Pediatric Toxicology 2007

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Pediatric Toxicology 2007

  1. 1. Overview of Pediatric Toxicology Unknown Exposures Trivial Ingestions Sometimes Severe Morbidity/Mortality Michael Wahl MD, FACEP, FACMT Emergency Physician, Evanston Northwestern Healthcare Medical Director, Illinois Poison Center
  2. 2. Pediatric Cases in Toxicology <ul><li>Why are Pediatric Ingestions so common? </li></ul><ul><ul><li>Pediatric Poisoning: Developmental Milestones </li></ul></ul><ul><li>Epidemiology of Pediatric Poisoning </li></ul><ul><ul><li>Poison Center Exposure Data </li></ul></ul><ul><ul><li>Toxic vs. Non-toxic Exposures </li></ul></ul><ul><ul><li>Trends </li></ul></ul><ul><ul><li>Significance </li></ul></ul><ul><li>Management issues </li></ul><ul><li>Cases </li></ul>
  3. 3. Poisoning is a matter of dose <ul><li>Paracelsus (1493-1551) Third Defense </li></ul><ul><li>“ What is there that is not poison? All things are poison and nothing without poison. Solely, the dose determines that a thing is not a poison” </li></ul>
  4. 4. Pediatric Development <ul><li>6-9 months: creep, crawl, and pick up </li></ul><ul><li>objects </li></ul>
  5. 5. Pediatric Development <ul><li>9-12 months: pick up a pellet and put it in a hand </li></ul>
  6. 6. Pediatric Development <ul><li>15 months: walking; pick up a pellet and put it in a bottle </li></ul>
  7. 7. Pediatric Development <ul><li>18 months: able to </li></ul><ul><li>consciously dump </li></ul><ul><li>pellet from bottle </li></ul><ul><li>(e.g. Tylenol, aspirin, vitamins, adult prescription medications) </li></ul>
  8. 8. California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years of Age <ul><li>0-6 months ABUSE </li></ul><ul><li>Overall: FALLS </li></ul>
  9. 9. Pediatric Poisoning <ul><li>#2 leading reason for injury-related hospitalization in children 0 to 3 years of age behind falls </li></ul>
  10. 10. Pediatric Poisoning <ul><li>#1 reason for hospitalization or death in children 18 months to 3 years of age </li></ul>
  11. 11. The #1 reason for injury-related hospitalization between 18 and 35 months is poisoning
  12. 13. Pediatric Poisoning Admission In Illinois <ul><li>Illinois Poison Center Data: </li></ul>
  13. 14. Pediatric Poisoning: Lots of exposures, small number admitted <ul><li>Pediatric Exposure calls to IPC under 6 years of age </li></ul><ul><li>1.3% of exposures admitted for observation </li></ul><ul><li>Less than one death reported per year (and those are usually pre-hospital) </li></ul>
  14. 15. Assessment of Pediatric Ingestion <ul><li>History </li></ul><ul><ul><li>Who </li></ul></ul><ul><ul><li>What </li></ul></ul><ul><ul><li>Where </li></ul></ul><ul><ul><li>When </li></ul></ul><ul><ul><li>Why </li></ul></ul><ul><ul><li>How </li></ul></ul><ul><ul><li>The scene? </li></ul></ul>
  15. 16. Difficulty with Pediatric History: Did they actually ingest the substance? <ul><li>Toxic Alcohol Evaluation of Pediatric Patients is often Incomplete </li></ul><ul><li>DesLauriers C, Mazor S, Metz J, Mycyk M </li></ul><ul><li>2 year retrospective review </li></ul><ul><li>33 pediatric cases of Toxic Alcohol Ingestion </li></ul><ul><li>21 with levels drawn </li></ul><ul><li>5/21 with measurable levels (24% of cases) </li></ul>
  16. 17. Pediatric Exposures Reported to AAPCC (National Data)
  17. 18. Pediatric Deaths Reported to AAPCC (National Data) <ul><li>~ 2/100,000 pediatric exposures result in death. </li></ul><ul><li>Adult Fatalities >500 times more prevalent due to intentional nature of exposures </li></ul>
