Autoimmune Hepatitis: Clinical Review with Insights into ...
Questions and answers for clinical insights
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Journal of Pediatric Health Care Clinical Insights (Q&A) 51 QUESTIONS AND ANSWERS FOR CLINICAL INSIGHTS (See page 40 for data.) 1. What infmmation does the PAT’ need immediately? A. Adam’s current condition When asked how Adam is at that moment his mother states, “He isn’t crying, but he is just lying here. His heart is beating really fast.” She adds that his skin is very red and his pupils are dilated. The PNI’ asks how he is breathing, and his mother states that he is breathing normally. B. The ingredients in Levsin and the possible side effects of an overdose Hyoscyamine sulfate USP is one of the prin- cipal anticholinergic/antispasmodic components of belladonna alkaloids. Levsin drops (hyoscy- amine sulfate oral solution USP, 0.125 mg/ml) are orange colored and flavored and contain 5% alcohol. Levsin-PB drops additionally contain phenobarbital 15 mg/ml and are red in color and cherry flavored (Physicians’ Desk Reference [PDR], 1991). Adam’s mother does not know which preparation Adam received. Signs and symptoms of hyoscyamine sulfate overdose as listed in the Handbook of Common Poisonings in Children (American Academy of Pe- diatrics [AAP], 1983), are headache, nausea, blurred vision, dilated pupils, flushed, hot, dry skin, dizziness, dryness of the mouth, difficulty in swallowing, rapid pulse and respiration, uri- nary retention, and central nervous system stim- ulation. The dropper that comes in a bottle of Levsin drops holds 0.25 ml and contains ten drops. Adam should have received four drops or 0.1 ml. Instead, he received 40 drops or 1 ml. C. Recommended management of an overdose The recommended management of an over- dose of hyoscyamine sulfate is immediate induc- tion of emesis using Ipecac Syrup (Paddock Lab- oratories, Minneapolis, Minn.) or gastric lavage. Maintenance of body temperature and blood pressure is essential. Respiratory support to pre- vent hypoxia may require oxygen and possibly intubation. If convulsions, hyperthermia, severe tachycardia, coma, or hypertension occur, treat- ment with physostigmine is indicated. If neces- sary 0.5 mg of physostigmine is injected slowly intravenously, over 1 minute. The dose may be repeated at 5- to lo-minute intervals, until re- versal of toxic effects or a maximum dose of 2 mg is administered (AAP, 1983). 2. Based on this infmmation, what recommendation is ap- proptiate? Once the PNP determines Adam has received a significant overdose, it becomes imperative to get him to a hospital emergency room immediately. Ad- am’s mother states that she has a car and will take him to the hospital immediately. The PNP calls the emergency room to alert them to Adam’s history and imminent arrival. When Adam arrived at the emergency room, his pulse was 243 beats /min, respiration 46 per minute, temperature 100.8” F, and blood pressure 84 mm Hg systolic. On examination he was extremely irri- table, with dilated pupils that were nonreactive. An intravenous infusion with a heparin lock was started, and a nasogastric tube was placed. Stomach contents were aspirated, and 10 gm of charcoal in two doses was administered. Physostigmine was not adminis- tered. After stabilization he was transported by am- bulance with a nurse attendant to a major medical center pediatric intensive care unit. Adam’s condition remained stable, and further laboratory tests were within normal limits. He was observed for any ad- ditional signs and symptoms of anticholinergic over- dose. His nasogastric tube was removed, and later that night he was bottle fed. He was discharged the next day in good condition; his mother was given instructions to take him to his primary care provider in 2 to 3 days. His subsequent examinations in the office have been within normal limits. 3. How m@.$t this experience alter instructions the PNP gives when prescribing medications in the fiture? Many pediatric medications are given by drops or dropper. One of the most commonly used medica- tion is acetaminophen, which is administered at one- half or one dropper, according to lines on the drop- per. Vitamins, fluoride, iron, and antacids (such as simethicone) are other medications also commonly administered in this manner. Potential side effects exist from an overdose of each of these. Other pe- diatric medications administered by drops or drop- per that can cause life-threatening side effects are phenobarbital, hyoscyamine sulfate, atropine sulfate, scopolamine hydrobromide (Donnatal; A.H. Rob- bins Company, Richmond, Va.), and digoxin. The PNP should be aware of the correct method of ad- ministration and how each medication is packaged and dispensed. Additionally, it would be helpful to have a sample bottle of the medication in the office
Transcript of Questions and answers for clinical insights
Journal of Pediatric Health Care Clinical Insights (Q&A) 51
QUESTIONS AND ANSWERS FOR CLINICAL INSIGHTS
(See page 40 for data.)
1. What infmmation does the PAT’ need immediately? A. Adam’s current condition
When asked how Adam is at that moment his mother states, “He isn’t crying, but he is just lying here. His heart is beating really fast.” She adds that his skin is very red and his pupils are dilated. The PNI’ asks how he is breathing, and his mother states that he is breathing normally.
B. The ingredients in Levsin and the possible side effects of an overdose
Hyoscyamine sulfate USP is one of the prin- cipal anticholinergic/antispasmodic components of belladonna alkaloids. Levsin drops (hyoscy- amine sulfate oral solution USP, 0.125 mg/ml) are orange colored and flavored and contain 5% alcohol. Levsin-PB drops additionally contain phenobarbital 15 mg/ml and are red in color and cherry flavored (Physicians’ Desk Reference [PDR], 1991). Adam’s mother does not know which preparation Adam received.
