Poisoning

Ali Alhaboo Assisstant Professor of

Pediatrics

PICU consultant

Overview of pediatric
poisoning, diagnosis and
treatment
Summary of the most
encountered poisoning

Epidemiology

Most of the toxic exposures have only
minor or no effect on the child
85% - 90% of pediatric poisoning
occurs in < 5 yrs of age (accidental)
usually single agent
10% - 15% in older age, mainly
adolescents (intensional) usually
several agents
3-4% of PICU admission are because of
toxic exposures

ED referral recommendations



Serious exposures
Younger than 6 months
History of previous toxic ingestion
Questionable or unreliable history

Routes of exposures in
children


Ingestion
Inhalation
Skin exposure

  Plants Analgesics: Paracetamol is the commonest cause of poisoning in children ( high doses more than 200 mg/kg) Less common but serious    causing severe hypoglycemia and LOC. Fe supplements: 2nd most common in females.Common agents   Cosmetics and personal care product Cleaning substance: flash is more serious than Clorox because it melts the esophagus and destroys it.  Note: OCPs are not harmful.   Anti-hypertensive. Antidepressants Anti-diabetics: Hydrocarbon . Pesticides: organophosphates.

g. What has been done to the child. The route of exposure Underlying medical problems The clinical effect (with few exceptions rapidity of symptoms progression correlates with severity of poisoning. The time elapsed and the dose taken (if it was unknown consider it serious).. acetaminophen) ? Trauma in addition to ingestion (change in LOC).e.History         Identification of the toxic agent Age of the child. .

hair. skin.Physical Exam     Weight (determine ? mg/kg ingested) Vital signs Check odors from the breath. clothing Thorough exam for any abnormal finding .

General presentations suggestive of poisoning      Severe vomiting. diarrhea Acutely disturbed consciousness Abnormal behavior Seizure unusual odor      Shock Arrhythmias Metabolic acidosis Cyanosis Respiratory distress .

Clinical clues to the diagnosis of unknown poisoning      Odor Skin Mucous membranes Temperature Blood pressure      Pulse rate Respiration Pulmonary edema CNS GI system .

phosphorous. methanol.Odor Signs or symptom     Poison Bitter almond Acetone  Oil of wintergreen Garlic       Alcohol Petroleum  Cyanide Isopropyl alcohol. organophosphates Ethanol. methanol Petroleum distillates . thallium. acetylsalicylic acid Methyl salicylate Arsenic.

phenacetin. organophosphates. benzocaine Carbon monoxide. boric acid. cyanide. LSD. anticholenergics Amphetamines. nitrites. barbiturates Anticholenergics . cocaine.Skin Sign or symptom   Cyanosis Red flush Poison     Sweating  Dry  Methemoglobinemia secondary to nitrates.

paraquat Caustics. irritant gases .Mucous membranes Signs or symptoms  Dry   Salvation   Oral lesions   Lacrimation  Poison Anticholenergics Organophosphates. organophosphates. carbamates Corrosives.

TCAs Anticholenergics. phenothiazines. theophylline .Temperature Signs or symptoms   Hypothermia Hyperthermia   Poison Sedatives hypnotics. salicylates. TCAs. clonidine. carbon monoxide. ethanol. phenothiazines. amphetamines. cocaine.

clonidine.Blood Pressure Signs or symptoms  Hypertension  Hypotension   Poison Sympathomimitics (especially phenylpropanolamine in overthe-counter cold remedies). organophosphates. amphetamine. beta blockers. phencyclidine. benzodiazepines. TCAs . barbiturates. cocaine Antihypertensives. Ca++ channel blockers.

sedatives hypnotics. TCAs Anticholenergics. betablockers. ethchlorvynol.Pulse rate Signs or symptoms  Bradycardia    Tachycardia   Arrhythmias Poison Digitalis. organophosphates. cyanide . phenothiazines. TCAs. carbon monoxide. digoxin. sympathomimetics. aspirin. beta blockers. amphetamines. opioids Antichlonergics. cocaine. alcohol. theophylline.

