Transcript The ABC of Toxicology

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
Which drugs are dangerous?
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)
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)
Substances most frequently involved
in pediatric exposures (<6 years)
Cosmetics personal care & cleaning –
23%
Analgesics - 8%
Topical preparations – 7.5%
Many exposures are non toxic
BUT…………
Rarely
One pill can kill!!!
Case # 1
1.5 Y male
Took 2 pills from drawer
PMHx: Healthy
Case # 1
Alert, crying, no respiratory distress,
pink
Vitals: HR 160/min, BP 100/75,
Temp 37.8 O2 sat 97%
Weight 10 kg
When to be worried?
Babysitter using oral contraceptives?
NO (regardless of dose)
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)
One pill can kill!!!
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 )
1-2 pills can kill!!!
When to be worried?
Sister with a psychiatric disease
What about atypical antypsychotics
Not enough data
When to be worried?
Sister with Depression?
SSRI
NO
When to be worried?
Sister with Depression?
Tricyclic antidepressants
Yes
Imipramine (minimal potential fatal
dose 15mg/kg; Max dose in unit
150mg - Israel 25mg)
One pill can kill!!!
If you think it is TCA which test may
help in predicting severe intoxication
(Seizures, arrhythmia?)
QRS >100ms
1/3 will develop
seizures and 14%
arrhytmias
When to be worried?
Mom pregnant taking Iron and
vitamins?
Iron
Number one killer (?)
A 10-kg toddler would need to
ingest approximately 6 Ferrogradumet 325-mg tablets (105 mg
of elemental iron per tablet) before
developing life-threatening toxicity
When to be worried?
Mom with SLE?
Yes
Antimalarial
When to be worried?
Father with NIDDM?
Yes
Oral hypoglycemics
When to be worried?
Grandma (parents do not know
which drugs she is using)?
Beta blockers?
Ca channel blockers?
Digoxin?
Aspirin?
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
Ca channel blockers
Sustained release preparations may contain high dose
Toddlers may chew
Ca channel blockers
Nifedipine XL
Minimal potential fatal dose
15mg/kg; Max dose in unit 150mg
Israel 60 mg
One tablet May Be Fatal
(Bar-Oz et al Pediatric Drugs 2004)
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Tricyclic antidepressants
Antipsychotics
Anti-arrhythmics
Quinine derivatives
Calcium channel blockers
Opioids (Methadone) (clonidine)
Oral hypoglycemics (Sulfonylurea)
Liquids
How much?
lamp oil
Eucalyptus oil
Camphor
Available in many nonprescription vaporized
or topical "cold" medications
Topical musculoskeletal anesthetic "rubs"
Cold sore" preparations
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 water
Prescribing Restrictions: None
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
Treatment & Investigations
DO NOT FORGET !
Airway
Breathing
Circulation
Treatment
Supportive
Reduce absorption
Enhance elimination
Specific antidote
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)