Accidents and Poisons

1. Accidents and Poisons Dr D. Barry

2. POISONING

3. Poisoning • Accidental; pre-school age (♂ > ♀) • Intentional; > 9 years (♀ > ♂) • Factitious / Münchausen by proxy (rare) • Iathrogenic

4. Statistics • Accidental poisoning preventable cause of morbidity and mortality • Ireland: • 3,000 annual poisons and 1,000 admissions annually (1-4 yrs) • 12 deaths 2001-2003

5. Poisoning • National Poisons centre-Beaumount Hosp • 2006 • Children<10yrs: 4466 enquiries/4726 products. • Drugs, Household, Chemical products(cosmetic and personal hygiene) • Adolescents10-19 yrs: 899 enquiries/1490 products. Drugs, industrial and household products (analgesics, anti-inflammatory)

6. Accidental Poisoning • Infants and young children will drink or eat ANYTHING! • If it looks interesting / smells good/ has a bright colour ----- They will eat / drink it • Substances taken are Medicines & Household Products; detergents, garden agents, pesticides • Most are not taken in sufficient quantity to cause harm • Children still die every year due to poisoning

7. What age do children pick up tablets? • What age can children open doors/presses? • What age can children open containers?

9. Prevention: Safety Information • Child resistant containers • Out of reach • Lock up household substances • No chemicals under the kitchen sink • Childminders/Visitors as above • Dispose of out of date meds • Know what meds/products are in your house

10. Presentations • Ingestion known/suspected • Eg. toddler found by carer playing with tablets / missing tablets from open container etc. • Disclosure by teenager / family etc • Symptomatic; • Reduced Consciousness • Metabolic acidosis (high anion gap) • Arrhythmia • GI upset (vomiting / abdo pain / anorexia etc) • Seizures

11. History • What toxin/medication was taken • Who was the witness • How much was taken • What time was it taken • What other medications or toxic substance was available to the child

12. Physical Examination • Toxic syndromes • Anticholinergics  hot as a hare, dry as a bone (dry mouth), red as a beet, blind as a bat (dilated pupils), mad as a hatter (delirium) • Organophosphates (cholinergic)  diarrhoea, diaphoresis, miosis, bradycardia, bronchosecretions, emesis, lacrimation, salivation

13. Physical Examination • Toxic syndromes • Cocaine/amphetamines (sympathomimetic)  mydriasis, tachycardia, hypertension, hyperthermia, seizures • Narcotics  miosis, bradycardia, hypotension, hypoventilation, coma

14. Management

15. Management • Stabilise patient / Resus • Accurate history & calculate ingestion • Initial work-up • Gastric elimination/decontamination • Monitoring, levels, nomograms - Discuss with Toxicology centre • Antidote etc. • Why / How did it happen follow-up

16. 1) Resuscitation • Airway • Breathing • Circulation • Cornerstone of management of acute poisoning is supportive care

17. 2) Investigations • Full blood count • Urea, creatinine, electrolytes • Blood glucose • Blood gas • Serum and urine for toxicology

18. 3) History • What toxin/medication was taken • Who was the witness • How much was taken • What time was it taken • What other medications or toxic substance was available to the child (Who’s in the house & what meds are they on?)

19. 4) Gastric Decontamination • Gastric evacuation • Induction of emesis • Gastric lavage • Chemical decontamination • Activated charcoal • Cathartics • Whole bowel irrigation • NB – corrosive substances are particularly dangerous – seek expert advice first!

20. Induction of Emesis • Rarely done anymore • Syrup of ipecac most commonly used • Induces vomiting in 20 - 60 minutes • Contraindicated in: • infants less than 6 months • poor conscious state • diminished gag reflex • hydrocarbons, acids, alkalis

21. Gastric Lavage • Large bore orogastric tube with normal saline irrigation • If conscious state is depressed, airway protection with an endotracheal tube prior to lavage is recommended • Contraindicated in hydrocarbons, acids and alkalis (risk of aspiration) • Most effective within 1 hour of ingestion, • Removes up to 40% of ingested toxin

22. Activated Charcoal • Complex Molecule with large surface area; binds many poisons • Not indicated in heavy metal poisoning (iron, lithium) or ingestion of acid or alkali where endoscopy may be required or alcohol ingestion • Promotes reabsorption from circulation into bowel & interrupt entero-hepatic circulation of some drugs (aspirin, barbituates) • Very unpalatable => give via NG / lavage tube (25-50g) • typical dose SE; severe lung damage if aspirated • Patient must be conscious or airway protected • Window of opportunity; 1 hour (↑ with salicylates) • Multidose charcoal-controversial

23. 5) Monitoring, levels, nomograms • You will not know the toxicity of every substance / drug • Poisons Information Centre provide invaluable help and advice 24 hours a day • Blood levels (often at 4 hours) • May have nomogram

24. Benzodiazepines Iron Opiates Paracetamol β-blockers Digoxin > Flumazenil > Desfuroximine > Naloxone > N-acetylcystine > Glucagon / Adrenaline > Fab antibodies 6) Antidotes

25. Some Potentially Harmful Poisons • Paracetamol • Iron • Aspirin (salicylates) • Substance abuse; Alcohol, Ecstasy, Cocaine, etc. • Digoxin/ Antiarrhythmics/ Any Cardiac Drug • Tricyclic Antidepressants • Benzodiazepines • Opiates • Ethylene glycol (anti-freeze/de-icer)

