Poisoning in children

1. Poisoning
Ali Alhaboo Assisstant Professor of
Pediatrics
PICU consultant
 Overview of pediatric
poisoning, diagnosis and
treatment
 Summary of the most
encountered poisoning

2. Epidemiology
 Most of the toxic exposures have
only minor or no effect on the child
 85% - 90% of pediatric poisoning
occurs in < 5 yrs of age
(accidental) usually single agent
 10% - 15% in older age, mainly
adolescents (intensional) usually
several agents
 3-4% of PICU admission are
because of toxic exposures

3. ED referral recommendations
 Serious exposures
 Younger than 6 months
 History of previous toxic ingestion
 Questionable or unreliable history

4. Routes of exposures in
children
 Ingestion
 Inhalation
 Skin exposure

5. Common agents Less common but
serious
 Cosmetics and
personal care product
 Cleaning substance:
flash is more serious than
Clorox because it melts the
esophagus and destroys it.
 Plants
 Analgesics: Paracetamol
is the commonest cause of
poisoning in children ( high
doses more than 200 mg/kg)
 Fe supplements:
2nd most
common in
females.
 Antidepressants
 Anti-diabetics:
causing severe
hypoglycemia and
LOC.
 Anti-
hypertensive.
 Pesticides:
organophosphates.
 Hydrocarbon
Note: OCPs are not harmful.

6. History
 Identification of the toxic agent
 Age of the child.
 What has been done to the child.
 The time elapsed and the dose taken (if it was
unknown consider it serious).
 The route of exposure
 Underlying medical problems
 The clinical effect (with few exceptions rapidity of
symptoms progression correlates with severity of
poisoning.e.g., acetaminophen)
 ? Trauma in addition to ingestion (change in LOC).

7. Physical Exam
 Weight (determine ? mg/kg ingested)
 Vital signs
 Check odors from the breath, skin, hair,
clothing
 Thorough exam for any abnormal finding

8. General presentations suggestive
of poisoning
 Severe vomiting,
diarrhea
 Acutely disturbed
consciousness
 Abnormal behavior
 Seizure
 unusual odor
 Shock
 Arrhythmias
 Metabolic acidosis
 Cyanosis
 Respiratory distress

9. Clinical clues to the diagnosis
of unknown poisoning
 Odor
 Skin
 Mucous
membranes
 Temperature
 Blood pressure
 Pulse rate
 Respiration
 Pulmonary
edema
 CNS
 GI system

10. Odor
Signs or symptom Poison
 Bitter almond
 Acetone
 Oil of
wintergreen
 Garlic
 Alcohol
 Petroleum
 Cyanide
 Isopropyl alcohol, methanol,
acetylsalicylic acid
 Methyl salicylate
 Arsenic, phosphorous, thallium,
organophosphates
 Ethanol, methanol
 Petroleum distillates

11. Skin
Sign or symptom Poison
 Cyanosis
 Red flush
 Sweating
 Dry
 Methemoglobinemia secondary to
nitrates, nitrites, phenacetin,
benzocaine
 Carbon monoxide, cyanide, boric
acid, anticholenergics
 Amphetamines, LSD,
organophosphates, cocaine,
barbiturates
 Anticholenergics

12. Mucous membranes
Signs or symptoms Poison
 Dry
 Salvation
 Oral lesions
 Lacrimation
 Anticholenergics
 Organophosphates,
carbamates
 Corrosives, paraquat
 Caustics, organophosphates,
irritant gases

13. Temperature
Signs or symptoms Poison
 Hypothermia
 Hyperthermia
 Sedatives hypnotics, ethanol,
carbon monoxide, clonidine,
phenothiazines, TCAs
 Anticholenergics, salicylates,
phenothiazines, cocaine,
TCAs, amphetamines,
theophylline

14. Blood Pressure
Signs or symptoms Poison
 Hypertension
 Hypotension
 Sympathomimitics (especially
phenylpropanolamine in over-
the-counter cold remedies),
organophosphates,
amphetamine, phencyclidine,
cocaine
 Antihypertensives,
barbiturates, benzodiazepines,
beta blockers, Ca++ channel
blockers, clonidine, TCAs

15. Pulse rate
Signs or symptoms Poison
 Bradycardia
 Tachycardia
 Arrhythmias
 Digitalis, sedatives hypnotics,
beta blockers, ethchlorvynol,
opioids
 Antichlonergics,
sympathomimetics,
amphetamines, alcohol,
aspirin, theophylline, cocaine,
TCAs
 Anticholenergics, TCAs,
organophosphates, digoxin,
phenothiazines, betablockers,
carbon monoxide, cyanide

