Dr.

Kay Bailey
Section of Child Health
 Poisoning can be defined as the
exposure of a victim to an agent
that by transference of chemical
or radiant energy, can cause
symptoms and signs of organ
dysfunction leading to injury or
death.
 Accidental
Therapeutic
Occupational
Suicidal
Munchausen by proxy
 1999 2.0 m calls to poison centers in the USA
52% children < 6yrs.
96% no or minor effect, 0.002% fatalities

90% occur at home

60% non-drug agent
Cosmetics, Personal care products, Cleaning
substances, Plants, Foreign bodies, Hydrocarbons
40% Pharmaceutical preparations
Analgesics, Cough and cold preps,
Antimicrobials, Vitamins
Most Commonly Reported Fatal
Ingestions

Pharmaceutical Non- Pharmaceutical

Prenatal iron Hydrocarbons
Antidepressants Alcohols
Cardiotonic agents Cleaning substances
Salicylates Pesticides
 Common Lethal Toxins
(1-2 tabs or tsp)

Benzocaine Methyl Salicylate

Camphor Quinine
Chloroquine Salt
Hydorocarbons Methanol
Lindane Theophylline
Methadone

Source EMC NA 2003

 Jan-Dec 2001
<5 M= 250 F= 196
5-9 M= 82 F= 51
10-19 M= 29 F= 21

Total Accidental Poisoning = 767

Total = 0.79% of total visits
(Falls = 3.88%)
Burden at BHC Casualty Jan-Nov 2002
56,282 patients seen
RTI 21.4%
Asthma 18.3%
GE 9.1%
MVA 0.4%
Burns 0.35%
Poisoning - 0.3%
Other injuries 3%
Other conditions 47%
Adapted from a lecture by Julie Steele-Duncan
 Most often involve products in use
Occur when parents are distracted
Occur in poor socioeconomic settings
because children are hungry
Occur most commonly in young children
because they tend to mouth objects
Are more likely when children have a cold
because they cannot smell
 Change in Sensorium Coma
Change in Behavior
Seizures
Nausea, Vomiting, Diarrhea ( Bloody)
Poison Ingestion
Toxidromes - constellation of signs
and symptoms typical of certain
agents
 Stabilize
Monitor
History
Examination
Investigations
Identify the poison - Toxic or Non- Toxic?
Does the patient need to be hospitalized?
Decontamination- Necessary? What Method?
Administer Antidote
Enhanced Elimination
Educate regarding prevention
STABILIZE
Airway - Clear airway
- Position the patient
- Intubate the patient if necessary

Breathing - Oxygenate, Ventilate

Circulation - Fluids
- CPR
- Vasopressors
- Manage Arrythmias
 MONITOR
Vital signs
Conscious level
Airway
Ventilation
Circulation
Temperature
Fluid Balance - Input Output
Acid Base balance
HISTORY
Age
Weight
Past Medical History may define whether patient
at special risk from toxin

When?
Time elapsed between exposure and symptoms
One time vs. chronic vs. acute on chronic.

Where?
Poisoning in kitchen likely to be different from
that in garage or bathroom
HISTORY

What route?
Ingestion - 75%
Inhalation
Ocular
Dermal
Parenteral
Bite
Sting.

Two routes or more may be involved.

Child may inhale chlorine vapor and splash
bleach in eye while drinking it .
HISTORY
What?
Single agents usual in children.
What medications at home?
What plants?
Ask parents to bring agent
How much?
Assume worst case.
One Swallow = 5 mls < 3 yrs
= 10mls < 10yrs
= 15mls adolescent
Count pills, Measure liquids
HISTORY

Course since exposure

Helps to identify agent

To indicate type of intervention needed
How successful it is likely to be
EXAMINATION
Breath odors

