One pill can kill (?) Eran Kozer MD Pediatric Emergency Medicine Assaf Harofeh Medical Center

Suggested reading zMichael JB, Sztajnkrycer MD Emerg Med Clin North Am Nov;22(4): Michael JBSztajnkrycer MD zBar Oz et al, Paediatr Drugs. 2004;6(2):123-6.

Outline zEpidemiology zCase scenario zWhich drugs are dangerous?

Epidemiology zMore than 2,000,000 calls to poison centers in the USA each year zMore than 1,000,000 visits to ED (McCaig LF, Burt CW J Toxicol Clin Toxicol. 1999)

Epidemiology z1-3y > 30% of calls zChildren <6y - more than 50% of all calls to poison centers zFatalities <6y less than 3% zChildren up to 19 >10% of all fatalities  (2004 Annual report of the American Association of Poison Control Centers American Journal Emergency Medicine 2005)

Substances most frequently involved in pediatric exposures (<6 years) zCosmetics personal care & cleaning – 23% zAnalgesics - 8% zTopical preparations – 7.5%

zMany exposures are non toxic zBUT…………

Rarely One pill can kill!!!

Case # 1 z1.5 Y male zTook 2 pills from drawer zPMHx: Healthy

Case # 1 zAlert, crying, no respiratory distress, pink zVitals: HR 160/min, BP 100/75, Temp 37.8 O2 sat 97% zWeight 10 kg

When to be worried? zBabysitter using oral contraceptives? zNO (regardless of dose)

When to be worried? zBrother came back from the far east? zYes – Why? zQuinine derivatives zChloroquine – minimal potential fatal dose 20mg/kg. Max dose in unit 500mg (in Israel 250mg)

One pill can kill!!!

When to be worried? zSister with a psychiatric disease yPsychosis? yYes yE.g Thioridazine (minimal potential fatal dose 15mg/kg - max dose per unit 200mg – in Israel 100mg )

1-2 pills can kill!!!

When to be worried? zSister with a psychiatric disease yWhat about atypical antypsychotics yNot enough data

When to be worried? zSister with Depression? zSSRI zNO

When to be worried? zSister with Depression? zTricyclic antidepressants zYes zImipramine (minimal potential fatal dose 15mg/kg; Max dose in unit 150mg - Israel 25mg)

One pill can kill!!!

zIf you think it is TCA which test may help in predicting severe intoxication (Seizures, arrhythmia?)

z QRS >100ms z 1/3 will develop seizures and 14% arrhytmias

When to be worried? yMom pregnant taking Iron and vitamins?

Iron  Number one killer (?)  A 10-kg toddler would need to ingest approximately 6 Ferro- gradumet 325-mg tablets (105 mg of elemental iron per tablet) before developing life-threatening toxicity

When to be worried? yMom with SLE? yYes yAntimalarial

When to be worried? yFather with NIDDM? yYes yOral hypoglycemics

When to be worried? zGrandma (parents do not know which drugs she is using)? yBeta blockers? yCa channel blockers? yDigoxin? yAspirin?

Beta-blockers zCommon use and wide availability z“Not one documented case of death or serious cardiovascular morbidity as a direct result of a beta-blocker exposure is to be found in an English language review for children under 6 years of age.” zThe risk to the toddler exposed to 1-2 tablets appears to be extremely small, zLove JN J Emerg Med. 2004

Ca channel blockers zSustained release preparations - may contain high dose zToddlers may chew

Ca channel blockers zNifedipine XL zMinimal potential fatal dose 15mg/kg; Max dose in unit 150mg zIsrael 60 mg

One tablet May Be Fatal (Bar-Oz et al Pediatric Drugs 2004) Tricyclic antidepressants Antipsychotics Anti-arrhythmics Quinine derivatives Calcium channel blockers Opioids (Methadone) (clonidine) Oral hypoglycemics (Sulfonylurea)

Liquids zHow much?

zlamp oil zEucalyptus oil

Camphor zAvailable in many nonprescription vaporized or topical "cold" medications zTopical musculoskeletal anesthetic "rubs" zCold sore" preparations

MENTHOLATUM BALM Active Ingredients: Menthol BP 1.35%, camphor BP 10%, eucalyptus oil 0.66%, pumilio pine oil 0.08%, methyl salicylate BP 0.66%. Dosage: Apply on skin or under nose or as inhal. in boiling water Prescribing Restrictions: None

Camphor z750 to 1000 (500?) mg are associated with the development of seizures and death zProducts with 10% camphor contain 500 mg in 5 mL

Treatment & Investigations DO NOT FORGET ! zAirway zBreathing zCirculation

Treatment zSupportive zReduce absorption zEnhance elimination zSpecific antidote

Summary zIf only 1-2 tablets are taken most drugs will not cause severe symptoms zFew drugs may be dangerous zDon’t forget your ABC (and D)

What would you do now? zFluids zCalcium zInotrops zGlucagon zInsulin+glucose