Transcript Pediatric Toxicology - PEM Database Online

Pediatric Toxicology
M Waseem, MD
Lincoln Hospital Bronx New York
7/17/2015
Epidemiology
2 million calls
 52% of poison center calls < 6years
 Peak age 18 months - 3 years

7/17/2015
Epidemiology

Unintentional (1-2 years)
– Exploratory
– Boys > girls

Intentional (adolescent)
– Purposeful
– Girls > boys
7/17/2015
Children are different
Unable to discriminate safe from unsafe
liquid
 Fail to recognize the suitability of the
drink

7/17/2015
Epidemiology
Around Meal time
 Grand parents home
 Kerosene or gasoline in a soda bottle
 Older sibling can pharmaceutically treat
younger sibling

7/17/2015
Very toxic!
Prenatal vitamin supplements
 Antidepressants
 Hydrocarbons

7/17/2015
Most often reported
Cleaning products
 Analgesics
 Cosmetics
 Cough & cold preparation
 Insecticides

7/17/2015
10.4%
10.3%
9%
5.1%
4%
ICU Admission
TCA
 Anticonvulsants
 Digitalis
 Opiates
 Hydrocarbon-based house-hold
products

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Toxic Exposures/Death
Analgesics
 Sedative-hypnotics
 Alcohols
 Gases & fumes
 Cleaning substances

7/17/2015
“Fatal Sip”
7/17/2015
Fatal Sip
Camphor (100mg/kg)
 Methyl Salicylate
(200 mg/kg)

7/17/2015
1gm/5 ml
1.4gm/ml
1/2 tsp
Fatal Sip

Benzocaine
– Methemoglobinemia
– Seizure
7/17/2015
2 ml
Malignant Swallow
Chloroquine (20 mg/kg)
 Theophylline (8.4 mg/kg)
 Imipramine (15 mg/kg)
 Chlorpromazine
(25 mg/kg)

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500 mg
500 mg
150 mg
200 mg
Malignant Swallow

Clonidine
– Bradycardia
– CNS depression
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0.3 mg tablet
Highly Toxic
Acetonitrile
 Ammonium Fluoride
 Benzocaine
 Camphor
 Pennyroyal Oil

7/17/2015
Acetonitriles
Artificial Nail Tip remover
 Methemolobinemia
 Delayed presentation (4-12 hours)
 Must be hospitalized

7/17/2015
Ammonium Fluoride
Glass etching, de-rusting and wheel
cleaning commercial products
 Armoral Quick Silver Wheel cleaner
(17% ammonium fluoride)
 only 2 ml

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Ammonium Fluoride
Inactivates proteolytic & glycolytic
enzymes
 Binds with Ca & Mg

– Acidosis, Dysrhythmia & coagulopathy

Direct effect on CNS
– Seizures
7/17/2015
Benzocaine
Teething gels (Orajel), first aid cream
hemorrhoidal preparations
 Methemoglobinemia
 < 6 months (methemoglobin reductase)

7/17/2015
Camphor
Vicks VapoRub
 Only 5 ml
 CNS effects

7/17/2015
Pennyroyal Oil
Health food products,
herbal preparations
 Depletes glutathione
 Toxicity to liver & lung
 < a teaspoon
 A tablespoon (fatal)

7/17/2015
Look-Alike, Sound-A-Like
Albuterol
 Celebrex
 Oruvail
 Lamictal
 Lotrimin
 Plendil

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Atenolol
Cerebrex
Elavil
Lomotil
Lotensin
Pindolol
Look-Alike, Sound-A-Like
Hydralazine
 Hydrocodone

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Hydroxyzine
Hydrocortisone
Plant Toxidromes
7/17/2015
Digitalis Effects
Lily-of-the-valley
 Foxglove
 Oleander
 Yew

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Nicotinic Effects

Poison hemlock
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Atropinic Effects

Jimsonweed
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Non-Toxic Products
Ball point ink
 Bubble bath soaps
 Candles (beeswax or paraffin)
 Chalk
 Cigarettes (< 3 butts)
 Crayons

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Non-Toxic Products
Deodorants
 Lipstick
 Pencil (graphite)
 Toothpaste
 Water colors

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Evaluation
History of poisoning
 Toxicologic physical examination
 Laboratory studies
 Gastrointestinal decontamination

