GOOD MORNING! WELCOME

APPLICANTS!December 1st, 2011

Ingestion Many medications

are brightly colored and taste like candy

Toddlers don’t know that pills can be toxic

Ingestion in older children and adolescents is usually intentional

Ingestion Availability of prescription or nonprescription

drugs should be entertained There may be no specific history of ingestion

In the absence of a clear cause of alteration of concsiousness (afebrile toddler or adolescent), a toxic ingestion should be suspected

If possible, the bottle of meds should be checked for remaining pills

Consult poison control. They are very helpful!!

1-800-222-1222

Risperdal Ingestion

Atypical antipsychotic Dopamine receptor blockade Causes side effects such as acute dystonia,

parkinsonism, akathisia, tardive dyskinesia Children are at increased risk of toxicity

Metabolize these drugs more rapidly Increased bioavailability

Toxicity usually begins within 1 to 2 hours, peaks by 4 to 6, and usually resolves by 12 to 48 hours

Risperdal Ingestion Clinical presentation

Nausea/vomiting Lethargy Drowsiness Somnolence Tachycardia CNS depression

Extrapyramidal side effects (EPS) are more common in children Acute dystonia - involuntary, sustained muscle

contractions that result in twisting and repetitive movements or abnormal postures

Risperdal Ingestion Management

Supportive care Continuous cardiac monitoring, IV access,

reevaluation of mental status Single dose of activated charcoal

Withold in patients who are sedated or unable to protect airway

EPS treated with anticholinergics Diphenhydramine Benztropine

Poisoning Potpourri !

15-year-old with nausea and vomiting. No other signs or symptoms. Mom found empty medicine bottle in trash can. On CMP elevated liver transaminases.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

16-year-old with suspected ingestion. HR 44, RR 10, BP 85/40. Pinpoint pupils on exam. Difficult to arouse.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

4-year-old "seems delirious" per mom. On PE, has a temperature of 104.2°F (40.1°C), heart rate of 160 beats/min, respiratory rate of 36 beats/min, and blood pressure of 135/87 mm Hg. Her pupils are dilated and sluggishly reactive.

Skin is flush. 5-year-old brother fed her pink “candy” today.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

6-year-old vomiting since last night and “not acting like himself.” Had low-grade fever this morning. Complaining of ringing in his ears. His BMP revealed an anion gap of 19. Dad has coronary artery disease and takes a few different medications.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

4-year-old acting “loopy.” On PE, tachycardic and hypertensive. Skin is dry, red, and warm. Pupils are dilated. ECG shows QRS widening. Older brother is being treated for bedwetting.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

16-year-old male brought into ER by friends with vomiting and ataxia. Has trouble following commands, and slurred speech. Glucose is 45. The friends report they have just left a party.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

4-year-old with vomiting, abdominal pain, and “acting funny.” BMP reveals anion gap of 18. Dad mentions that she was playing in the garage earlier today while he was working on the car.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

15-year-old male with coughing, tachypnea, retractions, and wheezing. Was involved in a dare earlier today with some friends. You suspect a chemical pneumonitis and order a CXR.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

5-year-old brought to ER for altered mental status. Had abdominal pain and vomiting earlier today. Also with excessing drooling, incontinence, and diarrhea. He had been playing outside while dad cut the grass.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

4-year-old found playing near the kitchen sink with a bottle of oven cleaner. She is drooling and is burns are starting to form on her lips and in her mouth.

A. Salicylates

B. Tricyclic antidepressants

C. Methanol

D. Acetaminophen

E. Acids, alkali, and alkaloids

F. Ethanol

G. Anticholinergic

H. Hydrocarbons

I. Opiates

J. Organophosphates

Acetaminophen Signs and symptoms

Nausea and vomiting 18 to 24 hours later hepatic damage

(elevated transaminases) 2 to 3 days progresses to severe hepatic damage (including fulminant failure)

Management (suspected or confirmed) Measure serum level between 4 and 10 hours Transaminases and coags Treat with N-acetylcysteine (initiate within 10

hours)

Opiates Signs and symptoms

Miosis Sedation, coma Respiratory depression Hypotension, bradycardia Constipation

Management Assessment and establishment of effective

ventilation and oxygenation Hemodynamic support Opioid antagonist

Naloxone

Anticholinergics Signs and symptoms

Hot as a hare Dry as a bone Blind as a bat Red as a beet Mad as a hatter Hypertension, tachycardia

Management ABCs Decontamination

ExamplesAntihistaminesTCAsPhenothiazinesAtropineBelladonna alkaloids (Jimson weed)

Salicylates Signs and symptoms

Nausea Vomiting Altered hearing (tinnitus) Fever Altered mental status Increased anion gap metabolic acidosis

Management Check electrolytes, blood gas, LFTs, serum level Consider activated charcoal Correct acidosis

Tricyclic Antidepressants Risk for accidental ingestion by siblings Signs and symptoms

Dry mouth Ileus Dilated pupils Urinary retention Delirium Agitation Convulsions Cardiac dysrhythmias

Cardiac dysrhythmias• Most occur in first 24 hours• *Reports of late dysrhythmias

( 2 to 5 days later)• Maximal QRS duration is useful

for predicting which patients will have dysrhythmias

Management• ABCs• Decontamination with activated

charcoal• Benzos for convulsions• Sodium bicarb bolus for

dysrhythmias

Ethanol

Ethanol Signs and symptoms

*Hypoglycemia Inebriation Vomiting Ataxia Respiratory depression Hypotension

Management Measure serum electrolytes, glucose, ethanol level Symptomatic and supportive *Can mask toxicities from other drugs

Methanol Found in windshield

washer fluid Nausea, abdominal

pain, vomiting Metabolized to formic

acid metabolic acidosis and ocular findings

Blurred vision, “snow field,” edema of optic disks

Correct acidosis Ethanol to block

metabolism Leucovorin or folate Dialysis

Hydrocarbons Cause chemical

pneumonitis if aspirated Tachypnea, retractions,

bronchospasm Peaks at 3 days

Oropharyngeal and gastric irritation

Coughing, choking Vomiting Supportive care

Blood gas Chest X-ray

Organophosphates Cholinergic poisoning Insecticides, lawn and garden care products Signs and symptoms

“SLUDGE” Salivation, lacrimation, urination, defecation, gastric

emesis Twitching, weakness, or paralysis

Management Stabilization Decontamination Antidote

Atropine

Acids, Alkali, and alkaloids Laundry detergent, toilet bowel cleaner,

stain and mildew removers, floor cleaner, ammonia, oven cleaner, window cleaner, batteries, pine oil cleaners

Acid ingestions are more likely to cause injury to the stomach and less likely to cause esophageal and pharyngeal injury

Alkaline ingestions tend to injure the esophagus and pharynx

Gastric lavage contraindicated Endoscopy within 12 to 48 hours

Have a Great Day! Noon ConferenceADHD, Dr. Khouri