Pediatric Toxicology

1
Pediatric Toxicology

• M Waseem, MD
• Lincoln Hospital Bronx New York

2
Epidemiology

• 2 million calls
• 52 of poison center calls lt 6years
• Peak age 18 months - 3 years

3
Epidemiology

• Unintentional (1-2 years)
• Exploratory
• Boys gt girls
• Intentional (adolescent)
• Purposeful
• Girls gt boys

4
Children are different

• Unable to discriminate safe from unsafe liquid
• Fail to recognize the suitability of the drink

5
Epidemiology

• Around Meal time
• Grand parents home
• Kerosene or gasoline in a soda bottle
• Older sibling can pharmaceutically treat younger
  sibling

6
Very toxic!

• Prenatal vitamin supplements
• Antidepressants
• Hydrocarbons

7
Most often reported

• Cleaning products 10.4
• Analgesics 10.3
• Cosmetics 9
• Cough cold preparation 5.1
• Insecticides 4

8
ICU Admission

• TCA
• Anticonvulsants
• Digitalis
• Opiates
• Hydrocarbon-based house-hold products

9
Toxic Exposures/Death

• Analgesics
• Sedative-hypnotics
• Alcohols
• Gases fumes
• Cleaning substances

10
Fatal Sip
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Fatal Sip

• Camphor (100mg/kg) 1gm/5 ml
• Methyl Salicylate 1.4gm/ml (200 mg/kg) 1/2
  tsp

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Fatal Sip

• Benzocaine 2 ml
• Methemoglobinemia
• Seizure

13
Malignant Swallow

• Chloroquine (20 mg/kg) 500 mg
• Theophylline (8.4 mg/kg) 500 mg
• Imipramine (15 mg/kg) 150 mg
• Chlorpromazine (25 mg/kg) 200 mg

14
Malignant Swallow

• Clonidine 0.3 mg tablet
• Bradycardia
• CNS depression

15
Highly Toxic

• Acetonitrile
• Ammonium Fluoride
• Benzocaine
• Camphor
• Pennyroyal Oil

16
Acetonitriles

• Artificial Nail Tip remover
• Methemolobinemia
• Delayed presentation (4-12 hours)
• Must be hospitalized

17
Ammonium Fluoride

• Glass etching, de-rusting and wheel cleaning
  commercial products
• Armoral Quick Silver Wheel cleaner (17 ammonium
  fluoride)
• only 2 ml

18
Ammonium Fluoride

• Inactivates proteolytic glycolytic enzymes
• Binds with Ca Mg
• Acidosis, Dysrhythmia coagulopathy
• Direct effect on CNS
• Seizures

19
Benzocaine

• Teething gels (Orajel), first aid cream
  hemorrhoidal preparations
• Methemoglobinemia
• lt 6 months (methemoglobin reductase)

20
Camphor

• Vicks VapoRub
• Only 5 ml
• CNS effects

21
Pennyroyal Oil

• Health food products, herbal preparations
• Depletes glutathione
• Toxicity to liver lung
• lt a teaspoon
• A tablespoon (fatal)

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Look-Alike, Sound-A-Like

• Albuterol Atenolol
• Celebrex Cerebrex
• Oruvail Elavil
• Lamictal Lomotil
• Lotrimin Lotensin
• Plendil Pindolol

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Look-Alike, Sound-A-Like

• Hydralazine Hydroxyzine
• Hydrocodone Hydrocortisone

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Plant Toxidromes
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Digitalis Effects

• Lily-of-the-valley
• Foxglove
• Oleander
• Yew

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Nicotinic Effects

• Poison hemlock

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Atropinic Effects

• Jimsonweed

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Non-Toxic Products

• Ball point ink
• Bubble bath soaps
• Candles (beeswax or paraffin)
• Chalk
• Cigarettes (lt 3 butts)
• Crayons

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Non-Toxic Products

• Deodorants
• Lipstick
• Pencil (graphite)
• Toothpaste
• Water colors

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Evaluation

• History of poisoning
• Toxicologic physical examination
• Laboratory studies
• Gastrointestinal decontamination

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History

• What?
• When?
• How much?

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What ?

• Medication
• Illicit drug
• Hazardous chemical

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What form?

• Pill
• Solid
• Liquid
• Gaseous

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What route ?

• Ingestion
• Inhalation
• Topical
• Intravenous

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When ?

