Evaluation and management of the poisoned child

Dr Hussein Abdeldayem, MDProfessor of Pediatrics. Alex Egypt

introduction• Circumstances of poisoning :

1-Commonly accidental especially in the under-5 age group .

2- homicidal. 3-suicidal (in older children)

mortality:Death is increasingly rare due to more effective management &preventive measures.

How Children Differ From Adults?

Developmental Considerations

(each age group is more vulnerable to specific

toxins)

Physical Considerations (there are many age-

related changes in vital signs).

Routes of administration of the poisons

Ingestion 79%Dermal 6.3%Ophthalmic 5.3%Inhalation 5.1%Bits and Stings 3.1%Parental 1%

Initial Assessment and

Management

Non specific. specific.

Kerosene. Caustic.

A-Non specific management:

1- removal of the source of poison away from the child .

2- initial resuscitation and stabilization.

3- removal of unabsorbed poison from GIT.

4-elimination of already absorbed poisons.

5-symptomatic and supportive measures.

1-removal of the poison .

Skin : triple wash ( water , soap , more water)

Eyes : saline wash.

Cavities : removed by irrigation.

2-Initial resuscitation and stabilization:

• it is the initial priority in treating poison children.

A:Assess airway patency.

B:Assess the adequacy of breathing .

C:Assess the circulation in terms of 1-cardiovascular status .2-effect of circulatory inadequacy to other organs

D:Assess neurological function in terms of:

-level of consciousness -pupillary size and reaction -bedside blood glucose concentration. -presence of any seizure

activity.

E:Record the child's temperature.

3-removal of unabsorbed poisons• from the GIT.1- Activated charcoal (AC):

it is the safest mode.

It is given if the child has taken a potentially toxic overdose within the previous hour.

• Mechanism and dose :

It adsorbs many toxins (except metals, alcohols & petroleum distillates) & reduces its absorbtion into the bloodstream.

Dose : 1 g/ kg.

Disadvantage: It is an odorless, tasteless, black powder so Children may be averse to its gritty texture & color.

if they cannot be cajoled with flavoring, an opaque cup, and straw, then it can be administered by a nasogastric tube.

2- Gastric lavage :

usually reserved for children who present within 1 h of ingesting a potentially life-threatening poison.

disadvantage: It is often difficult to remove the toxic agent from the GI tract because of the small size of lavage tube needed in pediatric patients.the child will often need to be intubated to facilitate this technique.

alkalis hydrocarbons acids

contraindicated

3- Whole-bowel irrigation:

Irrigation is a newer technique used to flush the toxin through the bowel , thereby preventing further absorption.

Polyethylene glycol 500 ml /h is given orally & continued until the rectal effluent is clear (in 4-6 h).

serial abdominal radiographs may also be used to demonstrate its effectiveness.

It is particularly useful for ingestions that are not adsorbed by AC such as:

Lead paint

batteriesiron tablets

Symptomatic Rx

hypotension

arrhythmia

convulsions

Pain

hypothermia

5-elimination of the already absorbed poisons.Absorption of poisons occurs after six hours after ingestion.The techniques are :

forced diuresis. peritoneal dialysis hemodialysis.

hemoperfusion. hemofiltration. plasmapheresis.

exchange transfusion.

KEROSENE POISONING

Kerosene poisoning is common in communities where kerosene is a major household fuel.

The circumstance is usually accidental ingestion (mistaken for water)

Management

Investigations Treatment

Investigationsto aid management and to monitor complications in other organ systems we do:

full blood count electrolytes

Urea& creatinine

level

liver function test

Chest x-ray is done in all symptomatic patient to :

1-determine the extent of injury . 2-rule out differentials which include -atelectasis -inhalation injury -Near Drowning -Pneumonia -Respiratory Distress syndrome

Perihilar opacity Bi-basal infiltration

Initially the chest radiograph may be normal but positive findings develop over the first few hours after ingestion of kerosene. Common findings include perihilar opacities and bi-basal infilteration.

Treatment:

maintenance of airway, breathing and circulation.

Stabilization of the airway is always the first priority of treatment.

Gastric lavage and induction of emesis ( e.g. use of Ipecac) should not be

considered in the management of kerosene poisoning as these may cause further aspiration and worsens the condition.

CorrosivesSubstances that cause tissue damage by chemical reaction

Inorganic non metal :–Acids as sulfuric acid and hydrochloric acid.–Bases (alkali)as ammonia, k permenganate .

Organic non metal: - Carbolic acid and oxalic acid.

Classification of corrosives:

• PH of saliva should be checked by PH paper.• Endoscopy is the only reliable way to establish the

severity of esophageal burn. It should be performed from 12- 24 hours after ingestion. (contraindicated if there is suspecting perforation)

Investigations

Routine investigation :Complete blood count, glucose and electrolyte determination level.

Chest and abdominal X-ray should be taken to rule out visceral perforation.

Ocular slit- lamp examination with topical fluorescein dye in cornel burns.

Treatment

No Gastric lavage

No Emesis

Not give activated charcoal

No bicarbonate or antidote

Assess the A –B- C

Give water (diluting) only 60 ml

Demulcent as cold milk

Analgesics and antibiotics

corticosteroids