Approach to a poisoned child
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The document provides guidance on poisonings in pediatric patients, noting the most common types of exposures include cosmetics, cleaning substances, analgesics, and plants. It describes approaches to assessing and managing poisoned patients, including identifying toxidromes based on symptoms, performing toxicology screening when helpful, and employing decontamination methods or antidotes to treat specific poisonings. Guidelines are offered on evaluating patients, looking for signs of organ dysfunction, and initiating supportive care or enhanced elimination techniques as appropriate for the suspected toxin.
Approach to a poisoned child
- 1. Guide –Dr Jyoti Singh
- 2. What is a poison? ▪ In common usage - poisons are chemicals or chemical products that are distinctly harmful to human ▪ More precisely - a poison is a foreign chemical (xenobiotic) that is capable of producing a harmful effect on a biologic system
- 3. Most common Pediatric Exposure Cosmetics and personal care products (13%) Cleaning substances (10%) Analgesics (7.8%) Foreign Bodies (7.4%) Topicals (7.4%) Cold and Cough Preparations (5.5%) Plants (4.6%) Pesticides (4.1%)
- 4. May be difficult because of non-specific symptoms High index of suspicion - especially occult poisoning ▪ history may be unreliable ▪ look for corroborative history - missing pills, empty container Course that a poison runs (toxidromes) ! - may help Toxicology screening - helpful only in a few
- 5. ▪ It is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occur together, so that the presence of one feature alerts the physician to the presence of the others.
- 10. S alivation *D iaphoresis/diarrhea L acrimation *U rination U rination *M iosis D efecation *B radycardia/bronchospasm G I secrestion/upset *E mesis E mesis *L acrimation excess *S alivation excess
- 12. Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat bowel, bladder lose their tone, & heart runs alone
- 13. Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat bowel , bladder lose their tone, & heart runs alone
- 14. Hot as a hare Dry as a bone Red as a beet Mad as a hatter Blind as a bat bowel , bladder lose their tone, &heart runs alone
- 15. disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea
- 16. disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea
- 17. disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea
- 18. disorientation Amphetamine hallucinations Cocaine Hallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure Ephedrine Toxidrome Hypertension Tachycardia Tachypnea
- 31. Very diverse and varied - depends on the poison Clinical examination should be focused on the possible manifestations of common poisons in the geographical area
- 32. Skin and mucosal damage Neurotoxic manifestations Cardiovascular manifestations Metabolic consequences Eye manifestations Hepatic , renal dysfunction Multiorgan dysfunction
- 33. Respiratory Airway protection Respiratory failure Cardiovascular Hypotension despite fluid challenge Heart block, arrhythmias, QTc prolongation as in TCA
- 34. Neurologic ▪ Low GCS ▪ Seizures Metabolic ▪ Hypoglycaemia ▪ Significant electrolyte abnormalities ▪ metabolic acidosis ▪ Hepatic failure ▪ Coagulopathy with bleeding
- 35. ASSESSMENT & THERAPY should proceed in parallel
- 37. Treat the patient, not the poison Assess General appearance Work of breathing Circulation ABCDs IV access and monitors High Suspicion
- 38. Directed exam (after ABCs) mental status vital signs pupillary size skin signs
- 39. Airway - ensure clear airway, clear secretions, check for cough/gag Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy Circulation - heart rate, rhythm, blood pressure
- 40. Neurologic - GCS, seizures, agitation, spasms, pupils, autonomic dysfunction Miscellaneous - odour, temperature, pallor, cyanosis, jaundice Abdomen - rigidity, bleeding, urine output
- 42. Cyanosis methemoglobinemia secondary to nitrites, nitrates, phenacetin, benzocaine-refractory tp o2 Red flush carbon monoxide, cyanide, boric acid, anticholinergics Joundice – c cl4. paracetamol
- 43. Dry anticholinergics Salivation organophosphates, carbamates Oral lesions corrosives, paraquat Lacrimation caustics, organophosphates, irritant gases
