pediatric toxicology
DESCRIPTION
Pediatric Toxicology. Jana Stockwell, MD. Epidemiology. 2 million calls 52% of poison center calls girls Unable to discriminate safe from unsafe liquid Intentional (adolescent) - PowerPoint PPT PresentationTRANSCRIPT
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Pediatric Pediatric ToxicologyToxicology
Jana Stockwell, MDJana Stockwell, MD
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EpidemiologyEpidemiology 2 million calls2 million calls 52% of poison center calls <6years52% of poison center calls <6years Peak ages: 18 months - 3 yearsPeak ages: 18 months - 3 years
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EpidemiologyEpidemiology Unintentional (1-2 years)Unintentional (1-2 years)
– ExploratoryExploratory– Boys > girlsBoys > girls– Unable to discriminate safe from unsafe Unable to discriminate safe from unsafe
liquidliquid
Intentional (adolescent)Intentional (adolescent)– PurposefulPurposeful– Girls > boysGirls > boys
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EpidemiologyEpidemiology Around meal timeAround meal time Grandparents homeGrandparents home Kerosene or gasoline in a soda Kerosene or gasoline in a soda
bottlebottle Older sibling can pharmaceutically Older sibling can pharmaceutically
treat younger siblingtreat younger sibling
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Most often reportedMost often reported Cleaning productsCleaning products
10%10% AnalgesicsAnalgesics 10%10% CosmeticsCosmetics 9%9% Cough & cold preparationCough & cold preparation 5%5% InsecticidesInsecticides 4%4%
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PICU AdmissionPICU Admission Tricyclic antidepressants (TCA)Tricyclic antidepressants (TCA) AnticonvulsantsAnticonvulsants DigoxinDigoxin OpiatesOpiates Hydrocarbon-based household Hydrocarbon-based household
productsproducts
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Toxic Exposures Toxic Exposures DeathDeath
AnalgesicsAnalgesics Sedative-hypnoticsSedative-hypnotics AlcoholsAlcohols Gases & fumesGases & fumes Cleaning substancesCleaning substances
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““Fatal Sip” Fatal Sip” Camphor (Vick’s VapoRub)Camphor (Vick’s VapoRub) 1000 mg/5 ml1000 mg/5 ml
– (100mg/kg)(100mg/kg) Methyl salicylate (wintergreen)Methyl salicylate (wintergreen) 1400 mg/ml1400 mg/ml
– (200 mg/kg)(200 mg/kg) Benzocaine (OraGel)Benzocaine (OraGel)
– 2 mL2 mL– Met-hemoglobinemiaMet-hemoglobinemia– SeizureSeizure
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““Malignant Swallow”Malignant Swallow” Chloroquine Chloroquine (20 mg/kg)(20 mg/kg) Theophylline Theophylline (8.4 mg/kg)(8.4 mg/kg) Imipramine Imipramine (15 mg/kg)(15 mg/kg) ChlorpromazineChlorpromazine (25 mg/kg)(25 mg/kg) ClonidineClonidine (0.3 mg tablet)(0.3 mg tablet)
– BradycardiaBradycardia– CNS depressionCNS depression
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Other Highly ToxicOther Highly Toxic Acetonitrile - nail tip remover Acetonitrile - nail tip remover
MetHgbMetHgb Ammonium fluoride – hub cap Ammonium fluoride – hub cap
cleaner (ArmorAll) cleaner (ArmorAll) sz, arrhythmias, sz, arrhythmias, acidosisacidosis
Pennyroyal Oil – some herbal teasPennyroyal Oil – some herbal teas
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Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike
AlbuterolAlbuterol CelebrexCelebrex OruvailOruvail LamictalLamictal LotriminLotrimin PlendilPlendil HydralazineHydralazine HydrocodoneHydrocodone
AtenololAtenolol CerebrexCerebrex ElavilElavil LomotilLomotil LotensinLotensin PindololPindolol HydroxyzineHydroxyzine HydrocortisoneHydrocortisone
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Poison plantsPoison plants Digitalis effectsDigitalis effects
– Lily-of-the-Lily-of-the-valley, Foxglove, valley, Foxglove, Oleander, YewOleander, Yew
Nicotinic effectsNicotinic effects– Poison hemlockPoison hemlock
Atropinic effectsAtropinic effects– Jimson weedJimson weed
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Non-Toxic ProductsNon-Toxic Products Ball point inkBall point ink Bubble bath Bubble bath
soapssoaps ChalkChalk Cigarettes (< 3 Cigarettes (< 3
butts)butts) CrayonsCrayons
DeodorantsDeodorants LipstickLipstick Pencil (graphite)Pencil (graphite) ToothpasteToothpaste Water colorsWater colors Candle wax Candle wax (but (but
candle oil is!)candle oil is!)
