Paediatric Poisoning & Drug overdose

Paediatric Poisoning &Drug overdose Done by: Dr. Abed Alhalim Shamout

Objectives • General management principles for ingestions and toxic exposures. • The principles of gastric decontamination. • The substances of low toxicity in pediatrics • The use of specific therapies for poisonings caused by: • Acetaminophen Iron • Alcohol • Salicylates • Tricyclic antidepressants • Household agents/corrosives

Introduction • Epidemiology- More than 2 million incidents of poisoning and toxic ingestions occur in the United States each year, accounting for 12,000 deaths. • Most episodes of accidental ingestion reported to poison control centers are for children under the age of 5 years. • Poisoning can be caused by either accidental or intentional exposure to toxic agents;accidental ingestion is responsible for approximately 85% of episodes in younger children.

Cont… • Nonpharmaceutical agents account for 60% of the childhood poisonings that occur under age 6 years. • The most commonly ingested substances in this age group are plants, household cleaners, over-the-counter medications, and cosmetics. • The vast majority of childhood poisonings occur around the house, ingestion of prescription medications, either in the home of the child’s or that of a relative (such as a grandparent).

Types of Poisoning Accidental poisoning • Mainly young children aged 1-3 years • Mainly drugs or household products • More common in household with recent disruptions • May be an indicator of maternal depression

Cont… Intentional Overdose • Mainly teenagers • Usually ingestion of drugs Drug abuse • Alcohol • Solvents • Other drugs Iatrogenic • Usually result of calculation error • Most frequently fatal drug: digoxin

Cont.. Child abuse • Munchhausen syndrome by proxy • May present as an unusual illness rather than poisoning Chronic poisoning • Mainly environmantal hazards • Commonest: Lead poisoning

EMERGENCY MANAGEMENT • Identification of the poison • Determine the product ingested,the amount the time of ingestion,the childs present condition. • In determining therapy, assume the largest estimated amount. • Physical Examination.

Cont… • A. Asymptomatic child • The asymptomatic child may have been exposed to, or ingested, a lethal dose of apoison, yet not have any manifestations of toxicity. Therefore, it is important to: 1) Quickly assess the potential danger. • A. If the toxin is known, the potential danger can be assessed by consulting acomputerized information resource. • Risk assessment will generally take into account the following: • 1. the dose ingested (mg/kg) • 2. the time interval since ingestion • 3. the presence of any clinical signs

GI Decontamination • The goal of gastric decontamination is to minimize exposure of the toxin by removing it from the GI tract, or by binding it to a non-absorbable agent. • At the present time, there is considerable controversy regarding the role of syrup of ipecac-induced emesis, gastric lavage, and activated charcoal in achieving gastric decontamination. • There is little evidence to support the use of induced emesis or gastric lavage, especially if performed 60minutes or longer after ingestion.

Cont… • Ipecac-induced emesis - Syrup of ipecac may be of some value if given within a few minutes after ingestion. It may prove to have a useful role in home management of pediatric ingestions. • Gastric lavage - In studies, gastric lavaage appears to be slightly more effective than induced emesis. • Gastric lavage, especially in the pediatric patient, does not allow removal of undissolved pills or pill fragments too large to pass through the diameter of the lavage tube. Gastric lavage is not necessary for small to moderate ingestions if activated charcoal is available for administration.

Cont.. • Activated charcoal - Recent studies indicate that the administration of charcoal alone may be as effective as emesis or gastric lavage, and may prove to be the mainstay of gastric decontamination.

Asymptomatic child…. • Observe the Child/Provide Parent Education/Perform a Risk Assessment a. Observe the asymptomatic child for an appropriate interval (usually 4-6 hours). b. Consider evaluation of the home situation, especially in accidental ingestions in children < 14-16 months or > 5 years of age. c. Intentional ingestions in adolescents, especially girls, raises the possibility of unwanted pregnancy, or sexual or physical abuse; these children require careful psychiatric evaluation for suicide risk. d. Because repeat ingestions occur, all parents require instructions about poisonprevention techniques.

