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PEDIATRIC TOXICOLOGY. Badrinath Narayan, PEM Fellow Pediatric AHD, Aug 5 th 2014. PEDIATRIC TOXICOLOGY. Objectives Provide a general approach to the poisoned patient History, physical, investigations Introduce types of decontamination with indications/complications List “Pills that Kill”.

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pediatric toxicology

PEDIATRIC TOXICOLOGY

Badrinath Narayan, PEM Fellow

Pediatric AHD, Aug 5th 2014

pediatric toxicology1
PEDIATRIC TOXICOLOGY
  • Objectives
    • Provide a general approach to the poisoned patient
      • History, physical, investigations
    • Introduce types of decontamination with indications/complications
    • List “Pills that Kill”
poisoning
Poisoning
  • Poisoning
    • One of the most common medical emergencies
    • Exploratory behaviour
    • Child abuse
    • Environmental exposures
    • Suicide attempts
    • In utero toxicants
    • Pediatricians have a role in advocacy
  • Modes of exposure:
    • Ingestion, ocular exposure, topical exposure, envenomation, inhalation and transplacental exposure.
approach
Approach
  • Brief window of opportunity to make critical diagnostic and management decisions
  • Prioritize critical assessment and simultaneous management interventions
slide5
14 year old female found unconscious in a park by friends

The patient is brought into the trauma bay at BCCH ED

What would you do?

primary survey abcdefg
Primary Survey - ABCDEFG

Apply monitors - O2, HR, RR, cycling BP

Obtain vitals: HR, RR, BP, O2 sat

A – Maintain patency, assess reflexes, note GCS, have airway equipment ready

B - Apply O2, consider ETCO2, ABG

C – Assess perfusion, Get two large bore Ivs

Disability (GCS, pupil size and reactivity), ? Signs of trauma

DecontaminationDrug Treatment – dextrose, oxygen, narcan

Bedside Glucose

primary survey
Primary Survey
  • Pay special attention to:
  • Evidence of impaired airway protective reflexes
  • Many poisoned patients will vomit
  • Elective endotracheal intubation may be indicated at a lower threshold
  • Anticipate imminent respiratory failure
    • Cyanosis/apnea are late findings
slide8
Case
  • The patient has been stabilized
  • What would you ask?
history known intoxicant
History – known intoxicant

Take standard AMPLE history plus:

What was ingested, How much, When, Why?

Obtain prescription bottles when possible, and be sure that bottles contain med listed

Talk to patient’s family and friends in ED/contact home

Ensure belongings are looked at to identify paraphernalia

In a toddler think single pills, in an adolescent think co-ingestions!!

when to suspect
When to suspect?
  • Suspected but unknown intoxicant:
    • Acute onset of illness
    • Pica-prone age (1-5)
    • History of pica, ingestions
    • Current household “stress”
    • Significantly altered mental status
    • Family medications/recent illnesses
    • Social: grandparents visiting, holiday parties, other events
slide11
Case
  • On exam what things might you see to suggest a toxicological cause for the child’s presentation?
physical
Physical
  • Vitals
  • GCS/mental status
  • Pupils, EOM, fundi
  • Mouth: corrosive lesions, odors, secretions
  • Respiratory: rate, chest excursion, air entry
  • CVS: rate, rhythm, perfusion
  • GI: motility, corrosive effects
  • Skin colour, burns, diaphorsis, piloerection, track marks
  • Bladder size
removal of toxic substance
Removal of toxic substance

Decontamination:

Removal of a substance prior to entry into the circulation

Elimination:

Removal of a substance by enhanced excretion once it has entered the circulation

approach to decontamination
Approach to decontamination

Get help -- Poison control centre

24-hour Line: 604-682-5050 or 1-800-567-8911

Healthcare professionals only line:

604-707-2787 or 1-866-298-5909 (outside the Lower Mainland)

Monday to Friday from 9 am - 4 pm

forms of decontamination
Forms of Decontamination

Topical

flush aggressively (ocular or skin), remove contaminated clothing

Dilution

Ipecac (no longer recommended; AAP statement against it)

Activated Charcoal

Gastric Lavage – also fallen out of favour

Whole Bowel Irrigation

dilution
Dilution
  • Indicated if toxin produces only simple irritation
  • Controversial for caustic agents
    • May be used in first few minutes
  • NOT for drugs – may increase absorption
  • Not if upper airway compromise
  • Water or milk
  • E.g. dish soap
activated charcoal
Activated Charcoal
  • “Activation” increases surface area of particles
  • Toxins adsorb to activated charcoal decreasing amount adsorbed by the body
  • Some toxins are not well adsorbed – most small molecules
    • Iron, the alcohols, lithium, strong acids and alkali, sodium, chloride.
  • Dose: 10:1 charcoal to drug ratio.
  • For unknown ingestions dosing is based on ability to tolerate the agent: Children - 1 gram/kg of body weight.
activated charcoal1
Activated Charcoal
  • Timing
    • If not contraindicated there does not seem to be a reasonable time that is too late to give AC, especially with SR or DR products
    • Dogma used to be an hour but studies with respect to delayed gastric emptying have challenged this data

