1. Dr Dunia Alhashimi Consultant pediatrician
Toxicology
Dr Dunia Alhashimi
Consultant pediatrician

2. Important areas to be covered
Activated charcoal, mechanism of action, indications, contraindications
Carbon monoxide Poisoning, signs and management
Ethylene glycol, common forms, signs and symptoms,
Hydrocarbons, types, Mgt

3. Caustic injury, types, Mgt Organophosphorus poisoning
Common medications:
Paracetamol, Elimination, S&S, Mgt, Acute vs chronic
TCA ingestion, S&S, Mgt
Salicylates, S&S, Mgt
Antihypertensives
Antihistamines
Multivitamins
Iron tablets
Caustic injury, types, Mgt
Organophosphorus poisoning

4. Household chemicals Oven cleaner Dettol Detergents Antiseptics
Silica gel
Mercury thermometers
Drain cleaner
Mothballs
Bleach
Rat poison
Nail polish remover
Ammonia
Window cleaner
Oven cleaner
Dettol

5. Q1
A 10kg 14 month old boy is brought to the A&E by his parents. His parents claim that he possibly ingested paracetamol, as six 500mg tablets were found to be missing from the family’s paracetamol container. This possible ingestion occurred within a 60-min window efore their presentation to the Emergency department. Which of th following is the most appropriate management action?
Measure plasma paracetamol levels
Administer ipecauanha to induce emesis
Perform a gastric lavage
Adminster N-acetyl cysteine
Administer activated charcoal

6. Q1 Ans E: Administer activated charcoal
The most appropriate management in this instance would be to administer activated charcoal, to limit further absorption of paracetamol, Inducing emesis with ipecuanha is now generally contraindicated. Measurement of plasma paracetmol level is useful only after 4 hours of ingestion. A gastric lavage maybe beneficial, but when you are given these five choices it would not be the first choice of treatment. N-acetylcysteine would not be the first line of treatment either.

7. Q2
The nomogram is used to determine when a patient is give N-acetyl cysteine is administered in patients even if their levels are below the nomogram line. Which one of the following is not a risk factor?
Alcoholism
patient on isoniazide
pt on cimetidine
fasting
malnutrition

8. Q2 Ans: C
If the serum level falls between the two nomogram lines, consider giving NAC if the patient is at increased risk for toxicity; e.g. the patient is alcoholic, malnourished or fasting or is taking drugs that induce P-450 2E1 activity (e.g. isoniazide INH); after multiple or subacute overdoses; or the patient is considered uncertain or unreliable.

9. Prescott Nomogram

10. High Risk Increased oxidation Reduces glutathione stores
Chronic alcohol use
Drugs
Reduces glutathione stores
Malnutrition
Eating disorders
Chronic liver disease

11. Q3
A 3 year old boy was found with a empty packet of extended-release paracetamol tablet. The parents claim that he took 8 500mg tablet. You are called in the emergency and decide to do a drug level. When is the best time to do a paracetamol drug level in the patients
Immediately as the dose is very high
A level stat and one after 4 hours
A level 4 hours after ingestion
A level 8 hours after ingestion
A level 8 hours and another after 12 hours

12. Q3 Ans:E
After ingestion of extended release tablets, which are designed for prolonged absorption, there may be a delay before the peak paracetamol level is reached. This can also occur after co-ingestion of drugs is reached. In such circumstances, repeat the serum paracetamol level at 8 hours and possible after 12 hours.

13. Q4
Which statement is true regarding liver toxicity from paracetamol overdose?
It is likely because paracetamol plasma half-life is approximately 2 to 3 hours.
It usually is evident 12 to 24 hours after ingestion
For a given toxic plasma level, children have a higher incidence of hepatic aminotransferase elevation than adults have.
Hepatic toxicity results from N-acetyl-p-benzoquinonemime (NAPQ1)
Diet, nutritional status, and age are not related to liver toxicity.

