308
Clinical note
The Journal of Pediatrics August 1978
Clinical note 11ypersensitivity to Vistaril in a child ivith asthma ttydroxyzine pamoate (Vistaril) is used for the management of allergic conditions, pruritus, motion sickness, asthma, for nausea and vomiting, and for its central calming actions. '~ Like diphenhydramine (Benadryl), it is a diphenylmethane antihistamine with anticholinergic and antiemetic properties?. ~ llydroxyzine is often used preoperatively for potentiation of narcotics, reportedly vdthout increasing respiratory depression. CASE REPORT
A well-developed, well-nourished (167.6 cm, 55.9 kg), 15-yearold boy was admitted for a possible bowel obstruction. The patient had a past history of extrinsic asthma, hay fever, and allergies to pollens, dust, and pine trees. There was no history of allergies to any medications. Admission medications included Aerolate Junior, diphenhydramine 25 mg, and occasionally Donnatal. On admission the following serum levels were within normal limits: calcium, inorganic phosphorus, blood urea nitrogen, glucose, uric acid, cholesterol, total protein, albumin, total bilirubin, hemoglobin, white blood count (with a normal differential), and lactic dehydrogenase, preoperative medication prior to laparotomy was Vistaril 50 mg intramuscularly. Within ten minutes of the Vistaril injection, the patient complained of chest tightness, became dyspneic, and began to wheeze. This acute reaction was treated with 0.3 mg of epinephrine, followed by Susphrine 1.5 mg subcutaneously. An infusion of 400 mg of aminophylline was started immediately afterward and administered over six hours. It was felt at this time that the wheezes and tightness in the chest were entirely emotional in nature. Three days later, without the patient's knov,'ledge, he was rechallenged with Vistaril 50 mg intramuscularly. Within ten minutes he developed wheezing and tightness in the chest. The acute reaction was treated as in the first episode. DISCUSSION A literature reviek' documented that hydroxyzine HCI, 1.0 mg/kg given intramuscularly, elicited bronchodilator effects with a subsequent significant increase in airway conductance.' As a result, hydroxyzine (although the pamoate salt was not
rhentioned) is often employed for asthmatic patients undergoing surgery. In another study, 14 "healthy individuals" and five geriatric patients (without respiratory conditions) developed tightness in the chest and wheezing when hydroxyzine (1tC 1 salt) was administered. Upon immediate intra-arterial injection of dexamethasone, the reaction subsided? lntra- or periarterial injections of hydroxyzine (liCI salt) in animals have produced similar resultsY It is important to note that antihistanfines have a histamine-releasing action which is frequently unknown to clinicians; therefore, reactions in atopic or histamine sensitive patients may not be recognized. This report deals with the intramuscular, injection of the pamoate salt of hydroxyzine, whereas all studies to date have been concerned with the tlCI salt. The physician should be aware that the use of any salt of hydroxyzine may precipitate a reaction; to substitute a different brand of the drug will not alleviate the problem. Neil Massoud, M.S., Pharm.D. Clinical Co-ordinator Vancouver General tlospital 855 IV. 12th St. Vancouver, B.C., Canada V5Z 1319 REFERENCES !. Miller RR, and Greenblatt JD: Drug effects in hospitalized patients, New York, 1976, John Wiley & Sons, Inc., pp 201202. 2. Goldfien A, Jawetz E, and Meyers HF: Review of medical pharmacology, Los Altos, Calif., 1976, Lange Medical Publications, pp 249-258. 3. AMA-Department of Drugs; AMA drug evaluations, Littleton, Mass., 1977, Publishing Sciences Group, Inc., pp 4171099. 4. tlewich A, Sousa-Poza M, and Lyons ltS: Bronchodilator effects of hydroxyzine HCI, Respiration 29:135, 1972. 5. Lauria J, Markello R, and King BD: Circulatory and respiratory effects of hydroxyzine in volunteers and geriatric patients, Anesth Analg 47:378, 1968. 6. Encole G, Sylvestor M, and Morris LE: tlazards of intraarterial injection of hydroxyzine, Can Anesth Soc J 16:425, 1969.
0022-3476/78/0293-0308500.10/0 9 1978 The C. V. Mosby Co.
