Clonidine for the treatment of Paroxysmal Autonomic Instability with Dystonia (PAID) following traumatic brain injury Sarah Dunne Associate Care Group Pharmacist for Child Health, Southampton University Hospitals NHS Trust
Severe Brain injury Temp ≥ 38. 5˚C Hypertension Dystonia What is PAID? Diaphoresis Pulse ≥ 130 bpm RR ≥ 140 breaths/min Agitation
Dysfunction of the autonomic centres DYSFUNCTION OF THE AUTONOMIC CENTRES
The syndrome, PAID n Other terms • Diencephalic seizures • Midbrain dysregulatory syndrome • Sympathetic storming n May be mistaken for… • • • Seizures Sepsis Side-effects of drugs Withdrawal from drugs Pain
Two Cases Presented n 14 yr male n Near drowning n Cyclist (no helmet) Vs Car (50 mph) n 20 mins under water n Decompressive craniectomy to control ICP n Out of hospital arrest n CT Head –severe hypoxic ischaemic insult n Traumatic subarachnoid haemorrhage Despite Tx with SNP, Nifedipine, Amlodipine, & Enalapril n Despite Tx with GTN & Atenolol n • • • BP remained high Excessive sweating Agitation ↑HR ↑Temp
Normal Observations in 14 yr old Male n Respiratory Rate 12 -15 breaths/min n Systolic BP 100 -120 mm. Hg n Heart Rate 60 -100 bpm
Observations recorded during NC inpatient stay, highlighting episodes of PAID IV clonidine started 200 micrograms 4˚ 800 micrograms 2˚ 400 micrograms 4˚ 150 micrograms 4˚ 800 micrograms 4˚ 600 micrograms 4˚
Observations recorded during GL inpatient stay, highlighting episodes of PAID Clonidine Started 500 micrograms 4˚ 250 micrograms 4˚
Clonidine n α 2 - adrenergic agonist • Located pre & postsynaptically on neurons in the brain • ↓ release of NA n Well absorbed orally n Peak plasma concn reached in 3 -5 hrs n T 1/2 8 hrs in children n Works by. . • ↓ sympathetic outflow from CNS; decreasing BP • Behaviour stabilising effect • Sedation
Supply n Tablets (if whole dose) • 100 microgram tab disperse within 2 mins when in 10 ml water • Flushes via 8 Fr NG tube without blockage • 25 microgram tab (film coated) can be crushed but does not disperse readily n Suspension made in house • 100 micrograms/ml and 300 micrograms/ml (not available at the same time) • 7 day expiry n Cardinal
Take home message n Manifestations of PAID can lead to… • Hypertensive or hyperthermic encephalopathy and even death n Rational approach to management • Rule out other causes • If diagnosis of PAID treat early with clonidine
References n n n Blackman J, Patrick P, Buck M et al. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol 2004; 61: 321 -328 White R. & Bradman V. Handbook of drug administration via enteral feeding tubes. Pharm Press 2007 With special thanks to my colleagues at Southampton General Hospital
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