Pediatric Toxicology

Pediatric Toxicology Jana Stockwell, MD Epidemiology 2 million calls  52% of poison center calls <6years  Peak ages: 18 months - 3 years  Epidemiology  Unintentional (1-2 years) – Exploratory – Boys > girls – Unable to discriminate safe from unsafe liquid  Intentional (adolescent) – Purposeful – Girls > boys Epidemiology Around meal time  Grandparents home  Kerosene or gasoline in a soda bottle  Older sibling can pharmaceutically treat younger sibling  Most often reported Cleaning products  Analgesics  Cosmetics  Cough & cold preparation  Insecticides  10% 10% 9% 5% 4% PICU Admission Tricyclic antidepressants (TCA)  Anticonvulsants  Digoxin  Opiates  Hydrocarbon-based household products  Toxic Exposures  Death Analgesics  Sedative-hypnotics  Alcohols  Gases & fumes  Cleaning substances  “Fatal Sip”    Camphor (Vick’s VapoRub) – (100mg/kg) Methyl salicylate (wintergreen) – (200 mg/kg) 1000 mg/5 ml 1400 mg/ml Benzocaine (OraGel) – 2 mL – Met-hemoglobinemia – Seizure “Malignant Swallow” Chloroquine  Theophylline  Imipramine  Chlorpromazine  Clonidine  (20 mg/kg) (8.4 mg/kg) (15 mg/kg) (25 mg/kg) (0.3 mg tablet) – Bradycardia – CNS depression Other Highly Toxic Acetonitrile - nail tip remover  MetHgb  Ammonium fluoride – hub cap cleaner (ArmorAll)  sz, arrhythmias, acidosis  Pennyroyal Oil – some herbal teas  Look-Alike, Sound-A-Like         Albuterol Celebrex Oruvail Lamictal Lotrimin Plendil Hydralazine Hydrocodone         Atenolol Cerebrex Elavil Lomotil Lotensin Pindolol Hydroxyzine Hydrocortisone Poison plants    Digitalis effects – Lily-of-the-valley, Foxglove, Oleander, Yew Nicotinic effects – Poison hemlock Atropinic effects – Jimson weed Non-Toxic Products Ball point ink  Bubble bath soaps  Chalk  Cigarettes (< 3 butts)  Crayons  Deodorants  Lipstick  Pencil (graphite)  Toothpaste  Water colors  Candle wax (but candle oil is!)  Evaluation History of poisoning  Physical examination  Laboratory studies  Gastrointestinal decontamination  History What?  When?  How much?  Reliability…  What ? Medication  Illicit drug  Hazardous chemical  What form? Pill  Solid  Liquid  Gaseous  What route ? Ingestion  Inhalation  Topical  Intravenous  When ?  Elapsed time How much ? Estimate amount  Concentration  “Clues” Bradycardia        Calcium channel blockers Digoxin Narcotics Organophosphates Carbon monoxide Beta-blockers Clonidine Tachycardia          Amphetamine (Ritalin) Atropine TCA’s Theophylline Salicylates (aspirin) Iron Cocaine PCP Synthroid Slow Respiration     Alcohol Narcotics Clonidine Sedatives Tachypnea     Amphetamines Salicylates Carbon monoxide Ethylene glycol (anti-freeze) Hypotension        Calcium channel blockers Carbon monoxide Cyanide Iron Narcotics Anti-hypertensives Met-hemoglobin Hypertension       OTC cold remedies Amphetamine PCP TCA Cocaine Diet pills V Tach       Amphetamines Carbamzepine (Tegretol) Chloral hydrate Cocaine Digitalis Theophylline Torsades de Pointes      Chloral hydrate Cisapride Organophosphates Terfenadine Phenothiazines Hypoglycemia (HOBBIES)       Hypoglycemia Oral hypoglycemic agents Beta-Blockers Insulin Ethanol Salicylates Hypothermia     Ethanol Narcotics Carbon monoxide Clonidine Hyperpyrexia      Atropine Salicylates Theophylline Cocaine TCA CNS - Coma    Narcotic Anti-cholinergics Carbon monoxide CNS - Delirium / Psychosis    Alcohol PCP / marijuana LSD CNS - Seizure       Cocaine Amphetamine Lead Salicylate Isoniazid Theophylline Pupils - Miosis (COPS)     Cholinergics, Clonidine Opiates, Organophosphates Phenothiazine, Pilocarpine Sedatives (barbiturates, ethanol) Pupils - Mydriasis (AAAS)     Anti-histamine Anti-depressant Anticholinergics (atropine) Sympathomimetics – amphetamine, cocaine, PCP Caution! Polydrug overdoses