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PHM 702- Toxicology > Pediatric Toxicology > Flashcards

Pediatric Toxicology Flashcards

1
Q

How many toxic exposures are reported annually, and how many of those are in children?

A

2 million, and ~50% of those are in kids <6

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2
Q

Most common toxins reported

A

Analgesics, cosmetics, household cleaning substances

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3
Q

Are infant/toddler toxic exposures intentional?

A

Usually not, they’re just curious about their surroundings and mimic adult behaviors

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4
Q

What happens if a child presents with an altered level of consciousness, metabolic disturbances, neurologic dysfunction, and/or cardiac/pulmonary distress?

A

Include toxic exposure as part of the differential

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5
Q

An evaluation of a poisoned child is like that of an adolescent or an adult, but with what differences?

A

Supportive care, history, evaluation

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6
Q

Supportive care for a poisoned child

A

Begin with airway stabilization and administer an antidote if indicated

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7
Q

History of a poisoned child

A

Get as much detail as possible!! (Volume ingested, tablet counts, containers of substance in question and a complete review of toxic substances in vicinity when the child was first exposed)

Ask about other places the child might’ve been

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8
Q

PE of a poisoned child

A

Mental status, vitals, neurologic exam (evaluation of pupil size and reactivity)

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9
Q

Lab evaluation of a poisoned child

A

Should be directed by the history and PE, but most patients presenting with suspected poisoning should have serum chemistries and acid-base status evaluated

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10
Q

If there is alcohol ingestion, what lab do you obtain?

A

Serum osmolality

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11
Q

If the child ingested beta-adrenergic blockers or CCBs, what do you obtain?

A

ECG

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12
Q

Serum chemistries allow for what?

A

Anion gap calculation

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13
Q

Anion gap formula

A

Na - [Cl-HCO3]

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14
Q

What serum concentrations should you obtain (what drugs)

A

APAP, salicylates, ethanol, iron- all of these are widely available in many products

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15
Q

Gastric decontamination in pediatric poisonings

A

Generally not recommended

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16
Q

GI decontamination in peds: syrup of ipecac

A

NOT RECOMMENDED

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17
Q

GI decontamination in peds: gastric lavage

A

NOT RECOMMENDED

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18
Q

GI decontamination in peds: AC

A

Consider use within 1 hour in patients with a potentially toxic ingestion

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19
Q

AC dose in peds

A

0.5-1g/kg

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20
Q

Optimal ratio of AC to drug in peds

A

10:1

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21
Q

ADE of AC

A

vomiting

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22
Q

GI decontamination: MDAC

A

Administration of more than 2 sequential doses of AC

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23
Q

What does MDAC prevent

A

Prolonged absorption or enterohepatic recirculation

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24
Q

Repeated doses of AC may enhance what?

A

Gastric dialysis of certain drugs (phenobarbital, phenytoin, CBZ, amitriptyline, digoxin)

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25
Q

MDAC dose

A

Loading dose of 1g/kg, followed by 0.5g/kg q4-6h x24 hours

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26
Q

GI decontamination: WBI

A

Polyethylene glycol and electrolytes

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27
Q

When to consider WBI in peds patients

A

If they consumed SR products, EC products, iron or other metals

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28
Q

Route of administration for WBI

A

PO, but ideally NG tube in peds due to the large volume

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29
Q

WBI dose in peds

A

0.5L/hr in small children, up to 1.2-2L/hr in older children and adolescents

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30
Q

What should you not use for WBI and why?

A

MiraLax, there’s no electrolytes!

31
Q

Toxic ingestion of APAP in peds

A

> 200mg/kg PO
60mg/kg IV

32
Q

APAP toxicity in peds: GI decontamination

A

AC within 1 hour of ingestion

33
Q

APAP antidote

A

NAC

(if you don’t know this by now you’re dumb)

34
Q

PO NAC dose in peds

A

140mg/kg x1, then 70mg/kg q4h x17 doses

35
Q

IV NAC dose in peds

A

150mg/kg infused over 1 hour

50mg/kg infusion over 4 hours

100mg/kg infused over 16 hours

36
Q

IV NAC dose should be diluted to what?

A

40mg/ml to prevent hyponatremia

37
Q

Ethylene glycol reaction

A

ethylene glycol → glycolaldehyde → glycolic acid → glyoxylic acid → oxalic acid

38
Q

ethylene glycol is metabolized to glycoaldehyde by what?

A

ADH

39
Q

gylcoaldehyde is metabolized to glycolic acid by what?

