See also

Poisoning – Acute Guidelines for Initial Management
Acute pain management 

Key points

1. Chloral hydrate is used safely for in-hospital sedation but it has been associated with deaths, particularly when used in the outpatient setting, usually in doses >10g,
2. Chloral hydrate has a narrow therapeutic index. Recommended dose is 10-50 mg/kg up to 2g. Severe toxicity is seen at >100 mg/kg

For 24 hour advice, contact Victorian Poisons Information Centre 13 11 26

Background

• Chloral hydrate is used primarily for sedation for radiological and dental procedures.
• Toxicity is rapid onset (<30 min) with CNS depression and cardiac dysrhythmias.
• It can be corrosive to mucosal surfaces in high doses

Pharmacokinetics

• Absorption is rapid, but slower if fasting.
• Peak serum concentration occurs in 30-60 mins.

Dose related toxicity

• Care should be taken with giving multiple doses over a short period of time.
• No more than 100 mg/kg should be given per procedure
• No more than 200 mg/kg should be given over a 24 hour period.
• Doses higher than the above are associated with coma and cardiac dysrhythmias.
• Acute overdose >10 g can cause gastric haemorrhage, perforation and strictures.

Patients requiring assessment

• All patients with deliberate self-poisoning or significant accidental ingestion
• Any symptomatic patient
• Dose >50 mg/kg

Non-accidental poisoning should be considered in any patient whose developmental age is inconsistent with accidental poisoning,

Risk Assessment

History

• Intentional overdose or accidental
• Dose:
  • Stated or likely dose taken
  • Calculate the maximum possible dose per kg
• Consider co-ingestants
• All adolescents who present with a deliberate self-poisoning should be assessed for ongoing mental health risk. 
  • Assessment should determine whether an adolescent needs: 
    • admission to an Adolescent Mental Health Ward for their safety, or
    • follow up support by a community based mental health service, and / or
    • linkage with a drug and alcohol support service

Examination

• CNS depression: drowsiness and ataxia progressing rapidly to coma
• Respiratory depression
• Hypotension
• Hypothermia
• GI corrosive injury

Always check for Medicalert bracelet in any unconscious patient, or any other signs of underlying medical condition (fingerprick marks etc)

Investigations:

• ECG: Multifocal PVC, AF, SVT, VT
• Consider endoscopy within 24 hours in ingestions >10g showing clinical signs of corrosive injury.
• Paracetamol level in all intentional overdoses

Acute Management

Resuscitation

• Standard procedures and supportive care
• Early intubation if progressive CNS depression or CVS toxicity.
• Dysrhythmias        
• Beta blocker: esmolol or propranolol
• Torsades
• add MgSO₄, though this may be ineffective
•  VT
• lignocaine may be effective
• Hypotension –
• IV fluids: 20 mL/kg 0.9% saline.
• Catecholamine inotropes are contraindicated as they may precipitate arrhythmias

Decontamination 

• Charcoal contraindicated unless airway protected.

Enhanced elimination

• Haemodialysis – consider if ongoing haemodynamic instability or arrhythmias

Consider consultation with local paediatric team when

Contact Victorian Poisons Information Centre 13 11 26 for advice

• Admission should be considered for all adolescent patients with an intentional overdose.

• Adolescents who NEED hospital admission for medical treatment of their poisoning:
  • Adolescent must be assessed for ongoing risk of deliberate self harm on the ward before transfer to the ward to enable appropriate supervision and support.
  • However, this should not delay urgent care, such as ICU admission.
• Adolescents who DO NOT NEED hospital admission for medical treatment of their poisoning
  • Liaise with your on-call hospital based Mental Health Service before discharge (if available)
  • Arrange ongoing support through a local mental health service: eg
    • Headspace National Youth Mental Health Foundation (12-25 years old), go to Headspace  and click “Find a centre”
  • Victorian Child and Adolescent Mental Health Services (CAMHS)  (0 – 18 years old), go to Mentalhealth Services and search by region based on residential address

 Consider transfer when

Patients with CVS depression or CVS arrhythmias should be managed in a paediatric ICU.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Discharge Criteria

• All symptomatic patients should be observed until asymptomatic
• Normal GCS
• Normal ECG
• Post at least 2 hours of cardiac monitoring
• For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self-harm in the discharge setting

Discharge information and follow-up

• Intentional self –harm: Referral to local mental health services eg Orygen Youth Health: 1800 888 320
• Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685
• Accidental ingestion: Parent information sheet from Victorian Poisons Information centre on the prevention of poisoning

Last Updated August 2018