Approach to a poisoned child
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Guide –Dr Jyoti Singh
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What is a poison?
▪ In common usage - poisons are chemicals or chemical products that are distinctly harmful to human
▪ More precisely - a poison is a foreign chemical (xenobiotic) that is capable of producing a harmful effect on a biologic system
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Most common Pediatric Exposure Cosmetics and personal care products
(13%) Cleaning substances (10%) Analgesics (7.8%) Foreign Bodies (7.4%) Topicals (7.4%) Cold and Cough Preparations (5.5%) Plants (4.6%) Pesticides (4.1%)
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May be difficult because of non-specific symptoms
High index of suspicion - especially occult poisoning▪ history may be unreliable▪ look for corroborative history - missing pills,
empty container
Course that a poison runs (toxidromes) ! - may help
Toxicology screening - helpful only in a few
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▪ It is the association of several clinically recognizable features, signs, symptoms, phenomena or characteristics which often occur together, so that the presence of one feature alerts the physician to the presence of the others.
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S alivation *D iaphoresis/diarrhea
L acrimation *U rinationU rination *M iosisD efecation *B
radycardia/bronchospasmG I secrestion/upset *E mesisE mesis *L acrimation excess
*S alivation excess
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Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel, bladder
lose their tone, &
heart runs alone
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Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder lose their tone, &
heart runs alone
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Hot as a hare
Dry as a bone
Red as a beet
Mad as a hatter
Blind as a bat
bowel , bladder
lose their tone,
&heart runs alone
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disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic PhencyclidineBenzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea
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disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic PhencyclidineBenzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea
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disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic PhencyclidineBenzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea
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disorientation Amphetamine
hallucinations Cocaine
Hallucinogenic hyperactive bowel Pseudoephedrine
panic PhencyclidineBenzodiazepenes
seizure Ephedrine
Toxidrome Hypertension
Tachycardia
Tachypnea
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Very diverse and varied - depends on the poison
Clinical examination should be focused on the possible manifestations of common poisons in the geographical area
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Skin and mucosal damage Neurotoxic manifestations Cardiovascular manifestations Metabolic consequences Eye manifestations Hepatic , renal dysfunction Multiorgan dysfunction
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Respiratory
Airway protection
Respiratory failure
Cardiovascular
Hypotension despite fluid challenge
Heart block, arrhythmias, QTc prolongation as in TCA
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Neurologic▪ Low GCS ▪ Seizures
Metabolic▪ Hypoglycaemia▪ Significant electrolyte abnormalities▪ metabolic acidosis▪ Hepatic failure▪ Coagulopathy with bleeding
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ASSESSMENT & THERAPY should proceed in parallel
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Treat the patient, not the poisonAssess
General appearance Work of breathing Circulation
ABCDs IV access and monitorsHigh Suspicion
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Directed exam (after ABCs)
mental status vital signs pupillary size skin signs
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Airway - ensure clear airway, clear secretions, check for cough/gag
Breathing - check oxygenation, supplemental O2, breathing pattern & adequacy
Circulation - heart rate, rhythm, blood pressure
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Neurologic - GCS, seizures, agitation, spasms, pupils, autonomic dysfunction
Miscellaneous - odour, temperature, pallor, cyanosis, jaundice
Abdomen - rigidity, bleeding, urine output
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Cyanosis methemoglobinemia secondary to
nitrites, nitrates, phenacetin, benzocaine-refractory tp o2
Red flush carbon monoxide, cyanide, boric acid,
anticholinergics
