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Board Review 12/17/2012. Poisonings and Environmental Exposures. Test Question. What topic should we do for January Board Review? Adolescent Disorders of the eye Sports Medicine and Physical Fitness. Poisoning basics…. Poison Control Centers. Multiple VERY helpful resources

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test question
Test Question

What topic should we do for January Board Review?

  • Adolescent
  • Disorders of the eye
  • Sports Medicine and Physical Fitness
poison control centers
Poison Control Centers
  • Multiple VERY helpful resources
    • Data on signs and symptoms of toxicities
    • Can help identify unknown toxins
    • Management of ingestions
  • 1-800-222-1222
  • Always have a high level of suspicion with an ingestion that there may be multiple agents involved
    • i.e. check an acetaminophen level when another ingestion is suspected
      • Very few initial signs/symptoms but high potential for poor outcome if missed
basic therapeutic options for gi decontamination
Basic Therapeutic Options for GI Decontamination
  • Emetics (ie syrup of ipecac)
  • Gastric Lavage
  • Activated Charcoal
  • Cathartics
  • Whole bowel irrigation
question 1
Question #1

A 4 year old is brought in by her parents because 20 minutes ago they found her playing with an empty bottle of grandmas atenolol which they knew previously had approximately 15 pills in it. You have a high suspicion that she ingested the medicine. She is anxious appearing but awake and alert with a heart rate of 70 and BP of 82/39. Which of the following would be the most appropriate action at this time?

  • Administer syrup of ipecac
  • Observation
  • Administer activated charcoal
  • Administer N-acetylcysteine
  • Draw an atenolol level
gi decontamination
GI Decontamination
  • Emetics (ie syrup of ipecac) or gastric lavage
    • No longer recommended for use in the home or ER
    • Only possible use must meet these criteria:
      • Consultation with qualified medical personnel
      • Substantial risk or serious toxicity of the substance ingested
      • No access to any alternative therapy for at least 1 hour
      • Administration within 30-90 minutes of ingestion
      • Administration will not adversely affect later treatment (ie activated charcoal or N-acetylcysteine
    • Absolute contraindications:
      • Severe HTN or bradycardia
      • Risk of or current AMS
      • Ingestion of caustic, corrosive or hydrocarbon substance
gi decontamination1
GI Decontamination
  • Activated Charcoal
    • Organic product with numerous micropores that allow a large surface area of absorption
      • **ONLY method of GI decontamination supported by poison control centers**
      • Discussion about use in homes
    • Best if within 60 minutes of ingestion
    • Not for use when ingested substances are alcohols, corrosives, iron, or lithium; caution with hydrocarbons
    • Dosing:0.5-1g/kg (adult range 25-100g); 10:1 ratio of AC to ingested toxin
    • Can drink or give via OG/NG
    • Contraindicated in patients with unprotected airway
gi decontamination2
GI Decontamination
  • Cathartics (laxatives)
    • Limited use; ? Benefit
    • Sometimes given with dose of AC
  • Whole bowl irrigation
    • Enteral administration of osmotically balanced solution
    • Can be used after AC
    • Used for “body packers”
question 2
Question #2

A 3yo boy is brought to the ER at 7AM after his parents found him unresponsive in bed. The last time they saw him was at 2AM while they were cleaning up from a cocktail party. On exam he has diaphoresis and moans to painful stimuli. His vitals are T96.4, HR145, RR20, BP 83/34, Sp02 98%. His pupils are mid-sized and sluggish. Of the following, what is the MOST important test to obtain at this time?