Moth Balls Camphor

Bitter Almonds Cyanide

Garlic - Arsenic, Organophosphates

Sweet/Fruity - Acetone, ethanol, nail polish

remover

Wintergreen - Methyl salicylate

Temperature
Hyperthermia - Antihistamines, Anticholinergics
- Aspirin

Hypothermia - Barbiturates, Ethanol

- Carbamezepine

Respiratory Rate
Tachypnea - Salicylates, Iron, Cyanide

Hypoventilation - Alcohol, Barbituates

- Hypoglycemics
Pulse Rate
Tachycardia
- Sympathomimetics e.g. salbutamol
- Anticholinergics e.g. antidepressants

Bradycardia - Beta blockers e.g. propranolol

- Organophosphates
- Digoxin
Blood Pressure

Hypertension - Phenylpropanolamine

Hypotension - Alcohol, Barbituates, Iron

CNS

Coma - Alcohols, Anticonvulsants, Barbituates

Seizures - Lead, Salicylates

Nystagmus - Phenytoin

Ears - Tinnitus e.g Salicylates

Eyes

Conjunctival injection - Ethanol, Marijuana

Pupils
- Miosis - Organophosphates, Narcotics
- Mydriasis - Antihistamines, Anticholinergics

Vision
- Blurred Alcholol
- Scotomas Salicylates
- Color - Digitalis
 Modified Glasgow Coma Scale

Eye Opening
Motor Response
Verbal Response
 Eye Opening
SCORE RESPONSE
< 1 year > 1year
4 Spontaneously Spontaneously
3 To shout To verbal command
2 To pain To pain
1 No response No response
 Best Motor Response
SCORE RESPONSE
< 1 year > 1year
6 Obeys Obeys
5 Localizes pain Localizes pain
4 Localizes pain Flexion
Withdrawal
3 Decorticate Decorticate
2 Decerebrate Decerebrate
1 No response No response
 Best Verbal Response
SCORE RESPONSE
0-23mths 2-5 yrs >5 yrs
5 Smiles, coos Appropriate oriented
words
4 Cries Inappropriate Disoriented
words
3 Inappropriate Cries/Screams Inappropriate
cry words
2 Grunts Grunts Incomprehensible

1 No response No response No response

Toxidromes

Toxin Symptoms and Signs

Anticholinergic Fever, flushing, dry skin, mydriasis,
Antihistamines dry mouth, delirium
Cholinergic Salivation, lacrimation, sweating,
Organophoshates bronchorrhea, fasculations, miosis
Hypermetabolic Fever, HR, RR, tinnitus, acidosis,
Salicylates seizures
Extrapyramidal Dystonic syndrome, coma,
Phenothiazines prolonged QTc interval, oculogyric
crisis
Toxidromes

Toxin Symptoms and Signs

Narcotics CNS depression, hypothermia, RR
heroin miosis, BP
Sympathomimetic Excitation, psychosis, seizures, RR
Phenylpropranolamine BP, mydriasis

Withdrawal Nausea, vomiting, shivering, sweating,

benzodiazepine, alcohol rhinorrhea, mydriasis, yawning

Iron Shock, fever, hyperglycemia,

bloody diarrhea
Physical Findings Adrenergic Anticholinergic

Vital signs
RR Increased No change
HR Increased Increased
Temp Increased Increased
Blood Pressure Increased No change /Increased

Physical Exam
Mental Status Alert/Agitated Depressed/Confused/Hallu
Pupils Dilated Dilated
Mucus membranes Wet Dry
Skin findings Diaphoretic Dry
Reflexes Increased Normal
Bowel sounds Increased Decreased
Urinary ability Increased Decreased
Other Possible seizures Possible seizures
Physical Findings Cholinergic Opioid
Anticholinesterase
Vital signs
RR No change Decreased
HR Decreased Normal/Decreased
Temp No change Normal/Decreased
Blood Pressure No change Normal/Decreased