A

aldehyde dehydrogenase

40
Q

Metabolite of ethylene glycol that’s responsible for the effects

A

Glycolic acid

41
Q

Glycolic acid effects

A

Metabolic acidosis, cardiopulmonary compromise

42
Q

How soon do the effects of glycolic acid set in?

A

12-24 hours after ingestion

43
Q

Ethylene glycol metabolites that further exacerbate the metabolic acidosis

A

Glycoxylic acid, oxalic acid

44
Q

Symptoms of ethylene glycol toxicity within the first few hours

A

decreased mental status, ataxia, slurred speech, coma

45
Q

Symptoms of ethylene glycol toxicity 1-2 days after ingestion

A

nephrotoxicity d/t calcium precipitation of oxalic acid in renal tubules, hypocalcemia → changes in ECGs may also occur

46
Q

Supportive treatment for ethylene glycol toxicity

A

Pyridoxine and thiamine 100mg/day (both are the same dose)

47
Q

Ethylene glycol and methanol antidotes

A

10% ethanol, fomepizole (first-line!)

48
Q

Goal of ethanol and fomepizole

A

Prevent accumulation of toxic metabolites and allows for renal and pulmonary elimination of parent alcohols

49
Q

10% ethanol dose

A

8ml/kg load over 1 hour

Infusion: 0.8ml/kg/hr

50
Q

10% ethanol route of administration

A

IV or PO

51
Q

Ethanol 10% downsides

A

Requires central venous catheter d/t high osmolarity

CNS depression and respiratory depression

Required TDM because it can cause hypothermia, hypoglycemia, hyponatremia

52
Q

Target serum concentration of 10% ethanol

A

100-150mg/dl

53
Q

How long to continue 10% ethanol treatment for

A

Until toxin concentrations are <25mg/dl

54
Q

Fomepizole dose

A

15mg/kg load

10mg/kg q12h x4 doses

15mg/kg q12h until serum concentrations of toxic alcohol are <25mg/dl

55
Q

Benefits of fomepizole

A

No alteration in level of consciousness, BG, electrolytes

No central venous access needed

No ICU monitoring needed if patient is stable

Less dosing errors

56
Q

Downside of fomepizole

A

It’s expensive

57
Q

Methanol metabolism reaction

A

methanol → formaldehyde → formic acid

58
Q

Methanol is metabolized to formaldehyde by what?

A

ADH

59
Q

Formaldehyde is metabolized to formic acid by what?

A

Aldehyde dehydrogenase

60
Q

Effects of methanol’s metabolites

A

Metabolic acidosis, blindness

61
Q

Methanol toxicity symptoms 12-24h after ingestion

A

depressed mental status → tachypnea
Accumulation of formic acid can result in hallmark visual disturbances (blurriness, blindness- can be permanent)

62
Q

Other signs and symptoms of methanol toxicity

A

GI distress, HA, shock, seizures

63
Q

Is GI decontamination recommended in ethylene glycol and methanol toxicity?

A

NO

64
Q

Household cleaners/caustic exposure: is GI decontamination recommended?

A

NO

65
Q

Is there an antidote for household cleaner/caustic exposure toxicity?

A

NO

66
Q

Management of household cleaner/caustic exposure toxicity

A

Supportive care

Fluids for asymptomatic/mildly symptomatic child

If GI injury occurs, further medical and pharmacologic management may be indicated

67
Q

Signs/symptoms of foreign body ingestion

A

vomiting, diarrhea, abdominal pain, fever, refusal to eat/drink, dysphagia

68
Q

GI decontamination for foreign body ingestion

A

Manual removal if esophageal impaction suspected- remove it ASAP!

69
Q

Disc battery ingestion in peds

A

Usually, it passed through the GI system in 1-2 weeks, but sometimes it can get lodged in the esophagus and and result in burns, perforations, and fistulas

70
Q

The complications of an impacted disc battery is due to what?

A

Alkaline electrolyte leakage from the battery → pressure necrosis and external currents generated when the battery comes into contact with tissue

71
Q

Cough and cold preparations: should kids be getting these?

A

No, avoid these in children <6

72
Q

Cough and cold preparations: GI decontamination

A

Use AC

73
Q

Symptomatic management of cough and cold preparation toxicity

A

HTN- labetalol, nicardipine

Arrhythmias- amiodatone

Seizures- BZDs

74
Q

How do kids get cough/cold preparation toxicity?

A

Given several drugs with similar ingredients, the dose-measurement was inaccurate, an adult formulation was used, or the child was given doses by multiple caregivers

PHM 702- Toxicology (12 decks)

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