Thyroid storm after pediatric levothyroxine ingestion.

A 2-year-old girl was found with an empty bottle of levothyroxine and blue coloring around her mouth. Forty tablets of 150-microg levothyroxine tablets were missing. Her 6-hour postingestion total thyroxine (T4) level was 68.1 microg/dL (normal range: 5-12 microg/dL), and her total triiodothyronine (T3) level was 472 ng/dL (normal range: 40-130 ng/dL). Serum levels of thyrotropin, T3, and T4 were then checked on days 3, 5, 7, and 10. On postingestion day 5, the child presented for follow-up with hyperthermia, vomiting, irritability, and increased lethargy. She was referred to the emergency department, where a heart rate of 220 beats per minute, a blood pressure of 130/80 mm Hg, and a temperature of 101 degrees F were recorded. She also had multiple episodes of diarrhea. The patient was treated with oral propranolol (0.8 mg/kg) every 6 hours, intravenous normal saline, and ibuprofen; all her vital signs improved. Serial T3, T4, and thyrotropin serum levels were measured. Her total T3 levels were >800, 798, 445, 446, and 98 ng/dL on days 3, 5, 6, 9, and 13, respectively. Total T4 measurement was repeated on day 13, and the concentration was found to be 11.9 microg/dL. Her thyrotropin levels remained undetectable throughout the course of treatment. The patient was discharged from the hospital after a 4-day PICU stay, in good condition, on oral propranolol 0.8 mg/kg every 8 hours. Propranolol administration was discontinued 8 days after initiation with no further tachycardia, hypertension, or hyperthermia. The child tolerated the recommended regimen.

Guideline for the out-of-hospital management of human exposures to minimally toxic substances.

All substances are capable of producing toxicity, so nothing is completely non-toxic. Minimally toxic substances are those which produce little toxicity, minor self-limited toxicity, or clinically insignificant effects at most doses. Examples include silica gel, A&D ointment, chalk, lipstick, and non-camphor lip balms, watercolors, hand dishwashing detergents, non-salicylate antacids (excluding magnesium or sodium bicarbonate containing products), calamine lotion, clay, crayons, diaper rash creams and ointments, fabric softeners/sheets, glow products, glue (white, arts, and crafts type), household plant food, oral contraceptives, pen ink, pencils, starch/sizing, throat lozenges without local anesthetics, topical antibiotics, topical antifungals, topical steroids, topical steroids with antibiotics, and water-based paints. Minimally toxic exposures have the following characteristics: (1) The information specialist has confidence in the accuracy of the history obtained and the ability to communicate effectively with the caller. (2) The information specialist has confidence in the identity of the product(s) or substance(s) and a reasonable estimation of the maximum amount involved in the exposure. (3) The risks of adverse reactions or expected effects are acceptable to both the information specialist and the caller based on available medical literature and clinical experience. (4) The exposure does not require a healthcare referral since the potential effects are benign and self-limited. However, decisions regarding patient disposition should take into account the patient's intent, symptoms, and social environment. In addition, individual patient circumstances (e.g., pregnancy, pre-existing medical conditions, therapeutic interventions) need to be considered. Minimally toxic exposures may vary in route (dermal, inhalation, ingestion, ocular), chronicity (acute, chronic), and substance composition (single or multi-ingredient, single or multiple product). Future categorization of substances as "minimally toxic" should be based on a process involving review of current knowledge, a thorough analysis of poisoning experience, and prospective validation.

Discrepant advice from poison centres and their medical directors.

OBJECTIVE: To characterize the recommendations of the medical directors of North American poison information centres for gastrointestinal decontamination of a hypothetical poisoned patient, and to examine the extent to which those recommendations agree with the advice previously issued by their poison information centres for the same scenario. METHODS: The medical directors of 72 poison centres in the United States and Canada were contacted and invited to participate in a survey. Each participant was asked to provide specific advice for gastrointestinal decontamination of a hypothetical patient presenting 1 h after a potentially life-threatening ingestion (32.5 g) of enteric-coated acetylsalicylic acid. The directors were then presented with the recommendation their poison centres had previously issued for the same overdose scenario. The main outcome measures were perceived agreement with their own centre's recommendation and director-centre concordance for each method of gastrointestinal decontamination. RESULTS: Sixty-seven of 72 (93%) medical directors participated in the survey. They issued 30 different management suggestions for our hypothetical patient, and were in full agreement with their own centres 27% of the time. Concordance was moderate for recommendations on syrup of ipecac (k=0.468, P<0.001), and fair for whole bowel irrigation (k=0.348, P=0.005) and the use of sorbitol with activated charcoal (k=0.305, P=0.005). Concordance was poorest for advice on gastric lavage (k=0.093, P=0.445) and multidose charcoal (k=0.039, P=0.745). CONCLUSIONS: The medical directors of North American poison centres offer widely varying advice on gastrointestinal decontamination for a hypothetical patient who is acutely poisoned with enteric-coated acetylsalicylic acid. Their advice was often different from that previously issued by their respective centres.