14. Q4 Ans: D
Liver toxicity results when NAPQ1, a reactive intermediary, is formed by cytochrome P-450 activity. Glutathione conjugates NAPQ1 to nontoxic conjugates. In an overdose, glutathione is depleted, and NAPQ1 binds covalently with hepatocytes to produce hepatic necrosis.

15. N-acetylcysteine Most effective within 8 hours
Precursor for glutathione production
Can cause anaphylactoid reactions
Consider starting before paracetamol result if:
Presenting > 8 hrs & >150mg/kg taken
Staggered overdose

16. Patient X
15 year old girl who presents after taking 24 paracetamol over a period of 24 hours
No drug history
Fit and well
Blood level 20mg/l

17. Staggered overdose. (www.pharmweb.net)
In patients who have taken several overdoses of paracetamol over a short period of time, the plasma paracetamol concentration will be more difficult to interpret as the treatment graph relates to a single acute ingestion.
Such patients should be considered as at serious risk and considered for treatment with N-acetylcysteine (NAC).
They can be discharged after NAC treatment or 24 hours from the last paracetamol dose provided they are asymptomatic and the International Normalised Ratio (INR), plasma creatinine and ALT are normal.

18. PARACETAMOL DEADLY PITFALLS The Prescott Nomogram High Risk Line
Staggered Overdoses
Management of late presentation
Recheck U&E, LFT, INR after N-acetylcysteine

19. Q5
A mother brings in her 1-year-old after he drank from a Dettol bottle. What is the most common cause of mortality after Dettol ingestion?
Neurological depression
Aspiration pneumonia
Gastric strictures
Uncontrolled seizures
Hypoglycemia

20. Q5 Ans: B
Dettol liquid (chloroxylenol 4.8%, pine oil and isopropyl alcohol) is a commonly used household disinfectant.
Labeled nonpoisonous,
Serious complications were reported in up to 8% of cases of ingestion
included aspirations with gastric content resulting in pneumonia,
cardiopulmonary arrest, bronchospasm, adult respiratory distress syndrome
severe laryngeal edema with upper airways obstruction.
"Burning" in the mouth and throat with nausea and vomiting. Later contaminated skin becomes erythematous and there is redness, swelling and superficial ulceration in the mouth and upper alimentary tract. The larynx may also be involved leading to breathlessness and stridor.

21. Q6
Which of the following ingestions could be seen with an increased anion gap?
Paracetamol
Isopropanol
Ethylene glycol
Ethylene dibromide
Methane

22. Q6 Ans: C
The etiologies of metabolic acidosis with elevated anion gap can be recalled with the mnemonic MUD-PILES:
Methanol, Uremia,Diabetic ketoacidois, paraldehyde, Iron, Isoniazid or Inhlaants, Lactic Acidosis, Ethylene glycol or chronic Ethanol abuse, Salicylates or Solvents.
In paracetamol poisoning metabolic acidois is uncommon.
Isopropyl alcohol results in high srum keones with little or no acidosis

23. Q7
Ethylene glycol poisoning is characterized by all of the following except:
Metabolic acidosis
Increased anion gap
Hypocalemia
Hypomagnesemia
Hypokalemia

24. Q7 Ans: E
Metabolic acidosis with increased anion gap is suggestive of methanol and ethylene glycol ingestion. Ethylene glycol toxicity results from its metabolite oxalate, which chelates calcium ion to form insoluble calcium oxalate crystals and results in hypocalcaemia. Hyopmagmasemia usually occurs with hypocalcemia. However, hyperkalemia results from muscle necrosis, the development of acute tubular necrosis and renal failure, and metabolic acidosis.

25. Q8
A 13-year-old girl comes to the A&E with a history of ingesting a bottle of diphenhydramine (Benadryl) tablets. Which of the following signs and symptoms would be expected on examining the patient?
Sweating, lacrimation, salivation, miosis, an blurred vision.
Lethargy, slow respiration, hypotension, and lured vision.
Agitation, tachycardia, sweating, and mydriasis
Flushed face, agitation, dry mucous membrane, and dilated pupils
Headache, tachycardia, tachypnoea, cherry red mucous membrane, and dim vision.

