04/24/23

Pediatric Pediatric ToxicologyToxicology

M Waseem, MDM Waseem, MDLincoln Hospital Bronx New Lincoln Hospital Bronx New

YorkYork

04/24/23

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

04/24/23

EpidemiologyEpidemiology Unintentional (1-2 years)Unintentional (1-2 years)

– ExploratoryExploratory– Boys > girlsBoys > girls

Intentional (adolescent)Intentional (adolescent)– PurposefulPurposeful– Girls > boysGirls > boys

04/24/23

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

04/24/23

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

04/24/23

Very toxic!Very toxic! Prenatal vitamin supplementsPrenatal vitamin supplements AntidepressantsAntidepressants HydrocarbonsHydrocarbons

04/24/23

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%

04/24/23

ICU AdmissionICU Admission TCATCA AnticonvulsantsAnticonvulsants DigitalisDigitalis OpiatesOpiates Hydrocarbon-based house-hold Hydrocarbon-based house-hold

productsproducts

04/24/23

Toxic Exposures/DeathToxic Exposures/Death AnalgesicsAnalgesics Sedative-hypnoticsSedative-hypnotics AlcoholsAlcohols Gases & fumesGases & fumes Cleaning substancesCleaning substances

04/24/23

““Fatal Sip”Fatal Sip”

04/24/23

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

04/24/23

Fatal SipFatal Sip BenzocaineBenzocaine 2 ml2 ml

– MethemoglobinemiaMethemoglobinemia– SeizureSeizure

04/24/23

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

04/24/23

Malignant SwallowMalignant Swallow ClonidineClonidine 0.3 mg tablet0.3 mg tablet

– BradycardiaBradycardia– CNS depressionCNS depression

04/24/23

Highly ToxicHighly Toxic AcetonitrileAcetonitrile Ammonium FluorideAmmonium Fluoride BenzocaineBenzocaine CamphorCamphor Pennyroyal OilPennyroyal Oil

04/24/23

AcetonitrilesAcetonitriles Artificial Nail Tip removerArtificial Nail Tip remover MethemolobinemiaMethemolobinemia Delayed presentation (4-12 hours)Delayed presentation (4-12 hours) Must be hospitalizedMust be hospitalized

04/24/23

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

04/24/23

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

04/24/23

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)

04/24/23

CamphorCamphor Vicks VapoRubVicks VapoRub Only 5 mlOnly 5 ml CNS effectsCNS effects

04/24/23

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)

04/24/23

Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike

AlbuterolAlbuterol AtenololAtenolol CelebrexCelebrex CerebrexCerebrex OruvailOruvail ElavilElavil LamictalLamictal LomotilLomotil LotriminLotrimin LotensinLotensin PlendilPlendil PindololPindolol

04/24/23

Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike

HydralazineHydralazine HydroxyzineHydroxyzine HydrocodoneHydrocodone HydrocortisoneHydrocortisone

04/24/23

Plant ToxidromesPlant Toxidromes

04/24/23

Digitalis EffectsDigitalis Effects Lily-of-the-valleyLily-of-the-valley FoxgloveFoxglove OleanderOleander YewYew

04/24/23

Nicotinic EffectsNicotinic Effects Poison hemlockPoison hemlock

04/24/23

Atropinic EffectsAtropinic Effects JimsonweedJimsonweed

04/24/23

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

04/24/23

Non-Toxic ProductsNon-Toxic Products DeodorantsDeodorants LipstickLipstick Pencil (graphite)Pencil (graphite) ToothpasteToothpaste Water colorsWater colors

04/24/23

EvaluationEvaluation History of poisoningHistory of poisoning Toxicologic physical examinationToxicologic physical examination Laboratory studiesLaboratory studies Gastrointestinal decontaminationGastrointestinal decontamination

04/24/23

HistoryHistory What?What? When?When? How much?How much?

