April 1, 2024

Hello everyone. Welcome to the month of April. This month, we will be discussing a topic that is near and dear to my heart: “One Pill Can Kill.”

While cases involving adult patients start with known exposures, child toxicities are more occult. What makes these toxicities more concerning is that children require smaller doses to cause poisoning. This is because they have a smaller mass, they have higher metabolic rates, and they have different pharmacokinetics. They are less able to communicate their exposure or what they took, are likely to mistake poisons for food and may not even know that they were exposed to a toxin.

The peak incidence for pediatric poisonings occurs in toddlers aged 1 – 3 years. Of course, most exposures in this age group are unintentional. It does not help that some children have easy access to and are attracted to some of these toxic chemicals based on color, appearance, and smell, therefore mistakenly identifying them as a beverage or candy. While most ingestions in the toddler ages are unintentional, as children get older, the ingestions become intentional.

The” one-pill” rule states that a single adult therapeutic dose would not be expected to produce significant toxicity in a child. As a result, it is commonly believed that ingestion of one or two tablets by a toddler is a benign act and not expected to produce any significant toxicity. Although this is true for most exposures, certain common agents have the potential to cause life-threatening toxicity or death despite the ingestion of only one or two tablets or sips. We will review these medications and substances in the coming weeks, but first, let us discuss the approach to a child with a possible unknown ingestion.

Sick children can be terrifying, and it is worse when the diagnosis is unknown. If there is suspected ingestion, there is a simple standard to follow:

1. Airway

2. Breathing

3. Circulation

4. Glucose

5. 5. +/- EKG

Remember that a poisoned child may go undiagnosed unless we maintain a high index of suspicion. 

Some questions to consider asking witnesses or those in the home when evaluating a child with concern for ingestion are:

• What was ingested?

• Is there a possibility of co-ingestions (medications mixed in the home, household products)?

• When was it likely ingested?

• How much was ingested?

• What is the weight of the child?

Look for a toxidrome and other presentations that can help to narrow the exam.

Examples include vital signs, capillary refill, pupillary size, skin appearance, and whether there were any immediate reactions (e.g., seizures).

That’s it for this week. Next week, we will delve more into examinations and start discussing the medications. 

Thank you all for your hard work. Stay safe out there. 

Regina Yaskey, MD

April 8, 2024

This week, we will continue our discussion regarding “One Pill Can Kill.” Let’s start with our overall management of pediatric patients with suggested ingestion /overdose. It is important to establish and maintain an adequate airway and ventilation. One way to do this is by giving supplemental oxygen 12L/min by nonrebreather mask. If a gag reflex is absent, make sure that you protect the airway, facilitate oxygenation, and remove secretions. Consider continuous capnography for somnolent patients not yet requiring intubation. An effective bag valve mask comes in handy in these situations. Remember to gain IV access early, monitor perfusion, and give IV fluids if needed. 

Treat coma promptly

–    Check a D-stick

–    If Opioid overdose is suspected (pinpoint pupils, hypoventilation)

• BVM to address hypercapnia

• Give IV Naloxone

• < 20kg: 0.1 mg/kg

• > 20kg: 0.4 – 2mg/kg (same as adult patients)

Treat seizures

–    Give Benzodiazepines

• Diazepam 0.1 – 0.2mg/kg or Lorazepam 0.05mg/kg

DO NOT FORGET ASSOCIATED ILLNESSES:

• Head trauma (focal neurologic deficits or asymmetric seizures)

• Other trauma causing hemorrhage or shock

• Infection (generalized or CNS)

• Hypothermia

• Hyperthermia

• Metabolic disorders (hyponatremia, hypoglycemia, hyperglycemia)

It is important to note that low doses of the substances below can cause significant toxicity or death. This is why prehospital providers should be familiar with both the generic and trade names of these medications so exposure can be recognized and appropriate treatment initiated. The pneumonic that we use to remember these groups of medications is:

ABC GET MOM

•     Antimalarials

•     Beta Blockers

•     Clonidine, Calcium Channel Blockers

•     Glyburide (or other sulfonylurea)

•     Ethylene Glycol (e.g., antifreeze)

•     Tricyclic antidepressants (e.g. amitriptyline)

•     Methanol (e.g., nail polish remover)

•     Opioids (e.g., hydromorphone, oxycodone)

•     Methyl salicylates (oil of wintergreen)

Next week, I will give an overview of each medication, their clinical manifestations, and their management. Stay tuned.

