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Common Pediatric Poisonings

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Brian Nuyen

on 15 March 2013

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Transcript of Common Pediatric Poisonings

Brian Nuyen
Student Seminar Presentations Common Acute Pediatric Poisonings 2.4 million+ reports of toxin exposures in the US
Most are:
Oral (76%)
Occurred in home (93%)
Unintentional (80%+)
Children younger than 6 accounted for a slight majority (51%)
*most nontoxic, and managed at home
>1,183 fatalities Background and Statistics: What's the problem here? Initial Assessment and Triage Emergency Stabilization Any respiratory, circulatory, or neurologic sx?
-> send to ED Thorough PEX Reassess often Hypoglycemia, with altered mental status?
...Give IV thiamine then dextrose, at 5 mL/kg for infants and 4 mL/kg for children

Suspected opioid overdose?
...Naloxone (Narcan), at 0.1 mg/kg for children <5yo and 0.1-0.8 mg/kg for older children Emergency Meds for Childhood Poisonings Labs HPI and ROS
are key. …Time and type of probable exposure
….Method of exposure
…Ingestion of meds brought into home?
...Do they always have to go to the ED?
….Caller should be kept online while poison control (800-222-1222) and ambulance are contacted Next step. HPI and ROS are key. Why, you ask? Commonly Ingested Substances: ~Most = mild or no symptoms
~Others: even a small amount may have consequences.
~These most toxic substances to a small child include IRON*, ANTIDEPRESSANTS, HYPOGLYCEMICS, CV DRUGS, SALICYLATES, AEDs, and ILLICIT drugs.
~Delayed effect? The Culprits Cosmetics and personal care products
Cleaning products
Topical Agents
Foreign Bodies
Cough and cold prep
Arts/Crafts/Office Supplies
Gastrointestinal symptoms
Hormones and hormone antagonists Prevalence of Substances in
Poisoned Children < 6 yo Selected Toxins with
Delayed Symptoms Delayed absorption:
Carbamazepine (Tegretol)
Concretions (iron*, aspirin, theophylline)
Diphenoxylate/atropine (Lomotil)
Enteric-coated preparations
Sustained-release preparations
Delayed mechanism:
Monoamine oxidase inhibitors
Thyroid hormones
Toxic mushrooms
Toxic metabolites:
Toxic alcohols (methanol, ethylene glycol)
Lithium Amphetamines, caffeine, cocaine, ephedrine, 3,4-methylenedioxymethamphetamine (also called Ecstasy), phenylpropanolamine (no longer available in the United States), theophylline, diphenoxylate/atropine (Lomotil) Sympathomimetics! Sx: Tachycardia, hypertension, mydriasis, agitation, seizures, diaphorsis, psychosis, hyperthermia

What is it? Last but not least… Tx: Octreotide (Sandostatin) Sulfonylureas Sx: Hypoglycemia, tachycardia, diaphoresis, clammy skin, mental status changes

What’s the poison and antidote? Type of Poisoning Tx: Dialysis and management of metabolic acidosis Salicylates Sx: Tinnitus, nausea, vomiting, fever, disorientation, lethargy, tachypnea

What’s the poison? Type of Poisoning E.g. morphine, hydrocodone, methadone

Tx: Short-acting naloxone, monitoring closely for withdrawal symptoms Opioids Sx: Hypoventilation, hypotension, miosis, sedation, hypothermia, ileus

Can you guess the poison and the antidote? Type of Poisoning Antidote: Deferoxamine (Desferal) Iron/Iron-containing products Sx: dyspepsia, nausea, vomiting, diarrhea, dark stools

Can you guess the poison and the antidote? Type of Poisoning Agents: Black widow spider bites, carbamates, insecticides, nicotine

Tx: Atropine/pralidoxime  Cholinergic Nicotinics Sx: Tachycardia, hypertension, fasciculations, gastrointestinal cramps, emesis, miosis

Can you guess the poison and the antidote? Type of Poisoning Agents: carbamates, some mushrooms, organophosphates, physostigmine, pilocarpine, pyridostigmine

Antidote: Atropine/pralidoxime Cholinergic Muscarinics Sx: Salivation, lacrimation, urination, diarrhea, bronchorrea, wheezing, bradycardia, vomiting

Can you guess the poison, and the antidote? Type of Poisoning? Calcium channel blockers, beta blockers, digoxin

Treatment? Calcium chloride, glucagons (Glucagen), digoxin immune fab (Digibind) Cardiac Medications Sx: Bradycardia, arrhythmias, hypotension, dizziness, heart block, nausea, vomiting

Can you guess what type of poisoning, and treatment? Type of Poisoning …which include Warfarin (coumadin), rodenticides

Emergently: Fresh frozen plasma, later, Vitamin K Anticoagulants! …which include antihistamines, atropine (Atreza), belladonna alkaloids, toxic mushrooms, psychoactive drugs Anticholinergics!! Sx: Tachycardia, hyperthermia, mydriasis, warm and dry skin, urinary retention, ileus, delirium

…can you guess what the poison is? Type of Poisoning Acetaminophen!!!

