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Pediatric Toxicology. M Waseem, MD Lincoln Hospital Bronx New York. Epidemiology. 2 million calls 52% of poison center calls < 6years Peak age 18 months - 3 years. Epidemiology. Unintentional (1-2 years) Exploratory Boys > girls Intentional (adolescent) Purposeful Girls > boys.

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pediatric toxicology

Pediatric Toxicology

M Waseem, MD

Lincoln Hospital Bronx New York

epidemiology
Epidemiology
  • 2 million calls
  • 52% of poison center calls < 6years
  • Peak age 18 months - 3 years
epidemiology3
Epidemiology
  • Unintentional (1-2 years)
    • Exploratory
    • Boys > girls
  • Intentional (adolescent)
    • Purposeful
    • Girls > boys
children are different
Children are different
  • Unable to discriminate safe from unsafe liquid
  • Fail to recognize the suitability of the drink
epidemiology5
Epidemiology
  • Around Meal time
  • Grand parents home
  • Kerosene or gasoline in a soda bottle
  • Older sibling can pharmaceutically treat younger sibling
very toxic
Very toxic!
  • Prenatal vitamin supplements
  • Antidepressants
  • Hydrocarbons
most often reported
Most often reported
  • Cleaning products 10.4%
  • Analgesics 10.3%
  • Cosmetics 9%
  • Cough & cold preparation 5.1%
  • Insecticides 4%
icu admission
ICU Admission
  • TCA
  • Anticonvulsants
  • Digitalis
  • Opiates
  • Hydrocarbon-based house-hold products
toxic exposures death
Toxic Exposures/Death
  • Analgesics
  • Sedative-hypnotics
  • Alcohols
  • Gases & fumes
  • Cleaning substances
fatal sip11
Fatal Sip
  • Camphor (100mg/kg) 1gm/5 ml
  • Methyl Salicylate 1.4gm/ml (200 mg/kg) 1/2 tsp
fatal sip12
Fatal Sip
  • Benzocaine 2 ml
    • Methemoglobinemia
    • Seizure
malignant swallow
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
malignant swallow14
Malignant Swallow
  • Clonidine 0.3 mg tablet
    • Bradycardia
    • CNS depression
highly toxic
Highly Toxic
  • Acetonitrile
  • Ammonium Fluoride
  • Benzocaine
  • Camphor
  • Pennyroyal Oil
acetonitriles
Acetonitriles
  • Artificial Nail Tip remover
  • Methemolobinemia
  • Delayed presentation (4-12 hours)
  • Must be hospitalized
ammonium fluoride
Ammonium Fluoride
  • Glass etching, de-rusting and wheel cleaning commercial products
  • Armoral Quick Silver Wheel cleaner (17% ammonium fluoride)
  • only 2 ml
ammonium fluoride18
Ammonium Fluoride
  • Inactivates proteolytic & glycolytic enzymes
  • Binds with Ca & Mg
    • Acidosis, Dysrhythmia & coagulopathy
  • Direct effect on CNS
    • Seizures
benzocaine
Benzocaine
  • Teething gels (Orajel), first aid cream hemorrhoidal preparations
  • Methemoglobinemia
  • < 6 months (methemoglobin reductase)
camphor
Camphor
  • Vicks VapoRub
  • Only 5 ml
  • CNS effects
pennyroyal oil
Pennyroyal Oil
  • Health food products, herbal preparations
  • Depletes glutathione
  • Toxicity to liver & lung
  • < a teaspoon
  • A tablespoon (fatal)
look alike sound a like
Look-Alike, Sound-A-Like
  • Albuterol Atenolol
  • Celebrex Cerebrex
  • Oruvail Elavil
  • Lamictal Lomotil
  • Lotrimin Lotensin
  • Plendil Pindolol
look alike sound a like23
Look-Alike, Sound-A-Like
  • Hydralazine Hydroxyzine
  • Hydrocodone Hydrocortisone
digitalis effects
Digitalis Effects
  • Lily-of-the-valley
  • Foxglove
  • Oleander
  • Yew
nicotinic effects
Nicotinic Effects
  • Poison hemlock
non toxic products
Non-Toxic Products
  • Ball point ink
  • Bubble bath soaps
  • Candles (beeswax or paraffin)
  • Chalk
  • Cigarettes (< 3 butts)
  • Crayons
non toxic products29
Non-Toxic Products
  • Deodorants
  • Lipstick
  • Pencil (graphite)
  • Toothpaste
  • Water colors
evaluation
Evaluation
  • History of poisoning
  • Toxicologic physical examination
  • Laboratory studies
  • Gastrointestinal decontamination
history
History
  • What?
  • When?
  • How much?
slide32
What ?
  • Medication
  • Illicit drug
  • Hazardous chemical
what form
What form?
  • Pill
  • Solid
  • Liquid
  • Gaseous
what route
What route ?
  • Ingestion
  • Inhalation
  • Topical
  • Intravenous
slide35
When ?
  • Elapsed time
how much
How much ?
  • Estimate amount
  • Concentration
bradycardia
Bradycardia
  • Digoxin
  • Narcotics
  • Organophosphates
  • Carbon monoxide
  • Beta-blocker
tachycardia
Tachycardia
  • Alcohol/amphetamine
  • Atropine/tricyclic
  • Theophylline
  • Salicylates, Iron
  • Cocaine/PCP
slow respiration
Slow Respiration
  • Alcohol
  • Narcotics
  • Clonidine
  • Sedatives
tachypnea
Tachypnea
  • Amphetamines
  • Salicylates
  • Carbon monoxide
hypotension
Hypotension
  • Methemoglobinemia
  • Carbon monoxide
  • Cyanide
  • Iron
  • Narcotics
hypertension
Hypertension
  • OTC cold remedies
  • Amphetamine
  • PCP
  • TCA
  • Cocaine
ventricular tachycardia
Ventricular Tachycardia
  • Amphetamines
  • Carbamzepine
  • Chloral hydrate
  • Cocaine
  • Digitalis
  • Theophylline
torsades de pointes
Torsades de Pointes
  • Chloral hydrate
  • Cisapride
  • Organophosphates
  • Terfenadine
  • Phenothiazines
hypoglycemia hobbies
Hypoglycemia (HOBBIES)
  • H-Hypoglycemia
  • O-Oral hypoglycemic agents
  • B-Beta-Blockers
  • I-Insulin
  • E-Ethanol
  • S-Salicylates
hypothermia
Hypothermia
  • Ethanol
  • Narcotics
  • Carbon monoxide
hyperpyrexia
Hyperpyrexia
  • Atropine
  • Salicylates
  • Theophylline
  • Cocaine
  • TCA
slide50
Coma
  • Narcotic
  • Anticholinergic
  • Carbon monoxide
delirium psychosis
Delirium/Psychosis
  • Alcohol
  • PCP/marijuana
  • LSD
convulsion
Convulsion
  • Cocaine/Amphetamine
  • Lead
  • Salicylate
  • Isoniazid
  • Theophylline
miosis cops
Miosis (COPS)
  • Cholinergics, Clonidine
  • Opiates, Organophosphates
  • Phenothiazine, Pilocarpine
  • Sedatives (Barbiturates)
mydriasis aaas
Mydriasis (AAAS)
  • Antihistamine
  • Antidepressant
  • Anticholinergics (atropine)
  • Sympathomimetics
    • Amphetamine, Cocaine, PCP
caution
Caution!
  • Polydrug overdoses with opposite pupillary actions
  • Nontoxin diagnoses
    • Head trauma
    • CNS hemorrhage
cyanosis