  • Acetylcholinesterase determination
  • Bedside glucose
  • Blood alcohol level
  • Serum osmolality
  • Urine toxicity
ethanol ethyl alcohol
Ethanol (ethyl alcohol)
  • Beverages, cough medications, mouthwashes, aftershaves
    • Multiple over-the-counter preparations
  • Clinical features
    • Dose-related CNS depressant
      • Ingestion of 0.5g/kg (1.5ml/kg body weight) can produce intoxication in a young child
    • Induces hypoglycemia (especially in children)**
      • Metabolism of ethanol creates a relative lack of pyruvateblocks gluconeogenesis  hypoglycemia
    • Hypothermia, inebriation, vomiting, ataxia, respiratory depression, coma, hypotension, death
ethanol ethyl alcohol1
Ethanol (ethyl alcohol)
  • May mask toxicities from other ingestion drugs**
    • Effects of stimulants are blunted
    • Effects of other depressants may be potentiated
  • Lab workup
    • Ethanol level, serum electrolytes, glucose
      • Watch for hypokalemia
    • Screen for other ingestions
  • Management
    • Supportive, IVFs
    • Correct electrolytes/glucose
    • No antidote; good prognosis
question 3
Question #3

Your 3yo child loves blueberry soda. You found him in the garage with an empty bottle of Windex. Upon arrival to the ER the child is lethargic and minimally responsive to painful stimuli. An ABG shows 7.11/30/60/12. All of the following are possible treatment modalities for this child, EXCEPT:

  • Ethylene glycol
  • Sodium bicarbonate
  • Leucovorin
  • Folate
  • Hemodialysis
methanol
Methanol
  • Windshield wiper fluid, cooking fuel, perfumes
  • Methanol itself causes n/v, inebriation
  • Metabolites (formaldehyde and formic acid) are more toxic
    • CNS depression, anion gap acidosis (can cause multiorgan dysfunction), optic changes
  • Testing: methanol level, ABGs
  • Treatment:
    • Sodium bicarb for acidosis
    • Folate or leucovorin (can help eliminate formic acid)
    • Ethanol: can help decrease formation of metabolites
    • Hemodialysis for severe cases
ethylene glycol
Ethylene glycol
  • Most commonly: Antifreeze
  • Causes severe metabolic acidosis and formation of calcium oxalate crystals in vital organs
    • Hypocalcemia
    • Nephrotoxicity
  • Treatment
    • Gastric emptying (if within 1hr)
    • Correction of acidosis and hypocalcemia
    • Thiamine and pyridoxine
      • Cofactors in the non-toxic pathway of ethylene glycol metabolism
    • Hemodialysis
hydrocarbons
Hydrocarbons
  • Gasoline is most common exposure
  • Irritating to GI and respiratory tract
  • Primary concern: chemical pneumonitis
    • Aspirated low-viscosity hydrocarbons spread to large areas of lung; destroy surfactant; alveolar collapse; VQ mismatch; hypoxemia
    • Direct capillary damage also leads to pneumonitis
question 4
Question #4

A2yo boy is brought to the emergency department by his father after they had spent several hours in the garage while the father worked on the car. The father reports that approximately 30 minutes ago he heard the child coughing and found him with an open bottle of lighter fluid in his hands. On exam, the child is awake and alert; temperature is 37.0°C, HR is 120 beats/min, RR is 24 breaths/min, BP is 90/60 mm Hg, and 02 sat 98%. Of the following, the MOST appropriate next step is to:

  • Obtain urine tox screen
  • Perform gastric lavage
  • Reassure the father and discharge the patient home
  • Obtain a STAT chest CT
  • Place the child under observation
hydrocarbons1
Hydrocarbons
  • Clinical manifestations
    • Initial: oropharyngeal and gastric irritation
      • Coughing and choking: could indicate inhalation of fumes; does not necessarily imply aspiration
      • Vomiting from gastric irritation
    • Aspiration: significant coughing and respiratory distress
      • “petroleum” smell on breath, tachypnea, retractions, bronchospasm, wheezing, rales,
      • Fulminant chemical pneumonitis: marked SOB and hypoxemia
      • Fever within 6 hrs indicates tissue damage (not infection)
      • Pulmonary damage reaches peak at 3 days after aspiration
hydrocarbons2
Hydrocarbons
  • Diagnosis
    • Based on history, signs/symptoms of respiratory involvement
    • If symptomatic: ABG, CXR
      • CXR findings can lag 4-6hrs after aspiration
  • Management
    • Asymptomatic patients: observe for 4-6 hrs
      • If abnormal CXR: consider admitting
    • Symptomatic: admit
      • Supportive care; no use for abx or steroids
  • Prognosis: good
    • Chemical pneumonitis often resolves completely
      • Rarely will have long term problems (pneumatoceles)
tricyclic antidepressants tca
Tricyclic antidepressants(TCA)
  • Amitriptyline, clomipramine, desipramine, etc
    • Used in children to treat enuresis
    • Block acetylcholine, prevent reuptake of norepinephrine, and block sodium channels in the myocardium
  • Clinical toxicity begins with 6-8hrs of ingestion and peaks within 24hrs**
  • Clinical effects:
    • Anticholinergic!
      • Dry mouth, ileus, dilated pupils, urinary retention, tachycardia, HTN, flushed
      • CNS: delirium, agitation, restlessness, hallucinations, convulsions
    • Life threatening toxicity due to cardiac dysrhythmias
question 5
Question #5

