pediatric poisonings

Pediatric PoisoningsPediatric Poisonings

Mark Sutter, MDMark Sutter, MD

OverviewOverview

Epidemiology Epidemiology

Important LegislationImportant Legislation

Packaging and Marketing ProblemsPackaging and Marketing Problems

Physiologic DifferencesPhysiologic Differences

IronIron

PesticidesPesticides

Deadly Pediatric PoisonsDeadly Pediatric Poisons

EpidemiologyEpidemiology

US Poison Centers receive 1.5 million calls a US Poison Centers receive 1.5 million calls a year regarding pediatric ingestions.year regarding pediatric ingestions.

79% of these calls involve children younger than 79% of these calls involve children younger than age six.age six.

56% of pediatric exposures are from products 56% of pediatric exposures are from products around the house including medicines, cleaning around the house including medicines, cleaning agents, pesticides, plants and cosmetics.agents, pesticides, plants and cosmetics.


99% of ingestions by children under 6 are 99% of ingestions by children under 6 are unintentional.unintentional.

Approximately 40% of ingestions reported Approximately 40% of ingestions reported to the poison center by adolescents are to the poison center by adolescents are intentional.intentional.

Approximately 56% of adolescent Approximately 56% of adolescent ingestions are by females.ingestions are by females.

LegislationLegislation

The Poison Prevention Packaging Act of The Poison Prevention Packaging Act of 1970. (PPPA)1970. (PPPA) Requires child protective packaging of Requires child protective packaging of

hazardous household products.hazardous household products. Over the last 30 years the list of substances Over the last 30 years the list of substances

regulated by the PPPA have expanded to regulated by the PPPA have expanded to include medicines, solvents, and oils.include medicines, solvents, and oils.

Data shows reduction of 45% mortality of Data shows reduction of 45% mortality of pediatric patients since the introduction and pediatric patients since the introduction and expansion of PPPA.expansion of PPPA.

Special Pediatric IssuesSpecial Pediatric Issues

ALL THINGS ALL THINGS TEND TO END TEND TO END UP IN THE UP IN THE MOUTHS OF MOUTHS OF YOUNG YOUNG CHILDREN!!CHILDREN!!

Which is Candy?Which is Candy?

Sweet Tarts vs. EcstacySweet Tarts vs. Ecstacy

Poison Center CampaignPoison Center Campaign


Blood brain barrier still more permeable to toxicologic substances Blood brain barrier still more permeable to toxicologic substances until around 4 months.until around 4 months.

No studies demonstrating increased permeability, rather this is an No studies demonstrating increased permeability, rather this is an estimate based on toxicity noted with smaller doses than expected.estimate based on toxicity noted with smaller doses than expected.

Higher metabolic demands.Higher metabolic demands.

Decreased ability to glucuronidate in the infant period. Second Decreased ability to glucuronidate in the infant period. Second trimester pregnancies that were terminated showed only 10% trimester pregnancies that were terminated showed only 10% activity of the P-450 system.activity of the P-450 system.

No better studies to date, but most believe between ages 2-4 years that No better studies to date, but most believe between ages 2-4 years that glucuronidation is equivalent to adults.glucuronidation is equivalent to adults.

Decreased glycogen stores.Decreased glycogen stores.


Increased body surface area can lead to Increased body surface area can lead to thermoregulatory issues.thermoregulatory issues.

Children reside lower to the ground. This puts Children reside lower to the ground. This puts them at higher risk for ingesting compounds them at higher risk for ingesting compounds heavier than air. Often adults will NOT have the heavier than air. Often adults will NOT have the same exposure.same exposure.

Inability to avoid hazards – they do not read Inability to avoid hazards – they do not read warning labels or “Do Not Enter” signs.warning labels or “Do Not Enter” signs.

IronIron

The most common The most common cause of death in cause of death in toddlers.toddlers.

Classically taught as Classically taught as having five clinical having five clinical stages.stages.

