Emergencies

β-Blocker / CCB Overdose

Bradycardia and shock that won't respond to atropine. Layer calcium, high-dose insulin, glucagon, and vasopressors, then rescue therapies.

Interactive pathway

Assess
Recognize toxicity
- Bradycardia, hypotension, AV block
- CCB: hyperglycemia (insulin release blocked); clear mentation until late
- BB: hypoglycemia possible; propranolol → seizures, wide QRS
Action
Initial management
- ABCs, IV access, fluids
- Activated charcoal if airway protected and early
- Whole bowel irrigation for sustained-release products
Atropine
1 mg IV
often ineffective
Medication
Calcium
- Repeat every 10–20 min × 3–4 doses or start infusion
Calcium chloride
1 g (10 mL of 10%) IV
central line preferred
Calcium gluconate
3 g (30 mL of 10%) IV
Medication
High-dose insulin euglycemia therapy
- Takes 15–60 min to work: start early
- Glucose every 15–30 min; K⁺ hourly
Insulin regular
1 U/kg IV bolus
then 1 U/kg/h; titrate up to 10 U/kg/h
Dextrose
25 g IV
if glucose < 250; then infusion to keep 100–250
Medication
Glucagon (especially β-blocker)
- Expect vomiting: protect the airway
Glucagon
3–5 mg (0.05 mg/kg) IV over 1–2 min
repeat up to 10 mg; then infuse the effective dose per hour
Medication
Vasopressors
Norepinephrine
titrate to MAP ≥ 65
Epinephrine
2–10 mcg/min and up
Decision
Refractory shock?

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