Beta Blocker Toxicity and Safety

Presentation By:
Christopher Khemraj
Mohamed Mohamed
Project Distribution By:
Ebey P. Soman

BETA-BLOCKERS

References
 Marks, Jay, and Omudhome Ogbru. "Beta Blockers." MedicineNet. MedicineNet, n.d. Web. 12 Nov 2010.
<http://www.medicinenet.com/beta_blockers/article.htm>.
 "Beta-adrenergic Blocking Agents (Systemic)." Drugs.com. N.p., 20 OCT 2010. Web. 12 Nov 2010.
<http://www.drugs.com/mmx/metoprolol-succinate.html>.
 "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag. Wolters Kluwer Health, Inc.
. Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.
 "Medication Package Insert Information for: TENORMIN TABLET 50MG ." MEDSort. N.p., n.d. Web. 13 Nov 2010.
<http://drugs.medsort.com/Drugs/DrugPackageInsert.aspx?MedID=5811#tablist>.
 Propranolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous Substances Data Bank
(HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~AGpJcu:1>.
 "Beta Blockers - Top 10 toxicities." University of Conneticut . Web. 14 Nov 2010.
<http://www.uconnem.org/toxicologyweb/cardiovascular.jpg>.
 Atenolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous Substances Data Bank
(HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~SpU8BZ:1>.
 Heitz, Cory et al. "BETA BLOCKER OVERDOSE." Emergency Medicine Education Online. Center for Simulation
Technology and Academic Research, n.d. Web. 15 Nov 2010.
<http://www.emedu.org/simlibrary/UploadFolder/152.11.191.200_-
8589677563690905358Beta%20Blocker%20Overdose%20FINAL.pdf>.
 Sharma, Adhi. "Beta Blocker Toxicity." Emedicine from WebMD. WebMD, 03 NOV 2010. Web. 15 Nov 2010.
<http://emedicine.medscape.com/article/813342-overview>.
 Rahm, Stephen. "A 4 year Old who ingested a medication." Pediatric Case Studies for the Paramedic. American
Academic of Orthopaedic Surgeons, n.d. Web. 15 Nov 2010. <http://books.google.com/books?id=wO-
5_8KqO94C&lpg=PP1&pg=PA65#v=onepage&q&f=false>.

Quick Facts & Figures
 The 2007 Annual Report of  Of the fatalities reported to the
the American Association of AAPCC, 68% were associated
Poison Control Centers' (AAPCC) with individuals younger than 50
National Poison Data years. Forty-three percent of all
System reported 9291 fatalities reported to the AAPCC
single exposures to beta- in 2004 were associated with
blockers. children younger than 6 years.
 In 2007, the AAPCC reported 413  Propranolol is the most toxic
minor outcomes, 631 moderate beta-blocker because it is non-
outcomes, 61 major outcomes, selective and the most
and 3 fatalities for beta-blocker frequently used in suicide
exposure attempts worldwide.
 According to the 2004 AAPCC
toxic exposure review, 51% of all Source: Sharma, Adhi. "Beta Blocker Toxicity."
Emedicine from WebMD. WebMD, 03 NOV 2010. Web. 15
exposures and 47.6% of all Nov 2010.
overdose fatalities are in women <http://emedicine.medscape.com/article/813342-
overview>.

So what are Beta-Blockers?
 Beta blockers are known as beta-adrenergic blocking
agents and they block norepinephrine and epinephrine
from binding to receptors on nerve cells.
 When norepinephrine and epinephrine are blocked, this
reduces heart rate and lowers blood pressure by dilating
the blood vessels.
 Beta blockers work mainly by blocking Beta 1 (heart,
kidney, eyes) and Beta 2 receptors (lungs, liver, muscles
etc.).
 Beta 3 is mostly in Adiposities and is blocked by
nonselective beta blockers like propanolol
 There are tons of beta-blockers on the market and majority
of these drugs used to treat cardiovascular diseases and
glaucoma.
Source: Marks, Jay, and Omudhome Ogbru. "Beta Blockers." MedicineNet. MedicineNet, n.d. Web. 12 Nov 2010.
<http://www.medicinenet.com/beta_blockers/article.htm>.

