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Poisoning in children MUDr. Jitka Dissou Pediatric Emergency Department, FN Motol Intoxication Definition Age By what Why Symptoms Assessment Therapy Specific poisons Intoxication - definition Ingestion (inhalation,..) of a substance, that can cause a serious change of patient´s condition serious symptoms in 10% of children Age groups of intoxicated children toddlers (accidental intoxication) prevention!!! adolescents (suicide attempts, experiments with drugs) Why Accidental (in toddlers – unattended medicinal drugs, household products – attractive bottles, poisonous plants) Accidental substitutions (another drug given by parents - eg. Vigantol x 60%spirit) Intentional (suicide attempt, assaciation attempt ) Recreational (alcohol, drugs experiments – Psilocybe-magic maschrooms, Datura-angel's trumpet, pervitin,..) The most common and the most serious poisoning in childhood drugs (antikoagulant, antiarrhythmic, antihypertensive, benzodiazepins, paracetamol..) chemicals (washing powder and tablets, cleaning products, caustics – acids, alkali..) poisonous plants (yew -tis, stramonium -durman, mistletoe - jmelí,..), mushrooms alcohol narcotics (canabinoids, amphetamins, opioids, ..) carbon monooxide History 1/ witness input 2/ clues found near patient – emtpy bottles of medication, chidl playing with drugs, etc. 3/ change in patient´s condition- unknown reason quick hit! – don´t forget to ask ! - what and how much has been ingested by child - time of ingestion - child´s weight CNS Behavior changes Altered mental status drowsiness agitation Thermoregulatory failure ventilation: Hypo/hyper Ventilaction Apnoic pauses symptomes of poisoning changes in color of skin, mucous membranes circulation: Arrythmias Hypo/hyper tension GIT vomiting Foetor ex ore Hypo/hyper tonus Initial management consultation with toxicology center TIS – tel. 224 91 92 93 blood sampling – blood level of poisonous substance, blood gases included COHb, coagulation, level of ionts, liver enzymes, glycemia urine sampling – metabolites sample from gastric lavage quick hit - write down information from TIS! -toxic level, elimination halftime, peak plasma concentration - syndromes of the intoxication, therapy Therapy I 1/ initial priority – ABC resuscitation approach: - airways + breathing - circulation – i.v. line - hypo/hyper tension, dysrrythmias - neurological function - level of consciousness , seizures 2/ decontamination – gastric lavage, rinse contaminated skin and removed clothes Therapy II 3/ inactivation charcoal (0,5-1g/kg) antidotes (see table) 4/ elimination: diuretics,hemoperfusion (barbiturates,carbamazepin, Amanita phaloides), hemodialysis (methanol, ethylenglykol) Gastric lavage • Indications the procedure can be performed within 60 minutes of ingestion • Contraindications when patient has a compromised, unprotected airway poisoning is due to a corrosive substance • Complications aspiration, mechanical injury (oesophagus, stomach), dysrrythmia, tube in airways Gastric lavage Antidote ANTIDOTA ANTIDOTA Toxická látka Dávka Antidotum acetaminofen(paracetamol) N-acetylcystein (ACC) 140mg/kg p.o. (i.v.) benzodiazepiny flumazenil (Anexate) 0.01-0.05mg/kg, max.2mg beta-blokátory glukagon 0.15mg/kg i.v. blokátory Ca kanálů CaCl2 10-20mg/kg i.v. ethylenglykol,methanol ethanol, fomepizol 7-10ml/kg 10% ethanolu kumarin vitamin K 0.3mg/kg i.v. kyanidy cyanokit opiáty naloxon (Intrenon) 0.01-0.03mg/kg i.v. organofosfáty atropin 0.05mg/kg TCA, rulík fysostigmin 0.5mg i.v. železo deferoxamin 15mg/kg/h Paracetamol poisoning I Paracetamol (=acetaminofen) Toxic dose 150mg/kg in children, In adults over 