1 / 48

به نام خدا

به نام خدا. زندگی عرصه یکتای هنرمندی ماست. هر کسی نغمه خود خواند و ازصحنه رود , صحنه پیوسته به جاست. خرم آن نغمه که مردم بسپارند به یاد..... نام درس:مسمومیت ها در اطفال نام مدرس:روانشاد دکتر مهدخت صدر بافقی نام ویادش جاودان باد. poisoning.

tamah
Download Presentation

به نام خدا

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. به نام خدا زندگی عرصه یکتای هنرمندی ماست. هر کسی نغمه خود خواند و ازصحنه رود, صحنه پیوسته به جاست. خرم آن نغمه که مردم بسپارند به یاد..... نام درس:مسمومیت ها در اطفال نام مدرس:روانشاد دکتر مهدخت صدر بافقی نام ویادش جاودان باد.

  2. poisoning The most common agents include: family member medication , cleaning solution, plants, cosmetic. most ingestion occur in home(92%). More than 50% occurred in children <5 yr.

  3. management history: Product name, amount of medication, time of exposure. age and weight of child progression of symptoms Medical history and underling disease

  4. Physical examination • Level of consciousness , vital signs pupillary size , presence of muscle faciculation bowel and bladder activity , cardiac arrhythmias , seizures , hypothermia. • Pulmonary edema • Certain symptoms and signs are specific . ( toxic syndromes)

  5. toxic syndromes Anticholnergic: • Thirst ,flushed skin • mydriasis • hyperthermia ,urinary retention, • delirium, hallucination, tachycardia • respiratory insufficiency

  6. Cholinergic • Exocrin glands secration, urination • nausea ,vomiting , diarrhea • muscle fasciculation, weakness or paralysis • bronchospasm , bradycardia or tachycardia , • convulsions , coma • miosis

  7. Extrapyramidal • Tremor ,rigidity, opisthotons ,torticollis • dysphonia ,fever , metabolic acidosis • tachycardia ,hyperpnea • restlessness , convulsion ,

  8. narcotic: • CNS depression • hypothermia • hypotention • hypoventilation • miosis

  9. Sympathomimetic • Psychosis • seizure • mydriasis • hypertension • tachypnea • hyperthermia

  10. complication • Coma DD: trauma , CVA , asphexia, meningitis • Pinpoint puils : Opiate, organophosphate ,phenothiazines ,hloral hydrate , • Dilated pupils: cyclic antidepressant , atropine -like agents

  11. Caustic ingestion • Dysphagia , epigasteric pain. • oral burns. • low-grade fever. • When lesion heal then strictureform . alkalia agents :(tastless) oropharynx and esophagial necrosis. button batteries : produce caustic injury if that remain in esophaguse should be removed.

  12. treatment: • dependents on agent ingested and presence or absence esophagial injury • Routine use of diluent as a first aid ??? • Antibiotic if there is signs of infection . • Dilatation of late forming strictures(2-3 weeks later) .

  13. Acid agents: lung , oral mucosa,esophgus and stomach injury and necrosis. • Mocusal and tissue damage less sever than alkali . (Acid taste) • Treatment: initial therapy like the alkali ingestion • (dilution and no emesis or nutralizing)

  14. Screening laboratory clues • Metabolic acidosis: • methanol, ethanol • uremia, diabetes • iron, isoniazid, salicylate , starvation • Determining : Blood gases, urin PH, Na, K, chloride, glucose, BUN, serum osmolality and anion gap

  15. Screening laboratory clues • Hyperglycemia: salysilate, phenothiazide, sympathomimetic, isoniazid, iron, • hypoglycemia: insulin, Ethanol , propranolol,Isonizid, oral hypoglycemic agents. • Hypo calcemia: Ethylene glycol, fluride , oxalate • Radiopaque substance: iron , phenothizine , Entric coted pills, Dental amalgam, Heavy metals, pothassium chloride

  16. Drugs monitoring for toxicity • Antibiotics : aminoglycosid, chloramphenicol, vancomycin. • Immuno suppression : methotrexide , cyclospurine • Antipyretic: Acetaminophen , salycilate • Others: digoxin, lithium, theophylin, anticonvulsant serotonin

