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Poisoning in Children 3: Common Medicines 400 LEADING ARTICLE Poisoning thioglycollate as an active ingredient. In Arch Dis Child: first published as 10.1136/adc.87.5.400 on 1 November 2002. Downloaded from ................................................................................... small quantities they cause oropharyn- geal irritation and burning if consumed. Larger amounts can cause corrosive Poisoning in children 3: Common injury or systemic toxicity. medicines ASTHMA MEDICATION Salbutamol is the most common asthma M Riordan, G Rylance, K Berry medication to be accidentally ingested by ................................................................................... children. In overdose salbutamol can induce tremor, tachycardia, agitation, A wide variety of medicines are ingested by children metabolic acidosis, hyperglycaemia, and hypokalaemia. Symptomatic ingestion is uncommon and associated with large n this, the third of a series of articles ORAL CONTRACEPTIVE PILLS doses (1 mg/kg). on the management of poisoning, we Accidental ingestion of oral contracep- Activated charcoal should be given if Ideal with medicines commonly in- tive pills rarely produces any toxic effect more than 1 mg/kg has been ingested. gested by children. other than transient gastrointestinal Asymptomatic children can be dis- upset on the following day. Parents charged at four hours post-ingestion. should be advised that vaginal bleeding Symptoms are generally short lived and 2 COUGH AND DECONGESTANT could occur, in girls of all ages, during resolve spontaneously. PREPARATIONS the first few days following ingestion. Theophylline is far more toxic in over- Proprietary preparations for the treat- dose but is encountered infrequently. ment of coughs, colds, and nasal conges- ANTIBIOTICS Symptoms include vomiting, tachycar- tion are frequently ingested accidentally. Accidental overdose of most commonly dia, tachypnoea, tremors, agitation, and Most preparations (75%) are made up of prescribed antibiotics is associated with convulsions. Metabolic disturbances in- more than one active ingredient. little in the way of adverse effects. clude hyperglycaemia, hypokalaemia, Sympathomimetic agents make up Transient gastrointestinal disturbance hypophosphataemia, metabolic acidosis, the largest group of ingredients. Their may occur. No treatment is required. and respiratory alkalosis. effects in overdose vary widely between Children who have consumed more agents. Individual susceptibility is also BENZODIAZEPINES than 15 mg/kg of theophylline require variable. Adverse effects are unusual and These are most frequently encountered hospital admission and treatment with occur fairly soon after ingestion. Severe by children in the form of sedatives or activated charcoal. Use of multiple doses cases are associated with hypertension, anxiolytics prescribed for adults. In over- of activated charcoal can enhance theo- reflex bradycardia, arrhythmias, convul- dose they produce drowsiness, ataxia, phylline elimination3; 0.5 g/kg should be sions, and coma. Treatment is support- hallucinations, confusion, and agitation. administered on a four hourly basis. ive. Respiratory depression, bradycardia, and Propanolol can be used to prevent the Paracetamol and aspirin make up the hypotension can also occur. metabolic disturbances caused by theo- second biggest group of ingredients. Activated charcoal should be adminis- phylline overdose (most are mediated by tered if presentation occurs within one β Their presence should not be overlooked direct sympathomimetic 2 http://adc.bmj.com/ as measurement of blood concentration hour of ingestion and conscious level is stimulation).4 When these metabolic not impaired. Asymptomatic children may be required, depending on the dose 1 abnormalities are established it is far less consumed. should be observed for four hours. efficacious.5 Hypokalaemia has been im- Opioid analgesics are found in a Symptomatic children require hospital plicated in the induction of cardiac admission. Treatment is largely support- number of preparations. Dextromethor- arrhythmias and convulsions which ac- ive. The use of flumazenil, a competitive 6 phan is most frequently encountered. It company theophylline poisoning. It antagonist to benzodiazepines, is not 7 has a low toxic potential and only should be corrected cautiously with generally indicated. Flumazenil can pro- produces side effects when ingested in intravenous supplementation. Hypergly- on October 2, 2021 by guest. Protected copyright. duce nausea, vomiting, flushing, and considerable quantity. Codeine is also caemia is transient and does not require transient hypotension. Its use should be found in a number of preparations. It is treatment. restricted to patients in whom adequate more toxic in overdose. Theophylline