Symptomatic child • Management is based on four general principles: • a. Supportive care • b. Preventing or minimizing absorption • c. Enhancement of excretion • d. Administration of antagonists

Cont.. • Attention to the ABCs is always the first priority. • Treat the patient, not the poison!!! • Ongoing assessment and serial vital signs are particularly important,as they may help to pinpoint the responsible agent and indicate the subtle signs of impending deterioration.

Initial Management • Establish and maintain a patent airway by positioning, suctioning and, ifneeded, endotrachal intubation. • b. Provide supplemental oxygen and assist ventilations, if needed. • c. Monitor the circulation by assessing the pulse, blood pressure and perfusion. • 1. Establish a large-bore IV line and draw labs (CBC with platelets, basic metabolic profile, serum CO2, toxicology screen, and specific drug levels if indicated).

Blood pressure • Monitor for variations in blood pressure. • a) Hypotension results from venodilation, arteriole dilation, depressed cardiac contractility, or a combination of causes. • Regardless of the etiology, most hypotensive children respond to volume therapy of 10-20 cc/kg boluses of Ringer's Lactate or Normal Saline and rarely need pharmacologic treatment.

Blood pressure • Hypertension should be treated if systolic pressure is > 160-170 mmHg or diastolic pressure is > 100-105 mmHG, in order to prevent intracranial hemorrhage or hypertensive encephalopathy. • Treat hypertension with sodium nitroprusside (continuous infusion: begin with 1.0 mg/kg/minute; range is 0.5-10.0 mg/kg/minute) with or without esmolol or propranolol; • Do not use beta-blockers alone as this may worsen the hypertension, particularly that resulting from cocaine toxicity.

Monitoring • Place the child on a cardiorespiratory monitor to assess for arrhythmias. • a) Arrhythmias are often caused by hypoxia or electrolyte imbalances. • 1) For ventricular tachycardias use lidocaine 1mg/kg/dose. • 2) For sympathomimetic-induced tachycardias, use esmolol 25-100 mg/kg/min IV and titrate to heart rate. • 3) For wide complex tachycardias resulting from TCA • administer 1-2 mEq/kg of NaHCO3 in repeated boluses until the QRS interval narrows to 0.12 seconds, or the serum pH exceeds 7.7.

Mental status • Assess the child's mental status. Use the Glasgow coma scale. • The most common cause of death in the comatose child is respiratory failure. • Respiratory failure may occur abruptly and can be complicated by aspiration, especially if the child is seizing or develops an altered level of consciousness after receiving ipecac.

Mental status… • In all comatose or convulsing children, check blood glucose and administer 2-4 cc/kg D25W if needed. • Although a specific benzodiazepine receptor antagonist (flumazenil) is available, its use may be complicated by seizures; most benzodiazepine ingestions are best managed conservatively with ventilatory support. • When indicated, flumazenil can be given in a dose of 0.2 mg over 30 seconds. If there is no response in 30 seconds, repeat with 0.3 mg, and then 0.5 mg, up to a cumulative dose of 3 mg.

Cont • Naloxone, 0.4-2 mg IV, should be used if there is any possibility of narcotic ingestion in a patient with a decreased level of consciousness. • Before giving medication for seizures, rule out other causes (such as hypoglycemia or metabolic disturbances). • Seizures are usually controlled with benzodiazepines and phenobarbital.

Additional assesment • Temperature • 1. Hyperthermia may be caused by a variety of drugs or toxins. • Treat it aggressively with skin cooling. • If necessary, intubate and chemically paralyzethe patient; monitor for ongoing seizure activity.

Temp • Hypothermia - Hypothermia may result from particular agents (ethanol,barbiturates, narcotics) or be related to environmental exposure. • Hypothermia may cause, or aggravate,hypotension. • Assessment of adequate perfusion is difficult in the hypothermic child. Gradual warming,with warm blankets, devices such as “bear huggers”, and warmed IV fluids utilizing devices such as the “HotLine” is usually successful in managing hypothermia.

