1. Emergency Medicine Grand Rounds James Huffman 05.20.2010

8. Emergency Medicine Grand Rounds: Pediatric Toxicology James Huffman 05.20.2010 Special Thanks to Dr. M. Yarema

9. Aren’t kids just little adults with big heads and small V d ?

10. Objectives 1.Epidemiology 2.Review “Deadly in a Dose” Medications 3.Idiosyncratic Reactions in Kids 4.Cough & Cold Preparations – what’s the fuss?

11. 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

12. 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)

13. 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.

14. 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

15. Deadly in a Dose (potentially) Eldridge, D. 2007. Emerg Med Clin N Am. 15:283-308 Goldfrank’s Toxicologic Emergencies. 8 th 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

16. 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

17. Calcium Channel Blockers Belson, 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

18. Salicylates Sztajnkrycer, 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 = 5mL 1 toddler’s mouthful = 5-10mL

19. Opiods Von 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)

20. 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….

21. “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

22. Sulfonylureas Bosse, GM. 1999. J Emerg Med; 17(4).  Bottom Line:  Observe for minimum of 12h  Frequent chemstrips  Often will require admission

23. Lomotil McCarron, 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!

24. Idiosyncratic Reactions

25. 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. 8 th Ed. (2006)

26. 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 Ethanol Goldfrank’s Toxicologic Emergencies. 8 th Ed. (2006)

27. Cough and Cold Preparations in Kids

28. 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.

29. Objectives 1.Epidemiology 2.Review “Deadly in a Dose” Medications 3.Idiosyncratic Reactions in Kids 4.Cough & Cold Preparations – what’s the fuss?

30. Questions?