16. Respirations
Signs or symptoms Poisoning
 Depressed
 Tachypnea
 Kussmaul’s
sign
 Wheezing
 Pneumonia
 Pulmonary
edema
 Alcohol, opioids, barbiturates,
sedatives/hypnotics, TCAs, paralytic
shelfish poisoning
 Salicylates, amphetamines, carbon
monoxide
 Methanol, ethylene glycol, salicylates
 Organophosphates
 Hydrocarbons
 Aspiration, salicylates, opioids,
sympathomimetics

17. CNS
Sings or symptoms Poison
 Seizures
 Fasciculation
 Hypertonus
 Myoclonus,
rigidity
 Camphor, carbon monoxide,
cocaine, amphetamines,
sympathomimetics,
anticholenergic, aspirin,
pesticides, organophosphates,
lead, PCP, phenothiazines, INH,
lithium, theophylline, TCAs
 Organophosphates
 Anticholenergics, phenothiazines
 Anticholenergics, phenothiazines,
haloperidol

18. CNS
Sings or symptoms Poison
 Delirium/psychos
is
 Coma
 Weakness,
paralysis
 Anticholenergics,
phenothiazines,
sympathomimetics, alcohol,
PCP, LSD, marijuana, cocaine,
heroin, heavy metals
 Alcohol, anticholenergics,
sedative hypnotics, opioids,
carbon monoxide, TCAs,
salicylates,
organophosphates
 Organophosphates,
carbamates, heavy metals

19. EYE
Signs or symptoms Poison
 Miosis
 Mydriasis
 Blindness
 Nystagmus
 Opioids, phenothiazines,
organophosphates,
benzodiazepines, barbiturates,
mushrooms, PCP
 Antichlenergics,
sympathomimitics (cocaine,
amphetamines, LSD, PCP), TCA,
methanol, glutethimide
 Methanol
 Diphenylydantoin, barbiturates,
carbamazepine, PCP,carbon
monoxide, glutethimide, ethanol

20. GI
Sings or symptoms Poison
 Vomiting,
diarrhea
 Iron, phosphorous, heavy
metals, lithium, mushroom,
fluoride, organophosphates

21. Toxidromes of Common Pediatric
Poisonings
Toxin Signs or symptoms
 Anticholenergi
cs (atropine,
scopolamine,
TCAs,
antihistamines,
mushrooms)
 Cholenergics
(organophosph
ates and
carbamate
insecticides)
 Fever, flushed, warm, dry skin,
dry mouth, mydriasis,
tachycardia, arrhythmias,
agitation, hallucinations, coma
 Salivation, lacrimation, sweating,
bronchorrhea, emesis, diarrhea,
miosis, bradycardia,
bronchospasm with wheezing,
confusion, weakness,
fasciculations, coma

22. Toxidromes of Common Pediatric
Poisonings
Toxin Signs or symptoms
 Opiates
 Narcotic
withdrawal
 Hypothermia,
hypoventilation, hypotension,
bradycardia, miosis, coma
 Nausea, vomiting, diarrhea,
abdominal pain, lacrimation,
diaphoresis, mydriasis,
tremor, irritability, delirium,
seizure

23. Toxidromes of Common Pediatric
Poisonings
Toxin Signs or symptoms
 Sedative/
hypnotics
 TCAs
 Phenothiazines
 Hypothermia, hypoventilation,
hypotension, tachycardia, coma
 Coma, convulsions, arrhythmias,
anticholenergic manifestations
 Hypotension, tachycardia,
dystonia syndrome, oculogyric
crisis, trismus, ataxia, coma,
anticholenergic manifestations

24. Toxidromes of Common Pediatric
Poisonings
Toxin Signs or symptoms
 Salicylates
 Iron
 Sympathomimetics
(amphetamines,
phenylpropanolamie
, ephedrine, caffeine,
cocaine,
aminophylline)
 Fever, hyperpnea, vomiting,
tinnitus, acidosis, seizure,
lethargy, coma
 Hyperglycemia, shock,
hemorrhagic diarrhea
 Tachycardia, arrhythmias,
psychosis, hallucinations,
nausea, vomiting,
abdominal pain

25. Laboratory tests
 Qualitative toxicology screening is rarely as helpful
as Hx and PE in determining the cause
 Best done on urine and gastric aspirate samples
 Quantitative serum level of known drug is indicated
when it can enable prediction of toxicity or
determination of treatment
 ABGs with respiratory symptoms and to assess
acid-base balance
 Blood glucose from 1st sample
 Liver and kidney function (metabolism&excretion)
 Serum electrolytes (anion gap, renal function)
 Serum osmolar gap
 CBC (anemia, hemolysis)
 DIC panel when suspected

