Project: Ghana Emergency Medicine Collaborative
Document Title: Toddler Toxicology: Drugs That Can Kill a Child With One
Pill or Swallow
Author(s): Joe Lex, MD, FACEP, FAAEM, (Temple University) 2013
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Toddler Toxicology:
Drugs That Can Kill a Child with
One Pill or Swallow
Joe Lex, MD, FAAEM
Temple University School of Medicine
Philadelphia, PA
How Far We’ve Come
• 1950: >400 pediatric overdose
deaths
• 2003: 34 fatalities from
overdose in children <6 years
• Can we be smug??
Peak Incidence: 1 to 3
• Attracted to toxic substances
based on color or appearance
of agent or container
• More willing to taste
dangerous substances
• Hand-mouth behavior nearly
10 times / hour
Peak Incidence: 1 to 3
• Physical environment change
plays significant role
• Half of accidental poisonings
due to product in use at time
of ingestion or recently moved
from usual storage site
• Top category: cosmetics and
personal care products
Peak Incidence: 1 to 3
• Plants also popular
• Amounts ingested by toddlers
small
• Ingestion of toxic substance
usually results in nontoxic or
minimally toxic outcomes
Poison Hunting on eBay
10 month hunt on eBay
• 121 products identified
• 24 “supertoxic”: strychnine,
arsenic trioxide, cyanide, etc.
• 63 “extremely toxic”
• 21 “very toxic”
• 13 “moderately-slightly toxic”
Cantrell FL. Clin Toxicol. 2005;43(5):375-9.
Baby Proof Home
“I baby-proofed
my home, but the
kids still somehow
manage to get
inside.”
Gideon Koren’s Article
Koren G. Medications which can
kill a toddler with one tablet
or spoonful. Clin Toxicol
1993;31:407–13
• Identified medicines lethal to
10-kg child in single pill or
swallow
Interest Builds
Liebelt EL,et al. Small doses,
big problems: a selected
review of highly toxic common
medications. Pediatr Emerg
Care 1993;9:292–7.
Interest Builds
Michael JB, Sztajnkrycer MD.
Deadly pediatric poisons: nine
common agents that kill at low
doses. Emerg Med Clin North
Am. 2004 Nov;22(4):1019-50.
Interest Builds
Matteucci MJ. One pill can kill:
assessing the potential for
fatal poisonings in children.
Pediatr Ann. 2005 Dec;
34(12):964-8.
Gideon Koren’s Return
Bar-Oz B, Levichek Z, Koren G.
Medications that can be fatal
for a toddler with one tablet
or teaspoonful: a 2004 update.
Paediatr Drugs. 2004;
6(2):123-6.
Some Assumptions
• Assume healthy toddler with
bodyweight 10 kg and normal
drug metabolism
• Use lowest described fatal
dose from literature
• Use maximal dose unit
available
Major Miscreants
•
•
•
•
•
•
•
TCAs
• Theophylline
Antimalarials
• Narcotics
Antipsychotics • Camphor
Anti-arrhythmics
Methyl salicylate
Oral hypoglycemics
Calcium channel blockers
Liquids
Cydone, Wikimedia Commons
Camphor
Camphor – A Case Study
• Multiple pediatric deaths
• AAP editorial in 1978:
Camphor: Who Needs It?
• 20% camphorated oil removed
from US pharmacies
• OTC camphor concentration
limited to 11% in OTCs
Camphor: Who needs it? Pediatrics. 1978
Sep;62(3):404-6.
Camphor
• Topical rubefacient: induces
local hyperemia, warmth
• Analgesic, antipruritic, and
antitussive agent
• Variety of OTC liniments:
Vick’s VapoRub, Ben-Gay,
Absorbine, Tiger Balm
Camphor
• Aromatic terpene ketone
derived from plants
• Distinct odor, pungent taste
• Some cultures use in cooking
• As little as 700 to 1000 mg
fatal
AAP Policy Statement. Pediatrics 1994;94:127.
Camphor
• 7805 cases of topical camphor
ingestion in children younger
than age 6 reported to poison
control centers in US in 2001
• Deaths rare since loss of 20%
oil
Camphor
• Cause of death: respiratory
depression, status epilepticus
• 3-year-old ingested 15mL
Vicks VapoRub®  seizures,
coma, respiratory depression
– 700 mg of camphor
Ruha AM, et al. Acad Emerg Med 2003;10:691.