YAY Can you guess? Sx: Abdominal pain, nausea, vomiting, elevated AST, jaundice, confusion, somnolence, coma, disorientation.

Antidotes: N-acetylcysteine (Acetadote)

What is the poison? Type of Poisoning: Toxidrome (portmanteau of toxic and syndrome) is a syndrome caused by a dangerous level of toxins in the body.

Coined in 1970 by Mofenson and Greensher. What are toxidromes? Sx: Ecchymoses, bleeding, prolonged prothrombin and bleeding times

What’s the poison and antidote? Type of Poisoning …Let’s get ready to rumble. Toxidromes Toxidromes ~Clinical suspicion

~Some comments on UTox:
...typically test JUST for drugs of abuse

...In one study, only 3 percent of screening test results in the pediatric ED were positive without suspicion of an exposure Laboratory Assessment Bicarbonate -> Renal failure
Blood glucose -> Hypoglycemic ingestion
Electrocardiography -> Cardiotoxicity
Electrolytes, BUN, serum creatinine -> Renal failure
Prothrombin time -> Coagulopathy
Pulse oximetry -> Hypoxia
Urine HcG -> pregnancy
ABG or VBG -> Hypoxemia
Creatine kinase -> Nephrotoxicity, rhabdomyolysis

Specific drug levels (e.g., salicylates, iron, digoxin, anticonvulsants, alcohol)

Urine drug screen
Opioid or street drug ingestion
Nephrotoxicity/renal failure Suggested Starting Point Lab Tests •Re-affirm stabilization and orders
for symptomatic treatment
•Watch and Wait
•When do you do gastric lavage?
•Routine use of activated charcoal effective?
•Role of syrup of ipecac Treatment Probably good. :)

Thanks for your attention, friends. Jimmy’s prognosis? IV glucose
Activated Charcoal ASAP
Glucagon (or Somatostatin) Management Jimmy is a 4yo male whose clinical presentation is consistent with oral hypoglycemic agent toxicity. Assessment Fingerstick glucose: 43 mg/dL
CBC: normal, slightly elevated white count
Electrolytes: Upper limit hyperkalemia, lower limit hyponatremia, hypocalcemia
Utox: Negative Labs Vitals: Wt: 17 kg…HR: 140…RR: 40…BP125/80...afebrile
Growth: 64% height, 52% weight
General Appearance: WDWN toddler, lethargic, irritable
HEENT and Neck: Blurred vision, pale conjunctiva, pupils dilated, round and reactive.
CV/Lungs: Sinus tachycardia, no extra heart sounds or murmurs/rubs/gallops. Tachypnea, CTAB, no wheezes, rales, rhonchi.
Abdomen: Diffuse abdominal pain, nontender to palpation, no rebound tenderness or induced signs. No masses or organomegaly.
Genitalia: Normal Tanner Stage 1 male
Extremities/Skin: Diaphoretic, pallorous, cold extremities.
Neurology: Normal
Psych: Normal PEX JFM is a 4yo Caucasian male whose presentation is called in by his mother.
He presents today with a 20-minute acute-onset history of lethargy, confusion, cold skin, and vomiting. He was playing in the living room by himself, out of sight from his mother, when his mother discovered him in the above state. ROS notable for nausea/vomiting, blurred vision, tremors, irritability, abdominal cramping, and sweating.
He has never had these symptoms before.

Birth history, development, past medical history, past surgical history are all normal/nonremarkable.

Social history: Lives with mother and father only.

Family history: Both mother and father are morbidly obese and have Type II Diabetes, for which they take insulin and sulfonylureas.

Medications: None, and NKDA HPI …You’re writing a history of present illness.
What do you want to know? Jimmy’s mom calls your office with this history. Jimmy is a 4-year old male with lethargy, confusion, and cold skin. Let’s talk about Jimmy 1. Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2005;23(5):589–666.
2. Hoffman R, Osterhoudt KC. Evaluation and management of pediatric poisonings. Pediatr Case Rev. 2002;2(1):51–63.
3. Barry JD. Diagnosis and management of the poisoned child. Pediatr Ann. 2005;34(12):937–946.
4. Liebelt E, DeAngelis C. Evolving trends and treatment advances in pediatric poisoning. JAMA. 1999;282(12):1113–1115.
5. Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. 2003;21(1):101–119. References 6. Litovitz T, White NC, Watson WA. Epidemiology of pediatric poison exposures: an analysis of 2003 poison control center data. Clin Pediatr Emerg Med. 2005;6(2):68–75.
7. Osterhoudt K. The toxic toddler: drugs that can kill in small doses. Contemp Pediatr. 2000;3:73–88.
8. Larsen LC, Cummings DM. Oral poisonings: guidelines for initial evaluation and treatment. Am Fam Physician. 1998;57(1):85–92.
9. Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or one teaspoonful: a 2004 update. Paediatr Drugs. 2004;6(2):123–126.
10. Morris CC. Pediatric iron poisonings in the United States. South Med J. 2000;93(4):352–358.
11. Woolf A, Litovitz T. Progress in the prevention of childhood iron poisoning. Arch Pediatr Adolesc Med. 2005;159(6):594–595.
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