Pediatric PoisoningPediatric PoisoningEdwin de Zoeten M.D. Ph.D.Edwin de Zoeten M.D. Ph.D.

PL-3PL-3

CaseCase::

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

Case con’t:Case con’t:

Vitals: T:38.9, P:130, R:30, BP 140/90Vitals: T:38.9, P:130, R:30, BP 140/90

PE: General: active, agitated, talking PE: General: active, agitated, talking about a dog in the roomabout a dog in the roomHEENT: NC, AT, pupils dilated at 6mm HEENT: NC, AT, pupils dilated at 6mm w/o reaction, +photophobia, o/p clear but w/o reaction, +photophobia, o/p clear but dry MM.dry MM.Skin: Hot, mildy red. No lesions or rashesSkin: Hot, mildy red. No lesions or rashesLungs: CTA BLungs: CTA BCV tachycardic with regular rhythm no CV tachycardic with regular rhythm no murmur.murmur.

Case continued:Case continued:

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

• More than 50% of childhood accidents in the United States involved More than 50% of childhood accidents in the United States involved toxic ingestions.toxic ingestions.

• More than 4 million poisoning cases are reported annually to poison More than 4 million poisoning cases are reported annually to poison centers throughout the US each year.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 Most unintentional encounters result in mild or no symptoms, and no morbidity. morbidity.

• There has been a significant decline in the number of pediatric poisoning There has been a significant decline in the number of pediatric poisoning deaths 216 in 1972 versus 25 in 1997.deaths 216 in 1972 versus 25 in 1997.

•Most frequently fatal pharmaceutic ingestions in children have been Most frequently fatal pharmaceutic ingestions in children have been prenatal iron supplements, antidepressants, cardiotonic agents and prenatal iron supplements, antidepressants, cardiotonic agents and salicylates.salicylates.

EpidemiologyEpidemiology

EvaluationEvaluation

• ABC’sABC’s• HistoryHistory• PhysicalPhysical• Urine/serum ToxUrine/serum Tox• OdorsOdors• ToxidromesToxidromes

ABC’sABC’s

º AAirwayirwayº BBreathingreathingº CCirculationirculationº DDiagnosisiagnosisº DDecontaminationecontaminationº EEnhanced removalnhanced removal

History: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

What’s the difference they’re just What’s the difference they’re just small adultssmall adults

• Airway resistance is greaterAirway resistance is greater• Cardiac output very dependent on heart rateCardiac output very dependent on heart rate• Young infants are very susceptible to Young infants are very susceptible to thermoregulatory problemsthermoregulatory problems• Mechanisms that typically distort mental Mechanisms that typically distort mental status may be masked by limited pediatric status may be masked by limited pediatric neurologic repertoireneurologic repertoire• Depressants may have an accelerated effect Depressants may have an accelerated effect in children as compared with adultsin children as compared with adults• Seizures are more likely in children than Seizures are more likely in children than adultsadults

Physical Exam FindingsPhysical Exam Findings

ConstrictedsympatholyticscholinergicsBarbituatesOpiatesPCPEthanol/Sedative hypnotics

DilatedsympathomimeticsAnticholinergics

Vital SignsVital 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.

Vitals continued:Vitals continued:

Hypertension: (CT SCAN) Cocaine, Thyroid, Hypertension: (CT SCAN) Cocaine, Thyroid, Theophyline, Sympathomimetic, Caffeine, Theophyline, Sympathomimetic, Caffeine, Anticholinergic, Nicotine.Anticholinergic, Nicotine.

Hypotension: (CRASH) Clonidine, CCB’s, Reserpine, Hypotension: (CRASH) Clonidine, CCB’s, Reserpine, Antidepressants, Sedative hypnotics, heroin.Antidepressants, Sedative hypnotics, heroin.

Seizures: (OTIS CAMPBELL)Organophosphates, Seizures: (OTIS CAMPBELL)Organophosphates, Tricyclics, INH, Insulin, Sympathomimetics, Camphor, Tricyclics, INH, Insulin, Sympathomimetics, Camphor, Cocaine, Amphetamines, Methylxanthines, PCP, Benzo Cocaine, Amphetamines, Methylxanthines, PCP, Benzo withdrawal, Ethanol withdrawal, Lithium, Lidocaine, withdrawal, Ethanol withdrawal, Lithium, Lidocaine, Lead, LindaneLead, Lindane

Toxidromes:Toxidromes:

