Kids Get Into theDarndest Things

• Lynn Browne-Wagner, RN, MSN• Banner University Poison and Drug Information Center

• 602.253.3334

GENERAL TOXICOLOGYGENERAL TOXICOLOGY

NOT ALL “POISONED” PATIENTS ARE POISONED

TRUSTING HISTORY

TIME BOMBS AND TRAUMA

NOT USING ENOUGH FLUIDS, NARCAN, BENZOS

How Times Have Changed

• More patients are overdosing• Greater access to medications• Prescription and OTC meds vs street drugs• Most overdoses involve multiple meds• Newer medications = less info• Beware long peak times

GENERAL INFORMATION• DO NOT WASTE TIME LOOKING FOR

ANTIDOTES

• DO NOT LAVAGE

• Activated Charcoal MAY BE USED FOR MOST PILL EXPOSURES WITHIN 1 HOUR OF INGESTION

• (not commonly recommended anymore)– BUT IF YOU DO = DOSE IS 1-2 gm/kg

• DO NOT INDUCE VOMITING

• TREATING SX/SX IS PRIORITY

QUESTIONS• WHO – HIPPA??• WHAT – EXACT PRODUCT• WHEN – PINPOINT TIME FOR T-1/2• WHERE - LOCATION• HOW – MECHANISM OF EXPOSURE

CHILDREN• SIBLINGS• PETS• AGE• ALONE TIME• EXPECTED LEVEL OF FUNCTION• PROTECTIVE CAPS• ABUSE/NEGLECT

SUICIDE, MISUSE, ABUSE• AGE• REASON• CHANGE OF PACKAGING• INTENT OF EXPOSURE• NUMBER OF PRODUCTS• We do not completely trust

the history – do aspirin and acetaminophen levels along with CUDS

ACIDS• lemon juice (citric acid 2-8%)• toilet bowl cleaners• drain cleaners• metal and antirust compounds• automobile battery fluid• pool sanitizers• chromic anhydride (photography, cement)• Hydrochloric acid (plumbing, metal refining)• nitric acid (engravers)• phosphoric acid (disinfectant, rust proofing)• acetic acid (hat makers, printing, dyeing)• formic acid (airplane glue, tanning)

ACID SYMPTOMS/SIGNS

• mild to moderate esophageal burns• most severe burns in the stomach/pyloric

region• perforations rare• vomiting is often spontaneous

thick white or blood stained foamy mucusthreads of tissue in mouthcoffee ground appearance

ACIDS

ACID MANAGEMENT

Activated charcoal is not recommended and of nobenefit

BLS MANAGEMENT FIRST WITH AIRWAY DO NOT INDUCE VOMITING

Can swish water in the mouth, but not swallow

If going to try dilution then SMALL amounts of water

DO NOT TRY TO NEUTRALIZE

ALKALINESWEAK IRRITANTS

– Borax– Sodium hydroxide 0.5 - 1%

STRONG IRRITANTS– Portland cement– potassium nitrate

Corrosive– Ammonia 5%

– Electric dishwasher soap– Low phosphate detergents– Oven cleaner pads/sprays

– Sodium hydroxide 1%

ALKALINE SYMPTOMS/SIGNS

• burn severity dependent on type/duration/concentration• may have esophageal burns without oral burns• stridor, vomiting, drooling, 50-67% esophageal burns• may have burns to lips, tongue, oral mucosa• may involve epiglottis, larynx, trachea• esophageal stricture• substernal or abdominal pain• gastric ulcers, necrosis, perforations

ALKALINE MANAGEMENT

Activated charcoal is not recommended

BLS MANAGEMENT FIRST WITH AIRWAY Do not give anything by mouth

If going to try dilution then SMALL amounts of water IF THE AIRWAY IS COMPROMISED - NO DILUTION DO NOT TRY TO NEUTRALIZE

DO NOT LAVAGE

Petroleum Distillates

Concerning S/S leading to chemical/aspiration pneumonitis

Cough that persists longer than 10-20 minsVomiting more than onceDyspnea

MANAGEMENT: Steaming in bathroom,Humidified O2, SVNIN ED – CXR, ABGs, Obs 6 hours

Visine, Murine, Afrin

• Eye drops and Nasal decongestants

• Imidazoline/Tetrahydrozaline

• Oxymetazoline/Naphazoline

• Vasoconstrictors - peripheral

Imidazoline Decongestants

• Stimulate Alpha 2 receptors:– inhibits release of NE

• Causes CNS depression• Effects similar to Clonidine – attach to

narcotic receptors in the brain

• More than 7.5 ml of 0.05% solution may be toxic in children

IMIDAZOLINESigns/Symptoms

• Drowsiness• Coma• Hypotension• Bradycardia• Seizures

IMIDAZOLINETreatment

• ABC’s AND EKG

• Benzodiazepines for seizures

• Atropine for symptomatic bradycardia

• Hypotension: Fluids, Dopamine

• Naloxone?