Remember prenatal Remember prenatal vitamins, supplements, vitamins, supplements, and “natural products”.and “natural products”.

IronIron

Toxic doses occur at 10-20mg/Kg of Toxic doses occur at 10-20mg/Kg of elemental iron.elemental iron.

Prenatal vitamins typically contain about Prenatal vitamins typically contain about 65 mg of elemental iron. 65 mg of elemental iron.

Childrens vitamins contain about 10-18 mg Childrens vitamins contain about 10-18 mg of elemental iron.of elemental iron.

The Five StagesThe Five Stages

Stage 1Stage 1 Nausea, vomitting, abdominal pain and diarrhea.Nausea, vomitting, abdominal pain and diarrhea.

Stage 2Stage 2 This is the latent phase often between 6-24 hours as the patient This is the latent phase often between 6-24 hours as the patient

resolves GI symptoms.resolves GI symptoms.

Stage 3Stage 3 Shock stage involving multiple organs including coagulopathy, Shock stage involving multiple organs including coagulopathy,

poor cardiac output, hypovolemia, lethargy and seizures.poor cardiac output, hypovolemia, lethargy and seizures.

Stage 4Stage 4 Continuing of hepatic failure and ongoing oxidative damage by Continuing of hepatic failure and ongoing oxidative damage by

the iron in the reticuloendothelial system.the iron in the reticuloendothelial system.

Stage 5Stage 5 Gastric outlet obstruction secondary to scarring and strictures.Gastric outlet obstruction secondary to scarring and strictures.

ManagementManagement

Detailed history and physical including a rectal Detailed history and physical including a rectal exam for frank blood.exam for frank blood.Aggressive fluid resuscitation and intravenous Aggressive fluid resuscitation and intravenous access.access.Whole bowel irrigation and KUB to look for pills.Whole bowel irrigation and KUB to look for pills.Laboratory analysis for CBC, chemistry, and iron Laboratory analysis for CBC, chemistry, and iron levels (peak around 4 hours).levels (peak around 4 hours).Will often require repeat levels with a repeat Will often require repeat levels with a repeat chemistry.chemistry.TIBC has no utility in the acute overdose setting.TIBC has no utility in the acute overdose setting.


If the patient is in shock, remember to atleast If the patient is in shock, remember to atleast type and screen (if not cross match) for blood.type and screen (if not cross match) for blood.

Give deferoxamine before iron level is back if the Give deferoxamine before iron level is back if the patient is in shock.patient is in shock.

Deferoxamine was derived from Deferoxamine was derived from streptomyces streptomyces pilosus.pilosus.

Hypotension and allergic reactions are seen.Hypotension and allergic reactions are seen.

ARDS is a known complication and usually limit ARDS is a known complication and usually limit its use to 24 hours or less.its use to 24 hours or less.

PesticidesPesticides

Specifically Specifically organophosphates and organophosphates and carbamates.carbamates.

They work by inhibiting They work by inhibiting acetylcholinesterase.acetylcholinesterase.

Present with Present with cholinergic symptomscholinergic symptoms

Cholinergic SymptomsCholinergic Symptoms

Nicotinic SymptomsNicotinic Symptoms

Remember the days of the week !Remember the days of the week !MydriasisMydriasisTachypneaTachypneaWeaknessWeaknessTachycardiaTachycardiaFasiculationsFasiculationsPediatric patients tend to present with a Pediatric patients tend to present with a predominance of nicotinic symptoms!!!predominance of nicotinic symptoms!!!

Weakness from PesticidesWeakness from Pesticides

TreatmentTreatment

Atropine 0.02 mg / Kg IV. Repeat as needed Atropine 0.02 mg / Kg IV. Repeat as needed and titrate to respiratory secretions. It will and titrate to respiratory secretions. It will likely take massive doses!!likely take massive doses!!