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EvaluationEvaluation History of poisoningHistory of poisoning Physical examinationPhysical examination Laboratory studiesLaboratory studies Gastrointestinal decontaminationGastrointestinal decontamination
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HistoryHistory What?What? When?When? How much?How much? Reliability…Reliability…
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What ?What ? MedicationMedication Illicit drugIllicit drug Hazardous chemicalHazardous chemical
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What form?What form? PillPill SolidSolid LiquidLiquid GaseousGaseous
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What route ?What route ? IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous
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When ?When ? Elapsed timeElapsed time
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How much ?How much ? Estimate amountEstimate amount ConcentrationConcentration
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““Clues”Clues”
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BradycardiaBradycardia Calcium channel Calcium channel
blockersblockers DigoxinDigoxin NarcoticsNarcotics OrganophosphatesOrganophosphates Carbon monoxideCarbon monoxide Beta-blockersBeta-blockers ClonidineClonidine
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TachycardiaTachycardia Amphetamine (Ritalin)Amphetamine (Ritalin) AtropineAtropine TCA’sTCA’s TheophyllineTheophylline Salicylates (aspirin)Salicylates (aspirin) IronIron CocaineCocaine PCPPCP SynthroidSynthroid
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Slow RespirationSlow Respiration AlcoholAlcohol NarcoticsNarcotics ClonidineClonidine SedativesSedatives
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TachypneaTachypnea AmphetaminesAmphetamines SalicylatesSalicylates Carbon monoxideCarbon monoxide Ethylene glycol Ethylene glycol
(anti-freeze)(anti-freeze)
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HypotensionHypotension Calcium channel Calcium channel
blockersblockers Carbon monoxideCarbon monoxide CyanideCyanide IronIron NarcoticsNarcotics Anti-hypertensivesAnti-hypertensives Met-hemoglobinMet-hemoglobin
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HypertensionHypertension OTC cold OTC cold
remediesremedies AmphetamineAmphetamine PCPPCP TCATCA CocaineCocaine Diet pillsDiet pills
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V TachV Tach AmphetaminesAmphetamines Carbamzepine (Tegretol)Carbamzepine (Tegretol) Chloral hydrateChloral hydrate CocaineCocaine DigitalisDigitalis TheophyllineTheophylline
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Torsades de PointesTorsades de Pointes Chloral hydrateChloral hydrate CisaprideCisapride OrganophosphateOrganophosphate
ss TerfenadineTerfenadine PhenothiazinesPhenothiazines
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Hypoglycemia Hypoglycemia (HOBBIES)(HOBBIES)
HHypoglycemiaypoglycemia OOral hypoglycemic ral hypoglycemic
agentsagents BBeta-eta-BBlockerslockers IInsulinnsulin EEthanolthanol SSalicylatesalicylates
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HypothermiaHypothermia EthanolEthanol NarcoticsNarcotics Carbon monoxideCarbon monoxide ClonidineClonidine
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HyperpyrexiaHyperpyrexia AtropineAtropine SalicylatesSalicylates TheophyllineTheophylline CocaineCocaine TCATCA
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CNS - ComaCNS - Coma NarcoticNarcotic Anti-cholinergicsAnti-cholinergics Carbon monoxideCarbon monoxide
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CNS - Delirium / CNS - Delirium / PsychosisPsychosis
AlcoholAlcohol PCP / marijuanaPCP / marijuana LSDLSD
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CNS - SeizureCNS - Seizure CocaineCocaine AmphetamineAmphetamine LeadLead SalicylateSalicylate IsoniazidIsoniazid TheophyllineTheophylline
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Pupils - MiosisPupils - Miosis (COPS) CCholinergics, holinergics, CClonidinelonidine OOpiates, piates, OOrganophosphatesrganophosphates PPhenothiazine, henothiazine, PPilocarpineilocarpine SSedatives (barbiturates, ethanol)edatives (barbiturates, ethanol)
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Pupils - MydriasisPupils - Mydriasis (AAAS)(AAAS)
