see also: [[Sotalol]] [Murray Beta blockers](x-devonthink-item://C8AE745C-C96E-4AEF-9010-D441840C6DF4?page=197) > [!Key Points] > - **risk dose:** toxicity does not correlate well with ingested dose > - **propranolol** and [[Sotalol]] bad ones > - Propranolol poisoning requires specific therapy for wide QRS, haemodynamic instability, seizures and coma. > - Sotalol poisoning requires specific therapy for QT prolongation > - co-ingestion with [[Calcium channel blocker overdose|calcium channel blocker]] or [[Digoxin toxicity|digoxin]] portends worse prognosis > - Antidote:: supportive care with [[atropine]], epinephrine or isoprenaline, consider [[Transcutaneous pacing]], tx #hypoglycaemia , consider [[ECMO]], consider [[Intralipid]] # Risk assessment - **propranolol** as little as 1 g, > 2g likely to cause significant toxicity including seizures within 6 hours ; usually within 2 hours - Has [[Sodium channel blocker]] effects as well - even timolol eye drops can do it!! # Toxic Mechanism Propranolol has two properties responsible for toxicity in overdose: - sodium channel blockade (membrane stabilising activity) - high lipid solubility (enhanced CNS penetration). # Clinical features - can **decrease** glucose - in contrast to [[Calcium channel blocker overdose]], where glucose may increase # Treatment - chronotropy (adrenaline or isoprenaline) HR >60 - ionotropy (adrenaline) MAP >90 - [[high dose insulin euglycemia therapy|HIET]] is **second line** for this - +/- any vasoplegia → noradrenaline - ECMO if failing - BSL > 4 - don't give glucagon anymore b/c of vagal response from vomiting and harder to manager # Disposition - most peak at 3 hours; if well then likely can d/c at 6 hours if ECG normal (12 hours if slow release) # Mnemonic