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Poisoning in children

Dr M A Maleque Molla, FRCP, FRCPCHConultant Pediatric Intensivist1September 14, 2015 PoisoningDefinition: Poisoning refers to an injury that results from being exposed to an exogenous substance that causes cellular injury or death*. Poisons can be inhaled, ingested, injected or absorbed. 2* WHOEpiodemiologyGlobal rate of poisoning 282.4 / 100,000 population WHO The global death rate from poisonings 1.8/ 100,000 population Non-fatal poisoning, more common among children aged 1 to 4 yearsHighest rates of fatal poisoning occurs among Children under the age of one year.Most poisoning occurs at home and common rout of poisoning is oral

3Most common agents involved Over-the-counter preparations: paracetamol, cough/cold remedies, vitamins and iron tablets, antihistamines and anti-inflammatory drugs.Prescription medications: Antidepressants, narcotics, analgesics and illicit drugs.Household products: Bleach, disinfectants, detergents, cleaning agents, cosmetics, vinegar.Paraffin/Kerosene.Pesticides: insecticides (Organophosphorus compound).Poisonous plants.Animal or insect bites: Scorpion sting, snake bite, Dog.

World report on child injury prevention, WHO 200444Evaluation of poisoned patientPriority: Stabilization of the Airway, Breathing,& CirculationDiagnosisHistoryPatient age and sex, wt.The type of substance involved, Method of exposure (i.e., skin contact, inhalation, or ingestion).Assessment of the severity of the exposurePhysical examinationInvestigationsNote: concomitant trauma or illness must be recognized and addressed prior to initiation of decontamination5HistoryWhat poison has been taken?How much has been taken?When the poison has been taken?What are the advarse effect of the poison?Reliability- Whether any poison has been taken?6History (cont..) What poison has been taken ?: can be identified from;Container Illustrated chart How much poison has been taken ?Calculating the missing amount from the container. In doubt, always calculate maximum amount of poison that has been consumed. When the poison has been taken?: Approximate time elapsed since ingestion or exposure.

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History (cont..) What are the adverse effects of the poison? Information can get from;From books, internet, pharmacyPoison Information centers: Tel no. Riyadh # 011 4355555/1999,2003, Jeddah # 021 6720711, Makkah # 021 5575065, Madinah# 041 8462564

8History(cont..) Whether any poison have been ingested?Any doubt, take that the child has ingested the poison. A history of medication used by the family members. Poisoning should be considered for any child, who present with acute onset of; Altered mental status. Multi organ system dysfunction of unexplained cause.Respiratory or cardiac compromise. Unexplained metabolic acidosis. Seizures, or a puzzling clinical picture. 9Physical examinationThorough physical examination from head to toe Evaluation of mental status and vital signs, should be repeated frequently The diagnosis may be assisted by; Temperature alterationsBlood pressure and heart rate alterationsRespiratory disturbancesPupillary findingsSkin findingsNeuromuscular abnormalities Mental status alterationsCharacteristic odors e.g. acetone, bitter almond, Garlic In case of unknown poison ingestion, physical findings should be sought to define a particular toxic syndrome (toxidrome).10ToxidromesAnticholinergics: Atropine, scopolamine, TCAs, phenothiazines, antihistamines, antipsychotic mushrooms, Hot as a hare, Blind as bat, dry as a bone, red as a beet, mad as a hatterCV: tachycardia, hypotension, hypertension, arrhythmiaGI/GU: decreased bowel sounds, urinary retentionNeuro: agitation, hallucinations, coma, extrapyramidal movements, mydriasis, hyperthermia11ToxidromesMascarinic effectNicotinic effectDiaphoresis/diarrheaUrinationMiosisBrdycardia/bronchospasmEmesisLacrimation excessSalivation excess

Muscle fasciculationCrampingWeakness (extreme is diaphragmatic failure)Autonomic hypertension, tachycardia, pupillary dilation, and pallor

Cholinergics: Organophosphates and carbamates1212ToxidromesSympathomimetic: Salbutamol, Amphetamine, Cocain, Ephedrine.Anxiety, Delusion, Diaphoresis, hyperreflexia, mydriasis, paranoia, seizure Tachycardia, hypertension, mydriasis, agitation, seizures, diaphoresis, psychosis, hyperthermia

OPIOID; Morphine, hydrocodone, methadoneHypoventilation, Hypotension, Miosis, Sedation, Hypothermia, Ileus.