  17. treatment Supportive care 1-ABC 100%O2 ,naloxane,glucose 1g/kg IV . • Diuresis • Hemoperfusion: rarly used in small children • Most liquid drugs absorbed within 10 min and solid within 1-2hr

  18. treatment • Prevention absorption : • Activated charcoal • Gastric lavage • Cathartics • Diuresis • Hemoperfusion • Dialysis: methanol, ethylen glycol, salycylate, theophylin

  19. Treatment(con) Gastric lavage: • Not documented efficacy in children. • Remove only a fraction of gastric contents. • It should only used in older children and selected situations

  20. treatment • Prevention absorption • syrup ipeca : ?? (Potentially complication without improve clinical outcome) • onset emesis after 20-30 min and several episodes over 1-2 hr. • 10 CC for small children 15CC =1-12years ,30 CC older children. • Remove 1/3 stomach content. • when ingestion is < 60 minute and air way protected • not be used as a general treatment.

  21. Treatment(con) • Contraindication ipeca : • minimaliy toxic agents • prior vomiting • air way unprotected • caustic agents, hydrocarbon , agent cause the rapid onset CNS or cardiovascular symptoms • foreign body

  22. treatment Activated charcoal:prevent toxin absorption. • single dose25-50g small children 50-100g> 12yr. Repeated doses in serious poisoning. • 25% of patients experience one episode of vomiting. • most benefit achieved within 1 hour of ingestion. • Ineffective against : caustic ,corrosive , hydrocarbon , heavy metals, glycols and water – insoluble compounds

  23. Treatment(con) Cathartics: ( sorbitol 1g/kg, magnesium citrate250cc/kg ).??? • combination with activated charcoal is not recommended (essential nelson) • complication: Electrilyt imbalance and dehydration

  24. Emergency Antidotes • Poison antidotes dose Mercury ,arsenic, gold BAL 5mg/kg Methyl alcohol Ethyl alcohol +dialysis 1ml/kg Nitrites methylene blue 1-2 mg/kg Opiates naloxan 0.1 m g /kg- 2

  25. Emergency Antidotes Poison antidotes dose organophosphate Atropin0.02- 0.05mg/kgIV paralydoxime20-50 mg/kg Sympathomimeticphentolamin agents β-blocking

  26. Acetaminophen • Acute toxic dose200mg/kg in children < 12 yr. • Repeated doses more than recommended may lead hepatic injury. • Children <6yr unlikly develop significant toxicity . • 1-2 hr of ingestion activated charcoal • antidot started as soon as possible ,oral N- acetylcysteine may be benefit if started 24-36 hr after ingestion

  27. stages in clinical course of Acetaminophen toxicity • 1 - ½-24 hr anorexia ,nausea ,vomiting ,pallor • 2- 24-48hr abdominal pain, bilirobin, PT↑ hepatic enzyme↑ • 3- 72-96 hr anorexia , nausea , vomiting , • peak liver abnormality • 4- 4days- 2 weeks resolution of hepatic dysfunction ↑or complete or liver failure

  28. salicylates • Nausea , vomiting, gastric irritation • hyperventilation, Respiratory alkalosis • dehydratoin • prograssive metabolic acidosis • Agitation, counfusion are common. • Hyperglycemia, or hypoglycemia. • Pulmonary edema

  29. salicylates( treatment) • Activated charcoal. • Rehydration , correction electrolyte. • Large quantities of Potassium , and bicarbonate. • Urine PH 7-7/5 ( using bicarbonate IV) • Dialysis in sever cases

  30. Antidepressant( TCA, SSRI) • Block reuptake serotonin , dopamin , norepinephrin • Myocardial depression ,dysrhythmia ½-6 hr • CNS effect 1/3 (lethargy , coma, drowsiness ),seizure • Anticholinergic effect. tachycardia ,mydriasis , • Hypertension ( no treatment ). • hypotension (rare but poor prognosis).

  31. Antidepressant( TCA, SSRI) treatment • ABC Emesis is contraindication(aspiration ,after onset CNS deprassion) • Activated charcoalshould be used . • Sodium bicarbonate ( to treat and prevent dysrhythmia) and if unresponsive…….. Lidocaine used . • Fluid therapy for hypotension. • Bezodiazepine for seizure. • Asymptomatic patient observe and ECG monitoring for 6 hr.

