Pediatric zolpidem ingestion demonstrating zero-order kinetics treated with flumazenil.

Zolpidem is a widely prescribed anti-insomnia agent. Although most pediatric zolpidem ingestions are benign, large ingestions can cause significant central nervous system (CNS) depression. Flumazenil has been reported to reverse the CNS effects of zolpidem. We describe a case of a large pediatric zolpidem ingestion resulting in profound CNS depression that responded to flumazenil administration. Serial zolpidem serum levels confirmed the ingestion. A 10-year-old boy with trisomy 21 presented to the emergency department 1 hour after he was found sedate with several zolpidem 5-mg tablets in his mouth. Seventeen tables (85 mg) were unaccounted for from a prescription bottle. He became unarousable approximately 2 hours after his ingestion. Flumazenil 0.2 mg intravenously was given with rapid return to his baseline mental status. He became resedate 1 hour later but was arousable. Sixteen hours after his presentation, he was asymptomatic. Serial zolpidem serum levels were obtained, showed an initial level of 310 ng/mL, and demonstrated zero-order kinetics. Zolpidem is an imidazopyridine, which binds to the benzodiazepine receptor. It is rapidly absorbed and has a short-half life. Unintentional pediatric ingestions of zolpidem are typically well tolerated. However, this case demonstrates that large ingestions may cause significant and prolonged CNS depression. Flumazenil, a benzodiazepine receptor antagonist, has been described to reverse the effects of zolpidem in adult ingestions. There are few published reports describing flumazenil use in pediatric ingestion patients. This case suggests that flumazenil may be an effective treatment for zolpidem-induced CNS depression in the pediatric patient.

Sticky situations: cyanoacrylate exposures reported to a poison control system.

INTRODUCTION: Cyanoacrylate (Super Glue®) exposures are commonly reported to poison control centers, but little has been published in the medical literature regarding these exposures. We sought to characterize cyanoacrylate exposures reported to a poison control system. METHODS: We performed a retrospective review of a poison system's database for all cases of single-substance human exposure to cyanoacrylate-containing products from 2005 to 2015. Data collected included age, gender, route of exposure, clinical effects, treatments recommended and medical outcome. RESULTS: There were a total of 893 patients, 505 (56.6%) of which were female. Patient ages ranged from 6 months to 88 years with a median of 11 years. The vast majority of exposures (n = 871, 97.5%) were unintentional, but a small number of exposures (n = 22, 2.5%) were due to intentional misuse (such as trying to stop a bleeding cut) or malicious intent (such as purposefully gluing a person's eyes shut as a prank). Routes of exposure included: ingestion, n = 337 (37.7%); ocular, n = 322 (36.1%); dermatologic, n = 285 (31.9%); inhalation, n = 16 (1.8%); nasal, n = 1 (0.1%); and otic, n = 1 (0.1%); some patients had multiple routes of exposure. Treatments recommended by the poison center included irrigation (n = 411), petroleum jelly (n = 143), mineral oil (n = 131), topical antibiotic ointment (n = 82), peanut butter (n = 6), acetone (n = 4) and WD-40® (n = 2). A total of 657 patients (73.6%) were managed on-site, while 236 (26.4%) were seen in a health care facility. Among all exposures, effects were classified as none (n = 287), minor (n = 529) and moderate (n = 77). No major effects or deaths were reported. CONCLUSIONS: In this case series, the majority of cases occurred in children and most exposures did not result in significant morbidity. Notably, there was wide variation in terms of recommended treatments; further study is needed to determine the optimal treatment method and to standardize poison center recommendations for treating patients with cyanoacrylate exposures.

Ingestion of Lantana camara is not associated with significant effects in children.

OBJECTIVE: We sought to identify characteristics of children with reported ingestion of Lantana camara. METHODS: We reviewed the California Poison Control System database for all reported pediatric ingestions of L. camara for the years 1997-2008. Data collected included age, gender, clinical effects, duration of effects, medical interventions, and outcomes. RESULTS: There were a total of 641 patients; patient ages ranged from 1 to 16 years, with a mean of 2.5 years. Reported effects included vomiting (n = 30), abdominal pain (n = 8), agitation (n = 6), diarrhea (n = 6), throat/mouth irritation (n = 5), tachycardia (n = 4), drowsiness (n = 3), nausea (n = 2), and mydriasis (n = 1). There was no difference in frequency of symptoms between patients who ingested ripe (15.5% [95% confidence interval: 9.1%-21.8%]) versus unripe (6.0% [95% confidence interval: 0.9%-11.1%]) berries or between patients who ingested berries (10.5% [95% confidence interval: 7.3%-13.8%]) versus other plant parts (7.1% [95% confidence interval: 4.0%-10.3%]). Fifty-one patients (8%) were treated in a health care facility and 2 (0.3%) were admitted. No significant effects and no deaths were recorded. CONCLUSIONS: Ingestion of L. camara (including unripe berries) was not associated with significant toxicity; patients who ingested unripe berries did not exhibit more-frequent or more-severe symptoms than did patients who ingested ripe berries or other plant parts. Most patients displayed no or minimal symptoms. Children with asymptomatic ingestions and those with mild symptoms can be treated at home.