Poisoning in Children

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Poisoning in Children

• Norah Al Khathlan M.D.
• Consultant Pediatrician
• Consultant Pediatric Intensivist
• 02/02/08

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Poisoning in Children

• Goals
• Learn the pertinent aspects of the history and
  physical exam relative to acute poisoning with
  particular emphasis on clinical recognition of
  major toxic syndromes (toxidromes).
• Understand the principles, methods, and
  controversies of decontamination and enhancement
  of elimination of toxins.
• Learn the presenting signs, symptoms, laboratory
  findings, pathophysiology and treatment of common
  therapeutic drug poisonings, drugs of abuse,
  natural toxins and general household poisons.

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Poisoning in Children

• Objectives
• At the end of this lecture the student will be
  able to
• Define poisoning.
• Identify specific Toxidromes.
• Identify risk factors for pediatric toxidromes.
• Differentiate between the different classes of
  toxidromes.
• Differentiate the routes of poisoning.
• Describe the general management of the
  toxidromes.
• Outline the management of specific toxidromes
• Iron
• Salicylates
• Paracetamole/ Acetaminophen
• Kerosene

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Poisoning in Children

• Definition of Poisoning
• Exposure to a chemical or other agent that
  adversely affects functioning of an organism.
• Circumstances of Exposure can be intentional,
  accidental, environmental, medicinal or
  recreational.
• Routes of exposure can be ingestion, injection,
  inhalation or cutaneous exposure.
• All substances are poisons...the right dose
  separates poison from a remedy.

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Poisoning in Children

• Ingestion of a harmful substance is among the
  most common causes of injury to children less
  than six years of age
• Toxicology. . . is the science that studies the
  harmful effects of drugs, environmental
  contaminants, and naturally occurring substances
  found in food, water, air and soil.
• Poisoning maybe a medical emergency depending on
  the substance involved.

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Poisoning in Children

• Constellation of signs symptoms seen in
  poisoning characterized by the type of substance.
• Major four toxidromes are
• Anticholinergic
• Sympathomimetic
• Opiates/Sedatives- Hypnotics/ Alcohol
• Cholinergic

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Poisoning in Children

• Examples
• ASA
• Acetaminophen
• TCA
• Narcotics drugs of abuse
• Benzodiazepines
• Iron supplements
• Alcohol

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Agents Most Commonly Ingested by Children Less
Than Six Years of Age, 1995 to 1998
Shannon M. N Engl J Med 2000342186-191
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Shannon M. N Engl J Med 2000342186-191
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Poisoning in ChildrenImportant history points

• What toxic agent/medications were found near the
  patient?
• What medications are in the home?
• What approximate amount of the toxic agent was
  ingested?
• How much was available before the ingestion?
• How much remained after the ingestion?
• When did the ingestion occur ?
• Were there any characteristic odors at the scene
  of the ingestion?
• Was the patient alert on discovery?
• Has the patient remained alert since the
  ingestion?
• How has the patient behaved since the ingestion?
• Does the patient have a history of substance
  abuse?

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Poisoning in ChildrenManagement

• General measures
• Quick assessment triage
• Identify the culprit.
• Limit absorption
• Vomiting
• Lavage
• Activated charcoal instillation
• Specific

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Poisoning in Children

• ABCs of Toxicology
• Airway
• Breathing
• Circulation
• Drugs
• Resuscitation medications if needed
• Universal antidotes
• Draw blood
• chemistry, coagulation, blood gases, drug levels
• Decontaminate
• Expose / Examine
• Full vitals / Foley / Monitoring
• Give specific antidotes / treatment

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Poisoning in Children

• Decontamination
• Ocular
• Flush eyes with saline
• Dermal
• Remove contaminated clothing
• Brush off
• Irrigate skin
• Gastro-intestinal
• Activated charcoal
• May Prevent /delay absorption of some
  drugs/toxins
• Almost always indicated
• Naso/oro-gastric Lavage
• Bowel Irrigation
• Recent ingestions 4-6 hrs
• Awake alert patient
• 500 cc NS Children / 2000cc adults
• Orally / Nasogastric tube
• Contraindications?

