pediatric toxicology
DESCRIPTION
Pediatric Toxicology. M Waseem, MD Lincoln Hospital Bronx New York. Epidemiology. 2 million calls 52% of poison center calls < 6years Peak age 18 months - 3 years. Epidemiology. Unintentional (1-2 years) Exploratory Boys > girls Intentional (adolescent) Purposeful Girls > boys. - PowerPoint PPT PresentationTRANSCRIPT
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Pediatric Pediatric ToxicologyToxicology
M Waseem, MDM Waseem, MDLincoln Hospital Bronx New Lincoln Hospital Bronx New
YorkYork
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EpidemiologyEpidemiology 2 million calls2 million calls 52% of poison center calls < 52% of poison center calls <
6years6years Peak age 18 months - 3 yearsPeak age 18 months - 3 years
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EpidemiologyEpidemiology Unintentional (1-2 years)Unintentional (1-2 years)
– ExploratoryExploratory– Boys > girlsBoys > girls
Intentional (adolescent)Intentional (adolescent)– PurposefulPurposeful– Girls > boysGirls > boys
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Children are differentChildren are different Unable to discriminate safe from Unable to discriminate safe from
unsafe liquidunsafe liquid Fail to recognize the suitability of Fail to recognize the suitability of
the drinkthe drink
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EpidemiologyEpidemiology Around Meal timeAround Meal time Grand parents homeGrand parents 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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Very toxic!Very toxic! Prenatal vitamin supplementsPrenatal vitamin supplements AntidepressantsAntidepressants HydrocarbonsHydrocarbons
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Most often reportedMost often reported Cleaning productsCleaning products
10.4%10.4% AnalgesicsAnalgesics 10.3%10.3% CosmeticsCosmetics 9% 9% Cough & cold preparationCough & cold preparation 5.1% 5.1% InsecticidesInsecticides 4% 4%
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ICU AdmissionICU Admission TCATCA AnticonvulsantsAnticonvulsants DigitalisDigitalis OpiatesOpiates Hydrocarbon-based house-hold Hydrocarbon-based house-hold
productsproducts
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Toxic Exposures/DeathToxic Exposures/Death AnalgesicsAnalgesics Sedative-hypnoticsSedative-hypnotics AlcoholsAlcohols Gases & fumesGases & fumes Cleaning substancesCleaning substances
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““Fatal Sip”Fatal Sip”
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Fatal SipFatal Sip Camphor (100mg/kg)Camphor (100mg/kg) 1gm/5 1gm/5
mlml Methyl Salicylate Methyl Salicylate
1.4gm/ml1.4gm/ml (200 mg/kg)(200 mg/kg)1/2 tsp1/2 tsp
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Fatal SipFatal Sip BenzocaineBenzocaine 2 ml2 ml
– MethemoglobinemiaMethemoglobinemia– SeizureSeizure
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Malignant SwallowMalignant Swallow Chloroquine (20 mg/kg)Chloroquine (20 mg/kg) 500 mg500 mg Theophylline (8.4 mg/kg)Theophylline (8.4 mg/kg) 500 mg500 mg Imipramine (15 mg/kg)Imipramine (15 mg/kg) 150 mg150 mg ChlorpromazineChlorpromazine
(25 mg/kg)(25 mg/kg) 200 200 mgmg
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Malignant SwallowMalignant Swallow ClonidineClonidine 0.3 mg tablet0.3 mg tablet
– BradycardiaBradycardia– CNS depressionCNS depression
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Highly ToxicHighly Toxic AcetonitrileAcetonitrile Ammonium FluorideAmmonium Fluoride BenzocaineBenzocaine CamphorCamphor Pennyroyal OilPennyroyal Oil