04/24/23

WhatWhat ? ? MedicationMedication Illicit drugIllicit drug Hazardous chemicalHazardous chemical

04/24/23

What form?What form? PillPill SolidSolid LiquidLiquid GaseousGaseous

04/24/23

What routeWhat route ? ? IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous

04/24/23

WhenWhen ? ? Elapsed timeElapsed time

04/24/23

How muchHow much ? ? Estimate amountEstimate amount ConcentrationConcentration

04/24/23

““Vital signs”Vital signs”

04/24/23

BradycardiaBradycardia DigoxinDigoxin NarcoticsNarcotics OrganophosphatesOrganophosphates Carbon monoxideCarbon monoxide Beta-blockerBeta-blocker

04/24/23

TachycardiaTachycardia Alcohol/amphetamineAlcohol/amphetamine Atropine/tricyclicAtropine/tricyclic TheophyllineTheophylline Salicylates, IronSalicylates, Iron Cocaine/PCPCocaine/PCP

04/24/23

Slow RespirationSlow Respiration AlcoholAlcohol NarcoticsNarcotics ClonidineClonidine SedativesSedatives

04/24/23

TachypneaTachypnea AmphetaminesAmphetamines SalicylatesSalicylates Carbon monoxideCarbon monoxide

04/24/23

HypotensionHypotension MethemoglobinemiaMethemoglobinemia Carbon monoxideCarbon monoxide CyanideCyanide IronIron NarcoticsNarcotics

04/24/23

HypertensionHypertension OTC cold remediesOTC cold remedies AmphetamineAmphetamine PCPPCP TCATCA CocaineCocaine

04/24/23

Ventricular TachycardiaVentricular Tachycardia AmphetaminesAmphetamines CarbamzepineCarbamzepine Chloral hydrateChloral hydrate CocaineCocaine DigitalisDigitalis TheophyllineTheophylline

04/24/23

Torsades de PointesTorsades de Pointes Chloral hydrateChloral hydrate CisaprideCisapride OrganophosphatesOrganophosphates TerfenadineTerfenadine PhenothiazinesPhenothiazines

04/24/23

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

04/24/23

HypothermiaHypothermia EthanolEthanol NarcoticsNarcotics Carbon monoxideCarbon monoxide

04/24/23

HyperpyrexiaHyperpyrexia AtropineAtropine SalicylatesSalicylates TheophyllineTheophylline CocaineCocaine TCATCA

04/24/23

Mental StatusMental Status

04/24/23

ComaComa NarcoticNarcotic AnticholinergicAnticholinergic Carbon monoxideCarbon monoxide

04/24/23

Delirium/PsychosisDelirium/Psychosis AlcoholAlcohol PCP/marijuanaPCP/marijuana LSDLSD

04/24/23

ConvulsionConvulsion Cocaine/AmphetamineCocaine/Amphetamine LeadLead SalicylateSalicylate IsoniazidIsoniazid TheophyllineTheophylline

04/24/23

Pupil sizePupil size

04/24/23

Miosis Miosis (COPS) CCholinergics, holinergics, CClonidinelonidine OOpiates, piates, OOrganophosphatesrganophosphates

PPhenothiazine, henothiazine, PPilocarpineilocarpine SSedatives (Barbiturates)edatives (Barbiturates)

04/24/23

Mydriasis Mydriasis (AAAS)(AAAS) AAntihistaminentihistamine AAntidepressantntidepressant AAnticholinergics (atropine)nticholinergics (atropine) SSympathomimeticsympathomimetics

– Amphetamine, Cocaine, PCPAmphetamine, Cocaine, PCP

04/24/23

Caution!Caution! Polydrug overdoses with Polydrug overdoses with

opposite pupillary actionsopposite pupillary actions Nontoxin diagnosesNontoxin diagnoses

– Head traumaHead trauma– CNS hemorrhageCNS hemorrhage

04/24/23

CyanosisCyanosisUnresponsive to Unresponsive to

oxygen oxygen methemoglobinemimethemoglobinemi

aa

04/24/23

CyanosisCyanosis Aniline dyesAniline dyes NitritesNitrites BenzocaineBenzocaine DapsoneDapsone

04/24/23

Dry SkinDry Skin

AnticholinergicAnticholinergic

04/24/23

Breath OdorsBreath Odors ArsenicArsenic GarlicGarlic CamphorCamphor MothballsMothballs CyanideCyanide Bitter almondBitter almond Methyl salicylateMethyl salicylate WintergreenWintergreen ParaldehydeParaldehyde PearsPears

04/24/23

ToxidromesToxidromes

04/24/23

CholinergicCholinergicDUMBBELDUMBBELSLUDGESLUDGE

04/24/23

DUMBBELSDUMBBELS DD DiarrheaDiarrhea UU UrinationUrination MM Miosis, muscle fasiculationMiosis, muscle fasiculation BB BradycardiaBradycardia BB BronchospasmBronchospasm

