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Infant and Toddler

Growth and
Development
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing
Growth of Infant
Cephalocaudal (head toe)
Proximodistal (trunk periphery)
General Specific (Large fine muscles)

1 a month during 1st 6 months


Average Ht
6 months 25 inches
12 months 29 inches

Use recumbent length until 3 years


than standing (vertical height)
Weight
5-7oz/wk until 5-6 months
Birth weight doubles at 6 month
Birth weight triples at one year

Always refer to kilograms


2.2 lbs = 1 kg

All medications based on weight in kg!


Head Circumference = HC
Reflects brain growth
Posterior fontanele closes @ 2 mos.
Anterior fontanel closes @12-18
mos.
Measure (Forehead Occiput)
For 1st 3 years
Chest (CC) and Abdomen
Chest = Head circumference @ 1 year
Measure @ nipple line.
Barrel chested as infant
Chest > Head after 3 years
After 1 year of age,
A/P transverse diameter = 1:2

Abdominal Girth
Measure above umbilicus
Abdominal distention
R/O liver or intestinal diseases
Growth Charts
Serial exams to assess growth progress
Plotted as percentiles:
25th %, 50th %, 75th %, 95th %.
@ 95th % = Pt > 95% of kids.
Used to notice any or in weight,
height, or HC.
Specific charts for premature infants
Denver Developmental
Screening Test (DDST)
Denver II
Assesses from birth 6 years
Age divided monthly 24 months,
then q 3 mos. 6 years
Not an intelligence test
Four categories
Personal/Social
Fine motor/Adaptive
Language
Gross motor
Infant Reflexes
Moro - Startle
Loud sound = extension & abduction of
extremities

Tonic neck Fencing


Turn head to one side
arm & leg extend on side

Babinski
Dorsiflexion of big toe and toes fan out

All of above disappear in about 3-4 months


Developmental Skills
Trust vs Mistrust (Birth to one year)
Social responsiveness to others
Trust develops with regular consistent,
loving care
Self reliance and develops confidence

Early infancy 0 - 3 months


Smiles at significant other
Holds head & chest up when prone
Reaches for objects-grasp
Laughs
Developmental Skills
Early Infancy 4-6 months
Pulls self to sitting position
Sits with support
Rolls over = Safety issue
Tummy back first at 2-3 months
Back tummy by 6 months
stronger head and arm control
Transfers objects from hand to hand
Makes vowel sounds oh-oh
Developmental Skills
Late Infancy 6-9 months
Hold own bottle
Develops preference for dominant hand
Probes with index finger
Feeds self finger foods
Pincer grasp @ 9 months
thumb and index finger used
Sits erect-unsupported
Crawls
Separation Anxiety cries with strangers

Object Permanance
Searches for items outside field of vision
Developmental Skills
9-12 months
Triple birth weight and height by 50%
Releases objects
Pulls self to feet
Sits from standing position
Walks with help
independent walking can be as late as 18
months!
Responds to name
Recognizes no
Says 4 -5 words: mama, dada, no, bye
Teething (age 6 = # of teeth)
12 mos 6 = 6 teeth
Cool cold items to chew on
Tylenol 10-15 mg/kg q 4-6 hours
Developmental Tasks
Achieve physiological equilibrium
Rest, eat, play patterns
Develop basic social interaction
Desire for affection
Manage a changing body
motor skills & eye-hand coordination
Learn to understand and control world
Develop a beginning symbol system
Communication
Immunizations
Regulated by CDC and American Academy of Pediatrics (AAP)
www.cdc.gov/nip/vacsafe
www.immunize.org

Infectious diseases = morbidity & mortality

incidence of recent outbreaks:


immigration from poorly compliant countries
religious beliefs or cultural influences
trust of medical care or poor education