Clinical note
The Journal of Pediatrics August 1978
Clinical note 11ypersensitivity to Vistaril in a child ivith asthma ttydroxyzine pamoate (Vistaril) is used for the management of allergic conditions, pruritus, motion sickness, asthma, for nausea and vomiting, and for its central calming actions. '~ Like diphenhydramine (Benadryl), it is a diphenylmethane antihistamine with anticholinergic and antiemetic properties?. ~ llydroxyzine is often used preoperatively for potentiation of narcotics, reportedly vdthout increasing respiratory depression. CASE REPORT
A well-developed, well-nourished (167.6 cm, 55.9 kg), 15-yearold boy was admitted for a possible bowel obstruction. The patient had a past history of extrinsic asthma, hay fever, and allergies to pollens, dust, and pine trees. There was no history of allergies to any medications. Admission medications included Aerolate Junior, diphenhydramine 25 mg, and occasionally Donnatal. On admission the following serum levels were within normal limits: calcium, inorganic phosphorus, blood urea nitrogen, glucose, uric acid, cholesterol, total protein, albumin, total bilirubin, hemoglobin, white blood count (with a normal differential), and lactic dehydrogenase, preoperative medication prior to laparotomy was Vistaril 50 mg intramuscularly. Within ten minutes of the Vistaril injection, the patient complained of chest tightness, became dyspneic, and began to wheeze. This acute reaction was treated with 0.3 mg of epinephrine, followed by Susphrine 1.5 mg subcutaneously. An infusion of 400 mg of aminophylline was started immediately afterward and administered over six hours. It was felt at this time that the wheezes and tightness in the chest were entirely emotional in nature. Three days later, without the patient's knov,'ledge, he was rechallenged with Vistaril 50 mg intramuscularly. Within ten minutes he developed wheezing and tightness in the chest. The acute reaction was treated as in the first episode. DISCUSSION A literature reviek' documented that hydroxyzine HCI, 1.0 mg/kg given intramuscularly, elicited bronchodilator effects with a subsequent significant increase in airway conductance.' As a result, hydroxyzine (although the pamoate salt was not
rhentioned) is often employed for asthmatic patients undergoing surgery. In another study, 14 "healthy individuals" and five geriatric patients (without respiratory conditions) developed tightness in the chest and wheezing when hydroxyzine (1tC 1 salt) was administered. Upon immediate intra-arterial injection of dexamethasone, the reaction subsided? lntra- or periarterial injections of hydroxyzine (liCI salt) in animals have produced similar resultsY It is important to note that antihistanfines have a histamine-releasing action which is frequently unknown to clinicians; therefore, reactions in atopic or histamine sensitive patients may not be recognized. This report deals with the intramuscular, injection of the pamoate salt of hydroxyzine, whereas all studies to date have been concerned with the tlCI salt. The physician should be aware that the use of any salt of hydroxyzine may precipitate a reaction; to substitute a different brand of the drug will not alleviate the problem. Neil Massoud, M.S., Pharm.D. Clinical Co-ordinator Vancouver General tlospital 855 IV. 12th St. Vancouver, B.C., Canada V5Z 1319 REFERENCES !. Miller RR, and Greenblatt JD: Drug effects in hospitalized patients, New York, 1976, John Wiley & Sons, Inc., pp 201202. 2. Goldfien A, Jawetz E, and Meyers HF: Review of medical pharmacology, Los Altos, Calif., 1976, Lange Medical Publications, pp 249-258. 3. AMA-Department of Drugs; AMA drug evaluations, Littleton, Mass., 1977, Publishing Sciences Group, Inc., pp 4171099. 4. tlewich A, Sousa-Poza M, and Lyons ltS: Bronchodilator effects of hydroxyzine HCI, Respiration 29:135, 1972. 5. Lauria J, Markello R, and King BD: Circulatory and respiratory effects of hydroxyzine in volunteers and geriatric patients, Anesth Analg 47:378, 1968. 6. Encole G, Sylvestor M, and Morris LE: tlazards of intraarterial injection of hydroxyzine, Can Anesth Soc J 16:425, 1969.
0022-3476/78/0293-0308500.10/0 9 1978 The C. V. Mosby Co.
