One Pill Can Kill: A Look at the Poisoned Pediatric Patient. Nancy Denke DNP, ACNP, FNP, FAEN, CEN, CCRN Toxicology Consultants of Arizona

Transcription

1 One Pill Can Kill: A Look at the Poisoned Pediatric Patient Nancy Denke DNP, ACNP, FNP, FAEN, CEN, CCRN Toxicology Consultants of Arizona

2 Objectives Understand the epidemiology of pediatric poisonings Perform a focused toxicologic physical examination & describe the various toxidromes Identify common ingestions seen in the pediatric population Determine which patient requires treatment after acute acetaminophen ingestion Identify which drugs can lead to QRS and QTc prolongation and the treatment for each abnormality

3 Remember This! Earthworms do have some nutritional value!!!

4 All Things Tend to End Up In Their Mouths!!!

5 Why Toddlers Put Things in Their Mouths Most FB ingestions between 6 mo & 3 years It s that phase of development Kids are like magpies- they are attracted by bright, shiny objects Kids seem to be proud to show you what they have put in their mouths Suspect FB ingestion with a sudden onset coughing/drooling or retrosternal or stomach pain

6 Not Little Adults! In truth, children do sometimes develop physiologic responses that are very similar to their adult counterparts Often they can be treated in similar ways BUT, there are a lot of key pathophysiologic differences in the pediatric poisoned patient General rule, a 12-year-old has much the same characteristics of an adult for the purposes of poisoning management

7 They Ingest a Higher Dose/kg in Similar Circumstances to Adult Exploratory ingestion of particular compounds is much more consequential in smaller patients. Thus the one pill can kill phenomenon, for things like calcium channel blockers and opioids (especially methadone). This also applies to things like envenomation Snake injecting venom doesn t calculate a dose Neither does a scorpion, which is why children become much sicker with North American bark scorpion (Centruroides) envenomations than adults

8 Higher Body Surface Area/kg Toxins absorbed dermally are delivered in a higher dose (i.e. Fentanyl, clonidine) Increased skin perfusion & hydration, so are more susceptible to dehydration and insensible losses Nerve agent or organophosphorus pesticide, some absorption of which will occur through the skin, delivering a higher dose

9 Higher Minute Ventilation/kg (Tidal volume x RR) TV same as adults (7 ml/kg) Respiratory rate is faster in young children delivering a higher dose of an airborne toxin Classic example of this is CO poisoning. All of the occupants of a house might become sickened from a CO exposure, but the smallest children are often most affected Seriously, you still don't have a CO detector in every sleeping area of your home? Get one!

10 Compensatory Mechanisms NOT the Same Have healthy myocardia which can tolerate tachycardia for days!!! Maintain a higher baseline adrenergic tone Kids can t shift SV very much, so HR is all there is! Toxin which causes bradycardia, (i.e CCB), bad things happen quickly!!! Higher metabolic rate means kids desat faster during periods of apnea or respiratory insufficiency & why more prone to acidemia (ASA OD)

11 Leftovers from Last Night s Party

12 Age & Weight Do Make a Difference Absorbed quickly from the stomach into the bloodstream

13 Ethyl Alcohol Low blood sugar is a dangerous effect in children who drink alcohol Typical toddler does not have much in the way of glycogen stores or muscle mass Fasting hypoglycemia is more likely to occur after exposures to toxins that alter glucose homeostasis (i.e alcohols & beta receptor antagonists)

14 Why Buy Alcohol When YOu Can Get This!!! The vanilla extract is usually 35 percent or 70 proof. Vodka is usually 70 or 80 percent proof

15 It Also Affects the CNS Might stagger when they walk, speak without making sense, or seem sleepy They might vomit because alcohol can irritate the stomach Breathing and HR might decrease, along with BP.

16 Pharmacokinetics Are NOT Mature Developmental differences in all phases of drug disposition absorption, distribution, metabolism and elimination Subtle changes in GI absorption and transit time influence the delivery of toxin from the GI tract into the circulation and target tissues Kids made up of more total body water (80-90% in infant compare to 55-60% in adult), and less fat, so hydrophilic drugs will have a larger volume of distribution in a skinny kid

17 The CYP450 Gang All of the enzyme systems we rely on for the metabolism of drugs ( CYP2D6, 3A4, and the rest of the gang) don t fully develop until several years of age See with acetaminophen hepatotoxicity. Others include metabolism of opioids (2D6), midazolam and carbamazepine (3A4), phenytoin (2C9), caffeine/theophylline (1A2), codeine (2D6), & benzodiazepines (2C19)

18 Renal Excretion Immature kidneys GFR is a moving target! It s sluggish at birth and increases to normal rates around 8 months

