Emerg Med Clin N Am 24 (2006) 159–177

ECG Manifestations:
The Poisoned Patient
Christopher P. Holstege, MD*, David L. Eldridge, MD,
Adam K. Rowden, DO
Division of Medical Toxicology, Department of Emergency Medicine,
University of Virginia, P.O. Box 800774, Charlottesville, VA 22908-0774, USA

Emergency physicians routinely evaluate and manage poisoned patients.

In 2003, more than 2 million human exposure cases were reported to poison
centers throughout the United States [1]. Of those cases, 22% were treated in
a health care facility with most of those cases evaluated in the emergency de-
partment. Cardiovascular drugs were listed as the fifteenth most frequently
encountered human exposure (66,401) and the fifth leading cause of poison-
ing deaths.
Drug-induced changes and abnormalities on the 12-lead electrocardio-
gram (ECG) are common. There are numerous drugs that can cause ECG
changes and lead to cardiac dysrhythmias. The diagnoses and subsequent
management of patients manifesting ECG changes following poisonings
can challenge even the most experienced physician. Drugs that are advocated
in Advanced Coronary Life Support protocols for cardiac dysrhythmias
may not apply or may even worsen the condition of overdose patients [2].
Despite that drugs have widely varying indications for therapeutic use,
many unrelated drugs share a common cardiac pharmacologic effect if taken
in overdose. The purpose of this article is to group together agents that
cause similar electrocardiographic effects, review their pharmacologic ac-
tions, and discuss the electrocardiographic findings reported in the medical
literature. The five main categories reviewed include potassium (Kþ) efflux
blockers, sodium (Naþ) channel blockers, sodium-potassium adenosine-tri-
phosphatase (Naþ/Kþ ATPase) blockers, calcium channel blockers (CCB),
and beta-adrenergic blockers (BB). It is important to keep in mind, however,
that many medications have actions that involve more than one of these

* Corresponding author.
E-mail address: ch2xf@virginia.edu (C.P. Holstege).

0733-8627/06/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2005.08.012 emed.theclinics.com
160 HOLSTEGE et al

actions, and thus may result in a combination or myriad of electrocardio-

graphic changes.

Cardiac physiology
To understand the ECG changes associated with various drugs, physi-
cians must have a clear understanding of basic myocardial cell function.
The myocardial cell membrane in its resting state is impermeable to Naþ
(Fig. 1). The Naþ/Kþ ATPase actively pumps three sodium ions out of
cardiac cells while pumping in two potassium ions to maintain a negative
electric potential of approximately 90 mV in the myocyte (phase 4). Depo-
larization of the cardiac cell membrane is caused by the rapid opening of
Naþ channels and subsequent massive Naþ influx (phase 0). This Naþ in-
flux causes the rapid upstroke of the cardiac action potential as it is con-
ducted through the ventricles and is directly responsible for the QRS
interval of the ECG. The peak of the action potential is marked by the clo-
sure of Naþ channels and the activation of Kþ efflux channels (phase 1).
Calcium (Caþþ) influx then occurs, allowing for a plateau in the action po-
tential (phase 2) and continued myocardial contraction. The cardiac cycle
ends with closure of the Caþþ channels and activation of Kþ efflux chan-
nels, causing the potential to again approach
90 mV (phase 3). It is this
potassium efflux from the myocardial cell that is directly responsible for
the QT interval on the ECG [3].

Fig. 1. Cardiac cycle action potential with corresponding electrocardiographic tracing. Dotted
line indicates the changes associated with Naþ channel blocker toxicity. Dashed line indicates
the changes associated with Kþ efflux blocker toxicity.
 ECG MANIFESTATIONS: THE POISONED PATIENT 161