Examples of Beta-Blockers (US)
 ACEBUTOLOL HYDROCHLORIDE  NEBIVOLOL
 ATENOLOL  OXPRENOLOL
 BETAXOLOL HYDROCHLORIDE  PENBUTOLOL SULFATE
 BISOPROLOL FUMARATE  PINDOLOL
 LABETALOLCARTEOLOL  PROPRANOLOL HYDROCHLORIDE
HYDROCHLORIDE  PROPRANOLOL HYDROCHLORIDE
INJECTION
 CARVEDILOL
 PROPRANOLOL HYDROCHLORIDE
 ESMOLOL HYDROCHLORIDE ORAL
 METOPROLOL  SOTALOL HYDROCHLORIDE
 METOPROLOL SUCCINATE ORAL  SOTALOL HYDROCHLORIDE
 METOPROLOL TARTRATE INJECTION INJECTION
 METOPROLOL TARTRATE ORAL  SOTALOL HYDROCHLORIDE ORAL
 NADOLOL  TIMOLOL MALEATE
 And many more exist, especially in
foreign markets

Source: "Beta-adrenergic Blocking Agents (Systemic)." Drugs.com. N.p., 20 OCT 2010. Web. 12 Nov
2010. <http://www.drugs.com/mmx/metoprolol-succinate.html>.

FDA Approved Indications
 Hypertension
 Pediatric hypertensive emergency
 Angina pectoris
 Cardiac arrhythmias/tachycardias
 MI
 CHF
 Pheochromocytoma
 Migraine prevention
 Hypertrophic subaortic stenosis
 Parkinsonian tremors
 Akathisia
 Bleeding in portal hypertension
 Atrial fibrillation
 Generalized anxiety disorder - Image Source: "Atenolol." 1aMeds. Web. 12 Nov
2010.
 Angina <http://www.1ameds.net/images/Atenolol.jpg>.
- Source: "Beta-Adrenergic Blocking Agents (Beta
 Thyrotoxicosis Blockers)." Facts and Comparisons 2010. n. pag.
 Fibromyalgia Wolters Kluwer Health, Inc. . Web. 12 Nov 2010.
<http://online.factsandcomparisons.com>.

How do they Work?
 Beta-adrenergic receptor blocking
agents compete with beta-adrenergic Above:
agonists for available beta receptor sites. Propranolol
 Propranolol, nadolol, timolol,
penbutolol, sotalol, and pindolol inhibit
both the beta 1 receptors and the beta
2receptors
 Metoprolol, acebutolol, bisoprolol,
esmolol, betaxolol, and atenolol are
more selective and inhibit beta -1
receptors (heart mostly)

Sources:
"Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and
Comparisons 2010. n. pag. Wolters Kluwer Health, Inc. . Web. 12 Nov
2010. <http://online.factsandcomparisons.com>.
"Atenolol Enantiomers Structural Formula." Wikipedia. Web. 12 Nov The 2
2010. <http://en.wikipedia.org/wiki/File:%28%C2%B1%29- Enantiomers
Atenolol_Enantiomers_Structural_Formulae.png>.
"Propranolol-2D-skeletal." Wikipedia. Web. 12 Nov 2010. of Atenolol
<http://en.wikipedia.org/wiki/File:Propranolol-2D-skeletal.png>.

Pharmacokinetics

Absorption Distribution
 Many beta blockers undergo  There is no simple
first pass metabolism upon relationship between dose
ingestion. given, drug plasma levels and
resulting therapeutic effect
 Only Pindolol and Sotalol since response to a beta
have no first pass effect blocker is individual based
 Having food in the stomach  Metoprolol and propranolol
decreases the absorption of can cross the blood brain
most beta blockers but barrier so they can produce
increases absorption of CNS effects in overdose.
metoprolol and propranolol. Atenolol does not cross BBB
Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and so less chances of CNS effects
Comparisons 2010. n. pag. Wolters Kluwer Health, Inc. . Web. 12 Nov 2010.

