Management of Beta Blocker-Induced Cardiogenic Shock

Primary Treatment Recommendations

The American Heart Association recommends high-dose insulin with glucose supplementation as the drug of choice for beta blocker overdose with refractory hypotension (Class 1, Level B-NR) 1
High-dose insulin improves myocardial inotropy in cardiogenic shock from beta blocker poisoning and demonstrates favorable outcomes with lower rates of vasoconstrictive complications compared to vasopressor-only therapy 1
The ACC/AHA/HRS 2018 guidelines give glucagon a Class IIa recommendation (reasonable) with level of evidence C-LD for symptomatic bradycardia or hemodynamic compromise due to beta blocker overdose 2, 1
Glucagon increases contractility and improves hemodynamics by activating hepatic adenylate cyclase, bypassing the blocked beta-adrenergic receptors entirely 1, 3

Initial dose of glucagon: 3-10 mg IV administered over 3-5 minutes, followed by continuous infusion of 3-5 mg/hour due to glucagon's transient effects 2, 1, 3

Immediately initiate vasopressors for hypotension (Class 1, Level C-LD), as they are readily available and act quickly, with norepinephrine as the preferred first-line vasopressor agent 1, 4
If hypotension persists despite vasopressors, administer glucagon 3-10 mg IV bolus followed by 3-5 mg/hour infusion (Class IIa, Level C-LD) 2, 1, 3
For refractory cases not responding to glucagon, escalate to high-dose insulin therapy (Class 1, Level B-NR) 1, 3

Glucagon is especially valuable in patients already taking beta blockers therapeutically who develop CHF exacerbation, as conventional catecholamines will have reduced efficacy due to receptor blockade 3
Intravenous Lipid Emulsion (ILE) is not likely to be beneficial for life-threatening beta blocker poisoning (Class 3: No Benefit, Level C-LD) 1

Initiate vasopressors immediately (norepinephrine preferred), administer glucagon 3-10 mg IV bolus + start 3-5 mg/hour infusion, and if inadequate response within 10-20 minutes, escalate to high-dose insulin protocol 1, 2, 3
Prepare for mechanical circulatory support or VA-ECMO if refractory 1
Frequent blood pressure measurements and continuous cardiac monitoring, regular assessment of mental status and peripheral perfusion, glucose monitoring every 15 minutes initially if using high-dose insulin, and potassium monitoring with target levels of 2.5-2.8 mEq/L during insulin therapy 3, 5