Potassium efflux blocker toxicity

Background
Medications in the Kþ efflux blocker category are listed in Table 1. These
medications all block the outward flow of potassium from intracellular to
extracellular spaces. Myocardial repolarization is driven predominantly by
this outward movement of potassium ions [3]. Blockade of the outward po-
tassium currents by drugs may prolong the cardiac cycle action potential
(Fig. 1) [4]. As a result, the primary electrocardiographic manifestation of
potassium efflux blocker toxicity is QT interval prolongation. In fact, studies
suggest that approximately 3% of total noncardiac prescriptions are associ-
ated with the potential for QT interval prolongation [5].
These medications vary in their propensity to induce QT interval prolon-
gation or associated dysrhythmias at therapeutic and toxic levels. Some of
these drugs, such as sotalol, are marketed specifically for their ability to in-
hibit this delayed rectifier current [6]. Other medications possess this activity
as an unwelcome side effect at therapeutic doses. Several medications, such
as terfenadine and cisapride, have been removed from the market in various
countries because of reports of associated torsades de pointes and sudden
death in patients taking these drugs [7,8]. Other medications in this class
rarely have been reported to cause QT interval prolongation except when
taken in massive overdose.
In addition, many of these drugs have other effects that can result in sig-
nificant cardiovascular and electrocardiographic changes. For example,
antipsychotic agents can cause muscarinic acetylcholine receptor and
alpha-adrenergic receptor blockade and cardiac cell potassium, sodium,
and calcium channel blockade.

Electrocardiographic manifestations
As noted, the primary electrocardiographic manifestation of Kþ efflux
blocker toxicity is QT interval prolongation (Fig. 2). When measuring the
QT interval, the ECG is best recorded at a paper speed of 50 mm/sec and
an amplitude of 0.5 mV/cm (the latter is equal to 20 mm/mV; the usual set-
tings are 25 mm/sec and 10 mm/mV). A tangent line then is drawn to the
steepest part of the descending portion of the T wave. The intercept between
that line and the isoelectric line is defined as the end of the T wave. The QT
interval then is measured from the beginning of the QRS complex to the end
of the T wave. Within any ECG tracing, there is lead-to-lead variation of the
QT interval. In general, the longest measurable QT interval on an ECG is
regarded as determining the overall QT interval for a given tracing [9].
The QT interval is influenced by the patient’s heart rate. The RR interval
should be measured to allow for rate correction. Several formulas have
been developed to correct the QT interval for the effect of heart rate
(QTc), with Bazett’s formula (QTc ¼ QT/RR1/2) being the most commonly
162 HOLSTEGE et al

Table 1
Kþ efflux channel blocking drugs
Antihistamines
Astemizole
Diphenhydramine
Loratidine
Terfenadine
Antipsychotics
Chlorpromazine
Droperidol
Haloperidol
Mesoridazine
Pimozide
Quetiapine
Risperidone
Thioridazine
Ziprasidone
Arsenic trioxide
Bepridil
Chloroquine
Cisapride
Citalopram
Class IA antidysrhythmics
Disopyramide
Quinidine
Procainamide
Class IC antidysrhythmics
Encainide
Flecainide
Moricizine
Propafenone
Class III antidysrhythmics
Amiodarone
Dofetilide
Ibutilide
Sotalol
Cyclic antidepressants
Amitriptyline
Amoxapine
Desipramine
Doxepin
Imipramine
Nortriptyline
Maprotiline
Fluoroquinolones
Ciprofloxacin
Gatifloxacin
Levofloxacin
Moxifloxacin
Sparfloxacin
Halofantrine
Hydroxychloroquine
Levomethadyl
 ECG MANIFESTATIONS: THE POISONED PATIENT 163

Table 1 (continued )
Macrolides
Clarithromycin
Erythromycin
Pentamidine
Quinine
Tacrolimus
Venlafaxine

used. QT interval prolongation is considered to occur when the QTc interval

is greater than 0.44 seconds in men and 0.46 seconds in women.
The potential risk for QT interval prolongation with this class of medica-
tions is not simply related to a drug dose or concentration. Other factors
also influence the QT interval, such as the patient’s sex and electrolyte con-
centrations. In addition to QT interval prolongation, there is also the poten-
tial emergence of T- or U-wave abnormalities on the ECG with this class of
medications [10].
Moreover, delay of repolarization causes the myocardial cell to have less
charge difference across its membrane. This change can result in activation
of the inward depolarization current (early after-depolarization), which may
in turn promote triggered activity. This triggered activity potentially can
progress to re-entry and subsequent polymorphic ventricular tachycardia,
or torsades de pointes [11]. These dysrhythmias are associated most com-
monly with QT intervals greater than 0.50 seconds, although the potential
for dysrhythmia for a given QT interval varies from drug to drug and pa-
tient to patient [3]. In addition, there is not a simple relationship between
the degree of drug-induced QT interval prolongation and the potential for

