This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

1. 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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3. Toddler Toxicology:
Drugs That Can Kill a Child with
One Pill or Swallow
Joe Lex, MD, FAAEM
Temple University School of Medicine
Philadelphia, PA

4. How Far We’ve Come
• 1950: >400 pediatric overdose
deaths
• 2003: 34 fatalities from
overdose in children <6 years
• Can we be smug??

8. 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

9. 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

10. 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

11. 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.

12. Baby Proof Home
“I baby-proofed
my home, but the
kids still somehow
manage to get
inside.”

13. 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

14. 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.

15. 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.

16. Interest Builds
Matteucci MJ. One pill can kill:
assessing the potential for
fatal poisonings in children.
Pediatr Ann. 2005 Dec;
34(12):964-8.

17. 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.

18. 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

19. Major Miscreants
• TCAs
• Antimalarials
• Antipsychotics
• Anti-arrhythmics
• Methyl salicylate
• Oral hypoglycemics
• Calcium channel blockers
• Theophylline
• Narcotics
• Camphor

20. Liquids
Cydone, Wikimedia Commons

21. Camphor

22. 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.

23. Camphor
• Topical rubefacient: induces
local hyperemia, warmth
• Analgesic, antipruritic, and
antitussive agent
• Variety of OTC liniments:
Vick’s VapoRub, Ben-Gay,
Absorbine, Tiger Balm

24. 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.

25. 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

26. 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.

27. 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.

29. Vicks VapoRub® Cream
Tatsuo Yamashita, Flickr

30. Campho-Phenique® (10.8%)
• Pain relieving antiseptic liquid
• For insect bites, scrapes & minor burns

31. 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

32. Methyl
Salicylate

33. Salicylates
• Present in numerous over-the-
counter products
– Aspirin (acetylsalicylic acid)
– Oil of wintergreen (methyl
salicylate)
– Pepto-Bismol (bismuth
subsalicylate)

34. Methyl Salicylate
• Methyl ester of salicylic acid
• Oil of wintergreen
• Deceptively toxic
• Minimal toxic ingested dose in
children: 150 mg/kg

35. 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-carbo-
methoxyphenol
• Methyl
hydroxybenzoate
• Linsal
• Metsal Liniment

36. 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

37. 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

38. 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

39. 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

40. Methyl Salicylate
Non-aspirin salicylates can be
converted to “aspirin
equivalent doses” with the
help of tables found in any
standard toxicology book

41. Methyl Salicylate 15%
Jeroen Elfferich, Flickr

42. Methyl Salicylate 29%
Eli Sagor, Flickr

43. Methyl Salicylate 40%
Steffen Buus Kristensen, Wikimedia Commons

44. Methyl Salicylate 0.06%
Jagwire, Wikimedia Commons

45. 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.

46. Methyl Salicylate
• 1996 report to AAPCC
• 10,733 toxic exposures to
methyl salicylate
• 7,712 were children
• Two deaths reported, both in
adults

47. Podophyllin
25%

48. 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.

49. 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.

50. 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.

51. Pastes, Ointments, Liniments
Scott Ehardt, Wikimedia Commons

52. Dibucaine

53. 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®)

54. Dibucaine
CNS toxicity
• Seizure
• Coma

55. Dibucaine
Cardiotoxicity
• Increased PR
• Widened QT
• Slowed conduction
• Slowed repolarization
• Reentrant dysrhythmias
– SVT
– PVC

56. 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.

57. 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®

58. Dibucaine
• Ointment USP, 1%
• Topical Anesthetic
• For External Use Only; Do not use in the eyes

59. Pills, Tablets & Capsules
Chaos, Wikimedia Commons

60. Anti-
Arrhythmics

61. 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

62. 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

63. 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.

64. 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.

65. 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.

66. Antiarrhythmics
Drug
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 1
Flecainide 25 mg/kg 150 mg 1 – 2

67. Antimalarials

68. Quinine
• See quinidine
CYL, Wikimedia Commons

69. Chloroquine
• Primary treatment for malaria
– Anti-inflammatory
– Antihistamine
– Anti-prostaglandin
• Hydroxychloroquine:
chemically similar

70. Chloroquine
• Quinolone family
• Now used to treat rheumatoid
arthritis, systemic / discoid
lupus erythematosus, other
connective tissue disorders

71. 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

72. 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.

73. 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.

74. 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.