13InvestigationsBlood glucose, urea & ElectrolytesBlood gas & Acid base statusSerum osmolality & osmolal gap, anion gapQuantitative serum concentration of drugs- paracetamol salicylate, IronUrine analysis; RabdomyolysisECG.Toxicology screens: indicated in children in whom the diagnosis of poisoning is uncertain.Samples of blood, first voided urine , vomitus, and gastric contents should be save for subsequent analysis. Plain radiographs of the chest & abdomen when indicated.14Management Management of the poisoned child depends uponSpecific poison(s) involved, Presenting and severity of illness,Elapsed time between exposure and presentation.

Remember the mainstay of therapy is supportive 15ManagementA. General ManagementABCDDecontamination: Techniques used to prevent the absorption of the toxic substance Enhanced elimination: techniques which accelerate removal of a toxins from the body

B. Specific ManagementAntidote: a substance which can counteract a form of poisoning16Surface decontamination e.g. Organophosphate poisoning; Removal of the cloths and wash with soap & waterIrrigation of eyes if affectedGI Decontamination:Gastric lavage: Not used routinely, use only selected casesActivated charcoalWhole bowel irrigationPurgation using catharticsDecontamination is notalways warranted and may be contraindicated.172. Decontamination

Activated charcoal(AC)It is an insoluble, non absorbable, fine carbon powder Maximum benefit, if administered within 1 hour of ingestion Dose: 0.5- 1g/kg (maximum 50 to 60 gm), can be repeated at 0.5g/kg Q4-6 hourMultiple-dose: in case of ingested life-threatening amounts of;Carbamazepine, Dapsone, Phenoberbital, Quinine, TheophylineCare must be taken to protect the airway, assess for the presence of bowel sounds.

18Activated charcoal(cont..)Contraindication:Absolute contraindication: Bowel obstruction or perforationDepressed level of consciousness Ingested non absorbable acidic or alkaline corrosives e.g. sodium or potassium hydroxide, or hydrochloric or sulfuric acid.Ingestion of hydrocarbons e.g., gasoline, kerosene, liquid furniture polish The poisons which are not bound by AC e.g. Iron, lead, arsenic.19Agents for which activated charcoal is not recommended

Heavy metalsArsenicLeadMercuryIronZincCadmiumInorganic ionsLithiumSodiumCalciumPotassiumMagnesiumFluorideIodideBoric acidCorrosivesAcidsAlkaliHydrocarbonsAlkanesAlkenesAlkyl halidesAromatic hydrocarbonsAlcoholsAcetoneEthanolEthylene glycolIsopropanolMethanolEssential oils20Whole bowel irrigation (WBI)It refers to the administration of polyethylene glycol electrolyte solution (PEG-ES) to induce liquid stool and mechanically flush pills, tablets, or drug packets from the GI tract. WBI significantly decreased absorption of toxic materials

21Whole bowel irrigation (WBI)Indication: Ingestion of large amounts of poisons that are not well bound to AC, sustained-release medications.Contraindications: Intestinal obstruction, perforation, ileus, or significant GI bleeding , Persistent vomitingTechnique: Administration polyethylene glycol electrolyte solution (PEG-ES) via nasogastric tubeDose: 20 to 40mL/kgper hour until the rectal effluent is clear, which takes 4-6 hours.

