Drug-Induced Extrapyramidal Symptoms at the Pediatric Emergency Department.

OBJECTIVES: Extrapyramidal symptoms (EPS) induced by pharmacologic agents can cause patient discomfort and lead to emergency department visits. Analyzing these cases at a pediatric emergency department may help to elucidate the characteristic features of extrapyramidal syndrome in children. METHODS: This retrospective study was conducted at Chang Gung Memorial Hospital in Taiwan. Pediatric patients with drug-induced extrapyramidal syndrome seeking treatment at our emergency department from January 2001 to December 2010 were enrolled. The patients' clinical features, drug history, demographic data, and treatment data were collected and analyzed. RESULTS: One hundred nineteen patients (61 females, 58 males) were enrolled. Ninety-six patients could provide their drug history; all of whom took dopamine antagonists and 90% of whom took dopamine antagonists as antiemetic agents, with only 9 patients taking them for antipsychotic purposes. Metoclopramide syrup overdose was the main cause of extrapyramidal syndrome in patients under 2 years old. The average emergency room stay of the patients who could provide their drug history was shorter than that of those who could not. CONCLUSIONS: It is not uncommon for patients with drug-induced EPS to present to a pediatric emergency room owing to the use of dopamine antagonists as antiemetic agents. Clinical symptoms with a clear drug history are helpful for the diagnosis and management. Emphasizing the correct usage of liquid medications will reduce the risk of EPS.

Fatal diphenidol poisoning: a case report and a retrospective study of 16 cases.

Diphenidol hydrochloride (DPN), a nonphenothiazinic antiemetic agent used primarily in patients with Meniere disease and labyrinthopathies to treat vomiting and vertigo, is considered to be a relatively safe drug. Since it was first approved in the United States in 1967, this drug has been widely used in Latin America and Asia and has contributed to sporadic suicidal and accidental poisonings in mainland China and Taiwan. However, its toxic or lethal concentration ranges have not yet been determined. We report a case of a 23-year-old female who suffered from DPN poisoning that resulted in death. At autopsy, there were no typical pathological findings, except for cerebral edema with high acetylcholinesterase expression. Postmortem analysis of DPN revealed 45 µg/ml in heart blood, 39 µg/ml in femoral vein blood, 141 µg/g in the liver, and 53 mg in the gastric contents. These concentrations indicated that the cause of death was DPN poisoning. The circumstances indicated that the manner of death was suicide. We also present a retrospective study, in which we review and summarize the literature from 1998 to 2014 and describe 16 cases of poisoning, including information from autopsy reports and postmortem drug concentrations. In forensic practice, drug residues at the scene, patients with convulsions and disturbance of consciousness, and rapidly occurring deaths, should draw attention to the possibility of this drug. Toxicological analysis and the exclusion of other diseases may ultimately be used to confirm DPN poisoning.

The associative factors of delayed-onset rhabdomyolysis in patients with doxylamine overdose.

OBJECTIVES: The aim of this study was to investigate the associative factors of rhabdomyolysis in patients with doxylamine overdose who had normal creatine phosphokinase levels at admission. METHODS: This study included 169 patients who visited the emergency department of a tertiary teaching hospital after doxylamine overdose between January 1, 1998, and March 31, 2009. Demographic information, clinical variables, and laboratory data were investigated for the associative factors of rhabdomyolysis. RESULTS: Thirty-five (21%) of the 169 patients developed rhabdomyolysis. Patients who developed rhabdomyolysis differed from those who did not in the amount of doxylamine ingested, sex, heart rate, initial value of serum creatinine, and alanine aminotransferase. In the multivariate regression analysis, the only reliable predictors of rhabdomyolysis were the amount of doxylamine ingested (P = .004) and heart rate (P < .001). CONCLUSION: Observation and laboratory follow-up are required for patients with large reported ingestions or tachycardia on admission, even if their creatine phosphokinase levels were normal.

[Dimenhydrinate overdosage in a 3(1/2) year-old-girl with dilative cardiomyopathy]. / Dimenhydrinat-Intoxikation bei einem 3(1/2) Jahre alten Mädchen mit dilatativer Kardiomyopathie.

