Poison sileshi-3

Poisonings
Poisoning
Sileshi Mulatu
UNIVERSTY OF GONDAR
COLLEGE OF MEDICINE AND HEALTH SCIENCE
DEPARTMENT OF NURSING
Dec, 2015
Gondar, Ethiopia 1

Definition
Presentation outline
oObjective
oIntroduction
oEpidemiology
oRisk factors
oType of poisoning
oLead poisoning
o Pesticide poising
o Food poising
o Medication poisoning and
o Alcohol poisoning
o Evidence
o Reference
2

Definition
Objective
– At the end of this session the student will
be able to:
Discus the overview of poisoning
Identify the common type of poisoning
Explain the cause of poisoning
Determine the effect of poisoning on children
Analyze the determinant factors of poisoning
Discus complication of poisoning
Explain the management of poisoning
3

Definition
Introduction
• Poison; Anything someone eats, drinks, breaths in, or
gets in their eyes or on their skin that can cause
illness or death if it gets into or on the body.
• A substance (solid, liquid or gas), which if introduced
in the living body, or brought into contact to a part
therefore, will produce ill health or death, by its
constitutional or local effects or both.
4

DEFINITION
Introduction
• The majority of poisonings are accidental,
especially in the under-5 age group
• Intentional overdoses and substance abuse are
seen in older children
http://emedicine.medscape.com/pediatrics_general/
5

DEFINITION
Introduction
• Deaths in children from poisoning are
becoming increasingly rare
• Factors responsible for this decline include:
1. Introduction of child-resistant
containers
2. Reducing the pack sizes
3. More effective management
http://emedicine.medscape.com/pediatrics_general/
6

Examples of Poisons Cont’d
Examples of Poisons
 Household products
 Medications
 Lead
 Pesticide
 Gases and Fumes
7

Cost
Poisoning in Children
Definition of Poisoning:
• Exposure to a chemical or other agent that adversely
affects functioning of an organism.
• Poisoning is the third leading cause of unintentional
injury death.
• Each year 3,000 young children aged 0 to 14 die of
acute poisoning
• Children 5 years and under account for the majority
of all poison exposures with children up to two years
old especially vulnerable. 8

Cost
• The term poisoning is used when cells are injured or
destroyed by inhalation, ingestion, injection or
absorption of a toxic substance.
• Curiosity and the desire to put everything in their
mouths place young children at considerably greater
risk for poison exposure than adults.
• They like things that smell good and are drawn to
attractive packaging and the colorful substances of
many of the products found around the home. 9

Definition• Children are curious and explore their world with all
their senses, including taste.
• As a result, the home and its surroundings can be a
dangerous place where poisonous substances are
inadvertently ingested.
• Common causes of poisoning in children are household
products including kerosene oil, drugs,
chemicals(corrosives) and pesticides.
10

Cost• Children are more likely to suffer serious
consequences because they are smaller, have
faster metabolic rates and their bodies are less
capable of neutralizing toxic chemicals.
• Circumstances of Exposure can be
intentional, accidental, environmental,
medicinal or recreational.
• Routes of exposure can be ingestion, injection,
inhalation or cutaneous exposure
11

Cost• Most exposures involved oral ingestion (76 percent),
occurred in the home (93 percent), and were
unintentional (more than 80 percent).
• Children younger than six years accounted for 51
percent of the exposures.
• Of these, 38 percent involved children three years or
younger.
• Most ingestions involved nontoxic substances and
were managed at home.
Tamara Mcgregor, 2009 12

Poisoning Facts in Children
Epidemiology
 In 2004, poisoning caused more than 45 000 deaths
in children and youth under 20 years of age.
 In the rate of fatal poisoning is highest for children
under one year, with another slight peak around 15
years.
 In fatal poisoning rates in low-income and middle-
income countries are four times that of high-income
countries.
 Common poisoning agents in low-income and
middle income countries are fuels such as paraffin
and kerosene, pharmaceuticals and cleaning agents. 13

Risk Factors for Poisoning
Epidemiology
• The prevalence and types of poisoning vary in
different parts of the world based on their economic
status.
• They depend on industrial development, agricultural
activities, cultural practices relating to supervision of
children and local beliefs and customs.
For example, medicinal drugs are the leading cause of non-
fatal poisoning in children in middle income to high-income
countries, and ingestion of fuels such as kerosene is a
common cause in low income countries.
14

• Unsupervised home setting
• African American race
• Males less than 5 years old
• Lower level of education
• Substance abuse
• Depressed adolescents
15

• Young children are particularly susceptible to the
ingestion of poisons, especially liquids.
• Adolescents, on the other hand, are more aware of the
consequences of their actions but peer pressure and
risk taking behavior can lead them to misuse alcohol or
drugs, leading to higher fatality rate
• Younger children are more susceptible to poisoning
because of their smaller size and less well-developed
physiology and immaturity 16

