pediatric toxicology 2007

Overview of Pediatric Toxicology

Unknown ExposuresTrivial Ingestions

Sometimes Severe Morbidity/Mortality

Michael Wahl MD, FACEP, FACMTEmergency Physician, Evanston Northwestern HealthcareMedical Director, Illinois Poison Center

Pediatric Cases in Toxicology

Why are Pediatric Ingestions so common? Pediatric Poisoning: Developmental Milestones

Epidemiology of Pediatric Poisoning Poison Center Exposure Data Toxic vs. Non-toxic Exposures Trends Significance

Management issues Cases

Poisoning is a matter of dose

Paracelsus (1493-1551) Third Defense

“What is there that is not poison? All things are poison and nothing without poison. Solely, the dose determines that a thing is not a poison”

Pediatric Development

6-9 months: creep, crawl, and pick upobjects

Pediatric Development

9-12 months: pick up a pellet and put it in a hand

Pediatric Development15 months: walking; pick up a

pellet and put it in a bottle

Pediatric Development

18 months: able to

consciously dumppellet from bottle

(e.g. Tylenol, aspirin, vitamins, adult prescription medications)

California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years of Age

0-6 months ABUSE Overall: FALLS

Pediatric Poisoning #2 leading reason for injury-related

hospitalization in children 0 to 3 years of age behind falls

Pediatric Poisoning#1 reason for hospitalization or death in

children 18 months to 3 years of age

The #1 reason for injury-related hospitalization between 18 and 35

months is poisoning

Pediatric Poisoning Admission In Illinois Illinois Poison Center Data:

0

100

200

300

400

500

600

2001 2003 2005

PediatricAdmissions

Pediatric Poisoning: Lots of exposures, small number admitted

Pediatric Exposure calls to IPC under 6 years of age

1.3% of exposures admitted for observation

Less than one death reported per year (and those are usually pre-hospital)

37000

38000

39000

40000

41000

42000

43000

44000

45000

2001 2003 2005

Exposures

Assessment of Pediatric Ingestion

History Who What Where When Why How The scene?

Difficulty with Pediatric History:Did they actually ingest the substance?

Toxic Alcohol Evaluation of Pediatric Patients is often IncompleteDesLauriers C, Mazor S, Metz J, Mycyk M

2 year retrospective review33 pediatric cases of Toxic Alcohol Ingestion21 with levels drawn5/21 with measurable levels (24% of cases)

Pediatric Exposures Reported to AAPCC (National Data)

1080000110000011200001140000116000011800001200000122000012400001260000

2000 2002 2004

PediatricExposures

Pediatric Deaths Reported to AAPCC (National Data)

~ 2/100,000 pediatric exposures result in death.Adult Fatalities >500 times more prevalent due to intentional nature of

exposures

0

5

10

15

20

25

30

35

2000 2002 2004

PediatricDeaths

Unpublished Data from National Benchmarking committee (22 centers)

95% of all pediatric calls to a poison center are managed at home without referral to a poison center.

86% of pediatric exposures that present to an ED without calling a poison center first are discharged from the ED

66% of pediatric exposures that are referred to ED are discharged from the ED

Pediatric Exposures

AAPCC Data Most Common Exposures Cosmetics and personal care products Cleaning substances Analgesics

Tylenol >200 mg/kg ASA >150 mg/kg Codiene >2 mg/kg Propoxyphen >10 mg/kg

Plants

Most Common Pediatric Exposures

Cough and cold preparations Bropheneramine >2 mg/kg Chlorpheneramine >1.4 mg/kg Phenylephrine >4 mg/kg Pseudoephedrine >16 mg/kg Dextromethorphan >10 mg/kg

Hydrocarbons Hormones/hormone antagonist

Pediatric Exposures

AAPCC Data Most Common Exposures Foreign bodies Topicals Pesticides and Rodenticides Antimicrobials Vitamins Gastrointestinal preparations Arts/crafts/office supplies

