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Poisoning Ali Alhaboo Assisstant Professor of Pediatrics PICU consultant

Poisoning Ali Alhaboo Assisstant Professor of Pediatrics PICU consultant. Overview of pediatric poisoning, diagnosis and treatment Summary of the most encountered poisoning. Epidemiology . Most of the toxic exposures have only minor or no effect on the child

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Poisoning Ali Alhaboo Assisstant Professor of Pediatrics PICU consultant

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  1. PoisoningAli Alhaboo Assisstant Professor of Pediatrics PICU consultant • Overview of pediatric poisoning, diagnosis and treatment • Summary of the most encountered poisoning

  2. Epidemiology • Most of the toxic exposures have only minor or no effect on the child • 85% - 90% of pediatric poisoning occurs in < 5 yrs of age (accidental) usually single agent • 10% - 15% in older age, mainly adolescents (intensional) usually several agents • 3-4% of PICU admission are because of toxic exposures

  3. ED referral recommendations • Serious exposures • Younger than 6 months • History of previous toxic ingestion • Questionable or unreliable history

  4. Routes of exposures in children • Ingestion • Inhalation • Skin exposure

  5. Cosmetics and personal care product Cleaning substance: flash is more serious than Clorox because it melts the esophagus and destroys it. Plants Analgesics: Paracetamol is the commonest cause of poisoning in children ( high doses more than 200 mg/kg) Fe supplements: 2nd most common in females. Antidepressants Anti-diabetics: causing severe hypoglycemia and LOC. Anti-hypertensive. Pesticides: organophosphates. Hydrocarbon Common agents Less common but serious Note: OCPs are not harmful.

  6. History • Identification of the toxic agent • Age of the child. • What has been done to the child. • The time elapsed and the dose taken (if it was unknown consider it serious). • The route of exposure • Underlying medical problems • The clinical effect (with few exceptions rapidity of symptoms progression correlates with severity of poisoning.e.g., acetaminophen) • ? Trauma in addition to ingestion (change in LOC).

  7. Physical Exam • Weight (determine ? mg/kg ingested) • Vital signs • Check odors from the breath, skin, hair, clothing • Thorough exam for any abnormal finding

  8. Severe vomiting, diarrhea Acutely disturbed consciousness Abnormal behavior Seizure unusual odor Shock Arrhythmias Metabolic acidosis Cyanosis Respiratory distress General presentations suggestive of poisoning

  9. Odor Skin Mucous membranes Temperature Blood pressure Pulse rate Respiration Pulmonary edema CNS GI system Clinical clues to the diagnosis of unknown poisoning

  10. Bitter almond Acetone Oil of wintergreen Garlic Alcohol Petroleum Cyanide Isopropyl alcohol, methanol, acetylsalicylic acid Methyl salicylate Arsenic, phosphorous, thallium, organophosphates Ethanol, methanol Petroleum distillates OdorSigns or symptom Poison

  11. Cyanosis Red flush Sweating Dry Methemoglobinemia secondary to nitrates, nitrites, phenacetin, benzocaine Carbon monoxide, cyanide, boric acid, anticholenergics Amphetamines, LSD, organophosphates, cocaine, barbiturates Anticholenergics SkinSign or symptom Poison

  12. Dry Salvation Oral lesions Lacrimation Anticholenergics Organophosphates, carbamates Corrosives, paraquat Caustics, organophosphates, irritant gases Mucous membranesSigns or symptoms Poison

  13. Hypothermia Hyperthermia Sedatives hypnotics, ethanol, carbon monoxide, clonidine, phenothiazines, TCAs Anticholenergics, salicylates, phenothiazines, cocaine, TCAs, amphetamines, theophylline TemperatureSigns or symptoms Poison

  14. Hypertension Hypotension Sympathomimitics (especially phenylpropanolamine in over-the-counter cold remedies), organophosphates, amphetamine, phencyclidine, cocaine Antihypertensives, barbiturates, benzodiazepines, beta blockers, Ca++ channel blockers, clonidine, TCAs Blood PressureSigns or symptoms Poison