Methyl Salicylate• Found in pain relief products like

Ben Gay and Icy Hot

• Concentrated form of Aspirin

• Rapidly absorbed

Methyl Salicylate:How It Works

• Stimulates CNS

• Interferes with Kreb’s cycle, causing metabolic acidosis

• Causes fluid, electrolyte and acid base disturbances

Methyl SalicylateRange of Toxicity• 30% methyl salicylate product

contains 420mg/ml salicylate

• Salicylate toxicity: 150mg/kg

• 14Kg child needs to ingest 1 tsp for toxicity

Methyl SalicylateSigns/Symptoms

• Tachypnea – KUSSMAUL RESP

• Nausea/Vomiting• Lethargy• Tinnitus• Seizures• Acidosis• Pulmonary Edema

Methyl SalicylateTreatment

• ABC’s

• Fluids

• Bicarb bolus, possible drip

• Seizure precautions

Coffee, Water, Glycerin, Caffeine, Taurine, Guarana, B-Vitamins, Sodium Benzoate (to assure flavor), and

Natural and Artificial Flavors

1 can = 4 to 5 cups of coffee Pouch = ¼ cup coffee

E-Cigarettes (still smokin’)

• E cigarette nicotine cartridges have been shown to contain varying amounts of nicotine (despite what is listed; again, not FDA regulated).

E CIGARETTES• LOWEST LETHAL DOSE

1 mg/kg (though it may be higher than this).

• E cigarettes contain (refillable) ‘cartridges’ that usually contain between 1 - 3 mg of liquid nicotine.

• Cartridge fluid is usually between 2.4% - 10% nicotine (24 mg/mL - 100mg/mL).

• One e-cigarette contains ~ 72mg (7.2 mg/kg in a 10kg child).

NICOTINE LEVELSFor regular (old fashioned) cigarettes:

Nicotine delivery devices:

• Cigarettes contain ~ 20 mg (varying doses)

• Cigarette butt ~ 5 mg

• Cigars ~ 30 mg

• Gum: 2 or 4 mg/piece• Lozenge: 2 mg• Patch: 7, 14 and 21

mg patches• Inhaler: 10mg• Nasal solution: 10

mg/mL

Nicotine

• Very toxic in children

• Rapid absorption

• Rapid onset of s/sx– 15-30 minutes with cigarettes– 15 minutes with gum or liquid

Nicotine Signs/symptoms

• Nausea/Vomiting

• Agitation, restlessness

• Tachycardia, or Bradycardia

• Tachypnea or Bradypnea

• Hypotension, Tremors, Seizures

Nicotine Treatment

• Activated charcoal – in first hour and not if vomiting

• ABC’s• Benzodiazepines for seizures• Atropine for symptomatic bradycardia

Orajel, Anbesol, baby Num-Zit

• Contains Benzocaine

• Concentrations from 7.5-20%

• Rapid absorption

• Rapid onset of SX/SX

BENZOCAINE• Methemoglobinemia

• A form of hemoglobin in which ferrous iron had been oxidized to ferric iron

• Methemoglobin cannot transport O2! (HGB carries H2O)

BENZOCAINE

• SIGNS AND SYMPTOMS– Cyanosis– Chocolate brown blood– Difficulty breathing…later sign– Lethargy/Coma– Seizures

BENZOCAINE

• Range of Toxicity– As little as 100mg may be toxic in infants

– This is ¼ teaspoon, 1.25ml of 7.5% solution• Older children: toxicity at 22-40mg/kg• 4ml of 7.5% or 1.5ml of 20%