You are called by the mother of a 3-year-old girl because the child appears confused and is pale and sweating. The mother thinks the child may have taken some of her grandmothers imipramine. You advise her to call 911 to have her taken to the ER. Of the following, what is the most appropriate action to take in the ER?

  • CXR to evaluate for pulmonary edema
  • EKG to monitor for dysrhythmia
  • ECHO to assess cardiac function
  • EEG to identify a seizure focus
  • Serum measurement of imipramine
slide22
TCAs
  • Work-up
    • Can check serum levels, but results do not contribute to treatment decisions
    • EKG**
      • Can help identify significant conduction defects
        • Prolonged PR
        • Widened QRS
          • Single most useful prognostic indicator for convulsions or dysrhythmias
        • OTc prolongation
        • Rightward shift of axis
        • AV block
        • Ventricular dysrhythmias
slide23
TCAs
  • Management
    • Activated charcoal for GI decontamination
    • CNS toxicity (convulsions) respond to benzos
    • Serial EKGs/monitor for the first 6 hrs after ingestion
    • For cardiac dysrhythmias:
      • Cardiac monitoring
        • Continued until all toxic effects have resolved for 24hrs
      • Sodium bicarb (1-2Meq/kg)
  • Prognosis is good
    • Resolution of toxicity generally in 24-48hrs
    • Can have late (2-5days after overdose) fatal dysrhythmia but this is found in seriously ill patients
question 6
Question #6

A 16yo girl is brought to the ER by her parents after she admitted to taking two handfulls of acetaminophen (500mg) because her boyfriend broke up with her. Which of the following is the MOST important piece of information you must obtain in order to determine your next course of action?

  • The name and address of the boyfriend
  • History of previous suicide attempts
  • How long ago the ingestion took place
  • A blood gas measurement
  • Glucose measurement
acetaminophen
Acetaminophen
  • One of most common medications used to treat fever and pain in children
  • Most common analgesic overdose in children less than 6yo
  • Toxicity arises from metabolism of the drug
    • During hepatic metabolism of large doses, a toxic metabolite accumulates in the hepatocyte and causes damage to liver cells
    • Minimum toxic dose: 140mg/kg
    • Severe toxicity for ingestions >250mg/kg
acetaminophen1
Acetaminophen
  • Initial signs/symptoms: nonspecific; nausea/vomiting
  • Within 18-24hrs hepatic damage may become evident with increased LFTs
    • If not treated, hepatic damage may worsen
    • Either gradually resolves OR if severe, will progress to severe hepatic damage  hepatic failure
      • Hepatic failure:
        • Coagulation abnormalities
        • Encephalopathy
          • In young children: altered ‘sleep/wake’ cycles, irritability
acetaminophen2
Acetaminophen
  • Only accurate predictor of hepatic toxicity from acetaminophen is measurement of a level 4-10hrs after overdose
    • Levels that fall above nomogram line  may be associated with hepatic damage
  • Treatment
    • N-acetylcysteine
      • Should be started within 10 hours of ingestion
question 7
Question #7

A 7 yo boy is brought to the ER due to altered mental status. He was well when he came home from school, but when he came inside for dinner after playing outside with friends he complained of abdominal pain and had an episode of NBNB emesis. Over the next 30 min he became increasingly lethargic. In the ER, he is unresponsive and drooling. Temp is 98.8, HR is 50, RR is 36, BP is 100/60. Sp02 is 82% on room air. Pupils are small and sluggish. Breath sounds are coarse bilaterally with increased WOB. You suspect a toxin exposure. What is the most appropriate treatment?