Thank you for all the great work you are doing. Stay safe and have a great week.

Regina Yaskey, MD

April 15, 2024

Greetings,

In week 3, we are continuing our discussion on “One Pill Can Kill.” Last week, I shared the pneumonic ABC GET MOM and the medications are as follows:

• Antimalarials

• Beta Blockers

• Clonidine, Calcium Channel Blockers

• Glyburide (or other sulfonylurea)

• Ethylene Glycol (antifreeze)

• Tricyclic antidepressants (amitriptyline)

• Methanol (nail polish remover)

• Opioids (hydromorphone)

• Methyl salicylates (oil of wintergreen)

Antimalarials

Malaria is a parasitic infection of human erythrocytes mostly seen in tropical and sub-tropical areas worldwide (mostly in the continent of Africa). Examples of antimalarials include the “Quinoline” derivatives. The most common medications are Hydroxychloroquine, Quinine, Primaquine, and Mefloquine. Symptoms of poisoning with antimalarial medications usually appear within 3 hours. They include:

• Drowsiness

• Hypotension

• Hypokalemia

• Seizures

• Cardiac dysrhythmias

• Respiratory failure

The earliest symptom is cardiac dysrhythmias (ventricular tachycardia and fibrillation) which can lead to cardiac arrest. Management includes obtaining vital signs, giving IV fluids, and providing supportive care (e.g. benzodiazepines for seizures). Getting an EKG early is important in these patients. An EKG showing T-wave inversion, widened QRS, or QT prolongation is concerning and should be cause for alert.

Beta-Blockers

Beta blockers are a class of medicines used to treat hypertension. Examples include Metoprolol, Propranolol and Sotalol. A child ingesting 1 beta-blocker can result in bradycardia, hypotension, and hypoglycemia. Management includes obtaining an EKG to monitor for bradycardia or heart block and administering Glucagon IV or IM. Glucagon is a great antidote for beta blocker ingestions because it increases the heart rate, myocardial contractility and improves AV conduction. Vasopressors can also be used for profound hypotension and calcium may be more effective in improving blood pressure and contractility.

Clonidine

Clonidine is an anti-hypertensive medication that works to decrease your blood pressure and comes in two forms: immediate release and extended release. Signs include:

• Opioid – like toxidrome

• Pinpoint /constricted pupils (miois)

• Respiratory depression

• CNS depression

Your patients can also present with bradycardia, hypotension, apnea and altered mental status. Management includes peripheral IV insertion, naloxone, atropine (for bradycardia), IV fluids (NS or LR) and vasopressors.

Calcium Channel Blockers (CCAs)

Calcium Channel Blockers disrupt the movement of calcium (Ca2+) through calcium channels in the heart. They are used to decrease blood pressure in patients with hypertension and are particularly effective against large vessel stiffness, a common cause of elevated systolic BP in elderly patients. Examples of these medications include:

• Amlodipine

• Nifedipine

• Diltiazem

Disturbances of the cardiovascular system are the hallmark of CCA overdose. Classic manifestations include bradycardia, hypotension, and cardiac arrest.

Management

Early assessment of hemodynamic status is paramount in all cases of reported CCA ingestion. Cardiac monitoring should be instituted, and access to transcutaneous or transvenous pacing should be instituted. Fluid resuscitation and atropine are appropriate initial interventions for hypotension and bradycardia. Hypotensive patients should be treated with NS boluses of 20ml/kg, up to 60ml/kg. Atropine is the first line agent in cases of drug-induced bradycardia.  Calcium chloride or Calcium Gluconate can also be used as treatment for CCA overdose. For a patient with undifferentiated shock, epinephrine may be the initial pressor of choice, owing to its α – adrenergic and β-adrenergic effects.

Glyburide (and other sulfonylureas)

Diabetes Mellitus is the most common endocrine disorder in Western Society with Type 2 diabetes accounting for 86% of cases. Oral hypoglycemic agents (sulfonylureas and biguanides) are the mainstay of pharmacologic treatment. Due to the rising prevalence of diabetes, there has been a marked increase in pediatric exposures to oral hypoglycemic agents.

