Poisoning

Beka Aberra C1

Outline• Introduction• Iron Toxicity•Organophosphate Poisoning•Drugs Toxicity•Hydrocarbon Poisoning•Principles of Management•Prevention of Poisoning

What is a poisoning? • A 2 year old eats

Chewable vitamins; A watch battery; A jade plant; The dog’s medicine….• A 4 year old with anemia has a father who is a

welder.• 16 year old girl takes mom’s Elavil(Antidepressant)

after a fight with her boyfriend.• Your patient on albuterol syrup gets a 10x dosing

error.• Mom is worried about toxic mold, mercury fillings,

vaccination risks, arsenic in the water….

Poison• Any substance (Liquid, Solid or Gas) that is harmful to the body

when Ingested, Inhaled, Injected, or Absorbed through the skin.• Does not include adverse reactions to medications taken

correctly.• Intentional poisoning: A person taking or giving a substance

with the intention of causing harm, e.g. Suicide and Assault• Unintentional poisoning: If the person taking or giving a

substance did not mean to cause harm, e.g. For recreational such as in an “Overdose” or Accidentally taken by a toddler• “Undetermined”: When the distinction between intentional

and unintentional is unclear.

• Poisoning is the fourth most common cause of accidents in children.• Ages less than 5…accidental.• Ages adolescents…intentional, experimental.•More than 90% of toxic exposures in children occur in the home.• Ingestion is the most common route of poisoning exposure (77%

of cases), with the dermal, inhalation, and ophthalmic routes accounting for approximately 7.5%, 6%, and 5% of cases, respectively.• Approximately 50% of cases involve nondrug substances, such as

common household products (cosmetics, personal care items, cleaning solutions, plants, foreign bodies, hydrocarbons).

Which is Candy??? Pharmaceutical preparations comprise the remainder; These are products that are familiar to young children; in addition, they are usually manufactured in visually appealing and great-tasting formulations.

•Acute exposure Is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less. •Chronic exposure Is contact that lasts for many days ,months or years.

How

Poisoning

May

Occur, &

Poisonous

Products!!!

• Overdosing on medicine or using medicine that doesn’t belong to you.

• Being bitten or stung by venomous animals.

• Swallowing or sniffing Paints.• Coming in contact with

poisonous chemicals.• Touching poisonous plants.

• Inhaling poisonous gases such as carbon monoxide, or fumes from strong cleaning products.

• Pesticides.• Petrochemical products e.g. Vasoline • Illegal drugs.• Household cleaning products.

Drug overdose

Poison Ivy

Cleaning Products Venomous Bites

FACTORS THAT CONTRIBUTE TO THE OCCURRENCE OF POISONING IN CHILDREN1. Developmental stage

2. Gender

3. Child-caring practices

4. Poverty

5. Children with special needs

Epidemiology1.Poisoning is divided into accidental poisoning and non accidental or self

poisoning. 2. Accessibility of the poisoning agent is the single most important

environmental risk factor.3. Most drug containers in use in the region are easy to open and do not have a

child lock.4. Many pediatric drug preparation are sugar coated or sweetened and may be

mistaken for sweets.5. Seasonal variations in poisoning occur.6. Illiteracy; unable to follow safety precautions written on the labels of various drugs and chemicals.7. Inadequate labeling of drugs and chemicals increase the risk of poisoning.8. Administration of the wrong drug or the wrong dose.

The effects of poisoning maybe None, Mild or Severe depending on:

• The amount of poison ingested.• The nature of the substance.• The age of the child.• The nutritional status of the child.• The state of the stomach-whether empty or full of food.

Toxic substances have seven common major pathophysiologic mechanisms that may produce symptom

Interfere with the transport or tissue utilization of O2 e.g. CODepress or stimulate CNS e.g. MDMAAffect autonomic nervous system e.g. Organophosphate Affect the lungs by aspiration e.g. HydrocarbonAffect the heart and vasculature myocardial dysfunction e.g.

Antidepressant Produce local damage e.g. Corrosive Affect on the liver e.g. Acetaminophen

Common Substances Causing Poisoning in ChildrenHousehold Agents:- Organophosphates, pesticides, malathion,

Rat poison, Désinfectants and bleach.

Médicaments:- Aspirin, Paracétamol, Anti-convulsant drugs (cabarmazepine, phenobarbitone), Haematinics (iron and vitamins), Major tranquilizers (phénothiazines), Some herbal therapies.

