Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine.
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Transcript of Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine.
![Page 1: Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine.](https://reader036.fdocuments.us/reader036/viewer/2022062300/56649e245503460f94b13342/html5/thumbnails/1.jpg)
Pediatrics ReviewEmergency
Gina Neto, MD FRCPCDivision of Emergency Medicine
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• Review pediatric resuscitation guidelines
• Recognize pediatric conditions that present to the emergency
• Describe management of pediatric emergency cases
Objectives
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Pediatric Resuscitation
• Pediatric Airway• Larger head• Bigger tongue• Narrowest part is
subglottic area• Epiglottis is more floppy• Larynx is more anterior
and cephalad• Chest wall more
compliant
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• Airway Management• Position, suctioning• Nasal/Oral airway• Endotracheal intubation
Cuffed tube size: age/4 + 3 (+/- 0.5mm)
• MedicationsAtropine (consider if< 6 yrs)Paralytic - Succinylcholine, RocuroniumKetamine, Midazolam/Fentanyl, Propofol
Pediatric Resuscitation
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• Bradycardia• Non-Cardiac causes (6 H’s, 5 T’s)
Hypoxia (Most Common) Hypovolemia, Hypo/Hyperkalemia,
Hypoglycemia, HypothermiaToxins, Tamponade, Thrombosis, Trauma (ICP)
• Cardiac causes - AV block, sick sinus
• Epinephrine 0.01 mg/kg (repeat every 5 min)• Consider Atropine 0.02 mg/kg
Pediatric Resuscitation
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Pediatric Resuscitation
• Tachycardia• Narrow• Wide• Stable or Unstable
• Know what is normal for age
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• Sinus Tachycardia• Rate usually < 220/min• Variable rate• Look for causes
Pain, fever, dehydration, resp distress, poor perfusion
• SVT• Rate usually > 220/min infants, > 160
teens• Rate is fixed
Pediatric Resuscitation
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• SVT• Vagal maneuvers
Ice to face, Valsalva
• Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg
• If Unstable:• Synchronized Cardioversion 0.5-1 J/kg
If not effective increase to 2 J/kg
Pediatric Resuscitation
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• Tachycardia with Wide QRS• Stable• Consider Adenosine• Amiodarone 5 mg/kg• Consult Cardiology
• Unstable with pulse• Cardioversion 0.5 - 1 J/kg 1st dose, then 2
J/kg
Pediatric Resuscitation
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• Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation• CPR
Start at 16:2 compressions/breath
• Defibrillation 2 J/kg Then 4 J/kg Increase subsequent shocks to max of 10 J/kg
• Epinephrine 0.01 mg/kg every 3-5 min• Amiodarone 5 mg/kg
Pediatric Resuscitation
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• 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days.
• T 36.5, RR 40, HR 130, O2 Sat 89%.• Suprasternal and scalene retractions,
decreased air entry, expiratory wheeze.
• Describe your management.
Case
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• Mild Asthma:• Salbutamol MDI x 3 doses prn
• Moderate Asthma:• Salbutamol MDI x 3 doses then prn• Steroids
Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)
Asthma
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• Severe Asthma:• Salbutamol via nebulization with• Ipratropium 250 mcg x 3 doses q20 min• Steroids
Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)
Asthma
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• If not improving within 60 min or signs of impending respiratory failure:• Magnesium Sulfate 50 mg/kg/dose IV
(max 2g)• Give over 20-30 min• May cause severe hypotension• IV NS 20 bolus ml/kg
• Methylprednisolone 1-2 mg/kg IV
Asthma
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• 2 mo male with 2 day hx rhinorrhea, poor feeding and cough. Few hrs resp distress.
• RR 60 HR 120 T 37C. Pink, well hydrated.• Chest - inspiratory crackles, exp wheezes.
• Diagnosis?• Treatment?
Case
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• RSV - Respiratory Syncytial Virus most common• Parainfluenza, Influenza A, Adenovirus,
Human metapneumovirus• Peak in winter• More serious illness• < 2 months• Hx of prematurity < 35 weeks• Congenital heart disease
Bronchiolitis
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• Treatment • Nebulized Epinephrine – short term relief
• ? Dexamethasone 1 mg/kg on Day 1 0.6 mg/kg for another 5 days
• ? Nebulized Hypertonic Saline
Bronchiolitis
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• 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough.
