Approach to a poisoned child

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  • Assessment triangle: -general appearance (sleepy, obtunded, wired, delirious,etc.) -work of breathing (too fast, too slow, too deep, too shallow) -circulation (hypertensive, hypotensive) Most toxic exposures can be treated with basic life support measures Oxygen, dextrose, and naloxone: diagnostic and therapeutic Toxidrome: constellation of symptoms which are most likely to indicate the ingestion of a certain class of medication. H&P plus lab eval.
  • Altered mental status: rule out other causes as clinically indicated: trauma (including abuse), infection, metabolic abnormality (DKA), etc.
  • Paracelsus = German physician, father of modern pharmacology
  • Approach to a poisoned child

    1. 1. Guide –Dr Jyoti Singh
    2. 2.  What is a poison? ▪ In common usage - poisons are chemicals or chemical products that are distinctly harmful to human ▪ More precisely - a poison is a foreign chemical (xenobiotic) that is capable of producing a harmful effect on a biologic system
    3. 3.  Most common Pediatric Exposure  Cosmetics and personal care products (13%)  Cleaning substances (10%)  Analgesics (7.8%)  Foreign Bodies (7.4%)  Topicals (7.4%)  Cold and Cough Preparations (5.5%)  Plants (4.6%)  Pesticides (4.1%)
    4. 4.  May be difficult because of non-specific symptoms High index of suspicion - especially occult poisoning ▪ history may be unreliable ▪ look for corroborative history - missing pills, empty container Course that a poison runs (toxidromes) ! - may help Toxicology screening - helpful only in a few
    5. 5. ▪ It is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occur together, so that the presence of one feature alerts the physician to the presence of the others.
    6. 6.  S alivation *D iaphoresis/diarrhea L acrimation *U rination U rination *M iosis D efecation *B radycardia/bronchospasm G I secrestion/upset *E mesis E mesis *L acrimation excess *S alivation excess
    7. 7. Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel, bladderlose their tone, &heart runs alone
    8. 8. Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel , bladder losetheir tone, &heart runs alone
    9. 9. Hot as a hareDry as a boneRed as a beetMad as a hatterBlind as a batbowel , bladderlose their tone,&heart runs alone
    10. 10. disorientation Amphetamine hallucinations CocaineHallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure EphedrineToxidrome Hypertension Tachycardia Tachypnea
    11. 11. disorientation Amphetamine hallucinations CocaineHallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure EphedrineToxidrome Hypertension Tachycardia Tachypnea
    12. 12. disorientation Amphetamine hallucinations CocaineHallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure EphedrineToxidrome Hypertension Tachycardia Tachypnea
    13. 13. disorientation Amphetamine hallucinations CocaineHallucinogenic hyperactive bowel Pseudoephedrine panic Phencyclidine Benzodiazepenes seizure EphedrineToxidrome Hypertension Tachycardia Tachypnea
    14. 14.  Very diverse and varied - depends on the poison Clinical examination should be focused on the possible manifestations of common poisons in the geographical area
    15. 15.  Skin and mucosal damage Neurotoxic manifestations Cardiovascular manifestations Metabolic consequences Eye manifestations Hepatic , renal dysfunction Multiorgan dysfunction
    16. 16.  Respiratory Airway protection Respiratory failure Cardiovascular Hypotension despite fluid challenge Heart block, arrhythmias, QTc prolongation as in TCA
    17. 17.  Neurologic ▪ Low GCS ▪ Seizures Metabolic ▪ Hypoglycaemia ▪ Significant electrolyte abnormalities ▪ metabolic acidosis ▪ Hepatic failure ▪ Coagulopathy with bleeding
    18. 18. ASSESSMENT & THERAPY should proceed in parallel
    19. 19.  Treat the patient, not the poison Assess  General appearance  Work of breathing  Circulation ABCDs IV access and monitors High Suspicion
    20. 20.  Directed exam (after ABCs)  mental status  vital signs  pupillary size  skin signs
    21. 21.  Airway - ensure clear airway, clear secretions, check for cough/gag Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy Circulation - heart rate, rhythm, blood pressure
