Pediatric Toxicology 2007

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

Pediatric Cases in Toxicology
Why are Pediatric Ingestions so common?
Pediatric Poisoning: Developmental Milestones
Epidemiology of Pediatric Poisoning
Poison Center Exposure Data
Toxic vs. Non-toxic Exposures
Trends
Significance
Management issues
Cases

Poisoning is a matter of dose
Paracelsus (1493-1551) Third Defense
“ 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”

Pediatric Development
6-9 months: creep, crawl, and pick up
objects

9-12 months: pick up a pellet and put it in a hand

15 months: walking; pick up a pellet and put it in a bottle

18 months: able to
consciously dump
pellet from bottle
(e.g. Tylenol, aspirin, vitamins, adult prescription medications)

California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years of Age
0-6 months ABUSE
Overall: FALLS

Pediatric Poisoning
#2 leading reason for injury-related hospitalization in children 0 to 3 years of age behind falls

Pediatric Poisoning
#1 reason for hospitalization or death in children 18 months to 3 years of age

The #1 reason for injury-related hospitalization between 18 and 35 months is poisoning

Pediatric Poisoning Admission In Illinois
Illinois Poison Center Data:

Pediatric Poisoning: Lots of exposures, small number admitted
Pediatric Exposure calls to IPC under 6 years of age
1.3% of exposures admitted for observation
Less than one death reported per year (and those are usually pre-hospital)

Assessment of Pediatric Ingestion
History
Who
What
Where
When
Why
How
The scene?

Difficulty with Pediatric History: Did they actually ingest the substance?
Toxic Alcohol Evaluation of Pediatric Patients is often Incomplete
DesLauriers C, Mazor S, Metz J, Mycyk M
2 year retrospective review
33 pediatric cases of Toxic Alcohol Ingestion
21 with levels drawn
5/21 with measurable levels (24% of cases)

Pediatric Exposures Reported to AAPCC (National Data)

Pediatric Deaths Reported to AAPCC (National Data)
~ 2/100,000 pediatric exposures result in death.
Adult Fatalities >500 times more prevalent due to intentional nature of exposures

Unpublished Data from National Benchmarking committee (22 centers)
95% of all pediatric calls to a poison center are managed at home without referral to a poison center.
86% of pediatric exposures that present to an ED without calling a poison center first are discharged from the ED
66% of pediatric exposures that are referred to ED are discharged from the ED

Pediatric Exposures
AAPCC Data Most Common Exposures
Cosmetics and personal care products
Cleaning substances
Analgesics
Tylenol >200 mg/kg
ASA >150 mg/kg
Codiene >2 mg/kg
Propoxyphen >10 mg/kg
Plants

Most Common Pediatric Exposures
Cough and cold preparations
Bropheneramine >2 mg/kg
Chlorpheneramine >1.4 mg/kg
Phenylephrine >4 mg/kg
Pseudoephedrine >16 mg/kg
Dextromethorphan >10 mg/kg
Hydrocarbons
Hormones/hormone antagonist

Pediatric Exposures
AAPCC Data Most Common Exposures
Foreign bodies
Topicals
Pesticides and Rodenticides
Antimicrobials
Vitamins
Gastrointestinal preparations
Arts/crafts/office supplies

Pediatric Exposures
Determination of non-toxic exposures
Call the Poison Center is easiest
It is what poison center staff person does 30 times a day

Pediatric Exposures
General guidelines for categorizing a non-toxic exposure for poison center staff
The product must be absolutely identified
Only a single product can be involved in the exposure
The exposure must be unintentional
The Consumer Product Safety Commission words CAUTION, WARNING, DANGER are not on label
Route of exposure is accurately assessed
No symptoms are noted
Follow-up must be possible

Management of Pediatric Exposures
Decontamination
Enhanced elimination
Antidotal Therapy
Supportive Care

Decontamination
Elimination from the gut and/or decreasing absorption
Emetic Agents (Syrup of Ipecac)
Cathartics (sorbitol, magnesium citrate)
Gastric Lavage
Whole Bowel Irrigation
Charcoal

Decontamination
All decontamination measures were started before the advent of evidence medicine.
No improvement in outcomes has been shown for any of the modalities.
Re-examination of practices are slowly removing them from practice.

Ipecac

Syrup of Ipecac

Syrup of Ipecac
Use of Ipecac promoted in the 1960’s on clinical opinion
AAP recommendation to no longer use ipecac in the home because of a lack of proven benefit.
Does lack of proven benefit equal lack of efficacy?
Prior to this, use decreased to less than <1% of poisonings.

Ipecac
Family Guy Video:

Charcoal
Effective at binding a variety of toxins, most beneficial if given within 60 minutes
Dose 1 gm/kg, up to 100 gm in a single dose

Charcoal Bond, Annals of EM, 2002

Charcoal

Charcoal
Not proven to change outcome
Every year 5 to 10 deaths in poison center data from charcoal aspiration
Always with drugs that cause decreased consciousness, vomiting or seizures
Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit
Risk Benefit Ratio?