• Elapsed time

36
How much ?

• Estimate amount
• Concentration

37
Vital signs
38
Bradycardia

• Digoxin
• Narcotics
• Organophosphates
• Carbon monoxide
• Beta-blocker

39
Tachycardia

• Alcohol/amphetamine
• Atropine/tricyclic
• Theophylline
• Salicylates, Iron
• Cocaine/PCP

40
Slow Respiration

• Alcohol
• Narcotics
• Clonidine
• Sedatives

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Tachypnea

• Amphetamines
• Salicylates
• Carbon monoxide

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Hypotension

• Methemoglobinemia
• Carbon monoxide
• Cyanide
• Iron
• Narcotics

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Hypertension

• OTC cold remedies
• Amphetamine
• PCP
• TCA
• Cocaine

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Ventricular Tachycardia

• Amphetamines
• Carbamzepine
• Chloral hydrate
• Cocaine
• Digitalis
• Theophylline

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Torsades de Pointes

• Chloral hydrate
• Cisapride
• Organophosphates
• Terfenadine
• Phenothiazines

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Hypoglycemia (HOBBIES)

• H-Hypoglycemia
• O-Oral hypoglycemic agents
• B-Beta-Blockers
• I-Insulin
• E-Ethanol
• S-Salicylates

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Hypothermia

• Ethanol
• Narcotics
• Carbon monoxide

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Hyperpyrexia

• Atropine
• Salicylates
• Theophylline
• Cocaine
• TCA

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Mental Status
50
Coma

• Narcotic
• Anticholinergic
• Carbon monoxide

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Delirium/Psychosis

• Alcohol
• PCP/marijuana
• LSD

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Convulsion

• Cocaine/Amphetamine
• Lead
• Salicylate
• Isoniazid
• Theophylline

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Pupil size
54
Miosis (COPS)

• Cholinergics, Clonidine
• Opiates, Organophosphates
• Phenothiazine, Pilocarpine
• Sedatives (Barbiturates)

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Mydriasis (AAAS)

• Antihistamine
• Antidepressant
• Anticholinergics (atropine)
• Sympathomimetics
• Amphetamine, Cocaine, PCP

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Caution!

• Polydrug overdoses with opposite pupillary
  actions
• Nontoxin diagnoses
• Head trauma
• CNS hemorrhage

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Cyanosis

• Unresponsive to oxygen methemoglobinemia

58
Cyanosis

• Aniline dyes
• Nitrites
• Benzocaine
• Dapsone

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Dry Skin

• Anticholinergic

60
Breath Odors

• Arsenic Garlic
• Camphor Mothballs
• Cyanide Bitter almond
• Methyl salicylate Wintergreen
• Paraldehyde Pears

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Toxidromes
62
Cholinergic

• DUMBBEL
• SLUDGE

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DUMBBELS

• D Diarrhea
• U Urination
• M Miosis, muscle fasiculation
• B Bradycardia
• B Bronchospasm

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DUMBBELS

• E Emesis
• L Lacrimation
• S Salivation

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SLUDGE

• S Salivation
• L Lacrimation
• U Urination
• D Diarrhea

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SLUDGE

• G GI complaint
• E Emesis

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Anticholinergic Syndrome

• Dry mouth
• Flushed appearance
• Dilated pupils
• Fever
• Ileus
• Urinary retention
• Disorientation

68
Anticholinergic

• Hot as a hare
• Blind as a bat
• Dry as a bone
• Red as a beet
• Mad as a hatter

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Anticholinergic

• Full as a flask

70
Anticholinergic

• Anticholinergic
• Wet
• Bowel sound

• Sympathomimetic
• Dry
• Absent bowel sound

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Narcotic

• Pinpoint pupils
• Coma
• Respiratory depression

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Salicylates

• Fever
• Tachypnea hyperpnea
• Lethargy
• Metabolic acidosis

73
Theophylline

• Protracted Vomiting
• Tremors
• Tachycardia
• Seizures
• Hypotension

74
Isoniazid

• Seizures
• Metabolic acidosis
• Hyperglycemia

75
Phencyclidine (4 Cs)

• Combative
• Catatonia
• Convulsion
• Coma
• Nystagmus

76
TCA

• Metabolic acidosis
• Prolonged QRS
• Seizures
• Dilated pupils
• Dysrhythmia

77
Cyanide

• Feeling of impending doom
• Sudden coma
• Metabolic acidosis
• Hypotension
• Bitter almond odor

78
Carbon monoxide

• Headache
• Lethargy
• Dizziness
• Influenza like syndrome
• Coma

79
Ethanol

• Hypoglycemia
• Lethargy
• Ataxia
• Seizure
• Characteristic breath odor

80
Methanol

• Severe Metabolic acidosis
• Sluggish pupils
• Hyperemic retina
• Blurred vision

81
Ethylene Glycol

• Lethargy or coma
• Metabolic acidosis
• Urinary sediment
• Crystalluria

82
Clonidine

• Hypothermia
• Bradycardia
• Miosis
• Respiratory depression

83
Elevated anion gap

• Methanol
• Paraldehyde phenformin
• Iron isoniazid
• Ethylene glycol ethanol
• Salicylate