  • Atropine
  • N-actylcysteine
  • Naloxone
  • Physostigmine
  • Ethanol
organophosphates
Organophosphates
  • Found in a wide array of products
    • Herbicides, pesticides, lawn care
    • 70% of exposures occur due to ingestion of improperly stored products
  • Mechanism of action: (Cholinergic poisoning)
    • Irreversibly inhibits acetylcholinesterase leads to accumulation of acetylcholine  excess acetylcholine overstimulatesmuscarinic, nicotinic, central receptors
      • Muscarinic: “SLUDGE” (salivation, lacrimation, urination, diarrhea, gastric emesis), miosis,bronchorrhea/resp distress, sweating, bradycardia, hypotension
      • Nicotinic: muscle twitching, weakness, paralysis
      • Central: confusion/AMS, HA, tremor, seizure, coma
organophosphates1
Organophosphates
  • Treatment
    • Decontamination
      • Skin washing, activated charcoal
    • Blocking effects of excess acetylcholine
      • Atropine: give every 10-30min until muscarinic effects gone
    • Reactivating acetylcholinesterase
      • Pralidoxime: best if given within 24-48hrs
    • Supportive measures
      • Ventilation, IVFs, vasopressors
question 8
Question #8

A 2-year-old boy is brought to the emergency department after his father found him with the leaf from a foxglove plant in his mouth. He has had one episode of emesis and is complaining of abdominal pain. On physical examination, his heart rate is 140 beats/min, respiratory rate is 24 breaths/min, blood pressure is 100/60 mm Hg, and oxygen saturation is 100%. His pupils are 4 mm and briskly reactive to 2 mm. The remainder of his examination findings are normal. After administering activated charcoal, what is the most appropriate next step?

  • Abdominal xray
  • EKG
  • Serum creatinephosphokinase
  • Serum sodium
  • Head CT
toxic plants
Toxic Plants
  • Ingestions most common in children < 6yo
    • Fewer than 10% result in need for medical treatment
  • Most ingestions are small in quantity and symptoms are generally short-lived
    • GI effects are most common
  • Treatment based on suspected ingestion/symptoms
    • ABCs
    • Decontamination: activated charcoal
    • Reversal:
      • Physostigmine for anticholinergic ingestion
      • Cardiac monitoring for cardiac glycoside ingestion
  • Call poison control for ANY question**
    • They can help identify unknown plant
question 9
Question #9

A 2 year old boy is brought to the ER because he has been difficult to arouse for an hour. The child is somnolent and responsive only to pain. His temperature is 101.5, HR 130, RR 56, and BP 90/60. ABG reveals pH 7.28/CO2 20/HCO3 15. The patient and his mom have been staying with grandma for the holidays. Mom is healthy, but the grandma takes a few different medications. The most likely explanation for this child’s findings is

  • Intracranial hemorrhage
  • Acetaminophen ingestion
  • Metoprolol ingestion
  • Sepsis
  • Aspirin ingestion
aspirin toxicity
Aspirin Toxicity
  • Remains one of the most serious ingestions in the pediatric population
  • Toxic dose for a child = >150mg/kg
  • Salicylates are found in various household products (not just in Aspirin tablets)
    • Mouthwash
    • Face cleanser
    • Powders
    • Bismuth compounds
    • ETC…
clinical manifestations
Clinical Manifestations
  • Symptoms
    • Nausea and vomiting from DIRECT gastric irritation.
    • Altered hearing…usually tinnitus
    • Fever
    • Altered mental status
      • Agitation
      • Seizures
      • Stupor and coma
  • Signs
    • Tachypnea
    • Tachycardia
    • Non-cardiac pulmonary edema (due to increased vascular permeability)
laboratory findings
Laboratory Findings
  • Anion gap metabolic acidosis!!
    • Methanol toxicity
    • Uremia
    • Diabetic Ketoacidosis
    • Paraldehyde ingestion
    • Iron/INH toxicity
    • Lactic acidosis
    • Ethylene glycol ingestion
    • SALICYLATES
    • So be sure to rule these things out!
  • Respiratory alkalosis
    • **in young children the metabolic acidosis tends to predominate
laboratory findings1
Laboratory Findings
  • Global hypokalemiadue to K+ excretion in the urine
    • Initial alkaline urine
      • HCO3 excreted in response to the respiratory alkalosis
    • Later…acidic urine as the kidney tries to preserve K+ in exchange for H+ (which is excreted)
      • Paradoxicaciduria in the face of respiratory alkalosis is a hallmark of aspirin toxicity
  • Salicylate levels
    • Peak 4-6 hours after ingestion
    • Correlate poorly with clinical symptoms
    • Should be followed q2-4 hours until decreasing or <30mg/dL
question 10
Question #10

