pediatric toxicology pills and poisonous bites high yield
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Pediatric Toxicology Pills and poisonous bites High Yield. Eiman Abdulrahman MD/MPH Pediatric Emergency Medicine Fellow Emory University. Outline. Important highlights in pediatric toxicology Young children vs Adolescents Prevention - PowerPoint PPT PresentationTRANSCRIPT
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Pediatric ToxicologyPills and poisonous bites
High Yield
Eiman Abdulrahman MD/MPHPediatric Emergency Medicine Fellow
Emory University
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Epidemiology
1.25 million annual cases in <6years. 15,447 fatalities; 537 (3.7%) in <6yrs;
397 (2.6%) in <2yrs (since 1983) Of 27 deaths in 2004; 19 were caused by
pharmaceuticals (analgesics and opioids) of which 14 were in <2yrs
12 deaths were pre-hospital
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Pediatric Toxicology Young children vs Teenagers
79% of all pediatric exposures occur in <6years and approx 99% are unintentional
Approx 40-45% of ingestions in adolescents are intentional and 56% are female (substance abuse vs suicide attempts)
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Young Children
Without suicidal intent Usually one substance Usually non-toxic Small amount Present for evaluation within one
hour
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Young children
Physiologic considerations High Metabolic Demands More permeable BBB until 4mos Decreased glycogen stores
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Adolescents
56% of seriously poisoned children Overdose from suicidal attempt Adverse effect while trying seeking
euphoria More frequently hospitalized than
younger children ( includes psych) 42% of AAPCC reported adolescent
fatalities from suicide vs 4% from medication errors and adverse reactions
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Prevention The Poison Prevention Packaging Act
(PPPA) of 1972 has reduced pediatric mortality by 45% Mandatory child protective packaging
in household products, medicines, solvents
FDA 1997 regulation with packaging with blister packs of 30mg Iron tablets (overturned in 2003) Significant decline in iron overdose
Small amounts of some substances can extremely toxic to children
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Lethal exposures
Analgesics Sedative/hypnotic/psychotics Antidepressants Stimulants and street drugs Cardiovascular drugs Alcohols Chemicals Gas and fumes Antihistamines
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Lethal Drugs
AntimalarialsAntidysrhythmicsBenzocaineβ-blockersCalcium channel blockers (CCBs)CamphorClonidine (and other imidazolines)
Lomotil (diphenoxylate/atropine)LindaneMethyl salicylateOpioids
SulfonylureasTheophyllineTricyclic antidepressants (TCAs)
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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General Approach
Airway Breathing Circulation Disability Drugs Decontamination
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Focused history
Three key questions: WHAT substance was ingested? WHEN did the ingestion occur? HOW MUCH was ingested?
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Key PE
Vital signs Level of consciousness, neuromuscular
status Eyes-pupils, EOM, fundi Mouth-corrosive lesions, odors CV- rate, rhythm, perfusion Resp- rate, chest excursion, air entry GI- motility Skin- color, bullae or burn, diaphoresis,
piloerection,
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Laboratory evaluation
CBC, co-oximetry ABG, serum osmolarity EKG/cardiac monitor CXR, abdominal xray Electrolytes, bun/cr, glucose,
calcium, LFT, UA Urine tox screen Quantitative tests (esp
acetaminophen)
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Assessment
Clinical findings Toxidromes Laboratory abnormalities
Anion gap: (Na + K)-(Cl + HCO3) Osmolarity: (2x Na)+ (Bun/2.8)+
(Glu/18) Osmolar gap: measured-calculated
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ToxidromesAnticholin-ergics
(Antihista-mines, Many
Others)
Organophosphates
(Insecticide Nerve Gases)
OpiatesClonidine
BarbituratesSedative-Hypnotics Salicylates
Theophylline
Sympathomimetics (Ampheta
mines, Cocaine)
MS/CNS Agitation, delirium, psychosis, convulsions
Delirium, psychosis, coma, convulsions
Confusion, fasciculations, coma
Euphoria, somnolence, coma
Somnolence, coma
Lethargy, convulsions
Agitation, tremor, convulsions
Heart rate Increased Increased Decreased (or increased)
Decreased — — Increased
Blood pressure
Increased Increased — Decreased Decreased — Increased
Temp Increased Increased — Decreased Decreased Increased Increased
Respirations
— — Increased Decreased Decreased Increased Increased
Pupils Large, reactive
Large, sluggish
Small Pinpoint — — Large
Bowel sounds
Present Diminished Hyperactive — — — —
Skin Dry skin Flushed, dry Diaphoresis — — — Diaphoresis
Misc — — “SLUDGE”a — — Vomiting Vomiting
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Detoxification
Reassess ABCDs GI decontamination:
Dilution, gastric emptying, Activated charcoal, catharsis, whole bowel irrigation
Urgent antidotal therapy Consider excretion enhancement
Diuresis, urine alkalinization, dialysis, hemoperfusion
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Case 1 “lethargic”
4 year old w/ ALOC Grandmother called 911 when girl
was not arousable VS: T 37.6 HR 60 RR 18 BP 80/60
Pulse Ox 98%
Differential?