04/24/23

DUMBBELSDUMBBELS EE EmesisEmesis LL LacrimationLacrimation SS SalivationSalivation

04/24/23

SLUDGESLUDGE SS SalivationSalivation LL LacrimationLacrimation UU UrinationUrination DD DiarrheaDiarrhea

04/24/23

SLUDGESLUDGE GG GI complaintGI complaint EE EmesisEmesis

04/24/23

Anticholinergic Anticholinergic SyndromeSyndrome

Dry mouthDry mouth Flushed appearanceFlushed appearance Dilated pupilsDilated pupils FeverFever IleusIleus Urinary retentionUrinary retention DisorientationDisorientation

04/24/23

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

04/24/23

AnticholinergicAnticholinergic

Full Full as aas a flask flask

04/24/23

AnticholinergicAnticholinergic AnticholinergicAnticholinergic WetWet Bowel sound +Bowel sound +

SympathomimeSympathomimetictic

DryDry Absent bowel Absent bowel

soundsound

04/24/23

NarcoticNarcotic Pinpoint pupilsPinpoint pupils ComaComa Respiratory depressionRespiratory depression

04/24/23

SalicylatesSalicylates FeverFever Tachypnea & hyperpneaTachypnea & hyperpnea LethargyLethargy Metabolic acidosisMetabolic acidosis

04/24/23

TheophyllineTheophylline Protracted VomitingProtracted Vomiting TremorsTremors TachycardiaTachycardia SeizuresSeizures HypotensionHypotension

04/24/23

IsoniazidIsoniazid SeizuresSeizures Metabolic acidosisMetabolic acidosis HyperglycemiaHyperglycemia

04/24/23

Phencyclidine (4 Cs)Phencyclidine (4 Cs) CombativeCombative CatatoniaCatatonia ConvulsionConvulsion ComaComa NystagmusNystagmus

04/24/23

TCATCA Metabolic acidosisMetabolic acidosis Prolonged QRSProlonged QRS SeizuresSeizures Dilated pupilsDilated pupils DysrhythmiaDysrhythmia

04/24/23

CyanideCyanide Feeling of impending doomFeeling of impending doom Sudden comaSudden coma Metabolic acidosisMetabolic acidosis HypotensionHypotension Bitter almond odorBitter almond odor

04/24/23

Carbon monoxideCarbon monoxide HeadacheHeadache LethargyLethargy DizzinessDizziness Influenza like syndromeInfluenza like syndrome ComaComa

04/24/23

EthanolEthanol HypoglycemiaHypoglycemia LethargyLethargy AtaxiaAtaxia SeizureSeizure Characteristic breath odorCharacteristic breath odor

04/24/23

MethanolMethanol Severe Metabolic acidosisSevere Metabolic acidosis Sluggish pupilsSluggish pupils Hyperemic retinaHyperemic retina Blurred visionBlurred vision

04/24/23

Ethylene GlycolEthylene Glycol Lethargy or comaLethargy or coma Metabolic acidosisMetabolic acidosis Urinary sedimentUrinary sediment CrystalluriaCrystalluria

04/24/23

ClonidineClonidine HypothermiaHypothermia BradycardiaBradycardia MiosisMiosis Respiratory depressionRespiratory depression

04/24/23

Elevated anion gapElevated anion gap MethanolMethanol Paraldehyde & phenforminParaldehyde & phenformin Iron & isoniazidIron & isoniazid Ethylene glycol & ethanolEthylene glycol & ethanol SalicylateSalicylate

04/24/23

ABCABCs s AAnticipatenticipateBBeforeeforeCComplicationsomplications

04/24/23

ABCABCAAirway irway

–C-spine immobilizationC-spine immobilizationBBreathingreathingCCirculationirculation

–secure IV accesssecure IV access

04/24/23

ABCABCDDisabilityisability

–consciousnessconsciousnessDDrugsrugsDDecontaminationecontamination

04/24/23

consciousnessconsciousness AA:: Alert Alert V: V: Responsive to Responsive to

verbal stimuliverbal stimuli P:P:Responsive to painResponsive to pain U: U: UnresponsiveUnresponsive

04/24/23

DrugsDrugsDextroseDextroseOxygenOxygenNaloxoneNaloxone

04/24/23

DecontaminationDecontamination Ocular- copious saline Ocular- copious saline

lavagelavage Skin- copious waterSkin- copious water GI-consider optionsGI-consider options

04/24/23

Lab EvaluationLab EvaluationNo “No “tox paneltox panel” that ” that is uniformly helpful is uniformly helpful