Physical Exam
Mental Status Depressed/Confused Depressed
Pupils Constricted Constricted
Mucus membranes Wet Normal
Skin findings Diaphoretic Normal
Reflexes Normal/Decreased Normal/Decreased
Bowel sounds Increased Decreased
Urinary ability Increased Normal
Other Muscle Fasciculation Possible seizures
Possible seizures
Physical Findings Seditive-Hypnotic Toxidrome

Vital signs
RR Decreased
HR Normal/Decreased
Temp Normal/Decreased
Blood Pressure Normal/Decreased

Physical Exam
Mental Status Depressed
Pupils Normal
Mucus membranes Normal
Skin findings Normal
Reflexes Normal/Decreased
Bowel sounds Normal
Urinary ability Normal
Other
 INVESTIGATIONS
CBC - wbc in lead and kerosene

U/E and Creatinine

Calculate osmolar gap - in alcohol poisoning

Osmolar Gap = Measured - Calculated Osmolarity

Calculated Osmolarity = 2Na + BUN/2.8 + Glucose/18

Normal = 290 mOsm/L
Osmolar Gap < 10
INVESTIGATIONS

Calculate anion gap

in salicylate, iron, ethanol, ethylene glycol,
methanol isoniazid and formaldehyde poisoning
in lithium and bromide

Anion Gap= Na - {Cl-+ CO2} Normal= 11mEq/L

Monitor renal function

INVESTIGATIONS

LFTs - paracetamol poisoning

Glucose - salicylates , iron , alcohol

- diabetic drugs

X-rays - opacities of calcium tabs enteric coated agents

ECG - identify and monitor arrythmias - propranol,

calcium channel blockers, phenothizines, lithium

Blood, Urine and Gastric contents for toxicology

Toxicology
ASA
Acetominophen
Iron
Lead
Lithium
Barbituates
Ethylene gylcol
Methanol
Carbon Monoxide
 Other Tests
Ferric chloride test - ASA, Phenothiazines

Antidotes
Desferoxamine and iron
Naloxone and opiates
DPH with phenothiazines
Organophosphates and atropine
 DECONTAMINATION

Not every child requires decontamination

Not required for

Non- toxic substances
Toxic substances in small amounts
Presentation long after exposure
Skin/ Mucus membranes/Eyes

Wash with lukewarm water 10-15mins

Use soap for skin
Wear gloves for Organophosphates

Inhalation

Remove from fumes

Give humidified Oxygen
GI DECONTAMINATION
1. CHEMICAL EMESIS
2. LAVAGE
3. ADSORBENTS - Activated Charcoal
4. CATHARTIC
5. WHOLE BOWEL IRRIGATION
6. DILUTION
7. NEUTRALIZATION
 GI DECONTAMINATION
1. CHEMICAL EMESIS
Most effective <1 hr post

Removes - 50 -60% < 30mins

- 30-40% <1hr
Syrup of ipecac used - 10mls <1yr, 15mls< 12ys

90% effective in producing vomiting in 20-30mins

Enhanced by giving 6-8 oz fluid.

Repeat x1 except patients < 1yr

1. CHEMICAL EMESIS - Contraindications

Strong acids and alkalis

Bleach
Hydrocarbons
? Patients who have ingested calcium channel
blockers and propranolol because of vagal
stimulation
Sharp objects
Coma
Seizures
Peptic ulcer disease
Children < 9 months
2. LAVAGE

Offers advantage of
Speed of evacuation
Administration of an adsorbent
+/- cathartic
+/- antidote

Most successful performed within 60-90mins

Removes - 38% drug 15 minutes post ingestion

- 13% 60 minutes post ingestion
 2. LAVAGE

Most useful with

Toxin associated with delayed gastric emptying
ASA, Iron

Drugs with anticholinergic properties

tricyclic antidepressants

Agents that form concretions lavage may

beneficial even hours later
sustained release preparations
2. LAVAGE

Patients with depressed airway reflexes

require cuffed ET tube
Use large bore 18 - 40F, 120ml syringe
Confirm placement by injecting air and
ausculltating over stomach
Patient on left side
Aspirate stomach contents.
100 -200 ml aliquots of warm saline till
clear
Pinch tube on removal to prevent aspiration
Contraindications:
Nontoxic agents
Agents already past the stomach or absorbed
Caustics
Sharp objects
Relative contraindications - hydrocarbons

