# Dizzy/Lightheaded



## Swimfinn (Aug 14, 2012)

You arrive on scene to a high school nurses office for a 14 y.o. M complaining of dizzy and light headed.

Pt is on tenex 1.5mg Tenex trial for ADHD
He also claims he took 20mg of Sudafed PE and 10mg of Claratin for a cold

Initial set of vitals taken by nurse are as follows

BP 92/20
HR 34
GCS 15
O2 Sat 89%

When you arrive on scene pt is laying down, ashen, shaking and on O2 via NRB at 10LPM (done by responding police officer)


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## adamjh3 (Aug 14, 2012)

Respiration rate? Tidal volume good or poor? Anything on the EKG? What about capnography? Hx besides adhd? Any orthostatic vitals? When did it start? How long has he been taking each medication? Anything on a physical exam?

Edit: Didn't see the "for a cold" in the OP


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## VFlutter (Aug 14, 2012)

Swimfinn said:


> You arrive on scene to a high school nurses office for a 14 y.o. M complaining of dizzy and light headed.
> 
> Pt is on tenex 1.5mg Tenex trial for ADHD
> He also claims he took 20mg of Sudafed PE and 10mg of Claratin for a cold
> ...


My first guess is a drug interaction / overdose.

Never heard of Tenex used for ADHD, but if IRRC it has a lot of cholernergic effects so mixing with Loratadine and sudafed isn't the best idea


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## FLdoc2011 (Aug 14, 2012)

Good case.


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## adamjh3 (Aug 14, 2012)

Also, did he recently change his dose of tenex?


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## Swimfinn (Aug 14, 2012)

resp of 9
normal tidal volume
ekg didn't show anything other than bradycardia 
only hx is adhd
unable to obtain orthostatic vitals due to pt unable to sit or stand long enough
s/s started ~ 15min before the tone
nothing shows up on a physical exam 
been on tenex for 3 weeks now, with a dose increase of .5mg one week prior
cold meds have been administered for the past 2 days


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## shiroun (Aug 14, 2012)

IIRC sudafed does cause some mild hypotension, especially when mixed with other drugs.

Question, I understand patient was 14 y.o, but whats her approximate height/weight? I'd almost like to believe this was drug-induced, but not by the drugs listed, perhaps something illegal? 

How were her pupils?


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## VFlutter (Aug 14, 2012)

My guess they are going to be constricted. Sounds like excessive parasympathetic stimulation secondary to the medications


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## adamjh3 (Aug 14, 2012)

Tenex's hypotensive effects are dose dependent. The change in dosage combined with the pseudoephedrine is likely to blame here. Any physical exertion prior to onset of s/s? His inability to increase his HR to compensate would trigger the dizziness etc. since his blood pressure isn't alarmingly low according to the initial set.

What vitals did you get while transporting?


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## Swimfinn (Aug 14, 2012)

i thought Phenylephrine (sudafed PE actually RAISED the BP)
pupils are equal and reactive normal sized
he is ~5'9" 100lb
no drugs or alcohol


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## Swimfinn (Aug 14, 2012)

bp went down to 88/21 pulse of 39

spo2 up to 93% with O2 therapy


very healthy at last physical exam. distance swimmer with a resting heart rate of ~50. normal bp is ~130/25


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## Dwindlin (Aug 14, 2012)

Swimfinn said:


> i thought Phenylephrine (sudafed PE actually RAISED the BP)
> pupils are equal and reactive normal sized
> *he is ~5'9" 100lb*
> no drugs or alcohol



If the bolded is correct that is a problem.

But this is likely due to his Tenex +/- some effect from the Sudafed.  Tenex can cause all the symptoms listed above on its own.


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## Swimfinn (Aug 14, 2012)

i actually didn't think much of the height and weight. why is that a problem?


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## Aidey (Aug 14, 2012)

Sudafed usually causes hypertension, not hypotension. Are we sure he didn't take too much of he tenex?

And 5'9 100lbs is definitely on the small side for a 14yo, but not unheard of if he just had a growth spurt and has little muscle.


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## Swimfinn (Aug 14, 2012)

sure of it. mother counted pills


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## Aidey (Aug 14, 2012)

Who talked to the mother?


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## Swimfinn (Aug 14, 2012)

school nurse. mother met us on scene prior to transport as well


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## Aidey (Aug 14, 2012)

And how exactly is he taking 1.5mgs, it doesn't come in that dose and the pills are not supposed to be cut in half.


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## Swimfinn (Aug 14, 2012)

doctor advised to split the tablets


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## Aidey (Aug 14, 2012)

Doc is an idiot. Tablets that aren't supposed to be split are that way for a reason. In fact the medication comes with a warning saying not to crush, chew or split the tablets.