Respirations Signs or symptoms  Depressed   Tachypnea  Kussmaul’s sign Wheezing Pneumonia Pulmonary edema         Poisoning Alcohol. sedatives/hypnotics. barbiturates. salicylates Organophosphates Hydrocarbons Aspiration. ethylene glycol. salicylates. amphetamines. opioids. sympathomimetics . paralytic shelfish poisoning Salicylates. carbon monoxide Methanol. opioids. TCAs.

cocaine. rigidity    Poison Camphor. PCP. aspirin. pesticides.CNS Sings or symptoms     Seizures  Fasciculation Hypertonus Myoclonus. amphetamines. lithium. organophosphates. haloperidol . phenothiazines Anticholenergics. sympathomimetics. phenothiazines. TCAs Organophosphates Anticholenergics. phenothiazines. INH. lead. carbon monoxide. anticholenergic. theophylline.

CNS Sings or symptoms    Poison Delirium/psychosis  Anticholenergics. anticholenergics. marijuana. heavy metals Coma  Alcohol. opioids. cocaine. carbon monoxide. salicylates. sedative hypnotics. heroin. paralysis carbamates. sympathomimetics. Weakness. LSD. PCP. alcohol. heavy metals . phenothiazines. TCAs. organophosphates  Organophosphates.

TCA. barbiturates.EYE Signs or symptoms  Miosis    Mydriasis     Blindness Nystagmus Poison Opioids. PCP Antichlenergics. PCP. amphetamines. benzodiazepines. PCP). LSD. glutethimide. carbamazepine. methanol.carbon monoxide. sympathomimitics (cocaine. organophosphates. glutethimide Methanol Diphenylydantoin. phenothiazines. ethanol . barbiturates. mushrooms.

phosphorous. fluoride. lithium. heavy metals.GI Sings or symptoms  Vomiting. diarrhea Poison  Iron. organophosphates . mushroom.

tachycardia. antihistamines. bronchorrhea. diarrhea. confusion. coma Salivation. emesis. fasciculations. bradycardia. weakness. dry skin.Toxidromes of Common Pediatric Poisonings Toxin   Anticholenergi cs (atropine. arrhythmias. mushrooms) Cholenergics (organophospha tes and carbamate insecticides) Signs or symptoms   Fever. agitation. scopolamine. hallucinations. lacrimation. coma . bronchospasm with wheezing. mydriasis. miosis. dry mouth. TCAs. flushed. sweating. warm.

seizure . abdominal pain. coma Nausea. miosis. mydriasis. tremor. hypotension. vomiting. bradycardia.Toxidromes of Common Pediatric Poisonings Toxin   Opiates Narcotic withdrawal Signs or symptoms   Hypothermia. hypoventilation. diarrhea. diaphoresis. irritability. lacrimation. delirium.

oculogyric crisis. anticholenergic manifestations . convulsions. hypoventilation. coma Coma. ataxia. tachycardia.Toxidromes of Common Pediatric Poisonings Toxin    Sedative/ hypnotics  TCAs  Phenothiazines  Signs or symptoms Hypothermia. tachycardia. dystonia syndrome. trismus. hypotension. coma. arrhythmias. anticholenergic manifestations Hypotension.

shock. lethargy. abdominal pain . arrhythmias. psychosis. hyperpnea. ephedrine. vomiting. vomiting. cocaine. phenylpropanolamie. hallucinations. seizure.Toxidromes of Common Pediatric Poisonings    Toxin Salicylates  Iron  Sympathomimetics (amphetamines. caffeine. aminophylline) Signs or symptoms  Fever. hemorrhagic diarrhea Tachycardia. acidosis. coma Hyperglycemia. nausea. tinnitus.

renal function) Serum osmolar gap CBC (anemia. hemolysis) DIC panel when suspected .Laboratory tests Qualitative toxicology screening is rarely as helpful as Hx and           PE in determining the cause Best done on urine and gastric aspirate samples Quantitative serum level of known drug is indicated when it can enable prediction of toxicity or determination of treatment ABGs with respiratory symptoms and to assess acid-base balance Blood glucose from 1st sample Liver and kidney function (metabolism&excretion) Serum electrolytes (anion gap.

