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One pill can kill (?)

One pill can kill (?). Eran Kozer MD Pediatric Emergency Medicine Assaf Harofeh Medical Center. Suggested reading. Michael JB , Sztajnkrycer MD Emerg Med Clin North Am. 2004 Nov;22(4):1019-50 Bar Oz et al, Paediatr Drugs. 2004;6(2):123-6. Outline. Epidemiology Case scenario

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One pill can kill (?)

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  1. One pill can kill (?) Eran Kozer MD Pediatric Emergency Medicine Assaf Harofeh Medical Center

  2. Suggested reading • Michael JB, Sztajnkrycer MD Emerg Med Clin North Am. 2004 Nov;22(4):1019-50 • Bar Oz et al, Paediatr Drugs. 2004;6(2):123-6.

  3. Outline • Epidemiology • Case scenario • Which drugs are dangerous?

  4. Epidemiology • More than 2,000,000 calls to poison centers in the USA each year • More than 1,000,000 visits to ED (McCaig LF, Burt CW J Toxicol Clin Toxicol. 1999)

  5. Epidemiology • 1-3y > 30% of calls • Children <6y - more than 50% of all calls to poison centers • Fatalities <6y less than 3% • Children up to 19 >10% of all fatalities • (2004 Annual report of the American Association of Poison Control Centers American Journal Emergency Medicine 2005)

  6. Substances most frequently involved in pediatric exposures (<6 years) • Cosmetics personal care & cleaning –23% • Analgesics - 8% • Topical preparations – 7.5%

  7. Many exposures are non toxic • BUT…………

  8. Rarely One pill can kill!!!

  9. Case # 1 • 1.5 Y male • Took 2 pills from drawer • PMHx: Healthy

  10. Case # 1 • Alert, crying, no respiratory distress, pink • Vitals: HR 160/min, BP 100/75, Temp 37.8 O2 sat 97% • Weight 10 kg

  11. When to be worried? • Babysitter using oral contraceptives? • NO (regardless of dose)

  12. When to be worried? • Brother came back from the far east? • Yes – Why? • Quinine derivatives • Chloroquine – minimal potential fatal dose 20mg/kg. Max dose in unit 500mg (in Israel 250mg)

  13. One pill can kill!!!

  14. When to be worried? • Sister with a psychiatric disease • Psychosis? • Yes • E.g Thioridazine (minimal potential fatal dose 15mg/kg - max dose per unit 200mg – in Israel 100mg )

  15. 1-2 pills can kill!!!

  16. When to be worried? • Sister with a psychiatric disease • What about atypical antypsychotics • Not enough data

  17. When to be worried? • Sister with Depression? • SSRI • NO

  18. When to be worried? • Sister with Depression? • Tricyclic antidepressants • Yes • Imipramine (minimal potential fatal dose 15mg/kg; Max dose in unit 150mg - Israel 25mg)

  19. One pill can kill!!!

  20. If you think it is TCA which test may help in predicting severe intoxication (Seizures, arrhythmia?)

  21. QRS >100ms • 1/3 will develop seizures and 14% arrhytmias

  22. When to be worried? • Mom pregnant taking Iron and vitamins?

  23. Iron • Number one killer (?) • A 10-kg toddler would need to ingest approximately 6 Ferro-gradumet 325-mg tablets (105 mg of elemental iron per tablet) before developing life-threatening toxicity

  24. When to be worried? • Mom with SLE? • Yes • Antimalarial

  25. When to be worried? • Father with NIDDM? • Yes • Oral hypoglycemics

  26. When to be worried? • Grandma (parents do not know which drugs she is using)? • Beta blockers? • Ca channel blockers? • Digoxin? • Aspirin?

  27. Beta-blockers • Common use and wide availability • “Not one documented case of death or serious cardiovascular morbidity as a direct result of a beta-blocker exposure is to be found in an English language review for children under 6 years of age.” • The risk to the toddler exposed to 1-2 tablets appears to be extremely small, • Love JN J Emerg Med. 2004

  28. Ca channel blockers • Sustained release preparations - may contain high dose • Toddlers may chew

  29. Ca channel blockers • Nifedipine XL • Minimal potential fatal dose 15mg/kg; Max dose in unit 150mg • Israel 60 mg

  30. One tablet May Be Fatal (Bar-Oz et al Pediatric Drugs 2004) • Tricyclic antidepressants • Antipsychotics • Anti-arrhythmics • Quinine derivatives • Calcium channel blockers • Opioids (Methadone) (clonidine) • Oral hypoglycemics (Sulfonylurea)

  31. Liquids • How much?

  32. lamp oil • Eucalyptus oil

  33. Camphor • Available in many nonprescription vaporized or topical "cold" medications • Topical musculoskeletal anesthetic "rubs" • Cold sore" preparations

  34. MENTHOLATUM BALM Active Ingredients:Menthol BP 1.35%, camphor BP 10%, eucalyptus oil 0.66%, pumilio pine oil 0.08%, methyl salicylate BP 0.66%.Dosage:Apply on skin or under nose or as inhal. in boiling waterPrescribing Restrictions:None

  35. Camphor • 750 to 1000 (500?) mg are associated with the development of seizures and death • Products with 10% camphor contain 500 mg in 5 mL

  36. Treatment & Investigations DO NOT FORGET ! • Airway • Breathing • Circulation

  37. Treatment • Supportive • Reduce absorption • Enhance elimination • Specific antidote

  38. Summary • If only 1-2 tablets are taken most drugs will not cause severe symptoms • Few drugs may be dangerous • Don’t forget your ABC (and D)

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