How should a patient with suspected Goodnight solution toxicity be managed?

Management of Goodnight Solution (Promethazine) Toxicity

Patients with suspected Goodnight solution toxicity require immediate airway assessment and supportive care, with benzodiazepines as first-line treatment for severe agitation or seizures, and most cases necessitating emergency department evaluation due to the high risk of respiratory depression and need for intensive care monitoring. 1

Immediate Recognition and Stabilization

• Airway management is the absolute priority - intubate immediately if the patient has coma, respiratory depression, or inability to protect their airway 2, 3
• Contact your regional poison control center immediately (1-800-222-1222 in the US) for expert toxicology guidance, as this is critical for managing antihistamine overdoses 2, 4
• Establish IV access and provide isotonic crystalloid resuscitation if hypotensive 4
• Place unconscious patients in the left lateral head-down position and administer glucose if hypoglycemic 5

Clinical Presentation and Risk Assessment

Promethazine (Goodnight) overdoses carry exceptionally high morbidity - in the New Zealand experience, 48% of patients required intensive care admission and 32% required intubation, with 60% of patients having ingested one or more full boxes 1

Key features to assess:

• Central nervous system depression ranging from sedation to coma 1
• Anticholinergic toxidrome including delirium, hallucinations, hyperthermia, mydriasis, dry mucous membranes, urinary retention, and decreased bowel sounds 3
• Respiratory depression requiring mechanical ventilation 1
• Cardiac dysrhythmias including QT prolongation 2

Pharmacologic Management

For Severe Agitation, Delirium, or Seizures

• Administer benzodiazepines as first-line therapy - diazepam is preferred, with midazolam as an acceptable alternative 2, 3, 6
• Titrate benzodiazepines to control symptoms without causing excessive respiratory depression 7

For Refractory Anticholinergic Toxicity

• Physostigmine is the definitive antidote for severe anticholinergic toxicity when benzodiazepines fail to control severe delirium, hallucinations, life-threatening hyperthermia, or refractory seizures 3
• Physostigmine should only be administered in a monitored setting with continuous cardiac monitoring due to risk of bradycardia and bronchospasm 3

For Respiratory Depression

• Provide bag-mask ventilation immediately if respiratory depression is present 5
• Proceed to endotracheal intubation if the patient cannot maintain adequate oxygenation or ventilation 2, 5

Gastrointestinal Decontamination

• Activated charcoal may be considered if less than 2 hours have elapsed since ingestion and the patient is fully conscious with intact airway reflexes 5, 8
• Do not induce emesis with ipecac syrup under any circumstances 5, 7
• Gastric lavage is not recommended as it carries serious risks and provides minimal benefit 5

Disposition and Monitoring

All patients with suspected Goodnight toxicity require emergency department evaluation given the documented high rate of ICU admission and intubation 1

Specific indications for immediate ED referral:

• Any suicidal intent or malicious administration 7, 8
• Ingestion of more than a therapeutic dose with any symptoms 1
• Moderate to severe symptoms including significant agitation, hallucinations, loss of consciousness, seizures, or respiratory depression 7
• Unknown ingestion amount 7

Hospital Monitoring Requirements

• Serial monitoring of respiratory status is essential as promethazine's duration of action may exceed 24 hours 2, 1
• Continuous cardiac monitoring for dysrhythmias 2
• Monitor for complications including aspiration pneumonia, rhabdomyolysis, and hyperthermia 3
• 20% of patients in the New Zealand series required 2-3 days of hospitalization, indicating the need for extended observation 1

Critical Pitfalls to Avoid

• Never delay treatment waiting for toxicology confirmation - diagnosis is clinical based on history and anticholinergic toxidrome 3
• Do not use neuromuscular blockers without adequate sedation, as they mask seizure activity without treating it 6
• Avoid flumazenil if benzodiazepines have been co-ingested, as it may precipitate seizures 2
• Do not discharge patients prematurely - the high ICU admission rate (48%) demonstrates that initial presentation may not reflect ultimate severity 1

Special Considerations

The availability of promethazine as an unrestricted pharmacy-only medication has resulted in significant morbidity and healthcare costs, with a dramatic increase in overdoses following market introduction of Goodnight in New Zealand 1. This underscores the importance of aggressive supportive care and low threshold for hospital admission in suspected cases.