Other risk factors for poisoning include those
related to the poisoning agent itself,
 Including toxicity, nature, physical appearance and
storage; season and weather conditions, policies,
standards and laws governing the manufacture,
labelling, distribution, storage and disposal of
poisoning agents; and access to quality health care
for treatment.
17

Types of Poisonings
Common Types of
Poisonings
18

Objectives
 Identify sources of lead
 Recognize the dangers of lead exposure
 Identify signs and symptoms of children who
have been exposed to lead
 Identify ways to prevent lead poisoning
1. Recognize ways of treatment of lead poisoning
20

Introduction
 Lead is a heavy metal with a bluish-grey color.
 It has a low melting point, is easily molded and shaped,
and can be combined with other metals to form alloys
 For these reasons, lead has been used by humans for
millennia and is widespread today in products as:
 pipes; storage batteries; pigments and paints; glazes; vinyl
products; weights, shot and ammunition; cable covers; and
radiation shielding.
21

Introduction
 Lead poisoning is one of the most common and best-recognized
childhood diseases of toxic environmental origin.
 Children around the world today are at risk of exposure to lead
from multiple sources.
 Lead poisoning accounts for about 0.6% of the global burden of
disease (WHO, 2009).
22

Sources of Lead exposure children
 lead added to gasoline
 lead from an active industry, such as mining (especially
in soils)
 lead-based paints and pigments,
 lead solder in food cans
 ceramic glazes
 drinking-water systems with lead solder and lead pipes
 lead in products, such as herbal and traditional medicines23

 lead released by incineration of lead-containing
waste
 lead in electronic waste (e-waste)
 lead in the food chain, via contaminated soil
 lead contamination as a legacy of historical
contamination from former industrial sites.
 Some toys, jewelry, hobby and sports objects (like
stained glass, ink, paint and plaster) may contain lead.
24

Children At Risk
 Children under the age of 6 years are at the greatest risk.
 They grow so rapidly and tend to put their hands or other
objects into their mouths.
 In the low-income world the informal recovery of lead from car
batteries and the open burning of waste are very important
sources of environmental lead contamination.
26

Children At Risk
 Socioeconomic factors are important predictors of
exposure to lead.
 Poor families are more likely to expose to lead
 Also, they are more likely to dwell on polluted lands, to work in
polluting industries, or to live in older housing with lead-based
paint.
 Finally, poor children are more likely to have iron or calcium
deficient diets, and as a result they may absorb lead more
efficiently. 27

Effect of Lead Poisoning
 Children can be exposed to lead through inhaling, swallowing
and in some cases, it can be absorbed into the skin.
 Once lead is in a child’s system, it is distributed through the body
like helpful minerals such as zinc and iron.
 If lead is in the bloodstream, it can cause damage to red blood
cells and limit their ability to carry oxygen to organs and tissue.
(Kids Health)
28

Long Term Effects of Lead Exposure
 Developmental Delays
 Speech and Language Problems
 Poor Muscle Coordination
 Damage to the nervous system, kidneys and hearing
 Decreased bone and muscle growth
 Seizures and unconsciousness
(Kids Health)
29

Signs and Symptoms of Lead Poisoning
 Headaches
 abdominal pain
 Loss of appetite
 Vomiting or nausea
 Constipation
 Seizures
 Weight loss
 Lethargy or fatigue
 Pallor (pale skin) from anemia
(lower than normal RBCs)
 Metallic taste in mouth
 Muscle and joint weakness or pain
 Irritability or behavioral problems
 Pica (eating of non-nutritious
things such as dirt and paint
chips)
30

 Siblings of children with lead in their bodies will also
be tested.
 Therapies are used with children who have small
amounts of lead present, in order to allow the body to
naturally eliminate the lead.
Lead Poisoning Treatment
31

Treatment
 Lead poisoning is treated depending on how much lead is in the
blood.
 Some children require hospitalization to receive a medication
called a chelating agent.
 This medication chemically binds with lead, through an IV to
make the lead weaker so the body can get rid of it naturally.
 This is for children with both severe and high levels of lead.
32

General measures
 Quick assessment
 Limit absorption:
– Vomiting
– Lavage
– Activated charcoal instillation
Treatment
33

Specific:
ABCD’s of Toxicology:
– Airway
– Breathing
– Circulation
– Drugs:
– Resuscitation medications if needed
– Universal antidotes
– Draw blood:
– chemistry, coagulation, blood gases, drug levels
– Decontaminate
– Expose / Examine
– Full vitals / Monitoring
– Give specific antidotes / treatment
Treatment
34

