BETA BLOCKER TOXICITY MARC RICHARDS, AM REPORT, 5.11.10 OBJECTIVES • • • • • Review of Beta receptors Epidemiology Toxicology Clinical S/Sx/WU Treatment BETA RECEPTORS • B1: • Heart Muscle • inc. HR, contractility, AV conduction • B2: • Smooth Muscle (lungs, peripheral vasculature), Heart • vasodilation, bronchodilation • B3: • Adipose Tissue, Heart • cat. Thermogenesis?, dec. contractility? EPIDEMIOLOGY • 2006: • 9041 BB exposures reported to poison centers • 613 moderate-major adverse outcomes • 4 deaths • Often associated with polyingestion • DDX: CaChB, Digoxin, Clonidine, Cholinergics PATHOPHYSIOLOGY • Direct Beta Blockade • All BBs • Membrane Stabilizing Activity (MSA): • Propanolol, Acebutolol • Fast Na Channel Inhibition (Heart) wide QRS • Lipophilicity: • Propanolol • Cross BBB into CNS sz, delirium • Intrinsic Sympathomimetic Activity (ISA): • Partial B agonist activity less pronounced Sx BETA BLOCKER PROPERTIES Agent Acebutolol Atenolol Betaxolol Bisoprolol Carteolol Carvedilol Esmolol Labetalol Metoprolol Nadolol Oxprenolol Penbutolol Pindolol Propranolol Sotalol Timolol Adrenergic Receptor Blocking Activity ß1 ß1 ß1 ß1 ß1, ß2 1, ß1, ß2 ß1 1, ß1, ß2 ß1 ß1, ß2 ß1, ß2 ß1, ß2 ß1, ß2 ß1, ß2 ß1, ß2 ß1, ß2 Intrinsic Sympathomim Lipid Solubility etic Activity Low Low Low Low Low High Low Moderate Moderate Low High High Moderate High Low Low to moderate Yes No No No Yes No No Yes No No Yes Yes Yes No No No Sodium Channel Blocking Yes No Yes No No No No No No No Yes No No Yes No No Shepherd 2006 PROPANOLOL: • • • • • • • Nonselective beta blocker High MSA Lipophilic Rec. Dose in Thyroid Storm: 1-3mg IVP x1 Rec. Dose for Tachyarrythmia: 1-3mg IVP, MR x1 Half Life: 3-6hr, Duration 6-12hr Metabolism: Liver CLINICAL MANIFESTATIONS • • • • • • • • Sx within 6 hours of Ingestion Hypotension Bradycardia SHOCK Arrythmias Neuro: sz, delirium, coma Bronchospasm Hypoglycemia WORKUP: • Get good ingestion history • H&P • LABS: • • • • BB screen/levels Glucose Chemistries Other ingestion labs (APAP, ASA, etc) • STUDIES: • EKG • CXR TREATMENT: THE BASICS 1. 2. 3. 4. 5. ABCs!!!! Hypotension IVF, Pressors (more on this in a minute) Bradycardia Atropine 0.5-1mg Q3-5min Hypoglycemia D50 Seizures Benzos TREATMENT: BEYOND THE BASICS GLUCAGON • Activates adenylyl cyclase increased CAMP increased Ca available for muscle contraction • 5mg IV x1, MR x1 to assess for VS improvement • If successful, start a 2-5mg/hr gtt • SE: Vomiting • NO GOOD DATA IN PEOPLE (just some in animals) CALCIUM • CaCl 1g IVP (max: 3g) OR CaGlc 1g IV (max: 3g) • Increase inotropy • DATA: Case reports only TREATMENT: BEYOND THE BASICS II PRESSORS: • Stimulate receptors to increase CAMP inotropy • No good data, but recommended if necessary to maintain MAPs • Competitive Inhibition PDE INHIBITORS: • Milrinone, Inamrinone • Inhibit CAMP breakdown by PDE • Data: isolated case reports only (although our patient did well!!) • SE: GI, Hypotension, Arrythmias TREATMENT: BEYOND THE BASICS III HDIDK (high dose insulin w/ dextrose and K): • Last line of defense at this point as data is preliminary (some good data with CaChB overdose) • BBs inhibit pancreatic insulin release less glucose available in muscle cells for energy extraction • Correct hypoglycemia first!!! MISCELLANEOUS: Charcoal Bicarb, Mg IABP CVVHD REFERENCES: • UpToDate- Beta Blocker Poisoning, Thyroid Storm, Beta Blockers in Management of Hyperthyroidism • Shepherd et, al. “Treatment of poisoning caused by Badrenergic and calcium-channel blockers”. Am J Health Syst. Pharm- Vol 63. Oct 1 2006. • Bailey B. Glucagon in beta blocker and calcium channel blocker overdoses: a systematic review. Journal of Clinical Toxicology. 2003; 41 (5); 595-602. • Leppikangas, et al. Levosimendan as a rescue drug in experimental propanolol-induced myocardial depression: a randomized study. Ann Emerg Med. 2009 Dec; 54(6): 811-817. MAZEL TOV!!!!!