  18. 19. Unpublished Data from National Benchmarking committee (22 centers) <ul><li>95% of all pediatric calls to a poison center are managed at home without referral to a poison center. </li></ul><ul><li>86% of pediatric exposures that present to an ED without calling a poison center first are discharged from the ED </li></ul><ul><li>66% of pediatric exposures that are referred to ED are discharged from the ED </li></ul>
  19. 20. Pediatric Exposures <ul><li>AAPCC Data Most Common Exposures </li></ul><ul><ul><li>Cosmetics and personal care products </li></ul></ul><ul><ul><li>Cleaning substances </li></ul></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><ul><li>Tylenol >200 mg/kg </li></ul></ul></ul><ul><ul><ul><li>ASA >150 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Codiene >2 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Propoxyphen >10 mg/kg </li></ul></ul></ul><ul><ul><li>Plants </li></ul></ul>
  20. 21. Most Common Pediatric Exposures <ul><ul><li>Cough and cold preparations </li></ul></ul><ul><ul><ul><li>Bropheneramine >2 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Chlorpheneramine >1.4 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Phenylephrine >4 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Pseudoephedrine >16 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Dextromethorphan >10 mg/kg </li></ul></ul></ul><ul><ul><li>Hydrocarbons </li></ul></ul><ul><ul><li>Hormones/hormone antagonist </li></ul></ul>
  21. 22. Pediatric Exposures <ul><li>AAPCC Data Most Common Exposures </li></ul><ul><ul><li>Foreign bodies </li></ul></ul><ul><ul><li>Topicals </li></ul></ul><ul><ul><li>Pesticides and Rodenticides </li></ul></ul><ul><ul><li>Antimicrobials </li></ul></ul><ul><ul><li>Vitamins </li></ul></ul><ul><ul><li>Gastrointestinal preparations </li></ul></ul><ul><ul><li>Arts/crafts/office supplies </li></ul></ul>
  22. 23. Pediatric Exposures <ul><li>Determination of non-toxic exposures </li></ul><ul><ul><li>Call the Poison Center is easiest </li></ul></ul><ul><ul><ul><li>It is what poison center staff person does 30 times a day </li></ul></ul></ul>
  23. 24. Pediatric Exposures <ul><li>General guidelines for categorizing a non-toxic exposure for poison center staff </li></ul><ul><ul><li>The product must be absolutely identified </li></ul></ul><ul><ul><li>Only a single product can be involved in the exposure </li></ul></ul><ul><ul><li>The exposure must be unintentional </li></ul></ul><ul><ul><li>The Consumer Product Safety Commission words CAUTION, WARNING, DANGER are not on label </li></ul></ul><ul><ul><li>Route of exposure is accurately assessed </li></ul></ul><ul><ul><li>No symptoms are noted </li></ul></ul><ul><ul><li>Follow-up must be possible </li></ul></ul>
  24. 25. Management of Pediatric Exposures <ul><li>Decontamination </li></ul><ul><li>Enhanced elimination </li></ul><ul><li>Antidotal Therapy </li></ul><ul><li>Supportive Care </li></ul>
  25. 26. Decontamination <ul><li>Elimination from the gut and/or decreasing absorption </li></ul><ul><ul><li>Emetic Agents (Syrup of Ipecac) </li></ul></ul><ul><ul><li>Cathartics (sorbitol, magnesium citrate) </li></ul></ul><ul><ul><li>Gastric Lavage </li></ul></ul><ul><ul><li>Whole Bowel Irrigation </li></ul></ul><ul><ul><li>Charcoal </li></ul></ul>
  26. 27. Decontamination <ul><li>All decontamination measures were started before the advent of evidence medicine. </li></ul><ul><li>No improvement in outcomes has been shown for any of the modalities. </li></ul><ul><li>Re-examination of practices are slowly removing them from practice. </li></ul>
  27. 28. Ipecac
  28. 29. Ipecac
  29. 30. Syrup of Ipecac
