haloperidol , a butyrophenone neuroleptic drug , is an antipsychotic used in the treatment of adult schizophrenia and mania .
it has been used for the management of various psychotic disorders in adults and for hyperactivity and behavioral disorders in children .
neuroleptic drugs block d-1 and d-2 receptors and also h1 and h2 , alpha 1 and alpha 2 , muscarinic and serotoninergic receptors .
extrapyramidal reactions occur frequently with haloperidol , and in most patients these reactions consist of parkinsonian symptoms ( e.g. , marked drowsiness and lethargy , drooling or hypersalivation , fixed stare ) .
it is an uncommon drug for overdose and serious complications may occur following ingestion of haloperidol .
there are few case reports of haloperidol poisoning in children mostly in the era before newer selective neuroleptics arrived in the market .
we report two siblings who presented as unknown poisoning and were later found to have accidentally consumed haloperidol .
since haloperidol is prescribed to ambulatory patients , unsupervised usage by children can be hazardous and even fatal .
this report is intended to alert physicians to haloperidol intoxications including its clinical presentation and treatment .
a 6 year old female child was brought with complaints of altered sensorium , persistent vomiting since the last 6 h. the patient responded to deep painful stimuli , and was intermittently agitated , febrile with a pulse of 104/min , respiratory rate 18/min , bp 80/40 mm hg with excessive sweating . on central nervous system ( cns )
examination , the pupils were normal , tone was dystonic with intermittent opisthotonus posturing , exaggerated reflexes and ill - sustained clonus was present .
the working diagnosis and management was of an unknown poisoning , and on deep probing , the history of alleged ingestion of haloperidol was obtained . the child and
her brother had consumed an indeterminate amount of 5 mg haloperidol tablets while playing in the backyard about 7 h prior to admission .
these tablets were apparently thrown in the open by a neighbor who was under treatment for schizophrenia .
the child was given gastric lavage , started on intravenous fluids , bladder catheterization was done .
promethazine hydrochloride 0.1 mg / kg and trihexyphenidyl 2 mg / dose thrice - daily was initiated and later increased to 3 mg / dose in view of persistent dystonia .
patient responded dramatically and regained consciousness after 12 h with complete resolution of dystonia within 72 h. the younger sibling , a 4 year - old male child was also brought with complaints of excessive sleepiness on the later part of the same day . on examination
, he was drowsy but arousable obeying verbal commands but not vocalizing . though his vitals were stable , he had anticholinergic symptoms such as diaphoresis , hyperthermia and urinary retention . on detailed cns exam
, generalized dystonia with intention tremors , perioral tremors , tongue fasciculations , nystagmus and hypereflexia was present .
on further enquiry , it was revealed that he too while playing along with his sister , had consumed an unknown number of the same tablets .
he was admitted , and after a stomach wash , started on trihexyphenidyl and symptomatic treatment .
after 24 h , his involuntary movements persisted so he was started on promethazine iv 0.1 mg / kg / dose single - dose after which , his symptoms subsided over a period of 72 h after admission and he gradually improved and regained consciousness . on follow - up after 1 week , both siblings were asymptomatic and doing well . psychiatric evaluation and counseling of the children and parents was done .
a 6 year old female child was brought with complaints of altered sensorium , persistent vomiting since the last 6 h. the patient responded to deep painful stimuli , and was intermittently agitated , febrile with a pulse of 104/min , respiratory rate 18/min , bp 80/40 mm hg with excessive sweating . on central nervous system ( cns )
examination , the pupils were normal , tone was dystonic with intermittent opisthotonus posturing , exaggerated reflexes and ill - sustained clonus was present .
the working diagnosis and management was of an unknown poisoning , and on deep probing , the history of alleged ingestion of haloperidol was obtained . the child and
her brother had consumed an indeterminate amount of 5 mg haloperidol tablets while playing in the backyard about 7 h prior to admission .
these tablets were apparently thrown in the open by a neighbor who was under treatment for schizophrenia .
the child was given gastric lavage , started on intravenous fluids , bladder catheterization was done .
promethazine hydrochloride 0.1 mg / kg and trihexyphenidyl 2 mg / dose thrice - daily was initiated and later increased to 3 mg / dose in view of persistent dystonia .
patient responded dramatically and regained consciousness after 12 h with complete resolution of dystonia within 72 h. the younger sibling , a 4 year - old male child was also brought with complaints of excessive sleepiness on the later part of the same day . on examination
, he was drowsy but arousable obeying verbal commands but not vocalizing . though his vitals were stable , he had anticholinergic symptoms such as diaphoresis , hyperthermia and urinary retention . on detailed cns exam
, generalized dystonia with intention tremors , perioral tremors , tongue fasciculations , nystagmus and hypereflexia was present .
