1. Poisoning in Children Norah Al Khathlan M.D. Consultant Pediatrician Consultant Pediatric Intensivist 02/02/08

2. 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). 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. 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. Learn the presenting signs, symptoms, laboratory findings, pathophysiology and treatment of common therapeutic drug poisonings, drugs of abuse, natural toxins and general household poisons.

3. Poisoning in Children Objectives: At the end of this lecture the student will be able to : 1. Define poisoning. 2. Identify specific Toxidromes. 3. Identify risk factors for pediatric toxidromes. 4. Differentiate between the different classes of toxidromes. 5. Differentiate the routes of poisoning. 6. Describe the general management of the toxidromes. 7. Outline the management of specific toxidromes: –Iron –Salicylates –Paracetamole/ Acetaminophen –Kerosene

4. Poisoning in Children Definition of Poisoning: 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. Circumstances of Exposure can be intentional, accidental, environmental, medicinal or recreational. Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure. Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure. “All substances are poisons...the right dose separates poison from a remedy.”

5. Poisoning in Children Ingestion of a harmful substance is among the most common causes of injury to children less than six years of age 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. 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. Poisoning maybe a medical emergency depending on the substance involved.

6. 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

7. Poisoning in Children Examples: ASA ASA Acetaminophen Acetaminophen TCA TCA Narcotics & drugs of abuse Narcotics & drugs of abuse Benzodiazepines Benzodiazepines Iron supplements Iron supplements Alcohol Alcohol

8. Shannon M. N Engl J Med 2000;342:186-191 Agents Most Commonly Ingested by Children Less Than Six Years of Age, 1995 to 1998

9. Shannon M. N Engl J Med 2000;342:186-191

10. Poisoning in Children Important history points What toxic agent/medications were found near the patient? What toxic agent/medications were found near the patient? What medications are in the home? What medications are in the home? What approximate amount of the “toxic” agent was ingested? 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 ? When did the ingestion occur ? Were there any characteristic odors at the scene of the ingestion? Were there any characteristic odors at the scene of the ingestion? Was the patient alert on discovery? 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? Does the patient have a history of substance abuse?

11. Poisoning in Children Management General measures: Quick assessment & triage Quick assessment & triage Identify the culprit. Identify the culprit. Limit absorption: Limit absorption: –Vomiting –Lavage –Activated charcoal instillation Specific:

12. Poisoning in Children ABC’s of Toxicology: Airway Airway Breathing Breathing Circulation Circulation Drugs: Drugs: Resuscitation medications if needed Resuscitation medications if needed Universal antidotes Universal antidotes Draw blood: Draw blood: chemistry, coagulation, blood gases, drug levels chemistry, coagulation, blood gases, drug levels Decontaminate Decontaminate Expose / Examine Expose / Examine Full vitals / Foley / Monitoring Full vitals / Foley / Monitoring Give specific antidotes / treatment Give specific antidotes / treatment

13. Poisoning in Children Decontamination: Decontamination: 1.Ocular: – Flush eyes with saline 2.Dermal: – Remove contaminated clothing – Brush off – Irrigate skin 3.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…?

14. Shannon M. N Engl J Med 2000;342:186-191 Agents Used for Gastrointestinal Decontamination in Children

15. Shannon M. N Engl J Med 2000;342:186-191 Circumstances under Which Administration of Ipecac Syrup Should Be Avoided

17. Important points

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

21. Acetaminophen poisoning Stage II: Stage II: –24-48 hrs after ingestion. Better, less symptoms. Better, less symptoms. Elevated bilirubin, transaminases and PT Elevated bilirubin, transaminases and PT

22. Acetaminophen poisoning Stage III Stage III –48-96 hrs ( 2- 4 days) after ingestion: Hepatic dysfunction Hepatic dysfunction (Rarely hepatic failure) (Rarely hepatic failure) Peak elevations in: Peak elevations in: –Bilirubin –Transaminases may reach > 1000 IU/L –Prolonged PT

23. Acetaminophen poisoning Stage VI Stage VI –168- 192 hrs (7-8 days) –Clinical improvement –LFTs returning to normal

25. Acetaminophen poisoning Probable toxicity should be treated with: 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 On presentation Daily Daily –Continue other support

26. Iron Poisoning Five Stages but variable Five Stages but variable –Stage 1 Gastro-intestinal stage: within several hrs of ingestion: 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

27. Iron Poisoning Stage 2 Stage 2 –Quiescent stage: 4-48hrs Clinical improvement Clinical improvement Subtle hemodynamic changes: Subtle hemodynamic changes: –Tachycardia –Decreased U.O.P.

28. Iron Poisoning Stage 3: Stage 3: –Circulatory collapse : 48-96 hrs Metabolic acidosis, hypotension, low Cardiac output. Metabolic acidosis, hypotension, low Cardiac output. Coagulopathy Coagulopathy Multiorgan system failure Multiorgan system failure

29. Iron Poisoning Stage 4: Stage 4: –Hepatic failure: 96 hrs Increased mortality Increased mortality Rarely fulminant hepatic failure Rarely fulminant hepatic failure Hepatic necrosis Hepatic necrosis –Liver transplant can save lives

30. Iron Poisoning STAGE 5: STAGE 5: –Bowel obstruction 2-6 wks –Due to scarring Gastric outlet obstruction Gastric outlet obstruction Small intestinal obstruction Small intestinal obstruction –May not pass through stage 4

31. Iron Poisoning Management: 1.Gastric decontamination: Forced emesis Forced emesis Gastric lavage with 5% NaHCO3 Gastric lavage with 5% NaHCO3 No activated char coal No activated char coal 2.Secure good IV 3.Get initial the 4hrs levels and TBC 4.Chelate with Deferoxamine if levels> 300mg/dL

32. Iron Poisoning Chelate with Deferoxamine: Chelate with Deferoxamine: –Stable pts : levels< 500 mg/dL 40mg/kg IM/IV –Unstable: bleeding/ level > 500 Give 20cc/kg NS/RL Give 20cc/kg NS/RL Deferoxamine at 15 mg/kg IV over 1hr Deferoxamine at 15 mg/kg IV over 1hr Continuous drip at 15mg/kg/hr Continuous drip at 15mg/kg/hr Continue till “vin rose” urine color disappears. Continue till “vin rose” urine color disappears.

33. Iron Poisoning Observe for: Observe for: –Systemic BP –ECG –CVP Signs of hepatic failure: Signs of hepatic failure: –Bleeding –Glucose intolerance –Hyperammonemia –Encepalopathy

34. SALICYLATES Oral ingestion commonest Oral ingestion commonest Transdermal less Transdermal less Peak levels at 12 hrs Peak levels at 12 hrs –Early : hyperpnea  respiratory alkalosis –Then metabolic acidosis –Severe cases: Cerebral edema and increased ICP

35. SALICYLATES MANAGEMENT MANAGEMENT –Treat electrolyte imbalance –IV hydration –Forced alkaline diuresis –Hemodialysis –Diuretics

36. Hydrocarbons Kerosene ingestion: 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.

37. Hydrocarbons Treatment: 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.

38. Poisoning in Children “Prevention is the vaccine for the disease of injury.” Host Host AGENTA causal relationship! AGENTA causal relationship! Environment Environment

44. Poisoning in Children “Prevention is the vaccine for the disease of injury.” Host Host AGENTA causal relationship! AGENTA causal relationship! Environment Environment

45. Poisoning in Children Prevention The reduction in the incidence of childhood poisonings in the past half-century has been dramatic. 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. 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.

46. Thank you Norah Khathlan M.D.