Camphor
• 2-year-old ingested 10mL
Campho-Phenique
• Seizures in 10 minutes, then
coma, respiratory depression
lasting 24 hours
Gibson DE, et al. Am J Emerg Med 1989;7:41–3.
Vicks VapoRub® Cream
Tatsuo Yamashita, Flickr
Campho-Phenique® (10.8%)
• Pain relieving antiseptic liquid
• For insect bites, scrapes & minor burns
Today
• 1996: 9,387 camphor
exposures reported to AAPCC
• 7404 in children under 6 years
• NO deaths reported
• Virtually eliminated as a
source of lethality in this
country
Methyl
Salicylate
Salicylates
• Present in numerous over-thecounter products
– Aspirin (acetylsalicylic acid)
– Oil of wintergreen (methyl
salicylate)
– Pepto-Bismol (bismuth
subsalicylate)
Methyl Salicylate
•
•
•
•
Methyl ester of salicylic acid
Oil of wintergreen
Deceptively toxic
Minimal toxic ingested dose in
children: 150 mg/kg
Methyl Salicylate
• Betula oil
• Panalgesic
• o-hydroxybenzoic
acid methyl ester
• Gaultheria oil
• Methyl o-hydroxy benzoate
• Sweet birch oil
• Teaberry oil
• Analgit
• Exagien
• Flucarmit
• 2-(methoxy
carbonyl)-phenol
• Anthrapole ND
• 2-carbomethoxyphenol
• Methyl
hydroxybenzoate
• Linsal
• Metsal Liniment
Methyl Salicylate
• One teaspoon of 98% methyl
salicylate contains 7000 mg of
salicylate
• Equivalent to 90 baby aspirin
• > 4 times potentially toxic
dose for 10-kg child
Methyl Salicylate
• Therapeutic serum ASA for
analgesia: 15 to 30 mg/dL
• Signs and symptoms of
toxicity: >30 mg/dL
• Life-threatening levels: >100
mg/dL
Methyl Salicylate
• Vd doubles or triples in toxic
states
• Therapeutic half-life: 1 to 2
hours
• Toxic levels with acid urine:
half-life up to 30 hours
Methyl Salicylate
• Children with rheumatoid
disease at steady state: toxic
through minor dietary changes
• Infants: may show just
dehydration, rapid breathing
• Older kids: GI symptoms, CNS
depression
Methyl Salicylate
Non-aspirin salicylates can be
converted to “aspirin
equivalent doses” with the
help of tables found in any
standard toxicology book
Methyl Salicylate 15%
Jeroen Elfferich, Flickr
Methyl Salicylate 29%
Eli Sagor, Flickr
Methyl Salicylate 40%
Steffen Buus Kristensen, Wikimedia Commons
Methyl Salicylate 0.06%
Jagwire, Wikimedia Commons
Methyl Salicylate
• 21-month-old: significant
poisoning, peak serum
concentration of 81 mg/dL,
after ingesting 4 mL
Howrie DL, et al. Pediatrics 1985;75:869–71.
• Fatality with ingestion <1 tsp
Stevenson CS. Am J Med Sci 1937;193:772–88.
Methyl Salicylate
• 1996 report to AAPCC
• 10,733 toxic exposures to
methyl salicylate
• 7,712 were children
• Two deaths reported, both in
adults
Podophyllin
25%
Podophyllin 25%
• Resinous powder from rhizome
of American Mayapple
• Used to treat genital warts
• Occasional adulterant in
herbal medicines
• 1989: Hong Kong outbreak
Ng THK, et al. J Neurol Sci 1991;101:107-13.
Podophyllin 25%
• Transient toxicity:
hallucinatory psychosis, bone
marrow depression, hepatic
dysfunction
• Persistent: severe peripheral
neuropathy
Filley CM, et al. Neurology. 1982 Mar;
32(3):308-11.
Podophyllin 25%
• Minimal potential fatal dose:
15 – 20 mg/kg
• Maximal dose unit available:
1.25 g/5mL
• Volume for potential lethality:
1mL
Filley CM, et al. Neurology. 1982 Mar;
32(3):308-11.
