Visine (Tetrahydrozoline) Overdose Management
Immediately secure the airway, establish IV access, and initiate continuous cardiorespiratory monitoring, as tetrahydrozoline overdose causes life-threatening bradycardia, hypotension, respiratory depression, and altered mental status through central alpha-2 adrenergic receptor activation. 1, 2, 3
Initial Resuscitation and Stabilization
Airway management is the first priority: Assess for respiratory depression and provide bag-mask ventilation or endotracheal intubation as needed, since tetrahydrozoline causes central nervous system and respiratory depression 1, 4, 5
Establish IV access immediately and perform bedside glucose testing to exclude hypoglycemia as a cause of altered mental status 6
Initiate continuous cardiac monitoring: Tetrahydrozoline causes bradycardia, complete heart block, QT prolongation, and hypotension that can persist for 24-36 hours 3, 7
Specific Clinical Manifestations to Anticipate
Cardiovascular effects: Expect bradycardia (potentially requiring atropine), hypotension, complete atrioventricular block, and QT prolongation 3, 4, 5
Neurological effects: Altered mental status, unconsciousness, and miosis are common presentations 4, 5
Hypothermia: This can persist for approximately 24 hours and requires passive warming measures 4
Respiratory depression: Irregular and superficial breathing patterns may necessitate mechanical ventilation 4
Treatment Approach
Atropine for symptomatic bradycardia: Administer 0.5-1.0 mg IV every 3-5 minutes as needed for hemodynamically significant bradycardia 1, 4
Supportive care is the mainstay: There is no specific antidote for tetrahydrozoline overdose 1, 8
Do NOT administer flumazenil or naloxone: These agents have no role in tetrahydrozoline toxicity and will not reverse the effects 1, 8, 6
Critical Monitoring Parameters
Continuous cardiac monitoring until complete symptom resolution: Cardiovascular effects can persist for 36+ hours 3, 7
Serial ECGs: Monitor for complete heart block, first-degree AV block, and QT prolongation 3
Vital signs monitoring: Track blood pressure, heart rate, respiratory rate, and temperature closely 4, 5
Mental status assessments: Document level of consciousness and neurological status serially 4, 5
Common Pitfalls to Avoid
Do not assume naloxone will help: Tetrahydrozoline is not an opioid despite causing similar CNS depression and miosis 1, 6
Do not discharge prematurely: Symptoms can persist or worsen over 24-36 hours, requiring extended observation 3, 7
Consider co-ingestions: Always evaluate for other substances that may require specific antidotes 8
Do not overlook intentional ingestion: Cases of suicide attempts and drug-facilitated assault have been reported, requiring psychiatric evaluation and forensic consideration 3, 9
Disposition
Admit to intensive care unit: All symptomatic patients require ICU-level monitoring given the risk of complete heart block, respiratory failure, and prolonged cardiovascular effects 4, 7
Minimum observation period: Continue monitoring until all sympathomimetic symptoms completely resolve and vital signs normalize for at least 24 hours 6, 7
Psychiatric evaluation mandatory: Required before discharge for intentional ingestions to assess suicide risk 6, 3