Poisoning and child safetyBlock 10

Dr Mulaudzi M.CPaediatrics

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General info

• Most common in the age group 1-5 yrs olds• Route of poisoning

• skin contamination• Inhaled fumes• Ingestion-this is the most common form of poisoning• Eye contamination

• Major poisons• Medicines and drugs left where children can reach• Paraffin• Cleaning liquids• insecticides

• Death from poisoning is an unnatural death

General information

• Poisoning can be accidental, suicidal or Para suicidal• When there is use of traditional medicine remember

to look for the underlying disease.• Older children needs psychologist • Parents often need counselling

• Nature of accident• Prevention of accidental poisoning in future• Crisis management esp. when child severely ill or dies or

complications

Major patterns of presentation

• Change in level of consciousness/coma• Respiratory distress• Metabolic acidosis• Gastrointestinal complaints• Abnormal cardiac rhythm• convulsions

Other Recognized syndromesin presentation of poisoning

in children

1. Increased sympathetic activity

2. Anti-cholinergic activity3. Cholinergic activity4. Metabolic acidosis

Increased sympathetic nervous system activity

• Symptoms– Pyrexia– Flushing– Tachycardia– Pupilary constriction– Hypertension– sweating

• Possible toxins– Cough and cold

preparations– Amphetamines– Cocaine– Ecstasy– theophylines

Anti-cholinergic activity

• Symptoms– Pupilary dilatation– Dry mouth

• Possible toxins– Tricyclic antidepressants– Antihistamines– Mushroom– Drugs for parkinsonism

Increased parasympathetic activity (Cholinergic)

• Symptoms– Pupilary constriction – Salivation– Diarrhoea– Urinary incontinence– Muscle fasciculation– paralysis

• Possible toxins– Organophosphates

pesticides– Pyridostigmine (Rx for

myasthenia gravis)

Metabolic Acidosis

• Symptoms– Tachypnoea– Kussmaul breathing

• Possible toxins– Salicylates– Ethanol– Diabetic oral meds– Carbon monoxides– Iron

Management of children presenting with poisoning

Management principles• First aid at home• Resuscitation (ABC)• Supportive therapy• Eliminating and preventing absorption of the

poison/toxin :– Emesis – Gastric lavage– Activated charcoal

• Specific poisons and antidotes• Prevention

First aid at home

• Inhaled:• remove from the gas, open windows and doors, get fresh air

• Skin contamination:• remove all clothes wash with water then with soap

• Eye contact:• irrigate with Lukewarm water

• Ingested poisons:• do not induce vomiting in following conditions

– Depressed level of consciousness– Hydrocarbons, paraffin, acids, alkali

Resuscitation and Supportive care

• Adequate airway and ventilation• Treatment of hypoglycaemia • Treat volume depletion and hypotension• Treat convulsions• Investigations:– UKE, LFT,anion gap, blood gas, glucose, FBC,

clotting profile, urine analysis and ECG may be more rewarding than toxic screen

Emesis

• Is of value up to six hours of ingestion• Epecacuanha may be used• Contra-indications

– Depressed level of consciousness – coma– Convulsions– Hydrocarbons, petroleum products, paraffin– Poisoning with corrosives, acids and alkali

Gastric lavage

• Effective within 2 hrs of ingestion• Contraindication

• Comatose unless ETT is inserted• Volatile hydrocarbons, petroleum products• Corrosives, acids, alkali

• Procedure• Position on left side with head in slightly lower position

than the body• Saline is used

Activated charcoal

• Binds and minimize the absorption of the poison• Not of benefit in corrosives, and not very effective in

poisoning due to lithium, organophosphates, petroleum products and organic solvents like methanol, ethylene glycol.

• Maximal benefit within 1 hour of ingestion• S/E vomiting, constipation,

gastrointestinal obstruction and perforation• Given oral/via NGT 10g in 100mls of water and in

children >6 yrs 20-50g in 100-300mls of water

Specific poisons

SalicylatesTricyclic anti-depressants

ParacetamolOrganophosphate/Carbamates

HydrocarbonsCaustic agents

Others

Salicylate poisoning

• Source: oral and or topical• Features: Hyperventilation, fever, respiratory failure, CNS depression

Pathology• Uncoupling of oxidative phosphorylation resulting in

– metabolic acidosis- tachypnoea, Kausmal breathing– Hepatotoxicity– Glucose metabolism disturbances

