Download Poisoning in Children

Chapter 18
Emergency Management
Poisoning in Children
• Definition of Poisoning:
– Exposure to a chemical or other agent that adversely
affects functioning of an organism.
• Circumstances of Exposure can be accidental,
environmental, medicinal or recreational.
• Routes of exposure can be ingestion, injection,
inhalation and others.
• Ingestion of a harmful substance is among the
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most common causes of injury to children less
than six years of age
Toxicology: is the science that studies the
harmful effects of drugs, environmental
contaminants,
and
naturally
occurring
substances found in food, water, air and soil.
Poisoning maybe a medical emergency
depending on the substance involved.
Poisoning in Children
Important history points
• What toxic agent/medications were found near the
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patient?
What medications are in the home?
– 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?
• Clinical manifestations:
• GIT symptoms: anorexia, abdominal pain, nausea,
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vomiting, and diarrhea…
CNS symptoms: convulsions (CNS stimulants),
coma (CNS depressants) as alcohol and barbiturates,
dilated pupils common in nicotine, cocaine and
ephedrine poisoning or pinpoint pupils due to opiates
or organophosphorus poisoning.
Skin symptoms: rashes, burn, eye inflammation,
skin irritation and cyanosis (cyanide).
Cardiopulmonary symptoms: dyspnea,
cardiopulmonary arrest.
Emergency treatment
General measures:
• Quick assessment & triage
• Identify the criminal.
• Limit absorption:
– Vomiting
– Lavage
– Activated charcoal instillation
Specific:
ABC’s of Toxicology:
• Airway
• Breathing
• Circulation
• Drugs:
• Resuscitation medications if needed
• Universal antidotes
• Draw blood:
• chemistry, coagulation, blood gases, drug
levels
• Decontaminate (Clean)
• Expose / Examine
• Full vitals / Foley / Monitoring
• Give specific antidotes / treatment
• Terminate exposure:
• Empty mouth of pills, plant part or other
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material.
Flush eyes continuously for 15-20 minutes.
Flush skin and wash with soap and a soft
cloth, remove contaminated clothes, especially if
a pesticide, acid, alkali or hydrocarbon is
involved.
Bring victim of an inhalation poisoning into
fresh air.
Give water to dilute ingested poison.
• 3. identify the poison:
• Ask the victim and witnesses.
• Save all evidence of poison ―empty bottle,
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opened container, vomitus and urine.
Be alert to signs and symptoms of potential
poisoning in absence of other evidence.
• 4. Remove poison and prevent absorption:
• a. Induce vomiting:
• Administer ipecac if ordered.
• 6-12 months: 10 ml doesn’t repeat.
• 1-12 years: 30 ml.
• Give 10-20 ml/kg of clear fluids after ipecac.
• b. Don’t induce vomiting if:
• Victim is comatose, in severe shock or convulsing or has lost the
gag reflex.
• Poison is or low-viscosity hydrocarbon, strong acid or alkali.
• c. Place the child in side lying or sitting position with head below
chest to prevent aspiration.
• d. Administer activated charcoal (1g/kg) 30-60 m. after vomiting
from ipecac if ordered.
1.
Corrosives substances “strong acids
or alkali”
• toilet cleanness, detergents, etc.
• Clinical manifestation:
• Severe burning pain in mouth, throats and stomach.
• White swollen mucous membranes.
• Edema of lips and tongue and pharynx (respiratory
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obstruction).
Violent vomiting and drooling and inability to clear
secretions.
Anxiety and agitation and signs of shock
Treatment:
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Inducing vomiting is contraindicated ―vomitus
will re-damage the mucosa.
Dilute corrosive with water; not milk unless
vomiting occurs.
Provide patent air way if needed.
Administer analgesics and don’t allow oral
intake
• Hydrocarbons: e.g. Kerosene, Lamp oil,
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Turpentine and paint remover.
Clinical manifestations:
Gagging, choking and coughing.
Nausea, vomiting, lethargy and weakness.
Respiratory symptoms (tachypnea, cyanosis
and grunting).
• N.B. Immediate danger is aspiration lead to
chemical pneumonia.
• Treatment:
• Inducing vomiting is generally contraindicated.
• Gastric lavage may be used.
• Symptomatic treatment of chemical
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pneumonia as oxygen therapy, humidification
and hydration.
Antibiotic for secondary infection
3. Acetaminophen:
• Clinical manifestations: occur in 4 stages:
• 1. Initial period (2-4 hours after ingestion)
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nausea, vomiting, sweating and pallor.
