Poisoning Pediatrics n n Ali Alhaboo Assisstant Professor

Poisoning Pediatrics n n Ali Alhaboo Assisstant Professor of PICU consultant Overview of pediatric poisoning, diagnosis and treatment Summary of the most encountered poisoning

Epidemiology n n Most of the toxic exposures have only minor or no effect on the child 85% - 90% of pediatric poisoning occurs in < 5 yrs of age (accidental) usually single agent 10% - 15% in older age, mainly adolescents (intensional) usually several agents 3 -4% of PICU admission are because of toxic exposures

ED referral recommendations n n Serious exposures Younger than 6 months History of previous toxic ingestion Questionable or unreliable history

Routes of exposures in children n Ingestion Inhalation Skin exposure

Common agents but n n Cosmetics and personal care product Cleaning substance: flash is more serious than Clorox because it melts the esophagus and destroys it. n n Plants Analgesics: Paracetamol is the commonest cause of poisoning in children ( high doses more than 200 mg/kg) Note: OCPs are not harmful. Less common serious n n n Fe supplements: 2 nd most common in females. Antidepressants Anti-diabetics: causing severe hypoglycemia and LOC. n n Antihypertensive. Pesticides: organophosphates. n Hydrocarbon

History n n n n Identification of the toxic agent Age of the child. What has been done to the child. The time elapsed and the dose taken (if it was unknown consider it serious). The route of exposure Underlying medical problems The clinical effect (with few exceptions rapidity of symptoms progression correlates with severity of poisoning. e. g. , acetaminophen) ? Trauma in addition to ingestion (change in LOC).

Physical Exam n n Weight (determine ? mg/kg ingested) Vital signs Check odors from the breath, skin, hair, clothing Thorough exam for any abnormal finding

General presentations suggestive of poisoning n n n Severe vomiting, diarrhea Acutely disturbed consciousness Abnormal behavior Seizure unusual odor n n n Shock Arrhythmias Metabolic acidosis Cyanosis Respiratory distress

Clinical clues to the diagnosis of unknown poisoning n n n Odor Skin Mucous membranes Temperature Blood pressure n n n Pulse rate Respiration Pulmonary edema CNS GI system

Odor Signs or symptom Poison n n Bitter almond Acetone n Oil of wintergreen Garlic n n n Alcohol Petroleum n Cyanide Isopropyl alcohol, methanol, acetylsalicylic acid Methyl salicylate Arsenic, phosphorous, thallium, organophosphates Ethanol, methanol Petroleum distillates

Skin Sign or symptom n Cyanosis n Red flush n Sweating n Dry n n Poison Methemoglobinemia secondary to nitrates, nitrites, phenacetin, benzocaine Carbon monoxide, cyanide, boric acid, anticholenergics Amphetamines, LSD, organophosphates, cocaine, barbiturates Anticholenergics

Mucous membranes Signs or symptoms Poison n Dry n n Salvation n n Oral lesions n n Lacrimation n Anticholenergics Organophosphates, carbamates Corrosives, paraquat Caustics, organophosphates, irritant gases

Temperature Signs or symptoms n Hypothermia n Hyperthermia n n Poison Sedatives hypnotics, ethanol, carbon monoxide, clonidine, phenothiazines, TCAs Anticholenergics, salicylates, phenothiazines, cocaine, TCAs, amphetamines, theophylline

Blood Pressure Signs or symptoms n Hypertension n Hypotension n n Poison Sympathomimitics (especially phenylpropanolamine in overthe-counter cold remedies), organophosphates, amphetamine, phencyclidine, cocaine Antihypertensives, barbiturates, benzodiazepines, beta blockers, Ca++ channel blockers, clonidine, TCAs

Pulse rate Signs or symptoms n Bradycardia n Tachycardia n Arrhythmias n n n Poison Digitalis, sedatives hypnotics, beta blockers, ethchlorvynol, opioids Antichlonergics, sympathomimetics, amphetamines, alcohol, aspirin, theophylline, cocaine, TCAs Anticholenergics, TCAs, organophosphates, digoxin, phenothiazines, betablockers, carbon monoxide, cyanide

