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 Ferro-
gradumet 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)
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
Dont forget your ABC (and D)