Decontamination:
1. Ocular:
– Flush eyes with saline
2. Dermal:
– Remove contaminated clothing
– Brush off
– Irrigate skin
3. Gastro-intestinal:
– Activated charcoal:
– May Prevent /delay absorption of some drugs/toxins
– Almost always indicated
– Naso/oro-gastric Lavage
– Bowel Irrigation:
– Recent ingestions 4-6 hrs
– 500 cc NS Children / 2000cc adults
– Orally / Nasogastric tube
Treatment
35

Agents Used for GI Decontamination in Children
Agent Dose Risks Contraindications
Activated charcoal*† 1 to 2 g per kg (maximum
of 50 to 60 g)
Aspiration,
constipation, vomiting
Unlikely to benefit patients
who ingested alcohols, strong
acids or bases, minerals, iron,
lithium, or hydrocarbon
Gastric lavage*† 10 to 15 mL per kg saline
instilled via large-bore
orogastric tube, repeated
until aspirates clear
Esophageal/laryngeal
trauma, aspiration,
nausea/vomiting,
impaired level of
consciousness
Unprotected airway, ingestion
of hydrocarbons or corrosives,
risk of perforation or
hemorrhage
Polyethylene glycol
(used with whole
bowel irrigation)
500 mL per hour for
children nine months to
five years of age 1,000 mL
per hour for children six
to 12 years of age
Vomiting, cramping Unprotected airway,
intractable vomiting,
gastrointestinal hemorrhage,
ileus, perforation, obstruction
Sorbitol (used with
activated charcoal)
1 to 2 g per kg Hypernatremia,
dehydration
Obstruction, perforation, ileus
*— May not be beneficial if given more than one hour after ingestion.
†— Not routinely recommended.
36

• Damp-mop floors, damp-wipe surfaces, and frequently wash a
child’s hands, pacifiers and toys to reduce exposure to lead
• Avoid using home remedies and cosmetics (such as kohl, alcohol)
that contain lead
• Take basic steps to decrease your exposure to lead (for example,
by showering and changing clothes after finishing the task), if
you remodel buildings built before 1978, or if your work or
hobbies involve working with lead-based products
Preventing Lead Poisoning
37

 Wash children's hands after they play outside, before eating
and going to bed
 Clean floors with a wet mop and wipe furniture, windowsills
and other dusty surfaces with a damp cloth.
 Restrict where children play.
 Don't let them play near major roadways or bridges.
 Prepare meals that are high in iron and calcium which helps
prevent lead absorption in your children's bodies.
38

Pesticide poisoning In Children
39

Objectives
 Identify sources of pesticides
 Recognize the dangers of Pesticides
 Identify possible risk factors for pesticides poisoning
 Identify ways to prevent Pesticides poisoning
 Recognize ways Pesticides poisoning is treated
40

Introduction
 Pesticides are toxic substances designed to kill, inhibit the growth
of living organisms
 They are used against insects, mammals, plants, fungi, nematodes
and other creatures that can pose problems for agriculture, public
health, or homes, schools, buildings and communities
 However, when improperly used or stored, these chemical agents
can also harm humans
 Pesticides impair the functioning of biological processes essential
for life, such as the nervous and reproductive systems 41

Introduction
 Key risks are cancer, birth defects, and damage to the nervous
system and the functioning of the endocrine system.
 People can be exposed to excessive pesticide while working; via
food, soil, water or air; or by directly ingesting pesticide
products.
 Pesticides are known to cause millions of acute poisoning cases
per year, of which at least one million require hospitalization.
42

Introduction
 It has been reported that an estimated 1 to 5 million
cases occur every year, resulting in 20,000 fatalities
among agricultural workers.
 Most of these poisonings take place in developing
countries, where safeguards typically are inadequate
 Although developing countries use 25% of the world’s
production of pesticides, they experience 99% of the
deaths 43

Sources of Pesticide Poisoning
 Once used, pesticides may accumulate in the air or water or on
land, where they can harm non-target species and diminish
biodiversity.
 Contaminating groundwater, lakes, rivers, and other bodies of
water, they can pollute drinking supplies, fish and other
resources that can be vital for human well-being.
 Polluting soil, they can endanger children at play or at work
44

Risk factors of Pesticide Poisoning
 The impact of an exposure to pesticides on human health
depends on a number of factors, including the class of pesticide
involved, the specific chemical and formulation, and the
amount, route, timing and duration of the dose.
 The route of exposure can be via breathing, drinking or eating,
or through the skin or mucous membranes.
 Other factors include the health of the person poisoned.
 Malnutrition and dehydration, for example, increase the
sensitivity to pesticides. 45