Joundice – c cl4. paracetamol
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Dry anticholinergics
Salivation organophosphates, carbamates
Oral lesions corrosives, paraquat
Lacrimation caustics, organophosphates, irritant
gases
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Anti-histamine Anti-depressant Anticholinergics (atropine) Sympathomimetics
amphetamine, cocaine, PCP
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Cholinergics, Clonidine Opiates, Organophosphates Phenothiazine, Pilocarpine Sedatives (barbiturates, ethanol)
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Alcohol PCP / marijuana LSD Anticholinergics Sympathomimet
ics Phenothiazines Cocaine Heroin heavy metals
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Coma alcohols, anticholinergics, sedative hypnotics, opioids, carbon monoxide, TCAs, salicylates, organophosphates
Weakness/paralysis organophosphates, carbamates, heavy
metals
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Atropine Salicylates Theophylline Cocaine TCA
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Ethanol Narcotics Carbon
monoxide Clonidine
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Bradycardia digitalis, sedative hypnotics, beta
blockers, opioids
Tachycardia anticholinergics, sympathomimetics,
amphetamines, alcohol, aspirin, theophylline, cocaine, TCAs
Arrythmias anticholinergics, TCAs, organophosphates,
digoxin, phenothiazines, beta blockers, carbon monoxide, cyanide
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OTC cold remedies
Amphetamine PCP TCA Cocaine Diet pills
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Calcium channel blockers
Carbon monoxide Cyanide Iron Narcotics Anti-hypertensives Met-hemoglobin
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Hypoglycemia Oral hypoglycemic
agents Beta-blockers Insulin Ethanol Salicylates
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Alcohol Narcotics Clonidine Sedatives
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Of limited value
Paracetamol levels, salicylate levels, alcohol, Red cell/pseudocholinesterase, anti-epileptic drug levels
Urinary drug screen - opiates, barbiturates, benzodiazepines, amphetamines, cocaine
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Anion gap & Osmolal gap
Increased anion gap (Normal 12 ± 4 mEq/L)▪ Ethylene glycol▪ Methanol▪ Salicylate poisoning
Increased osmolal gap (Normal 5 ± 7 m osmol/kg)▪ Ethylene glycol ▪ Methanol ▪ Acetone, ethanol, isopropyl alcohol,
propylene glycol
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Electrolytes▪ Hypokalemia▪ Isuline ,oral hypoglysemics ▪ Diuretics, Methyl xanthine, Toluene
▪ Hyperkalemia▪ Digoxin▪ Beta-blocker
Liver function tests▪ Acetaminophen, Ethanol, Carbon tetrachloride
Renal function tests▪ Ethylene glycol, NSAIDS
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ECGDigoxin toxicityTCA overdose - sinus tachycardia, QT prolongation,
increased QRSBeta-blockers - conduction abnormalities
Imaging
. CXR- hydrocarbon ingestion .Abdominal X-ray-- iron ingestion & radioopaque
ingestion. .Oesophagoscopy -for caustic ingestion.
. Abdominal usg- recently been used as a means of identifying presence of pharmaceutical material in GIT.
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Opiates Cocaine metabolite Amphetamine Benzodiazepines Barbiturates
* No urine screen can confirm intoxication, only exposure
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Reduce absorption of the toxin
Enhance elimination
Neutralise toxin
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Removal from surface skin & eye
Emesis induction
Gastric lavage
Activated charcoal administration & cathartics
Dilution - milk/other drinks for corrosives
Whole bowel irrigation
Endoscopic or surgical removal of ingested chemical
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Skin decontamination
▪ Important aspect – not to be neglected
▪ Remove contaminated clothing
▪Wash with soap and water (soaps containing 30% ethanol advocated)
▪However, no evidence for benefit even in OP poisoning
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Gastric decontamination
▪ Forced emesis if patient is awake▪Gastric lavage▪ Activated charcoal 25 gm 2 hourly▪ Sorbitol as cathartic
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Gastric lavage
▪ Gastric lavage decreases absorption by 42% if done 20 min and by 16% if performed at 60 min
▪ Performed by first aspirating the stomach and then repetitively instilling & aspirating fluid
▪ Left lateral position better - delays spont. absorption
▪ No evidence that larger tube better▪ Simplest, quickest & least expensive way ▪ Choice of fluid is tap water - 5-10 ml/kg
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Gastric lavage
▪ Preferrably done on awake patients
