2- Emergency paediatrics (2/2) Flashcards
Poisoning of unknown origin
- Accidental incidents common in children <6
- Intentional ingestions and recreational drug use in older children and adolescents
–>Mental illness (suicide and attempted self harm) - Think of Munchausen
common poisoning of unknown origin in <6
o Prenatal iron supplements
o Antidepressants
o Cardiotoxic agents
o Illicit drugs
o Analgesics
o Aspirin
common non drug poisoning of unknown origin in
o Hydrocarbons
o Alcohols
o Cleaning products e.g. laundry detergent and bleach)
o pesticides
Presentation POUO
Poisoning of unknown origin should be considered in the differentials of children who present with acute onset of:
- Multiorgan system dysfunction
- Altered mental state
- Resp or cardiac compromise
- Unexplained metabolic acidosis
- Seizures
- Puzzling clinical pictures
Risk factors POUO
- 1-4 yo
- Previous history of ingestion
- Prior history of substance misuse
approach to POUO
Initial evaluation and stabilisation
A to E
Diagnosis of poisoning
- Obtain accurate history
- Location, activity just before injesting
- Risk assessment I.e. suidice and self harm
- Ask paramedics about what they saw e.g. open containers, empty bottles, spilled content
- Toxicology screen
- Clinical response to antedote
Definitive management will depend on substance
Example managements of POUO
- Decontamination using charcoal
- Antidotes
o E.g. naloxone e.g. opioid
o E.g. NAC e.g. paracetamol
o E.g. Flumazenil (diazepam and cocaine)
poisoning antidotes and substrates
Paracetamol overdose (acetaminophen)
Background
- Drug most commonly overdose on are paracetamol, ibuprofen , aspirin, iron, cough medicines and the contraceptive pill
- Children with features of poisoning should be admitted to hospital
- Children who have taken poisons with delayed actions should also be admitted
Pathophysiology of paracetamol overdose
- Toxic doses of paracetamol may cause severe hepatocellular necrosis and much less frequently renal tubular necrosis -> lack of glutathione
- Liver damage is maximal 3-4 days after paracetamol overdose
- Can lead to liver failure, encephalopathy, coma and death
Presentation of paracetamol overdose
- Nausea and vomiting- early features (also recur after 2-3 days)
- Right subcostal pain and tenderness – hepatic necrosis
History for paracetamol overdose
- Dose
- Timing
- Associated ingestions
investigations for paracetamol overdose
Delay sampling to 4h after ingestion
* Paracetamol level.
* U&E – baseline renal status/risk of AKD.
* LFT – monitor ALT levels for hepatotoxicity.
* Glucose – hypoglycaemia common in liver necrosis.
* Clotting screen – INR as PT best indicator of liver necrosis.
* Venous gas –acidosis in 10% of acute liver failure.
Management of paracetamol overdose
Paracetamol Children taking >150mg/kg need assessment
- <1 hour ago give charcoal (prevents absorption) alongside NAC
- N-acetylcysteine: PO or NG loading 140mg/kg, then 70mg/kg/ dose qds for 17 doses.
- IV used if GI bleeding. Repeat blood level at 24hr
N-acetylcysteine MOA
Acts to increase synthesis of glutathione in the liver; which acts as antioxidant and facilitates conjugation of toxins, esp toxic metabolites of acetaminophen.
- Acts to prevent or reduce severity of liver damage
- Can be given up to and possibly beyond 24 hours of ingesting paracetamol
- Most effective if given within 8 hours
paracetamol overdose prognosis
management of aspirin overdose
ACTIVATED CHARCOAL 1G/KG
FLUID REPLACEMENT
URINE ALKALINISATION with sodium bicarbonate
BENZOS FOR SEIZURES (0.1MG/KG)
HAEMODIALYSIS IF SEVERE (ITU)
management of iron overdose
Activated charcoal DOES NOT bind iron
Deferoxamine (DFO)
Metabolic acidosis: 1-2 mmol/kg sodium bicarbonate (1-2 mL/kg 8.4% or 2-4 mL/kg 4.2%) over 20 minutes. Repeat as necessary, aiming for a normal pH.
- administer into a large vein (or via a central line).
Large flush before and after (irritant to vein)
management of benzos overdose
ACTIVATED CHARCOAL 1G/KG (<1H)
FLUMAZENIL
fatal household poisens
CAMPHOR (VICKS / TIGER BALM)
ESSENTIAL OILS
BLEACH
SOLVENTS
WEED KILLER / INSECTICIDES
BUTTON BATTERIES
button batteries
- halo sign on x-ray
- surgical removal
- emergency
- battery acid erodes stomach and can cause catastrophic bleed
mucosal ulceration / necrosis > haemorrhage > perf: FATAL
pneumothorax background
Background
- Occurs in 2% of term infants
- Increased in prematurity and respiratory disease
Presentation of pneumothorax
- Asymptomatic (if small)- most resolve spontaneously
- If large: Respiratory distress
- Tension pneumothorax
-> Respiratory distress
-> Cyanosis
-> Mediastinal shift away from affected side
-> Reduced chest movement and air entry on affected side
-> Transillumination lights up affected side
investigation for pneumothorax
o Ipsilateral translucency
o Lack of peripheral lung markings
o Collapsed lung
management of pneumothorax
- If asymptomatic: none
- If symptomatic
o Give oxygen as required
o Needle aspiration (2nd intercostal mid clavicular)
o Chest drain (4th mid axillary)
o In an emergency do a needle aspiration before chest drain
Pneumothorax: In an emergency: needle aspiration procedure
- Insert a 21-23G butterfly into affected side at the 2nd intercostal space in the midclavicular line
- Butterfily can be placed under water following insertion
Chest drain procedure
- Lie the child supine with the affected side raised by 30–45° using a towel.
- Raise the arm towards the head.
- Suitable sites are the fourth intercostal space in the mid-axillary line (be careful to avoid the nipple), and second intercostal space in mid- clavicle line.
- Chest drain insertion should be performed using strict aseptic technique.
- Wash hands and put on sterile gloves, gown, +/– surgical mask.
- Clean skin over the insertion site with antiseptic solution.
- Prepare sterile field, then infiltrate small amount of local anaesthetic into the tissues down to the pleura.
- Wait 1–2min, then make a small skin incision with the scalpel just above and parallel to rib. Note: Blood vessels lie just below each rib.
- Using artery forceps make a blunt dissection down to and through the parietal pleura.
- Using forceps clamp chest drain and then insert into pleural space. Most clinicians remove the trocar before insertion.
- Aim to push the chest drain tip towards the lung apex. In the event of a small pneumothorax aim the tip in the direction of the pneumothorax remembering to aim anteriorly (air rises in the ill child lying supine).
- Connect the drain tightly to the underwater drainage system, unclamp drain, and apply negative pressure of 5–10cmH2O. Bubbling should start to occur.
presentation of hypoglycaemia
specific nutritional deficiencies
Kwashiorkor
Characterised by bilateral pitting oedema, in the absence of another medical cause of oedema
- Typically associated with dietary protein deficiency
- Most often seen in sub-saharan Africa
- Can be seen in children with severely restricted diets (children with ASG)
- Typically occurs at the time of weaning and up to 5 years of age
diagnostic factors for kwashikor
parental feeding
e.g. TPN
- Indication: post op, treatment of IBD, oral feeds contraindicated e.g. NEC, intestinal failure e.g. short bowel syndrome, GI obstruction, oncology e.g. graft versus host
