Pediatric Toxicology

Jana Stockwell, MD

Epidemiology

   2 million calls 52% of poison center calls <6years Peak ages: 18 months - 3 years

Epidemiology

 Unintentional (1-2 years) – Exploratory – – Boys > girls Unable to discriminate safe from unsafe liquid  Intentional (adolescent) – Purposeful – Girls > boys

Epidemiology

    Around meal time Grandparents home Kerosene or gasoline in a soda bottle Older sibling can pharmaceutically treat younger sibling

Most often reported

     Cleaning products Analgesics Cosmetics Cough & cold preparation Insecticides 10% 10% 9% 5% 4%

PICU Admission

     Tricyclic antidepressants (TCA) Anticonvulsants Digoxin Opiates Hydrocarbon-based household products

Toxic Exposures



Death

     Analgesics Sedative-hypnotics Alcohols Gases & fumes Cleaning substances

“Fatal Sip”

   Camphor (Vick’s VapoRub) – (100mg/kg) Methyl salicylate (wintergreen) – (200 mg/kg) Benzocaine (OraGel) – 2 mL – – Met-hemoglobinemia Seizure 1000 mg/5 ml 1400 mg/ml

“Malignant Swallow”

     Chloroquine Theophylline Imipramine Chlorpromazine Clonidine – Bradycardia – CNS depression (20 mg/kg) (8.4 mg/kg) (15 mg/kg) (25 mg/kg) (0.3 mg tablet)

Other Highly Toxic

   Acetonitrile - nail tip remover  MetHgb Ammonium fluoride – hub cap cleaner (ArmorAll)  sz, arrhythmias, acidosis Pennyroyal Oil – some herbal teas

Look-Alike, Sound-A-Like

        Albuterol Celebrex Oruvail Lamictal Lotrimin Plendil Hydralazine Hydrocodone         Atenolol Cerebrex Elavil Lomotil Lotensin Pindolol Hydroxyzine Hydrocortisone

Poison plants

   Digitalis effects – Lily-of-the-valley, Foxglove, Oleander, Yew Nicotinic effects – Poison hemlock Atropinic effects – Jimson weed

Non-Toxic Products

     Ball point ink Bubble bath soaps Chalk Cigarettes (< 3 butts) Crayons       Deodorants Lipstick Pencil (graphite) Toothpaste Water colors Candle wax (but candle oil is!)

Evaluation

    History of poisoning Physical examination Laboratory studies Gastrointestinal decontamination

History

    What?

When?

How much?

Reliability…

What ?

   Medication Illicit drug Hazardous chemical

What form?

    Pill Solid Liquid Gaseous

What route ?

    Ingestion Inhalation Topical Intravenous

When ?

 Elapsed time

How much ?

  Estimate amount Concentration

“Clues”

Bradycardia

       Calcium channel blockers Digoxin Narcotics Organophosphates Carbon monoxide Beta-blockers Clonidine

Tachycardia

         Amphetamine (Ritalin) Atropine TCA’s Theophylline Salicylates (aspirin) Iron Cocaine PCP Synthroid

Slow Respiration

    Alcohol Narcotics Clonidine Sedatives

Tachypnea

    Amphetamines Salicylates Carbon monoxide Ethylene glycol (anti-freeze)

Hypotension

       Calcium channel blockers Carbon monoxide Cyanide Iron Narcotics Anti-hypertensives Met-hemoglobin

Hypertension

      OTC cold remedies Amphetamine PCP TCA Cocaine Diet pills

V Tach

      Amphetamines Carbamzepine (Tegretol) Chloral hydrate Cocaine Digitalis Theophylline

Torsades de Pointes

     Chloral hydrate Cisapride Organophosphates Terfenadine Phenothiazines

Hypoglycemia (HOBBIES)

     

H

ypoglycemia

O

ral hypoglycemic agents

B

eta-

B

lockers

I

nsulin

E

thanol

S

alicylates

Hypothermia

    Ethanol Narcotics Carbon monoxide Clonidine

Hyperpyrexia

     Atropine Salicylates Theophylline Cocaine TCA

CNS - Coma

   Narcotic Anti-cholinergics Carbon monoxide

CNS - Delirium / Psychosis

   Alcohol PCP / marijuana LSD

CNS - Seizure

      Cocaine Amphetamine Lead Salicylate Isoniazid Theophylline

Pupils - Miosis (COPS)

   

C

holinergics, Clonidine

O

piates, Organophosphates

P

henothiazine, Pilocarpine

S

edatives (barbiturates, ethanol)

Pupils - Mydriasis

(AAAS)

   

A

nti-histamine

A

nti-depressant

A

nticholinergics (atropine)

S

ympathomimetics – amphetamine, cocaine, PCP

Caution!