2. Latent period (24-36 hours), patient
improves.
3. Hepatic involvement (last up to 7 days), pain
in right upper quadrant, jaundice, confusion
stupor, coagulation abnormalities. Patient who
doesn’t die in hepatic stage gradually recover.
• Treatment:
• Emesis, lavage and activated charcoal.
• Antidote N-acetylcystine given by N.G.
tube or I.V. because of its offensive odor
―rotten eggs.
4. Aspirin:
• Clinical manifestations:
• Acute poisoning: nausea, vomiting,
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disorientation, dehydration, diaphoreses,
hyperpnea, hyperpyrexia, oliguria, tinnitus,
coma and convulsions.
Chronic poisoning: as mention above and
bleeding tendencies.
Acute ingestion toxic dose 300-500 mg/kg and
chronic ingestion toxic dose 100 mg/kg for 2 or
more days.
• Treatment:
• Home use of ipecac for moderate toxicity and
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hospitalization for severe toxicity.
Emesis, lavage, activated charcoal, sodium
bicarbonate to overcome metabolic acidosis.
Diazepam for seizures.
Oxygen and ventilation for respiratory
depression.
Vit. K. for bleeding.
Dialysis for severest toxicity.
5. Organophosphorus Poisoning
Parathion poisoning
• Clinical manifestations:
• Miosis (constriction of pupils), salivation,
lacrimation, urinary and stool incontinent.
• Pathology: it have three actions
• 1. Muscarinic action: (Acetylcholine receptors)
• Bronchospasm, dyspnea, cough, cyanosis,
increase bronchial secretions and frothy
secretions from mouth.
• 2. Nicotinic action:
• Muscle spasm (cramps), weakness,
hypertension, weak intercostal muscle that can
cause respiratory failure and death.
• 3. CNS action:
• Confusion, restlessness, drowsiness,
convulsions, general weakness, coma and/or
cardiopulmonary failure.
• Diagnosis:
• History and physical examination ―clinical
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manifestations‖.
Atropine test.
• Treatment:
• Remove clothes and wash skin ▪ Remove
poisonous by gastric lavage.
Give specific antidote:
• a. Atropine sulfate: block muscarinic action and
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CNS action BUT not nicotinic action. 0.02 mg0.04 mg/kg dose every 10 minutes until signs of
atropinization appear ―(dilated pupil, flush face
and dry mouth).
b. In severe cases Toxoguanin 5-8 mg/kg I.V.
will be given to activate acetylcholinestrase
enzyme in order to block nicotinic action of
parathion poisoning.
Communicable
Vaccination
Diseases
and
Normal functioning of the immune system
protects the body against the invasion of
outside microorganisms referred to as a
pathogen. Two of the most common
pathogens are bacteria and viruses. An
infection occurs when there is a successful
invasion of the host by a pathogen (antigen).
However, for this to happen, each link in the
chain of infection must be intact.
Chain of Infection
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The chain of infection describes the elements that
must be in place for the infection to occur. These
elements are:
• 1. Pathogen: Sufficient number of microorganisms
strong enough to enter and survive the body.
• 2. Reservoir: the proper environment within the body
to thrive must include oxygen water, food, and the best
pH balance and temperature.
• 3. Portal of exit: the pathogen must be able to exit its
existing environment. For example, the pathogen must
be able to leave the respiratory tract, gastrointestinal
(GI) tract, or skin of its present host to infect another
host.
• Mode of transmission: There must be a way for
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the pathogen to move from one host to another
such as by air droplets, water, or contact.
5. Portal of entry: The pathogen must be able to
enter the new host such as through a break in the
skin or via the respiratory tract.
6. Susceptible host: The host’s immune system
must be weak and unable to define against the
invading pathogen. A person who is very young or
very old or who has a low white blood cell count
or is taking anti-inflammatory medication typically
has a weakened immune system.
Staging of Infection
• The infectious process begins once the pathogen has
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successfully invaded the host. There are four stages of the
infectious process:
1. Incubation period: This is the interval between the
invasion and when the first symptoms appear.
2. Prodromal: This is the interval between the appearance
of nonspecific symptoms (e.g., I feel like I’m coming down
with something) to when specific symptoms appear (e.g.,
starting to feel warm and having a headache).
3. Illness: This is when symptoms for a specific type of
infection occur (e.g., fever, chills, headache, running nose).
