Extern ConferenceExtern Conference

16 Aug 2007

A one-year-old boy was referred to Siriraj hospital

due to an accidental ingestion of unknown liquid substance for two and a half

hours prior to admission.

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Present historyPresent history

2 ½ hours PTA, the patient was brought to his uncle’s house by his

father and his step-mother. While his father and his uncle were watching

the television, the step-mother found that her son was drinking some amount of liquid substance from plastic bottle which was used for

battery refilling.

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Present historyPresent history

The child was crying and sweeping his hand over his mouth.

His father washed the patient’s mouth with drinking water and gave

his son some milk to induce vomiting. The patient vomited the

ingested milk with sputum and saliva for 4 times.

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Present historyPresent history

Before his parents brought him to a nearby hospital, he vomited some streaks of blood with gastric

contents.

The parents did not notice that the patient was aspirated or not.

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Present historyPresent history

At emergency room, the patient was given

• Activated charcoal 10 g orally• Metoclopramide 2 mg intravenously• Ranitidine intavenously • Cetriaxone intravenously• NPO

Then the patient was referred toSiriraj hospital.

The patient was admitted at AN 5 on 6/8/50

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Past historyPast history

• He has no underlying disease.• He has no previous history of

unexplained injuries or poisoned.• He has normal developmental

milestones.• He has no previous history of drugs

or food allergy.

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Family historyFamily history

• The patient lived with his father, his step-mother, and his grandmother.

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Physical ExaminationPhysical Examination

V/S: T 37 oc, PR 148/min, RR 40/min, BP

98/72 mmHgGA: A crying Thai boy, looked distress,

no pallor, no jaundice, no dyspnea, no cyanosis, no evidence of trauma,

Ht 87 cm (P75-P90), Wt 11.5 kg (P50-P75)

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Physical ExaminationPhysical Examination

HEENT:nose: no swelling turbinate, no dischargeears: normal tympanic membranes, both sidesmouth & throat: mild dry lips, mild injected upper & lower lips, no injected oral mucosa, mild injected oropharynx

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Physical ExaminationPhysical Examination

RS: no stridor, normal breath sound, no adventitious sound

CVS: normal S1&S2, no murmurAbd: soft, no tenderness, active bowel

sound, liver & spleen cannot palpable

NS: pupil size 3 mm both RTL, otherwise unremarkable

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Problem listProblem list

1. Ingestion of unknown liquid substance

2. Mild injected upper and lower lips with mild injected oropharynx

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ImpressionImpression

• Suspected caustic ingestion

Management in poisoned child

1. Assessment and resuscitation

2. Diagnosis of poisoning

3. Decontamination / Enhanced elimination

4. Disposition

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1. Assessment and 1. Assessment and ResuscitationResuscitation

• Airway : Maintain airway

• Breathing : Proper ventilation and oxygenation

• Circulation : Adequate perfusion

• Disability : Assess level of consciousness and neurological examination

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2. Diagnosis of poisoning2. Diagnosis of poisoning

• History taking : – including the containers and labels of

the ingested substance

• Physical Examination: Focus on– Cardiopulmonary– Respiratory– Neurological– Toxidromes

• Proper investigation

How to obtain a poisoning history?

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What has been ingested?

• Ask for containers of the substance, they may offer more details.

• What is the substance used for?• The details of ingredients of the

commercial products and medications can be obtained from the poison center.

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Label

น้ำ���กลั่��น้ำ-กรด ตร�ปลั่�ทองใช้�สำ��หร�บเต�มใน้ำแบตเตอร��เท��น้ำ��น้ำ

คำ��เต�อน้ำ ถ้��สำ�มผั�สำถ้!กสำ�รน้ำ��ให�ร�บใช้�น้ำ���สำะอ�ดลั่��งท�น้ำท�

โทร : 081-xxxxxxx

NOTE : Information from patient’s father

The information from the manufacturer: 1.5 % Sulfuric Acid

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How much has been intake?

• Ask the parents or the caregivers who has been in the situation.

• In liquid ingestion, it is noted that the amount of the ingested substance may be over reported but should not be assumed to be wrong.

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When was it taken?

• Time since ingestion• This can help you to know a time for

onset of symptoms consequently you can obtain proper investigations and management.

• Crucial for poisons that require blood level monitoring (example: paracetamol)

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What symptoms or signs have been shown?

• These information can help to narrow down that class of ingested substance.

• Physical examination focused on cardiopulmonary, respiratory and neurological systems and look for secondary trauma : burned lips and oral cavity in the patient with caustic ingestion.

