Salbutamol

Clinical Effects:

ALBUTEROL AND RELATED AGENTS
  • USES: Used primarily as a bronchodilator for asthma or other pulmonary diseases. Also may be used for the treatment of hyperkalemia. Found in metered dose inhalers, unit doses for nebulizers, and as an oral syrup and tablets. PHARMACOLOGY: Selective beta2-adrenergic agonist which primarily causes smooth muscle relaxation. TOXICOLOGY: Results from over-stimulation of beta-adrenergic activity. In addition, beta-adrenergic selectivity is lost, so beta-1 effects can be seen. EPIDEMIOLOGY: Uncommon poisoning that rarely results in serious morbidity or death. MILD TO MODERATE TOXICITY: Tachycardia, hypertension, tachypnea, tremor, agitation, nausea, vomiting, hypokalemia, hyperglycemia. SEVERE TOXICITY: Severe effects include hypotension, dysrhythmias, seizures, and acidosis and are likely to occur only after ingestion. ADVERSE EFFECTS: Tachycardia, tremor, hyperactivity, nausea, vomiting.

Range of Toxicity:

ALBUTEROL AND RELATED AGENTS
  • TOXICITY: PEDIATRIC: Mild to moderate transient evidence of toxicity develops in children at doses above 1 mg/kg orally. THERAPEUTIC DOSE: ADULT: The oral adult dose is 2 to 4 mg 3 to 4 times/day; not to exceed a MAX daily dose of 32 mg. PEDIATRIC: Oral doses for children are 0.1 to 0.2 mg/kg. MAX daily doses: 32 mg (12-years and older), 24 mg (6- to 11-years); 12 mg (2- to 5-years). The inhalational dose is typically 0.1 to 0.15 mg/kg/dose or 0.5 mg/kg/hr for continuous administration.

Treatment:

ALBUTEROL AND RELATED AGENTS
  • Support: MANAGEMENT OF MILD TO MODERATE TOXICITY: The majority of albuterol overdoses require supportive care only. Activated charcoal can be used for oral ingestions if the patient presents early. Mild symptoms rarely require specific treatment. An antiemetic may be used. Hypokalemia may develop but usually does not require treatment because it only reflects cellular shifts and not a true body potassium depletion. Sinus tachycardia and hypertension rarely require treatment . The presence of other dysrhythmias or hypotension indicates a more severe poisoning. MANAGEMENT OF SEVERE TOXICITY: If hypotension is present, intravenous fluid should be used initially. If the hypotension does not respond, a beta-adrenergic blocking agent can be used. First line choices include esmolol or propranolol since the hypotension is often primarily due to the tachycardia. Alternatively, a vasopressor with pure alpha activity such as phenylephrine can be used. Tachycardia can also be treated if necessary with a beta-blocker, but this is rarely warranted. Premature ventricular contractions rarely require treatment.
  • Decontamination: PREHOSPITAL: There is no role for prehospital decontamination. HOSPITAL: In cases of ingestion, activated charcoal can be used if there is a recent, substantial ingestion and the patient is able to protect their airway.
  • Antidote: Beta-adrenergic blockers can be used specifically if there is refractory hypotension, dysrhythmias, or tachycardia requiring treatment. Esmolol (0.025 to 0.1 mg/kg/min IV) or propranolol (0.01 to 0.02 mg/kg IV) are considered first-line treatments. Esmolol is generally preferred as it is titratable.
  • Psychomotor agitation: Sedate patient with benzodiazepines as necessary; large doses may be required.
  • Monitoring of patient: Monitor vital signs and mental status. Specific levels are generally not available and not helpful. Obtain serum chemistries to monitor serum potassium levels in severely poisoned patients. Obtain electrocardiogram in patients with chest pain or severe tachycardia. Consider obtaining creatine kinase in severely agitated patients.
  • Enhanced elimination procedure: There is no role for enhanced elimination.
  • Patient disposition: HOME CRITERIA: Children with unintentional ingestions of less than 1 mg/kg with mild symptoms can be observed at home. Adults with unintentional overdose and mild symptoms may be observed at home. OBSERVATION CRITERIA: Patients with deliberate ingestions or children with ingestions greater than 1 mg/kg should be evaluated in a health care facility and observed for 4 to 8 hours for the onset of symptoms. ADMISSION CRITERIA: Patients with significant hypotension or dysrhythmias should be admitted. CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing severe poisonings.
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