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Management
The initial management of the critically ill patient who ingests β-adrenergic antagonists is similar to that of other acutely ill patients. It is important to have an organized approachto the care of these patients (Table 59-2). Airway and ventilation should be
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maintained with endotracheal intubation if necessary. Because laryngoscopy may induce a vagal response, it isreasonable to give atropine prior to intubation of the bradycardic patient. This is particularly true for children who are more susceptible to this complication. The initial treatment of bradycardia andhypotension consists of atropine and fluids. These measures will likely be insufficient in patients with severe toxicity, but may suffice in patients with mild poisoning or other etiologies.Gastrointestinal decontamination is warranted for all persons who have ingested significant amounts of a β-adrenergic antagonist. Induction of emesis is contraindicated because of the potential forcatastrophic deterioration of mental status and vital signs, and because vomiting increases vagal stimulation and can worsen bradycardia.152 Orogastric lavage is recommended for patients with significantsymptoms such as seizures, significant hypotension, or bradycardia, if the drug is still expected to be in the stomach. Orogastric lavage is also recommended for all patients who present shortly afteringestion of large (gram amount) ingestions of propranolol or one of the other more toxic β-adrenergic antagonists (acebutolol, betaxolol, metoprolol, oxprenolol, or sotalol). Because orogastric lavagecauses vagal stimulation and carries the risk of worsening bradycardia, it is reasonable to pretreat patients with
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standard doses of atropine. Activated charcoal alone is recommended forpatients with minor symptoms following an overdose with one of the more water-soluble β-adrenergic antagonists and who present more than 1 hour following ingestion. Whole-bowel irrigation with...