• HR 100 RR 28 T 37 • Mild distress. Stridor at rest.
• Diagnosis? • Treatment?
Case
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• Parainfluenza most common• Hoarse voice, barky cough, stridor • Peak fall and spring• Infants and toddlers • Treatment• Dexamethasone (0.6 mg/kg)• Nebulized Epinephrine if in respiratory
distress• Consider Nebulized Budesonide
Croup
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Steeple Sign
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• 18 month female with fever x 2 days. Difficulty swallowing.
• HR130 RR28 T39C• Exam normal except won’t move neck fully.
• What diagnostic test should be performed?
Case
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• < 6yrs• Complication of bacterial
pharyngitis• Infection of posterior
pharyngeal nodes – regress by school age
• Grp A strep, oral anaerobes and S. aureus
• Treatment• IV Clindamycin and
Cefuroxime• Consult ENT
Retropharyngeal Abscess
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Age (yrs) Maximum (mm)
0-1 1.5 x C2
1-3 0.5 x C2
3-6 0.4 x C2
6-14 0.3 x C2
Retropharyngeal Soft
Tissues *
Age (yrs) Maximum (mm)
0-1 2.0 x C5
1-2 1.5 x C5
2-3 1.2 x C5
3-6 1.2 x C5
6-14 1.2 x C5
Retrotracheal Soft Tissues *
*
*
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• 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling.
• Not immunized.
• HR 140 RR 20 T 39.5 • Very quiet, doesn't move. • Slight noise on inspiration. • Chest clear, exam normal.
Case
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• Rarely seen • Strep pneumoniae• H. influenzae uncommon
due to vaccine
• Do not disturb patient• Consult Anesthesia,
intubate • IV Ceftriaxone and
Clindamycin
Epiglottitis
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• 17 mo male with sudden onset noisy and abnormal breathing
• Was playing on floor before developing difficulty breathing
• VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
• Mild wheezing with mild inspiratory stridor
Case
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What investigation would you do next?
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ExpiratoryCXR
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Inspiratory Expiratory
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• Highest risk between 1 -3 yrs old Immature dentition, poor food control More common with food than toys
• peanuts, grapes, hard candies, sliced hot dogs
• Acute respiratory distress (resolved or ongoing)• Witnessed choking• Cough, Stridor, Wheeze, Drooling• Uncommonly…. Cyanosis and resp arrest
Foreign Body Aspiration
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• 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding.
• Looks well, alert and interactive• T 38.9o HR 176 RR 42 BP 100/50 • Font flat, neck supple, exam non remarkable
• What is your approach to this case?
Case
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• Etiology is organisms from birth canal Group B Streptococcus , Escherichia coli
(Gram neg), Listeria monocytogenes
• Highest rate of bacterial infection of any age group• <2 weeks - 25%• 0-4 weeks - 13%
• Septic Work Up• Admission, IV antibiotics
Fever < 1 month
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• May still see birth canal organisms, but also: Streptococcus pneumoniae , Neisseria
meningitidis, Haemophilus influenzae type b (uncommon)
• Overall rate of bacterial infection is ~8%Bacteremia 2%Meningitis 0.8%UTI 5%
• “Low Risk Infant” rate of bacterial infection is 1%
Bacteremia 0.5%
Fever 1-3 months
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• Well appearing infants 1-3 mos are low risk for serious bacterial infection if:
Previously healthy• Born at term (> 37 weeks)• No hyperbilirubinemia• No hospitalizations • No chronic or underlying diseases
No evidence of focal bacterial infection Laboratory parameters:
• WBC count 5-15/mm3
• Urinalysis WBC count < 5/hpf• Stool WBC count < 5/hpf (if infant has diarrhea)
Low Risk Criteria “Rochester” for Febrile Infants
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• Viral infections cause of fever in >90%• 6% of children seen in the ED have a
specific, recognizable viral syndrome e.g. croup, bronchiolitis, roseola, varicella,
coxsackie
• UTI in ~5% • Bacteremia very low rates now (< 0.2%)• 5% in 1980’s, HIB vaccine 1987• 2% in 1990’s, Pneumococcal vaccine 2000
Fever 3-36 months
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• 2 year old boy with generalized tonic clonic movements. Duration 5 min.
