1. Emergency department 11/10/17
Pediatric Ingestions
Emergency department
11/10/17

2. Case 1:
18 month old girl brought the ER by ambulance after grandmother was unable to wake her up from a long nap.
No concurrent illness
On exam: Shallow breathing, moans and withdraws in response to pain, does not open her eyes. Rest of physical exam is normal.
No fever. No evidence of trauma.
Based on this initial assessment : what should you do next?

3. Initial plan of action :
1. Airway – compromised?
2. Cardiac leads, EKG stat
3. Glucose level
4. Labs: routine ?
Grandmother states that the patient was found with her pill box earlier in the day.
Grandmother does not have the box with her and does not recall the medications she is taking.

4. What next? Which medications could be fatal in a small dose ?
- Opioids
- sedatives
- cardiac drugs
- hypoglycemic agents
Do you give activated charcoal or not?

5. CASE 2 3 year old is referred to ER by his pediatrician
Child came to the parents holding his throat and saying he had swallowed something. Unsure what it was. Soon after, refused to eat. Afebrile with normal vital signs and no respiratory distress.
Oropharynx and lung exam are clear
What, if any, imaging is recommended?
Is a surgical consult indicated
Can he be safely discharged home?

6. Case 3
15 year old adolescent girl is brought to the ER for possible suicide attempt. Patient reports taking an entire bottle of ‘pain pills’
An old bottle of acetaminophen with hydrocodone is now empty. She took the medications 4 hours ago
She is tearful and tired but rest of exam and vitals are within normal
Are there any specific drug levels that should be checked ?
Should u give naloxone or NAC?
When can the patient be medically cleared for transfer to a psychiatric facility?

7. Medicines known for high risk of fatality
Antiarrhythmics: block cardiac function
Anti-malarials: chloroquine, hydroxychloroquine and quinine act as class 1A antiarrhythmics to block sodium channels and also cause Respiratory and CNS depression
Anti-psychotics: Some possess sodium channel blockade properties and many can result in CNS depression and hypotension
Betablockers: Bradycardia, hyperkalemia, hypotension, CNS depression
Calcium channel blockers: Bradycardia, hypotension, hyperglycemia
Camphor: GI symptoms, altered mental status, seizure

8. Medicines known for high risk of fatality
Clonidine : alpha 2 receptor agonist: transient hypertension then bradycardia and hypotension, respiratory and CNS depression
Opioids: Severe respiratory and CNS depression
Methyl salicylate: Highly concentrated salicylates can cause respiratory alkalosis and metabolic acidosis
Sulfonylureas : hypoglycemia
Tricyclic antidepressants block sodium channels and also have anticholinergic properties

9. Pearls to remember: BK VIRUS : BETA blockers HYPERKALEMIA
Calcium gluconate: Calcium channel blockers, hyperglycemia

10. TOXIDROMES TO REMEMBER
Cholinergic
Anticholinergic
Bradycardia with hypotension
Hyperglycemia
Hypoglycemia
Opioid
Sedation
Seizure
Sympathomimetic
Serotonin

11. Rapid recall : Peripheral nervous system :
 Autonomic nervous system (regulates involuntary processes including digestion and breathing)
 Somatic nervous system (transmits signals from the central nervous system and external stimuli to skeletal muscle and also mediates hearing, sight, and touch)
Autonomic nervous system: Sympathetic and parasympathetic

13. Rapid review
Cholinergic drugs produce the same effects as acetylcholine.
Acetylcholine is the most common neurohormone of the parasympathetic nervous system, the part of the peripheral nervous system responsible for the every day work of the body.
While the sympathetic nervous system acts during times of excitation, the parasympathetic system deals with everyday activities such as salivation, digestion, and muscle relaxation.

14. Cholinergic effects
The effects of the cholinergic drugs are to produce the same effects as stimulation of the parasympathetic nervous system.
These effects include slowing of the heartbeat, increases in normal secretions including the digestive acids of the stomach, saliva and tears.

16. Cholinergic toxidrome
The possible adverse effects of cholinergic drugs are:
slow heart beat, possibly leading to cardiac arrest.
muscle weakness, muscle cramps, and muscle pain
convulsions
weak breathing, inability to breath
increased stomach acid and saliva
nausea and vomiting
dizziness, drowsiness, and headache

17. Examples of cholinergic drugs/uses
Not commonly used as a drug
Organophosphates
Carbamates
Anticholinesterase inhibitors

18. Anticholinergic Toxidrome : opposite of cholinergic toxidrome !
Hyperpyrexia*
Mydriasis
Tachycardia
Dry skin*
Ileus
Urinary retention
Altered mental status

20. Anticholinergic drugs or toxins
Antihistamines
Carbamazepine
Cyclobenzaprine
Jimson weed
Tricyclic antidepressants
*Anticholinergic : MydriAsis*

21. Opioid toxidrome Miosis Hypothermia Hypotension Respiratory depression
Ileus
Causes: Natural opioids: morphine and derivatives
synthetic opioids eg fentanyl
Semisynthetic opioids eg hydromorphone, hydrocodone
Methadone
Buprenorphine

