Pediatric Toxicology Jana Stockwell, MD

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

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

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

Most often reported n Cleaning products10% n Analgesics10% n Cosmetics9% n Cough & cold preparation5% n Insecticides4%

PICU Admission n Tricyclic antidepressants (TCA) n Anticonvulsants n Digoxin n Opiates n Hydrocarbon-based household products

Toxic Exposures  Death n Analgesics n Sedative-hypnotics n Alcohols n Gases & fumes n Cleaning substances

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

“Malignant Swallow” n Chloroquine (20 mg/kg) n Theophylline (8.4 mg/kg) n Imipramine (15 mg/kg) n Chlorpromazine(25 mg/kg) n Clonidine(0.3 mg tablet) –Bradycardia –CNS depression

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

Look-Alike, Sound-A-Like n Albuterol n Celebrex n Oruvail n Lamictal n Lotrimin n Plendil n Hydralazine n Hydrocodone n Atenolol n Cerebrex n Elavil n Lomotil n Lotensin n Pindolol n Hydroxyzine n Hydrocortisone

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

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

Evaluation n History of poisoning n Physical examination n Laboratory studies n Gastrointestinal decontamination

History History n What? n When? n How much? n Reliability…

What ? n Medication n Illicit drug n Hazardous chemical

What form? What form? n Pill n Solid n Liquid n Gaseous

What route ? What route ? n Ingestion n Inhalation n Topical n Intravenous

When ? n Elapsed time

How much ? How much ? n Estimate amount n Concentration

“Clues”

Bradycardia n Calcium channel blockers n Digoxin n Narcotics n Organophosphates n Carbon monoxide n Beta-blockers n Clonidine

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

Slow Respiration n Alcohol n Narcotics n Clonidine n Sedatives

Tachypnea n Amphetamines n Salicylates n Carbon monoxide n Ethylene glycol (anti-freeze)

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

Hypertension n OTC cold remedies n Amphetamine n PCP n TCA n Cocaine n Diet pills

V Tach n Amphetamines n Carbamzepine (Tegretol) n Chloral hydrate n Cocaine n Digitalis n Theophylline

Torsades de Pointes n Chloral hydrate n Cisapride n Organophosphates n Terfenadine n Phenothiazines

Hypoglycemia (HOBBIES) n Hypoglycemia n Oral hypoglycemic agents n Beta-Blockers n Insulin n Ethanol n Salicylates

Hypothermia n Ethanol n Narcotics n Carbon monoxide n Clonidine

Hyperpyrexia n Atropine n Salicylates n Theophylline n Cocaine n TCA

CNS - Coma n Narcotic n Anti-cholinergics n Carbon monoxide

CNS - Delirium / Psychosis n Alcohol n PCP / marijuana n LSD

CNS - Seizure n Cocaine n Amphetamine n Lead n Salicylate n Isoniazid n Theophylline

Pupils - Miosis Pupils - Miosis (COPS) n Cholinergics, Clonidine n Opiates, Organophosphates n Phenothiazine, Pilocarpine n Sedatives (barbiturates, ethanol)

Pupils - Mydriasis (AAAS) n Anti-histamine n Anti-depressant n Anticholinergics (atropine) n Sympathomimetics –amphetamine, cocaine, PCP

Caution! n Polydrug overdoses with opposite pupillary actions n Non-toxin diagnoses –Head trauma –CNS hemorrhage

Cyanosis n MetHgb –Unresponsive to O 2 n Aniline dyes n Nitrites n Benzocaine n Dapsone

Dry Skin n Anticholinergic

Breath Odors n ArsenicGarlic n CamphorMothballs n CyanideBitter almond n Methyl salicylateWintergreen n ParaldehydePears n HemlockCarrots

Cholinergic n “DUMBBELS” n “SLUDGE” Example – Organophosphates Nerve agents

DUMBBELS n Diarrhea, diaphoresis n Urination n Miosis, muscle fasiculation n Bradycardia n Bronchospasm n Emesis n Lacrimation n Salivation

SLUDGE n Lacrimation n Urination n Diarrhea n GI complaint n Emesis

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

Anti-cholinergic n Hot as a hare n Blind as a bat n Dry as a bone n Red as a beet n Mad as a hatter n Full as a flask

Narcotic n Pinpoint pupils n Coma n Respiratory depression

Salicylates n Fever n Tachypnea & hyperpnea n Lethargy n Metabolic acidosis

Theophylline n Protracted Vomiting n Tremors n Tachycardia n Seizures n Hypotension

Isoniazid n Seizures n Metabolic acidosis n Hyperglycemia

Phencyclidine (4 Cs) n Combative n Catatonia n Convulsion n Coma n Nystagmus

TCA n Metabolic acidosis n Prolonged QRS n Seizures n Dilated pupils n Dysrhythmia

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

Carbon monoxide n Headache n Lethargy n Dizziness n Influenza like syndrome n Coma

Ethanol n Hypoglycemia n Lethargy n Ataxia n Seizure n Characteristic breath odor

Methanol n Severe metabolic acidosis n Sluggish pupils n Hyperemic retina n Blurred vision

Ethylene Glycol n Lethargy or coma n Metabolic acidosis n Urinary sediment n Crystalluria

Clonidine n Hypothermia n Bradycardia n Miosis n Respiratory depression

Elevated anion gap n Methanol n Paraldehyde & phenformin n Iron & isoniazid n Ethylene glycol & ethanol n Salicylate

ABC’s n Airway n Breathing n Circulation n Disability n Decontamination

Consciousness n A:Alert n V: Responsive to verbal stimuli n P: Responsive to pain n U: Unresponsive

Drugs n Dextrose n Oxygen n Naloxone

Decontamination n Ocular- copious saline lavage n Skin- copious water n GI-consider options

Lab Evaluation n No “tox panel” that is uniformly helpful

Urine Screen n Marijuana5-10 days n Amphetamines48 hours n Barbiturates24 h-2 wks n Cocaine2-4 days n Opiates 2 days n PCP 8 days

EKG n All suspected ingestion n Tricyclics

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

Other tests n CXR - hydrocarbons n ABG - salicylates n Esophagoscopy - Caustics

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

Radiopaque (CHIPS) n Chloral hydrate n Heavy metals n Iron n Phenothiazine (laxatives) n Slow release

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

Urine alkalinization n Salicylates n Phenobarbital n Chlorpropamide

Extracorporeal methods n Hemodialysis –Severe poisoning –Renal failure n Hemoperfusion –Perferred in some toxic ingestions

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