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Hong Kong Poison Information Centre

Accidental poisoning in children & adolescents in

Hong Kong

Dr. Fei-lung Lau Director

Hong Kong Poison Information CentreUCH Toxicology Training Centre

Accidental poisoning in Hong Kong

Toilet bowl cleansing jelly

Over aggressive management

M/5live in outlying islandTaken 1 pack of mother’s Contraceptive pillsTransfer by helicopter for MX

Unnecessary Admission

F/2Swallow mercury in the broken thermometerAdmitted for Management

Unnecessary Admission

F/2

Swallow mercury in the broken thermometer

Admitted for Management

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Severity Pyramid of Poisoning

Invariably fatal

Potentially fatal

Definitely Toxic

Potentially Toxic

Trivial/nontoxic ingestion

Possible Exposure

Poisoning management according to Severity

Invariably fatal

Potentially fatal

Definitely Toxic

Potentially Toxic

Trivial/nontoxic Ingestion

Possible Exposure

Specific Treatment

Antidote

Decontamination

Supportive Treatment

Observation

Discharge + terminate re-exposure

Accidental Paediatric Poisoning

Single agentsmall amount, low toxicity substances

Mainly Observation +/- supportive RxRarely need GI decontamination Psychosocial concern

Poisons TypesHKPIC Data (Jul 08 – Mar 10)

N = 1558

Pharmaceutical

55%

Non-pharmaceutical

36%

Miscellaneous

1%Chinese Medicine

7%

Alternative Medicine

1%

Common Poisons

0

50

100

150

200

250

Analgesic

Melamine

Household prod

ucts

Toxin in foo

d

Chinese M

edicine

Street drugs

Antihista

mines

Sedatives an

d Hypnotics

Accidental (Unintentional)

0

50

100

150

200

250

0-<1

1-<2

2-<3

3-<4

4-<5

5-<6

6-<7

7-<8

8-<9

9-<1

0

10-<

11

11-<

12

12-<

13

13-<

14

14-<

15

15-<

16

16-<

17

17-<

18

Age Group

Accidental

M

F

3

Intentional (Self-Harm)

0

20

40

60

80

100

120

0-<

1

1-<

2

2-<

3

3-<

4

4-<

5

5-<

6

6-<

7

7-<

8

8-<

9

9-<

10

10-<

11

11-<

12

12-<

13

13-<

14

14-<

15

15-<

16

16-<

17

17-<

18

Age Group

Suicidal

M

F

Substance Abuse

0

10

20

30

40

50

60

70

0-<

1

1-<

2

2-<

3

3-<

4

4-<

5

5-<

6

6-<

7

7-<

8

8-<

9

9-<

10

10-<

11

11-<

12

12-<

13

13-<

14

14-<

15

15-<

16

16-<

17

17-<

18

Age Group

Substance Abuse

M

F

Outcome

N = 1017, exclude non-poison related cases

Outcome Definite Probable Possible

Death 0 2 0 2 (0%)

Major 12 7 2 21 (2%)

Moderate 38 23 17 78 (8%)

Mild 161 251 125 537 (53%)

No effect 131 145 103 379 (37%)

Total 342 428 247

GI Decontamination (Age <18) July 05 – March 08 N=871

Pediatric GI DecontaminationAggressive GI decontamination (GL/MDAC/WBI) rarely usedActivated charcoal most commonIpecac Induced Vomiting is outdated

Scenario 1: Pills missing

M/2 Found playing with grandma pills bottleOne tablet was recovered from the mouthBrought to AED in 1 hour

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General Rule

Toxic if > 10 tablets taken

Drug with narrow therapeutic index can be toxic <10 tablets taken

Very toxic drug can kill even with 1 pill

One pill/spoonful can kill (10kg infant)

NO CTNarcorticOral hypoglycaemic Oil (Methyl salicylate)Calcium blockersCamphorChloroquine / quinineTCA (imipramine)TheophyllineThioridazine /chlorpromazineToxic alcohol

Management of “Pills Missing”

A period of observationUsually 6 hours is adequateSearch for the drug

GI decontamination for I- pill- can- kill drugsSingle dose AC usually ok

Delayed Toxicity

Symptoms onset may be > 6 hours

Delayed absorption• Sustained released preparation

Metabolism to form toxic metabolites • Methanol, panadol

Exhaustion of the “reserve” • Oral hypoglycaemic, superwarfarin

Scenario 2: Sips of household product

M/3 Drink a mouthful? of cleaning agent in toilet Vomited once

Household Products

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Poison Type 0-5 6-12 13-17 Total

