Transcript Accidents and Poisons

Accidents and Poisons
Dr D. Barry
POISONING
Poisoning
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Accidental; pre-school age (♂ > ♀)
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Intentional; > 9 years (♀ > ♂)
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Factitious / Münchausen by proxy (rare)
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Iathrogenic
Statistics
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Accidental poisoning preventable cause of
morbidity and mortality
Ireland:
3,000 annual poisons and 1,000 admissions annually
(1-4 yrs)
 12 deaths 2001-2003
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Poisoning
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National Poisons centre-Beaumount Hosp
2006
 Children<10yrs: 4466 enquiries/4726 products.
 Drugs, Household, Chemical products(cosmetic and
personal hygiene)
 Adolescents10-19
yrs: 899 enquiries/1490
products. Drugs, industrial and household
products (analgesics, anti-inflammatory)
Accidental Poisoning
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Infants and young children will drink or eat
ANYTHING!
If it looks interesting / smells good/ has a
bright colour ----- They will eat / drink it
Substances taken are Medicines & Household
Products; detergents, garden agents, pesticides
Most are not taken in sufficient quantity to cause
harm
Children still die every year due to poisoning
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What age do children pick up tablets?
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What age can children open doors/presses?
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What age can children open containers?
Prevention:
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Safety Information
Child resistant containers
Out of reach
Lock up household substances
No chemicals under the kitchen sink
Childminders/Visitors as above
Dispose of out of date meds
Know what meds/products are in your house
Presentations
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Ingestion known/suspected
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Eg. toddler found by carer playing with tablets / missing
tablets from open container etc.
Disclosure by teenager / family etc
Symptomatic;
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Reduced Consciousness
Metabolic acidosis (high anion gap)
Arrhythmia
GI upset (vomiting / abdo pain / anorexia etc)
Seizures
History
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What toxin/medication was taken
Who was the witness
How much was taken
What time was it taken
What other medications or toxic substance was
available to the child
Physical Examination
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Toxic syndromes
Anticholinergics  hot as a hare, dry as a bone (dry
mouth), red as a beet, blind as a bat (dilated pupils),
mad as a hatter (delirium)
 Organophosphates (cholinergic)  diarrhoea,
diaphoresis, miosis, bradycardia, bronchosecretions,
emesis, lacrimation, salivation
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Physical Examination
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Toxic syndromes
Cocaine/amphetamines (sympathomimetic) 
mydriasis, tachycardia, hypertension, hyperthermia,
seizures
 Narcotics  miosis, bradycardia, hypotension,
hypoventilation, coma
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Management
Management
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Stabilise patient / Resus
Accurate history & calculate ingestion
Initial work-up
Gastric elimination/decontamination
Monitoring, levels, nomograms - Discuss
with Toxicology centre
Antidote etc.
Why / How did it happen follow-up
1) Resuscitation
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Airway
Breathing
Circulation
Cornerstone of management of acute poisoning
is supportive care
2) Investigations
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Full blood count
Urea, creatinine, electrolytes
Blood glucose
Blood gas
Serum and urine for toxicology
3) History
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What toxin/medication was taken
Who was the witness
How much was taken
What time was it taken
What other medications or toxic substance was
available to the child (Who’s in the house &
what meds are they on?)
4) Gastric Decontamination
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Gastric evacuation
Induction of emesis
 Gastric lavage
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Chemical decontamination
Activated charcoal
 Cathartics
 Whole bowel irrigation
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NB – corrosive substances are particularly
dangerous – seek expert advice first!
Induction of Emesis
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Rarely done anymore
Syrup of ipecac most commonly used
Induces vomiting in 20 - 60 minutes
Contraindicated in:
infants less than 6 months
 poor conscious state
 diminished gag reflex
 hydrocarbons, acids, alkalis
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Gastric Lavage
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Large bore orogastric tube with normal saline
irrigation
If conscious state is depressed, airway
protection with an endotracheal tube prior to
lavage is recommended
Contraindicated in hydrocarbons, acids and
alkalis (risk of aspiration)
Most effective within 1 hour of ingestion,
Removes up to 40% of ingested toxin
Activated Charcoal
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Complex Molecule with large surface area; binds many poisons
Not indicated in heavy metal poisoning (iron, lithium) or
ingestion of acid or alkali where endoscopy may be required or
alcohol ingestion
Promotes reabsorption from circulation into bowel & interrupt
entero-hepatic circulation of some drugs (aspirin, barbituates)
Very unpalatable => give via NG / lavage tube (25-50g)
typical dose SE; severe lung damage if aspirated
Patient must be conscious or airway protected
Window of opportunity; 1 hour (↑ with salicylates)
Multidose charcoal-controversial
5) Monitoring, levels, nomograms
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You will not know the toxicity of every
substance / drug
Poisons Information Centre provide invaluable
help and advice 24 hours a day
Blood levels (often at 4 hours)
May have nomogram
6) Antidotes
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Benzodiazepines
Iron
Opiates
Paracetamol
β-blockers
Digoxin
> Flumazenil
> Desfuroximine
> Naloxone
> N-acetylcystine
> Glucagon / Adrenaline
> Fab antibodies
Some Potentially Harmful Poisons
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Paracetamol
Iron
Aspirin (salicylates)
Substance abuse; Alcohol, Ecstasy, Cocaine, etc.
