Transcript Peds Dx 2001

Name that poison!
Kent R. Olson, MD
Medical Director, SF Division
California Poison Control System
Case
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9 month old being watched by
grandmother
Found flaccid, grunting, with
decreased level of consciousness
HR 70/min, BP 105/59
Resp agonal, O2 sat 80%
Pupils pinpoint
Continued . . .
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No response to naloxone
Treated supportively, eventually
recovered
Initial Hx: GM takes lisinopril, HCTZ
Also using eye drops for glaucoma
Continued . . .
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Alphagan™ (brimonidine 0.2%)
– used for open-angle glaucoma
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Stimulates -2 receptors (similar to
clonidine)
– CNS depression, bradycardia, HOTN
– Peripheral: alpha-agonist can elev BP
– J Tox Clin Tox 1997; 35:506 also
describes a case w/ recurrent episodes
of hypotonia, bradypnea
Case
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What’s
that?!?
Radiopaque pills and poisons
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“CHIPS”
– Chloral hydrate
– Iron, lead, other metals
– Phenothiazines
– Sodium
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Also:
– Potassium, Calcium
– Pepto-Bismol
– Some SR preparations
Iron pills
Pepto-Bismol
Enteric-coated
Potassium
Case
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Young woman with a headache
BP 138/100
HR 38/min, irregular
Phenylpropanolamine
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Strong alpha agonist:
–  vascular resistance
– Elevated BP
– Reflex bradycardia or even AV block
• not due to “Cushing reflex”
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Treatment:
– Vasodilator (eg, phentolamine, NP)
• caution if pt has already stroked
– Do NOT give atropine for bradycardia!
11-6-2000: FDA’s MedWatch
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“FDA is taking steps to remove
phenylpropanolamine hydrochloride
from all drug products due to the risk
of hemorrhagic stroke...
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“...FDA has significant concerns
because of the seriousness of stroke
and the inability to predict who is at
risk… ”
Case
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Healthy 2 yo F became agitated
T 102.7 F
HR 163/min RR 43/min
Pupils widely dilated
Profusely diaphoretic
Bowel sounds present
Accuchek blood glucose normal
Continued . . .
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The parents brought
in a half-empty bottle
of Amp II Pro Drops™
that had accidentally
been left open and was found near
the child
Product is a weight loss supplement
containing ephedrine
“...Based on thermogenesis, which increases the rate at
which the body burns fat. Amp II Pro Drops is a
synergistic, unique blend of ingredients. From improved
metabolic system functions, more energy can be achieved
and weight management maximized. It contains 5 herbal
extracts, DMAE and B-12. It is an appetite controller with
energizers; stimulates free breathing, enhances athletic
performance, increases stamina,
endurance and alertness.
(Do not use if you have high
blood pressure, are pregnant
or lactating)...”
Case
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6 yo F acting strange
Talking nonsense, ? hallucinating
Tremulous, ataxic
T 38º C, HR 160/min
Pupils a little dilated, bowel sounds
present, skin dry but not flushed
Urine toxicology screen negative
Continued . . .
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CT and LP negative
Blood Cx negative
Special analysis for
dextromethorphan was positive
Dextromethorphan (“DMX”)
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Common OTC cough suppressant
Odd pharmacology:
– d-isomer of opioid levorphanol
– antitussive but not analgesic
– antagonizes NMDA receptors
– inhibits serotonin reuptake
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Popular drug of abuse in teens
– OTC cough syrups, Coricidin
What's the DXM Trip Like?
“Well, that depends on how much you take. There
are four different kinds of experiences, based on the
dosage; these are called plateaus. The first plateau is
a mild stimulant effect with a little bit of a buzz...
The second plateau is more intoxicating and has
been compared to being drunk and stoned at the
same time. The third plateau is dissociative, like a
lower dose of ketamine. The fourth plateau is fully
dissociative like a higher dose of ketamine.”
More on dextromethorphan . . .
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Anecdotal reports of cases of
dramatic and unexpected responses
(esp. in Orientals)
Potential mechanism: geneticallyrelated poor liver metabolism
(CYP2D6 isoform)
Case
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Young woman had a seizure
Had been at a “Rave” party the night
before
Na 116 mEq/L
Had consumed about 5 L
water during the evening
Ecstasy-induced hyponatremia
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SIADH? or
Excessive water intake?
– a common practice in rave clubs to
reduce the risk of dehydration and heat
stroke