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SUBSTANCES THAT CAN KILL A TODDLER WITH ONE TABLET OR TEASPOON. Overview . Most substances ingested by a child in a small amount are harmless. Few substances that are ingested in a small amount can be deadly to a child. Most Toxic Pediatric Ingestions. Ethylene Glycol (Antifreeze)

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overview
Overview
  • Most substances ingested by a child in a small amount are harmless.
  • Few substances that are ingested in a small amount can be deadly to a child.
most toxic pediatric ingestions
Most Toxic Pediatric Ingestions
  • Ethylene Glycol (Antifreeze)
  • Methanol (Windshield washer fluid)
  • Clonidine
  • Imidazoline decongestants (Visine)
  • Calcium Channel Antagonists (Verapamil)
  • Beta Blockers (Toprol)
most toxic pediatric ingestions1
Most Toxic Pediatric Ingestions
  • Sulfonylureas (Glyburide)
  • Camphor (Campho-Phenique)
  • Theophylline
  • Lomotil (Diphenoxylate)
ethylene glycol
Ethylene Glycol
  • Toxic alcohol found in antifreeze
  • Sweet to the taste, appealing green color
  • Relatively easy for child to access
ethylene glycol1
Ethylene Glycol

Range of Toxicity

  • As little as a teaspoon can be toxic in a toddler.
  • Child may drink small amount from a radiator or from radiator drainage.
  • Often found out of original container in garages
ethylene glycol2
Ethylene Glycol

Clinical Presentation

  • Initially child will appear inebriated and may act drowsy.
  • Ethylene Glycol itself is not toxic, its metabolites are toxic.
slide8

Ethylene

Glycol

NAD+

Lactic Acid

Alcohol

Dehydrogenase

X

Pyruvate

NADH

Glycoaldehyde

Krebs

Cycle

Aldehyde

Dehydrogenase

Fomepizole

Glycolic Acid

Glycolic Acid

Oxidase

-Hydroxy--ketoadipic Acid

Glyoxylic Acid

Formic Acid

Hippuric Acid

Calcium

Oxalate

Crystals

Oxalic Acid + Calcium

ethylene glycol3
Ethylene Glycol

Treatment

  • Start iv fluids if possible and transport to nearest facility that can provide adequate care.
  • If large ingestion child may need transfer to tertiary facility that can provide hemodialysis
methanol
Methanol
  • Methanol is major component found in windshield washer fluid.
  • As little as mouthful may be toxic in a toddler.
methanol1
Methanol
  • Methanol is also toxic alcohol
  • Like EG, it is the metabolites that are toxic.
slide12

Fomepizole

Lactic Acid

Methanol

NAD+

Alcohol

Dehydrogenase

X

Pyruvate

NADH

Krebs

Cycle

Formaldehyde

Aldehyde

Dehydrogenase

pH

Formic Acid

Formate

dependent

Folate

Dependent

Detoxification

Folate /

Leucovorin

CO2 + H2O

methanol2
Methanol

Clinical Presentation

  • Initially child may have no noticeable symptoms, may appear normal.
  • May have long latent period as MEOH is converted to formic acid.
  • Can be dangerous as child appears normal and parents may be reluctant to transport.
  • If not treated after formic acid is formed will cause severe acidosis and death.
methanol3
Methanol

Treatment

  • Is bound by activated charcoal - again small molecule - will get minimal absorption
  • Start intravenous fluids if possible and transport to closest facility that can provide adequate care.
  • Child may need transfer to tertiary facility for possible hemodialysis.
clonidine
Clonidine
  • Clonidine is medication used to relieve hypertension.
  • Sometimes used in children to treat ADHD (new treatment).
clonidine1
Clonidine
  • Clonidine can cause hypotension and severe drowsiness.
  • Has long half life, child may appear asymptomatic for several hours or may present with sever drowsiness.
clonidine2
Clonidine
  • Readily bound by activated charcoal
  • Narcan has been shown to reverse drowsiness – must be given in large doses, start with 5 mg and repeat if not effective.
  • Narcan effective in some case and not others, reason is not known.
clonidine3
Clonidine

Treatment

  • Give activated charcoal (without sorbitol) if available.
  • Start intravenous fluids and give narcan, transport to nearest facility that can provide adequate care.
imidazoline decongestants
Imidazoline Decongestants
  • Imidazaoline decongestants found in many eye preparations and nasal preparations
  • Visine
  • Afrin
imidazoline decongestants1
Imidazoline Decongestants
  • These drugs have structure and effects very similar to Clonidine.
  • Imidazolines have presynaptic alpha-2 stimulant effects just like clonidine.
  • Treatment will be similar
imidazoline decongestants2
IMIDAZOLINE DECONGESTANTS

Range of Toxicity

As little as 7.5 ml of tetrahydrozoline has caused sedation in children.

