Children are curious and tend to explore their surroundings. While doing so they may run, ingest, or inhale potentially harmful substances. Tens of thousands of cases of childhood poisoning are reported annually and some are associated with major morbidity and mortality.

1. ACCIDENTAL POISONING,
EVALUATION AND
MANAGEMENT
DR. EMMANUEL ALI ADAMU
COLLEGE OF MEDICAL SCIENCES UNIVERSITY OF
MAIDUGURI,NIGERIA

2. OUTLINE
• Introduction
• Epidemiology
• Common Poisoning
• Clinical Presentation
• Evaluation
• Management
• Prevention
• Conclusion
• References

3. INTRODUCTION
• 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 when poisonous
substances are inadvertently ingested– every
year millions of calls are made to poison
control centres when this happens and
thousands of children are admitted to
emergency departments. Poisoning patterns
change according to age group, type of
exposure and the nature and dose of the
poison.(WHO/UNICEF)

4. TO THE CHILD, EVERYTHING GOES
TO THE MOUTH.

7. SOME PILLS RESEMBLING CANDY

8. DEFINITION
Poison, in biochemistry, is a substance, natural
or synthetic, that causes damage to living tissues
and has an injurious or fatal effect on the body,
whether it is ingested, inhaled, or absorbed or
injected through the skin.

9. DEFINITION
• Poisoning is when cells are injured or destroyed
by the inhalation, ingestion, injection or
absorption of a toxic substance. Key factors
that predict the severity and outcome of
poisoning are the nature, dose, formulation and
route of exposure of the poison; co-exposure to
other poisons; state of nutrition of the child or
(fasting status); age and pre-existing health
conditions.(WHO/UNICEF)

10. Epidemiology
Mortality
• In 2004, acute poisoning caused more than 45 000 deaths
in children and youth under 20 years of age – 13% of
all fatal accidental poisonings worldwide.
• In 16 high-income and middle-income countries, poisoning
is the fourth biggest cause of unintentional injury after
road traffic injuries, fires and drowning.
• The rate of fatal poisoning is highest for children under
one year, with another slight peak around 15 years.
• Fatal poisoning rates in low-income and middle-income
countries are four times that of high-income countries.

11. Epid...
• Africa and low-income and middle-income
countries in Europe and the Western Pacific
Regions have the highest rates.
• Common poisoning agents in high-income
countries include pharmaceuticals, household
products (e.g. bleach, cleaning agents), pesticides,
poisonous plants and bites from insects and
animals.
• Common poisoning agents in low-income and
middle income countries are fuels such as
paraffin and kerosene, pharmaceuticals and
cleaning agents.

12. Epid...
Morbidity
• Poisoning morbidity is a significant problem
but global data are not available and
regional data are not comparable because of
differing access to services and hospital
admission criteria.
• In some countries poisoning death rates are
highest in children under one year, while
non-fatal poisonings appear to be more
common among children aged 1 to 4.

13. Epid...
• Studies from both low-income and high-
income countries suggest that poisonings and
their management are costly.
• For example, a study conducted in South
Africa estimated that the direct costs of
hospitalization because of paraffin poisoning
alone are at least US$ 1.4 million(NGN700
million) per year.

14. Risk Factors
• Young children are particularly susceptible to the
ingestion of poisons, especially liquids, because they
are very inquisitive, put most items in their mouths
and are unaware of consequences.
• Adolescents, on the other hand, are more aware of
the consequences of their actions but peer pressure
and risktaking behaviour can lead them to misuse
alcohol or illicit drugs, leading to a fatality rate higher
than in younger children.
• Younger children are more susceptible to poisoning
because of their smaller size and less well-developed
physiology, particularly as the toxicity of most
substances relates to dose per kilogram of bodyweight.

15. Risk Factors...
• Boys have higher rates of poisoning than girls in
all regions of the world, probably because of
differences in socialization.
• Fatal and non-fatal poisonings are strongly
associated with lower socioeconomic status,
between and within countries.
• The prevalence and types of poisoning vary in
different parts of the world. They depend on
industrial development, agricultural activities,
cultural practices relating to supervision of children
and local beliefs and customs.