26. Paracetamol

27. Paracetamol Ingestion • Most widely available and commonly ingested Medicine • Infants almost never drink enough to require Blood levels to be tested!!! • Increasing incidence of deliberate ingestion • Mostly girls > 9 years old • Assess quantity and timing of ingestion • Do not trust information given; if large or unknown ingestion------ Treat as overdose

28. Paracetamol ingestion; symptoms • Initially asymptomatic (? Nausea) • 36 hours later; hepatic necrosis (? Right subcostal pain) +/- liver decompensation • Renal Failure (ATN) may occur

29. Paracetamol Overdose Management • Activated Charcoal (gastric lavage not helpful) in < 1 – 4 hour • Check level at 4 hours post ingestion • Map on Nomogram • N-Acetylcysteine IV • if > treatment line on normogram (*? High risk pt.?) • Monitor LFTs, Coag, U&E, blood level

31. Iron Ingestion • > 20mg/kg iron ingestion; toxicity possible • > 60mg/kg – serious toxicity • > 150mg/kg – fatal! • Calculate Iron content of tabs & possible intake • Tests; • PFA • FBC, G&X, glucose, VBG • serum iron (@ 4 hours)

32. Iron Ingestion; Symptoms • Stage 1; (30mins – 6 hours) abdo pain, vomiting, diarrhoea (+/- bloody; ie. haemorrhage • Stage 2 (10 hours – 30 hours); silent phase • (iron absorbs & accumulates in tissues, mitochondria etc.) • Stage 3; cellular & mitochondrial damage; • shock, encephalopathy, liver decompensation • Hypoglycaemia, lactic acidosis • Stage 4; (weeks later); GI strictures & obstruction, liver failure

33. Iron Ingestion; Management • Stabilise; A B C • Gastric Lavage in < 1 hour • Charcoal not helpful • Desferrioxamine (iron chelator) • ?PO (controversial) • IV

34. Salicylate (Aspirin) • Induces Gastric stasis! • Also slow/sustained release preparations • => may be recoverable up to 12 hours post ingestion • Gastric lavage up to 4 hours • ? Repeated charcoal doses • Serial blood levels (as levels can ↑ > 6 hours)

35. Salicylate Poisoning; Symptoms • Phase 1;(0-12 hours) Anxiety, sweating, fever, tachycardia, hyperventilation with Resp Alkalosis! => compensatory alkaline urine with loss of HCO3-, K+ • Phase 2; (may be immediate in young children) ↓ K+ (& paradoxic aciduria) • Phase 3;(up to 24 hours) dehydration, acidosis predominates, pulmonary oedema, resp failure

36. Specific management • Alkalisation of Urine to aid drug excretion • Sodium Bicarbonate • Fluids & K+ replacement • Serial levels & ongoing monitoring • Resp support!

37. Ethylene Glycol • Tastes sweet • In Anti-Freeze, De-icer fluid etc • Causes metabolic acidosis (high anion gap) • Widespread cellular damage (esp. Kidneys) Haemodialysis may be needed • Activated Charcoal doesn’t work! • Metabolised by Alcohol Dehydrogenase into toxic by-products • Ethanol (40%) is competitive inhibitor of Alcohol Dehydrogenase & may be used • Co-factors; thiamine, pyridoxine etc.

39. Caustic Ingestions • Eg. Acids / alkalis / batteries • Burns in mouth • necrosis of oesophagus • strictures common • Lung damage when aspirated • No emesis / lavage / charcoal etc.

40. 7) Follow-up of Poison Ingestion • Must consider; why did this happen? • NB – social history • Carers? • Supervision concern / Neglect? • Housing etc. • Child-proofing the home • Social Worker Involvement • Psyche involvement if deliberate

41. Metabolic acidosis (high anion gap) Salicylates Iron Ethanol, methanol, ethylene glycol Iron Hypoglycaemia Iron poisoning Alcohol poisoning Hypokalaemia Salicylates Β-blockers Hyperkalaemia digoxin Possible Metabolic abnormalities

42. Childhood Accidents Dr. D Barry

43. Childhood accidents • Leading cause of death and disability in children and young adults • More than 5 million deaths per year worldwide • Lack of global attention to childhood injuries • Leading cause of death in children over 1 year

44. Childhood Mortality by Age

45. Accident types • Falls • Drowning • Burns • Choking • RTA *****NB – when to consider NAI *****

46. FALLS • Children Fall all the time • Toddlers ( 1 – 3 Years) especially • Babies roll over, fall off beds , climb out of cots, fall out of high chairs etc. • Fractures are uncommon • Detailed History • Detailed FULL Examination

47. Falls • Clinical assessment will direct further investigations ( if any) • Many children < 1 Year with a head injury are observed as inpatients to ensure they remain well • All are referred to social work • > 99% are Genuine Accidents • But be Vigilant; ? NAI / safety concerns

48. Fractures in Children • Signs; • tenderness, • swelling, • deformity, • ↓ use etc. • Consider; • does the history fit the injury? NAI • Underlying condition predisposing bone to #

49. Management • X-ray (AP / lateral) • Rest • Immobilise & Protect • Analgesia • Physiotherapy • Consider – antibiotics / tetanus etc.

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