Pediatric Poisoning

Pediatric Poisonings

2011

objectives

what’s poisonig Types of poisoning Emergency management GI decontamination other modes of treatment

Definition of Poisoning:Exposure to a chemical or other agent that adversely affects functioning of an organism.
usually it involves children 1-5 yrs. 56% of pediatric exposures are from products around the house including medicines, cleaning agents, pesticides, plants and cosmetics.
Epidemiology:

Types of Poisoning

Accidental poisoning)without intent): Mainly young children aged 1-3 years Mainly drugs or household product May be an indicator of maternal depression


Intentional Overdose Mainly teenagers Usually ingestion of drugs Iatrogenic Usually result of calculation error Most frequently fatal drug: digoxin

Child abuse )non-accidental) May present as an unusual illness rather than poisoning. Chronic poisoning Mainly environmantal hazards Commonest: Lead poisoning



Poisoning in children may be: accidental - the vast majority deliberate self-poisoning (suicide)in older children non-accidental as a form of child abuse iatrogenic.

ALL THINGS TEND TO END UP IN THE MOUTHS OF YOUNG CHILDREN!!

EMERGENCY MANAGEMENT
Identification of the poisonDetermine the product ingested, the amount, the time of ingestion, the childs’ present condition. In determining therapy, assume the largest estimated amount.3. Physical Examination.

A. Asymptomatic child 1) Quickly assess the potential danger. If the toxin is known, the potential danger can be assessed . Risk assessment will generally take into account the following: 1. the dose ingested (mg/kg) 2. the time interval since ingestion 3. the presence of any clinical signs


2) Observe the Child/Provide Parent Education/Perform Risk Assessment: Observe the asymptomatic child (usually 4-6 hours). b. Consider evaluation of the home situation. c. Intentional ingestions in adolescents, especially girls, raises the possibility of unwanted pregnancy, or sexual or physical abuse. d. All parents require instructions about poison prevention techniques.

B.Symtomatic child

Management is based on four general principles: a. Supportive care b. Preventing or minimizing absorption c. Enhancement of excretion d. Administration of antagonist

Attention to the ABCs is always the first priority. Treat the patient, not the poison!!!

Ongoing assessment and serial vital signs are particularly important.

A: Establish a patent airway B: Provide supplemental oxygen and assist ventilations, if needed. C: Monitor the circulation : 1. Establish a large-bore IV line and draw blood (CBC with platelets, basic metabolic profile, serum CO2, toxicology screen, and specific drug levels if indicated).

2.Bood pressure

Monitor for variations in blood pressure. Hypotension results from venodilation, arteriole dilation, depressed cardiac contractility, or a combination of causes. Regardless of the etiology, most hypotensive children respond to volume therapy of 10-20 cc/kg boluses of Ringer's Lactate or Normal Saline and rarely need pharmacologic treatment.


b.Hypertension should be treated in order to prevent intracranial hemorrhage or hypertensive encephalopathy. Treat hypertension with sodium nitroprusside with or without esmolol or propranolol.

3.Monitoring

Place the child on a cardiorespiratory monitor to assess for arrhythmias. Arrhythmias are often caused by hypoxia or electrolyte imbalances. 1) For ventricular tachycardias lidocaine 2) For sympathomimetic-induced tachycardias esmolol 3) For wide complex tachycardias NaHCO3

b.Assess the child's mental status. Use the Glasgow coma scale. The most common cause of death in the comatose child is respiratory failure.

In all comatose or convulsing children, check blood glucose and administer 2-4 cc/kg D25W if needed.

Seizures are usually controlled with benzodiazepines and phenobarbital.

c.Temperature 1. Hyperthermia may be caused by a variety of drugs or toxins. Treat it aggressively with skin cooling.

2.Hypothermia : it may result from particular agents (ethanol,barbiturates, narcotics) or be related to environmental exposure.Hypothermia may cause, or aggravate, hypotension. Gradual warming with warm blankets, and warmed IV fluids utilizing devices such as the “HotLine” is usually successful in managing hypothermia.

d.Urine

1. Observe for adequate ( 1 ml/kg/hour) urine output as well as changes in the color/clarity of the urine.2. Send urine specimens to the lab for urinalysis, toxicology. X-rays1. Chest – Evaluate for infiltrates, possible aspiration, and pulmonary edema.2. Abdominal - Look for radiopaque materials, such as iron and enteric-coated pills.

GI Decontamination

The goal of gastric decontamination is to minimize exposure of the toxin by removing it from the GI tract, or by binding it to a non-absorbable agent.

Ipecac-induced emesis - Syrup of ipecac may be of some value if given within a few minutes after ingestion.

Gastric lavage - gastric lavage appears to be slightly more effective than induced emesis but rarely necessary.

1.In the home, syrup of ipecac may be used to induce emesis in the conscious,alert child. In the ED, ipecac is rarely used since its efficacy is diminished if administered 60min or more after ingestion. 2. Gastric lavage can be used when vomiting is contraindicated as a child with a depressed level of consciousness, seizures, compromised gag reflex, respiratory distress, or ingestion of a petroleum distillate.

Gastric lavage

Indications Overdose or Ingestion within 1 hour Specific overdose after 1 hour 1.Ingested drug slows peristalsis Anticholinergics Opioids (Narcotics) 2.Ingested drug of: Salicylates Iron
Complications Aspiration pneumonia. Laryngospasm. Hypoxia and hypercapnia. Mechanical injury to the throat, esophagus, and stomach. Fluid and electrolyte imbalance.


Activated charcoal - Recent studies indicate that the administration of charcoal alone may be as effective as emesis or gastric lavage, and may prove to be the mainstay of gastric decontamination.

Indications Patient presents within 60 minutes of ingestion B. Overdose of Antidepressant Aspirin Aminophylline Barbiturates Carbamazepine Digitalis Dilantin Dapsone
Substances for which charcoal is ineffective Pesticide Hydrocarbons Alcohols Acids Alkali Iron Lithium Solvents
Activated charcoal


Many children will not drink the needed dose; therefore, it may be necessary to administer activated charcoal via NG tube.

A cathartic mixed with charcoal shortens the transit time in the gut.

The cathartic sorbitol is rarely recommended in the pediatric age group, since magnesium citrate may cause symptomatic hypermagnesemia in children under the age of 2 years.

CatharticTypes: Sorbitol , Mg citrate

Contraindications A. Examination findings 1.Absent bowel sounds 2. Recent abdominal surgery or trauma 3.Intestinal Obstruction 4. Dehydration 5.Hypotension B. Poison ingestion of corrosive substance C. Poison ingestion with Diarrheal adverse effects

Whole bowel irrigation

uses polyethylene glycol solution ( Colyte) in large volumes at rapid rates to mechanically cleanse the GI tract. Whole bowel irrigation results in negligible fluid and electrolyte losses; it can be used when charcoal is ineffective (iron, lithium).

Enhancing elimination

Forced diuresis: increases GFR and enhances elimination of drugs excreted mainly by the kidneys(eg.lithium). IV isotonic fluids as twice as maintenance rate should sustain diuresis at 2-3 times normal.


Administering sodium bicarborate i.v results in an alkaline urine. Many drugs will diffuse more readily from the blood stream into alkaline urine.

e.g salicylates, phenobarbital poisoning .

Urinary alkalinization

Hemodialysis: Renal dialysis effectively removes select drugs (these must be low in molecular weight, water soluble, have small volumes of distribution, and exhibit low protein binding). Dialysis is most commonly used for alcohols, theophylline, salicylates, and lithium overdoses. Exchange transfusion: a. severe Methemoglobinemia b.Hemolysis

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