Cyanosis

Unresponsive to oxygen methemoglobinemia

cyanosis58
Cyanosis
  • Aniline dyes
  • Nitrites
  • Benzocaine
  • Dapsone
dry skin

Dry Skin

Anticholinergic

breath odors
Breath Odors
  • Arsenic Garlic
  • Camphor Mothballs
  • Cyanide Bitter almond
  • Methyl salicylate Wintergreen
  • Paraldehyde Pears
cholinergic

Cholinergic

DUMBBEL

SLUDGE

dumbbels
DUMBBELS
  • D Diarrhea
  • U Urination
  • M Miosis, muscle fasiculation
  • B Bradycardia
  • B Bronchospasm
dumbbels64
DUMBBELS
  • E Emesis
  • L Lacrimation
  • S Salivation
sludge
SLUDGE
  • S Salivation
  • L Lacrimation
  • U Urination
  • D Diarrhea
sludge66
SLUDGE
  • G GI complaint
  • E Emesis
anticholinergic syndrome
Anticholinergic Syndrome
  • Dry mouth
  • Flushed appearance
  • Dilated pupils
  • Fever
  • Ileus
  • Urinary retention
  • Disorientation
anticholinergic
Anticholinergic
  • Hot as a hare
  • Blindas a bat
  • Dry as a bone
  • Red as a beet
  • Mad as a hatter
anticholinergic69
Anticholinergic
  • Full as a flask
anticholinergic70
Anticholinergic

