Poisoning in ChildrenPoisoning in Children

Poisoning in ChildhoodPoisoning in Childhood• Definition of Poisoning:Definition of Poisoning:

– Exposure to a chemical or other agent that Exposure to a chemical or other agent that adversely affects functioning of an organism.adversely affects functioning of an organism.

• Circumstances of Exposure can be intentional, Circumstances of Exposure can be intentional, accidental, environmental, medicinal or accidental, environmental, medicinal or recreational.recreational.

• Routes of exposure can be ingestion, injection, Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure.inhalation or cutaneous exposure.

Poisoning in ChildrenPoisoning in Children

• Ingestion of a harmful substance Ingestion of a harmful substance is among the most common is among the most common causes of injurycauses of injury

Important history pointsImportant history points

• What toxic agent/medications were found near What toxic agent/medications were found near the patient?the patient?

• What medications are in the home?What medications are in the home?

• What approximate amount of the “toxic” agent What approximate amount of the “toxic” agent was ingested?was ingested?– How much was available before the ingestion?How much was available before the ingestion?– How much remained after the ingestion?How much remained after the ingestion?

• When did the ingestion occur ?When did the ingestion occur ?

• Were there any characteristic odorsWere there any characteristic odors– How has the patient behaved since the ingestion?How has the patient behaved since the ingestion?

• Does the patient have a history of substance Does the patient have a history of substance abuse?abuse?

ManagementManagement

General measures:General measures:• Quick assessment & triageQuick assessment & triage

• Limit absorption:Limit absorption:– VomitingVomiting– LavageLavage– Activated charcoal instillationActivated charcoal instillation

Specific:Specific:

ABC’s of Toxicology:ABC’s of Toxicology:• AAirwayirway• BBreathingreathing• CCirculationirculation• DDrugs: rugs:

• Resuscitation medications if neededResuscitation medications if needed• Universal antidotesUniversal antidotes

• DDraw blood: raw blood: • chemistry, coagulation, blood gases, drug levelschemistry, coagulation, blood gases, drug levels

• DDecontaminateecontaminate• EExpose / Examinexpose / Examine• FFull vitals / Monitoringull vitals / Monitoring• GGive specific antidotes / treatmentive specific antidotes / treatment

• Decontamination:Decontamination:1.1.Ocular:Ocular:

– Flush eyes with salineFlush eyes with saline2.2.Dermal:Dermal:

– Remove contaminated clothingRemove contaminated clothing– Brush offBrush off– Irrigate skinIrrigate skin

3.3.Gastro-intestinal:Gastro-intestinal:– Activated charcoal:Activated charcoal:

– May Prevent /delay absorption of some drugs/toxinsMay Prevent /delay absorption of some drugs/toxins– Almost always indicatedAlmost always indicated

– Naso/oro-gastric LavageNaso/oro-gastric Lavage– Bowel Irrigation:Bowel Irrigation:

– Recent ingestions 4-6 hrsRecent ingestions 4-6 hrs– 500 cc NS Children / 2000cc adults500 cc NS Children / 2000cc adults– Orally / Nasogastric tubeOrally / Nasogastric tube

poising Treatment poising Treatment

– Do not induce vomitingDo not induce vomiting– Do not attempt gastric lavageDo not attempt gastric lavage– Risk of aspiration outweighs any benefit Risk of aspiration outweighs any benefit

from removal of substancefrom removal of substance– CXR around 2-4 hrs “not before 2hrs”CXR around 2-4 hrs “not before 2hrs”– Observe in ER for 6-8 hrsObserve in ER for 6-8 hrs

PreventingPreventing

• Education is the major component of Education is the major component of any poison prevention programme.any poison prevention programme.

• Keep medicines, insecticides, etc… Keep medicines, insecticides, etc… out of the reach and sight of your out of the reach and sight of your children.children.

• Never store food & cleaning Never store food & cleaning products together. Store medicine products together. Store medicine and chemicals in original containers.and chemicals in original containers.

Hydrocarbon PoisoningHydrocarbon Poisoning

• These may be divided into These may be divided into aliphatic or aromatic compounds. aliphatic or aromatic compounds. Aliphatic hydrocarbons include Aliphatic hydrocarbons include kerosene, turpentine, lubricating kerosene, turpentine, lubricating oils, tar and have greatest risk of oils, tar and have greatest risk of aspiration and pulmonary aspiration and pulmonary symptoms. Aromatic compounds symptoms. Aromatic compounds have mainly neurological and have mainly neurological and hepatic toxicity and include hepatic toxicity and include benzene compounds. benzene compounds.

