Pediatric emergency medicine trisk 3069 3069
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manifestations include altered mental status that may range from lethargy to
coma. Patients may also develop hypothermia. In severe intoxications, coma,
miosis, and respiratory depression may appear. The cardiovascular changes that
accompany clonidine intoxications may range from an initial transient period of
hypertension (often resolved prior to arrival in the ED) to profound hypotension
and bradycardia. Clonidine-induced hypertension is believed to result from αadrenergic effects at peripheral vascular receptors prior to the central,
antihypertensive effect. The clinical picture of clonidine intoxication typically
lasts 8 to 24 hours.
Because patients with severe intoxication often have coma and respiratory
depression, emergency endotracheal intubation may be necessary. Also, because
of blood pressure instability, vascular access should be achieved immediately.
Hypotension should be treated with fluids and vasopressors as needed.
Hypertension is generally uncommon, is very transient, and rarely requires
specific treatment.
Activated charcoal binds clonidine. In addition to supportive care measures,
other pharmacologic interventions may be effective. Naloxone has been
suggested as a specific antidotal agent after clonidine intoxication, based on case
reports of improved mental status and cardiorespiratory function after its
administration. However, in reported case series, there have not been consistent
improvements after naloxone administration.
Because naloxone is a benign agent in an opioid-naïve child and may
potentially improve mental status to the extent that intubation becomes
unnecessary, administer a trial dose of 0.1 to 0.2 mg/kg. Large amounts of
naloxone (up to 8 mg) should be provided before concluding that the intoxication
is not responsive to naloxone. If effective, it may be necessary to administer
repeat doses or a continuous infusion. Other pharmacologic agents that have been
used in the past include yohimbine, tolazoline, and phentolamine, but evidence
for efficacy from these agents has not been demonstrated.
Digoxin
Current Evidence. Digoxin is still widely used in young infants with congenital
heart disease and elderly patients with congestive heart failure. This medication’s
continued popularity, its narrow therapeutic index, and the appealing color of
digoxin elixir make it a source of many childhood poisoning episodes annually.
Also, related agents, particularly the foxglove and oleander plants, are
occasionally ingested by children, leading to a clinical picture identical to that of
digoxin.
