poisoning Dr.mushriq A.hussein - PowerPoint Presentation

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poisoning

Dr.mushriq

A.hussein

Senior lecturer

Department of pediatrics

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ETIOLOGYThe most common agents ingested by young children include family members'

medications

.

The

most common poisonings that lead to hospitalization are due to acetaminophen, lead, and antidepressant

medications.

Fatal

childhood poisonings are commonly caused by carbon monoxide, hydrocarbons, medications (iron, cardiovascular drugs, cyclic anti-depressants), drugs of abuse, and caustic

ingestions.

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 EPIDEMIOLOGY 

more than 50% of poisoning annually occur in children <6 yr old

..

Poisoning exposures in children 6-12 yr old are much less common, involving only ~ 6%

of reported

pediatric exposures

.

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More than 90% of toxic exposures in children occur in the home, produce no (82%) or minor (17%) toxicity;

Approximately

50% of cases involve nondrug substances, such as cosmetics, personal care items, cleaning solutions, plants, and foreign

bodies.

COMMON NONTOXIC AND MINIMALLY TOXIC*

PRODUCTS

  

Antacids,

non-

salicylate

-containing

topical Antibiotics

,

topical

Antifungals

,  

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Approach to the patient

The

initial approach to the patient with a witnessed or suspected poisoning should be no different than that in any other sick child, starting with stabilization and rapid assessment of the airway, breathing, circulation, and mental status

.

History

:

historical features such as age of the child (toddler or adolescent), acute

onset

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of symptoms without prodrome, sudden alteration of mental status, multiple system organ dysfunction, or highs levels of household stress

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Description of the Exposure Whether

wittnessed

in the

site,referred

from other hospital

Time,amount

of substance

ingested,it

is better to be overestimated.

Symptoms

1.ODOR

:

Bitter almonds

Acetone

Garlic

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2.OCULAR SIGNS

:

Miosis

Mydriasis

Nystagmus

Lacrimation

Retinal hyperemia

3.CUTANEOUS

SIGNS

Diaphoresis

Alopecia

Erythema

Cyanosis (unresponsive to oxygen)

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4.ORAL SIGNS

Salivation

Oral Burns

Gum lines

5.GASTROINTESTINAL

SIGNS

:

Diarrhea

Hematemesis

6.CARDIAC SIGNS:

Bradycardia

Hypertension

Hypotension

tachycardia

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7.RESPIRATORY SIGNS

Depressed respirations

Tachypnea

8. CNS Signs.

Past Medical History

Social History

Physical Examination

COMPLICATIONS

 

A poisoned child can exhibit any one of six basic clinical patterns: coma, toxicity, metabolic acidosis, heart rhythm aberrations, gastrointestinal symptoms, and

seizures.

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Laboratory Evaluation For select intoxications (salicylates, some

anticonvulsants),

additional labs tests that may be helpful include electrolytes and renal function (an elevated anion gap suggests a number of ingestions), serum

osmolarity

,complete

blood count, liver function tests, urinalysis (crystals), co-oximetry, and a serum

creatine

kinase level

.

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Additional Diagnostic Testing An

electrocardiogram (ECG) is a quick and noninvasive bedside test that can yield

important

clues to diagnosis and

prognosis

.

Chest

x-ray may reveal signs of

pneumonitis (e.g., hydrocarbon ingestion),

pulmonary edema (e.g., salicylate toxicity), or a foreign body. Abdominal x-ray can suggest the presence of a bezoar,

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demonstrate radiopaque tabletsRADIOPAQUE SUBSTANCE ON KUB (MNEMONIC = CHIPPED), or reveal drug packets in a body packer.

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Hospital admission Children

who have features of poisoning should generally be admitted to hospital

.

Children

who have taken poisons with delayed actions should also be admitted, even if they appear

well.Delayed

-action

poisons include aspirin, iron,

paracetamol

,

tricyclic

antidepressants, and co-

phenotrope

(

diphenoxylate

with atropine,

Lomotilc

);

the

effects

of modified-release

preparations are also delayed

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Principles of Management The four principles of management of the poisoned patient are decontamination, enhanced elimination, antidotes, and supportive

care.

Decontamination

The goal of decontamination is to prevent absorption of the toxic

substance

decontamination should not be routinely employed for every poisoned

patien

.

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Dermal and ocular decontamination begin with removal of any contaminated clothing and particulate matter, followed by flushing of the affected area with tepid water or normal

saline.

Dermal decontamination, especially after exposure to adherent or lipophilic (e.g., organophosphates) agents, should include thorough cleansing with soap and water.

