Pediatric Pediatric ToxicologyToxicology

Jana Stockwell, MDJana Stockwell, MD

EpidemiologyEpidemiology 2 million calls2 million calls 52% of poison center calls <6years52% of poison center calls <6years Peak ages: 18 months - 3 yearsPeak ages: 18 months - 3 years

EpidemiologyEpidemiology Unintentional (1-2 years)Unintentional (1-2 years)

– ExploratoryExploratory– Boys > girlsBoys > girls– Unable to discriminate safe from unsafe Unable to discriminate safe from unsafe

liquidliquid

Intentional (adolescent)Intentional (adolescent)– PurposefulPurposeful– Girls > boysGirls > boys

EpidemiologyEpidemiology Around meal timeAround meal time Grandparents homeGrandparents 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

Most often reportedMost often reported Cleaning productsCleaning products

10%10% AnalgesicsAnalgesics 10%10% CosmeticsCosmetics 9%9% Cough & cold preparationCough & cold preparation 5%5% InsecticidesInsecticides 4%4%

PICU AdmissionPICU Admission Tricyclic antidepressants (TCA)Tricyclic antidepressants (TCA) AnticonvulsantsAnticonvulsants DigoxinDigoxin OpiatesOpiates Hydrocarbon-based household Hydrocarbon-based household

productsproducts

Toxic Exposures Toxic Exposures DeathDeath

AnalgesicsAnalgesics Sedative-hypnoticsSedative-hypnotics AlcoholsAlcohols Gases & fumesGases & fumes Cleaning substancesCleaning substances

““Fatal Sip” Fatal Sip” Camphor (Vick’s VapoRub)Camphor (Vick’s VapoRub) 1000 mg/5 ml1000 mg/5 ml

– (100mg/kg)(100mg/kg) Methyl salicylate (wintergreen)Methyl salicylate (wintergreen) 1400 mg/ml1400 mg/ml

– (200 mg/kg)(200 mg/kg) Benzocaine (OraGel)Benzocaine (OraGel)

– 2 mL2 mL– Met-hemoglobinemiaMet-hemoglobinemia– SeizureSeizure

““Malignant Swallow”Malignant Swallow” Chloroquine Chloroquine (20 mg/kg)(20 mg/kg) Theophylline Theophylline (8.4 mg/kg)(8.4 mg/kg) Imipramine Imipramine (15 mg/kg)(15 mg/kg) ChlorpromazineChlorpromazine (25 mg/kg)(25 mg/kg) ClonidineClonidine (0.3 mg tablet)(0.3 mg tablet)

– BradycardiaBradycardia– CNS depressionCNS depression

Other Highly ToxicOther Highly Toxic Acetonitrile - nail tip remover Acetonitrile - nail tip remover

MetHgbMetHgb Ammonium fluoride – hub cap Ammonium fluoride – hub cap

cleaner (ArmorAll) cleaner (ArmorAll) sz, arrhythmias, sz, arrhythmias, acidosisacidosis

Pennyroyal Oil – some herbal teasPennyroyal Oil – some herbal teas

Look-Alike, Sound-A-Look-Alike, Sound-A-LikeLike

AlbuterolAlbuterol CelebrexCelebrex OruvailOruvail LamictalLamictal LotriminLotrimin PlendilPlendil HydralazineHydralazine HydrocodoneHydrocodone

AtenololAtenolol CerebrexCerebrex ElavilElavil LomotilLomotil LotensinLotensin PindololPindolol HydroxyzineHydroxyzine HydrocortisoneHydrocortisone

Poison plantsPoison plants Digitalis effectsDigitalis effects

– Lily-of-the-Lily-of-the-valley, Foxglove, valley, Foxglove, Oleander, YewOleander, Yew

Nicotinic effectsNicotinic effects– Poison hemlockPoison hemlock

Atropinic effectsAtropinic effects– Jimson weedJimson weed

Non-Toxic ProductsNon-Toxic Products Ball point inkBall point ink Bubble bath Bubble bath

soapssoaps ChalkChalk Cigarettes (< 3 Cigarettes (< 3

butts)butts) CrayonsCrayons

DeodorantsDeodorants LipstickLipstick Pencil (graphite)Pencil (graphite) ToothpasteToothpaste Water colorsWater colors Candle wax Candle wax (but (but

candle oil is!)candle oil is!)