Pediatric Exposures

Determination of non-toxic exposures Call the Poison Center is easiest

It is what poison center staff person does 30 times a day

Pediatric Exposures

General guidelines for categorizing a non-toxic exposure for poison center staff The product must be absolutely identified Only a single product can be involved in the

exposure The exposure must be unintentional The Consumer Product Safety Commission words

CAUTION, WARNING, DANGER are not on label Route of exposure is accurately assessed No symptoms are noted Follow-up must be possible

Management of Pediatric Exposures

Decontamination Enhanced elimination Antidotal Therapy Supportive Care

Decontamination Elimination from the gut and/or

decreasing absorption Emetic Agents (Syrup of Ipecac) Cathartics (sorbitol, magnesium

citrate) Gastric Lavage Whole Bowel Irrigation Charcoal

Decontamination

All decontamination measures were started before the advent of evidence medicine.

No improvement in outcomes has been shown for any of the modalities.

Re-examination of practices are slowly removing them from practice.

Ipecac

Ipecac

Syrup of Ipecac

Syrup of Ipecac Use of Ipecac promoted in the 1960’s on

clinical opinion AAP recommendation to no longer use

ipecac in the home because of a lack of proven benefit. Does lack of proven benefit equal lack of

efficacy? Prior to this, use decreased to less than

<1% of poisonings.

Ipecac

Family Guy Video:

Charcoal Effective at binding a variety of

toxins, most beneficial if given within 60 minutes

Dose 1 gm/kg, up to 100 gm in a single dose

CharcoalBond, Annals of EM, 2002

Charcoal

Charcoal

Charcoal

Charcoal Not proven to change outcome Every year 5 to 10 deaths in poison center

data from charcoal aspiration Always with drugs that cause decreased

consciousness, vomiting or seizures

Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit

Risk Benefit Ratio?

Cathartics Use promoted because of clinical opinion Most commonly used in ED is sorbitol or

magnesium citrate Intended to decrease absorption by

increasing expulsion from the GI tract Dosing

Sorbitol 70 % 2 cc/kg per kg in adults Sorbitol 35 % 4 cc/kg per kg in children Mag citrate 4 cc/kg in children/adults

Cathartics Indications -- No proven benefit. By

convention it is usually given with the first dose, not used for multiple dose therapy

The IPC recently stopped recommending it routinely due to guideline recommendations

Gastric Lavage

Gastric LavageBond, Annals of EM, 2002

Gastric Lavage Indications -- Ingestion of a

potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure

contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding

Gastric Lavage Adults 36-40 french tube (children

24-28 French) 20 degrees trendelenburg, left

lateral position 200-300 cc aliquots of water or

saline (10 ml/kg chidren, saline)

Whole Bowel Irrigation Co-Lav Colovage Colyte Colyte-flavored Colyte with Flavor Packs Go-Evac GoLYTELY NuLYTELY NuLYTELY, Cherry Flavor

Whole Bowel Irrigation No proven efficacy Potential to reduce drug absorption by

rapidly cleansing the GI tract dosing

9 mo - 6 yo 500 ml/hr 6 yr - 12 yo 1000 ml/hr Adolescents/adults 1500-2000 ml/hr

Whole Bowel Irrigation

=+ =

Whole Bowel Irrigation Indications

sustained release or enteric coated drugs

Illicit drug packages Drugs not well absorbed by Charcoal

Whole Bowel Irrigation 18% of IPC cases documented at

recommended rate of administration and an endpoint of clear rectal effluent Difficult to accomplish Time consuming Can be messy Inexperience and uncomfortable for staff

General Approach ENHANCED ELIMINATION

Hemodialysis/Hemoperfusion MDAC Urinary Alkalinization

Enhanced Elimination Water soluble Small molecular weight Not highly protein bound Small Volume of distribution (<1

L/kg)

Dialysis Isopropyl Salicylates Theophylline Uremia Methanol Barbiturates (long-acting) Lithium Ethylene Glycol

MDAC Dialyzable

Enterohepatic recirculation

A (Theophylline) B (Phenobarbital) C

(Carbamazepine) D (Dapsone) Q (Quinine)

Antidotal Therapy

Acetaminophen NAC

Arsenic, mercury, gold BAL

Atropine Physostigmine

CO Oxygen

CN CN antidote kit

Ethylene glycol, methanol Ethanol, 4-MP

Iron Deferoxamine

Nitrites Methylene blue

Opiates Naloxone

Lead EDTA, BAL, Succimer

Organophosphates Atropine, Pralidoxime

Review of Select 2005 Pediatric Death Cases Reported to AAPCC

Already you know the outcome is going to be bad

The discussion of risk of exposure, treatment and outcomes is what important

Case #1 18 month old child thought to have a

respiratory infection (cough and vomiting) by family comes to ED for evaluaton.