    22. 22.  Neurologic - GCS, seizures, agitation, spasms, pupils, autonomic dysfunction Miscellaneous - odour, temperature, pallor, cyanosis, jaundice Abdomen - rigidity, bleeding, urine output
    23. 23.  Cyanosis  methemoglobinemia secondary to nitrites, nitrates, phenacetin, benzocaine-refractory tp o2 Red flush  carbon monoxide, cyanide, boric acid, anticholinergics  Joundice – c cl4. paracetamol
    24. 24.  Dry  anticholinergics Salivation  organophosphates, carbamates Oral lesions  corrosives, paraquat Lacrimation  caustics, organophosphates, irritant gases
    25. 25.  Anti-histamine Anti-depressant Anticholinergics (atropine) Sympathomimetics  amphetamine, cocaine, PCP
    26. 26.  Cholinergics, Clonidine Opiates, Organophosphates Phenothiazine, Pilocarpine Sedatives (barbiturates, ethanol)
    27. 27.  Alcohol PCP / marijuana LSD Anticholinergics Sympathomimetics Phenothiazines Cocaine Heroin heavy metals
    28. 28.  Coma  alcohols,  anticholinergics,  sedative hypnotics,  opioids,  carbon monoxide,  TCAs, salicylates,  organophosphates Weakness/paralysis  organophosphates, carbamates, heavy metals
    29. 29.  Atropine Salicylates Theophylline Cocaine TCA
    30. 30.  Ethanol Narcotics Carbon monoxide Clonidine
    31. 31.  Bradycardia  digitalis, sedative hypnotics, beta blockers, opioids Tachycardia  anticholinergics, sympathomimetics, amphetamines, alcohol, aspirin, theophylline, cocaine, TCAs Arrythmias  anticholinergics, TCAs, organophosphates, digoxin, phenothiazines, beta blockers, carbon monoxide, cyanide
    32. 32.  OTC cold remedies Amphetamine PCP TCA Cocaine Diet pills
    33. 33.  Calcium channel blockers Carbon monoxide Cyanide Iron Narcotics Anti-hypertensives Met-hemoglobin
    34. 34.  Hypoglycemia Oral hypoglycemic agents Beta-blockers Insulin Ethanol Salicylates
    35. 35.  Alcohol Narcotics Clonidine Sedatives
    36. 36.  Of limited value Paracetamol levels, salicylate levels, alcohol, Red cell/pseudocholinesterase, anti-epileptic drug levels Urinary drug screen - opiates, barbiturates, benzodiazepines, amphetamines, cocaine
    37. 37.  Anion gap & Osmolal gap Increased anion gap (Normal 12 ± 4 mEq/L) ▪ Ethylene glycol ▪ Methanol ▪ Salicylate poisoning Increased osmolal gap (Normal 5 ± 7 m osmol/kg) ▪ Ethylene glycol ▪ Methanol ▪ Acetone, ethanol, isopropyl alcohol, propylene glycol
    38. 38.  Electrolytes ▪ Hypokalemia ▪ Isuline ,oral hypoglysemics ▪ Diuretics, Methyl xanthine, Toluene ▪ Hyperkalemia ▪ Digoxin ▪ Beta-blocker Liver function tests ▪ Acetaminophen, Ethanol, Carbon tetrachloride Renal function tests ▪ Ethylene glycol, NSAIDS
    39. 39.  ECG Digoxin toxicity TCA overdose - sinus tachycardia, QT prolongation, increased QRS Beta-blockers - conduction abnormalitiesImaging . CXR- hydrocarbon ingestion .Abdominal X-ray-- iron ingestion & radioopaque ingestion. .Oesophagoscopy -for caustic ingestion. . Abdominal usg- recently been used as a means of identifying presence of pharmaceutical material in GIT.
    40. 40.  Opiates Cocaine metabolite Amphetamine Benzodiazepines Barbiturates* No urine screen can confirm intoxication, only exposure
    41. 41.  Reduce absorption of the toxin Enhance elimination Neutralise toxin
    42. 42.  Removal from surface skin & eye Emesis induction Gastric lavage Activated charcoal administration & cathartics Dilution - milk/other drinks for corrosives Whole bowel irrigation Endoscopic or surgical removal of ingested chemical
    43. 43.  Skin decontamination ▪ Important aspect – not to be neglected ▪ Remove contaminated clothing ▪ Wash with soap and water (soaps containing 30% ethanol advocated) ▪ However, no evidence for benefit even in OP poisoning
    44. 44.  Gastric decontamination ▪ Forced emesis if patient is awake ▪ Gastric lavage ▪ Activated charcoal 25 gm 2 hourly ▪ Sorbitol as cathartic
    45. 45.  Gastric lavage ▪ Gastric lavage decreases absorption by 42% if done 20 min and by 16% if performed at 60 min ▪ Performed by first aspirating the stomach and then repetitively instilling & aspirating fluid ▪ Left lateral position better - delays spont. absorption ▪ No evidence that larger tube better ▪ Simplest, quickest & least expensive way ▪ Choice of fluid is tap water - 5-10 ml/kg