BENZOCAINE

• High flow 02

• Aspiration precautions

• Seizure precautions

• Treat with Methylene Blue

Calcium Channel Blockers• Exposure to 1 tablet requires ED

evaluation and probable admission

• Sustained release product requires 24-48 hour monitor bed admit

• Non sustained release requires 8-12 hr ED observe

Oral Hypoglycemics• Sulfonylureas-lower blood sugar in NIDDM• Causes protracted hypoglycemia in diabetics and non-

diabetics • Onset of sx/sx may be delayed 18-24 hrs and persist >24

hrs • TYPES:

– glipizide – Glucotrol– glyburide – Diabeta, Micronase

– tolbutamide – Orinase– chlorpropamide – Diabinase

Oral HypoglycemicsED observe minimum 18 hrs with glucose checks q 2 hrs while awake and q 1 while asleep

• IF NO hypoglycemia and no dextrose given, can go home

• IF hypoglycemia or dextrose given, must be monitored until euglycemic for 24 hrs w/o any parenteral dextrose – NEED to be ADMITTED

• Any amount in a child requires admission

ACETAMINOPHEN• Peaks in 4 hours• Draw level at 4 hours• Sx/Sx – Abdominal pain, Nausea,

Vomiting– LIVER FAILURE – FREQUENT LFT’S

and COAGS MONITORED

Toxic level: 200 mg/kg

APAP Toxicity Management

• Antidote: Mucomyst– IV ACETADOTE:

• 150 mg/kg over 60 minutes• 12.5 mg/kg/hr for 4 hrs• 6.25 mg/kg/hr for 16 hrs• Repeat PT and AST 12 hrs into the 16 hr bag• If levels are elevated, continue Mucomyst until they are reducing

– DO NOT NEED TO RECHECK APAP LEVELS

ACETYLSALICYLIC ACID - ASA

• Peaks in 6 hours• Draw level on arrival and again in 4-6 hours to

see if level rising or falling• If toxic – level needs to be below

– 20 x 2- before discharge• Treat the Sx/Sx = Acidosis, Renal

– If alkalinizing, urine pH should be 7.5-8• Toxic:

» moderate 150-300 mg/kg» Severe 300+ mg/kg

FOOD POISONING

• Take a bite.• I can’t tell if it is

food poisoning or if he is just choking to death

• Various kinds:– Giardia – contaminated water– Listeria - milk– Shigella/E.coli – fecal oral route– Salmonella - eggs– Scombroid – spoiled fish like tuna, mahi-mahi,

sardines– Botulism – improper canning products

• Self limiting about 36 hours• Sx/Sx involve vomiting and diarrhea, chills• Manage for dehydration initially if unknown

cause. If worsens, needs to be seen in ED

COUGH AND COLD MEDICINE

Therapeutic error• Double and triple dosing

• LETHARGY

• ADVERSE RXNAgitation, N/V, hallucinations,

seizures

•ABUSE

2012 Drug Use age 12 and over

COUGH AND COLD MEDICINE

COUGH AND COLD• Coricidin – take 5-10 tabs, dissolve in

liquid, work up to 90 tabs/day• TRIPLE C, SKITTLES, REDS, TRIPLETS• ROBOFIRE, ROBOTRIP, AGENT LEMON• Dextromethorphan – either drink 1-3

bottles straight OR baggy, butane, ammonia, lemon flavoring, water = skim oil off, taking DEX with it, then smoke it

OTC/HEALTH FOODSYMPATHOMIMETICS

• Energy Pills, AND Drinks• Decongestants:

– Pseudoephedrine– Phenylephrine

• Diet aids with:– Caffeine

• Guarana• Yerbe Mate• Green Tea

– Ma Huang - herb– Ephedra - plant

Conjunctivitis, Abrasions, Blindness

WAX – BUTANE HONEY OIL• These concentrates can be abused using e-

cigarettes or consumed in edibles• Have significantly higher THC levels than leaf

marijuana. • In 2013, the THC content of leaf marijuana

averaged 12.55 percent• THC content of marijuana concentrates

averaged 52 percent, with some samples testing over 80 percent.

• Highly flammable

CAMPHOR • Easily found in inhalers or

vaporub – breathe it in by putting inhalers up their nose or smearing it inside a surgical mask.

