toxicity in a 2yo of glipizide - how much needs to be taken to cause toxicity: - peak effect time post-ingestion:

- how much needs to be taken to cause toxicity: 10mg tablet (hypoglycemia) - peak effect time: 2-3h, lasting 24h

Case 24: 2yo - toxic ingestion Flashcards by Marijana Waite

mnemonic for altered mental statsu

AEIOU TIPS

A lcohol (other toxins)
E pilepsy, encephalitis, endoctrine, electrolytes
I nfection
O verdose, opiates, O2 deprived
U remia (renal failure)

T rauma, temp
I nsulin
P sychosis
S trike, shock, space-occupying lesions

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physical exam findings for toxic ingestion: cholinergic

==> organophosphates

DUMBBELLS

D iaphoresis, diarrhea
U urination
M iosis == blurred vision
B radycardia
B ronchorrhea, bronchospasm
E mesis
L acrimation
L oss of muscle (twitching and weakness)
S alivation, seziures, coma

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physical exam findings for toxic ingestion: anticholinergic

EKG

==> diphenhydramine, TCAs, atropine, pralidoxine

blind as a bat ==> mydriasis (dilated)
dry as a bone ==> dry skin, constipation, ileus, urinary retention
mad as a hatter ==> delirium, seizures
red as a beet ==> red skin (flushed), tachycardia
hot as Hades ==> fever

EKG

irregular irregular rhythm
small P waves
widened QRS ==> risk of dysrrhythmia, seizures, coma,hypotension
prolonged QT

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physical exam findings for toxic ingestion: sedative-hypnotic

v. opiates?

==> benzos, barbituates

blurred vision (miosis / mydriasis)
hypotension
apnea, bradycardia
hypotonia
hypothermia
sedation/confusion/delirium/coma

v. opiates ==> does NOT cause respiratory depression

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physical exam findings for toxic ingestion: opiates

v. benzos?

==> codeine, morphine, heroin

miosis (small)
respiratory depression
bradycardia, hypotension
hypothermia
sedation/confusion/delirium/coma

v. benzos = does NOT cause mydriasis

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physical exam findings for toxic ingestion: sympathomimetics

==> cocaine, amphetamines, pseudophedrine

mydriasis
fever, diaphoresis
tachycardia
agitation, seizures

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identify the drug that the kid took:

decreased HR
diaphoretic
constricted pupils
hyperactive abdomen

cholinergic

WET
closed eyes, open abdomen (PNS effects)

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identify the drug that the kid took:

decreased HR, hyperthermia
dry skin
dilated pupils
hypoactive abdomen

anticholinergic

DRY
open eyes, closed abdomen (SNS effects)

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identify the drug that the kid took:

decreased HR, BP, RR
altered sensory exam
hypoactive abdomen

DOWNER

benzos

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identify the drug that the kid took:

decreased HR, BP, RR, hypothermia
constricted pupils
hypoactive abdomen

THE EYES

opiod

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identify the drug that the kid took:

increased HR, BP, RR, hyperthermia
diaphoretic
dilated pupils
hyperreflexia
hyperactive abdomen

everything is up

sympathomimetics == loosen the bowels

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what are typical accidental ingestions in toddlers

iron supplements

acetaminophen

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management of toxic ingestion

considerations on whether to initiate decontamination
methods of decontamination

considerations on whether to initiate decontamination

amount and timing of ingestion
nature of substance ingested
patient sxs == mental status, airway security

methods of decontamination

syprup if ipecac ==> secondary agent
activated charcoal ==> for ingestions not due to small molecules or heavy metals; may need more if slow GI motility (NOT for pt with loss of protective airway reflexes, ? intubation)
gastric lavage ==>
cathartics ==> + activatedcharcoal
hemodialysis ==>
hemoperfusion ==>
urinary alkalinization ==>

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toxicity in a 2yo of nortiptyline (TCA)

how much needs to be taken to cause toxicity:
peak effect time post-ingestion:
presentation
mechanism of toxicity
treatment

how much needs to be taken to cause toxicity: > 2.5mg/kg (2 pills)
peak effect time: 7-8h

-presentation == AMS, anticholinergic, HYPOTENSION, dysrrhythmia, seizure

mechanism
1) inhibition of NorE, Seretonin
2) antagonism of muscarinic acetylcholine receptors and peripheral alpha receptors ==> peripheral vasodilation
3) blocked Na channels, GABA receptors ==> direct myocardial depression

treatment = activated charcoal + catharsis

cardiac monitoring for 6h
serum alkalinization, Na loading = hypertonic HCO3 (1mEq/kg) q3-5min until QRS narrows, hypotension improves. Continue for 12-24h after EKG normalizes d/t drug redistribution from tissues. goal pH = 7.5-7.55
pH monitoring
antiarrhythmia
hypotension == voume expansion, serum alkalinization, Na loading (+/- norE)
anti-seizure (benzos, barbiturates, propofol)

