1. Poisoning in Children Kent R. Olson, MD Medical Director, San Francisco Division California Poison Control System Clinical Professor of Medicine, Pediatrics and Pharmacy, UCSF

2. Case study: A 2 year old child is found with a bottle of his mother’s prenatal vitamins Spontaneous vomiting after 30 minutes Paramedics report systolic BP 70/p, HR 130/min

3. Most common pediatric exposures* Category Hazard Factor Cosmetics0.2 Cleaning agents0.9 Plants0.1 Analgesics0.6 Cough & cold preparations0.5 Hydrocarbons2.2 Data from AAPCC 1985-1989

4. Relative risk of death/major effect Category Hazard Factor Rattlesnake bite244 Strychnine50 Alkaline drain cleaner22 Organophosphates5.6 Anticoagulants0.9 Cosmetics0.2

5. Pediatric poisoning deaths (AAPCC 1985-1989) PharmaceuticalsHazard Factor Iron8.5 Tricyclic antidepressants17.7 Cardiovascular drugs8.1 Non-pharmaceuticalsHazard Factor Pesticides2.1 Hydrocarbons2.2 Methanol5.1

6. More recent data - AAPCC 1999 24 deaths in children < 6 Pharmaceuticals Opioids (3) Iron (1) Nifedipine (1) Non-pharmaceuticals Carbon monoxide (7) Hydrocarbons (3) Ammonium bifluoride (2)

7. Case 1: Abdominal X-ray

8. Iron poisoning in children Leading cause of childhood poisoning deaths Pathophysiology: –corrosive effect on GI tract –cellular toxin Toxic dose > 40-60 mg/kg elemental Fe –adult strength preparations much more likely to cause toxicity than children’s chewables

9. Iron poisoning: clinical findings Vomiting Diarrhea Hypotension Metabolic acidosis Leukocytosis, hyperglycemia Radiopaque pills on plain x-ray Late complication: hepatic failure

10. Treatment of iron poisoning Volume replacement –IV crystalloid boluses Chelation therapy –deferoxamine (Desferal) is specific chelator –Iron chelate complex  “vin-rose” urine –IV route preferred (don’t use IM “test dose”) –avoid prolonged deferoxamine therapy

11. Gut decontamination for iron ingestion Home: –consider ipecac-induced emesis if recent OD –argument against ipecac: it masks spontaneous vomiting Hospital: –ipecac or gastric lavage? Neither very effective –lavage with HCO3, PO4? Dangerous –whole bowel irrigation = best method

12. Whole bowel irrigation Balanced electrolyte solution with non- absorbable polyethylene glycol (PEG) –no electrolyte disturbance –no net fluid gain or loss –well-tolerated GoLytely™Colyte™Method: GoLytely™ or Colyte™ –500 mL/hour by gastric tube until rectal effluent clear –Adolescents/adults: 1-2 L/hr

13. Case study: A toddler is found with an open daily medicine container belonging to his grandmother. Usual contents: –Lasix 40 mg –Cardizem-CD 240 mg –Multiple vitamin Container is now empty. Child asx.

14. ECG in a patient with verapamil OD

15. Negative Inotropic Effects Negative Inotropic Effects Decreased Automaticity & Conduction Decreased Automaticity & Conduction Dilated Vascular Smooth Muscle Dilated Vascular Smooth Muscle SVR SVR COHR AV Block SHOCKSHOCK Calcium Channel Blocker Poisoning

16. Calcium antagonist toxicity Shock caused by combination of: –Decreased automaticity & conduction –Negative inotropic effects –Vasodilation Treatment with calcium –most effective for negative inotropic effect –high doses may be needed –in the future: insulin + glucose?

17. Case study: An 18 month old is brought to the ER after a seizure No prior seizures No recent illness or fever HR 140/min, BP 105/70 Pupils dilated Skin flushed, dry

18. Case 2: ECG

19. Common drug-induced seizures Tricyclic antidepressants Cocaine & amphetamines Theophylline Diphenhydramine Isoniazid (INH) Phenothiazines Strychnine Many others (camphor, lindane, etc)

20. Case study, cont. ECG monitor shows wide QRS complex Repeat BP 70/p The child is intubated endotracheally A therapeutic drug is given:

21. Tricyclic antidepressant OD “Three C’s” –coma –convulsions –cardiac conduction defects … AND Anticholinergic effects –dilated pupils –tachycardia –jerking movements

22. Treatment of TCA overdose ABCs No ipecac! (use AC orally or by NG) Monitor asx child for at least 6 hours QRS prolongation: –Caused by Na channel block –Rx = Sodium Bicarbonate –1-2 mEq/kg IV bolus Do NOT use physostigmine

23. Another Case A child is found with an open container of “wire wheel cleaner” Contents: –ammonium bifluoride –hydrofluoric acid Child initially asymptomatic

24. Fluoride toxicity Sources: –wire wheel cleaners, degreasers, rust and water stain removers –fluoride tablets and drops Toxicity: –hypocalcemia (even from dermal exposure) –hyperkalemia –ventricular fibrillation Treatment: Calcium (oral and IV)

25. Case study: A 16 year old takes several “happy pills” provided by a friend. Develops a headache, vomits once. In ER: –awake, alert, c/o headache –HR 38/min (w/2nd degree AV block) –BP 166/100 mm

27. Phenylpropanolamine Common OTC product May be used to get “high” (not very effective) or as suicidal agent Hypertension common, often with reflex bradycardia or even AV block –intracranial hemorrhage may occur Treat with vasodilator, e.g. phentolamine, nitroprusside

28. 11-6-2000: FDA’s MedWatch “FDA is taking steps to remove phenylpropanolamine hydrochloride from all drug products due to the risk of hemorrhagic stroke... “... FDA has significant concerns because of the seriousness of stroke and the inability to predict who is at risk …”

30. Gut decontamination Current consensus: –Gut emptying of limited value –AC alone probably fine in most patients Some twists: –SI still useful at home w/in 5-10 min? –Lavage for selected cases? –Role of Whole Bowel Irrigation? –What about home AC?

31. Anyone for charcoal?

32. Use of ipecac is declining YearIpecac used 1983 13.4% 1988 8.4% 1993 3.7% 1998 1.2% Source: AAPCC 1999

33. Final “stumper” 9 month old being watched by grandmother Found flaccid, grunting, with decreased level of consciousness HR 70/min, BP 105/59 Respirations agonal, O2 sat 80% Pupils pinpoint

34. More information... No response to naloxone Treated supportively, eventually recovered Initial history: grandmother takes lisinopril, HCTZ Also using eye drops for glaucoma

35. Continued Alphagan™ (brimonidine 0.2%) –used for open-angle glaucoma Stimulates  -2 receptors (similar to clonidine) –CNS depression, bradycardia, HOTN –Peripheral: alpha-agonist can elevate BP

36. California Poison Control System Public Hotline: 1-800-876-4766 (8-POISON) Health Professionals: 1-800-411-8080 300,000 exposures/year –2/3 are kids –also: suicides, occupational, hazmat, veterinary, consumer product recalls,... Most kids can be managed at home –PCC can communicate with 9-1-1 or paramedics on scene