Pralidoxime (2-Pam) 20-40 mg / Kg bolus Pralidoxime (2-Pam) 20-40 mg / Kg bolus followed by 10-20 mg / Kg /hour infusion.followed by 10-20 mg / Kg /hour infusion.

Remember to send RBC and Plasma Remember to send RBC and Plasma Cholinesterase levels upon arrival and daily.Cholinesterase levels upon arrival and daily.

The Expanded “One Pill Kill”The Expanded “One Pill Kill”

The Deadly Pediatric PoisonsThe Deadly Pediatric Poisons

Calcium Channel Calcium Channel BlockersBlockers

Cyclic Cyclic AntidepressantsAntidepressants

LomotilLomotil

Opiates / OpiodsOpiates / Opiods

Salicylates (methyl)Salicylates (methyl)

Toxic AlcoholsToxic Alcohols

SulfonylureasSulfonylureas

CamphorCamphor

Clonidine and Clonidine and imidazolinesimidazolines

AntimalarialsAntimalarials

Calcium Channel BlockersCalcium Channel Blockers

Three major classesThree major classes PhenylalkylaminePhenylalkylamine BenzothiazepineBenzothiazepine DihydropyridineDihydropyridine

Block L-type channelsBlock L-type channelsCause hypotension, Cause hypotension, bradycardia, and bradycardia, and arrythmias.arrythmias.Immediate and sustained Immediate and sustained release.release.Usually not the childs Usually not the childs medication.medication.


Manage A, B, C’sManage A, B, C’s

Check Labs and EKGCheck Labs and EKG

FluidsFluids

CalciumCalcium

GlucagonGlucagon

PressorsPressors

High Dose InsulinHigh Dose Insulin

Atorpine and PacingAtorpine and Pacing


May be able to wean May be able to wean pressors with insulin.pressors with insulin.

Insulin dosage is 1 unit / Insulin dosage is 1 unit / kg bolus and 0.5 units / kg bolus and 0.5 units / kg / hour drip.kg / hour drip.

Monitor sugar Q20 Monitor sugar Q20 minutes for the first few minutes for the first few hours.hours.

Most will NOT become Most will NOT become hypoglycemic.hypoglycemic.

Cyclic AntidepressantsCyclic Antidepressants

They were the leading cause of poisoning fatality They were the leading cause of poisoning fatality until 1993.until 1993.

They interfere with reuptake of biogenic amines They interfere with reuptake of biogenic amines and seratonin at the nerve terminal.and seratonin at the nerve terminal.

Manifest toxicity by anticholinergic effects, Manifest toxicity by anticholinergic effects, alpha-1 inhibition, sodium channel blocade, and alpha-1 inhibition, sodium channel blocade, and can inhibit GABA.can inhibit GABA.

Cause CNS and cardiovascular toxicity with Cause CNS and cardiovascular toxicity with arrythmias leading to mortality.arrythmias leading to mortality.

EKG FindingsEKG Findings

Cyclic Antidepressant ManagmentCyclic Antidepressant Managment

Manage A, B, C’s aggressivelyManage A, B, C’s aggressively

Optimize electrolytesOptimize electrolytes

Follow serial EKG’s and use Bicarb if:Follow serial EKG’s and use Bicarb if: QRS >100 or 110 msecQRS >100 or 110 msec aVr > 3 mmaVr > 3 mm

If bicarbonate and magnesium are not effective, If bicarbonate and magnesium are not effective, lidocaine is the antidysrhythmic of choice.lidocaine is the antidysrhythmic of choice.

Norepinephrine is the pressor of choice for Norepinephrine is the pressor of choice for refractory hypotension.refractory hypotension.

Is it the Sodium or the Bicarb?Is it the Sodium or the Bicarb?

The answer is BOTH!The answer is BOTH!

Sodium overcomes Sodium overcomes the partial blockade the partial blockade from cyclic from cyclic antidepressants.antidepressants.

Alkalinization does Alkalinization does change binding change binding properties.properties.

