Download - Emergency Medicine Grand Rounds
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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” Medications3. Idiosyncratic Reactions in Kids4. 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 13 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 wasBoth the child and grandmother state they believe it was
only one pill.
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Case 1Vitals are normal Child is playful and
interactivePhysical examination is
normalBlood 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 1965-2005All 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/kgFatalities have been reported with doses of 300mg/kgOil 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 dadGot into a “few tablets” (non-Rx)Occurred “a couple” hours agoSeemed find so dad wasn’t worriedThen…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 blockers3. Lomotil4. Clonidine5. 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 toxicDelayed 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 ToxicologyAnswer: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 ToxicologyAnswer:When ingested by a toddler, this non-
pharmaceutical agent causes hypoglycemia and fluctuations in level of consciousness.
Question:What is Ethanol
Goldfrank’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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Objectives1. Epidemiology 2. Review “Deadly in a Dose” Medications3. Idiosyncratic Reactions in Kids4. Cough & Cold Preparations – what’s the fuss?
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Questions?