You are admitting a patient to the PICU with findings suspicious for Aspirin toxicity. The patient was initially awake upon presentation and was already given activated charcoal. The initial salicylate level was 80mg/dL. You know that aside from supportive care, the next BEST step to enhance salicylate elimination is…

  • Gastric lavage
  • Alkalinization of the urine
  • N-acetylcysteine
  • 100% Oxygen
  • Acidification of the urine
treatment
Treatment
  • Upon presentation
    • Activated charcoal if the patient is alert
    • Gastric lavage is NOT usually recommended UNLESS
      • Ingestion was a large, life-threatening dose
      • Brought to medical attention within 1 hour
  • Correction of metabolic derangements and dehydration
    • Fluid boluses
    • Alkalinization to enhance salicylate elimination
      • Goal serum pH 7.5 , goal urine pH >7.5
      • Rec: 1-2 mEq/kg bolus of NaHCO3 followed by a NaHCO3 drip
      • **Add K+ to fluids of patients without renal failure
  • Dialysis if level >100mg/dL or other worrisome signs
  • Intubation can suppress hyperventilation and may be dangerous!
carbon monoxide1
Carbon Monoxide
  • Has no color, odor, or taste
  • Has come to be known as the “silent killer”
  • Accounts for most of the poisoning deaths in the US
    • 300-500 people die annually from unintentional poisoning
    • We, as pediatricians, need to be able to recognize the signs and symptoms
pathophysiology
Pathophysiology
  • CO is inhaled and absorbed into the bloodstream
    • Forms carboxyhemoglobin by binding to hemoglobin with an affinity 250x that of oxygen
      • Unable to transport oxygen
      • Reduces oxygen delivery to the tissues by interfering with the dissociation of oxygen from the remaining oxyhemoglobin molecules
  • People (and organs) with higher metabolic rates are affected most
    • Infants and children are at a greater risk
    • Neurologic, cardiac, and pulmonary manifestations are seen more often
clinical manifestations1
Clinical Manifestations
  • People living in the same home present with similar, nonspecific symptoms
    • Fatigue
    • Dizziness
    • Headache
    • Nausea
    • Irregular breathing or dyspnea on exertion
    • Palpitations
    • Irritability/confusion/irrational behavior
  • Patients may appear pale or cyanotic
  • Symptoms can progress to LOC and death
  • Symptoms may improve when patient leaves the place of exposure
question 11
Question #11

A 5 year old boy is brought to the ED for 2 days of HA, nausea, and vomiting. He is afebrile and does not have diarrhea. Everyone at home, including the dog, has the same symptoms. On PE, he is mildly irritable but alert and oriented, and his mucous membranes appear bright red. His lung exam is clear, but he does have some mild increased WOB. Sats are 100% on RA. What is the MOST appropriate next step?

