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Poisoning in Children

Poisoning in Children. Kent R. Olson, MD Medical Director, San Francisco Division California Poison Control System Clinical Professor of Medicine, Pediatrics and Pharmacy, UCSF. Case study:. A 2 year old child is found with a bottle of his mother’s prenatal vitamins

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Poisoning in Children

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  1. Poisoning in Children Kent R. Olson, MD Medical Director, San Francisco Division California Poison Control System Clinical Professor of Medicine, Pediatrics and Pharmacy, UCSF

  2. Case study: • A 2 year old child is found with a bottle of his mother’s prenatal vitamins • Spontaneous vomiting after 30 minutes • Paramedics report systolic BP 70/p, HR 130/min

  3. Most common pediatric exposures* Category Hazard Factor • Cosmetics 0.2 • Cleaning agents 0.9 • Plants 0.1 • Analgesics 0.6 • Cough & cold preparations 0.5 • Hydrocarbons 2.2 Data from AAPCC 1985-1989

  4. Relative risk of death/major effect Category Hazard Factor • Rattlesnake bite 244 • Strychnine 50 • Alkaline drain cleaner 22 • Organophosphates 5.6 • Anticoagulants 0.9 • Cosmetics 0.2

  5. Pediatric poisoning deaths(AAPCC 1985-1989) Pharmaceuticals Hazard Factor • Iron 8.5 • Tricyclic antidepressants 17.7 • Cardiovascular drugs 8.1 Non-pharmaceuticals Hazard Factor • Pesticides 2.1 • Hydrocarbons 2.2 • Methanol 5.1

  6. More recent data - AAPCC 199924 deaths in children < 6 Pharmaceuticals • Opioids (3) • Iron (1) • Nifedipine (1) Non-pharmaceuticals • Carbon monoxide (7) • Hydrocarbons (3) • Ammonium bifluoride (2)

  7. Case 1: Abdominal X-ray

  8. Iron poisoning in children • Leading cause of childhood poisoning deaths • Pathophysiology: • corrosive effect on GI tract • cellular toxin • Toxic dose > 40-60 mg/kg elemental Fe • adult strength preparations much more likely to cause toxicity than children’s chewables

  9. Iron poisoning: clinical findings • Vomiting • Diarrhea • Hypotension • Metabolic acidosis • Leukocytosis, hyperglycemia • Radiopaque pills on plain x-ray • Late complication: hepatic failure

  10. Treatment of iron poisoning • Volume replacement • IV crystalloid boluses • Chelation therapy • deferoxamine (Desferal) is specific chelator • Iron chelate complex  “vin-rose” urine • IV route preferred (don’t use IM “test dose”) • avoid prolonged deferoxamine therapy

  11. Gut decontamination for iron ingestion • Home: • consider ipecac-induced emesis if recent OD • argument against ipecac: it masks spontaneous vomiting • Hospital: • ipecac or gastric lavage? Neither very effective • lavage with HCO3, PO4? Dangerous • whole bowel irrigation = best method

  12. Whole bowel irrigation • Balanced electrolyte solution with non-absorbable polyethylene glycol (PEG) • no electrolyte disturbance • no net fluid gain or loss • well-tolerated • Method: GoLytely™ or Colyte™ • 500 mL/hour by gastric tube until rectal effluent clear • Adolescents/adults: 1-2 L/hr

  13. Case study: • A toddler is found with an open daily medicine container belonging to his grandmother. • Usual contents: • Lasix 40 mg • Cardizem-CD 240 mg • Multiple vitamin • Container is now empty. Child asx.

  14. ECG in a patient with verapamil OD

  15. Decreased Automaticity & Conduction Negative Inotropic Effects Dilated Vascular Smooth Muscle SVR HR CO AV Block SHOCK Calcium Channel Blocker Poisoning

  16. Calcium antagonist toxicity • Shockcaused by combination of: • Decreased automaticity & conduction • Negative inotropic effects • Vasodilation • Treatment with calcium • most effective for negative inotropic effect • high doses may be needed • in the future: insulin + glucose?