Respirations Signs or symptoms n Depressed n Tachypnea n Kussmaul’s sign Wheezing Pneumonia Pulmonary edema n n n Poisoning Alcohol, opioids, barbiturates, sedatives/hypnotics, TCAs, paralytic shelfish poisoning Salicylates, amphetamines, carbon monoxide Methanol, ethylene glycol, salicylates ( deep & fast breathing ) n n n Organophosphates Hydrocarbons Aspiration, salicylates, opioids, sympathomimetics

CNS Sings or symptoms n n Seizures n Fasciculation Hypertonus Myoclonus, rigidity n n n Poison Camphor, carbon monoxide, cocaine, amphetamines, sympathomimetics, anticholenergic, aspirin, pesticides, organophosphates, lead, PCP, phenothiazines, INH, lithium, theophylline, TCAs Organophosphates Anticholenergics, phenothiazines, haloperidol

CNS Sings or symptoms n n n Poison Delirium/psychos n Anticholenergics, is phenothiazines, sympathomimetics, alcohol, PCP, LSD, marijuana, cocaine, heroin, heavy metals n Alcohol, anticholenergics, Coma sedative hypnotics, opioids, carbon monoxide, TCAs, salicylates, organophosphates n Organophosphates, Weakness, carbamates, heavy metals paralysis

EYE Signs or symptoms n n Miosis Mydriasis n n n Blindness Nystagmus n Poison Opioids, phenothiazines, organophosphates, benzodiazepines, barbiturates, mushrooms, PCP Antichlenergics, sympathomimitics (cocaine, amphetamines, LSD, PCP), TCA, methanol, glutethimide Methanol Diphenylydantoin, barbiturates, carbamazepine, PCP, carbon monoxide, glutethimide, ethanol

GI Sings or symptoms n Vomiting, diarrhea n Poison Iron, phosphorous, heavy metals, lithium, mushroom, fluoride, organophosphates

Toxidromes of Common Pediatric Poisonings Toxin symptoms n n Anticholenergi cs (atropine, scopolamine, TCAs, antihistamines, mushrooms) Cholenergics (organophosph ates and carbamate insecticides) Signs or n n Fever, flushed, warm, dry skin, dry mouth, mydriasis, tachycardia, arrhythmias, agitation, hallucinations, coma Salivation, lacrimation, sweating, bronchorrhea, emesis, diarrhea, miosis, bradycardia, bronchospasm with wheezing, confusion, weakness, fasciculations, coma

Toxidromes of Common Pediatric Poisonings Toxin symptoms n n Opiates Narcotic withdrawal Signs or n n Hypothermia, hypoventilation, hypotension, bradycardia, miosis, coma Nausea, vomiting, diarrhea, abdominal pain, lacrimation, diaphoresis, mydriasis, tremor, irritability, delirium, seizure

Toxidromes of Common Pediatric Poisonings Toxin symptoms n n n Signs or Sedative/ hypnotics n TCAs n Hypothermia, hypoventilation, hypotension, tachycardia, coma Coma, convulsions, arrhythmias, anticholenergic manifestations Phenothiazines n Hypotension, tachycardia, dystonia syndrome, oculogyric crisis, trismus, ataxia, coma, anticholenergic manifestations

Toxidromes of Common Pediatric Poisonings Toxin symptoms Salicylates n n n Iron Sympathomimetics (amphetamines, phenylpropanolamie, ephedrine, caffeine, cocaine, aminophylline) Signs or n n n Fever, hyperpnea, vomiting, tinnitus, acidosis, seizure, lethargy, coma Hyperglycemia, shock, hemorrhagic diarrhea Tachycardia, arrhythmias, psychosis, hallucinations, nausea, vomiting, abdominal pain

Iron toxicity 5 stages : 1 - pt feels gastric abset 2 - pt feels false relife 345 - end result is GI obstruction and abset n Do endoscopy to take the pills out

