Pediatric Primary Care Case Studies (78 page)

Dimercaptosuccinic acid (DMSA)
[Chemet] is a water-based oral agent approved in the treatment of heavy metals such as lead, cadmium, arsenic, and mercury toxicity by the Food and Drug Administration (FDA). DMSA is the safest of the chelating agents with a wide margin between the doses needed to be effective and the dosages that would be toxic.
British anti-lewit (BAL)
is oil-based and unpleasant to patients. Significantly, BAL forms a toxic substance when combined with iron, so it must
never
be given during iron therapy.
Edetate Calcium Disodium (Calcium EDTA)
is water-soluble and best given intravenously. It is possible to give intramuscularly, but is quite painful and should be drawn up with 2% procaine to minimize site discomfort. The primary risk associated with this chelating agent is that due to its actions within the body there is an increased likelihood of seizures.

Warfarin Intoxication

Vitamin K (phytonadione, AquaMEPHYTON) overcomes the coagulation, thereby blocking the effect of warfarin. It takes several hours for the liver to then produce clotting factors and release them into the circulation. Typical pediatric dosing is 1–5 mg orally; however, higher doses are necessary to
reverse the Super warfarin coagulopathies, and these doses need to be titrated based on the results of daily prothrombin times (Taketomo, Hodding, & Kraus, 2008). Consultation with a hematologist is recommended.

Although Oswaldo’s PT level is only slightly above the normal range, you initiate a call to your hematologist consultant to determine whether vitamin K is needed at this point and to discuss the issue of his IDA, elevated lead levels, and positive urinary metabolite screen.

Plan of Care

You discuss your plan of care with Oswaldo’s mother, which is as follows:

   Consult with hematologist regarding anemia, lead toxicity, and likely low level of warfarin ingestion.

   Department of Public Health involvement: Site visit and lead abatement.

   Visiting nurse to provide home monitoring, teaching, coaching, medication administration technique, and to promote success.

   Referral to early intervention program: for infant stimulation.

   Fer-in-sol (which comes in 75 mg/0.6 ml, in a 50 ml bottle) 6 mg/kg @ 9.2 kg = 0.2 ml orally bid, OR iron polysaccharide complex taken daily by mouth.

   Take with orange juice or cranberry juice.

   Wipe teeth clean after administering to minimize dark discoloration.

   Put medicine toward back of mouth if possible.

   Consider iron chelation therapy with BAL or Calcium EDTA (doses) if lead levels do not drop as the environment becomes less toxic. This will necessitate a follow-up discussion with the hematologist.

   Nutritional consult: There will be much information for Mrs. Garcia to absorb, so an ongoing consult would be appropriate until Oswaldo’s condition improves. Referral to address:

   Decrease cow’s milk to not greater than 16 ounces in a day.