2/19/2023 0 Comments Beta blocker antidote glucagon moa![]() ![]() Decontaminationĭecontamination is a complex and controversial issue that is an important consideration in every poisoned patient. Many treatment guidelines are based on expert consensus, and further research is encouraged to strengthen an evidence-based approach to the care of the poisoned patient. While this paper highlights current literature, it is important to remember that toxicology research is often limited to case series, case reports, and animal studies with few controlled trials. Major toxicology textbooks were also reviewed for expert consensus. ![]() Laboratory studies, studies targeting specific organs or tissue, and cases with multiple substances ingested were excluded. Case reports, case series, and human and animal studies pertinent to the etiologies of bradycardia discussed hereinafter were included. A MEDLINE search was conducted using the following search terms: Beta blocker OR beta antagonist, calcium channel blocker OR calcium antagonist, clonidine, digoxin, acetylcholinesterase inhibitor OR organophosphate OR carbamate overdose OR toxicity insulin, glucagon, calcium chloride OR calcium gluconate, lipid emulsion OR intralipid, vasopressors, epinephrine, norepinephrine, dopamine, vasopressin, atropine, Pralidoxime OR 2-PAM, naloxone, Digibind OR DigiFab, balloon pump, CVVHD, ECMO, and cardiopulmonary bypass. The goal is to focus on the evidence or lack of evidence for specific therapies but not to provide an exhaustive review of each toxin and/or medication. This paper discusses common treatment considerations that apply to the critically ill poisoned patient with a toxic bradycardia. This discussion will also briefly cover clonidine and acetylcholinesterase inhibitors, such as organophosphates and carbamates, because both have therapeutic consideration outside of standard supportive care. ![]() Beta blockers, calcium channel blockers, and cardiac glycosides (digoxin) represent the classes of medication most described in association with fatality due to drug exposure according to the American Association of Poison Control Centers. Recognition of a toxic etiology for compromised circulation in the setting of bradycardia is crucial in tailoring appropriate therapy. Toxic bradycardias are often refractory to standard ACLS protocols due to toxin effects on cardiac and vascular receptors and cellular physiology. Additionally, consultation with a toxicologist or poison control center is recommended to assist in caring for the poisoned patient. Standard resuscitation algorithms are often insufficient, and it is important to consider appropriate antidotes and adjunctive therapies when caring for the poisoned patient. Consideration and recognition of poisoning may shed light onto altered physiologic responses that may be refractory to traditional therapies. Polypharmacy, intentional or unintentional ingestions, and toxic exposures should be entertained in the differential diagnosis of the bradycardic critically ill patient. Cardiovascular drugs rank second only behind analgesics as the leading cause of fatality in poisoned patients. Nearly 2000 poisoned patients are seen per day in Emergency Departments across the United States, and unintentional poisoning is a significant cause of mortality even surpassing motor vehicle accidents as a cause of death in people aged 35–54. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians’ choices in caring for the poisoned patient. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. ![]()
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