Pediatric Toxicology Flashcards by Kim Nguyen

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

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

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Most common toxins reported

Analgesics, cosmetics, household cleaning substances

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Are infant/toddler toxic exposures intentional?

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

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

Include toxic exposure as part of the differential

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

Supportive care, history, evaluation

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Supportive care for a poisoned child

Begin with airway stabilization and administer an antidote if indicated

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History of a poisoned child

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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PE of a poisoned child

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

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Lab evaluation of a poisoned child

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

Serum osmolality

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

ECG

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Serum chemistries allow for what?

Anion gap calculation

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Anion gap formula

Na - [Cl-HCO3]

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What serum concentrations should you obtain (what drugs)

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

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Gastric decontamination in pediatric poisonings

Generally not recommended

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GI decontamination in peds: syrup of ipecac

NOT RECOMMENDED

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GI decontamination in peds: gastric lavage

NOT RECOMMENDED

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GI decontamination in peds: AC

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

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AC dose in peds

0.5-1g/kg

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Optimal ratio of AC to drug in peds

10:1

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ADE of AC

vomiting

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GI decontamination: MDAC

Administration of more than 2 sequential doses of AC

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What does MDAC prevent

Prolonged absorption or enterohepatic recirculation

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Repeated doses of AC may enhance what?

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

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MDAC dose

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

GI decontamination: WBI

Polyethylene glycol and electrolytes

When to consider WBI in peds patients

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

Route of administration for WBI

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

WBI dose in peds

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

What should you not use for WBI and why?

MiraLax, there's no electrolytes!

Toxic ingestion of APAP in peds

>200mg/kg PO >60mg/kg IV

APAP toxicity in peds: GI decontamination

AC within 1 hour of ingestion

APAP antidote

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

PO NAC dose in peds

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

IV NAC dose in peds

150mg/kg infused over 1 hour 50mg/kg infusion over 4 hours 100mg/kg infused over 16 hours

IV NAC dose should be diluted to what?

40mg/ml to prevent hyponatremia

Ethylene glycol reaction

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

ethylene glycol is metabolized to glycoaldehyde by what?

ADH

gylcoaldehyde is metabolized to glycolic acid by what?

aldehyde dehydrogenase

Metabolite of ethylene glycol that's responsible for the effects

Glycolic acid

Glycolic acid effects

Metabolic acidosis, cardiopulmonary compromise

How soon do the effects of glycolic acid set in?

12-24 hours after ingestion

Ethylene glycol metabolites that further exacerbate the metabolic acidosis

Glycoxylic acid, oxalic acid

Symptoms of ethylene glycol toxicity within the first few hours

decreased mental status, ataxia, slurred speech, coma

Symptoms of ethylene glycol toxicity 1-2 days after ingestion

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

Supportive treatment for ethylene glycol toxicity

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

Ethylene glycol and methanol antidotes

10% ethanol, fomepizole (first-line!)

Goal of ethanol and fomepizole

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

10% ethanol dose

8ml/kg load over 1 hour Infusion: 0.8ml/kg/hr

10% ethanol route of administration

IV or PO

Ethanol 10% downsides

Requires central venous catheter d/t high osmolarity CNS depression and respiratory depression Required TDM because it can cause hypothermia, hypoglycemia, hyponatremia

Target serum concentration of 10% ethanol

100-150mg/dl

How long to continue 10% ethanol treatment for

Until toxin concentrations are <25mg/dl

Fomepizole dose

15mg/kg load 10mg/kg q12h x4 doses 15mg/kg q12h until serum concentrations of toxic alcohol are <25mg/dl

Benefits of fomepizole

No alteration in level of consciousness, BG, electrolytes No central venous access needed No ICU monitoring needed if patient is stable Less dosing errors

Downside of fomepizole

It's expensive

Methanol metabolism reaction

methanol → formaldehyde → formic acid

Methanol is metabolized to formaldehyde by what?

ADH

Formaldehyde is metabolized to formic acid by what?

Aldehyde dehydrogenase

Effects of methanol's metabolites

Metabolic acidosis, blindness

Methanol toxicity symptoms 12-24h after ingestion

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

Other signs and symptoms of methanol toxicity

GI distress, HA, shock, seizures

Is GI decontamination recommended in ethylene glycol and methanol toxicity?

Household cleaners/caustic exposure: is GI decontamination recommended?

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

Management of household cleaner/caustic exposure toxicity

Supportive care Fluids for asymptomatic/mildly symptomatic child If GI injury occurs, further medical and pharmacologic management may be indicated

Signs/symptoms of foreign body ingestion

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

GI decontamination for foreign body ingestion

Manual removal if esophageal impaction suspected- remove it ASAP!

Disc battery ingestion in peds

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

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

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

Cough and cold preparations: should kids be getting these?

No, avoid these in children <6

Cough and cold preparations: GI decontamination

Use AC

Symptomatic management of cough and cold preparation toxicity

HTN- labetalol, nicardipine Arrhythmias- amiodatone Seizures- BZDs

How do kids get cough/cold preparation toxicity?

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