Poisoned Child Flashcards
What is special about childhood poisoning?
- Not usually deliberate self-harm
- History difficult
- Different types of material ingested
- Usually small amounts and not very toxic
- Small amounts of certain substances are potentially lethal: “one pill can kill”
- Smaller oesophagus and stomach can limit effectiveness of decontamination techniques.
What are the different causes for poisoning in the context of psychosocial problems?
Poisoning is a manifestation of an underlying psychosocial problem
- Adults
- Psychiatric
- Social
- Drug & Alcohol
- Environmental
- Workplace
- Children
- NAI
- Infants
- External force
- Toddlers
- Behavioural
- Children
- Behavioural
- Environmental
- Adolescents
- Similar to adults
- Infants
What kind of poison is the most common exposure for children under 5?
What is the most common disposition poisons calls for children?
List examples of non-toxic ingestions?
- Antacids
- Antibiotics
- Inks
- Bath oil
- Candles
- Mostdetergents- except “concentrated powerballs”
- Chalk
- Cigarettes
- Colognes & perfumes
- Corticosteroids
- Cosmetics
- Fertiliser
- Glues
- Hair products
- Hand lotions
- Incense
- Laxatives
- Lipstick
- Matches
- Newsprint
- Oral contraceptives
- Paint
- Shampoo
- Shavingcream
- Shoe polish
- Silica–dessicantin boxes
- Soap
- Suntanlotions
- Thermometermercury
- Vaseline
List some examples of potentially lethal “1 pill can kill” substances?
- Amphetamines
- Betablockers
- Calcium Channel Blockers
- Digoxin
- Opioids
- Sulphonylureas
- Tricyclic antidepressants
What are some non-pharmaceuticals that are potentially lethal?
- Pesticides
- Paraquat 1 mouthful
- organophosphates
- Hydrocarbons
- Kerosene
- Essential oils Eucalyptus
- Household products
- camphor
- napthalene
What are important points to remember when taking a history for suspected poisoning?
- Unreliable
- Ingestion is only a SUSPICION
- Time of ingestion unknown
- Calculate maximal possible ingestion on mg/kg basis
- If >1 child found with poison, need to assume that each child ingested all the poison
What are the principles of management for paediatric poisoning?
- Resuscitation ABC’s
- History & Examination
- Risk Assessment
- Poisons information: 13 11 26
- Ongoing management
- Supportive care and monitoring
- D-E-A-D
- Decontamination
- Enhanced elimination - Multi-dose charcoal and urine alkalinisation
- Antidotes
- Disposition
What are your aims on physical examination for suspected poisoning of a child?
- Identify and treat immediate threats to life
- Establish baseline clinical status
- Corroborate history- does it match?
- Identify toxidromes
- Look for alternative diagnoses “Tox vs Non Tox”
- Identify complications of poisoning
Describe initial assessment and stabilisation for a poisoned child
- Airway
- Breathing
- RR
- O2 saturation
- Circulation
- Pulse
- BP
- Cardiac Rhythm
- Level of Consciousness AVPU
- Presence of Seizure Activity
- Glucose
- Temperature
What factors do you consider when conducting risk assessment of poisoning?
- Substance/dose/time
- weight
- Clinical features
- Investigations incl. ECG/paracetamol
- This enables you to assess the likely severity and outcome
What will complete your examination when the poisoned child is stable?
- Full neurological examination
- Mental Status
- Pupil size
- Tone/reflexes
- Clonus
- Focal signs
- Evidence of trauma
- Skin
- colour
- sweating
- Bowel sounds
- Urine- retention?
What are the differentials for coma/altered mental status?
- Non-Tox vs Tox
- Head Injury
- CNS infections
- Metabolic
- hypo/hyperglycaemia
- hypo/hypernatraemia
- acute renal failure
- Hypo/hyperthermia
- Ictal and post-ictal states
- Drugs
What are some important secondary complications of poisoning?
- Pulmonary aspiration- vomit
- Rhabdomyolysis- long lie
- Acute renal failure
- Pressure areas
- Hypoxic brain injury
What are some helpful drug levels in the context of drug overdose?
- 4hr paracetamol level for any deliberate self poisoning
- Others only if clinically indicated:
- Anticonvulsants
- Phenytoin,carbamazepine,valproate,phenobarbitone
- Digoxin, aspirin, Li, Fe
- Anticonvulsants
Which drug levels are NOT helpful in drug overdose?
- Central Nervous System
- antidepressants
- benzodiazepines
- benztropine
- cocaine
- antipsychotics
- opiates
- phenothiazines
- THC
- Cardiovascular System
- ACE inhibitors
- beta blockers
- calcium channel blockers
- clonidine
Give examples of some common toxidromes
- Sympathomimetic
- Opioid
- Anti-cholinergic: “Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.”