Signs and symptoms of hyoscyamine sulfate overdose as listed in the Handbook of Common Poisonings in Children (American Academy of Pe- diatrics [AAP], 1983), are headache, nausea, blurred vision, dilated pupils, flushed, hot, dry skin, dizziness, dryness of the mouth, difficulty in swallowing, rapid pulse and respiration, uri- nary retention, and central nervous system stim-
ulation. The dropper that comes in a bottle of Levsin
drops holds 0.25 ml and contains ten drops. Adam should have received four drops or 0.1 ml. Instead, he received 40 drops or 1 ml.
C. Recommended management of an overdose The recommended management of an over-
dose of hyoscyamine sulfate is immediate induc- tion of emesis using Ipecac Syrup (Paddock Lab- oratories, Minneapolis, Minn.) or gastric lavage. Maintenance of body temperature and blood pressure is essential. Respiratory support to pre- vent hypoxia may require oxygen and possibly intubation. If convulsions, hyperthermia, severe tachycardia, coma, or hypertension occur, treat- ment with physostigmine is indicated. If neces- sary 0.5 mg of physostigmine is injected slowly intravenously, over 1 minute. The dose may be repeated at 5- to lo-minute intervals, until re- versal of toxic effects or a maximum dose of 2 mg is administered (AAP, 1983).
2. Based on this infmmation, what recommendation is ap- proptiate?
Once the PNP determines Adam has received a significant overdose, it becomes imperative to get him to a hospital emergency room immediately. Ad- am’s mother states that she has a car and will take him to the hospital immediately. The PNP calls the emergency room to alert them to Adam’s history and imminent arrival.
When Adam arrived at the emergency room, his pulse was 243 beats /min, respiration 46 per minute, temperature 100.8” F, and blood pressure 84 mm Hg systolic. On examination he was extremely irri- table, with dilated pupils that were nonreactive. An intravenous infusion with a heparin lock was started, and a nasogastric tube was placed. Stomach contents were aspirated, and 10 gm of charcoal in two doses was administered. Physostigmine was not adminis- tered. After stabilization he was transported by am- bulance with a nurse attendant to a major medical center pediatric intensive care unit. Adam’s condition remained stable, and further laboratory tests were within normal limits. He was observed for any ad- ditional signs and symptoms of anticholinergic over- dose. His nasogastric tube was removed, and later that night he was bottle fed. He was discharged the next day in good condition; his mother was given instructions to take him to his primary care provider in 2 to 3 days. His subsequent examinations in the office have been within normal limits.
3. How m@.$t this experience alter instructions the PNP gives when prescribing medications in the fiture?
Many pediatric medications are given by drops or dropper. One of the most commonly used medica- tion is acetaminophen, which is administered at one- half or one dropper, according to lines on the drop- per. Vitamins, fluoride, iron, and antacids (such as simethicone) are other medications also commonly administered in this manner. Potential side effects exist from an overdose of each of these. Other pe- diatric medications administered by drops or drop- per that can cause life-threatening side effects are phenobarbital, hyoscyamine sulfate, atropine sulfate, scopolamine hydrobromide (Donnatal; A.H. Rob- bins Company, Richmond, Va.), and digoxin. The PNP should be aware of the correct method of ad- ministration and how each medication is packaged and dispensed. Additionally, it would be helpful to have a sample bottle of the medication in the office
52 Clinical Insights (Q&A) Volume 6, Number 1
lanuary-February 1992
so that the PNP could demonstrate the correct method of administration to the parent/caregiver.
Many parents/caregivers think that 0.4 ml on a dropper is the same as 4 ml. Many parents are young, inexperienced, and may be overwhelmed with the medications necessary for their infant. A PNP who spends a few extra minutes describing and demon- strating proper medication administration may pre- vent a serious overdose or even death. n
REFERENCES Committee on Accident and Poison Prevention, American Academy
of Pediatrics. (1983). In R. Aronow (Ed.). Handbook ofCmnmon Poisonings in Children., Evanston, III: The American Academy of Pediatrics.
Physicians’ Desk Reference. (1991). Oradell, NJ: Medical Economics, pp. 2049-2050.
Phyicianr’ Desk Refweencc for Nonprescription Dvzlgs. ( 1991). Oradell, NJ: Medical Economics.
13TH ANNUAL NAPNAP CONFERENCE San Antonio, Texas March 11-14, 1992
ROUNDTABLE DISCUSSION LEADERS NEEDED
The 1992 NAPNAP Conference, “NAPNAP: Ad- vocates for Healthy Children,” will again offer breakfast roundtables to provide an opportunity for conference participants to network with colleagues on issues of interest to them. Each roundtable, which will last 1 hour 15 minutes, will have 10 participants who will be given 1.5 contact hours.
Roundtable topics will include
l Advocates for Children: issues and Ideas . ADHD: Working with Children and Families l Community Health: Access to Care and Poverty l Immunization Programs l Massage/Touch/Holistic Therapies l Networking Year-round l NPs and the Military l PNP Research in the Office Setting l Rural Child Health l Toileting Problems (Enuresis and Encopresis)
Discussion leaders will start, guide, and end the discussion according to developed objectives. If you are interested in being a discussion leader for a roundtable, please send the following information:
l Your name, address, and work and home phone numbers
l The roundtable topic you would like to lead l A copy of your resume
to: Ann Pron, 7930 Montgomery Ave., Elkins Park, PA 19117, (215) 635-3642.
DEADLINE for receipt of the stated information is January 1, 1992.