EvaluationEvaluation History of poisoningHistory of poisoning Physical examinationPhysical examination Laboratory studiesLaboratory studies Gastrointestinal decontaminationGastrointestinal decontamination

HistoryHistory What?What? When?When? How much?How much? Reliability…Reliability…

What ?What ? MedicationMedication Illicit drugIllicit drug Hazardous chemicalHazardous chemical

What form?What form? PillPill SolidSolid LiquidLiquid GaseousGaseous

What route ?What route ? IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous

When ?When ? Elapsed timeElapsed time

How much ?How much ? Estimate amountEstimate amount ConcentrationConcentration

““Clues”Clues”

BradycardiaBradycardia Calcium channel Calcium channel

blockersblockers DigoxinDigoxin NarcoticsNarcotics OrganophosphatesOrganophosphates Carbon monoxideCarbon monoxide Beta-blockersBeta-blockers ClonidineClonidine

TachycardiaTachycardia Amphetamine (Ritalin)Amphetamine (Ritalin) AtropineAtropine TCA’sTCA’s TheophyllineTheophylline Salicylates (aspirin)Salicylates (aspirin) IronIron CocaineCocaine PCPPCP SynthroidSynthroid

Slow RespirationSlow Respiration AlcoholAlcohol NarcoticsNarcotics ClonidineClonidine SedativesSedatives

TachypneaTachypnea AmphetaminesAmphetamines SalicylatesSalicylates Carbon monoxideCarbon monoxide Ethylene glycol Ethylene glycol

(anti-freeze)(anti-freeze)

HypotensionHypotension Calcium channel Calcium channel

blockersblockers Carbon monoxideCarbon monoxide CyanideCyanide IronIron NarcoticsNarcotics Anti-hypertensivesAnti-hypertensives Met-hemoglobinMet-hemoglobin

HypertensionHypertension OTC cold OTC cold

remediesremedies AmphetamineAmphetamine PCPPCP TCATCA CocaineCocaine Diet pillsDiet pills

V TachV Tach AmphetaminesAmphetamines Carbamzepine (Tegretol)Carbamzepine (Tegretol) Chloral hydrateChloral hydrate CocaineCocaine DigitalisDigitalis TheophyllineTheophylline

Torsades de PointesTorsades de Pointes Chloral hydrateChloral hydrate CisaprideCisapride OrganophosphateOrganophosphate

ss TerfenadineTerfenadine PhenothiazinesPhenothiazines

Hypoglycemia Hypoglycemia (HOBBIES)(HOBBIES)

HHypoglycemiaypoglycemia OOral hypoglycemic ral hypoglycemic

agentsagents BBeta-eta-BBlockerslockers IInsulinnsulin EEthanolthanol SSalicylatesalicylates

HypothermiaHypothermia EthanolEthanol NarcoticsNarcotics Carbon monoxideCarbon monoxide ClonidineClonidine

HyperpyrexiaHyperpyrexia AtropineAtropine SalicylatesSalicylates TheophyllineTheophylline CocaineCocaine TCATCA

CNS - ComaCNS - Coma NarcoticNarcotic Anti-cholinergicsAnti-cholinergics Carbon monoxideCarbon monoxide

CNS - Delirium / CNS - Delirium / PsychosisPsychosis

AlcoholAlcohol PCP / marijuanaPCP / marijuana LSDLSD

CNS - SeizureCNS - Seizure CocaineCocaine AmphetamineAmphetamine LeadLead SalicylateSalicylate IsoniazidIsoniazid TheophyllineTheophylline

Pupils - MiosisPupils - Miosis (COPS) CCholinergics, holinergics, CClonidinelonidine OOpiates, piates, OOrganophosphatesrganophosphates PPhenothiazine, henothiazine, PPilocarpineilocarpine SSedatives (barbiturates, ethanol)edatives (barbiturates, ethanol)

Pupils - MydriasisPupils - Mydriasis (AAAS)(AAAS)

