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1. Paediatric Poisoning
MBChB V
2016
1

2. Outline
• Definition
• Epidemiology
• Risk factors
• Prevention
• Management
– History
– Examination
– Antidotes
2

3. Definition
• Anything someone eats, drinks, breaths
in, or gets in their eyes or on their skin
that can cause illness or death
• Can be:
– solids,
– liquids,
– gases or aerosols
3

4. Types of Poisoning
• Acute
– Unintentional ingestions by toddlers
– Suicide attempt by adolescents
• Chronic
– Lead poisoning in children in old houses
– Daily pesticide exposure in children living
on farms
4

5. Epidemiology
5
Mother kills her two
children with poison
after dispute with
husband
The Star-Sep 30,
2015

6. Epidemiology
• ~ 50% are in children < 6 years
• 99% of ingestions by children under 6 are
unintentional
• ~ 40% of ingestions by adolescents are
intentional
• > 50% of pediatric exposures are from
products around the house
6

7. Epidemiology
• Developing countries:
– Pesticides
– Envenomation
– Plants
– Anti-malarials
– Metals - iron & lead
• Developed countries fatalities:
– Paracetamol
– Salicylates
– Antidepressants
– Stimulants 7

8. Risk factors
8

9. Risk Factors
• Unsupervised home
setting
• Males < 5 years old
• Lower level of
education
• Substance abuse
• Depressed adolescents
• Adolescent females
• Imitation
• Experimentation
• Exploration
• Strong Oral tendencies
• Curiosity
Exploration is part of growth and development
9

10. If Poisoning Occurs
• Stay calm.
• If the poison is swallowed: do not give the child
anything to eat or drink; do not make the person
throw up
• If the poison is inhaled, move the child to fresh air
• If the poison is on the skin, remove contaminated
clothing and rinse the skin with water for 10 minutes
• If the poison is in the eye, flush the eye with water
for 15 minutes
10

11. If Poisoning Occurs
• Contact the poison control center & have the
following information available:
– Time the poisoning occurred
– Product that the child was exposed to; have the
container nearby
– How much the child ingested
– Any treatment given
– Child’s age, weight, and condition
– Any preexisting medical problems
– Your name and telephone number
• Follow instructions given by the poison center.
11

12. POISONING TOLL FREE LINE
0800720021
(SAFARICOM)
12

13. Resuscitation & Stabilisation
• Prompt recognition & intervention of life-
threatening emergencies
• Primary Survey
– Airway
– Breathing
– Circulation
– Disability, Drugs, Depressed level of
conciousness, Decontamination
– Exposure 13

14. Resuscitation & Stabilisation
• Secondary Survey
– Focused History
– Focused Physical Examination
14

15. History
• Details are extremely important and will
strongly impact management
• Identify the potential poisons
– Determine substance & quantity
• Create an accurate time line
– How long was the child unattended?
• Medications in the home, visitors?
15

16. History (includes)
• What was done?
• What was the effect?
• Were other children involved?
• Could it have been shared?
• How are the others?
– (sleeping?, convulsions?)
16

17. Physical Exam
• Vital signs
• Mental status
– Agitated
– Depressed or Loss of conciousness
• Pupillary size
• Nystagmus
• Seizures
17

18. Physical Exam
• Hypothermia, hypotension or bradycardia:
– Narcotics
– Sedatives/hypnotics
– Antihypertensives
• Hyperthermia, hypertension or tachycardia:
– Anticholinergics
– Sympathomimetics
– Cocaine
– Amphetamines
18

19. Physical Exam
• Dilated pupils:
– Anticholinergics
– Sympathomimetics
– Cocaine
– Amphetamines
– Antihistamines
• Constricted Pupils:
– Narcotics
– Cholinergics
– Organophosphates
– PCP 19

20. Physical Exam
• Nystagmus:
– Alcohols
– Cabamazepine
– CO
– Ketamine
– Phenytoin
– Sedative/hypnotics
20

21. Labs
• On material
– Bottle
– Gastric aspiration
• On child
– Blood glucose
– Arterial blood gas analysis (ABG)
– Electrolytes
– Renal Function
– Quantitative tests
• Paracetamol & salycylate levels
– Qualitative tests
• Urine toxicology screens
21

22. Management
• Aim: Save life
• Minimize blood level concentrations
– Urgent removal of the agent
– Neutralize agent
– Inactivate poison (antidote)
22

23. GI Decontamination
• Gastric Lavage – Rarely
– Within 1 hour of ingestion
– When rapid deterioration expected - TCA’s
• Activated Charcoal – Infrequent
• Whole Bowel Irrigation – Rarely
– Considered in sustained release meds
• Enhance Elimination
23

24. Activated Charcoal
• Increases particle surface area to
absorb the toxins
• High risk patients presenting within 1
hour of ingestion
• Effective for most tablet ingestions
Dose = 1 g/ kg
24

25. Activated Charcoal
• Multi-dose activated charcoal (GI
dialysis) can decrease levels of:
– Theophylline
– Phenobarb
– Carbamazepine
– Quinine
– Dapsone
25

