II. Precaution

  1. Avoid Chloral Hydrate use due to risks and better alternatives
    1. IM or IV Route
      1. Ketamine
    2. Oral or Intranasal Route
      1. Midazolam
  2. Chloral Hydrate has an unpredictable time course of sedation
    1. See Pharmacokinetics below
    2. Erratic absorption (especially with patient Fasting)
    3. Recurrent sedation following awakening (related to the metabolite trichloroethanol's long duration of activity)
  3. If used despite disadvantages, Exercise vigilence
    1. Limit to short term sedation only
    2. Avoid repetitive dosing
    3. Procedural Sedation risks respiratory and cardiovascular depression
    4. Monitoring is critical
      1. See Procedural Sedation and Analgesia
      2. Case reports of pediatric deaths associated with outpatient use

III. Indications

  1. Pediatric Procedural Sedation
    1. Common use among pediatric dentists
    2. Alternative Sedatives are far preferred (see above)

IV. Mechanism

  1. Sedation only (offers no Analgesic effect)
  2. Older oral sedation agent similar to Ethanol with GABA-receptor mediated effects
  3. Chlorinated Hydrocarbon with similar risks in Overdose (see below)
  4. Rapidly metabolized to the active form, trichloroethanol
    1. Trichloroethanol has a long duration of action
    2. Trichloroethanol is responsible for the recurrent sedation following awakening

V. Dosing

  1. Dosing: 50-75 mg/kg/dose PO or PR
  2. Maximum: 1000 mg

VI. Pharmacokinetics

  1. Onset and duration are unpredictable and prolonged if Fasting (decreased and erratic absorption)
  2. Onset: 30 minutes
  3. Peak: 30 to 60 minutes
  4. Duration: 4 to 6 hours

VII. Adverse Effects

  1. Nausea or Vomiting
  2. Headache
  3. Dizziness
  4. Fever
  5. Paradoxic excitation or Agitation
  6. Possible carcinogenicity
    1. Aneuploidy
    2. Hepatic tumors

VIII. Management: Toxicity or Overdose

  1. Mechanism
    1. Chloral Hydrate has similar toxic effects to HydrocarbonOverdose
    2. Chloral Hydrate sensitizes the Myocardium to Catecholamines
  2. Presentation
    1. Respiratory Depression
    2. Myocardial toxicity and Arrhythmia (especially Ventricular Tachycardia)
  3. Antidote: Ventricular Tachycardia WITH a pulse
    1. Beta Blocker (Esmolol is preferred)
    2. Avoid Epinephrine or other Catecholamines (unless pulseless)

IX. References

  1. Nordt and Swadron in Majoewsky (2013) EM:Rap 13(5): 6
  2. Litman (2010) Anesth Analg 110(3): 739-46 [PubMed]

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