Pastes, Ointments, Liniments
Scott Ehardt, Wikimedia Commons
Dibucaine
Dibucaine
• Potent amide anesthetic
• Topical uses: hemorrhoids,
sunburn, episiotomy pain
• 10x as toxic as lidocaine
• 20x as toxic as procaine
• Mixed with secobarbitone,
used IV to euthanize large
animals (Somulose®)
Dibucaine
CNS toxicity
• Seizure
• Coma
Dibucaine
Cardiotoxicity
• Increased PR
• Widened QT
• Slowed conduction
• Slowed repolarization
• Reentrant dysrhythmias
– SVT
– PVC
Dibucaine
• ~1% of topical anesthetics
sold in US
• <5% nonfatal exposures to
topical anesthetics
• Caused 3 of 4 deaths due to
topical anesthetics over last
20 years
Dayan PS, et al. Ann Emerg Med. 1996 Oct;
28(4):442-5.
Dibucaine
• In 1995, US Consumer Product
Safety Commission issued rule
requiring childproof packing
for containers with >0.5 mg
dibucaine or >5 mg lidocaine
Corticaine®
Dibucort®
Dibusone®
Nupercainal®
Dibucaine
• Ointment USP, 1%
• Topical Anesthetic
• For External Use Only; Do not use in the eyes
Pills, Tablets & Capsules
Chaos, Wikimedia Commons
AntiArrhythmics
Quinidine
• D-isomer of quinine
• Derived from cinchona bark
• Side effects and toxicity
similar to quinine
• Main concerns: dysrhythmias,
cardiogenic shock, coma,
seizures, retinal damage
Dellocchio T, et al. Pediatrics. 1976 Aug;
58(2):288-90
Interesting History
• Founder of homoeopathy, Dr.
Samuel Hahnemann, took large
daily dose of quinine bark
• After 2 weeks, he felt
malaria-like symptoms
• “Like cures like” philosophy
was start of homoeopathy
Disopyramide
• Another Class 1A
• Falling out of favor
• More anticholinergic than
others in class
• 1 pill potentially lethal
Singer P, et al. J Anal Toxicol. 1995 Oct;
19(6):529-30.
Encainide
Encainide (Enkaid®) removed
from American market
voluntarily, still available on
“compassionate” basis
• Case report: infant swallowed
1 tablet (25 mg) with rapid
onset V-tach, but survival
Mortensen ME, et al. Ann Emerg Med. 1992 Aug;
21(8):998-1001.
Propafenone
Propafenone (Rhythmol®)
• 2 year-old ingested less than
one tablet  rapid
cardiovascular collapse
• Eventual recovery
McHugh TP, et al. Ann Emerg Med. 1987 Apr;
16(4):437-40.
Antiarrhythmics
Minimal
potential
fatal dose
Maximal
dose
available
No. of
tabs that
can cause
fatality
Quinidine
15 mg/kg
324 mg
1
Disopyramide
15 mg/kg
150 mg
1
Procainamide
70 mg/kg 1000 mg
Flecainide
25 mg/kg
Drug
150 mg
1
1–2
Antimalarials
Quinine
• See quinidine
CYL, Wikimedia Commons
Chloroquine
• Primary treatment for malaria
– Anti-inflammatory
– Antihistamine
– Anti-prostaglandin
• Hydroxychloroquine:
chemically similar
Chloroquine
• Quinolone family
• Now used to treat rheumatoid
arthritis, systemic / discoid
lupus erythematosus, other
connective tissue disorders
Chloroquine
• Initial symptom may be
cardiac arrest
• Pediatric overdoses: neuro
symptoms in 30 min to 1 hour
• Death seems related to
cardiac conduction system
depression and myocardium
Chloroquine
• Severity of hypokalemia
closely correlates with level
of chloroquine toxicity
• Potassium concentrations less
than 1.9 mEq/L correlated
with severe, life-threatening
ingestion
Angel G, et al. Lancet. 1995 Dec 16;
346(8990):1625.
Chloroquine
• GI absorption: rapid, almost
complete
• Peak plasma concentration: 1.5
to 3 hours
• Elimination half-life in
children: 75 to 136 hours
Cann HM, et al. Pediatrics 1961;27:95–102.
Chloroquine
•
•
•
•
Therapeutic dose: 10 mg/kg
Toxic effects:
20 mg/kg
Lethal dose:
30 mg/kg
Confirmed toddler death at
27 mg/kg
• Equivalent to 300mg tablet in
8 kg 12-month-old
Cann HM, et al. Pediatrics 1961;27:95–102.
