Pediatric Poisonings (1)

8/6/2019 Pediatric Poisonings (1)

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Objectives for Part 1

Epidemiology: the numbers and its impact

Evaluating the pediatric poisoning patient:

Initial triage

Assessment via history and physical exam

Labs and diagnostic evaluation

General principles of management Identification of treatment themes and toxidromes

Prevention and Education


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Definitions A poison exposure is the ingestionofor contact with a substance that canproduce toxic effects. A poisoning is a

poison exposure that resultsinbodilyharm.

Poison exposures canoccurby accidentwithout intent, and these exposures are

defined asunintentional poisonings.Insome situations, poison exposuresare the result ofa conscious, willfuldecision; these cases are defined asintentional poisonings.


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Poisoning agents


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Poisoning agents


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Epidemiology: the numbers 1 million reported poison exposures among

children


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Epidemiology: the numbers Nearly 90% of exposures occurring at home

During pre-adolescence:slight male predominance

This reverses in ages 13-19 with femalesaccounting for 55 percent of poisonings

Children, especially those under age 6, are morelikely to have unintentional poisonings than olderchildren and adults (Litovitz 2001).

Adolescents are also at risk for poisonings, bothintentional and unintentional. About half of allpoisonings among teens are classified as suicideattempts (Litovitz 2001).


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Epidemiology: the numbers Approximately 1/3 of ingestions of toxic

medications occur with medications that areintended for someone other than an immediate

family member Among the fatalities in children < 6 y.o:

Unintentional ingestions

Medication errors

Environmental exposures Bites/stings

Malicious intent/abuse


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Epidemiology: the numbers From 2000-2003, most common agents ingested

by children younger than 6 y.o Cosmetics and personal care products

Cleaning products Analgesics

Foreign bodies

Topical agents

Cold and cough preparations

Plants Pesticides

Vitamins

Antimicrobials

Arts/crafts/office supplies


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Epidemiology: the numbers From 2000-2003, most common agents involved

in fatality among children younger than 6 y.o Analgesic drugs

Fumes, gases, vapors (carbon monoxide) Cough/cold preparations

Insecticides/pesticides

Antidepressant drugs

Cardiovascular drugs

Cosmetics and personal care products Hydrocarbons

Stimulants and illicit drugs


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Epidemiology: the numbers Childhoodlead poisoningis consideredone of

the most preventable environmentaldiseasesofyoung childrenyet approximatelyone

million children have elevatedbloodlevels(CDC 2001).

Carbonmonoxide (CO) resultsinmore fatalunintentional poisoningsin the United States

than anyother agent, with the highest numberoccurringduring the wintermonths (CDC1999).


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Epidemiology: the numbers Risk Factors

Development factors (normal gross motor development,fine motor skills, cognition and social skills)

Developmental delay Supervision

Adolescent development with independence and senseof indestructibility

Depression and suicidal ideation ENVIRONMENTAL FACTORS, SOCIETAL

FACTORS, EDUCATION, ACCESS to CARE


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Epidemiology: the numbers The majority of poisoning cases can be

successfully managed at home with consultation

of a poison control center specialist:

Nearly 76 % of cases reported to US Poison Control

Centers in 2003 managed at non healthcare facility

For children


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Approaching the Poisoned Child


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Overview

Approach begins with initial evaluation andstabilization (ABCDE)!!!!!!!

This is followed by a thorough approach toidentify the agent(s) involved

Often, the suspected toxic agent will determine thepriorities of management

Supportive cares, prevention of poison absorption,antidotes, enhanced elimination may subsequentlybe involved


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Initial Evaluation/Stabilization Airway

Assessment of the younger childs airway

paying close attention to upper airway edema

and to the gag reflex; pay close attention even

in the patient who is talking or crying

C-spine precautions should be taken when thereis any suspected trauma


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Initial Evaluation/Stabilization Breathing

Evaluate the quality of breathing

Evaluate the oxygenation and supplement with O2 ifneeded

Many toxins can be responsible for primary respiratorydepression

Many causative factors for metabolic acidosis will

result in a compensatory respiratory alkalosis Less compensatory reserve in children make them more

susceptible to hypoxia and respiratory failure(especially in inhalation toxic exposure)


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Initial Evaluation/Stabilization Disability (Rapid Neuro Eval)/ Dextrose

Assess pupillary response

Assess mental status (GCS) Physiologic excitation (CNS stim, hyperthermia, tachycardia,

elevated BP, tachypnea)

Depression (CNS depression, hypothermia, hypotension,hypopnea, bradycardia)

Mixed

Administration ofOxygen or Naloxone (infusion)

Assess blood glucose

Administration of dextrose (infusion) and thiamine


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Initial Evaluation/Stabilization Exposure

Full head to toe survey of the undressed child or

adolescent Search for pill containers

Evaluate for hidden injuries

Appropriate thermal control

GI decontamination may have a role at this stage of the

initial stabilization for children who have ingestedpotentially life threatening amounts of toxin

Ocular decontamination

Dermal decontamination


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Diagnosis Focus effort now on agent identification,

assessment of severity, and prediction of

toxicity.

