Current Topics in Pediatric Toxicology What the Kids are into

Transcription

1 Current Topics in Pediatric Toxicology What the Kids are into Eric Hoppa, MD Assistant Professor Pediatrics and Emergency Medicine University of Connecticut School of Medicine April 7, 2017

2 Eric have you seen any kids with...?

3 Objectives Review epidemiology of pediatric toxicology Look at recent trends in ingestions and use of illicit substances Young children Adolescents Discuss basic management and prevention of these toxic ingestions

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5 Little Kids Get Into Things

6 Mowry, JB et al, 2016

7 Mowry, JB et al, 2016

8 Pediatric Fatalities 2015 Mowry, JB et al, 2016

9 Toxic Ingestion Epidemiology Younger child Male Unintentional Single substance Morbidity/mortality Substances Household chemicals Analgesics/OTC meds Foreign bodies Adult Rx meds Adolescent or adult Female Intentional Polypharmacy Morbidity/mortality Substances Drugs of abuse Analgesics Rx meds

10 Pediatric Exposures (<6 years) in 2015 % Cosmetic/Personal Care Products 13.6 Household Cleaning Substances 11.2 Analgesics 9.1 Foreign Bodies/Toys/Miscellaneous 6.5 Topical Preparations 5.3 Vitamins 4.6 Antihistamines 4.4 Pesticides 3.3 Dietary Supplements/Herbals/Homeopathic 3.0 Plants 2.7 Based on 1,059,993 Reported Pediatric Exposures Mowry, JB et al, 2016

11 Little Kids Get into Things

12 Button Batteries Peak age of ingestion 1-2 Hearing aids Testing the battery Suicide attempt Litovitz et al, 2010 & Jatana et al, 2013

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14 Button Batteries Range 6-25mm Size > 12mm more likely to be lodged in GI tract Multiple chemical components

15 Button Batteries Tissue Damage Electrical discharge Increased complications with lithium batteries (3 volts) More damage with newer batteries Injury in < 2 hours Leakage of contents Acidic environment seal of the battery erodes Pressure necrosis

16 Button Batteries Often asymptomatic Chest pain Drooling Dysphagia Cough Anorexia Vomiting/hematemesis Abdominal Pain

17 Button Batteries Management Emergent evaluation Radiograph Supportive care Endoscopic removal Jatana et al, 2013

18 Button Batteries

19 Button Batteries

20 Button Batteries Esophagus Emergent endoscopic removal Injury w/in 2 hours Monitoring for complications Esophageal perforation TEF Vascular injury Esophageal stricture/stenosis

21 Button Batteries Kramer RE, et al, 2015

22 Button Batteries Jatana et al, 2013

23 Little Kids Get into Things

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25 Laundry Detergent Pods 14,000 Laundry Pod Exposures 12,000 10,000 8,000 6,000 4,000 2, Laundry Pod Exposures

26 Laundry Detergent Pods ,230 laundry detergent pod exposures 4.4% hospitalized 0.6% required intubation 7.5% experience a moderate or major medical outcome (1 death) Valdez AL, et al, 2014

27 Laundry Detergent Pods VS

28 Laundry Detergent Pods Forrester MB, 2013

29 Laundry Detergent Pods Forrester MB, 2013

30 Laundry Detergent Pods Forrester MB, 2013

31 Laundry Detergent Pods Forrester MB, 2013

32 Laundry Detergent Pods Increased mucosal (GI and respiratory) injuries Corneal abrasions CNS depression Propylene glycol Ethoxylated alcohols Metabolic acidosis

33 Laundry Detergent Pods Supportive management Treat vomiting/dehydration Respiratory support Acidosis GI evaluation Eye irrigation/treatment of corneal abrasions

34 Laundry Detergent Pods Prevention Anticipatory Guidance Improved packaging Product warnings

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36 Little Kids Get into Things cbsnews.com

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38 E-Cigarettes Increase in 2013 ~ 50% in children < 5 Concentrated liquid in cigarettes/refills Dermal, ocular, and oral absorption Recent news March 2014 Press release by AAPCC January 2016 Child Nicotine Poison Prevention Act

39 E-Cigarettes

40 Nicotine Poisoning Signs/Symptoms Nausea/vomiting Eye irritation Lacrimation Bronchorrhea Hypertension Tachycardia Neuro findings Fasciculations, weakness, paralysis, coma, and seizure Management Supportive care IVF, anti-emetics Atropine Benzodiazepines Prevention

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42 Big Kids Also Get into Things

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44 Synthetic Drugs

45 Bath Salts Synthetic cathinones Cloud 9 or Bliss Not for human consumption Snorted, smoked, swallowed, or injected Legally sold until September 2011 Federal legislation in 2012 American Association of Poison Control Centers

46 Bath Salts Common ingredients 3,4-methylenedioxypyrovalerone (MDPV) Dopamine and NE reuptake inhibitor 4-methyl-cathinone (mephedrone) Stimulant (monamine re-uptake inhibitor?)