How does the bicarb work?How does the bicarb work?

Initially thought to increase protein binding thus Initially thought to increase protein binding thus limiting free drug in the bloodlimiting free drug in the blood

Rat study using alpha-1 acid glycoprotein (AAG) Rat study using alpha-1 acid glycoprotein (AAG) only decreased arrhythmias at massive doses. only decreased arrhythmias at massive doses. AAG is a proven TCA binder.AAG is a proven TCA binder.

Current theories is that the ionic form of the TCA Current theories is that the ionic form of the TCA binds to the sodium channel causing blockade binds to the sodium channel causing blockade and the bicarbonate changes the TCA from the and the bicarbonate changes the TCA from the ionic form to the neutral form causing less ionic form to the neutral form causing less blockade.blockade.

LomotilLomotil

Antidiarrheal agent containing both Antidiarrheal agent containing both diphenoxylate and atropine.diphenoxylate and atropine.

Both agents are absorbed by the GI tract and Both agents are absorbed by the GI tract and absorption may be delayed in overdose due to absorption may be delayed in overdose due to inhibitory effects on smooth muscle motility.inhibitory effects on smooth muscle motility.

Diphenoxylate is an opoid that is metabolized to Diphenoxylate is an opoid that is metabolized to difenoxin which is 5 times more potent than the difenoxin which is 5 times more potent than the parent compound and has half life of 12-14 parent compound and has half life of 12-14 hours.hours.

LomotilLomotil

Patients manifest Patients manifest signs and symptoms signs and symptoms of opiate toxicity.of opiate toxicity.Respond well to Respond well to naloxone and naloxone and supportive care.supportive care.Current Current recommendations are recommendations are for a minimum of 24 for a minimum of 24 hour observation.hour observation.

Opiates / OpiodsOpiates / Opiods

Typically present with respiratory Typically present with respiratory depression, altered mental status, and depression, altered mental status, and miosis.miosis.

Address the patient like any other “altered Address the patient like any other “altered mental status”mental status”

Key point is to remember to consider an Key point is to remember to consider an opiate ingestion.opiate ingestion.

Naloxone DosingNaloxone Dosing

Usually start with 0.01-0.1 mg / Kg.Usually start with 0.01-0.1 mg / Kg.

Repeat as frequently as needed to reverse Repeat as frequently as needed to reverse symptoms.symptoms.

If a drip is required, calculate how much If a drip is required, calculate how much naloxone was used in the first hour and naloxone was used in the first hour and start the drip at 2/3 that dose.start the drip at 2/3 that dose.

SalicylatesSalicylates

PharmacologyPharmacology

Irreversibly inhibits the enzyme cyclooxygenase. Irreversibly inhibits the enzyme cyclooxygenase. This inhibits prostaglandin synthesis. This inhibits prostaglandin synthesis.

Since prostaglandins are not synthesized, their Since prostaglandins are not synthesized, their downstream byproducts are never released such downstream byproducts are never released such as: IL-6, TNF, and alpha and beta interferons.as: IL-6, TNF, and alpha and beta interferons.

Believed to directly inhibit neutrophils to Believed to directly inhibit neutrophils to decrease the inflammatory response.decrease the inflammatory response.

Salicylate MetabolismSalicylate Metabolism

PathophysiologyPathophysiology

Salicylates stimulate the brainstem to cause Salicylates stimulate the brainstem to cause hyperventilation (respiratory alkalosis).hyperventilation (respiratory alkalosis).

Multifactorial renal impairment leads to Multifactorial renal impairment leads to accumulation of sulfuric and phosphoric acids.accumulation of sulfuric and phosphoric acids.

Interfere with the Krebs Cycle limiting substrates Interfere with the Krebs Cycle limiting substrates for ATP generation.for ATP generation.

Pathophysiology ContinuedPathophysiology Continued

Uncouples oxidative phosphorylation which Uncouples oxidative phosphorylation which leads to increased pyruvic and lactic acid level leads to increased pyruvic and lactic acid level and generates heat.and generates heat.