Desiccant 43 6 1 50

Detergents / cleanser 34 4 6 44

Mothball 27 0 1 28Antiseptic / Disinfectant

12 2 1 15

Bleach 9 1 2 12

Hydrocarbons 5 0 1 6

Insect repellent 4 0 0 4

Hand warmer 2 0 0 2

Corrosive 2 0 0 2

潔廁清香凍 2 0 0 2

Misc. 10 1 1 12

Total 150 14 13 177

Household Product Categories

Outcome of accidental pediatric household product poisoning

Age Group

Discharge General Ward

ICU/CCU/HDU Death

N/A

Total

0–5 95 48 1 0 6 150

6-12 11 2 0 0 0 13

13-17 8 6 0 0 0 14

Dangerous Stuffs

CausticsDrain openerToilet bowl cleaner

Organophosphate insecticide

Hydrofluoric acid

Management of “Dangerous Stuffs”

Generally require in-hospital management

Consider GI decontamination

Antidotes may be neededAtropine / 2-PAMCalcium

Specific Treatment

Antidote

Decontamination

Supportive Management

Non Toxic / Minimal Toxic Ingestion

Able to identify the product and its ingredientsKnown amountNo warning words on its containerReliable historyNo symptom & sign

In unsure : call HKPIC

Beware – Allergic reaction, Aspiration, NAI

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Agents with Low Toxicity on Ingestion

Antacids Laxatives

Battery (dry cell) Shampoos (liquid)

*Household Bleach Shaving cream

(<5% sodium hypochlorite) (soap, perfume, menthol)

Cigarettes or cigars (nicotine) Soap

Contraceptive pills Sweetening agents

(saccharin, cyclamate)

Crayons (marked AP or CP) *Thermometer (mercury)

Drying agent (silica gel) Toothpaste

Detergents Vitamins without iron

(most except electric dishwasher)

*Low toxicity except in large amounts 2008-10-17, 成報, A06, 港聞

Vitamin

Dose of concern

ToxicitySingle acute ingestion

Chronic (>1/52 in general)

A >300,000 IU (Child) >25,000 IU /day for months

CNS, LiverPeripherals

D Unlikely to produce toxicity

>50,000 IU /dayfor weeks

Hyper-calcaemia

Product Name(HK reg. no)

Contents(Each Tab)

Photos

Kawai Kanyu Drop S(HK-10544)

Vit A 2000 IUVit D2 200 IU

Kawai Kanyu Drop C20(HK-21020)

Vit A 1000 IUVit D2 100 IUVit C 20 mg

Kawai Kanyu Drop M400 (Pear)(HK-49278)

Vit A 1000 IUVit D2 100 IUCaPO4 100 mg

Kawai Kanyu Drop M400 (HK-35838)

Vit A 1000 IUVit D2 100 IUCaPO4 100 mg

Beware !!For treatment Vs supplement

Available as OTC medications

Scenario 3: Slimming agent poisoning in adolescents

F/16Progressive confusion x 2 days After weeks of taking slimming agents brought over internet

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Claim : L-Carnitine Sibutramine and phenolphthalein Dx: Sibutramine induced psychosisRespond to psychiatric Rx & drug withdrawal

Slimming Agent Poisoning

Age group / Period

2009 2010 2011 Total

0-5 1 1 2 4

6-12 0 0 0 0

13-17 1 5 3 9

Above 18 22 26 20 68Total : 81 cases

Slimming Agents

Stimulants Thyroid hormone or analoguesLaxatives / DiureticGut absorption blockerCannabinoid receptor inverse agonist

Slimming Agent Poisoning – TypeSlimming agents 09-11( HKPIC )

Type / Age

group

Cannabinoid Receptor blocker

Lipase inhibitor

Stimulant Thyroid hormone

Laxative/

diureticetc

0-5 0 1 1 0 2

6-12 0 0 0 0 0

13-17 0 0 2 1 6

Above 18

3 1 20 0 44

Total 3 2 23 1 52

Stimulant (Sympathomimetic)

Fenfluramine (Banned)Sibutramine (Banned lately)Phentermine

Sibutramine de-registratedin HK on 2 Nov 2010

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Sibutramine

Amphetamine-like anorexiantSerotonin norepinephrine reuptake inhibitor (SNRI)Amphetamine-like effects in overdose –sympathomimetic toxidromeMay cause serotonin syndrome

Serotonin Syndrome

Thyroid Hormones or Analogue

ThyroxineTiratricol (T3 metabolite)Animal thyroid tissue adulteration

Thyrotoxicosis, “funny” TFT

Take home messageMost accidental pediatric poisoning are minor with good outcome Management should be appropriate to the severity If in doubt : consult HKPIC at

26351111 or

27722211

Hong Kong Poison Information Centre

THANK YOU