26. Q8 Ans: D Benadryl (diphenhydramine) is an anticholinergic agent.
Toxidrome: Hot as a hare, Blind as a bat, Dry as a bone, Red as a beet, and Mad as a hatter
A: anticholinesterase inhibitors or cholinergic agents (organophoshates)
B: narcotic overdose
C: sympathomimetic agents (amphetamines)
E: carbon monoxide poisoning

27. Common causes Antidepressants-Tricyclics Antihistamines Atropine
Antipsychotics
Antispasmodics

28. Cholinergic Brady/tachycardia Confusion/reduced GCS Pinpoint pupils
Seizures
Weakness
SLUDGE
Pulmonary oedema

29. SLUDGE S sweating salivation L lacrymation U urinary frequency urgency
D diarrhoea
G gastrointestinal discomfort
E eyes pinpoint

30. Toxidromes Anticholinergic dry, tachycardic mydriasis Sedative-Opiate
bradycardic
miosis
Sympathomimetic
wet, tachycardic
Cholinergic
all wet, bradycardic

31. Q9
A 2-year old is brought to the A&E by his mother, who says her son may have ingested a few CBZ (Tegretol) chewable tablets used by his sibling. Which of the following clinical findings would best support the possibility of an ingestion?
Vomiting
Confusion and excitation
Tachycardia
Hyperreflexia
Nystagmus

32. Q9 Ans: E
Dizziness, ataxia, and nystagmus with deviating pupils are the classic triad seen in CBZ toxicity.
Although vomiting, confusion and excitement, tachycardia, and hyperreflexia are all possible signs of toxicity, the are nonspecific.

33. Q10
A grandmother brings in her 15-month-old toddler who may have swallowed one clonidine tablet (0.1mg) about 30minutes ago. The child is sitting quietly on her lap with heart rate (HR) 80 beats per minute, her blood pressure (BP) 130/80 mm Hg, and respiratory rate (RR) 20 breaths per minute. Which of the following would be the most appropriate management of this patient?
The patient can be discharged afte initial assessment
Look for other ingestants because hypertension is unlikely with a clonidine overdose
Nalaxone 0.1mg/kg IV boluis should be given because the patient is bradycardiac
Emesis should be immediately attempted with syrup of ipecac
Only supportive care and monitoring are needed because most patients recover in 12 to 24 hours

34. Q10 Ans: E
All children who are symptomatic after clonidine ingestion require admission, monitoring, and supportive care because symptoms may persist for up to 24 hours.
Although the toxic dose of clonidine is not known, significant toxicity has resulted with as little as 0.1mg 30 minutes after ingestion.
The central effects of clonidine predominate and cause tachycardia and hypotension, but initially there maybe peripheral α2 stimulation and reduced uptake of epinephrine, resulting in benign, transient paradoxic hypertension.

35. Q11
A 2-year old who swallowed digoxin tablets is found to have bradycardia. An electrocardiogram (ECG) shows ventricular bigeminy. Which of the following is true?
ECG findings of T wave depression and scooped ST segment correlate with significant digoxin toxicity
Digoxin immune FAB (Digibind) is indicated for life-threatening dysrhythmias
There is a wide margin between therapeutic and toxic doses
Hyperkalemia is not affected by digoxin immune FAB (Digibind) therapy
Forced alkaline diuresis may increase renal excretion

36. Q11 Ans: B
Digoxin immune FAB (Digibind) is indicated for use in treating life-threatening digoxin-induced dysrhythmias and for hyperkalemia. The ECG finding of T wave depression and scooped ST segemnts ar known as digitalis effect but do not indicate toxicity. Alkaline diuresis is not useful in digitalis elimination.

