See also:

Poisoning – Guidelines for initial management 
Resuscitation
Afebrile Seizures

Key points

1. The majority of NSAID overdoses are generally benign in lower doses
2. Large overdoses can cause shock, coma, seizures & acute renal failure
3. Overdose of mefenamic acid has been associated with seizures.

For 24 hour advice, contact Victorian Poisons Information Centre 13 11 26

Background

NSAIDs include celecoxib, diclofenac, etoricoxib, ibuprofen, indomethacin, ketoprofen, ketorolac, mefenamic acid, meloxicam, naproxen, parecoxib, piroxicam, sulindac, tiaprofenic acid.

Massive ingestions can cause shock, coma, seizures and acute renal failure.

Note: this guideline does not cover aspirin. Please see Salicylate poisoning

Children requiring assessment

All children with deliberate self-poisoning or significant accidental ingestion.
Any symptomatic child.
Any child whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be considered.

Risk assessment

History

Intentional overdose or accidental
Dose:

• Stated or likely dose taken
• If possible determine the exact name and tablet size.
• Calculate the maximum possible dose per kg
  

Examination

GIT: Epigastric pain, nausea, vomiting

CNS: Drowsiness, lethargy, seizures, coma

Metabolic: acute renal failure

CVS: Shock

Severity:

Mefenamic acid ingestion of >3.5 g can cause seizures.

Investigations

Symptomatic children or those with concurrent illness:

• FBC
• UEC
• LFTs

Consider paracetamol concentration in all intentional overdoses.

Acute Management

1. Resuscitation
Standard procedures and supportive care.
Ensure adequate hydration after large overdoses to reduce the likelihood of acute renal failure.

2. Decontamination 
Activated charcoal is not indicated.

Ongoing care and monitoring

• Discuss with toxicologist, particularly in symptomatic children and those with abnormal pathology results
• Use a proton pump inhibitor for epigastric pain
• Treat seizures as per afebrile seizure

Consider consultation with local paediatric team when

Specific Indications for admission for observation:

• All symptomatic children
• Acute ingestion of ibuprofen ≥200 mg/kg
• All intentional overdoses

 Consult Victorian Poisons Information Centre 131126 for advice

Consider transfer when

Children requiring care outside the capacity of the local centre.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Consider discharge when:

Asymptomatic children with normal vital signs 4 hours post-ingestion may be discharged.

Assessing risk and connecting to community services

Prior to discharge, adolescents who present with deliberate ingestions need a risk assessment regarding the likelihood of further ingestions or other attempts to self-harm. 

Assessment of other drug and alcohol use should also be undertaken.

If, after risk assessment, it is deemed safe to discharge a patient from hospital, but ongoing mental health or drug and alcohol needs are identified, the adolescent should be linked with appropriate services (see links below for services in the State of Victoria). 

Discharge information and follow-up:

Parent Information Sheet: Poisoning prevention for children

Victorian Poisons Information Centre: 13 11 26

Mental Health Services
HEADSPACE: National Youth Mental Health Foundation
Local headspace centres

CAMHS: Child and Adolescent Mental Health Services
Local services alphabetically by suburb / city

Drug and alcohol services
YoDAA: Victoria's Youth Drug and Alcohol Advice Service
1800 458 685                           

Last Updated April 2019