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AcetonitrilesAcetonitriles Artificial Nail Tip removerArtificial Nail Tip remover MethemolobinemiaMethemolobinemia Delayed presentation (4-12 hours)Delayed presentation (4-12 hours) Must be hospitalizedMust be hospitalized
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Ammonium FluorideAmmonium Fluoride Glass etching, de-rusting and Glass etching, de-rusting and
wheel cleaning commercial wheel cleaning commercial productsproducts
Armoral Quick Silver Wheel cleaner Armoral Quick Silver Wheel cleaner (17% ammonium fluoride)(17% ammonium fluoride)
only 2 mlonly 2 ml
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Ammonium FluorideAmmonium Fluoride Inactivates proteolytic & glycolytic Inactivates proteolytic & glycolytic
enzymesenzymes Binds with Ca & MgBinds with Ca & Mg
– Acidosis, Dysrhythmia & Acidosis, Dysrhythmia & coagulopathycoagulopathy
Direct effect on CNSDirect effect on CNS– SeizuresSeizures
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BenzocaineBenzocaine Teething gels (Orajel), first aid Teething gels (Orajel), first aid
cream hemorrhoidal preparationscream hemorrhoidal preparations MethemoglobinemiaMethemoglobinemia < 6 months (methemoglobin < 6 months (methemoglobin
reductase)reductase)
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CamphorCamphor Vicks VapoRubVicks VapoRub Only 5 mlOnly 5 ml CNS effectsCNS effects
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Pennyroyal OilPennyroyal Oil Health food products, Health food products,
herbal preparationsherbal preparations Depletes glutathioneDepletes glutathione Toxicity to liver & lungToxicity to liver & lung < a teaspoon< a teaspoon A tablespoon (fatal)A tablespoon (fatal)
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Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike
AlbuterolAlbuterol AtenololAtenolol CelebrexCelebrex CerebrexCerebrex OruvailOruvail ElavilElavil LamictalLamictal LomotilLomotil LotriminLotrimin LotensinLotensin PlendilPlendil PindololPindolol
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Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike
HydralazineHydralazine HydroxyzineHydroxyzine HydrocodoneHydrocodone HydrocortisoneHydrocortisone
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Plant ToxidromesPlant Toxidromes
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Digitalis EffectsDigitalis Effects Lily-of-the-valleyLily-of-the-valley FoxgloveFoxglove OleanderOleander YewYew
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Nicotinic EffectsNicotinic Effects Poison hemlockPoison hemlock
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Atropinic EffectsAtropinic Effects JimsonweedJimsonweed
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Non-Toxic ProductsNon-Toxic Products Ball point inkBall point ink Bubble bath soapsBubble bath soaps Candles (beeswax or paraffin)Candles (beeswax or paraffin) ChalkChalk Cigarettes (< 3 butts)Cigarettes (< 3 butts) CrayonsCrayons
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Non-Toxic ProductsNon-Toxic Products DeodorantsDeodorants LipstickLipstick Pencil (graphite)Pencil (graphite) ToothpasteToothpaste Water colorsWater colors
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EvaluationEvaluation History of poisoningHistory of poisoning Toxicologic physical examinationToxicologic physical examination Laboratory studiesLaboratory studies Gastrointestinal decontaminationGastrointestinal decontamination
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HistoryHistory What?What? When?When? How much?How much?
