absolutely massive) propranolol ingestion. To illustrate this last point, we had a 55-year old lady come through our department recently with a 4 gram (i.e.
Avoid amiodarone – It will only make things worse.Give adrenaline – 1mg every 3-5 minutes as per standard cardiac arrest algorithms.Intubate and hyperventilate (if you have not done so already).Push bicarb – Give boluses of IV sodium bicarbonate 1-2 mEq/kg every 1-2 minutes until return of perfusing rhythm.If you have not yet enlisted the advice and support of a clinical toxicologist in managing this patient, then get them on the phone now! (this is assuming that you have a spare person to talk to them… ideally get help before they arrest!) Call for help! – Toxicological arrest is approached differently to cardiac arrest from other causes.Conversely, cardioversion / defibrillation is unlikely to be successful in the poisoned heart. Start CPR – Good quality CPR may be life saving.pulseless VT) or progressive cardiogenic shock culminating in bradycardic PEA. Admit the patient to the intensive care unit for ongoing monitoring and supportive care.Ĭardiac arrest may occur in propranolol overdose due to sudden ventricular arrhythmias (i.e.Do not give pre-intubation due to risk of charcoal aspiration). As propranolol is rapidly absorbed, this treatment is most likely to be effective if given early, i.e < 1-2 hours post ingestion ( NB. This may reduce the dose of propranolol absorbed from the gut, limiting the duration and severity of toxicity. Once the airway is secure, place a nasogastric tube and give 50g (1g/kg) of activated charcoal.Paracetamol level, blood sugar and 12-lead ECG are recommended as initial screening tests in all patients with deliberate self-poisoning.Glucagon (once considered to be the “antidote” to beta-blocker poisoning) is no longer recommended as it is difficult to source in adequate quantities and offers no advantages over standard inotropes and chronotropes.This treatment appears to be very effective in massive propranolol overdose but takes time to work (30-45 minutes). If inotropes are required, consider early initiation of high-dose insulin euglycaemic therapy (as described in toxicology conundrum 028).Persistent bradycardia and hypotension is better treated with a titrated infusion of adrenaline or isoprenaline via a central venous catheter.Atropine (10-30 mcg/kg) can be used as a temporising measure for bradycardia.If this is unsuccessful in restoring BP, be prepared to rapidly escalate to more advanced circulatory support using inotropes and chronotropes. Treat hypotension with an initial crystalloid bolus (10-20 mL/kg).Management of Bradycardia and Hypotension Avoid Ia (procainamide) and Ic (flecainide) antiarrhythmics and amiodarone as they may worsen hypotension and conduction abnormalities.In established cardiotoxicity, the dose of sodium bicarbonate can be repeated every few minutes until the BP improves and QRS complexes begin to narrow.Lidocaine (1.5mg/kg) IV is a third-line agent (after bicarbonate and hyperventilation) once pH is > 7.5. If ventricular arrhythmias occur, the first step is to give moresodium bicarbonate.Hyperventilate to maintain a pH of 7.50 – 7.55.Administer IV sodium bicarbonate 100 mEq (1-2 mEq / kg).
AMPHETAMINE OVERDOSE SYMPTOMS SERIAL
Perform serial 12-lead ECGs to assess for sodium-channel blockade (QRS>100ms).Insert an arterial line for close haemodynamic monitoring.Treat seizures with IV benzodiazepines (e.g.Secure IV access, adminster high flow oxygen and attach monitoring equipment.This patient needs to be managed in a monitored area equipped for airway management and resuscitation.Propranolol overdose is managed primarily as a tricyclic antidepressant overdose (as early life-threats are due to its sodium-channel blocking effects) and secondarily as a beta-blocker overdose.
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