• T 39.2o HR 110 RR 24 BP 110/60 • Awake now, normal neurological exam.• Right TM bulging, neck supple, no rash. • Past med history unremarkable.
• Approach?
Case
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• Simple Febrile Seizure• T>38.5• 6 mo-5 yr• Generalized seizure, < 15 min• One seizure within 24 hours• Neurologically normal before and after
• Occur in ~ 5% of children• Recurrence in 30%
Febrile Seizure
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• Risk of epilepsy is 1% • ~ same as general population
• Higher risk (2.4%) if:• Multiple febrile seizures• < 12 mos at the time of first febrile seizure• Family history of epilepsy
Febrile Seizure
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• ABC's• IV access• Seizure treatment• 1st Line - Benzodiazepines
• Lorazepam or Diazepam (Rectal or IV)• Midazolam (Intranasal or Buccal)
• 2nd Line Phenytoin, Fosphenytoin Phenobarbitol
Seizure Management
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• Seizure treatment• 3rd Line
Midazolam infusion Thiopental Propofol Paraldehyde
• Observe in the ED until child returns to normal
• After simple febrile seizure no neurological investigations indicated (eg CT, EEG)
Seizure Management
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• 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea x 10 today. Voiding scant amounts.
• HR 120 RR 36 BP 100/50 T 38.5• Cap refill 2 sec, pink, decreased skin turgor.• Font sunken, eyes sunken.• Abdo + GU normal.
Case
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• What is the degree of dehydration of this child?
• Management?
Case
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• ORT with rehydration solution (eg Pedialyte)• 5 ml/kg/hr divided every 5 min, continue
until appears hydrated
• Consider Ondansetron (0.15 mg/kg)
• Early refeeding (including milk) within 12 hrs
• Rule out UTI
Gastroenteritis
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• Maintenance (D5NS)4ml/kg/hr for first 10 kg2ml/kg/hr for second 10 kg1 ml/kg/hr for rest of weight in kg
• Deficit (NS)• If severely dehydrated give NS bolus
20 ml/kg over 15-60 min • Replace over 24 hours
First half over 8hrs, second half over 16 hrs• Ongoing Losses• Diarrhea, Vomiting, Insensible losses with fever
Fluids and Electrolytes
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• 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus.
• HR130 RR24 T37 • Tender abdomen with fullness in RUQ
• Diagnosis?• Investigations?
Case
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• 1-3 years• Boys 2:1
• Classic Triad (10-30%)• Vomiting• Crampy abdominal pain• “Red currant jelly” stools
• Lethargy is common
Intussusception
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• 75% are ileo-colic• Lead point• Peyer's Patches
preceding viral infection• Meckel diverticulum• Polyps• Hematoma (Henoch Schonlein Purpura)• Lymphoma
Intussusception
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Intussusception
• Plain AXR• May be normal
• May have signs of bowel obstruction
• Paucity of air in RLQ • No air in Cecum on
Lateral Decubitus
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• Target Sign
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• Crescent Sign
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• Air Contrast Enema
• Success rate >80%• Recurrence 10-15%
Intussusception
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• 4 week old boy with vomiting for past week. Initially one emesis per day now emesis with every feed. Forceful. No bile.
• No fever. No diarrhea.
• Looks well. Mild dehydration. • Abdomen soft, non tender, BS present.
• DDx?
Case
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• Na 140 K 3.0 Cl 90 BUN 24 CR 50
• WBC 8.5 Hgb 120 Plts 360
• Venous gas pH 7.50, PCO2 44, HCO3 30
Case
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• Most common surgical condition < 2 mos
• 4-6 wks of age• Ratio male to female is 4:1• Increased in first born males
• Occurs in 5% of siblings and 25% if mother was affected
Pyloric Stenosis
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• Nonbilious vomiting• Emesis increases in frequency and
eventually becomes projectile
• Classic findings:• Hypertrophied pylorus palpable “olive” in
epigastric area• Peristaltic waves progressing from LUQ to
the epigastrium
Pyloric Stenosis
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Pyloric Stenosis
• Laboratory abnormalities:• Hypokalemia• Hypochloremia• Metabolic alkalosis
• Ultrasound• Thickened pylorus
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• 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability.
