eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Beta-blocker: Follow-up

Author: Adhi Sharma, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Chairman, Department of Emergency Medicine, Good Samaritan Hospital Medical Center; Medical Toxicology Consultant, New York City Department of Health and Poison Control Center
Coauthor(s): Lemeneh Tefera, MD, FAAEM, Attending Physician, Department of Emergency Medicine, Beth Israel Medical Center; Aman Aminzay, MD, Resident, Department of Emergency Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Apr 21, 2009

Follow-up

Further Inpatient Care

  • Noninvasive monitoring techniques
    • Simple methods of monitoring include repeat physical examinations, serial electrocardiograms, and continuous measurement of urinary output with a Foley catheter.
    • End points of therapy may include a heart rate more than 60 beats per minute, blood pressure of greater than 90 mm Hg systolic, and evidence of good organ perfusion (improved mentation or urine output).
  • Invasive monitoring techniques: The best monitoring methods for patients with severe toxicity are early insertion of an arterial blood pressure catheter and central venous pressure readings.

Further Outpatient Care

  • Patients who initially present without symptoms and remain asymptomatic can be safely discharged after an observation period of 6 hours. Increased caution is necessary if sustained-release products are ingested or child poisoning is involved. In these cases, admission to the hospital for 24 hours is recommended.
  • To avoid recurrent complications, adjust dosages or change medications for patients who have experienced adverse drug reactions due to combination therapy with calcium channel blockers or impaired metabolism caused by renal or hepatic dysfunction. These changes should be made in concert with the patient's primary care physician. If there is any suspicion of suicidality, and the patient is medically clear of any toxic overdose, the disposition planning should be made in concert with the consulting psychiatrist.

Transfer

  • Because of the potential for rapid deterioration, only asymptomatic patients who have been observed for a period of 6 hours should be considered stable for transfer.
  • If intensive care monitoring or therapy is not available, transfer the unstable patient to the closest facility with the necessary capabilities for care, including a medical toxicologist.

Prognosis

  • The prognosis mainly depends on the initial response to therapy 6-12 hours postingestion because drug levels are likely to have peaked at this time.
  • Underlying cardiac or pulmonary disease places the patient at increased risk for poor outcome.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize beta-blocker toxicity as a cause of bradycardia and hypotension when a history of intentional overdose is lacking
  • Failure to adequately monitor a patient on multiple cardiac vasopressors
  • Medically clearing a patient with beta-blocker toxicity before a 6-hour observation period
  • Failure to consult a psychiatrist for the evaluation of a patient who reports self-harm or where self-harm is suspected
  • Failure to administer large enough doses of antidotes, including catecholamines, glucagon, calcium, and potentially insulin

Special Concerns

Intravenous fat emulsion (IFE) has traditionally been used as a component of parenteral nutrition therapy. However, in the past decade, IFE has been demonstrated to reduce the mortality of local anesthetic toxicity in animal models as well as in case reports.3,4,5,6,7 It has been postulated that the IFE provides a "lipid sink" for fat-soluble drugs, removing them from the target organs. Animal models have shown improved mortality for both verapamil and propanolol toxicity.8,9 Though still in its infancy, IFE therapy may prove to be a useful treatment adjunct when used specifically for propanolol toxicity. Any consideration of its use is only recommended in consultation with a toxicologist familiar with the administration of IFE as an antidote.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Lada Kokan, MD.



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References
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Further Reading

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Keywords

beta-blocker toxicity, beta-blocker poisoning, beta-blocker overdose, beta-adrenergic antagonist overdose, beta-adrenergic antagonist toxicity, hypertension, postmyocardial infarction, migraine headaches, essential tremors, thyrotoxicosis, glaucoma, anxiety, propranolol, nadolol, timolol, pindolol, acebutolol, labetalol, sotalol, oxprenolol, practolol, esmolol, alprenolol, metoprolol, quinidinelike effects, Vaughan-Williams class I antiarrhythmic effects, QT interval prolongation, prolonged QT interval, multifocal premature ventricular contractions, PVCs, bigeminy, ventricular tachycardia, ventricular fibrillation, torsade de pointes, seizures, hypoglycemia

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Contributor Information and Disclosures

Author

Adhi Sharma, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Chairman, Department of Emergency Medicine, Good Samaritan Hospital Medical Center; Medical Toxicology Consultant, New York City Department of Health and Poison Control Center
Adhi Sharma, MD is a member of the following medical societies: American College of Clinical Toxicologists, American College of Emergency Physicians, and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

Lemeneh Tefera, MD, FAAEM, Attending Physician, Department of Emergency Medicine, Beth Israel Medical Center
Lemeneh Tefera, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Aman Aminzay, MD, Resident, Department of Emergency Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine
Aman Aminzay, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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