Hyperglycemia . iron. isopropyl alcohol. ethanol. isopropyl alcohol. acetaminophen.Ketonuria Isopropyl alcohol. CO. ethanol.Decreased hemoglobin saturation with normal or increased PO2 . ethylene glycol Salicylates. isoniazid. nitrites. methanol. ethylene glycol. phenfomin. salicylates . phenformin. oral hypoglycemic agents Ethylene glycol. benzocaine) Methanol. paraldehyde. isoniazid.Elevated anion gap metabolic acidosis .Routine Laboratory Tests That Can Suggest Poisoning .Hypocalcemia Agents causing methemoglobin (nitrates. cyanide Ethanol. organophosphates. isopropyl alcohol. salicylates. iron Insulin. methanol . salicylates.Oxalic acid crystalluria Ethylene glycol . toluene.Elevated osmolar gap . ethanol. isoniazid.Hypoglycemia .

Drugs with clinically useful serum level quantitation         Acetaminophen Anticonvulsants Carbon monoxide Cholinesterase Digoxin Ethanol Ethylene glycol Heavy metals         Iron Isopropanol Lead Lithium Methanol Methemoglobin Salicylate Theophylline .

Radiography indications     If head trauma cannot be excluded (skull and cervical spine film. head CT if physical findings are suggestive) If child abuse is suspected (skeletal survey) If patient is having respiratory distress (CXRay) If radiopaque substance is suspected .

Common substances that are radiopaque (CHIPES)       Chloral hydrate Heavy metals Iodine Phenothiazine Enteric coated and extended release medication Salt tablets (in Fe ingestion. serial films indicate movement and elemination) .

(N-acetylcesteine is the antidote for paracetamol. LFT. U/E. RFT. .Steps of management        First you have to start with ABC. If hypoglycemic give 5-10% dextrose (not higher than that because it might harm the vessel). if it was elevated give FFP or vitamin K) and albumin. Desfuroxemine is the antidote for iron. Check the O2 saturation Glucocheck for hypoglycemia. Transfer the patient to the ICU. Do toxicology screen. if there is no bed keep him in the ER. Give antidote as early as possible if available. Dose: 2-5 ml/Kg. coagulation profile (PT is the first to be affected. if hypotensive repeat ABCs.

 Breathing: clear secretions. do baseline ECG. continuous CR monitor. treat wheezing and stridor. rule out metabolic causes of seizure . use nonspecific antidote of D10W 2cc/kg and Naloxone 0.1mg/kg. watch for seizures. PALS guidelines  Neurologic status: frequent assessments. CXRay. watch for arrythmias. fluids for low BP.Treatment  Airway: patency and protective mechanisms (if absent. use nonspecific antidotes. early controlled intubation prefered  Circulation: frequent VS. if no response intubate. give O2. continuous O2 saturation. ABGs. the most common cause to admit intoxication to PICU.

adults 30 ml may repeat once     Contraindications Petroleum distillates Caustic agents Impaired consciousness. propoxyphene..GI decontamination Emesis-Syrup of Ipecac Therapy    Dosage in < 1 yr 10 ml Young children 15 ml Adolescents.g. seizures Rapid coma-inducing agents (e. TCAs) .

  We use lavage when the patient presents early and is stable. If late presentation where the drug has already passed to the duodenum use the activated charcoal( through a NG tube) where up to 1 million particles can adsorb to the medication. .

36-40 Fr for adolescents) Left recumbent Trendelenburg’s position to reduce the risk of aspiration Lavage with saline or 1/2 NS until return is clear Most successful for toxins that delay gastric emptying (aspirin. meprobamate) Contraindications    Corrosive caustic agents Controversial in petroleum distillates ingestion Stupor or coma unless airway is protected . anticholinergics) and for those forming concretions (iron. salicylates. iron.GI decontamination Therapy     Lavage Large bore orogastric hose (28 Fr for young children.

Adults 50-100 g Corrosive agents: charcoal interfers with GI endoscopy Most feared complication is aspiration leading to severe pneumonitis and ARDS . It should be only given for conscious patients.GI decontamination Therapy Activated Charcoal Contraindications    Administer in all cases after emesis.Children 1 g/kg . Dosage: .

