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Fifth stage
Pediatric
Lec-4
د.فارس
13/10/2015
Hazards & accidents
Hazards:
Could be trauma, accident, poisoning.
Most dangerous thing in infancy is infection.
Most dangerous thing in child (1-5 years old) is hazards because he want to explore
anything.
Hazards lead to death of children.
Poisoning:
You have to diagnose it definitely.
Take detailed history (rarely you can good and true history).
Any child who present to the emergency unit with bizarre symptoms which don't match
with any disease, this is considered as poisoning case until proven otherwise.
Any comatose child, consider poisoning until proven otherwise.
Most poisonings are accidental (80%) or incidental (20%).
If teenager present, consider suicidal attempt (intentional suicide).
Munchausen by proxy syndrome: in which the caregiver creates the child illness.
There is what's called iatrogenic poisoning (by doctors themselves).
You should now the type of drug and the amount of it.
Aspirin poisoning previously very common but now it is rare.
What to do? How to manage the case?
Firstly be sure of history of ingestion.
Stressed questions due to social circumstances.
Diagnosis can be done by exclusion.
Send the parent back to home to bring the materials that caused the poisoning (because
anti dote is very important in the management & this requires the knowledge of the
causative material).
Medico-legal purposes always to be considered in cases of poisoning.
Sometimes mother induce emesis to her child it is NOT allowed because there are
many volatile substances (Kerosene) & this leads to aspiration pneumonia.
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Treatment in general:
If baby take one tablet only no problem healthy child clinically send him home
and monitoring.
Syrup of ipecac (15ml) along with juice & you can repeat the dose of ipecac (induce
emesis).
Gastric lavage can be used with consideration to the contraindications:-
1. If more than 4 hours had been elapsed (exception for salicylate, lomotil, TCA).
2. If the material is alkali (because burn esophagus, lips, mouth).
3. If the substance was volatile (kerosene).
4. Comatose child.
Activated charcoal: multiple doses can be given.
Bowel irrigation (by phenomethylglycol).
Blood transfusion.
Peritoneal dialysis.
Hemodialysis.
Blood exchange.
Kerosene poisoning:
It is the commonest poison in children.
Kerosene has low viscosity & low surface tension & it is highly volatile.
Aspiration occurs at time of ingestion because of coughing & gagging so aspiration
occurs.
It is common in summer because of thirsty.
Lead pulmonary toxicity and chemical pneumonitis superadded infection.
Reduce the surfactant.
Less than 1 ml lead to pulmonary and systemic toxicity.
Symptoms:
o High fever (usually lasts for 10 days).
o Chemical pneumonitis.
o Granting.
o Pleural effusion.
o Pneumatocele.
o
Systemic toxicity.
CXR should be delayed for 6 hours see normal x-ray or patchy infiltration.
Observation should be continuous.
Don't send the child to home before 6 hours.
The course of kerosene poisoning is unpredictable all of sudden deteriorate and die.
Petrol more volatile so more dangerous than kerosene (no survival in petrol poisoning).
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Management:
o Supportive management is required.
o O2
o Hydration.
o Anti-pyretic (if needed).
o Ventilation.
o Observation.
o No need for Antibiotics (unless you suspect secondary bacterial infection).
o Corticosteroids has no role.
Education of parents careful attention, and keep kerosene away.
Iron poisoning:
Now it is very rare.
In pregnancy iron supplements taken rottenly (child take his this supplements).
Tablets is red and colorful so child take them.
Is very fatal (5mg is very fatal).
Clinical features:-
o Stage 1:-bloody diarrhea, vomiting, hypertension.
o Stage2:-latent phase (stable phase).
o Stage3:-hepatic failure, leukocytosis, hypocalcaemia, multi-organ failure & shock.
o Stage4:-pyloric stenosis, late Intestinal obstruction.
Treatment:
o Supportive management.
o Desferoxamine (10-15mg/kg/hr) IV.
o Complex will be formed that will readily excreted in the urine.
Tricyclic anti-depressants poisoning:
Tofranil is the most dangerous poisoning.
Clinical history mother take 5 or 7 years child with nocturnal enuresis to pediatrician
give him TCA his toddler brother take this medicine (colorful tablets).
Signs Coma, Convulsion, hypotension, Hyper reflexia, Mydriasis, Prolonged QT
interval, Cardiac arrest, Shock, arrhythmias.
Treatment Activated charcoal & lavage, Put on cardiac monitoring, Xylocaine &
sodium bicarbonate for acidosis.
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Phenothiazine group poisoning:
Anti-emetics (metochlopromide & domeperidone).
Treat the cause of vomiting and not give anti-emetic to child side effects of anti-
emetics are hypotension, ataxia, tachycardia, coma, occulogyric crisis, severe muscle
rigidity.
Vomiting can be seen in any systemic diseases so treat the cause not the symptom.
Influenza, pneumonia, UTI, gastroenteritis, tonsillitis, infective hepatitis, meningitis
all lead to diarrhea.
The only indication for use of anti-emetics in children are GERD and before performing
jejunual biopsy in celiac disease.
Treatment General Measures + Anti-dote (Benztropine) + anti-histamine
(chlorpheneramine) or diazepam (IV).
If you give diazepam only the case could be re-occur.
Carbon monoxide poisoning:
It has high affinity to bind to hemoglobin carboxy-Hb.
Clinical features: Headache, Dizziness, Coma.
Treatment: Hyperbaric O2 (100%).
Paracetamol (acetaminophen) poisoning:-
Is rare poisoning in children because the tablet is big and has bitter taste.
It is common in suicide.
Signs: Nausea, Jaundice, Hepatic failure (after72hrs).
Treatment General measures + Antidote: N-acetyl cysteine in first 16 hours
(140mg/kg) then (70mg/kg) for 17days.
Lomotil poisoning:
It is anti-diarrheal agent (like entero-stop).
It is anti-chonergic agent.
Signs: respiratory depression, Hypotension, hypo-reflexia, coma, and death.
Don’t give lomotil until age of 4-5 years due to side effects.
If there is no cause of diarrhea you can give lomotil.
Treatment general measures + Antidote: Naloxone (0.1mg/kg) and don't exceed
2mg/kg.
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Salicylate poisoning:
Now it is rare.
Signs: Tachypnea, Fever, Vomiting, Lethargy, diaphoresis, Coma, Early alkalosis then
metabolic acidosis.
Treatment: Forced alkaline diuresis, Sodium bicarbonate, Dose (1mg/kg).
Lead poisoning:
Rare in our community.
Occur in child with pica.
Chronic accumulative poisoning.
Diagnosis: Must be considered in any child with encephalopathy, anemia, abdominal
pain, increased ICP, papilledma.
Treatment: Pencillamine, Calcium editate, Dimercaprol.
Sagwa poisoning:
It is lead acetate compounds.
Symptoms: Convulsion, coma, encephalopathy death.
No surviving, it is acute positioning.
Organophosphate poisoning:
It used as Pesticides.
Very common.
Signs & symptoms Salivation, Lacrimation, Urination, Gastric emptying, Defecation,
Bradycardia, Bronchospasm, Bronchorrhea, muscle weakness, ataxia, late peripheral
neuropathy, bradycardia.
Treatement Cloths off, bathing, O2, Fluid resuscitation, Atropine (drug of choice),
Pralidoxime (reduce passage through BBB), Diazepam (in case of seizure).
Give atropine (0.2-0.5 mg/kg every 5 min) until full atropinization (the pupil become
mydriatic).
Alcohol poisoning:
Lead to liver damage and hypoglycemia.
Phenothiazine (drug of choice).