Guideline sources The following summarized guidelines for the evaluation and management of beta-blocker toxicity are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2020), the American Heart Association (AHA/HRS/ACC 2019), and the American Association of Poison Control Centers (AAPCC/AACT/ACMT 2005). 1 2 3 Guidelines 1. Diagnostic investigations Initial assessment: elicit history to determine the precise ingested dose of a -blocker, the presence of coingestants and comorbidities in patients without evidence of self-harm. B 2. Medical management Admission to emergency department: refer patients with stated or suspected self-harm or victims of a potentially malicious administration of -blocker to an emergency department immediately, guided by local poison center procedures, regardless of the dose reported. B Show 3 more https://web.pathway.md/diseases/recjHXvINa3LCqk5i 1/3 6/29/23, 3:17 AM Beta-blocker toxicity Pathway Gastric decontamination: Do not induce emesis in patients ingested a -blocker exceeding the referral dose. D Consider administering oral activated charcoal, if available and not contraindicated, but not delaying transportation. B Glucagon: As per AHA 2020 guidelines, consider administering IV glucagon in patients with -blocker overdose in refractory shock. C As per ACC 2019 guidelines, consider administering glucagon to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of -blocker overdose. C High-dose insulin: As per AHA 2020 guidelines, consider administering high-dose insulin with glucose in patients with -blocker overdose in refractory shock. C As per ACC 2019 guidelines, consider administering high-dose insulin to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of -blocker overdose. C Intravenous calcium: consider administering IV calcium in patients with -blocker overdose in refractory shock. C 3. Inpatient care Inpatient monitoring: Monitor asymptomatic patients referred to healthcare facilities for the following durations after ingestion: 6 hours for an immediate-release product other than sotalol 8 hours for a sustained-release product 12 hours for sotalol. B Do not obtain routine 24-hour inpatient monitoring in asymptomatic patients unintentionally ingested a sustained-release product. D 4. Therapeutic procedures Extracorporeal membrane oxygenation: consider performing ECMO in patients with -blocker overdose in shock refractory to pharmacological therapy. C 5. Follow-up and surveillance Outcome assessment: obtain follow-up calls depending on the specific circumstances to determine outcome at appropriate intervals for up to 12-24 hours based on the judgment of the https://web.pathway.md/diseases/recjHXvINa3LCqk5i 2/3 6/29/23, 3:17 AM Beta-blocker toxicity Pathway poison center staff. B Clinical findings Symptoms Medication history Seizure Beta-blockers Vital signs Neurological exam Bradycardia Altered mental status Hypotension Respiratory exam Cardiac exam Crackles Cardiogenic shock ECG findings Lab findings AV block Hyperkalemia serum glucose serum pH Imaging findings Pulmonary edema References 1. Paul M Wax, Andrew R Erdman, Peter A Chyka et al. beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol Phila). 2005;43 3 131 46. Open 2. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 3. Fred M Kusumoto, Mark H Schoenfeld, Coletta Barrett et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019 Aug 20;140 8):e382-e482. Open https://web.pathway.md/diseases/recjHXvINa3LCqk5i 3/3