Protecting Yourself, Workers and Family from Pesticide Poisonings.
Pediatric Poisonings (1)
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Transcript of Pediatric Poisonings (1)
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Objectives for Part 1
Epidemiology: the numbers and its impact
Evaluating the pediatric poisoning patient:
Initial triage
Assessment via history and physical exam
Labs and diagnostic evaluation
General principles of management Identification of treatment themes and toxidromes
Prevention and Education
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Definitions A poison exposure is the ingestionofor contact with a substance that canproduce toxic effects. A poisoning is a
poison exposure that resultsinbodilyharm.
Poison exposures canoccurby accidentwithout intent, and these exposures are
defined asunintentional poisonings.Insome situations, poison exposuresare the result ofa conscious, willfuldecision; these cases are defined asintentional poisonings.
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Poisoning agents
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Poisoning agents
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Epidemiology: the numbers 1 million reported poison exposures among
children
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Epidemiology: the numbers Nearly 90% of exposures occurring at home
During pre-adolescence:slight male predominance
This reverses in ages 13-19 with femalesaccounting for 55 percent of poisonings
Children, especially those under age 6, are morelikely to have unintentional poisonings than olderchildren and adults (Litovitz 2001).
Adolescents are also at risk for poisonings, bothintentional and unintentional. About half of allpoisonings among teens are classified as suicideattempts (Litovitz 2001).
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Epidemiology: the numbers Approximately 1/3 of ingestions of toxic
medications occur with medications that areintended for someone other than an immediate
family member Among the fatalities in children < 6 y.o:
Unintentional ingestions
Medication errors
Environmental exposures Bites/stings
Malicious intent/abuse
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Epidemiology: the numbers From 2000-2003, most common agents ingested
by children younger than 6 y.o Cosmetics and personal care products
Cleaning products Analgesics
Foreign bodies
Topical agents
Cold and cough preparations
Plants Pesticides
Vitamins
Antimicrobials
Arts/crafts/office supplies
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Epidemiology: the numbers From 2000-2003, most common agents involved
in fatality among children younger than 6 y.o Analgesic drugs
Fumes, gases, vapors (carbon monoxide) Cough/cold preparations
Insecticides/pesticides
Antidepressant drugs
Cardiovascular drugs
Cosmetics and personal care products Hydrocarbons
Stimulants and illicit drugs
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Epidemiology: the numbers Childhoodlead poisoningis consideredone of
the most preventable environmentaldiseasesofyoung childrenyet approximatelyone
million children have elevatedbloodlevels(CDC 2001).
Carbonmonoxide (CO) resultsinmore fatalunintentional poisoningsin the United States
than anyother agent, with the highest numberoccurringduring the wintermonths (CDC1999).
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Epidemiology: the numbers Risk Factors
Development factors (normal gross motor development,fine motor skills, cognition and social skills)
Developmental delay Supervision
Adolescent development with independence and senseof indestructibility
Depression and suicidal ideation ENVIRONMENTAL FACTORS, SOCIETAL
FACTORS, EDUCATION, ACCESS to CARE
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Epidemiology: the numbers The majority of poisoning cases can be
successfully managed at home with consultation
of a poison control center specialist:
Nearly 76 % of cases reported to US Poison Control
Centers in 2003 managed at non healthcare facility
For children
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Approaching the Poisoned Child
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Overview
Approach begins with initial evaluation andstabilization (ABCDE)!!!!!!!
This is followed by a thorough approach toidentify the agent(s) involved
Often, the suspected toxic agent will determine thepriorities of management
Supportive cares, prevention of poison absorption,antidotes, enhanced elimination may subsequentlybe involved
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Initial Evaluation/Stabilization Airway
Assessment of the younger childs airway
paying close attention to upper airway edema
and to the gag reflex; pay close attention even
in the patient who is talking or crying
C-spine precautions should be taken when thereis any suspected trauma
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Initial Evaluation/Stabilization Breathing
Evaluate the quality of breathing
Evaluate the oxygenation and supplement with O2 ifneeded
Many toxins can be responsible for primary respiratorydepression
Many causative factors for metabolic acidosis will
result in a compensatory respiratory alkalosis Less compensatory reserve in children make them more
susceptible to hypoxia and respiratory failure(especially in inhalation toxic exposure)
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Initial Evaluation/Stabilization Disability (Rapid Neuro Eval)/ Dextrose
Assess pupillary response
Assess mental status (GCS) Physiologic excitation (CNS stim, hyperthermia, tachycardia,
elevated BP, tachypnea)
Depression (CNS depression, hypothermia, hypotension,hypopnea, bradycardia)
Mixed
Administration ofOxygen or Naloxone (infusion)
Assess blood glucose
Administration of dextrose (infusion) and thiamine
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Initial Evaluation/Stabilization Exposure
Full head to toe survey of the undressed child or
adolescent Search for pill containers
Evaluate for hidden injuries
Appropriate thermal control
GI decontamination may have a role at this stage of the
initial stabilization for children who have ingestedpotentially life threatening amounts of toxin
Ocular decontamination
Dermal decontamination
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Diagnosis Focus effort now on agent identification,
assessment of severity, and prediction of
toxicity.
