Pediatric Toxicology Pills and poisonous bites High Yield

1. Pediatric ToxicologyPills and poisonous bitesHigh Yield Eiman Abdulrahman MD/MPH Pediatric Emergency Medicine Fellow Emory University

2. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

3. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

4. Epidemiology • 1.25 million annual cases in <6years. • 15,447 fatalities; 537 (3.7%) in <6yrs; 397 (2.6%) in <2yrs (since 1983) • Of 27 deaths in 2004; 19 were caused by pharmaceuticals (analgesics and opioids) of which 14 were in <2yrs • 12 deaths were pre-hospital

5. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

6. Pediatric Toxicology Young children vs Teenagers • 79% of all pediatric exposures occur in <6years and approx 99% are unintentional • Approx 40-45% of ingestions in adolescents are intentional and 56% are female (substance abuse vs suicide attempts)

7. Young Children • Without suicidal intent • Usually one substance • Usually non-toxic • Small amount • Present for evaluation within one hour

8. Young children • Physiologic considerations • High Metabolic Demands • More permeable BBB until 4mos • Decreased glycogen stores

9. Adolescents • 56% of seriously poisoned children • Overdose from suicidal attempt • Adverse effect while trying seeking euphoria • More frequently hospitalized than younger children ( includes psych) • 42% of AAPCC reported adolescent fatalities from suicide vs 4% from medication errors and adverse reactions

10. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

11. Prevention • The Poison Prevention Packaging Act (PPPA) of 1972 has reduced pediatric mortality by 45% • Mandatory child protective packaging in household products, medicines, solvents • FDA 1997 regulation with packaging with blister packs of 30mg Iron tablets (overturned in 2003) • Significant decline in iron overdose • Small amounts of some substances can extremely toxic to children

12. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

13. Lethal exposures • Analgesics • Sedative/hypnotic/psychotics • Antidepressants • Stimulants and street drugs • Cardiovascular drugs • Alcohols • Chemicals • Gas and fumes • Antihistamines

14. AntimalarialsAntidysrhythmicsBenzocaineβ-blockersCalcium channel blockers (CCBs)CamphorClonidine (and other imidazolines) Lomotil (diphenoxylate/atropine)LindaneMethyl salicylateOpioids SulfonylureasTheophyllineTricyclic antidepressants (TCAs) Lethal Drugs

15. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

16. General Approach • Airway • Breathing • Circulation • Disability • Drugs • Decontamination

17. Focused history • Three key questions: • WHAT substance was ingested? • WHEN did the ingestion occur? • HOW MUCH was ingested?

18. Key PE • Vital signs • Level of consciousness, neuromuscular status • Eyes-pupils, EOM, fundi • Mouth-corrosive lesions, odors • CV- rate, rhythm, perfusion • Resp- rate, chest excursion, air entry • GI- motility • Skin- color, bullae or burn, diaphoresis, piloerection,

19. Laboratory evaluation • CBC, co-oximetry • ABG, serum osmolarity • EKG/cardiac monitor • CXR, abdominal xray • Electrolytes, bun/cr, glucose, calcium, LFT, UA • Urine tox screen • Quantitative tests (esp acetaminophen)

20. Assessment • Clinical findings • Toxidromes • Laboratory abnormalities • Anion gap: (Na + K)-(Cl + HCO3) • Osmolarity: (2x Na)+ (Bun/2.8)+(Glu/18) • Osmolar gap: measured-calculated

21. Toxidromes

22. Detoxification • Reassess ABCDs • GI decontamination: • Dilution, gastric emptying, Activated charcoal, catharsis, whole bowel irrigation • Urgent antidotal therapy • Consider excretion enhancement • Diuresis, urine alkalinization, dialysis, hemoperfusion

23. Case 1 “lethargic” • 4 year old w/ ALOC • Grandmother called 911 when girl was not arousable • VS: T 37.6 HR 60 RR 18 BP 80/60 Pulse Ox 98% Differential?

