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One Pill Can Kill: The Kid Who Was Horsing Around
One Pill Can Kill is an online column authored by EMS World Advisory Board Member Blair Bigham drawn from real-life cases of pediatric toxicology.
You’re working a rural 24-hour shift as an EMT in the winter countryside when you receive a call 45 minutes away. You arrive at a paddock-ringed farm property with a century home up a long snow-covered dirt driveway and spot someone waving up another 200 yards at a barn.
You’re met by a calm but worried man in his 60s. “My granddaughter is visiting while her parents take the weekend to celebrate their anniversary,” he tells you. “I came out to call her in for dinner and found her on the ground, all doubled over. She’s been out here all day. She must have gotten into something while out here playing with the horses. She’s obsessed with horses.”
You decide to scoop up the five-year-old girl and carry her to the ambulance to get her out of the cold while your partner interviews the man further as they walk toward the tack room in search of potential poisons.
She moans as you carry her, and you notice she localizes to her upper abdomen.
In the ambulance, you recognize she is protecting her airway, though she’s obtunded—eyes closed, moaning spontaneously, and opening her eyes without making any eye contact with you.
Once on the cardiac monitor you note a heart rate of 160, sinus, an SpO2 of 97 on room air, and a blood pressure of 80/30 with capillary refill of 5 seconds. She has pupils 5 mm equal and reactive, clear lungs, a very tender, soft, non-distended abdomen on palpation, and oddly some edema to her legs. Her glucose and temperature is normal.
Your transport time is two hours to the nearest hospital, a 15-bed facility with a helipad, and five hours by land from the nearest pediatric facility. You decide to request that a helicopter meet you at the closest hospital for emergent transfer to a pediatric center, and are informed they are doing a weather check. “There’s some precipitation south of you, but we’ll see what they say,” your dispatcher says with a hint of hopelessness.
Your partner returns with some interesting information. “On the feed table, we found these,” she says, handing you a box of tablets labelled Butazolidin. A quick google search reveals it’s a non-steroidal anti-inflammatory used for horses to alleviate pain, with an active ingredient of phenylbutazone.
“She’s always pretending she’s a horse or a pony,” says the man, as he rubs his hand through his hair.
Phenylbutazone Toxicity
Phenylbutazone was once a human medication, similar in mechanism to NSAIDs such as ibuprofen, indomethacin and naproxen. However, its potency, slow metabolism and propensity to cause liver and renal failure and GI bleeding (like all NSAIDs might do at toxic levels) led it to be removed from the market (for humans). It remains a common analgesic for horses, and is restricted to veterinarian prescription in most jurisdictions. It is usually supplied as a powder to sprinkle over horse feed.
Phenylbutazone is rapidly absorbed. Symptoms of toxicity include tinnitus, blurred vision, agitation or coma, hypotension, bleeding from the GI and urinary tracts, GI and bladder hemorrhage, and peripheral edema. Vomiting, diarrhea and abdominal pain are common. It causes aplastic anemia and thrombocytopenia, and can disrupt the clotting cascade.
There is no antidote, and multiple doses of activated charcoal may be used early after ingestion. Supportive care includes airway and ventilatory assistance, blood pressure support, dialysis, liver protection with n-acetylcysteine, and coagulation support with fibrinogen, cryoprecipitate or other blood products. Seizures are treated with benzodiazepines.
En Route
En route to the closest hospital, you are told that the helicopter is unable to fly due to snow squalls. A blood pressure reading of 65/30 prompts a 20cc/kg bolus of sodium chloride, with the desired effect.
As you pull into the hospital, the patient has a seizure and you give one dose of your favorite benzo, which terminates the seizure. In the hospital, a point of care blood analyzer shows a low hemoglobin, low bicarbonate level, and acidosis.
The patient is intubated and a nurse and RT offer to jump in the back of your rig for the long drive to the pediatric referral hospital. Two weeks later, you hear rumors that after an ICU stay that included hemodialysis, she was discharged without any deficits.
Reference
Sawalha K, James R, Mazahreh F, et al. “Ain’t She a Bute?”: The Importance of Proper History Taking in a Case of Inappropriate Use of Horse NSAID in a Human. Clin Pract. 2021 Sep; 11(3): 455–458.
Blair Bigham is an award-winning journalist, scientist and physician who trained in emergency and critical care medicine at McMaster and Stanford Universities. He spent the first decade of his career as a flight paramedic before pursing medical school. He was a Global Journalism Fellow at the Munk School of Global Affairs and Associate Scientist at St Michael’s Hospital. His work has appeared in newspapers, magazines, newscasts, podcasts and medical journals. His first book, Death Interrupted: How Modern Medicine is Complicating the Way we Die, was published in September 2022.
Comments
This is fantastic! Will help me learn things that I don’t come across often. As a paramedic, I might have intubated her.
—Deb Crager