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History
 What?
 When?
 How
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much?
What ?
 Medication
 Illicit
drug
 Hazardous chemical
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What form?
 Pill
 Solid
 Liquid
 Gaseous
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What route ?
 Ingestion
 Inhalation
 Topical
 Intravenous
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When ?
 Elapsed
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time
How much ?
 Estimate
amount
 Concentration
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“Vital signs”
7/17/2015
Bradycardia
 Digoxin
 Narcotics
 Organophosphates
 Carbon
monoxide
 Beta-blocker
7/17/2015
Tachycardia
 Alcohol/amphetamine
 Atropine/tricyclic
 Theophylline
 Salicylates,
Iron
 Cocaine/PCP
7/17/2015
Slow Respiration
 Alcohol
 Narcotics
 Clonidine
 Sedatives
7/17/2015
Tachypnea
 Amphetamines
 Salicylates
 Carbon
7/17/2015
monoxide
Hypotension
 Methemoglobinemia
 Carbon
monoxide
 Cyanide
 Iron
 Narcotics
7/17/2015
Hypertension
 OTC
cold remedies
 Amphetamine
 PCP
 TCA
 Cocaine
7/17/2015
Ventricular Tachycardia
 Amphetamines
 Carbamzepine
 Chloral
hydrate
 Cocaine
 Digitalis
 Theophylline
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Torsades de Pointes
 Chloral
hydrate
 Cisapride
 Organophosphates
 Terfenadine
 Phenothiazines
7/17/2015
Hypoglycemia (HOBBIES)
H-Hypoglycemia
 O-Oral hypoglycemic agents
 B-Beta-Blockers
 I-Insulin
 E-Ethanol
 S-Salicylates

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Hypothermia
 Ethanol
 Narcotics
 Carbon
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monoxide
Hyperpyrexia
 Atropine
 Salicylates
 Theophylline
 Cocaine
 TCA
7/17/2015
Mental Status
7/17/2015
Coma
 Narcotic
 Anticholinergic
 Carbon
7/17/2015
monoxide
Delirium/Psychosis
 Alcohol
 PCP/marijuana
 LSD
7/17/2015
Convulsion
 Cocaine/Amphetamine
 Lead
 Salicylate
 Isoniazid
 Theophylline
7/17/2015
Pupil size
7/17/2015
Miosis (COPS)
 Cholinergics,
Clonidine
 Opiates, Organophosphates
 Phenothiazine, Pilocarpine
 Sedatives (Barbiturates)
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Mydriasis (AAAS)
Antihistamine
 Antidepressant
 Anticholinergics (atropine)
 Sympathomimetics

– Amphetamine, Cocaine, PCP
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Caution!
 Polydrug
overdoses with opposite
pupillary actions
 Nontoxin diagnoses
– Head trauma
– CNS hemorrhage
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Cyanosis
Unresponsive to oxygen
methemoglobinemia
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Cyanosis
 Aniline
dyes
 Nitrites
 Benzocaine
 Dapsone
7/17/2015
Dry Skin
Anticholinergic
7/17/2015
Breath Odors
Arsenic
 Camphor
 Cyanide
 Methyl salicylate
 Paraldehyde

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Garlic
Mothballs
Bitter almond
Wintergreen
Pears
Toxidromes
7/17/2015
Cholinergic
DUMBBEL
SLUDGE
7/17/2015
DUMBBELS
D
Diarrhea
 U Urination
 M Miosis, muscle fasiculation
 B Bradycardia
 B Bronchospasm
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DUMBBELS
E
Emesis
 L Lacrimation
 S Salivation
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SLUDGE
S
Salivation
 L Lacrimation
 U Urination
 D Diarrhea
7/17/2015
SLUDGE
G
GI complaint
 E Emesis
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Anticholinergic Syndrome
Dry mouth
 Flushed appearance
 Dilated pupils
 Fever
 Ileus
 Urinary retention
 Disorientation

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Anticholinergic
 Hot
as a hare
 Blind as a bat
 Dry as a bone
 Red as a beet
 Mad as a hatter
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Anticholinergic
 Full
7/17/2015
as a flask
Anticholinergic
Anticholinergic