Why are children at greater risk?
 Children are often more vulnerable than adults to the effects of
pesticides as a result of several risk factors.
 These include their smaller size, greater rates of exposure to
food, soil, water, air, differing metabolism, and rapidly growing
and developing organ systems.
 They put things in their mouths.
 Inexperience, lack of maturity, illiteracy and an inability to
assess risk
46

Why are children at risk?
 Infants
 Most infant poisonings are result of adult
error;
 Crawlers
 Explore everything within reach and put things in
their mouth
 Toddlers and preschoolers
 Reach higher, nothing is child-proof, look-alikes are
misleading
Stages of Development
47

Clinical symptoms
Acute poisoning can cause a range of symptoms in adults and
children, depending on the type of pesticide.
 For example, commonly used organophosphorus and
carbamate compounds can produce neurobehavioral effects,
such as fatigue, dizziness, and blurred vision; intestinal effects,
such as nausea; respiratory effects, such as dry throat and
difficulty with breathing; effects involving skin and mucous
membranes, such as stinging eyes, itchy skin, and a burning
nose; and muscular symptoms, such as stiffness and weakness 48

Treatment
Different treatments are available, depending on the poison.
 Activated charcoal – this substance stops the body absorbing the
poison, but must be given within one hour of child swallowing
the poison for it to be effective. It does not work with every
substance.
 Observation – some poisons have a delayed effect and your
child may have to stay in hospital, possibly overnight.
49

Treatment
 Monitoring – of heart rhythms and checking other vital signs
such as blood pressure and oxygen levels.
 Bloods tests – to check the level of poison in the blood. This
helps decide further treatment. In most cases the level is very
low and no problems are expected.
 Antidote – can be given for some poisons to reverse the effects.
 Admission – a few children need further treatment in hospital.
50

 Food poisoning, also called foodborne illness,
 Infectious organisms — including bacteria, viruses and parasites
or their toxins are the most common causes of food poisoning
 Food poisoning symptoms, which can start within hours of
eating contaminated food, often include nausea, vomiting or
diarrhea. Most often, food poisoning is mild and resolves
without treatment, But some people need to go to the hospital
53

 Is any illness resulting from the Ingestion of food or
Drink.
Contaminated with
 Living bacteria or
 Other toxins or
 Inorganic chemical substances &
 poisons from Plants & animals
54

Types Of The Food Poisoning
• Non – bacterial type of the food poisoning
• Bacterial Type of the food poisoning
55

Non – Bacterial Type Of The Food Poisoning
It is caused by the chemicals such as
• Arsenic
• Certain plants & sea foods
• The contamination food by the chemicals such as
 Fertilizer
 Pesticides
 Cadmium
 Mercury
56

Bacterial Food – Poisoning
• It is caused by the ingestion of the food contaminated by the
living bacteria or their toxins
• The conventional classification of the bacterial food poisoning in
to the toxic and infective type is becoming increasingly blurred,
with the knowledge that in some types both multiplication and
toxins production can involve.
E.g. Salmonella , Botulism, Staphylococcal are most common
food poisoning
57

Risk factors
 Child becoms ill after eating contaminated food depends on
the organism, the amount of exposure, the age and health.
High-risk groups include:
 Older adults. As you get older, your immune system may
not respond as quickly and as effectively to MOs
 Pregnant women. During pregnancy, changes in metabolism and
circulation may increase the risk of food poisoning.
 Infants and young children. Their immune systems poor
 People with chronic disease; as DM, liver disease or AIDS or receiving
chemotherapy or radiation therapy for CA reduces immune response
58

Symptoms
 Food poisoning symptoms vary with the source of contamination.
 Most types of food poisoning cause one or more of the following
signs and symptoms:
 Nausea, Vomiting, Watery diarrhea, Abdominal pain and cramps and Fever
 Signs and symptoms may start within hours after eating the
contaminated food, or they may begin days or even weeks later.
 Sickness caused by food poisoning generally lasts from a few
hours to several days.
60

Treatment
 The main treatment for food poisoning is putting
fluids back in the body (rehydration) through an IV
and by drinking.
 Do not eat solid food while nauseous or vomiting
but drink plenty of fluids.
 Anti-vomiting and diarrhea medications
 Antibiotics
61

Complications
 The most common serious complication of food poisoning is
dehydration a severe loss of water and essential salts and
minerals.
 If you're a healthy adult and drink enough to replace fluids you
lose from vomiting and diarrhea, dehydration shouldn't be a
problem.
 Infants, older adults and people with suppressed immune
systems or chronic illnesses may become severely dehydrated
when they lose more fluids than they can replace.
 In that case, they may need to be hospitalized and receive
intravenous fluids.
62