AAnti-histaminenti-histamine AAnti-depressantnti-depressant AAnticholinergics (atropine)nticholinergics (atropine) SSympathomimeticsympathomimetics
– amphetamine, cocaine, amphetamine, cocaine, PCPPCP
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Caution!Caution! Polydrug overdoses with opposite Polydrug overdoses with opposite
pupillary actionspupillary actions Non-toxin diagnosesNon-toxin diagnoses
– Head traumaHead trauma– CNS hemorrhageCNS hemorrhage
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CyanosisCyanosis MetHgbMetHgb
– Unresponsive to Unresponsive to OO22
Aniline dyesAniline dyes NitritesNitrites BenzocaineBenzocaine DapsoneDapsone
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Dry SkinDry Skin AnticholinergicAnticholinergic
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Breath OdorsBreath Odors ArsenicArsenic GarlicGarlic CamphorCamphor MothballsMothballs CyanideCyanide Bitter almondBitter almond Methyl salicylateMethyl salicylate WintergreenWintergreen ParaldehydeParaldehyde PearsPears HemlockHemlock CarrotsCarrots
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CholinergicCholinergic ““DUMBBELS”DUMBBELS” ““SLUDGE”SLUDGE”
Example –OrganophosphatesNerve agents
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DUMBBELSDUMBBELS DDiarrhea, diaphoresisiarrhea, diaphoresis UUrinationrination MMiosis, muscle fasiculationiosis, muscle fasiculation BBradycardiaradycardia BBronchospasmronchospasm EEmesismesis LLacrimationacrimation SSalivationalivation
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SLUDGESLUDGE SSalivationalivation LLacrimationacrimation UUrinationrination DDiarrheaiarrhea GGI complaintI complaint EEmesismesis
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Anti-cholinergic Anti-cholinergic syndromesyndrome
Dry mouthDry mouth Flushed Flushed
appearanceappearance Dilated pupilsDilated pupils FeverFever IleusIleus Urinary retentionUrinary retention DisorientationDisorientation
Examples –Anti-histaminesJimson weedLomotilTCACarbamazepineGlycopyrrolateAtropine
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Anti-cholinergicAnti-cholinergic HotHot as a as a harehare BlindBlind as a as a batbat DryDry as a as a bonebone RedRed as a as a beetbeet MadMad as a as a hatterhatter Full as a flaskFull as a flask
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NarcoticNarcotic Pinpoint pupilsPinpoint pupils ComaComa Respiratory depressionRespiratory depression
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SalicylatesSalicylates FeverFever Tachypnea & hyperpneaTachypnea & hyperpnea LethargyLethargy Metabolic acidosisMetabolic acidosis
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TheophyllineTheophylline Protracted VomitingProtracted Vomiting TremorsTremors TachycardiaTachycardia SeizuresSeizures HypotensionHypotension
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IsoniazidIsoniazid SeizuresSeizures Metabolic acidosisMetabolic acidosis HyperglycemiaHyperglycemia
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PhencyclidinePhencyclidine (4 Cs)(4 Cs) CCombativeombative CCatatoniaatatonia CConvulsiononvulsion CComaoma NNystagmusystagmus
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TCATCA Metabolic acidosisMetabolic acidosis Prolonged QRSProlonged QRS SeizuresSeizures Dilated pupilsDilated pupils DysrhythmiaDysrhythmia
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CyanideCyanide Feeling of impending doomFeeling of impending doom Sudden comaSudden coma Metabolic acidosisMetabolic acidosis HypotensionHypotension Bitter almond odorBitter almond odor
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Carbon monoxideCarbon monoxide HeadacheHeadache LethargyLethargy DizzinessDizziness Influenza like syndromeInfluenza like syndrome ComaComa
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EthanolEthanol HypoglycemiaHypoglycemia LethargyLethargy AtaxiaAtaxia SeizureSeizure Characteristic breath odorCharacteristic breath odor
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MethanolMethanol Severe metabolic acidosisSevere metabolic acidosis Sluggish pupilsSluggish pupils Hyperemic retinaHyperemic retina Blurred visionBlurred vision
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Ethylene GlycolEthylene Glycol Lethargy or comaLethargy or coma Metabolic acidosisMetabolic acidosis Urinary sedimentUrinary sediment CrystalluriaCrystalluria
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ClonidineClonidine HypothermiaHypothermia BradycardiaBradycardia MiosisMiosis Respiratory depressionRespiratory depression
