Torticollis after Benadryl OD?

[Job13_5]

I can't seem to wrap my head around this pt.

A 16 YOM tried to OD on 30 Benadryl OTC, and 30 Aleve 12-16hr prior to our arrival. He presented with obvious torticollis (ear turned down to the right, SCM under spasm, jaw deviated and elevated to the left, with left lateral rotation of the neck) that periodically worsened and then relaxed (but didn't go away). He was in the care of a local mental care facility, who had given him Paxil 2 hrs earlier. The nurse then noted the onset of his symptoms 2 minutes after that administration, and eventually called us when the pt complained of having difficulty breathing (laryngeal dystonia?). Pt was lucid, and able to answer questions, although had difficulty speaking.

What I don't understand is how this could happen given his recent history. He has never experienced this before; he's on two meds for GERD (hyoscyamin (an anti-cholinergic), and Xifaxan), but his OD included Benadryl.

Was this a dystonic reaction? If so, how could it happen with so many anti-cholinergics on board (although Benadryl half life is 2-8hrs)?

The only other thing I can think of would be serotonin toxicity from the paxil, but it doesn't fit as well.

Luckily we were only a few minutes from the ER. We ended up deferring medication because of the short transport time, although we considered Diazepam to give him a bit of relief.

Any help with this one?

Thanks all!

[fireflymedic]

Hey there,

First off, poor kid bet he was absolutely miserable. It does sound quite a bit like a dystonic reaction. I've seen it with phenergan and other similar medications that were taken in excess. However, the typical resolution for a dystonic reaction is benadryl which in the case of a benadryl OD wouldn't help the situation, it would only add to the problem. Seratonin syndrome doesn't quite fit the picture here from my experience though if he was alert I don't think valium would have been out of the question (though with the difficulty in breathing I would have had some concern with that so would have definitely gotten med control on board with it prior). Thankfully you had a short transport so you minimized discomfort time with that aspect - have you had the chance to follow up on the patient? If not, I'd suggest doing so especially if you have docs that are good about discussing patients with you.

[oz_paramedic_chick]

I have to agree with firefly and say that it does sound to me like a dystonic reaction. As for the cause i'm not that great on my pharmacology yet and really am not sure what would have caused it. The only dystonic reaction i've been to was from Maxolon (Metoclopramide). :-)

[chbare]

Sounds like a poly-substance over dose. Therefore, any number of things could have caused his signs and symptoms, if we are not absolutely certain of every substance that entered the patient's body. In addition, SSRI's have been known to cause dystonic reactions. True dystonic reactions are not even dose related in many cases, so this guy could have taken a small amount of something else and developed the said problems.

Take care,

chbare.

[fireflymedic]

Sounds like a poly-substance over dose. Therefore, any number of things could have caused his signs and symptoms, if we are not absolutely certain of every substance that entered the patient's body. In addition, SSRI's have been known to cause dystonic reactions. True dystonic reactions are not even dose related in many cases, so this guy could have taken a small amount of something else and developed the said problems.

Take care,

chbare.

Very true - I've seen that particularly with patients on initiating haldol as a treatment. It's not that uncommon. Also something to consider is to think about what happens when you give too much of a sedative - it has the opposite effect - it actually makes the person hyper. So if it truly was a benadryl overdose, depending upon his metabolism, it may not have entirely cleared his system and with the addition of other medications it may have enhanced or delayed metabolism and effects.

CB - also thanks for the note on SSRI's. I've not experienced one causing a dystonic reaction and only dealt with my first case of seratonin syndrome not long ago so I'm relatively inexperienced on that. Appreciate it !

Be smart and stay safe.