One year study done in Tikur Anbessa (2007/2008)• Acute poisoning with in one year was 116.• 75 male and 41 female.• Mean age 21 years. • 96.5% intentional. • Cause of poisoning - 43.1% House hold cleaning agents - 20.7% Organophosphate - 10.3% Phenobarbital • Mortality 8.6%,death occur by organophosphate and

Phenobarbital poisoning.

RecognitionIt may be easily observable that someone has been poisoned if:• Chemical products are evident at the victims scene.• Drugs are on or around the victim (medical or illegal).• A syringe is in or next to victim.• Warning signs of gases and chemicals are at/around the location.• Victim is conscious and tells first aider they have been poisoned.If none of these points are apparent in a possible poisoning case, there

are numerous signs and symptoms to look for in the victim, that will enable you to establish if they have been poisoned.

Sign indicating presence of hazardous chemicals Syringe

Example of poisonous chemical

Approach to the poisoned patient• A detailed history and physical examination serves as the foundation

for a thoughtful differential diagnosis and the formation of an initial prognosis.

• The history and physical examination should not await the collection of body fluid and the results of a “tox screen.”

• Toxicology laboratory analyses, or “screens,” in fact evaluate for only a small fraction of common pediatric exposures and rarely make (vs confirm) the diagnosis.

INITIAL PATIENT EVALUATION

Identification of the patient and toxic agent. What? Description of the toxin. How much? Magnitude of the exposure.When ?Time of exposure. Progression of symptoms. Medical history.

Cont.PATIENT HISTORY. Description of Toxins.

• Product names (brand, generic, chemical) and ingredients, along with their concentrations, may be obtained from labels.• Several characteristic toxic syndromes, or “toxidromes,” exist for some of the more common exposures and may assist in

identifying the offending agent.Example Increased sympathetic nervous system activity Poison Syndrome• Pyrexia • Flushing • Tachycardia Hypertension Associated Signs• Pupillary constriction • Sweating Cough and decongestant preparations Amphetamines Cocaine Possible Toxins Ecstasy Theophylline

Magnitude of Exposure• It is important to attempt to determine as accurately as possible how much of the substance has been

ingested by counting the remaining tablets or measuring the remaining volume of liquid.• It is better to overestimate than to underestimate.• Estimates can be refined as the patient is assessed over time and initial laboratory data become available. • Because the toxicity of most agents is dose-related, knowing the age or weight of the child aids in

assessment.• For inhalation, ocular, or dermal exposures, the concentration of the offending agent and the length of

contact time with the material should be determined, in addition to the time course for associated symptoms to occur, their progression, and possible resolution.

Time of Exposure.• For some products, toxic manifestations may be delayed for hr. or days. Knowing the time lapse between exposure

and the onset of symptoms and/or medical evaluation will markedly influence decisions about obtaining certain diagnostic testing as well as therapeutic intervention.

Progression of Symptoms.• Knowing the nature and progression of symptoms is very helpful for assessing the need for immediate life

support, the prognosis, and the type of intervention that may be needed.

Medical History• Underlying diseases may make a child more susceptible to the effects of a toxin. • Concurrent drug therapy may also increase susceptibility because certain drugs may interact

with the toxin. • Pregnancy is a common precipitating factor in adolescent suicide attempts and can influence

the patient evaluation and treatment plan. • At 6 mo of age or younger, it is very unlikely that an infant could become accidentally exposed

to a sufficient quantity of a potentially harmful product in the absence of other extraneous factors that require further investigation (social environment).

Signs & Symptoms of Poisoning • Lower level, if any of consciousness.• Altered mood: lethargic, ecstatic,

violent or hostile.• Differed breathing rate.• Increased or lowered heart rate.• Dilated or shrunken pupils• Change of colour around mouth• Cramps• Nausea• Vomiting• DiarrhoeaVomiting

ODORBitter almonds CyanideAcetone Isopropyl alcohol, Methanol, Paraldehyde, SalicylatesAlcohol EthanolWintergreen Methyl SalicylateGarlic Arsenic, Thallium, OrganophosphatesOCULAR SIGNSMiosis Narcotics (except meperidine), Organophosphates, muscarinic

mushrooms, clonidine, phenothiazine's, chloral hydrate, barbiturates (late), PCP

Mydriasis Atropine, alcohol, cocaine, amphetamines, antihistamines, cyclic antidepressants, cyanide, carbon monoxide

Nystagmus Phenytoin, barbiturates, éthanol, carbonmonoxideLacrimation Organophosphates, irritant gas or vaporsRetinal hyperemia MethanolPoor vision Methanol, botulism, carbon monoxide

