1. Poisoning in Children

2. Poisoning in Childhood
Definition of Poisoning:
Exposure to a chemical or other agent that adversely affects functioning of an organism.
Circumstances of Exposure can be intentional, accidental, environmental, medicinal or recreational.
Routes of exposure can be ingestion, injection, inhalation or cutaneous exposure.

3. Poisoning in Children
Ingestion of a harmful substance is among the most common causes of injury

4. Important history points
What toxic agent/medications were found near the patient?
What medications are in the home?
What approximate amount of the “toxic” agent was ingested?
How much was available before the ingestion?
How much remained after the ingestion?
When did the ingestion occur ?
Were there any characteristic odors
How has the patient behaved since the ingestion?
Does the patient have a history of substance abuse?

5. Management General measures: Quick assessment & triage
Limit absorption:
Vomiting
Lavage
Activated charcoal instillation

6. Full vitals / Monitoring Give specific antidotes / treatment
ABC’s of Toxicology:
Airway
Breathing
Circulation
Drugs:
Resuscitation medications if needed
Universal antidotes
Draw blood:
chemistry, coagulation, blood gases, drug levels
Decontaminate
Expose / Examine
Full vitals / Monitoring
Give specific antidotes / treatment

7. Decontamination: Ocular: Dermal: Gastro-intestinal:
Flush eyes with saline
Dermal:
Remove contaminated clothing
Brush off
Irrigate skin
Gastro-intestinal:
Activated charcoal:
May Prevent /delay absorption of some drugs/toxins
Almost always indicated
Naso/oro-gastric Lavage
Bowel Irrigation:
Recent ingestions 4-6 hrs
500 cc NS Children / 2000cc adults
Orally / Nasogastric tube

9. poising Treatment Do not induce vomiting Do not attempt gastric lavage
Risk of aspiration outweighs any benefit from removal of substance
CXR around 2-4 hrs “not before 2hrs”
Observe in ER for 6-8 hrs

10. Preventing
Education is the major component of any poison prevention programme.
Keep medicines, insecticides, etc… out of the reach and sight of your children.
Never store food & cleaning products together. Store medicine and chemicals in original containers.

11. Hydrocarbon Poisoning
These may be divided into aliphatic or aromatic compounds. Aliphatic hydrocarbons include kerosene, turpentine, lubricating oils, tar and have greatest risk of aspiration and pulmonary symptoms. Aromatic compounds have mainly neurological and hepatic toxicity and include benzene compounds.

12. Type of toxicity with a hydrocarbon depends on its volatility, viscosity or surface tension. The lower is viscosity, more is the risk of pulmonary aspiration. Mineral spirit, kerosene and furniture polish have both low volatility and viscosity and thus carry a higher risk of aspiration pneumonia.

13. Benzene derivates, toluene and xylene are components of various solvents and degreasers. These are highly volatile but have low viscosity. Inhalation is the primary route of toxicity which manifests with CNS symptoms. Gasoline and naphtha are constituents of lighter fuel and lacquer diluent and primarily cause depression of the central nervous system (CNS).

14. Turpentine oil is highly volatile but has low viscosity also
Turpentine oil is highly volatile but has low viscosity also. Toxicity results from inhalation and gastrointestinal absorption. They can also cause CNS toxicity.
Halogenated hydrocarbons are used as solvents and spot removers. Freon is used as a refrigerant.
Toxic exposure to hydrocarbons may result in cardia, gastrointestinal, neurological, pulmonary, renal, hepatic, metabolic and hematological manifestations.

15. Induced emesis or gastric lavage is contraindicated for kerosene oil poisoning. It is done only when large quantities of turpentine have been ingested or the hydrocarbons product contains benzene, toluene, halogenated hydrocarbons, heavy metals, pesticides or aniline dyes. Other specific modalities including steroids and antibiotics are not efficacious.

