Dr M A Maleque Molla, FRCP, FRCPCH Conultant Pediatric Intensivist

Dr M A Maleque Molla, FRCP, FRCPCH Conultant Pediatric Intensivist
Poisoning in children Dr M A Maleque Molla, FRCP, FRCPCH Conultant Pediatric Intensivist January 25, 2016 Case scenario You received a 3 years old childin ER who is breathing hard, not behaving well and not responding while calling and parent is concerned that child may have taken some thing. How do you approach the problem? A case suspected poisoning, the first step is to ascertain whether the patient is symptomatic or not. In ER patient, priority should be stabilization of ABC When the patient is stable, Evaluate the child by history & Physical examination a history should be obtained; patient age and sex, the time of probable or witnessed toxin exposure, the type of substance involved, and the method of exposure (i.e., skincontact, inhalation, or ingestion). Poisoning Definition: Poisoning refers to an injury that results from being exposed to an exogenous substance that causes cellular injury or death*. Poisons can be inhaled, ingested, injected or absorbed. *WHO Epiodemiology Global rate of poisoning 282.4 / 100,000 population WHO
The global death rate from poisonings 1.8/ 100,000 population Non-fatal poisoning, more common among children aged 1 to 4 years Highest rates of fatal poisoning occurs among Children under the age of one year. Most poisoning occurs at home and common rout of poisoning is oral Most common agents involved
Over-the-counter preparations: paracetamol, cough/cold remedies, vitamins and iron tablets, antihistamines and anti-inflammatory drugs. Prescription medications: Antidepressants, narcotics, analgesics and illicit drugs. Household products: Bleach, disinfectants, detergents, cleaning agents, cosmetics, vinegar. Paraffin/Kerosene. Pesticides:insecticides (Organophosphorus compound). Poisonous plants. Animal or insect bites: Scorpion sting, snake bite, Dog. World report on child injury prevention, WHO 2004 Evaluation of poisoned patient
Priority: Stabilization of the Airway, Breathing,& Circulation Diagnosis History Patient age and sex, wt. The type of substance involved, Method of exposure (i.e., skin contact, inhalation, or ingestion). Assessment of the severity of the exposure Physical examination Investigations Note: concomitant trauma or illness must be recognized and addressed prior to initiation of decontamination History What poison has been taken? How much has been taken?
When the poison has been taken? What are the advarse effect of the poison? Reliability- Whether any poison has been taken? History (cont..) What poison has been taken ?: can be identified from;
Container Illustrated chart How much poison has been taken ? Calculating the missing amount from the container. In doubt, always calculate maximum amount of poison that has been consumed. When the poison has been taken?: Approximatetime elapsed since ingestion or exposure. History (cont..) What are the adverse effects of the poison?
Information can get from; From books, internet, pharmacy Poison Information centers: Tel no. Riyadh # /1999,2003, Jeddah # , Makkah # , Madinah# History(cont..) Whether any poison have been ingested?
Any doubt, take that the child has ingested the poison. A history of medicationused by thefamily members. Poisoning should be considered forany child, who present with acute onset of; Altered mental status. Multi organ system dysfunction of unexplained cause. Respiratory or cardiac compromise. Unexplained metabolic acidosis. Seizures, or a puzzling clinical picture. Physical examination Thorough physical examination from head to toe
Evaluation of mental status and vital signs, should be repeated frequently The diagnosis may be assisted by; Temperature alterations Blood pressure and heart rate alterations Respiratory disturbances Pupillary findings Skin findings Neuromuscular abnormalities Mental status alterations Characteristic odors e.g. acetone, bitter almond, Garlic In case of unknown poison ingestion, physical findings should be sought to define a particular toxic syndrome (toxidrome). Toxidromes Anticholinergics: Atropine, scopolamine, TCAs, phenothiazines, antihistamines, antipsychoticmushrooms, Hot as a hare, Blind as bat, dry as a bone, red as a beet, mad as a hatter CV: tachycardia, hypotension, hypertension, arrhythmia GI/GU: decreased bowel sounds, urinary retention Neuro: agitation, hallucinations, coma, extrapyramidal movements, mydriasis, hyperthermia Toxidromes Cholinergics: Organophosphates and carbamates
