One Pill Killers

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March 20, 2018 by jtreb

2 year old male brought in by grandma after unknown ingestion. Grandma reports child was found down next to her purse. The contents of her purse were Altoids, Lorna Doone cookies, and a host of medications for the grandmother’s “medical things.”

What: “One-pill kill” list (medications that can be life-threatening to children when even a single dose or pill is ingested)

Who: Children, usually infants/toddlers (1-3 years). Some studies suggest younger children are most at risk due to performing hand-mouth behaviors up to 10 times an hour. Average toddler weights 10-15kg.

 

 

1) Opiods/Opiates 

  • CNS depression, respiratory depression, miosis
  • Tx = supportive care, naloxone, consider whole-bowel irrigation  \

 

A note about Naloxone: 

  • Onset of action is <2 minutes 
  • Half life in adults is 60-90 minutes 
  • In kids <5years, initial dose of life-threatening cases is 0.1mg/kg up to 2mg IV; if non-life-threatening, can do 0.01 mg/kg IV  
  • In kids >5years, 0.4mg IV (similar to adults) 

 

2) Camphor 

  • Over-the-counter meds such as Vick’s VapoRub, Ben-Gay(also contains salicylates), and Tiger Balm
  • Can manifest with GI symptoms within 10-20 minutes of ingestion; symptoms also include CNS hyperactivity (excitement, delirium, seizures and status epilepticus) and CNS depression (coma, respiratory depression)
  • Tx –> supportive care, benzos for seizures

 

3) Lomotil  

  • Antidiarrheal agent containing 2.5mg of the opioid diphenoxylate and 0.025mg of atropine
  • Can present with opioid and/or anticholinergic toxidrome
  • Tx –> Supportive care, naloxone

 

4) TCA 

  • Antidepressant medication with sodium channel blockade, anti-histamine effects, anti-muscarinic effects, a1 receptor blockade, and serotonergic effects
  • Can manifest with CNS symptoms (lethargy, coma, seizures), cardiovascular symptoms (widened QRS, dysrythmias, hypotension), anticholinergic toxidrome (mydriasis, flushing, tachycardia, dry skin, delirium)
  • Tx –> supportive care, sodium bicarb for widened QRS > 100 (initial bolus of sodium bicarb 1-2mEq/kg)

 

5) Calcium channel blockers 

  • Symptoms –> hypotension, bradycardia, drowsiness, and confusion; other symptoms include second and third degree heart blocks, cardiogenic shock/arrest (from negative inotropy)
  • Treatment —> cardiac monitoring (access to transcutaneous or transvenous pacing), activated charcoal within 1 hour, whole bowel irrigation if ingestion of sustained-release preparations, IVF, calcium, glucose/insulin

 

6) Salicylates 

  • Aspirin, oil of wintergreen (methyl salicylate); the latter is a concern due to its pleasant aroma
  • Minimal potentially toxic dose in kids is 150mg/kg
  • One teaspoon of 98% methyl salicylate = 7000mg of salicylate = 90 baby aspirin
  • Sx –> nausea, vomiting, diaphoresis, agitations, lethargy, coma, death; respiratory alkalosis and metabolic acidosis
  • Tx –> supportive care, sodium bicarb (initial bolus of 1-2 meq/kg followed by infusion at 1.5 to 2 times the calculated maintenance fluid requirements), hemodialysis

 

7) Sulfonylureas 

  • Oral hypoglycemic agents that increase endogenous insulin release from pancreatic beta cells
  • Sx –> hypoglycemia-related symptoms (lethargy, confusion, seizure, coma) and refractory hypoglycemia
  • Tx –> activated charcoal within 1 hour of ingestion, consider whole bowel irrigation, supportive care and dextrose-containing fluids

 

8) Clonidine 

  • Antihypertensive (a2 adrenergic receptor) with opioid functional overlap (mu receptor)
  • Can manifest with hypotension and an opioid toxidrome (miosis, respiratory depression, hypotonia, coma)
  • Patients may have hypertensive episode briefly prior to hypotension/bradycardia due to peripheral a1-adrenergic stimulation
  • Tx –> supportive care, naloxone (0.1mg/kg), atropine if needed for bradycardia

 

Other medications to think about on this list would be malaria medications (chloroquine, mefloquine), toxic alcohols (methanol, ethylene glycol), and MAOIs.

 

References:  

1) Kentab, O.Y. September 2007. Single dose killers in Pediatrics. Retrieved from http://www.emcongress.org/2007/presentations/16Kentab.pdf.

2) Pediatric toxicology. UpToDate 2018. Retrieved from https://www.uptodate.com/contents/table-of-contents/pediatrics/pediatric-toxicology

3) Velez LI, Shepherd JG, Goto CS. Approach to the child with occult toxic exposure. UpToDate 2018. Retrieved from https://www.uptodate.com/contents/approach-to-the-child-with-occult-toxic-exposure

 

 

 

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