به نام خدا

1. به نام خدا زندگی عرصه یکتای هنرمندی ماست. هر کسی نغمه خود خواند و ازصحنه رود, صحنه پیوسته به جاست. خرم آن نغمه که مردم بسپارند به یاد..... نام درس:مسمومیت ها در اطفال نام مدرس:روانشاد دکتر مهدخت صدر بافقی نام ویادش جاودان باد.

2. poisoning The most common agents include: family member medication , cleaning solution, plants, cosmetic. most ingestion occur in home(92%). More than 50% occurred in children <5 yr.

3. management history: Product name, amount of medication, time of exposure. age and weight of child progression of symptoms Medical history and underling disease

4. Physical examination • Level of consciousness , vital signs pupillary size , presence of muscle faciculation bowel and bladder activity , cardiac arrhythmias , seizures , hypothermia. • Pulmonary edema • Certain symptoms and signs are specific . ( toxic syndromes)

5. toxic syndromes Anticholnergic: • Thirst ,flushed skin • mydriasis • hyperthermia ,urinary retention, • delirium, hallucination, tachycardia • respiratory insufficiency

6. Cholinergic • Exocrin glands secration, urination • nausea ,vomiting , diarrhea • muscle fasciculation, weakness or paralysis • bronchospasm , bradycardia or tachycardia , • convulsions , coma • miosis

7. Extrapyramidal • Tremor ,rigidity, opisthotons ,torticollis • dysphonia ,fever , metabolic acidosis • tachycardia ,hyperpnea • restlessness , convulsion ,

8. narcotic: • CNS depression • hypothermia • hypotention • hypoventilation • miosis

9. Sympathomimetic • Psychosis • seizure • mydriasis • hypertension • tachypnea • hyperthermia

10. complication • Coma DD: trauma , CVA , asphexia, meningitis • Pinpoint puils : Opiate, organophosphate ,phenothiazines ,hloral hydrate , • Dilated pupils: cyclic antidepressant , atropine -like agents

11. Caustic ingestion • Dysphagia , epigasteric pain. • oral burns. • low-grade fever. • When lesion heal then strictureform . alkalia agents :(tastless) oropharynx and esophagial necrosis. button batteries : produce caustic injury if that remain in esophaguse should be removed.

12. treatment: • dependents on agent ingested and presence or absence esophagial injury • Routine use of diluent as a first aid ??? • Antibiotic if there is signs of infection . • Dilatation of late forming strictures(2-3 weeks later) .

13. Acid agents: lung , oral mucosa,esophgus and stomach injury and necrosis. • Mocusal and tissue damage less sever than alkali . (Acid taste) • Treatment: initial therapy like the alkali ingestion • (dilution and no emesis or nutralizing)

14. Screening laboratory clues • Metabolic acidosis: • methanol, ethanol • uremia, diabetes • iron, isoniazid, salicylate , starvation • Determining : Blood gases, urin PH, Na, K, chloride, glucose, BUN, serum osmolality and anion gap

15. Screening laboratory clues • Hyperglycemia: salysilate, phenothiazide, sympathomimetic, isoniazid, iron, • hypoglycemia: insulin, Ethanol , propranolol,Isonizid, oral hypoglycemic agents. • Hypo calcemia: Ethylene glycol, fluride , oxalate • Radiopaque substance: iron , phenothizine , Entric coted pills, Dental amalgam, Heavy metals, pothassium chloride

16. Drugs monitoring for toxicity • Antibiotics : aminoglycosid, chloramphenicol, vancomycin. • Immuno suppression : methotrexide , cyclospurine • Antipyretic: Acetaminophen , salycilate • Others: digoxin, lithium, theophylin, anticonvulsant serotonin

17. treatment Supportive care 1-ABC 100%O2 ,naloxane,glucose 1g/kg IV . • Diuresis • Hemoperfusion: rarly used in small children • Most liquid drugs absorbed within 10 min and solid within 1-2hr

18. treatment • Prevention absorption : • Activated charcoal • Gastric lavage • Cathartics • Diuresis • Hemoperfusion • Dialysis: methanol, ethylen glycol, salycylate, theophylin

19. Treatment(con) Gastric lavage: • Not documented efficacy in children. • Remove only a fraction of gastric contents. • It should only used in older children and selected situations

20. treatment • Prevention absorption • syrup ipeca : ?? (Potentially complication without improve clinical outcome) • onset emesis after 20-30 min and several episodes over 1-2 hr. • 10 CC for small children 15CC =1-12years ,30 CC older children. • Remove 1/3 stomach content. • when ingestion is < 60 minute and air way protected • not be used as a general treatment.

