poisoning

1
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2
poisoning

• The most common agents include
• family member medication , cleaning solution,
• plants, cosmetic.
• most ingestion occur in home(92).
• More than 50 occurred in children lt5 yr.

3
management

• history
• Product name, amount of medication, time of
  exposure.
• age and weight of child
• progression of symptoms
• Medical history and underling disease

4
Physical examination

• Level of consciousness , vital signs
• pupillary size , presence of muscle
  faciculation
• bowel and bladder activity , cardiac
  arrhythmias , seizures , hypothermia.
• Pulmonary edema
• Certain symptoms and signs are specific .
• ( toxic syndromes)

5
toxic syndromes

• Anticholnergic
• Thirst ,flushed skin
• mydriasis
• hyperthermia ,urinary retention,
• delirium, hallucination, tachycardia
• respiratory insufficiency

6

• Cholinergic
• Exocrin glands secration, urination
• nausea ,vomiting , diarrhea
• muscle fasciculation, weakness or paralysis
• bronchospasm , bradycardia or tachycardia ,
• convulsions , coma
• miosis

7

• Extrapyramidal
• Tremor ,rigidity, opisthotons ,torticollis
• dysphonia ,fever , metabolic acidosis
• tachycardia ,hyperpnea
• restlessness , convulsion ,

8

• narcotic
• CNS depression
• hypothermia
• hypotention
• hypoventilation
• miosis

9

• Sympathomimetic
• Psychosis
• seizure
• mydriasis
• hypertension
• tachypnea
• hyperthermia

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complication

• Coma
• DD trauma , CVA , asphexia, meningitis
• Pinpoint puils
• Opiate, organophosphate ,phenothiazines ,hloral
  hydrate ,
• Dilated pupils
• cyclic antidepressant , atropine -like agents

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Caustic ingestion

• Dysphagia , epigasteric pain.
• oral burns.
• low-grade fever.
• When lesion heal then strictureform .
• alkalia agents (tastless) oropharynx and
  esophagial necrosis.
• button batteries produce caustic injury if
  that remain in esophaguse should be removed.

12

• treatment
• dependents on agent ingested and presence or
  absence esophagial injury
• Routine use of diluent as a first aid ???
• Antibiotic if there is signs of infection .
• Dilatation of late forming strictures(2-3 weeks
  later) .

13

• Acid agents lung , oral mucosa,esophgus and
  stomach injury and necrosis.
• Mocusal and tissue damage less sever than alkali
  . (Acid taste)
• Treatment initial therapy like the alkali
  ingestion
• (dilution and no emesis or nutralizing)

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Screening laboratory clues

• Metabolic acidosis
• methanol, ethanol
• uremia, diabetes
• iron, isoniazid, salicylate , starvation
• Determining Blood gases, urin PH, Na, K,
  chloride, glucose, BUN, serum osmolality and
  anion gap

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Screening laboratory clues

• Hyper glycemia salysilate, phenothiazide,
  sympathomimetic, isoniazid, iron,
• hypoglycemia insulin, Ethanol ,
  propranolol,Isonizid, oral hypoglycemic agents.
• Hypo calcemia Ethylene glycol, fluride , oxalate
• Radiopaque substance
• iron , phenothizine , Entric coted pills,
  Dental amalgam, Heavy metals, pothassium chloride

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Drugs monitoring for toxicity

• Antibiotics
• aminoglycosid, chloramphenicol, vancomycin.
• Immuno suppression
• methotrexide , cyclospurine
• Antipyretic
• Acetaminophen , salycilate
• Others digoxin, lithium, theophylin,
  anticonvulsant serotonin

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treatment

• Supportive care
• 1-ABC 100O2 ,naloxane,glucose 1g/kg IV .
• Diuresis
• Hemoperfusion rarly used in small children
• Most liquid drugs absorbed within 10 min and
  solid within 1-2hr

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treatment

• Prevention absorption
• Activated charcoal
• Gastric lavage
• Cathartics
• Diuresis
• Hemoperfusion
• Dialysis
• methanol, ethylen glycol, salycylate,
  theophylin

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Treatment(con)

• Gastric lavage
• Not documented efficacy in children.
• Remove only a fraction of gastric contents.
• It should only used in older children and
  selected situations

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treatment

• Prevention absorption
• syrup ipeca ??
• (Potentially complication without improve
  clinical outcome)
• onset emesis after 20-30 min and several
  episodes over 1-2 hr.
• 10 CC for small children 15CC 1-12years ,30 CC
  older children.
• Remove 1/3 stomach content.
• when ingestion is lt 60 minute and air way
  protected
• not be used as a general treatment.

