An Analysis of Clinical Outcomes of Exploratory Pediatric Metformin Ingestions Reported to the Texas Poison Center Network From 2011 to 2021.

Background: Poison centers develop triage threshold guidelines for pediatric metformin ingestions. Our network uses 1700 mg, or 85 mg/kg. Objective: To describe the dose, clinical course, and outcomes for inadvertent metformin ingestions in children 5 years old and younger reported to our statewide poison center network. Methods: We searched the poison center database 2011 to 2021 for metformin ingestions in patients 5 years and younger. Variables included age, sex, weight, dose, symptoms, outcome, and more. We used descriptive statistics with medians and interquartile ranges (IQR) for continuous variables. Results: Of 669 cases, exposures by age were 208 (31.1%) 1 to 2 years, and 275 (41.1%) 2 years. Weight was recorded in 342 (51.1%) (median 13.5 kg; IQR: 3.7 kg), and dose in 149 (22.3%) (median 500 mg; IQR: 500 mg). Milligram/kilogram values were available for 103 (15.4%) with median 42.4 mg/kg, IQR: 39 mg/kg. Most (647, 98.5%) exposures were unintentional. Most (445/669, 66.5%) were managed at a non-healthcare facility, while 204 (30.7%) were already at or referred to a healthcare facility. Of these 204 patients, 169 (82.8%) were evaluated and treated at the emergency department and discharged. Four (2%) were admitted to critical care, and 7 (3.4%) to the ward. Medical outcomes by effect were 5 (0.7%) minor, 2 (0.3%) moderate, 253 (37.8%) none, 292 (43.6%) not followed (minimal effects possible), and no major effects or deaths. Of 20 clinical occurrences reported, vomiting was most common (8, 1.2%). Conclusion: Despite little recorded dosage information, pediatric metformin ingestions under 85 mg/kg had predominantly uneventful medical outcomes.

Efficacy of activated charcoal administered more than four hours after acetaminophen overdose.

To evaluate whether administration of activated charcoal, in addition to standard N-acetylcysteine (NAC) therapy, after acetaminophen overdose provides additional patient benefit over NAC therapy alone, a 1-year non-randomized prospective, multi-center, observational case series was performed at three poison centers and one poison center system. Entrance criteria were all acute acetaminophen overdoses with: 1) an acetaminophen blood concentration determined to be in the toxic range by the Rumack-Matthew nomogram; and 2) all therapies, including NAC and activated charcoal, initiated between 4 and 16 h post-ingestion. There were 145 patients meeting entrance criteria, of whom 58 patients (40%) received NAC only and 87 patients (60%) received NAC and activated charcoal. Overall, 23 patients had elevations of AST or ALT greater than 1000 IU/L, of which 21 patients received NAC only (38% of total NAC only group) and 2 patients received NAC and activated charcoal (2% of total NAC+AC group). Administration of activated charcoal in this series of patients with toxic acetaminophen concentrations treated with NAC was associated with reduced incidence of liver injury, as measured by elevated serum transaminases and prothrombin times.

Retrospective evaluation of tiagabine overdose.

BACKGROUND: Tiagabine is an anticonvulsant that blocks reuptake of the inhibitory neurotransmitter GABA. There are no published studies or case series of tiagabine overdoses. METHODS: The records of six poison centers and one statewide poison center network were searched for all exposures to tiagabine for the years 2000-2002. Inclusion criterion was a human tiagabine exposure with follow-up to a known outcome; exclusion criterion was multiple drug ingestion. RESULTS: 57 cases met the inclusion criterion. Thirty-seven patients were female (67%). Mean and median ages were 30.5 years (S.D. +/- 18.5) and 31 years, respectively, with a range of 2 to 80 years. Seven patients were < or = 6 years. Neurologic symptoms were common: lethargy, seizures (multiple), status epilepticus, seizure (single), coma, confusion, agitation, tremors, dizziness, dystonias/abnormal posturing, and hallucinations. Other symptoms included respiratory depression, tachycardia, hypertension, and hypotension. Therapies included benzodiazepines, mechanical ventilation, phenytoin, phenobarbital, diphenhydramine, and dopamine. The mean onset and duration of symptoms were 1.3 hours (+/- 0.5, range 1-2 hours) and 9.1 hours (+/- 3.8, range 4-24 hours), respectively. Dose ingested by history was known for 38 patients (67%). The lowest dose with the development of multiple seizures and coma was 96 mg. This occurred in a 36-year-old female with a history of epilepsy. The lowest dose with symptoms in a child was 8 mg, in a 6-year-old with drowsiness. Mean dose of those with and without symptoms was 102 mg and 10 mg, respectively. The mean dose for patients experiencing seizures was 224 mg (+/- 172, range 96 to 680 mg). The mean dose for patients experiencing coma and respiratory depression was 270 mg (+/- 204, range 96 to 680 mg). Fifty-two patients (91%) were evaluated in the ED of whom 43 were admitted for medical care. CONCLUSION: Seizures and altered mental status were common with tiagabine overdose, with rapid onset and resolution of symptoms. In this series, seizures did not occur until the ingestion was greater than three times the maximum recommended daily dose.