Digoxin/ Antiarrhythmics/ Any Cardiac Drug
Tricyclic Antidepressants
Benzodiazepines
Opiates
Ethylene glycol (anti-freeze/de-icer)
Paracetamol
Paracetamol Ingestion
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Most widely available and commonly ingested
Medicine
Infants almost never drink enough to require
Blood levels to be tested!!!
Increasing incidence of deliberate ingestion
Mostly girls > 9 years old
Assess quantity and timing of ingestion
Do not trust information given; if large or
unknown ingestion------ Treat as overdose
Paracetamol ingestion; symptoms
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Initially asymptomatic (? Nausea)
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36 hours later; hepatic necrosis (? Right
subcostal pain) +/- liver decompensation
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Renal Failure (ATN) may occur
Paracetamol Overdose Management
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Activated Charcoal (gastric lavage not helpful) in
< 1 – 4 hour
Check level at 4 hours post ingestion
Map on Nomogram
N-Acetylcysteine IV
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if > treatment line on normogram (*? High risk pt.?)
Monitor LFTs, Coag, U&E, blood level
Iron Ingestion
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> 20mg/kg iron ingestion; toxicity possible
> 60mg/kg – serious toxicity
> 150mg/kg – fatal!
Calculate Iron content of tabs & possible intake
Tests;
PFA
 FBC, G&X, glucose, VBG
 serum iron (@ 4 hours)
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Iron Ingestion; Symptoms
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Stage 1; (30mins – 6 hours) abdo pain, vomiting,
diarrhoea (+/- bloody; ie. haemorrhage
Stage 2 (10 hours – 30 hours); silent phase
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(iron absorbs & accumulates in tissues, mitochondria etc.)
Stage 3; cellular & mitochondrial damage;
shock, encephalopathy, liver decompensation
 Hypoglycaemia, lactic acidosis
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Stage 4; (weeks later); GI strictures &
obstruction, liver failure
Iron Ingestion; Management
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Stabilise; A B C
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Gastric Lavage in < 1 hour
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Charcoal not helpful
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Desferrioxamine (iron chelator)
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?PO (controversial)
IV
Salicylate (Aspirin)
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Induces Gastric stasis!
Also slow/sustained release preparations
=> may be recoverable up to 12 hours post
ingestion
Gastric lavage up to 4 hours
? Repeated charcoal doses
Serial blood levels (as levels can ↑ > 6 hours)
Salicylate Poisoning; Symptoms
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Phase 1; (0-12 hours) Anxiety, sweating, fever,
tachycardia, hyperventilation with
Resp Alkalosis!
=> compensatory alkaline urine with loss of HCO3-, K+
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Phase 2; (may be immediate in young children)
↓ K+ (& paradoxic aciduria)
Phase 3; (up to 24 hours) dehydration, acidosis
predominates, pulmonary oedema, resp failure
Specific management
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Alkalisation of Urine to aid drug excretion
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Sodium Bicarbonate
Fluids & K+ replacement
Serial levels & ongoing monitoring
Resp support!
Ethylene Glycol
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Tastes sweet
In Anti-Freeze, De-icer fluid etc
Causes metabolic acidosis (high anion gap)
Widespread cellular damage (esp. Kidneys)
Haemodialysis may be needed
Activated Charcoal doesn’t work!
Metabolised by Alcohol Dehydrogenase into toxic byproducts
Ethanol (40%) is competitive inhibitor of Alcohol
Dehydrogenase & may be used
Co-factors; thiamine, pyridoxine etc.
Caustic Ingestions
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Eg. Acids / alkalis / batteries
Burns in mouth
necrosis of oesophagus
strictures common
Lung damage when aspirated
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No emesis / lavage / charcoal etc.
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7) Follow-up of Poison Ingestion
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Must consider; why did this happen?
NB – social history
Carers?
 Supervision concern / Neglect?
 Housing etc.
