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Drugs which can kill a toddler with one dose or swallow

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Drugs which can kill a toddler with one dose or swallow

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    1. Drugs which can kill a toddler with one dose or swallow Joe Lex, MD, FACEP Chestnut Hill Hospital Philadelphia, PA April 22, 1998

    2. How far we’ve come 1950 - >400 pediatric overdose deaths 1996 - 29 fatalities from overdose in children <6 years Can we be smug??

    4. The terrible twos... Toddlers explore their world Much ends up in the mouth Childproof containers - a major difference

    6. Gideon Koren’s article 1993 - identified a few medicines lethal to a 10-kg child in single pill or swallow accounted for >40% childhood fatalities recommended better labeling, childproof packaging

    7. The major miscreants - 1990 Camphor Chloroquine /hydroxychloroquine TCAs - especially desipramine Phenothiazines Quinine Methyl salicylate Theophylline

    8. LIQUIDS

    9. Camphor - a case study Known since 13th century Multiple pediatric deaths AAP editorial in 1978 - “Camphor: Who Needs It” Removal of 20% camphorated oil from pharmacies in 1980

    10. Camphor Ban on concentrations greater than 11% since 1983 Higher concentrations still available in Canada

    11. Camphor preparations Camphorated oil*………………………... *no longer available in US Campho-Phenique®……………………... Mentholatum®…………………………… Vicks Vaporub®………………………….. 20.0% 10.8% 9.0% 4.73%

    12. Campho-Phenique®

    13. Campho-Phenique® Antiseptic Gel (10.8%)

    14. Campho-Phenique® Cold Sore Gel (10.8%)

    15. Campho-Phenique® Antiseptic Liquid (10.8%)

    16. Campho-Phenique® Maximum Strength (10.8%)

    17. Camphor poisoning today 1996 - 9,387 camphor exposures reported to AAPCC 7404 in children under 6 years NO deaths reported Virtually eliminated as a source of lethality in this country

    18. SUCCESS

    20. Methyl salicylate Oil of wintergreen Deceptively toxic 1 cc = 1,400 mg salicylate!! Toxic dose = 200 mg / kg <1 tsp. is lethal in toddler!

    21. Methyl salicylate Therapeutic half-life is 1 to 2 hours Toxic levels with acid urine - half-life up to 30 hours Vd doubles or triples in toxic states

    22. Methyl salicylate Children with rheumatoid disease who are at steady state can become toxic by relatively minor dietary changes Infants may show little more than dehydration and rapid breathing Older kids also have GI symptoms and CNS depression

    23. Methyl salicylate Non-aspirin salicylates can be converted to “aspirin equivalent doses” with the help of tables found in any standard toxicology book

    24. Methyl salicylate 15%

    25. Methyl salicylate 18.3%

    26. Methyl salicylate 30%

    27. Methyl salicylate 30%

    28. Methyl salicylate 40%

    29. Methyl salicylate ??%

    30. Methyl salicylate 0.060%

    31. Methyl salicylate 1996 report to AAPCC 10,733 toxic exposures to methyl salicylate 7,712 were children Two deaths reported, both in adults

    33. PASTES, OINTMENTS & LINIMENTS

    36. Dibucaine Potent amide anesthetic Topical uses - hemorrhoids, sunburn, episiotomy pain 10x as toxic as lidocaine 20x as toxic as procaine

    37. Dibucaine CNS toxicity seizure coma

    38. Dibucaine Cardiotoxicity Increased PR Widened QT Slowed conduction Slowed repolarization Reentrant dysrhythmias SVT PVC

    39. Dibucaine Accounts for 1% of topical anesthetics sold in US Implicated in <5% of nonfatal pediatric exposures to topical anesthetics Caused 3 of 4 deaths due to topical anesthetics over last 10 years

    40. Dibucaine In 1995, US Consumer Product Safety Commission issued rule requiring childproof packing for containers with >0.5 mg dibucaine or >5 mg lidocaine Corticaine® Dibucort® Dibusone® Nupercainal®

    42. PILLS, TABLETS & CAPSULES

    43. Chloroquine Primary treatment for malaria Anti-inflammatory Antihistamine Anti-prostaglandin Hydroxychloroquine - chemically similar

