Unknown Exposures Trivial Ingestions Sometimes Severe

Overview of Pediatric Toxicology

Unknown Exposures Trivial Ingestions

Sometimes Severe Morbidity/Mortality

Michael Wahl MD, FACEP, FACMT Medical Director, Illinois Poison Center Emergency Physician, Northshore University Healthsystems

Pediatric Cases in Toxicology

• Why are Pediatric Ingestions so common? – Pediatric Poisoning: Developmental Milestones

• Epidemiology of Pediatric Poisoning – Poison Center Exposure Data – Toxic vs. Non-toxic Exposures – Trends – Significance

• Management issues • Cases

Poisoning is a matter of dose

Paracelsus (1493-1551) Third Defense

“What is there that is not poison? All things are poison and nothing without poison. Solely, the dose determines that a thing is not a poison”

Pediatric Development

6-9 months: creep, crawl, and pick up objects

Pediatric Development

9-12 months: pick up a pellet and put it in a hand

Pediatric Development

15 months: walking; pick up a pellet and put it in a bottle

Pediatric Development

18 months: able to consciously dump pellet from bottle (e.g. Tylenol, aspirin,

vitamins, adult prescription medications)

California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years

of Age • 0-6 months ABUSE • Overall: FALLS

Pediatric Poisoning • #2 leading reason for injury-related

hospitalization in children 0 to 3 years of age behind falls

The #1 reason for injury-related hospitalization and death between 18 and 35 months is

poisoning

Pediatric Susceptibility to Poisoning

• Small size: less ingested to get to a toxic mg/kg ratio

• Large surface to body ratio for relative increased in dermal absorption (e.g. oil of wintergreen products, alcohols, etc.)

• Thinner skin for increased dermal absorption • Faster minute ventilation for increased

inhalation absorption

Assessment of Pediatric Ingestion

• History – Who – What – Where – When – Why – How – The scene?

Difficulty with Pediatric History: Did they actually ingest the substance?

Toxic Alcohol Evaluation of Pediatric Patients is often Incomplete DesLauriers C, Mazor S, Metz J, Mycyk M

2 year retrospective review 33 pediatric cases of Toxic Alcohol Ingestion 21 with levels drawn 5/21 with measurable levels (24% of cases)

Pediatric exposures 5 years and under reported to AAPCC (National Data)

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PediatricExposures

Pediatric Deaths Reported to AAPCC (National Data)

~ 4/100,000 pediatric exposures in PCC database result in death.

Adult Fatalities >500 times more prevalent due to intentional nature of exposures

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Selection bias in numbers as poison centers get calls on the living, not those that are deceased on scene

Unpublished Data from National Benchmarking committee (22 centers)

95% of all pediatric calls to a poison center are managed at home without referral to a poison center.

86% of pediatric exposures that present to an ED without

calling a poison center first are discharged from the ED 66% of pediatric exposures that are referred to ED are

discharged from the ED

Analgesics

• Double Dose • Unintentional

Overdose

Tylenol >200 mg/kg ASA >150 mg/kg OPIATES

AAPCC Data Most Common Exposures (2013)

Cosmetics and personal care products:

Cleaning Substances

Foreign bodies

Most Common Pediatric Exposures

– Topical Preparations – Cough and cold preparations

• Bropheneramine >2 mg/kg • Chlorpheneramine >1.4 mg/kg • Phenylephrine >4 mg/kg • Pseudoephedrine >16 mg/kg • Dextromethorphan >10 mg/kg

– Hydrocarbons – Hormones/hormone antagonist

Topical Preparations

Pediatric Exposures • AAPCC Data Most Common Exposures (6-10)

– Vitamin – Antihistamines – Pesticides and Rodenticides – Plants – GI Preparations (e.g. simethicone)

Pediatric Exposures

• Determination of non-toxic exposures – Call the Poison Center is easiest

• It is what poison center staff person does over 30 times a day

– My Child Ate Web Content

• www.illinoispoisoncenter.org • 14,000 visits to clinical content in June, 2014

Management of Pediatric Exposures

• Decontamination • Enhanced elimination • Antidotal Therapy • Supportive Care

Decontamination

• Elimination from the gut and/or decreasing absorption – Emetic Agents (Syrup of Ipecac) – Cathartics (sorbitol, magnesium citrate) – Gastric Lavage – Whole Bowel Irrigation – Charcoal

Decontamination

All decontamination measures were started before the advent of evidence-based medicine.

No improvement in outcomes has been shown for

any of the modalities. Re-examination of practices are slowly removing

them from practice.

Ipecac

Ipecac

Ipecac

Family Guy Video:

Charcoal

• Effective at binding a variety of toxins, most beneficial if given within 60 minutes

• Dose 1 gm/kg, up to 100 gm in a single dose

Charcoal Bond, Annals of EM, 2002

Charcoal

Charcoal

Charcoal

Charcoal • Not proven to change outcome • Every year 5 to 10 deaths in poison center data from

charcoal aspiration – Always with drugs that cause decreased consciousness,

vomiting or seizures

Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit

– Risk Benefit Ratio?

