1. Nifedipine Overdose in a 2 year-old boy Dr. Jenny Lam AED PWH

2. History of Present Illness M/2 good past health accidentally ingested 12 tablets, 20mg Adalat Retard at home ( as his father found the boy playing with the empty package, chewing the tablets which previously kept in his handbag )

3. History of Present Illness Brought to AED within an hour of ingestion Asymptomatic Alert and cheerful Cat. 2 To R Room

4. Physical Examination Alert and comfortable Perfusion and Hydration: good BP/P: 100/56 mmHg 146bpm SpO2 on RA: 100% CVS/ RS/ Abd/ CNS: normal

5. Investigations ECG: sinus tachycardia 178bpm Glucostix: 4.9 CXR: clear Blood for CBP/ R/LFT/ Ca/ Clotting/ toxicology screening: pending

6. Immediate Management Orogastric larvage with R/T Fr. 16 NS 1700 mL in 17 cycles 12.5 g activated charcoal via R/T Calcium gluconate 10% 5mL IV remained stable To Paediatric ward

7. Clinical Outcome Remained haemodynamically stable Blood results: normal No serum nifedipine level available Discharged after 48 hours monitoring

8. Literature Review on Nifedipine overdose Nifedipine, a dihydropyridine calcium channel blocker, mainly on peripheral receptors, causing systemic vasodilatation, less effect on cardiac conduction & contractility Unlike verapamil, diltiazem, overdose of Nifedipine not typically associated with mortality Kerns W II, Kline J, Ford MD. B-Blocker and calcium channel blocker toxicity. Emerg Med Clin North Am 1994;12:365-89.

9. Fatal Nifedipine Ingestions in Children A 2 y.o girl, accidentally ingested 20 tabs 10mg Nifedipine A 14 m.o. girl, ingested a single 10mg Nifedipine The journal of Emergency medicine, Vol. 19, No. 4, pp.359-361, 2000.

10. Increasing Incidence of Nifedipine overdose Nifedipine, gained widespread use in HT Increasing incidence of overdose The American Association of Poison Control Centres reported doubling the incidence in 1996 from 1989 Litovitz TL, Smilkstein M, Felberg L, et al. 1996 Annual Report of the American Association of Poison Control Centres Toxic Exposure Surveillance System. Am J Emerg Med 1997;15:447-500.

11. Special Features of Nifedipine Well absorbed orally, esp. sublingual route Maximum peak concentration within 1 hr in therapeutic doses Manifestations of toxicity may be delayed up to 12 hrs if extended-release tablets ingested Lethal serum concentrations or dosages in human unknown

12. Management of Nifedipine Overdose ABC’s GI Decontamination Orogastric Lavage Activated Charcoal/ MDAD for SR pills Whole bowel irrigation Drugs: Atropine/ Inotropics/ Norepinephrine/ Calcium/ Glucagon Others: Pacing/ Cardiopulmonary bypass

13. Bring Home Messages High index of suspicion! All patients with a history of a sustained release overdose, monitored for 24 hours even if asymptomatic! Home safety measures!

14. The End Thank You