CUTANEOUS SIGNSNeedle tracks Heroin, PCP, amphetaminesBullae Carbon monoxide, barbituratesDry, hot skin Anticholinergic agents, botulismDiaphoresis Organophosphates, nitrates, muscarinic mushrooms, aspirin, cocaineAlopecia Thallium, arsenic, lead, mercuryErythema Boric acid, mercury, cyanide, anticholinergicsORAL SIGNSSalivation Organophosphates, salicylates, corrosives, strychnineDry mouth Amphetamines, anticholinergics, antihistamineBurns Corrosives, oxalate-containing plantsGum lines Lead, mercury, arsenicDysphagia Corrosives, botulismINTESTINAL SIGNSCramps Arsenic, lead, thallium, OrganophosphatesDiarrhea Antimicrobials, arsenic, iron, boric acidConstipation Lead, narcotics, botulismHematemesis Aminophylline, corrosives, iron, salicylates

CARDIAC SIGNSTachycardia Atropine, aspirin, amphetamines, cocaine, cyclic antidepressants, theophylline

Bradycardia Digitalis, narcotics, mushrooms, clonidine, Organophosphates, β blockers, calcium channel blockers

Hypertension Amphetamines, LSD, cocaine, PCPHypotension Phenothiazines, barbiturates, cyclic antidepressants, iron, β blockers, calcium channel blockers

RESPIRATORY SIGNSDepressed respiration Alcohol, narcotics, barbituratesIncreased respiration Amphetamines, aspirin, ethylene glycol, carbon monoxide, cyanide

Pulmonary edema Hydrocarbons, heroin, Organophosphates, aspirinCNS SIGNSAtaxia Alcohol, antidepressants, barbiturates, anticholinergics, phenytoin, narcotics

Coma Sedatives, narcotics, barbiturates, PCP, Organophosphates, salicylates, cyanide, carbon monoxide, cyclic antidepressants, lead

Hyperpyrexia Anticholinergics, quinine, salicylates, LSD, phenothiazine's, amphetamines, cocaine

Muscle fasciculation Organophosphates, theophyllineMuscle rigidity Cyclic antidepressants, PCP, phenothiazines, haloperidol

Paresthesia Cocaine, camphor, PCP, MSGPeripheral neuropathy Lead, arsenic, mercury, organophosphatesAltered behavior LSD, PCP, amphetamines, cocaine, alcohol, anticholinergics, camphor

Iron Toxicity

• The most common cause of death in toddlers.•Classically taught as having five clinical stages.•Remember prenatal vitamins, supplements, and

“natural products”.• Toxic doses occur at 10-20mg/Kg of elemental iron.•Prenatal vitamins typically contain about 65 mg of

elemental iron. •Children's vitamins contain about 10-18 mg of

elemental iron.

The Five Stages• Stage 1• Nausea, vomiting, abdominal pain and diarrhea.

• Stage 2• This is the latent phase often between 6-24 hours as the patient resolves GI symptoms.

• Stage 3• Shock stage involving multiple organs including coagulopathy, poor cardiac output,

hypovolemia, lethargy and seizures.

• Stage 4• Continuing of hepatic failure and ongoing oxidative damage by the iron in the

reticuloendothelial system.

• Stage 5• Gastric outlet obstruction secondary to scarring and strictures.

• If possible, determining the number of pills ingested, how much iron was in each pill, and the formulation of iron in the supplement is important.

Different formulations of iron contain varying amounts of elemental iron: Ferrous sulfate - 20% elemental iron Ferrous gluconate- 12% elemental iron Ferrous fumarate - 33% elemental iron Ferrous lactate - 19% elemental iron Ferrous chloride - 28% elemental iron• The following is a formula used to calculate the amount of ingested iron

for a 10-kg child who consumed ten 320-mg tablets of ferrous gluconate (12% elemental iron per tablet):

10 tablets X 38.4 mg elemental iron per tablet = 384 mg/10 kg = 38.4 mg/kg

Laboratory Studies

• A serum iron level should be determined (during peak levels) at 2 -4 hours after ingestion:

> 300 mg/dL indicates mild intoxication, > 500 mg/dL indicates serious intoxication, but a serum iron level in

excess of the total iron-binding capacity does not serve as a useful predictor of iron poisoning. • Laboratory data may reveal leukocytosis, hyperglycemia& radiopaque

tablets on a flat plate of the abdomen.

