Pediatric Poisonings: 1

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Pediatric Poisonings 1

• Abhay Dandekar, MD
• CSMC
• July 2005

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Objectives for Part 1

• Epidemiology the numbers and its impact
• Evaluating the pediatric poisoning patient
• Initial triage
• Assessment via history and physical exam
• Labs and diagnostic evaluation
• General principles of management
• Identification of treatment themes and toxidromes
  
• Prevention and Education

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Definitions

• A poison exposure is the ingestion of or contact
  with a substance that can produce toxic effects.
  A poisoning is a poison exposure that results in
  bodily harm.
• Poison exposures can occur by accident without
  intent, and these exposures are defined as
  unintentional poisonings. In some situations,
  poison exposures are the result of a conscious,
  willful decision these cases are defined as
  intentional poisonings.

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Poisoning agents
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Poisoning agents
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Epidemiology the numbers

• 1 million reported poison exposures among
  children lt6 y.o
• 150-160,000 exposures in children 6-12
• 160-170,000 exposures in children 13-19
• Overall, these are underestimates
• Inst. Of Medicine estimates nearly 4.6 million
  cases with approximately
• 2/3 in patients lt20 y.o.
• ½ in children lt6 y.o
• ¼ in children lt2 y.o

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Epidemiology the numbers

• Nearly 90 of exposures occurring at home
• During pre-adolescenceslight male predominance
• This reverses in ages 13-19 with females
  accounting for 55 percent of poisonings
• Children, especially those under age 6, are more
  likely to have unintentional poisonings than
  older children and adults (Litovitz 2001).
• Adolescents are also at risk for poisonings, both
  intentional and unintentional. About half of all
  poisonings among teens are classified as suicide
  attempts (Litovitz 2001).

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Epidemiology the numbers

• Approximately 1/3 of ingestions of toxic
  medications occur with medications that are
  intended for someone other than an immediate
  family member
• Among the fatalities in children lt 6 y.o
• Unintentional ingestions
• Medication errors
• Environmental exposures
• Bites/stings
• Malicious intent/abuse

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Epidemiology the numbers

• From 2000-2003, most common agents ingested by
  children younger than 6 y.o
• Cosmetics and personal care products
• Cleaning products
• Analgesics
• Foreign bodies
• Topical agents
• Cold and cough preparations
• Plants
• Pesticides
• Vitamins
• Antimicrobials
• Arts/crafts/office supplies

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Epidemiology the numbers

• From 2000-2003, most common agents involved in
  fatality among children younger than 6 y.o
• Analgesic drugs
• Fumes, gases, vapors (carbon monoxide)
• Cough/cold preparations
• Insecticides/pesticides
• Antidepressant drugs
• Cardiovascular drugs
• Cosmetics and personal care products
• Hydrocarbons
• Stimulants and illicit drugs

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Epidemiology the numbers

• Childhood lead poisoning is considered one of the
  most preventable environmental diseases of young
  children yet approximately one million children
  have elevated blood levels (CDC 2001).
• Carbon monoxide (CO) results in more fatal
  unintentional poisonings in the United States
  than any other agent, with the highest number
  occurring during the winter months (CDC 1999).

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Epidemiology the numbers

• Risk Factors
• Development factors (normal gross motor
  development, fine motor skills, cognition and
  social skills)
• Developmental delay
• Supervision
• Adolescent development with independence and
  sense of indestructibility
• Depression and suicidal ideation
• ENVIRONMENTAL FACTORS, SOCIETAL FACTORS,
  EDUCATION, ACCESS to CARE

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Epidemiology the numbers

• The majority of poisoning cases can be
  successfully managed at home with consultation of
  a poison control center specialist
• Nearly 76 of cases reported to US Poison
  Control Centers in 2003 managed at non healthcare
  facility
• For children lt6y.o., nearly 90 did NOT require
  treatment at a medical facility
• Nearly half of all teenagers required a medical
  facility