Wet

Bowel sound +

Sympathomimetic

Dry

Absent bowel sound

Anticholinergic
narcotic
Narcotic
  • Pinpoint pupils
  • Coma
  • Respiratory depression
salicylates
Salicylates
  • Fever
  • Tachypnea & hyperpnea
  • Lethargy
  • Metabolic acidosis
theophylline
Theophylline
  • Protracted Vomiting
  • Tremors
  • Tachycardia
  • Seizures
  • Hypotension
isoniazid
Isoniazid
  • Seizures
  • Metabolic acidosis
  • Hyperglycemia
phencyclidine 4 cs
Phencyclidine (4 Cs)
  • Combative
  • Catatonia
  • Convulsion
  • Coma
  • Nystagmus
slide76
TCA
  • Metabolic acidosis
  • Prolonged QRS
  • Seizures
  • Dilated pupils
  • Dysrhythmia
cyanide
Cyanide
  • Feeling of impending doom
  • Sudden coma
  • Metabolic acidosis
  • Hypotension
  • Bitter almond odor
carbon monoxide
Carbon monoxide
  • Headache
  • Lethargy
  • Dizziness
  • Influenza like syndrome
  • Coma
ethanol
Ethanol
  • Hypoglycemia
  • Lethargy
  • Ataxia
  • Seizure
  • Characteristic breath odor
methanol
Methanol
  • Severe Metabolic acidosis
  • Sluggish pupils
  • Hyperemic retina
  • Blurred vision
ethylene glycol
Ethylene Glycol
  • Lethargy or coma
  • Metabolic acidosis
  • Urinary sediment
  • Crystalluria
clonidine
Clonidine
  • Hypothermia
  • Bradycardia
  • Miosis
  • Respiratory depression
elevated anion gap
Elevated anion gap
  • Methanol
  • Paraldehyde & phenformin
  • Iron & isoniazid
  • Ethylene glycol & ethanol
  • Salicylate
abc s
ABCs
  • Anticipate
  • Before
  • Complications
slide85
ABC
  • Airway
    • C-spine immobilization
  • Breathing
  • Circulation
    • secure IV access
slide86
ABC
  • Disability
    • consciousness
  • Drugs
  • Decontamination
consciousness
consciousness
  • A: Alert
  • V: Responsive to verbal stimuli
  • P:Responsive to pain
  • U: Unresponsive
drugs
Drugs
  • Dextrose
  • Oxygen
  • Naloxone
decontamination
Decontamination
  • Ocular- copious saline lavage
  • Skin- copious water
  • GI-consider options
lab evaluation

Lab Evaluation

No “tox panel” that is uniformly helpful

urine screen
Urine Screen
  • Marijuana 5-10 days
  • Amphetamines 48 hours
  • Barbiturates 24 h-2 wks
  • Cocaine 2-4 days
  • Opiates 2 days
  • PCP 8 days
slide92

EKG

All suspected ingestion

Tricyclics

pulse oximetry

Pulse oximetry

Measure of oxygen saturation of normal hemoglobin

pulse oximetry94

Pulse oximetry

Does not differentiate COHB from oxyhemoglobin

false low saturation
False low Saturation
  • Blue nail polish
  • Methylene blue
  • Poor distal perfusion
blood gas

Blood gas

Salicylates

chest x ray

Chest X-ray

Hydrocarbons

emergent lab analyses
Emergent Lab Analyses
  • Acetaminophen
  • Salicylates
  • Methanol
  • Ethylene glycol
  • Iron
emergent lab analyses100
Emergent Lab Analyses
  • Theophylline
  • Carbon monoxide
  • Lithium
optimum time
Optimum time
  • Actaminophen 4 hours
  • Salicylates 2-4 hours
  • Iron 4 hours
  • Carboxyhemoglobin Immediate
  • Methemoglobin Immediate
optimum time102
Optimum time
  • Ethanol 1/2-1 hour
  • Ethylene glycol 1/2-1 hour
  • Methanol 1/2-1 hour
  • Digoxin 4-6 hour
serial levels
Serial Levels
  • Salicylates
  • Carbamazepine
  • Digoxin
  • Phenobarbital
  • Theophylline
  • Valproic acid
radiopaque chips
Radiopaque (CHIPS)
  • Chloral hydrate
  • Heavy metals
  • Iron
  • Phenothiazine
  • Slow release
gi decontamination