  • Admit the patient for continuous pulse ox monitoring
  • Place the patient on 2L of O2 at 40% FiO2
  • Obtain a carboxyhemoglobin measurement
  • Administer IV Methylene Blue
  • Arrange for emergent hyperbaric oxygen therapy
diagnosis
Diagnosis
  • Measurement of carboxyhemoglobin levels can confirm exposure.
    • Extent of exposure and/or measure CO-Hb levels may not correspond to severity
  • O2 saturations obtained by routine pulse ox is falsely normal because O2-Hb and CO-Hb cannot be differentiated on standard pulse ox techniques
  • ABG: metabolic acidosis with a normal PaO2
management
Management
  • Separate patient from the source of CO exposure
  • Decrease oxygen consumption by maintaining bedrest and diminishing anxiety
  • Oxygen
    • Should be provided until symptoms resolve and CO-Hb levels decrease to 5% or less
    • 100% O2 via non-rebreather mask
      • Decreases elimination half-life of CO to 1 hour
    • Ventilatory support if needed
    • Hyperbaric oxygen
      • Indications for use are debatable
  • EKG monitoring for cardiac dysrhythmia
prevention
Prevention
  • Counsel parents on important sources of exposure for children
    • Traveling in vehicles
    • Living in homes with poorly ventilated gas cooking and heating appliances
    • Vehicles idling in attached garages
  • Carbon monoxide detectors
    • Show promise
    • Effect on saving lives has not been demonstrated
corrosive ingestion
Corrosive Ingestion
  • Corrosives are concentrated acid, alkaline, or oxidizing agents
  • Many are common household products
    • Laundry detergent
    • Toilet bowl cleaner
    • Stain and mildew removers
    • Various cleaners
    • Batteries
    • Bleaches
    • ETC!
  • These products are often attractive to children and easily accessible in the home.
clinical manifestations2
Clinical Manifestations
  • Depend on the amount and pH of the substance and the nature of the contact
    • Drooling, dysphagia
    • Stridor or wheezing
    • Burns on the mucosa, lips, chin, hands, nose, and chest
    • Odynophagia
    • Dysphonia
    • Nausea/vomiting
    • Chest pain
    • Hoarseness
    • Hematemesis
question 12
Question #12

A 3 year old boy was admitted for inpatient observation after presenting to the ER with a suspected corrosive ingestion. The patient was initially stable with no mucosal burns in his oropharynx. In fact, his examination on admit was normal except for fussiness. 48 hours later, the patient begins with gross hematemesis. Which agent was MOST likely ingested?

  • An acidic corrosive
  • Ethanol
  • An alkaline corrosive
  • Diet coke
  • Acetaminophen
clinical manifestations3
Clinical Manifestations
  • Alkaline ingestions
      • Cause deep, more extensive burns that may take longer to heal
    • Cause liquefactive necrosis and tissue edema that affects the squamous epithelium
    • Tend to injure the esophagus and pharynx
  • Acidic ingestions
    • Burn the top layer or skin, so children tend to stop drinking these substances more quickly
    • Cause coagulation necrosis
      • Squamous epithelium of OP and esophagus are fairly resistant
      • MORE likely be transported straight to the stomach and manifest a little later
        • Severe hematemesis, gastritis, strictures, gastric outlet obstruction
question 13
Question #13

A 2-year-old boy is brought to the emergency department after his mother found him with an open bottle of toilet bowl cleaner. She reports that he had spilled some on his shirt and had some on his face, but she does not know if he drank any of it. The child is awake and alert, and his vital signs are normal. He is drooling slightly, but examination of his oropharynx reveals no lesions.

