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Poisoning in Children

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Title: Poisoning in Children


1
Poisoning in Children
  • Norah Al Khathlan M.D.
  • Consultant Pediatrician
  • Consultant Pediatric Intensivist
  • 02/02/08

2
Poisoning in Children
  • Goals
  • Learn the pertinent aspects of the history and
    physical exam relative to acute poisoning with
    particular emphasis on clinical recognition of
    major toxic syndromes (toxidromes).
  • Understand the principles, methods, and
    controversies of decontamination and enhancement
    of elimination of toxins.
  • Learn the presenting signs, symptoms, laboratory
    findings, pathophysiology and treatment of common
    therapeutic drug poisonings, drugs of abuse,
    natural toxins and general household poisons.

3
Poisoning in Children
  • Objectives
  • At the end of this lecture the student will be
    able to
  • Define poisoning.
  • Identify specific Toxidromes.
  • Identify risk factors for pediatric toxidromes.
  • Differentiate between the different classes of
    toxidromes.
  • Differentiate the routes of poisoning.
  • Describe the general management of the
    toxidromes.
  • Outline the management of specific toxidromes
  • Iron
  • Salicylates
  • Paracetamole/ Acetaminophen
  • Kerosene

4
Poisoning in Children
  • Definition of Poisoning
  • Exposure to a chemical or other agent that
    adversely affects functioning of an organism.
  • Circumstances of Exposure can be intentional,
    accidental, environmental, medicinal or
    recreational.
  • Routes of exposure can be ingestion, injection,
    inhalation or cutaneous exposure.
  • All substances are poisons...the right dose
    separates poison from a remedy.

5
Poisoning in Children
  • Ingestion of a harmful substance is among the
    most common causes of injury to children less
    than six years of age
  • Toxicology. . . is the science that studies the
    harmful effects of drugs, environmental
    contaminants, and naturally occurring substances
    found in food, water, air and soil.
  • Poisoning maybe a medical emergency depending on
    the substance involved.

6
Poisoning in Children
  • Constellation of signs symptoms seen in
    poisoning characterized by the type of substance.
  • Major four toxidromes are
  • Anticholinergic
  • Sympathomimetic
  • Opiates/Sedatives- Hypnotics/ Alcohol
  • Cholinergic

7
Poisoning in Children
  • Examples
  • ASA
  • Acetaminophen
  • TCA
  • Narcotics drugs of abuse
  • Benzodiazepines
  • Iron supplements
  • Alcohol

8
Agents Most Commonly Ingested by Children Less
Than Six Years of Age, 1995 to 1998
Shannon M. N Engl J Med 2000342186-191
9
Shannon M. N Engl J Med 2000342186-191
10
Poisoning in ChildrenImportant history points
  • What toxic agent/medications were found near the
    patient?
  • What medications are in the home?
  • What approximate amount of the toxic agent was
    ingested?
  • How much was available before the ingestion?
  • How much remained after the ingestion?
  • When did the ingestion occur ?
  • Were there any characteristic odors at the scene
    of the ingestion?
  • Was the patient alert on discovery?
  • Has the patient remained alert since the
    ingestion?
  • How has the patient behaved since the ingestion?
  • Does the patient have a history of substance
    abuse?

11
Poisoning in ChildrenManagement
  • General measures
  • Quick assessment triage
  • Identify the culprit.
  • Limit absorption
  • Vomiting
  • Lavage
  • Activated charcoal instillation
  • Specific

12
Poisoning in Children
  • ABCs of Toxicology
  • Airway
  • Breathing
  • Circulation
  • Drugs
  • Resuscitation medications if needed
  • Universal antidotes
  • Draw blood
  • chemistry, coagulation, blood gases, drug levels
  • Decontaminate
  • Expose / Examine
  • Full vitals / Foley / Monitoring
  • Give specific antidotes / treatment

13
Poisoning in Children
  • Decontamination
  • Ocular
  • Flush eyes with saline
  • Dermal
  • Remove contaminated clothing
  • Brush off
  • Irrigate skin
  • Gastro-intestinal
  • Activated charcoal
  • May Prevent /delay absorption of some
    drugs/toxins
  • Almost always indicated
  • Naso/oro-gastric Lavage
  • Bowel Irrigation
  • Recent ingestions 4-6 hrs
  • Awake alert patient
  • 500 cc NS Children / 2000cc adults
  • Orally / Nasogastric tube
  • Contraindications?

