Emergency Medicine Grand Rounds

1. Emergency Medicine Grand Rounds James Huffman 05.20.2010

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

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

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

11. 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

12. 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)

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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….

21. “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

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

23. 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!

24. Idiosyncratic Reactions

25. 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)

26. 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)

27. Cough and Cold Preparations in Kids

28. 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.

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

30. Questions?