37. Q12
Which of the following regarding caustic injury to the esophagus is true?
Acid burns are usually deeper than alkali burns in the esophagus and thus cause greater long-term complications
If there are no orophayngeal lesions, esophagoscopy is not required because esophageal burns are unlikely
Patients who ingest caustics appear to have an increased risk of esophageal carcinoma
Only 50% of all stricture formation results within 2 months of ingestion
About 10% of first-degree burns results in esophageal strictures

38. Q12 Ans: C
Drain pipe cleaners usually contain sodium hydroxide as their principal components.
Patients who ingest caustics have an increased risk of developing esophageal carcinoma.
In the esophagus, acid burns usually cause a superficial coagulation necrosis with eschar formation of the mucosa, which limits penetration of the injury.
However, bases causes liquefaction necrosis of the fat and protein involving the mucosa, submucosa, and muscle and penetrate deeply, causing the potential for greater tissue damage.
Oropharyngeal lesions do not predict esophageal burns as only a third of patients with oral lesions develop esophageal burns, and about 10% to 15% of those with esophageal burns have no oral lesions.
First degree burns do not develop strictures; 15% to 30% of second-degree do; and almost 100% of third-degree burns do

39. Q13
A frantic mother calls you saying that her 2-year-old child just swallowed some household bleach. She gave him milk, which he drank without any drooling or vomiting. Which of the following is the most appropriate action to take?
Tell the mother to give her son syrup of ipecac immediately
Tell the mother to bring her child to the A&E for endoscopy to rule out esophageal strictures
Reassure the mother that it is a mild irritant and that her son will do fine as he has been drinking without problems
Warn the mother that because household bleach is an alkali, it can cause esophageal strictures even if oral lesions are not seen
Tell the mother to give her son antacid to buffer the effect of the bleach

40. Q13 Ans: C
Household bleach contains chlorine or sodium hypochlorin, which is a mild irritant and usually causes no tissue destruction.
Immediate dilution with water or milk is all that is required.

41. Salicylate DEADLY PITFALL
Salicylate levels can continue to rise following admission (10% of cases)
Repeat levels every until peaked

42. Q14
Which statement most accurately describes the effects of insecticides?
Carbamates create an irreversible bond with cholinesterase
Organophosphates stimulate the release of excessive amounts of acetylcholine at the synaptic junction
Insecticide poisoning can be confirmed by a rise in cholinesterase level in the blood
Humans have no biotransformation mechanism for metabolizinig (detoxifying) insecticides
Organophosphates inhibit the degradation of acetylcholine

43. Q14 Ans: E
Organophosphates exert their effect by interfering with the enzyme cholinesterase, which degrades acetylcholine but rather cause its accumulation by preventing degradation.
Insecticide poisoning causes cholinesterase levels to fall, and this test can be used to confirm the clinical impression of insecticide poisoning.
Humans are, in fact able to detoxify organophosphates by conjugation in the liver.
Carbamates form a reversible bond with cholinesterase.
In contrast, organophosphates irreversibly bind to cholinesterase via phosphorylation.

44. Q15
Which statement most accurately characterizes the differences between organophosphate and carbamate poisoning?
Carbamate exposure is more common than organophosphate exposure
Carbamate poisoning is usually of shorter duration
Pralidoxime must be started sooner to be effective in carbamate poisoning
Only organophosphates are absorbed through the skim
Both answers B and C are correct.

45. Q15 Ans: B

46. Q16
Which of the following statements concerning cholinergic poisoning treatment is most correct?
Pralidoxime is used to prevent irreversible deactivation of cholinesterase
Atropine restores the biologic activity of cholinesterase
The dose of atropine should not exceed 2 mg
Pralidoxime is more useful as a treatment for Carbamate exposure than for organophosphate exposure
Bronchorrhea must be treated by loop diuretics because atropine is ineffective for this

47. Q16 Ans: A
Pralidoxime reactivates cholinesterase by competing for the phosphate moiety of the organophosphate compound, thus releasing if from the cholinesterase enzyme.
Atropine counteracts the effects of acetylcholine excess but has no effect on the biological activity of cholinesterase.
There is no maximum dose of atropine in insecticide poisoning.
Rather, the dose is titrated to the patient’s clinical response.
Loop diuretics such as frusemide should be avoided in insecticide poisoning because they exacerbate already excessive urinary output.
Bronchorrhea generally is controlled with ventilation and atropine.

