Pediatric Toxicology Pills and poisonous bites High Yield

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Pediatric ToxicologyPills and poisonous
bitesHigh Yield

• Eiman Abdulrahman MD/MPH
• Pediatric Emergency Medicine Fellow
• Emory University

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Epidemiology

• 1.25 million annual cases in lt6years.
• 15,447 fatalities 537 (3.7) in lt6yrs 397
  (2.6) in lt2yrs (since 1983)
• Of 27 deaths in 2004 19 were caused by
  pharmaceuticals (analgesics and opioids) of which
  14 were in lt2yrs
• 12 deaths were pre-hospital

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Pediatric Toxicology Young children vs Teenagers

• 79 of all pediatric exposures occur in lt6years
  and approx 99 are unintentional
• Approx 40-45 of ingestions in adolescents are
  intentional and 56 are female (substance abuse
  vs suicide attempts)

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Young Children

• Without suicidal intent
• Usually one substance
• Usually non-toxic
• Small amount
• Present for evaluation within one hour

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Young children

• Physiologic considerations
• High Metabolic Demands
• More permeable BBB until 4mos
• Decreased glycogen stores

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Adolescents

• 56 of seriously poisoned children
• Overdose from suicidal attempt
• Adverse effect while trying seeking euphoria
• More frequently hospitalized than younger
  children ( includes psych)
• 42 of AAPCC reported adolescent fatalities from
  suicide vs 4 from medication errors and adverse
  reactions

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Prevention

• The Poison Prevention Packaging Act (PPPA) of
  1972 has reduced pediatric mortality by 45
• Mandatory child protective packaging in household
  products, medicines, solvents
• FDA 1997 regulation with packaging with blister
  packs of 30mg Iron tablets (overturned in 2003)
• Significant decline in iron overdose
• Small amounts of some substances can extremely
  toxic to children

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Lethal exposures

• Analgesics
• Sedative/hypnotic/psychotics
• Antidepressants
• Stimulants and street drugs
• Cardiovascular drugs
• Alcohols
• Chemicals
• Gas and fumes
• Antihistamines

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Lethal Drugs

• AntimalarialsAntidysrhythmicsBenzocaineß-blocke
  rsCalcium channel blockers (CCBs)CamphorClonidi
  ne (and other imidazolines)

• Lomotil (diphenoxylate/atropine)LindaneMethyl
  salicylateOpioids
• SulfonylureasTheophyllineTricyclic
  antidepressants (TCAs)

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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General Approach

• Airway
• Breathing
• Circulation
• Disability
• Drugs
• Decontamination

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Focused history

• Three key questions
• WHAT substance was ingested?
• WHEN did the ingestion occur?
• HOW MUCH was ingested?

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Key PE

• Vital signs
• Level of consciousness, neuromuscular status
• Eyes-pupils, EOM, fundi
• Mouth-corrosive lesions, odors
• CV- rate, rhythm, perfusion
• Resp- rate, chest excursion, air entry
• GI- motility
• Skin- color, bullae or burn, diaphoresis,
  piloerection,

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Laboratory evaluation

• CBC, co-oximetry
• ABG, serum osmolarity
• EKG/cardiac monitor
• CXR, abdominal xray
• Electrolytes, bun/cr, glucose, calcium, LFT, UA
• Urine tox screen
• Quantitative tests (esp acetaminophen)

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Assessment

• Clinical findings
• Toxidromes
• Laboratory abnormalities
• Anion gap (Na K)-(Cl HCO3)
• Osmolarity (2x Na) (Bun/2.8)(Glu/18)
• Osmolar gap measured-calculated

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Toxidromes
Anticholin-ergics (Antihista-mines, Many Others) Organophosphates (Insecticide Nerve Gases) Opiates Clonidine Barbiturates Sedative-Hypnotics Salicylates Theophylline Sympathomimetics (Amphetamines, Cocaine)
MS/CNS Agitation, delirium, psychosis, convulsions Delirium, psychosis, coma, convulsions Confusion, fasciculations, coma Euphoria, somnolence, coma Somnolence, coma Lethargy, convulsions Agitation, tremor, convulsions
Heart rate Increased Increased Decreased (or increased) Decreased Increased
Blood pressure Increased Increased Decreased Decreased Increased
Temp Increased Increased Decreased Decreased Increased Increased
Respirations Increased Decreased Decreased Increased Increased
Pupils Large, reactive Large, sluggish Small Pinpoint Large
Bowel sounds Present Diminished Hyperactive
Skin Dry skin Flushed, dry Diaphoresis Diaphoresis
Misc SLUDGEa Vomiting Vomiting
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Detoxification

• Reassess ABCDs
• GI decontamination
• Dilution, gastric emptying, Activated charcoal,
  catharsis, whole bowel irrigation
• Urgent antidotal therapy
• Consider excretion enhancement
• Diuresis, urine alkalinization, dialysis,
  hemoperfusion

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Case 1 lethargic

• 4 year old w/ ALOC
• Grandmother called 911 when girl was not
  arousable
• VS T 37.6 HR 60 RR 18 BP 80/60
• Pulse Ox 98
• Differential?