2003 Nigeria stopped IPV


Rumors that IPV could transmit AIDS
2006 20% of kids<5 no IPV and polio outbreak

2005 Amish Polio outbreak


2009 Immunizations
Hep B Hepatitis B Vaccine (IM)
Birth, one month and six months
Mom (+) HBsAg
give baby HBIG (0.5mL) & Hep B within 12H
@ 2 separate sites
90% infected infants chronic Hep B carriers
25%-50% infected before age 5 RT HBV Carriers

Transmission risk in adolescents


All kids entering 7th grade must have Hep B
3 dose series
Immunizations
IPV - Inactivated Polio Vaccine (SC)
2, 4, (6-18) months and (4-6) years
Formerly used OPV Virus shed
Contraindication; Allergy to neomycin

HIB - Hemophilus Influenza Type B (IM)


2, 4, 6 and (12-15) months
Not associated with Flu
Protects against many serious infections:
Epiglottitis and Bacterial Meningitis
Immunizations
PCV7 - Polysaccaride Conjugate Vaccine-
(Prevnar) (IM)
2,4,6 and (12-15) months

PPV Pneumococcal Polysaccharide (IM)


One dose > 2 years

Protects against Strep pneumonia


6-12 months of age at high risk for S.
pneumoniae

Risk patients
Sickle cell disease, HIV/immune deficiency
chronic cardiac or pulmonary etc
Must receive PPV vaccine in addition to PCV
Immunizations
DTaP - Diptheria, Tetanus and acellular Pertussis (IM)

Diptheria
Rare throat infection
Gray/yellow film
difficult to remove
Air flow obstruction
Sepsis

Tetanus
Clostridium produced in infected wounds
Severe muscle extension
Immunizations
Pertussis
Gram negative bordetella pertussis
whooping cough
Post-tussive vomiting
Cyanosis
Subconjuctival hemorrhage

Three stages:
catarrhal, paroxysmal (2 weeks) and decline
outbreaks in Adolescents and Adults
RT titers

www.pertussis.com
Immunizations
DTaP Schedule
2,4,6,15 months and 4-6 years for DTaP
Side Effect: Redness & swelling @ site

New booster recommendations 2005:


Tdap Adacel: one dose 11- 64 years or
Boostrix: single dose 10 -18 years of age
Adolescents 11-12 years of age should
receive single dose of Tdap instead of Td
(if up to date and have not yet received Td
booster)

Need 5 year interval from Td to Tdap to SE


Contraindication:
Encephalopathy in 7 days of DTaP
Immunizations
MMR - Measles, Mumps and Rubella (IM)

Measles
Viral illness - macular/papular rash
Kopliks spots oral mucosa
Encephalitis/pneumonia

Mumps
Inflammation salivary glands/parotid
Boys develop orichitis/sterility

Rubella
Viral illness- rash (face body extremities)

Pregnancy exposure:
Fetal deafness, cataracts, cardiac defects, encephalitis
Immunizations

MMR is live attenuated (weakened)


vaccine
12-15 months and 4 - 6years
Contraindication:
Pregnancy
Immunocompromised
Allergy to neomycin
Immunizations
Varicella (SC)
Varicella chickenpox
Live attenuated virus healthy children only
12-18 months
2nd dose @ 4-6 years
2005 - All kids entering 6th grade
Risk > 13 years
Give with MMR
MMRV new vaccine
Contraindication
Pregnancy
Immunocompromised or
Allergy to neomycin
Immunizations
MCV4 - Meningococcal Conjugate Vaccine 4 (IM)
MPSV4 - Meningococcal Polysacharide (SC)
Protects against N.meningitids (not all
strains!)