Start with H and P , supplement with labs
and investigations
AMPLE (Allergies, Meds, PMHx, lastmeal, events/environment)
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Diagnosis History can be challenging
Where/how was patient found?
Agents in kitchen may be different from other location
If known, details of exposure: agent, time, volume, immediate
clinical effects
Supervision, recent visitors
Assess for all suspect medications
Herbal products or home remedies
Ill contacts or those with similar symptoms
Recent similar exposures in household contacts Open bottles, pill containers, unusual odors
Household hobbies, industrial exposure
Substance in original container?
Recent illness or medications for the patient?
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Diagnosis History can be challenging
Corroborate the story of the adolescent
Symptoms or behavior after the reported ingestion
Work and school environments? Available bottles/pills?
Interventions in the pre-hospital setting
Illicit drug use in family members or close contacts?
Huffing, snorting,
PMHx, family history, allergies, ROS
Assume the worst case scenario in trying to calculate the ingestion
dose
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Diagnosis Physical Exam:
Vital signs and general appearance
Thorough PE
Close attention to neuro exam Pupils
Reflexes and posture
Mental status
Bowel sounds
Mucous membranes and skin moisture/appearance Characteristic odors
Nosebleeds, needle tracks, huffer rash, blistering
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Specific Toxidrome Patterns
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Common Toxidrome FindingsPhysical
Findings AdrenergicAnti-
cholinergic
Anti-
cholinesteraseOPIOID
Sedative-
hypnotic
RRIncreased No change No change Decreased Decreased
HR Increased Increased Decreased Normal/decreased
Normal/
decreased
TempIncreased Increased No change Normal/
decreased
Normal/
decreased
BP Increased NoChange/increased
No change Normal/
decreased
Normal/
decreased
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Common Toxidrome FindingsPhysical
Findings AdrenergicAnti-
cholinergic
Anti-
cholinestera
se
OPIOIDSedative-
hypnotic
Mentalstatus
Alert/agitated
Depressed/Confused/
hallucinate
Depressed/Confused/
Depressed Depressed
pupils Dilated Dilated Constrict Constrict Normal
Mucusmembrane
Wet Dry Wet Normal Normal
skin Diaphoretic Dry Diaphoretic Normal Normal
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Physical Exam Findings
See handout re: physical findings/odors
Sympathomimetic (meth, amphetamines, cocaine, opiatewithdrawal, PCP) Hyperthermia, tachycardia, hypertension, mydriasis, warm/moist
skin, agitated Cholinergic (organophosphates, betel nut, VX, Soman,
Sarin) SLUDGE (Salivation, Lacrimation, Urinary incontinence,
Diarrhea/Diaphoresis, GI upset/hyperactive bowel, Emesis)
Anticholinergic (antihistamines, atropine, phenothiazines,TCA) Hyperthermia, tachycardia, HTN, hot/red/dry skin, mydriasis,
unreactive pupils, unrinary retention, absent bowel sounds
Opioids (codeine, dextromethorphan, heroin)
Miosis, respiratory depresssion, mental status depression
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Diagnostic Considerations
Before proceeding, consider other aspects of thedifferential diagnosis ( CVA, trauma, meningitis, post-ictalstate, behavioral or psych disorders).