• Type of toxicity with a Type of toxicity with a hydrocarbon depends on its hydrocarbon depends on its volatility, viscosity or surface volatility, viscosity or surface tension. The lower is viscosity, tension. The lower is viscosity, more is the risk of pulmonary more is the risk of pulmonary aspiration. Mineral spirit, aspiration. Mineral spirit, kerosene and furniture polish kerosene and furniture polish have both low volatility and have both low volatility and viscosity and thus carry a higher viscosity and thus carry a higher risk of aspiration pneumonia.risk of aspiration pneumonia.

• Benzene derivates, toluene and Benzene derivates, toluene and xylene are components of various xylene are components of various solvents and degreasers. These are solvents and degreasers. These are highly volatile but have low viscosity. highly volatile but have low viscosity. Inhalation is the primary route of Inhalation is the primary route of toxicity which manifests with CNS toxicity which manifests with CNS symptoms. Gasoline and naphtha are symptoms. Gasoline and naphtha are constituents of lighter fuel and constituents of lighter fuel and lacquer diluent and primarily cause lacquer diluent and primarily cause depression of the central nervous depression of the central nervous system (CNS).system (CNS).

• Turpentine oil is highly volatile but has low Turpentine oil is highly volatile but has low viscosity also. Toxicity results from viscosity also. Toxicity results from inhalation and gastrointestinal absorption. inhalation and gastrointestinal absorption. They can also cause CNS toxicity.They can also cause CNS toxicity.

• Halogenated hydrocarbons are used as Halogenated hydrocarbons are used as solvents and spot removers. Freon is used solvents and spot removers. Freon is used as a refrigerant.as a refrigerant.

• Toxic exposure to hydrocarbons may result Toxic exposure to hydrocarbons may result in cardia, gastrointestinal, neurological, in cardia, gastrointestinal, neurological, pulmonary, renal, hepatic, metabolic and pulmonary, renal, hepatic, metabolic and hematological manifestations.hematological manifestations.

• Induced emesis or gastric lavage Induced emesis or gastric lavage is contraindicated for kerosene is contraindicated for kerosene oil poisoning. It is done only oil poisoning. It is done only when large quantities of when large quantities of turpentine have been ingested turpentine have been ingested or the hydrocarbons product or the hydrocarbons product contains benzene, toluene, contains benzene, toluene, halogenated hydrocarbons, halogenated hydrocarbons, heavy metals, pesticides or heavy metals, pesticides or aniline dyes. Other specific aniline dyes. Other specific modalities including steroids and modalities including steroids and antibiotics are not efficacious.antibiotics are not efficacious.

KEROSENE POISONINGKEROSENE POISONING

• EpidemiologyEpidemiology

• Clinical featuresClinical features

• InvestigationInvestigation

• TreatmentTreatment

Clinical featuresClinical features

• Age – 1 to 3 years Age – 1 to 3 years more than 70% symptomatic within more than 70% symptomatic within

10 hours10 hours

SYMPTOMSSYMPTOMS

RSRS – breathlessness, cough – breathlessness, coughCNSCNS – convulsions, coma – convulsions, coma GPEGPE – fever, restlessness, cyanosis – fever, restlessness, cyanosisGIGI – vomiting, diarrhea – vomiting, diarrhea

Kerosene poising Kerosene poising

• Kerosene ingestion:Kerosene ingestion:– Risk of aspirationRisk of aspiration– GIT & Respiratory effects.GIT & Respiratory effects.– Burning sensation, nausea and diarrheaBurning sensation, nausea and diarrhea– Cough, chocking, gagging and grunting.Cough, chocking, gagging and grunting.– CXR 2-8 hrs later: Pulmonary infiltrates CXR 2-8 hrs later: Pulmonary infiltrates

or perihilar densities. or perihilar densities. – pneumatoceles, pleural effusion or pneumatoceles, pleural effusion or

pneumothorax and bacterial pneumothorax and bacterial superinfection superinfection

– Resolution 2-7 days.Resolution 2-7 days.

