What are the treatment and management steps for a 3-year-old who ingested Wellbutrin (bupropion)?

Management of Bupropion Ingestion in a 3-Year-Old

Bupropion ingestion in a 3-year-old child is a medical emergency requiring immediate hospitalization due to high risk of seizures, cardiotoxicity, and potential fatality.

Immediate Assessment and Management

1. Call Poison Control Center immediately (1-800-222-1222) for up-to-date guidance 1

   • No known antidotes exist for bupropion
   • Provide supportive care with close medical supervision

2. Assess vital signs and neurological status

   • Monitor for seizures (occurs in approximately one-third of overdose cases) 1
   • Watch for tachycardia, hypertension, or bradycardia (may indicate cardiotoxicity) 2
   • Perform ECG to assess for conduction abnormalities

3. Decontamination measures

   • Do not induce vomiting due to risk of rapid seizure onset
   • Consider activated charcoal if presentation is within 1 hour of ingestion and patient is alert
   • Avoid whole bowel irrigation as it carries risk of aspiration and complications 2

Hospital Management

1. Seizure management

   • Establish IV access immediately
   • Administer benzodiazepines for seizure control
   • Prepare for possible status epilepticus (reported in pediatric bupropion overdose) 3
   • Consider EEG monitoring for subclinical seizures

2. Cardiac monitoring

   • Continuous cardiac monitoring for minimum 24 hours
   • Be prepared for delayed cardiac decompensation (can occur even after initial stabilization) 4
   • QRS prolongation may not respond to sodium bicarbonate 4
   • Watch for both tachycardia and bradycardia (latter may indicate severe toxicity) 2

3. Respiratory support

   • Maintain airway patency
   • Be prepared for intubation if respiratory depression occurs
   • Monitor oxygen saturation continuously

4. Laboratory studies

   • Complete blood count, comprehensive metabolic panel
   • Consider drug levels if available
   • Urine toxicology (note: bupropion can cause false-positive amphetamine results) 3

Risk Stratification

The severity of toxicity correlates with dose ingested:

• Low risk: <10 mg/kg - may not require referral to healthcare facility 5
• Moderate risk: 10-20 mg/kg - observation recommended
• High risk: >20 mg/kg - hospitalization required

Important Clinical Considerations

1. Seizures can occur rapidly and without warning

   • Seizure risk is dose-dependent
   • Multiple uncontrolled seizures can lead to status epilepticus 3

2. Cardiac effects can be severe and delayed

   • Initial tachycardia may resolve but does not indicate recovery 4
   • Delayed cardiac decompensation can occur up to 32 hours post-ingestion 4
   • Cardiac arrest has been reported in pediatric cases 3

3. Other serious manifestations include:

   • Hallucinations, altered mental status
   • Muscle rigidity, hyperreflexia
   • Hypotension, respiratory failure 1

Disposition

1. Observation period:

   • Minimum 24 hours of monitoring is recommended for symptomatic patients
   • Extended monitoring (48+ hours) for large ingestions or sustained-release formulations

2. Discharge criteria:

   • No seizures or cardiac abnormalities for 24 hours
   • Normal vital signs and mental status
   • Ability to tolerate oral intake

3. Follow-up:

   • Pediatric follow-up within 1 week
   • Consider child protective services involvement to prevent future exposures

Prevention

1. Parental education:
   • Keep all medications in childproof containers
   • Store medications out of reach and sight of children
   • Properly dispose of unused medications

Remember that bupropion overdose in children can be fatal, with deaths reported even in patients who initially appear stable. The combination of seizures, cardiac effects, and respiratory compromise requires aggressive management in a pediatric intensive care setting.