Deaths have been reported from IV administration but not from ingestion.

imidazoline decongestants3
IMIDAZOLINE DECONGESTANTS

Treatment

Establish IV access

Activated Charcoal per local protocol

Contact Poison Control

Supportive Care

Transport

calcium channel antagonists
CALCIUM CHANNEL ANTAGONISTS

Widely used medications to treat angina, hypertension, supraventricular tachycardia, and migraines

Examples: Diltiazem (Cardiazem) Nifedipine (Procardia)

calcium channel antagonists1
Calcium Channel Antagonists

Mechanism of Toxicity

  • Slow influx of calcium through cellular calcium channels
  • Results in coronary and peripheral vasodilatation
  • Slowed AV nodal conduction and depressed sinus node activity.
calcium channel antagonist
Calcium Channel Antagonist

Clinical Effects

  • Hypotension
  • Bradycardia
  • Nausea/Vomiting
  • Stupor/Confusion
calcium channel antagonist1
Calcium Channel Antagonist

Range of Toxicity

NO AMOUNT IN A CHILD IS SAFE TO OBSERVE AT HOME.

calcium channel antagonist2
Calcium Channel Antagonist

Treatment

  • Administer activated charcoal without cathartic if available - per local protocol
  • Establish IV Access
  • Contact Poison Control
  • Transport to Nearest ED - Child will need admission
beta blocking agents
BETA BLOCKING AGENTS

Agents are widely used for treatment of hypertension, angina, arrhythmias, and migraines.

Names Generally end in -olol

Examples: Atenolol (Tenormin, Toprol) Labetalol (Normodine)

beta blocking agents1
BETA BLOCKING AGENTS

Mechanism of Toxicity

  • Blockade of beta-adrenergic receptors - specificity seen in therapeutic use is lost in overdose amounts
  • Propranolol and other similar agents will further decrease myocardial contractility
  • Sotalol - has type III antiarrhythmic activity and may produce torsades
beta blocking agents2
BETA BLOCKING AGENTS

Clinical Presentation

  • Hypotension
  • Bradycardia
  • CNS Depression
  • Seizure Activity (Propranolol)
  • Hypoglycemia (Esp in children)
beta blocking agents3
BETA BLOCKING AGENTS

Range of Toxicity

  • Calculation is done based on child’s weight, mg amount ingestion and propranolol equivalency dosing.
  • CONTACT LOCAL POISON CENTER WHILE ON SCENE FOR THIS CALCULATION.
beta blocking agents4
BETA BLOCKING AGENTS

Equipotency Calculation

Mg amount ingestion/child’s weight (KG)/equipotent dose

beta blocking agents5
BETA BLOCKING AGENTS

Drug Adult Dose Equipotent Dose

  • Acebutolol 400-800 6.70
  • Atenolol 50-200 2.00
  • Betaxolol 5-20 2.00
  • Bisoprolol 2.5-5 2.00
  • Carteolol 2.5-5 2.00
  • Carvedilol 24-50 4.00
  • Labetalol 200-400 4.00
  • Metoprolol 100-450 2.00
  • Nadolol 40-320 2.00
  • Oxprenolol 120-480 2.00
  • Penbutolol 20-80 0.33
  • Pindolol 10-60 0.33
  • Propranolol 40-480 2.00
  • Sotalol 160-480 2-8 6.70
  • Timolol 20-60 0.33
beta blocking agents6
BETA BLOCKING AGENTS

Example Calculation

15 kg child ingested one 50 mg atenolol.

50mg/15mg/2(atenolol BBEC) = 1.66

Child must be transported as BBEC is greater than 1

beta blocking agents7
BETA BLOCKING AGENTS

Treatment

  • Contact Poison Center
  • Activated Charcoal - If available
  • Consider IV access
  • Transport
sulfonylureas
Sulfonylureas

Oral medications used to lower blood glucose levels.

