1. Pediatric Poisoning Edwin de Zoeten M.D. Ph.D. PL-3

2. Case : 11 year old male presents to the ER with altered mental status. Pt. was a previously healthy who went to bed at his GM’s home in his normal state of health. He was found wandering outside at 3:00 AM.

3. Case con’t: Vitals: T:38.9, P:130, R:30, BP 140/90 PE: General: active, agitated, talking about a dog in the room HEENT: NC, AT, pupils dilated at 6mm w/o reaction, +photophobia, o/p clear but dry MM. Skin: Hot, mildy red. No lesions or rashes Lungs: CTA B CV tachycardic with regular rhythm no murmur.

4. Case continued: Abd: soft NT, ND, no HSM, no Mass, decreased BS Extr: CR< 2 MAEW, doesn’t follow commands, is ataxic Neuro: DTR’S 3+, ataxic, restless with visual hallucinations. Poor finger to noses, unable to assess most exams. Babinski down going.

5. More than 50% of childhood accidents in the United States involved toxic ingestions. More than 50% of childhood accidents in the United States involved toxic ingestions. More than 4 million poisoning cases are reported annually to poison centers throughout the US each year. More than 4 million poisoning cases are reported annually to poison centers throughout the US each year. Greater than 53% of these events are in patients 5 years old or younger. Greater than 53% of these events are in patients 5 years old or younger. Most unintentional encounters result in mild or no symptoms, and no morbidity.Most unintentional encounters result in mild or no symptoms, and no morbidity. There has been a significant decline in the number of pediatric poisoning deaths 216 in 1972 versus 25 in 1997. There has been a significant decline in the number of pediatric poisoning deaths 216 in 1972 versus 25 in 1997. Most frequently fatal pharmaceutic ingestions in children have been prenatal iron supplements, antidepressants, cardiotonic agents and salicylates.Most frequently fatal pharmaceutic ingestions in children have been prenatal iron supplements, antidepressants, cardiotonic agents and salicylates.Epidemiology

6. Evaluation ABC’s History History Physical Physical Urine/serum Tox Urine/serum Tox Odors Odors Toxidromes Toxidromes

7. ABC’s º Airway º Breathing º Circulation º Diagnosis º Decontamination º Enhanced removal

8. History: What was ingested? Containers Ask EMS what was at the scene Available meds, plants etc. Quantity Elapsed time Route of exposure Cause for ingestion

9. What’s the difference they’re just small adults Airway resistance is greater Airway resistance is greater Cardiac output very dependent on heart rate Cardiac output very dependent on heart rate Young infants are very susceptible to thermoregulatory problems Young infants are very susceptible to thermoregulatory problems Mechanisms that typically distort mental status may be masked by limited pediatric neurologic repertoire Mechanisms that typically distort mental status may be masked by limited pediatric neurologic repertoire Depressants may have an accelerated effect in children as compared with adults Depressants may have an accelerated effect in children as compared with adults Seizures are more likely in children than adults Seizures are more likely in children than adults

10. Physical Exam Findings Constricted sympatholytics cholinergics Barbituates Opiates PCP Ethanol/Sedative hypnotics Dilated sympathomimetics Anticholinergics

11. Vital Signs Hypothermia (COOLS): CO, opiates, Oral hypoglycemics, alcohols, sedative hypnotics. Hyperpyrexia (NASA): Nicotine, Antihistamines, sympathomymetics, salicylates, amphetamines, anticholinergics. Tachycardia (FAST): Free Base, amphetamines, anticholinergics, sympathomymetics, Theophyline cyanide, cyclic antidepressants, propoxyphene, antihistamines, low dose iron. Bradycardia (PACED): Propranalol, Acetylcholinesterase, clonidine, Ca-channel blockers, Ethanol, sedative hypnotics, opiates, digoxin, nicotine. Tachypnea (PANT): PCP,paraquat, pneumonitis, ASA, non-cardio PE, Toxin induced Met acid, hydrocarbons, organophosphates, Bradypnea (SLOW): Sed-hypnotics, liquor, opiates, weed, acetone, barbiturates, ibuprofen, nicotine.