GI. Decontamination

Preventing absorption

decontamination107
Decontamination
  • Syrup of Ipecac
  • Gastric lavage
  • Activated Charcoal
  • Cathartics
  • WBI (bowel irrigation)
syrup of ipecac109
Syrup of Ipecac
  • Nonprescription
  • CTZ stimulant
  • use only under poison control direction
syrup of ipecac110
Syrup of Ipecac
  • No evidence of improved outcome
  • Delays AC or antidote for 2 hours
  • No role in hospital setting
adverse effect
Adverse effect
  • Protracted vomiting
  • Sedation
  • Diarrhea
  • Bradycardia
contraindications
Contraindications
  • Altered mental status
  • Seizure
  • hemetemesis
  • hydrocarbon
  • corrosives
contraindications113
Contraindications
  • Anticipated use of oral antidote or WBI
  • < 6 months old
gastric lavage115
Gastric Lavage
  • one hour (“golden hour”)
  • Life threatening ingestion
gastric lavage117
Gastric Lavage
  • Large bore orogastric tube (36 - 40 French)
  • 0.9% saline 15 ml/kg max 200-400 ml/cycle
gastric lavage118
Gastric Lavage
  • < 30% by 20-30 min
  • < 13% by 60 minutes
gastric lavage119
Gastric Lavage
  • Not a routine
  • With in one hour
  • Life-threatening ingestion
  • Absence of pill fragments does not rule out toxic ingestion
gastric lavage120
Gastric Lavage
  • TCA
  • Calcium-blocker
  • Colchicine
complications
Complications
  • Pulmonary aspiration
contraindications122
Contraindications
  • Caustic
  • Hydrocarbon
  • Sharp coingestion
activated charcoal

Activated Charcoal

Universal antidote

single dose ac

Single dose AC

adsorbing the ingested substance

activated charcoal125
Activated Charcoal
  • Oxidizing process
  • Increases the adsorptive capacity
  • Inert substance
  • Reduce the bioavailability of drug
activated charcoal126

Activated Charcoal

Surface area

950-2000m2/g

chemical camp
CHEMICaL CamP
  • C Cyanide
  • H Hydrocarbon
  • E Ethanol
  • M Metals
  • I Iron
  • C Caustics
  • L Lithium
chemical camp129
CHEMICaL CamP
  • C Camphor
  • P Phosphorus
recommended dose
Recommended Dose
  • Up to 1 year
    • 1g/kg
  • 1-12 year
    • 25-50 gm
complications131
Complications
  • Pulmonary aspiration
  • Emesis
  • Constipation
contraindications132
Contraindications
  • Hydrocarbon
  • Corrosive
  • Ileus
home ac
Home AC?
  • 1,208,860 exposure in < 6 year
  • 16 fatalities
  • 4 might have benefited from early administration of AC American Association of Poison Control Centers Toxic Exposure Surveillance System (1998)
benefits of home ac
Benefits of Home AC
  • Early administration
  • Reduced morbidity & mortality
risks of home ac
Risks of Home AC
  • Inappropriate administration
  • Inadequate dosing
  • Pulmonary aspiration
multiple dose ac

Multiple-Dose AC

Gastrointestinal Dialysis

multiple dose ac137
Multiple-Dose AC
  • Continue to adsorb remaining toxin
  • Interfere with enterohepatic circulation
  • Lower the free drug concentration
multiple dose ac138
Multiple-Dose AC
  • Phenobarbital
  • Carbamazepine
  • Phenytoin
  • Digoxin
  • Salicylates
  • Theophylline
  • TCA
cathartics

Cathartics

Decrease transit time

cathartics140
Cathartics
  • Sorbitol 70%(0.5g/kg)
  • 10 - 20 ml (children)
  • 50-100ml(adolescent)
complications141
Complications
  • Nausea
  • Abdominal cramps
  • Vomiting
  • Transient hypotension
contraindications142
Contraindications
  • Unprotected airway
  • Ileus
  • Absent bowel sounds
  • Intestinal obstruction
slide143