Fig. 2. Kþ efflux blocker toxicity. Note the marked QT interval prolongation on this 12-lead
ECG; hydroxychloroquine was the offending agent.
164 HOLSTEGE et al

the occurrence of torsades de pointes. Drug-induced torsades de pointes can

occur even without any substantial prolongation of the QT interval [3].
Similar to other members of this class, antipsychotic agents can cause sig-
nificant QT interval prolongation and associated dysrhythmias. Additionally,
other ECG abnormalities can be seen as a result of other actions of these
agents. QRS complex widening can occur as a result of Naþ channel
blockade (see later discussion). Sinus tachycardia can occur because of
the anticholinergic effect of these medications and from the reflex tachy-
cardia induced by alpha-adrenergic blockade in the peripheral vasculature.

Management
If a patient has drug-induced QT interval prolongation, therapy should
focus on immediate withdrawal of the potential cause and correction of
any coexisting medical problems, such as electrolyte abnormalities. Patients
who have newly diagnosed drug-induced prolongation of their QT interval
should be considered candidates for admission to a monitored setting. Intra-
venous magnesium sulfate is a highly effective and benign intervention to
suppress occurrence of dysrhythmias associated with QT interval prolonga-
tion, even though it typically does not result in shortening of the QT interval
itself [12]. In patients who have intermittent runs of torsades de pointes not
responsive to magnesium therapy, electrical overdrive pacing should be
considered. In the presence of a non-perfusing rhythm, such as ventricular
fibrillation, pulseless ventricular tachycardia, or torsades de pointes, unsyn-
chronized electrical defibrillation should be performed.

Sodium channel blocker toxicity

Background
The ability of drugs to induce cardiac sodium (Naþ) channel blockade
has been well described in numerous literature reports [13]. This Naþ chan-
nel blockade activity has been described as a membrane stabilizing effect,
a local anesthetic effect, or a quinidine-like effect. Cardiac voltage-gated
sodium channels reside in the cell membrane and open in response to de-
polarization of the cell (Fig. 1). The Naþ channel blockers bind to the trans-
membrane Naþ channels and decrease the number available for
depolarization. This creates a delay of Naþ entry into the cardiac myocyte
during phase 0 of depolarization. As a result, the upslope of depolarization
is slowed and the QRS complex widens. Myocardial Naþ channel blocking
drugs comprise a diverse group of pharmaceutical agents (Table 2). Specific
drugs may affect not only the myocardial Naþ channels, but also other
myocardial ion channels, such as the calcium influx and potassium efflux.
This may result in ECG changes and rhythm disturbances not related en-
tirely to the drug’s Naþ channel blocking activity. For example, sodium
 ECG MANIFESTATIONS: THE POISONED PATIENT 165

Table 2
Naþ channel blocking drugs
Amantadine
Carbamazepine
Chloroquine
Class IA antidysrhythmics
Disopyramide
Quinidine
Procainamide
Class IC antidysrhythmics
Encainide
Flecainide
Propafenone
Citalopram
Cocaine
Cyclic antidepressants
Amitriptyline
Amoxapine
Desipramine
Doxepin
Imipramine
Nortriptyline
Maprotiline
Diltiazem
Diphenhydramine
Hydroxychloroquine
Loxapine
Orphenadrine
Phenothiazines
Mesoridazine
Thioridazine
Propranolol
Propoxyphene
Quinine
Verapamil

channel blocking medications such as diphenhydramine, propoxyphene, and

cocaine also may develop anticholinergic, opioid, and sympathomimetic
syndromes, respectively [14–16]. Similarly, cyclic antidepressant toxicity re-
sults not only from myocyte sodium channel blockade, but also from their
action with respect to alpha-adrenergic blockade, muscarinic anticholinergic
effects, and presynaptic neurotransmitter reuptake inhibition.

