Cardiovascular Management

Medication Dosing

• The American College of Cardiology recommends initial dosing of medications for adults, including an initial dose of 3-10 mg IV bolus 1, maintenance infusion of 3-5 mg/hour 1, and dosing of 1-2 g IV calcium chloride (10%) every 10-20 minutes or infusion at 0.2-0.4 mL/kg/hour 1, 2
• Alternative dosing options include 3-6 g IV calcium gluconate (10%) every 10-20 minutes or infusion at 0.6-1.2 mL/kg/hour 1, 2, epinephrine dosing of 2-10 mcg/min IV or 0.1-0.5 mcg/kg/min IV titrated to effect 1, 2, and dopamine dosing of 5-20 mcg/kg/min IV, starting at 5 mcg/kg/min and increasing by 5 mcg/kg/min every 2 minutes 1, 2
• The American College of Cardiology also recommends dosing of 0.5-1 mg IV every 3-5 minutes to a maximum of 3 mg 1, 2

Advanced Therapies

• For refractory cases, consider VA-ECMO for life-threatening poisoning unresponsive to pharmacological therapy, as recommended by the American Heart Association 3
• Beta-blocker overdose is a life-threatening condition that requires prompt recognition and treatment, presenting with bradycardia, hypotension, and cardiogenic shock 3, 4
• The American Heart Association recommends high-dose insulin as the first-line antidote for beta-blocker overdose with refractory hypotension, with a Class 1, Level B-NR recommendation 5
• High-dose insulin therapy should be initiated with an initial bolus of 1 U/kg IV regular insulin, concurrent dextrose of 0.5 g/kg IV, and a maintenance infusion of 0.5-1 U/kg/hour, titrated to hemodynamic response, along with dextrose infusion of 0.5 g/kg/hour to maintain glucose levels between 100-250 mg/dL 5, 1, 3
• Glucagon is considered second-line after high-dose insulin, with a Class 2a, Level C-LD recommendation, but it commonly causes vomiting, which is a concern in patients with altered mental status 5, 6, 1, 4
• The American Heart Association specifically states that intravenous lipid emulsion therapy is "not likely to be beneficial for life-threatening β-blocker poisoning" (Class 3: No Benefit, Level C-LD) 5
• The recommended treatment approach includes initial stabilization with vasopressors, adding high-dose insulin therapy, considering glucagon if there is an inadequate response, and considering VA-ECMO for refractory cases 5, 3, 4, 6

Medication Guidelines

Monitoring and Management

• Very frequent glucose monitoring (every 15 minutes initially) and potassium monitoring are crucial during high-dose insulin therapy, with expected moderate hypokalemia 5, 3
• Central venous access for concentrated dextrose solutions and continuous cardiac monitoring are also essential 5, 3, 6
• Continuous cardiac monitoring, frequent assessment of mental status and peripheral perfusion, and regular monitoring of serum glucose, potassium, and calcium levels are essential for managing beta-blocker toxicity 6, 5
• End-organ perfusion, including urine output, mental status, and peripheral perfusion, should be closely monitored 5
• The American College of Cardiology recommends avoiding Class IA, Class IC, or Class III antiarrhythmics, as they may worsen cardiac toxicity 7
• Hemodialysis may be reasonable for life-threatening atenolol or sotalol poisoning 5
• VA-ECMO may be considered for life-threatening beta-blocker poisoning with cardiogenic shock refractory to pharmacological interventions 5, 3