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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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2
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Ross JA, Eldridge DL. Pediatric Toxicology. Emerg Med Clin North Am 2022; 40:237-250. [DOI: 10.1016/j.emc.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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4
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Essink J, Berg S, Montange J, Sankey A, Taylor V, Salomon J. Single-Pass Albumin Dialysis as Rescue Therapy for Pediatric Calcium Channel Blocker Overdose. J Investig Med High Impact Case Rep 2022; 10:23247096221105251. [PMID: 35856321 PMCID: PMC9309771 DOI: 10.1177/23247096221105251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Calcium channel blocker ingestions remain one of the leading causes of death
related to cardiovascular medication ingestion in both adults and pediatric
patients. We report a case of a 17-year-old, 103 kg female presenting after an
intentional polypharmacy ingestion, including 500 to 550 mg of amlodipine. She
presented with profound vasoplegia and cardiovascular collapse requiring
high-dose inotropes and eventual life support with extracorporeal membrane
oxygenation (ECMO). Current available treatments, designed for adults, including
lipid emulsion and methylene blue, provided no sustained clinical improvement.
This resulted in the initiation of single-pass albumin dialysis (SPAD). We aim
to describe the clinical implications, amlodipine toxic dose effects, and
clinical challenges associated with large pediatric patients and high-dose
medications. We also discuss several challenges encountered related to dosing
and concentration of medications, which led to fluid overload. Given the ongoing
obesity epidemic, we routinely see pediatric patients of adult size. This will
continue to challenge pediatric use of adult dosing and concentrations to avoid
excessive fluid administration for high-dose medications, such as insulin and
vasoactive agents. To our knowledge, this is the first successful case of using
SPAD in conjunction with ECMO for salvage therapy after refractory
life-threatening calcium channel blocker toxicity.
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Affiliation(s)
- Jenna Essink
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
| | - Sydney Berg
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Jaka Montange
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Andrew Sankey
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Veronica Taylor
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
| | - Jeffrey Salomon
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
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5
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Farrell NM, Hamilton S, Gendron BJ, Corio JL, Lookabill SK. Presence of "One Pill Can Kill" Medications in Medication Organizers: Implications for Child Safety. J Pharm Pract 2021; 35:898-902. [PMID: 34000923 DOI: 10.1177/08971900211017491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medication organizers increased compliance, but they do not contain child protective packaging. Medications organizers have been involved in some pediatric exposures; however, previous reports do not describe if "one pill can kill" (1PCK) medications were involved in the exposures. 1PCK medications may cause toxicity even with a single tablet. OBJECTIVE The purpose of this study is to describe the type and presence of 1PCK medications dispensed in medication organizers at a single center. METHODS Adult patients who received blister packed medications from September 1, 2017 to September 30, 2017 were included in this retrospective review. Medications were excluded if dispensed traditionally during this time. The primary outcome described included 1PCK medications (quantity and type). Secondary outcomes included total number of tablets dispensed, delayed- (DR) and extended-release (ER) formulations, average age of those dispensed 1PCK medications versus those without. RESULTS A total of 450 patients received 486 blister packs and 75.5% of which found to include 1PCK medications. Most commonly included 1PCK medications were beta-blockers and calcium channel blockers (42.4 and 49.4%, respectively). Patients receiving 1PCK medications were older (69.1 ± 12.6 vs 62.6 ± 16.7 years old, p < 0.0001) and included more medications (8.5 ± 2.9 vs 5.7 ± 2.9 medications, p < 0.0001). DR and ER formulations were in 150 packs. CONCLUSION The majority of dispensed medication organizers included 1PCK medications. Upon dispensing, patients should be questioned for possible proximity exposures. Additionally, they should receive education on medication safety for children that may be in proximity of the medications during home, work, or social activities.