75. Chloroquine

76. Antimalarials
Drug
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can
cause fatality
Chloroquine 20 mg/kg 500 mg 1
Hydroxy-
chloroquine
20 mg/kg 200 mg 1
Quinine 80 mg/kg 650 mg 1

77. Clonidine

78. Clonidine
• Initially nasal decongestants
• Later marketed as central
acting antihypertensive
• Alpha2-adrenergic agonist
–  central adrenergic tone
• Also bind to imidazoline
receptors in medulla

79. Imidazolines
• Decongestant imidazolines:
naphazoline, oxymetazoline,
tetrahydrozoline,
xylometazoline
• Ophthalmologic brimonidine
and apraclonidine used to
treat glaucoma

80. Imidazolines
• 2001: 1438 clonidine
exposures in children younger
than 6 years old
• 922 tetrahydrozoline
exposures in preschool
children

81. 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

82. Toxicity
• Toxicity in 30 to 90 minutes
• May persist for 1 to 3 days
• Children most at risk for
bradycardia, respiratory
depression, intermittent
apnea

83. 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

84. 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

85. Cases
• 21-month-old girl: coma,
bradycardia, hypotension
after ingesting 0.3-mg tablet
• 6-year-old girl: obtundation,
bradycardia after applying
patch she mistook for bandage
Killian CA, et al. Pediatr Emerg Care 1997;
13:340–1.
Neuvonen PJ, et al. Clin Toxicol 1979;14:369–74.

86. Cases
• 9-month-old boy lethargic 90
minutes after sucking on a
discarded clonidine patch
• 2-year-old child bradycardic,
recurrent apnea after
ingesting 5 mL apraclonidine
Everson G, et al. J Toxicol Clin Toxicol 1999;
37:629.
Caravati EM, et al. Ann Emerg Med 1988;17:175

87. 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

88. 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.

89. Tricyclic Anti-
depressants

90. 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.

91. Cyclic Antidepressants
• All TCAs dangerous in excess
• Desipramine seems especially
dangerous in children
• Anticholinergic toxidrome
(remember the mnemonic??)

92. 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

93. Pathophysiology
• Mortality 2o to cardiotoxicity,
CNS toxicity
• BP may be 2o arrhythmia-
induced cardiogenic shock,
PVR 2o to alpha-adrenergic
blockade, sympathomimetic
amine depletion

94. Pathophysiology
• Seizures associated with
cyclic antidepressant toxicity
typically generalized tonic-
clonic, self-limited
• Status epilepticus has been
reported
Lipper B, et al. Am J Emerg Med 1994;12:451–7.

95. 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.

96. 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.

97. TCA Case Reports
• 3-year-old girl: seizures,
cardiac dysrhythmias after
ingestion 100 mg desipramine
• 250 mg imipramine, amoxapine
have resulted in child fatality
Jue SG. Drug Intell Clin Pharm 1976;10:52–3.
Linakis JG. Clin Toxicol Rev 1988;10.
Manoguerra AS. Crit Care Q 1982;43–51.

98. 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

99. Tricyclic Antidepressants
Drug
Minimal
potential
fatal dose
Maximal
dose
available
No. of tabs
that can
cause fatality
Amitriptyline 15 mg/kg 100 mg 1 – 2
Imipramine 15 mg/kg 150 mg 1
Desipramine 15 mg/kg 75 mg 1 – 2

100. Calcium
Channel
Antagonists

101. 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

102. Categories
• Phenylalkylamines: verapamil
• Benzothiaprines: diltiazem
– Act predominantly on cardiac
tissue
• Dihydropyridines: nifedipine
– Acts predominately on vascular
smooth muscle

103. Presentation
• Hallmark: disturbance of
cardiovascular system
• Classic manifestations:
hypotension, bradycardia,
• Reflex tachycardia can be
seen with dihydropyridines

104. Presentation
• Conduction: 2nd and 3rd degree
heart block
• Negative inotropy: cardiogenic
shock or cardiac arrest
• Can be delayed in sustained-
release preparation ingestion

105. Presentation
• Hypotension can last >24
hours despite therapy,
• Hyperglycemia: multifactorial
– Hyperglycemia in setting of
bradycardia and hypotension
suggests CCA ingestion

106. Case #1
• 11-month-old girl developed
seizures 45 minutes after
ingesting 400 mg verapamil
Passal DB, Crespin FH. Pediatrics 1984;73:543–5.

107. 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.

108. 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.

109. Therapy
• Atropine: 1st-line agent in
bradycardia, only moderately
successful
• Optimal pharmacotherapy
poorly defined
• Calcium: conflicting data
– Most beneficial in mild toxicity

110. 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.

111. 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

112. Sulfonylureas

113. 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.

114. 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.

115. 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.

116. 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 5 mg 1

117. Opioids &
Opiates

118. 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

119. 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.

120. Treatment
• Supportive
• Naloxone as needed
– Onset of action: < 2 minutes
– Duration of action: 20 – 90
minutes
– Elimination half-life: 60 – 90
minutes

121. Opioids / Narcotics
Drug
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

122. Special Case: Lomotil®
• Antidiarrheal agent
– 2.5 mg opioid diphenoxylate
– 0.025 mg antimuscarinic
atropine
• Both absorbed rapidly
– May be delayed in overdose

123. 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

124. 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.

125. 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.

126. 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.

127. 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.

128. 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

129. 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

130. …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

131. 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.

132. Drugs Causing Toddler
Deaths: 1990-2000
Number of
Fatalities
Iron supplements 32
Antidepressants 13
Methadone 6
Nifedipine 5
Methyl salicylate 3
Diphenoxylate 1
Clonidine 1
Flecainide 1
Glipizide 1

133. 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