- Cholinergic: central, muscarinic, nicotinic (secretions)
- Serotonin toxicity
What symptoms do you get with a sympathomimetic toxidrome and list examples of substances
- Symptoms
- Hypertension
- Tachycardia
- Dilated pupils
- Agitation
- Sweating
- Hyperthermia (urgent attention)
- Treatment: benzodiazepines
- Examples
- Cocaine
- (met)Amphetamines
- Ecstasy/MDMA
- Khat
- Cathinones
- “Bath salts”
- Synthetic Cannabinoid Rc Agonists “synthetic marijuana”
What are some symptoms of an opioid toxidrome and what is the treatment?
- Symptoms
- Respiratory depression
- Sedation
- Pinpoint pupils
- Naloxone is antidote mainly for respiratory depression rather than GCS
What are some symptoms of an anti-cholinergic toxidrome, some common causes and treatment?
- Symptoms
- Think “anti-muscarinic”
- Agitated delirium-plants
- Pills usually partially sedate
- Visual hallucinations
- Tachycardia
- Hyperthermia
- Dilated pupils
- Dry flushed skin
- Urinary retention- IDC can benefit
- Ileus
- Treatment: benzo’s /physostigmine
- Common causes
- Anti-histamines
- Tricyclic antidepressants
- Phenothiazines
- Plant poisonings Datura, Brugmansia
- Benztropine (given for dystonia !)
What are some symptoms from a cholinergic toxidrome, examples of causes and treatment?
- DUMBBELS
- Diarrhoea
- Urination
- Miosis
- Bronchorrea, bradycardia- “Killer B’s”
- Emesis
- Lacrimation
- Salivation
- Nicotinic effects: weakness, fasciculations
- Central effects: coma, seizures
- Treatment:
- Intubate
- ATROPINE
- wash patient
- Examples
- organophosphates
- Carbamates
- Chemical attack
- VX
What are some symptoms of serotonin toxicity, examples of substances and treatment?
- Neuromuscular exam is key
- – hyperreflexia, clonus (ankle)
- Can also find:
- Altered sensorium
- confusion,agitation
- Autonomic changes
- Dilated pupils
- Sweating
- Hypertension
- Treatment: benzo’s /cyproheptadine
- Examples
- SSRIs/SNRIs
- MAOIs
- TCAs
- Amphetamines/MDMA
- Tramadol
- Opiates
- Usually combinations
What is a part of supportive care of poisoned patients?
- Airway: intubation
- Breathing: supplemental oxygen, ventilation
- Circulation
- defibrillation, antiarrhythmics, pacing
- intravenous fluids, inotropes
- control of hypertension
- cardiopulmonary bypass
- Metabolic
- glucose
- control of pH
- Sedation
- IV benzodiazepines
- Seizures
- IV benzodiazepines
- Do not load with phenytoin (a Na Channel blocker)
- Body temperature
- warming
- Cooling- control quickly
- Renal function
- hydration
- haemodialysis
What is the rationale for GI decontamination and some methods?
“If a poisonous substance can be removed from the gastrointestinal tract before it is absorbed, then it will be unable to exert its toxic effect.”
- Gastric Emptying-historical only
- Induced emesis
- Gastric lavage
- Adsorbent administration
- Activated Charcoal
- Whole Bowel Irrigation-Colonic Prep/Polyethylene glycol for slow release meds
- Endoscopy
What are some complications of ipecac (dried root that causes emesis)?
- Protracted vomiting
- Oesophageal/Mallory Weiss tears
- Pneumomediastinum
- Gastric rupture
- Intracranial Haemorrhage
What is activated charcoal?
- Produced by superheating charcoal to remove impurities and produce small porous particles.
- 1g/kg
- Mixed with water to form a suspension OR ICECREAM OR COLA!
- Given orally or via a nasogastric tube after CXR confirmation
- Effectiveness of preventing drug absorption decreases rapidly with time, the greatest benefit is within 1 hour of ingestion.
- Decreases Drug Concentration in some overdoses
- Clinical outcome studies – no studies to show that AC improves clinical outcome.
What are the complications of activated charcoal?
- Vomiting
- Charcoal aspiration/pneumonitis
- Adsorption of oral antidotes
- Messy
- Bowel obstruction/ileus
What are the indications for activated charcoal?
- Risk Assessment suggests that drug ingested is expected to lead to toxicity
- Charcoal can be administered within 1 hour of ingestion, longer if SR or massive amount
- Co-operative patient
- Patient is alert or airway protected
What are some contraindications to activated charcoal?
- NOT for metals (Li, K), alcohols, hydrocarbons, corrosives “MACH”
- Low GCS
- Seizure risk
- Ileus
When do you consider whole bowel irrigation and how do you prepare?
- WBI may be considered for potentially toxic ingestions of:
- Slow Release or Enteric Coated drugs: CCB
- Metals: K, Fe
- Body packers
- Similar to preparing bowel for colonoscopy- drinking bowel prep or via NG tube
What are contraindications to whole bowel irrigation?
- bowel obstruction,
- perforation,
- ileus,
- unprotected airway
What is enhanced elimination?