• Look for the signs and symptoms of toxidromes.

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3.Decontamination/Enhanced 3.Decontamination/Enhanced eliminationelimination

• Gastric lavage

• Ipecac

• Activated charcoal

• Whole bowel irrigation

• Hemodialysis

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4. Disposition4. Disposition

• Discharge from emergency department – Intensive care unit– Ward– Nonmedical facility eg. Psychiatric

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Recognition of child abuseRecognition of child abuse

• Unexplained delay in seeking treatment

• Parents are uninterested by an accident

• Is the history consistent each time?• Mechanism of injury inconsistent with

developmental capability• Reluctance to give information or

mention about previous injury.• Unexplained injury on examination.

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Investigations Investigations (in this patient) (in this patient)

• BUN 17.0 mg/dl• Cr 0.4 mg/dl • Na+ 135 mmol/L• K+ 4.4 mmol/L• Cl- 99 mmol/L• HCO3- 11 mmol/L

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CXR1st day of admission

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Activated charcoal

Functions of activated charcoal

1. Initial toxin absorption

2. Interruption of enterohepatic

circulation of toxic metabolite

3. gastrointestinal dialysis

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Activated charcoal

• Activated charcoal is being increasingly used in the management of childhood poisoning

• Adsorb toxic material in the gut by offering alternative binding site

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Activated charcoal

No advantage in

Alkali, Boric acid, Cyanide, DDT, Ferrous sulfate, Lithium, Mineral acids, Methanol, Malathion, N-methyl carbamate

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Activated charcoal

Route and doses

• 1 gm/kg/dose (maximum, 50-60 gm) oral

• Repeated every 2-6 hrs until charcoal is passed through the rectum

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Activated charcoal

Contraindications

1. People with an obstruction of the intestines

2. Person swallowed a corrosive agent, such as a strong acid or alkali

Accidental caustic ingestion

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Accidental caustic ingestion

• High risk group is children younger than 5 years old.

• Male > Female• The extent and severity of the

caustic injury depends on :1. The corrosiveness of the ingested

substance

2. Quantity and concentration

3. Duration of contact time

4. Subsequence secondary infection

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Caustic agents

• Caustics are typically classified as acids or alkalis.

• Zinc chloride, Phenol and button battery are capable of producing severe burns even though they have near physiologic pH.

• Hydrofluoric acid has not only local effects but also has fatal systemic effects eg. hypocalcemia, hypomagnesemia, hyperkalemia.

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Caustic agents

• Acid– Coagulation necrosis of tissue that

produces an “eschar” to have some protective effect on deeper tissue.

• Alkali– Saponification of lipids– Liquefaction necrosis which causes

much deeper ulceration because of no barrier to the alkali until it is sufficiently buffered by proteins, tissue fluid, and soaps.

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Complications

• Early complications– Local complications

• Upper GI Perforation• Respiratory inflammation (rare)

– Systemic complications• Renal insufficiency, hepatic

dysfunction, DIC, hemolysis

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Complications

• Late complications– Esophagus

• Stricture, fistula• Peptic esophagitis, hiatus hernia,

Barrett’s esophagus, esophageal carcinoma

– Stomach• Stricture, fistula• Anemia, vitamin B12 deficiency, growth

retardation in case of total gastrectomy

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Complications

• Children VS adults– In children, most such events are

inadvertent.– In adults, ingestion usually is a deliberate

attempt to commit suicide.– The lower mortality in series of pediatric

patients might be explained by ingestion of smaller amounts of the chemical agent.

– However, stricture formation in pediatric patient is relatively common.

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Management in caustic ingestion

• Acute management

– Initial assessment and stabilization should focus on airway.

– Steroids : The use of corticosteroids remains controversial. There was a reduction in the number of dilatations required and the number of patients who developed stricture when using 1 mg/kg/day of dexamethasone.

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Management in caustic ingestion

• Acute management– Antibiotics

• There are no control trials that identify the routine use of antibiotics after caustic ingestion

• Indications:– Grade 2 or greater lesion with deep ulcer– Elevated in temperature– Grade 3 lesion or perforation, antibiotics

should be started immediately

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Management in caustic ingestion

• Acute management– Acid suppression

• Should be used in cases of grade 2-3 esophageal injury.

• The refluxing acid from stomach will damage the exposed tissues of the esophageal wall and may inhibit the healing process by damaging in-growing new cells.