  32. Cholinsterase inhibitor ( organophosphate and carbamate) • Prevent degradation acetylcholine , bind to cholinesterase and inactiveted it . • muscarin signs: emesis, urinary and fecal incoutinence, drooling , bronchospasm, miosis, hypotention , bradycardia. • Nicotinic signs: muscle weakness , tremor , fasciculation, • hypertention ,hypoventilation , tachycardia , dysrehythmia, • CNS effects ; confusion, seizure , coma .

  33. Cholinsterase inhibitor ( organophosphate) • Treatment: • ABC • activated charcoal • Fluid and electrolyte replacement . • antidotes ( significant organophophate poisoning both antidotes is necessary) . even with treatment neurologic symptoms may occur and may be persist .

  34. Treatment( con) Antidotes 1- Atropin infusion : • blocks acetylcholine receptor . ( reversing the CNS and muscarinic effect) 2- paralidoxime : • breaks the bond between organophosphate and enzyme ,librating enzyme, degrading organophosphate

  35. Acute hydrocarbon risk assessment • Systemic and pulmonary toxicity Hydrocarbon ingestion result in systemic but more often pulmonary toxicity, Systemic: carbon tetrachloride, benzen, trichloroethylene. Local toxicity: kerosen, furniture polish, signal oil , gasolin Non toxic : tar asphalt, motor oil , lubricant, baby oil

  36. hydrocarbon 1. Aspiration pneumonia: (Low vicosity : gasolin, kereson , naphta , lamp oil ). Cough, fever (10 days),leukocytosis , chest Xray( may normal 6-12hr) 2. Systemic symptoms : most hydrocarbon can cause transient CNS depression. Few have renal toxicity ,carbon tetrachloride produce hepatic toxicity.

  37. Hydrocarbon ( treatment) • Emesis is contraindicacated. • Activated charcoal is not useful. • in pneumonit respiratory treatment is supportive. • Corticosteroid avoided . • Prophylacttic antibiotics should not be given. • Respiratory failure treated with standard ventilation (ECMO ?)

  38. Snake bite • خصوصيات سم مار پلي پپتيدها ، آنزيمهاي پروتئوليتيك‏وتوكسين‏ها، نوروتوكسيك ، سيتوليتيك • علائم كلينيكي سيستميك : ترس و وحشت : تهوع، استفراغ، اسهال، سنكوپ،تاكيكاردي ، پوست سرد و مرطوب، فاسيكولاسيون عضلاني، بندرت شوك علائم موضعي: محل نيش مار: دردفوري و در 90% مواردادم:ادم درطي نيم ساعت و گاهي چند ساعت بعدتاول: در طي چند ساعت، لنفاژيت، غدد لنفي حساس خفيف، متوسط ، شديدارزيابي بر اساس :علائم لوكال، سيستميك، انعقادي

  39. Guidelines for assessing • خفيف: ادم ، اريتم يا اكيموز و بدون علائم سيستميك و مشكلات انعقادي • متوسط : ادم پيشرونده بالاتر از محل گزش تهوع ،استفراغةپارستزي اطراف دهان و هيپوتانسيون خفيف علائم خفيف انعقادي • شديد: ادم سريع ،اريتم و يا اكيموزدر تمام عضو هيپوتانسيون شديد،تاكيكاردي ،تاكي پنه،تغيير سطح هوشياري مشكلات واضح انعقادي، ترومبوسيتوپني و خونريزي خودبخود

  40. treatment • آيا مار سمي بوده؟ • بيحركت كردن عضو • تورنيكه ممكن است ايسكمي را تشديد كند. • گذاشتن يخ و انسيزيون موضع ممكن است باعث آسيب بافت بشود. • زخم بايد تميز شود ، تتابولين • در اورژانس: كنترل راه هوايي، تنفس، گردش خون، گرفتن رگ، گرفتن شرح حال: زمان‏گزش - خصوصيات مار،شرايط مديكال همراه ، حساسيت دارويي و غذايي، سابقه مارگزيدگي و درمان آن