Golden Rules for Safe Food Preparation
1. Choose foods processed for safety
2. Cook food thoroughly
3. Eat cooked foods immediately
4. Store cooked foods carefully
5. Reheat cooked foods thoroughly
6. Avoid contact between raw foods and cooked foods
7. Wash hands repeatedly
8. Keep all kitchen surfaces meticulously clean
9. Protect foods from insects, rodents, and other animals
10. Use safe water
63

Safe Preservation of Food
 Refrigeration
 Drying
 Canning (Tin)
 Salting
 Preserving
 Smoking
 Chemicals (Sugar, salts, Citric acid, Benzoic acid)
64

Prevention & Control
(A)Food Sanitation
1. Food/ Meat Inspection
2. Personal Hygiene
3. Medical Inspection of Food handlers.
4. Food handling Technique (Golden rules).
5. Sanitary improvements.
6. Health Education
(B) Refrigeration
65

1. Keep hands and nails clean
We need to:
 wash hands and nails thoroughly
with warm, running water and
soap
 dry hands thoroughly
Strategies to prevent food poisoning
66

When cleaning plates and equipment, we need to:
 scrape and rinse off surface food
 wash in clean, soapy water
 rinse in clean water
 air dry where possible
 if drying immediately, use only a clean, dry towel.
Pest control and animals
 stop pests such as cockroaches and mice coming into the area
where food is kept
 discourage pests by not leaving food or dirty dishes out on the
benches
 keep animals out of the kitchen.
Keeping the kitchen clean
67

 avoid preparing food when sick or feeling unwell
 keep raw meats, poultry and seafood
separated from cooked food and food to be eaten raw
 protect food in the refrigerator by placing in covered
containers or covering with plastic wrap
 use clean equipment, plates or containers to prevent
contamination of cooked food
 use clean equipment, rather than hands, to pick up food
 wear clean clothes or a clean apron
 wash fruit and vegetables to be
eaten raw under running water.
Handling food safely
68

®
© 2013 National Safety Council
Medication poisoning
in children
69

70
70

71
Introduction
◦ Medicine is safe in the right amount for the right person.
◦ A child should be told that medicine is to make them feel better.
◦ We know it can be a struggle to give medication to a resistant
child, but never “fake” a child into taking medicine by calling it
“candy.” this may lower a child's fear or respect for a medication,
they may ingest it on their own, which may cause a toxic overdose.
71

72
Introduction
◦ Each year more than 60,000 children are treated in
emergency departments after getting into medicine
while adults were not looking
◦ In recent years, the number of accidental overdoses in
young children has increased by 20 percent.
72

73
Most common medicines and Vitamins
Pain relievers
◦ Ibuprofen, Acetaminophen, Aspirin
Cough and cold medicines
◦ Decongestants, Cough Suppressants, Antihistamines
Heart, blood pressure drugs
Psychotropic
Vitamins – especially iron 73

74
General- evaluation
◦ recognition of poisoning
◦ identification of agents which was taken
◦ assessment of severity
◦ prediction of toxicity

75
General- management
◦ provision of supportive care
◦ prevention of poison absorption
◦ enhancement of elimination of poison
◦ administration of antidotes

76
Supportive care
◦ ABC
◦ Vital signs, mental status, and pupil size
◦ Pulse oximetry, cardiac monitoring
◦ Protect airway
◦ Intravenous access
◦ cervical immobilization if suspect trauma
◦ Rule out hypoglycaemia

77
The common medication poisoning
Iron Poisoning
◦ Iron poisoning is the most common cause of
death due to poisoning in young children.
◦ It is also a significant problem in
adolescents and adults.

78
Iron Poisoning
◦ Ingestion of a number of tablets of ferrous sulphate may cause
acute poisoning.
◦ Lethal dose is 300 mg/kg of iron.
◦ Severe vomiting and diarrhea occur.
◦ These may contain blood due to extensive gastrointestinal bleeding.
◦ The child may go into severe shock, hepatic and renal failure
within a few hours or after a latent period of 1 to 2 days

79
Iron Poisoning
Five Stages but variable
Stage 1
Gastro-intestinal stage: within 30 mints to 6hrs of ingestion:
abdominal pain, fluid loss, bleeding, shock(acidosis,
tachycardia +/- hypotension)
Fever, Lethargy and Coma

80
Iron Poisoning
Stage 2
◦ Latent stage: 4-48hrs
A period where there is a small apparent improvement in the
patient’s GI condition.
◦ It is often tempting to discharge such patients.
◦ However, in the seriously poisoned, a metabolic acidosis is
evolving.
◦ This may be compounded by a lack of adequate fluid resuscitation.

