Calcium-Channel / Beta-Blocker Poisoning — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Severe/refractory?
   Bradycardia + hypotension — severe/refractory? (Calcium-channel blocker (verapamil/diltiazem) and beta-blocker overdose → bradycardia, hypotension, conduction block (AV block). CCBs often cause hyperglycemia (suppress insulin release); BBs may cause hypoglycemia; some BBs (propranolol) cause sodium-channel blockade with QRS widening. First ABC, ECG monitoring, check glucose.)
   • Severe (shock/severe bradycardia/conduction block) → Severe → multi-pronged
   • Mild, hemodynamically stable → Mild · observe
2. [End] Mild · observe
   Hemodynamically stable: ECG monitoring, fluids, serial observation; activated charcoal (early), whole-bowel irrigation for sustained-release; trial atropine for bradycardia. Have the escalation plan ready and manage as severe if it deteriorates.
3. [End] Severe → multi-pronged
   1) IV calcium (calcium gluconate/chloride, especially for CCB). 2) Atropine (bradycardia, often ineffective). 3) High-dose insulin euglycemia therapy (HIET): insulin 1 U/kg bolus → 1 U/kg/h infusion, may increase to 10 U/kg/h, with concurrent dextrose to maintain euglycemia, monitor glucose and potassium — the core inotropic support in severe CCB/BB. 4) Vasopressors (norepinephrine/epinephrine). 5) Glucagon (especially BB, 3–10 mg IV push then infusion, causes vomiting). 6) QRS widening (membrane-stabilizing effect of propranolol, etc.) → bicarbonate. 7) Refractory: lipid emulsion, transcutaneous/transvenous pacing, VA-ECMO; methylene blue for vasoplegia. ICU.

Source guidelines & references

• Calcium-channel blocker and beta-blocker poisoning (EMCrit IBCC)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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