- 44. Anti-histamine Anti-depressant Anticholinergics (atropine) Sympathomimetics amphetamine, cocaine, PCP
- 45. Cholinergics, Clonidine Opiates, Organophosphates Phenothiazine, Pilocarpine Sedatives (barbiturates, ethanol)
- 46. Alcohol PCP / marijuana LSD Anticholinergics Sympathomimetics Phenothiazines Cocaine Heroin heavy metals
- 47. Coma alcohols, anticholinergics, sedative hypnotics, opioids, carbon monoxide, TCAs, salicylates, organophosphates Weakness/paralysis organophosphates, carbamates, heavy metals
- 48. Atropine Salicylates Theophylline Cocaine TCA
- 49. Ethanol Narcotics Carbon monoxide Clonidine
- 50. Bradycardia digitalis, sedative hypnotics, beta blockers, opioids Tachycardia anticholinergics, sympathomimetics, amphetamines, alcohol, aspirin, theophylline, cocaine, TCAs Arrythmias anticholinergics, TCAs, organophosphates, digoxin, phenothiazines, beta blockers, carbon monoxide, cyanide
- 51. OTC cold remedies Amphetamine PCP TCA Cocaine Diet pills
- 52. Calcium channel blockers Carbon monoxide Cyanide Iron Narcotics Anti-hypertensives Met-hemoglobin
- 53. Hypoglycemia Oral hypoglycemic agents Beta-blockers Insulin Ethanol Salicylates
- 54. Alcohol Narcotics Clonidine Sedatives
- 56. Of limited value Paracetamol levels, salicylate levels, alcohol, Red cell/pseudocholinesterase, anti-epileptic drug levels Urinary drug screen - opiates, barbiturates, benzodiazepines, amphetamines, cocaine
- 57. Anion gap & Osmolal gap Increased anion gap (Normal 12 ± 4 mEq/L) ▪ Ethylene glycol ▪ Methanol ▪ Salicylate poisoning Increased osmolal gap (Normal 5 ± 7 m osmol/kg) ▪ Ethylene glycol ▪ Methanol ▪ Acetone, ethanol, isopropyl alcohol, propylene glycol
- 58. Electrolytes ▪ Hypokalemia ▪ Isuline ,oral hypoglysemics ▪ Diuretics, Methyl xanthine, Toluene ▪ Hyperkalemia ▪ Digoxin ▪ Beta-blocker Liver function tests ▪ Acetaminophen, Ethanol, Carbon tetrachloride Renal function tests ▪ Ethylene glycol, NSAIDS
- 59. ECG Digoxin toxicity TCA overdose - sinus tachycardia, QT prolongation, increased QRS Beta-blockers - conduction abnormalities Imaging . CXR- hydrocarbon ingestion .Abdominal X-ray-- iron ingestion & radioopaque ingestion. .Oesophagoscopy -for caustic ingestion. . Abdominal usg- recently been used as a means of identifying presence of pharmaceutical material in GIT.
- 60. Opiates Cocaine metabolite Amphetamine Benzodiazepines Barbiturates * No urine screen can confirm intoxication, only exposure
- 63. Reduce absorption of the toxin Enhance elimination Neutralise toxin
- 65. Removal from surface skin & eye Emesis induction Gastric lavage Activated charcoal administration & cathartics Dilution - milk/other drinks for corrosives Whole bowel irrigation Endoscopic or surgical removal of ingested chemical
- 66. Skin decontamination ▪ Important aspect – not to be neglected ▪ Remove contaminated clothing ▪ Wash with soap and water (soaps containing 30% ethanol advocated) ▪ However, no evidence for benefit even in OP poisoning
- 67. Gastric decontamination ▪ Forced emesis if patient is awake ▪ Gastric lavage ▪ Activated charcoal 25 gm 2 hourly ▪ Sorbitol as cathartic
- 68. Gastric lavage ▪ Gastric lavage decreases absorption by 42% if done 20 min and by 16% if performed at 60 min ▪ Performed by first aspirating the stomach and then repetitively instilling & aspirating fluid ▪ Left lateral position better - delays spont. absorption ▪ No evidence that larger tube better ▪ Simplest, quickest & least expensive way ▪ Choice of fluid is tap water - 5-10 ml/kg
- 69. Gastric lavage ▪ Preferrably done on awake patients ▪ Presence of an ET tube does not preclude aspiration, though preferred if GCS is low ▪ No human studies in OP poisoning showing benefit of gastric lavage
- 70. Single dose activated charcoal 0.5-1 gm/kg, adolescents 50-100 grams PO; maximum dose 100 grams More benefit if administered within 1 hour of ingestion, but still good for poison which slows gastric motility (anticholinergic, opiates, salicylates) Strongly consider for acetaminophen overdose > 4 hours