12. Vitals continued: Hypertension: (CT SCAN) Cocaine, Thyroid, Theophyline, Sympathomimetic, Caffeine, Anticholinergic, Nicotine. Hypotension: (CRASH) Clonidine, CCB’s, Reserpine, Antidepressants, Sedative hypnotics, heroin. Seizures: (OTIS CAMPBELL)Organophosphates, Tricyclics, INH, Insulin, Sympathomimetics, Camphor, Cocaine, Amphetamines, Methylxanthines, PCP, Benzo withdrawal, Ethanol withdrawal, Lithium, Lidocaine, Lead, Lindane

13. Toxidromes: Anticholinergics: Mad as a hatter Red as a beet Hot as a hare Blind as a bat Dry as a bone Cholinergic Muscarinic Salivation Lacrimation Urination Defacation GI motility Nicotinic Tachycardia Hypertension Fasciculations paralysis

14. Odors: Garlic: Arsenic, Organophosphates, Thallium Pear: Chloral Hydrate, Paraldehyde Acetone: Chloroform, Isopropyl alcohol Almond: Cyanide Oil of wintergreen: Methylsalicylate Mothballs: Naphthalene, paradichlorobenzene Carrot: Water Hemlock

15. Labs: Urine toxUrine tox Good for drugs of abuse - amphetamines, barbiturates, benzo’s, cocaine, cannabinoids, opiates, PCPGood for drugs of abuse - amphetamines, barbiturates, benzo’s, cocaine, cannabinoids, opiates, PCP Serum/plasma toxSerum/plasma tox Good for levels of selected substances - Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe, Li, Phenobarb.Good for levels of selected substances - Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe, Li, Phenobarb. Avoid a comprehensive tox screen.Avoid a comprehensive tox screen. Chem 7Chem 7 looking for an elevated anion gaplooking for an elevated anion gap

16. Elevated Anion Gap Gap = Na - Cl -CO 2 (should be 8-12) Methanol Uremia Lactic acidosis Ethylene Glycol Paraldehyde Alcohol Ketoacidosis Diabetes Mellitus Salicylates Toluene Iron, Isoniazide MULEPAKS

17. Abdominal X-rays Barium Enteric coated tablets Tricyclics Antihistamines Chloral hydrate, cocaine, condom Heavy metals Iodides Potassium, Phenothiazines Bet-A-Chip

18. Emesis Indications: Fe, Li, K at home managementIndications: Fe, Li, K at home management Contraindications:Contraindications: obtunded, comatose/convulsingobtunded, comatose/convulsing Likelihood of rapid progressionLikelihood of rapid progression corrosivescorrosives Petroleum distillatesPetroleum distillates Decontamination

19. Activated Charcoal Indications: Multiple poisonsIndications: Multiple poisons Contraindications:Contraindications: ileus, obstructionileus, obstruction CorrosivesCorrosives Some poisons not well absorbedSome poisons not well absorbed alcohols, alkalis, acidsalcohols, alkalis, acids CN, Fe, K, Li, PbCN, Fe, K, Li, Pb Decontamination

20. Gastric Lavage Indications:Indications: removal of ingested materialremoval of ingested material administration of charcoal/catharticsadministration of charcoal/cathartics Contraindications:Contraindications: Obtunded, comatose/convulsingObtunded, comatose/convulsing corrosivescorrosives Decontamination

21. Cathartics Magnesium Citrate (4ml/Kg) Magnesium Citrate (4ml/Kg) Use with caution in <2 yo. Use with caution in <2 yo. Generally not recommended Generally not recommended Decontamination

22. Enhanced elimination: Alkalinization of urine hemodialysishemoperfusion peritoneal dialysis Multidose charcoal whole bowel irrigation

23. AcetominophenCOHbDigoxin Ethylene Glycol IronLithiumMethanolSalicylateTheophyline N-acetylcysteine Oxygen, HBO Fab EtOH, Dialysis Deferoxamine Fluids, dialysis EtOH, Dialysis Alkalinization, dialysis repeat AC, hemoperfusion Specific Antidotes

24. What happened to that kid?

25. Back to the case: Labs:Chem7 EKG: Tachycardia, Mild prolonged QTc, sinus rhythm Urine Tox screen: Negative 139 4.3 112 190.6 9 105

26. Procedures: None/ObservationNone/Observation Discussed the use of physostigmine as an antidote not used.Discussed the use of physostigmine as an antidote not used. Patient gradually became more lucent. After a significant time period the patient admitted to ingesting seeds.

27. Jimson Weed