2 Poisoning in Childhood 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.
3 Poisoning in ChildrenIngestion of a harmful substance is among the most common causes of injury
4 Important 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 odorsHow has the patient behaved since the ingestion?Does the patient have a history of substance abuse?
6 Full vitals / Monitoring Give specific antidotes / treatment ABC’s of Toxicology:AirwayBreathingCirculationDrugs:Resuscitation medications if neededUniversal antidotesDraw blood:chemistry, coagulation, blood gases, drug levelsDecontaminateExpose / ExamineFull vitals / MonitoringGive specific antidotes / treatment
7 Decontamination: Ocular: Dermal: Gastro-intestinal: Flush eyes with salineDermal:Remove contaminated clothingBrush offIrrigate skinGastro-intestinal:Activated charcoal:May Prevent /delay absorption of some drugs/toxinsAlmost always indicatedNaso/oro-gastric LavageBowel Irrigation:Recent ingestions 4-6 hrs500 cc NS Children / 2000cc adultsOrally / Nasogastric tube
9 poising Treatment Do not induce vomiting Do not attempt gastric lavage Risk of aspiration outweighs any benefit from removal of substanceCXR around 2-4 hrs “not before 2hrs”Observe in ER for 6-8 hrs
10 PreventingEducation is the major component of any poison prevention programme.Keep medicines, insecticides, etc… out of the reach and sight of your children.Never store food & cleaning products together. Store medicine and chemicals in original containers.
11 Hydrocarbon Poisoning These may be divided into aliphatic or aromatic compounds. Aliphatic hydrocarbons include kerosene, turpentine, lubricating oils, tar and have greatest risk of aspiration and pulmonary symptoms. Aromatic compounds have mainly neurological and hepatic toxicity and include benzene compounds.
12 Type of toxicity with a hydrocarbon depends on its volatility, viscosity or surface tension. The lower is viscosity, more is the risk of pulmonary aspiration. Mineral spirit, kerosene and furniture polish have both low volatility and viscosity and thus carry a higher risk of aspiration pneumonia.
13 Benzene derivates, toluene and xylene are components of various solvents and degreasers. These are highly volatile but have low viscosity. Inhalation is the primary route of toxicity which manifests with CNS symptoms. Gasoline and naphtha are constituents of lighter fuel and lacquer diluent and primarily cause depression of the central nervous system (CNS).
14 Turpentine oil is highly volatile but has low viscosity also Turpentine oil is highly volatile but has low viscosity also. Toxicity results from inhalation and gastrointestinal absorption. They can also cause CNS toxicity.Halogenated hydrocarbons are used as solvents and spot removers. Freon is used as a refrigerant.Toxic exposure to hydrocarbons may result in cardia, gastrointestinal, neurological, pulmonary, renal, hepatic, metabolic and hematological manifestations.
15 Induced emesis or gastric lavage is contraindicated for kerosene oil poisoning. It is done only when large quantities of turpentine have been ingested or the hydrocarbons product contains benzene, toluene, halogenated hydrocarbons, heavy metals, pesticides or aniline dyes. Other specific modalities including steroids and antibiotics are not efficacious.
16 Epidemiology Clinical features Investigation Treatment KEROSENE POISONINGEpidemiologyClinical featuresInvestigationTreatment
17 Clinical features Age – 1 to 3 years more than 70% symptomatic within 10 hoursSYMPTOMSRS – breathlessness, coughCNS – convulsions, comaGPE – fever, restlessness, cyanosisGI – vomiting, diarrhea
18 Kerosene poising Kerosene ingestion: Risk of aspiration GIT & Respiratory effects.Burning sensation, nausea and diarrheaCough, chocking, gagging and grunting.CXR 2-8 hrs later: Pulmonary infiltrates or perihilar densities.pneumatoceles, pleural effusion or pneumothorax and bacterial superinfectionResolution 2-7 days.
19 Lab Investigations X – Ray changes Blood – Leukocytosis Changes appear within one hour- commonly right basal infiltrates- emphysema- pleural effusion- pneumatocoeles
20 Management Avoid emetics Avoid gastric lavage – In case of massive amount use a cuffed endotracheal tubeAfter lavage leave magnesium or sodium sulphate in the stomachOxygen may be usefulAssisted VentilationAntibiotics - PenicillinKanamycinSteroids – Not helpful
22 Organophosphorus Poisoning Organic phosphate insecticides cause irreversible inhibition of the enzyme cholinesterase. As result acetylcholine accumulates in various tissues. Excessive parasympathetic activity occurs. These agents are absorbed by all routes including skin and mucosa.
23 Symptoms manifest quickly usually within a few hours and include weakness, blurred vision, headache, nausea, and pain in chest. These patients have excessive secretion in the lungs and they sweat profusely. Salivation is marked. Pupils are constricted and papilledema may occur. Muscle twitching, convulsions and coma occur in severe cases. Reflexes are absent and sphincter control is lost.
24 TreatmentIf the insecticide was in contact with skin or eyes, these are thoroughly washed. Stomach wash is done.Atropine sulphate: 0.03 to 0.04 mg/kg IV (atropine sulphate is usually available in ampules 1 in 1,000 or 1 mg/mL). Other strengths may also be available. Repeat half the dose in 15 minutes and if necessary every hour (until signs of toxicity appear), subject to a maximum of 1 mg/kg in 24 hours.