Pharmacokinetics (Con’t)

Metabolism Excretion
 Majority of beta blockers  Atenolol is 50% excreted
are metabolized in the liver unchanged in feces
 Sotalol is not metabolized  Majority of beta blockers are
but no data exists for the excreted through urine
extend of Sotalol  Sotalol is excreted
absorption unchanged into the urine
 As mentioned before,  Only 30-40% of Acebutolol is
excreted via renal tubules,
many beta blockers
the rest are excreted in the
undergo first pass
bile and other routes
metabolism Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and

Black Box Warnings (BBW)
For atenolol, metoprolol, For sotalol
nadolol, propranolol & timolol
 Abrupt stop in beta-  Do not substitute sotalol
blocker treatment may for sotalol AF
worsen angina, give  If patient has drug induced
myocardial infarction and arrhythmia then monitor
ventricular arrythmias patient for 3 days in health
care facility when starting
 If you are going to stop the sotalol or sotalol AF
treatment, then taper the regimen
dose  Cardiac resuscitation, ECG
 If angina occurs, restart monitoring and renal
beta blocker therapy monitoring is needed
Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and

Pregnancy & Beta Blockers
Mostly Category C but…
 Atenolol is category D
 Atenolol crosses the placental
barrier
 Studies show mothers taking
Atenolol from 2nd trimester had
babies that were too small
 No studies on 1st trimester or
any other fetal harm
 Only Category B drugs are
acebutolol, pindolol & sotalol
 Most beta blockers are excreted So talk to your doctor if you have a little one
in breast milk on the way before taking beta blockers!
Sources: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag. Wolters Kluwer Health, Inc. .
Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.
"Pregnancy & Chiropractic." chiropracticatthecomo. Web. 13 Nov 2010.
<http://www.chiropracticatthecomo.com/Images/Pregnant.jpg>.

Signs & Symptoms of Overdose
Cardiac Issues GI & Metabolic issues
 Asystole  Mesenteric ischemia
 esophageal spasms
 Tachycardia
 Hyperkalemia
 prolonged QT interval
 hypoglycemia
(sotalol)
 prolonged QRS complex
 ventricular dysrhythmias
 Hypotension
 hypertension (partial
agonists)
 Bradycardia
 AV block
Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag.
Wolters Kluwer Health, Inc. . Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.
"Prolonged QRS Complex." natomy & Physiology Note Summaries. Web. 13 Nov 2010.
<http://legacy.owensboro.kctcs.edu/gcaplan/anat2/notes/Image347.gif>.

Signs & Symptoms (Con’t)

CNS & Renal Issues Respiratory Issues
 Seizures  Apnea
 Coma or depressed level of  Cyanosis
consciousness  respiratory depression
 Renal failure  bronchospasm

Source: Atenolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous Substances Data
Bank (HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~SpU8BZ:1>.
"Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag. Wolters Kluwer Health,
Inc. . Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.

Exposure Risk Assessment

 Before treating patient , try to determine the
following:
 Patient's age
 Past medical history or condition
 Name of product and strength (if possible)
 Time of overdose
 How much or what amount they swallowed
 Was it prescribed to the patient?
Source: Atenolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous
Substances Data Bank (HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-
bin/sis/search/f?./temp/~SpU8BZ:1>.

Time Frame of Exposure

 Symptoms may occur
within 6 hours after
ingestion and can be as
quick as 20 minutes
 Onset of detectable
symptoms will depend
on formulations.
Extended release Source: Propranolol: Toxicology Data Network (TOXNET). National
Library of Medicine :Hazardous Substances Data Bank (HSDA), Web.
formulations will take 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-
bin/sis/search/f?./temp/~AGpJcu:1>.
longer to manifest "Beta Blockers - Top 10 toxicities." University of Conneticut . Web. 14
Nov 2010.
<http://www.uconnem.org/toxicologyweb/cardiovascular.jpg>.

