Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra

SOCHIPE 2014

Dr.Enrique Paris

Epidemiologa y Tratamiento
general de las intoxicaciones.
Urgencias y Emergencias.
Tiempo es Vida
Dr.Enrique Paris M.
Director Centro Informacin Toxicolgica
Pontificia Universidad Catlica de Chile
CITUC.

Nios y Medio Ambiente.

Aiko is safely delivered in Kumamoto,
Japan, and can expect to live about 85
years. At the same time, Mariam comes
into this world in one of the poorest areas
of Freetown, Sierra Leone. She is
underweight and vitamin-deficient, and
has a 30% chance of dying before her
fifth birthday.

The last three decades have

witnessed an impressive decline in
child mortality, from 17 million a
year in the 1970s. Yet these gains
have not been enjoyed
everywhere. In some countries of
sub-Saharan Africa, child
mortality is rising as wars and the
ravage of the AIDS epidemic
undermine the medical, social and
economic structures of society.
At the turn of the century, the
world joined together in the fight
against poverty, and committed
itself to the Millennium
Development Goals, adopted by
the United Nations in 2000. To
reduce by two-thirds the
under-five mortality rate between
1990 and 2015 may be the most
ambitious of these goals.

ICELAND

Under-five mortality rate per 1000 live births

2000

FINLAND
SWEDEN

NORWAY

ESTONIA
UNITED
KINGDOM

Today, 35% of Africas children are

at higher risk of death than they
were ten years ago.

RUSSIAN
FED.

LATVIA
DENMARK

LITHUANIA

IRELAND
NETH.

SWITZ.
S. MARINO
MONACO

SPAIN

C A N A D A

over 175

11 25

101 175

10 and under

26 100

no data

Beacons of hope
greatest improvement
in child mortality rate
19702000

CZECH
UKRAINE
REPUBLIC SLOVAKIA

REP.

LUX.
FRANCE

ANDORRA

BELARUS

POLAND

GERMANY

BELGIUM

AUSTRIA HUNGARY ROMANIA MOLDOVA

SLOVENIA BOSNIA &
HERZEGOVINA
CROATIA
SERBIA & BULGARIA
MONTENEGRO
ITALY
ALBANIA
FYR MACEDONIA

PORTUGAL

RUSSIAN FEDERATION

GREECE

KAZAKHSTAN
MALTA

MONGOLIA
GEORGIA

TUNISIA

BAHAMAS

GUATEMALA
EL SALVADOR

LIBYAN
ARAB
JAMAHIRIYA

ALGERIA

CUBA

MEXICO

JORDAN

ISL. REP.
IRAN
IRAQ

HAITI
ST KITTS & NEVIS

NICARAGUA ST VINCENT & GRENADINES

GRENADA

COSTA RICA

VENEZUELA

PANAMA

CAPE VERDE

GUINEA-BISSAU

GUYANA
SURINAME

GUINEA

SIERRA LEONE
LIBERIA

COLOMBIA

NIGER

CHAD

UAE

INDIA

KIRIBATI

MYANMAR

OMAN

UGANDA

MALDIVES
SOMALIA

FIJI

COOK
ISLANDS

TONGA NIUE

SRI LANKA

PALAU

BRUNEI DAR.
MALAYSIA

MICRONESIA,
FED. STATES OF

SINGAPORE

KENYA

ANGOLA

VANUATU

PHILIPPINES

SEYCHELLES

BURUNDI
UNITED REP.
TANZANIA

PERU

SAMOA

VIET NAM

CAMBODIA

RWANDA

DEM. REP.
CONGO

CONGO

NAURU
TUVALU

LAO
PDR
THAILAND

YEMEN

ETHIOPIA

CENTRAL AFRICAN
REPUBLIC

GABON

MARSHALL
ISLANDS

BANGLADESH

DJIBOUTI

NIGERIA

SAO TOME
& PRINCIPE

BRAZIL

ERITREA

SUDAN

BURKINA
FASO
CTE
DIVOIRE

NEPAL

BHUTAN

QATAR

EGYPT

EQUATORIAL CAMEROON
GUINEA

ECUADOR

PAKISTAN

MALI

SENEGAL
GAMBIA

JAPAN

REP.
KOREA

C H I N A

AFGHANISTAN

KUWAIT

SAUDI
ARABIA

MAURITANIA

ANTIGUA & BARBUDA

DOMINICA
ST LUCIA
BARBADOS
TRINIDAD & TOBAGO

DPR
KOREA

KYRGYZSTAN
TAJIKISTAN

BAHRAIN

DOMINICAN
REP.