Chloroquine
Antimalarials
Drug
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can
cause fatality
Chloroquine
20 mg/kg 500 mg
1
Hydroxychloroquine
20 mg/kg 200 mg
1
Quinine
80 mg/kg 650 mg
1
Clonidine
Clonidine
• Initially nasal decongestants
• Later marketed as central
acting antihypertensive
• Alpha2-adrenergic agonist
–  central adrenergic tone
• Also bind to imidazoline
receptors in medulla
Imidazolines
• Decongestant imidazolines:
naphazoline, oxymetazoline,
tetrahydrozoline,
xylometazoline
• Ophthalmologic brimonidine
and apraclonidine used to
treat glaucoma
Imidazolines
• 2001: 1438 clonidine
exposures in children younger
than 6 years old
• 922 tetrahydrozoline
exposures in preschool
children
Toxicity
• Oral, transdermal delivery
• Patches contain 2.5 mg, 5 mg,
and 7.5 mg of clonidine,
• OD resembles opioid: LOC,
bradycardia, hypotension,
respiratory depression, miosis,
hypotonia
Toxicity
• Toxicity in 30 to 90 minutes
• May persist for 1 to 3 days
• Children most at risk for
bradycardia, respiratory
depression, intermittent
apnea
Cases
• Case series: 80 children admit
for clonidine ingestion
• Average time to onset of
symptoms: 35 minutes
• Most common presenting sign
or symptom: reduced level of
consciousness (96%)
Nichols MH, et al. Ann Emerg Med 1997;29:511
Cases
• Six required intubation
• No deaths reported
• 54% of the clonidine belonged
to patients’ grandmothers
Nichols MH, et al. Ann Emerg Med 1997;29:511
Cases
• 21-month-old girl: coma,
bradycardia, hypotension
after ingesting 0.3-mg tablet
Neuvonen PJ, et al. Clin Toxicol 1979;14:369–74.
• 6-year-old girl: obtundation,
bradycardia after applying
patch she mistook for bandage
Killian CA, et al. Pediatr Emerg Care 1997;
13:340–1.
Cases
• 9-month-old boy lethargic 90
minutes after sucking on a
discarded clonidine patch
Caravati EM, et al. Ann Emerg Med 1988;17:175
• 2-year-old child bradycardic,
recurrent apnea after
ingesting 5 mL apraclonidine
Everson G, et al. J Toxicol Clin Toxicol 1999;
37:629.
Management
• Imidazoline: supportive
• Symptomatic patients respond
variably to naloxone up to a
total of 10 mg
• Retrospective review: 39 / 80
patients (49%) got naloxone
– Positive response in 4 patients
Nichols MH, et al. Ann Emerg Med 1997;29:511
Management
• Symptomatic bradycardia:
start with atropine
• Hypotension unresponsive to
fluid resuscitation or
complicated by persistent
bradycardia: dopamine
Maggi JC, et al. Clin Paediatr 1986;25:453–5.
Tricyclic Antidepressants
Cyclic Antidepressants
• Leading cause of poisoning
fatality in the United States
until 1993
• Presently 2nd most common
class of agents ingested in
fatalities reported to AAPCC
Litovitz TL, et al. Am J Emerg Med 2002;
20:391–452.
Cyclic Antidepressants
• All TCAs dangerous in excess
• Desipramine seems especially
dangerous in children
• Anticholinergic toxidrome
(remember the mnemonic??)
Toxidrome Mnemonic
“blind as a bat” – dilated pupils
“dry as a bone” – dehydrated
“mad as a hen” – hallucinations
“red as a beet” – skin flushing
urinary retention
tachycardia
Pathophysiology
• Mortality 2o to cardiotoxicity,
CNS toxicity
• BP may be 2o arrhythmiainduced cardiogenic shock,
PVR 2o to alpha-adrenergic
blockade, sympathomimetic
amine depletion
Pathophysiology
• Seizures associated with
cyclic antidepressant toxicity
typically generalized tonicclonic, self-limited
• Status epilepticus has been
reported
Lipper B, et al. Am J Emerg Med 1994;12:451–7.
Pathophysiology
• Seizure activity greatest in
antidepressants showing
dopamine and norepinephrine
reuptake inhibition: bupropion,
amoxapine, venlafaxine
• Significant toxicity presents
within 6 hours of ingestion
Lipper B, et al. Am J Emerg Med 1994;12:451–7.
Morbidity / Mortality
• 10 to 20 mg/kg ingestion of
most TCAs likely to result in
significant CNS, CV symptoms
• 15 to 20 mg/kg ingestion
believed to represent lethal
exposure
Frommer DA, et al. JAMA 1987;257:521–6.
