Do you need a cuppa?

Dr. Anushma Sharma

ST5 Paediatrics

Department of Community Paediatrics Salford

AIM

1. Present an interesting case

2. Discuss the outcome

3. Discuss the causes of the presenting symptoms

Admission 1

1 year old

Vomiting, loose stools, unwell

Tachycardiac, irrtable, breathless

Metabolic acidosis – pH 7.13, pCO2 2.2, BE -23 , Lac 27, Glu 5.3

Improved quickly within 12 hours with ventilatory support and fluids + sodium bicarbonate correction

Metabolic disorder suspected

Investigations

ammonia

acyl carnitine

plasma amino acids

free fatty acids

urine organic and amino acids

LFT and renal funtions

salicylate levels

Admission 2

13 months

Had been well

Found unresponsive on bedroom floor at 0800

No hypoglycaemia

Severe metabolic acidosis pH 6.91, pCO2 2.96, Bicarb 4.3, BE -27.9, lactate>30

Sent to PICU and recovered in 12 hours

Skin biopsy and toxicology investigations

Previously.....

Parents 18 years old, both unemployed, separated

H/o domestic violence

Good pregnancy

NVD

No significant neonatal diagnoses

Satisfactory growth and development

Previously............

7 weeks old

Unwitnessed fall from sofa while being watched by mother's friend

Attended A+E promptly

Parietal skull fracture

Discharged back to mother after child protection investigations

11th admission

Recent Burn????

Toxicology

Urine positive for Glycolate

Antifreeze= Ethylene Glycol

Colourless

Odourless

Very sweet

Present in Radiator fluid, Deicer, Wind screen wash, Window cleaning fluid

Fake vodka health warning in UK

ingestion.

Counterfeit vodka seized by council trading standard teams. Photograph: Nottinghamshire County Council/PA

The Guardian, Saturday 31 December 2011

Ethylene Glycol Toxicity

Toxic dose requiring medical trematment is 0.1ml/kg body weight or 4 ml for 20 Kg child

Lethal dose in humans is 1.4ml/kg or 56 ml for a 20 kg child

Ethylene glycol does not evaporate so inhalational exposure is unlikelyEthylene glycol is not absorbed through skin so dermal exposure is also uncommon

OutcomeOutcome

Forensic samples obtained

Police investigations started and mother was taken in custody

BC and sister 10 months old in foster care

Metabolism

Ethyl alcoholFomipezole

NPIS annual Report 2010-2011

➲ Prospective audit➲ Toxic alcohol and glycol cases reported through telephone

enquiries to the NPIS in 2010➲ Aim: 1. To provide information on the frequency, current

management and outcomes of systemic toxic alcohol poisoning.2. To provide information on which to base the planning of clinical services for this type of poisoning, including appropriate availability of assays and antidotes.

Results

➲ 488 individual exposures➲ 250 in non hospital sourced

➲ 89 (18%) cases less than 5 years old➲ 238 in hospital sources➲ 182 potentially systemic exposures

➲ 99 (20%) reqiured treartment with antidotes➲ 33 haemodialysis, heamofiltration➲ At least 2 severe cases each week nationally

➲ Main difficulty in management is unavailability of lab assayand inadequate stock of antidote

Summary

➲ Glycol and Toxic alcohol toxicity though less common in UK is a significant differntial diagnosis to consider especially in cases of disproportionate metabolic acidosis

➲ It is important to plan and consider how we can treat such a case in our unit, especially when most of us donot stock any of the antidotes

Questions?