JAMAICA
BELIZE
HONDURAS

"It is not enough

to prepare our children for the world;
we must also prepare the world
for our children.
Luis J. Rodriguez (1954 )

SYRIAN ARAB
REPUBLIC

CYPRUS
LEBANON
ISRAEL

MOROCCO

UZBEKISTAN

AZERBAIJAN
TURKMENISTAN
ARMENIA

TURKEY

U S A

GHANA
TOGO
BENIN

ver 10 million children

under five die every year
98 per cent of them in developing
countries. Widespread
malnutrition hampers childrens
growth and development, opening
the door to the biggest killers of
children under five: perinatal
diseases, pneumonia, diarrhoea,
and malaria. This presents a sharp
contrast to the situation in the
industrialized world, where junk
food and a sedentary lifestyle have
triggered an unprecedented
epidemic of obesity in children,
leading to diabetes and heart
disease in adult life.

Child mortality rate

The Worlds Forgotten

Children

Produced by Myriad Editions

World Health Organization

I N D O N E S I A
COMOROS

PAPUA
NEW
GUINEA

SOLOMON
ISLANDS

TIMOR-LESTE

MALAWI

ZAMBIA

MADAGASCAR

BOLIVIA

ZIMBABWE
NAMIBIA

BOTSWANA

PARAGUAY

MAURITIUS

MOZAMBIQUE

US$ 17 billion

CHILE

SOUTH
AFRICA

AUSTRALIA

SWAZILAND
LESOTHO

URUGUAY

ARGENTINA

The price of life

The biggest killers of children under five
Main causes of child mortality
2002

Diarrhoea 15%

Acute respiratory
infection 18%

Malaria 11%
Deaths associated
with malnutrition:
54%

Other
24%

NEW
ZEALAND

US$ 7.5 billion

Measles 5%
Human Immunodeficiency
Virus (HIV) 4%
Perinatal diseases
(within 7 days of birth)
23%

Annual expenditure on pet food Annual cost of scaling-up vaccination,

in North America and Europe
malaria prevention and
1998
essential treatment to reach
every child in the developing world
2001

From Inheriting the World: The Atlas of Children's Health and the Environment WHO

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dying on the roads

Child Injuries
are Preventable

ICELAND

ESTONIA

Injuries are unnecessary and

avoidable. The use of seatbelts
and child car seats, and the
wearing of helmets are essential
to prevent the death of child
passengers or cyclists. Traffic
measures such as checking vehicle
roadworthiness, enforcing speed
limits and prosecuting drunk
drivers are particularly important
in developing countries, where
roads tend to be poorly
maintained and the number of
vehicles is growing rapidly.

RUSSIAN
FED.

LATVIA
DENMARK

LITHUANIA

IRELAND
NETH.

LUX.
FRANCE

SWITZ.

C A N A D A
PORTUGAL
SPAIN

CZECH
REPUBLIC

20.0 and over

2.5 4.9

10.0 19.9

under 2.5

5.0 9.9

no data

BELARUS

POLAND

GERMANY

BELGIUM

rowning is the most

common cause of injuries
for infants, killing approximately
60 000 children under five every
year and leaving roughly the same
number permanently disabled.
Children also suffer burns from
open fires and kerosene stoves,
and are injured in falls at home,
at school and at playgrounds.

UKRAINE

SLOVAKIA

REP.

MOLDOVA
HUNGARY
AUSTRIA
SLOVENIA
ROMANIA
CROATIA B-H SERBIA &
MONTENEGRO
BULGARIA
ITALY
ALBANIA
FYR MACEDONIA

R U S S I A N

F E D E R A T I O N

GREECE

K A Z A K H S T A N

MALTA

M O N G O L I A

A
GEORGIA

Deaths from road accidents

are projected to rise by 65%
by 2020, mostly in
developing countries.

