2. Ingestion of toxin substances is a common problem in
the pediatric age group.
Common causes are household products including
kerosene oil, drugs (barbiturates), chemicals (corrosives)
and pesticides (organophasphate compound.
Majority of poison are ingested by children at home,
include products that are familiar and visual appealing
due to glossy packing.
The inherent curiosity and tendency for exploration in
children contributes the high incidence of accidental
poisoning below 5 years of age.
Usually classified as accidental, homicidal or suicidal,
whereas in a majority of cases are accidental.
3. In toddlers the risk is high due to their spontaneous
activity, curiosity, mouthing of the objects &
imitation of the adults.
Pharmaceutical toxicity is most common due to self
administration by the parents for the minor ailments.
In developing countries the incidence is high due to
change in living habits and decreased awareness
about the industrial chemicals etc.
Poisoning should be suspected in case of any unusual
drowsiness, odour, convulsions, respiratory distress
& circulatory failure.
All children < 6 yrs with poisoning should be
hospitalised for at least 24 hrs for observation.
4. Common poisons
Hydrocarbon – Kerosene oil, solvents
Insecticides- DDT, glyphosate, malathion
Medicines – aspirin, iron, paracetamol etc.
Polish varnish
Detergents
Diagnosis:
Depend upon the type of poison and its severity.
Latter depends on the amount of substance
ingested.
Age of the patient.
5. Examination:
Vital parameters; Respiration, BP, Pulse,
temperature
Level of consciousness
Examination particularly observing pupillary size,
oral cavity, breath odor, skin color, sweating.
Any mark of injury, pigmentation, secretions from
oral and nasal orifices.
Abdominal examination for peristaltic activity and
urinary retention.
Some clues of the poison by urine color
Orange/Red- Rifampicin
Grey/Black- Phenols/cresols
Blue/green-Methylene blue
6. General Principles of Management
First Aid:
Decontamination:
Remove from the source of poison
Remove the clothing's
Irrigate the skin and eyes with normal saline or
lukewarm soap water
Treatment:
Patients should be transported nearest medical care
facility.
Initial treatment consist of managing the airway,
breathing and circulation.
Take care of airway by inserting an appropriate size
endotrachial tube.
Identification of poison& assess the type & amount of
the poison.
7. Maintain IV line.
In comatose patients a bolus of 2ml/kg of 25% Dextrose
may be given.
In adolescent & malnourished children Inj. Thiamine 50 –
100 mg iv/im to avoid precipitating acute wernicke’s
encephalopathy.
In comatose patient if respiration is shallow parental
naloxone in dose of 0.2 to 0.45ug/ kg is given.
Removal of the unabsorbed poison.
Gastrointestinal tract
Emesis can be induced by Sy. ipecac which induced
vomiting in 80% within 20 minutes is given 30 minutes of
ingestion.
Contra indicated in children below 6 month, corrosive or
caustic ingestion and those who are comatose.
8. Gastric Lavage:
Gastric lavage can be used in place of emesis
Done in left lateral position with head end low with
15 ml/kg NS ( max 400/clycle).
CI in hydrocarbons & corrosive & paralytic ileus,
heart disease
In comatose child only after cuffed endotracheal
intubation.
Prevention of GI absorption.
Activated charcoal-1 to 2 g/kg/dose(1 g in 8 ml of
water through NG tube after Gastric lavage every 4
hourly.
Avoid in acids, alkalies, iron poisonings.
Cathartics :Na & Mg sulphate 25 mg/kg/dose
9. Promotion of excretion:
Maintenance IV line
Diuresis:
Frusemide-2 to 4 mg/kg/day
Mannitol- .5 to 1 g/kg over 30 min
Forced alkaline diuresis in Salicylate & barbiturate
Specific antidotes:
Depending upon the type of poison ingested
Some clues of the poison by urine colour
Blue/green- Methylene blue
Orange/Red- Rifampicin
Grey/Black- Phenols/cresols
Lab. Investigation : Estimation of blood level for
glucose, urea, Serum creatinine, serum electrolytes,
ABG, ECG, X ray etc.
11. Kerosene & Other Hydrocarbon Poisoning
High volatile: Kerosene, Petroleum, Ether, Paint,
thinner
Low volatile: Furniture polish, Lubricating oils, Paraffin
wax.
Accidental ingestion of kerosene, petrol, diesel is
common.
Stored in unmarked container.
Taste prevent large amount to be consumed.
Systemic manifestations are due to absorption through
the lungs following aspiration;
Exceptions are non petroleum distillate hydrocarbons
(benzene, carbon tetrachloride, chloroform etc) which
are absorbed from GIT.