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Affiliation(s)
- Natalija M Farrell
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Bryan J Gendron
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jessica L Corio
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Sara K Lookabill
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA
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6
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Adrienne Hughes
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
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7
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, de Gamarra-Martínez EF, Nogué-Xarau S. Availability in Spain of “one-pill killers” and other highly toxic drugs in infants. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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8
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Martínez-Sánchez L, Aguilar-Salmerón R, Pi-Sala N, Gispert-Ametller MÀ, García-Peláez M, Broto-Sumalla A, Fernández de Gamarra-Martínez E, Nogué-Xarau S. [Availability in Spain of "one pill killers" and other highly toxic drugs in infants]. An Pediatr (Barc) 2020; 93:380-395. [PMID: 32284232 DOI: 10.1016/j.anpedi.2020.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To prepare a list of highly toxic drugs in infants (HTDs) marketed in Spain, comparing those that reach the lethal dose in a child of 10kg with the ingestion of 1 to 3 units. METHOD HTDs are defined as those capable of causing severe or lethal poisoning in children less than 8-year-old. Severe poisoning is considered as that corresponding to Grade 3 in the Poisoning Severity Score classification and to the "major effects" category in publications in the American Association of Poison Control Centers. A literature review was carried out on the annual reports of the American Association of Poison Control Centers, as well as in PubMed, between January 2000 and February 2019 (Keywords "severe", "fatal", "life-threatening", "poisoning", "child", "paediatric", "toxicological emergency"). An observational, retrospective study was also conducted on infants less than 8-year-old that were seen in a Paediatric Emergency Department due to suspected drug poisoning between July 2012 and June 2018. The active ingredients responsible marketed in Spain were selected, and the lethal or highly toxic doses were determined. The number of units (pills) necessary to reach this dose in children of 10kg was calculated. RESULTS A total of 7 HTD groups were identified: analgesics; psychotropics and other medication used in neurological disorders; catarrh decongestants - cough -antihistamine - asthma drugs; cardiovascular drugs; antibiotics, topical preparations, and other drugs. In 29 active ingredients, the ingestion of a single pill could cause death in 10kg infant, in another 13, the ingestion of 2 pills could cause death, as well as the ingestion of 3 pills in 10 cases. CONCLUSION There are numerous HTDs marketed in Spain, some of which are available in potentially fatal presentations with few pills.
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Affiliation(s)
- Lidia Martínez-Sánchez
- Servicio de Urgencias, Hospital Sant Joan de Déu, Barcelona, España; Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España
| | - Raquel Aguilar-Salmerón
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España.
| | - Núria Pi-Sala
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Clínica Girona, Girona, España
| | - Maria Àngels Gispert-Ametller
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Urgencias, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - Milagros García-Peláez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital ASEPEYO Sant Cugat, Sant Cugat del Vallès, España
| | - Antoni Broto-Sumalla
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Consorci Sanitari de Terrassa, Barcelona, España
| | - Edurne Fernández de Gamarra-Martínez
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Servicio de Farmacia, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Santiago Nogué-Xarau
- Grupo de Trabajo Red de Antídotos, Sociedad Española de Farmacia Hospitalaria-Societat Catalana de Farmàcia Clínica, España; Unidad de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Barcelona, España
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9
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Bartlett JW, Walker PL. Management of Calcium Channel Blocker Toxicity in the Pediatric Patient. J Pediatr Pharmacol Ther 2019; 24:378-389. [PMID: 31598101 DOI: 10.5863/1551-6776-24.5.378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Calcium channel blockers (CCBs) are commonly prescribed cardiovascular medications used in several disease states including hypertension, coronary artery disease, and atrial fibrillation. Inadvertent exposure or intentional overdose of CCBs may result in hypotension, bradycardia, dysrhythmias, conduction disturbances, and hyperglycemia. In the most severe cases, CCB toxicity can lead to rapid cardiovascular collapse. Given the risk of significant morbidity and mortality associated with CCB toxicity, it is important that health care professionals are able to recognize and treat patients who present with a potentially toxic ingestion. Due to the paucity of literature in managing pediatric patients with severe CCB toxicity, treatment strategies for pediatric patients are mostly limited to case reports and extrapolation from expert consensus recommendations for adults. All pediatric patients with a potentially toxic CCB ingestion should be evaluated in the emergency department. Activated charcoal may be considered for asymptomatic patients presenting within an hour of ingestion. Symptomatic patients should be placed under cardiac monitoring and treatments to stabilize the patient's hemodynamics should not be delayed. Traditional first-line IV therapies include small boluses of fluids, calcium, and vasopressors. High-dose insulin has been proposed to independently increase inotropy and improve CCB-induced hypoinsulinemia and insulin resistance that results from CCB inhibition of insulin release from pancreatic β-islet cells. High-dose insulin is recommended as first-line therapy for adults and shows promising efficacy and safety in several pediatric case reports. Intravenous lipid emulsion may be considered in patients who are refractory to first-line therapies, although the data for pediatric patients are extremely limited.