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Gastrointestinal (GI) decontamination is a controversial

,

In general, GI decontamination strategies are most likely to be effective in the first hour after an acute

ingestion,

GI absorption may be delayed after ingestion of agents that slow GI motility

,massive

pill ingestions, sustained-release preparations, and ingestions of agents that can form pharmacologic

bezoars

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Described methods of GI decontamination include induced emesis with ipecac, gastric

lavage

, cathartics, activated charcoal, and whole-bowel irrigation

(WBI).

Syrup of

ipecac

.

Criteria for use:

the

ipecac can be administered within 30-90 min of the ingestion.

There is a substantial risk of serious toxicity to the patient.

There are no contraindications to the use of ipecac

.

There is no alternative therapy available to decrease GI absorption.

The use of ipecac will not adversely affect more definitive therapy that may be provided at the hospital.

 

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Gastric Lavage

in most clinical scenarios, the use of gastric

lavage

is no longer

recommended?

Single-Dose

Activated Charcoal

:

activated charcoal is thought to potentially be the most

useful.

toxins are adsorbed onto its surface, thus preventing absorption from the GI tract.

Charcoal is most likely to be effective when given within 1 hr of ingestion

.

The dose of activated charcoal is 1 g/kg in children

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Some toxins, including heavy metals, iron, lithium, hydrocarbons, cyanide, and low-molecular-weight alcohols, are not significantly bound to charcoal.

one

must

ensure that the patient's airway is intact or protected and that he or she has a benign abdominal

exam

. Cathartics

(sorbitol, magnesium sulfate, magnesium citrate) have been used in conjunction with activated charcoal to prevent constipation and accelerate evacuation of the charcoal-toxin complex.

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WBI involves instilling large volumes (35 mL

/kg/hr in children or 1-2 L/hr in adolescents) of a polyethylene glycol electrolyte solution (e.g.,

GoLYTELY

) to “cleanse” the entire GI

tract.Complications

of WBI include vomiting,

abdominal

pain, and abdominal

distention

Enhanced Elimination

Multiple-Dose Activated Charcoal

MDAC is typically given as 0.5 g/kg every 4-6 hr (for ≤24 hr) and continued until there is significant clinical

improvement.

the airway and abdominal exam

should be assessed before each

dose.

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Urinary Alkalinization

:Urinary

alkalinization

is accomplished with a continuous infusion of sodium bicarbonate–containing intravenous fluids, with a goal urine pH of 7.5-8.

Alkalinization

of the urine is most useful in managing

salicylate

and

methotrexate

toxicity.

Alkalinization

may also be beneficial in managing

phenobarbital

toxicity

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Dialysis:Toxins that are amenable to dialysis have the following properties: low volume of distribution (<1 L/kg), low molecular weight, low degree of protein binding, and high degree of water

solubility.

toxins for which dialysis may be useful include

methanol and ethylene glycol, as well as large symptomatic ingestions of

salicylates

,

theophylline

, bromide, or

lithium

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Intralipid Emulsion TherapyA potentially life-saving intervention of infusing

Intralipid

emulsions is a means of sequestering fat-soluble drugs and decreasing their impact at target organs

Lipophilic

drugs are potentially bound by

Intralipidemulsions

, including calcium channel blockers (

verapamil

and

diltiazem

)

and

tricyclic

antidepressants.

Antidote:

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Glucagon and/or insulin and glucose

Calcium channel antagonists

Diphenhydramine and/or benztropine

Dystonic reactions

Calcium salts

Fluoride, calcium channel blockers

Protamine

Heparin

Folinic acid

Methotrexate, trimethoprim, pyrimethamine

Sodium bicarbonate

Sodium channel blockade (tricyclic antidepressants, type 1 antiarrhythmics)

Acetaminophen

N

-Acetylcysteine

physostigmine

anticholinergic

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Supportive Care The goal is to support the vital functions of the patient until the patient can eliminate the toxin from the

system. If the level of consciousness is depressed, and a toxic substance is suspected, glucose (1 g/kg IV), 100% oxygen, and

naloxone

should be administered.

PROGNOSIS :

Mortality from poisoning is rare

.The

most common exposures resulting in death include carbon monoxide, hydrocarbons, and opioids (all of which interfere with oxygen delivery to tissues).

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PREVENTIONProperly educating parents to use childproof medication containers, to store toxic substances in locked cabinets, and to label toxic chemicals properly is necessary for preventing ingestions

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Why Not Ipecac?

Variable percentage of removal of toxic medication

In adult volunteers:

51-83% removal (5 minutes after ingestion)

2-59% removal (30 minutes after ingestion)

May cause persistent vomiting, lethargy, and diarrhea

Vomiting may preclude later administration of oral antidotes

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Why Not Ipecac?

Lethargy and vomiting together increase risk of aspiration

Inappropriate use-following ingestion of acid .

Misuse-children with eating disorders

Misuse-Munchausen by proxy