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WhatWhat ? ? MedicationMedication Illicit drugIllicit drug Hazardous chemicalHazardous chemical
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What form?What form? PillPill SolidSolid LiquidLiquid GaseousGaseous
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What routeWhat route ? ? IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous
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WhenWhen ? ? Elapsed timeElapsed time
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How muchHow much ? ? Estimate amountEstimate amount ConcentrationConcentration
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““Vital signs”Vital signs”
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BradycardiaBradycardia DigoxinDigoxin NarcoticsNarcotics OrganophosphatesOrganophosphates Carbon monoxideCarbon monoxide Beta-blockerBeta-blocker
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TachycardiaTachycardia Alcohol/amphetamineAlcohol/amphetamine Atropine/tricyclicAtropine/tricyclic TheophyllineTheophylline Salicylates, IronSalicylates, Iron Cocaine/PCPCocaine/PCP
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Slow RespirationSlow Respiration AlcoholAlcohol NarcoticsNarcotics ClonidineClonidine SedativesSedatives
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TachypneaTachypnea AmphetaminesAmphetamines SalicylatesSalicylates Carbon monoxideCarbon monoxide
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HypotensionHypotension MethemoglobinemiaMethemoglobinemia Carbon monoxideCarbon monoxide CyanideCyanide IronIron NarcoticsNarcotics
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HypertensionHypertension OTC cold remediesOTC cold remedies AmphetamineAmphetamine PCPPCP TCATCA CocaineCocaine
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Ventricular TachycardiaVentricular Tachycardia AmphetaminesAmphetamines CarbamzepineCarbamzepine Chloral hydrateChloral hydrate CocaineCocaine DigitalisDigitalis TheophyllineTheophylline
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Torsades de PointesTorsades de Pointes Chloral hydrateChloral hydrate CisaprideCisapride OrganophosphatesOrganophosphates TerfenadineTerfenadine PhenothiazinesPhenothiazines
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HypoglycemiaHypoglycemia (HOBBIES) (HOBBIES) H-HH-Hypoglycemiaypoglycemia O-OO-Oral hypoglycemic agentsral hypoglycemic agents B-BB-Beta-eta-BBlockerslockers I-II-Insulinnsulin E-EE-Ethanolthanol S-SS-Salicylatesalicylates
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HypothermiaHypothermia EthanolEthanol NarcoticsNarcotics Carbon monoxideCarbon monoxide
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HyperpyrexiaHyperpyrexia AtropineAtropine SalicylatesSalicylates TheophyllineTheophylline CocaineCocaine TCATCA
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Mental StatusMental Status
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ComaComa NarcoticNarcotic AnticholinergicAnticholinergic Carbon monoxideCarbon monoxide
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Delirium/PsychosisDelirium/Psychosis AlcoholAlcohol PCP/marijuanaPCP/marijuana LSDLSD
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ConvulsionConvulsion Cocaine/AmphetamineCocaine/Amphetamine LeadLead SalicylateSalicylate IsoniazidIsoniazid TheophyllineTheophylline
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Pupil sizePupil size
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Miosis Miosis (COPS) CCholinergics, holinergics, CClonidinelonidine OOpiates, piates, OOrganophosphatesrganophosphates
PPhenothiazine, henothiazine, PPilocarpineilocarpine SSedatives (Barbiturates)edatives (Barbiturates)
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Mydriasis Mydriasis (AAAS)(AAAS) AAntihistaminentihistamine AAntidepressantntidepressant AAnticholinergics (atropine)nticholinergics (atropine) SSympathomimeticsympathomimetics
– Amphetamine, Cocaine, PCPAmphetamine, Cocaine, PCP
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Caution!Caution! Polydrug overdoses with Polydrug overdoses with
opposite pupillary actionsopposite pupillary actions Nontoxin diagnosesNontoxin diagnoses
– Head traumaHead trauma– CNS hemorrhageCNS hemorrhage
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CyanosisCyanosisUnresponsive to Unresponsive to
oxygen oxygen methemoglobinemimethemoglobinemi
aa
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CyanosisCyanosis 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
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ToxidromesToxidromes
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CholinergicCholinergicDUMBBELDUMBBELSLUDGESLUDGE
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DUMBBELSDUMBBELS DD DiarrheaDiarrhea UU UrinationUrination MM Miosis, muscle fasiculationMiosis, muscle fasiculation BB BradycardiaBradycardia BB BronchospasmBronchospasm
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DUMBBELSDUMBBELS EE EmesisEmesis LL LacrimationLacrimation SS SalivationSalivation
