Transcript Case continued

Pediatric Poisoning
Edwin de Zoeten M.D. Ph.D.
PL-3
Case:
11 year old male presents to the ER with
altered mental status. Pt. was a previously
healthy who went to bed at his GM’s home
in his normal state of health. He was
found wandering outside at 3:00 AM.
Case con’t:
Vitals: T:38.9, P:130, R:30, BP 140/90
PE: General: active, agitated, talking
about a dog in the room
HEENT: NC, AT, pupils dilated at 6mm
w/o reaction, +photophobia, o/p clear but
dry MM.
Skin: Hot, mildy red. No lesions or rashes
Lungs: CTA B
CV tachycardic with regular rhythm no
murmur.
Case continued:
Abd: soft NT, ND, no HSM, no Mass,
decreased BS
Extr: CR< 2 MAEW, doesn’t follow
commands, is ataxic
Neuro: DTR’S 3+, ataxic, restless with visual
hallucinations. Poor finger to noses, unable to
assess most exams. Babinski down going.
Epidemiology
• More than 50% of childhood accidents in the United States involved toxic
ingestions.
• More than 4 million poisoning cases are reported annually to poison
centers throughout the US each year.
• Greater than 53% of these events are in patients 5 years old or younger.
•Most unintentional encounters result in mild or no symptoms, and no
morbidity.
• There has been a significant decline in the number of pediatric poisoning
deaths 216 in 1972 versus 25 in 1997.
•Most frequently fatal pharmaceutic ingestions in children have been
prenatal iron supplements, antidepressants, cardiotonic agents and
salicylates.
Evaluation
• ABC’s
• History
• Physical
• Urine/serum Tox
• Odors
• Toxidromes
ABC’s
º Airway
º Breathing
º Circulation
º Diagnosis
º Decontamination
º Enhanced removal
History:
What was ingested?
• Containers
• Ask EMS what was at the scene
• Available meds, plants etc.
• Quantity
• Elapsed time
• Route of exposure
• Cause for ingestion
What’s the difference they’re just
small adults
• Airway resistance is greater
• Cardiac output very dependent on heart rate
• Young infants are very susceptible to
thermoregulatory problems
• Mechanisms that typically distort mental
status may be masked by limited pediatric
neurologic repertoire
• Depressants may have an accelerated effect
in children as compared with adults
• Seizures are more likely in children than
adults
Physical Exam Findings
Constricted
sympatholytics
cholinergics
Barbituates
Opiates
PCP
Ethanol/Sedative hypnotics
Dilated
sympathomimetics
Anticholinergics
Vital Signs
Hypothermia (COOLS): CO, opiates, Oral
hypoglycemics, alcohols, sedative hypnotics.
Hyperpyrexia (NASA): Nicotine, Antihistamines,
sympathomymetics, salicylates, amphetamines,
anticholinergics.
Tachycardia (FAST): Free Base, amphetamines,
anticholinergics, sympathomymetics, Theophyline
cyanide, cyclic antidepressants, propoxyphene,
antihistamines, low dose iron.
Bradycardia (PACED): Propranalol,
Acetylcholinesterase, clonidine, Ca-channel blockers,
Ethanol, sedative hypnotics, opiates, digoxin, nicotine.
Tachypnea (PANT): PCP,paraquat, pneumonitis, ASA,
non-cardio PE, Toxin induced Met acid, hydrocarbons,
organophosphates,
Bradypnea (SLOW): Sed-hypnotics, liquor, opiates,
weed, acetone, barbiturates, ibuprofen, nicotine.
Vitals continued:
Hypertension: (CT SCAN) Cocaine, Thyroid,
Theophyline, Sympathomimetic, Caffeine,
Anticholinergic, Nicotine.
Hypotension: (CRASH) Clonidine, CCB’s, Reserpine,
Antidepressants, Sedative hypnotics, heroin.
Seizures: (OTIS CAMPBELL)Organophosphates,
Tricyclics, INH, Insulin, Sympathomimetics, Camphor,
Cocaine, Amphetamines, Methylxanthines, PCP, Benzo
withdrawal, Ethanol withdrawal, Lithium, Lidocaine,
Lead, Lindane
Toxidromes:
Anticholinergics:
Mad as a hatter
Red as a beet
Hot as a hare
Blind as a bat
Dry as a bone
Cholinergic
Muscarinic
Nicotinic
• Salivation
•Tachycardia
• Lacrimation •Hypertension
• Urination
•Fasciculations
• Defacation
•paralysis
• GI motility
Odors:
Garlic: Arsenic, Organophosphates, Thallium
Pear: Chloral Hydrate, Paraldehyde
Acetone: Chloroform, Isopropyl alcohol
Almond: Cyanide
Oil of wintergreen: Methylsalicylate
Mothballs: Naphthalene, paradichlorobenzene
Carrot: Water Hemlock
Labs:
•Urine tox
•Good for drugs of abuse - amphetamines,
barbiturates, benzo’s, cocaine, cannabinoids,
opiates, PCP
•Serum/plasma tox
•Good for levels of selected substances Acetaminophen, ASA, CO, CBZ, Dig, EtOH, Fe,
Li, Phenobarb.
•Avoid a comprehensive tox screen.
•Chem 7
•looking for an elevated anion gap
Elevated Anion Gap
Gap = Na - Cl -CO2 (should be 8-12)
• Methanol
• Uremia
• Lactic acidosis
• Ethylene Glycol
• Paraldehyde
• Alcohol
• Ketoacidosis Diabetes Mellitus
• Salicylates
• Toluene
• Iron, Isoniazide
M
U
L
E
P
A
K
S
Abdominal X-rays
Barium
Enteric coated tablets
Tricyclics
Antihistamines
Chloral hydrate, cocaine, condom
Heavy metals
Iodides
Potassium, Phenothiazines
Bet-A-Chip
Decontamination
Emesis
•Indications: Fe, Li, K at home
management
•Contraindications:
•obtunded, comatose/convulsing
•Likelihood of rapid progression
•corrosives
•Petroleum distillates
Decontamination
Activated Charcoal
•Indications: Multiple poisons
•Contraindications:
•ileus, obstruction
•Corrosives
•Some poisons not well absorbed
•alcohols, alkalis, acids
•CN, Fe, K, Li, Pb
Decontamination
Gastric Lavage
•Indications:
•removal of ingested material
•administration of charcoal/cathartics
•Contraindications:
•Obtunded, comatose/convulsing
•corrosives
Decontamination
Cathartics
• Magnesium Citrate (4ml/Kg)
• Use with caution in <2 yo.
• Generally not recommended
Enhanced elimination:
Alkalinization of urine
hemodialysis
hemoperfusion
peritoneal dialysis
Multidose charcoal
whole bowel irrigation
Specific Antidotes
Acetominophen
COHb
Digoxin
Ethylene Glycol
Iron
Lithium
Methanol
Salicylate
Theophyline
N-acetylcysteine
Oxygen, HBO
Fab
EtOH, Dialysis
Deferoxamine
Fluids, dialysis
EtOH, Dialysis
Alkalinization, dialysis
repeat AC, hemoperfusion
What happened to that kid?
Back to the case:
Labs:
Chem7
139
4.3
112
19
9
0.6
105
EKG: Tachycardia, Mild prolonged QTc, sinus rhythm
Urine Tox screen: Negative
Procedures:
•None/Observation
•Discussed the use of
physostigmine as an antidote
not used.
Patient gradually became more lucent.
After a significant time period the
patient admitted to ingesting seeds.
Jimson Weed