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 products10%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 1000 mg/5
mlml
– (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
What route ?What route ?
IngestionIngestion InhalationInhalation TopicalTopical IntravenousIntravenous
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
Breath OdorsBreath Odors
ArsenicArsenic GarlicGarlic CamphorCamphor MothballsMothballs CyanideCyanide Bitter almondBitter almond Methyl salicylateMethyl salicylate WintergreenWintergreen ParaldehydeParaldehyde PearsPears HemlockHemlock CarrotsCarrots
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
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
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
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