# albuterol contraindications..



## kaisardog (May 14, 2013)

From NIH:  Albuterol   Cardiovascular Effects
"...Albuterol, like all other beta-adrenergic agonists, can produce a clinically significant cardiovascular effect in some patients as measured by pulse rate, blood pressure, and/or symptoms. Although such effects are uncommon after administration of Albuterol Inhalation Aerosol at recommended doses, if they occur, the drug may need to be discontinued. In addition, beta-agonists have been reported to produce electrocardiogram (ECG) changes, such as flattening of the T wave, prolongation of the QTc interval, and ST segment depression. The clinical significance of these findings is unknown. Therefore, albuterol, like all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension...'

so  my question  is:  do  your particular state's   protocols define a certain  hypertensive BP  or pulse  rate  or 'other  symptoms' /conditions  which  are contraindications   for  albuterol? (assume  the  EMT is to administer it  by assisting the Pt  with  own Rx  , because pt is  wheezing &   asthmatic. )   Have  you  seen adverse  reactions  in the  field   when  albuterol  is  admin  to pts  with  previously-unknown  cardiac  issues? 

thanks...


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## rmabrey (May 14, 2013)

Ive heard of already tachy patients going into SVT. Ive never seen it myself.


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## Aprz (May 14, 2013)

rmabrey said:


> Ive heard of already tachy patients going into SVT. Ive never seen it myself.


I think that sentence is confusing, and makes it sound like SVT is a rhythm of its own. I also wouldn't be surprised if somebody called it SVT based on the heart rate increasing to 150 or above.

In Santa Clara County, we are suppose to discontinue albuterol if the heart rate is above 160, if they have chest pain, a dysrhythmia, or suddent onset of new a symptom. Below is a link to that specific protocol.

Santa Clara County EMS - Respiratory distress (A11)

I did not know about the ECG changes, and find that interesting. It makes sense though since those would be signs of hypokalemia, and albuterol is used to treat hyperkalemia. I just happened to watch a video by Dr. Amal Mattu on hypokalemia a couple of hours ago so those ECG changes were screaming hypokalemia.

http://ekgumem.tumblr.com/post/50341728003


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## sir.shocksalot (May 14, 2013)

If you are administering albuterol appropriately you shouldn't see too many untoward side effects. Tachycardia and "jitteriness" are the only side effects I've seen. The patients you really need to worry about are the elderly with preexisting cardiac conditions, but even they tolerate albuterol well.

The key to minimizing reactions is making sure the patient is getting an appropriate treatment. An acute CHFer with flash pulmonary edema presenting as cardiac wheezing may not do well receiving a nebulizer. A 92 yro with SOB and bilateral global wheezes, a hx of COPD, but tachycardic will probably tolerate a B2 agonist well without any real concerns of SVT or other rhythm problems. The point is that the albuterol is treating the disease process of COPD not just a shot in the dark treatment for dyspnea.

Albuterol is fairly safe as evidenced by people getting sent home with it to use on their own volition. Don't scare yourself out of treating someone's asthma, emphysema, COPD etc just because they are already tachycardic. Dyspnea alone can cause tachycardia, let alone hypoxia or other disease process. Heck, in some cases a neb might lower a heart rate.


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## rmabrey (May 14, 2013)

Aprz said:


> I think that sentence is confusing, and makes it sound like SVT is a rhythm of its own. I also wouldn't be surprised if somebody called it SVT based on the heart rate increasing to 150 or above.



Yeah, I typed it fast as we were getting a run. A lot of medics here seem quick to call SVT based on rate alone. Judging by the medic I heard this from id be willing to bet that is the case.


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## NPO (May 14, 2013)

rmabrey said:


> Yeah, I typed it fast as we were getting a run. A lot of medics here seem quick to call SVT based on rate alone. Judging by the medic I heard this from id be willing to bet that is the case.



Hijack: refresh my EMT basic memory as its outside my scope. SVT is narrow complex tachycardia 150+ with an absent P wave, correct?


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## rmabrey (May 14, 2013)

NPO said:


> Hijack: refresh my EMT basic memory as its outside my scope. SVT is narrow complex tachycardia 150+ with an absent P wave, correct?



Correct


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## NomadicMedic (May 14, 2013)

Our protocol has us make med control contact for adults with a heart rate above 150 and above 180 for peds. Aside from that, no contraindications.


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## the_negro_puppy (May 14, 2013)

under 2 years of age 

and known adverse drug reaction


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## abckidsmom (May 14, 2013)

the_negro_puppy said:


> under 2 years of age
> 
> and known adverse drug reaction



Why under 2 years of age?


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## the_negro_puppy (May 14, 2013)

abckidsmom said:


> Why under 2 years of age?



I think the rationale is that Children under 2 years old won't be suffering from asthma or conditions causing bronchospasm-

Apparently bronchiolitis is far more common in wheezing children under 2 of which albuterol wont be effective.

This is just speculation on my behalf though. They haven't really explained why to us.


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## kaisardog (May 20, 2013)

thanks  to  all  for  a  most   enlightening  discussion .  our most  recent PA  BLS  protocol  for  albuterol  does  not  specify an  adult  bp above  which  albuterol  should  not  be  administered  without  medical control's  OK.


