FACILITATION OF THE TREATMENT OF TOXIC INGESTION BY ENDOSCOPIC GASTRIC DECONTAMINATION OF PILL FRAGMENTS IN A 2 MONTH OLD INFANT

Abstract

122 A 2 month old male infant was brought for emergency treatment after noting a change in mental status. The patient had been inadvertently left unattended for approximately 6 hours with a 2 year old sibling and on discovery, several open single dose pill containers were noted and emptied of their contents. These included a 'cold pill' (acetaminophen 325 mg, pseudoephedrine 30 mg, dextromethorphan 10 mg), ibuprofen (200 mg), and calcium carbonate (420 mg). A flat plate of the abdomen obtained on initial evaluation showed more than 30 pill fragments in the stomach. It was estimated that the patient ingested at least 1625 mg (230 mg/kg) of acetaminophen, 150 mg of pseudoephedrine, 200 mg of ibuprofen, 50 mg of dextromethorphan, and 20 or more tablets of calcium carbonate. The patient received activated charcoal and gastric lavage, but few of the pill fragments were retrieved. In an effort to facilitate gastric decontamination, an upper endoscopy was performed. A prototype for the new bard "half snare/net" was used to remove pill fragments. Eighteen of 32 pill fragments were retrieved after 14 passes of the upper endoscope. Gastric pill fragment analysis confirmed a toxic ingestion of acetaminophen and pseudoephedrine. Initial acetaminophen level obtained 6-8 hours after ingestion was 201. The patient subsequently received 17? doses of n-acetyl cysteine and acetaminophen levels steadily decreased, to a level of<10 twenty-four hours after admission to the hospital. Initial blood gas showed a pH of 7.21 and a HCO3 of 38. The patient initially required mechanical ventilation, but was weaned from the ventilator within 24 hours of admission and transferred out of the intensive care unit 48 hours after admission. The patient was subsequently discharged home without apparent sequelae. Conclusion: Endoscopic gastric decontamination of pill fragments may provide a useful adjunct in the treatment of toxic ingestions in children. Instruments designed specifically for pill removal would aid in this procedure.