A mother bring her 12 months old baby being more sleepy 2 hours after drinking unknown amount of his older brother's medicine while playing together.
On examination ,child is sleepy but arousable. Vital signs:HR 150 , BP: 120/70, T:37.5, RR:25,SPO2:98% in R.A, blood sugar:
6 mmol/l ,rest of examination is unremarkable
Q1What are the expected toxicity?
Q2 How you will manage this child?
Sleepy Baby Cont'
Thank you all for your excellent comments.
Antihistamine toxicity is variable specially with different generation , with newer generation having more cardiac than CNS manifestations
In general, toxicity occurs after ingestion of 3-5 times the usual daily dose of antihistamine.
Signs and symptoms resemble anticholinergic syndrome and appear within 30 minutes-2 hours after ingestion.
o CNS effects: excitation, psychomotor agitation, convulsions is common in children. Drowsiness,
sedation, delirium, hallucinations, coma are common in adults.
o Anticholinergic effects: hyperthermia, tachycardia, hypertension, fixed and dilated pupils, blurry vision , diplopia, dry mouth and
urinary retention.
o Cardiac effects: myocardial depression, QRS widening (common with diphenhydramine overdose), QT
prolongation-resulting in torsades de pointes (polymorphic VT), cardiac arrythemia
o GI effects: nausea, vomiting, diarrhea, or constipation, decreased bowel sounds
Management:
Mainly supportive and symptomatic patients need admission for observation.
Physostigmine: is used in pure anticholinergic poisoning and not routinely recommended for antihistamine drug overdose/poisoning due to its own toxicity (seizures, bronchoconstriction and asystole).
- It should be considered only in cases of severe toxicity (severe delirium, seizures and supraventricular
tachyarrhythmias unresponsive to other measures) of pure anticholinergic poisoning (not in tricyclic
antidepressant overdose, due to bradydysrhythmias and asystole in such cases).
References:
National management Guidelines of Poisoning.
I would consider physostigmine and It would be great to see an EKG. Is the child hallucinating?
——toxicity
Arrhythmia
High BP
AKI
rhabdomyolysis
Seizure
——-Management
-ABC
-vitals-BP,HR,Spo2,RR,temperature
-RBS
-ECG
-weight the child
-assess hydration-had risk of rhabdomyolysis and high BP
-Activated charcoal by NGT(1 g/kg) as he is a sleeping and risk of aspiration pneumonia(so confirm NGT by CXR)
-admit the child for 24 hr for observation as he had altered mental status
-as he had high BP for his age and sex-so check by proper size cuff each 2 hr
-check BP every 6 hrs if got normal reading
-keep him on monitor
-send and trace blood for RFT,urea ,LFT,CK
-meanwhile take more focused history (seizure,activity,urine color…)and give advise to prevent such events in future
This is antihistamine/anticholinergic toxicity.
The expected toxicity are CNS (seizures, agitation, sedation/drowsiness), anticholinergic effects such as hyperthermia, tachycardia, hypertension and urinary retention. CVS such as QT prolongation, tachyarrhythmias (polymorphic VT), and GI effects such as N/V, constipation. In this case he has lethargy, hypertension and tachycardia. The approach will be as following:
IV access to be established, basic labs need to be send (CBC, LFT, RFT, CK, ABG, serum paracetamol level).
Monitor vitals, cardiac activity for any arrhythmias, observe for seizures, symptomatic support and treatment for any adverse effects.
So, will admit the child for at least 24 hrs for observation of the above mentioned.