Pediatric/ Poisoning (1)

Hazards & accidents

Hazards:
 Could be trauma , accident, poisoning.
 Most dangerous thing in infancy is infection.
 Most dangerous thing in child (1 -5 years old) is hazard s because he want to explore
anything .
 Hazards lead to death of children.

Poisoning :

 You have to diagnose it definitely.
 Take detailed history (rarely you can good and true history).
 Any child who present to the emergency unit with bizarre symptoms which don't match
with any disease, this is considered as poisoning case until proven otherwise.
 Any comatose child, consider poisoning until proven otherwise.
 Most poisonings are accidental (80%) or incidental (20%).
 If teenager present, consider suicidal attempt (intentional suicide).
 Munchausen by proxy sy ndrome: in which the caregiver creates the child illness.
 There is what's called iatrogenic poisoning (by doctors themselves).
 You should now the type of drug and the amount of it.
 Aspirin poisoning previously very common but now it is rare.

What to do? How to manage the case?

 Firstly be sure of history of ingestion.
 Stressed questions due to social circumstances.
 Diagnosis can be done by exclusion.
 Send the parent back to home to bring the materials that caused the poisoning (because
anti dote is very important in the m anagement & this requires the know ledge of the
causative material).
 Medico -legal purposes always to be considered in cases of poisoning.
 Some times mother induce emesis to her child  it is NOT allowed because there are
many volatile substances (Kerosene ) & this leads to aspiration pneumonia.

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Treatment in general:

 If baby take one tablet only  no problem  healthy child clinically  send him home
and monitoring.
 Syrup of ipecac (15ml) along with juice & you can repeat the dose of ipecac (induce
emesis) .
 Gastric lavage can be used with consideration to the contraindications: -
1. If more than 4 hours had been elapsed (exception for sali cylate , lomotil , TCA).
2. If the material is alkali (because burn esophagus, lips, mouth).
3. If the substance was volatile (kerosene).
4. Comatose child.
 Activated charcoal: multiple doses can be given.
 Bowel irrigation (by phenomethylglycol).
 Blood transfusion .
 Peritoneal dialysis.
 Hemodialysis.
 Blood exchange .

Kerosene poisoning:

 It is the commonest poison in children.
 Kerosene has low viscosity & low surface tension & it is highly volatile.
 Aspiration occurs at time of ingestion because of coughing & gagging so aspiration
occurs.
 It is common in summer because of thirsty.
 Lead pulmonary toxicity and chemical pneumonitis  superadded infection.
 Reduce the surfactant.
 Less than 1 ml lead to pulmonary and systemic toxicity.
 Symptoms:
o High fever ( usuall y lasts for 10 days).
o Chemical pneumonitis.
o Granting.
o Pleural effusion.
o Pneumatocele.
o Systemic toxicity.
 CXR should be delayed for 6 hours  see normal x -ray or patchy infiltration.
 Observation should be continuous.
 Don't se nd the child to home before 6 hours .
 The course of kerosene poisoning is unpredictable  all of sudden deteriorate and die.
 Petrol more volatile so more dangerous than kerosene (no survival in petrol poisoning).

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 Management:

o Supportive management is required .
o O2
o Hydration.
o Anti -pyre tic (if needed).
o Ventilation.
o Observation.
o No need for Antibiotics (unless you suspect secondary bacterial infection).
o Corticosteroids has no role.
 Education of parents  careful attention, and keep kerosene away.

Iron poisoning:

 Now it is very rare.
 In pregnancy iron supplements taken rottenly (child take his this supplements).
 Tablets is red and colorful so child take them.
 Is very fatal (5mg is very fatal).
 Clinical features: -
o Stage 1: -bloody diarrhea, vomiting, hypertension.
o Stage2: -latent phase (stable phase).
o Stage3: -hepatic failure, leukocytosis, hypocalcaemia, multi -organ failure & shock.
o Stage4: -pyloric stenosis, late I ntestinal obstruction.
 Treatment:
o Supportive management.
o Desferoxamine (10 -15mg/kg/hr) IV.
o Complex will be formed that will readily excreted in the urine.