14
Agents Used for Gastrointestinal Decontamination
in Children
Shannon M. N Engl J Med 2000342186-191
15
Circumstances under Which Administration of
Ipecac Syrup Should Be Avoided
Shannon M. N Engl J Med 2000342186-191
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Important points
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19
Specific toxidromes
  • Acetaminophen
  • Stage I 0-24 hrs
  • Early symptoms
  • Mild
  • Serum acetaminophen level 4 hrs post ingestion
  • PLOT ON SPECIFIC NOMOGRAM.
  • No need to repeat levels
  • If gt 900 µmol/L ---gt POSSIBLE RISK
  • Nausea, vomiting, malaise and diaphoresis.
  • Normal bilirubin Transaminases and PT

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21
Acetaminophen poisoning
  • Stage II
  • 24-48 hrs after ingestion.
  • Better, less symptoms.
  • Elevated bilirubin, transaminases and PT

22
Acetaminophen poisoning
  • Stage III
  • 48-96 hrs ( 2- 4 days) after ingestion
  • Hepatic dysfunction
  • (Rarely hepatic failure)
  • Peak elevations in
  • Bilirubin
  • Transaminases may reach gt 1000 IU/L
  • Prolonged PT

23
Acetaminophen poisoning
  • Stage VI
  • 168- 192 hrs (7-8 days)
  • Clinical improvement
  • LFTs returning to normal

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Acetaminophen poisoning
  • Probable toxicity should be treated with
  • N-acetylcysteine bolus 140 mg/kg
  • Then 70 mg/kg Q 4 hrs for 17 doses.
  • Assess hepatic function
  • On presentation
  • Daily
  • Continue other support

26
Iron Poisoning
  • Five Stages but variable
  • Stage 1
  • Gastro-intestinal stage within several hrs of
    ingestion
  • V/D. Hematochezia and abdominal pain
  • Severe fluid loss, bleeding, shock(acidosis,
    tachycardia /- hypotension)
  • Fever. Lethargy. Coma

27
Iron Poisoning
  • Stage 2
  • Quiescent stage 4-48hrs
  • Clinical improvement
  • Subtle hemodynamic changes
  • Tachycardia
  • Decreased U.O.P.

28
Iron Poisoning
  • Stage 3
  • Circulatory collapse 48-96 hrs
  • Metabolic acidosis, hypotension, low Cardiac
    output.
  • Coagulopathy
  • Multiorgan system failure

29
Iron Poisoning
  • Stage 4
  • Hepatic failure 96 hrs
  • Increased mortality
  • Rarely fulminant hepatic failure
  • Hepatic necrosis
  • Liver transplant can save lives

30
Iron Poisoning
  • STAGE 5
  • Bowel obstruction 2-6 wks
  • Due to scarring
  • Gastric outlet obstruction
  • Small intestinal obstruction
  • May not pass through stage 4

31
Iron Poisoning
  • Management
  • Gastric decontamination
  • Forced emesis
  • Gastric lavage with 5 NaHCO3
  • No activated char coal
  • Secure good IV
  • Get initial the 4hrs levels and TBC
  • Chelate with Deferoxamine if levelsgt 300mg/dL

32
Iron Poisoning
  • Chelate with Deferoxamine
  • Stable pts levelslt 500 mg/dL 40mg/kg IM/IV
  • Unstable bleeding/ level gt 500
  • Give 20cc/kg NS/RL
  • Deferoxamine at 15 mg/kg IV over 1hr
  • Continuous drip at 15mg/kg/hr
  • Continue till vin rose urine color disappears.

33
Iron Poisoning
  • Observe for
  • Systemic BP
  • ECG
  • CVP
  • Signs of hepatic failure
  • Bleeding
  • Glucose intolerance
  • Hyperammonemia
  • Encepalopathy

34
SALICYLATES
  • Oral ingestion commonest
  • Transdermal less
  • Peak levels at 12 hrs
  • Early hyperpnea ? respiratory alkalosis
  • Then metabolic acidosis
  • Severe cases Cerebral edema and increased ICP

35
SALICYLATES
  • MANAGEMENT
  • Treat electrolyte imbalance
  • IV hydration
  • Forced alkaline diuresis
  • Hemodialysis
  • Diuretics

36
Hydrocarbons
  • Kerosene ingestion
  • Risk of aspiration
  • GIT Respiratory effects.
  • Burning sensation, nausea, belching and diarrhea
  • Cough, chocking, gagging and grunting.
  • CXR 2-8 hrs later Pulmonary infiltrates or
    perihilar densities.
  • pneumatoceles, pleural effusion or pneumothorax
    and bacterial superinfection
  • Resolution 2-7 days.

37
Hydrocarbons




  • Treatment
  • Do not induce vomiting
  • Do not attempt gastric lavage
  • Risk of aspiration outweighs any benefit from
    removal of substance
  • CXR around 2-4 hrs not before 2hrs
  • Observe in ER for 6-8 hrs if no symptoms ?
    discharge.


38
Poisoning in Children
  • Prevention is the vaccine for the disease of
    injury.
  • Host
  • AGENT A causal relationship!
  • Environment

39

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44
Poisoning in Children
  • Prevention is the vaccine for the disease of
    injury.
  • Host
  • AGENT A causal relationship!
  • Environment

45
Poisoning in Children
  • Prevention
  • The reduction in the incidence of childhood
    poisonings in the past half-century has been
    dramatic.
  • This reduction is largely the result of the
    combination of highly effective active and
    passive methods of intervention.
  • Passive interventions eg introduction of
    child-resistant containers for drugs and other
    dangerous household products. Child-resistant
    containers have been particularly effective in
    reducing the incidence of death from the
    ingestion of prescription drugs by children.
  • Active interventions, which require a change in
    behavior by parents and caretakers, include the
    safe storage of household products.

46
Thank you
  • Norah Khathlan M.D.
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