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Case of Lomotil Overdose

Case of Lomotil Overdose. Dr. Wong Oi Fung AED TMH. Case. M/2 Good past health 17 March 2005 22:29 Ingestion of 5 tablets of Lomotil at 10:30 Witnessed by another child. M/2 Lomotil ingestion. No convulsion No vomiting Normal urine output. Physical exmination. Temp 36 ° C

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Case of Lomotil Overdose

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  1. Case of Lomotil Overdose Dr. Wong Oi Fung AED TMH

  2. Case • M/2 • Good past health • 17 March 2005 22:29 • Ingestion of 5 tablets of Lomotil at 10:30 • Witnessed by another child

  3. M/2 Lomotil ingestion • No convulsion • No vomiting • Normal urine output

  4. Physical exmination • Temp 36°C • GCS 15/15, Pupils equal and reactive • Regular pulse, 139 beats/min • Chest clear • Abdomen soft and non tender, bowel sound +ve

  5. M/2 Lomotil ingestion - Ix • AXR: no dilated bowel • H’stix: 5.4 • ECG SR

  6. Management? Lomotil poisoning in child

  7. Lomotil poisoning • Common antidiarrheal agent • 2.5mg diphenoxylate + 0.025mg atropine • One of the agents that can kill at a low dose in pediatric group of patient • Calcium channel antagonists, camphor, clonidine and the imidazolines, cyclic antidepresants, opioids, lomotil, salicylates, sulfonylureas, toxic alcohols • Joshua B. Deadly pediatric poisons: nine common agents that kill at low doses. Emerg Med Clin N Am 22(2004)1019-1050

  8. Clinical Effects • Rapid absorption by GI tract • Biphasic: 2-3 hr-antimuscarinic, recover apparently then opioid symptoms • Anticholinergic effect: • Hot as a hare hyperthermia • Dry as a bone dry skin • Blind as a bat dilated pupils • Med as a hatter delirium, hallucination, iirritability • + tachycardia, urinary retention, decreased bronchosecretion • Opioid effects: • CNS and respiratory depression • Recurrence of symptoms due to active metabolite or return of gastric function • The lowest published fatal dose1.2mg/kg (Liebelt & Shannon, 1993) • The lowest toxic doses 0.5 to 2 tablets (Liebelt & Shannon, 1993)

  9. Pharmacokinetics GI TRACT Ester hydrolysis DiphenoxylateDifenoxine (5 times more active) • Peak plasma concentrations2hrs • Vol. of distribution3.8L/kg • t1/2 2.5 hours Soluble and excreted into bile Serum t1/2 4.4hrs Elimination t1/212 to 14hrs Anticholingeric effectopioid effect 49% of dose excreted in feces 13.7% excreted as free drug and metabolites in urine, over 96% Only 0.4% excreted unchanged in urine Atropine Peak plasma conc. 2hrs

  10. Lomotil overdose • Review of 28 cases in literature • 4 aspiration pneumonia • 1 cortical blindness • 3 cerebral edema and died • 7 cases: Respiratory depression recurred 13-24hr after ingestion • 2 cases: pills found in gastric lavage fluid 15 and 17 hours after ingestion • 4/36 (11%) showed atropinism followed by signs of opioid overdose • 21/36(58%) had atropinism before, during or after opioid symptoms • 15/42(42%) had only opioid symptoms • In most cases, CNS and resp. depression occurred ~15 to 18hrs after ingestion( accumulation of active long-acting opioid metabolite) Diphenoxylate-Atropine overdose in children: An update(Report of eight cases and review of the literature). Pediatrics Vol. 87 No5 May 1991

  11. Management • Resuscitation • ? Delayed gut decontamination • Naloxone for narcotic symptoms (0.4 to 2mg +/-infusion) • Physostigmine (0.02mg/kg up to 0.5mg) • To reverse severe anticholingic symptoms but rarely required • Close observation for 24 hours for delayed symptoms

  12. Lomotil poisoning- outcome • Admitted to P&A for cardiac monitor and neuro-observation • Discharged 12 hours after admission

  13. Take home message • Few tablets of lomotil can kill • Be aware of delayed opioid effect • Treat life-threatening condition • Close monitoring for at least 24 hours is necessary

  14. THANK YOU

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