1515 - Role of Dantrolene in Persistent Emesis in Traumatic Brain Injury Patients

Case Diagnosis: Persistent emesis secondary to Dantrolene use

Case Description: A 17-year-old male with history of obesity presented to inpatient rehabilitation unit after suffering severe TBI, polytrauma, including abdominal trauma requiring small bowel resection. Patient was status-post multiple laparoscopic abdominal procedures with g-tube placement. Dantrolene was started for spasticity and extensor posturing in all extremities. Patient developed persistent emesis with bolus tube feeds. Emesis was initially attributed to ileus from multiple abdominal procedures and increased bowel gas and constipation seen on imaging. Initially this improved with cessation of feeds. This continued after resuming feeds and many alterations in feed rate and formulas were trialed without improvement. Some improvement was seen with metoclopramide Patient was also started on various acid suppressants including Famotidine and Omeprazole as emesis continued, sometimes unrelated to tube feeds. Gastric emptying study and EGD were unremarkable. Antiemetic regimen included Zofran and Tigan, which did not provide relief. Discontinuation of Dantrolene was trialed and emesis fully resolved.

Discussions: This case highlights the importance of a thorough workup of persistent emesis in a TBI patient. Initial management includes feed changes, intestinal motility facilitation, and antiemetic administration. A medication review is necessary if initial changes fail. Side effects of Dantrolene include GI disturbances such as dysphagia, nausea, and vomiting which commonly occur with oral administration at a frequency of 1-10%. Other side effects include gastrointestinal hemorrhage and acute hepatotoxicity. Variables influencing adverse effects of Dantrolene include total dosage, patient age & body weight, volume of administered fluid, and degree of underlying medical conditions. Furosemide has been shown to curb the adverse effects of Dantrolene. CBC, BMP, and LFTs should be obtained prior to starting or altering the dose of Dantrolene.

Conclusions: Dantrolene cessation should be considered in TBI patients displaying spasticity with persistent emesis refractory to antiemetics and feeding changes.