DANGERS LURKING WITHIN YOUR CUPBOARDS: OUTCOMES AND MANAGEMENT OF INTENTIONAL OR ACCIDENTAL INGESTIONS

Session Goals

Content of annual report of the National Poison Data Summary (NPDS)

Review cases that highlight the ease of household ingestions whether or not intentional

Management of a common life threatening ingestion

Poison Control Services within California

Hypercalcemia

Symptoms at 12 Normal 9-10.5 Emergent if >15 >2500mg per day is considered toxic Cleared renally TUMs have 200-400mg per pill treatment with IVF fluids and salt then

diuretics and if needed biphosphinates and calcitonin

National Poison Data System (NPDS) There are 57 Poison Control Centers across

the country >2 million human poison exposures per year Maintain a data base of >350,000 drugs,

chemicals, and agents and their exposure behaviors

There are 4 poison control centers in California (SF, SD, Sacramento, Central Valley) originated in 1997. CPCS keeps 78% at home.

NPDS Summary 2011

1158 fatalities - 6% children <20 yo and 94% in adults

1077 intentional and 147 unintentional deaths 94.5% were either ingestion or

inhalation/nasal With children, death is unintentional and

adults is intentional Nearly 50% of exposures were in children <6

with the greatest number in 1-2 yo

NPDS Summary 2011

Nearly 50% of exposures are single substance Analgesics are the #1 exposure followed by

cosmetics and personal care products Kids <5 years old are exposed most often to

cosmetics/PC products Adults exposures are

analgesics/sedatives/hypnotics/antipsychotic 52 pediatric deaths (street, analgesics,

stimulants

Up and Away Campaign

1. Pick a place for medications where children cannot reach. 2. Put medications away after use… Every time! 3. Make sure the safety cap is locked. 4. Teach your children about medicine safety. 5. Tell guests about medication safety. 6. Be prepared in case of an emergency, have the number located for all to see. 1-800-222-1222

Most Common Drug Poisonings

Analgesics

Sedative/Hypnotics/Antipsychotics

acetaminophen, aspirin, ibuprofen, opioids

tranquilizers, sleeping

medications, mental health medicines

Topical Preparations Diaper rash ointment, hydrocortisone cream, decongestants, dextromethorphan

Cold and Cough Preparations Decongestants, dextromethorphan

Cardiovascular Medications Blood pressure medicines, cholesterol medicines

Antidepressants SSRIs Trazodone, amitriptyline, lithium

Antimicrobial antibiotics Antifungals, antivirals

Antihistamines Diphenhydramine, chlorpheniramine

Vitamins Chewable vit C, iron, calcium, prenatal vitamins

Gastrointestional Preparations Antacids, PPIs, H2 blockers

Most Common Non-drug Poisonings

Cosmetics/Personal Care Products

Household Cleaning Substances

toothpaste, lotion, mouthwash, deodorant

soap, bleach, pine oil, laundry detergent, shampoo

Foreign Bodies/toys/miscellaneous

Coins, silica gel, beads, batteries

Pesticides Rat bait, ant killer, snail killer, weed killer

Plants Poinsettia, oleander, dieffenbachia, dandelions, pyracantha, holly

Bites and envenomations Spiders, snakes, bees, hornets, bats, scorpions

Food Products/Food Spoiled food, botulism, salmonella, paralytic shellfish poisoning, food tampering

Chemicals Ammonia, arsenic, boric acid, strychnine, formaldehyde

Hydrocarbons Gasoline, charcoal lighter fluid, lamp oil, furniture polish

MMWR July 17, 2009 / 58(27);753

MMWR January 13, 2012 / 61(01);10-13

Why Expertise of CPCS matters:

NONTOXIC Nail polish Oil of Olay Barium sulfate Hair conditioner

TOXIC Nail glue remover Oil of wintergreen Barium chloride Hair straightener

Child ingestion

A 30-month-old, previously healthy and active toddler had two vomiting episodes that the parents believed to be due to an intestinal virus.

Later that day , the child was pale, weak and continued to vomit, resulting in a presentation to the emergency department.

At the hospital, the child was diagnosed with dehydration, and an X -ray revealed.....

Child Ingestion

The child developed a fever and abdominal swelling and was taken to surgery, where bowel perforation was found.

The injured bowel was surgically removed. Five days after the operation, the child

suffered a clot in the blood supply resulting in small intestine ischemia. In the operating room, the child was found to have a large area of dead bowel

Emergency Department Presentation 32 yo black female PMH of depression, remote suicide attempt,

obesity, chronic pain Meds: two antidepressants and two narcotics

and klonopin Arrived via 911 call unable to speak but

communicating via writing on paper stating that she had been unable to speak or take her pain meds for 3d and wanted a feeding tube

Had no other complaints

Physical examination

temp 37.0, BP 142/86, HR 98, RR 16, O2 96% RA

Appeared well, no distress Protruding tongue and muffled voice Enlarged chin and anterior neck Lungs clear and unable to examine the oral

cavity, full ROM of the neck Labs – abnl was INR at >13.7, all others

normal

Treatment Course

Immediate – clindamycin, dexamethasone, benadryl, famotadine, considered epinephrine

ENT consultation OR Nasal awake intubation for airway protection FFP, Vitamin K – LOTS In ICU for 2 weeks and transitioned to floor

and discharged on daily vitamin K

Sore Throat Presentation in ED

26 yo female with no PMH presented to the ED with unilateral sore throat for 3d

Progressive fullness on the right side of throat and fever to 101.7

No difficulty with secretions or respirations but odynaphagia

Did have difficulty speaking with muffled voice

Sore Throat Presentation to ED

Patient underwent a PTA aspiration after local use of Hurricaine Spray

Tolerated well and 10cc aspirated At discharge RN comes to NP and states the

discharge vital signs are abnormal with O2 sat at 91% which within 15 minutes becomes 88% and patient is symptomatic and rapidly moved to the resuscitation room.

