Good Morning! Welcome Applicants!

Good Morning! Welcome Applicants! December 1st, 2011

Ingestion • Many medications are brightly colored and taste like candy • Toddlers don’t know that pills can be toxic • Ingestion in older children and adolescents is usually intentional

Ingestion • Availability of prescription or nonprescription drugs should be entertained • There may be no specific history of ingestion • In the absence of a clear cause of alteration of concsiousness (afebrile toddler or adolescent), a toxic ingestion should be suspected • If possible, the bottle of meds should be checked for remaining pills • Consult poison control. They are very helpful!! 1-800-222-1222

Risperdal Ingestion • Atypical antipsychotic • Dopamine receptor blockade • Causes side effects such as acute dystonia, parkinsonism, akathisia, tardivedyskinesia • Children are at increased risk of toxicity • Metabolize these drugs more rapidly • Increased bioavailability • Toxicity usually begins within 1 to 2 hours, peaks by 4 to 6, and usually resolves by 12 to 48 hours

Risperdal Ingestion • Clinical presentation • Nausea/vomiting • Lethargy • Drowsiness • Somnolence • Tachycardia • CNS depression • Extrapyramidal side effects (EPS) are more common in children • Acute dystonia - involuntary, sustained muscle contractions that result in twisting and repetitive movements or abnormal postures

Risperdal Ingestion • Management • Supportive care • Continuous cardiac monitoring, IV access, reevaluation of mental status • Single dose of activated charcoal • Withold in patients who are sedated or unable to protect airway • EPS treated with anticholinergics • Diphenhydramine • Benztropine

Poisoning Potpourri !

15-year-old with nausea and vomiting. No other signs or symptoms. Mom found empty medicine bottle in trash can. On CMP elevated liver transaminases.

Salicylates • Tricyclic antidepressants • Methanol • Acetaminophen • Acids, alkali, and alkaloids F. Ethanol G. Anticholinergic H. Hydrocarbons I. Opiates J. Organophosphates

16-year-old with suspected ingestion. HR 44, RR 10, BP 85/40. Pinpoint pupils on exam. Difficult to arouse.

4-year-old "seems delirious" per mom. On PE, has a temperature of 104.2°F (40.1°C), heart rate of 160 beats/min, respiratory rate of 36 beats/min, and blood pressure of 135/87 mm Hg. Her pupils are dilated and sluggishly reactive. Skin is flush. 5-year-old brother fed her pink “candy” today.

6-year-old vomiting since last night and “not acting like himself.” Had low-grade fever this morning. Complaining of ringing in his ears. His BMP revealed an anion gap of 19. Dad has coronary artery disease and takes a few different medications.

4-year-old acting “loopy.” On PE, tachycardic and hypertensive. Skin is dry, red, and warm. Pupils are dilated. ECG shows QRS widening. Older brother is being treated for bedwetting.

16-year-old male brought into ER by friends with vomiting and ataxia. Has trouble following commands, and slurred speech. Glucose is 45. The friends report they have just left a party.

4-year-old with vomiting, abdominal pain, and “acting funny.” BMP reveals anion gap of 18. Dad mentions that she was playing in the garage earlier today while he was working on the car.

15-year-old male with coughing, tachypnea, retractions, and wheezing. Was involved in a dare earlier today with some friends. You suspect a chemical pneumonitis and order a CXR.

5-year-old brought to ER for altered mental status. Had abdominal pain and vomiting earlier today. Also with excessing drooling, incontinence, and diarrhea. He had been playing outside while dad cut the grass.

4-year-old found playing near the kitchen sink with a bottle of oven cleaner. She is drooling and is burns are starting to form on her lips and in her mouth.

Acetaminophen • Signs and symptoms • Nausea and vomiting • 18 to 24 hours later hepatic damage (elevated transaminases) 2 to 3 days progresses to severe hepatic damage (including fulminant failure) • Management (suspected or confirmed) • Measure serum level between 4 and 10 hours • Transaminases and coags • Treat with N-acetylcysteine(initiate within 10 hours)

Opiates • Signs and symptoms • Miosis • Sedation, coma • Respiratory depression • Hypotension, bradycardia • Constipation • Management • Assessment and establishment of effective ventilation and oxygenation • Hemodynamic support • Opioid antagonist • Naloxone

Anticholinergics • Signs and symptoms • Hot as a hare • Dry as a bone • Blind as a bat • Red as a beet • Mad as a hatter • Hypertension, tachycardia • Management • ABCs • Decontamination

Salicylates • Signs and symptoms • Nausea • Vomiting • Altered hearing (tinnitus) • Fever • Altered mental status • Increased anion gap metabolic acidosis • Management • Check electrolytes, blood gas, LFTs, serum level • Consider activated charcoal • Correct acidosis

Tricyclic Antidepressants • Risk for accidental ingestion by siblings • Signs and symptoms • Dry mouth • Ileus • Dilated pupils • Urinary retention • Delirium • Agitation • Convulsions • Cardiac dysrhythmias

Cardiac dysrhythmias • Most occur in first 24 hours • *Reports of late dysrhythmias ( 2 to 5 days later) • Maximal QRS duration is useful for predicting which patients will have dysrhythmias • Management • ABCs • Decontamination with activated charcoal • Benzos for convulsions • Sodium bicarb bolus for dysrhythmias

Ethanol

Ethanol • Signs and symptoms • *Hypoglycemia • Inebriation • Vomiting • Ataxia • Respiratory depression • Hypotension • Management • Measure serum electrolytes, glucose, ethanol level • Symptomatic and supportive • *Can mask toxicities from other drugs

Methanol • Found in windshield washer fluid • Nausea, abdominal pain, vomiting • Metabolized to formic acid metabolic acidosis and ocular findings • Blurred vision, “snow field,” edema of optic disks • Correct acidosis • Ethanol to block metabolism • Leucovorin or folate • Dialysis

Hydrocarbons • Cause chemical pneumonitis if aspirated • Tachypnea, retractions, bronchospasm • Peaks at 3 days • Oropharyngeal and gastric irritation • Coughing, choking • Vomiting • Supportive care • Blood gas • Chest X-ray

Organophosphates • Cholinergic poisoning • Insecticides, lawn and garden care products • Signs and symptoms • “SLUDGE” • Salivation, lacrimation, urination, defecation, gastric emesis • Twitching, weakness, or paralysis • Management • Stabilization • Decontamination • Antidote • Atropine

Acids, Alkali, and alkaloids • Laundry detergent, toilet bowel cleaner, stain and mildew removers, floor cleaner, ammonia, oven cleaner, window cleaner, batteries, pine oil cleaners • Acid ingestions are more likely to cause injury to the stomach and less likely to cause esophageal and pharyngeal injury • Alkaline ingestions tend to injure the esophagus and pharynx • Gastric lavage contraindicated • Endoscopy within 12 to 48 hours

Have a Great Day! Noon Conference ADHD, Dr. Khouri

Good Morning! Welcome Applicants!