Cont.. Urine • 1. Observe for adequate (_ 1 cc/kg/hour) urine output as well as changes in the color/clarity of the urine. • 2. Send urine specimens to the lab for urinalysis, toxicology. • Toxicology screens may take several days to be completed and are often not helpful in the acute clinical setting. X-rays • 1. Chest – Evaluate for infiltrates, possible aspiration, and pulmonary edema. • 2. Abdominal - Look for radiopaque materials, such as iron and enteric-coated pills.

Cont.. • Some rapid screening tests are also helpful in pinpointing a diagnosis: • Ferric chloride test - turns the urine a burgundy color in the presence of salicylates and purplish-green in the presence of phenothiazines. • Osmolar gap - To calculate the osmolar gap subtract the measured serum osmolality from the calculated serum osmolarity • [Calculated osmolality =2(Na) + glucose/18 + BUN/2.8].

Cont.. • An elevated osmolar gap (> 10 mosm/L)can indicate ethanol, isopropyl alcohol, methanol, or ethylene glycol exposure. • A wide osmolar gap will be seen with sorbitol and mannitol when administered therapeutically. • Anion gap [Na - (Cl+HCO3)]. • lactic acid= iron, INH, salicylate ingestion. • production of other acids (methanol, ethylene and other glycol ingestions)

Cont.. • Causes of a wide anion gap is MUDPILES: • Methanol, Uremia, Diabetic ketoacidosis, Phenformin ,Paraldehyde, Iron Isoniazid, Lactic acidosis, Ethanol Ethylen glycol, and Salicylates.

Sympt child.. • The second phase of management is to prevent or minimize absorption of the toxin. • In the case of symptomatic children, consider gastric lavage to prevent further absorption. • Intubate prior to lavage if the child is unable to protect his/her airway.

Gi decontamination • 1.In the home, syrup of ipecac may be used to induce emesis in the conscious,alert child. It is ideally administered within 30 minutes of ingestion. • In theED ipecac is rarely used, since its efficacy is diminished if administered 60minutes or more after ingestion. • 2. Gastric lavage can be used when vomiting is contraindicated. Such include the child with a depressed level of consciousness,seizures, compromised gag reflex, respiratory distress, or ingestion of apetroleum distillate.

Complications Aspiration pneumonia. Laryngospasm. Hypoxia and hypercapnia. Mechanical injury to the throat, esophagus, and stomach. Fluid and electrolyte imbalance. Indications Overdose or Ingestion within 1 hour Specific overdose after 1 hour Ingested drug slows peristalsis Anticholinergics Opioids (Narcotics) Ingested drug of: Salicylates Iron Gastric lavage

Activated charcoal • Recent studies indicate that administration of activated charcoal is the most effective gastric decontamination procedure. • Many toxicologists recommend charcoal be administered if the patient presents with 1-2 hours after ingestion.

Indications Patient presents within 60 minutes of ingestion Overdose or Antidepressants Aspirin Aminophylline Barbiturates Carbamazepine Digitalis Dilantin Dapsone Substances for which charcoal is ineffective Pesticides Hydrocarbons Alcohols Acids Alkali Iron Lithium Solvents Activated Charcoal

Activated Charcoal • Many children will not drink the needed dose; therefore, it may be necessary to administer activated charcoal via NG tube. This increases the risk of emesis, with subsequent possible aspiration. • A cathartic mixed with charcoal shortens the transit time in the gut. • The cathartic sorbitol is recommended in the pediatric age group, since magnesium citrate may cause symptomatic hypermagnesemia in children under the age of 2 years. • Recommended dose: 1 gm/kg with sorbitol. • Repeat dose charcoal is useful in the management of theophylline, phenobarbital, phenytoin, salicylates, and carbamazepine ingestions.

