Download Pediatric Toxicology

Document related concepts
no text concepts found
Transcript
Pediatric Toxicology
Jana Stockwell, MD
Epidemiology
2 million calls
 52% of poison center calls <6years
 Peak ages: 18 months - 3 years

Epidemiology

Unintentional (1-2 years)
– Exploratory
– Boys > girls
– Unable to discriminate safe from unsafe liquid

Intentional (adolescent)
– Purposeful
– Girls > boys
Epidemiology
Around meal time
 Grandparents home
 Kerosene or gasoline in a soda bottle
 Older sibling can pharmaceutically treat
younger sibling

Most often reported
Cleaning products
 Analgesics
 Cosmetics
 Cough & cold preparation
 Insecticides

10%
10%
9%
5%
4%
PICU Admission
Tricyclic antidepressants (TCA)
 Anticonvulsants
 Digoxin
 Opiates
 Hydrocarbon-based household products

Toxic Exposures  Death
Analgesics
 Sedative-hypnotics
 Alcohols
 Gases & fumes
 Cleaning substances

“Fatal Sip”


Camphor (Vick’s VapoRub)
– (100mg/kg)
Methyl salicylate (wintergreen)
– (200 mg/kg)

Benzocaine (OraGel)
– 2 mL
– Met-hemoglobinemia
– Seizure
1000 mg/5 ml
1400 mg/ml
“Malignant Swallow”
Chloroquine
 Theophylline
 Imipramine
 Chlorpromazine
 Clonidine

– Bradycardia
– CNS depression
(20 mg/kg)
(8.4 mg/kg)
(15 mg/kg)
(25 mg/kg)
(0.3 mg tablet)
Other Highly Toxic
Acetonitrile - nail tip remover  MetHgb
 Ammonium fluoride – hub cap cleaner
(ArmorAll)  sz, arrhythmias, acidosis
 Pennyroyal Oil – some herbal teas

Look-Alike, Sound-A-Like








Albuterol
Celebrex
Oruvail
Lamictal
Lotrimin
Plendil
Hydralazine
Hydrocodone








Atenolol
Cerebrex
Elavil
Lomotil
Lotensin
Pindolol
Hydroxyzine
Hydrocortisone
Poison plants



Digitalis effects
– Lily-of-the-valley,
Foxglove,
Oleander, Yew
Nicotinic effects
– Poison hemlock
Atropinic effects
– Jimson weed
Non-Toxic Products
Ball point ink
 Bubble bath
soaps
 Chalk
 Cigarettes (< 3
butts)
 Crayons

Deodorants
 Lipstick
 Pencil (graphite)
 Toothpaste
 Water colors
 Candle wax (but
candle oil is!)

Evaluation
History of poisoning
 Physical examination
 Laboratory studies
 Gastrointestinal decontamination

History
What?
 When?
 How much?
 Reliability…

What ?
Medication
 Illicit drug
 Hazardous chemical

What form?
Pill
 Solid
 Liquid
 Gaseous

What route ?
Ingestion
 Inhalation
 Topical
 Intravenous

When ?

Elapsed time
How much ?
Estimate amount
 Concentration

“Clues”
Bradycardia







Calcium channel blockers
Digoxin
Narcotics
Organophosphates
Carbon monoxide
Beta-blockers
Clonidine
Tachycardia









Amphetamine (Ritalin)
Atropine
TCA’s
Theophylline
Salicylates (aspirin)
Iron
Cocaine
PCP
Synthroid
Slow Respiration




Alcohol
Narcotics
Clonidine
Sedatives
Tachypnea




Amphetamines
Salicylates
Carbon monoxide
Ethylene glycol
(anti-freeze)
Hypotension







Calcium channel blockers
Carbon monoxide
Cyanide
Iron
Narcotics
Anti-hypertensives
Met-hemoglobin
Hypertension






OTC cold remedies
Amphetamine
PCP
TCA
Cocaine
Diet pills
V Tach






Amphetamines
Carbamzepine (Tegretol)
Chloral hydrate
Cocaine
Digitalis
Theophylline
Torsades de Pointes





Chloral hydrate
Cisapride
Organophosphates
Terfenadine
Phenothiazines
Hypoglycemia (HOBBIES)






Hypoglycemia
Oral hypoglycemic agents
Beta-Blockers
Insulin
Ethanol
Salicylates
Hypothermia




Ethanol
Narcotics
Carbon monoxide
Clonidine
Hyperpyrexia





Atropine
Salicylates
Theophylline
Cocaine
TCA
CNS - Coma



Narcotic
Anti-cholinergics
Carbon monoxide
CNS - Delirium / Psychosis



Alcohol
PCP / marijuana
LSD
CNS - Seizure






Cocaine
Amphetamine
Lead
Salicylate
Isoniazid
Theophylline
Pupils - Miosis (COPS)




Cholinergics, Clonidine
Opiates, Organophosphates
Phenothiazine, Pilocarpine
Sedatives (barbiturates, ethanol)
Pupils - Mydriasis (AAAS)




