Baclofen overdose
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Multi-system toxicities: case report A 17-year-old boy developed hypertension, sinus tachycardia, palpitations, difficulty breathing, subjective feeling of a squeezing sensation in his throat, somnolence and some respiratory depression and paradoxical autonomic features following overdose and toxicity of baclofen for muscle spasticity [dosage not stated]. The boy had a history of medication-resistant muscle spasticity, caused by cerebral palsy. He presented at 2–3h following a sudden onset of palpitations, difficulty breathing and a subjective feeling of a squeezing sensation in his throat. Approximately 10 years earlier, he underwent intrathecal baclofen-pump placement, with most recent replacement 4 days previously for pump malfunction. The pump had motor stalls and underfilling. His medical history and other unspecified medications were recently unaltered. On presentation, his vital signs were notable for tachycardia and hypertension, with a HR of 150–210 beats/min and BP of 177/110mm Hg. He had only a mildly increased respiratory rate. On neurological evaluation, his lower extremities were slightly less rigid than usual. An ECG showed regular, narrow complex tachycardia, without ischaemic changes or evidence of heart strain. Owing to the historical context of sudden onset of symptoms and persistent severe tachycardia, adenosine treatment was given. However, only a brief effect on conduction was noted. During this pause, definitive P-waves without evidence of atrial flutter were noted, confirming the rhythm as sinus tachycardia. The sinus-tachycardia persisted. Plain film radiography appeared to show an intact baclofen pump. The CT-angiography scan of chest revealed that the pump’s catheter tip had not been dislodged from its previous position. Treatment with lorazepam for presumed baclofen withdrawal was started. However, there was no notable change in vital signs or symptoms. Pump interrogation revealed that it was working appropriately, giving a basal rate with intermittent bolus dosing as programmed. An additional intrathecal baclofen bolus was administered. However, there was no change symptoms. He developed paradoxical autonomic features. He was admitted to the pediatric ICU, where his dosing schedule was changed from a basal with intermittent bolus strategy to a continuous infusion schedule. This resulted in notable somnolence and some respiratory depression. Baclofen dose was reduced. His somnolence resolved. After 24h, his baclofen dosing was set at half of his presenting dose. It was determined that his tachycardia and hypertension were the result of baclofen overdose and toxicity, and not withdrawal. Baclofen toxicity was attributed to error-free pump replacement, exposing him to a higher dose than he was previously receiving. He remained stable for another 24h, and was discharged home. Parker-Pitts CK, et al. Intrathecal Baclofen Overdose With Paradoxical Autonomic Features Mimicking Withdrawal. Journal of Emergency Medicine 58: 616-619, No. 4, Apr 803499437 2020. Available from: URL: http://do
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