84
ABCs

• Anticipate
• Before
• Complications

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ABC

• Airway
• C-spine immobilization
• Breathing
• Circulation
• secure IV access

86
ABC

• Disability
• consciousness
• Drugs
• Decontamination

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consciousness

• A Alert
• V Responsive to verbal stimuli
• PResponsive to pain
• U Unresponsive

88
Drugs

• Dextrose
• Oxygen
• Naloxone

89
Decontamination

• Ocular- copious saline lavage
• Skin- copious water
• GI-consider options

90
Lab Evaluation

• No tox panel that is uniformly helpful

91
Urine Screen

• Marijuana 5-10 days
• Amphetamines 48 hours
• Barbiturates 24 h-2 wks
• Cocaine 2-4 days
• Opiates 2 days
• PCP 8 days

92
EKG

• All suspected ingestion
• Tricyclics

93
Pulse oximetry

• Measure of oxygen saturation of normal hemoglobin

94
Pulse oximetry

• Does not differentiate COHB from oxyhemoglobin

95
False low Saturation

• Blue nail polish
• Methylene blue
• Poor distal perfusion

96
Blood gas

• Salicylates

97
Chest X-ray

• Hydrocarbons

98
Esophagoscopy

• Caustics

99
Emergent Lab Analyses

• Acetaminophen
• Salicylates
• Methanol
• Ethylene glycol
• Iron

100
Emergent Lab Analyses

• Theophylline
• Carbon monoxide
• Lithium

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Optimum time

• Actaminophen 4 hours
• Salicylates 2-4 hours
• Iron 4 hours
• Carboxyhemoglobin Immediate
• Methemoglobin Immediate

102
Optimum time

• Ethanol 1/2-1 hour
• Ethylene glycol 1/2-1 hour
• Methanol 1/2-1 hour
• Digoxin 4-6 hour

103
Serial Levels

• Salicylates
• Carbamazepine
• Digoxin
• Phenobarbital
• Theophylline
• Valproic acid

104
Radiopaque (CHIPS)

• Chloral hydrate
• Heavy metals
• Iron
• Phenothiazine
• Slow release

105
GI. Decontamination

• Preventing absorption

106
GI decontamination in a symptomatic patient?
107
Decontamination

• Syrup of Ipecac
• Gastric lavage
• Activated Charcoal
• Cathartics
• WBI (bowel irrigation)

108
Syrup of ipecac
109
Syrup of Ipecac

• Nonprescription
• CTZ stimulant
• use only under poison control direction

110
Syrup of Ipecac

• No evidence of improved outcome
• Delays AC or antidote for 2 hours
• No role in hospital setting

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Adverse effect

• Protracted vomiting
• Sedation
• Diarrhea
• Bradycardia

112
Contraindications

• Altered mental status
• Seizure
• hemetemesis
• hydrocarbon
• corrosives

113
Contraindications

• Anticipated use of oral antidote or WBI
• lt 6 months old

114
Gastric Lavage
115
Gastric Lavage

• one hour (golden hour)
• Life threatening ingestion

116
NG tube is not adequate
117
Gastric Lavage

• Large bore orogastric tube (36 - 40 French)
• 0.9 saline 15 ml/kg max 200-400
  ml/cycle

118
Gastric Lavage

• lt 30 by 20-30 min
• lt 13 by 60 minutes

119
Gastric Lavage

• Not a routine
• With in one hour
• Life-threatening ingestion
• Absence of pill fragments does not rule out toxic
  ingestion

120
Gastric Lavage

• TCA
• Calcium-blocker
• Colchicine

121
Complications

• Pulmonary aspiration

122
Contraindications

• Caustic
• Hydrocarbon
• Sharp coingestion

123
Activated Charcoal

• Universal antidote

124
Single dose AC

• adsorbing the ingested substance

125
Activated Charcoal

• Oxidizing process
• Increases the adsorptive capacity
• Inert substance
• Reduce the bioavailability of drug

126
Activated Charcoal

• Surface area
• 950-2000m2/g

127
Poorly bound by AC
128
CHEMICaL CamP

• C Cyanide
• H Hydrocarbon
• E Ethanol
• M Metals
• I Iron
• C Caustics
• L Lithium

129
CHEMICaL CamP

• C Camphor
• P Phosphorus

130
Recommended Dose

• Up to 1 year
• 1g/kg
• 1-12 year
• 25-50 gm

131
Complications

• Pulmonary aspiration
• Emesis
• Constipation

132
Contraindications

• Hydrocarbon
• Corrosive
• Ileus

133
Home AC?

• 1,208,860 exposure in lt 6 year
• 16 fatalities
• 4 might have benefited from early administration
  of AC American Association of Poison Control
  Centers Toxic Exposure Surveillance System (1998)

