Poisoning in children
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Poisoning in Children. Kent R. Olson, MD Medical Director, San Francisco Division California Poison Control System Clinical Professor of Medicine, Pediatrics and Pharmacy, UCSF. Case study:. A 2 year old child is found with a bottle of his mother’s prenatal vitamins

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Poisoning in Children

Kent R. Olson, MD

Medical Director, San Francisco Division

California Poison Control System

Clinical Professor of Medicine, Pediatrics and Pharmacy, UCSF


Case study:

  • A 2 year old child is found with a bottle of his mother’s prenatal vitamins

  • Spontaneous vomiting after 30 minutes

  • Paramedics report systolic BP 70/p, HR 130/min


Most common pediatric exposures*

Category Hazard Factor

  • Cosmetics0.2

  • Cleaning agents0.9

  • Plants0.1

  • Analgesics0.6

  • Cough & cold preparations0.5

  • Hydrocarbons2.2

    Data from AAPCC 1985-1989


Relative risk of death/major effect

Category Hazard Factor

  • Rattlesnake bite244

  • Strychnine50

  • Alkaline drain cleaner22

  • Organophosphates5.6

  • Anticoagulants0.9

  • Cosmetics0.2


Pediatric poisoning deaths(AAPCC 1985-1989)

PharmaceuticalsHazard Factor

  • Iron8.5

  • Tricyclic antidepressants17.7

  • Cardiovascular drugs8.1

    Non-pharmaceuticalsHazard Factor

  • Pesticides2.1

  • Hydrocarbons2.2

  • Methanol5.1


More recent data - AAPCC 199924 deaths in children < 6

Pharmaceuticals

  • Opioids (3)

  • Iron (1)

  • Nifedipine (1)

    Non-pharmaceuticals

  • Carbon monoxide (7)

  • Hydrocarbons (3)

  • Ammonium bifluoride (2)


Case 1:

Abdominal X-ray


Iron poisoning in children

  • Leading cause of childhood poisoning deaths

  • Pathophysiology:

    • corrosive effect on GI tract

    • cellular toxin

  • Toxic dose > 40-60 mg/kg elemental Fe

    • adult strength preparations much more likely to cause toxicity than children’s chewables


Iron poisoning: clinical findings

  • Vomiting

  • Diarrhea

  • Hypotension

  • Metabolic acidosis

  • Leukocytosis, hyperglycemia

  • Radiopaque pills on plain x-ray

  • Late complication: hepatic failure


Treatment of iron poisoning

  • Volume replacement

    • IV crystalloid boluses

  • Chelation therapy

    • deferoxamine (Desferal) is specific chelator

    • Iron chelate complex  “vin-rose” urine

    • IV route preferred (don’t use IM “test dose”)

    • avoid prolonged deferoxamine therapy


Gut decontamination for iron ingestion

  • Home:

    • consider ipecac-induced emesis if recent OD

    • argument against ipecac: it masks spontaneous vomiting

  • Hospital:

    • ipecac or gastric lavage? Neither very effective

    • lavage with HCO3, PO4? Dangerous

    • whole bowel irrigation = best method


Whole bowel irrigation

  • Balanced electrolyte solution with non-absorbable polyethylene glycol (PEG)

    • no electrolyte disturbance

    • no net fluid gain or loss

    • well-tolerated

  • Method: GoLytely™ or Colyte™

    • 500 mL/hour by gastric tube until rectal effluent clear

    • Adolescents/adults: 1-2 L/hr


Case study:

  • A toddler is found with an open daily medicine container belonging to his grandmother.

  • Usual contents:

    • Lasix 40 mg

    • Cardizem-CD 240 mg

    • Multiple vitamin

  • Container is now empty. Child asx.


ECG in a patient with verapamil OD


Decreased

Automaticity

& Conduction

Negative

Inotropic

Effects

Dilated Vascular

Smooth Muscle

SVR

HR

CO

AV Block

SHOCK

Calcium Channel Blocker Poisoning


Calcium antagonist toxicity

  • Shockcaused by combination of:

    • Decreased automaticity & conduction

    • Negative inotropic effects

    • Vasodilation

  • Treatment with calcium

    • most effective for negative inotropic effect

    • high doses may be needed

    • in the future: insulin + glucose?