Causes salicylate induced fatty acid metabolism Causes salicylate induced fatty acid metabolism which produces ketone bodies. This which produces ketone bodies. This ketoacidosis contributes a significant portion to ketoacidosis contributes a significant portion to the overall metabolic acidosis.the overall metabolic acidosis.

Clinical ManifestationsClinical Manifestations

Early symptoms are usually non-specific such as nausea and Early symptoms are usually non-specific such as nausea and vomiting.vomiting.

Tinnitus with or without hearing loss can also be an early sign.Tinnitus with or without hearing loss can also be an early sign.

Hyperventilation is often a warning sign of a significant Hyperventilation is often a warning sign of a significant ingestion.ingestion.

CNS signs can vary from vertigo to hallucinations to stupor. CNS signs can vary from vertigo to hallucinations to stupor. Coma is rare except in massive overdoses.Coma is rare except in massive overdoses.

In large overdoses, almost every organ system becomes In large overdoses, almost every organ system becomes involved.involved.

TreatmentTreatment

Address the A,B, C’s.Address the A,B, C’s.

Detailed history and exam.Detailed history and exam.

Laboratory evaluation and consider a blood gas Laboratory evaluation and consider a blood gas if your history suggests an ingestion.if your history suggests an ingestion.

Activated charcoal should be given. Evidence Activated charcoal should be given. Evidence for multidose charcoal is equivocal. for multidose charcoal is equivocal.

The use of sodium bicarbonate.The use of sodium bicarbonate.

Measure serial salicylate levels and chemistries.Measure serial salicylate levels and chemistries.

Sodium Bicarbonate TherapySodium Bicarbonate Therapy

The goal is to titrate the urinary pH to 8.The goal is to titrate the urinary pH to 8.

Potassium must be monitored closely because if Potassium must be monitored closely because if the potassium drops, the kidney will retain the the potassium drops, the kidney will retain the potassium and excrete hydrogen.potassium and excrete hydrogen.

Excretion of hydrogen will make it impossible to Excretion of hydrogen will make it impossible to titrate your therapy to a urinary pH of 8.titrate your therapy to a urinary pH of 8.

Indications for HemodialysisIndications for Hemodialysis

Renal failure.Renal failure.

Congestive heart failure (relative).Congestive heart failure (relative).

Acute lung injury.Acute lung injury.

Persistent CNS disturbance.Persistent CNS disturbance.

Severe acid-base or electrolyte imbalance, Severe acid-base or electrolyte imbalance, despite appropriate treatment.despite appropriate treatment.

Hepatic compromise with coagulopathy.Hepatic compromise with coagulopathy.

Salicylate concentration (acute) >100 mg/dL.Salicylate concentration (acute) >100 mg/dL.

Toxic AlcoholsToxic Alcohols

Ethylene GlycolEthylene Glycol AntifreezeAntifreeze Coolant MixturesCoolant Mixtures

MethanolMethanol Windshield wiper fluidWindshield wiper fluid MoonshineMoonshine

Ethylene Glycol and MethanolEthylene Glycol and Methanol

fomepizole

Mg, B6

folate

thiamine

The Osmolar GapThe Osmolar Gap

Clinical SymptomsClinical Symptoms

TreatmentTreatment

Fomepizole or ethanol – both inhibit Fomepizole or ethanol – both inhibit alcohol dehydrogenase. alcohol dehydrogenase.

CofactorsCofactors PyridoximePyridoxime FolateFolate MagnesiumMagnesium ThiamineThiamine

Fomepizole DosingFomepizole Dosing

Loading doseLoading dose 15 mg / Kg15 mg / Kg

Next 4 dosesNext 4 doses 10 mg / Kg10 mg / Kg

Subsequent dosesSubsequent doses 15 mg / Kg15 mg / Kg

Dosing schedule is every Dosing schedule is every 12 hours except during 12 hours except during dialysis. Then it is every dialysis. Then it is every 4 hours during dialysis as 4 hours during dialysis as it gets dialyzed off.it gets dialyzed off.