134
Benefits of Home AC

• Early administration
• Reduced morbidity mortality

135
Risks of Home AC

• Inappropriate administration
• Inadequate dosing
• Pulmonary aspiration

136
Multiple-Dose AC

• Gastrointestinal Dialysis

137
Multiple-Dose AC

• Continue to adsorb remaining toxin
• Interfere with enterohepatic circulation
• Lower the free drug concentration

138
Multiple-Dose AC

• Phenobarbital
• Carbamazepine
• Phenytoin
• Digoxin
• Salicylates
• Theophylline
• TCA

139
Cathartics

• Decrease transit time

140
Cathartics

• Sorbitol 70(0.5g/kg)
• 10 - 20 ml (children)
• 50-100ml(adolescent)

141
Complications

• Nausea
• Abdominal cramps
• Vomiting
• Transient hypotension

142
Contraindications

• Unprotected airway
• Ileus
• Absent bowel sounds
• Intestinal obstruction

143
WBI

• Decontaminate entire gastrointestinal tract

144
WBI

• Commonly used for agents not bound to activated
  charcoal

145
WBI

• polethylene glycol
• No fluid abnormality
• No electrolyte imbalance
• End point clear rectal effluent
• Sustained release preparation

146
WBI

• 9 months to 6 years
• 500 ml/hr
• 6-12 years (1000 ml/hr)
• over 12 years
• 1500-2000 ml/hr

147
WBI

• Calcium-channel-blockers
• Iron
• Arsenic
• Lead/zinc
• Packets of illicit drugs

148
Complications

• Nausea vomiting
• Bloating / cramps
• Pulmonary aspiration

149
Urinary Alkalinization

• Salicylates
• Phenobarbital
• Chlorpropamide

150
Urinary Acidification

• Never indicated
• Systemic acidosis
• Renal impairment in myoglobinuria

151
Extracorporeal Clearance
152
Hemodialysis

• Severe poisoning
• Renal failure

153
Hemodialysis

• 8-10 fold increased clearance
• Corrects acid-base imbalance
• Corrects electrolyte imbalance

154
Hemodialysis

• Small molecular weight
• Non-ionized, uncharged molecule
• Low plasma protein binding
• Small volume of distribution (lt1.0L/kg)

155
Hemodialysis

• Lithium 4 mEq/L
• Ethylene glycol 50 mg/dl
• Methanol 50 mg/dl
• Salicylates 100 mg/dl

156
Hemoperfusion

• A charcoal or resin cartridge
• More effective in selected poisonings
• Not limited by plasma protein binding
• Not limited by molecular size

157
Hemoperfusion

• Not effective for acid-base electrolyte
  imbalance correction
• Ineffective in patients with renal failure

158
Hemoperfusion

• Phenobarbital 100 mg/L
• Theophylline 60-100mg/L
• Paraquat 0.1 mg/dl
• Glutethimide 4 mg/dl
• Meprobamate 10 mg/dl

159
Antidotes
160
Antidotes

• Use only if specific criteria met

161
Immediate use

• Oxygen
• carbon monoxide
• Naloxone
• opioids

162
Immediate use

• Methylene blue 1
• severe cyanosis
• gt 40

163
Immediate use

• Sodium nitrite
• Cyanide
• Deferoxamine
• Iron

164
Antidotes

• Acetaminophen - N-Acetylcysteine
• 140 mg/kg PO
• 70 mg/kg q4h for 17 doses
• Anticholinergics - Physostigmine
• 0.5 mg IV

165
Antidotes

• Organophosphates
• Atropine 0.05-0.1 mg IM or IV
• Pralidoxime 25-50 mg/kg IV

166
Antidotes

• Benzodiazepine - Flumazenil
• 0.01 mg/kg IV
• Beta Blockers - Glucagon
• 50 ug/kg IV

167
Antidotes

• Isoniazid Pyridoxine 5-10
• 1 gm/gm of INH ingested IV
• TCA NaHCO3
• 1-2 mEq/kg IM or IV
• Warfarin Vitamin K
• 1-5 mg IV or IM

168
New Antidotes in the year 2000
169
New Antidotes

• Glucagon
• Beta-blocker Ca-channel blocker
• Insulin glucose ?
• Ca-channel blocker
• Octreotide
• Sulfonylureas induced hypoglycemia

170
New Antidotes

• Tricyclic antidepressant antibodies
• TCA
• Fomepizole (Antizol)
• Methanol ethylene glycol
• Nalmefene
• Opioid poisoning

171
New Antidotes

• Flumazenil (Romazicon)
• Benzodiazepine

172
Child Abuse by poisoning

• High index of suspicion
• Its not optional!
• Mandated to protect these children

173
Take home message

• Basic supportive care has saved more lives than
  all the antidotes put together
• Small quantities can have significant
  consequences
• Most pediatric ingestion are trivial

174
If you watch these kids, you may not have to do
anything
175
Resources

• Drug Information (AHFS)
• Poisindex computer database
• Regional poison center
• 212-POISONS