Evaluation and Management of childhood poisoning
Why poisoning is important in paediatrics
The fourth most common cause of accidents in Children.
Most are unintentional , oral ingestions . (80%)
More than 90% occurred at home.
Children under 6 years accounts for 51%
Children under 3 years accounts for 38%
Suicide and substance abuse are common in Adolescents
Commony ingested substances in children
Cosmetics 13.4%
Cleaning products 10 %
Analgesics 7.9 %
Topical agents 7.4 %
Foreign bodies 7.3 %
Plants 4.4 %
Pesticides 4.2 %
Substances with higher toxicity in children
Non Pharmacological agents.
1.Alcohols - Beverage ethanol, methanol
2.Caustic agents - Acids , alkalis ,cleaning agents
3.Foods - Flavoring additives
4.Hydrocarbans -Kerosene oil
5.Pesticides - Organophosphate , Paraquat
Pharmacological agents
1.Antidepressants and antipsychotics
-phenothiazines , TCA
2.Antimalarials -Chloroquine , quinine
3.Cardiovascular agents -beta blockers , CCB
4.opioids - cough syrup, atropine
Evaluation of children with suspected toxin ingestion
Initial assessment and Triage
Emergency stabilization of ABC
Thorough physical examination
Supportive treatment (Gastric decontamination)
Laboratory assessment
Toxin-specific treatments (Antidotes)
Monitoring
Key recommendations for practice
Any patient, ingested a toxin & has respiratory,
circulatory or neurologic symptoms should be
transported by an ambulance to nearest ETU.
History should include age, sex , time and type of
probable exposure and all medications present at home.
An asymptomatic child with suspected toxin ingestion
may have ingested a delayed action medication and
should be monitored for a longer period.
Gastric lavage is only recommended when performed
by a physician with experience placing NG tubes and
when administered within one hour of ingestion.
The routine use of activated charcoal is discouraged ,
except within one hour of ingestion.
Initial assessment & physical examination
First step is to ascertain whether the patient is symptomatic
(respiratory, circulatory or neurologic symptoms)
Symptomatic patients should be admitted to a Hospital.
If ingestion was witnessed ,non toxic agent was involved or patient
appears asymptomatic ,observation at home is appropriate after through
physical examination.
An asymptomatic patient with suspected toxic ingestion may have
taken a medication with delayed action and they may require a
longer period of observation
Selected toxins with delayed symptoms
Delayed absorption
1.Carbamazepine
2.Iron
3.Aspirin
4.Theophyline
5.Enteric coated preparations
6.Sustained release preparations
Delayed mechanism
1.Anticoagulants
2.Sulfonylureas
3.Thyroid hormones
4.Toxic mushrooms
Toxidromes/ toxic symptoms and antidotes
Laboratory assessment
Thorough history and physical examination are usually
sufficient to diagnose most poisoning.
Selective laboratory studies can provide vital information
to guide monitoring and treatment.
The probing subset of laboratory tests focuses on specific
findings according to clinical suspicion.
Toxicological screening of urine and blood typically test
for drug abuses(cocaine , opioids , marijuana)
Gastric Decontamination
Gastric Lavage
1. To empirically remove ingested toxin from the stomach
2. 10 to 15 ml per Kg normal saline via a large bore NG tube
repeated until
aspirates clear.
3.limited by poor tolerability because of the size , placement difficultyand gag stimulation.
4.possible complications are aspiration, vomiting , esophageal and laryngeal trauma
5.unlikely to be beneficial in patients with unprotected airways , risk of perforation and heamorrhage , ingestion of hydrocarbons and corrosives.
Activated Charcoal
1.Decrease the absorption of a wide variety of toxins in the stomach and intestinal tract.
2. It interrupts the enterohepatic and enteroenteric recirculation of drugs in the gut lumen.
3. A dose of 1 to 2 g per Kg for childern with ingestions of an unknown Quantity.
4.Use is limited because its taste, appearance ,and the tendency of children to vomit after administration
Whole bowel irrigation
1.Polyethylene glycol 500 ml per hour for children nine month to five years of age and 1000 ml per hour for children 6 to 12 years.
2.It is less likely cause electrolyte imbalance and beneficial in ingestion of heavy metals, long acting or sustained release medications.
3.Contraindicated in unprotected airways, intractable vomiting ,GI heamorrage and perforations.
Toxin specific treatments and further Mx
Toxin specific treatment such as an antidotes are usually given when the patient is stable, preferably within few hours of ingestion
May require multiple doses because of short
duration of action.
Childhood poisoning require supportive treatment, including monitoring and continued observation.
Psychiatric consultation is appropriate with
intentional ingestion.
EXTRA STUFF
check ppharm stuff
EXTRA STUFF ON CHILDHOOD POISOINING (important!!!!)Â
Identification of agent...
In case of pharmaceutical agents....
Go pharmacy or books with bank or websites or national poison center.... Ring them and ask... With massive database..... Ring in case.... Poisoning Ravindra fernando........
Last chapter of BNF has poisoningÂ
Review article on child hood poisoning GN lucas ceylon journal of paed.
Plant poisoning GN lucas ceylon journal of paed
Mx of poisoning Ravindra fernando in all wards
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Toxicology screening for forensic and substance abuse
Gastric lavage. Should use cuffed endotracheal tube as paediatric
Stuff to keep in head. Or stuff to know where to refer. Unfortunately what needs to refer have to keep in head for exams......
Sometimes grand mother comes in and don't know how much taken.... Ask when clinic. How much got... How much take.. Did you take everyday... And then estimate... Better to always overestimate.....
If small object then take plain x ray abdomen and ask mother to observe poop and see whether goes away... 3 days... Tiny marble....
Plain x ray.... Oesophagus... Can get stuck and can cough and go to the resotkary tract and die after stuck respiratory depression.Â
Pcm 90g/kg as toxic dose.... Normal paed dose?
In poisoning, must make through notes and focused clinical because can be used for legal procedures....
There's some instances that gastric lavage is performed even after 1 hour and some cases that absolutely prohibited.....
Check toxicity tute in pharmacology and plant pisiond tute forensic.... Toxicology in pharm and plan poisons tute..
Specific antidote...
Symotkmatic treatment
EtU can liase with icu if no ventilator
Gastric lavage how to do procedure
..
1 ) Review article on childhood poisioning in sri lanka - ceylon journal of child health
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2) plant poisons in sri lanka - journal of child health