81
Iron Poisoning-Stage 3
Circulatory collapse : 48-96 hrs
◦ Loss of adequate tissue perfusion and multi organ
failure: most deaths occur during this stage.
◦ Shock occurs secondary to gastrointestinal
hemorrhage, vomiting, vasodilation, and reduced
cardiac output (due to myocardial toxicity).

82
Iron Poisoning-Stage 3
Multi organ failure related to inadequate perfusion and
direct toxicity ensues and results in:
Altered mental status / coma
Seizure
Acute renal failure
Pulmonary edema

83
Iron Poisoning- Stage 4:
◦ Hepatic failure: 96hrs
Increased mortality
Hepatic dysfunction is a poor prognostic sign.
Patients suffer related:
Hypoglycemia
Coagulopathy and hemorrhage
Jaundice
Hepatic encephalopathy / coma

84
Iron Poisoning
STAGE 5:
◦ Bowel obstruction 2-6 wks
◦ Due to scarring
Gastric outlet obstruction
Small intestinal obstruction
◦ May not pass through stage 4

85
Pathophysiology
◦ Iron is potent catalyst of free radical formation and is
capable of oxidizing a wide range of substrates ,including
lipid, protein, DNA, and various biomolecules.
Typical iron poisoning targets:
◦ GI, CVS, Liver, CNS, Hematopoietic system and Metabolic
acidosis

86
Diagnosis
Clinical, History, physical exam
laboratory:
-abdominal radiograph,
-serum iron concentration,
-ABG, CBC, BS, BUN, Cr, Coagulation profiles, LFT, electrolytes
Differential diagnosis:
◦ consider metabolic acidosis, structural, infectious and other poisoning with GI
symptoms Gastroenteritis Hepatic failure

87
Laboratory Studies
◦ It is a clinical diagnosis
◦ Little is known about the absorption rate of iron in an
overdose or the timing of peak serum iron level
Serum levels Of :
Mild - Less than 300 µg/dl
Moderate - 300-500 µg/dl
Severe - More than 500 µg/dl

88
◦ Detailed history and physical including
a rectal exam for frank blood.
◦ Aggressive fluid resuscitation and intravenous access.
◦ Whole bowel irrigation
◦ Laboratory analysis for CBC, chemistry, and iron levels
(peak around 4 hours)
◦ Will often require repeat levels with a repeat chemistry
Iron Poisoning - Management

89
Iron Poisoning
Management:
1. Gastric decontamination:
 Forced emesis
 Gastric lavage with 5% NaHCO3
 No activated charcoal
2. Secure good IV
3. Get initial the 4hrs levels and TBC
4. Chelate with Deferoxamine if levels> 300mg/dl

90
Iron Poisoning
Management:
Chelate with Deferoxamine:
Stable pts : levels< 500 mg/dl 40mg/kg IM/IV
Unstable: bleeding/ level > 500
• Give 20cc/kg NS/RL
• Deferoxamine at 15 mg/kg IV over 1hr
• Continuous drip at 15mg/kg/hr
• Continue till “vin rose” urine color disappears.

91
Iron Poisoning
Management:
Observe for:
◦ Systemic BP
◦ ECG
Signs of hepatic failure:
◦ Bleeding
◦ Glucose intolerance
◦ Hyper ammonemia and Encephalopathy

92
Treatment
EMERGENCY STABILIZATION
◦ Emergency stabilization begins with checking the ABCs (airway,
breathing, and circulation), followed by a thorough physical
examination and laboratory testing. Because the patient’s status
can change rapidly, it is essential to reassess the patient often and
monitor the need for ventilator support.
92

93
Treatment
1. Stabilize patient as needed
2. Estimate risk for systemic toxicity by amount of elemental iron
3. IV access
4. Laboratory exam
5. GI decontamination: whole bowel irrigation if tablets are seen on
radiograph
6. Chelation

94
◦ Iron salts are chelated with desferrioxamine IV at
15mg/kg/hour until the serum iron is <300 mg/dl or till
24 hours after the child has stopped passing the
characteristic ‘vin rose’ colored urine.
◦ Presence of ‘vin rose’ color to urine indicates significant
poisoning.
Treatment

95
Indications for Deferoxamine treatment
- shock, altered mental status, persistent GI symptoms,
metabolic acidosis, pills visible on radiographs, serum
iron level greater than 500 µg/dl, or estimated dose
greater than 60 mg/kg of elemental iron
- if a serum iron level is not available and symptoms are
present

96
◦ If the patient is in shock, remember to at least type and screen (if not
cross match) for blood.
◦ Deferoxamine was derived from streptomyces pilosus.
◦ Ferrioxamin :This complex imparts a reddish, vin rosé, color to the
urine
◦ Hypotension and allergic reactions are seen.
◦ ARDS is a known complication and usually limit its use to 24 hours
or less.
Indications for Deferoxamine………

