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).
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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