• Looks unwell, irritable cry.• Abdomen distended.• Weak pulses, cap refill>5 sec.
• DDx? Management?
Case
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Volvulus
• Twisting of a loop of bowel around its mesenteric attachment.
• 80% present by the first month
40% present in the first week
Rarely can be seen in older children.
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Volvulus
• Sudden onset of bilious vomiting in a neonate.
• Acute abdomen with shock
• May have more gradual course with episodic vomiting
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• Evidence of small bowel obstruction • Dilated loops• Air fluid levels• Paucity of distal air
Volvulus
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• Upper GI series • “corkscrew”
appearance of the duodenum and jejunum
Volvulus
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• 2 yr old boy with fever for 6 days.
• Red eyes but no discharge.• Generalized rash.• Erythema of the palms of
hands and soles of feet.• Red, swollen lips.• Enlarged cervical lymph
nodes.
Case
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• Usually < 4 yrs old, peak between 1-2 yrs• Fever for > 5 days and 4 of the following:
Bilateral non-purulent conjunctivitis Polymorphous skin eruption Changes of peripheral extremities
• Initial stage: reddened palms and soles• Convalescent stage: desquamation of fingertips and
toes Changes of lips and oral cavity Cervical lymphadenopathy ( >1.5 cm)
Kawasaki Disease
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• Subacute phase - Days 11-21• Desquamation of extremities• Arthritis
• Convalescent phase - > Day 21• 25% develop coronary artery aneurysms if
untreated
• Other manifestations:• Uveitis, Pericarditis, Hepatitis, Gallbladder
hydrops• Sterile pyuria, Aseptic meningitis
Kawasaki Disease
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• Treatment
• IV Immunoglobulin• Reduces incidence of coronary aneurysms to 3%
if given within 10 days of onset of illness• Defervescence with 48 hrs
• ASA• High dose during acute phase then lower dose for
3 mos
Kawasaki Disease
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• 3 yr old girl with rash starting today.
• Recent URTI.
• Swollen ankles and knees. Painful walking.
• Diagnosis?
Case
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• Systemic vasculitis – IGA mediated
• 75% are 2-11 yrs • Clinical Features
Rash (non thrombocytopenic purpura) 100%
Arthritis (ankles, knees) - 68% Abdominal pain - 53% Nephritis - 38% (ESRD in ~1%)
• Intussusception (2-3%)
Henoch-Schonlein Purpura
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Case
• 1 yr old boy with mouth lesions for two days
• What are the two most likely causes?
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• Herpes Simplex• Severe primary
infection• HSV1 (80%), HSV2
(20%)
• Fever, irritability, poor intake
• Ulcers on mucous membranes
• Treatment• Acyclovir• Pain control, IV
hydration
Herpetic Gingivostomatitis
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Hand, Foot and Mouth Disease
• Coxsackievirus, usually A16• Summer• Ulcers on tonsilar pillars• can have generalized
stomatitis• Vesicles on hands and feet
• URTI, pharyngitis• Vomiting and diarrhea• Generalized maculopapular rash
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Case
• 5 yr old girl with itchy rash
• Varicella Zoster
• This child comes back to the ED three days later with worsening fever and pain...
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Diagnosis?Necrotizing
Fasciitis
• Invasive group A streptococcal infection
• IV Penicillin and Clindamycin
• Consult ID, surgery• MRI
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Case
• 3 yr old girl fever for 3 days, unwell
• Rash spreading over entire body with skin peeling
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Diagnosis?