Complications:
Aspiration
Esophageal Perforation
Electrolyte Abnormalities
Hypothermia
Arrythmias
Respiratory Distress
3. ADSORBENTS - Activated Charcoal

Odorless, tasteless black power

Residue from wood pulp

Relatively large surface area

Stable complex with ingested toxin

Prevents absorption
3. ADSORBENTS - Activated Charcoal

Give 1gm/kg in 8oz water or cathartic

q3-4h
Charcoal : drug ratio 10 : 1
Use after ipecac or lavage
Ineffective for
alcohols
caustics
cyanide
heavy metals, lithium, iron
hydrocarbons
some pesticides
CHARCOAL -Contraindication

Retching
Vomiting
Diarrhea
Constipation
Intestinal obstruction
Ileus
GI hemorrhage
Toxin not absorbed by charcoal
Esophageal endoscopy
4. CATHARTICS

Hastens intestinal transit time

Opportunity for intestinal absorption

decreased

Caution in < 2yr olds

risk of excessive fluid loss and dehydration.

Contraindications
caustic ingestions
ileus
recent bowel surgery
4. CATHARTICS

Magnesium sulfate 10% (Epsom salts) -

250mg/kg
not in renal failure

Magnesium citrate 6% - 4mg/kg

Sodium sulphate 10% - 250mg/kg

Sorbital 70% - 2ml/kg

5. WHOLE BOWEL IRRIGATION

Administration of 5-20 litres of electrolyte

balanced solution till rectal effluent clear

Particularly effective for iron tablets,

sustained or delayed release preps and
foreign bodies

Polyethylene glycol given by continuous

infusion by nasogastric infusion
0.5 L/hr < 6 years
1.5- 2 L/hr > 6 years
2 L/hr > 12 years
5. WHOLE BOWEL IRRIGATION

Give slowly with antiemetics to avoid

bloating and vomiting
Evacuation complete in 4 -6 hrs

Contraindications
GI hemorrhage or obstruction
Use of ipecac
level of consciousness
Uncooperative patient
6. DILUTION
Not effective. May be help GI upset
secondary to irritants

7. NEUTRALIZATION
Base/acid not recommended. Heat produced
may cause damage
 ENHANCED ELIMINATION

Used only in serious poisoning

Most cases of poisoning are handled

conservatively

Patient excretes or metabolizes the ingested

drug
ENHANCED ELIMINATION

DIURESIS

EXTRACORPORAL DRUG REMOVAL

ENHANCED ELIMINATION

DIURESIS
- Fluid, Ionized, Osmotic, Diuretic
- Renal clearance not proportional to urine
volume

Fluid
Enhances excretion by GFR 2-3 x normal
Ionized Diuresis

Drugs in the ionized state more readily excreted

Acidic compound like salicylates and long acting

barbiturates are more easily excreted by sustained
alkalization of the urine

IV Sodium Bicarbonate 1-2 meq/kg bolus

Then continuous infusion D5W with
sodium bicarbonate @ 1 - 2 x maintenance

Goal urine pH 7.8

Acidification not useful for weak bases

Amphetamines
Osmotic Diuresis

Osmotic load prevents renal reabsorption of

drugs excreted by kidney
Mannitol 0.5mg/kg/dose IV of 25% solution
q4-6h
Diuresis 2-3x normal
Careful monitoring
Contraindicated in renal failure and cardiac
disease
Diuretics

