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Pediatric Toxicology

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Pediatric Toxicology. Jana Stockwell, MD. Epidemiology. 2 million calls 52% of poison center calls girls Unable to discriminate safe from unsafe liquid Intentional (adolescent) - PowerPoint PPT Presentation
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Pediatric Pediatric Toxicology Toxicology Jana Stockwell, MD Jana Stockwell, MD
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Page 1: Pediatric Toxicology

Pediatric Pediatric ToxicologyToxicology

Jana Stockwell, MDJana Stockwell, MD

Page 2: Pediatric Toxicology

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

Page 3: Pediatric Toxicology

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

Page 4: Pediatric Toxicology

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

Page 5: Pediatric Toxicology

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%

Page 6: Pediatric Toxicology

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

productsproducts

Page 7: Pediatric Toxicology

Toxic Exposures Toxic Exposures DeathDeath

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

Page 8: Pediatric Toxicology

““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

Page 9: Pediatric Toxicology

““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

Page 10: Pediatric Toxicology

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

Page 11: Pediatric Toxicology

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

Page 12: Pediatric Toxicology

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

Page 13: Pediatric Toxicology

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!)

Page 14: Pediatric Toxicology

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

Page 15: Pediatric Toxicology

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

Page 16: Pediatric Toxicology

What ?What ? MedicationMedication Illicit drugIllicit drug Hazardous chemicalHazardous chemical

Page 17: Pediatric Toxicology

What form?What form? PillPill SolidSolid LiquidLiquid GaseousGaseous

Page 18: Pediatric Toxicology

What route ?What route ? IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous

Page 19: Pediatric Toxicology

When ?When ? Elapsed timeElapsed time

Page 20: Pediatric Toxicology

How much ?How much ? Estimate amountEstimate amount ConcentrationConcentration

Page 21: Pediatric Toxicology

““Clues”Clues”

Page 22: Pediatric Toxicology

BradycardiaBradycardia Calcium channel Calcium channel

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

Page 23: Pediatric Toxicology

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

Page 25: Pediatric Toxicology

TachypneaTachypnea AmphetaminesAmphetamines SalicylatesSalicylates Carbon monoxideCarbon monoxide Ethylene glycol Ethylene glycol

(anti-freeze)(anti-freeze)

Page 26: Pediatric Toxicology

HypotensionHypotension Calcium channel Calcium channel

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

Page 28: Pediatric Toxicology

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

Page 29: Pediatric Toxicology

Torsades de PointesTorsades de Pointes Chloral hydrateChloral hydrate CisaprideCisapride OrganophosphateOrganophosphate

ss TerfenadineTerfenadine PhenothiazinesPhenothiazines

Page 30: Pediatric Toxicology

Hypoglycemia Hypoglycemia (HOBBIES)(HOBBIES)

HHypoglycemiaypoglycemia OOral hypoglycemic ral hypoglycemic

agentsagents BBeta-eta-BBlockerslockers IInsulinnsulin EEthanolthanol SSalicylatesalicylates

Page 31: Pediatric Toxicology

HypothermiaHypothermia EthanolEthanol NarcoticsNarcotics Carbon monoxideCarbon monoxide ClonidineClonidine

Page 34: Pediatric Toxicology

CNS - Delirium / CNS - Delirium / PsychosisPsychosis

AlcoholAlcohol PCP / marijuanaPCP / marijuana LSDLSD

Page 36: Pediatric Toxicology

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

Page 37: Pediatric Toxicology

Pupils - MydriasisPupils - Mydriasis (AAAS)(AAAS)