48. Q17
A 22-month-old, 15-kg girl is found with an empty bottle of chewable vitamin tablets (15 mg of elemental iron per tablet). Although originally 100 tablets were in the bottle, the mother believes that at least 75 tables are found on the floor in the house. The child is asymptomatic when she comes to the ED 90minutes after the ingestion. Which of the following is the next most appropriate action?
Administer an immediate dose of activated charcoal and observe for 6 hours
Obtain a serum iron level, complete blood count, serum electrolytes, and liver function test and observe the patient for 6 hours in the ED
Obtain an abdominal radiograph, and if no iron tablets are seen, discharge the patient.
Administer syrup of ipecac and observe for 6 hours in the ED
Administer a desferoxamine challenge of 50mg/kg intramuscularly

49. Q17 Ans: B

50. Q18
Which of the following regarding Naloxone (Narcan) is most correct?
It can be administered intravenously, intramuscularly, and endotracheally, but not intraosseously
It is often effective in reversing miosis associated with barbiturate overdose
It can reverse the respiratory depression of a clonidine overdose
It is effective with natural and semisynthetic opioids and is ineffective with synthetic opioid
It has agonist as well as antagonist effects at higher doses

51. Q18 Ans: C

52. Q18
Naloxone has been shown to be effective antidote in narcotic and clonidine overdose, although its effect with clonidine is less consistent.
Naloxone can be safely administered via all routes, including all intraosseous infusion.
It is effective against all forms of opiods, including synthetic ones, but has no effect on barbiturate reversal.
Naloxone is a pure antagonist with no agonist effects.

53. Q19
A 13-year old boy comes in 3 hours after ingestion of salicylate. The maximal amount ingested is 35g of salicylate. He is complaining of tinnitus, nausea, and vomiting. At the time he arrives in the A&E his vital signs are BP 108/68 mmHg, P 124 beats per minute, and RR 26 breaths per minute. An arterial blood gas reveals a pH of 7.44, and his serum salicylate level is 44 mg/dl. Which of the following would not be expected in this patient?
Normal anion gap metabolic acidosis
Elevateion of prothrombin time (PT)
Lsctic acidosis
Hypoglycemia
Decreased serum ionized calcium

54. Q19 Ans :A
A quick calculation indicates that the child in the scenario ingested approximately 20mg of elemental iron per kilogram. This is the lower range at which toxicity can occur.
However, this child is currently asymptomatic. Because we cannot base our management approach on history alone, it is best to observe the child in the ED for symptoms while we wait for laboratory tests.
Iron does not bind to activated charcoal, and its administration will not be helpful.
An abdominal radiograph is useful when it is positive, but a negative abdominal radiograph is more commonly seen with chewable tablet ingestions.
The use of ipecac is questionable in this case.
A desferoxamine challenge test would be overly aggressive in this asymptomatic child with an estimated ingestion of 20 mg/kg.

55. Q20
Which of the following statements concerning the patient described is most accurate?
Activated charcoal is unlikely to be of value in this patient’s management because of the length of time since ingestion
The patient should not receive IV dextrose and NAHCO3 concomitantly because of the risk of cerebral edema
Alkalinization of the urine is unnecessary into his case because the salicylate level places the patient in the “mild” category
Effective alkalinization of the urine will require adequate replacement of potassium
NaHCO3 therapy should be avoided because the patient’s serum is already alkaline

56. Q20 Ans: D

57. Q21
Which of the following statements concerning the patient described is correct?
Hemodialysis and hemoperfusion would be about equally effective in removing salicylate from this patient
The serum salicylate level indicates that dialysis will not be needed
An acute ingestion of salicylates is more likely to require dialysis than a chronic ingestion
Hypothermia, seizures, and renal failure are indications for dialysis
If pulmonary edema develops, dialysis should be avoided

