Acute Toxicity

By Kena Daniel Medicine C-II

Moderator: Dr Abera Olani MD (pediatrician)
Outline
• introduction
• Epidemology
• Approach to the poisoned patient
• General Principles of Management
• Specific poisons
 Introduction
• Poisoning is injury or death due to swallowing, inhaling, touching or injecting
various drugs, chemicals, venoms or gases.

• Suspect poisoning in any unexplained illness in a previously healthy child.

• If the child arrives within 1hr of ingestion of poisons he/she will be taken as
an emergency because this needs urgent treatment.
 Epidemology

• More than 90% of toxic exposures in children occur in the home, and most
involve a single substance.

• Ingestion accounts for the majority of exposures, with a minority occurring by

the dermal, inhalational, and ophthalmic routes.

• Exposures in the adolescent age-group are primarily intentional (suicide or

abuse or misuse of substances) and thus often result in more severe toxicity
 APPROACH TO THE POISONED PATIENT

• Primary survey: Assess ABCDO with additional consideration of the

poisoning agent.
• Airway: Remove excessive secretions, look for any inhalational injury that
might potentially worsen with time.
• Check for signs of burns in or around the mouth or of stridor
(upperairway/laryngeal damage) suggesting ingestion of corrosives.
• Consider early intubation, if the patient has severe airway compromise.
• Breathing: Look for signs of respiratory distress and give oxygen if indicated.
• Circulation: Check the pulse, capillary refill and skin color. If there is shock treat
accordingly.
• Coma: check the AVPU and pupillary response.
• Determine serum glucose and give Dextrose if hypoglycemic or if the child
has reduced level of consciousness treat as if hypoglycemic.
• Dehydration: Assess hydration status (dry tounge, buccal mucosa and
sunken eyeball)
• Exposure: Remove all clothing and wash with soap and water and check
body temperature.
• Secondary survey: more specific evaluation with history and physical
examination and laboratory to identify the exact cause and extent with
simultaneous detoxification of the patient.

• History and physical examination:

 Taking history
• Find out full details of the poisoning agent
• Attempt to identify the exact agent involved requesting to see the container,
where relevant
• Try to find the best estimate of the agent dose or amount
• The route of exposure (inhalation, injection, ingestion, contact)
• The time of ingestion to presentation (important for the management)
• Check that no other children were involved.

Physical exam:Do detailed examination which help to identify the causes

: breath odor, temperature, eye sign( dilated vs. constricted pupil), skin (hot
flushed, dry) and bowel sound.
 General Principles of Management

Management of a child with acute poisoning includes four principles:

• Decontamination (GI, skin, eye)
• Enhancing elimination
• Giving antidote and
• Supportive care
 Gastrointestinal decontamination

• most effective if done within one hour of ingestion,, and after this time there
is usually little benefit.
• Methods of gastrointestinal tract (GIT) decontamination includes:
• ipecac induced vomiting,
• use of cathartics,
• gastric lavage,
• activated charcoal and
• whole bowel irrigation (WBI)
Syrup of ipecac and cathartics are not recommended to manage children
with acute poisoning
 Gastric emptying with lavage
• Gastric lavage is useful only if it is done within one hour of ingestion of
poisons (specially liquid)
• Perform lavage with 15 ml/kg/cycle body weight of normal saline (0.9%)
maximum 200 to 400ml.
• Lavage should be continued until the recovered lavage solution is clear of
particulate matter.
• Contraindications to gastric lavage are:
• Ingestion of corrosives or petroleum products
• unconscious child with unprotected airway
 Activated charcoal

• It is more effective if used with in 1 hour, may be given as late as 4 hours if

the toxic agent causes delayed intestinal movement.
• The usual dose of activated charcoal is 1 gm/kg; adolescents should receive
maximum of 50 g
• The amount of water is 8-10 times of the amount of the charcoal, e.g. 5 g in
40 ml of water.
• Charged molecules & liquids do not bind well to activated charcoal
 Whole bowel irrigation (WBI)
• WBI is administration of large volume of polyethylene glycol solution with
balanced electrolyte and its given by NGT.
• Effective after ingestion of slowly absorbed substances, substances poorly
adsorbed to activated charcoal (lithium, iron) and pills
• For children 35ml/kg/hr can be given and adolescents can take 1-2 lts per
hour
 skin decontamination
• Remove all clothing and personal effects and thoroughly clean all exposed
areas with copious amounts of tepid water.

• Use soap and water for oily substances.

• Attending staff should take care to protect themselves from secondary

contamination by wearing gloves and apron.

• Removed clothing and personal effects should be stored safely in a see-

through plastic bag that can be sealed, for later cleansing or disposal.
 Eye Decontamination

• Rinse the eye for 10–15 minutes with clean running water or saline, taking
care that the run-off does not enter the other eye by lying on the side and
running into the inner canthus and out of the outer canthus.

• Evert the eyelids and ensure that all surfaces are rinsed.

• Where possible, the eye should be thoroughly examined under fluorescein

staining for signs of corneal damage.

• If there is significant conjunctival or corneal damage, the child should be

seen urgently by an ophthalmologist.
 Decontamination for Inhaled poisons
• Remove from the source of exposure.

• Urgently call for help

• Administer supplemental oxygen, if there is respiratory distress or cyanosis

or oxygen saturation ≤90%

• Inhalation of poisonous gases may cause swelling and upper airway

obstruction, bronchospasm and delayed pneumonitis
 Multiple-Dose Activated Charcoal

• This method enhances poison elimination by interfering with enterohepatic

recirculation GI dialysis

• Give 0.25 to 0.5 g/kg every 3 to 4 hour until the patient condition is improved

• Considered in drug poising including phenobarbital, carbamazepine,

phenytoin, digoxin, salicylates, and theophylline

• Whereas single-dose activated charcoal is used as a method of

decontamination, multidose activated charcoal (MDAC) can help to enhance
the elimination of certain toxins.
• The word toxidrome describes a group of signs and symptoms and/or
characteristic effects associated with exposure to a particular substance or
class of substances.

