ToxCard: Pediatric Toxicology – One Pill/Taste Can Kill

Authors: Nikki Richardson, MD (Emergency Medicine Resident, Carolinas Medical Center), Kathryn T. Kopec, DO (Emergency Medicine Attending, Medical Toxicologist, Carolinas Medical Center) // Reviewed by: Cynthia Santos, MD (@CynthiaSantosMD), Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@Long_Brit) 

Case:

A 4-year-old female presents to the Emergency Department (ED) with her grandmother for altered mental status. The child was playing in the grandmother’s room earlier, and when the grandmother went to check on her the child was sleeping and difficult to arouse, so she called 911. Initial vital signs include HR 121, BP 100/62mmHg, RR 20 breaths/min, SpO2 99% on RA, temperature 37 °C. Blood glucose is 22. She is treated with oral glucose solution, which improves her mental status, with repeat glucose 92. While in the ED undergoing evaluation, she again becomes lethargic, and repeat glucose is 31. The patient has no medical history; however, her grandmother has a history of hyperlipidemia and type 2 diabetes.

Questions:

  1. What is your toxicological differential?
  2. What other evaluation is required?
  3. What is your treatment plan?

Background

Pediatric patients compromised 45.2% of the 2.6 million toxic exposure calls to US poison centers in 2017.1  Although most of these reports represent minor ingestions, there are at least 8 different classes of substances that can lead to severe toxicity or even death with even small ingestions in children. The 2017 data from the American Association of Poison Control Centers (AAPCC) reported 25 deaths in children less than 6 years of age.1 With the development of new pharmaceuticals and the expanded treatment indications for others, the availability of deadly drugs is only increasing.1,2 It is imperative for physicians to be familiar with the presenting signs and symptoms of potentially toxic ingestions in the pediatric population in order to be able to quickly initiate therapeutic and life-saving interventions.

Table 1: Commonly Cited ‘One Pill Can Kill’ Medications

Case Conclusion:

The grandmother reported taking glyburide for her DM, and the pills are kept in her bedroom side table. The patient’s presentation is consistent with a sulfonylurea ingestion, and upon the grandmother doing a pill count, it was discovered that 2 pills were missing. The patient was admitted, started on octreotide and glucose as needed, and recovered fully.

Main Points

  • If you have a child that presents concerning for toxic ingestion, contact the poison control center.
  • Identification of children with clinical toxidromes concerning for ingestion requires vigilance on the part of the clinician.
  • Careful questioning of the family/caretakers is required to identify potential exposures
  • In pediatric exposures with known time of ingestion and early presentation, activated charcoal may be considered for early decontamination in the asymptomatic patient who is protecting his/her airway.
  • Remember the ingestions listed in Table 1!

 

References

  1. Gummin D, Mowry J, Spyker D, Brooks D, Osterthaler K, Banner W. 2017 Annual Report of the American Associate of Poison Control Centers’ National Poison Data System (NPDS) 35th Annual Reports. Clinical Toxicology 2018 Dec; 56(12):1213-1415.
  2. Elizabeth Q. Hines; Jeffrey S. Fine. Pediatric Principals. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e New York, NY: McGraw-Hill. http://accesspharmacy.mhmedical.com/content.aspx?bookid=2569&sectionid=210276997. Accessed November 13, 2019.
  3. Henry K, Harris CR. Deadly Ingestions. Pediatr Clin N Am 2006; 53: 293-315.
  4. Little G, Bonifce K. Are one or two dangerous? Sulfonylurea exposure in toddlers. J Emerg Med 2005; 28(3):305-10.
  5. Toxicology (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com
  6. Toxicology (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com
  7. Treatment overview (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com
  8. Treatment overview (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com
  9. Treatment overview (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com
  10. Treatment overview (2019). In Micromedex (Columbia Basin College Library ed.) [Electronic version]. Greenwood Village, CO:Truven Health Analytics. Retrieved November 14th, 2019, from https://www.micromedexsolutions.com

 

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