AAnti-histaminenti-histamine AAnti-depressantnti-depressant AAnticholinergics (atropine)nticholinergics (atropine) SSympathomimeticsympathomimetics

– amphetamine, cocaine, amphetamine, cocaine, PCPPCP

Caution!Caution! Polydrug overdoses with opposite Polydrug overdoses with opposite

pupillary actionspupillary actions Non-toxin diagnosesNon-toxin diagnoses

– Head traumaHead trauma– CNS hemorrhageCNS hemorrhage

CyanosisCyanosis MetHgbMetHgb

– Unresponsive to Unresponsive to OO22

Aniline dyesAniline dyes NitritesNitrites BenzocaineBenzocaine DapsoneDapsone

Dry SkinDry Skin AnticholinergicAnticholinergic

Breath OdorsBreath Odors ArsenicArsenic GarlicGarlic CamphorCamphor MothballsMothballs CyanideCyanide Bitter almondBitter almond Methyl salicylateMethyl salicylate WintergreenWintergreen ParaldehydeParaldehyde PearsPears HemlockHemlock CarrotsCarrots

CholinergicCholinergic ““DUMBBELS”DUMBBELS” ““SLUDGE”SLUDGE”

Example –OrganophosphatesNerve agents

DUMBBELSDUMBBELS DDiarrhea, diaphoresisiarrhea, diaphoresis UUrinationrination MMiosis, muscle fasiculationiosis, muscle fasiculation BBradycardiaradycardia BBronchospasmronchospasm EEmesismesis LLacrimationacrimation SSalivationalivation

SLUDGESLUDGE SSalivationalivation LLacrimationacrimation UUrinationrination DDiarrheaiarrhea GGI complaintI complaint EEmesismesis

Anti-cholinergic Anti-cholinergic syndromesyndrome

Dry mouthDry mouth Flushed Flushed

appearanceappearance Dilated pupilsDilated pupils FeverFever IleusIleus Urinary retentionUrinary retention DisorientationDisorientation

Examples –Anti-histaminesJimson weedLomotilTCACarbamazepineGlycopyrrolateAtropine

Anti-cholinergicAnti-cholinergic 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 Full as a flaskFull as a flask

NarcoticNarcotic Pinpoint pupilsPinpoint pupils ComaComa Respiratory depressionRespiratory depression

SalicylatesSalicylates FeverFever Tachypnea & hyperpneaTachypnea & hyperpnea LethargyLethargy Metabolic acidosisMetabolic acidosis

TheophyllineTheophylline Protracted VomitingProtracted Vomiting TremorsTremors TachycardiaTachycardia SeizuresSeizures HypotensionHypotension

IsoniazidIsoniazid SeizuresSeizures Metabolic acidosisMetabolic acidosis HyperglycemiaHyperglycemia

PhencyclidinePhencyclidine (4 Cs)(4 Cs) CCombativeombative CCatatoniaatatonia CConvulsiononvulsion CComaoma NNystagmusystagmus

TCATCA Metabolic acidosisMetabolic acidosis Prolonged QRSProlonged QRS SeizuresSeizures Dilated pupilsDilated pupils DysrhythmiaDysrhythmia

CyanideCyanide Feeling of impending doomFeeling of impending doom Sudden comaSudden coma Metabolic acidosisMetabolic acidosis HypotensionHypotension Bitter almond odorBitter almond odor

Carbon monoxideCarbon monoxide HeadacheHeadache LethargyLethargy DizzinessDizziness Influenza like syndromeInfluenza like syndrome ComaComa

EthanolEthanol HypoglycemiaHypoglycemia LethargyLethargy AtaxiaAtaxia SeizureSeizure Characteristic breath odorCharacteristic breath odor

MethanolMethanol Severe metabolic acidosisSevere metabolic acidosis Sluggish pupilsSluggish pupils Hyperemic retinaHyperemic retina Blurred visionBlurred vision

Ethylene GlycolEthylene Glycol Lethargy or comaLethargy or coma Metabolic acidosisMetabolic acidosis Urinary sedimentUrinary sediment CrystalluriaCrystalluria