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10
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Shormanov VK, Kvachakhiya LL, Mitrokhina AV, Myasnyankina EA. [Features of the determination of amlodipine in a biological material]. Sud Med Ekspert 2019; 62:47-54. [PMID: 31407706 DOI: 10.17116/sudmed20196204147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The purpose of the work is to determine the optimal conditions for isolating amlodipine, to purify it by the method of column chromatography and to develop a method for detecting it in biological material. TLC, GC-MS, low pressure column chromatography, and HPLC were used for analysis. We studied the comparative isolation of amlodipine from biological material using 13 isolating agents of organic nature, water, and aqueous solutions. The use of acetone as an insulating agent for the extraction of amlodipine from tissues of cadaver organs has been substantiated. The possibility of purification of the analyzed compound from the endogenous substances of the biomaterial is shown by the method of reversed phase chromatography in a column of the Silasorp S-18 sorbent of 30 μm. A technique has been developed for detecting amlodipine in the tissues of cadaveric organs (liver), which corresponds to the necessary parameters of linearity, selectivity, accuracy, precision and stability. The limits of detection and quantification of amlodipine by the proposed method are 0.25·10-6 and 4.0·10-6 g, respectively, in 1 g of the biomaterial.
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Affiliation(s)
- V K Shormanov
- Department of Pharmaceutical, Toxicological and Analytical Chemistry, Kursk State Medical University, Kursk, Russia, 305041
| | - L L Kvachakhiya
- Department of Pharmaceutical, Toxicological and Analytical Chemistry, Kursk State Medical University, Kursk, Russia, 305041
| | - A V Mitrokhina
- Department of Pharmaceutical, Toxicological and Analytical Chemistry, Kursk State Medical University, Kursk, Russia, 305041
| | - E A Myasnyankina
- Department of Pharmaceutical, Toxicological and Analytical Chemistry, Kursk State Medical University, Kursk, Russia, 305041
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11
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Christensen MB, Petersen KM, Bøgevig S, Al-Gibouri S, Jimenez-Solem E, Dalhoff KP, Petersen TS, Andersen JT. Outcomes following calcium channel blocker exposures reported to a poison information center. BMC Pharmacol Toxicol 2018; 19:78. [PMID: 30482251 PMCID: PMC6258306 DOI: 10.1186/s40360-018-0271-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022] Open
Abstract
Background Calcium channel blockers (CCBs) are widely used drugs that have a narrow therapeutic index. Even minor overdoses must be treated in-hospital due to the risk of severe hypotension and bradycardia. We aimed to describe trends in CCB use and overdoses in Denmark. Methods Data on enquiries concerning CCBs reported to the Danish Poisons Information Center (DPIC) from January 2009 to January 2015 was coupled with data on hospitalization and mortality obtained from Danish National Registers. We obtained data on the general use of CCBs in Denmark and retrieved medical charts on fatal cases. Results From a total of 126,987 enquiries to the DPIC in 2009–2014 we identified 339 CCB unique exposures (3‰ of all). Children < 5 years accounted for 20% all exposures and these were classified as ‘intake during playing’ (61%) and ‘medication errors’ (39%). Among adults ‘suicidal poisonings’ (58%), and ‘medication errors’ (34%) were most frequent. A majority (81%) of exposures led to hospital admission. Seven patients (2%) died from the CCB exposure and all were adults with ‘suicidal poisoning’. Amlodipine accounted for 95% of all CCB prescriptions, was involved in 71% of enquiries and in 29% of fatalities. Verapamil accounted for 3% of prescriptions, was involved in 13% of enquiries and 57% of fatalities. Conclusion Four fifths of enquiries to the DPIC result in hospitalization and one fifth concern small children. Mortality were infrequent and occurred only in adults with suicidal exposures and with and an overrepresentation of verapamil exposures.