Laboratory: What to monitor
 Vital Signs such Blood
Pressure
 Mental Status: is the
patient alert?
 ECG – Important to
monitor for bradycardia,
heart failure or other
severe cardiac issues
 Serum electrolyte levels
will be low
 Renal failure can occur
 Blood glucose levels will Source: Propranolol: Toxicology Data Network (TOXNET). National
drop significantly Library of Medicine :Hazardous Substances Data Bank (HSDA), Web. 15
Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-
"Vital Signs Cartoons and Comics." CartoonStock. Web. 14 Nov 2010.
<http://www.cartoonstock.com/lowres/hsc0561l.jpg>.

Suggested Treatments

1-2 Hours after Ingestion
 Perform assessment of
patient condition
 Determine serum glucose
levels – if hypoglycemic, treat
with IV glucagon
 Give activated charcoal to all
patients and gastric lavage if
still within the 2 hour period
 If is ER tablets they ingested,
then do whole bowel
irrigation with polyethylene
glycol (PEG)
Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag. Wolters Kluwer Health,
Inc. . Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.
"Polyethylene Glycol." Drugs.com. Web. 13 Nov 2010. <http://www.drugs.com/pro/polyethylene-glycol.html>.

Treatments (Con’t)
Supportive Treatments Benzodiazepines for Seizures!

 chest radiography to
prevent cardiac failure
 serum electrolytes to
prevent potassium buildup
 Treat seizures with
benzodiazepines, if they
are not working, then treat
with barbiturates
 Make sure activated
charcoal is given Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n.
pag. Wolters Kluwer Health, Inc. . Web. 12 Nov 2010.
"Valium." Imageshack. Web. 13 Nov 2010.
<http://img31.imageshack.us/img31/2313/valium2.jpg>.

Treatments (Con’t)

Last step therapy
 Atenolol, acebutolol, sotalol,
and nadolol are the only beta
blockers that can be removed
by hemodialysis
 Treat bronchospasm with
beta agonists like albuterol
 In patients who are still not
responding to treatments
Source: "Beta-Adrenergic Blocking Agents (Beta
mentioned above, Blockers)." Facts and Comparisons 2010. n. pag. Wolters
Kluwer Health, Inc. . Web. 12 Nov 2010.
epinephrine (parenteral) may <http://online.factsandcomparisons.com>.
"Epinephrine." MaineVille. Web. 13 Nov 2010.
be needed <http://bdnimages.sprintout.com/uploads/large/127691247
3_8d68.jpg>.

Other Treatment Options
 Catecholamine agents –  Atropine – Most commonly
Epinephrine is most used alternative agent but
commonly used. However least effective. If patient does
isoproterenol and dopamine not respond to a 1mg dose of
can be used as well atropine, you verify beta
 Phosphodiesterase inhibitors - blocker toxicity (diagnosis
Milrinone, aminophylline and tool)
theophylline. Amrinone has  Pacemakers – Control cardiac
been shown to be good in pace in severe beta blocker
dog trials induced bradycardia
 Insulin – High doses  intra-aortic balloon pump – to
 Lipid Emulsion – IV, for restore perfusion and blood
propanolol overdose flow

Source: "Beta-Adrenergic Blocking Agents (Beta Blockers)." Facts and Comparisons 2010. n. pag. Wolters Kluwer Health, Inc. .
Web. 12 Nov 2010. <http://online.factsandcomparisons.com>.
Atenolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous Substances Data Bank (HSDA), Web.
15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~SpU8BZ:1>.

Treatment Dosages
 IV fluids 500 mL boluses up  If patient has QRS
to 2L to raise blood widening and ventricular
pressure if the patient is dysrhythmias, then treat
hypotensive with IV sodium bicarbonate
 1 to 2 mg lorazepam IV or 1 to 2 mEq/kg IV bolus
another benzodiazepine starting dose, titrate to
for seizures blood pH 7.45 to 7.55
 Propofol can be used along  Use lidocaine if sodium
with the lorazepam bicarb is not working
 Liquid Activated Charcoal:
1 g/kg PO up to 50-100
Source: Propranolol: Toxicology Data Network (TOXNET).
National Library of Medicine :Hazardous Substances Data Bank grams. For children up to
(HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-
15-30 grams
Sharma, Adhi. "Beta Blocker Toxicity." Emedicine from WebMD.
WebMD, 03 NOV 2010. Web. 15 Nov 2010.
<http://emedicine.medscape.com/article/813342-overview>.

