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

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

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

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

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

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

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

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

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

10. “Fatal Sip”
9/20/2018

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

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

13. 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

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

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

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

17. 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

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

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

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

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

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

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

24. Plant Toxidromes
9/20/2018

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

26. Nicotinic Effects
Poison hemlock
9/20/2018

27. Atropinic Effects
Jimsonweed
9/20/2018

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

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

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

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

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

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

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

35. When ?
Elapsed time
9/20/2018

36. How much ?
Estimate amount
Concentration
9/20/2018

37. “Vital signs”
9/20/2018

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

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

40. Slow Respiration
Alcohol
Narcotics
Clonidine
Sedatives
9/20/2018

41. Tachypnea
Amphetamines
Salicylates
Carbon monoxide
9/20/2018

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

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

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

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

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

47. Hypothermia
Ethanol
Narcotics
Carbon monoxide
9/20/2018

48. Hyperpyrexia
Atropine
Salicylates
Theophylline
Cocaine
TCA
9/20/2018

49. Mental Status
9/20/2018

50. Coma
Narcotic
Anticholinergic
Carbon monoxide
9/20/2018

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

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

53. Pupil size
9/20/2018

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

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

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

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

58. Cyanosis
Aniline dyes
Nitrites
Benzocaine
Dapsone
9/20/2018

59. Dry Skin
Anticholinergic
9/20/2018

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

61. Toxidromes
9/20/2018

62. Cholinergic
DUMBBEL
SLUDGE
9/20/2018

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

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

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

66. SLUDGE
G GI complaint
E Emesis
9/20/2018

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

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

69. Anticholinergic
Full as a flask
9/20/2018

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

71. Narcotic
Pinpoint pupils
Coma
Respiratory depression
9/20/2018

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

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

74. Isoniazid
Seizures
Metabolic acidosis
Hyperglycemia
9/20/2018

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

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

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

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

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

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

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

82. Clonidine Hypothermia Bradycardia Miosis Respiratory depression
9/20/2018

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

84. ABCs
Anticipate
Before
Complications
9/20/2018

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

86. ABC
Disability
consciousness
Drugs
Decontamination
9/20/2018

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

88. Drugs
Dextrose
Oxygen
Naloxone
9/20/2018

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

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

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

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

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

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

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

96. Blood gas
Salicylates
9/20/2018

97. Chest X-ray
Hydrocarbons
9/20/2018

98. Esophagoscopy
Caustics
9/20/2018

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

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

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

102. Optimum time Ethanol 1/2-1 hour Ethylene glycol 1/2-1 hour
Methanol 1/2-1 hour
Digoxin hour
9/20/2018

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

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

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

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

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

108. Syrup of ipecac
9/20/2018

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

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

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

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

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

114. Gastric Lavage
9/20/2018

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

116. “NG tube is not adequate”
9/20/2018

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

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

119. 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

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

121. Complications
Pulmonary aspiration
9/20/2018

122. Contraindications
Caustic
Hydrocarbon
Sharp coingestion
9/20/2018

123. Activated Charcoal
Universal antidote
9/20/2018

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

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

126. Activated Charcoal
Surface area
m2/g
9/20/2018

127. Poorly bound by AC
9/20/2018

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

129. CHEMICaL CamP
C Camphor
P Phosphorus
9/20/2018

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

131. Complications
Pulmonary aspiration
Emesis
Constipation
9/20/2018

132. Contraindications
Hydrocarbon
Corrosive
Ileus
9/20/2018

133. 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

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

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

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

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

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

139. Cathartics
Decrease transit time
9/20/2018

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

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

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

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

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

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

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

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

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

149. Urinary Alkalinization
Salicylates
Phenobarbital
Chlorpropamide
9/20/2018

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

151. Extracorporeal Clearance
9/20/2018

152. Hemodialysis
Severe poisoning
Renal failure
9/20/2018

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

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

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

156. 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

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

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

159. Antidotes
9/20/2018

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

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

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

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

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

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

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

167. 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

168. New Antidotes in the year 2000
9/20/2018

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

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

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

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

173. 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

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

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