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Treatment(con)

• Contraindication ipeca
• minimaliy toxic agents
• prior vomiting
• air way unprotected
• caustic agents, hydrocarbon , agent cause the
  rapid onset CNS or cardiovascular symptoms
• foreign body

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treatment

• Activated charcoalprevent toxin absorption.
• single dose25-50g small children 50-100ggt 12yr.
  Repeated doses in serious poisoning.
• 25 of patients experience one episode of
  vomiting.
• most benefit achieved within 1 hour of
  ingestion.
• Ineffective against caustic ,corrosive ,
  hydrocarbon , heavy metals, glycols and water
  insoluble compounds

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Treatment(con)

• Cathartics
• ( sorbitol 1g/kg, magnesium citrate250cc/kg
  ).???
• combination with activated charcoal is not
  recommended (essential nelson)
• complication Electrilyt imbalance and
  dehydration

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Emergency Antidotes

• Poison antidotes
  dose
• Mercury ,arsenic, gold BAL
  5mg/kg
• Methyl alcohol Ethyl
  alcohol dialysis 1ml/kg
• Nitrites
  methylene blue 1-2
  mg/kg
• Opiates
  naloxan 0.1 m g
  /kg- 2

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Emergency Antidotes

• Poison antidotes
  dose
• organophosphate Atropin
  0.02- 0.05mg/kgIV
• 
  paralydoxime 20-50 mg/kg
• Sympathomimetic
  phentolamin
• agents
  ß-blocking

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Acetaminophen

• Acute toxic dose200mg/kg in children lt 12 yr.
• Repeated doses more than recommended may lead
  hepatic injury.
• Children lt6yr unlikly develop significant
  toxicity .
• 1-2 hr of ingestion activated charcoal
• antidot started as soon as possible ,oral N-
  acetylcysteine may be benefit if started 24-36 hr
  after ingestion

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stages in clinical course of Acetaminophen
toxicity

• 1 - ½-24 hr anorexia
  ,nausea ,vomiting ,pallor
• 2- 24-48hr
  abdominal pain, bilirobin , PT?
• 
  hepatic enzyme ?
• 
  
• 3- 72-96 hr anorexia
  , nausea , vomiting ,
• 
  peak liver abnormality
• 4- 4days- 2 weeks
  resolution of hepatic dysfunction
• 
  ?or complete or liver failure

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salicylates

• Nausea , vomiting, gastric irritation
• hyperventilation, Respiratory alkalosis
• dehydratoin
• prograssive metabolic acidosis
• Agitation, counfusion are common.
• Hyperglycemia, or hypoglycemia.
• Pulmonary edema

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salicylates ( treatment)

• Activated charcoal.
• Rehydration , correction electrolyte.
• Large quantities of Potassium , and bicarbonate.
• Urine PH 7-7/5 ( using bicarbonate IV)
• Dialysis in sever cases

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Antidepressant( TCA, SSRI)

• Block reuptake serotonin , dopamin ,
  norepinephrin
• Myocardial depression ,dysrhythmia
• ½-6 hr
• CNS effect 1/3 (lethargy , coma, drowsiness
  ),seizure
• Anticholinergic effect. tachycardia ,mydriasis ,
• Hypertension ( no treatment ).
• hypotension (rare but poor prognosis).

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Antidepressant( TCA, SSRI) treatment

• ABC
• Emesis is contraindication( aspiration ,after
  onset CNS deprassion)
• Activated charcoalshould be used .
• Sodium bicarbonate ( to treat and prevent
  dysrhythmia) and if unresponsive.. Lidocaine
  used .
• Fluid therapy for hypotension.
• Bezodiazepine for seizure.
• Asymptomatic patient observe and ECG monitoring
  for 6 hr.