Electrocardiographic manifestations
As a result of its action in slowing the upslope of depolarization in the
cardiac cycle, Naþ channel blockers result in widening of the QRS complex
(Fig. 3) [17]. In some cases, the QRS complexes may take the pattern of rec-
ognized bundle branch blocks [18,19]. In the most severe cases, the QRS
prolongation becomes so profound that it is difficult to distinguish between
166 HOLSTEGE et al

Fig. 3. Naþ channel blocker poisoning. 12-lead ECG demonstrating QRS complex widening
and tachycardia as a result of tricyclic antidepressant overdose.

ventricular and supraventricular rhythms [20,21]. Continued prolongation

of the QRS complex may result in a sine wave pattern (Fig. 4) and eventual
asystole.
Sodium channel blockers also may induce ventricular tachycardia [22]. It
has been theorized that the Naþ channel blockers can cause slowed intra-
ventricular conduction, unidirectional block, the development of a re-
entrant circuit, and a resulting ventricular tachycardia (Fig. 5). These

Fig. 4. Naþ channel blocking agent toxicity. 12-lead ECG demonstrating sine wave pattern fol-
lowing overdose; atrial and ventricular activity are difficult to distinguish.
 ECG MANIFESTATIONS: THE POISONED PATIENT 167

Fig. 5. Wide complex tachydysrhythmia caused by Naþ channel blocker poisoning. ECG
rhythm strip revealing a wide complex tachycardia following overdose of diphenhydramine.

rhythms then can degenerate into ventricular fibrillation. Because many of

the Naþ channel blocking agents are also anticholinergic or sympathomi-
metic agents, bradydysrhythmias are rare. The Naþ channel blocking
agents, however, can affect cardiac pacemaker cells. Bradycardia may occur
because of slowed depolarization of pacemaker cells that depend on entry of
sodium ions. In Naþ channel blocker poisoning by anticholinergic and sym-
pathomimetic drugs, the combination of a wide QRS complex and brady-
cardia is an ominous sign and may indicate that the Naþ channel
blockade is so profound that tachycardia does not occur, despite clinical
muscarinic antagonism or adrenergic agonism [13].
In this class of agents, cyclic antidepressants produce several ECG
changes related to Naþ channel blockade and their other actions on cardio-
vascular function (see Fig. 3). Sinus tachycardia occurs frequently from the
anticholinergic effects of cyclic antidepressant toxicity. QRS complex widen-
ing occurs as a result of Naþ blockade, and this delayed conduction may be
seen more commonly involving the right side of the heart, manifesting as
a right bundle branch block [23]. In addition, QT interval prolongation
can occur with these agents. Finally, rightward axis deviation of the terminal
40 msec (0.04 seconds) of the frontal plane QRS axis has been associated
with tricyclic antidepressant poisoning [24,25]. The occurrence of this find-
ing in other Naþ channel blocking agents is unknown.
Cocaine is a unique sympathomimetic agent in its ability to cause cardiac
Naþ channel blockade. Together with QRS complex widening, increased
catecholamine activity seen with cocaine toxicity can result in several
rhythm disturbances, including sinus tachycardia, premature ventricular
contractions, wide complex dysrhythmias, ventricular tachycardia, and ven-
tricular fibrillation. In addition, morphologic changes in the ST segment and
T waves consistent with ischemia can be seen in the setting of sympathomi-
metic and cocaine toxicity.

Management
The management of Naþ channel blocking agents consists of administra-
tion of sodium or creation of an alkalosis [26–30]. Infusion of sodium bicar-
bonate by intermittent bolus or by continuous infusion has been advocated.
Hypertonic sodium infusion and hyperventilation also have been advocated
168 HOLSTEGE et al

[31–34]. Reasonable, literature-supported indications for sodium bicarbon-

ate infusion include a QRS duration of O0.10 seconds, persistent hypoten-
sion despite adequate hydration, and ventricular dysrhythmias. Lidocaine
has been suggested in the treatment of ventricular dysrhythmias, though
clear evidence is lacking. Class IA and IC antidysrhythmics should be
avoided because of their ability to block cardiac sodium channels.