with opposite pupillary actions  Non-toxin diagnoses – Head trauma – CNS hemorrhage  Cyanosis      MetHgb – Unresponsive to O2 Aniline dyes Nitrites Benzocaine Dapsone Dry Skin  Anticholinergic Breath Odors Arsenic  Camphor  Cyanide  Methyl salicylate  Paraldehyde  Hemlock  Garlic Mothballs Bitter almond Wintergreen Pears Carrots Cholinergic “DUMBBELS”  “SLUDGE”  Example – Organophosphates Nerve agents DUMBBELS         Diarrhea, diaphoresis Urination Miosis, muscle fasiculation Bradycardia Bronchospasm Emesis Lacrimation Salivation SLUDGE       Salivation Lacrimation Urination Diarrhea GI complaint Emesis Anti-cholinergic syndrome        Dry mouth Flushed appearance Dilated pupils Fever Ileus Urinary retention Disorientation Examples – Anti-histamines Jimson weed Lomotil TCA Carbamazepine Glycopyrrolate Atropine Anti-cholinergic Hot as a hare  Blind as a bat  Dry as a bone  Red as a beet  Mad as a hatter  Full as a flask  Narcotic Pinpoint pupils  Coma  Respiratory depression  Salicylates Fever  Tachypnea & hyperpnea  Lethargy  Metabolic acidosis  Theophylline Protracted Vomiting  Tremors  Tachycardia  Seizures  Hypotension  Isoniazid Seizures  Metabolic acidosis  Hyperglycemia  Phencyclidine (4 Cs) Combative  Catatonia  Convulsion  Coma  Nystagmus  TCA Metabolic acidosis  Prolonged QRS  Seizures  Dilated pupils  Dysrhythmia  Cyanide Feeling of impending doom  Sudden coma  Metabolic acidosis  Hypotension  Bitter almond odor  Carbon monoxide Headache  Lethargy  Dizziness  Influenza like syndrome  Coma  Ethanol Hypoglycemia  Lethargy  Ataxia  Seizure  Characteristic breath odor  Methanol Severe metabolic acidosis  Sluggish pupils  Hyperemic retina  Blurred vision  Ethylene Glycol Lethargy or coma  Metabolic acidosis  Urinary sediment  Crystalluria  Clonidine Hypothermia  Bradycardia  Miosis  Respiratory depression  Elevated anion gap Methanol  Paraldehyde & phenformin  Iron & isoniazid  Ethylene glycol & ethanol  Salicylate  ABC’s Airway  Breathing  Circulation  Disability  Decontamination  Consciousness A: Alert  V: Responsive to verbal stimuli  P: Responsive to pain  U: Unresponsive  Drugs Dextrose  Oxygen  Naloxone  Decontamination Ocular- copious saline lavage  Skin- copious water  GI-consider options  Lab Evaluation  No “tox panel” that is uniformly helpful Urine Screen Marijuana  Amphetamines  Barbiturates  Cocaine  Opiates  PCP  5-10 days 48 hours 24 h-2 wks 2-4 days 2 days 8 days EKG All suspected ingestion  Tricyclics  Pulse oximetry Measure of oxygen saturation of normal hemoglobin  Does NOT differentiate CO-Hgb from oxyHgb  Falsely low sats  – Nail polish – Methylene blue – Poor perfusion Other tests CXR - hydrocarbons  ABG - salicylates  Esophagoscopy - Caustics  Drug levels         Acetaminophen Salicylates Methanol Ethylene glycol Iron Theophylline Carbon monoxide (co-ox blood gas) Lithium Radiopaque (CHIPS) Chloral hydrate  Heavy metals  Iron  Phenothiazine (laxatives)  Slow release  GI tract decontamination Syrup of Ipecac (not used in hospital)  Gastric lavage – 1st hour  Activated charcoal  – Inert – Reduces bioavailability of drug – Not w/ HC or corrosives Cathartics – decrease transit time  WBI (whole bowel irrigation)…till clear  Urine alkalinization Salicylates  Phenobarbital  Chlorpropamide  Extracorporeal methods  Hemodialysis – Severe poisoning – Renal failure  Hemoperfusion – Perferred in some toxic ingestions Antidotes              Oxygen - carbon monoxide Naloxone – opioids Methylene blue – MetHgb Sodium nitrite - cyanide Deferoxamine – iron Acetoaminophen – N-acetylcysteine Anti-cholinergics – physostigmine Organophosphates – atropine, pralidoxime Benzodiazepines – flumazenil B-blockers – glucagon TCA – bicarb Coumadin – Vitamin K Fomepizole (Antizol) – ethylene glycol