26. Activated Charcoal
• No Utility in:
–Alcohols
–Iron
–Lithium
–Strong acids or alkalis
–Cyanide
–Hydrocarbons
26

27. Activated Charcoal
• Contraindications
– Patient with an unprotected airway
– Caustics – Vomiting may worsen
esophageal injury
– Suspected bowel obstruction or perforation
27

28. Enhanced Elimination
• Forced diuresis
• Urinary alkalinisation:
– Salicylates,
– Phenobarbital
• Hemodyalysis for coma, renal failure or
progressive instability:
– Ethylene glycol, Methanol,
– Phenobarbital,
– Procainamide,
– Salicylates 28

29. Toxidromes
29

30. Cholinergic
• Salivation
• Lacrimation
• Urination
• Defecation
• Gastric Cramping
• Emesis
• Tx:
– Atropine
– Pralidoxime 30

31. Anti-Cholinergic
• Red as a beet – Diffuse erythema
• Dry as a bone – Dry mucous membranes
• Mad as a hatter – Confusion, psychosis,
seizures
• Hot as Hades – Temperature elevation,
tachycardia, hypertension.
• Blind as a bat - Mydriasis, sluggish to light
• Tx:
– Benzodiazepines
– Antihypertensives
– Cooling 31

32. Sympathomimetics
• Agitation, confusion, combative, convulsion
• Tachycardia, Hypertension, Elevated
temperature
• Mydriasis, Reactive to Light
• Diaphoresis
• Tx:
– Benzodiazepines
– Short acting antihypertensives
32

33. Opiates
• Depressed level of conciuosness
• Pinpoint pupils
• Respiratory depression
• Bradycardia, hypotension
• Decreased body temperature
• Tx:
– Naloxone
33

34. Sedatives/Hypnotics
• Depressed level of conciousness
• Respiratory depression
• Hyporeflexia
• Tx:
– Flumazenil ?
34

35. Agents & Antidotes
• Paracetamol - N-acetyl cysteine
• Amphtamine - Benzodiazepine
• Anticholinesterase - Atropine,
Pralidoxime
• Benzodiazepine - Flumazenil
• B-Blocker - Glucagon
• Calcium channel Blocker - Calcium
• CO - Oxygen, hyperbaric oxygen
35

36. Agents & Antidotes
• Cocaine - Benzodiazepine
• Cyanide - Amyl & Sodium Nitrite,
thiosulphate, hydroxocobalamine
• TCA - Sodium bicarbonate
• Digoxin - Digoxin-specific Fab
fragments
• Ethylene Glycol - Fomepizole, ethanol
• Heparin - Protamine
• Hypoglycemic agent - Glucose,
octreotide, glucagon 36

37. Agents & Antidotes
• Iron - Deferoxamine
• Isoniazid - Pyridoxine
• Lithium - Hemodialysis
• Methanol - Fomepizole, ethanol
• Methemoglobin - Methylene blue
• Nitrites - Methylene blue
37

38. Agents & Antidotes
• Opiods - Naloxone
• Organophosphate - Atropine,
Pralidoxime
• Phenothaizine - Diphenhydramine
• Salicylate - Sodium bicarbonate,
hemodilaysis
• Theophylline - Charcoal,
Hemoperfusion
• Warfarin - Vitamin K, FFP 38

39. Antivenom
• Available for certain reptile or arthropod
venoms
• Purified polyvalent immunoglobulins
• Ensure that product is genuine & of high
quality
39

40. • Poisonings are Preventable
40

41. Poison Prevention
• Store all medications, including over-the-
counter medications:
– Out of sight and reach of children
– In child-resistant bottles
– In locked cabinets, Use cabinet latches
• Be sure that caps of medications & household
products are tight
• Do not remove child-resistant caps
• Never refer to medications or vitamins as
“candy” 41

42. Poison Prevention
• Teach children about poisonous substances
• Keep purses and other bags with medications
out of reach of children
• Do not take medications or give medications
to others in front of children
• Store all household products & chemicals out
of reach of children
42

43. Poison Prevention
• Store all household products in their original,
labeled containers
– do not transfer to other containers such as soda
cans, milk cartons, or water jugs
• Throw away old medications and other
potential poisons that are not used anymore
• Never leave a child alone with medications or
household products
43

44. Poison Prevention
• Know which plants in your home are toxic
• Make sure there is no peeling or chipped paint in
areas where children eat, sleep or play
• Install functioning smoke detectors near sleeping
areas
• Teach grandparents, other relatives & friends to take
precautions before children visit their homes
• Keep poison control center number near all
telephones
44

45. 45

46. Summary
• Poisoning is common
– Intentional/unintentional
– Acute or chronic
• Poisoning is preventable
46

47. Summary
• Don’t be fooled if they “look good” as
significant toxicity is still possible.
• Contact the poison center early
– knowing the dosage and time of ingestion
influences management
47

48. POISONING TOLL FREE LINE
0800720021
(SAFARICOM)
48