ClonidineClonidine HypothermiaHypothermia BradycardiaBradycardia MiosisMiosis Respiratory depressionRespiratory depression

Elevated anion gapElevated anion gap MethanolMethanol Paraldehyde & phenforminParaldehyde & phenformin Iron & isoniazidIron & isoniazid Ethylene glycol & ethanolEthylene glycol & ethanol Salicylate Salicylate

ABC’sABC’s AAirwayirway BBreathingreathing CCirculationirculation DDisabilityisability DDecontaminationecontamination

ConsciousnessConsciousness AA:: AlertAlert VV: : Responsive to verbal Responsive to verbal

stimulistimuli PP: : Responsive to painResponsive to pain UU: : UnresponsiveUnresponsive

DrugsDrugs DextroseDextrose OxygenOxygen NaloxoneNaloxone

DecontaminationDecontamination Ocular- copious saline lavageOcular- copious saline lavage Skin- copious waterSkin- copious water GI-consider optionsGI-consider options

Lab EvaluationLab Evaluation No “No “tox paneltox panel” that is ” that is

uniformly helpfuluniformly helpful

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

EKGEKG All suspected ingestionAll suspected ingestion TricyclicsTricyclics

Pulse oximetryPulse oximetry Measure of oxygen saturation of Measure of oxygen saturation of

normal hemoglobinnormal hemoglobin Does NOT differentiate CO-Hgb Does NOT differentiate CO-Hgb

from oxyHgbfrom oxyHgb Falsely low satsFalsely low sats

– Nail polishNail polish– Methylene blueMethylene blue– Poor perfusionPoor perfusion

Other testsOther tests CXR - hydrocarbonsCXR - hydrocarbons ABG - salicylatesABG - salicylates Esophagoscopy - CausticsEsophagoscopy - Caustics

Drug levelsDrug levels AcetaminophenAcetaminophen SalicylatesSalicylates MethanolMethanol Ethylene glycolEthylene glycol IronIron TheophyllineTheophylline Carbon monoxide (co-ox blood gas)Carbon monoxide (co-ox blood gas) LithiumLithium

RadiopaqueRadiopaque (CHIPS)(CHIPS) CChloral hydratehloral hydrate HHeavy metalseavy metals IIronron PPhenothiazine henothiazine

(laxatives)(laxatives) SSlow releaselow release

GI tract GI tract decontaminationdecontamination

Syrup of Ipecac (not used in hospital)Syrup of Ipecac (not used in hospital) Gastric lavage – 1Gastric lavage – 1stst hour hour Activated charcoalActivated charcoal

– InertInert– Reduces bioavailability of drugReduces bioavailability of drug– Not w/ HC or corrosivesNot w/ HC or corrosives

Cathartics – decrease transit timeCathartics – decrease transit time WBI (whole bowel irrigation)…till clearWBI (whole bowel irrigation)…till clear

Urine alkalinizationUrine alkalinization SalicylatesSalicylates PhenobarbitalPhenobarbital ChlorpropamideChlorpropamide

Extracorporeal Extracorporeal methodsmethods

HemodialysisHemodialysis– Severe poisoningSevere poisoning– Renal failureRenal failure

HemoperfusionHemoperfusion– Perferred in some toxic ingestionsPerferred in some toxic ingestions

AntidotesAntidotes Oxygen - carbon monoxideOxygen - carbon monoxide Naloxone – opioidsNaloxone – opioids Methylene blue – MetHgbMethylene blue – MetHgb Sodium nitrite - cyanideSodium nitrite - cyanide Deferoxamine – ironDeferoxamine – iron Acetoaminophen – N-acetylcysteineAcetoaminophen – N-acetylcysteine Anti-cholinergics – physostigmineAnti-cholinergics – physostigmine Organophosphates – atropine, pralidoximeOrganophosphates – atropine, pralidoxime Benzodiazepines – flumazenilBenzodiazepines – flumazenil B-blockers – glucagonB-blockers – glucagon TCA – bicarbTCA – bicarb Coumadin – Vitamin KCoumadin – Vitamin K Fomepizole (Antizol) – ethylene glycolFomepizole (Antizol) – ethylene glycol