evaluation of poisoning

8/6/2019 Evaluation of Poisoning

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Evaluation and ManagementEvaluation and Management

of a poisoned childof a poisoned child

Professor Dr. Hassan Elkinany.

Faculty of Medicine, Alexandria University.

Pediatric department ( PICU )



Can you imagine or predict «Can you imagine or predict «The number of poisons the we are subjected

to ?

They are innumerable «!!!



Do you know.. ?Do you know.. ?

Poisoned patients constitute a substantialnumber of cases that you would meet during

the initial days you will practice your career

as a caring physician in the ER (may be the

first day)



Objectives of the lecture :Objectives of the lecture : To know a global view as regards the

epidemiology, routes and the circumstances that

accompany the intake of poisons. To learn how can you diagnose or suspect the

³poisoning state´.

To be able to deal with and manage a poisoned

or a suspected poisoned child initially in the ER



The detailed information about the clinical

picture of the so many poisons as well as

their ultimate management is not among

the objectives of this lecture.



EpidemiologyE

pidemiology In 2007, the ER department of El-Shatby

Alexandria University Children Hospital

received 967cases with poisoning. Of these, 21 cases needed admission to

PICU

In USA, t

he AAPCC reports an annualnumber ranging from 2.1-2.8 million

( 1998-2005 ).



Routes of poison intake :

Routes of poison intake :

Oral

Parenteral

Inhalation

Trough skin or eyes



Circumstances of poisoning :Circumstances of poisoning :

Accidental : Mainly in toddlers.

Sui cidal : Mainly in adolescents.

Homi cidal : Consider ³

child abuse´.

Dr ug abuse : B2 agonists, tranquilizers..

I atro g eni c : Lomotil, digoxin«



Diagnosis or Suspicion of Diagnosis or Suspicion of

the diagnosis :the diagnosis :In practice you will be confronted with two sit uations :

1. Frank history :

Here you will need to have answers for the followingquestions :

a. When ?

b. How much ?

c. Symptoms and signs.

d. Actions done by the parents.

Remember, you should match the clinical findings with the name of the poison given



2. Denied or suspected poisoning :

In this situation you may ask some questions as :

Drugs given at homeOpen bottles

The usual habits and life style

Visit or visited by somebody

Special odors

Symptoms and signs



Diagnostic tips :Diagnostic tips : Poisoning should be highly suspected in any

previously healthy child who presents with acute

deterioration of 3 major organ/systems :1. CNS

2. Liver

3. Lungs Poisoning is ruled out in the presence of

lateralsing or focal neurological signs.



Management

Management

Remember t hat:

the proper management requires a skilled

teamwork and an easy access to a poison center, ahandbook and/or a computer or internet facility(information store or reservoir).

The initial skilled and rapid interventions are themost determinant factors that predict the outcomeand prognosis of a poisoned child.



Situation 1Situation 1: Frank history: Frank history

Management accordingly«..

Apply what you know about the basics of

life support measures ..(if needed)

Give an antidote if there is«

Try to minimize toxin absorption

Assess organs and systems«and«

Monitor«««.



Situation 2 Situation 2 : Denied or suspected: Denied or suspected

poisoningpoisoning

Evaluation of organs and systems (Which

are the most important ? )

Initially and«..

Continuously i.e. monitoring

And manage accordingly

³You might reach the diagnosis later on´



You can get very valuable informationthrough the careful examination of :

Vital signs

EyesSkin

NB. Revise and keep in close contact to you a

table which demonstrates the correlation

between some clinical signs and certain poisons.



Diagnostic cluesDiagnostic cluesSigns Drugs

Tachypnoea Aspirin, theophylline, CO, cyanide

Bradypnoea Opiates, barbiturates, sedatives, ethanol

Metabolic acidosis CO, ethanol, ethylene glycol

Tachycardia TCA, sympathomimetics, amphetamines, cocaine..

Bradycardia B-blockers, digoxin, clonidine

Hypotension Barbiturates, benzodiazepines, B-blockers, calcium channel blockers, opiates, iron,T

CA...

Hypertension Amphetamines, cocaine, sympathomimetics..

