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Pediatric Poisoning Edwin de Zoeten M.D. Ph.D. PL-3

Pediatric Poisoning Edwin de Zoeten M.D. Ph.D. PL-3. Case : 11 year old male presents to the ER with altered mental status. Pt. was a previously healthy who went to bed at his GM’s home in his normal state of health. He was found wandering outside at 3:00 AM. Case con’t:

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Pediatric Poisoning Edwin de Zoeten M.D. Ph.D. PL-3

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  1. Pediatric Poisoning Edwin de Zoeten M.D. Ph.D. PL-3

  2. Case: 11 year old male presents to the ER with altered mental status. Pt. was a previously healthy who went to bed at his GM’s home in his normal state of health. He was found wandering outside at 3:00 AM.

  3. Case con’t: Vitals: T:38.9, P:130, R:30, BP 140/90 PE: General: active, agitated, talking about a dog in the room HEENT: NC, AT, pupils dilated at 6mm w/o reaction, +photophobia, o/p clear but dry MM. Skin: Hot, mildy red. No lesions or rashes Lungs: CTA B CV tachycardic with regular rhythm no murmur.

  4. Case continued: Abd: soft NT, ND, no HSM, no Mass, decreased BS Extr: CR< 2 MAEW, doesn’t follow commands, is ataxic Neuro: DTR’S 3+, ataxic, restless with visual hallucinations. Poor finger to noses, unable to assess most exams. Babinski down going.

  5. Epidemiology • More than 50% of childhood accidents in the United States involved toxic ingestions. • More than 4 million poisoning cases are reported annually to poison centers throughout the US each year. • Greater than 53% of these events are in patients 5 years old or younger. • Most unintentional encounters result in mild or no symptoms, and no morbidity. • There has been a significant decline in the number of pediatric poisoning deaths 216 in 1972 versus 25 in 1997. • Most frequently fatal pharmaceutic ingestions in children have been prenatal iron supplements, antidepressants, cardiotonic agents and salicylates.

  6. Evaluation • ABC’s • History • Physical • Urine/serum Tox • Odors • Toxidromes

  7. ABC’s • Airway • Breathing • Circulation • Diagnosis • Decontamination • Enhanced removal

  8. History: • What was ingested? • Containers • Ask EMS what was at the scene • Available meds, plants etc. • Quantity • Elapsed time • Route of exposure • Cause for ingestion

  9. What’s the difference they’re just small adults • Airway resistance is greater • Cardiac output very dependent on heart rate • Young infants are very susceptible to thermoregulatory problems • Mechanisms that typically distort mental status may be masked by limited pediatric neurologic repertoire • Depressants may have an accelerated effect in children as compared with adults • Seizures are more likely in children than adults

  10. Physical Exam Findings Constricted sympatholytics cholinergics Barbituates Opiates PCP Ethanol/Sedative hypnotics Dilated sympathomimetics Anticholinergics

  11. Vital Signs Hypothermia (COOLS): CO, opiates, Oral hypoglycemics, alcohols, sedative hypnotics. Hyperpyrexia (NASA): Nicotine, Antihistamines, sympathomymetics, salicylates, amphetamines, anticholinergics. Tachycardia (FAST): Free Base, amphetamines, anticholinergics, sympathomymetics, Theophyline cyanide, cyclic antidepressants, propoxyphene, antihistamines, low dose iron. Bradycardia (PACED): Propranalol, Acetylcholinesterase, clonidine, Ca-channel blockers, Ethanol, sedative hypnotics, opiates, digoxin, nicotine. Tachypnea (PANT): PCP,paraquat, pneumonitis, ASA, non-cardio PE, Toxin induced Met acid, hydrocarbons, organophosphates, Bradypnea (SLOW): Sed-hypnotics, liquor, opiates, weed, acetone, barbiturates, ibuprofen, nicotine.

  12. Vitals continued: Hypertension: (CT SCAN) Cocaine, Thyroid, Theophyline, Sympathomimetic, Caffeine, Anticholinergic, Nicotine. Hypotension: (CRASH) Clonidine, CCB’s, Reserpine, Antidepressants, Sedative hypnotics, heroin. Seizures: (OTIS CAMPBELL)Organophosphates, Tricyclics, INH, Insulin, Sympathomimetics, Camphor, Cocaine, Amphetamines, Methylxanthines, PCP, Benzo withdrawal, Ethanol withdrawal, Lithium, Lidocaine, Lead, Lindane

  13. Toxidromes: Anticholinergics: Mad as a hatter Red as a beet Hot as a hare Blind as a bat Dry as a bone Cholinergic • Muscarinic • Salivation • Lacrimation • Urination • Defacation • GI motility • Nicotinic • Tachycardia • Hypertension • Fasciculations • paralysis

  14. Odors: Garlic: Arsenic, Organophosphates, Thallium Pear: Chloral Hydrate, Paraldehyde Acetone: Chloroform, Isopropyl alcohol Almond: Cyanide Oil of wintergreen: Methylsalicylate Mothballs: Naphthalene, paradichlorobenzene Carrot: Water Hemlock

  15. Labs: • Urine tox • Good for drugs of abuse - amphetamines, barbiturates, benzo’s, cocaine, cannabinoids, opiates, PCP • Serum/plasma tox • Good for levels of selected substances - Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe, Li, Phenobarb. • Avoid a comprehensive tox screen. • Chem 7 • looking for an elevated anion gap

  16. Elevated Anion Gap Gap = Na - Cl -CO2 (should be 8-12) • Methanol • Uremia • Lactic acidosis • Ethylene Glycol • Paraldehyde • Alcohol • Ketoacidosis Diabetes Mellitus • Salicylates • Toluene • Iron, Isoniazide M U L E P A K S

  17. Abdominal X-rays Barium Enteric coated tablets Tricyclics Antihistamines Chloral hydrate, cocaine, condom Heavy metals Iodides Potassium, Phenothiazines Bet-A-Chip

  18. Decontamination • Emesis • Indications: Fe, Li, K at home management • Contraindications: • obtunded, comatose/convulsing • Likelihood of rapid progression • corrosives • Petroleum distillates

  19. Decontamination • Activated Charcoal • Indications: Multiple poisons • Contraindications: • ileus, obstruction • Corrosives • Some poisons not well absorbed • alcohols, alkalis, acids • CN, Fe, K, Li, Pb

  20. Decontamination • Gastric Lavage • Indications: • removal of ingested material • administration of charcoal/cathartics • Contraindications: • Obtunded, comatose/convulsing • corrosives

  21. Decontamination • Cathartics • Magnesium Citrate (4ml/Kg) • Use with caution in <2 yo. • Generally not recommended

  22. Enhanced elimination: Alkalinization of urine hemodialysis hemoperfusion peritoneal dialysis Multidose charcoal whole bowel irrigation

  23. Specific Antidotes Acetominophen COHb Digoxin Ethylene Glycol Iron Lithium Methanol Salicylate Theophyline N-acetylcysteine Oxygen, HBO Fab EtOH, Dialysis Deferoxamine Fluids, dialysis EtOH, Dialysis Alkalinization, dialysis repeat AC, hemoperfusion

  24. What happened to that kid?

  25. Back to the case: Labs: Chem7 EKG: Tachycardia, Mild prolonged QTc, sinus rhythm Urine Tox screen: Negative 139 112 9 105 4.3 19 0.6

  26. Procedures: • None/Observation • Discussed the use of physostigmine as an antidote not used. Patient gradually became more lucent. After a significant time period the patient admitted to ingesting seeds.

  27. Jimson Weed

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