Pediatric emergency department often encounters various situations such as accidental ingestion and overdose, among which the most common is antipyretics. So what should I do if I encounter excessive oral antipyretics?
One
Routine Dosage
The safest antipyretics most commonly used in children include acetaminophen and ibuprofen. What are the usual doses of these two medicines? How much is too much to eat?
It can be seen from the characteristics of the two drugs[1]:
Table source: Expert consensus on the rational use of antipyretic analgesics in the symptomatic treatment of children with fever
The maximum daily dose of acetaminophen is 2 g or 60 mg/kg/d for under 2 years, 75 mg/kg/d for 2-12 years, and ibuprofen 2.4 g or 40 mg/kg/d, more than the above dose is overdose.
Two
How to deal with an antipyretic overdose[2]?
The general handling principles are as follows:
01. Closely monitor vital signs: including respiration, pulse, blood pressure, body temperature, urine output, skin and mucous membranes, state of consciousness, etc.; if the child’s vital signs are stable, It should be transported as soon as possible after initial treatment; if vital signs are unstable, rescue measures to stabilize vital signs should be performed.
02. Removal of unabsorbed toxins from the digestive tract: including emesis, gastric lavage, catharsis, bowel cleansing, etc.
03. Promote the excretion of absorbed toxins: including rehydration, diuresis, acidification, and alkalinization of urine.
04. Use a powerful antidote in a timely manner.
05. Symptomatic and supportive treatment: including gastric mucosal protectant, blood purification, etc.
06.Transportation: If it cannot be handled, it should be transported in time after the vital signs are stabilized.
What to do if I overdose on acetaminophen[1,3]?
01. Monitor blood levels and liver function.
02.Removal of acetaminophen from the digestive tract:
① Emesis: ipecac syrup can aggravate the symptoms of nausea and vomiting, and reduce the efficacy of activated charcoal and oral antidote, so it should not be used routinely;
② Gastric lavage: gastric lavage should be considered only after taking a potentially life-threatening dose of poison, and it should be performed within 60 minutes after taking the medicine;
③ Activated carbon adsorption: A single dose of activated carbon should be administered within 1 hour, and there is no sufficient evidence to support or exclude the use of activated carbon after 1 hour;
④ Catharsis: laxatives are not recommended;
⑤ Whole-intestinal cleansing: When taking an excessive amount of sustained-release preparations or enteric-coated tablets, consider using the whole-intestinal cleansing method.
03.Special antidote:
① N-acetylcysteine: N-acetylcysteine is an antidote for acetaminophen, 8-10 hours of administration can significantly reduce liver toxicity, more than 24 hours The curative effect is poor. Begin with oral 140 mg/kg, followed by 70 mg/kg every 4 hours, for a total of 17 doses (total dose 1330 mg/kg).
② Reduced glutathione: studies in animals and humans have shown that this drug can resist a variety of substances, including acetaminophen-induced cell damage, protect liver cell membranes, and generally The dosage is 30 mg/kg/d [4].
Source: Medication Assistant APP
2. What should I do if I overdose on ibuprofen?
When ibuprofen is overdose, supportive therapy is generally used, and more fluids are added to increase urine output and excrete toxins. Gastric mucosal protective agents can be used for gastric mucosal damage.such as sucralfate.
It has been reported[6] that when ibuprofen exceeds 100 mg/kg, induce vomiting or gastric lavage in time, and take activated charcoal. Monitor liver and kidney function and blood pH at the same time. If abnormal liver and kidney function occurs, symptomatic and supportive treatment should be given in time. Generally, the patient recovers well.
There is no specific antidote for ibuprofen poisoning[5], and there is no drug overdose in the instructions for chabuprofen. to the following processing.
Source: Medication Assistant APP
Three
What are the adverse effects of each drug at normal doses? How to deal with it?
Table source: Expert consensus on the rational use of antipyretic analgesics in the symptomatic treatment of children with fever
Normal dose, when should acetaminophen not be used[1]?
01.Liver damage
Children’s liver damage meets the following criteria:
▶ Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) greater than 8 times the upper limit of reference value (ULN); or ALT or AST greater than 5 times the ULN for 2 Week;
▶ or ALT or AST greater than 3 times ULN with total bilirubin greater than 2 times ULN or International Normalized Ratio (INR) >1.5;
▶ or ALT or AST greater than 3 times ULN, progressively worse, with fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash and/or eosinophils greater than 5%, and Liver insufficiency with high fever.
Acetaminophen is contraindicated except for etiological treatment [7].
02.Glucose-6-phosphate dehydrogenase (G6PD) deficiency
G6PD is mainly distributed in red blood cells and can protect red blood cells from oxidative damage. It is mentioned in the 2020 edition of “Expert Consensus on the Rational Use of Antipyretic and Analgesics in the Symptomatic Treatment of Children’s Fever” Antipyretic analgesics such as acetaminophen are contraindicated in children with G6PD deficiency [8].
When should ibuprofen be used with caution?
01. Kidney damage: ibuprofen may aggravate kidney damage, and it is contraindicated in children with moderate or above abnormal renal function damage or renal insufficiency with fever ibuprofen [7].
02.Heart insufficiency, heart failure: increases the risk of heart failure[9];
03. When associated with active peptic ulcer, hemophilia and other bleeding diseases, gastrointestinal mucosal stress syndrome is prone to occur, which aggravates the ulcer and causes gastric Bleeding, purpura, etc.
Planning: Zhang Jie
Title image: Zhanku Hailuo
[2] Cui Yun, Shi Jingyi. Emergency treatment of acute poisoning in children [J]. Chinese Journal of Practical Pediatrics, 2018,33(18):1381-1384.
[3] Zuo Xiaocong, Liu Yulan. Treatment of paracetamol overdose [J]. China Journal of New Medicine, 2000(10):730-732.
[4] Wang Yanli, Zhu Jiali, Wang Yongjian, Yu Changjiu, Zhang Suping. The effect of reduced glutathione in the treatment of acetaminophen poisoning [J]. Journal of Practical Medicine, 2018,34 (08):1347-1350.
[5] Smilkstein MJ, Knapp GL, Kulig KW, et al. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985) [ J]. N Engl J Med, 1988, 319(24):1557-1562. DOI: 10. 1056/NEJM198812153192401.
[6] Ye Jinchao. Toxic and side effects of ibuprofen and its treatment [J]. Journal of Pharmacoepidemiology, 1994,(03):143-145.
[7] Drug-induced liver disease group of liver disease branch of Chinese Medical Association. Guidelines for the diagnosis and treatment of drug-induced liver injury[J]. Journal of Practical Liver Diseases, 2017, 20 (2): 257-274. D01: 10. 3969/j. issn. 1672-5069. 2017.02.039.
[8] National Pharmacopoeia Commission. Pharmacopoeia of the People’s Republic of China for Clinical Drug Use [M]. Beijing: People’s Health Press, 2005: 697.
[9]Anwar A, Anwar U, Delafontaine P. Elevation of cardiovascular risk by non-steroidal anti-inflammatory drugs [J]. Trends Cardiovasc Med ,2015, 25(8) :726 -735. DOI: 10. 1016/j. tcm. 2015.03.006.