MCV4/ Menactra:
One dose 11-12 years or @ high school entry or
college freshman in dormitories
(risk smoking and crowds)

MPSV4/Menomune:
Children> 2- 10 years risk factors
Sickle cell disease.
Immunizations
TIV -Trivalent Inactivated Vaccine Influenza (IM)
Influenza virus pneumonia and death
2004 -152 pediatric deaths
# of cases in February
6 mos - 5 years of age annually
> 5 years only high risk population.
0.25ml<3 years or 0.5ml>3 years
Contraindication Egg Allergy
Eat baked goods can have vaccine

LAIV - Live Attentuated Influenza Vaccine


> 5 years (2 doses 1st time)
New Vaccines Added
Rotavirus vaccine Rototeq
Rotavirus is primary cause of acute
gastroenteritis in US
Three oral doses given at 2, 4 and 6 months
Dosing must be complete by 8 months of age
No catch-up for older infants
Do not re-administer if infant spits up
New Vaccines Added
Human Papillomavirus (HPV)
Non-enveloped dbl stranded DNA virus
>100 types with 15-20 oncogenic types
75% of sexually experienced men and women age 15-49 years
have had some type of HPV

Quadrivalent HPV vaccine (Gardasil)


Protects against HPV 6,11, 16 & 18
Type 16 and 18 account for approx 70% of cervical cancers
ACIP recommended 6/29/06
Routine vaccination of girls 11-12 years but may begin @ 9
Catch-up vaccination for adolescents and young women who
have not been previously vaccinated
Not indicated in pregnancy or hypersensitivity to substances
New Vaccines Added
HPV administration (3 separate doses 0.5ml IM )
1st dose on elective date
2nd 2 months from first
3rd 6 months after first dose

SE:
Very painful
Syncope & tonic clonic movements
Pt remains seated or lies down x 15 minutes

Compliancy Issues:
Moral issues can intervene
Study with boys shows = a good immune response
Vaccinate girls RT risk of Cervical CA
Only true contraindications
to vaccine administration
Fever >102
Immunocompromised: (No MMR & Varicella)
HIV, Leukemia, Lymphoma
Alkylating agents or Antimetabolites
Daily Corticosteroids Dose:
> 2 mg/kg or 20 mg/day
Allergy to vaccine component
Vaccine Adverse Event Reporting System
(VAERS)
Congenital defects
Cleft palate
1/750 births cleft lip

1/2500 births cleft palate

Incomplete closure of the roof of the mouth


6th -10th week of gestation

Opening from uvula soft palate hard palate lip

Cleft palate 1st sign


Formula coming out of nose

Gloved finger to assess soft and hard palate in


newborn
Etiology
Multifactorial
Genetic-familial tendency
in Asians and lowest in African Americans
Caffeine
ETOH
Dilantin or Valium
Folic Acid Vit A
Sequella
Feeding difficulties
Speech difficulties
High risk for Otitis Media
Serous and Bacterial
Interventions
Review defect
Impact on infant
Before and after photos
Support Groups

3P Feeding technique
Position - upright
Pore - soft, premie nipples
enlarged opening
Patience - burp frequently
Surgery
Lip repair usually 1-3 months
Protect incision line after operation
Palate repair @ 18 months
Supine with HOB
Elbow restraints
I&O
Tracheoesophageal (TEF)
Fistula
Fistula
Opening between trachea and esophagus
Fluids enter lungs
Aspiration PN
Large amounts of air into stomach

Esophageal Atresia EA
Esophagus ends in a blind pouch

in Pre-term and/or Polyhydramnois


30-50% multiple anomalies
TEF/ EA Clinical Signs
Increased salivation
Drooling
3 Cs
Choking
Coughing
Cyanotic episodes
Laryngospasms
Abdominal distension
Unable to pass NGT with atresia
Interventions
NPO
HOB>30
Maintain patent airway
NGT to low intermittent suction
Prophylactic antibiotics
Aspiration PN
Surgery correction of fistula
ASAP
Safety in Infants
Accidents leading cause of death btwn 6-12 mos