Start with H and P , supplement with labs

and investigations

AMPLE (Allergies, Meds, PMHx, lastmeal, events/environment)


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Diagnosis History can be challenging

Where/how was patient found?

Agents in kitchen may be different from other location

If known, details of exposure: agent, time, volume, immediate

clinical effects

Supervision, recent visitors

Assess for all suspect medications

Herbal products or home remedies

Ill contacts or those with similar symptoms

Recent similar exposures in household contacts Open bottles, pill containers, unusual odors

Household hobbies, industrial exposure

Substance in original container?

Recent illness or medications for the patient?


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Diagnosis History can be challenging

Corroborate the story of the adolescent

Symptoms or behavior after the reported ingestion

Work and school environments? Available bottles/pills?

Interventions in the pre-hospital setting

Illicit drug use in family members or close contacts?

Huffing, snorting,

PMHx, family history, allergies, ROS

Assume the worst case scenario in trying to calculate the ingestion

dose


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Diagnosis Physical Exam:

Vital signs and general appearance

Thorough PE

Close attention to neuro exam Pupils

Reflexes and posture

Mental status

Bowel sounds

Mucous membranes and skin moisture/appearance Characteristic odors

Nosebleeds, needle tracks, huffer rash, blistering


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Specific Toxidrome Patterns


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Common Toxidrome FindingsPhysical

Findings AdrenergicAnti-

cholinergic

Anti-

cholinesteraseOPIOID

Sedative-

hypnotic

RRIncreased No change No change Decreased Decreased

HR Increased Increased Decreased Normal/decreased

Normal/

decreased

TempIncreased Increased No change Normal/

decreased

Normal/

decreased

BP Increased NoChange/increased

No change Normal/

decreased

Normal/

decreased


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Common Toxidrome FindingsPhysical

Findings AdrenergicAnti-

cholinergic

Anti-

cholinestera

se

OPIOIDSedative-

hypnotic

Mentalstatus

Alert/agitated

Depressed/Confused/

hallucinate

Depressed/Confused/

Depressed Depressed

pupils Dilated Dilated Constrict Constrict Normal

Mucusmembrane

Wet Dry Wet Normal Normal

skin Diaphoretic Dry Diaphoretic Normal Normal


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Physical Exam Findings

See handout re: physical findings/odors

Sympathomimetic (meth, amphetamines, cocaine, opiatewithdrawal, PCP) Hyperthermia, tachycardia, hypertension, mydriasis, warm/moist

skin, agitated Cholinergic (organophosphates, betel nut, VX, Soman,

Sarin) SLUDGE (Salivation, Lacrimation, Urinary incontinence,

Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)

Anticholinergic (antihistamines, atropine, phenothiazines,TCA) Hyperthermia, tachycardia, HTN, hot/red/dry skin, mydriasis,

unreactive pupils, unrinary retention, absent bowel sounds

Opioids (codeine, dextromethorphan, heroin)

Miosis, respiratory depresssion, mental status depression


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Diagnostic Considerations

Before proceeding, consider other aspects of thedifferential diagnosis ( CVA, trauma, meningitis, post-ictalstate, behavioral or psych disorders).

Labs to evaluate glucose, acid-base status and electrolytes,

BUN/Cr, carboxyhemoglobin, hepatic enzyme levels,urinalysis (UA preg), serum osmolality, serumacetaminophen levels

EKG

Woods lamp/Radiography

Save samples of blood, urine, gastric contents

General qualitative tox screens of little value (except whenabuse is suspected), but are rapid and could offer clue toantidote; may have role in the difficult dx or critically ill;Quantitive measurements in certain toxic exposures


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Ocular/dermal: pH testing may reveal acid or alkali

Hypoxemic while asymptomatic may suggest methemoglobinemia

Cardiac

EKG shows arrhythmia (TCA) Blood color on filter paper that remains brown after air exposure

suggests methemoglobinemia (possibly from benzocaine-containing products, aniline dyes, nitrites)

Signs of hypocalcemia in ethylene glycol, hydrofluric acid

Urine fluorescence in ethylene glycol Ferric Cl creates purple reaction with salicylates and

phenothiazines in urine

Small opacities on x-ray may show halogenated toxins,heavy metals, lithium, densely packed products,

phenothiazines, enteric-coated meds


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MUDPILES CAT for high anion gap acidosis Methanol or metformin