T U R K E Y

ALGERIA

MEXICO
CUBA
JAMAICA

GUATEMALA
EL SALVADOR

BELIZE
HONDURAS

HAITI

DOMINICA
ST LUCIA
BARBADOS
TRINIDAD & TOBAGO

GRENADA

VENEZUELA

GUYANA
SURINAME

COLOMBIA

MAURITANIA
CAPE VERDE

NEPAL

GUINEA

SIERRA LEONE
LIBERIA

BANGLADESH

SAO TOME
& PRINCIPE

CAMEROON

UGANDA

GABON

TUVALU

VIET NAM
SAMOA
NIUE

FIJI

PHILIPPINES

VANUATU

CAMBODIA
SRI LANKA

MALDIVES

TONGA

BRUNEI DAR.
M A L A Y S I A
SINGAPORE

SOMALIA

MICRONESIA,
FED. STATES OF

SEYCHELLES

RWANDA
BURUNDI
UNITED REP.
TANZANIA

PERU

B R A Z I L

COMOROS

ANGOLA

COOK
ISLANDS

PALAU

KENYA

DEM. REP.
CONGO

CONGO

LAO
PDR
THAILAND

ETHIOPIA

CENTRAL
AFRICAN REPUBLIC

TOKELAU

NAURU

MYANMAR

YEMEN
DJIBOUTI

NIGERIA

KIRIBATI

MARSHALL
ISLANDS

I N D I A
OMAN

ERITREA

S U D A N

CHAD

BURKINA
FASO
CTE
DIVOIRE

BHUTAN

UAE

MALI
NIGER

SENEGAL
GAMBIA

GUINEA-BISSAU

EQUATORIAL
GUINEA

ECUADOR

PAPUA
NEW
GUINEA
SOLOMON
ISLANDS

TIMOR-LESTE

MALAWI

ZAMBIA

MADAGASCAR

BOLIVIA

ZIMBABWE
NAMIBIA

CHILE

C H I N A

PAKISTAN

SAUDI ARABIA
ANTIGUA & BARBUDA

ST VINCENT &
GRENADINES

PANAMA

JAPAN

REP.
KOREA

TAJIKISTAN

AFGHANISTAN

KUWAIT
BAHRAIN
QATAR

E G Y P T

DOMINICAN
REP.
ST KITTS & NEVIS

NICARAGUA

COSTA RICA

JORDAN

DPR
KOREA

KYRGYZSTAN

UZBEKISTAN

ISL. REP.
IRAN

IRAQ

WEST BANK
AND GAZA

LIBYAN
ARAB
JAMAHIRIYA

AZERBAIJAN
TURKMENISTAN
ARMENIA

SYRIAN ARAB
REPUBLIC

CYPRUS
LEBANON
ISRAEL

TUNISIA

MOROCCO

BAHAMAS

GHANA
TOGO
BENIN

In older children, however, the

overriding cause of injuries is
road traffic accidents, killing
approximately 180 000 children
under 15 each year. Children are
rarely the cause of road traffic
accidents but suffer as pedestrians,
cyclists and passengers. Boys,
often given greater freedom to
roam, are more likely to be
injured than girls.

Deaths due to road traffic accidents of children aged 014 years

per 100 000
2002
by WHO sub-region

FINLAND
SWEDEN

NORWAY

UNITED
KINGDOM

Emeka slipped while drawing water from

the river near her village in Nigeria and
did not return home . . .

Produced by Myriad Editions

World Health Organization

Dr.Enrique Paris

BOTSWANA

PARAGUAY

MAURITIUS

MOZAMBIQUE

A U S T R A L I A

SWAZILAND

SOUTH
AFRICA

LESOTHO

URUGUAY

How children are injured

ARGENTINA

111 559
89 955

Causes of deaths worldwide

due to unintentional injuries
for children under 15 years
2002

NEW
ZEALAND

71 261

Injuries from road traffic

accidents already cost developing
countries US$ 65 billion a year
more than the annual amount of
development assistance they
receive.