16. Risk factors...
• 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.
• 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. Common Agents
• Over-the-counter preparations such as
paracetamol, cough/ cold remedies, vitamins
and iron tablets, antihistamines and
antiinflammatory drugs.
• Prescription medications such as
antidepressants, narcotics, analgesics and illicit
drugs.

18. Agents...
• Household products such as bleach,
disinfectants, detergents, cleaning agents,
cosmetics, vinegar.
• Paraffin/kerosene.
• Pesticides, including insecticides, rodenticides
and herbicides.
• Poisonous plants.
• Animal or insect bites.

19. GENERAL MANAGEMENT OF
POISONING
1. Stabilization
2. Laboratory assessment
3. Decontamination of the
gastrointestinal tract, skin, eyes, e.t.c
4. Elimination of the toxin
5. Administration of an antidote
6. Observation and disposition

20. HISTORY
The following questions should be asked
• What other medicines are in the house?
• What was the patient been doing that day?
• Have there been recent emotional or traumatic
events?
• Is the patient eating a special diet or taking a new
health food, alternative medication or performance
enhancer?
• Could the patient inadvertently have taken too much
of prescribed medication?
• If it can be identified, is the substance non-toxic?

21. PHYSICAL EXAMINATION
• Body temperature
• Hypothermia (exposure to cold, hypoglycaemia,
barbiturates, ethanol overdose),
• Hyperthemia (LDS, cocaine, salicylates poisoning)
• Pulse Rate
• Bradycardia – overdose of digitalis, beta blockers,
calcium channel blockers
• but also it may be seen with hypothermia and spinal
cord injury
• Blood Pressure
• Hypertension – intoxication with cocaine,
amphetamines, sympathomimetics

22. PHYSICAL EXAM...
• Respiratory System
• Inhalation of toxic gases may produce wheezing
• tricyclic antidepressant overdose – pulmonary
edema
• Pneumothorax in patients who smoke cocaine,
methamphetamine
• CNS
• Pupils – pinpoint pupils – overdose clonidine,
opiates, organophosphate, insecticides
• Level of consciousness

23. LABORATORY EXAMINATION
• CBC: PCV, Leucocytosis
• EUCr, Ca
• Urinalysis + Urine drug screening
• Prothrombin Time
• LFT: ASAT, ALAT
• Pulse Oximetry
• ECG
• Tox Screen for possible substances

24. LABORATORY EXAMINATION
• Urine pregnancy test in a teenage girl
• CXR –aspiration pneumonia, pulmonary
edema,
• CT scan – if underlying trauma is suspected
• LP – to rule out meningitis in a patient with
fever and coma

25. SKIN DECONTAMINATION
• The range of dermal toxins is broad and most of these
substances are corrosive agents capable of producing
burns that may become full thickness( i.e third degree)
• Other types of agents are irritants, sensitizers, allergens,
vesicants and exfoliants
• The skin of infants is notable for being more permeable
than that of adults to substances of all classes
• If the victim is immersed in a toxic fluid, the first step is
his or her extrication, the victim should be disrobed,
washed with water
• Emergency medical personnel should provide themselves
every level available of self- protection

26. EYE DECONTAMINATION
• Initial management of all chemical ocular injuries requires
immediate decontamination by irrigation
• Early application of a topical anesthetic is recommended
to facilitate irrigation and enhance the patient comfort
• The most commonly available solution include sterile
water , normal saline and lactated Ringers
• The upper and the lower eyelids should be retracted,
inspected for retained solid material and injury and
irrigated
• Immediate referral to an ophthalmologist is necessary for
all significant burns

27. GIT DECONTAMINATION
Gastric lavage
• Involves blind placement of a large –bore gastric tube into
the stomach, in a patient who can either protect his or her
airway or in whom the airway has been protected by an
endotracheal tube, with the goal of removing toxicant
remaining in the stomach through a combination of
instillation of water or physiological saline, followed by
suction or gravity induced drainage
• The cycle of instillation/drainage is repeated until the
effluent is clear or until several liters of water /saline
have been passed through the tube.
• Left recumbent Trendelenburg’s position to reduce the risk
of aspiration

28. GIT DECONT...
• Indications for gastric lavage
• Recent ingestion (less than 1 hr, unless the ingestion
involves agents that decrease gastric motility such as
anticholinergics)
• Contraindications
• low viscosity petroleum or corrosive products,
• Inability to protect the airway
• Complications
• hypoxia,
• perforation of the gastrointestinal tract or pharynx,
• aspiration pneumonitis,
• electrolyte abnormalities