PEG-ES (GoLYTELY)2222Cathartics accelerate the evacuation by fluid load in the intestine and stimulating bowel motility. They shouldneverbe used as the sole method of GI decontamination.Recommended agent:0.5g/kg(1 to 2mL/kg)of 7 percent Sorbitol(0.9g/mL)4mL/kgor 250 mL of Magnesium citratein a 6 percent suspensionSorbitol is not recommended for use in children younger than one year of ageIf a cathartic is used, it should be limited to a single dose in order to minimize adverse effects23Use of CatharticsEnhance elimination of PoisonsUrinary alkalinization and forced diuresis: eg, salicylates and Phenobarbital.Hemodialysis: significant ingestion of alcohols, theophylline, Lithium, Salicylates.Hemoperfusion: Theophylline, Carbamazepine, valproic acid, procainamide.Exchange transfusion: arsine or sodium chlorate poisoningPeritoneal dialysis, Hemofiltration 24Specific treatmentAntidotesVery few poisons have antidotes.Information can be found in books or from Poison Information Center25Table. Antidotes for some common toxicantPOISONANTIDOTEParacetamolN-AcetylcysteineAnticholinergicsPhysiostigmine Lead/Heavy MetalsBAL in oil (dimercaprol)AnticholinergicsPhysiostigmineBeta BlockersGlucagon, CateholaminesCarbon MonoxideOxygenCyanideAmyl nitrate, Sodium Nitrate, Sodium ThiosulfateEthylene GlycolDialysis, Fomepizole, EthanolIronDesferoxamineIsonazidPyridoxineLead/Heavy MetalsDMSA, BAL, EDTAMethemoglobin Producing agentsMethylene blueNarcoticsNarcanOrganophosphatesAtropine, PralodiximePhenothiazinesBenadryl26DispositionPatient can send home after 4-6 hour of observation if poison is less toxic. Always admit if Symptomatic. Ingestion of iron, tricyclic antidepressant, digoxin and aspirin.Unconscious child should be admitted in pediatric intensive care unit.

27SPECIFIC POISONING28ParacetamolMost common ingestion in toddlers, preschoolers and adolescentsToxic dose: > 150 mg/kgKinetics dictate that a serum level to be checked 4 hours after ingestion4 hour toxic blood level 150ug/dlApply the level to the management nomogram

29Rumack-Matthew nomogram for single acute paracetamol ingestions30

30Paracetamol PoisoningStage I(1/2 - 24 hours)Malaise, nausea, vomiting, pallor, diaphoresisStage II (24 - 72 hours)Asymptomatic, right upper quadrant pain, increasing LFTs, PT, PTT & INRStage III (72 - 96 hours)Liver failure, in severe cases renal failure & multi organ failureStage IV (4 - 14 days)Resolution of liver injury & Recovery

31ManagementActivated charcoal 1 gm/kgPlasma paracetamol level at 4 hours and plot on nomogramN-Acetylcysteine(NAC), orally:If serum level above the line of possible hepatotoxicityIngested > 150 mg/kg & no facilities to do serum level of paracetamol, Patients with an unknown time of ingestion beyond 24 hours and a serumconcentration >10mg/L(66mol/L)Dose of NAC: Loading Dose: 140mg/kg. Maintenance Dose: 70mg/kg, 4 hourly for 17 dosesIV : Indicated if patient is unable to take orally and present within 8-16 hours of ingestionDose: (Acetadote) 150 mg/kg over 1hr, followed by 50 mg/kg over 4 hr, followed by 100 mg/kg over 16 hr

32NAC therapyIs most effective when initiated within 8 hr of ingestion, Shown to have benefit even in patients who present in fulminant hepatic failureThere is no benefit before 4 hr post ingestion. 33Iron34Available preperationFerrous sulfate -20% elemental ironFerrous gluconate- 12% elemental ironFerrous fumerate -33% elemental iron

Toxic Dose: Elemental Iron60 mg/kg potentially life threatening

Clinical featuresPhase I (Gastrointestinal): 30 min 6 hoursNausea, Vomiting correlate with high toxicity, Diarrhea; abdominal painGI haemorrhage bloody diarrhea, hematemesisSevere hypotensionPhase II (Latent): 6-24 hours post ingestionPatient appears better apparent improvementIn severe poising, this stage may be absent.In this stage, iron accumulates in mitochondria and various organs

355 Phases5 stagesPhase III (Shock): 6-72 hours post ingestion; Hypoglycemia, Metabolic acidosis, Circulatory Failure-ShockPhase IV (Hepatotoxic): 22-96 days post ingestionSigns of hepatic necrosis raised AST, ALT and direct bilirubin, prolonged PTRenal Failure, Metabolic Acidosis, Bleeding diathesis, Adult Respiratory Distress SyndromeComa DeathPhase V: 2-8 weeks after ingestionSigns of intestinal obstruction due to scarring and pyloric stenosis