Key Toxic Alcohol PointsKey Toxic Alcohol Points

Send levels for toxic alcohols as soon as Send levels for toxic alcohols as soon as possible and make them “STAT”.possible and make them “STAT”.

Talk to nephrology early as preparing for dialysis Talk to nephrology early as preparing for dialysis can take time. (especially in kids)can take time. (especially in kids)

Remember to check serum osmolality and Remember to check serum osmolality and calculate serum osmolarity.calculate serum osmolarity.

Measured osms – ( 2X NA + glu/18 +bun/2.8 + etoh/4.6)

Mechanism of ActionMechanism of Action

Sulfonylureas keep Sulfonylureas keep the potassium efflux the potassium efflux channel closed.channel closed.This keeps the cell This keeps the cell depolarized which depolarized which allows the voltage-allows the voltage-gated calcium gated calcium channel to remain channel to remain open.open.This stimulates insulin This stimulates insulin release.release.


Since sulfonylureas stimulate insulin release, Since sulfonylureas stimulate insulin release, this can result in prolonged hypoglycemia.this can result in prolonged hypoglycemia.

Continued doses of dextrose will continue to Continued doses of dextrose will continue to stimulate insulin release.stimulate insulin release.

Octreotide works by antagonizing insulin Octreotide works by antagonizing insulin release. Exact mechanism is still being debated.release. Exact mechanism is still being debated.

OctreotideOctreotide

The dose is 1-2 mcg / Kg bolus IV.The dose is 1-2 mcg / Kg bolus IV.

Some papers suggest a continuous infusion Some papers suggest a continuous infusion while others suggest an every 8 hour dosing while others suggest an every 8 hour dosing regimen.regimen.

If placed on an octreotide regimen, the If placed on an octreotide regimen, the octreotide must be off a minimum of 24 hours octreotide must be off a minimum of 24 hours without another episode of hypoglycemia before without another episode of hypoglycemia before discharge.discharge.

Key FactsKey Facts

A retrospective study showed 4 of 25 A retrospective study showed 4 of 25 patients developed delayed hypoglycemia patients developed delayed hypoglycemia including 1 at 16 hours post ingestion.including 1 at 16 hours post ingestion.

If a sulfonylurea is ingested, a minimum of If a sulfonylurea is ingested, a minimum of 24 hours of observation is recommended.24 hours of observation is recommended.

CamphorCamphor

Aromatic ketone Aromatic ketone derived from plants.derived from plants.Acts as a topical Acts as a topical rubefacient.rubefacient.Usually ingested as a Usually ingested as a liquid.liquid.Often in preparations Often in preparations combined with other combined with other medicines such as medicines such as salicylates.salicylates.

CamphorCamphor

Initial symptoms are gastrointestinal Initial symptoms are gastrointestinal distress and generalized feelings of distress and generalized feelings of warmth.warmth.

Symptoms usually progress quickly to Symptoms usually progress quickly to nervous system involvement from nervous system involvement from restlessness to seizures.restlessness to seizures.

Delayed seizures have been reported up Delayed seizures have been reported up to 9 hours after ingestion. to 9 hours after ingestion.

CamphorCamphor

Ingestions of 1-2 grams have been fatal in Ingestions of 1-2 grams have been fatal in children.children.A 19 month old died after ingesting 5 ml of 20% A 19 month old died after ingesting 5 ml of 20% camphorated oil.camphorated oil.Asymptomatic patients should be observed 6-8 Asymptomatic patients should be observed 6-8 hours and discharged if not developing hours and discharged if not developing symptoms.symptoms.Remember about hydrocarbon aspiration if Remember about hydrocarbon aspiration if product is an oil with a history of coughing or product is an oil with a history of coughing or vomitting.vomitting.

