Paediatric ToxicologySSEM Sept 2012 by Dr. Mark Little

24th Oct 2012Dr. Julia Ng

Emergency Physician

Take Home Message

• Most children age 1-2 y.o• Most harmless substance• Most do not need hospital care• Death or serious harm is exceptionally rare• Small list of 1-2 tablets can kill children

Management

• Resuscitation ABCDE• D detect and correct 1) seizure using benzo benzo and benzo, no phenytoin• 2) hypoglycemia• 3) hyper or hypothermia eg serotonin • E emergency antidote - naloxone sodium bicar• • Risk assessment• Agent eg carbamazepine 50mg/kg• Dose• Time since ingestion• Clinical features and progress• Patient factors eg weight, comorbidities• • Supportive• Investigation• Decontamination• Enhanced elimination• Antidote• Disposition

Risk assessment in children

• Dose- response in mg/kg is usually the same as for adults• Children rarely ingested > 2-3 tablets• Exact dose and time may be difficult to estimate• May need to resort to a ' worst case scenario '• Assume the time of ingestion is the latest possible• Assume all missing tablets have been ingested• Do not attempt to account for spillage• If more than one child is involved, assume each child

ingested the amount• Consider NAI in large and repeated dose

Investigation

• Routine investigation :• Paracetamol and ECG for cardio toxicity• Paracetamol can be occult

List of 1-2 tablets lethal in children !

• Amphetamine• Clonidine• Calcium channel• Chloroquine hydrochloride• Dextroproxyphine -VT• Propranolol• Opioids• Sulphonyureas• Theophylline• TCA

Unknown pill

• Admit 12hours for unknown pills• Ability to ETT/BVM• No IVC if alert and running• If flop check BSL• Monitor for level of consciousness and vital

signs•

Case 1

• 2 y.o old was brought to triage by mother, ate 1-2 pellets

Ratsak

• Long acting warfarin - up to 6-8 months

• Kids ingested 1 packet to have significant poison

• Adults 3 packets to be toxic

• Discharged home from triage, no need for blood test

If delibrated self harm,

• Check INR first • no vitamins K• if toxic may need 100mg vit K for 3-6 months• Serial INR check• If INR> 2-3, intervene

Case 2

• 2 y.o brought into ED : • Drowsy• RR 8• Pinpoint pupil

• What is the toxidrome ?

opioid

• Check undisturbed RR• If < 10 , need intervention : naloxone• Dose ?• Alternative vital ETCO• If need a second dose of naloxone , start an

infusion at 2/3 of reversal dose.• Especially if it is overnight

Case 3

• 2.y.o has been playing , possibly ingested grandmother’s antihypertensive medication in a dosette box.

• Grandmother is on a beta blcoker.

• Is this dangerous ?

Case 3

• Atenolol and metoprolol in kids usualy cause slight lower BP and reduced PR

• Settled with fluid

• But propranolol and sotalol the worst :• Propranolol – CNS and class I sodium channel

blockade• Sotalol – K channel blockade, QT prolongation

Case 4

• 2 y.o girl was brought to ED ingested 5mg glipizide.

• Is this a concern ?

Case 4

• Up to 8 hours course of hypoglycaemia

• Dextrose 10% only in adult due to high volume infusion

• Used octretide – stop release of insulin and safe

• Dose ?

Case 5

• 2 y.o boy has ingested 2 lomotil tablets 1 hour ago presented to triage.

• Triage nurse thought it only causes constipation as a result but come to ask you if she can discharge the child and maybe suggest some laxative if constipated.

• What do you do ?

Case 5

• Has anticholinergic ( atropine 23 mcg ) and opioid ( diphenoxylate 2.5mg )

• Symptom onset within 4 hours

Case 6

• 2 children , siblings, had been playing with a bottle of 100% eucalyptus oil and ? ingestion

Case 6

• First sign : coughing• Implies pneumonitis• Within 2 hour drowsy• Then seizure and coma usually short lived• If asymptomatic by 4-6 hours, safe for

discharge

Case 7

• 2 y.o ingested grandfather’s digoxin.

• Is this dangerous ?

• Toxic lethal dose 4mg for child

• Sign of vomiting within 4 hours

Case 8

• 2 y.o ingested unknown amount of iron tablet

Is this a concern ?

Case 8

• If < 40mg/kg elemental iron, no vomiting• AXR to count the tablets to work out dose per

kg• Progressive lowering of Bicarbonate level• Treatment is to maintain HCO > 18

Case 9

• 2 y.o ingested grandfather ‘s colchicine

Case 9

• Vomiting early within 2 hours

• Lethal dose 0.5mg/kg -0.8mg/kg