Sodium–potassium ATPase blocker toxicity

Background
Cardiac glycosides are agents that inhibit the sodium–potassium adeno-
sine triphosphatase (Naþ/Kþ ATPase) pump. Digoxin and other digitalis
derivatives are the cardiac glycosides encountered most widely, but numer-
ous other similar acting agents also exist (Box 1). Digoxin historically has
been administered to treat supraventricular tachydysrhythmias and conges-
tive heart failure, but its use has been decreasing as newer agents have been
developed. Nonprescription medication cardiac glycosides also have been
associated with human toxicity, such as after ingestion of specific plants
and contaminated herbal products [35–40].
The cardiac glycosides inhibit active transport of Naþ and Kþ across cell
membranes by inhibiting the Naþ/Kþ ATPase. This results in an increase
in extracellular Kþ and intracellular Naþ. An increased intracellular
Naþ reduces the transmembrane Naþ gradient and subsequent increased
activity of the Naþ–Ca2þ exchanger. This activity, in turn, increases the in-
tracellular calcium concentration, which then augments myofibril activity in
cardiac myocytes and results in a positive inotropic effect. The cardiac gly-
cosides also increase vagal tone that may lead to a direct atrioventricular
(AV) nodal depression. Therapeutically, digitalis derivatives are used to in-
crease myocardial contractility or slow AV conduction. These actions, how-
ever, can result in significant cardiac disturbances and ECG abnormalities in
the setting of toxicity.

Box 1. Na+/K+ ATPase blocking agents and substances

Bufadienolides
Digoxin
Digitoxin
Foxglove
Lily of the valley
Oleander
Red squill
 ECG MANIFESTATIONS: THE POISONED PATIENT 169

Electrocardiographic manifestations
Digitalis derivatives at therapeutic doses have been associated with several
electrocardiographic changes. These findings include the so-called ‘‘digitalis
effect’’ manifesting with abnormal inverted or flattened T waves coupled
with ST segment depression, frequently described as a sagging or scooped
ST segment/T wave complex. These findings are most pronounced in leads
with tall R waves. In addition, other findings include QT interval shorten-
ing as a result of decreased ventricular repolarization time, PR interval
lengthening as a result of increased vagal activity, and increased U-wave
amplitude. It is important to remember that these electrocardiographic
manifestations are seen with therapeutic digoxin levels and do not corre-
late with toxicity.
Electrocardiographic abnormalities with cardiac glycoside toxicity are
the result of the propensity for increased automaticity (from increased intra-
cellular calcium) accompanied by slowed conduction through the AV node.
As a result, cardiac glycoside toxicity may result in a wide array of dysrhyth-
mias [41,42]. Excitant activity (atrial, junctional, and ventricular premature
beats, tachydysrhythmias, and triggered dysrhythmias), suppressant activity
(sinus bradycardia, bundle branch blocks, first-, second-, and third-degree
AV blocks), and any combination of excitant and suppressant activity (atrial
tachycardia with AV block, second-degree AV block with junctional prema-
ture beats) have all been reported (Fig. 6) [43–45].
The most common dysrhythmia associated with toxicity induced by these
agents is frequent premature ventricular beats [42]. Paroxysmal atrial tachy-
cardia with variable block or accelerated junctional rhythm is highly sugges-
tive of digitalis toxicity. Marked slowing of the ventricular response in
a patient who has atrial fibrillation who is on digoxin should suggest the
possibility of toxicity (Fig. 6). Bidirectional ventricular tachycardia is stated
to be specific for digitalis toxicity, but rarely is seen [46].

Fig. 6. Naþ/Kþ ATPase blocker toxicity. 12-lead ECG demonstrating an irregular bradydysr-
hythmia as a result of conduction block from chronic digoxin toxicity.
170 HOLSTEGE et al

The ECG may demonstrate findings associated not only with cardiac gly-
coside toxicity but also with hyperkalemia. Acute toxicity most closely cor-
relates with hyperkalemia as the Naþ/Kþ ATPase is inhibited and
extracellular Kþ increases. In chronic toxicity, hyperkalemia may not be
seen because of the slower increase in Kþ, allowing for renal compensation.