21. Treatment(con) • Contraindication ipeca : • minimaliy toxic agents • prior vomiting • air way unprotected • caustic agents, hydrocarbon , agent cause the rapid onset CNS or cardiovascular symptoms • foreign body

22. treatment Activated charcoal:prevent toxin absorption. • single dose25-50g small children 50-100g> 12yr. Repeated doses in serious poisoning. • 25% of patients experience one episode of vomiting. • most benefit achieved within 1 hour of ingestion. • Ineffective against : caustic ,corrosive , hydrocarbon , heavy metals, glycols and water – insoluble compounds

23. Treatment(con) Cathartics: ( sorbitol 1g/kg, magnesium citrate250cc/kg ).??? • combination with activated charcoal is not recommended (essential nelson) • complication: Electrilyt imbalance and dehydration

24. Emergency Antidotes • Poison antidotes dose Mercury ,arsenic, gold BAL 5mg/kg Methyl alcohol Ethyl alcohol +dialysis 1ml/kg Nitrites methylene blue 1-2 mg/kg Opiates naloxan 0.1 m g /kg- 2

25. Emergency Antidotes Poison antidotes dose organophosphate Atropin0.02- 0.05mg/kgIV paralydoxime20-50 mg/kg Sympathomimeticphentolamin agents β-blocking

26. Acetaminophen • Acute toxic dose200mg/kg in children < 12 yr. • Repeated doses more than recommended may lead hepatic injury. • Children <6yr unlikly develop significant toxicity . • 1-2 hr of ingestion activated charcoal • antidot started as soon as possible ,oral N- acetylcysteine may be benefit if started 24-36 hr after ingestion

27. stages in clinical course of Acetaminophen toxicity • 1 - ½-24 hr anorexia ,nausea ,vomiting ,pallor • 2- 24-48hr abdominal pain, bilirobin, PT↑ hepatic enzyme↑ • 3- 72-96 hr anorexia , nausea , vomiting , • peak liver abnormality • 4- 4days- 2 weeks resolution of hepatic dysfunction ↑or complete or liver failure

28. salicylates • Nausea , vomiting, gastric irritation • hyperventilation, Respiratory alkalosis • dehydratoin • prograssive metabolic acidosis • Agitation, counfusion are common. • Hyperglycemia, or hypoglycemia. • Pulmonary edema

29. salicylates( treatment) • Activated charcoal. • Rehydration , correction electrolyte. • Large quantities of Potassium , and bicarbonate. • Urine PH 7-7/5 ( using bicarbonate IV) • Dialysis in sever cases

30. Antidepressant( TCA, SSRI) • Block reuptake serotonin , dopamin , norepinephrin • Myocardial depression ,dysrhythmia ½-6 hr • CNS effect 1/3 (lethargy , coma, drowsiness ),seizure • Anticholinergic effect. tachycardia ,mydriasis , • Hypertension ( no treatment ). • hypotension (rare but poor prognosis).

31. Antidepressant( TCA, SSRI) treatment • ABC Emesis is contraindication(aspiration ,after onset CNS deprassion) • Activated charcoalshould be used . • Sodium bicarbonate ( to treat and prevent dysrhythmia) and if unresponsive…….. Lidocaine used . • Fluid therapy for hypotension. • Bezodiazepine for seizure. • Asymptomatic patient observe and ECG monitoring for 6 hr.