Suffocation/Aspiration
# 1 cause of fatal injuries <1 year
toys, mobiles
No H2O mattress or pillows
Falls
Walkers 45%
Burns
H2O temp @ 160 scalds skin in 10 seconds
Temp to 120
Poisonings
Plants, Cleaners, Grandmas purse meds
Cars
Car seat < 1 year back seat, facing rear
Nutrition
Vitamins for Infants
Fluoride
0.25mg/day > 6 months - 3 years
Poly-vi-flor 1cc QD
>3 years 0.50mg/day

FeSO4
0.5mg/kg/day > 6 months
if BF mother not taking supplements
after 6 months fetal stores are depleted)

Vit D
400 IU/day
if BF mother not taking supplements
Breast Milk
Contains all nutrients and
A,B, E
Immunoglobulin IgA, T and B cells
Lacks Vit C, D and Fe
Twice sugar (lactose)= laxative
effect
# of stools
lactalbumun more complete protein
caesin easier to digest
Formula

No more than 32 oz/day


No whole milk in infants!
No iron in milk
Infants unable to properly digest
irritation of intestinal mucosa,
bleeding and anemia
Solids
Begin at 4-6 months
Too early introduction of solids
incidence of allergies and celiac disease.
No cereal in formula bottle!
Assess physiological readiness
Tongue extrusion reflex
Coordinated suck & swallow
Tooth eruption biting & chewing
Pancreatic enzymes for complex nutrients

Introduce foods one at time


New food after 3 days:
Cereal vegetables fruits meats egg yolks

No egg whites <1 year


No honey/corn syrup <2 years
Risk of botulism
No Nuts, Seeds or Popcorn
Kwashikor
Severe protein deficiency
Adequate caloric intake and carb diet
Mycotoxin mold found in intestines

Signs and Symptoms


Scaly, dry skin and pigmentation
Hair thin/dry and coarse
Ascites
Edema RT protein
Muscle atrophy
Irritable, lethargic, withdrawn
Permanent Blindness
DiarrheaInfection Death
Nursing Interventions
Assess degree of malnutrition
Neurological/muscular impairments
Developmental milestones
Hyperalimentation
Protein diet
Antibiotics
Skin Care
Collaborate with OT and PT
Skin Disorders
Eczema (5-7% Infants)
RT allergies (egg, soy and cows milk)
Ig E levels RT Histamine,
Prostaglandins, Cytokines
with stress
90% develop asthma
Signs and Symptoms
in winter
Skin Rash
Erythematous, edematous,
Pruritic, dry and cracked
Lesions in skin creases,
Cheeks, forehead & scalp
Risk of secondary infections
Treatment
Hydrate
Brief bath with Dove soap
Lubricants Eucerin cream
Topical steroids
Antibiotics if secondary infections
Elidel and Protopic 0.03% non-steroidal
Pimercrolimus and Tacrolimus
Only for children > 2 years
Black box warning
? risk of cancer
Impetigo
Toddlers and Preschoolers
incidence in Summer (hot/humid)
1st Skin is broken via bug bite
infected - staph A or B strep
Very contagious
1st Macular & Pruritic
2nd Honey crusted, thick & bleed
Therapy
Wash lesion c warm soapy H2O
Soak and remove crusts
Bactraban BID 7 days
PO Antibiotics
PCN, EES, Lorabid, Zithromax
Sebborrheic Dermatitis
Cradle Cap
Chronic inflammatory
condition
Dysfunction of
sebaceous glands
Infants produce a lot of sebum
Yellow scales from eyelids Scalp

Therapy
Apply lotion, massage scalp
Fine comb remove scales
Toddler 12-36 months
Growth slows Physiological anorexia
Average weight gain 4-6 lbs/year
BW quadrupled by 2 years
Height 3 inches/year
HC growth slows
A/P diameter 1:2