Dimenhydrinate overdosage in a 3(1/2) year-old-girl with dilative cardiomyopathy. Dimenhydrinate (Vomex(R)) is frequently used in the treatment of sickness and vomiting. The symptoms of overdosage present like an anticholinergic syndrome. We report on the clinical findings of an intoxication with dimenhydrinate in a 3(1/2) year-old-girl with functional dilative cardiomyopathy following a congenital left ventricular diverticle. Especially in small children, with the application of 40 mg suppositories once or twice per day the maximum dose of 3.75 mg/kgBW/d is achieved.

Obtundation and seizure following ondansetron overdose in an infant.

INTRODUCTION: Ondansetron, an increasingly prescribed 5-HT(3) antagonist used in the management of nausea and vomiting of various etiologies, has a well-established safety profile in therapeutic use. However, little is known about its effects in the setting of an overdose. We describe the first case of severe toxicity in an infant who unintentionally ingested a large quantity of ondansetron. CASE REPORT: A 12-month-old infant who ingested seven to eight tablets of his mother's Zofran (ondansetron) ODT 8 mg rapidly developed obtundation and myoclonic movements. While treated by health care providers, he developed seizures, hepatotoxicity, QTc prolongation, and a serotonin syndrome that required endotracheal intubation and intensive care unit management. His clinical status improved over the course of 24 h with supportive care, and he was discharged to home with no sequelae. DISCUSSION: With the increasing popularity of ondansetron among health care providers, particularly for the control of nausea in pregnant women, toddlers in the household may become inadvertently exposed to ondansetron toxicity. This case portrays that, despite the safety of this agent in therapeutic dosage, severe toxicity may be seen in excessive amounts, particularly in infants. CONCLUSION: Health care providers should recognize the risk for acute toxicity following ondansetron overdose, particularly in infants and toddlers.

Dolasetron overdose resulting in prolonged QTc interval and severe hypotension: a case report and literature review.

Dolasetron (Anzemet) overdose is uncommon, and, to our knowledge, this is the only case report of an intentional overdose. Dolasetron (dolasetron mesylate) is a selective 5-hydroxytryptamine 3 antagonist derived from pseudopelletierine, and is used in the prevention and treatment of nausea and vomiting. Transient and asymptomatic ECG changes, including QRS widening and PR and QTc prolongation, have been reported in therapeutic doses. The case of a 21-year-old woman who presented after an intentional overdose of 10x200 mg dolasetron tablets resulting in prolongation of the QTc interval and severe hypotension is reported here. Management of hypotension included intravenous fluid resuscitation and norepinephrine infusion with invasive monitoring in a high dependency unit. Sodium cardiac channel block contributes to cardiotoxicity observed in dolasetron overdose. Sodium bicarbonate was used in an attempt to reduce cardiac sodium channel block, although we observed no apparent benefit. As dolasetron becomes more commonly used in the outpatient setting, both doctors and patients need to be aware of the dangers of dolasetron in toxic doses. The pharmacology and toxicology of dolasetron are discussed.

Clinical experience in acute overdosage of diphenidol.

BACKGROUND: Diphenidol (Cephadol, Vontrol), an antiemetic agent used in the treatment of vomiting and vertigo, has been reported to cause various adverse effects including drowsiness, hypotension, confusion, hallucination, restlessness, and other antimuscarinic effects. Serious toxic effects might be anticipated after intentional or accidental ingestion. MATERIALS AND METHODS: Retrospective analysis of all case records of the PCC-Taiwan defining diphenidol overdose during 1985-1996. RESULTS: The data of 21 patients with diphenidol overdose were analyzed; 17 were < 3 years old and unintentionally poisoned, in contrast to the suicide attempts by four adults. The average amount of ingestion was 222.5 mg with a range of 25-800 mg. Most patients manifested only transient CNS, cardiovascular, or oculo-facial effects, but four children suffered from severe toxicity after an ingestion of 11.7-80 mg/kg diphenidol. Commonly reported toxicity in diphenidol overdose included facial flush (10), tachycardia, restlessness (6), seizures (4), dyspnea, drowsiness, mydriasis, coma, and fever (3). With supportive therapy, a good recovery was the rule except for one fatality of a 2 1/2-year-old boy who ingested 15 mg/kg diphenidol and presented with recurrent seizures, hypotension, respiratory failure, and coma. CONCLUSIONS: Although not previously reported, accidental diphenidol overdose may result in serious anticholinergic toxicity in children. Treatment is supportive and the therapeutic role of physostigmine in diphenidol poisoning is still unclear.