32. Cholinsterase inhibitor ( organophosphate and carbamate) • Prevent degradation acetylcholine , bind to cholinesterase and inactiveted it . • muscarin signs: emesis, urinary and fecal incoutinence, drooling , bronchospasm, miosis, hypotention , bradycardia. • Nicotinic signs: muscle weakness , tremor , fasciculation, • hypertention ,hypoventilation , tachycardia , dysrehythmia, • CNS effects ; confusion, seizure , coma .

33. Cholinsterase inhibitor ( organophosphate) • Treatment: • ABC • activated charcoal • Fluid and electrolyte replacement . • antidotes ( significant organophophate poisoning both antidotes is necessary) . even with treatment neurologic symptoms may occur and may be persist .

34. Treatment( con) Antidotes 1- Atropin infusion : • blocks acetylcholine receptor . ( reversing the CNS and muscarinic effect) 2- paralidoxime : • breaks the bond between organophosphate and enzyme ,librating enzyme, degrading organophosphate

35. Acute hydrocarbon risk assessment • Systemic and pulmonary toxicity Hydrocarbon ingestion result in systemic but more often pulmonary toxicity, Systemic: carbon tetrachloride, benzen, trichloroethylene. Local toxicity: kerosen, furniture polish, signal oil , gasolin Non toxic : tar asphalt, motor oil , lubricant, baby oil

36. hydrocarbon 1. Aspiration pneumonia: (Low vicosity : gasolin, kereson , naphta , lamp oil ). Cough, fever (10 days),leukocytosis , chest Xray( may normal 6-12hr) 2. Systemic symptoms : most hydrocarbon can cause transient CNS depression. Few have renal toxicity ,carbon tetrachloride produce hepatic toxicity.

37. Hydrocarbon ( treatment) • Emesis is contraindicacated. • Activated charcoal is not useful. • in pneumonit respiratory treatment is supportive. • Corticosteroid avoided . • Prophylacttic antibiotics should not be given. • Respiratory failure treated with standard ventilation (ECMO ?)

38. Snake bite • خصوصيات سم مار پلي پپتيدها ، آنزيمهاي پروتئوليتيك‏وتوكسين‏ها، نوروتوكسيك ، سيتوليتيك • علائم كلينيكي سيستميك : ترس و وحشت : تهوع، استفراغ، اسهال، سنكوپ،تاكيكاردي ، پوست سرد و مرطوب، فاسيكولاسيون عضلاني، بندرت شوك علائم موضعي: محل نيش مار: دردفوري و در 90% مواردادم:ادم درطي نيم ساعت و گاهي چند ساعت بعدتاول: در طي چند ساعت، لنفاژيت، غدد لنفي حساس خفيف، متوسط ، شديدارزيابي بر اساس :علائم لوكال، سيستميك، انعقادي

39. Guidelines for assessing • خفيف: ادم ، اريتم يا اكيموز و بدون علائم سيستميك و مشكلات انعقادي • متوسط : ادم پيشرونده بالاتر از محل گزش تهوع ،استفراغةپارستزي اطراف دهان و هيپوتانسيون خفيف علائم خفيف انعقادي • شديد: ادم سريع ،اريتم و يا اكيموزدر تمام عضو هيپوتانسيون شديد،تاكيكاردي ،تاكي پنه،تغيير سطح هوشياري مشكلات واضح انعقادي، ترومبوسيتوپني و خونريزي خودبخود

40. treatment • آيا مار سمي بوده؟ • بيحركت كردن عضو • تورنيكه ممكن است ايسكمي را تشديد كند. • گذاشتن يخ و انسيزيون موضع ممكن است باعث آسيب بافت بشود. • زخم بايد تميز شود ، تتابولين • در اورژانس: كنترل راه هوايي، تنفس، گردش خون، گرفتن رگ، گرفتن شرح حال: زمان‏گزش - خصوصيات مار،شرايط مديكال همراه ، حساسيت دارويي و غذايي، سابقه مارگزيدگي و درمان آن

