1 / 30

Emergency Medicine Grand Rounds

Emergency Medicine Grand Rounds. James Huffman 05.20.2010. Emergency Medicine Grand Rounds: Pediatric Toxicology. James Huffman 05.20.2010 Special Thanks to Dr. M. Yarema. Aren’t kids just little adults with big heads and small V d ?. Objectives. Epidemiology

wyman
Download Presentation

Emergency Medicine Grand Rounds

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Emergency Medicine Grand Rounds James Huffman 05.20.2010

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

  3. Aren’t kids just little adults with big heads and small Vd?

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

  5. National Poison Data SystemReport(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

  6. 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)

  7. 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.

  8. 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

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

  10. Tricyclic Antidepressants Rosenbaum, TG. 2005. J of Emerg Med; 28(2).McFee, RB. 2008. AcadEmerg 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

  11. Calcium Channel BlockersBelson, 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

  12. SalicylatesSztajnkrycer, MJ. 2004. Emerg Med Clin NA; 22(4).Henry K. 2006. PedClin 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

  13. OpiodsVon 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)

  14. 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….

  15. “Trepidation at Triage” • When to worry when the child looks well at triage: • Oral hypoglycemics (particularly sulfonylureas) • Sustained release calcium channel blockers • Lomotil • Clonidine • Chloroquine (antimalarials) • Salicylates

  16. SulfonylureasBosse, GM. 1999. J Emerg Med; 17(4). • Bottom Line: • Observe for minimum of 12h • Frequent chemstrips • Often will require admission

  17. LomotilMcCarron, 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!

  18. Idiosyncratic Reactions

  19. 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’sToxicologic Emergencies. 8th Ed. (2006)

  20. 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’sToxicologic Emergencies. 8th Ed. (2006)

  21. Cough and Cold Preparations in Kids

  22. Cough and Cold Bottom Line • Potential harm • Sedation, ADE, very rarely death • Little to no benefit compared to placebo • honey might be better! • If you’re going to use/recommend them  know the dosing and trust the patient.

  23. Objectives • Epidemiology • Review “Deadly in a Dose” Medications • Idiosyncratic Reactions in Kids • Cough & Cold Preparations – what’s the fuss?

  24. Questions?

More Related