Mascarinic effect Nicotinic effect Diaphoresis/diarrhea Urination Miosis Brdycardia/bronchospasm Emesis Lacrimation excess Salivation excess Muscle fasciculation Cramping Weakness (extreme is diaphragmatic failure) Autonomic hypertension, tachycardia, pupillary dilation, and pallor Toxidromes Sympathomimetic: Salbutamol, Amphetamine, Cocain, Ephedrine. Anxiety, Delusion, Diaphoresis, hyperreflexia, mydriasis, paranoia, seizure Tachycardia, hypertension, mydriasis, agitation, seizures, diaphoresis, psychosis, hyperthermia OPIOID; Morphine, hydrocodone, methadone Hypoventilation, Hypotension, Miosis, Sedation, Hypothermia, Ileus. Investigations Blood glucose, urea & Electrolytes
Blood gas & Acid base status Serum osmolality & osmolal gap, anion gap Quantitativeserum concentration of drugs- paracetamolsalicylate, Iron Urine analysis;Rabdomyolysis ECG. Toxicology screens: indicated in children in whom the diagnosis of poisoning is uncertain. Samples of blood, first voided urine , vomitus, and gastric contents should be save for subsequent analysis. Plain radiographs of the chest & abdomen when indicated. Management Management of the poisoned child depends upon
Specific poison(s) involved, Presenting and severity of illness, Elapsed time between exposure and presentation. Remember the mainstay of therapy is supportive Management A. General Management B. Specific Management ABCD
Decontamination: Techniques used to prevent the absorption of the toxic substance Enhanced elimination: techniques which accelerate removal of a toxins from the body B. Specific Management Antidote: a substance which can counteract a form of poisoning 2. Decontamination Surface decontamination e.g. Organophosphate poisoning; Removal of the cloths and wash with soap & water Irrigation ofeyes if affected GI Decontamination: Gastric lavage: Not used routinely, use onlyselected cases Activated charcoal Whole bowel irrigation Purgationusing cathartics Decontamination is notalways warranted and may be contraindicated. Activated charcoal(AC)
It is an insoluble, non absorbable, fine carbon powder Maximum benefit, ifadministered within 1 hour of ingestion Dose: g/kg (maximum 50 to 60 gm), can be repeated at 0.5g/kg Q4-6 hour Multiple-dose: in case of ingested life-threatening amounts of; Carbamazepine, Dapsone, Phenoberbital, Quinine, Theophyline Care must be taken to protect the airway, assess for the presence of bowel sounds. Activated charcoal(cont..)
Contraindication: Absolute contraindication: Bowel obstruction or perforation Depressed level of consciousness Ingested non absorbable acidic or alkaline corrosives e.g. sodium or potassium hydroxide, or hydrochloric or sulfuric acid. Ingestion ofhydrocarbonse.g., gasoline, kerosene, liquid furniture polish The poisons which are not bound by AC e.g. Iron, lead, arsenic. Agents for which activated charcoal is not recommended
Heavy metals Arsenic Lead Mercury Iron Zinc Cadmium Inorganic ions Lithium Sodium Calcium Potassium Magnesium Fluoride Iodide Boric acid Corrosives Acids Alkali Hydrocarbons Alkanes Alkenes Alkyl halides Aromatic hydrocarbons Alcohols Acetone Ethanol Ethylene glycol Isopropanol Methanol Essential oils Whole bowel irrigation (WBI)
It refers to the administration of polyethylene glycol electrolyte solution (PEG-ES) to induce liquid stool and mechanically flush pills, tablets, or drug packets from the GI tract. WBI significantly decreased absorption oftoxic materials Whole bowel irrigation (WBI)
Indication: Ingestionoflarge amounts of poisons that are not well bound to AC, sustained-release medications. Contraindications: Intestinal obstruction, perforation, ileus, or significant GI bleeding , Persistent vomiting Technique: Administrationpolyethylene glycol electrolyte solution (PEG-ES)via nasogastric tube Dose: 20 to 40mL/kgper hour until the rectal effluent is clear, which takes 4-6 hours. PEG-ES (GoLYTELY) Use of Cathartics Cathartics accelerate the evacuation by fluid load in the intestine and stimulating bowel motility. They shouldneverbe used as the sole method of GI decontamination. Recommended agent: 0.5g/kg(1 to 2mL/kg)of 7 percent Sorbitol(0.9g/mL) 4mL/kgor 250 mL of Magnesium citratein a 6 percent suspension Sorbitol is not recommended for use in children younger than one year of age If a cathartic is used, it should be limited to a single dose in order to minimize adverse effects Enhance elimination of Poisons
Urinary alkalinization and forced diuresis:eg, salicylates and Phenobarbital. Hemodialysis: significant ingestion of alcohols, theophylline, Lithium, Salicylates. Hemoperfusion:Theophylline, Carbamazepine, valproic acid, procainamide. Exchange transfusion: arsine or sodium chlorate poisoning Peritoneal dialysis, Hemofiltration Specific treatment Antidotes Very few poisons have antidotes.