Laboratory tests n n n n n Qualitative toxicology screening is rarely as helpful as Hx and PE in determining the cause Best done on urine and gastric aspirate samples Quantitative serum level of known drug is indicated when it can enable prediction of toxicity or determination of treatment ABGs with respiratory symptoms and to assess acid-base balance Blood glucose from 1 st sample Liver and kidney function (metabolism&excretion) Serum electrolytes (anion gap, renal function) Serum osmolar gap CBC (anemia, hemolysis) DIC panel when suspected

Routine Laboratory Tests That Can Suggest Poisoning

Drugs with clinically useful serum level quantitation n n n n Acetaminophen Anticonvulsants Carbon monoxide Cholinesterase Digoxin Ethanol Ethylene glycol Heavy metals n n n n Iron Isopropanol Lead Lithium Methanol Methemoglobin Salicylate Theophylline

Radiography indications n n If head trauma cannot be excluded (skull and cervical spine film, head CT if physical findings are suggestive) If child abuse is suspected (skeletal survey) If patient is having respiratory distress (CXRay) If radiopaque substance is suspected

Common substances that are radiopaque (CHIPES) n n n Chloral hydrate Heavy metals Iodine Phenothiazine Enteric coated and extended release medication Salt tablets (in Fe ingestion, serial films indicate movement and elemination)

ﻣﻬﻢ - ﻛﻼﻡ ﺍﻟﺪﻛﺘﻮﺭ Steps of management n n n n 1 st : First you have to start with ABCDE, if hypotensive repeat ABCs. 2 nd : Check the O 2 saturation and Vital signs 3 rd : look at the pt : smell and take a look at the skin and the pubil 4 th : Glucocheck for hypoglycemia. If hypoglycemic give 5 -10% dextrose (not higher than that because it might harm the vessel). Dose: 2 -5 ml/Kg. 5 th : Do toxicology screen. 6 th : LFT, U/E, RFT, coagulation profile (PT is the first to be affected, if it was elevated give FFP or vitamin K) and albumin. 7 th If early do Gastric lavage

Cont NB : contraindications of gastric lavage : Coma pt Corrosive or inhelated toxication Late presentation n 8 th : Give antidote as early as possible if available. (N-acetylcesteine is the antidote for paracetamol. Desfuroxemine is the antidote for iron. n 9 th : Give Activated charcol in early condition : give it by NG tube NB : contraindications : Iron toxcicity MCZ Lead toxicity n 10 th : give Mg sulfate to facilitate Bowl movement n 11 th : total bowel irrigation n 12 th : investigate the pt for damage : (( 1 st : level of the Med – 2 nd : renal and liver function – cbc ) n Transfer the patient to the ICU, if there is no bed keep him in the ER.

Treatment n Airway: patency and protective mechanisms (if absent, use nonspecific antidote of D 10 W 2 cc/kg and Naloxone 0. 1 mg/kg; if no response intubate. n Breathing: clear secretions, give O 2, continuous O 2 saturation, ABGs, CXRay, treat wheezing and stridor, early controlled intubation prefered n Circulation: frequent VS, continuous CR monitor, fluids for low BP, do baseline ECG, watch for arrythmias, PALS guidelines n Neurologic status: frequent assessments, the most common cause to admit intoxication to PICU, use nonspecific antidotes, watch for seizures, rule out metabolic causes of seizure

GI decontamination Emesis-Syrup of Ipecac Therapy n n n Dosage in < 1 yr 10 ml Young children 15 ml Adolescents, adults 30 ml may repeat once Contraindications n n Petroleum distillates Caustic agents Impaired consciousness, seizures Rapid coma-inducing agents (e. g. , propoxyphene, TCAs)

n n We use lavage when the patient presents early and is stable. If late presentation where the drug has already passed to the duodenum use the activated charcoal( through a NG tube) where up to 1 million particles can adsorb to the medication.