29. Activated charcoal
• binds to diverse substances , rendering them less available for
systemic absorption from the gastrointestinal tract
• Single Dose – 1g/kg in children max dose 50g, 25-100g in adults ,
administred orally( in water ) or via nasogastric tube .
• Indications
• phenytoin, glutethimide, PCM, benzodiazepine poisoning
• Contraindications
• ingestion of caustics,
• in case of risk for gastrointestinal hemorrhage or perforation,
• in any patient in whom the airway protection is not assured,
• in case of ileus or mechanical bowel obstruction
• Adverse reactions and complications
• vomiting, diarrhoea and constipation, pulmonary aspiration, direct
administration into the lungs via misplaced nasogastric tube

30. Multiple dose Activated Charcoal
• used in the case of drugs that undergo extensive enterohepatic
or enteroenteric circulation
• Indication
• carbamazepine, dapsone, phenobarbital, quinine, theophylline
• Contraindications
• same as for single dose but the presence of decreased peristalsis
should provoke caution
• CATHARTICS
• magnesium salts and nondigestible sorbitol .
• May induce significant harm in children with renal disease .
• Mannitol 20% - dose 4-5 ml/kg , Sorbitol 70% 1-2 ml /kg.
• Complications – nausea, vomiting, hypermagnesaemia and
cardiac dysrhythmias, dehydration.

31. Whole Bowel Irrigation
Involves administration by mouth or nasogastric tube of large
amounts of an iso-osmotic polyethylene glycol electrolyte
solution to remove unabsorbed toxin from the
gastrointestinal tract as rapidly as possible by rectal expulsion
• Dose 25 ml /kg/hr for 4 -6 hr .
• Total dose 500 ml /hr under the age of 6 yrs ,
• 1000ml /hr under the age of 10 yrs ,
• 1500-2000 ml /hr in adolescents
• Indications – iron ,lithium , drug packets
• Contraindications – mechanical or functional obstruction ,
gastrointestinal haemorrhage

32. ANTIDOTE ADMINISTRATION
• Only a small proportion of poisoned patients
are amenable to antidotal therapy
• Only a few poisoning is antidotal therapy
urgent
• Carbon monoxide
• cyanide
• organophosphates and
• opioid intoxication

33. INTOXICANTS WITH THEIR
SPECIFIC ANTIDOTES
• Paracetamol: N-
acetylCysteine
• Anticholinergics:
physostigmine
• Beta-blockers:
isoproterenol,
Glucagon,
Dopamine,
Epinephrine
• Digitalis: Specific FAB
antibodies
• Benzodiazepines:
Flumazenil
• Carbon monoxide:
Oxygen
• Cyanide: Amylnitrite,
Sodium nitrite,
Sodium Thiosulfate

34. INTOXICANTS WITH THEIR
SPECIFIC ANTIDOTES
• Ethylene glycol:
Ethanol
• Methanol: Ethanol
• Iron salts:
Desferioxamine
• Isoniazid: Pyridoxine
(Vit. B6)
• Narcotics: Naloxone,
Naltrexone
• Organophosphates:
Atropine, Pralidoxime
• Phenothiazines:
Diphenhydramine
• Methemoglobinemic
agents: Methylene
blue

35. ENHANCED ELIMINATION OF THE TOXIN
• 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 eliminate weak acids
can be achieved by adding NaHCO3 to the IV
fluids, the goal is urine pH of 7-8(salicylates,
barbiturates and methotrexate),
• Serum alkalinization in tricyclic antidepressant
toxicity

36. ENHANCED ELIMINATION OF THE
TOXIN
• Hemodialysis in low molecular weight
substances with low volume of distribution
and low binding to plasma proteins
(barbiturate, methanol, ethyleneglycol,
heavy metals, lithium)
• Haemoperfusion, protein binding is not a
limitation

37. KEROSENE POISONING
• Common in children under five years of age due
to poor storage techniques.
• Frequent in the developing countries as it is used
for cooking fuel and lightening and most times
store in empty water containers.
• Poorly absorbed in the GI tract but rapidly
through the respiratory mucosa due to high
volatility, low surface tension and low viscosity.
• Large volume is rarely ingested due to its
unpleasant taste.