Multiple-dose activated charcoal

sustained-release products

useful with drugs with low Vd, low protein binding, long half-life

activated charcoal2
Activated Charcoal

Activated charcoal not useful with:

P esticides

H ydrocarbons

A cids, Alkali, Alcohols

I ron

L ithium, Liquids

S olvents

activated charcoal3
Activated Charcoal

Contraindications

absent gut motility or perforation

if endoscopic visualization is required (e.g. caustic ingestions)

loss of protective airway reflexes

Complications

fatal aspiration

small bowel obstruction

gastric lavage
Gastric Lavage

Orogastric lavage with a large bore tube (36-40 F for adult; no smaller than 22-24 F for children)

RARELY recommended – not been demonstrated to improve outcome, several risks

Might be considered: VERY early or after very dangerous ingestions (colchicine, arsenic)

Ensure airway protected

Place patient in left lateral decubitus position with the head down

Have suction available for secretions

Place tube (tragus-nose-xyphoid) and confirm position

Lavage until fluids clear

whole bowel irrigation
Whole Bowel Irrigation

Whole bowel irrigation of the entire GI tract by instillation of large volumes of fluid

Usually takes hours

Has been used safely in children

Most useful for substances with delayed absorption ( i.e. extended release ), not amenable to activated charcoal and with body stuffers/packers

whole bowel irrigation1
Whole Bowel Irrigation

Accomplished by orally taking (or through NG) large volumes of Nulytely (approved for children and adults), Colyte, or Golytely

Adolescents: mininum of 1.5-2 L/hour

Children: 25 mL/kg/h

Give until rectal effluent is clear.

whole bowel irrigation2
Whole Bowel Irrigation

Contraindications:

absent bowel sounds

bowel obstruction or perforation

unprotected compromised airway

hemodynamic instability

forms of elimination
Forms of Elimination

Urine alkalinization

- promotes excretion of salicylate, enhances clearance of some drugs

Dialysis

Charcoal Hemoperfusion

dialysis
Dialysis

Consider nephrology consult with dialysis if:

S alicylates

T heophylline

U remia

M ethanol

B arbiturates

L ithium

E thylene Glycol

antidotes
Antidotes
  • Avoid physostigmine if TCA ingestion present - has potential to worsen ventricular conduction defects and to lower seizure threshold.
investigations
Investigations

Select tests only

Help confirm diagnosis

Help monitor

Help identify “silent” killers

Tox screens not useful in acute management

investigations1
Investigations

All symptomatic patients with unknown ingestion should get electrolytes, glucose, osmolarity, acetaminophen/ASA levels, blood gas, EKG

All suicidal patients should get acetaminophen level (~1:500 patients without a history of APAP ingestion will have a potentially toxic blood level - NYPCC) and ASA level

Other tests based on history, physical, level of suspicion

CBC

Specific drug levels

Urinanalysis

BHCG

Calcium, liver function panel

slide31
Increased anion gap metabolic acidosis

(Na – (Cl + HCO3)

M ethanol (hx of alcohol abuse, methanol level), metformin

U remia (BUN)

DKA, AKA, SKA (hx; urine ketones)

P araldehyde (distinctive odor)

I soniazid (seizure; lactate level)

Lactic acidosis

Ethylene glycol(level)

S alicylates/solvents (level)

slide32
Increased Osmolar gap (serum – calculated)

“Two salts and a sticky BUN”

Mannitol

Alcohols

Dye

Glycerol

Acetone

Sorbitol

pitfalls of osmolar gap
Pitfalls of osmolar gap
  • Cannot distinguish between type of toxic alcohol
  • Insensitive in late presentations
  • Not sufficiently sensitive to exclude small ingestion
  • Cannot rule out ingestion based on a normal OG
radio opaque drugs
Radio-opaque drugs
  • Chloral Hydrate
  • Opioid packets (latex)
  • Iron and other heavy metals
  • Neuroleptics
  • Sustained release tablets/Salicylates
slide35
ECG
  • Findings include:
    • Toxicologictachcyardia/bradycardia
    • QRS widening
    • Prolonged QT (www.qtdrugs.org)
  • Findings can develop late so obtain serial ECGs
slide36
Case
  • A 2 year old girl is found playing with his grandmother’s pill box. Some pills may be missing and a powder residue is found in the child’s mouth.
  • What medications would most concern you if this child ate “just one pill”?
slide38
Case
  • A 3 yo male presents to the ED comatose with a GCS of 6. He was found on the bathroom floor. Following stabilization, what is the most immediate course of action?
  • A. Head CT
  • B. ECG
  • C. Tox screen
  • D. Broad spectrum Abx