  30. 31. Syrup of Ipecac <ul><li>Use of Ipecac promoted in the 1960’s on clinical opinion </li></ul><ul><li>AAP recommendation to no longer use ipecac in the home because of a lack of proven benefit. </li></ul><ul><ul><li>Does lack of proven benefit equal lack of efficacy? </li></ul></ul><ul><li>Prior to this, use decreased to less than <1% of poisonings. </li></ul>
  31. 32. Ipecac <ul><li>Family Guy Video: </li></ul>
  32. 33. Charcoal <ul><li>Effective at binding a variety of toxins, most beneficial if given within 60 minutes </li></ul><ul><li>Dose 1 gm/kg, up to 100 gm in a single dose </li></ul>
  33. 34. Charcoal Bond, Annals of EM, 2002
  34. 35. Charcoal
  35. 36. Charcoal
  36. 38. Charcoal
  37. 39. Charcoal <ul><li>Not proven to change outcome </li></ul><ul><li>Every year 5 to 10 deaths in poison center data from charcoal aspiration </li></ul><ul><ul><li>Always with drugs that cause decreased consciousness, vomiting or seizures </li></ul></ul><ul><ul><li>Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit </li></ul></ul><ul><ul><li>Risk Benefit Ratio? </li></ul></ul>
  38. 40. Cathartics <ul><li>Use promoted because of clinical opinion </li></ul><ul><li>Most commonly used in ED is sorbitol or magnesium citrate </li></ul><ul><li>Intended to decrease absorption by increasing expulsion from the GI tract </li></ul><ul><li>Dosing </li></ul><ul><ul><li>Sorbitol 70 % 2 cc/kg per kg in adults </li></ul></ul><ul><ul><li>Sorbitol 35 % 4 cc/kg per kg in children </li></ul></ul><ul><ul><li>Mag citrate 4 cc/kg in children/adults </li></ul></ul>
  39. 41. Cathartics <ul><li>Indications -- No proven benefit. By convention it is usually given with the first dose, not used for multiple dose therapy </li></ul><ul><li>The IPC recently stopped recommending it routinely due to guideline recommendations </li></ul>
  40. 42. Gastric Lavage
  41. 43. Gastric Lavage Bond, Annals of EM, 2002
  42. 44. Gastric Lavage <ul><li>Indications -- Ingestion of a potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure </li></ul><ul><li>contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding </li></ul>
  43. 45. Gastric Lavage <ul><li>Adults 36-40 french tube (children 24-28 French) </li></ul><ul><li>20 degrees trendelenburg, left lateral position </li></ul><ul><li>200-300 cc aliquots of water or saline (10 ml/kg chidren, saline) </li></ul>
  44. 47. Whole Bowel Irrigation <ul><li>Co-Lav </li></ul><ul><li>Colovage </li></ul><ul><li>Colyte </li></ul><ul><li>Colyte-flavored </li></ul><ul><li>Colyte with Flavor Packs </li></ul><ul><li>Go-Evac </li></ul><ul><li>GoLYTELY </li></ul><ul><li>NuLYTELY </li></ul><ul><li>NuLYTELY, Cherry Flavor </li></ul>
  45. 48. Whole Bowel Irrigation <ul><li>No proven efficacy </li></ul><ul><li>Potential to reduce drug absorption by rapidly cleansing the GI tract </li></ul><ul><li>dosing </li></ul><ul><ul><li>9 mo - 6 yo 500 ml/hr </li></ul></ul><ul><ul><li>6 yr - 12 yo 1000 ml/hr </li></ul></ul><ul><ul><li>Adolescents/adults 1500-2000 ml/hr </li></ul></ul>
  46. 49. Whole Bowel Irrigation <ul><ul><ul><ul><ul><li>= </li></ul></ul></ul></ul></ul>+ =
  47. 50. Whole Bowel Irrigation <ul><li>Indications </li></ul><ul><ul><li>sustained release or enteric coated drugs </li></ul></ul><ul><ul><li>Illicit drug packages </li></ul></ul><ul><ul><li>Drugs not well absorbed by Charcoal </li></ul></ul>
  48. 51. Whole Bowel Irrigation <ul><li>18% of IPC cases documented at recommended rate of administration and an endpoint of clear rectal effluent </li></ul><ul><ul><li>Difficult to accomplish </li></ul></ul><ul><ul><li>Time consuming </li></ul></ul><ul><ul><li>Can be messy </li></ul></ul><ul><ul><li>Inexperience and uncomfortable for staff </li></ul></ul>