Visual acuity 20/40


Eyes can accommodate objects @ distance

Neuromuscular control
Manipulates objects & people
Psychosocial Development
Autonomy vs. Shame and Doubt
Me do stage
Intense exploration of environment
Fighting for autonomy
Negativism No
Ritualistic behavior to control their
environment
Body Image develops
Psychosocial
2nd Separation Anxiety
Cling and cry when left by parent
Be honest regarding separation do not
disappear!!
Body image develops
knows certain body parts: eye, pee pee
Begins to acquire socially accepted
behaviors
Toilet training
Holding on and letting go is very important!
Need to recognize the urge to let go

1st Bowel control after 18 months


2nd Bladder control @ 2 - 3 years

Daytime bladder control before nighttime


Regular BM and patterns or child will alert you
Needs awareness and self discipline
Harder to train children with history of
constipation
Temper tantrums

Common response to helplessness or


frustration

Inadequate verbal skills


Cant communicate needs!
Strike out physically

Monitor for speech delay children!


Interventions
Set appropriate, clear and consistent
limits
Safely isolate and ignore behavior
Remove from situation
Redirect or introduce another activity to
restore self-esteem
Time out = minute per age
Do not let toddler get too tired, hungry
or stimulated
After tantrum subsides provide love and
attention
Developmental skills
300 words by 2 years.
Understand more than they say
2 yr old 65% of speech should be
comprehendible
Knows first and last name
Dressing - takes off own clothes
Walk, run, and jump with both feet
Ride tricycle, build tower of blocks
Parallel play
Possession = ownership
Ritualism
Comforting & Anxiety
Intellectual development
5th Stage of Sensorimotor @12-18 months
Object permanence
Exists when not visible Whered it go?
Peek a Boo
Active experimentation
Time perception
Holidays, morning, noon, night
1 minute = 1 hour
Space perception
Nesting
Stands on stool to get object

Magical thinking
Pre-operational Stage
Transitional Stage 18 - 24 mos
Trial and error
Memory and imitates actions.
sweeping floor with broom is mom cleaning

Problem solving

Egocentric- I me mine

Concrete thinking
Literal translation
A little stick for IV = tree branch

Sense of Time
Orientation RT activities
Mom will be back after nap instead of at 2 oclock.
Toddler Developmental Tasks
Differentiate self from others

Toleration of separation of parents

Slight delayed gratification

Basic toilet training

Socially acceptable behavior


Biting and spitting bad!
Communicates effectively
Transitional objects
Favorite toy, blanket
stress
Nutrition
Growth period = protein and fluids
Physiological Anorexia @ 18 mos
nutritional need = appetite
Daily diet
Milk 2-3 cups/day
FE, CA, PO4
Very fussy and food jags (1-2 items only!)
Only peanut butter and bananas!
Want to feed themselves = MESSY!
May eat a lot one day
and not much following day
Nutrition
Offer small, frequent nutritious
snacks
Toddlers love to graze
Not too much milk or juice ( sugar)
Fills them up = wont eat
Do not force child to eat.
Will eat when hungry.
If child is not losing weight it is ok.
Dentition

Twenty primary teeth by 30 months


Brush teeth 2 x/day!
No bottles of juice or milk at
bedtime.
Dental carries can occur.
Safety
Toddlers have no sense of danger
Locomotion = DANGER!!
Injuries cause > death in ages 1-4
Motor Vehicle Crash (MVC) = #1!
Caused by lack or improper restraint
SUV
toddlers wander behind truck and get hit.
DWI
2500 kids/year
7/10 in car with impaired parent
Car Seat Safety Rules
Universal Child Safety System (UCSS)
2 point attachment with tether system
by 2002 all new cars must have entire UCSS

<12 years of age = sit in back of car


Infant = rear facing (1 yr and 20 lbs)
Forward facing convertible seat till 40 lbs
>40 lbs belt positioning booster seat

New York State Seatbelt Laws


March 2005 any child <7 years of age
appropriate restraint system or booster seat