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## Swimfinn (Aug 14, 2012)

does splitting the tabs even have any relevance to the case?


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## Aidey (Aug 14, 2012)

Yes. Tabs that are meant to be split have a score on them, making it easier to split them evenly. Tabs that do not have a score tend to not split evenly. Pt may have got 1.8mg rather than 1.5mgs.

Plus if the doctor was willing to tell them to split the tablets, even though you aren't supposed to, it may indicate that the kid had a strong reaction to the 1mg and the doc wasn't comfortable going up to 2mg.


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## FLdoc2011 (Aug 14, 2012)

Aidey said:


> Doc is an idiot. Tablets that aren't supposed to be split are that way for a reason. In fact the medication comes with a warning saying not to crush, chew or split the tablets.



The extended release formulations should not be split but I don't think Tenex is an extended release version.  I don't prescribe or have any experience with it, just going off drug database info.


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## Aidey (Aug 14, 2012)

The Intuniv brand is extended release per epocrates. But all 3 had do not split warnings.


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## FLdoc2011 (Aug 14, 2012)

Aidey said:


> The Intuniv brand is extended release per epocrates. But all 3 had do not split warnings.



The do no split/crush warnings are only for intuniv.   Tenex can be split/crushed and is what you'd have to use for children who can't swallow pills.  

But in general this is an important point to specify what meds they are on, how they are taking them and if that could be a potential source for the patient's problem.


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## Swimfinn (Aug 14, 2012)

well i mean 1mg to 2mg is quite a jump. i can understand why he prescribed 1.5mg


from my current research on google though, guanfacine is only used in ADHD with the extended release tabs


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## Aidey (Aug 14, 2012)

If it was such a jump one would expect that it would be offered in half mg doses. Not in whole mg doses that have an explicit do not crush/chew/cut warning.

My point is that this specific pt may have been sensitive to it, or already have low BP, some reason that the MD went so far to advise them to split the pills. 

It is also possible mom miscounted. There is a reason that multiple people perform pill counts when checking narc inventory or on potential overdoses.


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## bahnrokt (Aug 14, 2012)

Swimfinn said:


> i actually didn't think much of the height and weight. why is that a problem?



Id be interested to know if he recently had a growth spurt which can also have an hypovolemic effect. 

Also where was he when he got dizzy? Was it sitting in math class or did a period of exertion set it off like gym class or running up a flight of stairs?


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## Swimfinn (Aug 14, 2012)

was sitting in french class


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## Swimfinn (Aug 14, 2012)

how do i know all this? 

it was me. never got an hx from the hospital..uncle was my medic and now i am a Basic myself


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## VFlutter (Aug 14, 2012)

The symptom that stands out to me is the bradycardia. Why a HR that low? If he was hypotensive due to hypovolemia I would expect him to be tachycardic.


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## Swimfinn (Aug 14, 2012)

i think tenex is an adrenoreceptor antagonist..that could have caused the bradycardia...


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## shiroun (Aug 14, 2012)

Swimfinn said:


> i think tenex is an adrenoreceptor antagonist..that could have caused the bradycardia...



Still, 39 is unusually low. My resting HR is 44, but I'm extremely active (5 miles of running a day, at minimum), and i'm not on any drugs. Do you have other HRs recorded while on the meds?


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## Swimfinn (Aug 14, 2012)

nope but as i stated above (i think) that i am a distance swimmer and at my physical exam before the incident my hr was ~50


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## FLdoc2011 (Aug 14, 2012)

Tenex is an alpha-2 agonist.  Some of the side effects are bradycardia and hypotension, basically decreases sympathetic tone.    Was anything like atropine given/tried?


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## Aidey (Aug 14, 2012)

This thread is basically asking for medical advice, and thus is not allowed.


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## Swimfinn (Aug 14, 2012)

Aidey said:


> This thread is basically asking for medical advice, and thus is not allowed.



it is? i am asking what you guys think of my own case as to what happened...this happend 3 years ago i couldn't possibly be asking for medical ADVISE. a consult maybe...


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## NomadicMedic (Aug 14, 2012)

It became questionable the minute you said that you were the patient. I would bet this thread will be closed shortly.


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## STXmedic (Aug 14, 2012)

Whether it's ADVICE or a consult, it should be done through your physician  They'd be much better suited to answer such questions anyway.


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## bigbaldguy (Aug 14, 2012)

Nah I'm ok with it give him all the advice he wants 

Not.

Thread closed while we review the evidence. Please stand by (or don't if you have better things to do).


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