  41. treatment • معاينه فيزيكي: • معاينه قلبي، ريوي، نورولوژيك، توجه به محل گزش • اندازه گيري قطرمحل گزش وتكرار اندازه گيري هر 20-15 دقيقه تا توقف تورم • گرفتن نمونه خون جهت PTT,PT,CBC -فيبرينوژن ، FDP ، گروه خون ، اوره ، كراتينين • تجويز آنتي ونوم:(در طي 4 ساعت و حد اكثر 12 ساعت پس از گزش ) اثر اوقات در طي چند دقيقه ودر تمام مواقع در طي 6 ساعت علامت دار ميشود. اكثر بچه ها درجه 2ويا 3 مسموميت بوده و اكثر اوقات نياز به آنتي ونوم و با مقدار زيادتر دارند كنترل اوليه ابتدا 5-10 ويال crifab antivenin)(در صورت كنترل ، 2 ويال در فواصل ساعات 6 و 12و18گزيدگي با مارcoral نياز به 3-5 ويال آنتي ونوم پروفيلاكسي دارد. ايمونيزاسيون كزاز آنتي بيوتيك‏در‏صورت‏عوارض باكتريال

  42. classification of envenomation • Grade0 : no envenomation • Grade 1 mild : local swelling and pain • Grade 2 moderate: swelling, pain or echymosis progressing beyond the site Mild systemic or laboratory manifestation • Grade 3 sever: sever systemic finding and labratory

  43. scorpion Patogenesis: • Hyaluronidase ,sertonin, histamin and neurotoxin • neurotoxin bind to presynaptic membranes and release acetylcholin and stimulation of both sympathetic and parasympathetic nervous systems.

  44. Clinical manifestation • Most sting cause immediate local reaction .(mild burning to sever pain) • Severe envenomation causes autonomic dysfunction within 1 hr. • Symtoms : Agitation,irritability,salivation,bluredvision, hypertension, tachycardia,tachypnea and nystagmus. Rarely in smal children respiratory failure,convulsion or coma.

  45. Clinical manifestation • علائم سيتميك :تب ، تعريق، افزايش بزاق، پوست سرد و مرطوب، تاكيكاردي و تاكي پنه • علائم عصبي: بيقراري ، گيجي ، خواب آلودگي ، افزايش رفلكسها، همي پلژي، تشنج، كوما • ريه: ادم ريه قطع تنفس، فلح عضلات تنفس • كليه: تغييرات‏حجم ادرار،هماتوري،هموگلوبينوري، نارسايي كليه • خوني:هموليز ، ترمبوز عروق و گانگرن • رقلبي :: CHF، تغييرات فشار خون • گوارش:افزايش دفعات اجابت مزاج ، خونريزي گوارشي، تهوع و استفراغ ،پانكراتيت • مرگ و مير در اطفال و افراد مسن ، از چنددقيقه تا 2 روز ، اغلب در 12 ساعت اول • علت مرگ : اثر سم رويCNS ، مركز تنفس، ميوكارديت، نارسايي قلب، آريتمي، خونريزي

  46. Scorpion envenomation • Grade 1: local discomfort and paresthesia. • Grade 2: pain and parestesia extend up the extremity. • Grade 3: cranial nerve dysfunction, dysphagia, roving eyes, facial , paresthesia, restlessness. • Grade 4: cranial nerve dysfunction ,drooling, uncontrollable eye movements, faciculation , opisthotonos, convulsion,wheezing, hyperthermia ,cyanosis

  47. treatment • Localized pain: ice and analgesics.(pain deminish within 24hr) hospital admission: Sever envenomation + autonomic instability. • Symptoms resole within 24-48hr • In cardiopulmonary compromise should be given antivenin. (complete resolution symptoms within 1 hr)

  48. treatment • اطلاع از عقربهاي منطقه • تسكين درد با ليدوكائين، گذاشتن يخ ، شستشوي محل زخم ، استامينوفنت • تورنيكه، انسيزيون و ساكشن مؤثر نيست. • آنتي ونوم: در علائم شديد سيستميك • كلسيم:در كرامپ عضلاني • تشنج:ديازپام، فنوباربيتال • هموليز:: تزريق خون+ مايعات كافي و قليائي كردن ادرار

More Related