Download Pediatric Poisoning

Dr .EMAN ISAM
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Definition of Poisoning:
Exposure to a chemical or other agent that
adversely affects functioning of an
organism.
Circumstances of Exposure can be: Intentional, accidental, environmental,
medicinal or recreational.
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Routes of exposure can be:Ingestion, injection, inhalation or cutaneous
exposure.
 usually it involves children younger than 6 yrs
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“All substances are poisons...the right dose
separates poison from a remedy.”
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What toxic agent/medications were found near the
patient?
What medications are in the home?
What approximate amount of the “toxic” agent was
ingested?
 How much was available before the ingestion?
 How much remained after the ingestion?
When did the ingestion occur ?
Were there any characteristic odors at the scene of the
ingestion?
Was the patient alert on discovery?
 Has the patient remained alert since the ingestion?
 How has the patient behaved since the ingestion?
Does the patient have a history of substance abuse?
SPECIFIC management:
ABC’s of Toxicology:
 Airway
 Breathing
 Circulation
 Drugs:
 Resuscitation medications if needed
 Universal antidotes
 Draw blood:
 chemistry, coagulation, blood gases, drug
levels
 Decontaminate
 Expose / Examine
 Full vitals / Foley / Monitoring
 Give specific antidotes / treatment
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Decontamination:
Ocular:
– Flush eyes with saline
2. Dermal:
– Remove contaminated clothing
– Brush off
– Irrigate skin
3. Gastro-intestinal:
– Activated charcoal:
 May Prevent /delay absorption of some drugs/toxins
 Almost always indicated
Only in the 1st hour !!!!
– Naso/oro-gastric Lavage
– Bowel Irrigation:
 Used in recent ingestions
 In awake alert patient
 By using 500 cc NS Children / 2000cc adults
 Orally / Nasogastric tube
1.
A. Asymptomatic child
1) 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 usually 4-6 hours &
consider evaluation of the home situation.
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
a) Hypotension
Regardless of the etiology, most
hypotensive children respond to10-20 cc/kg
boluses of Ringer's Lactate or Normal
Saline.
b.Hypertension should be treated in order
to prevent intracranial hemorrhage or
hypertensive encephalopathy.
Treat with Na nitroprusside with or
without esmolol or propranolol.
3.Monitoring
Place the child on a cardiorespiratory monitor
a) 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 25% DW if needed.
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 or be related to
environmental exposure.
Gradual warming with warm blankets, and
warmed IV fluids utilizing devices.
d.Urine
1. Observe urine output & color
2. Send urine specimens to the lab for
urinalysis, toxicology.
X-rays
1. Chest – Evaluate for infiltrates, possible
aspiration, and pulmonary edema.
2. Abdominal - Look for radiopaque materials,
such as iron .
GI Decontamination
The goal of gastric decontamination is to
minimize exposure of the toxin by removing it
from the GIT, or by binding it to a nonabsorbable agent.
Ipecac-induced emesis - Syrup of ipecac may
be of some value if given within a few minutes
after ingestion. In the ED, ipecac usage is
reduced since its efficacy is diminished if
administered 60min or more after ingestion.
Gastric lavage - gastric lavage appears to be
slightly more effective than induced emesis. Its
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
A. Overdose or
Ingestion within
1 hour
B. Specific
overdose after 1
hour
1.Ingested drug slows
peristalsis
a.
Anticholinergics
b.
Opioids
(Narcotics)
2.Ingested drug of:
a.
Salicylates
b.
Iron
Complications
•Aspiration pneumonia.
•Laryngospasm.
•Hypoxia and hypercapnia.
•Mechanical injury to the throat
esophagus, and stomach.
•Fluid and electrolyte imbalance
Activated Charcoal:
Decrease or prevent the intestinal absorption of a few drugs and toxins
as well as enhance the elimination of drugs already absorbed and
present within the systemic circulation .
specially prepared to have a very large adsorptive surface area.
Many, but not all, toxins are adsorbed onto its surface.
Dose of 10–50 g (≈1 g/kg) for a child and 50–100 g for an
adolescent or an adult is administered. In practice.
Airway reflexes must be preserved or the airway
protected by endotracheal intubation.
Many children will not drink the needed dose; therefore, it may be
necessary to administer activated charcoal via NG tube.
Activated charcoal
Indications
A.
B.
Patient presents
within 60 minutes of
ingestion
Overdose of
Antidepressant
Aspirin
Aminophylline
Barbiturates
Carbamazepine
Digitalis
Dilantin
Dapsone
Substances for which
charcoal is
ineffective
A.
B.
C.
D.
E.
F.
G.
H.
Pesticide
Hydrocarbons
Alcohols
Acids
Alkali
Iron
Lithium
Solvents
Whole bowel irrigation WBI
uses polyethylene glycol solution ( Colyte) in large
volumes at rapid rates to mechanically cleanse the
GI tract.
Enhancing elimination
Forced diuresis: using I.V. fluid & diuretic to
increase GFR and enhances elimination.
Urinary alkalinization
Administering sodium bicarborate i.v results
in an alkaline urine
Hemodialysis:
Renal dialysis effectively removes select drugs.
Exchange transfusion:
a. severe Methemoglobinemia
b.Hemolysis