The majority of literature on<unk><unk>  blocker overdose management is low-quality evidence and high-dose insulin and extracorporeal life support have the best evidence; other therapies include<unk> , dopamine, norepinephrine, and lipid emulsion therapy may be beneficial but are poorly studied
Monotherapy only successful for trivial overdoses
Charcoal
1g/kg (max 50g) x1
Consider if present within 1-2hr with delayed-release preparation
Consider whole bowel irrigation if sustained or extended-release, esp if the drug is verapamil or diltiazem
1g/kg (max 50g) x1
Consider if present within 1-2hr with delayed-release preparation
Initial 20cc/kg bolus especially if source of hypotension is undifferentiated and also possibly hypovolemic or due to Sepsis
Mechanism of Action: Insulin has a positive inotropic effect on the heart by improving metabolic support of cardiac tissues during hypotensive shock (cardiac tissues preferentially utilize fatty acid as an energy source during normal condition; under stressed conditions, cardiac tissues rely on glucose metabolism as their primary energy source). Some studies have also demonstrated that high doses of insulin can induce endothelial nitric oxide synthase activity and improve microvascular dysfunction by a vasodila- tory effect in cardiac and pulmonary vasculature
Takes 30-60min for effect
Glucose:
Adult: 50mL of D50W
Ped: 2.5mL/kg of D10
Insulin bolus 1 unit/kg given with 1amp of D50, then 0.5 – 1 unit/kg/hr continuous infusion
Titrate infusion until hypotension is corrected or max 2u/kg/hr
Titrate dextrose drip to avoid hypoglycemia
initial glucose checks q15 minutes until blood sugar stability established
Potassium
If <3 administer 20mEq IV
Adult: 50mL of D50W
Ped: 2.5mL/kg of D10
Titrate infusion until hypotension is corrected or max 2u/kg/hr
Titrate dextrose drip to avoid hypoglycemia
initial glucose checks q15 minutes until blood sugar stability established
If <3 administer 20mEq IV
1.5mL/kg bolus of 20% lipid followed by 0.25mL/kg/minute
Norepinephrine is agent of choice
Start at 2mcg/min, uptitrate rapidly, goal MAP 65mmHg
Start at 2mcg/min, uptitrate rapidly, goal MAP 65mmHg
Adult: 0.5-1mg IV q2-3min to max of 3g
Ped: 0.02mg/kg (minimum is 0.1mg)
Administer to anyone with symptomatic bradycardia
Avoid if digoxin toxicity is possible<unk>  gluconate 3g (30-60mL of 10% soln)<unk>  chloride 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)
Preferred over<unk>  gluconate because it provides triple the amount of<unk>  on a weight-to-weight basis 
Give<unk>  1g Q5min to titrate to BP effect
If effect in BP is seen can give as a drip at 10-50mg/kg/hr
can safely push serum<unk>  levels to 15-18 or even low 20s if patient tolerates (double normal)
Preferred over<unk>  gluconate because it provides triple the amount of<unk>  on a weight-to-weight basis 
Give<unk>  1g Q5min to titrate to BP effect
If effect in BP is seen can give as a drip at 10-50mg/kg/hr
can safely push serum<unk>  levels to 15-18 or even low 20s if patient tolerates (double normal)
5mg IV bolus q10min x 2
will often cause severe nausea/vomiting, give Zofran prior
Calcium channel blocker toxicity
Cardiac
Tricyclic antidepressant toxicity
Inferior MI 
Clonidine toxicity
Sick sinus syndrome
Beta-blocker toxicity
Neurocardiogenic/reflex-mediated