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
04/24/23
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
04/24/23
New AntidotesNew Antidotes Tricyclic antidepressant Tricyclic antidepressant
antibodiesantibodies– TCATCA
Fomepizole (Antizol)Fomepizole (Antizol)– Methanol & ethylene glycolMethanol & ethylene glycol
NalmefeneNalmefene– Opioid poisoningOpioid poisoning
04/24/23
New AntidotesNew Antidotes Flumazenil (Romazicon)Flumazenil (Romazicon)
– BenzodiazepineBenzodiazepine
04/24/23
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
04/24/23
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
04/24/23
If you watch these kids, If you watch these kids, you may not have to do you may not have to do
anythinganything
04/24/23
ResourcesResources Drug InformationDrug Information (AHFS) (AHFS) PoisindexPoisindex computer database computer database Regional poison centerRegional poison center
– 212-POISONS212-POISONS
Top Related