Do you need a cuppa?

1. Do you need a cuppa? Dr. Anushma Sharma ST5 Paediatrics Department of Community Paediatrics Salford

2. AIM 1. Present an interesting case 2. Discuss the outcome 3. Discuss the causes of the presenting symptoms

3. Admission 1 • 1 year old • Vomiting, loose stools, unwell • Tachycardiac, irrtable, breathless • Metabolic acidosis – pH 7.13, pCO2 2.2, BE -23 , Lac 27, Glu 5.3 • Improved quickly within 12 hours with ventilatory support and fluids + sodium bicarbonate correction

4. Metabolic disorder suspected • Investigations ammonia acyl carnitine plasma amino acids free fatty acids urine organic and amino acids LFT and renal funtions salicylate levels

5. Admission 2 • 13 months • Had been well • Found unresponsive on bedroom floor at 0800 • No hypoglycaemia • Severe metabolic acidosis pH 6.91, pCO2 2.96, Bicarb 4.3, BE -27.9, lactate>30 • Sent to PICU and recovered in 12 hours • Skin biopsy and toxicology investigations

6. Previously..... • Parents 18 years old, both unemployed, separated • H/o domestic violence • Good pregnancy • NVD • No significant neonatal diagnoses • Satisfactory growth and development

7. Previously............ • 7 weeks old • Unwitnessed fall from sofa while being watched by mother's friend • Attended A+E promptly • Parietal skull fracture • Discharged back to mother after child protection investigations • 11th admission • Recent Burn????

8. Toxicology Urine positive for Glycolate

9. Antifreeze= Ethylene Glycol Colourless Odourless Very sweet Present in Radiator fluid, Deicer, Wind screen wash, Window cleaning fluid

10. Fake vodka health warning in UK The Guardian, Saturday 31 December 2011 ingestion. Counterfeit vodka seized by council trading standard teams. Photograph: Nottinghamshire County Council/PA

11. Ethylene Glycol Toxicity • Toxic dose requiring medical trematment is 0.1ml/kg body weight or 4 ml for 20 Kg child • Lethal dose in humans is 1.4ml/kg or 56 ml for a 20 kg child • Ethylene glycol does not evaporate so inhalational exposure is unlikely • Ethylene glycol is not absorbed through skin so dermal exposure is also uncommon

12. Outcome • Forensic samples obtained • Police investigations started and mother was taken in custody • BC and sister 10 months old in foster care

13. Metabolism Ethylalcohol Fomipezole

15. NPIS annual Report 2010-2011 • Prospective audit • Toxic alcohol and glycol cases reported through telephone enquiries to the NPIS in 2010 • Aim: 1. To provide information on the frequency, current management and outcomes of systemic toxic alcohol poisoning. 2. To provide information on which to base the planning of clinical services for this type of poisoning, including appropriate availability of assays and antidotes.

16. Results • 488 individual exposures • 250 in non hospital sourced • 89 (18%) cases less than 5 years old • 238 in hospital sources • 182 potentially systemic exposures • 99 (20%) reqiured treartment with antidotes • 33 haemodialysis, heamofiltration • At least 2 severe cases each week nationally • Main difficulty in management is unavailability of lab assay and inadequate stock of antidote

20. Summary • Glycol and Toxic alcohol toxicity though less common in UK is a significant differntial diagnosis to consider especially in cases of disproportionate metabolic acidosis • It is important to plan and consider how we can treat such a case in our unit, especially when most of us donot stock any of the antidotes

21. Questions?