Treatment Dosages (Con’t)
 Glucagon: Initial dosing is 5 to 15 mg
slow IV push with an infusion rate of
5 to 15 mg/hour.
 Phosphodiesterase inhibitor
(Inamrinone) - 1 mg/kg bolus then 3
to 6 mcg/kg/minute
 Calcium for beta blocker
(propranolol or atenolol) &
verapamil overdose - calcium
chloride 0.2 mL/kg or calcium
gluconate 0.6 mL/kg intravenously
 Dextrose bolus is another option.
Give to patient with blood glucose
of less than 250 mg/dL
- Adults: 25 to 50 mL dextrose 50%
- Children: 0.25 g/kg dextrose 25%
Source: Propranolol: Toxicology Data Network (TOXNET). National Library of Medicine :Hazardous
Substances Data Bank (HSDA), Web. 15 Nov. 2010. <http://toxnet.nlm.nih.gov/cgi-
"Dextrose." Vetone Pharmaceuticals . Web. 15 Nov 2010.
<http://www.vetone.net/images/pharmaceuticals/dextrose.jpg>.

Case Study 1
 Chief Complaint: “weak and tired”
 Patient is a 65 year old previously healthy Caucasian male, who came to
the ED today because he feels “weak all over”. Symptoms began 2 days
ago.
 Vital Signs: Heart rate 49, Blood Pressure 90/60, Respiratory Rate 12,
Pulse Oximetry 95% on room air, Temperature 96.9 degrees Fahrenheit
 Past Medical History: He has had two previous myocardial infarctions
(with a stent placed in his right coronary artery 2 years ago), congestive
heart failure with an ejection fraction of 40%, hypertension,
hyperlipidemia, diabetes mellitus type II, osteoarthritis, depression.
 Medications and Allergies: Only provide medication list if specifically
requested. Medications include aspirin, glipizide, furosemide,
metoprolol, clopidogrel, simvastatin, sertraline. Allergy to penicillin
(rash)
 Family and Social History: 40 pack-year history of smoking, occasional
alcohol use, denies illicit drug use. His mother died of a stroke at 82.
Source: Heitz, Cory. "BETA BLOCKER OVERDOSE." Emergency Medicine Education Online. Center for Simulation Technology
and Academic Research, n.d. Web. 15 Nov 2010. <http://www.emedu.org/simlibrary/UploadFolder/152.11.191.200_-

Cast Study 1 (Con’t)
 History given by patient: The patient reports that
symptoms began 2 days ago and have worsened.
 He feels dizzy and as if he’s going to pass out. He has had
no syncope. The dizziness is worse when he goes from a
sitting to standing position.
 Associated symptoms: The patient has intermittent chest
pains, which are described as sharp, fleeting, substernal,
and without radiation. He has no chest pain currently. He
has had mild dyspnea on exertion, a persistent dry cough,
and mild nausea. He denies vomiting, diaphoresis, and
hemoptysis. He has had a decreased appetite for one week.
He has had no recent surgery, and no history of cancer,
deep venous thrombosis, or pulmonary embolism. He
denies headache, neck pain, visual changes, abdominal
pain, fevers, rashes, or change in his bowel movements.

Case Study 1 (Con’t)

Initial Exam:
 Patient is a healthy appearing male. Patient is
awake, alert, and oriented. Comfortable without
distress. Appears slightly fatigued.
 Cardiovascular: Bradycardia with regular
rhythm.
 Lungs: Scattered rhonchi and end-expiratory
wheezes bilaterally, with no rales.
 All other physical examination results were
normal however the patient got worse during
the physical exam and condition deteriorated


 Lab Results:
Sodium: 144, Chloride: 98, BUN: 36, Potassium
4.5, Bicarb: 18, Creatinine 1.7, glucose 138
Urinalysis: Normal
INR: 1.0
Plateletes 383, WBC 8.4, Hemoglobin 11.1,
Hematocrit 34.0