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toxicity in a 2yo of glipizide

how much needs to be taken to cause toxicity:
peak effect time post-ingestion:

how much needs to be taken to cause toxicity: 10mg tablet (hypoglycemia)
peak effect time: 2-3h, lasting 24h

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diffdx of ingestion causing altered mental status and mydriasis

presentation:
amount needed to cause sxs:

TCAs

presentation: + agitation, cardiac (hypotension), anti-chol
amount needed to cause sxs: 1-2 pills (>2mg/kg)

SSRIs

presentation: diaphoresis, agitation, fever, AMS, diarrhea, myoclonus
amount needed to cause sxs: SIGNIFICANT

Anti-histamine==> presentation (like TCAs) w/out cardiac problems

Decongestant (phenylphedrine) ==> presentation (SNS) =tachycardia, HTN, agitation, sweating, fever, mydriasis, seizures

Iron ==> severe abd pain, shock

beta-blocker ==> bradycardia

acetaminophen ==> GI problems, then liver toxicity

WITHOUT MYDRIASIS

aspirin ==> agitation, tachycardia
opioid ==> sedation, miosis

evaluation of altered mental status

CBC ==> infection
electrolytes ==> metabolic acidosis +/- AG (aspirin/NSAID)
glucose ==> hypoglycemia
calcium ==> abn levels can affected cardiac
blood gas ==> metabolic acidosis +/- AG
toxicology screen (urine, blood)
acetaminophen levels == initially presents with minimal sxs
EKG ==> dysrrhythmias

treatment of glypizide or insulin overdose

1) maintenance dextrose

2) octreotide (somatostain analog) == inhibit insulin release

why is it so easy to miss acetaminophen overdose?

while it’s one of the most common toxicities, it starts with minimal sxs

management of child with altered mental status

1) CAB + DFG (glucose)
2) then more info + hx + physical exam + tests
3) evaluation via tests +/- lumbar puncture

immediate treatment of hypoglycemia, hypotension, and tachycardia

1) boluses of 20cc/kg NS
2) 25% dextrose
3) MIVF of D10W + NS + KCl

is NGT indicated for toxic ingestion

NO == no clinical benefit

also technically difficult to pass a tube large enough in a 2yo kid

is syrup of ipecac indicated as first-line therapy for toxic ingestion?

NO –> d/t potential side effects (cardiac, seizures)

CONTRAINDICATED if risk of aspiration due to altered mental status

what are the top 5 in initial assessment of altered mental status?

What should be the steps in your initial assessment? (Select the top five.)

 Multiple Choice Answer:
A 	Obtain more history from the mother
B 	Assess the patency of her airway
C 	Observe for cyanosis or respiratory depression
D 	Check the vital signs
E 	Order a CT scan of the head
F 	Check for evidence of circulatory compromise
G 	Order a serum drug screen
H 	Perform a complete neurological exam
I 	Obtain a fingerstick blood glucose

B Assess the patency of her airway
C Observe for cyanosis or respiratory depression
D Check the vital signs
F Check for evidence of circulatory compromise
I Obtain a fingerstick blood glucose

ABC DFG

Which of the following medications would cause mydriasis (dilated pupils)? (Select all that apply.) ``` Multiple Choice Answer: A Diphenhydramine B Aspirin C Codeine D Pseudoephedrine E Lorazepam F Acetaminophen ``` what else?

antihistamines (anticholinergic) pseudoephedrine (SNS) TCAs SSRIs

Which of the following medications would cause miosis (constricted pupils)? (Select all that apply.) ``` Multiple Choice Answer: A Diphenhydramine B Aspirin C Codeine D Pseudoephedrine E Lorazepam F Acetaminophen ``` which causes neither miosis or mydriasis

codeine (opiate) cholinergics (organophosphates) NEITHER lorazepam acetaminophen aspirin

most common cause of death from TCA overdose

refractory hypotension

toxicity in a 2yo of iron - how much needs to be taken to cause toxicity: - peak effect time post-ingestion: - presentation - mechanism of toxicity - labs - complication: - tx

- peak effect time post-ingestion: 6h - presentation 1) GI hemorrhage == mucosal cell nephrosis ==> hematemesis, melena, GI edema, ulceration +/- infarction, necrosis 2) metabolic acidosis == mitochondrial toxicity --> inhibited Krebs, uncoupled ==> lethargy, tachycardia, metabolic acidosis oxidative phosphorylation ==> lethargy, tachycaria 3) shock == direct vasodilitation, negative ionotropy, hemorrhage ==> lethargy, hyperventilation, seizures, coma 4) coagulopathy == inhibited thrombin 5) hepatotoxicity - mechanism of toxicity: oxidative stress --> loss of cellular integrity ==> INCREASED Fe absorption - labs == AG metabolic acidosis; anemia; high serum iron; elevated glucose/WBC - tx 1) GI decontamination = polyethylene glycol 2) deferoxamine - complication: gastric outlet obstruction (2-8w) d/t strictures, scarring