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Approaching the Poisoned Child
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Overview

• Approach begins with initial evaluation and
  stabilization (ABCDE)!!!!!!!
• This is followed by a thorough approach to
  identify the agent(s) involved
• Often, the suspected toxic agent will determine
  the priorities of management
• Supportive cares, prevention of poison
  absorption, antidotes, enhanced elimination may
  subsequently be involved

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Initial Evaluation/Stabilization

• Airway
• Assessment of the younger childs airway paying
  close attention to upper airway edema and to the
  gag reflex pay close attention even in the
  patient who is talking or crying
• C-spine precautions should be taken when there is
  any suspected trauma

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Initial Evaluation/Stabilization

• Breathing
• Evaluate the quality of breathing
• Evaluate the oxygenation and supplement with O2
  if needed
• Many toxins can be responsible for primary
  respiratory depression
• Many causative factors for metabolic acidosis
  will result in a compensatory respiratory
  alkalosis
• Less compensatory reserve in children make them
  more susceptible to hypoxia and respiratory
  failure (especially in inhalation toxic exposure)

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Initial Evaluation/Stabilization

• Circulation
• Establish large bore IV access, Bolus as needed
• Monitor pulse and blood pressure
• EKG monitoring
• Assess skin color and capillary refill
• Continue to reassess for cardiovascular
  compromise or arrhythmias

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Initial Evaluation/Stabilization

• Disability (Rapid Neuro Eval)/ Dextrose
• Assess pupillary response
• Assess mental status (GCS)
• Physiologic excitation (CNS stim, hyperthermia,
  tachycardia, elevated BP, tachypnea)
• Depression (CNS depression, hypothermia,
  hypotension, hypopnea, bradycardia)
• Mixed
• Administration of Oxygen or Naloxone (infusion)
• Assess blood glucose
• Administration of dextrose (infusion) and
  thiamine

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Initial Evaluation/Stabilization

• Exposure
• Full head to toe survey of the undressed child or
  adolescent
• Search for pill containers
• Evaluate for hidden injuries
• Appropriate thermal control
• GI decontamination may have a role at this stage
  of the initial stabilization for children who
  have ingested potentially life threatening
  amounts of toxin
• Ocular decontamination
• Dermal decontamination

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Diagnosis

• Focus effort now on agent identification,
  assessment of severity, and prediction of
  toxicity.
• Start with H and P , supplement with labs and
  investigations
• AMPLE (Allergies, Meds, PMHx, last meal,
  events/environment)

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Diagnosis

• History can be challenging
• Where/how was patient found?
• Agents in kitchen may be different from other
  location
• If known, details of exposure agent, time,
  volume, immediate clinical effects
• Supervision, recent visitors
• Assess for all suspect medications
• Herbal products or home remedies
• Ill contacts or those with similar symptoms
• Recent similar exposures in household contacts
• Open bottles, pill containers, unusual odors
• Household hobbies, industrial exposure
• Substance in original container?
• Recent illness or medications for the patient?

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Diagnosis

• History can be challenging
• Corroborate the story of the adolescent
• Symptoms or behavior after the reported ingestion
• Work and school environments?
• Available bottles/pills?
• Interventions in the pre-hospital setting
• Illicit drug use in family members or close
  contacts?
• Huffing, snorting,
• PMHx, family history, allergies, ROS
• Assume the worst case scenario in trying to
  calculate the ingestion dose

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Diagnosis

• Physical Exam
• Vital signs and general appearance
• Thorough PE
• Close attention to neuro exam
• Pupils
• Reflexes and posture
• Mental status
• Bowel sounds
• Mucous membranes and skin moisture/appearance
• Characteristic odors
• Nosebleeds, needle tracks, huffer rash,
  blistering

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Specific Toxidrome Patterns
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Common Toxidrome Findings
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Common Toxidrome Findings
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Physical Exam Findings