Clonidine and imidazolinesClonidine and imidazolines

Clonidine is an alpha-2 agonist that is Clonidine is an alpha-2 agonist that is used for hypertension.used for hypertension.

Imidazolines, such as oxymetazoline Imidazolines, such as oxymetazoline (afrin) are used as decongestants.(afrin) are used as decongestants.

Symptoms typically present like an opiate Symptoms typically present like an opiate overdose ? overdose ?

Why?Why?

? Like an Opiate Overdose ?? Like an Opiate Overdose ?

They are NOT structurally related to They are NOT structurally related to opiates.opiates.The alpha-2 receptor targeted by clonidine The alpha-2 receptor targeted by clonidine has significant functional overlap with the has significant functional overlap with the opiate receptor. Both may be located on opiate receptor. Both may be located on the same neuron, both coupled by via G-the same neuron, both coupled by via G-protein to the same potassium channel.protein to the same potassium channel.May require larger doses of naloxone to May require larger doses of naloxone to reverse symptoms.reverse symptoms.

AntimalarialsAntimalarials

These include cloroquine, hydroxychloroquine, These include cloroquine, hydroxychloroquine, quinine and their relatives.quinine and their relatives.

They work by both sodium channel blockade as They work by both sodium channel blockade as well as blockade of the potassium rectifier well as blockade of the potassium rectifier channel.channel.

These lead to QRS widening as well as QT These lead to QRS widening as well as QT prolongation.prolongation.

Torsades is a known complication of overdose.Torsades is a known complication of overdose.

SymptomsSymptoms

Small therapeutic index.Small therapeutic index.

Presents with symptomatology known as Presents with symptomatology known as “cinchonism” which is tachycardia, “cinchonism” which is tachycardia, nausea, vomitting, hearing loss, tinnitus, nausea, vomitting, hearing loss, tinnitus, headache, vertigo, dystonia, and diarrhea.headache, vertigo, dystonia, and diarrhea.

Patients often known to have a flushed Patients often known to have a flushed appearance.appearance.

TreatmentTreatment

These patients require aggressive These patients require aggressive management of electrolytes.management of electrolytes.

If the QRS widens, treatment with sodium If the QRS widens, treatment with sodium bicarbonate is indicated.bicarbonate is indicated.

Magnesium should be used for Torsades.Magnesium should be used for Torsades.

If ventricular arrythmias occur despite If ventricular arrythmias occur despite optimal management, lidocaine is the optimal management, lidocaine is the treatment of choice. (Avoid class 1a, 1c)treatment of choice. (Avoid class 1a, 1c)

Selected Toxic DosagesSelected Toxic Dosages

SummarySummary

Remember the “Deadly Pediatric Poisons”Remember the “Deadly Pediatric Poisons”

Don’t be fooled if the “look good” as Don’t be fooled if the “look good” as significant toxicity is still possible.significant toxicity is still possible.

Contact the poison center early as Contact the poison center early as knowing the dosage and time of ingestion knowing the dosage and time of ingestion can influence your managementcan influence your management

Review ArticlesReview Articles

Michael JB, Sztanjnkrycer MD. Deadly pediatric Michael JB, Sztanjnkrycer MD. Deadly pediatric poisons: nine common agents that kill at low doses. poisons: nine common agents that kill at low doses. Emergency Medicine Clinics of North America 2004; Emergency Medicine Clinics of North America 2004; (22): 1019-1050.(22): 1019-1050.

Bar-Oz B, Levichek Z, Koren G. Medications that can be Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful. fatal for a toddler with one tablet or teaspoonful. Pediatric Drugs 2004; 6(2): 123-126.Pediatric Drugs 2004; 6(2): 123-126.

pediatric poisonings

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pediatric ingestions

pediatric exposures

iron levels

shock stage

mgkg of elemental iron

prenatal vitamins

adolescent ingestions

children younger