Lab InvestigationsLab Investigations• Blood – LeukocytosisBlood – Leukocytosis

X – Ray changesX – Ray changes

Changes appear within one hourChanges appear within one hour - commonly right basal infiltrates- commonly right basal infiltrates - emphysema- emphysema - pleural effusion- pleural effusion - pneumatocoeles- pneumatocoeles

ManagementManagement

• Avoid emeticsAvoid emetics• Avoid gastric lavage – In case of massive Avoid gastric lavage – In case of massive

amount use a cuffed endotracheal tubeamount use a cuffed endotracheal tube• After lavage leave magnesium or sodium After lavage leave magnesium or sodium

sulphate in the stomachsulphate in the stomach• Oxygen may be usefulOxygen may be useful• Assisted VentilationAssisted Ventilation• Antibiotics - PenicillinAntibiotics - Penicillin• KanamycinKanamycin• Steroids – Not helpfulSteroids – Not helpful

ComplicationsComplications

• PneumothoraxPneumothorax• PneumatocoelesPneumatocoeles• Pleural effusionPleural effusion• BronchopneumoniaBronchopneumonia• ComaComa

Organophosphorus Organophosphorus PoisoningPoisoning

• Organic phosphate insecticides Organic phosphate insecticides cause irreversible inhibition of the cause irreversible inhibition of the enzyme cholinesterase. As result enzyme cholinesterase. As result acetylcholine accumulates in acetylcholine accumulates in various tissues. Excessive various tissues. Excessive parasympathetic activity occurs. parasympathetic activity occurs. These agents are absorbed by all These agents are absorbed by all routes including skin and mucosa. routes including skin and mucosa.

• Symptoms manifest quickly usually Symptoms manifest quickly usually within a few hours and include within a few hours and include weakness, blurred vision, headache, weakness, blurred vision, headache, nausea, and pain in chest. These nausea, and pain in chest. These patients have excessive secretion in patients have excessive secretion in the lungs and they sweat profusely. the lungs and they sweat profusely. Salivation is marked. Pupils are Salivation is marked. Pupils are constricted and papilledema may constricted and papilledema may occur. Muscle twitching, convulsions occur. Muscle twitching, convulsions and coma occur in severe cases. and coma occur in severe cases. Reflexes are absent and sphincter Reflexes are absent and sphincter control is lost.control is lost.

TreatmentTreatment • If the insecticide was in contact with If the insecticide was in contact with

skin or eyes, these are thoroughly skin or eyes, these are thoroughly washed. Stomach wash is done.washed. Stomach wash is done.

• Atropine sulphate: 0.03 to 0.04 mg/kg Atropine sulphate: 0.03 to 0.04 mg/kg IV (atropine sulphate is usually IV (atropine sulphate is usually available in ampules 1 in 1,000 or 1 available in ampules 1 in 1,000 or 1 mg/mL). Other strengths may also be mg/mL). Other strengths may also be available. Repeat half the dose in 15 available. Repeat half the dose in 15 minutes and if necessary every hour minutes and if necessary every hour (until signs of toxicity appear), subject (until signs of toxicity appear), subject to a maximum of 1 mg/kg in 24 hours.to a maximum of 1 mg/kg in 24 hours.

• Pralidoxime (PAM) is given in dose of Pralidoxime (PAM) is given in dose of 25-50 mg/kg IM or IV over 30 min 25-50 mg/kg IM or IV over 30 min infusion. The dose may be repeated in infusion. The dose may be repeated in 1-2 hours, then at 6-12 hour intervals 1-2 hours, then at 6-12 hour intervals as needed. Monitor for hypertension. as needed. Monitor for hypertension. Never inject morphine, theophylline, Never inject morphine, theophylline, aminophylline or chlorpromazine. aminophylline or chlorpromazine. Intravenous fluids should only be Intravenous fluids should only be given with caution. No oral given with caution. No oral tranquilizers are administered. tranquilizers are administered. Artificial respiration may be Artificial respiration may be necessary to sustain life.necessary to sustain life.

• Metabolic acidosis supervenes Metabolic acidosis supervenes quickly due to disturbances of quickly due to disturbances of oxidative phosphorylation and oxidative phosphorylation and reduction of hepatic glycogen reduction of hepatic glycogen with resultant ketonemia. The with resultant ketonemia. The patients are treated with patients are treated with adequate replacement of fluids adequate replacement of fluids to restore renal function. to restore renal function.