55 104
34 238

39 969
22 294

boys
girls
Road traffic accidents

boys
girls
Drowning

boys

girls
Fires

14 713

boys

girls
Falls

19 818

15 797

boys
girls
Poisonings

From Inheriting the World: The Atlas of Children's Health and the Environment WHO

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

LIFETIME EXPOSURES
Air
Drinking water
Domestic environments
Soil: dermal

Soil: ingestion
Normal food

Breastfeeding
Occupational exposure

Intrauterine

Birth 6 m

1 yr

5 yr

16 yr

45 yr

65yr

www.cituc.cl

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

EPIDEMIOLOGIA

EPIDEMIOLOGIA

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

EPIDEMIOLOGIA

EPIDEMIOLOGIA

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Primeros Centros Toxicolgicos 60.
Formados por Pediatras.
Campaas Masivas.
Semana de la Prevencin.
Uso Responsable del Medicamento.

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
CITUC.

263 53 800 .

Fundado 1992.
Financiamiento: Ley de Donaciones.
Llamadas diarias : prom. 90.
Llamadas acumuladas : 410.000
www.cituc.cl

Intoxicaciones.
CITUC.
Entregar una informacin profesional,

oportuna, adecuada y actualizada, para

contribuir al manejo del Paciente
Intoxicado.

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

EPIDEMIOLOGIA

EPIDEMIOLOGIA

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

EPIDEMIOLOGIA

EPIDEMIOLOGIA

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

SUSTANCIAS MAS
FRECUENTES

Medicamentos
Prod. Ind. Y Qumicos
Productos Aseo
Fitosanitarios
Animales
Plaguicidas domsticos
Cosmticos
Metales
Cuerpo Extrao
Alimentos
Gases
Plantas
Otro
0

1000

2000

3000 4000

5000

6000

7000

8000

9000 10000

Llamadas

MEDICAMENTOS MAS
FRECUENTES
Otros
Agentes gastrointestinales
Antispticos/desinfectantes
Vitaminas/Minerales
Sistema Cardiovascular
Sist. Nervioso Autnomo
Sist. Hormonal
Antibiticos
Sistema Respiratorio
AINES
Sistema Nervioso Central
0

1000

2000

3000

4000

LLAMADAS

10

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

GRUPO MAS FRECUENTE SNC

OTRAS DROGAS SNC

ANFETAMINAS

ANTICONVULSIVANTES
FENOTIAZINAS
Y DROGAS
RELACIONADAS
ANTIDEPRESIVOS
BENZODIAZEPINAS

200

400

600

800

1000

LLAMADAS

PRODUCTOS DE ASEO

OTROS
AGENTES
LIMPIADORES

LAVALOZAS

DETERGENTES

CLORO

200

400

600

800

1000

LLAMADAS

11

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

PRODUCTOS INDUSTRIALES

OTROS
PEGAMENTOS
ACIDOS/ALKALIS
ALCOHOLES
HIDROCARBUROS

200

400

600

800

1000

1200

LLAMADAS

PLAGUICIDAS DE USO
DOMESTICO

PIRETROIDES
25%

OTRO
10%

ORGANOFOSFORADOS
30%

ANTICOAGU-LANTE
35%

12

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Figure 1. A 21-year-old dental assistant a1empted suicide by injec8ng 10 ml (135 g) of elemental

mercury (quicksilver) intravenously. She presented to the emergency room with tachypnea, a
dry cough, and bloody sputum. While breathing room air, she had a par8al pressure of oxygen of
86 mm Hg. A chest radiograph showed that the mercury was distributed in the lungs in a
vascular pa1ern that was more pronounced at the bases. The pa8ent was discharged aNer one
week, with improvement in her pulmonary symptoms. Oral chela8on therapy with dimercaprol
was given for nine months, un8l the pa8ent stopped the treatment;

Intoxicaciones.
Diagnstico.
- Sospechar el Diagnstico.
- Anamnesis.
- Examen Fsico . Sindromes Txicos.
- Examenes de Laboratorio.

13

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Sindromes Txicos.
- Sindrome Anticolinrgico.
- Sindrome Colinrgico.
- Sindrome Opiode Alcohlico.
- Sindrome Catecolaminrgico.