Benzonatate Ingestion Reported to the National Poison Center Database System (NPDS).

Little has been published on benzonatate ingestion, with the few case reports suggesting significant risk of seizures after poisoning. A 7-year retrospective review of all single substance ingestion of benzonatate reported to the National Poison Center Database System (NPDS) from 2000 to 2006. In this review, there were 2,172 patients, of which 1,280 (58%) were female. Mean age was 20 years, with 676 (30%) <6 years. Serious outcomes occurred in 116 (moderate, n = 81, 4%; major, n = 31, 1%; and death, n = 4, 0.2%). Mean age of those with serious outcome was 21 years, with 41 (35%) in children less than 6 years old. Forty-nine percent (1,084) patients were treated in a healthcare facility (HCF) of which 148 (7%) were admitted for medical care. Clinically significant effects that were documented included tachycardia (n = 31, 1%), agitation (n = 30, 1%), seizure (n = 23, 1%), coma (n = 14, 0.6%), ventricular dysrhythmia (n = 9, 0.4%), cardiac arrest (n = 8, 0.3%), hypotension (n = 7, 0.3%), and asystole (n = 6, 0.2%). Of patients with seizures reported, eight patients (0.4%) had multiple/discrete seizures and two had status epilepticus documented. Dysrhythmias but not seizures occurred in all fatalities in this review. Significant CNS and cardiac effects occurred in a small subset of this study (<1%), while half the patients received direct medical care in an HCF. No correlation between age and severity of medical outcome was detected by statistical analysis. A prospective study to better evaluate potential HCF triage criteria such as dosage, age, or preexisting conditions may be warranted. The fatalities from this study were due to dysrhythmias rather than seizures as previously reported in previous case reports. There were no clinical correlations between severity of outcomes and dose ingested. A median dose of 200 mg or greater suggests a potential for producing serious outcomes in a benzonatate exposure.

Atomoxetine ingestions in children: a report from poison centers.

BACKGROUND: Atomoxetine uses a novel non-stimulant approach to the treatment of attention deficit hyperactivity disorder. There is limited information on overdose of atomoxetine in children or adults. OBJECTIVE: To provide information on atomoxetine in overdose. METHODS: Case series were conducted at 3 regional poison centers for atomoxetine ingestion in children (age < or = 17 y). Exclusion criteria were polypharmacy or lack of follow-up. RESULTS: Forty patients were included (25 boys; 63%) in the study. The mean +/- SD age was 6.1 +/- 4.9 years (range 9 mo-17 y). Twenty-five patients were managed at home, 14 in hospital emergency departments (3 children were admitted), and 1 patient was managed in a physician's office. Symptoms reported were tachycardia, drowsiness, nausea, hypertension, and vomiting. A seizure was reported in one child who had recently started atomoxetine therapy. No arrhythmias beyond sinus tachycardia were reported. Mean maximum heart rate in patients with tachycardia was 131 +/- 14 beats/min. The mean dose ingested, categorized by medical outcome, was: no effect (n = 22), 40 +/- 32 mg; minor effect (n = 14), 167 +/- 221 mg; and moderate effect (n = 4), 249 +/- 326 mg. There were no major outcomes or fatalities. The lowest dose ingested that resulted in hypertension was 480 mg, in a 14-year-old girl (BP 136/95 mm Hg). CONCLUSIONS: In this case series, clinically significant cardiovascular effects requiring direct intervention did not occur. Activated charcoal and/or observation appear to be sufficient for accidental ingestion. Further investigation may be needed to indicate whether seizures occur from atomoxetine ingestion.

Skin breakdown and blisters from senna-containing laxatives in young children.

BACKGROUND: At the direction of the Food and Drug Administration, phenolphthalein was removed from all over-the-counter laxatives in 1999. Phenolphthalein was then replaced in most laxative products with the natural product senna from Cassia acutifolia Delile, which contains various anthraquinones. No data are available on the safety of senna use in children <6 years of age. OBJECTIVE: To describe the clinical outcomes of exposure to unintentional ingestion of senna-containing laxatives in young children. METHODS: All ingestion exposures of senna-containing laxatives in children <5 years of age from 6 poison centers over a 9-month period were evaluated. Inclusion criteria required 24-hour follow-up and the presence of diarrhea to confirm ingestion. Parents were told routinely that severe diaper rash was possible and to protect the perianal area with frequent cleansing and a barrier ointment if the child was wearing diapers. RESULTS: During the study period, 111 cases were reported: 19 children experienced no diarrhea, 4 were lost to follow-up, and 88 exposures were evaluated. Fifty-two children (59%) were