Emergency Medicine Grand Rounds

James Huffman05.20.2010

Emergency Medicine Grand Rounds:

Pediatric Toxicology

James Huffman05.20.2010Special Thanks to Dr. M. Yarema

Aren’t kids just little adults with big heads and small Vd?

Objectives

1. Epidemiology 2. Review “Deadly in a Dose” Medications3. Idiosyncratic Reactions in Kids4. Cough & Cold Preparations – what’s the fuss?

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

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)

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.

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

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

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

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

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

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)

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….

“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

SulfonylureasBosse, GM. 1999. J Emerg Med; 17(4).

Bottom Line: Observe for minimum of 12h Frequent chemstrips Often will require admission

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!

Idiosyncratic Reactions

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)

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)

Cough and Cold Preparations in Kids

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.

Objectives1. Epidemiology 2. Review “Deadly in a Dose” Medications3. Idiosyncratic Reactions in Kids4. Cough & Cold Preparations – what’s the fuss?

Questions?