16. Epidemiology Clinical features Investigation Treatment
KEROSENE POISONING
Epidemiology
Clinical features
Investigation
Treatment

17. Clinical features Age – 1 to 3 years more than 70% symptomatic within
10 hours
SYMPTOMS
RS – breathlessness, cough
CNS – convulsions, coma
GPE – fever, restlessness, cyanosis
GI – vomiting, diarrhea

18. Kerosene poising Kerosene ingestion: Risk of aspiration
GIT & Respiratory effects.
Burning sensation, nausea and diarrhea
Cough, chocking, gagging and grunting.
CXR 2-8 hrs later: Pulmonary infiltrates or perihilar densities.
pneumatoceles, pleural effusion or pneumothorax and bacterial superinfection
Resolution 2-7 days.

19. Lab Investigations X – Ray changes Blood – Leukocytosis
Changes appear within one hour
- commonly right basal infiltrates
- emphysema
- pleural effusion
- pneumatocoeles

20. Management Avoid emetics
Avoid gastric lavage – In case of massive amount use a cuffed endotracheal tube
After lavage leave magnesium or sodium sulphate in the stomach
Oxygen may be useful
Assisted Ventilation
Antibiotics - Penicillin
Kanamycin
Steroids – Not helpful

21. Complications Pneumothorax Pneumatocoeles Pleural effusion
Bronchopneumonia
Coma

22. Organophosphorus Poisoning
Organic phosphate insecticides cause irreversible inhibition of the enzyme cholinesterase. As result acetylcholine accumulates in various tissues. Excessive parasympathetic activity occurs. These agents are absorbed by all routes including skin and mucosa.

23. Symptoms manifest quickly usually within a few hours and include weakness, blurred vision, headache, nausea, and pain in chest. These patients have excessive secretion in the lungs and they sweat profusely. Salivation is marked. Pupils are constricted and papilledema may occur. Muscle twitching, convulsions and coma occur in severe cases. Reflexes are absent and sphincter control is lost.

24. Treatment
If the insecticide was in contact with skin or eyes, these are thoroughly washed. Stomach wash is done.
Atropine sulphate: 0.03 to 0.04 mg/kg IV (atropine sulphate is usually available in ampules 1 in 1,000 or 1 mg/mL). Other strengths may also be available. Repeat half the dose in 15 minutes and if necessary every hour (until signs of toxicity appear), subject to a maximum of 1 mg/kg in 24 hours.

25. Pralidoxime (PAM) is given in dose of mg/kg IM or IV over 30 min infusion. The dose may be repeated in 1-2 hours, then at 6-12 hour intervals as needed. Monitor for hypertension. Never inject morphine, theophylline, aminophylline or chlorpromazine. Intravenous fluids should only be given with caution. No oral tranquilizers are administered. Artificial respiration may be necessary to sustain life.

26. Metabolic acidosis supervenes quickly due to disturbances of oxidative phosphorylation and reduction of hepatic glycogen with resultant ketonemia. The patients are treated with adequate replacement of fluids to restore renal function.

27. Urine is alkalinized by administering 1-2 mEq/kg of sodium bicarbonate at half hourly intervals for 4 hours to promote excretion of urine, because in alkaline urine, salicylates do not diffuse back into the tubular cells from the lumen. Potassium salts should be given (3-5 mEq/kg/day) to replace the potassium losses

28. paracetamol
It is safe in pharmacological doses. Overdosage may cause hepatic damage. Acetaminophen overdosage is treated with acetylcysteine to be used orally within 16 hours after ingestion in a loading dosage of 140 mg/kg diluted to 5 percent solution orally followed by 70 mg/kg q 4h for another 16 doses.

29. Carbon Monoxide Poisoning
Carbon monoxide poisoning results from inhalation of fire smoke, automobile exhaust, fumes from faulty gas stoves and ingestion of paint and varnish removers. Clinical manifestations include headache, cyanosis, convulsions, and coma. Patients are administered 100 percent oxygen and if carboxyhemoglobin levels are above 40 percent, hyperbaric oxygen therapy is considered.