▪ Presence of an ET tube does not preclude aspiration, though preferred if GCS is low
▪ No human studies in OP poisoning showing benefit of gastric lavage
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Single dose activated charcoal 0.5-1 gm/kg, adolescents 50-100 grams
PO; maximum dose 100 grams More benefit if administered within 1
hour of ingestion, but still good for poison which slows gastric motility (anticholinergic, opiates, salicylates)
Strongly consider for acetaminophen overdose > 4 hours
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P – Pesticides, petroleum distillates, unprotected airway
H – Hydrocarbons, heavy metals, > 1h delay in administration
A – Acids, alkali, alcohol, altered level of consciousness, aspiration risk
I – Iron, ileus, intestinal obstructionL – Lithium, lack of gag reflexS – seizures
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Nonabsorbable, isotonic polyethylene glycol
Toxins “pushed” through GI tract; prevents absorption
Concentration gradient created by this allows absorbed toxin to diffuse back into GI tract
Used where toxins NOT absorbed by charcoal
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Recommended for: Iron tablets Lead paint chips Theophylline Crack vials/packets Button batteries Sustained release calcium channel
blockers
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Bowel perforation Bowel obstruction Clinically significant gastrointestinal
hemorrhage Ileus Unprotected or compromised airway Hemodynamic instability Uncontrollable intractable vomiting
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Methods▪ Keeping a good urine output 150-200 ml/hr▪ Alkalinisation of urine - clinical efficacy accepted for salicylate & phenobarbital poisoning▪ Extracorporeal removal▪Hemodialysis - Barbiturates, Salicylates, Acetaminophen, Valproate, Alcohols, Glycols▪Hemoperfusion - theophylline, digitalis, lipid soluble drugs
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Plasmapheresis Works very well with highly protein
(albumin) bound drugs Not a routine methodology, but has
been used to remove theophylline and digoxin/ digibind complexes
Exchange transfusion Use in smaller infants where
vascular access for extracorporeal techniques can’t be done
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Renal failure. Congestive heart failure (relative). Acute lung injury. Persistent CNS disturbance. Severe acid-base or electrolyte
imbalance, despite appropriate treatment.
Hepatic compromise with coagulopathy.
Salicylate concentration (acute) >100 mg/dL.
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Acetaminophen N-acetyl cysteine Anti-cholinergics Physostigmine Benzodiazepenes Flumazenil Ca channel blockers Glucagon, Insulin + dextrose, Calcium Carbamate Atropine Cyanide Thiosulphate, nitrate Digoxin Digoxin antibodies INAH Pyridoxine Methanol Ethanol, Fomepizole Glycol Ethanol, Fomepizole Opioid Naloxone Oral hypoglycaemics Glucose Organophosphate Atropine, PAM Warfarin(rat kill poison) Vitamin K
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Iron Desferroxamine Copper Penicillamine, Dimercaprol, CaEDTA Lead CaEDTA, Dimercaprol (BAL) Mercury DMPS, DMSA, BAL Arsenic BAL & derivatives Antimony BAL & derivatives
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Calcium channel blockers: bradycardia and hypotension; 1 - 10 mg tablet of nifedipine
Camphor: respiratory depression and seizures; 15 mL of Vicks vapo-rub (700 mg of camphor)
Clonidine: severe bradycardia; 0.1 mg
Tricyclic antidepressants: cardiovascular and CNS toxicity; 10-20mg/kg
Opioids: CNS and respiratory depression; 2.5 mg of hydrocodone.
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Lomotil: anticholinergic overdose (tachycardia, seizures, coma); ½ tablet
Salicylates: cerebral edema, acidosis, coma; ½ teaspoon of wintergreen fatal
Sulfonylureas: severe hypoglycemia; 1 tablet
Toxic alcohols: cardiac and CNS depression; 2.9mL of 95% ethylene glycol has been fatal
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National Poisons Information Centre (NPIC)
Department of PharmacologyAll India Institute of Medical SciencesNew Delhi, IndiaTel. No.: 26589391, 26593677, Fax: 26850691, 26862663Email: [email protected] provides round-the-clock, 7 days-a-
week, 365 days service on telephone.
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Poisoning a common problem in our country
A high index of suspicion required to diagnose
Know common toxidrome & antidotes
Charcoal is only given if likely to benefit
Patients receiving decontamination must have airway protection
Don’t panic and follow a plan of actionDecreasing absorptionEnhancing eliminationNeutralising toxins
Avoid potentially harmful Rxs - risk vs benefit
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