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Management in caustic ingestion• Decontamination, dilution,

neutralization – Dilutional therapy is of limited

benefit beyond the first few moments following ingestion but should be avoid in patient with nausea, drooling, stridor or abdominal distension as it may induce vomiting.

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Management in caustic ingestion• Decontamination, dilution,

neutralization – GI decontamination is usually

limited in the patient with caustic ingestion.

– Induce emesis is contraindicated.– Caustic agents are poorly

absorbed by activated charcoal.

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Management in caustic ingestion• Decontamination, dilution,

neutralization – Neutralization of caustics should

be avoided because of potentially tissue damaging by forming gas and generating heat.

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Management in caustic ingestion

• Surgical management :

– Evidence of perforation either by endoscopic or diagnostic imaging

– Severe abdominal rigidity

– Persistent hypotension

– Severe extensive burns

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Management in caustic ingestion

• Subacute management– Early endoscopy should be

performed in every patients to assess

• Extent of lesions • Severity • Further management.

Classification of Caustic injury

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Grade Visible effect Clinical Significance

Grade 0 History of ingestion, no visible damage or symptoms.

Able to take fluid immediately.

Grade 1 Edema, loss of normal vascular pattern, hyperemia. No

transmucosal injury.

Temporary dysphagia, able to swallow within 0-2 days. No long-term

sequalae.

Grade 2a Trans-mucosal injury with fragility, hemorrhage,blistering, exudates, scattered superficial ulceration.

Scarring, no circumferential damage = no stenosis. No long

term sequelae.

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Grade Visible effect Clinical Significance

Grade 2b Plus deep discrete ulceration and/or circumferential.

Small risk of perforation. Scarring which may result in

later stenosis.

Grade 3a Scattered deep ulceration with necrosis of tissue.

Risk of perforation. High risk of later

stenosis.

Grade 3b Extensive necrotic tissue. High risk of perforation and death. High risk of

stenosis.

Note : Grade 4 may be used to indicate perforation

Progression

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Progress

RanitidineCefotaxime

Dexamethasone

NPOTPN

EGD

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Pictures

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Esophagogastroduodenoscopy

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Esophagogastroduodenoscopy

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EG junction: White membrane at junction

Esophagogastroduodenoscopy

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Body: Erythema, bleeding, necrotic, friability, ulcer

Esophagogastroduodenoscopy

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Body: Erythema, bleeding, necrotic, friability, ulcer

Esophagogastroduodenoscopy

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Body: Erythema, bleeding, necrotic, friability, ulcer

Esophagogastroduodenoscopy

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Body: Erythema, bleeding, necrotic, friability, ulcer

Esophagogastroduodenoscopy

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Antrum: Erythema, bleeding, necrotic, friability, ulcer

Esophagogastroduodenoscopy

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Bulb:

Some erythema, white lesion, desquamation of mucosa

Esophagogastroduodenoscopy

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Bulb:

Some erythema, white lesion, desquamation of mucosa

Esophagogastroduodenoscopy

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2nd portion of duodenum:

Marked edema, necrotic

Esophagogastroduodenoscopy

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3rd portion of duodenum:

Marked edema,necrotic

Esophagogastroduodenoscopy

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3rd portion of duodenum:

Marked edema,necrotic

Esophagogastroduodenoscopy

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Summary of EGD ReportSummary of EGD Report

• Procedure : none

• Complication : no immediate complication

• Diagnosis : caustic ingestion

• CLO test : not done

• Recommendation : -• Specimens : -• Plan : Re-EGD 17/8/50

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Preventing childhood Preventing childhood poisoningpoisoning

1. Insist on packages with safety closures and learn how to use properly

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Preventing childhood Preventing childhood poisoningpoisoning

2. Keep household cleaning supplies, medicines, garage products, and insecticides out of the reach and sight of your child

3. Never store food and cleaning products together. Store medicine and chemicals in original containers and never in food or beverage containers

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Preventing childhood Preventing childhood poisoningpoisoning

4. Avoid taking medicine in your child’s presence. Children love to imitate. Never suggest that medicine is candy.

5. Never use medicine from an unlabeled or unreadable container

6. If you are interrupt while using a product take it with you.

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Preventing childhood Preventing childhood poisoningpoisoning

7. Know what your child can do physically. For example , if you have a crawling infant, keep household product stored above floor level.

8. Keep the phone numbers of your doctor, poison center ,hospital ,police department, and emergency medical system near the phone

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Toxic centerToxic center

• Toxbuster@hotmail.com

• Siriraj Poison Center– Tel.02-419-7007

Thank you for your Thank you for your attentionattention