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Common Poisoning among Children

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  1. 1. Poisoning Lutfi Abdallah
  2. 2. Epidemiology • Data in sub-Saharan Africa is limited • American Association of Poison Control Centres > 2 million human poisoning exposure reported annually • > 50% in children 5 yr of age or younger • Almost all are unintentional • > 90% occur in the home - ingestion
  3. 3. • Ingestion  It is the most common route of poisoning exposure (77%) with dermal, inhalation, ophthalmic route account 7.5%, 6%, 5% respectively  Common household products ie cosmetics, person care item, cleaning solution
  4. 4. Pharmaceutical preparations ie analgesic,cough and cold products,antimicrobial agent. Plants, berries In children 6-12 yr of age are much less common • Adolescents – intentional suicide, abuse
  5. 5. Approach to the poisoned patient • Approach is no different than that in any other sick child • Emergency assessment – A,B,C etc • Emergency Treatment • History • Physical exam
  6. 6. know ; • Clear cut history of poisoning • A reliable person witnessed the event • The substance is known • Amount ingested ? • Poisoning witnessed • Substance unknown • Amount ? • Differential diagnosis in any unexplained illness in a previously healthy child.
  7. 7. OVERVIEW OF COMMON ACCIDENTAL INGESTION INGESTION CLINICAL MANIFESTATI ON NURSING TREATMENT INTERVENTION S Salicylate (Aspirin) Tinnitus Hyperpyrexia Seizures Bleeding Hyperventilation Emesis Hydration Vitamin K Activated charcoal Anticipatory guidance Bleeding precautions Counseling if suicide attempt Acetaminophen (Tylenol) Liver necrosis in 2-5 days; nausea; vomiting; pain in R upper quadrant; jaundice; coagulation; abnormalities, hepatoxic -Emesis Mucomyst (antidote) -Counseling if suicide attempt - Liver assessment
  8. 8. Lead (paint, also in soil near heavily trafficked roadways, household dust) -Developmental regression -Impaired growth (encelophalopath y) -Irritability -Increased clumsiness -Chelation therapy -EDTA -Bal -Child must be well hydrated -Neuro assessment -Diet high in calcium, iron -Educate parents to wash chuld’s hands, toys frequently to remove lead dust -Lead abatement Hydrocarbons (kerosene, turpentine, gasoline) -Burning in mouth - choking and gagging -CNS depression -DO NOT INDUCE EMESIS -Activated charcoal -Gastric lavage If vomiting, reduce aspiration Corrosives (drain or oven cleanser, chlorine bleach, battery acid) -Burning in mouth -White swollen mucous membranes -Violent vomiting - DO NOT INDUCE EMESIS -Dilute toxin with water -Activated charcoal Keep warm and inactive
  9. 9. Specific poisonings • Acetaminophen
  10. 10. Specific poisonings • 4 stages of Acetaminophen if left untreated • Stage 1 – In the first 24 h after ingestion, the patient develop nausea, vomiting and diaphoresis • Stage 2 – During the next 24 -48 h, there is clinical involvement. During this time serum AST, ALT, bilirubin, and prothrombin increase. The patient develop right upper quadrant pain. • Stage 3 – From 72 to 96h after ingestion, the patient has peak liver function abnormalities. GI symptoms may again develop. • Stage 4 – From 4 days to 2 weeks after ingestion, the patient’s hepatic problems resolve. <1% will develop fulminant hepatic necrosis.
  11. 11. Specific poisonings If within 1 hour of ingestion give activated charcoal, if available, or induce vomiting UNLESS an oral antidote may be required. ➤Decide if antidote is required to prevent liver damage: ingestions of 150mg/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). ➤If more than 8 hours after ingestion, or the child cannot take oral treatment, give IV acetylcysteine.
  12. 12. Specific poisonings Aspirin(Salicylates)
  13. 13. Specific poisonings 3 phases of salicylate ingestion Phase 1 – The patient has respiratory alkalosis and potassium and sodium bicarbonate are excreted in the urine. This phase last approx. 12h in an adolescent but may not be evident in small children. Phase 2 – As alkalosis continues, a “paradoxical aciduria” occurs approx. 12 – 24 h after salicylate ingestion in the adolescent. This phase may begin shortly after salicylate ingestion in the young child. Phase 3 – Metabolic acidocic, dehydration and hypokalemia appear 4-6h after ingestion of salicylates in an infant, and ≥ 24h after ingestion in an adolescent.
  14. 14. Specific poisonings Diagnostic tests - WBC, Hct, platelets ↑ - BUN, cratinine ↑ - Hypernatremia or hyper- or hypokalemia - Hyper- or hypoglycemia - The arterial blood gas will show a metabolic acidosis and respiratory compensation in children and a respiratory alkalosis alone in adolescents.