- 71. P – Pesticides, petroleum distillates, unprotected airway H – Hydrocarbons, heavy metals, > 1h delay in administration A – Acids, alkali, alcohol, altered level of consciousness, aspiration risk I – Iron, ileus, intestinal obstruction L – Lithium, lack of gag reflex S – seizures
- 72. Nonabsorbable, isotonic polyethylene glycol Toxins “pushed” through GI tract; prevents absorption Concentration gradient created by this allows absorbed toxin to diffuse back into GI tract Used where toxins NOT absorbed by charcoal
- 73. Recommended for: Iron tablets Lead paint chips Theophylline Crack vials/packets Button batteries Sustained release calcium channel blockers
- 74. Bowel perforation Bowel obstruction Clinically significant gastrointestinal hemorrhage Ileus Unprotected or compromised airway Hemodynamic instability Uncontrollable intractable vomiting
- 76. Methods ▪ Keeping a good urine output 150-200 ml/hr ▪ Alkalinisation of urine - clinical efficacy accepted for salicylate & phenobarbital poisoning ▪ Extracorporeal removal ▪ Hemodialysis - Barbiturates, Salicylates, Acetaminophen, Valproate, Alcohols, Glycols ▪ Hemoperfusion - theophylline, digitalis, lipid soluble drugs
- 77. Plasmapheresis Works very well with highly protein (albumin) bound drugs Not a routine methodology, but has been used to remove theophylline and digoxin/ digibind complexes Exchange transfusion Use in smaller infants where vascular access for extracorporeal techniques can’t be done
- 78. Renal failure. Congestive heart failure (relative). Acute lung injury. Persistent CNS disturbance. Severe acid-base or electrolyte imbalance, despite appropriate treatment. Hepatic compromise with coagulopathy. Salicylate concentration (acute) >100 mg/dL.
- 80. Acetaminophen N-acetyl cysteine Anti-cholinergics Physostigmine Benzodiazepenes Flumazenil Ca channel blockers Glucagon, Insulin + dextrose, Calcium Carbamate Atropine Cyanide Thiosulphate, nitrate Digoxin Digoxin antibodies INAH Pyridoxine Methanol Ethanol, Fomepizole Glycol Ethanol, Fomepizole Opioid Naloxone Oral hypoglycaemics Glucose Organophosphate Atropine, PAM Warfarin(rat kill poison) Vitamin K
- 81. Iron Desferroxamine Copper Penicillamine, Dimercaprol, CaEDTA Lead CaEDTA, Dimercaprol (BAL) Mercury DMPS, DMSA, BAL Arsenic BAL & derivatives Antimony BAL & derivatives
- 82. Calcium channel blockers: bradycardia and hypotension; 1 - 10 mg tablet of nifedipine Camphor: respiratory depression and seizures; 15 mL of Vicks vapo-rub (700 mg of camphor) Clonidine: severe bradycardia; 0.1 mg Tricyclic antidepressants: cardiovascular and CNS toxicity; 10-20mg/kg Opioids: CNS and respiratory depression; 2.5 mg of hydrocodone.
- 83. Lomotil: anticholinergic overdose (tachycardia, seizures, coma); ½ tablet Salicylates: cerebral edema, acidosis, coma; ½ teaspoon of wintergreen fatal Sulfonylureas: severe hypoglycemia; 1 tablet Toxic alcohols: cardiac and CNS depression; 2.9mL of 95% ethylene glycol has been fatal
- 84. National Poisons Information Centre (NPIC) Department of Pharmacology All India Institute of Medical Sciences New Delhi, India Tel. No.: 26589391, 26593677, Fax: 26850691, 26862663 Email: npicaiims@hotmail.com provides round-the-clock, 7 days-a-week, 365 days service on telephone.
- 85. Poisoning a common problem in our country A high index of suspicion required to diagnose Know common toxidrome & antidotes Charcoal is only given if likely to benefit Patients receiving decontamination must have airway protection Don’t panic and follow a plan of action Decreasing absorption Enhancing elimination Neutralising toxins Avoid potentially harmful Rxs - risk vs benefit
Editor's Notes
- #39: Assessment triangle: -general appearance (sleepy, obtunded, wired, delirious,etc.) -work of breathing (too fast, too slow, too deep, too shallow) -circulation (hypertensive, hypotensive) Most toxic exposures can be treated with basic life support measures Oxygen, dextrose, and naloxone: diagnostic and therapeutic Toxidrome: constellation of symptoms which are most likely to indicate the ingestion of a certain class of medication. H&P plus lab eval.
- #40: Altered mental status: rule out other causes as clinically indicated: trauma (including abuse), infection, metabolic abnormality (DKA), etc.
- #119: Paracelsus = German physician, father of modern pharmacology