CatharticTypes: Sorbitol 2ml/kg,Mg citrate 4-8ml/kg • Used only with Activated Charcoal. • Hasten intestinal transit of GIT contents so it decrease systemic absorption. Contraindications A.Examination findings 1.Absent bowel sounds 2. Recent abdominal surgery or trauma 3.Intestinal Obstruction 4. Dehydration 5.Hypotension B.Poison ingestion of corrosive substance C.Poison ingestion with Diarrheal adverse effects 1.Organophosphate 2. Carbamate 3.Heavy metal poisoning

Whole bowel irrigation • uses polyethylene glycol solution (Golytely, Colyte) in large volumes at rapid rates to mechanically cleanse the GI tract. • Whole bowel irrigation results in negligible fluid and electrolyte losses; it can be used when charcoal isineffective (iron, lithium), when there is ingestion of a large volume of toxic substance (cocaine swallowed in packages), or for ingestion of sustained-release drugs. (Valporic acis,theophylline,aspirin) • Whole bowel irrigation requires large volumes (1-2 L/hour in adolescents and 25 cc/kg/hour in children). • If the child is not able todrink the polyethylene glycol solution, an NG tube is necessary for administration.

Enhancing elimination • Forced diuresis: increases GFR and enhancines elimination of drugs excreted mainly by the kidneys(eg.lithium). • IV isotonic fluids at twice at maintance rate should sustain diuresis at 2-3 times normal. • Clinically, this method has been shown to have little benefit.

Enhancing elimination • Urinary alkalinization - Administering sodium bicarborate intravenously results in an alkaline urine. • Many drugs will diffuse more readily from the blood stream into alkaline urine. • urinary PH 7.5-9.0 . • promotes excreation of weak acid . • for salicylates, phenobarbital poisoning . • NaHco3 50-100 mEq + 1 liter DS …..250-500ml/hour for the first 1-2 hours • Maintain urine output 2-3ml/kg/h

Enhancing elimination • Hemodialysis - Renal dialysis effectively removes select drugs (these must be low in molecular weight, water soluble, have small volumes of distribution, and exhibit low protein binding). • Dialysis is most commonly used for alcohols, theophylline, salicylates, and lithium overdoses. • Exchange transfusion: a. severe Methemoglobinemia b.Hemolysis

Ballpoint inks Bar soap Bathtub floating toys Battery (Dry cell) Bublle bath soap Candles Chalk Clay(modeling) Crayons Detergents (anionic) Eye makeup Fishbowl additives Hand lotion and creams Ink (blue,black,red) Lipstick Pencils (lead and coloring) Shampoo Shaving creams and lotions Shoe polish(occasionaly aniline dyes) Striking surface materials of matchboxes Sweetening agents(Saccharin,cyclamate) Thermometers Afterchave lotion Body conditioners Colognes Deodorants Fabric softeners Hair dyes Hair sprays Hair tonic Matches(+20wooden matches ) Oral cotraceptives. Perfumes Toilet water Toothpaste No treatment required Remove if large amount

Benzocaine Chloriquine Codiene Hydrocarbones. Hypoglycemic sulfonylureas Imipramine Iron Lindane Methyl salicylate Theophylline Thioridazine verapamil 2ml of 10%gel One 500mg tablet Three 60mg tab One swallow if aspirated Two 5mg glyburide tab One 150 mg tab Ten adult strength tab Two teaspoons 10ml Less than 5ml oil of witergreen One 500mg tablet One 200mg tab One –two 240mg tab Potent Pediatric Poisons

SPECIFIC POISONS Part II

SPECIFIC POISONS • Acetaminophen • Salicylates • Alcohols • Tricyclic Antidepressants (TCA) - • Household Products/Corrosives • Iron • Hydrocarbones. • Organophosphorus (Cholinergic Insecticides). • Cardiac drugs • Antibiotics.

Thanks for listening To be continued in part II Specific poisions ما كان من توفيق فمن اللــه وحـده , وما كان من خطأ أو سهـو أو نسيــان فمنـي ومن الشيــطان . واللــه ولـي التوفيــق

Paediatric Poisoning & Drug overdose