Anti-histamine
Anti-depressant
Anticholinergics (atropine)
Sympathomimetics
– amphetamine, cocaine, PCP
Caution!
Polydrug overdoses with opposite
pupillary actions
 Non-toxin diagnoses
– Head trauma
– CNS hemorrhage

Cyanosis





MetHgb
– Unresponsive to O2
Aniline dyes
Nitrites
Benzocaine
Dapsone
Dry Skin

Anticholinergic
Breath Odors
Arsenic
 Camphor
 Cyanide
 Methyl salicylate
 Paraldehyde
 Hemlock

Garlic
Mothballs
Bitter almond
Wintergreen
Pears
Carrots
Cholinergic
“DUMBBELS”
 “SLUDGE”

Example –
Organophosphates
Nerve agents
DUMBBELS








Diarrhea, diaphoresis
Urination
Miosis, muscle fasiculation
Bradycardia
Bronchospasm
Emesis
Lacrimation
Salivation
SLUDGE






Salivation
Lacrimation
Urination
Diarrhea
GI complaint
Emesis
Anti-cholinergic syndrome







Dry mouth
Flushed appearance
Dilated pupils
Fever
Ileus
Urinary retention
Disorientation
Examples –
Anti-histamines
Jimson weed
Lomotil
TCA
Carbamazepine
Glycopyrrolate
Atropine
Anti-cholinergic
Hot as a hare
 Blind as a bat
 Dry as a bone
 Red as a beet
 Mad as a hatter
 Full as a flask

Narcotic
Pinpoint pupils
 Coma
 Respiratory depression

Salicylates
Fever
 Tachypnea & hyperpnea
 Lethargy
 Metabolic acidosis

Theophylline
Protracted Vomiting
 Tremors
 Tachycardia
 Seizures
 Hypotension

Isoniazid
Seizures
 Metabolic acidosis
 Hyperglycemia

Phencyclidine (4 Cs)
Combative
 Catatonia
 Convulsion
 Coma
 Nystagmus

TCA
Metabolic acidosis
 Prolonged QRS
 Seizures
 Dilated pupils
 Dysrhythmia

Cyanide
Feeling of impending doom
 Sudden coma
 Metabolic acidosis
 Hypotension
 Bitter almond odor

Carbon monoxide
Headache
 Lethargy
 Dizziness
 Influenza like syndrome
 Coma

Ethanol
Hypoglycemia
 Lethargy
 Ataxia
 Seizure
 Characteristic breath odor

Methanol
Severe metabolic acidosis
 Sluggish pupils
 Hyperemic retina
 Blurred vision

Ethylene Glycol
Lethargy or coma
 Metabolic acidosis
 Urinary sediment
 Crystalluria

Clonidine
Hypothermia
 Bradycardia
 Miosis
 Respiratory depression

Elevated anion gap
Methanol
 Paraldehyde & phenformin
 Iron & isoniazid
 Ethylene glycol & ethanol
 Salicylate

ABC’s
Airway
 Breathing
 Circulation
 Disability
 Decontamination

Consciousness
A: Alert
 V: Responsive to verbal stimuli
 P: Responsive to pain
 U: Unresponsive

Drugs
Dextrose
 Oxygen
 Naloxone

Decontamination
Ocular- copious saline lavage
 Skin- copious water
 GI-consider options

Lab Evaluation

No “tox panel” that is uniformly
helpful
Urine Screen
Marijuana
 Amphetamines
 Barbiturates
 Cocaine
 Opiates
 PCP

5-10 days
48 hours
24 h-2 wks
2-4 days
2 days
8 days
EKG
All suspected ingestion
 Tricyclics

Pulse oximetry
Measure of oxygen saturation of
normal hemoglobin
 Does NOT differentiate CO-Hgb
from oxyHgb
 Falsely low sats

– Nail polish
– Methylene blue
– Poor perfusion
Other tests
CXR - hydrocarbons
 ABG - salicylates
 Esophagoscopy - Caustics

Drug levels








Acetaminophen
Salicylates
Methanol
Ethylene glycol
Iron
Theophylline
Carbon monoxide (co-ox blood gas)
Lithium
Radiopaque (CHIPS)
Chloral hydrate
 Heavy metals
 Iron
 Phenothiazine (laxatives)
 Slow release

GI tract decontamination
Syrup of Ipecac (not used in hospital)
 Gastric lavage – 1st hour
 Activated charcoal

– Inert
– Reduces bioavailability of drug
– Not w/ HC or corrosives
Cathartics – decrease transit time
 WBI (whole bowel irrigation)…till clear

Urine alkalinization
Salicylates
 Phenobarbital
 Chlorpropamide

Extracorporeal methods

Hemodialysis
– Severe poisoning
– Renal failure

Hemoperfusion
– Perferred in some toxic ingestions
Antidotes













Oxygen - carbon monoxide
Naloxone – opioids
Methylene blue – MetHgb
Sodium nitrite - cyanide
Deferoxamine – iron
Acetoaminophen – N-acetylcysteine
Anti-cholinergics – physostigmine
Organophosphates – atropine, pralidoxime
Benzodiazepines – flumazenil
B-blockers – glucagon
TCA – bicarb
Coumadin – Vitamin K
Fomepizole (Antizol) – ethylene glycol
Related documents