Cathartics
Use promoted because of clinical opinion
Most commonly used in ED is sorbitol or magnesium citrate
Intended to decrease absorption by increasing expulsion from the GI tract
Dosing
Sorbitol 70 % 2 cc/kg per kg in adults
Sorbitol 35 % 4 cc/kg per kg in children
Mag citrate 4 cc/kg in children/adults

Cathartics
Indications -- No proven benefit. By convention it is usually given with the first dose, not used for multiple dose therapy
The IPC recently stopped recommending it routinely due to guideline recommendations

Gastric Lavage

Gastric Lavage Bond, Annals of EM, 2002

Gastric Lavage
Indications -- Ingestion of a potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure
contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding

Gastric Lavage
Adults 36-40 french tube (children 24-28 French)
20 degrees trendelenburg, left lateral position
200-300 cc aliquots of water or saline (10 ml/kg chidren, saline)

Co-Lav
Colovage
Colyte
Colyte-flavored
Colyte with Flavor Packs
Go-Evac
GoLYTELY
NuLYTELY
NuLYTELY, Cherry Flavor

No proven efficacy
Potential to reduce drug absorption by rapidly cleansing the GI tract
dosing
9 mo - 6 yo 500 ml/hr
6 yr - 12 yo 1000 ml/hr
Adolescents/adults 1500-2000 ml/hr

=
+ =

Indications
sustained release or enteric coated drugs
Illicit drug packages
Drugs not well absorbed by Charcoal

18% of IPC cases documented at recommended rate of administration and an endpoint of clear rectal effluent
Difficult to accomplish
Time consuming
Can be messy
Inexperience and uncomfortable for staff

General Approach
ENHANCED ELIMINATION
Hemodialysis/Hemoperfusion
MDAC
Urinary Alkalinization

Enhanced Elimination
Water soluble
Small molecular weight
Not highly protein bound
Small Volume of distribution (<1 L/kg)

Dialysis
I sopropyl
S alicylates
T heophylline
U remia
M ethanol
B arbiturates (long-acting)
L ithium
E thylene Glycol

MDAC
Dialyzable
Enterohepatic recirculation
A (Theophylline)
B (Phenobarbital)
C (Carbamazepine)
D (Dapsone)
Q (Quinine)

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

Review of Select 2005 Pediatric Death Cases Reported to AAPCC
Already you know the outcome is going to be bad
The discussion of risk of exposure, treatment and outcomes is what important

Case #1
18 month old child thought to have a respiratory infection (cough and vomiting) by family comes to ED for evaluaton.
CXR shows FB in esophagus and stomach

Button Batteries
Fatal in rare cases
Ingestion of cylindrical and button batteries: an analysis of 2382 cases Litovitz et al, Pediatrics April 1992
2320 button batteries: no deaths
2 in esophagus with severe burns

Button Battery Ingestion
Severe esophageal damage due to button battery ingestion: Can it be prevented? Yardeni et al, Pediatric Surgery International 2004 July
State 19 cases reported in literature from 1979 to 2004
Brief Literature search showed multiple nasal and ear canal damage/reconstruction due to button battery insertion

Button Battery Ingestion
Size
<15 mm unlikely to become lodged in esophagus
>20 mm likely to cause burns
Locate the battery
Esophagus – immediate removal
Stomach/Intestine – expectant management with serial x-rays if not detected in stool

Button Battery Case
Time delay in transfer to appropriate facility
Both batteries removed endoscopically
Admitted for 4 days. Barium swallow with undefined esophageal deviation
Discharged with fever on abx and medication for acid reflux
4 days later found cyanotic and in shock
Death Certificate with aorto-esophageal ulcer/fistula

Hydrocarbons
15 month old female found vomiting, cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child
2 yo child ingested unknown amount of cigarette lighter fluid (Zippo)
18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits

Hydrocarbons
17,685 exposures reported to AAPCC
3 deaths – all respiratory
Unknown number admitted with significant sequelae

Hydrocarbons
Important History:
When
How much (often unreliable)
Coughing
Vomiting (increases aspiration potential)
Behavior changes (lethargy, drowsiness)

Hydrocarbon
Important signs and diagnostic exam results
Mental status
Respiratory status
Cough
Tachypnea
Grunting/Flaring/Retractions
Fever
Pulse ox
CXR

Hydrocarbons
15 mo female: Taken to community hospital. Arrested and expired before helicopter transport
2 yo male with cigarette lighter fluid: Died in ED
18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center

Calcium Channel Blockers
19 month old male found with mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills.

AAPCC data with 22,082 pediatric exposures to “cardiac medications”
No breakdown of Ca Channel blockers
Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%)
Extropolating to national data: over 2100 pediatric calcium channel blocker exposures
Are they all true exposures?

Calcium Channel blocker
Triage Criteria Proposed by AAPCC, ACMT, AACT
(Triage amounts in mg/kg so small, may not be clinically useful)

Hyperglycemia
Calcium Channel blockers in the pancreatic B islet cells
Decreased release of insulin
Can lead to HYPERGLYCEMIA

Calcium Channel blockers
2 yo male with ingestion of up to 450 mg sustained release nifedipine
Unremarkable vitals initially. Glucose 253
Upon arrival to tertiary care center, resting tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours.
Arrested the day after admission to tertiary care center, unable to resuscitate

Opiates
5 deaths in 2005 (9 in 2005)
3 deaths from Methadone
Two from morphine/MS Contin
Deaths were pre-hospital or secondary to anoxic brain injury

Opiates
Not tracked historically (AAPCC database created 1983)
rapid increase of opiate use and abuse somewhat recent phenomena
A concerted effort to monitor and publish pediatric exposure data not yet established

Pediatric Toxicology Summary
Pediatric Poisoning Exposure is a common occurrence
Determining the dose is important, but frequently can be unreliable
Death is rare as a percentage

Final Keys
Know where to get knowledge about the substances involved
Know where to get information on the clinical course and treatment

1-800-222-1222
Questions?

Pediatric Toxicology 2007

by Illinois Poison Center

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Pediatric Toxicology 2007 Presentation Transcript