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Pediatric Toxicology

Pediatric Toxicology. Jana Stockwell, MD. Epidemiology. 2 million calls 52% of poison center calls <6years Peak ages: 18 months - 3 years. Epidemiology. Unintentional (1-2 years) Exploratory Boys > girls Unable to discriminate safe from unsafe liquid Intentional (adolescent)

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Pediatric Toxicology

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  1. Pediatric Toxicology Jana Stockwell, MD

  2. Epidemiology • 2 million calls • 52% of poison center calls <6years • Peak ages: 18 months - 3 years

  3. Epidemiology • Unintentional (1-2 years) • Exploratory • Boys > girls • Unable to discriminate safe from unsafe liquid • Intentional (adolescent) • Purposeful • Girls > boys

  4. Epidemiology • Around meal time • Grandparents home • Kerosene or gasoline in a soda bottle • Older sibling can pharmaceutically treat younger sibling

  5. Most often reported • Cleaning products 10% • Analgesics 10% • Cosmetics 9% • Cough & cold preparation 5% • Insecticides 4%

  6. PICU Admission • Tricyclic antidepressants (TCA) • Anticonvulsants • Digoxin • Opiates • Hydrocarbon-based household products

  7. Toxic Exposures  Death • Analgesics • Sedative-hypnotics • Alcohols • Gases & fumes • Cleaning substances

  8. “Fatal Sip” • Camphor (Vick’s VapoRub) 1000 mg/5 ml • (100mg/kg) • Methyl salicylate (wintergreen) 1400 mg/ml • (200 mg/kg) • Benzocaine (OraGel) • 2 mL • Met-hemoglobinemia • Seizure

  9. “Malignant Swallow” • Chloroquine (20 mg/kg) • Theophylline (8.4 mg/kg) • Imipramine (15 mg/kg) • Chlorpromazine (25 mg/kg) • Clonidine (0.3 mg tablet) • Bradycardia • CNS depression

  10. Other Highly Toxic • Acetonitrile - nail tip remover  MetHgb • Ammonium fluoride – hub cap cleaner (ArmorAll)  sz, arrhythmias, acidosis • Pennyroyal Oil – some herbal teas

  11. Albuterol Celebrex Oruvail Lamictal Lotrimin Plendil Hydralazine Hydrocodone Atenolol Cerebrex Elavil Lomotil Lotensin Pindolol Hydroxyzine Hydrocortisone Look-Alike, Sound-A-Like

  12. Poison plants • Digitalis effects • Lily-of-the-valley, Foxglove, Oleander, Yew • Nicotinic effects • Poison hemlock • Atropinic effects • Jimson weed

  13. Ball point ink Bubble bath soaps Chalk Cigarettes (< 3 butts) Crayons Deodorants Lipstick Pencil (graphite) Toothpaste Water colors Candle wax (but candle oil is!) Non-Toxic Products

  14. Evaluation • History of poisoning • Physical examination • Laboratory studies • Gastrointestinal decontamination

  15. History • What? • When? • How much? • Reliability…

  16. What ? • Medication • Illicit drug • Hazardous chemical

  17. What form? • Pill • Solid • Liquid • Gaseous

  18. What route ? • Ingestion • Inhalation • Topical • Intravenous

  19. When ? • Elapsed time

  20. How much ? • Estimate amount • Concentration

  21. “Clues”

  22. Bradycardia • Calcium channel blockers • Digoxin • Narcotics • Organophosphates • Carbon monoxide • Beta-blockers • Clonidine

  23. Tachycardia • Amphetamine (Ritalin) • Atropine • TCA’s • Theophylline • Salicylates (aspirin) • Iron • Cocaine • PCP • Synthroid

  24. Slow Respiration • Alcohol • Narcotics • Clonidine • Sedatives

  25. Tachypnea • Amphetamines • Salicylates • Carbon monoxide • Ethylene glycol (anti-freeze)

  26. Hypotension • Calcium channel blockers • Carbon monoxide • Cyanide • Iron • Narcotics • Anti-hypertensives • Met-hemoglobin

  27. Hypertension • OTC cold remedies • Amphetamine • PCP • TCA • Cocaine • Diet pills

  28. V Tach • Amphetamines • Carbamzepine (Tegretol) • Chloral hydrate • Cocaine • Digitalis • Theophylline

  29. Torsades de Pointes • Chloral hydrate • Cisapride • Organophosphates • Terfenadine • Phenothiazines

  30. Hypoglycemia (HOBBIES) • Hypoglycemia • Oral hypoglycemic agents • Beta-Blockers • Insulin • Ethanol • Salicylates

  31. Hypothermia • Ethanol • Narcotics • Carbon monoxide • Clonidine

  32. Hyperpyrexia • Atropine • Salicylates • Theophylline • Cocaine • TCA

  33. CNS - Coma • Narcotic • Anti-cholinergics • Carbon monoxide

  34. CNS - Delirium / Psychosis • Alcohol • PCP / marijuana • LSD

  35. CNS - Seizure • Cocaine • Amphetamine • Lead • Salicylate • Isoniazid • Theophylline

  36. Pupils - Miosis(COPS) • Cholinergics, Clonidine • Opiates, Organophosphates • Phenothiazine, Pilocarpine • Sedatives (barbiturates, ethanol)

  37. Pupils - Mydriasis(AAAS) • Anti-histamine • Anti-depressant • Anticholinergics (atropine) • Sympathomimetics • amphetamine, cocaine, PCP

  38. Caution! • Polydrug overdoses with opposite pupillary actions • Non-toxin diagnoses • Head trauma • CNS hemorrhage

  39. Cyanosis • MetHgb • Unresponsive to O2 • Aniline dyes • Nitrites • Benzocaine • Dapsone

  40. Dry Skin • Anticholinergic

  41. Breath Odors • Arsenic Garlic • Camphor Mothballs • Cyanide Bitter almond • Methyl salicylate Wintergreen • Paraldehyde Pears • Hemlock Carrots

  42. Toxidromes

  43. Cholinergic • “DUMBBELS” • “SLUDGE” Example – Organophosphates Nerve agents

  44. DUMBBELS • Diarrhea, diaphoresis • Urination • Miosis, muscle fasiculation • Bradycardia • Bronchospasm • Emesis • Lacrimation • Salivation

  45. SLUDGE • Salivation • Lacrimation • Urination • Diarrhea • GI complaint • Emesis

  46. Anti-cholinergic syndrome • Dry mouth • Flushed appearance • Dilated pupils • Fever • Ileus • Urinary retention • Disorientation Examples – Anti-histamines Jimson weed Lomotil TCA Carbamazepine Glycopyrrolate Atropine

  47. Anti-cholinergic • Hot as a hare • Blind as a bat • Dry as a bone • Red as a beet • Mad as a hatter • Full as a flask

  48. Narcotic • Pinpoint pupils • Coma • Respiratory depression

  49. Salicylates • Fever • Tachypnea & hyperpnea • Lethargy • Metabolic acidosis

  50. Theophylline • Protracted Vomiting • Tremors • Tachycardia • Seizures • Hypotension

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