Wet
 Bowel sound +



7/17/2015
Sympathomimetic
Dry
 Absent bowel
sound
Narcotic
 Pinpoint
pupils
 Coma
 Respiratory
7/17/2015
depression
Salicylates
 Fever
 Tachypnea
& hyperpnea
 Lethargy
 Metabolic
7/17/2015
acidosis
Theophylline
 Protracted
Vomiting
 Tremors
 Tachycardia
 Seizures
 Hypotension
7/17/2015
Isoniazid
 Seizures
 Metabolic
acidosis
 Hyperglycemia
7/17/2015
Phencyclidine (4 Cs)
 Combative
 Catatonia
 Convulsion
 Coma
 Nystagmus
7/17/2015
TCA
 Metabolic
acidosis
 Prolonged QRS
 Seizures
 Dilated pupils
 Dysrhythmia
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Cyanide
 Feeling
of impending doom
 Sudden coma
 Metabolic acidosis
 Hypotension
 Bitter almond odor
7/17/2015
Carbon monoxide
 Headache
 Lethargy
 Dizziness
 Influenza
 Coma
7/17/2015
like syndrome
Ethanol
 Hypoglycemia
 Lethargy
 Ataxia
 Seizure
 Characteristic
7/17/2015
breath odor
Methanol
 Severe
Metabolic acidosis
 Sluggish pupils
 Hyperemic retina
 Blurred vision
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Ethylene Glycol
 Lethargy
or coma
 Metabolic acidosis
 Urinary sediment
 Crystalluria
7/17/2015
Clonidine
Hypothermia
 Bradycardia
 Miosis
 Respiratory depression

7/17/2015
Elevated anion gap
 Methanol
 Paraldehyde
& phenformin
 Iron & isoniazid
 Ethylene glycol & ethanol
 Salicylate
7/17/2015
ABCs
Anticipate
Before
Complications
7/17/2015
ABC
Airway
–C-spine immobilization
Breathing
Circulation
–secure IV access
7/17/2015
ABC
Disability
–consciousness
Drugs
Decontamination
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consciousness
 A: Alert
 V:
Responsive to
verbal stimuli
 P:Responsive to pain
 U: Unresponsive
7/17/2015
Drugs
Dextrose
Oxygen
Naloxone
7/17/2015
Decontamination
 Ocular-
copious saline lavage
 Skin- copious water
 GI-consider options
7/17/2015
Lab Evaluation
No “tox panel” that is
uniformly helpful
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Urine Screen
Marijuana
 Amphetamines
 Barbiturates
 Cocaine
 Opiates
 PCP

7/17/2015
5-10 days
48 hours
24 h-2 wks
2-4 days
2 days
8 days
EKG
All suspected ingestion
Tricyclics
7/17/2015
Pulse oximetry
Measure of oxygen
saturation of normal
hemoglobin
7/17/2015
Pulse oximetry
Does not differentiate COHB
from oxyhemoglobin
7/17/2015
False low Saturation
 Blue
nail polish
 Methylene blue
 Poor distal perfusion
7/17/2015
Blood gas
Salicylates
7/17/2015
Chest X-ray
Hydrocarbons
7/17/2015
Esophagoscopy
Caustics
7/17/2015
Emergent Lab Analyses
 Acetaminophen
 Salicylates
 Methanol
 Ethylene
 Iron
7/17/2015
glycol
Emergent Lab Analyses
 Theophylline
 Carbon
 Lithium
7/17/2015
monoxide
Optimum time
 Actaminophen
4 hours
 Salicylates
2-4 hours
 Iron
4 hours
 Carboxyhemoglobin Immediate
 Methemoglobin
Immediate
7/17/2015
Optimum time
 Ethanol
 Ethylene
 Methanol
 Digoxin
7/17/2015
glycol
1/2-1
1/2-1
1/2-1
4-6
hour
hour
hour
hour
Serial Levels
Salicylates
 Carbamazepine
 Digoxin
 Phenobarbital
 Theophylline
 Valproic acid