26. Routine Laboratory Tests That Can
Suggest Poisoning
- Decreased hemoglobin
saturation with normal
or increased PO2
Agents causing methemoglobin (nitrates,
nitrites, benzocaine)
- Elevated anion gap
metabolic acidosis
Methanol, ethanol, isopropyl alcohol,
ethylene glycol, salicylates, isoniazid,
paraldehyde, toluene, iron, phenformin,
CO, cyanide
- Elevated osmolar gap Ethanol, methanol, isopropyl alcohol,
ethylene glycol
- Hyperglycemia Salicylates, isoniazid,
organophosphates, iron
- Hypoglycemia Insulin, ethanol, isopropyl alcohol,
isoniazid, phenfomin, acetaminophen,
salicylates, oral hypoglycemic agents
- Hypocalcemia Ethylene glycol, methanol
- Oxalic acid crystalluria Ethylene glycol
- Ketonuria Isopropyl alcohol, ethanol, salicylates

27. Drugs with clinically useful serum
level quantitation
 Acetaminophen
 Anticonvulsants
 Carbon
monoxide
 Cholinesterase
 Digoxin
 Ethanol
 Ethylene glycol
 Heavy metals
 Iron
 Isopropanol
 Lead
 Lithium
 Methanol
 Methemoglobin
 Salicylate
 Theophylline

28. Radiography indications
 If head trauma cannot be excluded
(skull and cervical spine film, head CT
if physical findings are suggestive)
 If child abuse is suspected
(skeletal survey)
 If patient is having respiratory distress
(CXRay)
 If radiopaque substance is suspected

29. Common substances that are
radiopaque (CHIPES)
 Chloral hydrate
 Heavy metals
 Iodine
 Phenothiazine
 Enteric coated and extended
release medication
 Salt tablets
(in Fe ingestion, serial films indicate movement and elemination)

30.  First you have to start with ABC, if hypotensive repeat ABCs.
 Check the O2 saturation
 Glucocheck for hypoglycemia. If hypoglycemic give 5-10%
dextrose (not higher than that because it might harm the
vessel). Dose: 2-5 ml/Kg.
 Do toxicology screen.
 LFT, U/E, RFT, coagulation profile (PT is the first to be affected,
if it was elevated give FFP or vitamin K) and albumin.
 Give antidote as early as possible if available. (N-acetylcesteine
is the antidote for paracetamol. Desfuroxemine is the antidote
for iron.
 Transfer the patient to the ICU, if there is no bed keep him in
the ER.
Steps of management

31. Treatment
 Airway: patency and protective mechanisms (if
absent, use nonspecific antidote of D10W 2cc/kg
and Naloxone 0.1mg/kg; if no response intubate.
 Breathing: clear secretions, give O2, continuous
O2 saturation, ABGs, CXRay, treat wheezing and
stridor, early controlled intubation prefered
 Circulation: frequent VS, continuous CR monitor,
fluids for low BP, do baseline ECG, watch for
arrythmias, PALS guidelines
 Neurologic status: frequent assessments, the
most common cause to admit intoxication to PICU,
use nonspecific antidotes, watch for seizures, rule
out metabolic causes of seizure

32. GI decontamination
Emesis-Syrup of Ipecac
Therapy Contraindications
 Dosage in < 1 yr 10 ml
 Young children 15 ml
 Adolescents,
adults 30 ml
may repeat once
 Petroleum distillates
 Caustic agents
 Impaired
consciousness,
seizures
 Rapid coma-inducing
agents (e.g.,
propoxyphene, TCAs)

33.  We use lavage when the patient presents
early and is stable.
 If late presentation where the drug has
already passed to the duodenum use the
activated charcoal( through a NG tube)
where up to 1 million particles can adsorb
to the medication.

34. GI decontamination
Lavage
Therapy Contraindications
 Large bore orogastric hose (28 Fr
for young children, 36-40 Fr for
adolescents)
 Left recumbent Trendelenburg’s
position to reduce the risk of
aspiration
 Lavage with saline or 1/2 NS until
return is clear
 Most successful for toxins that
delay gastric emptying (aspirin,
iron, anticholinergics) and for
those forming concretions (iron,
salicylates, meprobamate)
 Corrosive
caustic agents
 Controversial in
petroleum
distillates
ingestion
 Stupor or coma
unless airway is
protected

35. GI decontamination
Activated Charcoal
Therapy Contraindications
 Administer in all
cases after
emesis. It should
be only given for
conscious
patients.
 Dosage:
- Children 1 g/kg
- Adults 50-100 g
 Corrosive agents:
charcoal interfers
with GI endoscopy
Most feared complication
is aspiration leading to
severe pneumonitis and
ARDS

36. GI decontamination
Cathartics
Therapy Contraindications
 MgSO4 250 mg/kg/dose
P.O.(max dose 30 g) in
10%-20% solution
 Sorbitol magnesium
citrate
Repeat above
doses every 2-4 hrs
until passage of
charcoal stained stools
 Avoid MgSO4 in
renal failure