GI decontamination Lavage Therapy Contraindications n n Large bore orogastric hose (28 Fr for young children, 36 -40 Fr for adolescents) Left recumbent Trendelenburg’s position to reduce the risk of aspiration Lavage with saline or 1/2 NS until return is clear Most successful for toxins that delay gastric emptying (aspirin, iron, anticholinergics) and for those forming concretions (iron, salicylates, meprobamate) n n n Corrosive caustic agents Controversial in petroleum distillates ingestion Stupor or coma unless airway is protected

GI decontamination Therapy n n Activated Charcoal Administer in all cases after emesis. It should be only given for conscious patients. Dosage: Children 1 g/kg Adults 50 -100 g Contraindications n Corrosive agents: charcoal interfers with GI endoscopy Most feared complication is aspiration leading to severe pneumonitis and ARDS

GI decontamination Therapy n n Cathartics Mg. SO 4 250 mg/kg/dose P. O. (max dose 30 g) in 10%-20% solution Sorbitol magnesium citrate Repeat above doses every 2 -4 hrs until passage of charcoal stained stools Contraindications n Avoid Mg. SO 4 in renal failure

Enhanced elimination n Forced diuresis by administering 2 -3 times the maintenance fluid to achieve U. O = 2 -5 cc/kg/hr (contraindicated in pulmonary or cerebral edema and renal failure) n Urinary alkalinization to eleiminate weak acids(salicylates, barbiturates and methotrexate), can be achieved by adding Na. HCO 3 to the IV fluids, the goal is urine p. H of 7 -8 n n Serum alkalinization in TCAs toxicity Hemodialysis in low molecular weight substances with low volume of distribution and low binding to plasma proteins n Hemoperfusion, protein binding is not a limitation

Antidotal Therapy n n Only a small proportion of poisoned patients are amenable to antidotal therapy Only a few poisoning is antidotal therapy urgent (e. g. , CO, cyanide, organophosphate and opioid intoxication)

Specific Intoxications and Their Antidotes

Specific Intoxications and Their Antidotes

Acetaminophen (paracetamol) poisoning n n n Nausea, vomiting and malaise for 24 hrs Improvement for 24 -48 hrs Hepatic dysfunction after 72 hrs (AST is the earliest and most sensitive) Death may occur from fulminant hepatic failue Toxicity likely with ingestion of > 150 mg/kg Rumack-Matthew nomogram defines the risk of hepatic damage in acute intoxication (level at 4 hrs post ingestion)

Acetaminophen (paracetamol) poisoning management n n GI decontamination Activated charcoal within 4 hrs of ingestion Antidote N-acetylcysteine is most effective if given within 8 hrs of ingestion, total of 17 doses, P. O or IV (However, NAC should be given even with > 24 hrs presentation) NAC should be given if serum acetaminophen level is either in the “possible” or “probable” hepatotoxic range

ﻫﺬﺍ ﺍﻟﻤﻮﺿﻮﻉ ﻗﺮﺍﺀﻩ ﻓﻘﻂ Salicylate toxicity Clinical manifestations Common n n Fever Sweating Nausea Vomiting Dehydration Hyperpnea Tinnitus Seizures Coma Coagulopathy Uncommon n n n Respiratory depression Pulmonary edema SIADH Hemolysis Renal failure Hepatotoxicity Cerebral edema

Laboratory findings in salicylate toxicity n n Metabolic acidosis Respiratory alkalosis Mixed (resp alkalosis &metabolic acidosis) Hyperglycemia, Hypoglycemia n n n Hypernatremia, hyponatremia Hypokalemia Hypocalcemia Prolonged PT Ketouria

Prediction of acute salicylate toxicity n n Ingested dose can predict the severity < 150 mg/kg toxicity not expected (asymptomatic) 150 -300 mg/kg toxicity mild to moderate (mild to moderate hyperpnea, lethargy or excitability) 300 -500 mg/kg severe toxicity (severe hyperpnea, coma or semicoma, sometimes with convulsions)

Management of salicylate toxicity GI decontamination n n n Correct dehydration and force diuresis Urine alkalinization and acidosis correction with IV Na. HCO 3 Monitor electrolytes, glucose, calcium Vit K for hemorrhagic diathesis Decrease fever with external cooling Hemodialysis for severe intoxication (Dome nomogram), severe acidosis unresponsive to Na. HCO 3, renal failure, pulmonary edema and severe CNS manifestation