TCA Case Reports
• 3-year-old girl: seizures,
cardiac dysrhythmias after
ingestion 100 mg desipramine
Jue SG. Drug Intell Clin Pharm 1976;10:52–3.
• 250 mg imipramine, amoxapine
have resulted in child fatality
Linakis JG. Clin Toxicol Rev 1988;10.
Manoguerra AS. Crit Care Q 1982;43–51.
Management
• Lecture in itself
• Sodium bicarbonate remains
mainstay of treatment to
reverse cardiotoxic effects
• Beneficial with even normal
arterial pH
• Optimal dosing strategy
remains to be determined
Tricyclic Antidepressants
Drug
Minimal
potential
fatal dose
Maximal
dose
available
Amitriptyline 15 mg/kg 100 mg
No. of tabs
that can
cause fatality
1–2
Imipramine
15 mg/kg 150 mg
1
Desipramine
15 mg/kg 75 mg
1–2
Calcium
Channel
Antagonists
Epidemiology
•
•
•
•
9264 CCA exposures in 2001
100% increase from 1990
2249 in children under 6 years
88 moderate to major
outcomes
• No pediatric deaths reported
• 10 CCAs available in US
Categories
• Phenylalkylamines: verapamil
• Benzothiaprines: diltiazem
– Act predominantly on cardiac
tissue
• Dihydropyridines: nifedipine
– Acts predominately on vascular
smooth muscle
Presentation
• Hallmark: disturbance of
cardiovascular system
• Classic manifestations:
hypotension, bradycardia,
• Reflex tachycardia can be
seen with dihydropyridines
Presentation
• Conduction: 2nd and 3rd degree
heart block
• Negative inotropy: cardiogenic
shock or cardiac arrest
• Can be delayed in sustainedrelease preparation ingestion
Presentation
• Hypotension can last >24
hours despite therapy,
• Hyperglycemia: multifactorial
– Hyperglycemia in setting of
bradycardia and hypotension
suggests CCA ingestion
Case #1
• 11-month-old girl developed
seizures 45 minutes after
ingesting 400 mg verapamil
Passal DB, Crespin FH. Pediatrics 1984;73:543–5.
Case #2
• 14-month-old girl pale,
hypotensive, tachycardic
after ingesting single 10 mg
nifedipine tablet
– Aggressive interventions
– Bradycardia  pulseless
– Died 3 hours after presentation
Lee DC, et al. J Emerg Med 2000;19:359–61.
Case Series
• Pediatric case series: 16
symptomatic patients among
283 recorded exposures
• Five occurred after ingestion
single tablet
• Maximal time to symptom
onset from 3 to 14 hours
Belson MG, et al. Am J Emerg Med 2000;18:581.
Therapy
• Atropine: 1st-line agent in
bradycardia, only moderately
successful
• Optimal pharmacotherapy
poorly defined
• Calcium: conflicting data
– Most beneficial in mild toxicity
Therapy
• TOC refractory CCA toxicity:
high-dose glucose-insulin
– Insulin: positive inotrope
• Case series: 5 patients with
refractory shock after CCA
overdose improved after
glucose-insulin infusions
Yuan TH, et al. J Toxicol Clin Toxicol
1999;37:463–74.
Calcium Channel Blockers
Drug
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can
cause fatality
Nifedipine
15 mg/kg 90 mg
1–2
Verapamil
15 mg/kg 360 mg
1
Diltiazem
15 mg/kg 360 mg
1
Sulfonylureas
Sulfonylureas
• Children 12 years and under
• Hypoglycemia in 56/185 (30%)
• 54/56 (96%) developed
hypoglycemia within 8 hours
of ingestion
• Clinical observation with oral
feeding alone appears safe
Spiller HA, et al. J Pediatr. 1997 Jul;131(1 Pt
1):141-6.
Sulfonylureas
• Clear symptoms hypoglycemia
or glucose levels < 60 mg/dL:
admit for supplemental
glucose (oral or IV), monitor
• Refractory to IV glucose:
octreotide, diazoxide may help
Little GL, et al. J Emerg Med. 2005 Apr;
28(3):305-10.
Sulfonylureas
• 2-year-old boy observed to
ingest 5 mg glipizide
• Activated charcoal given
within 35 minutes
• Hypoglycemia with serum
glucose 49 mg/dL 11 hrs later
Szlatenyi CS, et al. Ann Emerg Med. 1998 Jun;
31(6):773-6.
