Extern Conference

1. Extern Conference 16 Aug 2007

2. A one-year-old boy was referred to Siriraj hospital due to an accidental ingestionof unknown liquid substance for two and a half hours prior to admission.

3. Present history 2 ½ hours PTA, the patient was brought to his uncle’s house by his father and his step-mother. While his father and his uncle were watching the television, the step-mother found that her son was drinking some amount of liquid substance from plastic bottle which was used for battery refilling.

4. Present history The child was crying and sweeping his hand over his mouth. His father washed the patient’s mouth with drinking water and gave his son some milk to induce vomiting. The patient vomited the ingested milk with sputum and saliva for 4 times.

5. Present history Before his parents brought him to a nearby hospital, he vomited some streaks of blood with gastric contents. The parents did not notice that the patient was aspirated or not.

6. Present history At emergency room, the patient was given • Activated charcoal 10 g orally • Metoclopramide 2 mg intravenously • Ranitidine intavenously • Cetriaxone intravenously • NPO Then the patient was referred to Siriraj hospital. The patient was admitted at AN 5 on 6/8/50

7. Past history • He has no underlying disease. • He has no previous history of unexplained injuries or poisoned. • He has normal developmental milestones. • He has no previous history of drugs or food allergy.

8. Family history • The patient lived with his father, his step-mother, and his grandmother.

9. Physical Examination V/S:T 37 oc, PR 148/min, RR 40/min, BP 98/72 mmHg GA: A crying Thai boy, looked distress, no pallor, no jaundice, no dyspnea, no cyanosis, no evidence of trauma, Ht 87 cm(P75-P90), Wt 11.5 kg(P50-P75)

10. Physical Examination HEENT: nose: no swelling turbinate, no discharge ears: normal tympanic membranes, both sides mouth & throat: mild dry lips, mild injected upper & lower lips, no injected oral mucosa, mild injected oropharynx

11. Physical Examination RS: no stridor, normal breath sound, no adventitious sound CVS:normal S1&S2, no murmur Abd: soft, no tenderness, active bowel sound, liver & spleen cannot palpable NS: pupil size 3 mm both RTL, otherwise unremarkable

12. Problem list • Ingestion of unknown liquid substance • Mild injected upper and lower lips with mild injected oropharynx

13. Impression • Suspected caustic ingestion

14. Management in poisoned child 1. Assessment and resuscitation 2. Diagnosis of poisoning 3. Decontamination / Enhanced elimination 4. Disposition

15. 1. Assessment and Resuscitation • Airway : Maintain airway • Breathing : Proper ventilation and oxygenation • Circulation : Adequate perfusion • Disability : Assess level of consciousness and neurological examination

16. 2. Diagnosis of poisoning • History taking : • including the containers and labels of the ingested substance • Physical Examination: Focus on • Cardiopulmonary • Respiratory • Neurological • Toxidromes • Proper investigation

17. How to obtain a poisoning history?

18. What has been ingested? • Ask for containers of the substance, they may offer more details. • What is the substance used for? • The details of ingredients of the commercial products and medications can be obtained from the poison center.

19. Label น้ำกลั่น-กรด ตราปลาทอง ใช้สำหรับเติมในแบตเตอรี่เท่านั้น คำเตือน ถ้าสัมผัสถูกสารนี้ให้รีบใช้น้ำสะอาดล้างทันที โทร : 081-xxxxxxx NOTE : Information from patient’s father The information from the manufacturer: 1.5 % Sulfuric Acid

20. How much has been intake? • Ask the parents or the caregivers who has been in the situation. • In liquid ingestion, it is noted that the amount of the ingested substance may be over reported but should not be assumed to be wrong.

21. When was it taken? • Time since ingestion • This can help you to know a time for onset of symptoms consequently you can obtain proper investigations and management. • Crucial for poisons that require blood level monitoring (example: paracetamol)

22. What symptoms or signs have been shown? • These information can help to narrow down that class of ingested substance. • Physical examination focused on cardiopulmonary, respiratory and neurological systems and look for secondary trauma : burned lips and oral cavity in the patient with caustic ingestion. • Look for the signs and symptoms of toxidromes.

23. 3.Decontamination/Enhanced elimination • Gastric lavage • Ipecac • Activated charcoal • Whole bowel irrigation • Hemodialysis

24. 4. Disposition • Discharge from emergency department • Intensive care unit • Ward • Nonmedical facility eg. Psychiatric

25. Recognition of child abuse • Unexplained delay in seeking treatment • Parents are uninterested by an accident • Is the history consistent each time? • Mechanism of injury inconsistent with developmental capability • Reluctance to give information or mention about previous injury. • Unexplained injury on examination.