58. Q21 Ans: A

59. Q22
Which of the following statements concerning the patient described is correct?
Hemodialysis and hemoperfusion would be about equally effective in removing salicylate from this patient
The serum salicylate level indicates that dialysis will not be needed
An acute ingestion of salicylates is more likely to require dialysis than a chronic ingestion
Hypothermia, seizures, and renal failure are indications for dialysis
If pulmonary edema develops, dialysis should be avoided

60. Q22 Ans: B

61. Q23
Which of the following metabolic complications is most likely to occur in the setting of both therapeutic use and overdose of valproic acid?
Elevated ammonia
Elevated calcium
Elevated carnitine
Low sodium
Metabolic alkalosis

62. Q23 Ans:A Disruption of urea cycle
Metabolic acidosis, hypernatremia, hypocalcemia, low carnitine, elevated ammonia (complication of therapeutic use)
Hyperammonia: MS changes
Sometimes hepatitis with bumps in AST/ALT.
Carnitine may be beneficial.
Very rarely renal failure, urea elevation

63. Q24 Activated Charcoal will adsorb all the following meds except:
Phenobarbital
Theophylline
Ferrous sulfate
Verapamil
Salicylates

64. Q24 Activated Charcoal will adsorb all the following meds except:
Phenobarbital
Theophylline
Ferrous sulfate
Verapamil
Salicylates

65. Q25
A 10-month boy is brought in by his parents after he turned blue at home. The mother says he has been fussy recently, which she presumed to be caused by teething; she has been treating him with a topical teething gel. On exam, the boy has marked cyanosis, including the perioral area and nail beds, mild tachypnea and tachycardia, room air O2 sat 88% does not improve with oxygen. Lungs are clear; work of breathing and heart sounds are normal.

66. Q25
Which treatment is most likely to be successful in treating the cyanosis?
Botulinum antitoxin
Deferoxamine
Methylene blue
Prostaglandin E1
Sodium bicarbonate
RR normal, not A
No gi symptoms. No signs of iron tox
Prost E1 heart nl
Asa? 02 normally improves.

67. Q25 Ans: C

68. MetHb
Cyanosis: increased deoxygenated Hb or abnormal pigments, e.g. silver (argyria)
Oxidation of Fe in Hb from ferrous 2+ to ferric 3+: cannot bind O2, impairs 02 release from remaining normal Hb, shifting curve left
Overdose: benzocaine (teething gels), amyl nitrate, pyridium, sulfonamides
Chocolate-brown blood
Methylene blue accelerates NADPH-methemoglobin reductase, contraindicated in G6PD, need exchange transfusion

69. Availability? USA, 2000 16 recommended ‘antidotes’: Acetylcysteine
Atropine
Crotalid snake anvenim
Calcium salts
Cyanide antidote kit
Deferoxamine
Digoxin antibodies
Dimercaprol
Ethanol
Fomepizole
Glucagon
Methylene blue
Naloxone
Pralidoxime
Pyridoxine
Sodium bicarbonate
No consensus:
. Flumazenil
. Physostigmine

70. Antidotes Opiates – naloxone Paracetamol – acetylcysteine/methionine
Beta-blockers – glucagon
Insulin – glucose
Iron – desferrioxamine
Carbon monoxide – oxygen
Methanol - ethanol
(Benzodiazepines – flumazenil)

71. Common Non toxic ingestions
A variety of product commonly found around the home are completely nontoxic or have little or no toxicity after typical accidental ingestion
Treatment is rarely required because the ingredients are non toxic or potentially harmful material is present in minimal doses

72. Confirm ingredients
In all cases, attempt to confirm the identity and/or ingredients of the product
Ensue no other toxic product was involved
Advise parents that mild GI upset may occur
Water or other liquid may be given to reduce the taste and texture of the product

