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1. PEDIATRICS EMERGENCIES DRUG INTOXICATION PRESSENTED BY DR ZARAFSHA RESIDENT OF PEDIATRICS ( R2 ) SUPERVISOR : LT COL DR SYED QAMAR ZAMAN (MBBS,DCH, FCPS PAEDS ,MRCPCH UK )

2. SEQUENCE Case presentation Case discussion Introduction Common SSRIs Toxic dose Clinical features Serotonin syndrome Diagnosis Management Prevention

3. Selective serotonin reuptake inhibitors ingestion

4. Case Presentation D/o Sq Ldr Haris Age 4yrs Residence Risalpur Cantt D.O.A 14 th June 2024 M.O.A OPD

5. Presenting Complaints Ingestion of 2 tablets of sertraline 50mg 30 minutes ago Drug ingestion was noticed by mother Removed left over residuals from mouth before coming to hospital

6. Examination A thin lean girl of normal build lying on bed seemed to be anxious and restless Heart rate 160/m Temperature 100.4 F Respiratory rate 29/m SPO2 97 Percent at RA BSR 101mg/dl BP 110/98 mmHg

7. Systemic examination CVS : S1 _S2_ 0 Resp : Normal vesicular breathing GIT : Abd Soft Non distended with audible Bowel sounds CNS : GCS 15/15 Pupils dilated bilateral Tone Normal Power 5/5 in all limbs Plantars Normal Reflexes exaggerated knee jerks

8. CNS GCS 15/15 Pupils dilated bilateral Tone Normal Power 5/5 in all limbs Plantars Normal Reflexes exaggerated knee jerks Clonus Present

9. INVESTIGATION QTC = QT/√RR =0.66

10. LABS .

11. LABS..

12. LABS…

13. Managment Airway Breathing Circulation Decontamination Gastric lavage, General management Specific management , cyproheptadine , dexmetomidine

14. Introduction SSRIs (Selective Serotonin Reuptake Inhibitors) are commonly prescribed antidepressants that increase serotonin levels in the brain. While generally safe at therapeutic doses, accidental ingestion or overdose in children can lead to toxicity.

15. Common SSRIs Involved in Intoxication Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro)

16. Toxic Dose Considerations Children are more susceptible to toxicity due to lower body weight.Mild symptoms may occur at 5-10 mg/kg, while severe toxicity is more common with >10 mg/kg doses.Citalopram and Escitalopram have a higher risk of cardiac toxicity even at lower doses.

17. Clinical Features of SSRI Intoxication Mild Symptoms: Nausea, vomiting, diarrhea Drowsiness, dizziness Mild tachycardia

18. Moderate to Severe Toxicity Agitation, tremors, hyperreflexia Hypertension Seizures (rare but possible) Serotonin Syndrome (in severe cases)

19. Serotonin Syndrome Features: Mental status changes (agitation, confusion) Autonomic instability (fever, sweating, tachycardia)  Neuromuscular abnormalities (clonus, hyperreflexia )

20. . Diagnosis Clinical history and physical examination   Serum drug levels (not routinely done)   ECG (to monitor for QT prolongation, especially with Citalopram/Escitalopram)

21.   Management Supportive Care: Airway, breathing, circulation (ABCs) monitoring IV fluids for dehydration Activated charcoal (if within 1-2 hours of ingestion and no contraindications )

22. Symptomatic Treatment: Benzodiazepines for agitation, tremors, and seizures  Cooling measures for hyperthermia Anti-hypertensives for severe hypertension (e.g., short-acting agents like esmolol) Cyproheptadine (a serotonin antagonist) in severe serotonin syndrome

23. ECG Monitoring: Watch for QT prolongation, especially in citalopram overdose Treat cardiac arrhythmias as needed Prognosis; Most mild cases resolve with supportive care. Severe cases (e.g., serotonin syndrome, seizures) require intensive care but have a good prognosis with prompt treatment.

24. Prevention Child-resistant packaging. Safe storage of medications out of children's reach .

25. THANKS