Cathartics

• Use initially promoted because of clinical opinion • Most commonly used in ED is sorbitol or

magnesium citrate • Intended to decrease absorption by increasing

expulsion from the GI tract • Dosing

– Sorbitol 70 % 2 cc/kg per kg in adults – Sorbitol 35 % 4 cc/kg per kg in children – Mag citrate 4 cc/kg in children/adults

Cathartics

• Indications -- No proven benefit. By convention it was usually given with the first dose, not used for multiple dose therapy

• No longer recommending it routinely due to guideline recommendations

Gastric Lavage

Gastric Lavage Bond, Annals of EM, 2002

Gastric Lavage

• Indications -- Ingestion of a potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure

• contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding

Gastric Lavage

• Adults 36-40 french tube (children 24-28 French)

• 20 degrees trendelenburg, left lateral position • 200-300 cc aliquots of water or saline (10

ml/kg chidren, saline)

Whole Bowel Irrigation • Co-Lav • Colovage • Colyte • Colyte-flavored • Colyte with Flavor Packs • Go-Evac • GoLYTELY • NuLYTELY • NuLYTELY, Cherry Flavor

Whole Bowel Irrigation

• No proven clinical efficacy in changing outcomes • Potential to reduce drug absorption by rapidly

cleansing the GI tract • dosing

– 9 mo - 6 yo 500 ml/hr – 6 yr - 12 yo 1000 ml/hr – Adolescents/adults 1500-2000 ml/hr

Whole Bowel Irrigation

= + =

Whole Bowel Irrigation

• Indications – sustained release or enteric coated drugs – Illicit drug packages – Drugs or compounds not well absorbed by

Charcoal (e.g. iron, lead, lithium)

Whole Bowel Irrigation • 18% of IPC cases documented at

recommended rate of administration and an endpoint of clear rectal effluent – Difficult to accomplish – Time consuming – Can be messy – Inexperience and is uncomfortable for staff

General Approach

• ENHANCED ELIMINATION – Hemodialysis/Hemoperfusion – MDAC – Urinary Alkalinization

Enhanced Elimination Hemodialysis

• Water soluble • Small molecular weight • Not highly protein bound • Small Volume of distribution (<1 L/kg)

Review of Select Pediatric Cases Reported to AAPCC

• Outcome is going to be bad • Discussion of risk of exposure, treatment and

outcomes

Case #1 (Christmas Tox)

• 18 month old child thought to have a respiratory infection (cough and vomiting) by family comes to ED for evaluaton.

• CXR shows FB in esophagus and stomach

Button Battery Case #1

• Time delay in transfer to appropriate facility • Both batteries removed endoscopically • Admitted for 4 days. Barium swallow with undefined

esophageal deviation • Discharged with fever on abx and medication for acid

reflux • 4 days later found cyanotic and in shock • Death Certificate with aorto-esophageal ulcer/fistula

Button Battery # 2 • 4 yo female found pulseless and apneic with

blood around mouth and nares • Initially thought to be trauma • CXR with button battery in esophagus • Taken to operating room • Unable to resuscitate • Intra-operative finding?

Button Battery Case #3 • 4 yo cough for over a week. May have been

treated with acetaminophen. • CXR showed a 20 mm disc in esophagus • Transferred to tertiary care center, removed

endoscopically • Admitted to ICU • Developed massive GI bleed, liver failure,

renal failure • Child arrested during exploratory laparoscopy

Button Batteries • Fatal in rare cases • Over 5,500 ED visits in 2009 • Larger, newer batteries most often implicated • Burns can occur in 2 to 2.5 hours

Three hours of Hotdog vs. Button Battery

Hydrocarbons (Garage and Kitchen Sink Tox)

• 15 month old female found vomiting, cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child

• 2 yo child ingested unknown amount of cigarette lighter fluid (Zippo)

• 18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits

Hydrocarbons

• 2 yo female with Trisomy-21, swallowing problem, fed through g-tube entire life, found mineral oil bottle and thought to have ingested 5 – 10 ml.

• 15 mo male ingested and aspirated tiki torch oil at home

Hydrocarbons

• 33,000 exposures reported to AAPCC (2013) • 10,000 involved children • Low rate of admission and death

Hydrocarbons

• Important History: – When – How much (often unreliable) – Coughing – Vomiting (increases aspiration potential) – Behavior changes (lethargy, drowsiness)

Hydrocarbons

• Important signs and diagnostic exam results – Mental status – Respiratory status

• Cough • Tachypnea • Grunting/Flaring/Retractions • Fever • Pulse ox • CXR

Hydrocarbons

• 15 mo female: Taken to community hospital. Arrested and expired before helicopter transport

• 2 yo male with cigarette lighter fluid: Died in ED

• 18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center

Hydrocarbons

• 2 yo female with Down’s syndrome, rocky, long complicated course in ICU complicated by cardiac arrest, hypothermia, abdominal compartment syndrome (day 44) and expired on hospital day 45

• 15 mo male, intubated in ER, transferred to tertiary care center for ECMO, aggressive treatment for 4 days – 4th day declared brain dead

Garage Tox • Grandmother gave child an unmarked bottle

she thought was water. It was actually tire/wheel cleaner (HF)

• Child complained of pain and brought to ER drooling

• Child arrested 3 hours after presentation. Resuscitated with calcium and magnesium

• Transferred to tertiary care center, terminal arrest 7 hours after ingestion

Rattle Tox • Parents gave a bottle of Aspirin 325 mg to an

11 m/o child to play with. Unknown amount ingested, 7 tablets unaccounted for.

