#1: Stick or Sniff? IM Midazolam Has the Edge for Pediatric Seizure
Spoon Feed —
In pediatric seizures requiring non-IV benzodiazepine treatment, intramuscular (IM) midazolam was associated with faster seizure termination and a lower need for rescue therapy compared with intranasal (IN) midazolam.
Source
Intranasal Versus Intramuscular Midazolam in Pediatric Seizure Control: A Systematic Review and Meta-Analysis. Prehosp Emerg Care. 2026 May 6:1-9. doi: 10.1080/10903127.2026.2658592. Epub ahead of print. PMID: 41996547.
#2: How to Treat Beta-Blocker & Calcium Channel Blocker Overdose
Spoon Feed —
Consider beta blocker (BB) and calcium channel blocker (CCB) toxicity in patients presenting with bradycardia and hypotension. Hallmarks of treatment are quick action, escalation to vasopressors, high dose insulin (HDI) if initial treatment fails, and subsequent consideration of ECMO and intralipid rescue therapy in the sickest patients.
Pressors, insulin, lipid, ECMO: The rescue ladder for BB/CCB poisoning
BB and CCB toxicity is associated with high mortality and morbidity; thus, early recognition and intervention are keys to survival and positive outcomes.
Take-home Points:
- Presentation: While hypotension and bradycardia are the key clues to recognize in both, BBs may also cause neuro symptoms, more pronounced QRS or QTc prolongation and hypoglycemia depending on the type of BB.
- Initial therapy consists of activated charcoal if there is no airway compromise, atropine for bradycardia, calcium salts, and if BB toxicity is a concern, glucagon can be considered.
- If patients fail initial management, start vasopressors and use ultrasound to assess for evidence of diminished cardiac contractility: if present, consider HDI.
- For persistent shock in dihydropyridine toxicity, methylene blue is an option.
- If patients break through the above therapies, intralipid therapy can be used if ECMO is not available, with the latter initiated for persistent refractory hypotension and bradycardia if feasible and available.
As an expert narrative review without systematic methods or new primary data, recommendations rest largely on animal models, case reports, small series, and heterogeneous observational studies, limiting the strength, quantification, and generalizability of proposed management strategies.
How will this change my practice?
This is a great summary of the approach and management of BB and CCB toxicity. It serves as a reference for the nuances of particular medication types, but also lays out an organized approach to initial management and subsequent care in sicker patients. These are cases where I always lean on a toxicology center call and consultation to assist and follow these patients through their management.
Source
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.