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

– amphetamine, cocaine, amphetamine, cocaine, PCPPCP

Page 38: Pediatric Toxicology

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

pupillary actionspupillary actions Non-toxin diagnosesNon-toxin diagnoses

– Head traumaHead trauma– CNS hemorrhageCNS hemorrhage

Page 39: Pediatric Toxicology

CyanosisCyanosis MetHgbMetHgb

– Unresponsive to Unresponsive to OO22

Aniline dyesAniline dyes NitritesNitrites BenzocaineBenzocaine DapsoneDapsone

Page 40: Pediatric Toxicology

Dry SkinDry Skin AnticholinergicAnticholinergic

Page 41: Pediatric Toxicology

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

Page 42: Pediatric Toxicology
Page 43: Pediatric Toxicology

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

Example –OrganophosphatesNerve agents

Page 44: Pediatric Toxicology

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

Page 45: Pediatric Toxicology

SLUDGESLUDGE SSalivationalivation LLacrimationacrimation UUrinationrination DDiarrheaiarrhea GGI complaintI complaint EEmesismesis

Page 46: Pediatric Toxicology

Anti-cholinergic Anti-cholinergic syndromesyndrome

Dry mouthDry mouth Flushed Flushed

appearanceappearance Dilated pupilsDilated pupils FeverFever IleusIleus Urinary retentionUrinary retention DisorientationDisorientation

Examples –Anti-histaminesJimson weedLomotilTCACarbamazepineGlycopyrrolateAtropine

Page 47: Pediatric Toxicology

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

Page 48: Pediatric Toxicology

NarcoticNarcotic Pinpoint pupilsPinpoint pupils ComaComa Respiratory depressionRespiratory depression

Page 49: Pediatric Toxicology

SalicylatesSalicylates FeverFever Tachypnea & hyperpneaTachypnea & hyperpnea LethargyLethargy Metabolic acidosisMetabolic acidosis

Page 50: Pediatric Toxicology

TheophyllineTheophylline Protracted VomitingProtracted Vomiting TremorsTremors TachycardiaTachycardia SeizuresSeizures HypotensionHypotension

Page 51: Pediatric Toxicology

IsoniazidIsoniazid SeizuresSeizures Metabolic acidosisMetabolic acidosis HyperglycemiaHyperglycemia

Page 52: Pediatric Toxicology

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

Page 53: Pediatric Toxicology

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

Page 54: Pediatric Toxicology

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

Page 55: Pediatric Toxicology

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

Page 56: Pediatric Toxicology

EthanolEthanol HypoglycemiaHypoglycemia LethargyLethargy AtaxiaAtaxia SeizureSeizure Characteristic breath odorCharacteristic breath odor

Page 57: Pediatric Toxicology

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

Page 58: Pediatric Toxicology

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

Page 59: Pediatric Toxicology

ClonidineClonidine HypothermiaHypothermia BradycardiaBradycardia MiosisMiosis Respiratory depressionRespiratory depression

Page 60: Pediatric Toxicology

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

Page 61: Pediatric Toxicology

ABC’sABC’s AAirwayirway BBreathingreathing CCirculationirculation DDisabilityisability DDecontaminationecontamination

Page 62: Pediatric Toxicology

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

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

Page 63: Pediatric Toxicology

DrugsDrugs DextroseDextrose OxygenOxygen NaloxoneNaloxone

Page 64: Pediatric Toxicology

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

Page 65: Pediatric Toxicology

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

uniformly helpfuluniformly helpful

Page 66: Pediatric Toxicology

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

Page 67: Pediatric Toxicology

EKGEKG All suspected ingestionAll suspected ingestion TricyclicsTricyclics

Page 68: Pediatric Toxicology

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

Page 69: Pediatric Toxicology

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

Page 70: Pediatric Toxicology

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

Page 71: Pediatric Toxicology

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

(laxatives)(laxatives) SSlow releaselow release

Page 72: Pediatric Toxicology

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

Page 73: Pediatric Toxicology

Urine alkalinizationUrine alkalinization SalicylatesSalicylates PhenobarbitalPhenobarbital ChlorpropamideChlorpropamide

Page 74: Pediatric Toxicology

Extracorporeal Extracorporeal methodsmethods

HemodialysisHemodialysis– Severe poisoningSevere poisoning– Renal failureRenal failure

HemoperfusionHemoperfusion– Perferred in some toxic ingestionsPerferred in some toxic ingestions

Page 75: Pediatric Toxicology

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


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