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## Brandon O (May 20, 2013)

kaisardog said:


> so  my question  is:  do  your particular state's   protocols define a certain  hypertensive BP  or pulse  rate  or 'other  symptoms' /conditions  which  are contraindications   for  albuterol? (assume  the  EMT is to administer it  by assisting the Pt  with  own Rx  , because pt is  wheezing &   asthmatic. )   Have  you  seen adverse  reactions  in the  field   when  albuterol  is  admin  to pts  with  previously-unknown  cardiac  issues?



Our state BLS protocol for nebulized albuterol requires that the patient be prescribed bronchodilators and have no history of ischemic heart disease. The idea being that with no history, their dyspnea is unlikely to be secondary to an ischemic cardiac cause that you'd be exacerbating.

But no, I've never seen it actually exacerbate anything; I really don't think it's ever done much to anybody. (You can actually puff an albuterol inhaler a couple dozen times for a quick rush... not that you heard it here.)



NPO said:


> Hijack: refresh my EMT basic memory as its outside my scope. SVT is narrow complex tachycardia 150+ with an absent P wave, correct?



No no no no no. No no no.

Sorry -- we've been trying to stamp this out and it's terrifying how far it's spread. The strictest definition of an SVT is any rhythm that begins above the ventricles. What's typically meant is AVNRT, which presents as a narrow complex tachycardia without normal P waves, but there is no "number" that defines it; often it'll be within a certain range, but can be faster or slower.

Some Joker-like evil villain came up with this idea that everything narrow over 150 is "SVT," and has infected all of EMS with it. The meme is even spilling into nursing and medicine. Let's kill it now and forever.


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## Rialaigh (May 20, 2013)

I have seen a cardiac patient go into V-Tach during an albuterol treatment. It was confirmed later that the treatment was the cause of the V-tach (with a pule). Pt stated no pain or abnormal feelings, after pulling the treatment off she converted back in around 4 minutes. This was on our CV-Tele floor at the hospital. I am sure this is a very rare occurance but it taught me that if I put someone other than a child on a breathing treatment they are also going on the monitor.


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## FLdoc2011 (May 20, 2013)

I think the literature doesn't support any significant adverse arrhythmic effects from nebulized albuterol.   

I know in the hospital people are trying to substitute albuterol for levalbuterol all the time when the patient becomes tachycardic but the evidence just isn't there.   All they're doing is increasing costs.  

Recall a 2011 CHEST journal article I think that showed no evidence for tachycardia or tachyarrhythmias in critically ill adult patients.


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## the_negro_puppy (May 20, 2013)

Rialaigh said:


> I have seen a cardiac patient go into V-Tach during an albuterol treatment. It was confirmed later that the treatment was the cause of the V-tach (with a pule). Pt stated no pain or abnormal feelings, after pulling the treatment off she converted back in around 4 minutes. This was on our CV-Tele floor at the hospital. I am sure this is a very rare occurance but it taught me that if I put someone other than a child on a breathing treatment they are also going on the monitor.



Perhaps a little excessive considering millions of people in America use their own albuterol at home unmonitored.

But to each their own. You will never get in trouble being overly cautious.


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## TheLocalMedic (May 21, 2013)

Where I work the only contraindication is a known sensitivity to it.  

There is talk from out medical director about simply lifting the cap on how much albuterol you can give.  I believe his word were "Give it if they're short of breath and just keep on giving it".  

Most CPAP patients in my area are also being given an in-line neb treatment as well.  The only side effect I've ever seen (and I've given a TON of albuterol out and sometimes have long long long transport times) is shakiness and a small bump in heart rate.  Nothing major.


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## Clipper1 (May 21, 2013)

Rialaigh said:


> I have seen a cardiac patient go into V-Tach during an albuterol treatment. It was confirmed later that the treatment was the cause of the V-tach (with a pule). Pt stated no pain or abnormal feelings, after pulling the treatment off she converted back in around 4 minutes. This was on our CV-Tele floor at the hospital. I am sure this is a very rare occurance but it taught me that if I put someone other than a child on a breathing treatment they are also going on the monitor.



The patient probably had a low potassium before the albuterol treatment. 

IF the patient was on tele, they may have been getting a higher dose or a more effective nebulizer to give more of the medication without losing it.  They may use a BAN or an electric particle generator. 

Some EMS agencies are doing 5 mg instead of the standard UD of 2.5 mg. But, the nebulizers used give only about 10 - 30% of the medication. This includes when it is used inline with CPAP since the high flows create turbulence which does very little for particle deposition and the exhalation ports allow most of it to escape.


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## Brandon O (May 21, 2013)

This just came up, and seems apropos

http://www.medpagetoday.com/AllergyImmunology/Asthma/39276 (might need to register to view, but it's worthwhile)


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## Christopher (May 22, 2013)

rmabrey said:


> NPO said:
> 
> 
> > Hijack: refresh my EMT basic memory as its outside my scope. SVT is narrow complex tachycardia 150+ with an absent P wave, correct?
> ...



Incorrect.

SVT is defined by but one rate: >100. And that is because it has 'tachycardia' in the name.

Hmmm, wait, so that means it should actually be relative to their age since tachycardia is age dependent.

So maybe even >100 is a poor definition.

Ok, so SVT is not, nor has been, nor ever will be, defined by a quantitative rate.

People mistakenly claim it is defined by a rate. But they're just that: mistaken.

*Supraventricular tachycardia is any tachycardia which originates in or is dependent on atrial or atrioventricular nodal tissue.*

Any other definition is misleading.

(ed: _oops just noticed Brandon knocked this one out for me, my bad_)


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