CXR shows FB in esophagus and stomach

Button Batteries Fatal in rare cases Ingestion of cylindrical and button

batteries: an analysis of 2382 cases Litovitz et al, Pediatrics April 1992

2320 button batteries: no deaths 2 in esophagus with severe burns

Button Battery Ingestion Severe esophageal damage due to

button battery ingestion: Can it be prevented? Yardeni et al, Pediatric Surgery International 2004 July State 19 cases reported in literature

from 1979 to 2004Brief Literature search showed multiple nasal and ear canal damage/reconstruction due to button battery insertion

Button Battery Ingestion Size

<15 mm unlikely to become lodged in esophagus

>20 mm likely to cause burns Locate the battery

Esophagus – immediate removal Stomach/Intestine – expectant

management with serial x-rays if not detected in stool

Button Battery Case Time delay in transfer to appropriate facility Both batteries removed endoscopically Admitted for 4 days. Barium swallow with

undefined esophageal deviation Discharged with fever on abx and

medication for acid reflux 4 days later found cyanotic and in shock Death Certificate with aorto-esophageal

ulcer/fistula

Hydrocarbons 15 month old female found vomiting,

cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child

2 yo child ingested unknown amount of cigarette lighter fluid (Zippo)

18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits

Hydrocarbons 17,685 exposures reported to AAPCC 3 deaths – all respiratory Unknown number admitted with

significant sequelae

Hydrocarbons Important History:

When How much (often unreliable) Coughing Vomiting (increases aspiration potential) Behavior changes (lethargy, drowsiness)

Hydrocarbon Important signs and diagnostic exam

results Mental status Respiratory status

Cough Tachypnea Grunting/Flaring/Retractions Fever Pulse ox CXR

Hydrocarbons 15 mo female: Taken to community

hospital. Arrested and expired before helicopter transport

2 yo male with cigarette lighter fluid: Died in ED

18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center

Calcium Channel Blockers 19 month old male found with

mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills.

Calcium Channel Blockers AAPCC data with 22,082 pediatric

exposures to “cardiac medications” No breakdown of Ca Channel blockers

Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%)

Extropolating to national data: over 2100 pediatric calcium channel blocker exposures Are they all true exposures?

Calcium Channel blockerTriage Criteria Proposed by AAPCC, ACMT, AACT

(Triage amounts in mg/kg so small, may not be clinically useful)

Calcium Channel Blockers

Calcium Channel Blockers Hyperglycemia Calcium Channel blockers in the

pancreatic B islet cells Decreased release of insulin Can lead to HYPERGLYCEMIA

Calcium Channel blockers 2 yo male with ingestion of up to 450 mg

sustained release nifedipine Unremarkable vitals initially. Glucose 253 Upon arrival to tertiary care center,

resting tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours.

Arrested the day after admission to tertiary care center, unable to resuscitate

Opiates 5 deaths in 2005 (9 in 2005) 3 deaths from Methadone Two from morphine/MS Contin Deaths were pre-hospital or

secondary to anoxic brain injury

Opiates Not tracked historically (AAPCC

database created 1983) rapid increase of opiate use and

abuse somewhat recent phenomena A concerted effort to monitor and

publish pediatric exposure data not yet established

Pediatric Toxicology Summary

Pediatric Poisoning Exposure is a common occurrence

Determining the dose is important, but frequently can be unreliable

Death is rare as a percentage

Final Keys Know where to get knowledge

about the substances involved Know where to get information on

the clinical course and treatment

1-800-222-1222

Questions?