  15. Bradycardia Tachycardia Arrhythmias Digitalis, sedatives hypnotics, beta blockers, ethchlorvynol, opioids Antichlonergics, sympathomimetics, amphetamines, alcohol, aspirin, theophylline, cocaine, TCAs Anticholenergics, TCAs, organophosphates, digoxin, phenothiazines, betablockers, carbon monoxide, cyanide Pulse rateSigns or symptoms Poison

  16. Depressed Tachypnea Kussmaul’s sign ( deep & fast breathing ) Wheezing Pneumonia Pulmonary edema Alcohol, opioids, barbiturates, sedatives/hypnotics, TCAs, paralytic shelfish poisoning Salicylates, amphetamines, carbon monoxide Methanol, ethylene glycol, salicylates Organophosphates Hydrocarbons Aspiration, salicylates, opioids, sympathomimetics RespirationsSigns or symptoms Poisoning

  17. Seizures Fasciculation Hypertonus Myoclonus, rigidity Camphor, carbon monoxide, cocaine, amphetamines, sympathomimetics, anticholenergic, aspirin, pesticides, organophosphates, lead, PCP, phenothiazines, INH, lithium, theophylline, TCAs Organophosphates Anticholenergics, phenothiazines Anticholenergics, phenothiazines, haloperidol CNSSings or symptoms Poison

  18. Delirium/psychosis Coma Weakness, paralysis Anticholenergics, phenothiazines, sympathomimetics, alcohol, PCP, LSD, marijuana, cocaine, heroin, heavy metals Alcohol, anticholenergics, sedative hypnotics, opioids, carbon monoxide, TCAs, salicylates, organophosphates Organophosphates, carbamates, heavy metals CNSSings or symptoms Poison

  19. Miosis Mydriasis Blindness Nystagmus Opioids, phenothiazines, organophosphates, benzodiazepines, barbiturates, mushrooms, PCP Antichlenergics, sympathomimitics (cocaine, amphetamines, LSD, PCP), TCA, methanol, glutethimide Methanol Diphenylydantoin, barbiturates, carbamazepine, PCP,carbon monoxide, glutethimide, ethanol EYESigns or symptoms Poison

  20. Vomiting, diarrhea Iron, phosphorous, heavy metals, lithium, mushroom, fluoride, organophosphates GISings or symptoms Poison

  21. Anticholenergics (atropine, scopolamine, TCAs, antihistamines, mushrooms) Cholenergics (organophosphates and carbamate insecticides) Fever, flushed, warm, dry skin, dry mouth, mydriasis, tachycardia, arrhythmias, agitation, hallucinations, coma Salivation, lacrimation, sweating, bronchorrhea, emesis, diarrhea, miosis, bradycardia, bronchospasm with wheezing, confusion, weakness, fasciculations, coma Toxidromes of Common Pediatric PoisoningsToxin Signs or symptoms

  22. Opiates Narcotic withdrawal Hypothermia, hypoventilation, hypotension, bradycardia, miosis, coma Nausea, vomiting, diarrhea, abdominal pain, lacrimation, diaphoresis, mydriasis, tremor, irritability, delirium, seizure Toxidromes of Common Pediatric PoisoningsToxin Signs or symptoms

  23. Sedative/ hypnotics TCAs Phenothiazines Hypothermia, hypoventilation, hypotension, tachycardia, coma Coma, convulsions, arrhythmias, anticholenergic manifestations Hypotension, tachycardia, dystonia syndrome, oculogyric crisis, trismus, ataxia, coma, anticholenergic manifestations Toxidromes of Common Pediatric PoisoningsToxin Signs or symptoms

  24. Salicylates Iron Sympathomimetics (amphetamines, phenylpropanolamie, ephedrine, caffeine, cocaine, aminophylline) Fever, hyperpnea, vomiting, tinnitus, acidosis, seizure, lethargy, coma Hyperglycemia, shock, hemorrhagic diarrhea Tachycardia, arrhythmias, psychosis, hallucinations, nausea, vomiting, abdominal pain Toxidromes of Common Pediatric PoisoningsToxin Signs or symptoms

