Pediatric flecainide toxicity from a double dose.

A 23-month-old boy was brought to the emergency department of an adult and pediatric tertiary care center 1 hour after an inadvertent "double dose" of 120 mg flecainide (9.2 mg/kg). His electrocardiogram revealed sinus rhythm with a terminal R wave in aVR greater than 7 mm, a bifascicular block, and prolonged QRS and QTc intervals. A dramatic improvement in the bifascicular block and terminal R wave occurred after the administration of sodium bicarbonate. He was discharged after 36 hours with no complications. This case demonstrates that flecainide can cause significant cardiac conduction disturbances in doses much lower than previously described. All supratherapeutic ingestions should be assessed in hospital.

Seizures secondary to lamotrigine toxicity in a two-year-old.

OBJECTIVE: To report a case of acute pediatric lamotrigine ingestion resulting in seizures. CASE SUMMARY: A 2-year-old boy presented to the emergency department after an acute ingestion of up to 43 mg/kg of lamotrigine. He had 2 generalized seizures, with the first occurring 60 minutes after ingestion. Examination revealed alternate drowsiness and irritability, as well as nystagmus and hyperreflexia. Results of electrocardiogram, blood glucose, complete blood count, urea, electrolytes, and venous blood gas evaluations were all within normal limits. There was a mildly raised lactate level of 3.4 mEq/L (reference range 0.7-2.5). He was given intravenous diazepam 1 mg for irritability. After a 12-hour observation period, the patient was discharged with no further complications. DISCUSSION: The Naranjo probability scale in this case suggested a probable causality between the acute lamotrigine ingestion and seizures. This is the lowest acute dose causing pediatric seizure reported in the literature; however, this dose is still significantly higher than a therapeutic dose. A MEDLINE search (1966-January 2010) using the search terms lamotrigine, seizures, toxicity, overdose, ingestion, and pediatric/paediatric, not limited to English-language literature, revealed 5 other cases of seizures in children after lamotrigine ingestion. In all the acute cases, time to first seizure onset ranged from 20 to 60 minutes after ingestion. Two children had gastrointestinal decontamination, both after the onset of seizures. All had full recovery with supportive care. CONCLUSIONS: Lamotrigine has the ability to cause seizures in children from acute single ingestion at a lower dose than previously described. There is not enough information available to establish a toxic dose or dose that requires hospital assessment. Gastrointestinal decontamination should be contraindicated. Supportive care, including administration of benzodiazepines, is appropriate.

Tramadol: does it have a role in emergency medicine?

Tramadol is a synthetic analgesic new to the Australasian market where its use is rapidly increasing. It is used extensively overseas, particularly in Europe where it has been popular since its introduction in Germany in the late 1970s. Tramadol has a dual mechanism of action: weak mu opioid receptor agonist and a reuptake inhibitor of serotonin and noradrenaline. Thus, it has distinct advantages and disadvantages compared to other available analgesics. Its use is advocated in a variety of acute and chronic pain states as well as some non-analgesic applications. The use of tramadol in an emergency setting is not well studied, with most published trials assessing its efficacy and tolerability in postoperative or dental models. This literature review concludes that tramadol does not offer any particular benefits over existing analgesics for the majority of emergency pain relief situations.