M Waseem, MD Lincoln Hospital Bronx New York Pediatric Toxicology M Waseem, MD Lincoln Hospital Bronx New York 9/20/2018

Epidemiology 2 million calls 52% of poison center calls < 6years Peak age 18 months - 3 years 9/20/2018

Epidemiology Unintentional (1-2 years) Intentional (adolescent) Exploratory Boys > girls Intentional (adolescent) Purposeful Girls > boys 9/20/2018

Children are different Unable to discriminate safe from unsafe liquid Fail to recognize the suitability of the drink 9/20/2018

Epidemiology Around Meal time Grand parents home Kerosene or gasoline in a soda bottle Older sibling can pharmaceutically treat younger sibling 9/20/2018

Very toxic! Prenatal vitamin supplements Antidepressants Hydrocarbons 9/20/2018

Most often reported Cleaning products 10.4% Analgesics 10.3% Cosmetics 9% Cough & cold preparation 5.1% Insecticides 4% 9/20/2018

ICU Admission TCA Anticonvulsants Digitalis Opiates Hydrocarbon-based house-hold products 9/20/2018

Toxic Exposures/Death Analgesics Sedative-hypnotics Alcohols Gases & fumes Cleaning substances 9/20/2018

“Fatal Sip” 9/20/2018

Fatal Sip Camphor (100mg/kg) 1gm/5 ml Methyl Salicylate 1.4gm/ml (200 mg/kg) 1/2 tsp 9/20/2018

Fatal Sip Benzocaine 2 ml Methemoglobinemia Seizure 9/20/2018

Malignant Swallow Chloroquine (20 mg/kg) 500 mg Theophylline (8.4 mg/kg) 500 mg Imipramine (15 mg/kg) 150 mg Chlorpromazine (25 mg/kg) 200 mg 9/20/2018

Malignant Swallow Clonidine 0.3 mg tablet Bradycardia CNS depression 9/20/2018

Highly Toxic Acetonitrile Ammonium Fluoride Benzocaine Camphor Pennyroyal Oil 9/20/2018

Acetonitriles Artificial Nail Tip remover Methemolobinemia Delayed presentation (4-12 hours) Must be hospitalized 9/20/2018

Ammonium Fluoride Glass etching, de-rusting and wheel cleaning commercial products Armoral Quick Silver Wheel cleaner (17% ammonium fluoride) only 2 ml 9/20/2018

Ammonium Fluoride Inactivates proteolytic & glycolytic enzymes Binds with Ca & Mg Acidosis, Dysrhythmia & coagulopathy Direct effect on CNS Seizures 9/20/2018

Benzocaine Teething gels (Orajel), first aid cream hemorrhoidal preparations Methemoglobinemia < 6 months (methemoglobin reductase) 9/20/2018

Camphor Vicks VapoRub Only 5 ml CNS effects 9/20/2018

Pennyroyal Oil Health food products, herbal preparations Depletes glutathione Toxicity to liver & lung < a teaspoon A tablespoon (fatal) 9/20/2018

Look-Alike, Sound-A-Like Albuterol Atenolol Celebrex Cerebrex Oruvail Elavil Lamictal Lomotil Lotrimin Lotensin Plendil Pindolol 9/20/2018

Look-Alike, Sound-A-Like Hydralazine Hydroxyzine Hydrocodone Hydrocortisone 9/20/2018

Plant Toxidromes 9/20/2018

Digitalis Effects Lily-of-the-valley Foxglove Oleander Yew 9/20/2018

Nicotinic Effects Poison hemlock 9/20/2018

Atropinic Effects Jimsonweed 9/20/2018

Non-Toxic Products Ball point ink Bubble bath soaps Candles (beeswax or paraffin) Chalk Cigarettes (< 3 butts) Crayons 9/20/2018

Non-Toxic Products Deodorants Lipstick Pencil (graphite) Toothpaste Water colors 9/20/2018

Evaluation History of poisoning Toxicologic physical examination Laboratory studies Gastrointestinal decontamination 9/20/2018

History What? When? How much? 9/20/2018

What ? Medication Illicit drug Hazardous chemical 9/20/2018

What form? Pill Solid Liquid Gaseous 9/20/2018

What route ? Ingestion Inhalation Topical Intravenous 9/20/2018

When ? Elapsed time 9/20/2018

How much ? Estimate amount Concentration 9/20/2018

“Vital signs” 9/20/2018

Bradycardia Digoxin Narcotics Organophosphates Carbon monoxide Beta-blocker 9/20/2018

Tachycardia Alcohol/amphetamine Atropine/tricyclic Theophylline Salicylates, Iron Cocaine/PCP 9/20/2018

