What are the treatment options for a pediatric albuterol (salbutamol) overdose?

Management of Pediatric Salbutamol (Albuterol) Overdose

The treatment of pediatric salbutamol overdose requires prompt recognition of symptoms and supportive care focused on managing cardiovascular, metabolic, and respiratory effects, with close monitoring for late complications such as hypoglycemia.

Clinical Manifestations of Salbutamol Overdose

• Common manifestations include tachycardia (with rates up to 200 beats/min in children), hypertension, tremor, agitation, and metabolic disturbances 1, 2
• Cardiovascular effects: tachycardia, widened pulse pressure, and occasionally hypotension 2
• Metabolic effects: hypokalemia, hyperglycemia initially (followed by potential late hypoglycemia), and lactic acidosis 3, 4
• Neuromuscular effects: tremor, agitation, restlessness 3, 2
• In severe cases, seizures may occur 1

Initial Assessment and Management

• ABC approach (Airway, Breathing, Circulation) with team-based care to accomplish multiple tasks simultaneously 5
• Remove any remaining medication and maintain airway patency 5
• Administer high-flow oxygen if respiratory distress is present 5
• Obtain baseline vital signs with continuous cardiac monitoring 5
• Establish intravenous access for fluid administration and medication if needed 5

Supportive Care

• Intravenous fluid hydration to support circulation and enhance elimination 3
• Consider activated charcoal for recent oral ingestions (within 1 hour) 3
• Monitor vital signs frequently, with particular attention to heart rate and blood pressure 5
• Elevate patient's legs if hypotension develops 5

Laboratory Monitoring

• Obtain baseline electrolytes with particular attention to potassium levels 4, 2
• Monitor blood glucose levels regularly (initially and at 4-hour intervals) due to risk of late hypoglycemia 3
• Consider arterial blood gas analysis in severe cases to assess for metabolic acidosis 4
• Serial ECG monitoring for patients with significant tachycardia or arrhythmias 5

Management of Specific Complications

Cardiovascular Effects

• For severe tachycardia or hypertension that is hemodynamically significant, consider cardiology consultation 5
• Most cardiovascular effects resolve within 4-6 hours with supportive care alone 3

Metabolic Abnormalities

• For hypokalemia: potassium replacement if symptomatic or levels <3.0 mEq/L 4, 2
• For hypoglycemia: intravenous glucose administration (2-4 ml/kg of 10% dextrose) 3
• Continue glucose monitoring for at least 24 hours due to risk of late hypoglycemia 3

Respiratory Effects

• For bronchospasm (rare in overdose but possible in withdrawal): consider ipratropium bromide 250-500 μg via nebulizer 5
• In severe cases with persistent bronchospasm, consider IV magnesium sulfate 5

Observation Period and Disposition

• Most patients can be discharged after 6 hours of observation if symptoms are resolving 2
• Extended observation (24 hours) is recommended for:
  • Patients with significant metabolic abnormalities 3, 4
  • Patients with persistent tachycardia beyond 6 hours 2
  • Ingestions exceeding 1 mg/kg (threshold dose for multiple toxic effects) 2
  • Children under 2 years of age 2

Special Considerations

• The threshold dose for developing three or more signs of toxicity is approximately 1 mg/kg 2
• Most cases of salbutamol overdose in children are benign and self-limiting 2
• Specific antidotes are generally not required; treatment is primarily supportive 2
• Consider transfer to pediatric intensive care for patients requiring IV salbutamol for severe asthma (not overdose) who exceed protocol doses (>1.0-1.5 mcg/kg/min) 4

Follow-up Recommendations

• Ensure proper medication storage and supervision to prevent future accidental ingestions 2
• Review asthma management plan if overdose occurred in context of poor symptom control 6
• Follow-up with primary care provider within one week 5