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Elevated anion gapElevated anion gap MethanolMethanol Paraldehyde & phenforminParaldehyde & phenformin Iron & isoniazidIron & isoniazid Ethylene glycol & ethanolEthylene glycol & ethanol Salicylate Salicylate
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ABC’sABC’s AAirwayirway BBreathingreathing CCirculationirculation DDisabilityisability DDecontaminationecontamination
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ConsciousnessConsciousness AA:: AlertAlert VV: : Responsive to verbal Responsive to verbal
stimulistimuli PP: : Responsive to painResponsive to pain UU: : UnresponsiveUnresponsive
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DrugsDrugs DextroseDextrose OxygenOxygen NaloxoneNaloxone
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DecontaminationDecontamination Ocular- copious saline lavageOcular- copious saline lavage Skin- copious waterSkin- copious water GI-consider optionsGI-consider options
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Lab EvaluationLab Evaluation No “No “tox paneltox panel” that is ” that is
uniformly helpfuluniformly helpful
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Urine ScreenUrine Screen MarijuanaMarijuana 5-10 days5-10 days AmphetaminesAmphetamines 48 hours48 hours BarbituratesBarbiturates 24 h-2 wks24 h-2 wks CocaineCocaine 2-4 days2-4 days OpiatesOpiates 2 days 2 days PCPPCP 8 days 8 days
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EKGEKG All suspected ingestionAll suspected ingestion TricyclicsTricyclics
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Pulse oximetryPulse oximetry Measure of oxygen saturation of Measure of oxygen saturation of
normal hemoglobinnormal hemoglobin Does NOT differentiate CO-Hgb Does NOT differentiate CO-Hgb
from oxyHgbfrom oxyHgb Falsely low satsFalsely low sats
– Nail polishNail polish– Methylene blueMethylene blue– Poor perfusionPoor perfusion
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Other testsOther tests CXR - hydrocarbonsCXR - hydrocarbons ABG - salicylatesABG - salicylates Esophagoscopy - CausticsEsophagoscopy - Caustics
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Drug levelsDrug levels AcetaminophenAcetaminophen SalicylatesSalicylates MethanolMethanol Ethylene glycolEthylene glycol IronIron TheophyllineTheophylline Carbon monoxide (co-ox blood gas)Carbon monoxide (co-ox blood gas) LithiumLithium
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RadiopaqueRadiopaque (CHIPS)(CHIPS) CChloral hydratehloral hydrate HHeavy metalseavy metals IIronron PPhenothiazine henothiazine
(laxatives)(laxatives) SSlow releaselow release
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GI tract GI tract decontaminationdecontamination
Syrup of Ipecac (not used in hospital)Syrup of Ipecac (not used in hospital) Gastric lavage – 1Gastric lavage – 1stst hour hour Activated charcoalActivated charcoal
– InertInert– Reduces bioavailability of drugReduces bioavailability of drug– Not w/ HC or corrosivesNot w/ HC or corrosives
Cathartics – decrease transit timeCathartics – decrease transit time WBI (whole bowel irrigation)…till clearWBI (whole bowel irrigation)…till clear
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Urine alkalinizationUrine alkalinization SalicylatesSalicylates PhenobarbitalPhenobarbital ChlorpropamideChlorpropamide
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Extracorporeal Extracorporeal methodsmethods
HemodialysisHemodialysis– Severe poisoningSevere poisoning– Renal failureRenal failure
HemoperfusionHemoperfusion– Perferred in some toxic ingestionsPerferred in some toxic ingestions
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AntidotesAntidotes Oxygen - carbon monoxideOxygen - carbon monoxide Naloxone – opioidsNaloxone – opioids Methylene blue – MetHgbMethylene blue – MetHgb Sodium nitrite - cyanideSodium nitrite - cyanide Deferoxamine – ironDeferoxamine – iron Acetoaminophen – N-acetylcysteineAcetoaminophen – N-acetylcysteine Anti-cholinergics – physostigmineAnti-cholinergics – physostigmine Organophosphates – atropine, pralidoximeOrganophosphates – atropine, pralidoxime Benzodiazepines – flumazenilBenzodiazepines – flumazenil B-blockers – glucagonB-blockers – glucagon TCA – bicarbTCA – bicarb Coumadin – Vitamin KCoumadin – Vitamin K Fomepizole (Antizol) – ethylene glycolFomepizole (Antizol) – ethylene glycol