Pediatric Poisonings: 1

Abhay Dandekar, MD CSMC July 2005

Objectives for Part 1

Epidemiology: the numbers and its impact Evaluating the pediatric poisoning patient:
Initial triage Assessment via history and physical exam Labs and diagnostic evaluation

General principles of management

Identification of treatment themes and toxidromes

Prevention and Education

Definitions
A poison exposure is the ingestion of or contact with a substance that can produce toxic effects. A poisoning is a poison exposure that results in bodily harm. Poison exposures can occur by accident without intent, and these exposures are defined as unintentional poisonings. In some situations, poison exposures are the result of a conscious, willful decision; these cases are defined as intentional poisonings.

Poisoning agents

Poisoning agents

Epidemiology: the numbers

1 million reported poison exposures among children <6 y.o 150-160,000 exposures in children 6-12 160-170,000 exposures in children 13-19 Overall, these are underestimates:
Inst. Of Medicine estimates nearly 4.6 million cases with approximately :
2/3 in patients <20 y.o. in children <6 y.o in children <2 y.o

Epidemiology: the numbers

Nearly 90% of exposures occurring at home During pre-adolescence:slight male predominance This reverses in ages 13-19 with females accounting for 55 percent of poisonings Children, especially those under age 6, are more likely to have unintentional poisonings than older children and adults (Litovitz 2001). Adolescents are also at risk for poisonings, both intentional and unintentional. About half of all poisonings among teens are classified as suicide attempts (Litovitz 2001).

Epidemiology: the numbers

Approximately 1/3 of ingestions of toxic medications occur with medications that are intended for someone other than an immediate family member Among the fatalities in children < 6 y.o:
Unintentional ingestions Medication errors Environmental exposures Bites/stings Malicious intent/abuse

Epidemiology: the numbers

From 2000-2003, most common agents ingested by children younger than 6 y.o
Cosmetics and personal care products Cleaning products Analgesics Foreign bodies Topical agents Cold and cough preparations Plants Pesticides Vitamins Antimicrobials Arts/crafts/office supplies

Epidemiology: the numbers

From 2000-2003, most common agents involved in fatality among children younger than 6 y.o
Analgesic drugs Fumes, gases, vapors (carbon monoxide) Cough/cold preparations Insecticides/pesticides Antidepressant drugs Cardiovascular drugs Cosmetics and personal care products Hydrocarbons Stimulants and illicit drugs

Epidemiology: the numbers

Childhood lead poisoning is considered one of the most preventable environmental diseases of young children yet approximately one million children have elevated blood levels (CDC 2001). Carbon monoxide (CO) results in more fatal unintentional poisonings in the United States than any other agent, with the highest number occurring during the winter months (CDC 1999).

Epidemiology: the numbers

Risk Factors
Development factors (normal gross motor development, fine motor skills, cognition and social skills) Developmental delay Supervision Adolescent development with independence and sense of indestructibility Depression and suicidal ideation ENVIRONMENTAL FACTORS, SOCIETAL FACTORS, EDUCATION, ACCESS to CARE

Epidemiology: the numbers

The majority of poisoning cases can be successfully managed at home with consultation of a poison control center specialist:
Nearly 76 % of cases reported to US Poison Control Centers in 2003 managed at non healthcare facility For children <6y.o., nearly 90 % did NOT require treatment at a medical facility Nearly half of all teenagers required a medical facility

Approaching the Poisoned Child

Overview
Approach begins with initial evaluation and stabilization (ABCDE)!!!!!!! This is followed by a thorough approach to identify the agent(s) involved Often, the suspected toxic agent will determine the priorities of management Supportive cares, prevention of poison absorption, antidotes, enhanced elimination may subsequently be involved

Initial Evaluation/Stabilization
Airway
Assessment of the younger childs airway paying close attention to upper airway edema and to the gag reflex; pay close attention even in the patient who is talking or crying C-spine precautions should be taken when there is any suspected trauma

Initial Evaluation/Stabilization
Breathing
Evaluate the quality of breathing Evaluate the oxygenation and supplement with O2 if needed Many toxins can be responsible for primary respiratory depression Many causative factors for metabolic acidosis will result in a compensatory respiratory alkalosis Less compensatory reserve in children make them more susceptible to hypoxia and respiratory failure (especially in inhalation toxic exposure)

Initial Evaluation/Stabilization
Circulation
Establish large bore IV access, Bolus as needed Monitor pulse and blood pressure EKG monitoring Assess skin color and capillary refill Continue to reassess for cardiovascular compromise or arrhythmias

Initial Evaluation/Stabilization
Disability (Rapid Neuro Eval)/ Dextrose
Assess pupillary response Assess mental status (GCS)
Physiologic excitation (CNS stim, hyperthermia, tachycardia, elevated BP, tachypnea) Depression (CNS depression, hypothermia, hypotension, hypopnea, bradycardia) Mixed Administration of Oxygen or Naloxone (infusion)

