Fatal "crack" cocaine ingestion in an infant

A French study of cocaine intoxication/exposure in children (2010-2020)

BACKGROUND AND OBJECTIVE

In the European Union, the record of cocaine-related seizures indicates an expanding supply. The purity has also been increasing. The health impact of these trends remains poorly documented, in particular, the changes and clinical manifestations of intoxication in young children. We attempted to evaluate the trend in French pediatric admissions for cocaine intoxication/exposure over an 11-year period (2010-2020).

METHODS

A retrospective, national, multicenter, study of a pediatric cohort. All children less than 15 years of age admitted to a tertiary-level pediatric emergency unit for proven cocaine intoxication (compatible symptoms and positive toxicological screening) during the reference period were included.

RESULTS

Seventy-four children were included. Forty-six percent were less than 6 years old. Annual admissions increased by a factor of 8 over 11 years (+700%) and 57% of all cases were admitted in the last two years. The main clinical signs were neurologic (59%) followed by cardiovascular symptoms (34%). Twelve patients were transferred to the pediatric intensive care unit. Factors significantly associated with the risk of being transferred to the pediatric intensive care unit were initial admission to the pediatric resuscitation area (P < 0.001), respiratory impairment (P < 0.01), mydriasis (P < 0.01), cardiovascular symptoms (P = 0.014), age of less than 2 years (P = 0.014). Blood and/or urine toxicological screening isolated eighteen other substances besides cocaine in 46 children (66%).

CONCLUSION

Children are collateral victims of the changing trends in cocaine availability, use and purity. Admissions of intoxicated children to pediatric emergency departments are more frequent and there is an increase in severe presentations. Therefore, this is a growing public health concern.

Children intoxications: what is abuse and what is not abuse

The curiosity and the natural tendency to explore the environment put young children at an increased risk of poisoning over older children and adults. Poisonings are a significant area of concern from 1 year of age and progressively contribute more to overall rates of morbidity and mortality until children reach adulthood. Particularly, the abuse of children by poisoning is also highly common with thousands of fatalities. A practical strategy is presented that aims to alert health, forensic, and law enforcement professionals to this problem and to demystify the preconception that it is a rare form of abuse or neglect. Compounds that are foreign to a living organism (xenobiotics) and those present within body (endobiotics), mainly involved in children intoxications and contextual examples related to exposure are also reviewed. Particular concern is given to concepts in the field of children poisoning. The described history and the clinical and toxicological evaluation are discussed, and harmonized protocols regarding correct procedures for sample collection to forensic toxicological analysis are proposed. Since children are particularly vulnerable to the toxic effects of high doses of xenobiotics and endobiotics, special consideration on the preparation of the environment that surrounds children in order minimize all possible risks will be also considered.

[Drugs of abuse acute intoxication in paediatric emergencies]

Documented cases show that acute drugs of abuse intoxication in children usually is the Fritz clinical evidence of a chronic exposure. Published clinical reports of drugs of abuse acute poisonings in children are reviewed, above all those with an underlying chronic exposure to the same or another substance. Biological matrices and exposure biomarkers useful in toxicology analysis in Paediatrics are reviewed. In toxicology, biomarkers refer to original parental substances and its metabolites and matrices refer to body substances where biomarkers are detected. In these matrices acute and chronic (previous days, weeks or months) exposures can be detected. Hair analysis has become the gold standard of drugs of abuse chronic exposure. Recommendation includes to confirm previous chronic exposure to drugs of abuse by hair analysis of children and their parents. This protocol must be applied in all cases with suspicion of acute drugs of abuse intoxication, parental consumption and/or children living in a risk environment.

Drugs of abuse: management of intoxication and antidotes

Illicit drug intoxications are an increasing public health problem for which, in most cases, no antidotes are clinically available. The diagnosis and treatment of these intoxications requires a trained clinician with experience in recognizing the specific signs and symptoms of intoxications to individual drugs as well as polydrug intoxications, which are more the rule than the exception. To make the diagnosis, the clinical observation and a urine toxicology test are often enough. Evaluating the blood levels of drugs is frequently not practical because the tests can be expensive and results may be delayed and unavailable to guide the establishment of a treatment plan. Other laboratory tests may be useful depending on the drug or drugs ingested and the presence of other medical complications. The treatment should be provided in a quiet, safe and reassuring environment. Vital signs should be closely monitored. Changes in blood pressure, respiratory frequency and temperature should be promptly treated, particularly respiratory depression (in cases of opiate intoxication) or hyperthermia (in cases of cocaine or amphetamine intoxication). Intravenous fluids should be administered as soon as possible. Other psychiatric and medical complication should receive appropriate symptomatic treatment. Research on immunotherapies, including vaccines, monoclonal and catalytic antibodies, seems to be a promising approach that may yield specific antidotes for drugs of abuse, helping to ameliorate the morbidity and mortality associated with illicit drug intoxications.

Fatal blood and tissue concentrations of more than 200 drugs

Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.