 Child-proofing the home
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Social Worker Involvement
Psyche involvement if deliberate
Possible Metabolic abnormalities
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Metabolic acidosis
(high anion gap)
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Salicylates
Iron
Ethanol, methanol,
ethylene glycol
Iron
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Hypoglycaemia
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Hypokalaemia
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Iron poisoning
Alcohol poisoning
Salicylates
Β-blockers
Hyperkalaemia
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digoxin
Childhood Accidents
Dr. D Barry
Childhood accidents
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Leading cause of death and disability in children
and young adults
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More than 5 million deaths per year worldwide
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Lack of global attention to childhood injuries
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Leading cause of death in children over 1 year
Childhood Mortality by Age
30%
25%
SIDS
Congenital anomaly
Infecton
Neoplasms
Accidents
20%
15%
10%
5%
0%
< 1 year
1 - 4 years
> 5 years
Accident types
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Falls
Drowning
Burns
Choking
RTA
*****NB – when to consider NAI *****
FALLS
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Children Fall all the time
Toddlers ( 1 – 3 Years) especially
Babies roll over, fall off beds , climb out of cots,
fall out of high chairs etc.
Fractures are uncommon
Detailed History
Detailed FULL Examination
Falls
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Clinical assessment will direct further
investigations ( if any)
Many children < 1 Year with a head injury are
observed as inpatients to ensure they remain
well
All are referred to social work
> 99% are Genuine Accidents
But be Vigilant; ? NAI / safety concerns
Fractures in Children
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Signs;
tenderness,
 swelling,
 deformity,
 ↓ use etc.
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Consider;
does the history fit the injury? NAI
 Underlying condition predisposing bone to #
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Management
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X-ray (AP / lateral)
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Rest
Immobilise & Protect
Analgesia
Physiotherapy
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Consider – antibiotics / tetanus etc.
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What’s this?
Salter-Harris #
Growth Plates – vulnerable to #
 Joint capsule, surrounding ligaments tendons etc
stronger than cartilaginous growth plate
 Shearing / Avulsion therefore possible
 Types 1 - 5
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Salter-Harris Fracture
What’s going to happen here?
Pulled elbow
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‘nursemaid’s’ elbow
Sudden pull on hand with elbow extended
 Radial head subluxes
 Child holds forearm unwilling to move it
 Reduced simply by supinating forearm, then flex!
 Immediate recovery!
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Pulled elbow
What’s this?
Toddler’s fracture
Shaft of tibia
 9 months – 3 years
 Low –energy forces
 Spiral appearance, non-displaced
 Limp / not weight bearing
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Drowning
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Leading cause of Accidental Death worldwide < 15 yr
2% mortality < 4 yr olds
“the process of experiencing respiratory impairment
from submersion/immersion in liquid”
PREVENTION;
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Water Safety, Life Guards etc.
Supervision while swimming and in the bath
Known epileptics – must be supervised
Drowning Pathology
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Upon submersion; apnoea, bradycardia
Hypoxia, Acidosis (due to apnoea) -> tachyc.
20 secs – 5 mins; fluid inhaled
Laryngeal spasm (as fluid hits glottis)
Alvoelitis
Pulmonary oedema (up to 12-24 hours later)
Hypothermia common*
+/- injuries incurred (esp. C-spine injury)
Drowning; What type water?
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Salt water; pulls fluid into air spaces by osmotic
gradient => this washes away surfactant
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Freshwater; disrupts alveolar surfactant =>
alveoli collapse. Fluid transudes into air spaces
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Dirty/Contaminated? – consider what antibiotic
choice
Burns / Scalds
Burns / Scalds
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Most common less than 5 years old
Major source of morbidity & mortality
Scalds most commonly from cups of tea, bath
water etc.
Burns / Scalds
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Prevention through practical household
measures and Public Health Campaigns are the
most important factors
Management of Burns / Scalds---(covered by Mr. Orr)
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Choking/ Strangulation/ Suffocation
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Toddlers & young children particularly at risk
Choking on aspirated food/ small toys
 Accidental strangulation of infants– entangled
in
any cord/ telephone wire etc.
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Increasing incidence of both accidental and
intentional hanging in teenage boys
Choking/ Strangulation/ Suffocation
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Prevention
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Public Health Campaigns
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Parent & Child Education
Choking; Management
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Back blows x 5
Chest thrusts x 5
Check mouth
Mouth to Mouth
Back blows x 5
Abdominal thrusts x 5 (not < 1 year)
Heimlich manouvre (older child)
Foreign bodies
Road Traffic Accidents
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Most common cause of accidental death in
Children
4 out of 5 children who die in RTA s are not
properly restrained
Booster Seats
Road Traffic Accidents
Pedestrians & Cyclists
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Speed in school and residential areas major
factor
Greatest risk; Boys 5 -10 years old;
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Unable to judge car speed and lack of danger
awareness
Seat Belt Laws Need to be enforced more
strictly
Ongoing campaign has improved compliance
Prevention
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School / Residential Zone speed limit reduction
and enforcement
Supervision & Education of Children
Helmets and cycle lanes for cyclists-----------Not useful if cyclists are ignored by motorists
Questions?