Organophosphate Poisoning (Pesticides)Insecticides (worldwide).Nerve gas (sarin, tabun).• Chlorpyrifos, parathion, diazinon, famphur, phorate,

terbufos, and malathion are examples of organophosphates while• Carbofuran, aldicarb, and carbaryl, are carbamates.• They work by inhibiting acetyl cholinesterase resulting

in an overabundance of acetylcholine at synapses & the myoneural junction. • Present with cholinergic symptoms• Cutaneous exposure• Inhalation• Ingestion

MECHANISM OF ACTION

Organophosphorous compounds contain carbon and phosphorous acid derivatives.

They bind to acetyl cholinesterase (AChE), also known as red blood cell (RBC) acetyl cholinesterase or neural acetyl cholinesterase, and render this enzyme non-functional.

Incapable of degrading the neurotransmitter acetylcholine. Acetylcholine accumulate at neuromuscular junctions and

synapses.Stimulate the muscarinic and nicotinic receptors.

Cholinergic Symptoms

Signs of overexposure (within the first few hours)

1. Parasympathetic (muscarinic)

Sweating

Salivation

Lacrimation

Bradycardia

2. Sympathetic nervous system (nicotinic)

HypertensionMuscle

fasciculation'sMotor weakness

Tachycardia

3. CNS

Giddiness Anxiety

Drowsiness

Convulsions

CLINICAL FEATURESOnset and duration of AChE inhibition varies depending:- - On the Organophosphorous agent's rate of AChE inhibition - The route of absorption

For most agents, oral or respiratory exposures generally result in signs or symptoms within three hours.

While symptoms of toxicity from dermal absorption may be delayed up to 12 hours.

Cont.Primary toxic effects involve the autonomic nervous system,

neuromuscular junction, and central nervous system (CNS).

The parasympathetic nervous system is particularly dependent on acetylcholine regulation.

Both the autonomic ganglia and the parasympathetic nervous system are regulated by nicotinic and muscarinic cholinergic receptor subtypes, respectively.

Cont.The muscarinic signs can be remembered by use of one of two mnemonics:SLUDGEBB (Salivation, Lacrimation, Urination, Defecation, Gastric Emesis,

Bronchospasm, Bradycardia)

DUMBELS (Defecation, Urination, Miosis, Bradycardia, Emesis, Lacrimation, Salivation)

Stimulation of nicotinic receptors Release of epinephrine and nor epinephrine ,muscle weakness, fasciculation

hypertension, central respiratory depression, lethargy convulsion and coma.

Cont.

Depends on the balance between stimulation of muscarinic and nicotinic receptor.

The balance depend on the - Type of organophosphate - Dose - Route and rate of absorption - Individual factor

DIAGNOSIS

• The diagnosis of organophosphate poisoning is made on clinical grounds.

• If doubt exists as to whether an organophosphate has been ingested, a trial of atropine 0.01 to 0.02 mg/kg may be employed.

• The absence of signs or symptoms of anticholinergic effects following atropine challenge strongly supports the diagnosis of poisoning.

Nicotinic Symptoms• Remember the days of the week!!!!!• Mydriasis• Tachypnea• Weakness• Tachycardia• Fasciculation's• Pediatric patients tend to present with a predominance of nicotinic symptoms!!!

Weakness from Pesticides

Laboratory Studies• Obtain a CBC count to rule out infectious causes.• Chemistry tests may be useful in ruling out electrolyte disturbances.• Hypokalemia, hyperglycemia ,leukocytosis, proteinuria, glycosuria• ECG sinus tachycardia.• RBC cholinesterase tests may reveal decreased activity, which confirms

the diagnosis.

Legislation

•The Poison Prevention Packaging Act of 1970. (PPPA)•Requires child protective packaging of hazardous household

products.•Over the last 30 years the list of substances regulated by the

PPPA have expanded to include medicines, solvents, and oils.•Data shows reduction of 45% mortality of pediatric patients

since the introduction and expansion of PPPA.

Bibliography• Nelson Textbook of Pediatrics, 18th ed.Copyright © 2007 Saunders, An Imprint of Elsevier• Up to date• World Health Organization: • Michael JB, Sztanjnkrycer MD. Deadly pediatric poisons: nine

common agents that kill at low doses. Emergency Medicine Clinics of North America 2004; (22): 1019-1050

• ‘First aid international , fractures, Poisons.’http://www.firstaidinternational.com.au/poisons%20bites%20stings.htm Retrieved: 5-8-08

THANK YOU“Everything is poisonous, there is nothing that is nonpoisonous. Solely the dose separates a poison from a remedy.”

Paracelsus, Father of Toxicology