7,5g (~15tbl. 500mg Paralen) Peak plasmatic concentration 4h after ingestion Paracetamol is converted in liver by cytochrom P450 to N-acetyl-p-benzochinonimin (NAPQI) which is detoxified by conjugation with glutathione to form cysteine and mercapturic acid conjugates Paracetamol poisoning II in case of overdose, hepatocellular supplies of glutathione become depleted (NAPQI)remains in its toxic form in the liver and reacts with cellular membrane molecules acute hepatic necrosis signs of intoxication: nonspecifics– nausea, vomiting, abdominal pain after 24 h, elevation of liver enzymes adn INR, acute kidney and liver failure Paracetamol poisoning III Management : Rumack-Mathewův normogram timed serum paracetamol level plotted on the nomogram appears to be the best marker indicating the potential for liver injury 4h after ingestion, use an antidote After 24h - ALT, AST, INR Therapy : 1/nonspecific – within 1 h Gastric lavage, charcoal 1g/kg 2/specific - antidote N-acetylcystein (donor of SH group) – dose 140mg/kg p.o. (i.v.) Caustic ingestions • cleaning substances burns of oropharynx, hypopharynx, and esophagus, • alkaline liquefactive necrosis, acid ingestions coagulation necrosis, perforation of oesophagus - mediastinitis • endoscopy, NGT for 6 weeks, ATB, endoscopy after 6 weeks, surgery Caustic ingestion 2 years old girl, playing unattended in bathroom, ingestion of Drain-cleaniner (NaOH) burns of lips and oropharynx admitted to ENT ward no injury of oesophagus seen on endoskopy Carbon monooxide toxicity • colorless, odorless, non-irritating gas from fires, automobile exhaust,..– incomplete combustion of organic matter due to insufficient oxygen supply • reason of toxicity – CO binds Hb - COHb (karboxyhemoglobin =karbonylhemoglobin) CO binds hemoglobin 230-270 times more avidly than oxygen • symptomes– headache,vertigo, nausea, vomiting,altered mental status, tachycardia, hypertension Carbon monooxide toxicity • labs – blood gases, plasmatic level of COHb COHb – normal less 1%, smokers 10%, intoxication 10% and more • COHb measuring– non-invasice CO oximetry cooxymetrie, blood level, Breath CO monitoring (50ppm~6%COHb) • therapy – 02 15l/min, GCS less than 8 - UPV withFiO2 1,0 - hyperbaric chamber – indications - COHb more than 10% + altered mental status, pregnancy Alcohol intoxication • the most common type of intoxication in adolescents • EtOH involves – CNS, GIT, inhibits glukoneogenesis – hypoglycemia • signs of intoxication– 4 stages 1/euforic. – less than 0,5promile 2/hypnotic – clumsiness, incoordination, ataxia, drowesiness 3/narcotic- altered mental status, miosis, hypothermia, hypoglycemia, hypoventilation 4/asfyctic – hypoventilation, circulation impairment Alcohol intoxication • labs – glycemia, level of EtOH, osmolality, blood gases, biochemistry • therapy – ABC, treatment of hypothermia, parenteral rehydratation – infusion with glucose quick hit Level of EtOH mmol/l x0,046 = promile of EtOH Very poisonous plants in Czech republic Dieffenbachia, Belladonna, Yew-tree, Oleander, Foxglove, Hellebore, Lily of the valley,…. Conclusion • Intoxication in children are not rare • TIS – tel. 224 91 92 93 • prevention !!! References • • • • Lebl J., Janda J., Pohunek P., Starý J.: Klinická pediatrie, Galén 2012 Novák I. et.al.: Intenzivní péče v pediatrii, Galén 2008 Šeblová J., Knorr J. : Urgentní medicína v klinické praxi lékaře, Grada 2013 Ševela K., Ševčík P. : Akutní intoxikace a lékové poškození v intenzivní medicíně, Grada 2011 http://www.tis-cz.cz/ http://www.tis-cz.cz/index.php/informace-pro-odborniky/dostupnost-antidot http://www.urgmed.cz/postupy/cizi/2009_co.pdf www.uptodate.com www.medscape.com