Widely used medication

Glypizide, Glyburide

sulfonylureas1
Sulfonylureas

Mechanism of Toxicity

  • Lower blood glucose levels - primarily by stimulating endogenous pancreatic insulin secretion.
  • Secondarily by enhancing the peripheral insulin receptor sensitivity and reducing overall glycogenolysis.
sulfonylureas2
Sulfonylureas

Clinical Presentation

  • Hypoglycemia may be delayed in onset
  • Manifestations of hypoglycemia include: agitation, confusion, tachycardia, seizure activity.
  • These drugs have a delayed peak and prolonged duration of action.
sulfonylureas3
Sulfonylureas

Range of Toxicity

NO AMOUNT MAY BE SAFLEY OBSERVED AT HOME, MUST BE ADMITTED FOR MIN 23 HOURS

sulfonylureas4
Sulfonylureas

Treatment

  • Contact Poison Center
  • Consider Activated Charcoal
  • IV Access
  • Transport
  • Do not give Glucose unless child has documented hypoglycemia.
camphor
Camphor

Strong smelling essential oil derived from plants.

Usually found in over the counter products such as BenGay, Vicks Vapor Rub.

Largest percentages is in products such as Campho-Phenique (10.8%) and Camphorated oil (20%)

camphor1
Camphor

Mechanism of Toxicity

  • Rapidly absorbed from GI Tract
  • CNS stimulant - leads to seizure activity
  • Exact mechanism is unknown - may be from metabolites.
camphor2
Camphor

Clinical Presentation

  • Oral irritation
  • Nausea/Vomiting
  • Typically results in abrupt seizure activity - 20-30 minutes after ingestion
  • Death may occur from CNS depression or respiratory arrest due to status epilepticus.
camphor3
Camphor

Range of Toxicity

  • Serious symptoms and death have occurred from ingestion of as little as 1 Gram of camphor
  • This is 10 ml of Campho-Phenique or 5 ml of camphorated oil
camphor4
Camphor

Treatment

  • Contact Poison Center
  • Protect Airway
  • Consider Activated Charcoal - must protect airway
  • Seizure precautions
  • Transport
theopylline
THEOPYLLINE

Older drug used in treatment of asthma

Most commonly used in sustained release tablets

Absorption may be delayed

theopylline1
THEOPYLLINE

Mechanism of Toxicity

Exact mechanism is not known - antagonist of adenosine receptors.

Releases endogenous catecholamines - may stimulate beta-adrenergic receptors.

theopylline2
THEOPYLLINE

Clinical Presentation

  • Vomiting
  • Tremors
  • Anxiety
  • Tachycardia
  • With higher doses will see hypotension and seizures.
theopylline3
THEOPYLLINE

Range of Toxicity

  • An acute ingestion of 8-10 mg/kg can raise serum levels by 15-20 mg/L.
  • Therapeutic serum level are10-20 mg/L
  • Less than one tablet may be observed at home depending on the child’s weight and the availability of family for follow-up
theopylline4
THEOPYLLINE

Treatment

  • Contact Poison Center - determine if dose was toxic
  • Activated Charcoal
  • Transport
lomotil
Lomotil

Lomotil is an antidiarrheal medication that is a combination of diphenoxylate (opiod) and atropine (anticholinergic)

lomotil1
Lomotil

Mechanism of Toxicity

  • Combination of drugs makes it very dangerous.
  • Initially may see mild anticholinergic effects or child may appear fine.
  • Can see delayed (6-8 hours) opiate effects.
lomotil2
Lomotil

Clinical Presentation

  • Initially may see minor anticholinergic symptoms - flushed face, dry mouth, mild agitation
  • Can see delayed opiate effects - profound CNS and respiratory depression.
lomotil3
Lomotil

Range of Toxicity

NO AMOUNT IS SAFE IN CHILD UNDER THE AGE OF 2

GREATER THAN THERAPUEUTIC AMOUNT IN CHILD OVER 2 MUST BE TRANSPORTED

lomotil4
Lomotil

Treatment

  • Contact Poison Center
  • Activated Charcoal
  • Transport to Closest hospital that can provide care - child will need to be admitted.