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Emergency Medicine Grand Rounds
James Huffman05.20.2010
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Emergency Medicine Grand Rounds:
Pediatric Toxicology
James Huffman05.20.2010Special Thanks to Dr. M. Yarema
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Aren’t kids just little adults with big heads and small Vd?
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Objectives
1. Epidemiology
2. Review “Deadly in a Dose” Medications
3. Idiosyncratic Reactions in Kids
4. Cough & Cold Preparations – what’s the fuss?
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National Poison Data System Report(2008)Bronstein, A. 2009. Clinical Toxicology; 47:10.
About 2.5 million human exposures reported to American Association of Poison Control Centres
39% occurred in children less than 3 years old
65% occurred in children up to age 20
8% of all poisoning fatalities were in kids under 20
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Tox Fatalities <6 yrs (1983-2004)Eldridge, D. 2007. Emerg Med Clin N Am. 15:283-308
Analgesics (60) Acetaminophen (14) Salicylates (14) NSAIDS (3) Opiods (29)
Anesthetics (8)
Anticonvulsants (39)
Antihistamines (9)
Antimicrobials (7) Chloroquine (2) Cefotaxime (1)
Cardiovascular Medications (23) CCB (12) Digoxin (5) BB (0)
Cough & Cold Medications (5)
Diabetic medications (2) Insulin (2)
Supplements (45) Iron (42)
Methylxanthines (7) Theophylline (5)
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Case 1
3 year old girl swallowed a single tablet of one of her grandmother’s medication’s ~25 min ago.
Grandma isn’t sure which medication it was
Both the child and grandmother state they believe it was only one pill.
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Case 1
Vitals are normal
Child is playful and interactive
Physical examination is normal
Blood glucose is 5mmol/L
Grandma’s Med list:
Amitriptyline
Norvasc
Clonidine
ASA
Glyburide
Oxycodone
multivitamin
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Deadly in a Dose (potentially)Eldridge, D. 2007. Emerg Med Clin N Am. 15:283-308Goldfrank’s Toxicologic Emergencies. 8th Ed (2006)
Antimalarials Chloroquine
Antihistamines
Antidysrhythmics
Benzocaine
Beta Blockers
Calcium Channel Blockers
Camphor
Conidine
Higher Alcohols
Lomotil
Lindane
Methyl Salicylate
Opiods
Oral hypoglycemics
Theophylline
TCA’s
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Tricyclic Antidepressants Rosenbaum, TG. 2005. J of Emerg Med; 28(2).McFee, RB. 2008. Acad Emerg Med; 8(2).
No symptoms reported with doses < 5mg/kg (Amitriptyline)
12 children with fatal TCA ingestions from 1965-2005
All fatal cases had doses ≥ 15mg/kg (usually > 30mg/kg)
Available in 10-150mg pills 1 pill is potentially fatal for a 10kg (1 year old) toddler
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Calcium Channel BlockersBelson, MG. 2000. Am J Emerg Med; 18(5).Lee, DC. 2000. J. Emerg Med; 19(4).
Belson: no deaths and very few symptoms in a 6 year retrospective case series of 212 one pill CCB exposures
Concluded that exposures less than 2.7mg/kg (nifedipine) and less than 12mg/kg (verapamil) could be sent home.
BUT: nifedipine – available in 90mg tabs 1 tab exceeds “safe” dose up
to 20kg Case reports of death after ingestion of a single pill of nifedipine
Bottom line: CCBs still scare me – especially SR formulations
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SalicylatesSztajnkrycer, MJ. 2004. Emerg Med Clin NA; 22(4).Henry K. 2006. Ped Clin NA; 53(2).
Readily available in many OTC products.
Toxicity has been reported in doses of 150mg/kg
Fatalities have been reported with doses of 300mg/kg
Oil of wintergreen: 98% methyl salicylate 1mL contains 1400mg of salicylate the toxic dose for a 10kg
child
FYI:1tsp = 5mL1 toddler’s mouthful = 5-10mL
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OpiodsVon Muhlendahl, KE. 1976. The Lancet; 308(7980).Sachdeva, DK. 2005. J Emerg Med; 29(1).
Codeine No toxic effects < 5mg/kg Deaths from respiratory depression are documented at 7mg/kg
Methadone Multiple case reports of lethal toxicity at 0.5mg/kg Supplied as either 5mg, 10mg tabs, or 1mg/mL liquid When onset of effects not consistently reported
Others Limited data, no reports of toxic effects developing after 6h
Bottom Line: 6h observation is probably appropriate (exception for methadone 24h admission)
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Case 2
2 year old boy being watched by dad
Got into a “few tablets” (non-Rx)
Occurred “a couple” hours ago
Seemed find so dad wasn’t worried
Then…Mom got home….
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“Trepidation at Triage”
When to worry when the child looks well at triage:
1. Oral hypoglycemics (particularly sulfonylureas)
2. Sustained release calcium channel blockers
3. Lomotil
4. Clonidine
5. Chloroquine (antimalarials)
6. Salicylates
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SulfonylureasBosse, GM. 1999. J Emerg Med; 17(4).
Bottom Line: Observe for minimum of 12h Frequent chemstrips Often will require admission
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LomotilMcCarron, MM. 1991. Pediatrics; 87(5).
Antidiarrheal product combining: Opiod (diphenoxylate) Anticholinergic (atropine)
Can present with either toxidrome
Small doses toxic
Delayed presentation in kids ~10% after 12h
Bottom line:
Admit/Monitor for 24h!
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Idiosyncratic Reactions
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Idiosyncratic Drug Reactions in Pediatric Toxicology
Answer:
This pharmaceutical presents with CNS
depression, respiratory depression, miosis,
bradycardia and hypotension and is NOT an
opiod.
Question:
What is Clonidine
Goldfrank’s Toxicologic Emergencies. 8th Ed. (2006)
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Idiosyncratic Drug Reactions in Pediatric Toxicology
Answer:
When ingested by a toddler, this non-
pharmaceutical agent causes hypoglycemia
and fluctuations in level of consciousness.
Question:
What is EthanolGoldfrank’s Toxicologic Emergencies. 8th Ed. (2006)
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Cough and Cold Preparations in Kids
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Cough and Cold Bottom Line
1. Potential harm Sedation, ADE, very rarely
death
2. Little to no benefit compared to placebo
honey might be better!
3. If you’re going to use/recommend them know the dosing and trust the patient.
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Objectives
1. Epidemiology
2. Review “Deadly in a Dose” Medications
3. Idiosyncratic Reactions in Kids
4. Cough & Cold Preparations – what’s the fuss?
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Questions?