Anticholinergics:Mad as a hatterRed as a beetHot as a hareBlind as a batDry as a bone

Cholinergic

Muscarinic• Salivation• Lacrimation• Urination• Defacation• GI motility

Nicotinic•Tachycardia•Hypertension•Fasciculations•paralysis

Odors:Odors:

Garlic:Garlic: Arsenic, Organophosphates, Thallium Arsenic, Organophosphates, ThalliumPear:Pear: Chloral Hydrate, Paraldehyde Chloral Hydrate, ParaldehydeAcetone:Acetone: Chloroform, Isopropyl alcohol Chloroform, Isopropyl alcoholAlmond:Almond: Cyanide Cyanide Oil of wintergreen:Oil of wintergreen: Methylsalicylate MethylsalicylateMothballs:Mothballs: Naphthalene, paradichlorobenzene Naphthalene, paradichlorobenzeneCarrot:Carrot: Water Hemlock Water Hemlock

Labs:Labs:

•Urine toxUrine tox•Good for drugs of abuse - amphetamines, Good for drugs of abuse - amphetamines, barbiturates, benzo’s, cocaine, cannabinoids, barbiturates, benzo’s, cocaine, cannabinoids, opiates, PCPopiates, PCP

•Serum/plasma toxSerum/plasma tox•Good for levels of selected substances - Good for levels of selected substances - Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe, Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe, Li, Phenobarb.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

Elevated Anion GapElevated Anion GapGap = Na - Cl -CO2 (should be 8-12)

• Methanol• Uremia• Lactic acidosis • Ethylene Glycol• Paraldehyde• Alcohol• Ketoacidosis Diabetes Mellitus• Salicylates• Toluene• Iron, Isoniazide

MMUULLEEPPAAKKSS

Abdominal X-raysAbdominal X-rays

BariumEnteric coated tabletsTricyclicsAntihistaminesChloral hydrate, cocaine, condomHeavy metalsIodidesPotassium, Phenothiazines

Bet-A-ChipBet-A-Chip

EmesisEmesis

•Indications: Fe, Li, K at home Indications: Fe, Li, K at home managementmanagement•Contraindications:Contraindications:

•obtunded, comatose/convulsingobtunded, comatose/convulsing•Likelihood of rapid progressionLikelihood of rapid progression•corrosivescorrosives•Petroleum distillatesPetroleum distillates

DecontaminationDecontamination

Activated CharcoalActivated 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

DecontaminationDecontamination

Gastric LavageGastric 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

DecontaminationDecontamination

CatharticsCathartics

• Magnesium Citrate (4ml/Kg)Magnesium Citrate (4ml/Kg)• Use with caution in <2 yo.Use with caution in <2 yo.• Generally not recommendedGenerally not recommended

DecontaminationDecontamination

Enhanced elimination:Enhanced elimination:

Alkalinization of urineAlkalinization of urinehemodialysishemodialysishemoperfusionhemoperfusionperitoneal dialysisperitoneal dialysisMultidose charcoalMultidose charcoalwhole bowel irrigationwhole bowel irrigation

AcetominophenAcetominophenCOHbCOHbDigoxinDigoxinEthylene GlycolEthylene GlycolIronIronLithiumLithiumMethanolMethanolSalicylateSalicylateTheophylineTheophyline

N-acetylcysteineN-acetylcysteineOxygen, HBOOxygen, HBOFabFabEtOH, DialysisEtOH, DialysisDeferoxamineDeferoxamineFluids, dialysisFluids, dialysisEtOH, DialysisEtOH, DialysisAlkalinization, dialysisAlkalinization, dialysisrepeat AC, hemoperfusionrepeat AC, hemoperfusion

Specific AntidotesSpecific Antidotes

What happened to that kid?What happened to that kid?

Back to the case:Back to the case:

Labs: Labs:

Chem7Chem7

EKG: EKG: Tachycardia, Mild prolonged QTc, sinus rhythmTachycardia, Mild prolonged QTc, sinus rhythm

Urine Tox screen: Urine Tox screen: NegativeNegative

1391394.34.3

1121121919 0.60.6

99105105

Procedures:Procedures:•None/ObservationNone/Observation•Discussed the use of Discussed the use of physostigmine as an antidote physostigmine as an antidote not used.not used.

Patient gradually became more lucent.Patient gradually became more lucent.After a significant time period the After a significant time period the patient admitted to ingesting seeds.patient admitted to ingesting seeds.

Jimson WeedJimson Weed