Download Pediatric Poisoning

Pediatric Poisonings
2011
objectives
what’s poisonig
Types of poisoning
Emergency management
GI decontamination
other modes of treatment
Definition of Poisoning:
Exposure to a chemical or other agent that adversely
affects functioning of an organism.
Epidemiology:
usually it involves children 1-5 yrs.
56% of pediatric exposures are from products
around the house including medicines, cleaning
agents, pesticides, plants and cosmetics.
Types of Poisoning
Accidental poisoning)without intent):
Mainly young children aged 1-3 years
Mainly drugs or household product
May be an indicator of maternal
depression
Intentional Overdose
Mainly teenagers
Usually ingestion of drugs
Iatrogenic
Usually result of calculation error
Most frequently fatal drug:
digoxin
Child abuse )non-accidental)
May present as an unusual illness
rather than poisoning.
Chronic poisoning
Mainly environmantal hazards
Commonest: Lead poisoning
Poisoning in children may be:
• accidental - the vast majority
deliberate self-poisoning (suicide)in older
children
non-accidental as a form of child abuse
iatrogenic.
ALL THINGS
TEND TO END
UP IN THE
MOUTHS OF
YOUNG
CHILDREN!!
EMERGENCY MANAGEMENT
Identification of the poison
1. Determine the product ingested, the
amount, the time of ingestion, the childs’
present condition.
2. In determining therapy, assume the largest
estimated amount.
3. Physical Examination.
A. Asymptomatic child
1) Quickly assess the potential danger.
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/Provide Parent Education/Perform
Risk Assessment:
a. Observe the asymptomatic child (usually 4-6
hours).
b. Consider evaluation of the home situation.
c. Intentional ingestions in adolescents, especially girls,
raises the possibility of unwanted pregnancy, or sexual
or physical abuse.
d. All parents require instructions about poison
prevention techniques.
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
Monitor for variations in blood pressure.
a) Hypotension results from venodilation,
arteriole dilation, depressed cardiac
contractility, or a combination of causes.
Regardless of the etiology, most
hypotensive children respond to volume
therapy of 10-20 cc/kg boluses of Ringer's
Lactate or Normal Saline and rarely need
pharmacologic treatment.
b.Hypertension should be treated in order
to prevent intracranial hemorrhage or
hypertensive encephalopathy.
Treat hypertension with sodium
nitroprusside with or without esmolol or
propranolol.
3.Monitoring
Place the child on a cardiorespiratory monitor to
assess for arrhythmias.
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 D25W if needed.
Seizures are usually controlled with
benzodiazepines and phenobarbital.
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 (ethanol,barbiturates, narcotics) or be
related to environmental exposure.
Hypothermia may cause, or aggravate,
hypotension.
Gradual warming with warm blankets, and
warmed IV fluids utilizing devices such as
the “HotLine” is usually successful in managing
hypothermia.
d.Urine
1. Observe for adequate ( 1 ml/kg/hour) urine
output as well as changes in the color/clarity of
the urine.
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 and enteric-coated pills.
GI Decontamination
The goal of gastric decontamination is to
minimize exposure of the toxin by removing it
from the GI tract, 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.
Gastric lavage - gastric lavage appears to be
slightly more effective than induced emesis but
rarely necessary.
1.In the home, syrup of ipecac may be used to
induce emesis in the conscious,alert child.
In the ED, ipecac is rarely used since its
efficacy is diminished if administered 60min or
more after ingestion.
2. Gastric lavage can be 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 - Recent studies
indicate that the administration of charcoal
alone may be as effective as emesis or
gastric lavage, and may prove to be the
mainstay of gastric decontamination.
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
Many children will not drink the needed
dose; therefore, it may be necessary to
administer activated charcoal via NG
tube.
A cathartic mixed with charcoal shortens
the transit time in the gut.
The cathartic sorbitol is rarely recommended in the
pediatric age group, since magnesium citrate may
cause symptomatic hypermagnesemia in children
under the age of 2 years.
Cathartic
Types: Sorbitol , Mg citrate
Contraindications
A. Examination findings
1.Absent bowel sounds
2. Recent abdominal
surgery or trauma
3.Intestinal Obstruction
4. Dehydration
5.Hypotension
B. Poison ingestion of corrosive substance
C. Poison ingestion with Diarrheal adverse effects
Whole bowel irrigation
uses polyethylene glycol solution ( Colyte) in large
volumes at rapid rates to mechanically cleanse the
GI tract.
Whole bowel irrigation results in negligible fluid and
electrolyte losses; it can be used when charcoal is
ineffective (iron, lithium).
Enhancing elimination
Forced diuresis: increases GFR and
enhances elimination of drugs excreted mainly
by the kidneys(eg.lithium).
IV isotonic fluids as twice as maintenance rate
should sustain diuresis at 2-3 times normal.
Urinary alkalinization
Administering sodium bicarborate i.v results
in an alkaline urine.
Many drugs will diffuse more readily from the
blood stream into alkaline urine.
e.g salicylates, phenobarbital poisoning .
Hemodialysis:
Renal dialysis effectively removes select
drugs (these must be low in molecular
weight, water soluble, have small
volumes of distribution, and exhibit
low protein binding).
Dialysis is most commonly used for
alcohols, theophylline, salicylates, and
lithium overdoses.
Exchange transfusion:
a. severe Methemoglobinemia
b.Hemolysis
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