Management
In cardiac glycoside toxicity, digoxin-specific antibody (Fab) fragments
are the first-line therapy in patients who have symptomatic cardiac dys-
rhythmias [41,47]. Because cardiac glycoside-enhanced vagal activity may
be reversed by atropine sulfate, this agent has been used successfully in pa-
tients exhibiting AV block on ECG [48]. Cardiac pacing has been advocated
for bradydysrhythmias unresponsive to atropine, but care should be exer-
cised as the pacing wire itself may induce ventricular fibrillation [49]. The
classic antidysrhythmic of choice for ventricular dysrhythmias is phenytoin,
because it increases the ventricular fibrillation threshold in the myocardium
and enhances conduction through the AV node [41]. Quinidine and procai-
namide are contraindicated because they depress AV nodal conduction and
may worsen cardiac toxicity [50].

Calcium channel blocker toxicity

Background
There are currently nine cardiac calcium channel blockers (CCBs) that
have been approved for clinical use in the United States. These nine are sub-
classified within four classes of compounds (Box 2). Over the past decade,

Box 2. Ca++ channel blocking drugs

Dihydropyridines
Nicardipine
Nifedipine
Isradipine
Amlodipine
Felodipine
Nimodipine
Phenylalkylamine
Verapamil
Benzothiazepine
Diltiazem
Diarylaminopropylamine ether
Bepridil
 ECG MANIFESTATIONS: THE POISONED PATIENT 171

the number of exposures to these agents has increased dramatically as they

have become available on the market. In 2001, CCBs accounted for 40% of
all the deaths caused by cardiovascular drugs reported to the AAPCC [51].
All cardiac CCBs inhibit the voltage sensitive L-type calcium channel
within the cell membrane [52]. This channel resides in heart and smooth
muscle cell membranes. The inhibition of this channel prevents movement
of calcium from extracellular sites through the cell membrane to intracellu-
lar sites. Decreased intracellular calcium within the myocardial cells results
in slowing of conduction, decreased contractility, and decreased cardiac
output.
Blockade of calcium influx within the vascular smooth muscle cells results
in vasodilation. Decreased cardiac output coupled with vasodilation can re-
sult in profound hypotension. The dihydropyridine class of drugs tends to
have a higher affinity for the peripheral vascular smooth muscle cells, less
effect on the cardiac calcium channels, and is associated more often with hy-
potension with a resulting reflex tachycardia. Verapamil and diltiazem, on
the other hand, have strong affinity for cardiac and vascular calcium chan-
nels and subsequently the combination of hypotension with bradycardia
may be seen. In animal models and human case series, CCBs also have
been associated with cardiac sodium channel blockade [53,54].

Electrocardiographic manifestations
The inhibition of calcium influx within the conduction system results in
slowing of cardiac conduction. CCB toxicity initially causes a sinus brady-
cardia that may or may not be symptomatic. Depending on the agent in-
gested, reflex tachycardia may not be seen. As levels of CCB increase, the
patient may develop various degrees of AV block (first-, second-, and
third-degree) and junctional and ventricular bradydysrhythmias on ECG
(Fig. 7). A widening of the QRS complex may be encountered. This may
be caused by ventricular escape rhythms or by CCB-induced sodium chan-
nel blockade causing a delay of phase 0 of depolarization. This delay and
subsequent QRS complex widening also increases the potential for dys-
rhythmias (see the previous section on Sodium channel blocker toxicity)

Fig. 7. CCB toxicity. 12-lead ECG demonstrating a marked bradydysrhythmia with a heart
rate in the thirties.
172 HOLSTEGE et al

[53,54]. In the final stages, asystole may occur. Sudden shifts from brady-
dysrhythmias to cardiac arrest have been reported [53]. In addition, ECG
changes associated with cardiac ischemia may occur as a result of the hypo-
tension and changes in cardiovascular status, particularly in patients who
have pre-existing cardiac disease.

Management
A symptomatic acute CCB overdose can be one of the most challenging
poisonings encountered by a physician. CCB poisonings are prone to devel-
oping severe bradydysrhythmias and hypotension and other complications,
including pulmonary edema and heart failure [55]. Specific pharmacologic
therapy includes the use of atropine, calcium, glucagon, insulin, sodium bi-
carbonate, or various catecholamines [56,57].

