682: UNINTENTIONAL PEDIATRIC ORAL INGESTION OF BRIMONIDINE EYE DROPS

Abstract

Introduction: Brimonidine is a central alpha-2 adrenergic agonist agent chemically similar to clonidine. When used for glaucoma treatment, activation of alpha-2 receptors in the ciliary musculature culminates in decreased intraocular pressure by reducing aqueous humor production and stimulating outflow. While intended use is intraocular, oral ingestion and associated neurological and cardiovascular toxicities are not robustly documented in pediatric literature. In this case report, we present the toxic oral ingestion of brimonidine eye drops in a pediatric patient. Description: A two year old, previously healthy female presented to the emergency department (ED) with acute altered mental status, found dizzy and unresponsive by her grandmother around 9pm; she was last known well before going to bed at 8pm. On arrival to the ED, the patient was crying, intermittently somnolent, and opening her eyes spontaneously. Her vital signs were as follows: temperature 97.2F, heart rate 79 beats per minute, respiratory rate 22 time per minute, blood pressure 126/86 mmHg. Venous blood gas showed respiratory alkalosis and lactate 2.1mmol/L. A urine toxicology screen was negative and serum acetaminophen, salicylate, alcohol, and tricyclic levels were undetectable. Head imaging and electrocardiograms were normal. Upon further review, the patient’s grandmother revealed she recently underwent kidney transplantation. She detailed that none of her oral medications were missing but had found an empty bottle of brimonidine eye drops under the couch. The grandmother was unable to share whether it was a 5mL or 15mL bottle of 0.1% or 0.2% eye drops. With concern that the patient may have ingested brimonidine, she received empiric intravenous naloxone 0.1mg/kg amounting to 1.5mg. Rapid improvement in wakefulness and mental status was observed. The child was admitted for monitoring in an intensive care unit, did not require any additional naloxone, and was discharged after approximately 36 hours. Discussion: Oral ingestion of brimonidine eye drops may cause somnolence and bradycardia in pediatric patients. Additionally, naloxone utilization may not elicit an appropriate response. This case describes the successful identification of toxicity and use of empiric naloxone for diagnostic and treatment purposes in a pediatric patient.