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• Exotoxin causes separation of epidermis• < 2yr• Fever, toxic appearance, generalized
erythema• Exfoliation of skin, accentuated in flexor
surfaces• skin lifts to touch (Nikolsky’s sign)
• Perioral crusting, “honey coloured” lesions
• Fluid resuscitation• IV Cloxacillin, Cefazolin or Clindamycin
Staphylococcal Scalded Skin Syndrome
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• 10 yr old boy with fever
• Unwell today• Rapidly progressing
rash since this morning
Case
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• Usually < 5 yrs, Adolescents outbreaks• Fever, toxic appearance• Petechiae, purpura• DIC, shock• High mortality (25-80%)
• Resuscitation• IV Ceftriaxone• Treat household contacts
Meningococcemia
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• How are you going to resuscitate this child?
• First intervention?
• Next?• Next?• Next?
Septic Shock
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• Leading cause of death in infants and children
6 million deaths per year worldwide
• Etiology of sepsis• Streptococcus pneumonia• Escherichia coli • Neisseria meningitidis• Other: Group A strep, other Gram neg bacilli,
Staph. aureus, Enterococcus
• IV Antibiotics: Ceftriaxone and Vancomycin
Septic Shock
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• Sepsis if systemic inflammatory response signs (SIRS) and signs of infection• Fever, or HR, RR, or WBC
• Severe sepsis if signs of organ dysfunction or tissue hypoperfusion
• Septic Shock if cardiovascular dysfunction
Septic Shock
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• Hypotension is DECOMPENSATED SHOCK
• Most children have “cold shock” Decreased cardiac output and increased
systemic vascular resistance Poor perfusion, cool extremities, delayed cap
refill
• Adolescents more likely to have “warm shock”
Low systemic vascular resistanceBounding pulses, wide pulse pressure
Septic Shock
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Case
• 6 month old with swollen L leg
• Parents state 3 yr old brother fell onto baby
• Approach to this case?
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• Suspect if history vague, inconsistent with injury or child’s development
Bruises• Can not date bruises by color• “If they don’t cruise they don’t bruise”• Toddlers don’t bruise buttocks, inner arms/legs,
neck or trunk• Patterned marks – linear, hand prints• Bites – adult if > 3 cm
Child Abuse
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Fractures• Metaphyseal (corner, bucket handle)
Shearing force from shakingUsually < 1yr
• Posterior ribs• Femur in non-ambulatory child• Multiple fractures, different ages
• Low risk – clavicle, tibia in toddler
Child Abuse
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Head trauma• Direct contact injuries
Scalp hematoma Depressed skull fracture Epidural hematoma
• Rotational acceleration injuries Subdural hemorrhages Retinal hemorrhages
Child Abuse
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• Admit all children < 2 yrs
• Skeletal survey for < 2 yrs (consider for 2-5 yrs)
• CT head if < 1 yr• Opthalmologic exam
Ideally within 24 hours (must be <72 hrs)
• Mandatory reporting to child welfare agency
Child Abuse
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• 2 yr old at grandmother’s house• Took unknown amount of pills that he found
in her purse 30 minutes ago
• No symptoms
• What is your approach?
Case
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• Young childrenExploratory ingestionIngest small amount of a single substance
• Can grasp single pill at 1 yr • Can’t hold handful of pills until > 15 mos• Child preparations have small opening – spills out
• AdolescentsIngest large amounts of one or more
substancesSuicidal gesture
Poisoning in Children
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• Common ingestions• Household products• Cough/cold, vitamins, antibiotics• Acetaminophen and Ibuprofen• Antidepressants
• Pills that are harmful if single dose taken• Oral hypoglycemics, calcium channel
blockers, tricyclic antidepressants
Poisoning in Children
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• History• Attempt to identify possible drug ingested• Friends, parents, paramedics, police
• Physical Exam• Look for toxidrome signs• Neurologic impairment• Skin marks, Breath odour• Look for signs of trauma, head injury
Approach to Unknown Ingestion