• See handout re physical findings/odors
• Sympathomimetic (meth, amphetamines, cocaine,
  opiate withdrawal, PCP)
• Hyperthermia, tachycardia, hypertension,
  mydriasis, warm/moist skin, agitated
• Cholinergic (organophosphates, betel nut, VX,
  Soman, Sarin)
• SLUDGE (Salivation, Lacrimation, Urinary
  incontinence, Diarrhea/Diaphoresis, GI
  upset/hyperactive bowel, Emesis)
• Anticholinergic (antihistamines, atropine,
  phenothiazines, TCA)
• Hyperthermia, tachycardia, HTN, hot/red/dry skin,
  mydriasis, unreactive pupils, unrinary retention,
  absent bowel sounds
• Opioids (codeine, dextromethorphan, heroin)
• Miosis, respiratory depresssion, mental status
  depression

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Diagnostic Considerations

• Before proceeding, consider other aspects of the
  differential diagnosis ( CVA, trauma, meningitis,
  post-ictal state, behavioral or psych disorders).
• Labs to evaluate glucose, acid-base status and
  electrolytes, BUN/Cr, carboxyhemoglobin, hepatic
  enzyme levels, urinalysis (UA preg), serum
  osmolality, serum acetaminophen levels
• EKG
• Woods lamp/Radiography
• Save samples of blood, urine, gastric contents
• General qualitative tox screens of little value
  (except when abuse is suspected), but are rapid
  and could offer clue to antidote may have role
  in the difficult dx or critically ill Quantitive
  measurements in certain toxic exposures

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Diagnostic Considerations

• Ocular/dermal
• pH testing may reveal acid or alkali
• Hypoxemic while asymptomatic may suggest
  methemoglobinemia
• Cardiac
• EKG shows arrhythmia (TCA)
• Blood color on filter paper that remains brown
  after air exposure suggests methemoglobinemia
  (possibly from benzocaine-containing products,
  aniline dyes, nitrites)
• Signs of hypocalcemia in ethylene glycol,
  hydrofluric acid
• Urine fluorescence in ethylene glycol
• Ferric Cl creates purple reaction with
  salicylates and phenothiazines in urine
• Small opacities on x-ray may show halogenated
  toxins, heavy metals, lithium, densely packed
  products, phenothiazines, enteric-coated meds

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Diagnostic Considerations

• MUDPILES CAT for high anion gap acidosis
• Methanol or metformin
• Uremia
• DKA
• Paraldehyde or phenformin
• Iron, INH, Ibuprofen
• Lactic acidosis
• Ethylene glycol
• Salicylates
• Cyanide
• Alcohol or acids (valproate)
• Toluene or Theophylline

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Diagnostic Considerations

• Toxins requiring quantitative levels at a set
  point
• Acetaminophen
• Carbon monoxide
• Ethanol, ethylene glycol
• Heavy metals (24 hour urine)
• Iron
• Methanol
• Methemoglobin
• Toxins requiring quantitative serial levels
• Aspirin/salicylates, tegretol, digoxin,
  phenobarbital, phenytoin, VPA, theophylline

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Management Considerations

• Supportive care is the mainstay of therapy and
  recovery and may involve decontamination,
  antidotal therapy, enhanced elimination
  techniques
• Systemic support for airway security,
  ventilation, hemodynamic stability, and adequate
  CNS function
• Careful attention to pain and agitation
• Activating multi-faceted team approach early