Glyburide and long-acting Glipizide have been associated with the greatest risk for hypoglycemia at therapeutic doses. Clinical manifestations of an overdose include prolonged hypoglycemia, lethargy, confusion, headache, irritability, and seizures. Secondary sequelae include permanent neurologic impairment and death. If concern for ingestion is present, first thing to do is to check a D-Stick.  Give IV fluids containing Dextrose (if D5, then give a 10ml/kg bolus; if D10, then give a 5ml/kg). IM Glucagon should be given if unable to get IV access. Octreotide can be given for persistent hypoglycemia.

Next week we will continue discussing more of these medications. Thank you for all the great work you are doing and have a great week. 

Regina Yaskey, MD

April 22, 2024

•     Severe Intoxication:

•     Non-cardiogenic pulmonary edema

•     Cerebral edema

•     Coma

•     Death

•     *Hyperthermia is often a preterminal finding

•     Lab Findings include:

•     Respiratory alkalosis

•     Anion gap metabolic acidosis

•     Hyperglycemia or hypoglycemia

*Oil of wintergreen poses a particular hazard to children because it has a nice aroma. Its salicylate content is 98 – 100% methyl salicylate. Less than 1 teaspoon has been fatal in a child3.

Management includes aggressive supportive care. Urinary alkalinization should be started immediately with sodium bicarbonate (goal urine pH 7.5 or higher).

References:

1. Gaither JR, Shabanova V, Leventhal JM, US National trends in pediatric deaths from prescription and illicit opioids. 1999 – 2016 JAMA Netw open; 2018;1(8); e186558

2. OMA Committee on Pharmacy. Codeine; Ont Med Rev 1977;44:447-8

3. Stevenson CS. Oil of Wintergreen (methyl salicylate poisoning: report of three cases, one with autopsy, and a review of the literature, Am j Med Sci 193; 772 -88

This concludes our discussion for this week. Next week, we will focus on topical products. Thank you so much for all your hard work. Have a great week and be safe out there.

Regina Yaskey, MD

April 29, 2024

Hello everyone. We are now in Week 5 of our lecture series: “One Pill Can Kill.” We have covered the evaluation process and reviewed the medications responsible. However, it is not just medicines that can be lethal to children when ingested. Topical agents can also pose a huge threat. 

CAMPHOR

Camphor is an anesthetic in over-the-counter topical rubs to relieve chest colds. If ingested, it can cause breathing difficulties, seizures, and coma. Seizures within minutes are the first sign of ingestion. These ingestions are usually easy to diagnose because the smell of camphor is potent. Examples of such topical agents include:

• Camphorated oil

• Campho-phenique

• Ben-Gay Children’s rub

• Vicks Vapor Rub

• Sloan’s Liniment

BENZOCAINE

Benzocaine is a local anesthetic found in teething gels such as Orajel. Applying too much to the mouth can decrease oxygen getting to the tissues causing low oxygen levels. It can also cause difficulty breathing, heart rhythm problems, seizures, shock, coma, and possibly death. Products containing benzocaine include:

• Baby Orajel

• Baby Orajel nighttime formula

• Baby Anbesol gel

• Anbesol Maximum strength

• Vagisil cream

• Hemorrhoid creams

• Throat lozenges

LINDANE

Lindane is available in lotions, shampoos, and creams to treat lice and scabies. It is also found in flea collars, pet shampoos, and household sprays. Ingestion can cause seizures, hyperthermia, difficulty breathing and hypotension.

When intaking a patient’s history, pay particular attention to details of how the child accessed the substances and if the story and presentation align. Do not disregard the possibility of purposeful misadministration of medications. At a minimum, parents should be provided the education about proper medication storage and handling for safety in the home. It is important to be aware of the toxic potential of medications that members of the home may use and to keep them out of the reach of children. Remember to look for toxidromes and other presentations that can help narrow down causative agents. Another challenge with pediatric overdoses is the consideration for neglect, abuse, and child safety. That should also be on your differential. 

This concludes our five-week lecture series. I hope it has been informative for you all. Wishing you all a great week. Thank you for all the amazing work that you do. Stay safe.

Regina Yaskey, MD