37. Enhanced elimination
 Forced diuresis by administering 2-3 times the
maintenance fluid to achieve U.O = 2-5 cc/kg/hr
(contraindicated in pulmonary or cerebral edema and
renal failure)
 Urinary alkalinization to eleiminate weak
acids(salicylates, barbiturates and methotrexate), can
be achieved by adding NaHCO3 to the IV fluids, the goal
is urine pH of 7-8
 Serum alkalinization in TCAs toxicity
 Hemodialysis in low molecular weight substances
with low volume of distribution and low binding to
plasma proteins
 Hemoperfusion, protein binding is not a limitation

38. Antidotal Therapy
 Only a small proportion of
poisoned patients are amenable to
antidotal therapy
 Only a few poisoning is antidotal
therapy urgent (e.g., CO, cyanide,
organophosphate and opioid
intoxication)

39. Specific Intoxications and Their Antidotes
Poison Antidote Indications
Acetaminophen N-Acetylcysteine
(Mucomyst)
Serum level in “probable”
hepatotoxic range
Anticholenergics Physostigmine SVT with hemodynamic
compromise
Beta blockers Glucagon Bradycardia
Isopreterenol,
dopamine,
epinephrine
Bradycardia
Benzodiazepines Flumazenil Symptomatic intoxication
Carbon monoxide O2 Level > 5-10%
Cyanide Amyl nitrite,
sodium nitrite,
sodium thiosulfate
Symptomatic intoxication
Digitalis Specific Fab
antibodies

40. Specific Intoxications and Their Antidotes
Poison Antidote Indications
Ethylene glycol Ethanol Osmolar gap and metabolic acidosis or
Serum level >20 mg/dl regardless of
symptomatology
Iron salts Desferoxamine Symptomatic patients
Serum iron > 350 g/ml or > TIBC
Positive deferoxamine challenge test
Isoniazid Pyridoxine
(vit B6)
Methanol Ethanol Metabolic acidosis and elevated
osmolar gap regardless of symptoms
Methemoglobinemi
a producing agents
Methylene blue Symptomatic poisoning
Methemoglobin level > 30-40 %
Narcotics Naloxane Symptomatic intoxication
Organophosphate
insecticides
Atropine
Pralidoxime
Cholenergic crisis
Fasciculation and weakness
Phenothiazines Diphenhydramine Symptomatic intoxication (oculogyric
crisis)

41. Acetaminophen
(paracetamol) poisoning
 Nausea, vomiting and malaise for 24 hrs
 Improvement for 24-48 hrs
 Hepatic dysfunction after 72 hrs (AST is the
earliest and most sensitive)
 Death may occur from fulminant hepatic failue
 Toxicity likely with ingestion of > 150 mg/kg
 Rumack-Matthew nomogram defines the risk of
hepatic damage in acute intoxication (level at 4
hrs post ingestion)

42. Acetaminophen (paracetamol)
poisoning management
 GI decontamination
 Activated charcoal within 4 hrs of ingestion
 Antidote N-acetylcysteine is most effective if
given within 8 hrs of ingestion, total of 17
doses, P.O or IV (However, NAC should be
given even with > 24hrs presentation)
 NAC should be given if serum acetaminophen
level is either in the “possible” or “probable”
hepatotoxic range

43. Salicylate toxicity
Clinical manifestations
Common Uncommon
 Fever
 Sweating
 Nausea
 Vomiting
 Dehydration
 Hyperpnea
 Tinnitus
 Seizures
 Coma
 Coagulopathy
 Respiratory
depression
 Pulmonary
edema
 SIADH
 Hemolysis
 Renal failure
 Hepatotoxicity
 Cerebral edema

44. Laboratory findings in salicylate
toxicity
 Metabolic acidosis
 Respiratory alkalosis
 Mixed (resp alkalosis
&metabolic acidosis)
 Hyperglycemia,
Hypoglycemia
 Hypernatremia,
hyponatremia
 Hypokalemia
 Hypocalcemia
 Prolonged PT
 Ketouria

45. Prediction of acute salicylate
toxicity
 Ingested dose can predict the severity
 < 150 mg/kg toxicity not expected
(asymptomatic)
 150-300 mg/kg toxicity mild to moderate
(mild to moderate hyperpnea,
lethargy or excitability)
 300-500 mg/kg severe toxicity
(severe hyperpnea, coma
or semicoma, sometimes
with convulsions)

46. Management of salicylate toxicity
 GI decontamination
 Correct dehydration and force diuresis
 Urine alkalinization and acidosis correction with
IV NaHCO3
 Monitor electrolytes, glucose, calcium
 Vit K for hemorrhagic diathesis
 Decrease fever with external cooling
 Hemodialysis for severe intoxication (Dome
nomogram), severe acidosis unresponsive to
NaHCO3, renal failure, pulmonary edema and
severe CNS manifestation