04/24/23

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

04/24/23

EKGEKG

All suspected All suspected ingestioningestionTricyclicsTricyclics

04/24/23

Pulse oximetryPulse oximetry

Measure of oxygen Measure of oxygen saturation of normal saturation of normal

hemoglobinhemoglobin

04/24/23

Pulse oximetry Pulse oximetry

Does notDoes not differentiate differentiate COHB from oxyhemoglobinCOHB from oxyhemoglobin

04/24/23

False low SaturationFalse low Saturation Blue nail polishBlue nail polish Methylene blue Methylene blue Poor distal perfusionPoor distal perfusion

04/24/23

Blood gasBlood gas

SalicylatesSalicylates

04/24/23

Chest X-rayChest X-ray

HydrocarbonsHydrocarbons

04/24/23

EsophagoscopyEsophagoscopy

CausticsCaustics

04/24/23

Emergent Lab AnalysesEmergent Lab Analyses AcetaminophenAcetaminophen SalicylatesSalicylates MethanolMethanol Ethylene glycolEthylene glycol IronIron

04/24/23

Emergent Lab AnalysesEmergent Lab Analyses TheophyllineTheophylline Carbon monoxideCarbon monoxide LithiumLithium

04/24/23

Optimum timeOptimum time ActaminophenActaminophen 4 hours4 hours SalicylatesSalicylates 2-4 hours2-4 hours IronIron 4 hours4 hours CarboxyhemoglobinCarboxyhemoglobin

ImmediateImmediate MethemoglobinMethemoglobin ImmediateImmediate

04/24/23

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

04/24/23

Serial LevelsSerial Levels SalicylatesSalicylates CarbamazepineCarbamazepine DigoxinDigoxin PhenobarbitalPhenobarbital TheophyllineTheophylline Valproic acidValproic acid

04/24/23

Radiopaque Radiopaque (CHIPS)(CHIPS) CChloral hydratehloral hydrate HHeavy metalseavy metals IIronron PPhenothiazinehenothiazine SSlow releaselow release

04/24/23

GI. DecontaminationGI. Decontamination

Preventing Preventing absorptionabsorption

04/24/23

GI decontamination in a GI decontamination in a symptomatic patient?symptomatic patient?

04/24/23

DecontaminationDecontamination Syrup of IpecacSyrup of Ipecac Gastric lavageGastric lavage Activated CharcoalActivated Charcoal CatharticsCathartics WBI (bowel irrigation)WBI (bowel irrigation)

04/24/23

Syrup of ipecacSyrup of ipecac

04/24/23

Syrup of IpecacSyrup of Ipecac NonprescriptionNonprescription CTZ stimulant CTZ stimulant use only under poison use only under poison

control directioncontrol direction

04/24/23

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

04/24/23

Adverse effectAdverse effect Protracted vomitingProtracted vomiting SedationSedation DiarrheaDiarrhea BradycardiaBradycardia

04/24/23

ContraindicationsContraindications Altered mental statusAltered mental status SeizureSeizure hemetemesishemetemesis hydrocarbonhydrocarbon corrosivescorrosives

04/24/23

ContraindicationsContraindications Anticipated use of oral Anticipated use of oral

antidote or WBIantidote or WBI < 6 months old< 6 months old

04/24/23

Gastric LavageGastric Lavage

04/24/23

Gastric LavageGastric Lavage one hour (“golden one hour (“golden hour”)hour”)

Life threatening ingestionLife threatening ingestion

04/24/23

““NG tube is not NG tube is not adequate”adequate”

04/24/23

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

04/24/23

Gastric LavageGastric Lavage < 30%< 30% by 20-30 min by 20-30 min < 13%< 13% by 60 minutes by 60 minutes

04/24/23

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

04/24/23

Gastric LavageGastric Lavage TCATCA Calcium-blockerCalcium-blocker ColchicineColchicine

04/24/23

ComplicationsComplications Pulmonary aspirationPulmonary aspiration

04/24/23

ContraindicationsContraindications CausticCaustic HydrocarbonHydrocarbon Sharp coingestionSharp coingestion