Oral Hypoglycemics
Drug
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can cause
fatality
Chlorpropamide
5 mg/kg
25 mg
1
Glibenclamide
0.1 mg/kg 2.5 mg
1
Glipizide
0.1 mg/kg
1
5 mg
Opioids &
Opiates
Epidemiology
• 5914 reported ingestions by
children younger than 6 years
old in 2001
• Most common: hydrocodone
with acetaminophen (Vicodin®)
• Time to peak toxicity: 1 hour
• Most deaths 2o to respiratory
depression, hypoxia
Pathophysiology
• Infants and children more
susceptible to toxic effects
• Half of children exposed to
more than 1 mg/kg of codeine
develop toxicity
• 2.5 mg of hydrocodone has
been lethal in infant
OMA Committee on Pharmacy. Codeine: Ont Med
Rev 1977;44:447–8.
Treatment
• Supportive
• Naloxone as needed
– Onset of action: < 2 minutes
– Duration of action: 20 – 90
minutes
– Elimination half-life: 60 – 90
minutes
Opioids / Narcotics
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can
cause fatality
Codeine
7-14
mg/kg
60 mg
1–2
Hydrocodone
elixir
1.5
mg/kg
60 mg
/ 5mL
<1 tsp
Methadone
1-2
mg/kg
40 mg
1
Drug
Special Case: Lomotil®
• Antidiarrheal agent
– 2.5 mg opioid diphenoxylate
– 0.025 mg antimuscarinic
atropine
• Both absorbed rapidly
– May be delayed in overdose
Special Case: Lomotil®
• Diphenoxylate metabolized to
difenoxin, 5x more active than
parent compound
• Elimination half-life 12 – 14
hours
• Little correlation between
ingested dose and outcome
Special Case: Lomotil®
Classically described as
“biphasic reaction”
• Initial antimuscarinic
symptoms in 2 – 3 hours
• Delayed opioid symptoms
• Recent studies show this
occurs in only few cases
McCarron MG, et al. Pediatrics 1991;87:694–700.
Special Case: Lomotil®
Case series
• 4/36 developed early
anticholinergic symptoms
• 15/36 developed opioid
toxicity only
McCarron MG, et al. Pediatrics 1991;87:694–700.
Special Case: Lomotil®
• Catastrophic outcomes
reported after ingestion by
children
Wasserman GS, et al. Am Fam Physician 1975;
11:93–7.
• Toxicity reported after
ingestion of one-half tablet
Ginsberg CM, et al. Clin Toxicol 1969;2:377–82.
Management
• Similar to other opioids
• Initial symptoms, including
coma, may be delayed
• Symptoms have recurred 24
hours after initial resolution
• Recommend: admit, monitor
for no less than 24 hours
Manoguerra AS, et al. Poisindex, Vol. 117;
9/2003.
Household Products
• Methanol in deicing solutions,
windshield washer fluid,
carburetor cleaners
• Concentration may be 95%
• Ingestion of 4 mL by 10-kg
toddler  serum methanol
concentration of 50 mg/dL
Household Products
• Ethylene glycol in antifreeze,
some fire extinguishers, inks,
and adhesives
• Concentration may be 95%
• Ingestion of 2.9 mL by 10-kg
toddler  serum ethylene
glycol concentration of 50
mg/dL
…and Don’t Forget
• Theophylline still in use
• Extended release preparation
available
• Minimal fatal dose: 8.4 mg/kg
• Maximal available unit dose:
500 mg
• One tablet can definitely kill
Primum non Nocere
• No literature suggests better
outcomes with charcoal
• Deaths reported from
activated charcoal aspiration
– Some in children when they
consumed nontoxic products
Menzies DG, et al. BMJ 1988;297:459–460.
Harsch HH. N Engl J Med 1986;314:318.
Elliott CG, et al. Chest 1989;96:672–674.
Drugs Causing Toddler
Deaths: 1990-2000
Iron supplements
Antidepressants
Methadone
Nifedipine
Methyl salicylate
Diphenoxylate
Clonidine
Flecainide
Glipizide
Number of
Fatalities
32
13
6
5
3
1
1
1
1
Summary
• Vast majority of toddler
ingestions are benign
• Dozen or so medicines can kill
10-kg toddler with one pill or
swallow
• Treatment: usually supportive
• Activated charcoal can kill