  25. Iron toxicity • 5 stages : 1- pt feels gastric abset 2- pt feels false relife 3- 4- 5- end result is GI obstruction and abset  Do endoscopy to take the pills out

  26. Laboratory tests • Qualitative toxicology screening is rarely as helpful as Hx and PE in determining the cause • Best done on urine and gastric aspirate samples • Quantitative serum level of known drug is indicated when it can enable prediction of toxicity or determination of treatment • ABGs with respiratory symptoms and to assess acid-base balance • Blood glucose from 1st sample • Liver and kidney function (metabolism&excretion) • Serum electrolytes (anion gap, renal function) • Serum osmolar gap • CBC (anemia, hemolysis) • DIC panel when suspected

  27. Routine Laboratory Tests That Can Suggest Poisoning

  28. Acetaminophen Anticonvulsants Carbon monoxide Cholinesterase Digoxin Ethanol Ethylene glycol Heavy metals Iron Isopropanol Lead Lithium Methanol Methemoglobin Salicylate Theophylline Drugs with clinically useful serum level quantitation

  29. Radiography indications • If head trauma cannot be excluded (skull and cervical spine film, head CT if physical findings are suggestive) • If child abuse is suspected (skeletal survey) • If patient is having respiratory distress (CXRay) • If radiopaque substance is suspected

  30. Common substances that are radiopaque (CHIPES) • Chloral hydrate • Heavy metals • Iodine • Phenothiazine • Enteric coated and extended release medication • Salt tablets (in Fe ingestion, serial films indicate movement and elemination)

  31. كلام الدكتور - مهم Steps of management • 1st : First you have to start with ABCDE, if hypotensive repeat ABCs. • 2nd : Check the O2 saturation and Vital signs • 3rd : look at the pt : smell and take a look at the skin and the pubil • 4th :Glucocheck for hypoglycemia. If hypoglycemic give 5-10% dextrose (not higher than that because it might harm the vessel). Dose: 2-5 ml/Kg. • 5th : Do toxicology screen. • 6th : LFT, U/E, RFT, coagulation profile (PT is the first to be affected, if it was elevated give FFP or vitamin K) and albumin. • 7th If early do Gastric lavage

  32. Cont NB : contraindications of gastric lavage : • Coma pt • Corrosive or inhelated toxication • Late presentation • 8th : Give antidote as early as possible if available. (N-acetylcesteine is the antidote for paracetamol. Desfuroxemine is the antidote for iron. • 9th : Give Activated charcol  in early condition : give it by NG tube NB : contraindications : • Iron toxcicity MCZ • Lead toxicity • 10 th : give Mg sulfate to facilitate Bowl movement • 11th : total bowel irrigation • 12th : investigate the pt for damage : (( 1st : level of the Med – 2nd : renal and liver function – cbc ) • Transfer the patient to the ICU, if there is no bed keep him in the ER.

  33. Treatment • Airway:patency and protective mechanisms (if absent, use nonspecific antidote of D10W 2cc/kg and Naloxone 0.1mg/kg; if no response intubate. • Breathing:clear secretions, give O2, continuous O2 saturation, ABGs, CXRay, treat wheezing and stridor, early controlled intubation prefered • Circulation: frequent VS, continuous CR monitor, fluids for low BP, do baseline ECG, watch for arrythmias, PALS guidelines • Neurologic status:frequent assessments, the most common cause to admit intoxication to PICU, use nonspecific antidotes, watch for seizures, rule out metabolic causes of seizure

  34. Dosage in < 1 yr 10 ml Young children 15 ml Adolescents, adults 30 ml may repeat once Petroleum distillates Caustic agents Impaired consciousness, seizures Rapid coma-inducing agents (e.g., propoxyphene, TCAs) GI decontaminationEmesis-Syrup of Ipecac Therapy Contraindications

  35. We use lavage when the patient presents early and is stable. • If late presentation where the drug has already passed to the duodenum use the activated charcoal( through a NG tube) where up to 1 million particles can adsorb to the medication.