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SLUDGESLUDGE SS SalivationSalivation LL LacrimationLacrimation UU UrinationUrination DD DiarrheaDiarrhea
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SLUDGESLUDGE GG GI complaintGI complaint EE EmesisEmesis
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Anticholinergic Anticholinergic SyndromeSyndrome
Dry mouthDry mouth Flushed appearanceFlushed appearance Dilated pupilsDilated pupils FeverFever IleusIleus Urinary retentionUrinary retention DisorientationDisorientation
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AnticholinergicAnticholinergic 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
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AnticholinergicAnticholinergic
Full Full as aas a flask flask
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AnticholinergicAnticholinergic AnticholinergicAnticholinergic WetWet Bowel sound +Bowel sound +
SympathomimeSympathomimetictic
DryDry Absent bowel Absent bowel
soundsound
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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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Phencyclidine (4 Cs)Phencyclidine (4 Cs) CombativeCombative CatatoniaCatatonia ConvulsionConvulsion ComaComa NystagmusNystagmus
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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 SalicylateSalicylate
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ABCABCs s AAnticipatenticipateBBeforeeforeCComplicationsomplications
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ABCABCAAirway irway
–C-spine immobilizationC-spine immobilizationBBreathingreathingCCirculationirculation
–secure IV accesssecure IV access
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ABCABCDDisabilityisability
–consciousnessconsciousnessDDrugsrugsDDecontaminationecontamination
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consciousnessconsciousness AA:: Alert Alert V: V: Responsive to Responsive to
verbal stimuliverbal stimuli P:P:Responsive to painResponsive to pain U: U: UnresponsiveUnresponsive
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DrugsDrugsDextroseDextroseOxygenOxygenNaloxoneNaloxone
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DecontaminationDecontamination Ocular- copious saline Ocular- copious saline
lavagelavage Skin- copious waterSkin- copious water GI-consider optionsGI-consider options
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Lab EvaluationLab EvaluationNo “No “tox paneltox panel” that ” that is uniformly helpful is uniformly 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 All suspected ingestioningestionTricyclicsTricyclics
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Pulse oximetryPulse oximetry
Measure of oxygen Measure of oxygen saturation of normal saturation of normal
hemoglobinhemoglobin
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Pulse oximetry Pulse oximetry
Does notDoes not differentiate differentiate COHB from oxyhemoglobinCOHB from oxyhemoglobin
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False low SaturationFalse low Saturation Blue nail polishBlue nail polish Methylene blue Methylene blue Poor distal perfusionPoor distal perfusion
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Blood gasBlood gas
SalicylatesSalicylates
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Chest X-rayChest X-ray
HydrocarbonsHydrocarbons
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EsophagoscopyEsophagoscopy
CausticsCaustics
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Emergent Lab AnalysesEmergent Lab Analyses AcetaminophenAcetaminophen SalicylatesSalicylates MethanolMethanol Ethylene glycolEthylene glycol IronIron
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Emergent Lab AnalysesEmergent Lab Analyses TheophyllineTheophylline Carbon monoxideCarbon monoxide LithiumLithium
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Optimum timeOptimum time ActaminophenActaminophen 4 hours4 hours SalicylatesSalicylates 2-4 hours2-4 hours IronIron 4 hours4 hours CarboxyhemoglobinCarboxyhemoglobin
ImmediateImmediate MethemoglobinMethemoglobin ImmediateImmediate
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Optimum timeOptimum time EthanolEthanol 1/2-1 hour1/2-1 hour Ethylene glycolEthylene glycol 1/2-1 hour1/2-1 hour MethanolMethanol 1/2-1 hour1/2-1 hour DigoxinDigoxin 4-6 hour 4-6 hour
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Serial LevelsSerial Levels SalicylatesSalicylates CarbamazepineCarbamazepine DigoxinDigoxin PhenobarbitalPhenobarbital TheophyllineTheophylline Valproic acidValproic acid
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Radiopaque Radiopaque (CHIPS)(CHIPS) CChloral hydratehloral hydrate HHeavy metalseavy metals IIronron PPhenothiazinehenothiazine SSlow releaselow release
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GI. DecontaminationGI. Decontamination
Preventing Preventing absorptionabsorption
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GI decontamination in a GI decontamination in a symptomatic patient?symptomatic patient?