Intoxicaciones.
Sndromes Txicos.

Sndrome Anticolinrgico.
Causas.
Antihistamnicos, antidepresivos tricclicos
antiespasmdicos, chamico, atropina.CBZ.
Sintomatologa.
Taquicardia, vasodilatacin, retencin
urinaria, silencio abdominal, alucinaciones
y convulsiones.Midriasis.Mucosas secas.

14

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Sndromes Txicos.

Sndrome Colinrgico.
Causas.
Hongos, carbamatos, rganofosforados,
fisostigmina.
Sintomatologa.
Depresin SNC, hipotona, salivacin,
lagrimacin, incontinencia urinaria y fecal,
bradicardia y convulsiones.Miosis.

Intoxicaciones.
Sndromes Txicos.

Sndrome Opioide alcohlico.

Causas.
Codena, morfina, barbitricos, BDZ,
etanol, clonidina.
Sintomatologa.
Coma, depresin respiratoria, hipotensin,
miosis, bradicardia, hipotermia, edema
pulmonar, shock distributivo.

15

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Sndromes Txicos.

Sndrome Catecolaminergico.
Causas.
Cocana, amfetaminas, efedrina, cafena,
pseudoefedrina, fenilpropanolamina.
Sintomatologa.
Taquicardia, hipertensin, hipertermia,
diaforesis, midriasis, convulsiones y
arritmias.Dolor anginoso.

Intoxicaciones.
Tratamiento .

Siempre tratar primero al Paciente:

ABC de la Reanimacin.
Despus tratar al Txico.
ABC de la Intoxicacin.

16

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Tratamiento .

Siempre tratar primero al Paciente:

ABC de la Reanimacin.
Via Aerea Permeable.Oxigenar.
Asegurar una buena ventilacion.
Dos vias venosas gruesas.
Monitoreo Cardaco. Saturacin.

Intoxicaciones.
ABC de la Intoxicacin.

evitar la absorcin.
favorecer la adsorcin.
favorecer la eliminacin.
antagonizar al txico.

17

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Evitar absorcin :

Lavado Gstrico.
Solo en la primera hora post ingestin.
Proteger la va aerea si existe compromiso de
Conciencia.
Indicado principalmente en Txicos que
comprometen gravemente la vida del paciente.
Contraindicado en Casticos e Hidrocarburos.

Intoxicaciones.
Favorecer adsorcin :Carbn Activado.
Muy Importante.
Dosis Unica. 2 a 3 gr /kg Nios.
Dosis Secuenciales. 0,5 a 1 gr/ kg
c/4, 6 u 8 hrs.
Contraindicado en Casticos y Obst.Intestinal
Inutil en Litio y Fierro.

18

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Carbn Activado.
Concomitantemente usar Lactulosa.
10 a 15 ml con cada dosis de Carbn.

Intoxicaciones.
Favorecer la Eliminacin.
Ventilacin del lugar del accidente.
Forzar diuresis. Alcalinizar o Acidificar
orina.
Lavado Gastrointestinal total. Solucin de
Colon.
Oxigenar . Cmara Hiperbrica.

19

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Antagonizar al Txico.
Usar un Antagonista no es la
Panacea.
Lo importante es Tratar al Paciente.

Intoxicaciones.
Paradoja.
Uso de flumazenil en Intoxicacin
Mixta de BDZ y Antidepresivos Tricclicos.
se debe usar flumazenil ?

20

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.
Antdotos.
N-Acetilcistena.
Atropina.
Benztropina.
Difenhidramina.
Digibind.
Etanol.
Fitomenadiona
Glucagn.

Flumazenil.
Glucosa.
Naloxona.
Obidoxima.
Oxgeno.
Piridoxina.
Succimer.
Fomepizol.

Intoxicaciones.
Prevencin.
- Educacin a toda la Familia.
- almacenar correctamente los txicos.
- Uso correcto del Medicamento.
- Promover el Envase Seguro.
- Promover los Centros de Informacin.

21

Educacin Mdica Continua SAVAL

Formacin de competencias en pediatra
SOCHIPE 2014

Dr.Enrique Paris

Intoxicaciones.

Gracias !

22