GI decontamination Therapy   Cathartics MgSO4 250 mg/kg/dose P.(max dose 30 g) in 10%-20% solution Sorbitol magnesium citrate Repeat above doses every 2-4 hrs until passage of charcoal stained stools  Contraindications Avoid MgSO4 in renal failure .O.

barbiturates and methotrexate). protein binding is not a limitation . the goal is urine pH of 7-8   Serum alkalinization in TCAs toxicity Hemodialysis in low molecular weight substances with low volume of distribution and low binding to plasma proteins  Hemoperfusion.O = 2-5 cc/kg/hr (contraindicated in pulmonary or cerebral edema and renal failure)  Urinary alkalinization to eleiminate weak acids(salicylates.Enhanced elimination  Forced diuresis by administering 2-3 times the maintenance fluid to achieve U. can be achieved by adding NaHCO3 to the IV fluids.

Antidotal Therapy   Only a small proportion of poisoned patients are amenable to antidotal therapy Only a few poisoning is antidotal therapy urgent (e. cyanide. CO.g.. organophosphate and opioid intoxication) .

Specific Intoxications and Their Antidotes Poison Antidote Indications Acetaminophen N-Acetylcysteine (Mucomyst) Serum level in “probable” hepatotoxic range Anticholenergics Physostigmine SVT with hemodynamic compromise Beta blockers Glucagon Isopreterenol. epinephrine Flumazenil Bradycardia Bradycardia Benzodiazepines Symptomatic intoxication Carbon monoxide O2 Level > 5-10% Cyanide Amyl nitrite. sodium thiosulfate Symptomatic intoxication Digitalis Specific Fab antibodies . sodium nitrite. dopamine.

Specific Intoxications and Their Antidotes Poison Antidote Indications Ethylene glycol Ethanol Osmolar gap and metabolic acidosis or Serum level >20 mg/dl regardless of symptomatology Iron salts Desferoxamine Symptomatic patients Serum iron > 350 g/ml or > TIBC Positive deferoxamine challenge test Isoniazid Pyridoxine (vit B6) Methanol Ethanol Metabolic acidosis and elevated osmolar gap regardless of symptoms Methemoglobinemi Methylene blue a producing agents Symptomatic poisoning Methemoglobin level > 30-40 % Narcotics Naloxane Symptomatic intoxication Organophosphate insecticides Atropine Pralidoxime Cholenergic crisis Fasciculation and weakness Phenothiazines Diphenhydramine Symptomatic intoxication (oculogyric crisis) .

vomiting and malaise for 24 hrs Improvement for 24-48 hrs Hepatic dysfunction after 72 hrs (AST is the earliest and most sensitive) Death may occur from fulminant hepatic failue Toxicity likely with ingestion of > 150 mg/kg Rumack-Matthew nomogram defines the risk of hepatic damage in acute intoxication (level at 4 hrs post ingestion) .Acetaminophen (paracetamol) poisoning       Nausea.

NAC should be given even with > 24hrs presentation) NAC should be given if serum acetaminophen level is either in the “possible” or “probable” hepatotoxic range . P.Acetaminophen (paracetamol) poisoning management     GI decontamination Activated charcoal within 4 hrs of ingestion Antidote N-acetylcysteine is most effective if given within 8 hrs of ingestion. total of 17 doses.O or IV (However.

Salicylate toxicity Clinical manifestations Common           Fever Sweating Nausea Vomiting Dehydration Hyperpnea Tinnitus Seizures Coma Coagulopathy        Uncommon Respiratory depression Pulmonary edema SIADH Hemolysis Renal failure Hepatotoxicity Cerebral edema .

Laboratory findings in salicylate toxicity     Metabolic acidosis Respiratory alkalosis Mixed (resp alkalosis &metabolic acidosis) Hyperglycemia. hyponatremia Hypokalemia Hypocalcemia Prolonged PT Ketouria . Hypoglycemia      Hypernatremia.

lethargy or excitability) 300-500 mg/kg severe toxicity (severe hyperpnea. sometimes with convulsions) .Prediction of acute salicylate toxicity     Ingested dose can predict the severity < 150 mg/kg toxicity not expected (asymptomatic) 150-300 mg/kg toxicity mild to moderate (mild to moderate hyperpnea. coma or semicoma.

glucose. renal failure. pulmonary edema and severe CNS manifestation .Management of salicylate toxicity        GI decontamination Correct dehydration and force diuresis Urine alkalinization and acidosis correction with IV NaHCO3 Monitor electrolytes. severe acidosis unresponsive to NaHCO3. calcium Vit K for hemorrhagic diathesis Decrease fever with external cooling Hemodialysis for severe intoxication (Dome nomogram).