on further enquiry , it was revealed that he too while playing along with his sister , had consumed an unknown number of the same tablets .
he was admitted , and after a stomach wash , started on trihexyphenidyl and symptomatic treatment .
after 24 h , his involuntary movements persisted so he was started on promethazine iv 0.1 mg / kg / dose single - dose after which , his symptoms subsided over a period of 72 h after admission and he gradually improved and regained consciousness . on follow - up after 1 week , both siblings were asymptomatic and doing well . psychiatric evaluation and counseling of the children and parents was done .
a 6 year old female child was brought with complaints of altered sensorium , persistent vomiting since the last 6 h. the patient responded to deep painful stimuli , and was intermittently agitated , febrile with a pulse of 104/min , respiratory rate 18/min , bp 80/40 mm hg with excessive sweating . on central nervous system ( cns )
examination , the pupils were normal , tone was dystonic with intermittent opisthotonus posturing , exaggerated reflexes and ill - sustained clonus was present .
the working diagnosis and management was of an unknown poisoning , and on deep probing , the history of alleged ingestion of haloperidol was obtained . the child and
her brother had consumed an indeterminate amount of 5 mg haloperidol tablets while playing in the backyard about 7 h prior to admission .
these tablets were apparently thrown in the open by a neighbor who was under treatment for schizophrenia .
the child was given gastric lavage , started on intravenous fluids , bladder catheterization was done .
promethazine hydrochloride 0.1 mg / kg and trihexyphenidyl 2 mg / dose thrice - daily was initiated and later increased to 3 mg / dose in view of persistent dystonia .
patient responded dramatically and regained consciousness after 12 h with complete resolution of dystonia within 72 h.
the younger sibling , a 4 year - old male child was also brought with complaints of excessive sleepiness on the later part of the same day . on examination
, he was drowsy but arousable obeying verbal commands but not vocalizing . though his vitals were stable , he had anticholinergic symptoms such as diaphoresis , hyperthermia and urinary retention . on detailed cns exam , generalized dystonia with intention tremors , perioral tremors , tongue fasciculations , nystagmus and
on further enquiry , it was revealed that he too while playing along with his sister , had consumed an unknown number of the same tablets .
he was admitted , and after a stomach wash , started on trihexyphenidyl and symptomatic treatment .
after 24 h , his involuntary movements persisted so he was started on promethazine iv 0.1 mg / kg / dose single - dose after which , his symptoms subsided over a period of 72 h after admission and he gradually improved and regained consciousness . on follow - up after 1 week , both siblings were asymptomatic and doing well .
the main features of severe over dosage are extrapyramidal reactions , hypotension , respiratory difficulty and impairment of consciousness .
other adverse neuromuscular reactions have been reported less frequently , but are often more severe and include feelings of motor restlessness ( i.e. , akathisia ) , tardive dystonia , and dystonic reactions such as hyperreflexia , opisthotonus , oculogyric crisis , torticollis , and trismus . tremor or muscle twitching , muscle spasm , rigidity and convulsions may also be seen .
adverse anticholinergic effects of haloperidol include dry mouth ( xerostomia ) , blurred vision , constipation , urinary retention , and diaphoresis .
sometimes there can be cardiac arrhythmias including ventricular fibrillation , conduction defects and cardiac arrest .
there are reports of delayed onset of hypertension , hence inpatient observation of children with accidental haloperidol poisoning is recommended .
literature shows that haloperidolinduced dystonia occurs more often in children . the neuroleptic malignant syndrome associated with haloperidol
the treatment of acute dystonic reaction , akathisia and parkinsonism observed during the administration of haloperidol includes parenteral administration of antiparkinsonism agents .
drugs that have been used for treatment include biperiden and promethazine , both of which can lead to an immediate improvement .
our patients had parkinsonian symptoms to a varying degree along with anticholinergic symptoms and responded dramatically to antiparkinsonian drugs .
the value of a good personal history can not be understated along with a vigilance to inquire the social and family history .
 haloperidol , a butyrophenone neuroleptic drug , is an antipsychotic used in the treatment of adult schizophrenia and mania . 
 it is used in children with neurological disorders like chorea and developmental disorders such as hyperactivity . with the advent of newer selective neuroleptics use of haloperidol 
 is now on decline . 
 however , in adults it is still the preferred drug especially in resource challenged settings . 
 extrapyramidal reactions occur frequently with haloperidol predominantly as parkinsonian symptoms . 
 there are few case reports of accidental haloperidol poisoning in children and this one of them . 
Introduction
Case Reports
None
Case 1
Case 2
Discussion