Clonidine Toxicity Clinical Presentation

  • Author: David Riley, MD, MS, RDMS, RDCS; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 3, 2012
 

History

While elucidating the amount and timing of the clonidine ingestion is helpful, in practice, signs and symptoms guide therapy. Always suspect other co-ingestants and screen appropriately.

Children are particularly susceptible to toxic reaction from small doses (ie, normal adult therapeutic doses) of clonidine.

The Catapres TTS patch appears similar to a small Band-Aid or sticker, and a child could pull the patch off a sleeping caretaker. Several case reports document patches detaching spontaneously from a sleeping parent in a bed shared with a child and subsequently adhering to the child with resultant toxicity. In cases of possible clonidine toxicity involving children, always question family, friends, and emergency medical services (EMS) as to whether a child may have had access to clonidine.

Irritability may be noted.

Next

Physical

Symptoms develop rapidly (usually within 30-60 min) postingestion and may resemble an opioid overdose with miosis, bradycardia, respiratory depression, and coma. From a differential standpoint, comatose-appearing children with clonidine toxicity may awaken and be intermittently lucid when subjected to vigorous stimuli (eg, physical, verbal), whereas patients with opioid overdoses subjected to the same stimuli may awaken but are obtunded. Symptoms tend to be relatively more severe in pediatric patients. Toxic presentations also may include hypotension, hypertension, mydriasis, hypothermia, ileus, hypotonia, hyporeflexia, intermittent apnea, atrioventricular (AV) nodal heart block, and seizures.

With significant ingestions, patients usually present with bradycardia.

Associated hypotension may be severe and last up to 24 hours.

Hypertension is less common and usually more transient.

Hypothermia has been reported but is usually mild.

Patients may present with CNS depression, which may range from mild drowsiness (common) to coma.

Baseline mental status usually returns within 24-48 hours of ingestion.

Hyporeflexia may develop.

Seizures may occur.

Dysrhythmias may occur and include AV nodal block, Wenckebach, and tachycardia.

Pallor and cool extremities have been reported.

Pulmonary

Respiratory depression is common, especially in children, and may require endotracheal intubation.

Respiratory failure usually occurs within 1-2 hours of ingestion.

Ataxic breathing may be observed.

Patient may experience periods of apnea.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

David Riley, MD, MS, RDMS, RDCS  Assistant Clinical Professor of Medicine, Director of Emergency Ultrasonography and Ultrasound Research, Attending Physician, Department of Emergency Medicine, Columbia University Medical Center-New York Presbyterian Hospital

David Riley, MD, MS, RDMS, RDCS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, American Society of Echocardiography, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  2. Hegenbarth MA, American Academy of Pediatrics Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics. Feb 2008;121(2):433-43. [Medline].

  3. American Academy of Pediatrics. American Academy of Pediatrics Committee on Drugs: Naloxone dosage and route of administration for infants and children: addendum to emergency drug doses for infants and children. Pediatrics. Sep 1990;86(3):484-5. [Medline].

  4. Anderson RJ, Hart GR, Crumpler CP, et al. Clonidine overdose: report of six cases and review of the literature. Ann Emerg Med. Feb 1981;10(2):107-12. [Medline].

  5. Domino LE, Domino SE, Stockstill MS. Relationship between plasma concentrations of clonidine and mean arterial pressure during an accidental clonidine overdose. Br J Clin Pharmacol. Jan 1986;21(1):71-4. [Medline].

  6. Fiser DH, Moss MM, Walker W. Critical care for clonidine poisoning in toddlers. Crit Care Med. Oct 1990;18(10):1124-8. [Medline].

  7. Glassman AH, Stetner F, Walsh BT, et al. Heavy smokers, smoking cessation, and clonidine. Results of a double- blind, randomized trial. JAMA. May 20 1988;259(19):2863-6. [Medline].

  8. Gold MS, Pottash AC, Sweeney DR, et al. Opiate withdrawal using clonidine. A safe, effective, and rapid nonopiate treatment. JAMA. Jan 25 1980;243(4):343-6. [Medline].

  9. Gulec S, Aydin Y, Uzuner K. Effects of clonidine pre-treatment on bupivacaine and ropivacaine cardiotoxicity in rats. Eur J Anaesthesiol. Mar 2004;21(3):205-9. [Medline].

  10. Killian CA, Roberge RJ, Krenzelok EP, et al. "Cloniderm" toxicity: another manifestation of clonidine overdose. Pediatr Emerg Care. Oct 1997;13(5):340-1. [Medline].

  11. Lowenthal DT, Matzek KM, MacGregor TR. Clinical pharmacokinetics of clonidine. Clin Pharmacokinet. May 1988;14(5):287-310. [Medline].

  12. Mikawa K, Maekawa N, Nishina K, et al. Efficacy of oral clonidine premedication in children. Anesthesiology. Nov 1993;79(5):926-31. [Medline].

  13. Moiseev VM, Edel' IuP. [Development of forensic medical expertise in Kharkov during the years of Soviet rule]. Sud Med Ekspert. Jan-Mar 1989;32(1):54-5. [Medline].

  14. Nichols MH, King WD, James LP. Clonidine poisoning in Jefferson County, Alabama. Ann Emerg Med. Apr 1997;29(4):511-7. [Medline].

  15. Prisant LM, Elliott WJ. Drug delivery systems for treatment of systemic hypertension. Clin Pharmacokinet. 2003;42(11):931-40. [Medline].

  16. Roberge RJ, Kimball ET, Rossi J, et al. Clonidine and sleep apnea syndrome interaction: antagonism with yohimbine. J Emerg Med. Sep-Oct 1998;16(5):727-30. [Medline].

  17. Roberge RJ, Krenzelok EP, Mrvos R. Transdermal drug delivery system exposure outcomes. J Emerg Med. Feb 2000;18(2):147-51. [Medline].

  18. Roberge RJ, McGuire SP, Krenzelok EP. Yohimbine as an antidote for clonidine overdose. Am J Emerg Med. Nov 1996;14(7):678-80. [Medline].

  19. Roth A, Kaluski E, Felner S, et al. Clonidine for patients with rapid atrial fibrillation. Ann Intern Med. Mar 1 1992;116(5):388-90. [Medline].

  20. Sanklecha M, Jog A, Raghavan K. Clonidine casualty. Indian J Pediatr. Jul-Aug 1993;60(4):611-2. [Medline].

  21. Spies CD, Dubisz N, Neumann T, et al. Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma: results of a prospective, randomized trial. Crit Care Med. Mar 1996;24(3):414-22. [Medline].

  22. Stieger DS, Cantieni R, Frutiger A. Acute colonic pseudoobstruction (Ogilvie's syndrome) in two patients receiving high dose clonidine for delirium tremens. Intensive Care Med. Jul 1997;23(7):780-2. [Medline].

  23. Wasserberger J, Ordog GJ. Naloxone-induced hypertension in patients on clonidine. Ann Emerg Med. May 1988;17(5):557. [Medline].

  24. Williams PL, Krafcik JM, Potter BB, et al. Cardiac toxicity of clonidine. Chest. Dec 1977;72(6):784-5. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.