Pediatric poisoning from over-the-counter imidazoline-containing products

Higgins, George L.; Campbell, Bruce; Wallace, Kevin L.; Talbot, Susan

doi:10.1016/s0196-0644(05)82388-1

Cited by 39 publications

(49 citation statements)

References 16 publications

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“…Multiple studies showed that onset of symptoms are rapid and usually within 2 h, and most of the children showed complete resolution of symptoms within 24 h [41][42][43]. Prolonged hypothermia up to 24 h has been reported [44].…”

Section: What Is the Expected Onset And Duration Of Imidazoline Toxicmentioning

confidence: 99%

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

2014

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An 18-month-old child was brought to the emergency department (ED) by his mother for evaluation of diarrhea, vomiting, and somnolence. He was lethargic, with "pinpoint" pupils. Blood pressure was 125/77 mmHg, heart rate was 70/min, temperature was 36.5°C, respiratory rate was 25/min, and pulse oximetry saturation (SpO 2 ) was 99 % on room air. Blood glucose was 101 mg/dL. Other initial laboratory investigation was unremarkable. Ethanol, acetaminophen, and aspirin were below detection limits. Urine drug screening was negative for amphetamine, methamphetamine, MDMA, barbiturates, benzodiazepines, cocaine, methadone, oxycodone, and opiates. Initial ECG done 3 h after ED arrival showed bradycardia with first-degree heart block. There was no response to 1 mg IV naloxone.

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Section: What Is the Expected Onset And Duration Of Imidazoline Toxicmentioning

confidence: 99%

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

2014

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“…Blood pressure also returned to normal during this period without treatment; its highest value was 130/80 mmHg (blood pressure percentile >99th/99th) with no subsequent hypotension. The patient was discharged 20 h later.Naphazoline has a narrow therapeutic to toxic window and intoxication may occur at a dose of 0.05 mg/kg body weight [2]. Systemic side effects are observed rarely, despite frequent and uncontrolled use because of partial availability without doctor's prescription.…”

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confidence: 99%

“…Inappropriate use or unintentional ingestion of naphazoline, especially in children, can quickly cause severe central nervous system depression and cardiovascular adverse effects [2,6].…”

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confidence: 99%

“…Naphazoline has a narrow therapeutic to toxic window and intoxication may occur at a dose of 0.05 mg/kg body weight [2]. Systemic side effects are observed rarely, despite frequent and uncontrolled use because of partial availability without doctor's prescription.…”

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Naphazoline intoxication in children

et al. 2006

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Inappropriate use or unintentional ingestion of naphazoline, especially in children, can quickly cause severe central nervous system depression and cardiovascular adverse effects [2,6].A five-year-old boy arrived at the Emergency Room 90 min after the ingestion of approximately 10 ml of Euboral Oftálmico solution (9.7 g of sodium-tetraborate, 0.1 g of naphazoline-chlorhydrate and 0.2 g of methylparaben for 1 l dilution, for topical use), prepared in a bottle without a label in a 0.02% concentration, which was twice that of the manufacturer's recommendation. During the physical examination, bradycardia (heart rate 45-50 bpm), hypothermia (35.5°C) and a blood pressure of 100/ 70 mmHg (blood pressure percentile 75th/90th) were observed. Gastric lavage and activated carbon administration were performed. A few minutes later, the patient presented somnolence, sweating, persistence of the bradycardia and hypothermia. Blood pressure and oxygen saturation were normal. At the EKG (electrocardiogram), sinusal bradycardia of 48 bpm was observed and laboratory parameters showed no abnormalities. Blood analysis of standard toxicological drugs was performed with negative results.Infusion therapy was started to force diuresis and the patient was admitted to the hospital in order to monitor vital parameters. Bradycardia lowest value (47 bpm) was observed 3 h after the ingestion. Somnolence and hypothermia (35.2°C) were maximum 7 h after the ingestion and sweating persisted until 12 h later. Blood pressure also returned to normal during this period without treatment; its highest value was 130/80 mmHg (blood pressure percentile >99th/99th) with no subsequent hypotension. The patient was discharged 20 h later.Naphazoline has a narrow therapeutic to toxic window and intoxication may occur at a dose of 0.05 mg/kg body weight [2]. Systemic side effects are observed rarely, despite frequent and uncontrolled use because of partial availability without doctor's prescription. They can progress potentially up to intoxication with vitally threatening cardiovascular symptoms (arterial hypertension with reflex bradycardia defined as a heart rate under 60 bpm and possible ischaemia of vital functions), pulmonary and central nervous symptoms. The central nervous system effects concern the reduction of vigilance ranging from drowsiness to coma, persisting cardiovascular hypotension and reduced respiration rate up to the Cheyne-Stokes breathing and possible pulmonary edema, hypothermia, mydriasis, hyperhydrosis and transient excitation hyperreflexia [1]. Our patient presented a large number of the symptoms described above, especially those affecting cardiovascular and central nervous systems. Blood analysis of standard toxicological drugs excluded alternative causes of intoxication.Because of rapid absorption, we wonder whether gastric lavage and carbon-activated administration are the suitable Eur J Pediatr (2006) 165:815-816

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Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

et al. 2019

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Objectives/Hypothesis: Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures. Study Design: Prospective trial. Methods: Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharma-codynamic modeling. Results: The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3–18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6–3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44–90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04–7.6 μg/L). Conclusions: Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects.

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Pediatric poisoning from over-the-counter imidazoline-containing products

Cited by 39 publications

References 16 publications

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

Unintentional Pediatric Ophthalmic Tetrahydrozoline Ingestion: Case Files of the Medical Toxicology Fellowship at the University of California, San Francisco

Naphazoline intoxication in children

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

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