Transcript Pediatric Toxicology
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