Information can be found in books or from Poison Information Center Table. Antidotes for some common toxicant
POISON ANTIDOTE Paracetamol N-Acetylcysteine Anticholinergics Physiostigmine Lead/Heavy Metals BAL in oil (dimercaprol) Beta Blockers Glucagon, Cateholamines Carbon Monoxide Oxygen Cyanide Amyl nitrate, Sodium Nitrate, Sodium Thiosulfate Ethylene Glycol Dialysis, Fomepizole, Ethanol Iron Desferoxamine Isonazid Pyridoxine DMSA, BAL, EDTA Methemoglobin Producing agents Methylene blue Narcotics Narcan Organophosphates Atropine, Pralodixime Phenothiazines Benadryl Disposition Patient can send home after 4-6 hour of observation if poison is less toxic. Alwaysadmit if Symptomatic. Ingestion ofiron, tricyclic antidepressant, digoxin and aspirin. Unconscious child should be admitted in pediatric intensive care unit. SPECIFIC POISONING Paracetamol Toxic dose: > 150 mg/kg
Most common ingestion in toddlers, preschoolers and adolescents Toxic dose: > 150 mg/kg Kinetics dictate that a serum level to be checked 4 hours after ingestion 4 hour toxic blood level 150ug/dl Apply the level to the management nomogram Rumack-Matthew nomogram for single acute paracetamol ingestions Paracetamol Poisoning
Stage I(1/ hours) Malaise, nausea, vomiting, pallor, diaphoresis Stage II ( hours) Asymptomatic, right upper quadrant pain, increasing LFTs, PT, PTT & INR Stage III ( hours) Liver failure,in severe cases renal failure & multi organ failure Stage IV ( days) Resolution of liver injury & Recovery Management Activated charcoal 1 gm/kg
Plasma paracetamol level at 4 hours and plot on nomogram N-Acetylcysteine(NAC),orally: If serum level above the line of possible hepatotoxicity Ingested > 150 mg/kg & no facilities to do serum level of paracetamol, Patients with an unknown time of ingestion beyond 24 hours and a serumconcentration >10mg/L(66mol/L) Dose of NAC: Loading Dose: 140mg/kg. Maintenance Dose: 70mg/kg,4 hourly for 17 doses IV: Indicated if patient is unable to take orally and present within 8-16 hours of ingestion Dose: (Acetadote) 150 mg/kg over 1hr, followed by 50 mg/kg over 4 hr, followed by 100 mg/kg over 16 hr NAC therapy Is most effective when initiated within 8 hr of ingestion,
Shown to have benefit even in patients who present in fulminant hepatic failure There is no benefit before 4 hr post ingestion. Iron Available preperation Ferrous sulfate -20% elemental iron
Ferrous gluconate- 12% elemental iron Ferrous fumerate -33% elemental iron Toxic Dose: Elemental Iron 60 mg/kg potentially life threatening Clinical features 5 Phases
Phase I (Gastrointestinal): 30 min 6 hours Nausea, Vomiting correlate with high toxicity, Diarrhea; abdominal pain GI haemorrhage bloody diarrhea, hematemesis Severe hypotension Phase II (Latent): hours post ingestion Patient appears better apparent improvement In severe poising, this stage may be absent. In this stage, iron accumulates in mitochondria and various organs Clinical features(cont..)