24. Case 1 “lethargic” • MNEMONIC FOR ALOC • A- Alcohol • E- Epilepsy • I- Insulin/intussusception • O-Overdose • U- Uremia • T- Trauma • I- Infection • P- Psychiatric • S- Shock

25. Case 1 “lethargic” • PE: • 1mm pupils reactive • Dry skin • No trauma except for “bandaid” on Rt knee Diagnosis?

26. Case 1 “lethargic” • Clonidine patch on Rt knee • Fluid resuscitation- NS20ml/kg • Naloxone w/ no effect • Admitted to PICU • D/C next day

27. Outline • Important highlights in pediatric toxicology • Young children vs Adolescents • Prevention • Overview of pills potentially fatal in children even in small amounts • Approach to management • Snake and spider bites

29. Brown Recluse Spider(Loxosceles) • Southern and mid-western states • Brown violin shaped mark on dorsum of cephalothorax • Usually outdoors, but make indoor nests in closets • Shy and will only attack when provoked • Venom is cytotoxic and hemolytic

30. Clinical presentation • 2-8 hours • Local reaction with mild-moderate pain (stinging sensation) • Erythema, central blister or pustule • 24 hours • Fever, chills, malaise weakness, N/V, rash with petechiae, joint pain, DIC, hematuria, renal failure • Subcutaneous discoloration that spreads over • 3-4 days • Spreads to 10-15 cm • Pustule drains leaving ulcerated crater that scars • Scar formation is rare after 72 hrs • Reaction varies according to amount of envenomation

35. Management • Unless spider is brought for ID, definitive diagnosis cannot be made • Good local wound care • If systemic symptoms, then CBC with platelets, U/A, BUN, creatinine • Vigorous supportive care in PICU • Surgical excision and skin grafting after necrosis is demarcated • Steroids, heparin, and hyperbaric O2 don’t work • No Dapsone for kids – methemoglobinemia • No antivenom available • Have wound rechecked daily for progression

37. Black Widow Spider(Latrodectus) • Shiny black spider with brilliant red hourglass marking on abdomen • Only the female bite is dangerous • Male spiders are ¼ the size of females and bite cannot penetrate human skin • Females not aggressive unless provoked or guarding egg sac • Produces a neurotoxin

38. Clinical presentation • No local symptoms • 1-8 hours after bite • Generalized pain and muscle rigidity • Cramping pain to abdomen, flanks, thighs, chest • Chills • Urinary retention • Priapism • Death from cardiovascular collapse • Mortality 50% in young children

40. Management • Supportive ABC’s • Tetanus • Treatment of spasm with narcortics and benzo’s • Children < 40kg: Antivenin given as soon as bite confirmed • Dose: 2.5ml (one vial) • Children >40kg: not as urgent to give immediately unless having respiratory difficulty or significant hypertension • Admit to PICU

42. Other Spiders… • Tarantulas • Do not bite unless provoked • Venom is mild and not a problem • Wolf Spider and Jumping spider • Mild venom only causes local reaction • Treatment is good local wound care

45. Snake characteristics • cold blooded (seeks shelter at 55 degrees) • - poor vision, great smell • - slow but can strike 11 feet/sec. • - Rattles are interlocking keratin rings • - Jacobson’s organ at end of the forked tongue used to ID prey • - venom with potent enzymes that effect coagulation, multi-organ function • Play major role in ecosystem as rodent predators

46. Snakes Bites • Epidemiology • approx 400,000 bites worldwide • Approx 45,000 bites in USA • Approx 8,000 poisonous bites • 5-15 deaths annually

47. Over 95% in the pit viper (Crotadilae) family: Eastern diamondback rattlesnake (Crotalus) Copperhead (Agkistrodon) Cottonmouth (Agkistrodon) - 1% Coral snake(elapidae) family Georgia is home to 41 different snakes of which 6 are venomous Snake Types

48. Rattlesnakes, cottonmouths, water moccasins Proteolytic enzymes and anticoagulant esterases=> digest victim!! Mojave rattlesnake only pit viper with neurotoxin venom Pit Vipers (Crotalinae)

49. Clinical Presentation • Local effects: • edema within 1 hr (mod-severe bites) spreads centrally over 8-24hrs. • Ecchymosis, Petechiae and Hemorrhagic bullae • Systemic Effects: • Nausea, vomiting, paresthesias, dizziness, and diaphoresis. In severe envenomations-hypotension, rhabdomyolysis, renal failure and AMS • Coagulopathy: • Increase in PT, PTT, thrombocytopenia and hemolysis. DIC in severe cases