Of the following, the MOST appropriate next step is to

  • Administer activated charcoal
  • Give syrup of ipecac
  • Perform a gastric lavage
  • Observe overnight and the DC without further intervention
  • Consult GI for an urgent endoscopy
management1
Management
  • ABCs…with particular attention to airway!
  • NO syrup of ipecac
  • NO gastric lavage
    • Re-exposes damaged mucosa to same corrosive agent
    • Can lead to more necrosis and further damage
  • Labs/Imaging
    • Electrolytes, BUN/Cr, ABG if respiratory distress
    • CXR to ensure no signs of aspiration pneumonitis, mediastinitis, or pleural effusion
  • Endoscopy
    • Within 12-48 hours!!!
    • Assess extent of injury and look for burns/stricture/bleeding
anticipatory guidance
Anticipatory Guidance
  • All household products should be moved up and our of the reach of children
  • Corrosives should NOT be placed in unlabeled containers or food containers. They should be kept in the original packaging.
  • Large labels/symbols of poison should be marked on the product, and kids should be taught the meaning of these symbols.
  • 1-800-222-1222 kept close to phone
environmental contaminants1
Environmental Contaminants
  • Most health conditions associated with contaminants in food, water, the home, and the community present initially to the primary care physician.
  • Children’s susceptibility to environmental contaminants differs from adults.
    • Fetal development is affected by exposure to drugs, chemicals, and infections.
    • Carcinogenic cells have more time to develop into tumors.
    • Children eat more food, drink more water, and breathe more air than adults on a per kilogram basis…so they receive a “higher dose” of contaminant.
    • Unique developmental stages increase their exposure to certain contaminants.
question 14
Question #14

What is the BEST method to screen for ALL types of environmental exposure in your general pediatrics patients?

  • Obtain lead levels every 2 years on all patients
  • Send a heavy metal screen on everyone
  • Sample the drinking water of your patients
  • Obtain a thorough environmental exposure history
  • Do a personal assessment of all patient homes
exposure history
Exposure History
  • One of the most important tools in discerning the importance of environmental hazards for health consequences or to prioritize anticipatory guidance is the environmental history!
  • Ask about generally recognized exposures of concern
    • Tobacco smoke, lead, radon, pesticides, parents’ occupations
  • Also focus on more locally relevant factors
    • Toxic waste sites, wood smoke, well water, sports fishing
  • In the context of illness or disease, an environmental history helps discern the link between environmental factors and the nature, onset, worsening, and improvement of symptoms.
drinking water contaminants
Drinking Water Contaminants
  • Community or public drinking water supplies are regularly monitored under the Safe Drinking Water Act.
  • This oversight does not apply to the 15-20% of households in the U.S. that obtain their water from private wells.
  • Asking patients about their sources of drinking water, such as whether it is from a public source or private well is a key component of the environmental history.
question 15
Question #15

What are the two MOST COMMON microbiologic WATER contaminants of concern for children?