80 lbs or 4 ft 9 inches may use seatbelt


Seat belt must fit properly:
on hips not stomach
on shoulder not neck
Drowning
# 2 cause of death for toddlers
Totally Preventable!
Only need 1 of H2O to drown
Bucket to clean car
Ponds
Pools
Beach
Always supervise near water!
Burns
3rd cause of death (boys)
2nd among girls
20,000 injuries/year and 1,000 deaths
16% RT child abuse
Types
Thermal- flames, scalds (85%),hot objects
Electrical- socket, chewing wires
Chemical- Ingesting cleaning products
Radiation- sunburn
First Degree/Superficial
(epidermis)
Minor sunburn

Red, dry and painful

Heals spontaneously
3-7 days

No therapy needed
Second Degree
Partial Thickness
Involves epidermis and upper layer of
dermis

Moist, bulla
Skin bright red
Painful

Heals in 14 - 21 days with scarring


Third Degree/ Full Thickness
Includes subcutaneous tissue
Dry, pale or brown/black
PAINLESS
Eschar-
thick leather like
dead skin

Healing requires skin grafting


painful
Fourth Degree/ Full thickness

Extends all the way to bone

Dry, whitish leathery appearance

Sensation to pain

Scarring and contractures


Total Body Surface Area
(TBSA)
Varies with age
age = TBSA
surface area = Injury
Rule of Nines
Determines % of burns
Transfer to burn unit BSA>10%
Open palm of hand = 1 % of BSA
Thorax 18% Head 19%
Arm 8% Leg 13%
Management
Respiratory
Maintain patent airway
R/O Inhalation injury
Smoke, steam, toxic fumes
Charred lips, singed nasal hairs,
soot covered nares

Humidified 100% O2
Assess for:
Respiratory Acidosis:
RR, retractions, nasal flaring, effort, O2

Moist Breath sounds = Pulmonary edema


Carboxyhemoglobin (CoHb) levels
> 10% need hyperbaric chamber
Fluid Resuscitation
Hypovolemic Burn Shock
capillary permeability
Leakage of intravascular fluids
Perfusion, BP, HR, Output

Parkland Formula = 4mL LR x kg x %TBSA


1st 24 - 48 hours until capillary integrity is restored

IV Maintenace Fluids: 4:2:1 Rule

4mL/kg for 1st 10 kg 45 kg child: 4 x 10 = 40 mL


2mL/kg for 10-20 kg 2 x 10 = 20 mL
1mL/kg >20 kg 1 x 25 = 25 mL
85 mL/H
Maintain urine output 1-2ml/kg/hour-(foley)
Strict I & O!
SG Wt.
VS and LOC
Monitor Lab values
Hyperglycemia
NE/E, stress, insulin resistance, glycogen released
Hyponatremia
3rd spacing 1st 24 hours = NA excretion
Hyperkalemia
1st 24 hours = cell release of K+
Hypokalemia
2nd 24 -48 fluid shifts back to cell K+
Hypoalbuminia (<2)
serum proteins 3rd spacing
Albumin 1 gm/kg/day
Metabolic acidosis
Renal failure, tissue damage RT sepsis

BUN Creatine = SG
Dehydration & renal failure
Pain Management
Acute
Burned skin and exposed nerves
Moaning, grimacing, restlessness, guarding,
dilated pupils, clenched fists, movement
Procedures: PAIN
Dressing changes anxiety & fear
Medicate prior to all procedures.
MSO4, Propofol, Fentanyl, Hydromorphone

Imagery, relaxation, distraction

Therapeutic Touch
Wound Care
Aseptic/sterile technique
risk of infection
Invasive lines, compromised immune
Protective Isolation
Debridement
Remove dead tissue
Hydrotherapy
Soaking wounds - remove old dsg
10 mins to prevent electrolyte and fluid loss
Washing area
Clean area & assess wound
color, drainage, odor, sloughing,
granulation tissue
Antimicrobial creams

Mafenide Acetate (Sulfamylon cream)