36Clinical features(cont..)InvestigationSerum Iron 2-6 hours post ingestion, TIBCSerum Iron >350gm/dl- mild to moderate toxicitySerum Iron >500gm/dl- severe toxicity needs urgent interventionGreater than 1000mcg/dL Significant morbidity and mortalityBlood glucose; Blood glucose >150 mg/dl moderate to severe toxicityCBC, U&Es LFT, WBC > 15000 /cmm- associated with moderate to severe toxicityPlain x-ray abdomenABG/VBG37ManagementSupportive careABCD Correct dehydration Removal of IronWhole bowel irrigation with colonic solution (colyte, golytely) if large number of tablets are ingested.No activated charcoal to be given because it does not bind iron.Repeat x-ray on abdomen after decontamination.If clumps of tablets can be seen in x-ray and fail to remove with usual procedures, surgical removal is indicated in rare cases.Desferoxamine orally promote iron absorption, so should not be given orally38ManagementDefinitive treatment: Desferoxamine intravenous infusion.Indications:Serum Iron at 4-8 hours >500g/dl regardless of symptoms orSerum Iron >350g/dl + moderate to severe symptomModerate to severe symptom regardless of serum ironSignificant no. of pills on abdominal x-RayDose:By IV infusion 15mg/kg/hour maximum 6 g/24 hoursBy intramuscular 90mg/kg/dose 8 hourly maximum 6g/24 hours

3939SALICYLATE POISONINGToxic Dose: >150 mg/kgClinical Manifestation:Early: nausea vomiting tachypnea, deep sighing respiration, tinnitus, high temperature, lethargy, and dehydration.Late: Bleeding tendency, coma.

40Clinical featuresImportant signs and laboratory findings:Phase I: First 12 hoursTachypneaAlkalosisPhase II - 12-24 hoursTachypnea persist HypokalemiaParadoxical aciduriaPhase III - 4 to 6 in an infant, or 24 hours in an adolescent or adultDehydration 5-10%Worsening acidosisHypokalemia; hyperglycemia/hypoglycemiaPulmonary edema, pulmonary hemorrhageCerebral edema

41InvestigationsPlasma Salicylate level no sooner than 6 hours and plot on the nomogramUrine pH hourlyBlood gasGlucose, serum urea electrolytes and creatinine 6 hourlyPTLFT.

42Nomogram for Salicylate43

ManagementPlasma salicylate levels 45-65 mg/dl (moderate poisoning), treat and admit the patient.Plasma salicylate level >65 mg/dl (severe poisoning), treat and admit in the ICUDecontamination:Activated charcoal 1 gm/kg.Multiple dose of AC may be needed in severe poisoningVolume resuscitation:Rehydrate the child and correct electrolyte specially potassium;Enhance eliminationUrine alkalinization by IV bicarbonateThe goal is to achieve a urine pH >7.5 while maintaining a serum pH 7.55.Hemodialysis44Organophosphate poisoning1. Mascarinic effectDiaphoresis/diarrheaUrinationMiosisBrdycardia/bronchospasmEmesisLacrimation excessSalivation excess

2. Nicotinic effectMuscle fasciculationCrampingWeakness (extreme is diaphragmatic failure)Autonomic : hypertension, tachycardia, pupillary dilation, and pallor

Agents: Malathion, Parathion, Diazenon, Chlorothion45Clinical features3. CNS manifestations: Anxiety, restlessness, tremor, confusion, coma, convulsion45ManagementABCRemove cloths and wash the skin with soap and waterAtropine (vagal block)IV 0.02-0.05 mg/kg every 15 minute until complete atropinization ( dilated pupil, dry mouth tachycardia, fever) then 1-4 hourly for 24 hourPralidoxime (Protopam, 2-PAM)Regenerates acetylcholinesterase20 - 50 mg/kg/dose (IM or IV)Repeat in 1-2 hour if muscle weakness does not relieve

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47Thanks for attention