  • Salmonella and Listeria
  • E. coli and Campylobacter
  • Toxoplasma and Bacillus cereus
  • E. coli and cryptosporidium
  • H. pylori and Clostridium difficile
drinking water contaminants1
Drinking Water Contaminants
  • Arsenic
    • Known human carcinogen and potential neuro-developmental toxin
  • Lead
    • 20% of child’s exposure is attributable to drinking water
    • Leaches into drinking water from lead-containing pipes
    • “run water for 2 minutes before drinking…”
  • Bacteria
    • E. coli and cryptosporidium are the 2 most common
    • Boiling water for at least 1 minute is required for decontamination (due to small size of cryptosporidium)
  • Nitrate
    • Common contaminant in well water from sewage contamination or fertilizer
    • Young infants are at risk for METHEMOGLOBINEMIA due to the conversion of nitrate  nitrate in their stomachs
  • Trichloroethylene and perchloroethylene (industrial solvents)
community exposures
Community Exposures
  • Community characteristics, such as proximity to pesticide-treated fields, high-traffic roadways, industrial sites, or waste sites should be assessed because contaminants can affect the health of children.
    • Pesticides
    • Industrial wastes
    • Traffic pollutants
  • The Air Quality Index can provide local information on daily air quality and help guide decisions on outdoor activities.
  • Pets and people can track pesticide residues from treated fields to the indoor area and contaminate surfaces where children crawl and play…”take –home pathway.”
chemical exposures at home
Chemical Exposures at Home
  • Children spend most of their time indoors at home.
    • More than 90% of the 2 million poisonings reported each year occur in the home
    • Daily, low-dose exposure to contaminants may increase chronic health risks such as asthma or cognitive/behavioral problems
  • Mold
    • Leaks and water damage increase risk
    • May result in URI symptoms, cough/wheeze/asthma in sensitized individuals
  • Radon
    • Estimated to cause 21,000 lung cancer deaths each year
    • Comes from the radioactive decay of naturally occurring uranium in soil, rock, and water can infiltrate through holes in foundation.
    • All homes below the 3rd floor should be tested!!
chemical exposures at home1
Chemical Exposures at Home
  • Carbon Monoxide
    • Improper or inadequate ventilation can allow build-up from household combustion sources (furnace, fireplace, attached garage)
    • Discussion of a functioning CO detector should be a part of anticipatory guidance
  • Household members that work
    • Exposures may be brought home as dust or residues on clothing or shoes, so it is important to ask about parents’ occupations.
    • Examples: farmers with pesticide exposure, painters, renovation workers, chemical plants, etc.
    • Hygeine practices of removing work clothes/shoes and showering before entering the home can reduce the “take-home pathway”
home renovations
Home Renovations
  • Improper remediation and repair may result in concerning indoor exposures.
    • Asbestos
      • Friable ceiling material or degraded insulation around pipes, boilers, and furnaces
      • Use of asbestos-containing building materials has declines since the 1970s
    • Lead
      • Exposure is associated with a reduced IQ and behavioral problems, including ADHD
      • Deteriorating lead-containing paint is the most common cause in young children
        • Lead dust can form when paint is scraped, sanded, or heated
        • Dust accumulates in windowsills, on floors, and in the soil
      • Lead-based paint banned in 1978
      • Home repairs/renovations should be performed by trained individuals to apply special containment methods
nsaids
NSAIDs
  • Most children will be asymptomatic
  • Nausea/vomiting
  • Management:
    • Supportive care for GI upset
    • Obtain additional history for possibility of co-ingestion (especially in adolescents)
antihypertensives
Antihypertensives
  • Clinical signs
    • Depressed sensorium
    • Bradycardia
    • Hypotension
    • +/- diaphoresis
  • Management
    • Observation on a CR monitor
coin ingestion
Coin ingestion
  • Most common foreign body ingested: COINS
    • 95% will pass within 4-6 days
    • If do not progress past the stomach in 24 hrs they should be removed
    • Esophogeal
      • Proximal esophagus: should be removed ASAP via endoscopy
      • Middle-lower esophagus: observe for 12-24 hrs if asymptomatic
        • Endoscopy if the coin does not pass
button battery
Button Battery
  • Management depends on location of battery
    • AP and lat radiographs from mouth to anus
  • Esophageal
    • Batteries lodged in the esophagus should be immediately removed with direct endoscopic visualization
  • Stomach
    • Usually pass in 48hrs
    • Reimage after 48hrs
      • If still present  remove
slide75
Iron
  • Toxic ingestion occurs at doses >40mg/kg of elemental iron
  • Clinical manifestations
    • Phase 1: vague GI complaints (v/d/abd pain) within 6hrs
    • Phase 2: Decreased GI symptoms; deceptive improvement (hours 6-24)
    • Phase 3: multisystem effects
      • Metabolic acidosis
      • Coagulopathy
      • Cardiovascular collapse
    • Phase 4: obstruction due to scarring/stricture
slide76
Iron
  • Management
    • ANY symptoms within 6 hours  bring to medical attention
    • Serum iron level >350, WBC >15, glucose >150 = BAD
    • Symptomatic patient
      • Abdominal films to identify iron tablets
    • Chelation
      • For severe symptoms, anion gap acidosis, iron level >500, pills visible on abdominal film
      • Deferoxaminechelation
        • Causes urine to be pink/red
        • Can be stopped once urine returns back to normal color
terrorism
Terrorism
  • Anthrax
    • Virtually all cases are cutaneous form
      • Lesions: pruritic papule  central bullous lesion  becomes necrotic  central black painless eschar
      • Surrounding tissue is swollen and red; no tenderness
      • Eschar falls off in 1-2weeks
extra pearls
Extra pearls
  • It is important to ask about complimentary/alternative medicines
    • Especially in children with complex medical conditions such as autism
  • Over-the-counter cough and cold preparations have not been adequately studied in children <6yo
    • Not recommended for use to treat common cold
  • Active ingredients for cold medicines
    • Dextromethorphran, antihistamines, pseudoephedrine, guaifenesin
    • Multiple side effects