26. Investigations (in this patient) • BUN 17.0 mg/dl • Cr 0.4 mg/dl • Na+135 mmol/L • K+4.4 mmol/L • Cl-99 mmol/L • HCO3-11 mmol/L

27. CXR1st day of admission

28. Activated charcoal Functions of activated charcoal 1. Initial toxin absorption 2. Interruption of enterohepatic circulationof toxic metabolite 3. gastrointestinal dialysis

29. Activated charcoal • Activated charcoal is being increasingly used in the management of childhood poisoning • Adsorb toxic material in the gut by offering alternative binding site

30. Activated charcoal No advantage in Alkali, Boric acid, Cyanide, DDT, Ferrous sulfate, Lithium, Mineral acids, Methanol, Malathion, N-methyl carbamate

31. Activated charcoal Route and doses • 1 gm/kg/dose (maximum, 50-60 gm) oral • Repeated every 2-6 hrs until charcoal is passed through the rectum

32. Activated charcoal Contraindications • People with an obstruction of the intestines • Person swallowed a corrosive agent, such as a strong acid or alkali

33. Accidental caustic ingestion

34. Accidental caustic ingestion • High risk group is children younger than 5 years old. • Male > Female • The extent and severity of the caustic injury depends on : • The corrosiveness of the ingested substance • Quantity and concentration • Duration of contact time • Subsequence secondary infection

35. Caustic agents • Caustics are typically classified as acids or alkalis. • Zinc chloride, Phenol and button battery are capable of producing severe burns even though they have near physiologic pH. • Hydrofluoric acid has not only local effects but also has fatal systemic effects eg. hypocalcemia, hypomagnesemia, hyperkalemia.

36. Caustic agents • Acid • Coagulation necrosis of tissue that produces an “eschar” to have some protective effect on deeper tissue. • Alkali • Saponification of lipids • Liquefaction necrosis which causes much deeper ulceration because of no barrier to the alkali until it is sufficiently buffered by proteins, tissue fluid, and soaps.

37. Complications • Early complications • Local complications • Upper GI Perforation • Respiratory inflammation (rare) • Systemic complications • Renal insufficiency, hepatic dysfunction, DIC, hemolysis

38. Complications • Late complications • Esophagus • Stricture, fistula • Peptic esophagitis, hiatus hernia, Barrett’s esophagus, esophageal carcinoma • Stomach • Stricture, fistula • Anemia, vitamin B12 deficiency, growth retardation in case of total gastrectomy

39. Complications • Children VS adults • In children, most such events are inadvertent. • In adults, ingestion usually is a deliberate attempt to commit suicide. • The lower mortality in series of pediatric patients might be explained by ingestion of smaller amounts of the chemical agent. • However, stricture formation in pediatric patient is relatively common.

40. Management in caustic ingestion • Acute management • Initial assessment and stabilization should focus on airway. • Steroids : The use of corticosteroids remains controversial. There was a reduction in the number of dilatations required and the number of patients who developed stricture when using 1 mg/kg/day of dexamethasone.

41. Management in caustic ingestion • Acute management • Antibiotics • There are no control trials that identify the routine use of antibiotics after caustic ingestion • Indications: • Grade 2 or greater lesion with deep ulcer • Elevated in temperature • Grade 3 lesion or perforation, antibiotics should be started immediately

42. Management in caustic ingestion • Acute management • Acid suppression • Should be used in cases of grade 2-3 esophageal injury. • The refluxing acid from stomach will damage the exposed tissues of the esophageal wall and may inhibit the healing process by damaging in-growing new cells.

43. Management in caustic ingestion • Decontamination, dilution, neutralization • Dilutional therapy is of limited benefit beyond the first few moments following ingestion but should be avoid in patient with nausea, drooling, stridor or abdominal distension as it may induce vomiting.

44. Management in caustic ingestion • Decontamination, dilution, neutralization • GI decontamination is usually limited in the patient with caustic ingestion. • Induce emesis is contraindicated. • Caustic agents are poorly absorbed by activated charcoal.

45. Management in caustic ingestion • Decontamination, dilution, neutralization • Neutralization of caustics should be avoided because of potentially tissue damaging by forming gas and generating heat.

46. Management in caustic ingestion • Surgical management : • Evidence of perforation either by endoscopic or diagnostic imaging • Severe abdominal rigidity • Persistent hypotension • Severe extensive burns

47. Management in caustic ingestion • Subacute management • Early endoscopy should be performed in every patients to assess • Extent of lesions • Severity • Further management.

48. Classification of Caustic injury

50. Note : Grade 4 may be used to indicate perforation