ECG Shows Bradycardia


 IV fluids can be administered in response to his
worsening hypotension, but IV fluid alone will
not correct his low blood pressure.
 None of the lab results are helpful in identifying
beta blocker toxicity
 Atropine was given, but did not resolve the
patient’s bradycardia due to severe toxicity
 Physician suspected beta blocker toxicity so
administered glucagon which brought BP and
heart rate back to normal – without continuous
glucagon infusion, the BP and heart rate will
began to fail again


 After multiple doses of glucagon failed to
maintain the patient’s vital signs,
vasopressors were initiated.
 Dopamine or norephinephrine was okay to
use
 Glucagon infusion helped resolve bradycardia
 The patient was stabilized and given under
the care of a cardiologist.
Source: Heitz, Cory, et al. "BETA BLOCKER OVERDOSE." Emergency Medicine Education Online. Center for Simulation
Technology and Academic Research, n.d. Web. 15 Nov 2010.
<http://www.emedu.org/simlibrary/UploadFolder/152.11.191.200_-

Case Study 2
 EMS was called after a 4
year old female child was
found unconscious by her
mother
 Child’s mother says the
child accidently ingested
her husband’s blood
pressure medication and
she does not know how
many the child took
Source: Rahm, Stephen. "A 4 year Old who ingested a
 EMS identified the medication." Pediatric Case Studies for the Paramedic.
medication as Sectral SR American Academic of Orthopaedic Surgeons, n.d. Web. 15
Nov 2010. <http://books.google.com/books?id=wO-
which is a extended release 5_8KqO94C&lpg=PP1&pg=PA65#v=onepage&q&f=false>.
beta blocker "BabyTemperament." BabySleepSite. Web. 15 Nov 2010.
<http://www.babysleepsite.com/wp-
content/uploads/2009/06/BabyTemperament.jpg>.


Initial Assessment:
 Child is 35 pounds or 16kg
 The Child is unconscious and unresponsive
 Rapid shallow respiratory rate
 Slow and weak pulse
 Skin is cool and cyanosis is noted
 Capillary refill time was 3 seconds
 Bilateral wheezing is heard in the lungs
 No trauma or injury or bleeding found
Source: Rahm, Stephen. "A 4 year Old who ingested a medication." Pediatric Case Studies for the Paramedic. American Academic of
Orthopaedic Surgeons, n.d. Web. 15 Nov 2010. <http://books.google.com/books?id=wO-


Assessment Values:
 Blood glucose reading says her glucose level is
40mg/dl
 Blood Pressure: 70/40 mm Hg
 Pulse: 66 beats/min
 Respiratory Rate: 48 breaths/min

Child’s ECG
reading shows
bradycardia

Source: Rahm, Stephen. "A 4 year Old who ingested a medication." Pediatric Case Studies for the Paramedic.
American Academic of Orthopaedic Surgeons, n.d. Web. 15 Nov 2010. <http://books.google.com/books?id=wO-
"bradycardiac." Emedicine. Web. 15 Nov 2010.
<http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-812410-813342-1371539.jpg>.


 Opened the child’s airway  Glucagon 0.05-0.1 mg/kg
and intubated the child IV up to 1mg dose. 1mg
 Ventilate with 100% dose is repeated every 20
oxygen since RR is too low minutes to raise BP and
heart rate
 Agonize beta 2 receptor
sites via nebulizer solution  Monitored child to make
of albuterol – this will sure child was responsive
cause broncodilation to the glucagon.
 Albuterol dose was 10mg
(2ml) diluted in 3ml of
normal saline Source: Rahm, Stephen. "A 4 year Old who ingested a medication."
Pediatric Case Studies for the Paramedic. American Academic of
Orthopaedic Surgeons, n.d. Web. 15 Nov 2010.
<http://books.google.com/books?id=wO-

Case Study 3
 39-year-old man was found
unresponsive with empty
bottle of atenolol, and
some empty beer bottles
 Patient’s color was pale
and dusky
 EMS personnel initiated an
intravenous line and
administered 2 mg of
naloxone, 100 mg of Source: Slater, T. (2001). A 39-year-old man with an overdose
thiamine, and one ampule of beta-blockers. Journal Of Emergency Nursing: JEN: Official
of d-glucose (D50W) Publication Of The Emergency Department Nurses Association,
27(4), 323-326. Retrieved from MEDLINE database.
intravenously without Image Source: "Beta Blocker Overdose." Buzzle. Web. 15 Nov
2010. <http://www.buzzle.com/img/articleImages/438293-
effect 2623-34.jpg>.