22. Bradycardia with hypotension
Beta blockers
Calcium channel blockers
Clonidine
Digoxin

23. Hyperglycemia Alpha agonists Beta agonists Calcium channel blockers
Colchicine
Methylxanthines

24. Sedation Anticonvulsants Antipsychotics Barbiturates Benzodiazepines
Ethanol
Opioids

25. Seizures Anticholinergic agents Buproprion Hypoglycemic agents
Isoniazid
Sympathomimetic drugs

26. Sympathomimetic toxidrome
Hyperpyrexia
Mydriasis
Tachycardia
Hypertension
Diaphoresis
Altered mental status
Seizures
Causes: amphetamines, cocaine, ephedrine, phenethylamines, Bath salts

27. Serotonin Syndrome
Potentially life-threatening condition associated with increased serotonergic activity in the central nervous system (CNS).
Therapeutic medication use
Inadvertent interactions between drugs
Intentional self-poisoning.
Clinical findings often include mental status changes, autonomic hyperactivity, and neuromuscular abnormalities.

28. Serotonin Syndrome

29. Drugs implicated in Serotonin Syndrome
SSRIs : Citalopram, escitalopram, fluoxetine, paroxetine, sertraline
SNRIs: Desvenlafaxine, duloxetine, venlafaxine
Buproprion
St John’s Wort
Metoclopramide
Lithium

30. Serotonin Syndrome- Hunter criteria
Clinical diagnosis
Includes ingestion of a serotonergic drug and one of:
- Spontaneous clonus
- Inducible clonus and agitation or diaphoresis
- Tremor and Hyperreflexia
- Hypertonia
- Temperature >38C and ocular clonus or inducible clonus

31. Serotonin Syndrome : clinical features
Hyperthermia
Agitation
Slow, continuous, horizontal eye movements (referred to as ocular clonus)
Dilated pupils
Tremor
Akathisia : restlessness
Deep tendon hyperreflexia (common)
Deep tendon hyperreflexia (common)
Inducible or spontaneous muscle clonus (common)
Muscle rigidity
Bilateral Babinski signs
Dry mucus membranes
Flushed skin and diaphoresis
Increased bowel sounds  

32. Serotonin Syndrome

34. Anticholinergic vs Serotonin Syndrome

36. Altered mental status or not
Things to remember :
Pupils
Diaphoresis
Altered mental status or not
Temperature

37. Initial stabilization
PALS algorithm: airway, breathing circulation
History: allergies, medications, past medical history, events before presentation
Focused history for ingestion: name, strength, formulation, quantity and time of ingestion
Initial testing: blood glucose, EKG
- blood gas: equivocal impact
- pregnancy testing in adolescent females

38. Physical exam Vital signs including temperature
Tachycardia: sympathomimetic/anticholinergic
Bradycardia: beta blocker, calcium channel blocker, digoxin, clonidine
Respiratory rate: increased in salicylates, decreased in narcotics or sedatives
Skin: hot, dry or sweaty, petechiae, bruising
Mouth : caustic substances
Pupils
Tremulousness: hypoglycemia, hypocalcemia, lithium ingestion
Seizures: electrolyte derangement, buproprion, isoniazid, antihistamine, antiepileptic drugs.

39. Diagnostic studies: ANION GAP (Na – Cl – HCO3)
ANION GAP with ill appearing child, suspected ingestion
M : methanol, metformin
U: Uremia
D: diabetic ketoacidosis
P: propylene glycol, paraldehyde
I : Isoniazid, iron
L: lactate
E: ethylene glycol
S: salicylate

40. Acetaminophen and salicylate levels
Diagnostic studies
EKG
Acetaminophen and salicylate levels
Radiographic studies
Urine tox screens

41. Diagnostic studies
Acetaminophen: 4 hours later or immediately on admission if time of ingestion unknown
Salicylate: Generally symptomatic so usefulness is low.
However symptoms can be masked If opioids also ingested
Can have nonspecific symptoms so recommend testing if unsure of ingestion
Ethanol levels: may be helpful in obtundation
Iron levels: may help

42. EKG Screening for unknown ingestions
Digoxin: first degree heart block, sagging ST segment, hyperkalemia
Tachycardia
Widened QRS interval: Anti arrythmics that block fast sodium channels
Prolonged QTc interval: Anti arrythmics that block potassium efflux channels
TCAs have both sodium and potassium blockage properties : tachycardia, QRS widening, QTc prolongation
Low sensitivity, specificity and not clinically useful in studies done on pediatric ingestion

43. Radiographic studies
Strongly radio opaque medications: ferrous sulfate, calcium carbonate, potassium chloride, foreign bodies with lead
Useful most in distinguishing coins from button batteries: AP radiograph with double rim or step off on lateral film.

44. Ingested button battery with double rim

45. Urine toxicology screen
Know what the hospital screen offers and limitations to screening

46. The End!