• Initial effect is CNS stimulation and then causes CNS depression, so they crash for 30 mins to 4 hours (rest time) and then are up to continue the party

SALVIA DIVINORUM• Psychotropic plant

from Mexico

• Sold in liquid, powder, capsule form

• NOT Illegal in AZ

NUTMEG(Myristica fragrans)

• “narcotic properties”• “hallucinations”• The amount to get

“high” on is actually the toxic amount for ingestion

DATURA

ANTICHOLINERGIC

• Dry as a bone• Red as a beet• Hot as a pistol• Mad as a hatter• Loony as a toon

• Hypertension• Tachycardia• Seizures• Hallucinations

OPIATES• Next 4 slides provide information

retrieved from lecture presentation

• 2016, Wang, S. A. Pediatric Exposures to Prescription Opioid Analgesics: Trends Over Time

Poison Center Opioid Exposures in Children < 6 years

January 2006 – December 2014Total (n=55,241), %

DemographicsMedian Age (IQR) 2 (1.5,2.5)Male (%) 29,134(52.7)Unknown sex 195(0.4)Exposure Site (%)Own home 36,438(66.0)Other home 2,218(4.0)Other 617(1.1)Unknown location 15,968(28.9)

Poison Center Opioid Exposures in Children < 6 years

January 2006 – December 2014Total (n=55,241), %

Route of ExposureIngest 14,479(26.2)Inhale 32(0.1)Injection 9(0)Dermal 80(0.1)Transdermal 814(1.5)Other 2,460(4.5)Unknown 37,367(67.6)Medical OutcomeNo effect 26,012(47.1)Minor effect 8,037(14.5)Moderate effect 2,902(5.3)Major effect 504(0.9)Death 23(<0.1)Unknown 42(0.1)Unable to follow 17,721(32.1)

Poison Center Opioid Exposures in Children < 6 years

January 2006 – December 2014

Opioid Total (n=55,241), %

Hydrocodone 22,082 (40%)

Oxycodone 11,413 (21%)

Tramadol 9,655 (17%)

Buprenorphine 6,446 (12%)

Morphine 2,392 (4%)

Methadone 2,050 (4%)

Fentanyl 375 (<1%)

Oxymorphone 222 (<1%)

Office1

Slide 76

Office1 Does this look similar to abused and/or prescribed opioids in the adult population?Microsoft Office User, 4/18/2016

RADARS Poison Center Deaths in Children < 6 Years

Opioid Number of Deaths, n(%)

Methadone 7 (30.4)

Hydrocodone 4 (17.4)

Oxycodone 3 (13)

Buprenorphine 3 (13)

Tramadol 2 (8.7)

Fentanyl 1 (4.3)

CommonNon-Toxic Pediatric Exposures

• Disc Battery

• Need to go for x-ray to be sure out of esophagus

• If in esophagus obs and if does not move then needs GI consult

• If in stomach or lower, PCC f/u at home for elimination of item

• Magnets

• Send to ED for xray

• If more than 1 or they are touching they have to be surgically removed

• If only 1 then can track through bowel by checking feces each time for up to 7 days

Bleach• Ingestion causes throat irritation

and GI upset• Aspiration – go in for Resp Mgmt.• No Aspiration then

– They can stay home and PCC f/u– Cool liquids like popsicles/ice cubes

Rat Poison (stay home)• Dcon Mouse Prufe II• Contains anticoagulant Brodifacoum• Comes in plastic container with

pellets.• Child must consume at least half the

container of pellets for toxicity.

Glow Necklace

• Kids bite into them or get fluid in eyes• Contains Dibutyl Phthalate• Skin and eye irritant• Irritation usually resolved with flushing• Plastic container FB concern

Antacids

• Tums, Rolaids• Calcium• Acute ingestion is non-toxic• Mild GI upset

Toothpaste

• Fluoride• Large ingestion required for toxicity

– About 2 oz at once– HF acid (GI bleed) or ASYSTOLE

• Usually mild GI upset• Calcium is antidote

Chewable Vitamins• Iron content usually 15-18mg per tablet• 60mg/kg of iron from chewable product

is toxic • 14Kg child would have to ingest 46-56

tablets• Usually mild GI upset• _______________________________________________________________________________________________________

• PRENATAL VITS – 3 TO 4 – PROB REQUIRE HOSPITAL CARE AND ADMIT

Ex-Lax• Look like chocolate• New formulations contain Senna• Abdominal cramps• Diarrhea• Dehydration risk

Dog Poop, Cat Poop, Their Own Poop

• Not toxic, just gross!• Fluids• Observe for S/SX bacterial food

poisoning

Take Home Points• Patient/parent histories often

unreliable• Manage Airway• Provide fluids (20/kg) prn• Call PCC for recommendations