poisoning in children

1. Poisoning in Children Norah Al Khathlan M.D. Assistant Professor of Pediatrics Consultant Pediatrician Consultant Pediatric Intensivist 31/03/09

3. Poisoning in Children Objectives: At the end of this lecture the student will be able to : Define poisoning. Differentiate the routes of poisoning. Identify risk factors for pediatric toxidromes. Identify specific Toxidromes. Differentiate between the different classes of toxidromes. Describe the general management of the toxidromes. Identify the universal antidotes. Outline the management of specific toxidromes: Iron Salicylates Paracetamole/ Acetaminophen Kerosene & Corrosives Organophosphorus

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 Organophosphorus

8. Table 1. Agents Most Commonly Ingested by Children Less Than Six Years of Age, 1995 to 1998.Table 1. Agents Most Commonly Ingested by Children Less Than Six Years of Age, 1995 to 1998.

9. Table 2. Primary Agents Involved in Fatal Poisonings among Children Less Than Six Years of Age, 1995 to 1998.Table 2. Primary Agents Involved in Fatal Poisonings among Children Less Than Six Years of Age, 1995 to 1998.

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 A…..B…..C….. Identify the culprit. Limit absorption: Vomiting Lavage Now not recommended !!!! 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 Only in the 1st hour !!!! Naso/oro-gastric Lavage Bowel Irrigation: Recent ingestions Awake alert patient 500 cc NS Children / 2000cc adults Orally / Nasogastric tube Contraindications…?

14. Table 3. Agents Used for Gastrointestinal Decontamination in Children.Table 3. Agents Used for Gastrointestinal Decontamination in Children.

16. Important points Induced vomiting with syrup of Ipecac has NO role in poisoning in children or adults, in hospital and pre-hospital Other methods of “enhanced elimination” such as forced diuresis, or continuous gastric suction are not recommended. The new recommendation is to withhold gastric lavage and activated charcoal instillation as a method of gastric decontamination. We can use only if within the 1st hour post ingestion !!

18. 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

20. Acetaminophen poisoning Stage II: 24-48 hrs after ingestion. Better, less symptoms. Elevated bilirubin, transaminases and PT

21. 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

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

24. 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 i.e. Shock Coagulopathy Multi Organ Failure Syndrome MOFS

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: Gastric lavage with 5% NaHCO3 No activated charcoal to be used!!! Secure good IV Get initial then 4hrs levels and TBC Chelate with Deferoxamine if levels> 300mg/dL

32. Iron Poisoning Chelate with Deferoxamine: Stable pts : levels< 500 mg/dL ? dose =40mg/kg IM/IV Unstable: bleeding/ level > 500 Give 20cc/kg NS/RL as resuscitation 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

35. 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

36. SALICYLATES MANAGEMENT Treat electrolyte imbalance IV hydration Forced alkaline diuresis Hemodialysis Diuretics

38. 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 peri-hilar densities. Pneumatoceles, pleural effusion or pneumothorax and bacterial super-infection Resolution 2-7 days.

39. 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.

40. Corrosives A…B…C… Stabilize Alkali are the worst…! Cause coagulative necrosis Do not induce vomiting No gastric lavage Urgent upper endoscopy & Naso-gastric insertion May develop: Strictures of oral cavities Esophageal strictures Airway Injury & stenosis Perforation & Mediastenitis

42. Quiz 5 year old girl came back from a picnic with: Vomiting Abdominal pain Salivation Breathing difficulties Cyanosis Sudden loss of consciousness.

43. Quiz On examination: Tachycardia at 180 b/min Bp 100/60 / afebrile Cyanosed and gasping Frothy oral secretion Soft abdomen Lung coarse crepitation both sides Comatose and flaccid. Constricted pin-point pupils

44. Organophosphorus compounds Organophosphorus compounds: Insecticides Inhibition of Cholinesterase enzymes all over. Muscarinic N/V Abdominal pain/ fecal incontinence Cholinergic : cough, resp.secretions, crepitation and even pulmonary edema CVS : Tachycardia/ bradycardia/ block/ hypotension Nicotinic: restlessness, confusion, coma, meiosis, flaccidity/convulsion

45. Organophosphorus compounds Diagnosis: blood Cholinesterase levels < 50% indicates poisoning. Atropine as test dose Management: A….B….C….. Stabilization Wash hair and body with soap & water Consider Gastric lavage if within 1hr Atropine sulphate I.V. till pupils are normal size. Dose = 0.02 mg/kg Q 15-20 mins

46. Organophosphorus compounds Atropine sulphate I.V. till pupils are normal size. Remember…Atropine has no effect on muscle paralysis ? must support breathing USE Cholinestrase reactivator such as Pralidoxime Dose = 1gm /kg IV Q 30 mins

48. 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. Remember Poisoning center!! You can call them anytime to get information

49. Thank you