Case study:

  • An 18 month old is brought to the ER after a seizure

  • No prior seizures

  • No recent illness or fever

  • HR 140/min, BP 105/70

  • Pupils dilated

  • Skin flushed, dry


Case 2: ECG


Common drug-induced seizures

  • Tricyclic antidepressants

  • Cocaine & amphetamines

  • Theophylline

  • Diphenhydramine

  • Isoniazid (INH)

  • Phenothiazines

  • Strychnine

  • Many others (camphor, lindane, etc)


Case study, cont.

  • ECG monitor shows wide QRS complex

  • Repeat BP 70/p

  • The child is intubated endotracheally

  • A therapeutic drug is given:


Tricyclic antidepressant OD

  • “Three C’s”

    • coma

    • convulsions

    • cardiac conduction defects

      … AND

  • Anticholinergic effects

    • dilated pupils

    • tachycardia

    • jerking movements


Treatment of TCA overdose

  • ABCs

  • No ipecac! (use AC orally or by NG)

  • Monitor asx child for at least 6 hours

  • QRS prolongation:

    • Caused by Na channel block

    • Rx = Sodium Bicarbonate

    • 1-2 mEq/kg IV bolus

  • Do NOT use physostigmine


Another Case

  • A child is found with an open container of “wire wheel cleaner”

  • Contents:

    • ammonium bifluoride

    • hydrofluoric acid

  • Child initially asymptomatic


Fluoride toxicity

  • Sources:

    • wire wheel cleaners, degreasers, rust and water stain removers

    • fluoride tablets and drops

  • Toxicity:

    • hypocalcemia (even from dermal exposure)

    • hyperkalemia

    • ventricular fibrillation

  • Treatment: Calcium (oral and IV)


Case study:

  • A 16 year old takes several “happy pills” provided by a friend.

  • Develops a headache, vomits once.

  • In ER:

    • awake, alert, c/o headache

    • HR 38/min (w/2nd degree AV block)

    • BP 166/100 mm


Phenylpropanolamine

  • Common OTC product

  • May be used to get “high” (not very effective) or as suicidal agent

  • Hypertension common, often with reflex bradycardia or even AV block

    • intracranial hemorrhage may occur

  • Treat with vasodilator, e.g. phentolamine, nitroprusside


11-6-2000: FDA’s MedWatch

  • “FDA is taking steps to remove phenylpropanolamine hydrochloride from all drug products due to the risk of hemorrhagic stroke...

  • “... FDA has significant concerns because of the seriousness of stroke and the inability to predict who is at risk …”


Gut decontamination

  • Current consensus:

    • Gut emptying of limited value

    • AC alone probably fine in most patients

  • Some twists:

    • SI still useful at home w/in 5-10 min?

    • Lavage for selected cases?

    • Role of Whole Bowel Irrigation?

    • What about home AC?


Anyonefor

charcoal?


Use of ipecac is declining

YearIpecac used

1983 13.4%

1988 8.4%

1993 3.7%

1998 1.2%

Source: AAPCC 1999


Final “stumper”

  • 9 month old being watched by grandmother

  • Found flaccid, grunting, with decreased level of consciousness

  • HR 70/min, BP 105/59

  • Respirations agonal, O2 sat 80%

  • Pupils pinpoint


More information . . .

  • No response to naloxone

  • Treated supportively, eventually recovered

  • Initial history: grandmother takes lisinopril, HCTZ

  • Also using eye drops for glaucoma


Continued

  • Alphagan™ (brimonidine 0.2%)

    • used for open-angle glaucoma

  • Stimulates -2 receptors (similar to clonidine)

    • CNS depression, bradycardia, HOTN

    • Peripheral: alpha-agonist can elevate BP


California Poison Control System

  • Public Hotline: 1-800-876-4766 (8-POISON)

  • Health Professionals: 1-800-411-8080

  • 300,000 exposures/year

    • 2/3 are kids

    • also: suicides, occupational, hazmat, veterinary, consumer product recalls, ...

  • Most kids can be managed at home

    • PCC can communicate with 9-1-1 or paramedics on scene


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