WBI

Decontaminate entire gastrointestinal tract

slide144

WBI

Commonly used for agents not bound to activated charcoal

slide145
WBI
  • polethylene glycol
  • No fluid abnormality
  • No electrolyte imbalance
  • End point clear rectal effluent
  • Sustained release preparation
slide146
WBI
  • 9 months to 6 years
    • 500 ml/hr
  • 6-12 years (1000 ml/hr)
  • over 12 years
    • 1500-2000 ml/hr
slide147
WBI
  • Calcium-channel-blockers
  • Iron
  • Arsenic
  • Lead/zinc
  • Packets of illicit drugs
complications148
Complications
  • Nausea & vomiting
  • Bloating / cramps
  • Pulmonary aspiration
urinary alkalinization
Urinary Alkalinization
  • Salicylates
  • Phenobarbital
  • Chlorpropamide
urinary acidification
Urinary Acidification
  • Never indicated
  • Systemic acidosis
  • Renal impairment in myoglobinuria
hemodialysis
Hemodialysis
  • Severe poisoning
  • Renal failure
hemodialysis153
Hemodialysis
  • 8-10 fold increased clearance
  • Corrects acid-base imbalance
  • Corrects electrolyte imbalance
hemodialysis154
Hemodialysis
  • Small molecular weight
  • Non-ionized, uncharged molecule
  • Low plasma protein binding
  • Small volume of distribution (<1.0L/kg)
hemodialysis155
Hemodialysis
  • Lithium 4 mEq/L
  • Ethylene glycol 50 mg/dl
  • Methanol 50 mg/dl
  • Salicylates 100 mg/dl
hemoperfusion
Hemoperfusion
  • A charcoal or resin cartridge
  • More effective in selected poisonings
  • Not limited by plasma protein binding
  • Not limited by molecular size
hemoperfusion157
Hemoperfusion
  • Not effective for acid-base & electrolyte imbalance correction
  • Ineffective in patients with renal failure
hemoperfusion158
Hemoperfusion
  • Phenobarbital 100 mg/L
  • Theophylline 60-100mg/L
  • Paraquat 0.1 mg/dl
  • Glutethimide 4 mg/dl
  • Meprobamate 10 mg/dl
antidotes160

Antidotes

Use only if specific criteria met

immediate use
Immediate use
  • Oxygen
    • carbon monoxide
  • Naloxone
    • opioids
immediate use162
Immediate use
  • Methylene blue 1%
    • severe cyanosis
    • > 40%
immediate use163
Immediate use
  • Sodium nitrite
    • Cyanide
  • Deferoxamine
    • Iron
antidotes164
Antidotes
  • Acetaminophen - N-Acetylcysteine
    • 140 mg/kg PO
    • 70 mg/kg q4h for 17 doses
  • Anticholinergics - Physostigmine
    • 0.5 mg IV
antidotes165
Antidotes
  • Organophosphates
    • Atropine 0.05-0.1 mg IM or IV
    • Pralidoxime 25-50 mg/kg IV
antidotes166
Antidotes
  • Benzodiazepine - Flumazenil
    • 0.01 mg/kg IV
  • Beta Blockers - Glucagon
    • 50 ug/kg IV
antidotes167
Antidotes
  • Isoniazid Pyridoxine 5-10%
    • 1 gm/gm of INH ingested IV
  • TCA NaHCO3
    • 1-2 mEq/kg IM or IV
  • Warfarin Vitamin K
    • 1-5 mg IV or IM
new antidotes
New Antidotes
  • Glucagon
    • Beta-blocker & Ca-channel blocker
  • Insulin & glucose ?
    • Ca-channel blocker
  • Octreotide
    • Sulfonylureas induced hypoglycemia
new antidotes170
New Antidotes
  • Tricyclic antidepressant antibodies
    • TCA
  • Fomepizole (Antizol)
    • Methanol & ethylene glycol
  • Nalmefene
    • Opioid poisoning
new antidotes171
New Antidotes
  • Flumazenil (Romazicon)
    • Benzodiazepine
child abuse by poisoning
Child Abuse by poisoning
  • High index of suspicion
  • Its not optional!
  • Mandated to protect these children
take home message
Take home message
  • Basic supportive care has saved more lives than all the antidotes put together
  • Small quantities can have significant consequences
  • Most pediatric ingestion are trivial
resources
Resources
  • Drug Information (AHFS)
  • Poisindex computer database
  • Regional poison center
    • 212-POISONS