Pediatric emergency medicine trisk 3084 3084
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particularly those of the head and neck. Patients may develop torticollis, bruxism,
tongue protrusion, or oculogyric crisis. Dystonic reactions are unrelated to the
amount of ingested phenothiazine. They may or may not occur after the first dose.
Their onset is 8 to 40 hours after ingestion of a single dose of phenothiazine. This
marked delay between ingestion and clinical manifestations often interferes with
obtaining an accurate history of ingestion. Fortunately, although painful and
distressing, dystonic reactions are rarely life threatening and usually resolve
quickly after administration of anticholinergics.
The clinical chemistry of the newer antipsychotic agents is varied and complex.
CNS depression, seizures, prolongation of the QT interval, and α-adrenergic
blockade–mediated hypotension are common.
Treatment of acute phenothiazine intoxication depends on the severity of
ingestion. The autonomic signs are most often transient and require no treatment.
In patients with moderate or severe overdoses, the potential for life-threatening
manifestations requires prompt evaluation of vital signs, GI decontamination (if
ingestion was within an hour of ED arrival), vascular access, and cardiac
monitoring. Pressors such as norepinephrine (see Chapter 10 Shock ) may be used
to correct the hypotension. In those rare instances of hypertension, the use of
nitroprusside (see Chapter 37 Hypertension ) may be indicated. Severe
arrhythmias should be treated aggressively. Attention should be directed to the
treatment of temperature instability and other autonomic disturbances.
Dystonic reactions are effectively controlled by the IM or IV administration of
diphenhydramine in a dose of 1 to 2 mg/kg (max 50 mg/dose). Repeat this dose in
15 to 20 minutes if no effect is noted. An alternative agent is benztropine
mesylate (1 to 2 mg for an older child/adolescent). This agent reportedly causes
less sedation than diphenhydramine. Another potential alternative, especially in
younger children, is diazepam (0.1 to 0.2 mg/kg). After resolution of the dystonic
reaction, continue oral treatment for an additional 24 to 72 hours to prevent
recurrences.
Salicylates
CLINICAL PEARLS