  15. 15. Give activated charcoal if available. Note that salicylate tablets tend to form a concretion in the stomach leading to delayed absorption, so it is worthwhile giving several doses of charcoal. If charcoal is not available and a severely toxic dose has been given, then perform gastric lavage or induce vomiting. ➤Give IV sodium bicarbonate 1 mmol/kg over 4 hours to correct acidosis and to raise the pH of the urine to above 7.5 so that salicylate excretion is increased. Give supplemental potassium too. Monitor urine pH hourly. ➤Give IV fluids at maintenance requirements unless child shows signs of dehydration in which case give adequate rehydration. ➤Monitor blood glucose every 6 hours and correct as necessary. ➤Give vitamin K 10mg IM or IV.
  16. 16. Specific poisonings Complications/Follow-up: Some causes of death from salicylate ingestion include respiratory failure, cerebral edema, hemorrhage and cardiovascular collapse.
  17. 17. Specific poisonings Iron ■ Check for clinical features of iron poisoning: nausea, vomiting, abdominal pain and diarrhoea. The vomit and stools are often grey or black. In severe poisoning there may be gastrointestinal haemorrhage, hypotension, drowsiness, convulsions and metabolic acidosis. Gastrointestinal features usually appear in the first 6 hours and a child who has remained asymptomatic for this time probably does not require antidote treatment. ➤Activated charcoal does not bind to iron salts, therefore consider giving a gastric lavage if potentially toxic amounts of iron were taken. ➤Decide whether to give antidote treatment. Since this can have side-effects it should only be used if there is clinical evidence of poisoning. ➤If you decide to give antidote treatment, give deferoxamine (50 mg/kg IM up to a maximum of 1 g) by deep IM injection repeated every 12 hours; if very ill, give IV infusion 15 mg/kg/hour to a maximum of 80 mg/kg in 24 hours.
  18. 18. Specific poisonings Carbon Monoxide A 5 year old is brought to the Emergency centre for the first time seizure. The child was previously well, and has never had a seizure. His father states that the child was travelling cross-country in an older model vehicle when the seizure occurred. The child was sleeping on the floor of the vehicle, and there were five adults who were smoking tobacco at the time of the event. On physical examination the child appears drowsy, but otherwise, the physical examination is unremarkable. The pulse oximetry reads 97%
  19. 19. Specific poisonings Definition: CO is colorless, odorless gas produced from the combustion of carbon-containing fuel. Risk factors/ Etiology: The affinity of CO to hemoglobin is 250 times that of oxygen. This results in the formation of caboxyhemoglobin, decreasing the oxygen carrying capacity of blood.
  20. 20. Specific poisonings Presentation: Symptom depend on the carboxyhemoglobin levels 0-10% None 11-20% Mild headache 21-30% Throbbing headache, irritability 31-40% Severe headache, lethargy, nausea, vomiting 41-50% Confusion, syncope, tachycardia, tachypnea 51-60% Syncope, coma, seizure 61-70% Coma, hypertension, respiratory failure, death >70% Death
  21. 21. Specific poisonings ➤Give 100% oxygen to accelerate removal of carbon monoxide (note patient can look pink but still be hypoxaemic) until signs of hypoxia disappear. ➤Monitor with pulse oximeter but be aware that these can give falsely high readings. If in doubt, be guided by presence or absence of clinical signs of hypoxaemia.
  22. 22. Specific poisonings Caustics(Acids and Alkalis) A 2 year- old boy present to the emergency centre with his parent who say that they found the patient drinking some Caustic Soda Beads. The patient was crying profusely, and has blisters and burns in his mouth. The patient is drooling. Defn: Caustics include both acids and alkali(base)
  23. 23. Specific poisonings Acids cause tissue necrosis, and the alkali produce liqufaction necrosis with the risk of perforation if the burn is located in the intestinal tract. Serious injuries tend to occur with a pH <2 or >2 Presentation: Burns mucous membranes may be visualized. The patient may drool and refuse to swallow secondary to pain. Esophageal stricture may be found. Acids may be responsible for delayed gastric emptying from pylorus scarring. Diagnostic Test: CBC, Abdominal radiograph
  24. 24. Specific poisonings Treatment: • Do not induce vomiting or use activated charcoal when corrosives have been ingested as this may cause further damage to the mouth, throat, airway, oesophagus and stomach. • Give milk or water as soon as possible to dilute the corrosive agent. • Then give the child nothing by mouth and arrange for surgical review to check for oesophageal damage/rupture, if severe.
  25. 25. Specific poisonings • Petroleum compounds e.g. kerosene, turpentine substitutes, petrol ➤Do not induce vomiting or give activated charcoal as inhalation can cause respiratory distress with hypoxaemia due to pulmonary oedema and lipoid pneumonia. Ingestion can cause encephalopathy.