Successful treatment of chloral hydrate cardiac toxicity with propranolol

Drugs of Abuse-Opioids, Sedatives, Hypnotics

Over the last 2 decades, prescription and nonprescription substance use has significantly increased. In this article, 3 particular drug classes-opioids, sedatives, and hypnotics-are discussed. For each class, a brief history of the agent, a description of relevant pharmacology, the clinical presentation of overdose, the management of specific drug overdoses, and a summary of salient points are presented. The intent is to provide a clinically relevant and comprehensive approach to understanding these potential substance exposures in order to provide a framework for management of opioid, sedative, and hypnotic overdoses.

Two Cases of Chloral Hydrate Overdose

Chloral hydrate overdose is associated with cardiac toxicities, gastrointestinal tract injuries, central nervous system and respiratory depression. Among all the complications, cardiac arrhythmias are particularly concerning and frequently reported in the literature. The majorities of fatalities from chloral hydrate overdose are due to refractory cardiac arrhythmia. Chloral hydrate-induced arrhythmias are resistant to most of the standard anti-arrhythmic agents but have good response to propranolol. We report two cases of severe chloral hydrate overdose presenting with alarming cardiac rhythm disturbances. One of the patients was successfully treated with intravenous propranolol in the accident and emergency department. The management of chloral hydrate overdose in particular to its cardiac toxicity is reviewed.

Pediatric chloral hydrate poisonings and death following outpatient procedural sedation

INTRODUCTION

Chloral hydrate has been used medicinally since the 1800 s as a sedative hypnotic, most commonly for procedural sedation. As it is administered orally and available in a liquid formulation, it is used almost exclusively in pediatric patients despite many safer and more effective alternative agents being available.

CASE SERIES

We present three cases of pediatric chloral hydrate poisoning, all occurring following procedural sedation in outpatient clinic settings and presenting to the emergency department. The ages ranged from 15 months to 4 years of age and all required resuscitation. Unfortunately, the 4-year-old died.

CONCLUSION

Choral hydrate is associated with significant adverse effects, including death, and safer alternatives for pediatric procedural sedation should be sought and utilized. There are a number of more effective sedative agents with more predictable pharmacokinetic and safety profiles than chloral hydrate including parenteral and oral agents. The practice of pre-procedure sedation should be performed only in a supervised setting where cardiorespiratory monitoring can occur in all cases.

Toxicology in the ICU: Part 2: specific toxins

This is the second of a three-part series that reviews the generalized care of poisoned patients in the ICU. This article focuses on specific agents grouped into categories, including analgesics, anticoagulants, cardiovascular drugs, dissociative agents, carbon monoxide, cyanide, methemoglobinemia, cholinergic agents, psychoactive medications, sedative-hypnotics, amphetamine-like drugs, toxic alcohols, and withdrawal states. The first article discussed the general approach to the toxicology patient, including laboratory testing; the third article will cover natural toxins.

Electrocardiographic changes with segmental akinesia after chloral hydrate overdose

We report a case of deliberate ingestion of 12.5 g chloral hydrate in a 25-year-old psychiatric patient. Coma and life-threatening ventricular dysrhythmias were observed soon after ingestion. Repeated electrocardiographic examination was consistent with ischemic changes appearing on day 3. They were associated with segmental abnormal left ventricular wall motion by echocardiography. A coronary angiogram was performed and was normal. Toxic metabolites of chloral hydrate, trichloroethanol and trichloroacetic acid were found in the urine until day 7. This case illustrates that with halogenated aliphatic hydrocarbons, sustained changes in cardiac contractility may occur in addition to early life-threatening ventricular dysrhythmias.

Adverse effects of sedatives in children

The application of sedation/analgesia in paediatric patients is rapidly expanding as less invasive, non-operative techniques of diagnosis and treatment are applied to the paediatric population. Medical providers who are asked to provide sedation may include radiologists, paediatricians, nurses and emergency physicians, as well as anaesthesiologists and intensive care physicians. At the same time, the range of drugs used in these settings has expanded considerably. As there is no single drug fulfilling the criteria for the ideal sedative (rapid-onset, rapid recovery, no adverse effects, immobility appropriate to procedure being performed), multiple drugs may be used in combination. It is imperative that practitioners using drugs for sedation/analgesia in children be aware of the adverse effect profile(s) of these drugs, both individually and in combination. The purpose of this review is to describe the adverse effects of sedative and reversal agents currently used in paediatric sedation/analgesia.