We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Chloral hydrate toxicity
From WikEM
Contents
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
- Sedation, ataxia, coma
- GI
- Erosive gastritis, upper gastrointestinal bleeding, strictures
- Hepatitis
- Breath smells like pears
- Renal
- Nephrotoxicity, proteinuria
- CV
- Hypotension
- Myocardial depression
- Tachydysrhythmias secondary to catecholamine hypersensitivity: Sinus tachycardia, PVCs, ventricular tachycardia, ventricular fibrilation, Torsades
- Resp
- Resp depression, airway obstruction (from muscle relaxation)
- Aspiration pneumonitis
Differential Diagnosis
Sedative/hypnotic toxicity
- Toxic alcohols
- Benzodiazepines
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
- Barbiturates
- Opioids
- Chloral hydrate
- Absinthe
Evaluation
Evaluation
- Clinical diagnosis
Workup
- ECG: Dysrhythmias
- CXR: Pneumonitis or pulmonary edema
- 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 propanolol[3]
- Give or titrate BB until response
- Decontamination not useful for isolated chloral hydrate ingestions due to rapidl 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.
