Altered Mental Status??

[AZCEP]

Secure an airway, get enroute to a facility.

[chbare]

The patient is RSI'd and an age appropriate ETT is placed with confirmed subjective and objective findings. You are enroute the the hospital.

Take care,

chbare.

[AZCEP]

Vitals every 5 minutes.

Second IV, fluid bolus, and consider a pressor.

Perhaps even a follow up Narcan dose.

Without being able to gather the information from the parents, this is going to be tricky at best. A normally healthy, 21 month old should not be reacting this way to OTC cough medicine. If in fact he did ingest it, he would have had to suck down a lot to get this reaction.

With the airway secured, I'm less concerned about waking him up now. His heart rate and blood pressure are my focus.

[chbare]

Second IV is placed and a bolus of NS 250 ML is administered. The blood pressure stabilizes after the bolus and you give careful doses of benzos to maintain sedation and control the seizures. Upon arrival at the hospital the patients hemodynamic status is much more stable. The grandma arrives with all of her medications. The medications she takes include:

Lisinopril 10 mg po q day

Lasix 40 mg po Q day

K Dur 20 MEq po Q day

Albuterol MDI 2 puffs Q 4 hours PRN

Albuterol SVN 2.5 mg Q 4 hours PRN

Zithromax 250 mg po Q day (3rd day of the pack)

Benzonatate 100 mg tid

Tylenol 650 mg po Q 6 hours PRN

Tussin DM OTC 2 teaspoons PO PRN

MVI PO Q day

She is not sure how many pills may be missing and the bottles are all in bulk, so you are unable to get an accurate count of the meds and determine what was taken.

What med is the culprit and what do we do?

Take care,

chbare.

[AnthonyM83]

Are we sure we can rule out anticholinergics?

Benadryl seems like a common drug founds in "cough medicines" and would account for the lethargy and low BP and possibly irregular HB...Could that stress lead to a heart block? (A topic I know little about)

I would request PD assistance, having them respond to the grandmother's house to look through her medicine, perhaps even taking the family to point out what the baby took.

[AZCEP]

An anticholinergic toxidrome is significantly different from how this patient is presenting.

http://www.intox.org/databank/documents/tr...ate/trt05_e.htm

The antihistamine effects of benadryl are a possibility since the 21 month old nervous system hasn't fully developed it's parasympathetic response. The more likely cause of the problem, if the eight year old is to be believed is the kiddo got into the Tussin DM.

Repeated doses of Narcan have been anectdotally effective, but very unreliable for management of the problem.

I'd truly consider letting this patient sleep it off. Maintain vital functions and closely monitor, but the specific treatment of a DM ingestion is supportive care only.

[chbare]

The patient's brother comes foreword and says he took these.

Take care,

chbare.

[AnthonyM83]

Is that a round gel capsule with a only a T on it?

[chbare]

Yes, that is what the medication in question looks like. Think about some of the patients symptoms. Focus on the neurological symptoms and think about the mechanism of action of the suspect medications. This is a hard scenario to solve and knowing the cause will do little to change our treatment; however, it will help us understand the patient's signs and symptoms.

Take care,

chbare.

[mediccjh]

Would that be Tussin? It's the only T I can think of that looks like a gel.

Hi-flow O2, BVM, ETT if needed

IV or IO, blood sugar

Narcan 0.1 mg/kg

Dextrose if blood sugar <60 mg/dL

Next time, take that pill that says W for Water, or P for Placebo.