Pediatric emergency medicine trisk 3068 3068
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or poison control center consultant familiar with its use. Bolus dosing of 1 unit/kg
IV of regular insulin is then followed by an infusion at 0.5 units to 1 unit/kg with
titration performed based on hemodynamics. Carefully monitor blood glucose
levels. Lipid emulsion infusion has shown promise in animal studies and case
reports of verapamil toxicity; it is typically given if toxicity is refractory to
conventional therapies, including insulin, or if the patient has a cardiac arrest.
Severe cases may also benefit from pacemaker insertion and consideration of
aortic balloon pump and/or ECMO. It is unlikely that hemodialysis or
hemoperfusion would benefit in most cases.
Current indications for admission or discharge: Any symptomatic patient
should be admitted to the hospital, with level of care determined primarily by the
severity of symptoms and hemodynamic parameters. Patients who present after
exploratory, small-volume ingestions (especially of water-soluble β-blockers) and
remain asymptomatic may be candidates for discharge from the ED, but we
would recommend discussing all of these cases with your local poison control
center or toxicologist to guide management decisions.
Clonidine
Current Evidence. Clonidine is a centrally acting α2 -adrenergic agonist used for
management of hypertension, but has also gained popularity for management of
ADHD, agitation, and opioid withdrawal. Given these expanded indications,
clonidine has been an increasing agent in both exploratory and intentional
ingestions in pediatric patients. In addition to enteral formulations, clonidine is
available in a transdermal patch formulation.
Clonidine exerts its antihypertensive effect through stimulation of CNS α2 adrenergic receptors. Their stimulation results in decreased secretion of
catecholamines into the synaptic cleft, resulting in decreased pulse and blood
pressure. In addition, clonidine can lead to release of β-endorphins, which may
explain the depressed mental status and miosis associated with toxicity. An
imidazoline compound, clonidine is related to other medications, including
tetrahydrozoline and oxymetazoline (common vasoconstrictors found in nasal
decongestants and ophthalmic agents), brimonidine (ophthalmic agent), and
guanfacine (ADHD).
Clinical Considerations. Clonidine is an extremely potent drug with typical doses
of 100 to 200 μg in adults. Therefore, ingestions of small amounts, even a single
adult tablet, can potentially lead to significant toxicity in children. Initial toxic
