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Sarah Dunne

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. Dysfunction of the autonomic centres.

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Sarah Dunne

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  1. 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

  2. Dysfunction of the autonomic centres DYSFUNCTION OF THE AUTONOMIC CENTRES

  3. The syndrome, PAID • Other terms • Diencephalic seizures • Midbrain dysregulatory syndrome • Sympathetic storming • May be mistaken for… • Seizures • Sepsis • Side-effects of drugs • Withdrawal from drugs • Pain

  4. 14yr male Near drowning 20mins under water Out of hospital arrest CT Head –severe hypoxic ischaemic insult Despite Tx with SNP, Nifedipine, Amlodipine, & Enalapril BP remained high Excessive sweating Agitation ↑HR ↑Temp 14yr male Cyclist (no helmet) Vs Car (50mph) Decompressive craniectomy to control ICP Traumatic subarachnoid haemorrhage Despite Tx with GTN & Atenolol BP remained high Excessive sweating Agitation ↑HR ↑Temp Two Cases Presented

  5. Normal Observations in 14 yr old Male • Respiratory Rate 12-15 breaths/min • Systolic BP 100-120mmHg • Heart Rate 60-100bpm

  6. Observations recorded during NC inpatient stay, highlighting episodes of PAID 200micrograms 4˚ 800micrograms 2˚ IV clonidine started 200micrograms 4˚ 400micrograms 4˚ 800micrograms 4˚ 150micrograms 4˚ 600micrograms 4˚

  7. Observations recorded during GL inpatient stay, highlighting episodes of PAID 500micrograms 4˚ 250micrograms 4˚

  8. Clonidine • α2- adrenergic agonist • Located pre & postsynaptically on neurons in the brain • ↓ release of NA • Well absorbed orally • Peak plasma concn reached in 3-5hrs • T1/2 8hrs in children • Works by.. • ↓ sympathetic outflow from CNS; decreasing BP • Behaviour stabilising effect • Sedation

  9. Supply • Tablets (if whole dose) • 100microgram tab disperse within 2mins when in 10ml water • Flushes via 8Fr NG tube without blockage • 25microgram tab (film coated) can be crushed but does not disperse readily • Suspension made in house • 100micrograms/ml and 300micrograms/ml (not available at the same time) • 7 day expiry • Cardinal

  10. Take home message • Manifestations of PAID can lead to… • Hypertensive or hyperthermic encephalopathy and even death • Rational approach to management • Rule out other causes • If diagnosis of PAID treat early with clonidine

  11. References • 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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