97
Complications
◦ Infectious -Yersinia enterocolitica septicemia
◦ Pulmonary - Acute respiratory distress syndrome (ARDS)
◦ Gastrointestinal - Fulminant hepatic failure, hepatic
cirrhosis, pyloric or duodenal stenosis

98
Prevention
◦ Keep out of reach of children
◦Put it up, Lock it up
◦ Use child-resistant caps
◦ Follow dosing instructions
◦ Be aware of multiple ingredients
98

®
Alcohol poisoning in children

100
 Depressant
 Contains intoxicating substance called ethyl alcohol or
ethanol
 Slows down the functions of the brain and other parts of
the nervous system
 Produced by a fermentation process
What is Alcohol
100

101
 Alcohol poisoning is a serious and sometimes deadly consequence
of drinking large amounts of alcohol
 Alcohol poisoning occurs when a person drinks a toxic amount of
alcohol, usually over a short period of time.
 Alcohol poisoning can also occur if a person drinks household
products that contain alcohol
 If you suspect someone has alcohol poisoning, call for emergency
medical help right away
Alcohol Poisoning
101

102
If you're with someone who has been drinking a lot of alcohol
• Call local emergency number immediately.
• Never assume that a person will sleep off alcohol poisoning.
• Be sure to tell hospital or emergency personnel the kind and
amount of alcohol the person drank, and when.
• Don't leave an unconscious person alone.
• While waiting for help, don't try to make the person vomit
because he or she could choke.
102

103
• Young children put everything in their mouths.
• It is not uncommon for children to accidentally swallow alcohol.
• But even a small amount of alcohol can cause alcohol poisoning in
children.
• This can result in serious illness and sometimes death.
• Children’s bodies absorb alcohol rapidly.
• it can occur in less than 30 minutes.
Alcohol and Infant/Toddler, Child
103

104
Effects of Alcohol
◦Heart/Blood Vessels
Short term
◦Perspiration increases and skin becomes flushed
Long Term
◦High BP and damage to the heart muscle; blood
vessels harden and become less flexible

105
More Effects
◦Brain/Nervous System
Short Term
◦ Speech is slurred and difficulty walking
Long Term
◦ Brain cells are destroyed and unable to be replaced; damage to
nerves in body resulting in numbness in hands and feet

106
…The Rest of Alcohol Effects
◦Liver
Short Term
◦ Liver changes alcohol into water and carbon dioxide
Long Term
◦ Liver is damaged possibly resulting in cirrhosis (scarring and
destruction of the liver)

107
Liver
◦ Can only oxidize about 1 serving of alcohol an hour
◦ NO WAY to speed up this process
◦ Until liver has had time to oxidize all of the alcohol ingested, it
keeps circulating through the bloodstream
◦ Alcohol interferes with body’s ability to break down fats.
◦ Excess fat blocks flow in liver resulting in reduced oxygen and cell
death can be REVERSED when drinking stops

108
…The Rest of Alcohol Effects
◦Stomach/Pancreas
Short Term
◦ Stomach acids increase, which often results in nausea
and vomiting
Long Term
◦ Irritation occurs in the stomach lining, causing open
sores called ulcers; pancreas becomes inflamed

109
 Symptoms can include confusion, vomiting, and seizures.
 The child may have difficulty breathing and flushed or pale skin.
 Alcohol impairs the gag reflex.
 This can cause choking.
 Alcohol may also cause low blood sugar in children.
 This can result in a coma from the alcohol and/or the low sugar
Symptoms
109

110
• Slow down brain functions so one can lose his/her balance.
 Irritate the stomach which causes vomiting and it stops gag reflex
from working properly
 Affect the nerves that control your breathing and heartbeat, it can
stop both.
 Dehydrate you, which can cause permanent brain damage.
 Lower the body’s temperature, which can lead to hypothermia.
 Lower your blood sugar levels, so you could suffer seizures.
Complication
110

111
• Alcohol ingestion in children needs to be treated immediately.
• Glucose may be given intravenously (IV).
• Sometimes a tube is inserted into the stomach to remove the
contents of the stomach.
• Children are observed until they recover.
• Some children may need to be stay in the hospital for evaluation.
• If there is evidence of neglect, child protective services may be
notified.
Treatment
111

112
1. Know what products in your home contain alcohol.
2. Keep all alcoholic drinks on a high shelf, out of your child’s reach.
3. Preferably, store them in locked cabinets.
4. All liquids should be kept in their original, labeled containers.
5. Avoid leaving them out on a counter.
6. Return all liquids to locked cabinets immediately after use.
7. Discard used containers where child will not find them.
8. Teach child the dangers of sampling any substance without your permission
Preventing Alcohol poisoning
112