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• Management• ABC’s• Check Glucose• Cardiac Monitoring• Gastric decontamination – Charcoal, WBI• Antidotes• Benzodiazepines for agitation, seizures• NaHCO3 for arrhythmias
Approach to Unknown Ingestion
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• Diagnostic testing• CBC, lytes, BUN/Cr, glucose, gas,
osmolalityAnion gap, Osmolar gap
• Specific serum drug levels (Acet, ASA, Alcohols)
• ECG• Abd Xray for radio-opaque toxins
C - Calcium, Condoms H - Heavy metals I - Iron P - Phenothiazines, Potassium S - Slow-release preparations
Approach to Unknown Ingestion
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Toxidromes
• AnticholinergicMad as a hatter - Agitation and hallucinationsBlind as a bat - Dilated pupilsHot as hell - Fever, FlushedDry as a bone - MM, skin; Urine retention; Decreased GI
motilityTachycardia. Hypertension
• CholinergicSalivation, Lacrimation, Urination, Defecation, GI
cramps, EmesisPulmonary edemaBradycardiaAgitation, confusion. seizures
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Toxidromes
• SympathomimeticAgitation and hallucinationsDilated pupilsFever, Tachycardia, Hypertension
• Diaphoretic• Increased bowel sounds
• OpioidComaRespiratory depressionHypotensionMiosis
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• Activated Charcoal• 1 g/kg• Greatest benefit is within 1 hr of ingestion
At 30 min 89% decreaseAt 1 hr 37% decrease
• Not useful forAlcoholsHydrocarbonsAnions or Cations (Iron, Lithium)Acids or Alkali
GI Decontamination
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• Whole Bowel Irrigation• PegLyte
0.5-2 L per hour via NG
• For substances not adsorbed by charcoal and sustained release preparationsIronLithiumEC ASA
GI Decontamination
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• Clinical Effects• 0-24 hrs
GI irritation, may be asymptomatic
• 24-48 hrsSigns of liver involvement begin
• 72-96 hrs Fulminant hepatic failureRenal failure
Acetaminophen
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Acetaminophen
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Acetaminophen
• > 4 hr Acetaminophen level
• Plot on nomogram
• N-AcetylcysteinePrecursor for glutathione Increases sulfation
metabolismDirectly reduces NAPQI to
APAPDirectly conjugates NAPQI
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Salicylates
• Clinical Effects• GI upset - N&V, Gastritis • Tinnitus – often the first symptom• CNS – Confusion, Lethargy, Cerebral
edema• Hyperpnea – Early have respiratory
alkalosis• Hyperthermia• Renal and Liver toxicity – rare• Impaired platelet function
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Salicylates
• Mechanism of Action• Uncoupling of oxidative phosphorylation
HyperthermiaGlycogenolysis, LipolysisHyperglycemia initially then hypoglycemia
from impaired gluconeogenesis
• Inhibits Kreb’s cycle Anaerobic metabolismLactic acidosis
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• Urine alkalinization• Ion trapping – ASA is weak acid
• Hemodialysis• If signs of multiorgan failure
Salicylates
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• Triad of clinical effects:• Cardiovascular
Prolonged QRS, QT, PR, ArrhythmiasHypotension
• CNSComa, Seizures
• Anticholinergic symptoms
Tricyclic Antidepressants
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Tricyclic Antidepressants• Mechanisms of toxicity
• Blockade of fast Na+ channels
• Type 1A “quinidine-like effects”
• Membrane stabilizing effects
• Inhibition of GABA reuptake
• Blockade of alpha 1 receptors
• Anticholinergic effects
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• NaHCO3• 1-2 meq/Kg then infusion
D5W + 150 meq NaHCO3/L at 1.5 x maintenance
• Benzodiazepines• Sedation, seizures
• Lipid therapy• May be helpful, case reports
Tricyclic Antidepressants
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• Much safer than TCA’s
• Clinical Effects:• N&V• Sedation• QT prolongation• Seizures
• Serotonin Syndrome
SSRI’s
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• Serotonin SyndromeAgitation, HypervigilanceMyoclonus, Muscle rigiditySeizuresDiaphoresis, shiveringHyperthermia, Autonomic dysfunction – HR, BPDiarrhea
• Treatment• Benzodiazepines, Active cooling
SSRI’s
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• Review of pediatric emergency cases: Resuscitation Respiratory emergencies Fever in infant, 3-36 months Febrile seizures, Status epilepticus GI presentation Rashes associated with serious illness Sepsis Child abuse Poisoning
Summary
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Questions ?