CLIPP case 24. 2yo toxic ingestion

Question 1

2yo girl who became acutely agitated and then difficult to arouse at home. Her family lives with her great-aunt who is a diabetic and her father found pills in an opened plastic container on the floor. On exam she is
agitated, mildly febrile, slightly hypotensive and tachycardic with dilated pupils.
She is hypoglycemic on presentation.

Answer 1

• Hypoglycemia - glipizide
• AMS not improving with D25. ECG shows long wide complex tachycardia, irregularly irregular - TCA
• Tx: D10 MIVF, cathartic agent, activated charcoal, serum alkalization, sodium loading
• DDx: TCA, SSRI, Decongestant, Antihistimine, Anti-hyperglycemic

Question 2

Cholinergic toxidrome

Answer 2

*SLUDGE: salivation, lacrimation, urination, defecation, GI motility, emesis + bradycardia, seizures/coma, bronchospasm, twitching/weakness, miosis/blurry vision

Question 3

Anticholinergic toxidrome (diphenhydramine, TCA)

Answer 3

• Red, hot, dry, blind, mad
• Mydriasis (dilated pupils)
• Decreased gastric motility (ileus)
• Urinary retention
• Tachycardia and hypertension (hypotension in TCA)
• Delirium and seizures

Question 4

Sedative-hypnotic toxidrome (BZD, barbs)

Answer 4

• Blurred vision (miosis OR mydriasis)
• Hypotension
• Apnea and bradycardia
• Hypothermia
• Sedation, confusion, delirium, coma

Question 5

Opioids toxidrome (codeine, morphine, heroine)

Answer 5

• Miosis (constricted pupils)
• Respiratory depression
• Bradycardia and hypotension
• Hypothermia
• Depressed mental status (sedation, confusion, coma)

Question 6

Sympathomimetic toxidrome (cocaine, amphetamine, pseudoephedrine, clonidine, decongestants)

Answer 6

• Mydriasis
• Fever and diaphoresis
• Tachycardia
• Agitation and seizures

Question 7

Iron toxidrome

Answer 7

-Severe abdominal symptoms followed by signs of shock

Question 8

Beta blocker toxidrome

Answer 8

Bradycardia

Question 9

Acetaminophen toxidrome

Answer 9

-Minimal initial symptoms (GI), followed by symptoms of liver toxicity

Question 10

Aspirin toxidrome

Answer 10

Agitation and tachycardia; no mydriasis

Question 11

SSRI toxidrome

Answer 11

-Serotonin syndrome: Profuse sweaty skin, agitation, fever, mental status changes, diarrhea, myoclonus, hyperreflexia, ataxia, and shivering

Question 12

Hypoglycemia management

Answer 12

• IV bolus of dextrose 25% followed by maintenance fluids with D10
• Frequent BG checks
• Octreotide inhibits insulin release in dextrose-refractory sulfonylurea overdose

Question 13

Toxin elimination with gastric decontamination

Answer 13

• Activated charcoal: For ingestions NOT due to small molecules or heavy metals. Aspiration risk - consider elective intubation.
• Cathartic agent: A single dose with the initial dose of charcoal
• Gastric lavage: No consistent clinical benefit, except w/in 1 hour of TCA? Difficult to pass large enough tube in child.
• Syrup of ipecac: Induces vomiting. AAP recommends against due to SE (aspiration, cardiac, seizures)
• Hemodialysis and hemoperfusion: Not with TCA ingestion due to protein-binding
• Urinary alkalinization: Salicylate intoxication, severe TCA (NaHCO3)

Question 14

TCA cardiotoxicity and seizures

Answer 14

• Conduction delays, dysrhythmias, hypotension: Cardioresp monitoring, serum alkalinization and sodium loading (NaHCO3) also for hypotension, lidocaine, norepi for refractory hypotension
• Seizures: Benzodiazepines, barbiturates, or propofol in addition to alkalization. No phenytoin d/t cardiotox