Small pupils Opiates, OPC, phenothiazines

Large pupils Amphetamines, atropine, cannabis, cocaine, TCA, quinine..

Hypothermia Barbiturates, ethanol, phenothiazines, opiates

Hyperthermia Amphetamines, cocaine, salicylates, phenothiazines, anti-cholinergics..

Convulsions OPC, TCA, phenothiazines

Tremors Hg, arsenic, lithium..

Focal neurologic signs Rule out poisoning



Management tipsManagement tips³if poisoning is denied or suspected´³if poisoning is denied or suspected´

In the conscious child : you can send him home if he

remains asymptomatic for 6 hours in the ER,

provided that he can easily return to hospital if

necessary. (Why and what is the value of this concept

?? )

The exception is if there is a documented or suspected

intake of a drug whose onset of action is delayed

(anticoagulants or sustained release medications).

In the unconscious child : Give Naloxone 0.1-0.2

mg/kg rapid IV. ( What is the idea ?, What is the

coma cocktail ? )



Methods to diminish toxinMethods to diminish toxin

absorption :absorption :These measures are only done if the time lapsed afterpoison ingestion is not more t han 2 hours.

1. Ipecac syrup: 10-15 ml followed by water. It must notbe used in children with depressed level of consciousness. It better be given within the first 30 minutes of the drug intake and it is of limited value if given after 1 hour.

2. Gastric lavage: using saline in infants and water inolder children. Only effective if given within 1 hour of the poison intake. The lavage tube can be usedthereafter as a route for a specific antidote or activated

charcoal. ( contraindications ?? )



3. Activated charcoal: It has a surface area of 1000 m2/g and is

capable of adsorbing nearly all drugs (except alcohol and

iron). Now it is available as colored granules, and is given in adose of 1-2 g/kg mixed with a chocolate milk or any sweet

drink. Repeated doses (at 2-hourly interval) are useful in

some drugs as they promote drug reabsorption from the

circulation back to the bowel and interrupt enterohepatic

cycling (aspirin, barbiturates and theophylline).

It can be given through a NGT or the stomach lavage tube

after the washout.

In the unconscious child it should be given after airway

protection as it can cause severe lung damage.



4.Cathartics ³As magnesium citrate and

sorbitol´ : They are used only in olderchildren

Whole bowel irrigation : using a polyethylene glycol (Colyte ) ???

Others«.(diuretics, dialysis,hemoperfusiom..)



ToxidromesT

oxidromesThe term refers to a group of related signsand symptoms that can occur with a group

of poisons. EXAMPLES :C holiner g i c toxidrome : diminished

level of consciousness, salivation,lacrimation, bronchorr hea, bradycardia, pin point pupil and incontinence.

Drugs/poisons : OPC, Nicotine



Anti-choliner g i c toxidrome : agitation,salivation, sweating, mydriasis, hyperpyrexia,tachycardia and urine retention.

Drugs/poisons : Anticholinergics, antihistamines,tricyclic antidepressants..

Opiates toxidrome : sensorium, hypothermia,

hypotention and pin point pupil.Drugs/poisons : Heroin, morphine, fentanyl,lomotil«



Please

Remember

Please

Remember

All that surround us could be a poison.

Child abuse«.

Unexplained deterioration of 3 systems greatly

arouse the possibility of poisoning (what are

them?).

Focal neurological signsrules out

poisoning. Basic life support measures .. AND«

continuous monitoring«



In an asymptomatic child with suspected historyyou can send him home after «..hours.

In an unconscious child without a clear cause it isa good policy to add«« by rapid IV infusion tothe coma cocktail.

Induction of emesis and stomach lavage are not

needed if ««h

ours lapsed after poison intake. Be sure of an easy contact with an information

store.



List of drugs and toxins in theList of drugs and toxins in the

curriculumcurriculum Tricyclic antidepressants (TCA)

OPC

Paracetamol

Aspirin

Theop

hylline

Iron



For M

Dcurriculum

For M

Dcurriculum

Digoxin

Opiates

Lead, Mercury and arsenic

Food poisoning



Thank youThank you

evaluation of poisoning

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