Chloral hydrate toxicity: Difference between revisions
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''Similar to [[barbiturates]] and [[hydrocarbons]]<ref>Whyte IM. Chapter 140 Miscellaneous Anziolytics, Sedatives and Hypnotics; in Dart R, Medical Toxicology (3rd edition), Philadelphia: Lippincott Williams and Wilkins, 2004.</ref>'' | ''Similar to [[barbiturates]] and [[hydrocarbons]]<ref>Whyte IM. Chapter 140 Miscellaneous Anziolytics, Sedatives and Hypnotics; in Dart R, Medical Toxicology (3rd edition), Philadelphia: Lippincott Williams and Wilkins, 2004.</ref>'' | ||
*Neuro | *Neuro | ||
**Sedation, ataxia, coma | **Sedation, [[ataxia]], [[coma]] | ||
*GI | *GI | ||
**Erosive gastritis, [[upper gastrointestinal bleeding]], strictures | **Erosive [[gastritis]], [[upper gastrointestinal bleeding]], strictures | ||
**[[Hepatitis]] | **[[Hepatitis]] | ||
**Breath smells like pears | **Breath smells like pears | ||
*Renal | *Renal | ||
**Nephrotoxicity, proteinuria | **Nephrotoxicity, [[proteinuria]] | ||
*CV | *CV | ||
**[[Hypotension]] | **[[Hypotension]] | ||
**Myocardial depression | **Myocardial depression | ||
** | **[[Tachyarrhythmias]] secondary to catecholamine hypersensitivity: [[Sinus tachycardia]], [[PVCs]], [[ventricular tachycardia]], [[ventricular fibrilation]], [[Torsades]] | ||
* | *Respiratory | ||
** | **[[Respiratory failure|Respiratory depression]], airway obstruction (from muscle relaxation) | ||
**Aspiration pneumonitis | **[[Aspiration pneumonitis]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 45: | Line 45: | ||
*[[ECG]]: Dysrhythmias | *[[ECG]]: Dysrhythmias | ||
*[[CXR]]: | *[[CXR]]: | ||
**Pneumonitis or pulmonary edema | **[[Pneumonitis]] or [[pulmonary edema]] | ||
**Chloral hydrate may be | **Chloral hydrate may be radiopaque | ||
*LFTs: monitor for hepatic injury | *[[LFTs]]: monitor for hepatic injury | ||
*BUN/Cr: monitor for renal injury | *BUN/Cr: monitor for renal injury | ||
*[[Troponin]]: Myocardial injury | *[[Troponin]]: Myocardial injury | ||
| Line 56: | Line 56: | ||
*Airway management with intubation and ventilation for CNS depression | *Airway management with intubation and ventilation for CNS depression | ||
*BP monitoring | *BP monitoring | ||
**IVF | **[[IVF]] | ||
**Avoid catecholaminergic [[vasopressors]] | **Avoid catecholaminergic [[vasopressors]] | ||
*Monitor for dysrhythmias | *Monitor for dysrhythmias | ||
| Line 62: | Line 62: | ||
**Give or titrate BB until response | **Give or titrate BB until response | ||
*Decontamination not useful for isolated chloral hydrate ingestions due to | *Decontamination not useful for isolated chloral hydrate ingestions due to rapid absorption | ||
*Assume corrosive GI injury until ruled out. | *Assume corrosive GI injury until ruled out. | ||
Latest revision as of 18:04, 16 October 2019
Background
- Sedative-hypnotic used for insomnia
- Binds GABA-A receptor
- Active metabolite trichloroethanol (TCE)
- Sometimes still used in pediatrics for children undergoing procedures
- Rarely used in practice in adult medicine
- ‘Mickey Finn’ most commonly refers to a mixture of ethanol and chloral hydrate, aka a "knockout drink."
Pharmacokinetics
- Onset: 30-60 min[1]
- Duration: 4-8 hr
- Half-Life: 5 mins (for chloral hydrate)
- 8-11 hr (active metabolite)
- Metabolism: Hepatic metabolism
- Excretion: Mostly in urine; some feces
- Potential toxic dose
- <6 years old: 50mg/kg
- Adults: 3-10g
Clinical Features
Similar to barbiturates and hydrocarbons[2]
- Neuro
- GI
- Erosive gastritis, upper gastrointestinal bleeding, strictures
- Hepatitis
- Breath smells like pears
- Renal
- Nephrotoxicity, proteinuria
- CV
- Hypotension
- Myocardial depression
- Tachyarrhythmias secondary to catecholamine hypersensitivity: Sinus tachycardia, PVCs, ventricular tachycardia, ventricular fibrilation, Torsades
- Respiratory
- Respiratory depression, airway obstruction (from muscle relaxation)
- Aspiration pneumonitis
Differential Diagnosis
Sedative/hypnotic toxicity
- Absinthe
- Barbiturates
- Benzodiazepines
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Opioids
- Toxic alcohols
- Xylazine toxicity
Evaluation
Evaluation
- Clinical diagnosis
Workup
- ECG: Dysrhythmias
- CXR:
- Pneumonitis or pulmonary edema
- Chloral hydrate may be radiopaque
- LFTs: monitor for hepatic injury
- BUN/Cr: monitor for renal injury
- Troponin: Myocardial injury
- Consider endoscopy
Management
Generally supportive care
- Airway management with intubation and ventilation for CNS depression
- BP monitoring
- IVF
- Avoid catecholaminergic vasopressors
- Monitor for dysrhythmias
- Treat with beta-blockers to include esmolol infusion, metoprolol, or propranolol[3]
- Give or titrate BB until response
- Decontamination not useful for isolated chloral hydrate ingestions due to rapid absorption
- Assume corrosive GI injury until ruled out.
Disposition
Asymptomatic
- Observe for 4 hours
Symptomatic
- Admit for monitoring
- GI: Endoscopy within 24 hrs
- CV: Telemetry
See Also
External Links
References
- ↑ Medscape: Chloral hydrate
- ↑ Whyte IM. Chapter 140 Miscellaneous Anziolytics, Sedatives and Hypnotics; in Dart R, Medical Toxicology (3rd edition), Philadelphia: Lippincott Williams and Wilkins, 2004.
- ↑ Zahedq A, Grant MH, Wong DT. Successful treatment of chloral hydrate cardiac toxicity with propranolol. American Journal of Emergency Medicine 1999; 17(5):490-491.