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DecontaminationDecontamination Syrup of IpecacSyrup of Ipecac Gastric lavageGastric lavage Activated CharcoalActivated Charcoal CatharticsCathartics WBI (bowel irrigation)WBI (bowel irrigation)
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Syrup of ipecacSyrup of ipecac
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Syrup of IpecacSyrup of Ipecac NonprescriptionNonprescription CTZ stimulant CTZ stimulant use only under poison use only under poison
control directioncontrol direction
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Syrup of IpecacSyrup of Ipecac No evidence of improved No evidence of improved
outcomeoutcome Delays AC or antidote for 2 Delays AC or antidote for 2
hourshours No role in hospital settingNo role in hospital setting
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Adverse effectAdverse effect Protracted vomitingProtracted vomiting SedationSedation DiarrheaDiarrhea BradycardiaBradycardia
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ContraindicationsContraindications Altered mental statusAltered mental status SeizureSeizure hemetemesishemetemesis hydrocarbonhydrocarbon corrosivescorrosives
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ContraindicationsContraindications Anticipated use of oral Anticipated use of oral
antidote or WBIantidote or WBI < 6 months old< 6 months old
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Gastric LavageGastric Lavage
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Gastric LavageGastric Lavage one hour (“golden one hour (“golden hour”)hour”)
Life threatening ingestionLife threatening ingestion
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““NG tube is not NG tube is not adequate”adequate”
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Gastric LavageGastric Lavage Large bore orogastric Large bore orogastric
tube (36 - 40 French)tube (36 - 40 French) 0.9% saline 15 ml/kg 0.9% saline 15 ml/kg
max 200-400 ml/cycle max 200-400 ml/cycle
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Gastric LavageGastric Lavage < 30%< 30% by 20-30 min by 20-30 min < 13%< 13% by 60 minutes by 60 minutes
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Gastric LavageGastric Lavage Not a routineNot a routine With in one hourWith in one hour Life-threatening ingestionLife-threatening ingestion Absence of pill fragments does Absence of pill fragments does
not rule out toxic ingestionnot rule out toxic ingestion
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Gastric LavageGastric Lavage TCATCA Calcium-blockerCalcium-blocker ColchicineColchicine
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ComplicationsComplications Pulmonary aspirationPulmonary aspiration
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ContraindicationsContraindications CausticCaustic HydrocarbonHydrocarbon Sharp coingestionSharp coingestion
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Activated CharcoalActivated Charcoal
Universal antidoteUniversal antidote
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Single dose ACSingle dose AC
adsorbing the adsorbing the ingested substanceingested substance
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Activated CharcoalActivated Charcoal Oxidizing process Oxidizing process Increases the adsorptive Increases the adsorptive
capacitycapacity Inert substanceInert substance Reduce the bioavailability of Reduce the bioavailability of
drugdrug
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Activated CharcoalActivated Charcoal
Surface areaSurface area950-2000m950-2000m22/g/g
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Poorly bound by ACPoorly bound by AC
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CHEMICaL CamPCHEMICaL CamP CC CCyanideyanide HH HHydrocarbonydrocarbon EE EEthanolthanol MM MMetalsetals II IIronron CC CCausticsaustics LL LLithiumithium
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CHEMICaL CamPCHEMICaL CamP CC CCamphoramphor PP PPhosphorushosphorus
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Recommended DoseRecommended Dose Up to 1 yearUp to 1 year
–1g/kg1g/kg 1-12 year1-12 year
–25-50 gm25-50 gm
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ComplicationsComplications Pulmonary aspirationPulmonary aspiration EmesisEmesis ConstipationConstipation
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ContraindicationsContraindications HydrocarbonHydrocarbon CorrosiveCorrosive IleusIleus
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Home AC?Home AC? 1,208,860 exposure in < 6 year1,208,860 exposure in < 6 year 16 fatalities16 fatalities 4 might have benefited from early 4 might have benefited from early