Slow Respiration Alcohol Narcotics Clonidine Sedatives 9/20/2018

Tachypnea Amphetamines Salicylates Carbon monoxide 9/20/2018

Hypotension Methemoglobinemia Carbon monoxide Cyanide Iron Narcotics 9/20/2018

Hypertension OTC cold remedies Amphetamine PCP TCA Cocaine 9/20/2018

Ventricular Tachycardia Amphetamines Carbamzepine Chloral hydrate Cocaine Digitalis Theophylline 9/20/2018

Torsades de Pointes Chloral hydrate Cisapride Organophosphates Terfenadine Phenothiazines 9/20/2018

Hypoglycemia (HOBBIES) H-Hypoglycemia O-Oral hypoglycemic agents B-Beta-Blockers I-Insulin E-Ethanol S-Salicylates 9/20/2018

Hypothermia Ethanol Narcotics Carbon monoxide 9/20/2018

Hyperpyrexia Atropine Salicylates Theophylline Cocaine TCA 9/20/2018

Mental Status 9/20/2018

Coma Narcotic Anticholinergic Carbon monoxide 9/20/2018

Delirium/Psychosis Alcohol PCP/marijuana LSD 9/20/2018

Convulsion Cocaine/Amphetamine Lead Salicylate Isoniazid Theophylline 9/20/2018

Pupil size 9/20/2018

Miosis (COPS) Cholinergics, Clonidine Opiates, Organophosphates Phenothiazine, Pilocarpine Sedatives (Barbiturates) 9/20/2018

Mydriasis (AAAS) Antihistamine Antidepressant Anticholinergics (atropine) Sympathomimetics Amphetamine, Cocaine, PCP 9/20/2018

Caution! Polydrug overdoses with opposite pupillary actions Nontoxin diagnoses Head trauma CNS hemorrhage 9/20/2018

Unresponsive to oxygen methemoglobinemia Cyanosis Unresponsive to oxygen methemoglobinemia 9/20/2018

Cyanosis Aniline dyes Nitrites Benzocaine Dapsone 9/20/2018

Dry Skin Anticholinergic 9/20/2018

Breath Odors Arsenic Garlic Camphor Mothballs Cyanide Bitter almond Methyl salicylate Wintergreen Paraldehyde Pears 9/20/2018

Toxidromes 9/20/2018

Cholinergic DUMBBEL SLUDGE 9/20/2018

DUMBBELS D Diarrhea U Urination M Miosis, muscle fasiculation B Bradycardia B Bronchospasm 9/20/2018

DUMBBELS E Emesis L Lacrimation S Salivation 9/20/2018

SLUDGE S Salivation L Lacrimation U Urination D Diarrhea 9/20/2018

SLUDGE G GI complaint E Emesis 9/20/2018

Anticholinergic Syndrome Dry mouth Flushed appearance Dilated pupils Fever Ileus Urinary retention Disorientation 9/20/2018

Anticholinergic Hot as a hare Blind as a bat Dry as a bone Red as a beet Mad as a hatter 9/20/2018

Anticholinergic Full as a flask 9/20/2018

Anticholinergic Wet Bowel sound + Dry Absent bowel sound Sympathomimetic Dry Absent bowel sound 9/20/2018

Narcotic Pinpoint pupils Coma Respiratory depression 9/20/2018

Salicylates Fever Tachypnea & hyperpnea Lethargy Metabolic acidosis 9/20/2018

Theophylline Protracted Vomiting Tremors Tachycardia Seizures Hypotension 9/20/2018

Isoniazid Seizures Metabolic acidosis Hyperglycemia 9/20/2018

Phencyclidine (4 Cs) Combative Catatonia Convulsion Coma Nystagmus 9/20/2018

TCA Metabolic acidosis Prolonged QRS Seizures Dilated pupils Dysrhythmia 9/20/2018

Cyanide Feeling of impending doom Sudden coma Metabolic acidosis Hypotension Bitter almond odor 9/20/2018

Carbon monoxide Headache Lethargy Dizziness Influenza like syndrome Coma 9/20/2018

Ethanol Hypoglycemia Lethargy Ataxia Seizure Characteristic breath odor 9/20/2018

Methanol Severe Metabolic acidosis Sluggish pupils Hyperemic retina Blurred vision 9/20/2018

Ethylene Glycol Lethargy or coma Metabolic acidosis Urinary sediment Crystalluria 9/20/2018

Clonidine Hypothermia Bradycardia Miosis Respiratory depression 9/20/2018

Elevated anion gap Methanol Paraldehyde & phenformin Iron & isoniazid Ethylene glycol & ethanol Salicylate 9/20/2018

ABCs Anticipate Before Complications 9/20/2018

ABC Airway Breathing Circulation C-spine immobilization secure IV access 9/20/2018

