ED Workup: CBC, BMP, LFT, Ca-Mag-Phos, Troponin, ECG.

Presentation not consistent with digoxin toxicity, clonidine toxicity, infectious bradycardia, increased ICP, inferior MI involving RCA,

ED interventions: Activated Charcoal, atropine, IVF, Calcium gluconate 3g (30-60mL of 10% soln), Glucagon 5 mg IV bolus over one minute.

Consults: Poison Control
Disposition: Admit to ICU

• PEARLS
• General Beta Blocker Toxicity
  • Overdose → beta-2 mediated Bradycardia followed by Hypotension and AMS
  • peak effect (in normal-release preparations) is in the 1 to 4 hour range
• Hallmark Findings: Bradycardia + Normoglycemia
• Tx: Reverse hypotension caused by negative inotropy and peripheral vasodilation
  • Calcium chloride or calcium gluconate
    • increases extracellular calcium → intracellular calcium flux and may be improve contraction.
  • Glucagon
    • bypasses the beta-receptors → activates adenyl cyclase → improved contraction
  • High-dose insulin (HDI)
    • bolus of 1 unit/kg of regular insulin followed by a drip of 1 – 10 units/kg/hr. Paired with infusion of dextrose to prevent hypoglycemia. Exact mechanism of action is not known
  • Atropine helps combat AV block by decreasing vagal tone but does not reverse global myocardial depression and is therefore ineffective

• General Calcium Channel Blocker Toxicity
• Hallmarks: Bradycardia + Hyperglycemia (Calcium channel blockers block insulin release and therefore have higher glucose)