04/24/23

Activated CharcoalActivated Charcoal

Universal antidoteUniversal antidote

04/24/23

Single dose ACSingle dose AC

adsorbing the adsorbing the ingested substanceingested substance

04/24/23

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

04/24/23

Activated CharcoalActivated Charcoal

Surface areaSurface area950-2000m950-2000m22/g/g

04/24/23

Poorly bound by ACPoorly bound by AC

04/24/23

CHEMICaL CamPCHEMICaL CamP CC CCyanideyanide HH HHydrocarbonydrocarbon EE EEthanolthanol MM MMetalsetals II IIronron CC CCausticsaustics LL LLithiumithium

04/24/23

CHEMICaL CamPCHEMICaL CamP CC CCamphoramphor PP PPhosphorushosphorus

04/24/23

Recommended DoseRecommended Dose Up to 1 yearUp to 1 year

–1g/kg1g/kg 1-12 year1-12 year

–25-50 gm25-50 gm

04/24/23

ComplicationsComplications Pulmonary aspirationPulmonary aspiration EmesisEmesis ConstipationConstipation

04/24/23

ContraindicationsContraindications HydrocarbonHydrocarbon CorrosiveCorrosive IleusIleus

04/24/23

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)

04/24/23

Benefits of Home ACBenefits of Home AC Early administrationEarly administration Reduced morbidity & mortalityReduced morbidity & mortality

04/24/23

Risks of Home ACRisks of Home AC Inappropriate administrationInappropriate administration Inadequate dosingInadequate dosing Pulmonary aspirationPulmonary aspiration

04/24/23

Multiple-Dose ACMultiple-Dose AC

Gastrointestinal DialysisGastrointestinal Dialysis

04/24/23

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

04/24/23

Multiple-Dose ACMultiple-Dose AC PhenobarbitalPhenobarbital CarbamazepineCarbamazepine PhenytoinPhenytoin DigoxinDigoxin SalicylatesSalicylates TheophyllineTheophylline TCATCA

04/24/23

CatharticsCathartics

Decrease transit timeDecrease transit time

04/24/23

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)

04/24/23

ComplicationsComplications NauseaNausea Abdominal crampsAbdominal cramps VomitingVomiting Transient hypotensionTransient hypotension

04/24/23

ContraindicationsContraindications Unprotected airwayUnprotected airway IleusIleus Absent bowel soundsAbsent bowel sounds Intestinal obstructionIntestinal obstruction

04/24/23

WBIWBI

Decontaminate entire Decontaminate entire gastrointestinal tractgastrointestinal tract

04/24/23

WBIWBI

Commonly used for Commonly used for agents not bound to agents not bound to activated charcoalactivated charcoal

04/24/23

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

04/24/23

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

04/24/23

WBIWBI Calcium-channel-blockersCalcium-channel-blockers IronIron ArsenicArsenic Lead/zincLead/zinc Packets of illicit drugsPackets of illicit drugs

04/24/23

ComplicationsComplications Nausea & vomitingNausea & vomiting Bloating / crampsBloating / cramps Pulmonary aspirationPulmonary aspiration

04/24/23

Urinary AlkalinizationUrinary Alkalinization SalicylatesSalicylates PhenobarbitalPhenobarbital ChlorpropamideChlorpropamide

04/24/23

Urinary AcidificationUrinary Acidification Never indicatedNever indicated Systemic acidosisSystemic acidosis Renal impairment in Renal impairment in

myoglobinuriamyoglobinuria

04/24/23

Extracorporeal Extracorporeal ClearanceClearance

04/24/23

HemodialysisHemodialysis Severe poisoningSevere poisoning Renal failureRenal failure

04/24/23

HemodialysisHemodialysis 8-10 fold increased clearance 8-10 fold increased clearance Corrects acid-base imbalanceCorrects acid-base imbalance Corrects electrolyte imbalanceCorrects electrolyte imbalance

04/24/23

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)

04/24/23

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

04/24/23

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

04/24/23

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

04/24/23

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

04/24/23

AntidotesAntidotes

04/24/23

AntidotesAntidotes

Use only if specific Use only if specific criteria metcriteria met

04/24/23

Immediate useImmediate use OxygenOxygen

–carbon monoxidecarbon monoxide NaloxoneNaloxone

–opioidsopioids

04/24/23

Immediate useImmediate use Methylene blue 1%Methylene blue 1%

–severe cyanosissevere cyanosis–> 40%> 40%

04/24/23

Immediate useImmediate use Sodium nitriteSodium nitrite

–CyanideCyanide DeferoxamineDeferoxamine

–IronIron

04/24/23

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

04/24/23

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

04/24/23

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

04/24/23

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

04/24/23

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