1. Pediatric Toxicology M Waseem, MD Lincoln Hospital Bronx New York

2. Epidemiology • 2 million calls • 52% of poison center calls < 6years • Peak age 18 months - 3 years

3. Epidemiology • Unintentional (1-2 years) • Exploratory • Boys > girls • Intentional (adolescent) • Purposeful • Girls > boys

4. Children are different • Unable to discriminate safe from unsafe liquid • Fail to recognize the suitability of the drink

5. Epidemiology • Around Meal time • Grand parents home • Kerosene or gasoline in a soda bottle • Older sibling can pharmaceutically treat younger sibling

6. Very toxic! • Prenatal vitamin supplements • Antidepressants • Hydrocarbons

7. Most often reported • Cleaning products 10.4% • Analgesics 10.3% • Cosmetics 9% • Cough & cold preparation 5.1% • Insecticides 4%

8. ICU Admission • TCA • Anticonvulsants • Digitalis • Opiates • Hydrocarbon-based house-hold products

9. Toxic Exposures/Death • Analgesics • Sedative-hypnotics • Alcohols • Gases & fumes • Cleaning substances

10. “Fatal Sip”

11. Fatal Sip • Camphor (100mg/kg) 1gm/5 ml • Methyl Salicylate 1.4gm/ml (200 mg/kg) 1/2 tsp

12. Fatal Sip • Benzocaine 2 ml • Methemoglobinemia • Seizure

13. Malignant Swallow • Chloroquine (20 mg/kg) 500 mg • Theophylline (8.4 mg/kg) 500 mg • Imipramine (15 mg/kg) 150 mg • Chlorpromazine (25 mg/kg) 200 mg

14. Malignant Swallow • Clonidine 0.3 mg tablet • Bradycardia • CNS depression

15. Highly Toxic • Acetonitrile • Ammonium Fluoride • Benzocaine • Camphor • Pennyroyal Oil

16. Acetonitriles • Artificial Nail Tip remover • Methemolobinemia • Delayed presentation (4-12 hours) • Must be hospitalized

17. Ammonium Fluoride • Glass etching, de-rusting and wheel cleaning commercial products • Armoral Quick Silver Wheel cleaner (17% ammonium fluoride) • only 2 ml

18. Ammonium Fluoride • Inactivates proteolytic & glycolytic enzymes • Binds with Ca & Mg • Acidosis, Dysrhythmia & coagulopathy • Direct effect on CNS • Seizures

19. Benzocaine • Teething gels (Orajel), first aid cream hemorrhoidal preparations • Methemoglobinemia • < 6 months (methemoglobin reductase)

20. Camphor • Vicks VapoRub • Only 5 ml • CNS effects

21. Pennyroyal Oil • Health food products, herbal preparations • Depletes glutathione • Toxicity to liver & lung • < a teaspoon • A tablespoon (fatal)

22. Look-Alike, Sound-A-Like • Albuterol Atenolol • Celebrex Cerebrex • Oruvail Elavil • Lamictal Lomotil • Lotrimin Lotensin • Plendil Pindolol

23. Look-Alike, Sound-A-Like • Hydralazine Hydroxyzine • Hydrocodone Hydrocortisone

24. Plant Toxidromes

25. Digitalis Effects • Lily-of-the-valley • Foxglove • Oleander • Yew

26. Nicotinic Effects • Poison hemlock

27. Atropinic Effects • Jimsonweed

28. Non-Toxic Products • Ball point ink • Bubble bath soaps • Candles (beeswax or paraffin) • Chalk • Cigarettes (< 3 butts) • Crayons

29. Non-Toxic Products • Deodorants • Lipstick • Pencil (graphite) • Toothpaste • Water colors

30. Evaluation • History of poisoning • Toxicologic physical examination • Laboratory studies • Gastrointestinal decontamination

31. History • What? • When? • How much?

32. What ? • Medication • Illicit drug • Hazardous chemical

33. What form? • Pill • Solid • Liquid • Gaseous

34. What route ? • Ingestion • Inhalation • Topical • Intravenous

35. When ? • Elapsed time

36. How much ? • Estimate amount • Concentration

37. “Vital signs”

38. Bradycardia • Digoxin • Narcotics • Organophosphates • Carbon monoxide • Beta-blocker

39. Tachycardia • Alcohol/amphetamine • Atropine/tricyclic • Theophylline • Salicylates, Iron • Cocaine/PCP

40. Slow Respiration • Alcohol • Narcotics • Clonidine • Sedatives

41. Tachypnea • Amphetamines • Salicylates • Carbon monoxide

42. Hypotension • Methemoglobinemia • Carbon monoxide • Cyanide • Iron • Narcotics

43. Hypertension • OTC cold remedies • Amphetamine • PCP • TCA • Cocaine

44. Ventricular Tachycardia • Amphetamines • Carbamzepine • Chloral hydrate • Cocaine • Digitalis • Theophylline

45. Torsades de Pointes • Chloral hydrate • Cisapride • Organophosphates • Terfenadine • Phenothiazines

46. Hypoglycemia (HOBBIES) • H-Hypoglycemia • O-Oral hypoglycemic agents • B-Beta-Blockers • I-Insulin • E-Ethanol • S-Salicylates

47. Hypothermia • Ethanol • Narcotics • Carbon monoxide

48. Hyperpyrexia • Atropine • Salicylates • Theophylline • Cocaine • TCA

49. Mental Status

50. Coma • Narcotic • Anticholinergic • Carbon monoxide