Assessment:
 respiratory rate was only 8 breaths per
minute
 Pulse: 20 beats per minute
 Blood pressure: 74 mm Hg systolic
 Glasgow Coma Score was 7
 EKG showed underlying rhythm of sinus
arrest
Source: Slater, T. (2001). A 39-year-old man with an overdose of beta-blockers. Journal Of
Emergency Nursing: JEN: Official Publication Of The Emergency Department Nurses
Association, 27(4), 323-326. Retrieved from MEDLINE database.


 Patient put on  50g of activated
ventilator with 100% charcoal were
oxygen 14 breaths per administered via the
minute nasogastric tube
 One mg of IV atropine  Gastric lavage showed
was administered no pill fragments
without effect  Poison control center
 Patient put on external was contacted for
cardiac pacing of 70 further instructions
beats per minute


 Poison control advised 12 mg of glucagon was
given by IV bolus which raised BP to 80 mm Hg
but heart rate was still low at 30 beats/min
 3 gm of calcium chloride were administered via Iv
boluses
 An isoproterenol infusion was initiated at 5 μg
per minute
 Patient’s BP and heart rate began to go down
more, Poison Control was contact and told
hospital to discontinue Isoproterenol infusion


After initial treatment After lab work
 Since the patient was getting  Dopamine infusion was titrated up
to 20 μg/kg/minute
worse, a complete blood and
toxicology workup was  simultaneous infusion of
norepinephrine was added to try
ordered. to keep the patient’s systolic blood
 Everything was negative pressure greater than 90mm Hg
except for exception of a  A glucagon infusion was also
added at a rate of 10 mg/h. The
blood glucose level of 211 patient’s blood sugar level was
mg/dL and a blood alcohol checked every 4 hours
level of 318 mg/dL.  insulin was administered as
needed to treat the hyperglycemia
 Metabolic acidosis was caused by the glucagon.
discovered during the blood Source: Slater, T. (2001). A 39-year-old man with an overdose of
test as well beta-blockers. Journal Of Emergency Nursing: JEN: Official
Publication Of The Emergency Department Nurses Association, 27(4),
323-326. Retrieved from MEDLINE database.


 Investigation revealed the
patient ingested 1500 to 2000
mg of sustained-release atenolol
 Supportive care with continuous
infusions of dopamine,
norepinephrine, and glucagon,
along with cardiac pacing,
sustained the patient until the
effects of the atenolol subsided.
Source: Slater, T. (2001). A 39-year-old man with an overdose
 Approximately 26 hours after his of beta-blockers. Journal Of Emergency Nursing: JEN: Official
Publication Of The Emergency Department Nurses Association,
overdose, this patient’s blood 27(4), 323-326. Retrieved from MEDLINE database.
"Discharge From Hospital." Imagine.com. Web. 15 Nov 2010.
pressure and heart rate <http://images.inmagine.com/img/hana/hana023/hana023175
stabilized and he was released .jpg>.

Case Study 4

 16-year-old female
presented to the ED
approximately 1.5 h after
ingesting 6.0 g of
acebutolol (brand name
Sectral) in a suicide
attempt
 Patient was sleepy with
“shallow respirations”
and was complaining of Source: Love, J. (2000). Acebutolol overdose resulting in
fatalities. The Journal Of Emergency Medicine, 18(3), 341-
nausea. 344. Retrieved from MEDLINE database.
"Coma Picture." Getty Images. Web. 15 Nov 2010.
 She had pale and cool <http://images.mirror.co.uk/upl/m4/nov2009/9/3/coma-

skin with low pulse pic-getty-51293773.jpg>.


