128: Beta Blocker Toxicity in the PICU: Slow Heart, Fading Mind, and Falling Sugar

In this episode of *PICU Doc on Call*, Drs. Pradip Kamat and Rahul Damania dive into the topic of beta-blocker toxicity. They walk through a case of a 15-year-old who comes in with bradycardia, hypotension, hypoglycemia, and altered mental status after an intentional ingestion. Using a board-style question, they break down how to tell the difference between beta-blocker and calcium channel blocker poisoning and review key points about cardiac physiology and receptor signaling.

Drs. Kamat and Damania discuss management strategies, including glucagon, high-dose insulin therapy, vasopressors, calcium, and ECMO as a last resort. They also spend some time focusing on specific agents like propranolol and sotalol, highlighting what makes their toxicologic profiles unique. This is a high-yield episode packed with pearls for pediatric intensivists!

Show Highlights:

• Clinical case of a 15-year-old patient with bradycardia and hypotension due to intentional drug ingestion
• Beta-blocker toxicity and its clinical features
• Differentiation between beta-blocker and calcium channel blocker toxicity
• Key physiological concepts related to cardiac action potentials and beta receptor function
• Clinical presentation and diagnostic workup for beta-blocker toxicity
• Management strategies for beta blocker overdose, including airway control and fluid resuscitation
• Specific toxicologic profiles of common beta-blockers (e.g., propranolol, sotalol, metoprolol)
• Importance of recognizing hypoglycemia and CNS effects in beta-blocker toxicity
• Summary of critical management steps and take-home points for pediatric intensivists
• Encouragement for further learning and engagement on related topics

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 126. Toxidromes and their treatment. Joshi P. Pages 1504-1505
• Reference 1: Rogers textbook of Pediatric Intensive Care: Chapter 36: Poisoning. Nares M, Jeyapalan A, Weisman R: pages 525-543
• Reference 2: Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; American Heart Association. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Oct 17;148(16):e149-e184. doi: 10.1161/CIR.0000000000001161. Epub 2023 Sep 18. PMID: 37721023.
• Suarez F, Koyfman A, Long B. Pearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity. J Emerg Med. 2026 May;84:1-11. doi: 10.1016/j.jemermed.2026.01.021. Epub 2026 Jan 27. PMID: 41833262.