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Cholinsterase inhibitor ( organophosphate and
carbamate)

• Prevent degradation acetylcholine , bind to
  cholinesterase and inactiveted it .
• muscarin signs emesis, urinary and fecal
  incoutinence, drooling , bronchospasm, miosis,
  hypotention , bradycardia.
• Nicotinic signs muscle weakness , tremor ,
  fasciculation,
• hypertention ,hypoventilation , tachycardia ,
  dysrehythmia,
• CNS effects confusion, seizure , coma .

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Cholinsterase inhibitor ( organophosphate)

• Treatment
• ABC
• activated charcoal
• Fluid and electrolyte replacement .
• antidotes ( significant organophophate poisoning
  both antidotes is necessary) .
• even with treatment neurologic symptoms may
  occur and may be persist .

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Treatment( con) Antidotes

• 1- Atropin infusion
• blocks acetylcholine receptor .
• ( reversing the CNS and muscarinic
  effect)
• 2- paralidoxime
• breaks the bond between organophosphate and
  enzyme ,librating enzyme, degrading
  organophosphate

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Acute hydrocarbon risk assessment

• Systemic and pulmonary toxicity
• Hydrocarbon ingestion result in systemic but
  more often pulmonary toxicity,
• Systemic carbon tetrachloride, benzen,
  trichloroethylene.
• Local toxicity kerosen, furniture polish, signal
  oil , gasolin
• Non toxic tar asphalt, motor oil , lubricant,
  baby oil

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hydrocarbon

• 1. Aspiration pneumonia
• (Low vicosity gasolin, kereson , naphta ,
  lamp oil ).
• Cough, fever (10 days),leukocytosis , chest
  Xray ( may normal 6-12hr)
• 2. Systemic symptoms most hydrocarbon can
  cause transient CNS depression. Few have renal
  toxicity ,carbon tetrachloride produce hepatic
  toxicity.

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Hydrocarbon ( treatment)

• Emesis is contraindicacated.
• Activated charcoal is not useful.
• in pneumonit respiratory treatment is
  supportive.
• Corticosteroid avoided .
• Prophylacttic antibiotics should not be given.
• Respiratory failure treated with standard
  ventilation (ECMO ?)

38
Snake bite

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39
Guidelines for assessing

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40
treatment

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41
treatment

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42
classification of envenomation

• Grade0 no envenomation
• Grade 1 mild local swelling and pain
• Grade 2 moderate swelling, pain or echymosis
  progressing beyond the site
• Mild systemic or laboratory manifestation
• Grade 3 sever sever systemic finding and
  labratory

43
scorpion

• Patogenesis
• Hyaluronidase ,sertonin, histamin and neurotoxin
• neurotoxin bind to presynaptic membranes and
  release acetylcholin and stimulation of both
  sympathetic and parasympathetic nervous systems.

44
Clinical manifestation

• Most sting cause immediate local reaction .(mild
  burning to sever pain)
• Severe envenomation causes autonomic dysfunction
  within 1 hr.
• Symtoms
• Agitation,irritability,salivation,bluredvision,
  hypertension, tachycardia,tachypnea and
  nystagmus.
• Rarely in smal children respiratory
  failure,convulsion or coma.

45
Clinical manifestation

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  2 ??? ? ???? ?? 12 ???? ???
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  ??????? ???? ??????? ???????

46
Scorpion envenomation

• Grade 1 local discomfort and paresthesia.
• Grade 2 pain and parestesia extend up the
  extremity.
• Grade 3 cranial nerve dysfunction, dysphagia,
  roving eyes, facial , paresthesia, restlessness.
• Grade 4 cranial nerve dysfunction ,drooling,
  uncontrollable eye movements, faciculation ,
  opisthotonos, convulsion,wheezing, hyperthermia
  ,cyanosis

47
treatment

• Localized pain
• ice and analgesics.(pain deminish within 24hr)
• hospital admission Sever envenomation
  autonomic instability.
• Symptoms resole within 24-48hr
• In cardiopulmonary compromise should be given
  antivenin. (complete resolution symptoms within
  1 hr)

48
treatment

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