Uremia

DKA

Paraldehyde or phenformin Iron, INH, Ibuprofen

Lactic acidosis

Ethylene glycol

Salicylates

Cyanide

Alcohol or acids (valproate)

Toluene or Theophylline


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Toxins requiring quantitative levels at a set point: Acetaminophen

Carbon monoxide

Ethanol, ethylene glycol Heavy metals (24 hour urine)

Iron

Methanol

Methemoglobin

Toxins requiring quantitative serial levels Aspirin/salicylates, tegretol, digoxin, phenobarbital, phenytoin,

VPA, theophylline


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Management Considerations

Supportive care is the mainstay of therapy and

recovery and may involve decontamination,

antidotal therapy, enhanced elimination techniques

Systemic support for airway security, ventilation,

hemodynamic stability, and adequate CNS

function

Careful attention to pain and agitation Activating multi-faceted team approach early


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Decontamination Priority after stabilization

Activated Charcoal is preferred method, and may be indicated evenin the patient with equivocal exposure history

Adsorption of toxins to prevent their absorption Dependant on toxin

Heavy metals (lead, arsenic, mercury, iron), inorganic ions, boric acid,corrosives, hydrocarbons, alcohols, and essential oils are generally not welladsorbed by charcoal

Dependant on surface area of the charcoal preparation

Use 1g/kg prepared in slurry with a cathartic and chocolate milk, cola,fruit syrup. Can be repeated every 4-6 hours at the dose, andmultiple doses can help interrupt enterohepatic circulation.

Efficacy decreases over time; gastric lavage that follows or precededand follows may be more effective than charcoal alone.

Contraindications in child with depressed levels of consciousness and

non-secure airway; caustics, hydrocarbons, ileus/perforation risk


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Decontamination Priority after stabilization

If ingestion has occurred within 1 hour,or a highly toxic substance is ingestedthat is usually not well bound to

charcoal gastric lavage may beattempted; but no longer the routine

Controversial in the asymptomaticpatient or who has presented more than

one hour after ingestion Contraindicated if prior vomiting,

hydrocarbon, unprotected airway,caustics, foreign body, at risk forhemorrhage

Risk includes aspiration, trauma to

anatomic structure.


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Whole bowel irrigation may be necessary in theingestion of a sustained release product or toxin

Large volumes of balanced electrolyte solution used to

decontaminate the GI tract Used in fewer than 1 percent, not well studied in

pediatrics

Can be useful in ingestion of enteric coated pills, illicitdrug packets, large ingestions of substances that are

poorly bound by activated charcoal

Contraindicated in bowel obstruction, GI bleed,perforation, unprotected airway


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Ipecac syrup induces vomiting by stimulatingcentral emetic centers.

No longer recommended for routine home use.

Can be used only in the alert, conscious child over 6 mowho has ingested a potentially toxic amount of poison.

(No longer routinely recommended to be used becauseof its questionable effect on outcome).

Contraindicated in children less than 6mo, ingestion ofa non-toxic substance, corrosive ingestion, hydrocarboningestion, altered mental status or airway compromise,GI bleed or coagulopathy,


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Ocular exposure requires copious irrigation with

saline using a Morgan lens, measure pH and

maintain at 7.5-8

Dermal cleansing with water or normal saline and

subsequent identification:

Pay close attention to burns, pain, infection

Water is absolutely contraindicated with reactivemetals; use mineral oil instead

Tar can be removed safely with vaseline


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Inhalation injuries need fresh humidified and

oxygenated air

Treatment with B-agonists, corticosteroids

Removal of offending environment

Hemodialysis and Hemoperfusion

Require anti-coagulation


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Drugs that can kill the toddler in one or twodoses!:

Benzocaine, Ca antagonists, camphor, chloroquine,clonidine, TCA, Lomotil, Visine/Afrin, Lindane,Sulfonylureas, theophylline, phenylpropanolamine,

phenothiazines, selenious acids, hydrocarbonaspiration, oil of wintergreen.among others


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Activate Poison

Control:1-800-876-4766 or

1-800-222-1222www.calpoison.org


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Prevention Strategies/Themes-primary Store potentially toxic substances in higher places or out of

reach/sight

Store safe items within the childs reach; dont take medicine infront of kids

Child-proof latches

Avoid chemicals in the fridge, or insect traps that are accessible

Remove toxic plants; avoid exposure to toxic animals

Keep matches, combustibles out of reach

Dispose of partially consumed alcohol

Carbon monoxide detection system

Read labels on products carefully

Advocate for protective legislation


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Management considerations

Prevention Strategies/Themes-secondary

Identify poison control center and number

Education

Decontamination

Prevention Strategies/Themes-tertiary

EMS

Antidotes


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Documents

Pediatric Poisonings (1)