  17. Case study: • An 18 month old is brought to the ER after a seizure • No prior seizures • No recent illness or fever • HR 140/min, BP 105/70 • Pupils dilated • Skin flushed, dry

  18. Case 2: ECG

  19. Common drug-induced seizures • Tricyclic antidepressants • Cocaine & amphetamines • Theophylline • Diphenhydramine • Isoniazid (INH) • Phenothiazines • Strychnine • Many others (camphor, lindane, etc)

  20. Case study, cont. • ECG monitor shows wide QRS complex • Repeat BP 70/p • The child is intubated endotracheally • A therapeutic drug is given:

  21. Tricyclic antidepressant OD • “Three C’s” • coma • convulsions • cardiac conduction defects … AND • Anticholinergic effects • dilated pupils • tachycardia • jerking movements

  22. Treatment of TCA overdose • ABCs • No ipecac! (use AC orally or by NG) • Monitor asx child for at least 6 hours • QRS prolongation: • Caused by Na channel block • Rx = Sodium Bicarbonate • 1-2 mEq/kg IV bolus • Do NOT use physostigmine

  23. Another Case • A child is found with an open container of “wire wheel cleaner” • Contents: • ammonium bifluoride • hydrofluoric acid • Child initially asymptomatic

  24. Fluoride toxicity • Sources: • wire wheel cleaners, degreasers, rust and water stain removers • fluoride tablets and drops • Toxicity: • hypocalcemia (even from dermal exposure) • hyperkalemia • ventricular fibrillation • Treatment: Calcium (oral and IV)

  25. Case study: • A 16 year old takes several “happy pills” provided by a friend. • Develops a headache, vomits once. • In ER: • awake, alert, c/o headache • HR 38/min (w/2nd degree AV block) • BP 166/100 mm

  26. Phenylpropanolamine • Common OTC product • May be used to get “high” (not very effective) or as suicidal agent • Hypertension common, often with reflex bradycardia or even AV block • intracranial hemorrhage may occur • Treat with vasodilator, e.g. phentolamine, nitroprusside

  27. 11-6-2000: FDA’s MedWatch • “FDA is taking steps to remove phenylpropanolamine hydrochloride from all drug products due to the risk of hemorrhagic stroke... • “... FDA has significant concerns because of the seriousness of stroke and the inability to predict who is at risk …”

  28. Gut decontamination • Current consensus: • Gut emptying of limited value • AC alone probably fine in most patients • Some twists: • SI still useful at home w/in 5-10 min? • Lavage for selected cases? • Role of Whole Bowel Irrigation? • What about home AC?

  29. Anyonefor charcoal?

  30. Use of ipecac is declining Year Ipecac used 1983 13.4% 1988 8.4% 1993 3.7% 1998 1.2% Source: AAPCC 1999

  31. Final “stumper” • 9 month old being watched by grandmother • Found flaccid, grunting, with decreased level of consciousness • HR 70/min, BP 105/59 • Respirations agonal, O2 sat 80% • Pupils pinpoint

  32. More information . . . • No response to naloxone • Treated supportively, eventually recovered • Initial history: grandmother takes lisinopril, HCTZ • Also using eye drops for glaucoma

  33. Continued • Alphagan™ (brimonidine 0.2%) • used for open-angle glaucoma • Stimulates -2 receptors (similar to clonidine) • CNS depression, bradycardia, HOTN • Peripheral: alpha-agonist can elevate BP

  34. California Poison Control System • Public Hotline: 1-800-876-4766 (8-POISON) • Health Professionals: 1-800-411-8080 • 300,000 exposures/year • 2/3 are kids • also: suicides, occupational, hazmat, veterinary, consumer product recalls, ... • Most kids can be managed at home • PCC can communicate with 9-1-1 or paramedics on scene

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