adenosine contraindicated with bronchospasm????

[zzyzx]

Here is a case study from a site for med students. The patient was given albuterol, after which her HR jumped from 115 to 189. Note that they say that adenosine is contraindicated with bronchospasm. What do you guys think?

http://clinicalcases.blogspot.com/2004/01/...ol-what-is.html

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SVT - HR 189 bpm after Albuterol, What is TSH?

Author: V. Dimov, M.D., Cleveland Clinic

Reviewer: A. Aneja, M.D., Cleveland Clinic

70 yo AAF is admitted to the hospital with CC: SOB x 2-3 days.

PMH:

COPD on home O2, multiple episodes of CP, catheterization showed normal coronaries 1 year ago (0% stenosis), EF 65%, HTN.

SOB is typical of her COPD exacerbations.

The patient is a member of the so called "50-50 club", which means that both her PaCO2 and PaO2 are in the range of 50 mm Hg.

She is visibly SOB and not able to talk with full sentences.

On physical exam she is using accessory muscles, tachycardic at 125 bpm, and not moving much air. She has never been intubated before.

SpO2 is 94% on 3L. Her home O2 is 2L/min.

After one aerosol treatment with Albuterol, her HR increases to 189 bpm, BP is 150/90.

The monitor shows a narrow complex tachycardia and she is fully AAO x 3.

What is going on?

Narrow complex tachycardia in response to Albuterol?

R/O ischemia - but the coronaries are normal?

What to do?

Follow the ACLS guidelines.

The carotid sinus massage failed to slow down the HR.

Adenosine and Lopressor are contraindicated b/o bronchospasm.

Try Cardizem?

What happened?

Cardizem 10 mg IV over 2 min brought HR down to 115 over 7 minutes.

The patient felt better.

Her aerosol Tx was switched to Xopenex and Atrovent. Solu-Medrol 40 mg IV q 6 hr was started.

TSH is <0.05 style="font-weight: bold;">Final diagnosis:

Narrow complex tachycardia due to hyperthyroidism and Albuterol.

Ischemia was ruled out.

Spiral CT ruled out PE (probably not needed - PaO2 was at baseline)

What did we learn from this case?

Always order TSH in the tachycardia work-up.

Cardizem works and it is usually safe.

Adenosine and beta-blockers are CI in acute bronchospasm.

Created: 04/2006

Updated: 03/05/2007

[AZCEP]

Look a bit deeper at what happened to this patient.

The tachycardia, was initiated by bronchospasm and worsened by a medication (Albuterol). Because the patient was still stable, they could have opted to just observe the patient until the effects of the medication wore off. This patient did not absolutely need any more cardiac specific treatment at that moment.

Adenosine can worsen bronchospasm, and there are many documented cases of it doing so. This is a known side effect of the drug, and you don't really want to add to a known problem if you can avoid it. At the same time, the effect will not last very long, and most likely would not yield a therapeutic benefit anyway. Remember, this SVT was initiated by the albuterol, not a intrinsic cardiac problem.

A beta blocker is not absolutely contraindicated for asthmatics either, but you must consider their mechanism of action. Lopressor is relatively cardio-specific, and should be safe for an attempt at slowing this rate. It would probably have a better response than the Adenosine based on it's longer duration.

With the amount of history this patient has, I wonder if this response to Albuterol had been documented previously. This is a rather unusual first time response to a medication that she would likely be on at home. Knowing how many doses of her own MDI she had used would be useful information to gather, and might lead one to switch to Xopenex to begin with.

Blanket statements about what to do should be disregarded entirely.

[Ridryder 911]

Unfortunately, they were treating the monitor NOT the patient. Like AZCEP, it has been long known the s/e of Adenocard yet, the reason to use it instead of treating appropriately puzzles me!

I would had definitely NOT published this...and let everyone know..

R/r 911

[VentMedic]

The initial rhythm was tachycardic? If multifocal atrial tach which is a baseline rhythm in some COPD pts, adenosine is not useful. if that was the underlying. MAT rate usually exacerbates with the COPD exacerbation and hyoxemia. The pt can have normal coronary arteries with cor pulmonale with EF being affected in later stages.

The use of levalbuterol (Xopenex) over the more traditionally used racemic albuterol is controversial among health care professionals. That using levalbuterol instead of albuterol produces less direct effect on beta 1 adrenergic receptors and/or less cardiac side effects has been suggested, but not consistently proven by long term, well designed clinical trials. There are differing opinions on whether there is sufficient therapeutic benefit to using levalbuterol that outweighs the 5-10 times higher price tag.

The problem that occurs when using Xopenex; it is recommended for q6 - 8 hours. Doctors want to run it frequently like they do an Albuterol protocol. Some doctors order continuous Xopenex like Albuterol. The jury is still out on that one. In most US hospitals, this is cost prohibitive. There is also more chance of paradoxical bronchospasm which is hard to pull out of.

If the doc wants a bronchodilator ran frequently, I'll take my chances with albuterol. More treatment options and versatility. Atrovent thrown in every 4 - 6 hrs. If it's a COPD pt, Diltiazem or Verapamil on board and procede with the bronchodilator protocol if pt and airways want it while watching the HR. If HR continues to increase or pt gets unstable, then treat cardiac more aggressively. Albuterol can still do some dilation until large doses of IV Beta blockers get on board. Some albuterol will remain bound to receptors during b-blocker therapy.

[Dustdevil]

Unfortunately, they were treating the monitor NOT the patient.

This is, without a doubt, among the top 5 mantras commonly repeated in medicine. We hear it all the time. We see it all the time. Yet, I am just appalled by the frequency with which it still occurrs! And not just in EMS, but in clinical and hospital practice too. I've lost respect for so many providers over the years as I watched them get tunnel vision on the monitor and totally lose sight of their patient's actual condition. When will this madness stop? :?

[AZCEP]

Probably about the time that providers come to understand the shortcomings of each piece of technology they are currently using.

Short of breath? You get the pulse oximeter and the cardiac monitor. The fact that neither will tell you what you need to know is immaterial. Some may even get the capnograph. Because it is so new, even fewer truly understand it's utility. For this patient, it would have been some useful information to obtain with the others.

Chest pain? You get the same things, and the provider gets even less specific information. Unless you are one of the 40-45% of patients that will actually show ECG changes while you are having an MI, we've just wasted a couple minutes hooking you up, and asking you to remain still so we can get a useless strip.

God help you if you have a complaint that falls in some other region of the body. Oh, we can push and prod on the abdominal pain, and perform our simplified stroke assessment, but we don't gather any clinically useful information from any technology prehospital.

Just for fun, someone should study what happens when all levels of providers have their technological support eliminated from their application. I wager that there would be a great number of people sitting in corners, weeping.

[sledogg1]

Adenosine is a no-no for asthmatics and broncospasms...............did she go into flash edema from the salbutamol now CHF, can't cardiovert V/S stable.

[zzyzx]

I found this in the drug insert for the adenosine that we use:

"Adenosine administration by inhalation has been reported to cause bronchoconstriction in asthmatic patients, presumably due to mast cell degranulation and histamine release. These effects have not been observed in normal subjects. Adenocard has been administered to a limited number of patients with asthma and mild to moderate exacerbation of their symptoms has been reported. REspiratory compromise has occured during adenosine infusion in patients with COPD. Adenocard should be used with caution in patients with obstructive lung disease not associated with bronchoconstriction (i.e. emphysema, bronchitis, ect.) and should be avoided in patients with bronchoconstriction or bronchospasm (e.g. asthma). Adenocard should be discontinued in any patient who develops severe respiratory difficulties."