• Thoughts? • How to approach

Rattle Tox

• 6 hour salicylate level 107 mg/dl. Peaked at 123 mg/dl

• Labs drawn, given charcoal, started on sodium bicarbonate drip.

• In PICU became tachycardic to 220, tachypneic (50) and hyperthermic

• Patient intubated and set up for transfer to tertiary care center for dialysis and died.

Teething Tox

• 13 mo old twin A cared for by 16 yo sibling while parents went to PICU to see ill twin B.

• Brother called 911 for Twin A who developed sz (and subsequent cardiac arrest)

• Taken to ED, intubated and then patient became bradycardic and then pulseless

• 90 minute PALS care unable to resuscitate patient

Teething Tox

• Police went home and found 2% viscous lidocaine on the dining room table

• Surviving twin B with elevated lidocaine levels on blood test

• Post mortem on twin A with elevated lidocaine levels

16 yo brother had been putting lidocaine in bottles to relieve teething pain

Calcium Channel Blockers (Medicine Cabinet Or Purse Tox Or

Visiting Grandparents Tox)

• 19 month old male found with mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills.

Calcium Channel Blockers • AAPCC data with 22,082 pediatric exposures to

“cardiac medications” – No breakdown of Ca Channel blockers

• Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%)

• Extropolating to national data: over 2100 pediatric calcium channel blocker exposures – Are they all true exposures?

Calcium Channel Blockers

Calcium Channel Blockers

• Hyperglycemia • Calcium Channel blockers in the pancreatic B

islet cells • Decreased release of insulin • Can lead to HYPERGLYCEMIA

Calcium Channel blockers

• 2 yo male with ingestion of up to 450 mg sustained release nifedipine

• Unremarkable vitals initially. Glucose 253 • Upon arrival to tertiary care center, resting

tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours.

• Arrested the day after admission to tertiary care center, unable to resuscitate

Toy Tox

• 19 mo old male with complaints for vomiting and diarrhea. Discharged home

• Found unresponsive the next morning, 911 called and CPR started

• EMS and police found insecticide in room and toys

Toy Tox

• Child expired in ER • Skeletal survey done in ER to look for signs of

abuse showed portal venous gas, pneumatosis and 7 spherical bodes in the left abdomen

• Autopsy: ischemic bowel with pressure necrosis from magnets

Laundry Detergent Unit Doses (Pods)

Laundry Tox

• 7 mo male bit a laundry pod. Crying, cough and then became somnolent

• Vomiting en route to ED (vomiting and somnolence)

• Had seizure in ED • Intubated • Arrested 3 hours post exposure • Significant Right sided pulmonary congestion

and cerebral edema

Pediatrics December 2014 Evaluated poison center data for 2012 – 2013 17,000 exposures • Vomiting: 56% • Lethargy: 8% • Cough/choke: 15% • Intubation (0.6%) 1:170

Opiate Tox

• 2 yo female found with bottle of atropine/diphenoxylate (lomotil). 16 tablets removed from mouth, unknown how many ingested

• Went to ER, normal after 4 hours observation and discharged

Thoughts?

Opiate Tox • Found next morning unresponsive with

frothing at mouth and yellow secretions. • Called pediatrician and then brought to ER

when child would not awaken after 2 hours of trying to get her awake

Complicated course with aspiration pneumonia, cerebral infarction and anoxic injury, eventual herniation and death

Methadone Tox

• 9 yo had trouble sleeping. Family usually gave him benadryl, but ran out. Gave some of mom’s methadone instead.

• 2 yo drank juice then said her tongue felt funny. Went to take a nap and found cold and limp. At ER intubated and transferred to Tertiary care hospital. Drug screen came back + for methadone.

Opiate Tox

• 13 mo male given bottle of suboxone (buprenorphine and naloxone) to play with as a rattle

• Parents noted that the bottle was open and pill fragments in mouth.

• Fed child and put him to bed • Next morning child found cold and

unresponsive (Declared upon arrival to ED)

Pediatric Toxicology Summary

• Pediatric Poisoning Exposure is a common occurrence (1,000,000 + calls to PCC annually)

• Determining the dose is important, but frequently can be unreliable – Exposure does not necessarily mean poisoning – Calling poison center can help with triage decisions in

unintentional pediatric exposures

• Death is rare as a percentage of total exposed

Questions?