5 stages Phase III (Shock): 6-72 hours post ingestion; Hypoglycemia, Metabolic acidosis, Circulatory Failure-Shock Phase IV (Hepatotoxic): days post ingestion Signs ofhepatic necrosis raised AST, ALT and direct bilirubin, prolonged PT Renal Failure, Metabolic Acidosis, Bleeding diathesis, Adult Respiratory Distress Syndrome Coma Death Phase V: 2-8 weeks after ingestion Signs of intestinal obstruction due to scarring and pyloric stenosis Investigation Serum Iron 2-6 hours post ingestion, TIBC
Serum Iron >350gm/dl- mild to moderate toxicity Serum Iron >500gm/dl- severe toxicity needs urgent intervention Greater than 1000mcg/dL Significant morbidity and mortality Blood glucose; Blood glucose >150 mg/dl moderateto severe toxicity CBC, U&Es LFT, WBC> /cmm- associated with moderate to severe toxicity Plain x-ray abdomen ABG/VBG Management Supportive care ABCD Correct dehydration Removal of Iron
Gastric lavage with a large-bore orogastric tube may be indicated for patients with overdoses of large amounts of iron who have a large number of visible pills in the stomach on abdominal radiograph Whole bowel irrigation with colonic solution (colyte, golytely) if large number of tablets are ingested. No activated charcoal to be given because it does not bind iron. Repeat x-ray on abdomen after decontamination. If clumps of tablets can be seen in x-ray and fail to remove with usual procedures, surgical removal is indicated in rare cases. Desferoxamine orally promote iron absorption, so should not be given orally Management Definitive treatment: Desferoxamine intravenous infusion.
Indications: Serum Iron at 4-8 hours >500g/dl regardless of symptoms or Serum Iron >350g/dl + moderate to severe symptom Moderate to severe symptom regardless of serum iron Anion gap metabolic acidosis Significant no. of pills on abdominal x-Ray Dose: By IV infusion 15 mg/kg/hour maximum 6 g/24 hours By intramuscular 90mg/kg/dose 8 hourly maximum 6g/24 hours Duration: duration of desferoxamine therapy until resolution of clinical symptoms, usually 24 hour SALICYLATE POISONING Toxic Dose: >150 mg/kg Clinical Manifestation:
Early: nausea vomiting tachypnea, deep sighing respiration, tinnitus, high temperature, lethargy, and dehydration. Late: Bleeding tendency, coma. Clinical features Important signs and laboratory findings:
Phase I: First 12 hours Tachypnea Alkalosis Phase II hours Tachypnea persist Hypokalemia Paradoxicalaciduria Phase III - 4 to 6 in an infant, or 24 hours in an adolescent or adult Dehydration 5-10% Worsening acidosis Hypokalemia; hyperglycemia/hypoglycemia Pulmonary edema, pulmonary hemorrhage Cerebral edema Investigations Plasma Salicylate level no sooner than 6 hours and plot on the nomogram Urine pH hourly Blood gas Glucose, serum urea electrolytes and creatinine 6 hourly PT LFT. Nomogram for Salicylate Management Plasma salicylate levels mg/dl (moderate poisoning), treat and admit the patient. Plasma salicylate level >65 mg/dl (severe poisoning), treat and admit in the ICU Decontamination: Activated charcoal 1 gm/kg. Multiple dose of AC may be needed in severe poisoning Volume resuscitation: Rehydrate the child and correct electrolyte specially potassium; Enhance elimination Urine alkalinization by IV bicarbonate The goal is to achieve a urine pH >7.5 while maintaining a serum pH 7.55. Hemodialysis Organophosphate poisoning
Agents: Malathion, Parathion, Diazenon, Chlorothion Clinical features 1. Mascarinic effect Diaphoresis/diarrhea Urination Miosis Brdycardia/bronchospasm Emesis Lacrimation excess Salivation excess 2. Nicotinic effect Muscle fasciculation Cramping Weakness (extreme is diaphragmatic failure) Autonomic : hypertension, tachycardia, pupillary dilation, and pallor 3. CNS manifestations: Anxiety, restlessness, tremor, confusion, coma, convulsion Management ABC Remove cloths and wash the skin with soap and water
Atropine (vagal block) IV mg/kg every 15 minute until complete atropinization ( dilated pupil, dry mouth tachycardia, fever) then 1-4 hourly for 24 hour Pralidoxime (Protopam, 2-PAM) Regenerates acetylcholinesterase mg/kg/dose (IM or IV) Repeat in 1-2 hour if muscle weakness does not relieve Thanks for attention