Metoclopramide toxicity in an infant.

Metoclopramide (4-amino-5-chloro-N-2-methoxybenzamide) is a central and peripheral acting dopamine antagonist. It also stimulates motility in the upper gastrointestinal tract and increases lower esophageal sphincter pressure. In the pediatric population, it is used extensively as an antiemetic and in the treatment of gastroesophageal reflux disease. The case of a six-month-old infant who was accidentally overdosed with 24 mg (3 mg/kg) of metoclopramide within a nine-hour period is presented. The patient demonstrated toxic extrapyramidal effects. There have been multiple early reports in the European literature of acute extrapyramidal reactions in the pediatric population, but no reports of toxicity exist in the current emergency medicine literature.

Lessons to be learned: a case study approach. Hyperactivity and confusion in the presentation of hyoscine overdose.

The case report is presented of a ten-and-a-half year old boy with acute onset of confusion and visual hallucinations, subsequently confirmed to be due to hyoscine toxicity following ingestion of over-the-counter (OTC) travel sickness tablets. It is suggested that packs of such pills should carry a prominent cautionary label. A clear clinical history is very important--not only in aiding the differentiation of acute viral infections involving the central nervous system (such as acute encephalitis) from drug toxicity, but also in rationalizing any further diagnostic investigations. The possible underlying reasons for drug ingestion in this case are discussed.

[Tetanus: problems of differential diagnosis in the presence of contemporaneous administration of metoclopramide]. / Tetano: problemi di diagnosi differenziale in presenza di contemporanea assunzione di metoclopramide.

Here we report a clinical case concerning differential diagnosis between tetanus and metoclopramide intoxication. A 67 year old woman was admitted to our intensive care unit complaining of both trisma and four limbs hypertone soon after a massive metoclopramide bolus administration. The patient was affected by a chronicle renal insufficiency and a diagnosis of metoclopramide intoxication was made. The long lasting dystonic symptomatology together with respiratory insufficiency ruled out the hypothesis of drug overdose. The intensive care physicians would take into account that at least a 24 hours clinical observation is mandatory in order to perform a correct diagnosis.

Promethazine toxicity in a seven-month-old Doberman pinscher.

A 7-mo-old female Doberman Pinscher undergoing antibiotic treatment for tonsillitis was presented in near collapse with markedly low blood pressure, tachycardia, dilatation of pupils (non-responsive to light), and gastrointestinal distress. Since the owner could provide no history of significant toxin exposure, general supportive and non-specific toxicologic treatment protocols were initiated. Within 4 h marked improvement was observed. The owner's wife revealed that promethazine suppositories had been administered at a toxic level to control the vomition accompanying the tonsillitis.

Rapid emesis from high-dose ipecac syrup in adults and children intoxicated with antiemetics or other drugs.

The effect of ipecac syrup as an emetic in adults as well as children who had ingested antiemetics or other drugs was evaluated. Adults or children over five years of age were given 30 ml of ipecac syrup followed by 360 ml of water; children aged one to five years were given 15 ml ipecac syrup followed by 240 ml of water. If emesis was not induced within 30 minutes, a second dose was administered. Of 232 patients studied (199 adults and 33 children), 188 (81%) vomited following the first dose, 34 (15%) required two doses and seven (3%) did not vomit. Of 63 patients who had ingested drugs with antiemetic properties, 51 (81%) vomited following the first dose, nine (14%) required a second dose and three (5%) did not vomit. The time from ipecac administration to the onset of emesis in all 232 patients averaged 24.2 minutes. Ipecac was successful in inducing rapid emesis in both adults and children who had ingested antiemetics or other drugs, probably as a result of its irritating effect on the gastric mucosa.