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Affiliation(s)
- Mikkel B Christensen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark. .,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Kasper M Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Søren Bøgevig
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Salam Al-Gibouri
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kim P Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tonny S Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jon T Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Verhoeven AR, Harris CR. Deadly Drug Ingestions. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Unintentional pediatric ophthalmic tetrahydrozoline ingestion: case files of the medical toxicology fellowship at the University of California, San Francisco. J Med Toxicol 2015; 10:388-91. [PMID: 24760708 DOI: 10.1007/s13181-014-0400-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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14
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Pharmacotherapy of pediatric advanced life support and toxicological emergencies. AACN Adv Crit Care 2013; 23:398-412; quiz 413-4. [PMID: 23095965 DOI: 10.1097/nci.0b013e31826b4c70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Guidelines for pediatric advanced life support have been available for nearly a quarter of a century. Recommendations for the pharmacological management of pediatric cardiac arrest have changed over these years. Several important differences have been observed between adult advanced cardiac life support and pediatric advanced life support that must be recognized when children require resuscitation, such as the cause of the arrest, age-specific monitoring parameters, weight-based medication dosing, and obstacles in obtaining venous access. To make matters more complicated, differences also exist across neonatal and pediatric age spectrums. In addition, some toxicological emergencies commonly occurring in children require pharmacological management with agents that have a unique mechanism of action for cardiac support.
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15
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Price D, Radke J, Albertson T. Hypocalcaemia after an occult calcium channel blocker overdose: a case report and literature review. Basic Clin Pharmacol Toxicol 2013; 114:217-21. [PMID: 24034162 DOI: 10.1111/bcpt.12121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/22/2013] [Indexed: 12/27/2022]
Abstract
Hypocalcaemia is a rare complication of calcium channel blocker overdose, having been reported only once previously (J Toxicol Clin Toxicol, 1992, 30, 309). In this article, we report a case of a 37-year-old woman who developed hypocalcaemia after a verapamil overdose, review the literature and propose a mechanism for this rare finding.
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Affiliation(s)
- David Price
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
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16
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Zimmerman E, Frieberg EM, DeBord J, Akingbola O, Yang SG, Yosypiv IV. Acute onset of multi-organ system dysfunction. Clin Pediatr (Phila) 2012; 51:96-8. [PMID: 21685215 DOI: 10.1177/0009922811412588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Kalkan S, Hocaoglu N, Oransay K, Unverir P, Tuncok Y. Cardiovascular medication exposures and poisonings in Izmir, Turkey: A 14-year experience. Hum Exp Toxicol 2010; 30:347-53. [DOI: 10.1177/0960327110371256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular medications (CVMs) are frequently prescribed for cardiovascular diseases. The unconscious use of cardiovascular drugs may lead to severe clinical manifestations, even to death, especially when in overdose. The objective of this study is to clarify the profile of CVM exposures admitted to Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2006. Case demographics, type of the medication, route and reason for exposure, clinical effects and outcome were recorded. Related to the CVM exposures, 105 poisoning cases were admitted. Mean age of children and adults were 12.8 ± 1.0 and 30.1 ± 1.8, respectively. Females were dominating (77.1%). Poisoning by accident occurred mainly among children in the 0—6 age group (64.3%) and suicide attempt was predominant in the 19—29 age group (47.8%). The most common ingested CVMs admitted to EMDEU were calcium channel blockers (19.7%), beta-blockers (17.3%), angiotensin converting enzyme inhibitors and diuretics (11.8%). Most of the patients were asymptomatic (59.1%). Frequently observed symptom was altered consciousness (18.6%). Antihypertensive drugs are responsible for the most of the CVM exposures. Prospectively designed multi-centered studies are needed to reflect the epidemiological properties of cardiovascular drug exposures throughout our country and would be very valuable for the determination of preventive measures.