ABC Disability consciousness Drugs Decontamination 9/20/2018

consciousness A: Alert V: Responsive to verbal stimuli P:Responsive to pain U: Unresponsive 9/20/2018

Drugs Dextrose Oxygen Naloxone 9/20/2018

Decontamination Ocular- copious saline lavage Skin- copious water GI-consider options 9/20/2018

No “tox panel” that is uniformly helpful Lab Evaluation No “tox panel” that is uniformly helpful 9/20/2018

Urine Screen Marijuana 5-10 days Amphetamines 48 hours Barbiturates 24 h-2 wks Cocaine 2-4 days Opiates 2 days PCP 8 days 9/20/2018

All suspected ingestion Tricyclics EKG All suspected ingestion Tricyclics 9/20/2018

Measure of oxygen saturation of normal hemoglobin Pulse oximetry Measure of oxygen saturation of normal hemoglobin 9/20/2018

Does not differentiate COHB from oxyhemoglobin Pulse oximetry Does not differentiate COHB from oxyhemoglobin 9/20/2018

False low Saturation Blue nail polish Methylene blue Poor distal perfusion 9/20/2018

Blood gas Salicylates 9/20/2018

Chest X-ray Hydrocarbons 9/20/2018

Esophagoscopy Caustics 9/20/2018

Emergent Lab Analyses Acetaminophen Salicylates Methanol Ethylene glycol Iron 9/20/2018

Emergent Lab Analyses Theophylline Carbon monoxide Lithium 9/20/2018

Optimum time Actaminophen 4 hours Salicylates 2-4 hours Iron 4 hours Carboxyhemoglobin Immediate Methemoglobin Immediate 9/20/2018

Optimum time Ethanol 1/2-1 hour Ethylene glycol 1/2-1 hour Methanol 1/2-1 hour Digoxin 4-6 hour 9/20/2018

Serial Levels Salicylates Carbamazepine Digoxin Phenobarbital Theophylline Valproic acid 9/20/2018

Radiopaque (CHIPS) Chloral hydrate Heavy metals Iron Phenothiazine Slow release 9/20/2018

Preventing absorption GI. Decontamination Preventing absorption 9/20/2018

GI decontamination in a symptomatic patient? 9/20/2018

Decontamination Syrup of Ipecac Gastric lavage Activated Charcoal Cathartics WBI (bowel irrigation) 9/20/2018

Syrup of ipecac 9/20/2018

Syrup of Ipecac Nonprescription CTZ stimulant use only under poison control direction 9/20/2018

Syrup of Ipecac No evidence of improved outcome Delays AC or antidote for 2 hours No role in hospital setting 9/20/2018

Adverse effect Protracted vomiting Sedation Diarrhea Bradycardia 9/20/2018

Contraindications Altered mental status Seizure hemetemesis hydrocarbon corrosives 9/20/2018

Contraindications Anticipated use of oral antidote or WBI < 6 months old 9/20/2018

Gastric Lavage 9/20/2018

Gastric Lavage one hour (“golden hour”) Life threatening ingestion 9/20/2018

“NG tube is not adequate” 9/20/2018

Gastric Lavage Large bore orogastric tube (36 - 40 French) 0.9% saline 15 ml/kg max 200-400 ml/cycle 9/20/2018

Gastric Lavage < 30% by 20-30 min < 13% by 60 minutes 9/20/2018

Gastric Lavage Not a routine With in one hour Life-threatening ingestion Absence of pill fragments does not rule out toxic ingestion 9/20/2018

Gastric Lavage TCA Calcium-blocker Colchicine 9/20/2018

Complications Pulmonary aspiration 9/20/2018

Contraindications Caustic Hydrocarbon Sharp coingestion 9/20/2018

Activated Charcoal Universal antidote 9/20/2018

adsorbing the ingested substance Single dose AC adsorbing the ingested substance 9/20/2018

Activated Charcoal Oxidizing process Increases the adsorptive capacity Inert substance Reduce the bioavailability of drug 9/20/2018

Activated Charcoal Surface area 950-2000m2/g 9/20/2018

Poorly bound by AC 9/20/2018

CHEMICaL CamP C Cyanide H Hydrocarbon E Ethanol M Metals I Iron C Caustics L Lithium 9/20/2018

CHEMICaL CamP C Camphor P Phosphorus 9/20/2018

Recommended Dose Up to 1 year 1g/kg 1-12 year 25-50 gm 9/20/2018

Complications Pulmonary aspiration Emesis Constipation 9/20/2018

Contraindications Hydrocarbon Corrosive Ileus 9/20/2018

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) 9/20/2018

Benefits of Home AC Early administration Reduced morbidity & mortality 9/20/2018

Risks of Home AC Inappropriate administration Inadequate dosing Pulmonary aspiration 9/20/2018

