Dizzy/Lightheaded

[Swimfinn]

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)

 

[adamjh3]

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

 

[VFlutter]

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)

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

 

[FLdoc2011]

Good case.

 

[adamjh3]

Also, did he recently change his dose of tenex?

 

[Swimfinn]

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

 

[shiroun]

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?

 

[VFlutter]

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

 

[adamjh3]

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?

 

[Swimfinn]

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

 

[Swimfinn]

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

 

[Dwindlin]

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.

 

[Swimfinn]

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

 

[Aidey]

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.

 

[Swimfinn]

sure of it. mother counted pills

 

[Aidey]

Who talked to the mother?

 

[Swimfinn]

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

 

[Aidey]

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.

 

[Swimfinn]

doctor advised to split the tablets

 

[Aidey]

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.