Increased output 2-3x normal

Furosamide 2mg/kg/dose IV or IM

Monitor electrolytes
EXTRACORPORAL DRUG REMOVAL

Hemodialysis, Hemoperfusion, Peritoneal

Dialysis and Exchange Transfusion

Not part of the usual emergency

management of poisoning

Used for most severe poisonings

Indications

Stage 3- 4 coma or hyperactivity

Hypotension threatening renal or hepatic

function

Apnea and no ventilation available

Electrolyte, acid base or hyperosmolar

disturbances not responsive to treatment

Marked hypo/hyperthermia
 Hemodialysis and Hemoperfusion most
effective techniques for toxin removal

Substances with
small volume of distribution (present primarily
in the intravascular space)
low protein binding, water soluble
small molecular weight benefit from these
methods

Hemodialysis offers the advantage of

permitting correction of concomitant
electrolyte or acidbase disturbances
Hemoperfusion

Uses a charcoal cartridge

Selectively removes the toxin as the blood

flows past

Effective only for substances that bind to

charcoal

Some large molecules, lipid soluble

molecules and those having high plasma
protein binding can be removed by
this method
 Hemodialysis Hemoperfusion

Distribution time Short Short

Low endogenous <4 mL/min/kg <4 mL/min/kg
clearance
Volume of 1 L/kg 1 L/kg
distribution
Protein binding Low Low or high
Solubility Water Water or lipid
Molecular weight 500 daltons 40,000 daltons
40,000 daltons
 Common agents removed
Hemodialysis Hemoperfusion
Barbiturates * Theophylline *
Ethylene glycol Barbiturates
Lithium Carbamezapine
Methanol Procainamide
Salicylates **
Procainamide
 Complications
Hemodialysis
Hypotension
Hemoperfusion
Hypotension
Bleeding
Thrombocytopenia
Problems assoc with
Leukopenia
vascular access
Electrolyte
Infection disturbances - Ca,
Air emboli PO4, Glu
Hemolysis Charcoal
Electrolyte embolisation
imbalance
Peritoneal dialysis
Less effective but easier in children

Should be used only when hemodialysis or

hemoperfusion cannot be performed

Used for
methanol
ethylene gylcol
salicylate
theophylline

Exchange transfusion
Reserved for young children who cannot undergo
hemodialysis or hemoperfusion
 ANTIDOTES.
The number of poisons for which
there is a specific antidote is small

Acetaminophen
Panadol, Cetamol, Tylenol, Calpol
N- aceytlcysteine
Dose: 140mg/kg then 70mg/kg x17 doses
 Organophosphates ( Weed killers)
Atropine 1-4mg or 0.05mg/kg IV
Repeated doses 2mg at 2-5min intervals to
reduce muscarinic effects till full
atropinization
then prn to maintain atropinization

Iron
Desferoximine 50mg/kg IM Max 1gm q4h

Warfarin
Vitamin K 2-5 mg/kg IM/IV
 PREVENTION
Lock up - out of reach, out of sight

Safety Closures

Store food away from chemicals, cleaning

products and medicines

Store medicines and chemicals in original

containers. Never food or drink containers

Avoid taking medicines in the presence of

children
 PREVENTION
Never say medicine is candy

Read labels

Never use medicine from unlabeled or

unreadable container

Never pour medicines in a darkened area

Take medicines with you if interrupted

 PREVENTION

Know what your child can do and store

potential poison out of his/her reach

Plan of action for poisoning

* Contact doctor or poison center
* Keep syrup of ipecac handy
* Know contraindications to vomiting
* Wash mouth, Wash eye, Wash skin
 Further Reading
Antidotes
Organophosphate , Iron, Lead, Alcohol,
Kerosene and other hydrocarbons,
Aspirin, Acetaminophen
Ingestions not requiring intervention
Drugs and chemicals adsorbed by
charcoal
 Sources
Nelson
Manual of Paediatric Therapeutics
Diagnosis of an Unknown Poison
PIR July 92
Common Poisonings - PIR April 94
Poisoning in children and adolescents
PIR Nov 93
Emergency Medicine Clinic of NA Feb 2002
Emergency Medicine Clinic of NA Feb 2003