- Increasing elimination of drugs already absorbed
- Multi dose activated charcoal- enterohepatic circulation
- carbamazepine, mushrooms,
- Urinary alkalinisation- only for salicylates, “ion trapping” of drug in urine
- Haemodialysis/CVVHD/Haemoperfusion
What pharmacokinetic properties are suitable for haemodialysis?
- Drug must have particular pharmacokinetic properties
- low molecular weight
- low protein-binding
- Water soluble
- small volume of distribution, ie: drug mostly in the blood, not in tissues
What substances are suited for haemodialysis?
- Indicated for severe poisoning by
- Toxic alcohols-methanol, anti-freeze (PEG)
- Lithium
- Salicylates-severe only
- Theophylline
- Valproic acid-severe
- Carbamazepine -severe
What is considered as toxic ingestion of paracetamol and how do you use a nomogram?
- Toxic ingestion >200mg/kg
- Nomogram:
- Single ingestion
- Known time of ingestion
- Level after 4hr to ensure post- peak
- If above line, start IV N-acetylcysteine antidote
- For chronic paracetamol and slow release -> consult guidelines or a toxocologist
What are some symptoms with clonidine overdose?
- Centrally acting alpha 2-agonist
- Common because of ADD
- Symptoms
- CNS depression and bradycardia >24 hours
- Transient initial hypertension
- Treatments
- Generally responds to IV fluid bolus and IV atropine
- Naloxone controversial
Symptoms of red back spider bite and how to treat?
- Commonest spider-bite in ED
- 10-20% envenomation risk
- Local Fx:
- Pain, redness
- Piloerection, sweating
- Systemic Fx:
- Regional pain
- Diaphoresis, hypertension
- Antivenom:
- Current controversy about efficacy, not often used now.
- Generous analgesia is usually all that is needed.
- No bandage needed
What are some symptoms of a bite from funnel-web spider/big black spider?
- Neuromuscular excitation
- Fasciculations (tongue!), tremor, paraesthesia (lips!)
- Autonomic storm
- Excessive secretions, pilo-erection
- Tachycardia, hypertension & cardiac arrhythmias
- Other effects
- N/V & abdo pain
- Non-cardiogenic pulmonary oedema
How do you manage a bite from funnel-web spider/big black spider?
- Pressure Bandage Immobilisation
- ResuscitationwithABC
- Large bore IV access
- Anti-Venom if signs of systemic envenomation
- Consult with Clinical Toxicologist (PIC)
- Admit to ICU
What are some symptoms of a brown snake bite?
- Collapse-cardiotoxins
- Venom Induced Consumptive coagulopathy
- Low fibrinogen
What are some symptoms from a bite from the black snake group?
- RBBS, BBBS
- Local & systemic symptoms
- Mulga & Collett’s snakes
- Myotoxic
- Rhabdomyolysis
- Renal failure
What are some symptoms from tiger snakes and taipans?
- Neurotoxic (pre-synaptic)
- EYES: Ptosis and opthalmoplegia
- VICC coagulopathy
What are some symptoms from a death adder snake bite?
- Neurotoxicity (post-synaptic)
What are some do’s and don’ts for snake bites?
- Do:
- Remove from danger
- Keep still
- Apply pressure bandage
- Immobilise entire limb
- Don’t:
- Panic or run
- Attempt to catch snake
- Apply tourniquet
- Wash, suck or cut bite site
- Remove pressure immobilisation bandage until adequate facilities and antivenom available
What are some indications for pressure immobilisation bandages?
- All Australian snake bites (incl. sea snake)
- Funnel web spider bite
- Blue-ringed octopus
- Cone shell sting
Describe the technique for pressure immobilisation bandages?
- Firm bandage to bitten area
- Bandage entire limb
- Immobilise with splint
- Instructions
- Apply bandage over the bite site as for sprain
- Extend bandage to cover rest of limb, from distal to proximal, including fingers/toes
- Keep limb still using splint
How do you diagnose snake envenomation?
- Clinical diagnosis based on
- Geography
- Circumstances of the bite
- Symptoms & signs
- Laboratory results
How do you use a snake venom detection kit?
- Detects the presence of venom from:
- Bitesite
- Urine
- Snake fangs
- NOT blood
- Preferably done by lab technician NOT you!
- Does NOT tell you about:
- envenomation
- When to give AV
- How much AV to give
How do you give snake antivenom?
- Horse-derived blood product
- Given IV over 30min (diluted in 100mL N/S)
- Pre-treatment with steroids/antihistamines is NOT used in most cases
- Same dose for adults and children
- Adverse reactions
- Anaphylaxis can occur
- Serum sickness (delayed)- outpatient steroids if occurs
What is a complication from box jelly fish envenomation?
Cardiac arrest in a few minutes
How do you treat a box jelly fish sting?
- Remove tentacles
- Vinegar
- Anti-venom available
How do you treat bluebottle stings?
- Painful- responds to heat
- Put other limb in hot water too as a control to avoid burns