Painful but penetrates eschar
Gram (+)/(-) coverage
Apply & leave OTA or light dsg
Sulfa allergies
Hypersensitivity reaction
SE: Metabolic acidosis
Antimicrobial creams
Silver Sufadiazine (Silvadene)
Painless
Gram (-)/(+) coverage
Not to use on face or electrical burns

1st Clean wound


Apply & leave OTA or light dsg

Sulfa allergy
SE: Transient leukopenia
Antimicrobial creams
Silver nitrate 0.5%
Most gram (+) & some gram (-)
Painless soak
Dampen dsg q 2H or TID
Need large bulky dsgs
Stains clothing and linens -black
SE: K+ Na+ Cl+
lytes
Skin Grafts
Autograft
Patients own skin
risk for Host Versus Graft (HVG) response

Transcyte
Newborn foreskin
Bioactive skin substitute
Re-epithelialization
dsg changes hospitalization
scarring
Nutritional Support
NPO x 24 hours
Bowel sounds Abd girth N & V

Curlings Ulcer
GI perfusion occult blood via NGT & stool

2-3 times daily calories for wound healing


BMR RT Protein & N loss

Protein 25% of calories-


eggs, peanut butter and milk

Vit A and C important for skin


oranges, grapefruit
strawberries, broccoli
Psychological Needs
Contractures & ROM RT scars
Pressure Ace wrap cover to scars
Increase involvement in care
Play therapy & counseling
Ease transition community
Prepare friends and school
Wounds/scarring & emotional needs
Support groups
Poisoning
150,000 kids < 5 years old = 120 deaths/year
risk @ 2 years (improper storage)

Poison Control # = 1-800-222-1222


www.nyc.gov/html/doh/html/poison/poison.shtml

Aspirin Intoxication-
# 1 most ingested drug
ASA acetylsalicylic Acid
Availability in home
Combination OTC meds:
Peptol bismal, cough and cold, wart preparations

Therapeutic Dose 40 -100 mg/kg


Toxic dose 200mg/kg
Severe toxicity 300 - 500mg/kg
Signs and symptoms
6 H delay before toxicity signs noted
Hyperventilation
RR CO2
Metabolism
BMR O2 use Glucose
Metabolic acidosis
ketones and organic acids
Bleeding
platelets
Interventions
Serum salicylate levels
Therapeutic 5-20mg/dl
Toxic >25mg/dl

Gastric lavage up to 4 hours post ingestion


Activated Charcoal (1g/kg)
absorption & elimination via GI tract
Vit K for bleeding
Correct lyte imbalances-
Ca+ K+
Hydration
Flush kidneys
Calories
May need hemodialysis
Acetaminophen Overdose
Most common acute drug poisoning
Risk c combination drugs
Risk for liver damage
RT metabolites binding to hepatocytes
life = 3 hours
Liver necrosis within 2-5 days if not treated
Therapeutic dose = 90 mg/kg
Toxic dose = 150mg/kg
Clinical signs
Phase one (1st 24 hours)
N/V, anorexia and malaise

Phase two (24-36 hours)


Hepatomegaly, RUQ pain, LFTs
INR, PT, hyperbillirubin and oliguria

Phase three (2-5 days)


Encephalopathy, cardiomyopathy, anorexia, emesis,
liver failure, hypoglycemia, coagulopathy, renal failure
and death

Phase four (7-8 days)


Recovery or fatal hepatic failure
Interventions
Serum acetaminophen levels
validity 4 hours post ingestion.
Therapeutic level = 2 -20 mg
Toxic level > 50 mg
If extended release level 8 hours after ingestion.
Must know actual ingestion time.
INR (1.0 WNL)
Earliest and most sensitive for hepatotoxicity
LFTs (AST Aspartate Transaminase)
Bilirubin, PT
Released with hepatic injury
BMP/ Panel 7
Renal- BUN
Interventions cont
Gastric lavage most effective with extended release
Activated charcoal most effective 1-2 hours after
injestion.