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Affiliation(s)
- Sule Kalkan
- Department of Pharmacology, Dokuz Eylul University School of Medicine, Inciralti, Izmir Turkey,
| | - Nil Hocaoglu
- Department of Pharmacology, Dokuz Eylul University School of Medicine, Inciralti, Izmir Turkey
| | - Kubilay Oransay
- Department of Pharmacology, Dokuz Eylul University School of Medicine, Inciralti, Izmir Turkey
| | - Pinar Unverir
- Department of Emergency Medicine, Dokuz Eylul University School of Medicine, Balcova, Izmir, Turkey
| | - Yesim Tuncok
- Department of Pharmacology, Dokuz Eylul University School of Medicine, Inciralti, Izmir Turkey
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Abstract
Calcium channel blockers continue to be used for the management of a wide variety of adult and pediatric conditions including hypertension, angina pectoris, atrial arrhythmias, Raynaud phenomenon, and migraine headaches. With increased use comes increased potential for misuse and abuse. This article serves as a review of calcium channel blocker physiology with emphasis on presentation and management of the pediatric patient with calcium channel blocker toxicity.
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19
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Benson BE, Spyker DA, Troutman WG, Watson WA, Bakhireva LN. Amlodipine toxicity in children less than 6 years of age: a dose-response analysis using national poison data system data. J Emerg Med 2009; 39:186-93. [PMID: 19535212 DOI: 10.1016/j.jemermed.2009.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 12/18/2008] [Accepted: 02/06/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Amlodipine is a long-acting calcium channel blocker capable of producing hypotension and dysrhythmia in overdose. The toxic doses of amlodipine in children are unclear. OBJECTIVES The purposes of this study were to describe amlodipine poisoning in children and to determine whether a dose-response relationship could be detected in this population using standardized call data from United States (US) poison centers. PATIENTS AND METHODS 1251 amlodipine-only ingestions in children < 6 years of age were reviewed. Cases with doses coded as "Exact" or "Estimated" and with dose, age, and medical outcome were analyzed (n = 678). Ingestions reported as a "taste or lick" (n = 53) were included as a dose of 1/10 of the dosage form involved. A clinically important response was defined as bradycardia, hypotension, dysrhythmia, conduction disturbance, or hyperglycemia. The risk of such responses was examined over four dosage intervals (< 2.5 mg, 2.5-5 mg, 5.1-10 mg, and > 10 mg). RESULTS The median estimated dose ingested was 5 mg (range 0.25-200 mg). Clinically important responses developed in 27 patients (3.98%), and the prevalence of such response significantly increased from 0% for the lowest to 11.1% for the highest dose interval (p = 0.001). The smallest dose to produce a clinically important response was 2.5 mg (0.15 mg/kg). Children who ingested > 10 mg were 4.4 times more likely to develop clinically important responses than those ingesting < or = 5 mg. CONCLUSION Hypotension may occur in children with amlodipine doses as low as 2.5 mg. The National Poison Data System might provide useful insights regarding dose-response.
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Affiliation(s)
- Blaine E Benson
- New Mexico Poison & Drug Information Center, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA
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