Beta-adrenergic blocker toxicity

Background
BBs are used increasingly because of their efficacy in the treatment of hy-
pertension, ischemic heart disease, and dysrhythmias. BBs competitively in-
hibit various b-adrenergic receptors. Inhibition of b1-receptors results in
a decrease in the force and rate of myocardial contraction, a decrease in
AV nodal conduction velocity, and a decrease in renin secretion. Inhibition
of b2-receptors results in a decrease in glycogenolysis, decrease in gluconeo-
genesis, and decrease in relaxation of smooth muscles in blood vessels, bron-
chi, and the gastrointestinal tract. There are currently numerous BBs
available (Box 3). These agents share in common the mechanism of

Box 3. Beta-adrenergic blocking drugs

Acebutolol
Atenolol
Betaxolol
Bisoprolol
Carvedilol
Esmolol
Labetalol
Metoprolol
Nadolol
Pindolol
Propranolol
Sotalol
Timolol
 ECG MANIFESTATIONS: THE POISONED PATIENT 173

competitive b-adrenergic receptor antagonism. Some of these agents have

equal affinity for b1 and b2 receptors (eg, propranolol), whereas others are
selective and have greater b1 than b2 receptor blocking activity (eg, metopro-
lol). Some agents also block other receptors, such as a-adrenergic receptors
(eg, labetalol), cardiac sodium channels (eg, propranolol, acebutolol), and
cardiac potassium efflux channels (eg, sotalol) [58,59].

Electrocardiographic manifestations
In acute overdose, the most pronounced effects of BBs are on the cardio-
vascular system [60]. Bradycardia (from decreased sinoatrial node function),
varying degrees of AV block, and hypotension are generally the hallmarks
of significant beta-blocker toxicity. One prospective study attempted to
characterize electrocardiographic findings in symptomatic BB overdose
[61]. Only 3 of 13 symptomatic patients had bradycardia on their initial
ECG (performed while they were classified as symptomatic). First-degree
AV block was common, however. In fact, 10 of 12 symptomatic patients
with a measurable PR interval (the thirteenth patient had atrial fibrillation)
demonstrated a first-degree AV block and had a mean PR interval of 0.22
seconds. This finding was the most common abnormality to be found on
electrocardiograms in this symptomatic patient group.
Besides bradycardia and AV block, there are other specific findings that
can be seen with individual members within this group of medications. Pro-
pranolol is unique because of its Naþ channel blocking activity in overdose
that can result in a prolonged QRS interval (O0.10 seconds) [58,61–63].
Propranolol overdose has been associated with a higher mortality rate com-
pared with other BBs [66]. These same investigators also found that a QRS
interval O0.10 seconds in these patients was predictive of propranolol-
induced seizures. Sotalol is a unique BB in that it possesses the ability to
block delayed rectifier potassium channels in a dose-dependent fashion
[64]. Acebutolol preferentially blocks b1 receptors and possesses partial ag-
onist activity and membrane stabilizing activity similar to propranolol. QRS
interval widening on ECG and ventricular tachycardia have been reported
in several cases [59,65,66].

Management
Specific pharmacologic therapy for BB toxicity may include atropine, glu-
cagon, calcium, insulin, or various catecholamines [67]. Atropine may be
considered in an attempt to reverse bradycardia, but has been shown to
have poor effect and no impact on blood pressure. Glucagon infusion, which
increases intracellular cAMP, should be considered in symptomatic BB toxic
patients [60]. Calcium has been shown to have efficacy at reversing the hy-
potensive effects of BB toxicity in animal models and human case reports
[60,68]. Insulin infusions have been advocated for BB toxicity based on an
174 HOLSTEGE et al

animal model [69]. Catecholamine infusions may be considered after the

therapies discussed previously fail to give adequate response. Pacemaker in-
sertion, balloon pump, and bypass all may be considered in cases not re-
sponding to pharmacologic therapy.

Summary
Toxicologic, medication- and drug-induced changes and abnormalities
on the 12-lead electrocardiogram (ECG) are common. A wide variety of
electrocardiographic changes can be seen with cardiac and noncardiac
agents and may occur at therapeutic or toxic drug levels. In many instances,
however, a common mechanism affecting the cardiac cycle action potential
underlies most of these electrocardiographic findings. Knowledge and un-
derstanding of these mechanisms and their related affect on the 12-lead
ECG can assist the physician in determining those ECG abnormalities asso-
ciated with specific toxidromes.

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