    46. 46.  Gastric lavage ▪ Preferrably done on awake patients ▪ Presence of an ET tube does not preclude aspiration, though preferred if GCS is low ▪ No human studies in OP poisoning showing benefit of gastric lavage
    47. 47.  Single dose activated charcoal  0.5-1 gm/kg, adolescents 50-100 grams PO; maximum dose 100 grams  More benefit if administered within 1 hour of ingestion, but still good for poison which slows gastric motility (anticholinergic, opiates, salicylates)  Strongly consider for acetaminophen overdose > 4 hours
    48. 48.  P – Pesticides, petroleum distillates, unprotected airway H – Hydrocarbons, heavy metals, > 1h delay in administration A – Acids, alkali, alcohol, altered level of consciousness, aspiration risk I – Iron, ileus, intestinal obstruction L – Lithium, lack of gag reflex S – seizures
    49. 49.  Nonabsorbable, isotonic polyethylene glycol Toxins “pushed” through GI tract; prevents absorption Concentration gradient created by this allows absorbed toxin to diffuse back into GI tract Used where toxins NOT absorbed by charcoal
    50. 50.  Recommended for:  Iron tablets  Lead paint chips  Theophylline  Crack vials/packets  Button batteries  Sustained release calcium channel blockers
    51. 51.  Bowel perforation Bowel obstruction Clinically significant gastrointestinal hemorrhage Ileus Unprotected or compromised airway Hemodynamic instability Uncontrollable intractable vomiting
    52. 52.  Methods ▪ Keeping a good urine output 150-200 ml/hr ▪ Alkalinisation of urine - clinical efficacy accepted for salicylate & phenobarbital poisoning ▪ Extracorporeal removal ▪ Hemodialysis - Barbiturates, Salicylates, Acetaminophen, Valproate, Alcohols, Glycols ▪ Hemoperfusion - theophylline, digitalis, lipid soluble drugs
    53. 53.  Plasmapheresis  Works very well with highly protein (albumin) bound drugs  Not a routine methodology, but has been used to remove theophylline and digoxin/ digibind complexes Exchange transfusion  Use in smaller infants where vascular access for extracorporeal techniques can’t be done
    54. 54.  Renal failure. Congestive heart failure (relative). Acute lung injury. Persistent CNS disturbance. Severe acid-base or electrolyte imbalance, despite appropriate treatment. Hepatic compromise with coagulopathy. Salicylate concentration (acute) >100 mg/dL.
    55. 55. Acetaminophen N-acetyl cysteineAnti-cholinergics PhysostigmineBenzodiazepenes FlumazenilCa channel blockers Glucagon, Insulin + dextrose, CalciumCarbamate AtropineCyanide Thiosulphate, nitrateDigoxin Digoxin antibodiesINAH PyridoxineMethanol Ethanol, FomepizoleGlycol Ethanol, FomepizoleOpioid NaloxoneOral hypoglycaemics GlucoseOrganophosphate Atropine, PAMWarfarin(rat kill poison) Vitamin K
    56. 56. Iron DesferroxamineCopper Penicillamine, Dimercaprol, CaEDTALead CaEDTA, Dimercaprol (BAL)Mercury DMPS, DMSA, BALArsenic BAL & derivativesAntimony BAL & derivatives
    57. 57.  Calcium channel blockers: bradycardia and hypotension; 1 - 10 mg tablet of nifedipine Camphor: respiratory depression and seizures; 15 mL of Vicks vapo-rub (700 mg of camphor) Clonidine: severe bradycardia; 0.1 mg Tricyclic antidepressants: cardiovascular and CNS toxicity; 10-20mg/kg Opioids: CNS and respiratory depression; 2.5 mg of hydrocodone.
    58. 58.  Lomotil: anticholinergic overdose (tachycardia, seizures, coma); ½ tablet Salicylates: cerebral edema, acidosis, coma; ½ teaspoon of wintergreen fatal Sulfonylureas: severe hypoglycemia; 1 tablet Toxic alcohols: cardiac and CNS depression; 2.9mL of 95% ethylene glycol has been fatal
    59. 59. National Poisons Information Centre (NPIC)Department of PharmacologyAll India Institute of Medical SciencesNew Delhi, India Tel. No.: 26589391, 26593677, Fax: 26850691, 26862663 Email: npicaiims@hotmail.comprovides round-the-clock, 7 days-a-week, 365 days service on telephone.
    60. 60.  Poisoning a common problem in our country A high index of suspicion required to diagnose Know common toxidrome & antidotes Charcoal is only given if likely to benefit Patients receiving decontamination must have airway protection Don’t panic and follow a plan of action Decreasing absorption Enhancing elimination Neutralising toxins Avoid potentially harmful Rxs - risk vs benefit

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