• Urine is alkalinized by Urine is alkalinized by

administering 1-2 mEq/kg of administering 1-2 mEq/kg of sodium bicarbonate at half sodium bicarbonate at half hourly intervals for 4 hours to hourly intervals for 4 hours to promote excretion of urine, promote excretion of urine, because in alkaline urine, because in alkaline urine, salicylates do not diffuse back salicylates do not diffuse back into the tubular cells from the into the tubular cells from the lumen. Potassium salts should lumen. Potassium salts should be given (3-5 mEq/kg/day) to be given (3-5 mEq/kg/day) to replace the potassium losses replace the potassium losses

paracetamolparacetamol

• It is safe in pharmacological doses. It is safe in pharmacological doses. Overdosage may cause hepatic Overdosage may cause hepatic damage. Acetaminophen damage. Acetaminophen overdosage is treated with overdosage is treated with acetylcysteine to be used orally acetylcysteine to be used orally within 16 hours after ingestion in a within 16 hours after ingestion in a loading dosage of 140 mg/kg loading dosage of 140 mg/kg diluted to 5 percent solution orally diluted to 5 percent solution orally followed by 70 mg/kg q 4h for followed by 70 mg/kg q 4h for another 16 doses.another 16 doses.

Carbon Monoxide PoisoningCarbon Monoxide Poisoning

• Carbon monoxide poisoning results from Carbon monoxide poisoning results from inhalation of fire smoke, automobile inhalation of fire smoke, automobile exhaust, fumes from faulty gas stoves exhaust, fumes from faulty gas stoves and ingestion of paint and varnish and ingestion of paint and varnish removers. Clinical manifestations include removers. Clinical manifestations include headache, cyanosis, convulsions, and headache, cyanosis, convulsions, and coma. Patients are administered 100 coma. Patients are administered 100 percent oxygen and if carboxyhemoglobin percent oxygen and if carboxyhemoglobin levels are above 40 percent, hyperbaric levels are above 40 percent, hyperbaric oxygen therapy is considered.oxygen therapy is considered.

• The label should be read before using The label should be read before using the drug. No drug should be given or the drug. No drug should be given or taken in the dark. Drugs after their taken in the dark. Drugs after their expiry date should be disposed in a expiry date should be disposed in a safe manner. Avoid taking medicine safe manner. Avoid taking medicine in your child’s presence. Never in your child’s presence. Never suggest that medicine is candy.suggest that medicine is candy.

• Children should be taught not to eat Children should be taught not to eat plants or berries.plants or berries.

Iron IntoxicationIron Intoxication

• Ingestion of a number of tablets of Ingestion of a number of tablets of ferrous sulphate may cause acute ferrous sulphate may cause acute poisoning. Lethal dose is 300 mg/kg of poisoning. Lethal dose is 300 mg/kg of iron. Severe vomiting and diarrhea iron. Severe vomiting and diarrhea occur. These may contain blood due to occur. These may contain blood due to extensive gastrointestinal bleeding. extensive gastrointestinal bleeding. The child may go into severe shock, The child may go into severe shock, hepatic and renal failure within a few hepatic and renal failure within a few hours or after a latent period of 1 to 2 hours or after a latent period of 1 to 2 days days

Iron PoisoningIron Poisoning

• Five Stages but variableFive Stages but variable– Stage Stage 11

•Gastro-intestinal stage: within Gastro-intestinal stage: within several hrs of ingestion:several hrs of ingestion:– abdominal painabdominal pain– Severe: fluid loss, bleeding, Severe: fluid loss, bleeding,

shock(acidosis, tachycardia +/- shock(acidosis, tachycardia +/- hypotension)hypotension)

– Fever. Lethargy. ComaFever. Lethargy. Coma

Iron PoisoningIron Poisoning

•StageStage 22

– Quiescent stage: 4-48hrsQuiescent stage: 4-48hrs•Clinical improvementClinical improvement

•Subtle hemodynamic changes:Subtle hemodynamic changes:– TachycardiaTachycardia

Iron PoisoningIron Poisoning

•Stage Stage 33::– Circulatory collapse : 48-96 hrsCirculatory collapse : 48-96 hrs

•Metabolic acidosis, hypotension, Metabolic acidosis, hypotension, low Cardiac low Cardiac outputoutput..

•CoagulopathyCoagulopathy

•Multiorgan system failureMultiorgan system failure

Iron PoisoningIron Poisoning

•Stage 4:Stage 4:– Hepatic failure: 96 hrsHepatic failure: 96 hrs

•Increased mortalityIncreased mortality

•Rarely fulminant hepatic failureRarely fulminant hepatic failure

•Hepatic necrosisHepatic necrosis

– Liver transplant can save lives Liver transplant can save lives

Iron PoisoningIron Poisoning

•STAGE 5:STAGE 5:– Bowel obstruction 2-6 wksBowel obstruction 2-6 wks– Due to scarringDue to scarring

