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 2000;342:186-191

9. Shannon M. N Engl J Med 2000;342:186-191

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 ABC’s 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 2000;342:186-191

15. Circumstances under Which Administration of Ipecac Syrup Should Be Avoided Shannon M. N Engl J Med 2000;342:186-191

17. Important points

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 > 900 µmol/L ---> POSSIBLE RISK • Nausea, vomiting, malaise and diaphoresis. • Normal bilirubin Transaminases and PT

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 > 1000 IU/L • Prolonged PT

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

25. 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 levels> 300mg/dL

32. Iron Poisoning • Chelate with Deferoxamine: • Stable pts : levels< 500 mg/dL 40mg/kg IM/IV • Unstable: bleeding/ level > 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

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.