30. The label should be read before using the drug
The label should be read before using the drug. No drug should be given or taken in the dark. Drugs after their expiry date should be disposed in a safe manner. Avoid taking medicine in your child’s presence. Never suggest that medicine is candy.
Children should be taught not to eat plants or berries.

31. Iron Intoxication
Ingestion of a number of tablets of ferrous sulphate may cause acute poisoning. Lethal dose is 300 mg/kg of iron. Severe vomiting and diarrhea occur. These may contain blood due to extensive gastrointestinal bleeding. The child may go into severe shock, hepatic and renal failure within a few hours or after a latent period of 1 to 2 days

32. Iron Poisoning Five Stages but variable
Gastro-intestinal stage: within several hrs of ingestion:
abdominal pain
Severe: fluid loss, bleeding, shock(acidosis, tachycardia +/- hypotension)
Fever. Lethargy. Coma

33. Iron Poisoning Stage 2 Quiescent stage: 4-48hrs Clinical improvement
Subtle hemodynamic changes:
Tachycardia

34. Iron Poisoning Stage 3: Circulatory collapse : 48-96 hrs
Metabolic acidosis, hypotension, low Cardiac output.
Coagulopathy
Multiorgan system failure

35. Iron Poisoning Stage 4: Hepatic failure: 96 hrs
Increased mortality
Rarely fulminant hepatic failure
Hepatic necrosis
Liver transplant can save lives

36. Iron Poisoning STAGE 5: Bowel obstruction 2-6 wks Due to scarring
Gastric outlet obstruction
Small intestinal obstruction
May not pass through stage 4

37. Treatment
Vomiting should be induced and stomach should be washed with sodium bicarbonate solution. Shock is corrected by infusion of fluids parenterally. Three mL of 7.5 percent sodium bicarbonate solution per kg of body weight are diluted with 3 times its volume of 5 percent glucose solution and injected intravenously for treatment of acidosis. This dose may be repeated after an hour if acidosis is persisting.

38. Iron salts are chelated with desferrioxamine IV at 15mg/kg/hour until the serum iron is <300 mg/dL or till 24 hours after the child has stopped passing the characteristic ‘vin rose’ colored urine. Presence of ‘vin rose’ color to urine indicates significant poisoning.

39. Iron Poisoning Management: Gastric decontamination: Secure good IV
Forced emesis
Gastric lavage with 5% NaHCO3
No activated charcoal
Secure good IV
Get initial the 4hrs levels and TBC
Chelate with Deferoxamine if levels> 300mg/dL

40. Iron Poisoning Chelate with Deferoxamine:
Stable pts : levels< 500 mg/dL 40mg/kg IM/IV
Unstable: bleeding/ level > 500
Give 20cc/kg NS/RL
Deferoxamine at 15 mg/kg IV over 1hr
Continuous drip at 15mg/kg/hr
Continue till “vin rose” urine color disappears.

41. Iron Poisoning Observe for: Signs of hepatic failure: Systemic BP ECG
Bleeding
Glucose intolerance
Hyperammonemia
Encepalopathy

42. SALICYLATES Oral ingestion commonest Transdermal less
Peak levels at 12 hrs
Early : hyperpnea  respiratory alkalosis
Then metabolic acidosis
Severe cases: Cerebral edema and increased ICP

43. Salicylate Poisoning
Ingestion of 150 mg/kg of salicylates causes intoxication. Salicylate level of mg/dL causes moderate symptoms. Severe symptoms are associated with blood levels above 80 mg/dL.
Initially, there is a respiratory alkalosis, because of hyperventilation induced by sensitization of the respiratory center by salicylates. Kidneys compensate for this alkalsis by increasing the excretion of sodium and potassium bicarbonate

44. SALICYLATES MANAGEMENT Treat electrolyte imbalance IV hydration
Hemodialysis
Diuretics