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Agents Used for Gastrointestinal Decontamination
in Children
Shannon M. N Engl J Med 2000342186-191
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Circumstances under Which Administration of
Ipecac Syrup Should Be Avoided
Shannon M. N Engl J Med 2000342186-191
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Important points
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Specific toxidromes

• Acetaminophen
• Stage I 0-24 hrs
• Early symptoms
• Mild
• Serum acetaminophen level 4 hrs post ingestion
• PLOT ON SPECIFIC NOMOGRAM.
• No need to repeat levels
• If gt 900 µmol/L ---gt POSSIBLE RISK
• Nausea, vomiting, malaise and diaphoresis.
• Normal bilirubin Transaminases and PT

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Acetaminophen poisoning

• Stage II
• 24-48 hrs after ingestion.
• Better, less symptoms.
• Elevated bilirubin, transaminases and PT

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Acetaminophen poisoning

• Stage III
• 48-96 hrs ( 2- 4 days) after ingestion
• Hepatic dysfunction
• (Rarely hepatic failure)
• Peak elevations in
• Bilirubin
• Transaminases may reach gt 1000 IU/L
• Prolonged PT

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Acetaminophen poisoning

• Stage VI
• 168- 192 hrs (7-8 days)
• Clinical improvement
• LFTs returning to normal

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Acetaminophen poisoning

• Probable toxicity should be treated with
• N-acetylcysteine bolus 140 mg/kg
• Then 70 mg/kg Q 4 hrs for 17 doses.
• Assess hepatic function
• On presentation
• Daily
• Continue other support

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Iron Poisoning

• Five Stages but variable
• Stage 1
• Gastro-intestinal stage within several hrs of
  ingestion
• V/D. Hematochezia and abdominal pain
• Severe fluid loss, bleeding, shock(acidosis,
  tachycardia /- hypotension)
• Fever. Lethargy. Coma

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Iron Poisoning

• Stage 2
• Quiescent stage 4-48hrs
• Clinical improvement
• Subtle hemodynamic changes
• Tachycardia
• Decreased U.O.P.

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Iron Poisoning

• Stage 3
• Circulatory collapse 48-96 hrs
• Metabolic acidosis, hypotension, low Cardiac
  output.
• Coagulopathy
• Multiorgan system failure

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Iron Poisoning

• Stage 4
• Hepatic failure 96 hrs
• Increased mortality
• Rarely fulminant hepatic failure
• Hepatic necrosis
• Liver transplant can save lives

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Iron Poisoning

• STAGE 5
• Bowel obstruction 2-6 wks
• Due to scarring
• Gastric outlet obstruction
• Small intestinal obstruction
• May not pass through stage 4

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Iron Poisoning

• Management
• Gastric decontamination
• Forced emesis
• Gastric lavage with 5 NaHCO3
• No activated char coal
• Secure good IV
• Get initial the 4hrs levels and TBC
• Chelate with Deferoxamine if levelsgt 300mg/dL

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Iron Poisoning

• Chelate with Deferoxamine
• Stable pts levelslt 500 mg/dL 40mg/kg IM/IV
• Unstable bleeding/ level gt 500
• Give 20cc/kg NS/RL
• Deferoxamine at 15 mg/kg IV over 1hr
• Continuous drip at 15mg/kg/hr
• Continue till vin rose urine color disappears.

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Iron Poisoning

• Observe for
• Systemic BP
• ECG
• CVP
• Signs of hepatic failure
• Bleeding
• Glucose intolerance
• Hyperammonemia
• Encepalopathy

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SALICYLATES

• Oral ingestion commonest
• Transdermal less
• Peak levels at 12 hrs
• Early hyperpnea ? respiratory alkalosis
• Then metabolic acidosis
• Severe cases Cerebral edema and increased ICP

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SALICYLATES

• MANAGEMENT
• Treat electrolyte imbalance
• IV hydration
• Forced alkaline diuresis
• Hemodialysis
• Diuretics

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Hydrocarbons

• Kerosene ingestion
• Risk of aspiration
• GIT Respiratory effects.
• Burning sensation, nausea, belching and diarrhea
• Cough, chocking, gagging and grunting.
• CXR 2-8 hrs later Pulmonary infiltrates or
  perihilar densities.
• pneumatoceles, pleural effusion or pneumothorax
  and bacterial superinfection
• Resolution 2-7 days.

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Hydrocarbons

• Treatment
• Do not induce vomiting
• Do not attempt gastric lavage
• Risk of aspiration outweighs any benefit from
  removal of substance
• CXR around 2-4 hrs not before 2hrs
• Observe in ER for 6-8 hrs if no symptoms ?
  discharge.

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Poisoning in Children

• Prevention is the vaccine for the disease of
  injury.
• Host
• AGENT A causal relationship!
• Environment

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Poisoning in Children

• Prevention is the vaccine for the disease of
  injury.
• Host
• AGENT A causal relationship!
• Environment

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Poisoning in Children

• Prevention
• The reduction in the incidence of childhood
  poisonings in the past half-century has been
  dramatic.
• This reduction is largely the result of the
  combination of highly effective active and
  passive methods of intervention.
• Passive interventions eg introduction of
  child-resistant containers for drugs and other
  dangerous household products. Child-resistant
  containers have been particularly effective in
  reducing the incidence of death from the
  ingestion of prescription drugs by children.
• Active interventions, which require a change in
  behavior by parents and caretakers, include the
  safe storage of household products.

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Thank you

• Norah Khathlan M.D.