19 Hemoglobin Not the Same First 2-3 months of life fetal Hgb persists and has increased affinity for oxygen- thus causing false elevate carboxyhemoglobin Also an age-related deficiency in methemoglobin reductase enzymes, making infants more prone to methemoglobinemia. Why we go straight to sodium thiosulfate or hydroxocobalamin in smoke inhalation in children

20 Treatment Can be Tricky! Infusing IV fluids quickly is hard through a 24 gauge IV in the hand Obtaining a larger gauge is often technically difficult Sometimes opt for intraosseous (IO)

21 Pediatric Marijuana Ingestions Primary psychoactive ingredient in marijuana is THC, which binds to cannabinoid receptors in the brain and produces stimulant, hallucinogenic or sedative effects depending on the dose and time after ingestion Onset of effects is within 30 minutes to 2 hours with a peak of 1 to 4 hours

22 Pure THC Found in edibles can have significantly different toxic effects than unprocessed marijuana In children, the most common symptoms reported after acute ingestion are CNS depression (i.e.. lethargy, coma), confusion, agitation, and ataxia Nausea and vomiting have also been reported as well as bradycardia, hypotension, and respiratory depression requiring intubation

23 Edibles Single cookie or package of gummy bears can contain as much as 100 mg of THC Recommended psychotropic dose is mg. Colorado has established guidance on edible products including a standard size for an edible serving with a maximum of 10 mg of THC Many products contain several servings, and in some cases, the labeling of a serving size has been found to be incorrect NEJM 2015;372:989-93

24 Why Are Teens Putting Detergent Pods in Their Mouths? Ingredients in the pods include ethanol, hydrogen peroxide and polymers a highly-toxic mix of detergent meant to wipe out dirt and grime.

25 Detergent Pods Bright & colorful: they can look like candy Elderly adults with dementia were confused & have also ingested it The danger to little kids is so high that researchers have recommended the parents of children < 6 years old not buy these at all and instead use regular detergent only

26 Tide Pod Challenge Its caustic mixture of ethanol, hydrogen peroxide, and soap can burn holes in soft tissue, and the toxicity can be deadly Serious effects can occur quickly. They include severe vomiting, severe breathing trouble, burns to the esophagus & coma The liquid from laundry pods also can cause burns to the eye and skin

27 Serious damage can occur within 2 hours! Non-specific symptoms combined with an unwitnessed placement can lead to a delay in diagnosis and even greater injury- alkali caustic Most serious injuries associated with 20 mm diameter batteries, about the size of a nickel

28 National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline

29 Buprenorphine Suboxone and Subutex Prescribed for opioid dependence or chronic pain Mistake pills or films for candy Symptoms of buprenorphine poisoning in children are drowsiness, vomiting, slow breathing, increased heart rate, and agitation

30 Acetaminophen Ingestion

31 Rumack-Matthew Nomogram

32 When to Treat?

33 Why NAC (Acetadote)? 90% to 95% of acetaminophen metabolism takes place in the liver Goal with NAC is to reduce the amount of hepatotoxic metabolite, NAPQI, by biotransforming it into a nontoxic form

34 Calcium Channel Blocker (CCB) Hyperglycemia is a calling card of this drug overdose Calcium Channel blockers in the pancreatic B islet cells Decreased release of insulin Can lead to HYPERGLYCEMIA

35 Tricyclics

36 Anticholinergic 4 Effects of TCA Somnolence, tachycardia, Seizures Alpha blockade Hypotension and tachycardia Re-uptake inhibition Serotonin syndrome risk Sodium Channel Blockade What is the concern?

37 a) Calcium gluconate b) Magnesium sulfate c) Potassium chloride d) Sodium bicarbonate

38 Dextromethorphan (DXM) Popular Street Names Purple drank Lean Sizzurp Double cup Skittles Orange crush Dex Red devils

39 DMX 1 in 10 American teenagers has used DXM to get high also known as robotripping Dissociative effects prompt some teens to use it for anxiety- get a powerful buzz dose for dissociative effect is around 1000mg or about 500mL of cough syrup Many mix with ETOH or weed or opioids to intensify the effect

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41 Triple C Coricidin products (Schering-Plough HealthCare Products Inc, Kenilworth, NJ) agents of abuse with a high prevalence in the adolescent population Dextromethorphan & chlorpheniramine maleate Poor man s PCP The street terms for illicit use are skittling and robo-tripping

42 One Teens Thoughts!! After the first time I did it I just really loved it. I would take them when I got up in the morning, before school, during school, after school, before I went to bed. I hallucinated a lot. It was kind of like I was in a dream or something, like so disassociated. I liked that feeling of not being in reality. And I just kept using it after that.