  Polydrug overdoses with opposite pupillary actions Non-toxin diagnoses – Head trauma – CNS hemorrhage

Cyanosis

     MetHgb – Unresponsive to O 2 Aniline dyes Nitrites Benzocaine Dapsone

Dry Skin

 Anticholinergic

Breath Odors

      Arsenic Camphor Cyanide Garlic Mothballs Bitter almond Methyl salicylate Wintergreen Paraldehyde Pears Hemlock Carrots

Cholinergic

 

“DUMBBELS” “SLUDGE”

Example – Organophosphates Nerve agents

DUMBBELS

       

D

iarrhea, diaphoresis

U

rination

M

iosis, muscle fasiculation

B

radycardia

B

ronchospasm

E

mesis

L

acrimation

S

alivation

SLUDGE

     

S

alivation

L

acrimation

U

rination

D

iarrhea

G

I complaint

E

mesis

Anti-cholinergic syndrome

       Dry mouth Flushed appearance Dilated pupils Fever Ileus Urinary retention Disorientation Examples – Anti-histamines Jimson weed Lomotil TCA Carbamazepine Glycopyrrolate Atropine

Anti-cholinergic

      Hot as a hare Blind as a bat Dry as a bone Red as a beet Mad as a hatter

Full as a flask

Narcotic

   Pinpoint pupils Coma Respiratory depression

Salicylates

    Fever Tachypnea & hyperpnea Lethargy Metabolic acidosis

Theophylline

     Protracted Vomiting Tremors Tachycardia Seizures Hypotension

Isoniazid

   Seizures Metabolic acidosis Hyperglycemia

Phencyclidine

(4 Cs)     

C

ombative

C

atatonia

C

onvulsion

C

oma

N

ystagmus

TCA

     Metabolic acidosis Prolonged QRS Seizures Dilated pupils Dysrhythmia

Cyanide

     Feeling of impending doom Sudden coma Metabolic acidosis Hypotension Bitter almond odor

Carbon monoxide

     Headache Lethargy Dizziness Influenza like syndrome Coma

Ethanol

     Hypoglycemia Lethargy Ataxia Seizure Characteristic breath odor

Methanol

    Severe metabolic acidosis Sluggish pupils Hyperemic retina Blurred vision

Ethylene Glycol

    Lethargy or coma Metabolic acidosis Urinary sediment Crystalluria

Clonidine

    Hypothermia Bradycardia Miosis Respiratory depression

Elevated anion gap

     Methanol Paraldehyde & phenformin Iron & isoniazid Ethylene glycol & ethanol Salicylate

ABC’s

    

A

irway

B

reathing

C

irculation

D

isability

D

econtamination

Consciousness

   

A

: Alert

V

: Responsive to verbal stimuli

P

: Responsive to pain

U

: Unresponsive

Drugs

   Dextrose Oxygen Naloxone

Decontamination

   Ocular- copious saline lavage Skin- copious water GI-consider options

Lab Evaluation

 No “tox panel” that is uniformly helpful

Urine Screen

      Marijuana Amphetamines Barbiturates Cocaine Opiates PCP 5-10 days 48 hours 24 h-2 wks 2-4 days 2 days 8 days

EKG

  All suspected ingestion Tricyclics

Pulse oximetry

   Measure of oxygen saturation of normal hemoglobin Does NOT differentiate CO-Hgb from oxyHgb Falsely low sats – Nail polish – – Methylene blue Poor perfusion

Other tests

   CXR - hydrocarbons ABG - salicylates Esophagoscopy - Caustics

Drug levels

        Acetaminophen Salicylates Methanol Ethylene glycol Iron Theophylline Carbon monoxide (co-ox blood gas) Lithium

Radiopaque

(CHIPS)

    

C

hloral hydrate

H

eavy metals

I

ron

P

henothiazine (laxatives)

S

low release

GI tract decontamination

     Syrup of Ipecac (not used in hospital) Gastric lavage – 1 st hour Activated charcoal – Inert – Reduces bioavailability of drug – Not w/ HC or corrosives Cathartics – decrease transit time WBI (whole bowel irrigation)…till clear

Urine alkalinization

   Salicylates Phenobarbital Chlorpropamide

Extracorporeal methods

  Hemodialysis – – Severe poisoning Renal failure Hemoperfusion – Perferred in some toxic ingestions

            

Antidotes

Oxygen - carbon monoxide Naloxone – opioids Methylene blue – MetHgb Sodium nitrite - cyanide Deferoxamine – iron Acetoaminophen – N-acetylcysteine Anti-cholinergics – physostigmine Organophosphates – atropine, pralidoxime Benzodiazepines – flumazenil B-blockers – glucagon TCA – bicarb Coumadin – Vitamin K Fomepizole (Antizol) – ethylene glycol