Assess blood glucose

Administration of dextrose (infusion) and thiamine

Initial Evaluation/Stabilization
Exposure
Full head to toe survey of the undressed child or adolescent
Search for pill containers

Evaluate for hidden injuries Appropriate thermal control GI decontamination may have a role at this stage of the initial stabilization for children who have ingested potentially life threatening amounts of toxin Ocular decontamination Dermal decontamination

Diagnosis
Focus effort now on agent identification, assessment of severity, and prediction of toxicity. Start with H and P , supplement with labs and investigations AMPLE (Allergies, Meds, PMHx, last meal, events/environment)

Diagnosis
History can be challenging
Where/how was patient found?
Agents in kitchen may be different from other location

If known, details of exposure: agent, time, volume, immediate clinical effects Supervision, recent visitors
Assess for all suspect medications

Herbal products or home remedies Ill contacts or those with similar symptoms
Recent similar exposures in household contacts

Open bottles, pill containers, unusual odors Household hobbies, industrial exposure Substance in original container? Recent illness or medications for the patient?

Diagnosis
History can be challenging
Corroborate the story of the adolescent Symptoms or behavior after the reported ingestion Work and school environments? Available bottles/pills? Interventions in the pre-hospital setting Illicit drug use in family members or close contacts?
Huffing, snorting,

PMHx, family history, allergies, ROS Assume the worst case scenario in trying to calculate the ingestion dose

Diagnosis
Physical Exam:
Vital signs and general appearance Thorough PE Close attention to neuro exam
Pupils Reflexes and posture Mental status

Bowel sounds Mucous membranes and skin moisture/appearance Characteristic odors Nosebleeds, needle tracks, huffer rash, blistering

Specific Toxidrome Patterns

Common Toxidrome Findings

Physical Findings Adrenergic Anticholinergic Anticholinesterase OPIOID Sedativehypnotic

RR HR Temp BP

Increased Increased

No change No change Decreased Increased Decreased Normal/ decreased

Decreased Normal/ decreased Normal/ decreased Normal/ decreased

Increased

Increased

No change Normal/ decreased

Increased

NoChange No change Normal/ /increased decreased

Common Toxidrome Findings

Physical Findings Adrenergic AntiAnticholinestera cholinergic se OPIOID Sedativehypnotic

Mental status pupils

Alert/ agitated Dilated

Depressed/ Depressed/ Depressed Depressed Confused/ Confused/ hallucinate Dilated Dry Constrict Wet Constrict Normal Normal Normal

Mucus Wet membrane skin

Diaphoretic

Dry

Diaphoretic

Normal

Normal

Physical Exam Findings

See handout re: physical findings/odors Sympathomimetic (meth, amphetamines, cocaine, opiate withdrawal, PCP)
Hyperthermia, tachycardia, hypertension, mydriasis, warm/moist skin, agitated

Cholinergic (organophosphates, betel nut, VX, Soman, Sarin)

SLUDGE (Salivation, Lacrimation, Urinary incontinence, Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)

Anticholinergic (antihistamines, atropine, phenothiazines, TCA)

Hyperthermia, tachycardia, HTN, hot/red/dry skin, mydriasis, unreactive pupils, unrinary retention, absent bowel sounds

Opioids (codeine, dextromethorphan, heroin)

Miosis, respiratory depresssion, mental status depression

Diagnostic Considerations
Before proceeding, consider other aspects of the differential diagnosis ( CVA, trauma, meningitis, post-ictal state, behavioral or psych disorders). Labs to evaluate glucose, acid-base status and electrolytes, BUN/Cr, carboxyhemoglobin, hepatic enzyme levels, urinalysis (UA preg), serum osmolality, serum acetaminophen levels EKG Woods lamp/Radiography Save samples of blood, urine, gastric contents General qualitative tox screens of little value (except when abuse is suspected), but are rapid and could offer clue to antidote; may have role in the difficult dx or critically ill; Quantitive measurements in certain toxic exposures

Diagnostic Considerations
Ocular/dermal:
pH testing may reveal acid or alkali Hypoxemic while asymptomatic may suggest methemoglobinemia

Cardiac
EKG shows arrhythmia (TCA) Blood color on filter paper that remains brown after air exposure suggests methemoglobinemia (possibly from benzocainecontaining products, aniline dyes, nitrites)

Signs of hypocalcemia in ethylene glycol, hydrofluric acid Urine fluorescence in ethylene glycol Ferric Cl creates purple reaction with salicylates and phenothiazines in urine Small opacities on x-ray may show halogenated toxins, heavy metals, lithium, densely packed products, phenothiazines, enteric-coated meds