7/17/2015
Radiopaque (CHIPS)
 Chloral
hydrate
 Heavy metals
 Iron
 Phenothiazine
 Slow release
7/17/2015
GI. Decontamination
Preventing absorption
7/17/2015
GI decontamination in a
symptomatic patient?
7/17/2015
Decontamination
 Syrup
of Ipecac
 Gastric lavage
 Activated Charcoal
 Cathartics
 WBI (bowel irrigation)
7/17/2015
Syrup of ipecac
7/17/2015
Syrup of Ipecac
 Nonprescription
 CTZ
stimulant
 use only under poison
control direction
7/17/2015
Syrup of Ipecac
 No
evidence of improved outcome
 Delays AC or antidote for 2 hours
 No role in hospital setting
7/17/2015
Adverse effect
 Protracted
vomiting
 Sedation
 Diarrhea
 Bradycardia
7/17/2015
Contraindications
 Altered
mental status
 Seizure
 hemetemesis
 hydrocarbon
 corrosives
7/17/2015
Contraindications
 Anticipated
use of oral
antidote or WBI
 < 6 months old
7/17/2015
Gastric Lavage
7/17/2015
Gastric Lavage
 one
 Life
7/17/2015
hour (“golden hour”)
threatening ingestion
“NG tube is not adequate”
7/17/2015
Gastric Lavage
 Large
bore orogastric tube
(36 - 40 French)
 0.9% saline 15 ml/kg
max 200-400 ml/cycle
7/17/2015
Gastric Lavage
<
30% by 20-30 min
 < 13% by 60 minutes
7/17/2015
Gastric Lavage
 Not
a routine
 With in one hour
 Life-threatening ingestion
 Absence of pill fragments does not
rule out toxic ingestion
7/17/2015
Gastric Lavage
 TCA
 Calcium-blocker
 Colchicine
7/17/2015
Complications
 Pulmonary
7/17/2015
aspiration
Contraindications
 Caustic
 Hydrocarbon
 Sharp
7/17/2015
coingestion
Activated Charcoal
Universal antidote
7/17/2015
Single dose AC
adsorbing the ingested
substance
7/17/2015
Activated Charcoal
 Oxidizing
process
 Increases the adsorptive capacity
 Inert substance
 Reduce the bioavailability of drug
7/17/2015
Activated Charcoal
Surface area
2
950-2000m /g
7/17/2015
Poorly bound by AC
7/17/2015
CHEMICaL CamP
C
H
E
M
I
C
L

7/17/2015
Cyanide
Hydrocarbon
Ethanol
Metals
Iron
Caustics
Lithium
CHEMICaL CamP
C Camphor
 P Phosphorus

7/17/2015
Recommended Dose
 Up
to 1 year
–1g/kg
 1-12
year
–25-50 gm
7/17/2015
Complications
 Pulmonary
aspiration
 Emesis
 Constipation
7/17/2015
Contraindications
 Hydrocarbon
 Corrosive
 Ileus
7/17/2015
Home AC?
1,208,860 exposure in < 6 year
 16 fatalities
 4 might have benefited from early
administration of AC
American Association of Poison
Control Centers Toxic Exposure
Surveillance System (1998)

7/17/2015
Benefits of Home AC
 Early
administration
 Reduced morbidity & mortality
7/17/2015
Risks of Home AC
 Inappropriate
administration
 Inadequate dosing
 Pulmonary aspiration
7/17/2015
Multiple-Dose AC
Gastrointestinal Dialysis
7/17/2015
Multiple-Dose AC
Continue to adsorb remaining toxin
 Interfere with enterohepatic circulation
 Lower the free drug concentration

7/17/2015
Multiple-Dose AC
Phenobarbital
 Carbamazepine
 Phenytoin
 Digoxin
 Salicylates
 Theophylline
 TCA

