1. Poisoning & Accidents DR. Sanjeev

2. Poisoning & Accidents Poison: A poison is a substance that causes harm if it gets into the body Poisoning Severity Grades: – None (0): No symptoms or signs – Minor (1): Mild, transient and spontaneously resolving symptoms – Moderate (2): Prolonged symptoms – Severe (3): Severe or life threatening symptoms

3. Initial Management of the poisoned patient (ABCD’s) First, the airway should be cleared of vomitus or any other obstruction and an oral airway or endotracheal tube inserted if needed. Breathing should be assessed by observation and oximetry and, if in doubt by measuring arterial blood gases patients with respiratory insufficiency should be intubated and mechanically ventilated Circulation should be assessed by continuous monitoring of pulse rate, blood pressure, urinary output. An intravenous line should be placed and blood drawn fro serum glucose and other routine determinations Dextrose to treat hypoglycemia (0.5gm/kg)

4. History & Physical Exam Lab and Imaging procedures: – Arterial Blood Gases – Electrolytes: Sodium, Potassium, Chloride, Bicarbonate – Renal Function Tests: Blood Urea, Creatinine – Electrocardiogram

5. Decontamination Decontamination procedure should be undertaken simultaneously with initial stabilization, diagnostic assessment and lab evaluation Decontamination involves removing toxins from the skin or GIT

6. A) Skin Contaminated clothing should be completely removed and double bagged to prevent illness in health care providers and for possible lab analysis Wash contaminated skin with soap and water

7. B) GIT 1.Emesis: Emptying of stomach in conscious children – Syrup: Ipecac (6-12 months 10 ml single dose and >1 yr 15 ml) *repeated in 20 mins for those more than 1 yr. 2.Gastric Lavage: – 0.9% saline, Left Lateral position 3.Activated Charcoal 4.Catharsis: Laxative and purgatives – Mannitol (1-2 gm/kg) – Magnesium or sodium sulfate (200-300 mg/kg) * Specific Antidotes*

8. Methods of enhancing elimination of toxins A)Dialysis procedures 1.Peritoneal dialysis 2.Hemodialysis: useful in overdose cases 3.Forced Diuresis and urinary PH Manipulation Prevention of poisoning 1.Protection of the child from the poisonous substances 2.Education of parents about the potential household poisons 3.Parental supervision 4.Safety Regulation

9. Organo-Phosphorus Absorbed through: Skin, Bronchial Mucosa and GUT Inhibit Cholinesterase, causing accumulation of Ach. at nerve endings and neuro-muscular junctions Irreversible binding of cholinesterase develops after some mins or hrs

10. Clinical Features Minor exposure to organophosphates may cause subclinical poisoning with decrease cholinesterase levels, but no symptoms or signs Symptoms may be delayed by 12-24 hrs after skin exposure

11. Muscarinic findings Diarrhea, urination, miosis, bradycardia, bronchorrhea, bronchospasm, emesis, lacrimation and salivation (DUMBELS) Wheezing and/or bronchoconstriction Pulmonary edema Increased pulmonary and oropharyngeal secretions Sweating Abdominal cramping and intestinal hypermotility

12. Nicotinic findings Muscle fasciculations (twitching) Fatigue Paralysis Respiratory muscle weakness Diminished respiratory effort Tachycardia (nicotinic ACh receptors are present in both sympathetic and parasympathetic ganglia. These ganglionic effects in the sympathetic system may contribute to tachycardia) Hypertension

13. CNS findings Anxiety Restlessness Confusion Headache Slurred speech Seizures Coma Central respiratory paralysis Altered level of consciousness and/or hypotonia

14. Management Wear protective clothing and avoid getting yourself contaminated Give supportive treatment as needed Clear the airway and remove bronchial secretions Give 02 if necessary Prevent further absorption by removing soiled clothing and washing the skin, or by gastric lavage after ingestion in the previous 1 hr Take blood for cholinesterase

15. Manage. (contd.) If there are profuse bronchial secretion and/or bronchospasm, give – Atropine IV 0.02 mg/kg, repeated every 10-30 mins until there is improvement or obvious signs of Atropinization – Atropinization means Dry mouth, Tachycardia, Dilated Pupils – Very large quantities may be needed

16. Manage. (contd.) In moderate or severe poisoning give: – Pralidoxime mesylate (also called P2s) 30 mg/kg IV over 5-10 mins, repeated if necessary every 4 hrs – Improvement is usually apparent within 30 mins - Give Diazepam to decrease agitation and control convulsion 30 days to 5 years: 0.2-0.5 mg IV slowly q2- 5min until symptoms resolve; not to exceed 5 mg >5 years: 1 mg IV slowly q2-5min until symptoms resolve; not to exceed 10 mg

17. Carbon Monoxide Poisoning CO: tasteless and odourless May occur from: car exhaust, fire smoke, faulty gas heaters CO decrease O2 carrying capacity of the blood by binding Hb to form CoHb Impairs O2 delivery from blood to the tissues and also inhibits cytochrome oxidase, blocking O2 utilization Cause severe tissue hypoxia

18. Clinical Features Early features: Headache, Malaise, Nausea, Vomiting In severe poisoning: – There is coma with hyperventilation, hypotension, Increase Muscle Tone, Increase reflexes and convulsions and extensor plantars (Babinski response) – Cherry Red coloring of skin (Fatal CO Poisoning) – Pulmonary Oedema, MI and cerebral oedema

19. Management Remove from exposure Clear the airway and maintain ventilation with as high a concentration of O2 as possible: for a conscious patient use a tight fitting mask with an O2 reservoir, but if unconscious intubate and provide IPPV (Intermittent Positive Pressure Ventilation on 100% O2) Record ECG and monitor heart rhythm (for arrhythmias and sings of acute MI) Check ABG Check COHb levels Correct metabolic acidosis by ventilation and O2 Consider mannitol if cerebral oedema is suspected