Assessment Values Treatment
 No cyanosis and the lungs  Dopamine was begun at 5
were clear mg/kg/min and titrated up
 Heart rate was 70 beats per to 30 mg/kg/min with no
minute effect
 Blood pressure was 114/87  glucagon (two 10-mg
mmHg boluses), isoproterenol
 Within 10 min of arrival to ED, (titrated to 9.0 mg/min),
blood pressure dropped to and calcium chloride (10
55/45 mmHg while the pulse mL of a 10% solution) were
remained 70 bpm added without success
Source: Source: Love, J. (2000). Acebutolol overdose resulting in fatalities. The Journal Of
Emergency Medicine, 18(3), 341-344. Retrieved from MEDLINE database.


 Initial ECG showed PR =  Whenever ventricular
0.200 seconds, QRS = tachycardia occurred due
0.167 seconds, QTc = to QRS waves widening,
0.574 seconds with 70 defibrillation and
bpm for heart rate lidocaine was used to
 1 Hour later, ECG treat it with no effect
showed heart rates at  The patient had one
120 bpm with no P seizure during this time
waves. to defibrillations but not
 QRS waves widened to reoccurring seizures
0.200 seconds with
bizarre variability Source: Source: Love, J. (2000). Acebutolol overdose
resulting in fatalities. The Journal Of Emergency
Medicine, 18(3), 341-344. Retrieved from MEDLINE
database.


 Since the patient was not responding,
epinephrine was given - 9 boluses of 1.0 mg
followed by a infusion titrated to 25 mg/min
 Sodium bicarbonate given - 3 boluses at 1
meq/kg)
 Charcoal was recommended by the Poison
Control Center but never given
 Suddenly the patient with into bradycardia – she
did not respond to atropine 3.0 mg and external
cardiac pacing
 She was pronounced dead in the ED within 4 h of
her ingestion. Source: Source: Love, J. (2000). Acebutolol overdose resulting in fatalities. The
Journal Of Emergency Medicine, 18(3), 341-344. Retrieved from MEDLINE database.


What went wrong? So what does that all mean?
 The patient did not respond  Acetbutolol blocked beta
to a number of therapies receptors while blocking the
sodium and potassium channels in
 Acebutolol is a partial agonist the heart leading to ventricular
and membrane-stabilizing dysrhythmias being developed
activity  Due to significant ion imbalances
 This agent blocked sodium in the heart, this is a complex
channels which prolonged PR tachycardia which lead to
ventricular fibrillation – so the
and QRS intervals patient crashed.
 In addition to this, Acebutolol  Acebutolol is one of the most toxic
blocks potassium channels so beta blockers when taken in an
ventricular repolarization overdose and has highest fatality
time increases in beta blocker overdoses
Source: Source: Love, J. (2000). Acebutolol overdose resulting in fatalities. The Journal Of
Emergency Medicine, 18(3), 341-344. Retrieved from MEDLINE database.

Summary
 Propranolol is the most common beta-blocker involved in severe beta-blocker
poisoning. It is nonselective and can lead to CNS depression, seizures, and
prolongation of the QRS complex.
 Beta blocker toxicity is notably distinguished by bradycardia, low respiratory
rate and hypoglycemia
 Seizures and other CNS effects can occur with beta blockers that can cross the
blood brain barrier (more rarely with the other beta blockers)
 Overdoses of beta blockers with a combination of other drugs can have wide
ranging systemic effects
 If within a short time after ingestion, give activated charcoal
 Treat with glucagon to raise blood glucose levels
 Widely used treatment is currently Atropine though it is considered less effective
 Treat bronchospasm with beta agonists like Albuterol
 Treat Seizures with Benzodiazepines like Valium
 If the patient is still unresponsive or the condition is still deteriorating, treat with
epinephrine

Source: "Infant Feeding Myths." Mohav
County WIC. Web. 15 Nov 2010.
<http://legacy.co.mohave.az.us/WIC/image
s/theEnd.gif>.

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