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Management Considerations

• Decontamination
• Priority after stabilization
• Activated Charcoal is preferred method, and may
  be indicated even in the patient with equivocal
  exposure history
• Adsorption of toxins to prevent their absorption
• Dependant on toxin
• Heavy metals (lead, arsenic, mercury, iron),
  inorganic ions, boric acid, corrosives,
  hydrocarbons, alcohols, and essential oils are
  generally not well adsorbed by charcoal
• Dependant on surface area of the charcoal
  preparation
• Use 1g/kg prepared in slurry with a cathartic and
  chocolate milk, cola, fruit syrup. Can be
  repeated every 4-6 hours at ½ the dose, and
  multiple doses can help interrupt enterohepatic
  circulation.
• Efficacy decreases over time gastric lavage that
  follows or preceded and follows may be more
  effective than charcoal alone.
• Contraindications in child with depressed levels
  of consciousness and non-secure airway caustics,
  hydrocarbons, ileus/perforation risk

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Management Considerations

• Decontamination
• Priority after stabilization
• If ingestion has occurred within 1 hour, or a
  highly toxic substance is ingested that is
  usually not well bound to charcoal gastric lavage
  may be attempted but no longer the routine
• Controversial in the asymptomatic patient or who
  has presented more than one hour after ingestion
• Contraindicated if prior vomiting, hydrocarbon,
  unprotected airway, caustics, foreign body, at
  risk for hemorrhage
• Risk includes aspiration, trauma to anatomic
  structure.

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Management Considerations

• Whole bowel irrigation may be necessary in the
  ingestion of a sustained release product or toxin
• Large volumes of balanced electrolyte solution
  used to decontaminate the GI tract
• Used in fewer than 1 percent, not well studied in
  pediatrics
• Can be useful in ingestion of enteric coated
  pills, illicit drug packets, large ingestions of
  substances that are poorly bound by activated
  charcoal
• Contraindicated in bowel obstruction, GI bleed,
  perforation, unprotected airway

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Management Considerations

• Ipecac syrup induces vomiting by stimulating
  central emetic centers.
• No longer recommended for routine home use.
• Can be used only in the alert, conscious child
  over 6 mo who has ingested a potentially toxic
  amount of poison.
• (No longer routinely recommended to be used
  because of its questionable effect on outcome).
• Contraindicated in children less than 6mo,
  ingestion of a non-toxic substance, corrosive
  ingestion, hydrocarbon ingestion, altered mental
  status or airway compromise, GI bleed or
  coagulopathy,

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Management Considerations

• Ocular exposure requires copious irrigation with
  saline using a Morgan lens, measure pH and
  maintain at 7.5-8
• Dermal cleansing with water or normal saline and
  subsequent identification
• Pay close attention to burns, pain, infection
• Water is absolutely contraindicated with reactive
  metals use mineral oil instead
• Tar can be removed safely with vaseline

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Management Considerations

• Inhalation injuries need fresh humidified and
  oxygenated air
• Treatment with B-agonists, corticosteroids
• Removal of offending environment
• Hemodialysis and Hemoperfusion
• Require anti-coagulation

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Management Considerations

• Drugs that can kill the toddler in one or two
  doses!
• Benzocaine, Ca antagonists, camphor, chloroquine,
  clonidine, TCA, Lomotil, Visine/Afrin, Lindane,
  Sulfonylureas, theophylline, phenylpropanolamine,
  phenothiazines, selenious acids, hydrocarbon
  aspiration, oil of wintergreen.among others

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Management Considerations

• Activate Poison Control
• 1-800-876-4766 or
• 1-800-222-1222
• www.calpoison.org

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Management Considerations

• Prevention Strategies/Themes-primary
• Store potentially toxic substances in higher
  places or out of reach/sight
• Store safe items within the childs reach dont
  take medicine in front of kids
• Child-proof latches
• Avoid chemicals in the fridge, or insect traps
  that are accessible
• Remove toxic plants avoid exposure to toxic
  animals
• Keep matches, combustibles out of reach
• Dispose of partially consumed alcohol
• Carbon monoxide detection system
• Read labels on products carefully
• Advocate for protective legislation

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Management considerations

• Prevention Strategies/Themes-secondary
• Identify poison control center and number
• Education
• Decontamination
• Prevention Strategies/Themes-tertiary
• EMS
• Antidotes

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