increases cardiac con- measures to protect the airway, support duction velocity,increases catecholamine Expectorants make up the final group respiration, and maintain circulation of ingredients. These are mucosal irri- have failed. Flumazenil may precipitate liberation, reduces coronary blood flow, tants or stimulants. Their putative mech- convulsions in patients on long term and decreases the ventricular fibrillation anism of action is to increase respiratory benzodiazepine treatment, for epilepsy. threshold. It can produce both supraven- tract fluid, thereby facilitating its expul- tricular and ventricular arrhythmias. sion. Expectorants include guaiphen- VITAMIN PREPARATIONS Arrhythmias are concentration depend- esin, ipecacuanha, ammonium salts, cin- Vitamin preparations are generally of ent and are exacerbated by hypoxia, eole, creosote, squill, and tolu. These low toxicity in overdose, but they may hypercapnia, and acidosis. Children are agents may act as emetics in overdosage contain iron and this may not be explicit less prone to theophylline induced ar- 5 but because of their low dosage, toxicity from the product name. rhythmias than adults. is generally overshadowed by other Propanolol is the first line treatment ingredients. TOPICAL MEDICINAL PRODUCTS for both supraventricular and ventricular The presence of several active ingredi- Most topical medicinal products are of arrhythmias. Esmolol is an alternative in ents in a single preparation may produce low toxicity when ingested. Nausea, asthmatic patients.5 Adenosine may also a confusing clinical picture and potenti- vomiting, and diarrhoea may occur. prove effective.1 ate adverse effects. Poison centre advice Exceptions include products with poten- should be sought if the maximum daily tially toxic active ingredients, for exam- ANTIHISTAMINES therapeutic dose of any preparation is ple, salicylates in wart and callus treat- Antihistamines cause central nervous exceeded. ments. Depilatory creams contain system depression and anticholinergic www.archdischild.com LEADING ARTICLE 401 15 side effects in overdose. Hypotension, for nocturnal enuresis, chronic pain dis- with tricyclic antidepressants. While Arch Dis Child: first published as 10.1136/adc.87.5.400 on 1 November 2002. Downloaded from muscle weakness, paradoxical central orders, or attention deficit disorder. In these compounds are much safer in nervous system stimulation, and convul- overdose tricyclics produce anticholiner- overdose than tricyclic sions can also occur. gic symptoms, drowsiness, ataxia, and antidepressants,16 17 adverse effects have Antihistamine overdose can produce a agitation. Convulsions, central nervous been documented. Adverse effects in- variety of cardiac arrhythmias. For the system depression, and hypotension also clude vomiting, agitation, tremor, nys- majority of antihistamines this effect is occur. tagmus, and drowsiness. Convulsions mediated by myocardial sodium channel Cardiac arrhythmias occur frequently and arrhythmias18 have also been re- blockade—a quinidine like effect. Two of and are the most common cause of ported. the newer non-sedating antihistamines, death. The mechanism of cardiac toxicity A “serotonin syndrome” has been terfenadine and astemizole, cause de- is complex. Blockade of noradrenaline described. This most commonly occurs in layed cardiac repolorisation by potas- reuptake at the adrenergic synapse pro- adults receiving combinations of drugs, sium channel blockade. This is associ- duces initial stimulation followed by α two or more of which inhibit the ated with prolongation of the QT interval adrenergic blockade. Tricyclics also exert reuptake or metabolism of serotonin, or and may predispose to the development a quinidine like membrane stabilising enhance its release. Examples of such of ventricular tachyarrhythmias. effect. This causes delayed conduction drugs include selective serotonin re- Children should be observed for a and myocardial depression. The anti- uptake inhibitors, tricyclic antidepres- minimum of four hours following inges- cholinergic effects of tricyclics on the sants, monoamine oxidase inhibitors, tion. Symptomatic children, and those heart are not of major significance. and amphetamines. Symptoms include who have ingested terfenadine, astemi- Activated charcoal should be adminis- autonomic dysfunction, hyperpyrexia, zole, or slow release preparations, even in tered if the maximum recommended circulatory collapse, convulsions, and the absence of symptoms, require admis- daily dose has been exceeded. rhabdomyolysis.19 Reports suggest that sion. Activated charcoal should be con- A 12 lead ECG should be performed in this constellation of symptoms may also sidered up to four hours post-ingestion all cases. The best indicator of risk for occur following
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