41. treatment • معاينه فيزيكي: • معاينه قلبي، ريوي، نورولوژيك، توجه به محل گزش • اندازه گيري قطرمحل گزش وتكرار اندازه گيري هر 20-15 دقيقه تا توقف تورم • گرفتن نمونه خون جهت PTT,PT,CBC -فيبرينوژن ، FDP ، گروه خون ، اوره ، كراتينين • تجويز آنتي ونوم:(در طي 4 ساعت و حد اكثر 12 ساعت پس از گزش ) اثر اوقات در طي چند دقيقه ودر تمام مواقع در طي 6 ساعت علامت دار ميشود. اكثر بچه ها درجه 2ويا 3 مسموميت بوده و اكثر اوقات نياز به آنتي ونوم و با مقدار زيادتر دارند كنترل اوليه ابتدا 5-10 ويال crifab antivenin)(در صورت كنترل ، 2 ويال در فواصل ساعات 6 و 12و18گزيدگي با مارcoral نياز به 3-5 ويال آنتي ونوم پروفيلاكسي دارد. ايمونيزاسيون كزاز آنتي بيوتيك‏در‏صورت‏عوارض باكتريال

42. classification of envenomation • Grade0 : no envenomation • Grade 1 mild : local swelling and pain • Grade 2 moderate: swelling, pain or echymosis progressing beyond the site Mild systemic or laboratory manifestation • Grade 3 sever: sever systemic finding and labratory

43. scorpion Patogenesis: • Hyaluronidase ,sertonin, histamin and neurotoxin • neurotoxin bind to presynaptic membranes and release acetylcholin and stimulation of both sympathetic and parasympathetic nervous systems.

44. Clinical manifestation • Most sting cause immediate local reaction .(mild burning to sever pain) • Severe envenomation causes autonomic dysfunction within 1 hr. • Symtoms : Agitation,irritability,salivation,bluredvision, hypertension, tachycardia,tachypnea and nystagmus. Rarely in smal children respiratory failure,convulsion or coma.

45. Clinical manifestation • علائم سيتميك :تب ، تعريق، افزايش بزاق، پوست سرد و مرطوب، تاكيكاردي و تاكي پنه • علائم عصبي: بيقراري ، گيجي ، خواب آلودگي ، افزايش رفلكسها، همي پلژي، تشنج، كوما • ريه: ادم ريه قطع تنفس، فلح عضلات تنفس • كليه: تغييرات‏حجم ادرار،هماتوري،هموگلوبينوري، نارسايي كليه • خوني:هموليز ، ترمبوز عروق و گانگرن • رقلبي :: CHF، تغييرات فشار خون • گوارش:افزايش دفعات اجابت مزاج ، خونريزي گوارشي، تهوع و استفراغ ،پانكراتيت • مرگ و مير در اطفال و افراد مسن ، از چنددقيقه تا 2 روز ، اغلب در 12 ساعت اول • علت مرگ : اثر سم رويCNS ، مركز تنفس، ميوكارديت، نارسايي قلب، آريتمي، خونريزي

46. Scorpion envenomation • Grade 1: local discomfort and paresthesia. • Grade 2: pain and parestesia extend up the extremity. • Grade 3: cranial nerve dysfunction, dysphagia, roving eyes, facial , paresthesia, restlessness. • Grade 4: cranial nerve dysfunction ,drooling, uncontrollable eye movements, faciculation , opisthotonos, convulsion,wheezing, hyperthermia ,cyanosis

47. treatment • Localized pain: ice and analgesics.(pain deminish within 24hr) hospital admission: Sever envenomation + autonomic instability. • Symptoms resole within 24-48hr • In cardiopulmonary compromise should be given antivenin. (complete resolution symptoms within 1 hr)

48. treatment • اطلاع از عقربهاي منطقه • تسكين درد با ليدوكائين، گذاشتن يخ ، شستشوي محل زخم ، استامينوفنت • تورنيكه، انسيزيون و ساكشن مؤثر نيست. • آنتي ونوم: در علائم شديد سيستميك • كلسيم:در كرامپ عضلاني • تشنج:ديازپام، فنوباربيتال • هموليز:: تزريق خون+ مايعات كافي و قليائي كردن ادرار