7/17/2015
Cathartics
Decrease transit time
7/17/2015
Cathartics
 Sorbitol
70%(0.5g/kg)
 10 - 20 ml (children)
 50-100ml(adolescent)
7/17/2015
Complications
 Nausea
 Abdominal
cramps
 Vomiting
 Transient
7/17/2015
hypotension
Contraindications
 Unprotected
airway
 Ileus
 Absent
bowel sounds
 Intestinal obstruction
7/17/2015
WBI
Decontaminate entire
gastrointestinal tract
7/17/2015
WBI
Commonly used for
agents not bound to
activated charcoal
7/17/2015
WBI
 polethylene
 No
glycol
fluid abnormality
 No electrolyte imbalance
 End point clear rectal effluent
 Sustained release preparation
7/17/2015
WBI
9
months to 6 years
–500 ml/hr
 6-12
years (1000 ml/hr)
 over 12 years
–1500-2000 ml/hr
7/17/2015
WBI
 Calcium-channel-blockers
 Iron
 Arsenic
 Lead/zinc
 Packets
7/17/2015
of illicit drugs
Complications
 Nausea
& vomiting
 Bloating / cramps
 Pulmonary aspiration
7/17/2015
Urinary Alkalinization
 Salicylates
 Phenobarbital
 Chlorpropamide
7/17/2015
Urinary Acidification
 Never
indicated
 Systemic acidosis
 Renal impairment in myoglobinuria
7/17/2015
Extracorporeal Clearance
7/17/2015
Hemodialysis
 Severe
poisoning
 Renal failure
7/17/2015
Hemodialysis
 8-10
fold increased clearance
 Corrects acid-base imbalance
 Corrects electrolyte imbalance
7/17/2015
Hemodialysis
 Small
molecular weight
 Non-ionized, uncharged molecule
 Low plasma protein binding
 Small volume of distribution
(<1.0L/kg)
7/17/2015
Hemodialysis
 Lithium
4 mEq/L
 Ethylene glycol
50 mg/dl
 Methanol
50 mg/dl
 Salicylates
100 mg/dl
7/17/2015
Hemoperfusion
A charcoal or resin cartridge
 More effective in selected poisonings
 Not limited by plasma protein binding
 Not limited by molecular size

7/17/2015
Hemoperfusion
Not effective for acid-base & electrolyte
imbalance correction
 Ineffective in patients with renal failure

7/17/2015
Hemoperfusion
 Phenobarbital
 Theophylline
 Paraquat
 Glutethimide
 Meprobamate
7/17/2015
100 mg/L
60-100mg/L
0.1 mg/dl
4 mg/dl
10 mg/dl
Antidotes
7/17/2015
Antidotes
Use only if specific
criteria met
7/17/2015
Immediate use
 Oxygen
–carbon monoxide
 Naloxone
–opioids
7/17/2015
Immediate use
 Methylene
blue 1%
–severe cyanosis
–> 40%
7/17/2015
Immediate use
 Sodium
nitrite
–Cyanide
 Deferoxamine
–Iron
7/17/2015
Antidotes
 Acetaminophen
- N-Acetylcysteine
– 140 mg/kg PO
– 70 mg/kg q4h for 17 doses
 Anticholinergics
– 0.5 mg IV
7/17/2015
- Physostigmine
Antidotes
 Organophosphates
– Atropine 0.05-0.1 mg IM or IV
– Pralidoxime
25-50 mg/kg IV
7/17/2015
Antidotes
 Benzodiazepine
- Flumazenil
– 0.01 mg/kg IV
 Beta
Blockers
– 50 ug/kg IV
7/17/2015
- Glucagon
Antidotes
 Isoniazid
Pyridoxine 5-10%
– 1 gm/gm of INH ingested IV
 TCA
NaHCO3
– 1-2 mEq/kg IM or IV
 Warfarin
Vitamin K
– 1-5 mg IV or IM
7/17/2015
New Antidotes in the year
2000
7/17/2015
New Antidotes
 Glucagon
– Beta-blocker & Ca-channel blocker
 Insulin
& glucose ?
– Ca-channel blocker
 Octreotide
– Sulfonylureas induced hypoglycemia
7/17/2015
New Antidotes
 Tricyclic
antidepressant antibodies
– TCA
 Fomepizole
(Antizol)
– Methanol & ethylene glycol
 Nalmefene
– Opioid poisoning
7/17/2015
New Antidotes
 Flumazenil
(Romazicon)
– Benzodiazepine
7/17/2015
Child Abuse by poisoning
 High
index of suspicion
 Its not optional!
 Mandated to protect these children
7/17/2015
Take home message
Basic supportive care has saved more
lives than all the antidotes put together
 Small quantities can have significant
consequences
 Most pediatric ingestion are trivial

7/17/2015
If you watch these kids, you
may not have to do anything
7/17/2015
Resources
 Drug
Information (AHFS)
 Poisindex computer database
 Regional
poison center
– 212-POISONS
7/17/2015