12. Clinical Features :
Topical effects :
Irritation of oral, esophageal & gastric mucosa.
Pulmonary effects :
Fever, tachycardia, tachypnoea, cough, cyanosis and
rarely pulmonary edema.
CNS effects:
Euphoria, headache, restlessness, muscle twitching,
in coordination , confusion, lethargy ,stupor, coma &
convulsions.
Other features:
Liver damage, renal tubular, bone marrow depression
& myocardial toxicity.
13. Management Protocol:
Asymptomatic for a period of six hours- observe at
home
Symptomatic-
Oxygen inhalation
If required IPPV
Emesis is contra indicated
Maintain iv fluids
Antibiotics are required in the presence of pre-existing
respiratory illness.
Chest X ray if normal, observe for 6 hrs & may be dis
charged and if shows lesions observe for 24 hrs & if no
symptoms may be discharged.
14. Organophosphate Poisoning
Mostly used as insecticides & pesticides viz Malathion,
Parathion, carbamates, Fenthion, TEPP
Cause an irreversible inhibition of cholinesterase
resulting in excessive accumulation of ach at receptor
sites leading to excessive cholinergic manifestations
Clinical features.-
Muscarinic effects :
Lacrimation
Excessive salivation
Urination
Diarrhea
Nausea
Vomiting
Bradycardia
Pin pointed pupil
16. Diagnosis:
Based on history and clinical features.
RBC, cholinesterase level is less then 50% in case where only
exposure and less then 20% in symptomatic patients.
Management :
Cloth should be removed & skin washed with soap and
water.
Gastric decontamination done by lavage or emesis
Children older then 12 years Atropine 1.0–2.0 mg iv every
10–30 minutes until cholinergic sign are reversed. Younger
children 0.02-0.05 mg/kg every 10-30 min till signs of
atropinisation including warm, Dry skin, dry mouth,
tachycardia and pupillary dilatation.
Pralidoxime is the specific antidote for organ phosphorus
compound but muscarinic or central action are not
significantly reversed. Drug used in dose of 25-50 mg/kg
older then 12years over a period 15–30 minutes & repeated
after 1-2 hours.
17. Corrosive poisonings:
Include washing soda, acids, alkalies, bleaching
powder, toilet & drain cleaners, strong detergent
granules.
Acids produce coagulative necrosis, which cause
superficial damage while alkali cause a deep
penetrating liquefaction necrosis.
Acid ingestion cause gastric perforation & peritonitis
while alkali commonly cause damage in esophagus &
in severe case pneumonia.
18. Clinical features:
Vomiting
Dysphagia
Drooling
Abdominal pain
Involvement of glottis leads to stridor & shock.
Oral cavity shows edema, ulceration & pseudo
membrane over the palate, uvula and pharynx.
Absence of oral burns& lack of symptoms do not rule
out the involvement of esophagus.
Esophageal & gastric perforation leads to peritonitis.
If required upper intestinal tract endoscopy with
fibrotic endoscope should be performed within 24-48
hours & after 2-3 weeks by an experienced person to
determine the extent of the injury.
19. Management Protocol
Vomiting should not be induced.
Small amount of water or milk to wash away any
residual caustic from the oral mucosa.
Detailed history about the type & amount of the
corrosive.
Ingestion with concentrated solutions of acid and
alkalis need hospitalization.
Such children kept nil orally.
Gastric lavage contraindicated.
Neutralization by acid/alkali is also not recommended
Milk of magnesia & antacids may be used to neutralize
strong acids.
Irrigation of skin & eyes if involved
H2 blockers - Ranitidine 2-4 mg/kg/day 12 hrly orally
for 6-8 wks or 1-2 mg/kg/d IV 12 hrly.
20. Use of corticosteroids is controversial.
As long as the child is able to swallow, liquids are
offered by mouth coz drinking is a self-dilatation & may
decrease the likely hood of esophageal stricture
formation.
Antibiotics if infection suspected
Drooling & dysphasia beyond 12-24 hrs have been
reported to be a good predictor of scar formation &
should prompt upper GI endoscopy.
Placement of a rubber tube in the esophagus allows it to
scar down in a functional position leaving a lumen.
Prognosis:
Mild cases have full recovery of corrosive injuries.
Moderate and severe cases will result in stricture
formation requiring regular dilatation and possible
surgery.
21. Avoid keeping poisonous plant in or around
house.
Take care while eating products such as berries,
roots or mushrooms.
Keep all potentially p oisonous substance out of
children reach.
Label the poisons in your home.
Store medicines, cleaning detergents, mosquito
repellants and paints carefully.