Investigations• Salicylate levels• Supportive - glucose, electrolytes, blood gas, urine output, liver functions and

ammonia to exclude Reye’ syndromeTreatment

• General measures• Correct hypoglycaemia, dehydration, and acidosis• Sodium bicarbonate infusion to maintain urine pH above 7.5• Dialysis may be done in severe cases

Tricyclic anti depressants

• Problem therapeutic/toxic ratio is narrow• Symptoms - Get anti-cholinergic effects

• Delirium, fever, dry mouth, tachycardia, urinary retention, dilated pupils

• arrhythmias

• Treatment • “Tri”: Induce emesis, do gastric lavage, administer activated

charcoal.• Monitor for arrhythmias and treat when present• Keep the pH between 7,45 and 7,55 with the use of sodium

bicarbonate infusion

Paracetamol

• Common agent in suicide attempt with adolescents

• Pathology - centrilobular necrosis of the liver• Clinical features

• usually delayed for 48 to 72 hrs• Nausea, vomiting, pallor, jaundice, liver failure

Treatment• Use activated charcoal• N-acetylcysteine is given (most effective within 16 hrs of

ingestion)• Paracetamol levels helps to give prognoses

Organophosphates and carbamates

• Used as insecticides• Poisoning due to organophosphate is a notifiable condition• Pathology

• Inhibition of cholinesterase resulting in accumulation of acetylcholine

• Clinical features • Muscuranic symptoms: Salivation, sweating, increased bronchial

secretion, diarrhoea, pinpoint pupils• Nicotinic symptoms: fasciculation, confusion, convulsion, and coma

• Treatment• General measures• Atropine initially at a dose of 0.05mg/kg then a continuous infusion • Pralidoxime may be given with organophosphate, it disrupt the

phosphate-cholinesterase bond

Volatile Hydrocarbons

• E.g paraffin, thinners• Clinical presentation

• Aspiration or inhalation causing a chemical pnuemonitis• CNS depression• Fever• Paraffin may be associated with fires and burns

• Treatment • No emesis or gastric lavage• Maintaining hydration, oxygenation• Relieving fever

Caustic agents• Presentation

• Dysphagia, epigastric pain, oral mucosal burns, and low grade fever and drooling

• Patients with oesophageal lesions may not have oral lesions• Alkali tend to cause more damage than acids because acids may

limit the injury because of the bitter/sour taste• Therapy

• Initially, dilution by drinking milk or water • vomiting should not be attempted• Latter depends on the degree of injury to the oesophagus• Endoscope if persistent dysphagia and drooling• Referral to paediatric surgeons

Others

• Carbon monoxide• Headaches, dizziness, coma, skin bullae• Treatment with 100%, hyperbaric oxygen

• Prescribed drugs• E,G digoxin, phenothiazines, iron, benzodiazepines,

betablockers, etc• some have their specific antidotes

Specific antidote

Prevention safe keeping of medicines and cleaning

agents

• preferably in a lockable cupboard or child proof cupboards• Do not tell your children that your tablets are adults

sweets• Children should not take their medicine unsupervised• Return or dispose your unused medicine properly (return

them back to pharmacy)• Empty the suspensions down the drain• Do not leave alcohol, medicines, cleaning agents within

reach for children• Be careful and read labels especially with over the counter

medicines

Prevention Paraffin and pesticides

• Never place non-edible products in food containers or visa versa e.g. paraffin in a juice/milk or cool drink bottles

• Use funnel to refill paraffin appliances rather than a cup

• Water to drink should be accessible for children to drink otherwise they will drink paraffin

• Before applying pesticides remove children and their toys

• Children need constant supervision

Prevention child safety

• Prevent chocking– Keep small object out of reach of small children– A plastic bag can be lethal to a child– Do not give small children peanuts

• Prevent children from drowning– Pools appropriately secured– Children can drown from buckets and bath there should not be

left unsupervised in the bath or around buckets filled with water– Empty bath and container after use

• Prevent other injuries from falling drowning– Most accidents happen after nappy change– Use safety rail on a bed or use a cot to prevent fall

Emergency contacts

• Know emergency casualty numbers for hospitals in your area

• Poisoning centre number: 0800 333 444• Tygerberg Hospital 021 931 6129• Red cross hospital: 012 658 5428• Police: 10 111