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.

In this episode of PICU Doc on Call, third-year PICU fellow Dr. Alexandria Edwards joins Drs. Pradip Kamat, Monica Gray, and Rahul Damania for a quick and practical dive into pediatric transport medicine. Dr. Edwards walks us through her go-to framework for handling transport calls, highlighting the importance of systematically checking vitals, respiratory support, the physical exam, labs, and any interventions. The team uses a real-life case of a 12-year-old with severe status asthmaticus to talk through how to pick the right transport mode, why it’s best to avoid intubation if you can, and how to make sure you’re on the same page with the ICU team before the patient arrives. The main message? Build a solid, structured approach to transport calls and practice it every time.

Show Highlights:

• Overview of pediatric intensive care unit (PICU) fellowship and training
• Importance of transport medicine in the PICU setting
• Framework for handling transport calls effectively
• Key considerations for assessing patient stability during transport
• Importance of vital signs and current patient status in decision-making
• Strategies for communicating with referring providers
• Discussion of a specific case involving a pediatric patient with asthma exacerbation
• Decision-making process for mode of transport (ground vs. air)
• Role of critical care transport teams in patient transfer
• Tips for preparing the receiving ICU team for incoming patients

We welcome your feedback and reviews. Please visit our website at https://picudoconcall.org/, where you can find our episodes.

In this episode, Drs. Pradip Kamat, Monica Gray, and Rahul Damania talk through a heartbreaking case involving a 14-year-old girl with a history of psychiatric illness who intentionally took 45 tablets of metformin and empagliflozin. Things went downhill quickly—she developed severe lactic acidosis, hypoglycemia, acute kidney injury, and eventually suffered a cardiac arrest that required ECMO and continuous dialysis. Sadly, even with the most aggressive care, she didn’t make it. The doctors walk listeners through the pharmacology and toxicity of metformin and empagliflozin, discuss how these drugs can cause harm, and share key management strategies. They really stress the importance of early recognition, using extracorporeal therapies, and working as a multidisciplinary team when dealing with severe pediatric overdoses of antidiabetic medications.

Show Highlights:

• Case study of a 14-year-old girl with intentional ingestion of an oral antidiabetic agent
• Presentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrest
• Discussion of the pharmacology and toxicology of metformin and empagliflozin
• Mechanisms of metformin toxicity and its effects on metabolic processes
• Differentiation between types of lactic acidosis related to metformin
• Importance of early recognition and management of metformin toxicity
• Supportive care strategies for managing severe metformin overdose
• Role of extracorporeal therapies, including ECMO and dialysis, in treatment
• Multidisciplinary approach involving intensivists, nephrologists, and toxicologists
• Clinical implications and outcomes of severe metformin toxicity in pediatric patients

Resources:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing found
• Reference 1: Noites I, Figueiredo M, Shchomak Z, Boto L, Camilo C. Fatal Pediatric Metformin-Associated Lactic Acidosis: When Severity Goes Unnoticed. Cureus. 2026 Feb 16;18(2):e103719.
• Reference 2: Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015 Aug;31(8):589-90.