    44. Chloroquine Overdose rapid in onset, usually within 30 minutes Untreated, death is rapid - within hours Initial symptom may be cardiac arrest

    45. Chloroquine GI absorption is rapid and almost complete Peak plasma concentrations within 1.5 to 3 hours Elimination half-life in children is 75 to 136 hours

    46. Chloroquine Survivors frequently have long-term neurologic sequelae Hypokalemia frequently reported, but over-correction can lead to lethal hyperkalemia

    47. Chloroquine Therapeutic dose - 10 mg/kg Toxic effects - seen at 20 mg/kg Lethal dose - 30 mg/kg Confirmed deaths in toddlers as low as 27 mg/kg 300mg tablet in 8 kg 12-month-old

    48. Chloroquine 1996 - 323 cases of anti-malarial medication overdoses 88 were children 2 deaths, neither in a child

    49. Desipramine (Norpramin®) All tricyclics are dangerous in excess Desipramine seems especially dangerous in children Anticholinergic toxidrome (remember the mnemonic??)

    50. Desipramine (Norpramin®) “blind as a bat” - dilated pupils “dry as a bone” - dehydrated “mad as a hatter” - hallucinations “red as a beet” - skin flushing urinary retention tachycardia

    51. Desipramine (Norpramin®) Hypertension early Hypotension late - ominous sign Convulsions, coma, and dysrhythmias follow

    52. Desipramine (Norpramin®) Cardiac in kids similar to adults PR lengthening QRS widening QT prolongation T-wave flattening / inversion ST depression right bundle branch block complete heart block

    53. Desipramine (Norpramin®) Kids may appear normal at first, then suffer catastrophic deterioration If COMPLETELY normal after 6 hours, may discharge Everyone else - 24 hours ICU monitoring

    54. Desipramine (Norpramin®) Norpramin® 10 mg

    55. Norpramin® 25mg 50 mg

    56. Norpramin® 75 mg 100 mg

    57. Desipramine

    58. Desipramine (Norpramin®) In this decade, 4 confirmed deaths in toddlers due to desipramine

    59. Clozapine (Clozaril®) “Broad spectrum” agonist for refractory schizophrenia Effective at these receptors: dopamine D1 & D2 alpha1 and alpha2 adrenoreceptors serotonin (5-HT2) histamine (H1) acetylcholine (muscarinic)

    60. Clozapine (Clozaril®) Low incidence extrapyramidal effects No tardive dyskinesia, even after prolonged use …BUT 1 to 2% develop agranulocytosis ? neutropenic sepsis ? death Saved for refractory cases of schizophrenia

    61. Clozapine (Clozaril®) overdose Drowsiness and restlessness Hyperreflexia and areflexia Agitation, confusion, disorientation, delirium Hypotension and hypertension Dysrhythmia, tachycardia, and heart block Respiratory depression

    62. Clozapine (Clozaril®) overdose Hypothermia Hypoactive bowel sounds Hypersalivation and dry skin Urinary retention Pancreatitis Adult Respiratory Distress Syndrome Myocarditis Sudden death

    63. Clozapine (Clozaril®) overdose Case reports emphasize the small amount of drug needed to cause life threat in a toddler 3 cases of coma with less than one pill One fatality reported

    64. Clozapine (Clozaril®)

    65. Some scary possibilities - nifedipine (Procardia®) One case report of a toddler dying after ingestion single 10 mg nifedipine tablet

    66. Some scary possibilities - nifedipine (Procardia®)

    67. Some scary possibilities - encainide (Enkaid®) Encainide (Enkaid®) has been removed from American market voluntarily, but still available on “compassionate” basis Case report of infant swallowing 1 tablet (25 mg) with rapid onset V-tach, but survival

    68. Some scary possibilities - propafenone (Rhythmol®) 2 year-old ingested less than a full tablet and rapidly went into cardiovascular collapse Eventual recovery

    69. Propafenone (Rhythmol®)

    70. Some scary possibilities Two deaths reported from charcoal aspiration in 1996 Both children had consumed nontoxic medications

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