  49. 52. General Approach <ul><li>ENHANCED ELIMINATION </li></ul><ul><ul><li>Hemodialysis/Hemoperfusion </li></ul></ul><ul><ul><li>MDAC </li></ul></ul><ul><ul><li>Urinary Alkalinization </li></ul></ul>
  50. 53. Enhanced Elimination <ul><li>Water soluble </li></ul><ul><li>Small molecular weight </li></ul><ul><li>Not highly protein bound </li></ul><ul><li>Small Volume of distribution (<1 L/kg) </li></ul>
  51. 54. Dialysis <ul><li>I sopropyl </li></ul><ul><li>S alicylates </li></ul><ul><li>T heophylline </li></ul><ul><li>U remia </li></ul><ul><li>M ethanol </li></ul><ul><li>B arbiturates (long-acting) </li></ul><ul><li>L ithium </li></ul><ul><li>E thylene Glycol </li></ul>
  52. 55. MDAC <ul><li>Dialyzable </li></ul><ul><li>Enterohepatic recirculation </li></ul><ul><li>A (Theophylline) </li></ul><ul><li>B (Phenobarbital) </li></ul><ul><li>C (Carbamazepine) </li></ul><ul><li>D (Dapsone) </li></ul><ul><li>Q (Quinine) </li></ul>
  53. 56. Antidotal Therapy Acetaminophen NAC Arsenic, mercury, gold BAL Atropine Physostigmine CO Oxygen CN CN antidote kit Ethylene glycol, methanol Ethanol, 4-MP Iron Deferoxamine Nitrites Methylene blue Opiates Naloxone Lead EDTA, BAL, Succimer Organophosphates Atropine, Pralidoxime
  54. 57. Review of Select 2005 Pediatric Death Cases Reported to AAPCC <ul><li>Already you know the outcome is going to be bad </li></ul><ul><li>The discussion of risk of exposure, treatment and outcomes is what important </li></ul>
  55. 58. Case #1 <ul><li>18 month old child thought to have a respiratory infection (cough and vomiting) by family comes to ED for evaluaton. </li></ul><ul><li>CXR shows FB in esophagus and stomach </li></ul>
  56. 61. Button Batteries <ul><li>Fatal in rare cases </li></ul><ul><li>Ingestion of cylindrical and button batteries: an analysis of 2382 cases Litovitz et al, Pediatrics April 1992 </li></ul><ul><li>2320 button batteries: no deaths </li></ul><ul><li>2 in esophagus with severe burns </li></ul>
  57. 62. Button Battery Ingestion <ul><li>Severe esophageal damage due to button battery ingestion: Can it be prevented? Yardeni et al, Pediatric Surgery International 2004 July </li></ul><ul><ul><li>State 19 cases reported in literature from 1979 to 2004 </li></ul></ul><ul><li>Brief Literature search showed multiple nasal and ear canal damage/reconstruction due to button battery insertion </li></ul>
  58. 63. Button Battery Ingestion <ul><li>Size </li></ul><ul><ul><li><15 mm unlikely to become lodged in esophagus </li></ul></ul><ul><ul><li>>20 mm likely to cause burns </li></ul></ul><ul><li>Locate the battery </li></ul><ul><ul><li>Esophagus – immediate removal </li></ul></ul><ul><ul><li>Stomach/Intestine – expectant management with serial x-rays if not detected in stool </li></ul></ul>
  59. 64. Button Battery Case <ul><li>Time delay in transfer to appropriate facility </li></ul><ul><li>Both batteries removed endoscopically </li></ul><ul><li>Admitted for 4 days. Barium swallow with undefined esophageal deviation </li></ul><ul><li>Discharged with fever on abx and medication for acid reflux </li></ul><ul><li>4 days later found cyanotic and in shock </li></ul><ul><li>Death Certificate with aorto-esophageal ulcer/fistula </li></ul>
  60. 65. Hydrocarbons <ul><li>15 month old female found vomiting, cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child </li></ul><ul><li>2 yo child ingested unknown amount of cigarette lighter fluid (Zippo) </li></ul><ul><li>18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits </li></ul>