indications for deferoxamine use

- Metabolic acidosis - Repetitive vomiting - Lethargy or toxic appearance - Hypotension or signs or shock - Serum iron concentration > 500 mcg/ml

indications for serum alkalinization for TCA toxicity

CARDIOTOXICITY == conduction delays, dysrrhythmias, hypotension - QRS > 100 msec - R wave in AVR > 3mm - Wide-complex tachycardias - Fluid-refractory hypotension - Seizures ==> hypertonic HCO3 (1mEq/kg) q3-5min until QRS narrows, hypotension improves. Continue for 12-24h after EKG normalizes d/t drug redistribution from tissues. goal pH = 7.5-7.55

indications for serum alkalinization for TCA toxicity

what pressors are contraindicated in TCA toxicity?

beta-adrenergic agonists dopamine d/t effects on the heart NorE is okay b/c it mostly works on vasoconstriction (not heart)

what anti-seizure meds are contraindicated in TCA toxicity?

phenytoin ==> cardiac toxicity

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. Her father suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested? ``` Single Choice Answer: Please select one answer. A Iron B Amitriptyline C Insecticides D Hydromorphone ```

D decreased HR, RR, BP, Temp constricted pupils slowed bowels Opioids such as hydromorphone can cause respiratory depression, bradycardia, hypotension, hypothermia, constipation, nausea, vomiting, sedation, confusion, and/or miosis.

A 2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion? ``` Single Choice Answer: Please select one answer. A Pseudoephedrine B Codeine C Iron pill D Acetaminophen E Propranolol ```

A increased HR, T, BP, RR diaphoresis mydriasis vasoconstriction SNS Ingestion of a sympathomimetic like pseudoephedrine stimulates the beta and alpha adrenergic receptors, causing elevated HR, RR, BP and hypothermia along with diaphoresis, dilated pupils, hyperreflexia, and hyperactivity.

toxicity in a 2yo of acetaminophen - how much needs to be taken to cause toxicity: - peak effect time post-ingestion: - presentation - mechanism of toxicity - labs - complication: - tx

- how much needs to be taken to cause toxicity: 150mg/kg - peak effect time post-ingestion: <1h - presentation: (1) N/V, malaise, diaphoresis --> (2) hepatotoxicity, AST elevated first, PT prolonged next, (3) fulminant hepatic failure, coaguopathy - mechanism of toxicity: metabolized in the liver ==> depleted glutathione, accumulation of NAPQ1 - labs: acetaminophen levels (4h post); AST - complication: - tx (indicated when elevated AST) 1) control of N/V 2) charcoal 1g/kg 3) NAC (esp within 8h)

You are working in the pediatric ED when a 3-year-old girl, Jenny, presents with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after Jenny started acting agitated and “looking very sick.” The mother reports “she feels so warm, I think she has a fever and has become dehydrated.” On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested one of her mother’s medications. An overdose of which of the following medications could cause Jenny’s symptoms? ``` Single Choice Answer: Please select one answer. A Tricyclic antidepressant B SSRI C Decongestant D Acetaminophen E ACE inhibitor ```

A 6 hours ago mydriasis = TCA NOT SSRI, decongestant (SNS), acetaminophen, ACEI increased HR decreased BP TCA toxicity presents with agitation, tachycardia, hypotension, dilated pupils, and hot, dry skin from the anticholinergic effects of TCAs. B. SSRI is incorrect, because serotonin syndrome will usually present with a fever and sweaty, not dry, skin. Also, serotonin syndrome usually does not present with hypotension. C. Decongestant is not the correct answer. Decongestant overdose will elicit a sympathomimetic response, including agitation and tachycardia. However, unlike TCA overdose, decongestant overdose will cause hypertension, constricted pupils, fever/sweating. Additionally, severe overdose of decongestant may cause seizures. D. Acetaminophen is not the correct answer. Acetominophen overdose will produce mild and nonspecific symptoms and include right upper quadrant pain, with elevation in liver enzymes, resulting in liver failure at toxic levels. E. ACE inhibitor is not the correct answer. The typical adverse event for ACE inhibitors is cough.

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His heart rate is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms? ``` Single Choice Answer: Please select one answer. A Organophosphates B Tricyclic antidepressant C Barbiturates D Codeine E Pseudoephedrine ```

A vomiting, AMS pinpoint pupils + WET (drool, sweat) == cholinergic Increased RR, SOB (bronchorrhea, bronchospasm) Organophosphates cause cholinergic effects, such as miosis, sweating, lacrimation, salivation, urination, increased gastric mobility (vomiting, diarrhea), muscle twitching, bronchospasm, bradycardia, and seizures. A good mnemonic is SLUDGE (salivation, lacrimation, urination, defecation, GI mobility, emesis).