38. CLINICAL PRESENTATION
SYMPTOMS
• Cough
• Difficulty in breathing
• Chest pain
• Seizures
• LOC
• Abdominal pain
• Vomiting
• Diarrhoea
SIGNS
•Tachypnea
•Rales
•Crepitations
•Grunting
•Chest retraction
•Cyanosis
•Pyrexia

39. MANAGEMENT OF KEROSENE
POISONING
• If symptoms do not appear within 6 hours, the patient is
likely to remain normal.
• For patients with symptoms, stabilize the airway and
administer oxygen.
• For patients with severe symptoms, early intubation and
mechanical ventilation are required.
• Induction of vomiting and gastric lavage should be
avoided due to risk of aspiration.
• Activated charcoal may be used but there maybe
associated with vomiting
• Severe cases require parenteral antibiotics (penicillin G
and Gentamicin)

40. INVESTIGATIONS
• CXR: Infiltrates, pnemothorax, atelectasis,
perihillar opacities.
• CBC: Leukocytosis

41. COMPLICATIONS
Respiratory system
• Bacterial
pneumonia
• Pnematocoeles
• Pneumothorax
• Pleural effusion
• Emphysema
Digestive System
• Hepatitis
• Acute hepatic failure
• Cardiovascular system
• Cardiac dysrhythmias
• Myocardial irritability
• Death

42. PARACETAMOL POISONING
• Acetaminophen is one of the commonest drugs
prescribed for relief of fever.
• It is marketed under different names and is readily
available at the patent medicine stores.
• Maximum allowable dose in children is
75mg/kg/day
• Minimum hepatotoxic dose is 150mg/kg/single
dose for children 1-6years.
• Oral PCM is absorbed rapidly from the gut with
serum concentration peaking at 1-2 hours post
ingestion.

43. PCM POISON...
• It is metabolized in the liver by conjugation to
non toxic metabolites at therapeutic doses.
• In acute Poisoning, PCM is oxidatively
metabolized by CYP450 enzymes to a
hepatotoxic N-acetyl-p-
benzoquinoneimine(NAPQI).
• Most patients remain asymptomatic until 24-
48 hours postingestion when acute organ
damage occurs.

44. PHASES OF PCM POISONING
• PHASE I
• Occurs within 30 min
to 24 hours
• Anorexia, Nausea,
vomiting, malaise
• Diaphoresis, pallor
• PHASE II
• 18-72 hours
• RUQ pain, nausea,
vomiting,
• Tachycardia,
hypotension, oliguria

45. PHASES OF PCM POISONING
• PHASE III
• Hepatic phase(72-96hr)
• Features of phase II +
Jaundice, hypoglycemia,
coagulopathy, hepatic
encephalopathy
• AKI
• Death from MODS
• PHASE IV
• Recovery phase (4/7-
3/52)
• Patients who survived
phase III start having
resolution of
symptoms.

46. MANAGEMENT
• Activated charcoal for those presenting within 1
hour of ingestion and are conscious.
• NAC is given within 8 hours of ingestion to
protect the liver, but can be given up to 24
hours.
• It is given at a loading dose of 150mg/kg, then
17 doses of 70mg/kg every 4 hours continued
up to 72 hours.
• Surgical evaluation and liver transplant for
those with progressive hepatic failure.

47. ALCOHOL POISONING
• Ethanol is the main alcohol content in beverages such as
strong liquor, beer and wine.
• As a habit some mothers can give any of these to make their
children sleep and keep calm.
• In some cultures older children and adults freely share alcohol
during funeral and wedding festivals. Leftover drinks in glasses
can be very easily consumed by toddlers.
• Numerous house hold products such as antiseptics, window
cleaners, hand sanitizers and mouthwashes contain varying
concentrations of alcohol which can be dangerous if any of
these is consumed by children.
• Hand sanitizers contain 60 -80 percent of alcohol;
Mouthwashes contain 10-27 percent of ethanol alcohol