Tricyclic anti -depressants poisoning :

 Tofranil is the most dangerous poisoning.
 Clinical history  mother take 5 or 7 years child with nocturnal enuresis to pediatrician
 give him TCA  his toddler brother take this medici ne (colorful tablets).
 Signs  Coma, Convulsion, hypotension, Hyper reflexia, Mydriasis, Prolonged QT
interval, Cardiac arrest, Shock, arrhythmias.
 Treatment  Activated charcoal & lavage, Put on cardiac monitoring, Xylocaine &
sodium bicarbonate for aci dosis.

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Phenothiazine group poisoning:

 Anti -emetic s (metochlopromide & domeperidone).
 Treat the cause of vomiting and not give anti -emetic to child  side effects of anti -
emetics are hypotension, ataxia, tachycardia, coma, occulogyric crisis, severe muscle
rigidity.
 Vomiting can be seen in any systemic diseases so treat the cause not the symptom.
 Influenza, pneumonia, UTI, gastroenteritis, tonsillitis, infective hepatitis, meningitis 
all lead to diarrhea.
 The only indication for use of anti -emetic s in children are GERD and before performing
jejunual biopsy in celiac disease.
 Treatment  General Measures + Anti -dote ( Benztropine ) + anti -histamine
(chlorpheneramine) or diazepam (IV).
 If you give diazepam only the case could be re -occur.

Carbon monoxide poisoning:

 It has high affinity to bind to hemoglobin  carboxy -Hb.
 Clinical features: Headache, Dizziness , Coma.
 Treatment: Hyperbaric O2 (100%) .

Paracetamol (acetaminophen) poisoning: -

 Is rare poisoning in children because the tablet is big and has bitter taste.
 It is common in suicide.
 Signs: Nausea, Jaundice, Hepatic failure (after72hrs).
 Treatment  General measures + Antidote: N-acetyl cysteine in first 16 hours
(140mg/kg) then (70mg/kg) for 17days.

Lomotil poisoning :

 It is anti -diarrheal agent (like entero -stop).
 It is anti -chonergic agent.
 Signs: respiratory depression, Hypotension, hypo -reflexia, coma, and death.
 Don’t give lomotil until age of 4 -5 years  due to side effects.
 If there is no cause of diarrhea you can give lomotil.
 Treatment  general measures + Antidote: Naloxone (0.1mg/kg) and d on't exceed
2mg /kg.

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Salicylate poisoning:

 Now it is rare.
 Signs: Tachypnea, Fever, Vomiting, Lethargy, diaphoresis, Coma, Early alkalosis then
metabolic acidosis.
 Treatment: Forced alkaline diu resis, Sodium bicarbonate, Dose (1mg/kg).

Lead poisoning:

 Rare in our community.
 Occur in child with pica.
 Chronic accumulative poisoning.
 Diagnosis: Must be considered in any child with encephalopathy, anemia, abdominal
pain, increased ICP, papilledma.
 Treatment: Pencillamine , Calcium editate, Dimercaprol.

Sagwa poisoning:

 It is lead acetate compounds.
 Symptoms: Convulsion, coma, encephalopathy  death.
 No surviving, it is acute positioning.

Organophosphate poisoning:

 It used as Pesticides.
 Very common.
 Signs & symptoms  Salivation, Lacrimation , Urination, Gastric emptying, Defecation,
Bradycardia, Bronchospasm, Bronchorrhea, muscle weakness, ataxia, late peripheral
neuropathy, bradycardia.
 Treatement  Cloths off, bathing, O2, Fluid resuscitation, Atropine (drug of choice),
Pralidoxime (reduce passage through BBB), Diazepam (in case of seizure).
 Give atropine (0.2 -0.5 mg/kg every 5 min) until full atropinization (the pupil become
mydriatic).

Alcohol poisoning:

 Lead to liver damage and hypoglycemia.
 Phenothiazine (drug of choice).