25 Pralidoxime (PAM) is given in dose of mg/kg IM or IV over 30 min infusion. The dose may be repeated in 1-2 hours, then at 6-12 hour intervals as needed. Monitor for hypertension. Never inject morphine, theophylline, aminophylline or chlorpromazine. Intravenous fluids should only be given with caution. No oral tranquilizers are administered. Artificial respiration may be necessary to sustain life.
26 Metabolic acidosis supervenes quickly due to disturbances of oxidative phosphorylation and reduction of hepatic glycogen with resultant ketonemia. The patients are treated with adequate replacement of fluids to restore renal function.
27 Urine is alkalinized by administering 1-2 mEq/kg of sodium bicarbonate at half hourly intervals for 4 hours to promote excretion of urine, because in alkaline urine, salicylates do not diffuse back into the tubular cells from the lumen. Potassium salts should be given (3-5 mEq/kg/day) to replace the potassium losses
28 paracetamolIt is safe in pharmacological doses. Overdosage may cause hepatic damage. Acetaminophen overdosage is treated with acetylcysteine to be used orally within 16 hours after ingestion in a loading dosage of 140 mg/kg diluted to 5 percent solution orally followed by 70 mg/kg q 4h for another 16 doses.
29 Carbon Monoxide Poisoning Carbon monoxide poisoning results from inhalation of fire smoke, automobile exhaust, fumes from faulty gas stoves and ingestion of paint and varnish removers. Clinical manifestations include headache, cyanosis, convulsions, and coma. Patients are administered 100 percent oxygen and if carboxyhemoglobin levels are above 40 percent, hyperbaric oxygen therapy is considered.
30 The label should be read before using the drug The label should be read before using the drug. No drug should be given or taken in the dark. Drugs after their expiry date should be disposed in a safe manner. Avoid taking medicine in your child’s presence. Never suggest that medicine is candy.Children should be taught not to eat plants or berries.
31 Iron IntoxicationIngestion of a number of tablets of ferrous sulphate may cause acute poisoning. Lethal dose is 300 mg/kg of iron. Severe vomiting and diarrhea occur. These may contain blood due to extensive gastrointestinal bleeding. The child may go into severe shock, hepatic and renal failure within a few hours or after a latent period of 1 to 2 days
32 Iron Poisoning Five Stages but variable Gastro-intestinal stage: within several hrs of ingestion:abdominal painSevere: fluid loss, bleeding, shock(acidosis, tachycardia +/- hypotension)Fever. Lethargy. Coma
34 Iron Poisoning Stage 3: Circulatory collapse : 48-96 hrs Metabolic acidosis, hypotension, low Cardiac output.CoagulopathyMultiorgan system failure
35 Iron Poisoning Stage 4: Hepatic failure: 96 hrs Increased mortalityRarely fulminant hepatic failureHepatic necrosisLiver transplant can save lives
36 Iron Poisoning STAGE 5: Bowel obstruction 2-6 wks Due to scarring Gastric outlet obstructionSmall intestinal obstructionMay not pass through stage 4
37 TreatmentVomiting should be induced and stomach should be washed with sodium bicarbonate solution. Shock is corrected by infusion of fluids parenterally. Three mL of 7.5 percent sodium bicarbonate solution per kg of body weight are diluted with 3 times its volume of 5 percent glucose solution and injected intravenously for treatment of acidosis. This dose may be repeated after an hour if acidosis is persisting.
38 Iron salts are chelated with desferrioxamine IV at 15mg/kg/hour until the serum iron is <300 mg/dL or till 24 hours after the child has stopped passing the characteristic ‘vin rose’ colored urine. Presence of ‘vin rose’ color to urine indicates significant poisoning.
39 Iron Poisoning Management: Gastric decontamination: Secure good IV Forced emesisGastric lavage with 5% NaHCO3No activated charcoalSecure good IVGet initial the 4hrs levels and TBCChelate with Deferoxamine if levels> 300mg/dL
40 Iron Poisoning Chelate with Deferoxamine: Stable pts : levels< 500 mg/dL 40mg/kg IM/IVUnstable: bleeding/ level > 500Give 20cc/kg NS/RLDeferoxamine at 15 mg/kg IV over 1hrContinuous drip at 15mg/kg/hrContinue till “vin rose” urine color disappears.
41 Iron Poisoning Observe for: Signs of hepatic failure: Systemic BP ECG BleedingGlucose intoleranceHyperammonemiaEncepalopathy
42 SALICYLATES Oral ingestion commonest Transdermal less Peak levels at 12 hrsEarly : hyperpnea respiratory alkalosisThen metabolic acidosisSevere cases: Cerebral edema and increased ICP
43 Salicylate PoisoningIngestion of 150 mg/kg of salicylates causes intoxication. Salicylate level of mg/dL causes moderate symptoms. Severe symptoms are associated with blood levels above 80 mg/dL.Initially, there is a respiratory alkalosis, because of hyperventilation induced by sensitization of the respiratory center by salicylates. Kidneys compensate for this alkalsis by increasing the excretion of sodium and potassium bicarbonate
44 SALICYLATES MANAGEMENT Treat electrolyte imbalance IV hydration HemodialysisDiuretics
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