47 Bath Salts Signs and Symptoms Agitation/aggression Altered mental status Psychosis/paranoia Tachycardia/HTN Seizures Nausea/vomiting Bruxism Chest pain Abnormal lab values Leukocytosis Acidosis Renal failure Transaminitis Elevated CK EKG changes

48 Bath Salts Prevention Monitoring for the Future Study, University of Michigan Federal legislation in 2012

49 Synthetic Marijuana Synthetic Marijuana Europe in 2004 US in 2009 Sold as incense Spice or K2 Contain cannabimimetics Full agonist of canniboid receptor (CB1) American Association of Poison Control Centers

50 Synthetic Marijuana Signs and Symptoms Agitation/anxiety Dysphoria/hallucinatio ns Seizures HTN/tachycardia Nausea/vomiting

51 Synthetic Marijuana Monitoring for the Future Study, University of Michigan

52 Synthetic Drug Prevention Education Synthetic Drug Abuse Prevention Act of 2012 Bans mephedrone, MDPV, methylone, and compounds found in synthetic marijuana Authorizes temporary bans on new chemicals Up against technology and international development

53 Future of Synthetic Drugs

54 Opioid Abuse

55 Opioid Abuse NUMBERS

56 Opioid Abuse

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60 Opiate Deaths in CT Opiate Deaths in State of CT Heroin Morpine or Codeine Oxycodone Hydrocodone Fentanyl CT OCME

61 Pediatric and Adolescent Deaths Age (yrs) No Age Adjusted Rate No. Age Adjusted Rate Percent Increase , , Rudd RA, et al, 2016

62 11,066 OPIOID EXPOSURES* Jan. 1 - Feb. 28, 2017 *These numbers reflect multiple substance exposures to opioids reported to poison centers

63 Hot off the Press

64 McDonald EM, et al, 2017

65 Prevention Primary prevention Acute treatment Chronic treatment

66 CT State Law Public Act If prescribing > 72 hours of any controlled substance (schedule II-V) the practitioner must review the patient s CPMRS If prescribing chronically must review the patient s record every 90 days As of July 2016 pharmacy must report filling of controlled substance to database within 24 hours

67 CT State Law Naloxone (Narcan) 2011 Good Samaritan Law 2012 Narcan Law 2015 Pharmacists who have been trained/certified to prescribe and dispense naloxone directly to customers requesting it 2016 Protection from civil liability for administering naloxone, each municipality must train and equip first responders with naloxone

68 Conclusion

69 References Mowry JB, Spyker DA, et al Annual report of the American Association of Poison Control Centers National Poison Data System (NPDS): 33 rd annual report. Clin Toxicol Dec;54(10) Litovitz T, Whitaker N, et al. Emerging battery ingestion hazard: clinical implications. Pediatrics Jun;125(6): Litovitz T, Whitaker N, and Clark L. Preventing button battery ingestion: an analysis of 8648 cases. Pediatrics Jun;125(6): Jatahna KR, Litovitz T, et al. Pediatric button battery ingestions: 2013 task force update. Int J Pediatr Otorhinolaryngol Sep;77(9): Sinclair K, Hill ID. Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management. In: UpToDate, Wiley, JF (Ed), UpToDate, Waltham, MA, Kramer RE, Lerner DG, et al. Management of ingested foreign bodies in children: A clinical report of the NASPGHAN endoscopy committee. J Pediatr Gastroenterol Nutr Apr;60(4): Forrester MB. Comparision of pediatric exposures to concentrated pack and traditional laundry detergents. Pediatr Emerg Care Apr;29(4): Valdez AL, Casarant MJ, et al. Pediatric exposure to laundry detergent pods. Pediatrics Dec;134(6): Rigotti NA, Kalkhoran S. E-cigarettes. In: UpToDate, Melin JA (Ed), UpToDate, Waltham, MA, Johnston CD, Miech RA, et al. (December 13, 2016) Teen use of any illicit drug other than marijuana at new low, same true for alcohol." University of Michigan News Service: Ann Arbor, MI. Retrieved 03/24/2017 from Jones C, Paulozzi L, Mack K. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, Jama Int Med 2014;174(5): Rudd RA, Aleshire N, et al. MMWR Morb Mortal Wkly Rep Jan 1;64(50-51): doi: /mmwr.mm6450a3. Finkelstein Y, Macdonald EM, et al; Canadian Drug Safety And Effectiveness Research Network (CDSERN) Overdose risk in young children of women prescribed opioids. Pediatrics Mar;139(3). Epub 2017 Feb 20. McDonald EM, Kennedy-Hendricks A, et al. Safe storage of opioid pain relievers among adults living in households with children. Pediatrics Mar;139(3). Epub 2017 Feb 20.