Fasano Charles J, O'Malley Gerald F, Lares Claudia, Rowden Adam K
Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA.
Pediatr Emerg Care. 2009 Apr;25(4):258-9. doi: 10.1097/PEC.0b013e31819e3775.
We describe the first ziprasidone overdose with quantitative serum levels of a pediatric patient in coma and with pinpoint pupils. This case is an important contribution to the pediatric ziprasidone literature because it illustrates that ingestion of just 1 pill may result to profound mental status and respiratory depression in a child. H.C., a 30-month-old girl, presented to the emergency department approximately 30 minutes after an accidental ingestion of an adult family member's medication. The child was found on the floor surrounded by numerous pills and was witnessed to have ingested at least 1 tablet by a caregiver. After finding the child with the pills, the family observed the child for a brief period but transported her to the hospital after she became lethargic and unresponsive. The child received 2 doses of 0.4 mg of intravenous naloxone without change in her neurologic status. The child then underwent a rapid sequence intubation for airway protection and subsequently received gastrointestinal decontamination with 15 g of activated charcoal via the orogastric tube. Ziprasidone is an atypical antipsychotic drug that was approved by the Food and Drug Administration in February 2001 for the general treatment of schizophrenia in adults. Previously reported pediatric ziprasidone overdoses describe a syndrome of sedation, tachycardia, hypotonia, and coma consistent with that of the patient described in this paper. In pediatric ziprasidone overdose, QTc prolongation and hypotension have also been illustrated, but seizures have not been reported. An interesting aspect of this case is the development of pinpoint pupils unresponsive to naloxone. This phenomenon has been reported before with overdose of olanzapine, a similar atypical antipsychotic. The mechanism of miosis associated with overdose of atypical antipsychotics is unclear but is likely related to interference with central innervation of the pupil. Pupil size is maintained by a balance between sympathetic and parasympathetic neurohumeral tones. We propose that an overdose of an alpha-1 receptor blocking agent, such as ziprasidone, results in unopposed parasympathetic stimulation resulting in miosis.
我们描述了首例血清定量水平明确的齐拉西酮过量摄入病例，患儿昏迷且瞳孔针尖样缩小。该病例对儿科齐拉西酮文献具有重要贡献，因为它表明儿童仅摄入1片该药就可能导致严重的精神状态改变和呼吸抑制。H.C.是一名30个月大的女孩，在意外误服一名成年家庭成员的药物后约30分钟被送至急诊科。发现孩子时她躺在地上，周围有许多药片，一名看护者目睹她至少吞服了1片。发现孩子身边有药片后，家人观察了一小会儿，但在孩子变得嗜睡且无反应后将她送往了医院。孩子接受了2剂0.4毫克静脉注射纳洛酮，但神经状态未改变。随后孩子接受了快速顺序插管以保护气道，接着通过口胃管给予15克活性炭进行胃肠道去污。齐拉西酮是一种非典型抗精神病药物，于2001年2月被美国食品药品监督管理局批准用于成人精神分裂症的一般治疗。先前报道的儿科齐拉西酮过量病例描述了一种与本文所述患者一致的镇静、心动过速、肌张力减退和昏迷综合征。在儿科齐拉西酮过量病例中，也已证实有QTc延长和低血压情况，但未报道有癫痫发作。该病例一个有趣的方面是出现了对纳洛酮无反应的针尖样瞳孔。这种现象之前在过量服用奥氮平（一种类似的非典型抗精神病药物）时也曾有报道。非典型抗精神病药物过量导致瞳孔缩小的机制尚不清楚，但可能与干扰瞳孔的中枢神经支配有关。瞳孔大小由交感和副交感神经体液调节之间的平衡维持。我们推测，过量服用α-1受体阻断剂（如齐拉西酮）会导致未受拮抗的副交感神经刺激，从而引起瞳孔缩小。