administration of ACadministration of AC American American Association of Poison Control Association of Poison Control Centers Toxic Exposure Centers Toxic Exposure Surveillance System (1998)Surveillance System (1998)
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Benefits of Home ACBenefits of Home AC Early administrationEarly administration Reduced morbidity & mortalityReduced morbidity & mortality
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Risks of Home ACRisks of Home AC Inappropriate administrationInappropriate administration Inadequate dosingInadequate dosing Pulmonary aspirationPulmonary aspiration
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Multiple-Dose ACMultiple-Dose AC
Gastrointestinal DialysisGastrointestinal Dialysis
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Multiple-Dose ACMultiple-Dose AC Continue to adsorb remaining toxinContinue to adsorb remaining toxin Interfere with enterohepatic Interfere with enterohepatic
circulationcirculation Lower the free drug concentrationLower the free drug concentration
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Multiple-Dose ACMultiple-Dose AC PhenobarbitalPhenobarbital CarbamazepineCarbamazepine PhenytoinPhenytoin DigoxinDigoxin SalicylatesSalicylates TheophyllineTheophylline TCATCA
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CatharticsCathartics
Decrease transit timeDecrease transit time
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CatharticsCathartics Sorbitol 70%(0.5g/kg)Sorbitol 70%(0.5g/kg) 10 - 20 ml (children)10 - 20 ml (children) 50-100ml(adolescent)50-100ml(adolescent)
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ComplicationsComplications NauseaNausea Abdominal crampsAbdominal cramps VomitingVomiting Transient hypotensionTransient hypotension
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ContraindicationsContraindications Unprotected airwayUnprotected airway IleusIleus Absent bowel soundsAbsent bowel sounds Intestinal obstructionIntestinal obstruction
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WBIWBI
Decontaminate entire Decontaminate entire gastrointestinal tractgastrointestinal tract
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WBIWBI
Commonly used for Commonly used for agents not bound to agents not bound to activated charcoalactivated charcoal
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WBIWBI polethylene glycolpolethylene glycol No fluid abnormalityNo fluid abnormality No electrolyte imbalanceNo electrolyte imbalance End point clear rectal effluentEnd point clear rectal effluent Sustained release preparationSustained release preparation
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WBI WBI 9 months to 6 years9 months to 6 years
–500 ml/hr500 ml/hr 6-12 years (1000 ml/hr)6-12 years (1000 ml/hr) over 12 yearsover 12 years
–1500-2000 ml/hr1500-2000 ml/hr
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WBIWBI Calcium-channel-blockersCalcium-channel-blockers IronIron ArsenicArsenic Lead/zincLead/zinc Packets of illicit drugsPackets of illicit drugs
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ComplicationsComplications Nausea & vomitingNausea & vomiting Bloating / crampsBloating / cramps Pulmonary aspirationPulmonary aspiration
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Urinary AlkalinizationUrinary Alkalinization SalicylatesSalicylates PhenobarbitalPhenobarbital ChlorpropamideChlorpropamide
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Urinary AcidificationUrinary Acidification Never indicatedNever indicated Systemic acidosisSystemic acidosis Renal impairment in Renal impairment in
myoglobinuriamyoglobinuria
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Extracorporeal Extracorporeal ClearanceClearance
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HemodialysisHemodialysis Severe poisoningSevere poisoning Renal failureRenal failure
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HemodialysisHemodialysis 8-10 fold increased clearance 8-10 fold increased clearance Corrects acid-base imbalanceCorrects acid-base imbalance Corrects electrolyte imbalanceCorrects electrolyte imbalance
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HemodialysisHemodialysis Small molecular weightSmall molecular weight Non-ionized, uncharged Non-ionized, uncharged
moleculemolecule Low plasma protein bindingLow plasma protein binding Small volume of distribution Small volume of distribution
(<1.0L/kg)(<1.0L/kg)
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HemodialysisHemodialysis LithiumLithium 4 mEq/L 4 mEq/L Ethylene glycolEthylene glycol 50 mg/dl 50 mg/dl MethanolMethanol 50 mg/dl 50 mg/dl SalicylatesSalicylates 100 mg/dl100 mg/dl
