 mcg/kg) then 3–5 mg/h IV bolus then infusion — Refractory bradycardia/hypotension (cAMP inotrope adjunct; pretreat antiemetic (AACT/ACMT 2023))
10. magnesium sulfate 2 g IV over 1–2 min then infusion IV bolus then infusion — Sotalol QT prolongation / torsades (First-line for sotalol TdP (Kerns 2007))
11. sodium bicarbonate 1–2 mEq/kg IV bolus, repeat to QRS narrowing IV repeat PRN — Propranolol wide QRS (>120 ms) (Reverses Na-channel membrane-stabilizing effect (Kerns 2007))

Non-pharmacologic actions:
- IV access ×2 + continuous cardiac monitor (critical-care tox review 2024)
- Activated charcoal 1 g/kg only if early + airway protected (AACT/ACMT 2023)
- Whole-bowel irrigation for sustained-release once airway secured (AACT/ACMT 2023)
- Early airway protection for propranolol CNS depression / seizure (Kerns 2007)
- Prepare transcutaneous pacing pads; alert ICU + ECMO/cardiology early (critical-care tox review 2024)

AVOID / contraindication checks:
- HIET requires mandatory dextrose co infusion and glucose/K monitoring to prevent iatrogenic hypoglycemia/hypokalemia (Engebretsen 2011)
- Do not over replace potassium during HIET — insulin driven intracellular shift not true depletion (AACT/ACMT 2023)
- Avoid activated charcoal with unprotected airway / declining mentation (lipophilic propranolol CNS toxicity) (AACT/ACMT 2023)
- Lipid emulsion is rescue only and may interfere with HIET lab assays / ECMO oxygenator — coordinate with poison center (critical care tox review 2024)
- Hemodialysis ineffective for lipophilic propranolol (high Vd / protein binding) — reserve for atenolol/sotalol (Kerns 2007)
- Transcutaneous/transvenous pacing capture often fails in severe BB toxicity — do not delay HIET/ECMO awaiting pacing (AACT/ACMT 2023)
- Avoid class Ia/Ic and additional QT prolonging agents in sotalol toxicity — use magnesium / isoproterenol / overdrive pacing (Kerns 2007)

Monitoring

Regimen monitoring:
- continuous telemetry + serial 12-lead ECG (QRS for propranolol, QT for sotalol) (AACT/ACMT 2023)
- point-of-care glucose q15–30 min during HIET initiation then q1h (Engebretsen 2011)
- potassium q1–2h during HIET (AACT/ACMT 2023)
- q1h vitals + MAP target ≥65 mmHg (critical-care tox review 2024)
- lactate clearance q2–4h as perfusion marker (critical-care tox review 2024)
- strict fluid balance / urine output during HIET (large dextrose volumes) (Engebretsen 2011)
- neuro checks for propranolol CNS toxicity / seizure (Kerns 2007)

Setting (ed) monitoring:
- HR + BP + rhythm continuous (AACT/ACMT 2023)
- Glucose q15–30 min once HIET started (Engebretsen 2011)
- K q1–2h on HIET (AACT/ACMT 2023)
- Serial ECG for QRS/QT (Kerns 2007)

Follow-up plan: 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)
- Close-out criterion: Safe-discharge criteria met + psych / prevention follow-up arranged

Monitoring phase: 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)

Disposition

Current setting: ed — Resuscitate bradycardia/hypotension, confirm the BB toxidrome (HYPOglycemia distinguishes from CCB), start the ladder early (do not over-rely on atropine), and escalate to ICU (AACT/ACMT 2023)

Disposition criteria:
- ICU: any instability, HIET/pressors, sustained-release, propranolol or sotalol ingestion (AACT/ACMT 2023)
- Monitored bed with prolonged observation: asymptomatic sustained-release pending peak window (AACT/ACMT 2023)
- Discharge candidacy only after ≥6 h asymptomatic immediate-release with normal ECG/glucose + psych clearance if intentional (critical-care tox review 2024)

Escalation triggers (move to higher acuity):
- Refractory to fluids/atropine → HIET + ICU (Engebretsen 2011)
- Cardiogenic shock / arrest → vasopressors + lipid emulsion (propranolol) + ECMO activation (critical-care tox review 2024)
- Sotalol torsades → magnesium + isoproterenol/overdrive pacing + ICU (Kerns 2007)
- Propranolol wide QRS / seizure → bicarbonate + airway + ICU (Kerns 2007)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Persistent shock despite crystalloid + atropine (AACT/ACMT 2023)
- [LIFE_THREATENING] Propranolol ingestion with QRS >120 ms, seizures, or coma (Kerns 2007)
- [LIFE_THREATENING] Sotalol ingestion with prolonged QT and/or torsades de pointes (Kerns 2007)

Citations

- 2023–2025 critical-care toxicology reviews on beta-blocker / CCB cardiotoxicity; Engebretsen high-dose insulin euglycemia (HIET) evidence; AACT/ACMT position statements on HIET and lipid emulsion; Kerns toxicology of beta-blocker poisoning [PMID:21391999](https://pubmed.ncbi.nlm.nih.gov/21391999/)
- Cited evidence (PMID 17265544) [PMID:17265544](https://pubmed.ncbi.nlm.nih.gov/17265544/)
- Cited evidence (PMID 26174336) [PMID:26174336](https://pubmed.ncbi.nlm.nih.gov/26174336/)
- Cited evidence (PMID 27749343) [PMID:27749343](https://pubmed.ncbi.nlm.nih.gov/27749343/)
- Cited evidence (PMID 24777177) [PMID:24777177](https://pubmed.ncbi.nlm.nih.gov/24777177/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2023–2025 critical-care toxicology reviews on beta-blocker / CCB cardiotoxicity; Engebretsen high-dose insulin euglycemia (HIET) evidence; AACT/ACMT position statements on HIET and lipid emulsion; Kerns toxicology of beta-blocker poisoning — PMID:21391999
  • Cited evidence (PMID 17265544) — PMID:17265544
  • Cited evidence (PMID 26174336) — PMID:26174336
  • Cited evidence (PMID 27749343) — PMID:27749343
  • Cited evidence (PMID 24777177) — PMID:24777177