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Case 1 lethargic

• MNEMONIC FOR ALOC
• A- Alcohol
• E- Epilepsy
• I- Insulin/intussusception
• O-Overdose
• U- Uremia
• T- Trauma
• I- Infection
• P- Psychiatric
• S- Shock

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Case 1 lethargic

• PE
• 1mm pupils reactive
• Dry skin
• No trauma except for bandaid on Rt knee
• Diagnosis?

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Case 1 lethargic

• Clonidine patch on Rt knee
• Fluid resuscitation- NS20ml/kg
• Naloxone w/ no effect
• Admitted to PICU
• D/C next day

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Outline

• Important highlights in pediatric toxicology
• Young children vs Adolescents
• Prevention
• Overview of pills potentially fatal in children
  even in small amounts
• Approach to management
• Snake and spider bites

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Brown Recluse Spider(Loxosceles)

• Southern and mid-western states
• Brown violin shaped mark on dorsum of
  cephalothorax
• Usually outdoors, but make indoor nests in
  closets
• Shy and will only attack when provoked
• Venom is cytotoxic and hemolytic

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Clinical presentation

• 2-8 hours
• Local reaction with mild-moderate pain (stinging
  sensation)
• Erythema, central blister or pustule
• 24 hours
• Fever, chills, malaise weakness, N/V, rash with
  petechiae, joint pain, DIC, hematuria, renal
  failure
• Subcutaneous discoloration that spreads over
• 3-4 days
• Spreads to 10-15 cm
• Pustule drains leaving ulcerated crater that
  scars
• Scar formation is rare after 72 hrs
• Reaction varies according to amount of
  envenomation

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Management

• Unless spider is brought for ID, definitive
  diagnosis cannot be made
• Good local wound care
• If systemic symptoms, then CBC with platelets,
  U/A, BUN, creatinine
• Vigorous supportive care in PICU
• Surgical excision and skin grafting after
  necrosis is demarcated
• Steroids, heparin, and hyperbaric O2 dont work
• No Dapsone for kids methemoglobinemia
• No antivenom available
• Have wound rechecked daily for progression

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Black Widow Spider(Latrodectus)

• Shiny black spider with brilliant red hourglass
  marking on abdomen
• Only the female bite is dangerous
• Male spiders are ¼ the size of females and bite
  cannot penetrate human skin
• Females not aggressive unless provoked or
  guarding egg sac
• Produces a neurotoxin

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Clinical presentation

• No local symptoms
• 1-8 hours after bite
• Generalized pain and muscle rigidity
• Cramping pain to abdomen, flanks, thighs, chest
• Chills
• Urinary retention
• Priapism
• Death from cardiovascular collapse
• Mortality 50 in young children

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Management

• Supportive ABCs
• Tetanus
• Treatment of spasm with narcortics and benzos
• Children lt 40kg Antivenin given as soon as bite
  confirmed
• Dose 2.5ml (one vial)
• Children gt40kg not as urgent to give immediately
  unless having respiratory difficulty or
  significant hypertension
• Admit to PICU

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Other Spiders

• Tarantulas
• Do not bite unless provoked
• Venom is mild and not a problem
• Wolf Spider and Jumping spider
• Mild venom only causes local reaction
• Treatment is good local wound care

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Snake characteristics

• cold blooded (seeks shelter at 55 degrees)
• - poor vision, great smell
• - slow but can strike 11 feet/sec.
• - Rattles are interlocking keratin rings
• - Jacobsons organ at end of the forked tongue
  used to ID prey
• - venom with potent enzymes that effect
  coagulation, multi-organ function
• Play major role in ecosystem as rodent predators

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Snakes Bites

• Epidemiology
• approx 400,000 bites worldwide
• Approx 45,000 bites in USA
• Approx 8,000 poisonous bites
• 5-15 deaths annually

