Pediaric toxicology

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  • 1. PEDIATRICTOXICOLOGY2005 Adel M A Hassan, M.D Sen. Cons. Anesthesia, ICU, Interventional Pain Management. dradel.hassan@gmail.com

2. Epidemiology 64 Poison Centers serving 295 million people 2.4 million exposures last year 39% are children younger than 3 years 52% in children younger than 6 years 106 deaths in age 100mg/dl early and more aggressive dialysis recommended Street drugs (124) Antidepressants (112) Amitriptyline 4. Epidemiology 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%) 5. Epidemiology Unintentional (1-2 years) Exploratory Boys > girls Unable to discriminate safe from unsafe liquid Intentional (adolescent) Purposeful Girls > boys 6. Epidemiology Around meal time Grandparents home Kerosene or gasoline in a soda bottle Older sibling can pharmaceutically treat younger sibling 7. Evaluation of Suspected Poisoning ABCs and routine ICU management Establishing the diagnosis Must consider poisoning, especially in at risk age groups Less than 6 year old with acute decompensation (AMS, arrhythmias, hypotension, metabolic acidosis, etc.) 8. Evaluation History of poisoning Physical Examination Laboratory studies Gastrointestinal decontamination 9. History What? When? How much? Reliability 10. What? Medication Illicit drug Hazardous chemical 11. What forms? Pill Solid Liquid Gaseous 12. What route? Ingestion Inhalation Topical Intravenous 13. When? Elapsed time 14. How much? Estimate amount Concentration 15. PICU Admission Tricyclic antidepressants (TCA) Anticonvulsants Digoxin Opiates Hydrocarbon-based household products 16. Toxic Exposure - Death Analgesics Sedative-hypnotics Alcohols Gases & fumes Cleaning substances 17. Toxidromes Anticholinergics Atropine, scopolamine, TCAs, phenothiazines, antihistamines, mushrooms, jimson weed Hot as a hare, dry as a bone, red as a beet, mad as a hatter Neuro: agitation, hallucinations, coma, extrapyramidal movements, mydriasis, hyperthermia CV: tachycardia, hypotension, hypertension, arrhythmia GI/GU: decreased bowel sounds, urinary retention 18. Toxidromes Cholinergics Organophosphates and carbamates 19. Muscarinic Effects of Organophosphate Poisoning S alivation *D iaphoresis/diarrhea L acrimation *U rination U rination *M iosis D efecation *B radycardia/bronchospasm G I secrestion/upset*E mesis E mesis *L acrimation excess *S alivation excess 20. Nicotinic Effects of Organophosphate Poisoning Muscle fasciculation Cramping Weakness (extreme is diaphragmatic failure) Autonomic nicotinic effects include hypertension, tachycardia, pupillary dilation, and pallor 21. CNS Effects of Organophosphate Poisoning Anxiety Restlessness Confusion Ataxia Seizures Insomnia Dysarthria Tremors Coma 22. Toxidromes Opiates: Morphine, Methadone, Dextromethorphan 23. Toxidromes Opiates Morphine, methadone, dextromethorphan Resp: decreased respiratory rate, pulmonary edema CV: hypotension, bradycardia Neuro: miosis, AMS, coma, hypothermia, seizures 24. Toxidromes Sedatives/hypnotics Benzodiazepines, barbiturates Resp: slow respirations CV: tachycardia, hypotension Neuro: AMS, coma, seizures, hypothermia 25. Toxidromes Tricyclic antidepressants Amitryptiline, nortryptiline, etc. See anticholinergic effects CV: arrhythmias, hypotension Neuro: coma, seizures 26. Toxidromes Salicylates ASA, oil of wintergreen Resp: tachypnea 27. Laboratory Tests Suggestive of Poisoning Elevated osmolar gap (>10) Serum osm = (Na x 2) + BUN/2.8 + glucose/18 Volatile alcohols, mannitol Elevated anion gap (>12) MUDPILES Low anion gap Lithium, iodine, bromine, fluoride Hyperkalemia Postassium, lithium, digoxin, fluoride Hypokalemia Theophylline, toluene 28. Laboratory Tests Suggestive of Poisoning Hyperglycemia ASA, theophylline, caffeine, iron Hypocalcemia Ethylene glycol, ASA UA Glowing urine ethylene glycol Calcium oxalate crystals ethylene glycol 29. Laboratory Testing What is in a urine drug screen? Amphetamines, Barbiturates, Cocaine, Benzodiazepine, Opiates, THC, PCP What is in a serum drug screen? Acetaminophen, ETOH, Salicylate, TCA What is in a comprehensive drug screen? Barbiturates, Salicylates, Cannabinoids, PCP, TCA, Sedatives, Benzodiazepines, Stimulants, Opium alkaloid, Synthetic Narcotics, Tranquilizers, Cocaine 30. Laboratory Testing Grady unfortunately doesnt do HPLC anymore Options for more comprehensive screen Quest lab if needed in 24 hours or less ARUP 2-4 days turn around SERUM: Acetaminophen, alcohols, barbiturates, benzodiazepines, carbamazepine, carisoprodol, disopyramide, meprobamate, phenytoin, primidone, salicylate, theophylline, tricyclic and other antidepressants URINE: acetaminophen, alcohols, barbiturates, benzodiazepines, carbamazepines, carisoprodol, chlorpheniramine, cocaine & metabolites, diphenhydramine,ethchlorvynol, ibuprefen, lidocaine, meprobamate, narcotics & synthetics, phencyclidine, phenothiazines, phenytoin, primidone & metabolites, pyrilamine, salicylate, sympathomimetic amines, theophylline, tricyclic and other antidepressants, trimethoprim 31. Laboratory Testing Additional testing is helpful if you have a specific substance that you suspect Usually less helpful as a fishing expedition and wont affect management Am J Emerg Med. 1999 May:17(3):221-4. Belson MG, Simon HK Evaluate the clinical utility and cost-effectiveness of the limited component vs the HPLC component of comprehensive toxicologic screens in children Retrospective from HSCH ED Jan 1994-July 1995 The comprehensive test included a broad-spectrum HPLC component as well as a limited component that examined serum for ethanol, aspirin, and acetaminophen and urine for benzodiazepines, barbiturates, amphetamines, cocaine, phencyclidien, and opiates Comprehensive toxicology screens were performed in 463 cases during the study period; 234 (51%0 were positive for exogenous toxin 32. Laboratory Testing In 227 of 234 positive screens (97%), toxins were either suspected by history and/or physical, were present on the limited portion of the toxicology screens, or were clinically insignificant The remaining 7 of the 234 positive screens (3%) were clinically significant and detected solely by the broad-spectrum HPLC portion of the comprehensive screen However, in none of these 7 cases was patient management clinically altered as a result of the positive screen The total additional cost of the HPLC component was $16,205 ($35x464), an average distributive charge of $2,315 per patient in whom the HPLC portion provided additional clinical information ($16,205/7) Although adding significant charges to the evaluation of suspected toxic exposures in children, the HPLC component of the comprehensive drug screen was of no additional clinical benefit compared with its limited component alone 33. Urine Drug Screens THC 1-3 weeks* Cocaine 2-4 days Amphetamine 2 days Barbiturates 1-2 days Opiates 1-2 days PCP 5-7 days LSD 1-2 days Steroids 3 days or longer * Longer if prolonged exposure 34. Antidotes Poison Antidote Tylenol NAC Anticholinergics Beta Blockers Carbon Monoxide Cyanide Ethylene Glycol 35. Antidotes Poison Antidote Tylenol NAC Anticholinergics Physiostigmine Beta Blockers Carbon Monoxide Cyanide Ethylene Glycol 36. Antidotes Poison Antidote Tylenol NAC Anticholinergics Physiostigmine Beta Blockers Glucagon, catecholamine Carbon Monoxide Cyanide Ethylene Glycol 37. Antidotes Poison Antidote Tylenol NAC Anticholinergics Physiostigmine Beta Blockers Glucagon, Catecholamine Carbon Monoxide Oxygen Cyanide Ethylene Glycol 38. Antidotes Poison Antidote Tylenol NAC Anticholinergics Physiostigmine Beta Blockers Glucagon, Catecholamines Carbon Monoxide Oxgygen Cyanide Amyl Nitrate, Sodium Nitrate, Sodium Thiosulfate Ethylene Glycol 39. Antidotes Poison Antidote Tylenol NAC Anticholinergics Physiostigmine Beta Blockers Glucagon, Cateholamines Carbon Monoxide Oxygen Cyanide Amyl nitrate, Sodium Nitrate, Sodium Thiosulfate Ethylene Glycol Dialysis, Fomepizole, Ethanol 40. Antidotes Poison Antidote Iron Isonazid Lead/Heavy Metals Methemoglobin Producing agents Narcotics Organophosphates Phenothiazines 41. Antidotes Poison Antidote Iron Desferoxamine Isonazid Lead/Heavy Metals Methemoglobin Producing agents Narcotics Organophosphates Phenothiazines 42. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals Methemoglobin Producing agents Narcotics Organophosphates Phenothiazines 43. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals DMSA, BAL, EDTA Methemoglobin Producing agents Narcotics Organophosphates Phenothiazines 44. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals DMSA, BAL, EDTA Methemoglobin Producing agents Methylene blue Narcotics Organophosphates Phenothiazines 45. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals DMSA, BAL, EDTA Methemoglobin Producing agents Methylene blue Narcotics Narcan Organophosphates Phenothiazines 46. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals DMSA, BAL, EDTA Methemoglobin Producing agents Methylene blue Narcotics Narcan Organophosphates Atropine, Pralodixime Phenothiazines 47. Antidotes Poison Antidote Iron Desferoxamine Isonazid Pyridoxine Lead/Heavy Metals DMSA, BAL, EDTA Methemoglobin Producing agents Methylene blue Narcotics Narcan Organophosphates Atropine, Pralodixime Phenothiazines Benadryl 48. Elimination of Poisons Surface decontamination Reduce any additional absorption Ipecac Not routinely recommended anymore Possible useful in an obse