Download POISONING IN CHILDREN

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