48. ALCOHOL POISONING...
• Methanol or Methyl alcohol usually referred to
as methylated spirit used in antifreeze has a
sweet taste and children can easily gulp down
a large amount of it.
• In children, the primary and commonest source
of alcohol poisoning is by ingesting ethanol.
Ethanol concentrations in some common
alcohol beverages are as follows: Whiskey, 40-
60%; liqours, 22-50%; wine, 8-16%; beer, 3-7%

49. PATHOGENESIS
• Ethanol absorption starts from the oral mucosa and
continues in the stomach and intestine. The peak serum
concentration typically occurs 30-60 minutes after
ingestion.
• In young children, ethanol causes hypoglycaemia and
hypoglycaemic seizures.
• Approximately 90% of ethanol is metabolised in the
liver, and the remainder in the kidneys and lungs.
• In the liver, ethanol is broken down into acetaldehyde
by alcohol dehydrogenase, the acetaldehyde is further
broken down to acetic acid by acetaldehyde
dehydrogenase. The acetic acid feeds into the Krebs
cycle and ultimately broken down into carbon dioxide
and water.

50. CLINICAL PRESENTATION
• Stupor and confusion
• Vomiting
• Tachycardia with a bounding pulse
• Hypothermia
• Depressed respiration leading to
apnoea
• Convulsions and coma.

51. MANAGEMENT
• Stabilize airway and administer oxygen
• Intubation may be required
• RBS and Treat hypoglycemia with bolus
4mg/kg of 10% Dextrose followed by
maintenance.
• Monitor vital signs closely and watch
out for hypothermia.

52. IRON POISONING
• Iron overdose has been an important cause of poisoning
deaths in children younger than 6 years.
• Iron is used as a paediatric or prenatal vitamin
supplement and for treatment of anaemia.
• Iron-containing drugs are in the forms of ferrous sulphate,
ferrous gluconate or fumarate.
• Of all these, the most common source of poisoning is the
ferrous sulphate tablets which young children see it as a
sweet and often consume in toxic doses.
• The severity of the poisoning is related to the amount of the
emental iron in the tablet.
• More than 60mg/kg of elemental iron produces toxicity.

53. PATHOGENESIS
• Iron is corrosive to the gut and is
absorbed 1-2 hours post ingestion.
• It leads to cellular injury with most
effects on hepatocytes.
• Other organs are also affected
• There is inhibition of oxidative
phosphorylation and mitochondrial
dysfunction leading to energy failure.

54. CLINICAL FEATURES
• abdominal pain,
• nausea
• severe vomiting
• diarrhoea
• haematemesis
• melaena
• pallor.
• metabolic acidosis
• encephalopathy,
• cardiovascular collapse,
• convulsions and coma.
• Severe hepatic necrosis
can occur but is
extremely rare

55. MANAGEMENT
• Ipecac-induced emesis, and gastric lavage using
desferroxamine (2 g/litre of warm water).
• After gastric lavage, leaving a solution of
desferroxamine in the stomach is no more
recommended as this may increase the absorption
of iron.
• If the child is severely ill, 5% dextrose in half-
strength saline drip is set up and desferroxamine
added to this solution at the dose of
15mg/kg/hour, up to a maximum of 80mg/kg/day.

56. GENERAL PREVENTION OF
POISONINGS.
Primary Prevention
• Health education
• Keep all medicines out of reach of children
• Improving the socioeconomic status of the
populace.
• Policies on manufacturing, proper labelling,
distribution, and storage of drugs and harmful
substances.
• Establishment of a regional child poison control
centers

57. PREVENTION...
Secondary prevention
• Early diagnosis and treatment
• Prompt referral to child poison control
centers for any suspected case of Poisoning.
• Anticipate and Prevent complications

58. PREVENTION...
Tertiary prevention
• Rehabilitation from disabilities

59. CONCLUSION
• Acute Poisoning is a common and life
threatening event especially in children whom
are unaware of the consequences with poorly
developed organs responsible for elimination
of these substances.
• Prevention is the key as morbidity and
mortality still remains high even in the
developed world where Treatment services
are robust.

60. REFERENCES
• Children and Poisoning: WHO/UNICEF PDF
@childinjury.who.int
• Lecture notes on Childhood Poisoning by DR.
Ibrahim BA.ppt
• Paediatrics and Childhealth in a Tropical Region
3rd Edition by Azuibuke and Nkanginieme.