• coma + dilated pupils+tachycardia+ increased muscle tone,reflexes and ext

plantaris =tricyclic anti depressant or orphenadrine poisoning
• Coma + hypotension + respiratory depression + decreased muscle tone
• = Barbiturates, clomethiazole and benzodiazepine with alchol
• coma + slow respiration + pin point pupils = opiod poisoning
• tinnitus + deafness + Hyperventilation = Salicylate posioning
• Agitation + tremor + oilated pupil + tachycardia =
amphetamine,cocaine,sympatomimetics
 Further Management of the Poisoned Child

• Give specific antidote if this is availble and indicated

• Keep the child under observation for 4–24 hours depending on the poison
swallowed
• Keep unconscious children in the recovery position.

• Refer the child to the next level health facility, only when appropriate and
where this can be done safely
• If the child is unconscious or has deteriorating conscious level, has burns to
mouth and throat, is in severe respiratory distress, is cyanosed or is in heart
failure, stabilize him/her before referral
 Specific poisons
• Corrosive compounds
• Hydrocarbons
• Organophosphate and carbamate poisoning
• Paracetamol
• Carbon monoxide poisoning
 Organophosphate and carbamate poisoning

• These are commonly used insecticides and herbicides

• it irreversibly inhibits acetylcholine esterase enzyme increasing the

concentration of ach at the cholinergic synapse.

• Eg. organophosphorus (malathion, parathion, TEPP, mevinphos/Phosdrin) and

carbamates (methiocarb and carbaryl)
 cont

•Muscarinic effects of these poisons can be memorized with

mnemonic "DUMBBELLS"

• – Diarrhoea
• – Urination
• – Miosis
• – Bradycardia
• – Bronchorrhea
• – Emesis
• – Lacrymation
• – Salivation
 Management

• Remove poison by irrigating eye or washing skin (if in eye or on skin)

• Give activated charcoal within 1 hours of ingestion, however it could be given up to 4

hours after ingestion of the poison.

• In a serious ingestion where activated charcoal cannot be given, consider careful

aspiration do gastric lavage (the airway should be protected).

• After decontamination, antidotal therapy begins with administration of atropine

sulfate

• Give a dose of 0.05 to 0.1 mg per kg to children and 2 to 5 mg for adolescents IV or

IM.
 cont...

• This dose should be repeated every 10 to 30 minutes or as needed until chest

secretions and pulmonary rales cleared.

• Therapy is continued until all absorbed organophosphate has been

metabolized and may require 2 mg to more than 2,000 mg of atropine may be
required for a few hours to several days.

• If muscle weakness develops after atropinization, give pralidoxime

(cholinesterase reactivator) 25–50mg/kg diluted with 15 ml water by IV infusion
over 30 minutes repeated once or twice, or followed by an intravenous infusion
of 10 to 20 mg/kg/hour, as necessary.
 Paracetamol
• Though data is not avaliable for our country in the USA actaminophen is
responsible for approximately 50% of acute liver failure.

• Paracetamol is administered about 15-20mg/kg/dose and ingestion of 150-

200mg/kg will cause toxicity in children.
cont...
 management
• Give activated charcoal within 4 hours of ingestion Decide if antidote is
required to prevent liver damage: ingestions of 150 mg/ kg or more, or toxic 4
hour paracetamol level where this is available.

• Antidote is more often required for older children who deliberately ingest
paracetamol or when parents overdose children by mistake.

• If within 8 hours of ingestion give oral methionine or IV acetylcysteine.

• Methionine can be used if the child is conscious and not vomiting (<6 years:
1 gram every 4 hours for 4 doses; 6 years or older: 2.5 grams every 4 hours
for 4 doses).
 cont...

• If more than 8 hours after ingestion, or the child cannot take oral treatment, give IV
acetylcysteine.

• For children <20 kg give the loading dose of 150 mg/kg in 3 ml/kg of 5% glucose
over 15 minutes, followed by 50 mg/kg in 7 ml/kg of 5% glucose over 4 hours, then
100 mg/kg IV in 14 ml/kg of 5% glucose over 16 hours.
• Continue infusion of acetyl cysteine beyond 20 hours if late presentation or
evidence of liver toxicity.

• If liver enzymes can be measured and are elevated, continue IV infusion until
enzyme levels are falling.
 Carbon monoxide poisoning

• Carbon monoxide (CO) is an odorless, tasteless, colorless, nonirritating gas

formed by hydrocarbon combustion.

• CO binds to hemoglobin with much greater affinity than oxygen, forming

carboxyhemoglobin (COHb) and resulting in impaired oxygen transport and
utilization.

• CO can also precipitate an inflammatory cascade that results in CNS lipid

peroxidation and delayed neurologic sequelae.
 cont...

• Fire-related smoke inhalation is responsible for most cases of carbon

monoxide (CO) poisoning.

• The mortality rate is higher for intentional poisoning than for inadvertent
exposure.

• Methylene chloride (dichloromethane) is an industrial solvent and a

component of paint remover. Inhaled or ingested methylene chloride is
metabolized to CO by the liver, causing CO toxicity in the absence of ambient
CO.
clnical presentation
cont...
cont...
• Reference
• uptodate 2018
• ETAT+ ETHIOPIA GUIDELINE MAY 2014
• NELSON TEXT BOOK OF PEDIATRICS 21st edition
THANK YOU