•Gastric outlet obstructionGastric outlet obstruction

•Small intestinal obstructionSmall intestinal obstruction

– May not pass through stage 4May not pass through stage 4

TreatmentTreatment

• Vomiting should be induced and Vomiting should be induced and stomach should be washed with stomach should be washed with sodium bicarbonate solution. Shock is sodium bicarbonate solution. Shock is corrected by infusion of fluids corrected by infusion of fluids parenterally. Three mL of 7.5 percent parenterally. Three mL of 7.5 percent sodium bicarbonate solution per kg of sodium bicarbonate solution per kg of body weight are diluted with 3 times body weight are diluted with 3 times its volume of 5 percent glucose its volume of 5 percent glucose solution and injected intravenously solution and injected intravenously for treatment of acidosis. This dose for treatment of acidosis. This dose may be repeated after an hour if may be repeated after an hour if acidosis is persisting. acidosis is persisting.

• Iron salts are chelated with Iron salts are chelated with desferrioxamine IV at 15mg/kg/hour desferrioxamine IV at 15mg/kg/hour until the serum iron is <300 mg/dL or until the serum iron is <300 mg/dL or till 24 hours after the child has till 24 hours after the child has stopped passing the characteristic stopped passing the characteristic ‘vin rose’ colored urine. Presence of ‘vin rose’ colored urine. Presence of ‘vin rose’ color to urine indicates ‘vin rose’ color to urine indicates significant poisoning.significant poisoning.

Iron PoisoningIron Poisoning

Management:Management:1.1. Gastric decontamination:Gastric decontamination:

• Forced emesisForced emesis• Gastric lavage with 5% NaHCO3Gastric lavage with 5% NaHCO3• No activated charcoalNo activated charcoal

2.2. Secure good IV Secure good IV 3.3. Get initial the 4hrs levels and TBCGet initial the 4hrs levels and TBC4.4. Chelate with Deferoxamine if Chelate with Deferoxamine if

levels> 300mg/dLlevels> 300mg/dL

Iron PoisoningIron Poisoning

•Chelate with Deferoxamine:Chelate with Deferoxamine:– Stable pts : levels< 500 mg/dL Stable pts : levels< 500 mg/dL

40mg/kg IM/IV40mg/kg IM/IV– Unstable: bleeding/ level > 500Unstable: bleeding/ level > 500

•Give 20cc/kg NS/RLGive 20cc/kg NS/RL

•Deferoxamine at 15 mg/kg IV over 1hrDeferoxamine at 15 mg/kg IV over 1hr

•Continuous drip at 15mg/kg/hrContinuous drip at 15mg/kg/hr

•Continue till “vin rose” urine color Continue till “vin rose” urine color disappears.disappears.

Iron PoisoningIron Poisoning

•Observe for:Observe for:– Systemic BPSystemic BP– ECGECG

•Signs of hepatic failure:Signs of hepatic failure:– BleedingBleeding– Glucose intoleranceGlucose intolerance– HyperammonemiaHyperammonemia– EncepalopathyEncepalopathy

SALICYLATESSALICYLATES

• Oral ingestion commonestOral ingestion commonest

• Transdermal lessTransdermal less

• Peak levels at 12 hrsPeak levels at 12 hrs– Early : hyperpnea Early : hyperpnea respiratory respiratory

alkalosisalkalosis– Then metabolic acidosisThen metabolic acidosis– Severe cases: Cerebral edema and Severe cases: Cerebral edema and

increased ICPincreased ICP

Salicylate PoisoningSalicylate Poisoning

• Ingestion of 150 mg/kg of salicylates Ingestion of 150 mg/kg of salicylates causes intoxication. Salicylate level of causes intoxication. Salicylate level of 50-80 mg/dL causes moderate 50-80 mg/dL causes moderate symptoms. Severe symptoms are symptoms. Severe symptoms are associated with blood levels above 80 associated with blood levels above 80 mg/dL.mg/dL.

• Initially, there is a respiratory alkalosis, Initially, there is a respiratory alkalosis, because of hyperventilation induced by because of hyperventilation induced by sensitization of the respiratory center sensitization of the respiratory center by salicylates. Kidneys compensate for by salicylates. Kidneys compensate for this alkalsis by increasing the excretion this alkalsis by increasing the excretion of sodium and potassium bicarbonate of sodium and potassium bicarbonate

SALICYLATESSALICYLATES

• MANAGEMENTMANAGEMENT– Treat electrolyte imbalanceTreat electrolyte imbalance– IV hydrationIV hydration– HemodialysisHemodialysis– DiureticsDiuretics