A 3 years old boy brought by his family 30 min after ingesting one tablet of his grandma medication
On arrival,he is playful and active , normal vitals and blood sugar 6 mmol/l. Your junoir want to give me dextrose infusion for 2 hours then discharge him home.
Grandma Pill Cont’ Thanks all for your excellent comments Many of the sulfonylureas have long durations of action, which explains the unusually long period of hypoglycemia that occurs in both therapeutic use and overdose. Second-generation sulfonylureas (glimepiride, glipizide, glyburide) have half-lives that approach 24 hours.The sulfonylureas frequently cause hypoglycemia which could have delayed onset following overdose. In a prospective poison control center study of sulfonylurea exposures in children, 56 of 185 (30%) patients developed hypoglycemia, with a time of onset ranging from 1 to 21 hours and a mean of 5.3 hours Management : *AC is recommended if no contraindication *Children who unintentionally ingest one or more sulfonylurea tablets should generally be hospitalized for 24 hours observation *Symptomatic patients with hypoglycemia require immediate treatment with 0.5 to 1 g/kg hypertonic intravenous dextrose in the form of D50W in adults, D25W in children, and D10W in neonates.
*Octreotide is recommended for recurrent hypoglycemia *Asymptomatic children are best managed without prophylactic intravenous dextrose, which could contribute to delayed onset of hypoglycemia. Elevations in glucose concentrations stimulate insulin release by the pancreas. Such patients instead are best managed by early feeding, frequent checks of glucose concentrations, and observation of mental status. References 1- Goldfrank’s Toxic logic Emergencies 11th edition 2.Hypoglycemia in Pediatric Sulfonylurea Poisoning: An 8-Year Poison Center Retrospective Study.Derrick D. Lung and Kent R. OlsonPediatrics June 2011, 127 (6) e1558-e1564; DOI: https://doi.org/10.1542/peds.2010-3235
What about doing ECG and send paracetamol level at 4 hr?
Sulfonylureas can have markedly prolonged half-lives and long elimination times: Delayed hypoglycemia and refractory hypoglycemia are common
1. Hypoglycemia: D50 bolus, then: IV infusion D5W or D10W to maintain euglycemia or mild hyperglycemia Food (if mental status improves or normalizes)
2. Neuroglycopenia: May persist shortly after serum glucose corrected
3. Persistent symptoms require further dextrose administration
4. Decontamination: Consider administration of activated charcoal for recent or large ingestion of oral agent (sulfonylurea). Activated charcoal: 1 g/kg PO Dextrose: 50–100 mL D50 (peds: 2 mL/kg of D25 over 1 min) IV; repeat if necessary
5. Provide supportive care
6. Hypotension: 0.9% NS IV fluid bolus
7. FOLLOW-UP DISPOSITION: Admission Criteria-Hypoglycemia owing to sulfonylurea agents (may require several days of monitoring) or long-acting insulin preparations Any patient requiring a constant infusion of dextrose to maintain euglycemia
8. Discharge Criteria: Accidental hypoglycemia owing to short-acting insulin injection in the setting of dietary insufficiency: Must be tolerating oral intake Ensure return to baseline mental status
9. Discharge after glucose correction and a 4 hr period of observation
-Good morning Dr.Suad,
-Blessed Friday with many thanks for sharing us this interesting case
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- I will explain to my junior that despite it is one tablet only , for peadiatric age it can cause fetal hypoglycemia which will apear 8 hrs post ingestion and some tablet has long extended release up to 24 hours, so this patient should be kept under obsevation for 24 hours , monitering his BS .
*we can give 1g/kg pediatric dose of AC ,since he came within less tham 1 hr
*we should not give dextrose unless documented hypoglyucemia
*if patient develop hypoglycemia, then will start giving dextrose, if still BS not pick up so will consider octrrotide .
We should admit the child in the hospital with:
1) activated charcoal 1 g/kg
2) regular monitoring for blood sugar. if hypoglycemia, give dexrose and octerotide (if refractory hypoglycemia)
If remained stable and asymptomatic for 24 hours can be discharged.
This child has ingested a tablet of sulfonylurea type of OHA, which is known to produce prolonged effect of hypoglycemia. One tablet at pediatric age can lead to coma and death.
Since the child has took the tablet 30 minutes ago, it’s still too early for the toxic effect which is usually starts 6-8 hours post ingestion. Sulfonylurea can also have paradoxical hypoglycemia. So regardless of the normal glucose and the amount ingested, this child needs admission for at least 24 hours and shouldn’t be discharge until his BS is normalized and monitored.
Plan:
activated charcoal 1g /kg
5 ml/kg of D10W
Check blood sugar frequently
Admit under monitoring for 24 hours at least
Consider octreotide subq if any hypoglycemia occurred unresponsive to dextrose.
To counsel the family to keep the medications away from kids hands