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

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

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

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

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

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 1999 24 deaths in children 6

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)


Poisoning in children

Case 1:

Abdominal X-ray


Iron poisoning in children

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

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

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

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

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 study1

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.


Poisoning in children

ECG in a patient with verapamil OD


Poisoning in children

Decreased

Automaticity

& Conduction

Negative

Inotropic

Effects

Dilated Vascular

Smooth Muscle

SVR

HR

CO

AV Block

SHOCK

Calcium Channel Blocker Poisoning


Calcium antagonist toxicity

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 study2

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


Poisoning in children

Case 2: ECG


Common drug induced seizures

Common drug-induced seizures

  • Tricyclic antidepressants

  • Cocaine & amphetamines

  • Theophylline

  • Diphenhydramine

  • Isoniazid (INH)

  • Phenothiazines

  • Strychnine

  • Many others (camphor, lindane, etc)


Case study cont

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

Tricyclic antidepressant OD

  • “Three C’s”

    • coma

    • convulsions

    • cardiac conduction defects

      … AND

  • Anticholinergic effects

    • dilated pupils

    • tachycardia

    • jerking movements


Treatment of tca overdose

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

Another Case

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

  • Contents:

    • ammonium bifluoride

    • hydrofluoric acid

  • Child initially asymptomatic


Fluoride toxicity

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 study3

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

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


Poisoning in children

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

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?


Poisoning in children

Anyonefor

charcoal?


Use of ipecac is declining

Use of ipecac is declining

YearIpecac used

1983 13.4%

1988 8.4%

1993 3.7%

1998 1.2%

Source: AAPCC 1999


Final stumper

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

More information . . .

  • No response to naloxone

  • Treated supportively, eventually recovered

  • Initial history: grandmother takes lisinopril, HCTZ

  • Also using eye drops for glaucoma


Continued

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

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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