43 Toxic Effects It is a strong non-competitive N-methyl-Daspartate (NMDA) receptor antagonist. When it binds to and blocks these receptors, it can produce euphoria, hyperactivity, and psychosis Serotonin syndrome a likely result of abusing the drug sharp in HR, diaphoresis, extreme anxiety, hypertermia

44 Serotonin Syndrome Dextromethorphan can act as a nonselective serotonin reuptake inhibitor Important to recognize serotonin syndrome so you avoid adding another serotoninergic agent such as ondansetron (Zofran)! Hallmark of serotonin syndrome is clonus Treatment Cool them IV fluids and benzodiazepines

45 cted-triple-c-means-life/

46 Stage 1 4 Different Levels of Intoxication Inebriation, much like drunkenness from alcohol. This can include symptoms like the inability to walk straight, agitation, excitement, and exhibiting a willingness to engage in risky behavior. Stage 2 A deepened intoxication, causing slurred speech and in some cases mild cases of hallucination. At this stage, short-term memory can also be adversely affected.

47 Stage 3 4 Levels (continued) Usually reached through heavy doses of DXM (up to 1,500 milligrams) results in a completely changed mode of consciousness. Associated with heavy hallucinations, loss of vision or other senses, & complete loss of control Stage 4 This is the highest plateau of experience when taking DXM for a high, and can result in an out of body experience, with all physical senses being shut off completely. This level of high can be compared to taking PCP, a highly dangerous and addictive synthetic drug.

48 Case 17 yo found at a supermarket exhibiting bizarre behavior after he had purchased and rapidly ingested about 30 tablets of Coricidin HBP to get high ED: tremulous, diaphoretic demonstrating a clouded sensorium, euphoric mood, & paranoid thought process He stated that he could look at people and know exactly what they were thinking VS : 187/112, 116, 16, 98.9, 100% RA Awake with eyes open but slowly responsive GCS was 12 Pupils were dilated and slowly reactive The rest of the exam was essentially negative

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50 Remember Dextromethorphan at high doses acts as a dissociative general anesthetic and hallucinogen similar to Ketamine and Phencyclidine (PCP) by antagonizing the NMDA receptor in a dose dependent manner Appealing to teens as they are easily available (OTC), legal, inexpensive, and preceived as safe.

51 Treatment Dextromethorphan not detected by basic drug screens and should be considered when evaluating patients with a dissociative toxidrome Always get a Acetaminophen levels!!!!! Consider liver panel and INR No specific antidote exists for dextromethorphan toxicity- symptomatic care! Benzodiazepines should be administered for seizures and aggressive cooling measures for hyperthermia

52 Immodium (Lope Dope!) Or Poor Man s Methadone Loperamide a common OTC anti-diarrheal Considered safe in the 2-16 mg daily Within these levels, rapid metabolism & poor bloodbrain barrier penetration active ingredients: diphenoxylate (similar to Demerol) and atropine (anti-cholinergic) Potent mu-opioid receptor agonist & anticholinergic agent

53 Loperamide Will Stop You Up but It Can Also Bring You Down!!! Hard to believe that people will chug down pills to get high Former heroin addict was taking Lomotil pills with alcohol to achieve euphoria Ingestion of higher (> 50 mg) associated with euphoria, CNS depression, & cardiotoxicity

54 Pills go for $9 to $30 "M"on one side & "30 on other!

55 Deadly Fentanyl Disguised as Oxycodone (M 30 s) You may not have known what you are actually buying Can be pure Fentanyl or Carfentanil used to cut drugs to stretch product Carfentanil similar in structure to fentanyl, with potency 10,000x that of morphine used by vets to immobilize certain large animals, including elephants

56 The Good News! They eat soap instead of Seroquel Majority of pediatric poisonings are smallvolume, exploratory ingestions Mostly we observe and discharge, after whatever period of time seems safe depending on the characteristics of the exposure

57 Refereneces Antoniou T, & Juurlink D.N. (2014). Dextromethorphan abuse. Canadian Medical Association Journal. 186(16):E631 Aytha S.K., Dannaram S., Moorthy S. & Sharma A. (2013). A case of acute psychosis secondary to Coricidin overdose. The Primary Care Companion for CNS Disorders.15(6). Retrieved from ntable Bryner J.K, Wang K, et al. (2006). Dextromethorphan abuse in adolescence Archives of Pediatrics & Adolescent Medicine. 160(12), Button Battery Task Force (2018). Retrieved from

58 References Discovering a dangerous new use for OTC Loperamide May 17 ISMP Medication Safety Alert! Acute Care. 23(10): 3-4. Retrieved from: Jatana K.R., Rhoades K., Milkovich S.& Jacobs I,N, (2017). Basic mechanism of button battery injuires and novel mitigation strategies after diagnosis and removal. Laryngoscope, 127(6), Poison and Prevention Information (By Age). (2018). Retrieved from