Toxicology: Pediatrics and Approach to Poisoned Patient Flashcards
Evaluation of a Poisoned Child
Child presents with altered level of consciousness, metabolic disturbances, neurological dysfunction, cardiac/pulmonary distress?
Include toxic exposure as part of differential
Pediatrics Supportive Care Guidelines
Pediatric Advanced Life Support (PALS) Guidelines
Early airway stabilization
Early antidote administration (if indicated):
Organophosphates (insecticides or pesticides) —> Atropine
Iron —> Deferoxamine
Digoxin —> Digoxin antibody fragments (Fab)
Benzodiazepines —> Flumazenil
Lead —> Edetate Calcium Disodium (EDTA)
Methemoglobinemia —> Methylene Blue
Heparin —> Protamine
TCAs or Salicylates —> Sodium Bicarbonate
Warfarin —> Vitamin K
Pediatrics - Gastric Decontamination
Lack of evidence of efficacy limits use and discourages some methods
Syrup of ipecac - NOT recommended
Gastric Lavage - NOT recommended. Lack of efficacy data and relatively high complication rate
Activated Charcoal: Use within 1 hour at 0.5 to 1 g/kg. Optimal ratio 10:1 AC:drug. Vomiting most common ADE
Multiple dose activated charcoal (MDAC): >2 sequential dose administrations to prevent prolonged absorption or enterohepatic recirculation. MDAC enhances gastric dialysis of certain drugs. Loading dose of 1 g/kg followed by 0.5 g/kg every 4-6h for up to 24h
Whole Bowel Irrigation (WBI) - polyethylene glycol and electrolyte solution
Considered in patients who ingested: SR, EC, or iron (or other metals)
Can be given PO, but via NG tube is easier with kids
0.5 L/hr (smaller children) up to 1.2-2L/hr (older children and adolescents) for 4-6 hours
GoLYTELY, NuLYTELY, CoLyte
Do NOT use Miralax —> No electrolytes = electrolyte imbalances
Pediatrics - Acetaminophen
Toxic ingestion>200 mg/kg (oral) or >60 mg/kg (IV) in children
GI Decontamination: Activated Charcoal within 1 hour
Antidote: n-acetylcysteine (NAC). AEs: N/V/D, anaphylactoid rxns (rare)
Oral NAC: 140 mg/kg x1 then 70 mg/kg q4h x17 doses
IV NAC: (more often used in younger patients) 150 mg/kg infused over 1 hour, 50 mg/kg infused over 4 hours, 100 mg/kg infused over 16 hours
To avoid hyponatremia in children, product should be diluted to a concentration of 40 mg/mL
Pediatrics - Ethylene Glycol
Engine Coolant
Metabolized by alcohol dehydrogenase to glycoaldehyde —> glycolic acid —> glyoxylic acid and oxalic acid
Results in metabolic acidosis and cardiopulmonary compromise
GI decontamination NOT recommended
Pyridoxine (B6) and Thiamine (B1) both given IV at 100mg/day because low risk
Antidote: Fomepizole or Ethanol
Pediatrics - Methanol
Solvents, antifreeze, fuels, windshield washer fluid, etc.
Metabolized by alcohol dehydrogenase
Methanol —> formaldehyde —> formic acid
GI decontamination: NOT recommended
Folic Acid 1 mg/kg (max 50mg) every 4-6 hours for 24 hours because low risk
Antidote: Fomepizole or Ethanol
Ethylene Glycol and Methanol Antidotes
Impede alcohol dehydrogenase activity, preventing toxic aldehyde formation
Fomepizole: Load: 15 mg/kg, 10 mg/kg every 12 hours x 4 doses, 15 mg/kg every 12 hours until serum concentrations of toxic alcohol are <25 mg/dL
*4x as expensive as ethanol, but more cost effective because no ICU monitoring
*Less dosing errors
*Less monitoring
Ethanol (10%): Load: 8 mL/kg over 1 hour ; Infusion: 0.8 mL/kg/hour ; Serum concentrations of 100-150 mg/dL
*Requires central venous catheter
*Central nervous system depression
*Respiratory depression
*Therapeutic drug monitoring
Pediatrics - Household Cleaners / Caustic Exposures
2nd most reported exposure in children
• Household cleaners = bleaches, detergents, soaps
• Caustics = toilet cleaners, drain cleaners, oven cleaners
• GI decontamination: NOT recommended
• Antidote: none
• Management: supportive
If GI injury occurs, further medical and pharmacologic management (e.g., proton pump inhibitors) may be indicated
Pediatrics - Foreign Body Ingestion
Kind of self intuitive treatment (just read this once, maybe twice)
Examples: toys, disc batteries, ornaments
• GI decontamination: manual removal if esophageal impaction suspected
Disc batteries usually pass-through esophagus into the stomach and pass-through intestinal tract within 1-2 weeks
However, battery may become lodged in the esophagus and result in serious and life-threatening
complications such as burns, perforations and fistulae
Signs/Symptoms: vomiting, diarrhea, abdominal pain, fever, refusal to eat or drink, dysphagia
National Battery Ingestion Hotline
Pediatrics - Cough and Cold Products
Little, if any, evidence supports the use of cough and cold preparations in children for the
management of cold symptoms
• Often, children are 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
• 2007: FDA Advisory Panel recommended that these drugs be avoided in children younger than 6 years
• Gastric decontamination: Activated Charcoal
• Symptomatic management of hypertension (e.g., labetalol, nicardipine), arrhythmias (e.g.,
amiodarone), and seizures (e.g., benzodiazepines)
Why are most pediatric ingestions not serious?
Small volumes of products being ingested and often no intent to cause self harm result in less severe outcomes
Poison Prevention Counseling Points
Child proof caps
Child proof containers
Storage location
Environmental precautions
E.g. opening the garage door
Taking appropriate doses
Disposing of unused, expired drugs
Never mix household products
General Information to Collect During Overdoses
Valuable information to collect
‘ Age and weight
́ Health history
́ Time of exposure
́ Route of exposure (cutaneous, oral, etc.)
́ Present symptoms
́ Exact name of product, if available
́ Estimate to how much may have been ingested
́ Strength of product
́ Formulation of product (IR, XR, etc)
́ Occupation, as applicable
́ Suicide notes or similar
General Treatment Approach During Overdose
Assess the patient
́ Level of exposure
́ Amount
́ Symptoms
Self-treatment (at home)
́ Guidelines available for select exposures
Referral to hospital
́ Moderate to severe exposure
́ Intentional ingestions
ABCs of Overdose Management
• Airway
• Breathing
• Circulation
• Dextrose/Decontamination
• EKG/Elimination