Labs to evaluate glucose, acid-base status and electrolytes,
BUN/Cr, carboxyhemoglobin, hepatic enzyme levels,urinalysis (UA preg), serum osmolality, serumacetaminophen levels
EKG
Woods lamp/Radiography
Save samples of blood, urine, gastric contents
General qualitative tox screens of little value (except whenabuse is suspected), but are rapid and could offer clue toantidote; may have role in the difficult dx or critically ill;Quantitive measurements in certain toxic exposures
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Diagnostic Considerations
Ocular/dermal: pH testing may reveal acid or alkali
Hypoxemic while asymptomatic may suggest methemoglobinemia
Cardiac
EKG shows arrhythmia (TCA) Blood color on filter paper that remains brown after air exposure
suggests methemoglobinemia (possibly from benzocaine-containing products, aniline dyes, nitrites)
Signs of hypocalcemia in ethylene glycol, hydrofluric acid
Urine fluorescence in ethylene glycol Ferric Cl creates purple reaction with salicylates and
phenothiazines in urine
Small opacities on x-ray may show halogenated toxins,heavy metals, lithium, densely packed products,
phenothiazines, enteric-coated meds
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Diagnostic Considerations
MUDPILES CAT for high anion gap acidosis Methanol or metformin
Uremia
DKA
Paraldehyde or phenformin Iron, INH, Ibuprofen
Lactic acidosis
Ethylene glycol
Salicylates
Cyanide
Alcohol or acids (valproate)
Toluene or Theophylline
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Diagnostic Considerations
Toxins requiring quantitative levels at a set point: Acetaminophen
Carbon monoxide
Ethanol, ethylene glycol Heavy metals (24 hour urine)
Iron
Methanol
Methemoglobin
Toxins requiring quantitative serial levels Aspirin/salicylates, tegretol, digoxin, phenobarbital, phenytoin,
VPA, theophylline
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Management Considerations
Supportive care is the mainstay of therapy and
recovery and may involve decontamination,
antidotal therapy, enhanced elimination techniques
Systemic support for airway security, ventilation,
hemodynamic stability, and adequate CNS
function
Careful attention to pain and agitation Activating multi-faceted team approach early
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Management Considerations
Decontamination Priority after stabilization
Activated Charcoal is preferred method, and may be indicated evenin the patient with equivocal exposure history
Adsorption of toxins to prevent their absorption Dependant on toxin
Heavy metals (lead, arsenic, mercury, iron), inorganic ions, boric acid,corrosives, hydrocarbons, alcohols, and essential oils are generally not welladsorbed by charcoal
Dependant on surface area of the charcoal preparation
Use 1g/kg prepared in slurry with a cathartic and chocolate milk, cola,fruit syrup. Can be repeated every 4-6 hours at the dose, andmultiple doses can help interrupt enterohepatic circulation.
Efficacy decreases over time; gastric lavage that follows or precededand follows may be more effective than charcoal alone.
Contraindications in child with depressed levels of consciousness and
non-secure airway; caustics, hydrocarbons, ileus/perforation risk
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Management Considerations
Decontamination Priority after stabilization
If ingestion has occurred within 1 hour,or a highly toxic substance is ingestedthat is usually not well bound to
charcoal gastric lavage may beattempted; but no longer the routine
Controversial in the asymptomaticpatient or who has presented more than
one hour after ingestion Contraindicated if prior vomiting,
hydrocarbon, unprotected airway,caustics, foreign body, at risk forhemorrhage
Risk includes aspiration, trauma to
anatomic structure.
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Management Considerations
Whole bowel irrigation may be necessary in theingestion of a sustained release product or toxin
Large volumes of balanced electrolyte solution used to
decontaminate the GI tract Used in fewer than 1 percent, not well studied in
pediatrics
Can be useful in ingestion of enteric coated pills, illicitdrug packets, large ingestions of substances that are
poorly bound by activated charcoal
Contraindicated in bowel obstruction, GI bleed,perforation, unprotected airway
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Management Considerations
Ipecac syrup induces vomiting by stimulatingcentral emetic centers.
No longer recommended for routine home use.
Can be used only in the alert, conscious child over 6 mowho has ingested a potentially toxic amount of poison.
(No longer routinely recommended to be used becauseof its questionable effect on outcome).
Contraindicated in children less than 6mo, ingestion ofa non-toxic substance, corrosive ingestion, hydrocarboningestion, altered mental status or airway compromise,GI bleed or coagulopathy,
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Management Considerations
Ocular exposure requires copious irrigation with
saline using a Morgan lens, measure pH and
maintain at 7.5-8
Dermal cleansing with water or normal saline and
subsequent identification:
Pay close attention to burns, pain, infection
Water is absolutely contraindicated with reactivemetals; use mineral oil instead
Tar can be removed safely with vaseline
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Management Considerations
Inhalation injuries need fresh humidified and
oxygenated air
Treatment with B-agonists, corticosteroids
Removal of offending environment
Hemodialysis and Hemoperfusion
Require anti-coagulation
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Management Considerations
Drugs that can kill the toddler in one or twodoses!:
Benzocaine, Ca antagonists, camphor, chloroquine,clonidine, TCA, Lomotil, Visine/Afrin, Lindane,Sulfonylureas, theophylline, phenylpropanolamine,
phenothiazines, selenious acids, hydrocarbonaspiration, oil of wintergreen.among others
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Management Considerations
Activate Poison
Control:1-800-876-4766 or
1-800-222-1222www.calpoison.org
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Management Considerations
Prevention Strategies/Themes-primary Store potentially toxic substances in higher places or out of
reach/sight
Store safe items within the childs reach; dont take medicine infront of kids
Child-proof latches
Avoid chemicals in the fridge, or insect traps that are accessible
Remove toxic plants; avoid exposure to toxic animals
Keep matches, combustibles out of reach
Dispose of partially consumed alcohol
Carbon monoxide detection system
Read labels on products carefully
Advocate for protective legislation
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Management considerations
Prevention Strategies/Themes-secondary
Identify poison control center and number
Education
Decontamination
Prevention Strategies/Themes-tertiary
EMS
Antidotes
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