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Case 1 “lethargic”
MNEMONIC FOR ALOC A- Alcohol E- Epilepsy I- Insulin/intussusception O-Overdose U- Uremia T- Trauma I- Infection P- Psychiatric S- Shock
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Case 1 “lethargic”
PE: 1mm pupils reactive Dry skin No trauma except for “bandaid” on
Rt knee
Diagnosis?
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Case 1 “lethargic”
Clonidine patch on Rt knee Fluid resuscitation- NS20ml/kg Naloxone w/ no effect Admitted to PICU D/C next day
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Outline
Important highlights in pediatric toxicology
Young children vs Adolescents Prevention Overview of pills potentially fatal in
children even in small amounts Approach to management Snake and spider bites
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Brown Recluse Spider(Loxosceles)
Southern and mid-western states Brown violin shaped mark on
dorsum of cephalothorax Usually outdoors, but make indoor
nests in closets Shy and will only attack when
provoked Venom is cytotoxic and hemolytic
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Clinical presentation 2-8 hours
Local reaction with mild-moderate pain (stinging sensation)
Erythema, central blister or pustule 24 hours
Fever, chills, malaise weakness, N/V, rash with petechiae, joint pain, DIC, hematuria, renal failure
Subcutaneous discoloration that spreads over 3-4 days
Spreads to 10-15 cm Pustule drains leaving ulcerated crater that scars
Scar formation is rare after 72 hrs Reaction varies according to amount of envenomation
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Management Unless spider is brought for ID, definitive
diagnosis cannot be made Good local wound care If systemic symptoms, then CBC with platelets,
U/A, BUN, creatinine Vigorous supportive care in PICU
Surgical excision and skin grafting after necrosis is demarcated
Steroids, heparin, and hyperbaric O2 don’t work No Dapsone for kids – methemoglobinemia No antivenom available Have wound rechecked daily for progression
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Black Widow Spider(Latrodectus)
Shiny black spider with brilliant red hourglass marking on abdomen
Only the female bite is dangerous Male spiders are ¼ the size of
females and bite cannot penetrate human skin
Females not aggressive unless provoked or guarding egg sac
Produces a neurotoxin
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Clinical presentation
No local symptoms 1-8 hours after bite
Generalized pain and muscle rigidity Cramping pain to abdomen, flanks, thighs,
chest Chills Urinary retention Priapism Death from cardiovascular collapse
Mortality 50% in young children
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Management Supportive ABC’s Tetanus Treatment of spasm with narcortics and
benzo’s Children < 40kg: Antivenin given as
soon as bite confirmed Dose: 2.5ml (one vial)
Children >40kg: not as urgent to give immediately unless having respiratory difficulty or significant hypertension
Admit to PICU
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Other Spiders…
Tarantulas Do not bite unless provoked Venom is mild and not a problem
Wolf Spider and Jumping spider Mild venom only causes local
reaction Treatment is good local wound
care
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Snake characteristics cold blooded (seeks shelter at 55
degrees) - poor vision, great smell - slow but can strike 11 feet/sec. - Rattles are interlocking keratin rings - Jacobson’s organ at end of the forked
tongue used to ID prey - venom with potent enzymes that effect
coagulation, multi-organ function Play major role in ecosystem as rodent
predators
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Snakes Bites
Epidemiology approx 400,000 bites worldwide Approx 45,000 bites in USA Approx 8,000 poisonous bites 5-15 deaths annually
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Snake Types Over 95% in the pit viper
(Crotadilae) family: Eastern
diamondback rattlesnake (Crotalus)
Copperhead (Agkistrodon)
Cottonmouth (Agkistrodon)
- 1% Coral snake(elapidae) family
Georgia is home to 41 different snakes of which 6 are venomous
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Pit Vipers (Crotalinae) Rattlesnakes,
cottonmouths, water moccasins
Proteolytic enzymes and anticoagulant esterases=> digest victim!!