  61. 66. Hydrocarbons <ul><li>17,685 exposures reported to AAPCC </li></ul><ul><li>3 deaths – all respiratory </li></ul><ul><li>Unknown number admitted with significant sequelae </li></ul>
  62. 67. Hydrocarbons <ul><li>Important History: </li></ul><ul><ul><li>When </li></ul></ul><ul><ul><li>How much (often unreliable) </li></ul></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Vomiting (increases aspiration potential) </li></ul></ul><ul><ul><li>Behavior changes (lethargy, drowsiness) </li></ul></ul>
  63. 68. Hydrocarbon <ul><li>Important signs and diagnostic exam results </li></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Respiratory status </li></ul></ul><ul><ul><ul><li>Cough </li></ul></ul></ul><ul><ul><ul><li>Tachypnea </li></ul></ul></ul><ul><ul><ul><li>Grunting/Flaring/Retractions </li></ul></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Pulse ox </li></ul></ul></ul><ul><ul><ul><li>CXR </li></ul></ul></ul>
  64. 69. Hydrocarbons <ul><li>15 mo female: Taken to community hospital. Arrested and expired before helicopter transport </li></ul><ul><li>2 yo male with cigarette lighter fluid: Died in ED </li></ul><ul><li>18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center </li></ul>
  65. 70. Calcium Channel Blockers <ul><li>19 month old male found with mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills. </li></ul>
  66. 71. Calcium Channel Blockers <ul><li>AAPCC data with 22,082 pediatric exposures to “cardiac medications” </li></ul><ul><ul><li>No breakdown of Ca Channel blockers </li></ul></ul><ul><li>Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%) </li></ul><ul><li>Extropolating to national data: over 2100 pediatric calcium channel blocker exposures </li></ul><ul><ul><li>Are they all true exposures? </li></ul></ul>
  67. 72. Calcium Channel blocker <ul><li>Triage Criteria Proposed by AAPCC, ACMT, AACT </li></ul><ul><li>(Triage amounts in mg/kg so small, may not be clinically useful) </li></ul>
  68. 73. Calcium Channel Blockers
  69. 74. Calcium Channel Blockers <ul><li>Hyperglycemia </li></ul><ul><li>Calcium Channel blockers in the pancreatic B islet cells </li></ul><ul><li>Decreased release of insulin </li></ul><ul><li>Can lead to HYPERGLYCEMIA </li></ul>
  70. 75. Calcium Channel blockers <ul><li>2 yo male with ingestion of up to 450 mg sustained release nifedipine </li></ul><ul><li>Unremarkable vitals initially. Glucose 253 </li></ul><ul><li>Upon arrival to tertiary care center, resting tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours. </li></ul><ul><li>Arrested the day after admission to tertiary care center, unable to resuscitate </li></ul>
  71. 76. Opiates <ul><li>5 deaths in 2005 (9 in 2005) </li></ul><ul><li>3 deaths from Methadone </li></ul><ul><li>Two from morphine/MS Contin </li></ul><ul><li>Deaths were pre-hospital or secondary to anoxic brain injury </li></ul>
  72. 77. Opiates <ul><li>Not tracked historically (AAPCC database created 1983) </li></ul><ul><li>rapid increase of opiate use and abuse somewhat recent phenomena </li></ul><ul><li>A concerted effort to monitor and publish pediatric exposure data not yet established </li></ul>
  73. 78. Pediatric Toxicology Summary <ul><li>Pediatric Poisoning Exposure is a common occurrence </li></ul><ul><li>Determining the dose is important, but frequently can be unreliable </li></ul><ul><li>Death is rare as a percentage </li></ul>
  74. 79. Final Keys <ul><li>Know where to get knowledge about the substances involved </li></ul><ul><li>Know where to get information on the clinical course and treatment </li></ul>
  75. 80. 1-800-222-1222 <ul><li>Questions? </li></ul>

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