Unexplained hypoxia

Hurricane spray is benzocaine Occurs with several other medications such

as dapson or chloroquine and nitrates.

Methemoglobinemia Acquired or Inherited

Rare reaction

Treatment

Methylene blue – 1-2 mg/kg over 3-5 minutes in 1% NS solution. Repeat every 30 minutes as needed up to 7mg/kg to goal of methemaglobin below 20%. Must have functional G6PD

Ascorbic acid – 500mg/day with Riboflavin 20mg/d. Not a good choice with renal stone Hx

Hyperbaric oxygen therapy or exchange infusions

Lithium Ingestion

Homeless male 34 with PMH of ETOH abuse and depression

Presented intoxicated and unable to walk, well known to ED, similar presentation

Usual observation and resident did no labs or ETOH level

Returned within 8 hours via ambulance ataxic with slurred speech

Renal clearance imperative and competes with other medications

Lithium level has a very narrow therapeutic window 0.6 to 1.5meq/l. Patient’s was 2.8

Lithium Overdose

Overdose symptoms are generally GI related but include weakness and dizziness

These are followed by neurological symptoms such coma, dysarthria and dysmetria, and uncontrolled eye movements

If only GI symptoms then usually reversible but if neurological symptoms develop, they can be irreversible.

Lithium Overdose

TREATMENT Time to treatment may warrant activated

charcoal IVF and dialysis Gastric lavage is used less often and only if exact

time and amount of ingestion is known Symptom management of nausea

Tylenol Overdose 3 phases of tylenol toxicity over a 3-5 day

period Despite the serious liver damage and hepatic

failure, full recovery of hepatic function is possible with prompt treatment

Children are more likely to have early symptoms and vomit after ingestion making toxicity less likely but mimics other GI illnesses

Tylenol overdose

Important to understand how drugs are metabolized

Normal metabolism involves 95% conjugation and then 5% cytochrome 450 enzyme system oxidation in the liver.

Normally involves the conversion to toxic N-acetyl-p-benzoquinoneimine via cytochrome P450 system but overdose overwhelms glutathione stores.

Tylenol overdose

Toxicity in adults vs children >10grams (20 extra strength tylenol tabs) >200mg/kg in children

Time from ingestion to treatment is important as influences effectiveness of therapy and hepatic recovery

If ingestion is considered and many hours after ingestion, treatment is indicated as laboratory studies are pending

Tylenol overdose treatment

activated charcoal , 1 g/kg (maximum dose 50 g) by mouth in all patients presenting within 4 hours of ingestion

Oral dosing available 1330mg/kg given over 72 hours (140 mg/kg loading dose followed by 17 doses of 70 mg/kg every four hours) with antiemetic

300 mg/kg of N-acetylcysteine (NAC) is given intravenously over 21 hours (over 40kg same as adults) Loading dose given over 60 minutes 2nd Dose given over 4 hours Maintenance dose completed over 16 hours Incorrect NAC dosing in children and anaphylaxis in all ages are

considerations with IV treatment.

Patients ≤20 kg: Loading dose: 150 mg/kg in 3 mL per kg of diluent given IV over 60 minutes Second dose: 50 mg/kg in 7 mL per kg of diluent given IV over 4 hours (12.5 mg/kg NAC per hour) Third dose: 100 mg/kg in 14 mL per kg of diluent given IV over 16 hours (6.25 mg/kg NAC per hour) Patients >20 and <40 kg: Loading dose: 150 mg/kg in 100 mL of diluent given IV over 60 minutes Second dose: 50 mg/kg in 250 mL of diluent given IV over 4 hours (12.5 mg/kg NAC per hour) Third dose: 100 mg/kg in 500 mL of diluent administered over 16 hours (6.25 mg/kg NAC per hour)

Public Hotline – 1-800-222-1222 Callers to the hotline have immediate access to interpreters fluent in over 100 languages. Immediate assessment and recommendations for managing poison exposure on-site, referrals to health care facilities when necessary, and follow-up telephone calls. TTY Line – 1-800-972-3323 For use by the hearing and speech impaired. Medical Consultation Line Poison exposure and overdose diagnosis and treatment assistance to hospital personnel and health care professionals. Specialty consultants are available to aid in the care of hospitalized poisoning victims. Emergency Personnel Line 9-1-1 ambulance dispatchers, police and fire personnel have access to a dedicated CPCS line for assistance in assessing the severity of a poison exposure. The CPCS provides treatment advice and helps determine if transport to a health care facility is necessary.

Newer Drugs

Pradaxa No known antidote Treat with FFP, Vit K, Bebulin and hope for the

best