  36. Large bore orogastric hose (28 Fr for young children, 36-40 Fr for adolescents) Left recumbent Trendelenburg’s position to reduce the risk of aspiration Lavage with saline or 1/2 NS until return is clear Most successful for toxins that delay gastric emptying (aspirin, iron, anticholinergics) and for those forming concretions (iron, salicylates, meprobamate) Corrosive caustic agents Controversial in petroleum distillates ingestion Stupor or coma unless airway is protected GI decontaminationLavage Therapy Contraindications

  37. Administer in all cases after emesis. It should be only given for conscious patients. Dosage: - Children 1 g/kg - Adults 50-100 g Corrosive agents: charcoal interfers with GI endoscopy GI decontaminationActivated Charcoal Therapy Contraindications Most feared complication is aspiration leading to severe pneumonitis and ARDS

  38. MgSO4 250 mg/kg/dose P.O.(max dose 30 g) in 10%-20% solution Sorbitol magnesium citrate Repeat above doses every 2-4 hrs until passage of charcoal stained stools Avoid MgSO4 in renal failure GI decontaminationCathartics Therapy Contraindications

  39. Enhanced elimination • Forced diuresisby administering 2-3 times the maintenance fluid to achieve U.O = 2-5 cc/kg/hr (contraindicated in pulmonary or cerebral edema and renal failure) • Urinary alkalinizationto eleiminate weak acids(salicylates, barbiturates and methotrexate), can be achieved by adding NaHCO3 to the IV fluids, the goal is urine pH of 7-8 • Serum alkalinizationin TCAs toxicity • Hemodialysisin low molecular weight substances with low volume of distribution and low binding to plasma proteins • Hemoperfusion, protein binding is not a limitation

  40. Antidotal Therapy • Only a small proportion of poisoned patients are amenable to antidotal therapy • Only a few poisoning is antidotal therapy urgent (e.g., CO, cyanide, organophosphate and opioid intoxication)

  41. Specific Intoxications and Their Antidotes

  42. Specific Intoxications and Their Antidotes

  43. Acetaminophen (paracetamol) poisoning • Nausea, vomiting and malaise for 24 hrs • Improvement for 24-48 hrs • Hepatic dysfunction after 72 hrs (AST is the earliest and most sensitive) • Death may occur from fulminant hepatic failue • Toxicity likely with ingestion of > 150 mg/kg • Rumack-Matthew nomogram defines the risk of hepatic damage in acute intoxication (level at 4 hrs post ingestion)

  44. Acetaminophen (paracetamol) poisoning management • GI decontamination • Activated charcoal within 4 hrs of ingestion • Antidote N-acetylcysteine is most effective if given within 8 hrs of ingestion, total of 17 doses, P.O or IV (However, NAC should be given even with > 24hrs presentation) • NAC should be given if serum acetaminophen level is either in the “possible” or “probable” hepatotoxic range

  45. Fever Sweating Nausea Vomiting Dehydration Hyperpnea Tinnitus Seizures Coma Coagulopathy Respiratory depression Pulmonary edema SIADH Hemolysis Renal failure Hepatotoxicity Cerebral edema هذا الموضوع قراءه فقط Salicylate toxicityClinical manifestationsCommon Uncommon

  46. Metabolic acidosis Respiratory alkalosis Mixed (resp alkalosis &metabolic acidosis) Hyperglycemia, Hypoglycemia Hypernatremia, hyponatremia Hypokalemia Hypocalcemia Prolonged PT Ketouria Laboratory findings in salicylate toxicity

  47. Prediction of acute salicylate toxicity • Ingested dose can predict the severity • < 150 mg/kg toxicity not expected (asymptomatic) • 150-300 mg/kg toxicity mild to moderate (mild to moderate hyperpnea, lethargy or excitability) • 300-500 mg/kg severe toxicity (severe hyperpnea, coma or semicoma, sometimes with convulsions)

  48. Management of salicylate toxicity • GI decontamination • Correct dehydration and force diuresis • Urine alkalinization and acidosis correction with IV NaHCO3 • Monitor electrolytes, glucose, calcium • Vit K for hemorrhagic diathesis • Decrease fever with external cooling • Hemodialysis for severe intoxication (Dome nomogram), severe acidosis unresponsive to NaHCO3, renal failure, pulmonary edema and severe CNS manifestation

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