4. Convalescence: This is the interval when the specific
systems abate (i.e., starting to feel better but not yet back
to normal).
• Good Defense
• 1. Natural immunity: the immune system recognizes the
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pathogen as a foreign cell that attacks and destroys the
pathogen using nonpathogen-specific phagocytic action.
2. Naturally acquired active immunity: The immune
system develops antibodies to a pathogen once the
pathogen infected the host previously. Antibodies then
attack and destroy subsequent invasion by the
pathogen.
3. Naturally acquired passive immunity: passed from
mother to fetus
4. Artificially acquired active immunity: A low potent or
dead portion of the pathogen is introduced to the host in
a vaccine causing the immune system to develop
antibodies against
• 5. Artificially acquired passive immunity: The
host is administered antibodies from a different
host in the form of immunoglobulin such as
gammaglobulin or convalescent serum globulin.
Artificially acquired passive immunity
provides short-term protection.
• The Defender
• Lymphocytes divided into B cells and T cells.
• B cells: Provide a humoral immune response because
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they produce an antigen-specific antibody.
T cells: Provide a cellular immune response. Mature T
cells are composed of CD4 and CD8 cells.
CD4 cells, known as helper T cells, stimulate immune
functions, such as B cells and macrophages.
A macrophage is a cell whose functions include
ingesting foreign or cells
CD8 cells are responsible for destroying foreign and viral
inhabited cells, and they suppress immunologic
functions
Vaccinations
• There are three types of vaccinations:
• 1. Live, attenuated: This vaccination contains a
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weakened pathogen.
2. Inactivated: This vaccination contains portions
of a dead pathogen
3. Toxoids: Amicroorganism itself might not
cause an infection, but toxin released by the
microorganism might cause the infection.
Toxoids are vaccines that are a defense against
the toxin
Immunization:
• The recommended age for beginning
primary immunization for infants is 2
month, except for types of vaccination
e.g. tuberculosis vaccine and hepatitis B
vaccine.
• Types of immunization:• 1. B.C.G. (Bacillus Calmette Guerin)
vaccine offers protection against
tuberculosis
• Frequency: the vaccine is given by intradermal
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injection (0.1 ml).
dose at birth during the first month of life.
• 2. Hepatitis B vaccine (HBV):- affords protection against
hepatitis B virus.
• Frequency: 3 doses, given intramuscular injections of
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separate site.
1st dose within the first 12 hours after birth.
2nd dose at one month of age.
3 rd. dose at 6 month of age.
• Diphtheria, tetanus, & pertussis vaccine: (DPT) afford
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protection against diphtheria, tetanus and pertussis. (0.5
ml) toxoids vaccine mixtures, given I.M deeply, don't
repeat the injection at the same site.
Frequency:
The first dose at 2 months of age.
The second dose 4 months of age.
The third dose at 6 months of age.
The first booster 18 months of age.
The second booster at 4 - 6 years.
The third booster at 14 - 16 years DT only.
• Contraindication:• Febrile illness.
• History of nervous system disease.
• For Pertussis:- C.N.S disturbances.
• Oral poliovirus vaccine: (OPV) offered for protection of
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poliomyelitis, vaccine is alive virus - 2 - 3 drops given
orally.
Frequency:
1st dose at 2 months.
2nd dose at 4 months.
3rd dose at 6 months.
4th dose at 18 months booster.
5th dose at 2.5 years booster.
• Precautions: ask mother not to feed the infant for 2 hours after the
vaccine is given.
• Contraindication:• Febrile illness.
• Gastro enteritis.
• Immunologic disease e.g. Leukemia.
• 5. Measles, mumps and rubella vaccine (MMR): affords
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for protection against measles, mumps and rubella.
Attenuated virus vaccine given S.C. at 15 month of age.
Storage at 2 - 8 c. and protect from light, expired date 8
hours. Check temperature before giving the vaccine.
Rubella (German measles): Given to children from 12
month or older. Unimmunized Prepupertal children and
adolescence female.
Measles: given for children at 15 month of age repeated
at 4 - 6 years.
Mumps: given for children over 12 months of age given
at 15 mon
• Reaction:
• Measles:- anorexia, malaise, rush, fever 5 - 7
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days after immunization.
Rubella:- mild rashes lasts 1 - 2 days after
vaccination, arthralgia, arthritis.
Mumps:- mild fever
Contraindication:
Febrile illness.
Pregnancy.
Food allergy such as eggs.
Thank you
DR Areefa Albahri