N-acetylcystein-Mucomyst- PO
Loading dose = 140 mg/kg x 1 PO
then 70 mg/kg x 17 doses PO q 4H.
Most effective with-in 8 hours of ingestion
Must be initiated with-in 16 hours.
Mix with coke smells like rotten eggs
Charcoal may bind with mucomyst give 1 hour apart

May use IV mucomyst if pt not tolerating PO


Lead poisoning Plumbism
Home built before 1960s
Risk for lead based paint (banned in 1978)
Recent ongoing renovations
Nearby industry
Battery plants, gas stations
Leaded gasoline in soil children place hands in mouth
Old furniture, ceramic pottery and lead toys
Folk Remedies
Azarcon, Greta, Ligra & Surma (200x Pb!)
Risk
< 6 years
Urban areas
Medicaid recipients 3 xs lead levels

Lead Screening
Screen at 9 months to 1 year and then 2 years
Earlier/ASAP with risk factors
Clinical signs
Most kids are asymptomatic! Level
Pb serum level > 10 is toxic
Pb > 45 = RX
Pb > 70 = Medical Emergency (RX & ICU)
90% Pb attaches to RBC
Interferes binding of iron to heme molecules
H and H , Fe
HgB = Anemia
Absorption of Pb > Excretion

24 H Urine (lead) >3 mg


Damages cells of proximal tubules

Lead deposits in tissues, bones, gums and abdomen


Lead lines (bones, nails)
X-rays; Femur and Tib/Fib for deposits
Abdominal pain (paint chips on X-Ray)
Vomiting & Constipation
CNS Symptoms
Hyperactivity
Aggression-irritability
Impulsiveness
Learning disabilities
Developmental delays
Lead Encephalopathy = Irreversible!
ICP
Seizures
Cortical atrophy-
Permanent brain damage Mental retardation
Coma and death
Treatment
Chelation Therapy for level >45mg/dl
Binds Pb to H20 water soluble form excretion via urine
Must use two meds if levels >70mg/dl

1. CaNa EDTA (calcium disodium edetate) IM/IV (20 doses)


adequate kidney function
Painful injections
Apply EMLA 2 H before and inject with procaine.

2. BAL (dimercaprol) IM (24 doses)


renal function
Contraindicated with peanut allergy or G6PD
Usually not single therapy use in conjunction with EDTA

3.Succimer (Chemet or DMSA) PO (43 doses)


Alternate treatment for EDTA
19 day therapy
Hydrocarbons
Gasoline and kerosene
Risk for aspiration/pulmonary toxicity
Turpentine = systemic toxicity
Antifreeze
Carbon Tetrachloride
Baby Oil
Camphor (Moth Balls)
Inhaled or ingested
Signs and symptoms
Gagging, Choking, Cyanosis
N & V
RR Retractions Dyspnea
Grunting
Aspiration PN in RUL
Seizures
Renal failure
Coma
Therapy
No emesis RT Risk of aspiration
Gastric lavage
Humidified O2 + PEEP
Hydration
Antibiotics
Prophylactic for PN
Lye, Corrosives
Strong alkali with PH
Dishwasher detergent (Electrosol tablets)
Batteries
Denture cleaners
Oven/ Drain cleaners
Erodes esophagus can cause perforation
Signs and symptoms
Severe Burning Pain
Mouth, throat and stomach
White swollen mucous membranes:
lips, tongue, pharynx
Inspiratory stridor & Dyspnea RT
Esophageal and tracheal edema
Drooling
Violent vomiting - blood & tissue
Anxiety
Treatment
Dont induce Vomiting!
Maintain patent airway
Administer analgesics
NPO or Dilute corrosive with 120 ml H2O
only!
Steroids Methylprednisolone 2mg/kg/day
Humidified O2
Surgery
Batteries can cause esophageal and gastric burns
Esophageal strictures