Diagnostic Considerations
MUDPILES CAT for high anion gap acidosis
Methanol or metformin Uremia DKA Paraldehyde or phenformin Iron, INH, Ibuprofen Lactic acidosis Ethylene glycol Salicylates Cyanide Alcohol or acids (valproate) Toluene or Theophylline

Diagnostic Considerations
Toxins requiring quantitative levels at a set point:
Acetaminophen Carbon monoxide Ethanol, ethylene glycol Heavy metals (24 hour urine) Iron Methanol Methemoglobin

Toxins requiring quantitative serial levels

Aspirin/salicylates, tegretol, digoxin, phenobarbital, phenytoin, VPA, theophylline

Management Considerations
Supportive care is the mainstay of therapy and recovery and may involve decontamination, antidotal therapy, enhanced elimination techniques Systemic support for airway security, ventilation, hemodynamic stability, and adequate CNS function Careful attention to pain and agitation Activating multi-faceted team approach early

Management Considerations
Decontamination
Priority after stabilization Activated Charcoal is preferred method, and may be indicated even in the patient with equivocal exposure history
Adsorption of toxins to prevent their absorption Dependant on toxin
Heavy metals (lead, arsenic, mercury, iron), inorganic ions, boric acid, corrosives, hydrocarbons, alcohols, and essential oils are generally not well adsorbed by charcoal

Dependant on surface area of the charcoal preparation

Use 1g/kg prepared in slurry with a cathartic and chocolate milk, cola, fruit syrup. Can be repeated every 4-6 hours at the dose, and multiple doses can help interrupt enterohepatic circulation. Efficacy decreases over time; gastric lavage that follows or preceded and follows may be more effective than charcoal alone. Contraindications in child with depressed levels of consciousness and non-secure airway; caustics, hydrocarbons, ileus/perforation risk

Management Considerations
Decontamination
Priority after stabilization If ingestion has occurred within 1 hour, or a highly toxic substance is ingested that is usually not well bound to charcoal gastric lavage may be attempted; but no longer the routine Controversial in the asymptomatic patient or who has presented more than one hour after ingestion Contraindicated if prior vomiting, hydrocarbon, unprotected airway, caustics, foreign body, at risk for hemorrhage Risk includes aspiration, trauma to anatomic structure.

Management Considerations
Whole bowel irrigation may be necessary in the ingestion of a sustained release product or toxin
Large volumes of balanced electrolyte solution used to decontaminate the GI tract Used in fewer than 1 percent, not well studied in pediatrics Can be useful in ingestion of enteric coated pills, illicit drug packets, large ingestions of substances that are poorly bound by activated charcoal Contraindicated in bowel obstruction, GI bleed, perforation, unprotected airway

Management Considerations
Ipecac syrup induces vomiting by stimulating central emetic centers.
No longer recommended for routine home use. Can be used only in the alert, conscious child over 6 mo who has ingested a potentially toxic amount of poison. (No longer routinely recommended to be used because of its questionable effect on outcome). Contraindicated in children less than 6mo, ingestion of a non-toxic substance, corrosive ingestion, hydrocarbon ingestion, altered mental status or airway compromise, GI bleed or coagulopathy,

Management Considerations
Ocular exposure requires copious irrigation with saline using a Morgan lens, measure pH and maintain at 7.5-8 Dermal cleansing with water or normal saline and subsequent identification:
Pay close attention to burns, pain, infection Water is absolutely contraindicated with reactive metals; use mineral oil instead Tar can be removed safely with vaseline

Management Considerations
Inhalation injuries need fresh humidified and oxygenated air
Treatment with B-agonists, corticosteroids Removal of offending environment

Hemodialysis and Hemoperfusion

Require anti-coagulation

Management Considerations

Drugs that can kill the toddler in one or two doses!:

Benzocaine, Ca antagonists, camphor, chloroquine, clonidine, TCA, Lomotil, Visine/Afrin, Lindane, Sulfonylureas, theophylline, phenylpropanolamine, phenothiazines, selenious acids, hydrocarbon aspiration, oil of wintergreen.among others

Management Considerations

Activate Poison Control:

1-800-876-4766 or 1-800-222-1222 www.calpoison.org

Management Considerations
Prevention Strategies/Themes-primary
Store potentially toxic substances in higher places or out of reach/sight Store safe items within the childs reach; dont take medicine in front of kids Child-proof latches Avoid chemicals in the fridge, or insect traps that are accessible Remove toxic plants; avoid exposure to toxic animals Keep matches, combustibles out of reach Dispose of partially consumed alcohol Carbon monoxide detection system Read labels on products carefully Advocate for protective legislation

Management considerations
Prevention Strategies/Themes-secondary
Identify poison control center and number Education Decontamination

Prevention Strategies/Themes-tertiary
EMS Antidotes