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Snake Types

• Over 95 in the pit viper (Crotadilae) family
• Eastern diamondback rattlesnake (Crotalus)
• Copperhead (Agkistrodon)
• Cottonmouth (Agkistrodon)
• - 1 Coral snake(elapidae) family
• Georgia is home to 41 different snakes of which 6
  are venomous

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Pit Vipers (Crotalinae)

• Rattlesnakes, cottonmouths, water moccasins
• Proteolytic enzymes and anticoagulant esterasesgt
  digest victim!!
• Mojave rattlesnake only pit viper with neurotoxin
  venom

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Clinical Presentation

• Local effects
• edema within 1 hr (mod-severe bites) spreads
  centrally over 8-24hrs.
• Ecchymosis, Petechiae and Hemorrhagic bullae
• Systemic Effects
• Nausea, vomiting, paresthesias, dizziness, and
  diaphoresis. In severe envenomations-hypotension,
  rhabdomyolysis, renal failure and AMS
• Coagulopathy
• Increase in PT, PTT, thrombocytopenia and
  hemolysis. DIC in severe cases

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Coral snakes

• Eastern coral snakeAR, NC, SC, FL, GA, LA, MS,
  TX
• Local damage usu mild and doesnt correlate with
  severity of envenomation
• All confirmed coral snake envenomations are
  defined as severe and require antivenom

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Clinical Presentation

• Mild local finding
• Venom potent neurotoxin
• Paresthesia, weakness, cranial nerve dysfunction,
  confusion, fasciculations, and lethargy
• Common early sxdiplopia, ptosis, and dysarthia
• Nausea, vomiting, and salivation are also common
• Respiratory paralysis common cause of death

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Lab evaluation

• CBC, coagulation studies, DIC panel
• CK, renal function, UA
• Type and crossmatch in severe envenomations

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Prehospital treatment

• Prehospital
• Remove from vicinity of snake
• Immobilize bite site below heart level
• Minimize all physical activity (decrease
  absorption)
• DO not incise bite marks
• Transport to nearest hospital

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ED management

• ABC, IV hydration
• Coral snakes monitor neurologic sx (intubate if
  resp compromise)
• Antivenom (moderate to severe pit vipers and all
  confirmed eastern coral snake bites)
• Admission criteria admit all pts w/ confirmed
  coral snake bites if no envenomation observe for
  6hr if local pain or erythema, observe for 12hr
  admit all pts with progressive symptoms to ICU
  bitten by Mojave rattlesnake or exotic snake

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Question 1

• The four major steps in treatment of any poisoned
  
• patient include all of the following EXCEPT
• A. prompt hemodialysis or hemoperfusion
• B. decontamination and prevention of absorption,
  while preventing contamination of health care
  workers
• C. support of vital signs (ABCs) and symptomatic
  treatment specific antidote, if available
• D. enhancement of toxin excretion or elimination

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Question 2

• Syrup of Ipecac is the first line
• therapy for gastric decontamination
• of the poisoned patient
• A. True
• B. False

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Question 3

• Very few drugs are fatal for a 10 kg
• toddler upon ingestion of one
• commercially available dose unit.
• Examples of drugs in which ingestion
• of one dose can be potentially fatal in
• this population include all of the
• following EXCEPT
• A. Chloroquine
• B. TCA
• C. Calcium Channel Blockers
• D. SSRIs

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Question 4

• Which of the following statements is TRUE
• regarding intentional overdoses?
• A. Intentional overdoses are most commonly seen
  in the preschool age group.
• B. These overdoses are usually of one agent known
  to be lethal.
• C. Intentional overdoses frequently involve more
  than one agent Intentional overdoses are seldom
  fatal.
• D. None of the above are TRUE.

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THANK YOU
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Reference

• Fine SJ. Pediatric Principles. Goldfrank LR et
  al. editors Goldfranks Toxicologic Emergencies.
  8th Edition. Mc Graw-Hill
• Henry K, Harris CR. Deadly Ingestions. Pediatr
  Clin N Am 53 (2006) 293-315
• Ranniger C. Roche C. Are one or two dangerous?
  Calcium Channel Blocker Exposure in Toddlers.
  Journal of Emergency Medicine. Vol 33 No.2.
  145-154, 2007
• Eldridge DL, Van Eyk J, Kornegay C. Pediatric
  Toxicology. Emerg Med Clin N Am 15 (2007) 283-308
• Carson RH. The toxicology handbook for
  clinicians. Mosby, 2006