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HemoperfusionHemoperfusion A charcoal or resin cartridgeA charcoal or resin cartridge More effective in selected More effective in selected
poisoningspoisonings Not limited by plasma protein Not limited by plasma protein
bindingbinding Not limited by molecular size Not limited by molecular size
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HemoperfusionHemoperfusion Not effective for acid-base & Not effective for acid-base &
electrolyte imbalance correctionelectrolyte imbalance correction Ineffective in patients with renal Ineffective in patients with renal
failurefailure
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HemoperfusionHemoperfusion PhenobarbitalPhenobarbital 100 mg/L100 mg/L TheophyllineTheophylline 60-60-
100mg/L100mg/L ParaquatParaquat 0.1 mg/dl0.1 mg/dl GlutethimideGlutethimide 4 mg/dl 4 mg/dl MeprobamateMeprobamate 10 mg/dl 10 mg/dl
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AntidotesAntidotes
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AntidotesAntidotes
Use only if specific Use only if specific criteria metcriteria met
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Immediate useImmediate use OxygenOxygen
–carbon monoxidecarbon monoxide NaloxoneNaloxone
–opioidsopioids
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Immediate useImmediate use Methylene blue 1%Methylene blue 1%
–severe cyanosissevere cyanosis–> 40%> 40%
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Immediate useImmediate use Sodium nitriteSodium nitrite
–CyanideCyanide DeferoxamineDeferoxamine
–IronIron
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AntidotesAntidotes Acetaminophen - N-Acetaminophen - N-
AcetylcysteineAcetylcysteine– 140 mg/kg PO140 mg/kg PO– 70 mg/kg q4h for 17 doses70 mg/kg q4h for 17 doses
Anticholinergics - Anticholinergics - PhysostigminePhysostigmine– 0.5 mg IV0.5 mg IV
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AntidotesAntidotes OrganophosphatesOrganophosphates
– AtropineAtropine 0.05-0.1 mg IM or IV0.05-0.1 mg IM or IV– PralidoximePralidoxime 25-50 mg/kg IV25-50 mg/kg IV
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AntidotesAntidotes Benzodiazepine - FlumazenilBenzodiazepine - Flumazenil
– 0.01 mg/kg IV0.01 mg/kg IV Beta Blockers - GlucagonBeta Blockers - Glucagon
– 50 ug/kg IV50 ug/kg IV
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AntidotesAntidotes IsoniazidIsoniazid Pyridoxine 5-10%Pyridoxine 5-10%
– 1 gm/gm of INH ingested IV1 gm/gm of INH ingested IV TCATCA NaHCO3NaHCO3
– 1-2 mEq/kg IM or IV1-2 mEq/kg IM or IV WarfarinWarfarin Vitamin KVitamin K
– 1-5 mg IV or IM1-5 mg IV or IM
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New Antidotes in the New Antidotes in the year 2000year 2000
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New AntidotesNew Antidotes GlucagonGlucagon
– Beta-blocker & Ca-channel blockerBeta-blocker & Ca-channel blocker Insulin & glucose ?Insulin & glucose ?
– Ca-channel blockerCa-channel blocker OctreotideOctreotide
– Sulfonylureas induced Sulfonylureas induced hypoglycemiahypoglycemia
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New AntidotesNew Antidotes Tricyclic antidepressant Tricyclic antidepressant
antibodiesantibodies– TCATCA
Fomepizole (Antizol)Fomepizole (Antizol)– Methanol & ethylene glycolMethanol & ethylene glycol
NalmefeneNalmefene– Opioid poisoningOpioid poisoning
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New AntidotesNew Antidotes Flumazenil (Romazicon)Flumazenil (Romazicon)
– BenzodiazepineBenzodiazepine
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Child Abuse by Child Abuse by poisoningpoisoning
High index of suspicionHigh index of suspicion Its not optional!Its not optional! Mandated to protect these Mandated to protect these
childrenchildren
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Take home messageTake home message Basic supportive care has saved Basic supportive care has saved
more lives than all the antidotes more lives than all the antidotes put togetherput together
Small quantities can have Small quantities can have significant consequencessignificant consequences
Most pediatric ingestion are trivialMost pediatric ingestion are trivial
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If you watch these kids, If you watch these kids, you may not have to do you may not have to do
anythinganything
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ResourcesResources Drug InformationDrug Information (AHFS) (AHFS) PoisindexPoisindex computer database computer database Regional poison centerRegional poison center
– 212-POISONS212-POISONS