73. Non toxic products Crayons Clay Silica gel Supergle Wax
Zinc oxide ointment

74. Non toxic products with minimal gastrointestinal irritation
Antibiotic ointment
Baby soap
Bar soap
Bleach ( household, less than 6% hypochlorite)
Hair shampoo
Prednisolone
Toothpaste

75. Other low toxicity products
Oral contraceptives:
In excessive amounts may cause GI upset
in females even prepubertal my cause vaginal spotting
Thermometer:
Household thermometers contain less than 0.5ml liquid mercury which is harmless if swallowed. Clean cautiously to avoid dispersing mercury as mist or vapor (i.e. Do not vacuum)

76. Q26
Whole bowel irrigation is recommended in all of the following ingestions except:
Lead paint chips
Cocaine packets
Button batteries
Hydrocarbons
Sustained-release lithium tablets

77. Q26 Ans:D
Whole bowel irrigation is recommended in all of the following ingestions except:
Lead paint chips
Cocaine packets
Button batteries
Hydrocarbons
Sustained-release lithium tablets

78. GI Decontamination Whole Bowel Irrigation Heavy metals
Sustained-release meds
GoLytely
500 – 2000 ml/hr
25cc/kg/hr peds
+/- metoclopropamide
4-6 hours duration
May adsorb some methanol, ethylene glycol

79. Q27
A 14-year-old girl comes to the ED I hour after ingesting 36g of sustained release-enteric coated aspirin tablets. Which of the following statements concerning this patient’s condition is true?
It is unlikely that any aspirin remains in the stomach at the time the patients arrives
Peak serum levels of aspirin will occur at approximately 6 hours
The pills should be visible on a plain radiograph of the abdomen
Management should be withheld until a serum drug level confirms the overdose or the patient becomes symptomatic
Arrangements should be initiated to perform hemoperfusion for the patient.

80. Q27 Ans: A

81. Q27
Enteric-coated tablets are often visible on plain x-ray films, especially enteric –coated salicylate tablets.
Salicylate induces pyloric spasm and forms concretions that adhere to the gastric mucosa, thereby making it probable that some aspirin remains in the stomach.
Although the Done nomogram uses 6 hours for the peak level in salicylate overdoses, this is an overdose of enteric-coated tablets, and the nomogram is therefore unreliable because it is unlikely that the peak level will achieved in 6 hours.
Because this is a potentially serious overdose, management should begin as soon as possible pending the results of the drug level.
The definitive treatment of choice for salicylate poisoning is hemodialysis, not hemoperfusion.
Arrangements need not be instituted until the levels are obtained from this patient because it is early in the poisoning and hemodialysis might not be necessary.

82. Salicylate Salicylism Dehydration Confusion /coma Seizures
Haemetemesis
Hypoglycaemia

83. Salicylate Metabolic and acid-base disturbance Complex
Respiratory alkalosis – direct stimulation to over breathe
Metabolic acidosis- acid, impaired normal metabolism, production of lactic acid
Check ABG / VBG

84. Salicylate Severity of ingested dose: >150 mg/kg: mild
>250 mg/kg: moderate
>500 mg/kg: severe

85. Salicylate management
Tailor treatment to symptoms
Fluids
Reduce absorption:
Activated charcoal
Gastric lavage (>500 mg/kg and <1 hour)
Increase elimination:
Urinary alkalinisation
Cooling
Glucose if hypoglycaemic

86. Salicylate management
<350mg/L: oral fluids
>350mg/L: urinary alkalinisation
>700mg/L: haemodialysis
DISCUSS WITH NPIS

87. Q28
Which of the following household substance, if ingested by a toddler, should cause the most concern?
Silica gel (dehumidifying packets)
Pencil lead
Eye make up
Mercury from a broken thermometer
A whole cigarette

88. Q28 Ans: E

89. Q28
A whole cigarette can produce symptomatic nicotine poisoning in a small child.
Pencil lead, of course is not lead but carbon.
Silica gel and eye make up are nontoxic
The amount of mercury ingested from a broken thermometer would also be non toxic, especially because its absorption would be minimal.