Studies show that between 14% and 51% of adolescent
attempters repeat their attempts depending partially on
length of follow-up period
Urban exposure can be significant, largely as a result of the use of
insecticides for the control of flies, fleas, cockroaches and other
pests in the home, whether they are from household sprays or
pesticides applied by professional exterminators.
Meriel Watts, 2013
Evidence
113

Evidence
A recent study in Australia found that there was widespread
chronic exposure of preschool children to organophosphate and
pyrethroid insecticides and that, although most exposures were
higher in the rural area, urban children’s exposure to
chlorpyrifos and bifenthrin was just as great, probably because
they are used widely in domestic situations as well as in
agriculture.
(Babina et al 2012).
114

Evidence
study showed that age 01- 05years is the major group involved in
poisoning (59%) as compared to ages 6-10 years( 23%) and age
between 11-15 years is (18%) .
Kerosene oil poisoning is most common (27%) followed by
organophosphates, corrosives, naphthalene and unknown
poisoning. Ayesha Asghar, 2010
Signs and symptoms of ingestion include burning and irritation of
oral mucosa, nausea, vomiting, gastric irritation, jitteriness,
breathing difficulties, and change in level of consciousness 115

Evidence
General management of poisoning included supportive care and
ABC’s, treatment obtaining a history of exposure, vital signs
assessment, routine lab assessment, toxicology lab assessment, use
of antidotes, skin decontamination, gastric decontamination, whole
bowel irrigation, post diuresis and urinary pH manipulation,
dialysis and hemoperfusion.
116

Evidence
The study in West Bengal, India, revealed that consumption of food
from contaminated areas was another source of chronic As
poisoning, since food products like vegetables and rice were
cultivated using As-contaminated ground water.
Rahman et al., 2003
The study showed that the average IQ of 720 children in the
endemic area was 92.07 compared to 93.78 children in the
control area, with 10.38% falling into the “low” IQ category versus
4.24% in the control area. Yongping Li, 2008117

Evidence
A 2010 meta-analysis of 15 studies on residential pesticide use
and childhood leukemia finds an association with exposure during
pregnancy, as well as to insecticides and herbicides. An association
is also found for exposure to insecticides during childhood.
Turner, M.C., et al. 2010.
A meta-analysis study by scientists at the Harvard University’s
School of Public Health finds that children’s exposure to pesticides
in and around the home results in an increased risk of developing
certain childhood cancers.
Chen M, Chi-Hsuan C, Tao L, et al. 2015.
118

Evidence
 A 2010 analysis observed that women who use pesticides in their
homes or yards were two times more likely to have children with
neural tube defects than women without these reported exposures.
Brender, JD., et al. 2010
 One 2014 analysis of 129 preschool children, ages 20 to 66
months, found that children were exposed to indoor
concentrations of pyrethroids, organophosphates and
organochlorines pesticides which were detected in soil, dust and
indoor air.
Lu, C. et al. 2008.
119

Reference difficult to use the la
1. Accidental poisoning in children health Emergency department factsheets
2. Poisoning in Children Khurshid Ahmad Wani MD; Mushtaq Ahmad MD; Rauf-ur-Rashid Kaul MD; A S
Sethi MD; Shabnum MBBS
3. Federal Democratic Republic of Ethiopia Ministry of Health Food Hygiene and Safety Measures
Extension Package, 2004
4. A comparative retrospective study of poisoning cases in central, zonal and district hospitals Deepak
Pokhrel, Sirjana Pant, Anupama Pradhan, Saffar Mansoor, 2008
5. Dr K Berry Poisoning in children, 2008
6. AAea. Accidental Poisoning In Children J Biomed Sci and Res 2010;12(4):284-9.
7. Rahman, M.M.; Mandal, B.K.; Chowdhury, T.R.; Sengupta, M.K.; Chowdhury, U.K.; Lodh, D.; Chanda,
C.R.; Basu, G.K.; Mukherjee, S.C.; Saha, K.C.; Chakraborti, D. Arsenic groundwater contamination and
sufferings of people in North 24-Parganas, one of the nine arsenic affected districts of West Bengal,
India. J. Environ. Sci. Health, 2003, A38, 25–59.
8. Brender, JD., et al. 2010. Maternal Pesticide Exposure and Neural Tube Defects in Mexican Americans.
Ann Epidemiol. 20(1):16-22
9. Turner, M.C., et al. 2010. Residential pesticides and childhood leukemia: a systematic review and meta-
analysis. Environ Health Perspect 118(1):33-41
10. Lowengart, R., et al. 1987. “Childhood Leukemia and Parent’s Occupational and Home
Exposures,” Journal of the National Cancer Institute 79:39.
120

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