Mojave rattlesnake only pit viper with neurotoxin venom
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Clinical Presentation Local effects:
edema within 1 hr (mod-severe bites) spreads centrally over 8-24hrs.
Ecchymosis, Petechiae and Hemorrhagic bullae
Systemic Effects: Nausea, vomiting, paresthesias,
dizziness, and diaphoresis. In severe envenomations-hypotension, rhabdomyolysis, renal failure and AMS
Coagulopathy: Increase in PT, PTT, thrombocytopenia
and hemolysis. DIC in severe cases
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Coral snakes
Eastern coral snake:AR, NC, SC, FL, GA, LA, MS, TX
Local damage usu mild and doesn’t correlate with severity of envenomation
All confirmed coral snake envenomations are defined as severe and require antivenom
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Clinical Presentation
Mild local finding Venom potent neurotoxin
Paresthesia, weakness, cranial nerve dysfunction, confusion, fasciculations, and lethargy
Common early sx:diplopia, ptosis, and dysarthia
Nausea, vomiting, and salivation are also common
Respiratory paralysis common cause of death
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Lab evaluation
CBC, coagulation studies, DIC panel
CK, renal function, UA Type and crossmatch in severe
envenomations
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Prehospital treatment
Prehospital Remove from vicinity of snake Immobilize bite site below heart
level Minimize all physical activity
(decrease absorption) DO not incise bite marks Transport to nearest hospital
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ED management ABC, IV hydration Coral snakes: monitor neurologic sx
(intubate if resp compromise) Antivenom (moderate to severe pit vipers
and all confirmed eastern coral snake bites)
Admission criteria: admit all pts w/ confirmed coral snake bites; if no envenomation observe for 6hr; if local pain or erythema, observe for 12hr; admit all pts with progressive symptoms to ICU; bitten by Mojave rattlesnake or exotic snake
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Question 1
The four major steps in treatment of any poisoned patient include all of the following EXCEPT: A. prompt hemodialysis or hemoperfusion B. decontamination and prevention of absorption,
while preventing contamination of health care workers
C. support of vital signs (ABCs) and symptomatic treatment specific antidote, if available
D. enhancement of toxin excretion or elimination
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Question 2
Syrup of Ipecac is the first line
therapy for gastric decontamination
of the poisoned patient: A. True B. False
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Question 3
Very few drugs are fatal for a 10 kgtoddler upon ingestion of onecommercially available dose unit.Examples of drugs in which ingestionof one dose can be potentially fatal inthis population include all of thefollowing EXCEPT:A. ChloroquineB. TCAC. Calcium Channel BlockersD. SSRI’s
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Question 4
Which of the following statements is TRUEregarding intentional overdoses? A. Intentional overdoses are most
commonly seen in the preschool age group.
B. These overdoses are usually of one agent known to be lethal.
C. Intentional overdoses frequently involve more than one agent Intentional overdoses are seldom fatal.
D. None of the above are TRUE.
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THANK YOU
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Reference Fine SJ. Pediatric Principles. Goldfrank LR et al.
editors Goldfrank’s Toxicologic Emergencies. 8th Edition. Mc Graw-Hill;
Henry K, Harris CR. Deadly Ingestions. Pediatr Clin N Am 53 (2006) 293-315
Ranniger C. Roche C. Are one or two dangerous? Calcium Channel Blocker Exposure in Toddlers. Journal of Emergency Medicine. Vol 33 No.2. 145-154, 2007
Eldridge DL, Van Eyk J, Kornegay C. Pediatric Toxicology. Emerg Med Clin N Am 15 (2007) 283-308
Carson RH. The toxicology handbook for clinicians. Mosby, 2006