Gastrointestinal Dialysis Multiple-Dose AC Gastrointestinal Dialysis 9/20/2018

Multiple-Dose AC Continue to adsorb remaining toxin Interfere with enterohepatic circulation Lower the free drug concentration 9/20/2018

Multiple-Dose AC Phenobarbital Carbamazepine Phenytoin Digoxin Salicylates Theophylline TCA 9/20/2018

Cathartics Decrease transit time 9/20/2018

Cathartics Sorbitol 70%(0.5g/kg) 10 - 20 ml (children) 50-100ml(adolescent) 9/20/2018

Complications Nausea Abdominal cramps Vomiting Transient hypotension 9/20/2018

Contraindications Unprotected airway Ileus Absent bowel sounds Intestinal obstruction 9/20/2018

Decontaminate entire gastrointestinal tract WBI Decontaminate entire gastrointestinal tract 9/20/2018

Commonly used for agents not bound to activated charcoal WBI Commonly used for agents not bound to activated charcoal 9/20/2018

WBI polethylene glycol No fluid abnormality No electrolyte imbalance End point clear rectal effluent Sustained release preparation 9/20/2018

WBI 9 months to 6 years 6-12 years (1000 ml/hr) over 12 years 9/20/2018

WBI Calcium-channel-blockers Iron Arsenic Lead/zinc Packets of illicit drugs 9/20/2018

Complications Nausea & vomiting Bloating / cramps Pulmonary aspiration 9/20/2018

Urinary Alkalinization Salicylates Phenobarbital Chlorpropamide 9/20/2018

Urinary Acidification Never indicated Systemic acidosis Renal impairment in myoglobinuria 9/20/2018

Extracorporeal Clearance 9/20/2018

Hemodialysis Severe poisoning Renal failure 9/20/2018

Hemodialysis 8-10 fold increased clearance Corrects acid-base imbalance Corrects electrolyte imbalance 9/20/2018

Hemodialysis Small molecular weight Non-ionized, uncharged molecule Low plasma protein binding Small volume of distribution (<1.0L/kg) 9/20/2018

Hemodialysis Lithium 4 mEq/L Ethylene glycol 50 mg/dl Methanol 50 mg/dl Salicylates 100 mg/dl 9/20/2018

Hemoperfusion A charcoal or resin cartridge More effective in selected poisonings Not limited by plasma protein binding Not limited by molecular size 9/20/2018

Hemoperfusion Not effective for acid-base & electrolyte imbalance correction Ineffective in patients with renal failure 9/20/2018

Hemoperfusion Phenobarbital 100 mg/L Theophylline 60-100mg/L Paraquat 0.1 mg/dl Glutethimide 4 mg/dl Meprobamate 10 mg/dl 9/20/2018

Antidotes 9/20/2018

Use only if specific criteria met Antidotes Use only if specific criteria met 9/20/2018

Immediate use Oxygen carbon monoxide Naloxone opioids 9/20/2018

Immediate use Methylene blue 1% severe cyanosis > 40% 9/20/2018

Immediate use Sodium nitrite Cyanide Deferoxamine Iron 9/20/2018

Antidotes Acetaminophen - N-Acetylcysteine 140 mg/kg PO 70 mg/kg q4h for 17 doses Anticholinergics - Physostigmine 0.5 mg IV 9/20/2018

Antidotes Organophosphates Atropine 0.05-0.1 mg IM or IV Pralidoxime 25-50 mg/kg IV 9/20/2018

Antidotes Benzodiazepine - Flumazenil Beta Blockers - Glucagon 0.01 mg/kg IV Beta Blockers - Glucagon 50 ug/kg IV 9/20/2018

Antidotes Isoniazid Pyridoxine 5-10% TCA NaHCO3 Warfarin Vitamin K 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 9/20/2018

New Antidotes in the year 2000 9/20/2018

New Antidotes Glucagon Insulin & glucose ? Beta-blocker & Ca-channel blocker Insulin & glucose ? Ca-channel blocker Octreotide Sulfonylureas induced hypoglycemia 9/20/2018

New Antidotes Tricyclic antidepressant antibodies Fomepizole (Antizol) TCA Fomepizole (Antizol) Methanol & ethylene glycol Nalmefene Opioid poisoning 9/20/2018

New Antidotes Flumazenil (Romazicon) Benzodiazepine 9/20/2018

Child Abuse by poisoning High index of suspicion Its not optional! Mandated to protect these children 9/20/2018

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 9/20/2018

If you watch these kids, you may not have to do anything 9/20/2018

Resources Drug Information (AHFS) Poisindex computer database Regional poison center 212-POISONS 9/20/2018