CHILDHOOD POISONING

BAKARE KAFILAT
MARIAM GIWA
 OUTLINE
• What is poisoning
• Epidemiology of childhood poisoning
• Predisposing factors to childhood poisoning
• General principles of poisoning management
• Kerosine poisoning
• Salicylate poisoning
• Paracetamol poisoning
• Ibuprofen poisoning
• Alcohol poisoning
• Iron poisoning
• Caustic poisoning
 WHAT IS POISONING
Ingestion of harmful substance or large amounts
of non-poisonous substance.
 EPIDEMIOLOGY OF CHILDHOOD
POISONING
• Can occur at any age but pre-school age (<
5yrs) child at risk.
• It is commoner in males than females.
• The agents involved depends on:
– Custom of people
– Standard of living
– Occupation of parents
 EPIDEMIOLOGY OF CHILDHOOD
POISONING (CONT)
• The most common drugs are:
– Paracetamol
– Aspirin
– Iron tablets
– Alcohol
 EPIDEMIOLOGY OF CHILDHOOD
POISONING (CONT)
• The commonest household chemicals are:
– Paraffin(kerosine)
– Disinfectants
– Cleansing agents
– Insecticides
 PREDISPOSING FACTORS TO
CHILDHOOD POISONING
• Curiosity
• Poor supervision
• Children of:
– Drug addits
– Medical personnel
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING
• History
– When
– How
– Where
– Why
– Who
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Physical examination
– Odour
• Alcohol; kerosene
– Patient sensorium
• Excitement
• Incoordination/tremor
• Coma
– Pupils
• Dilatation → atropine poisoning
• Constriction → organophosphate poisoning
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Physical examination (cont)
– Respiratory system
• Tachypnoea → aspirin poisoning
• Respiratory depression→ barbiturate poisoning
– Mouth
• Burns
• Particles of tablets
• Discolouration
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Physical examination (cont)
– CVS
– Body fluids
• Vomitus
–Haematemesis
»Iron tab poisoning
»Aspirin poisoning
• Urine
• Blood
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• General management
– Identify the poison(s)
– Estimate the quantity ingested
– Find out the time of ingestion
– Maintain patent airways
– Ensure breathing
– Maintain circulation
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• General management
– Admit all children who have:
• Ingested iron, pesticides, paracetamol, aspirin,
narcotics, or antidepressants drugs
• Ingested deliberately
• Been given the drug or poison intentionally by another
child or adult
• Children who have ingested corrosive or petroleum
products
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Removal of the poison by:
– Emesis
• Should not be induced in the unconscious patient
or after ingestion of corrosives, kerosene
methylated spirit.
• It may be ineffective after the ingestion of
antiemetics, phenothiazines, atropine and
amphetamines
– Gastric lavage
• Useful within 30min of ingestion of a liquid poison or 2hrs of a
solid except when salicylates or anticholinergic drugs e.g
antidepressants, have been taken
• Is only necessary if removal of the poison is urgent or if emesis has
failed
• Exception to the use of lavage are:
– If a corrosive poison has been taken
– If household paraffin(kerosine) has been taken
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Removal of the poison by (cont)
– Activated charcoal administration
• Is an adsorbent
• Can reduce the absorption of many drugs including
aspirin,paracetamol,carbemazepine,phenytoin,kerosene,bar
biturates and TCA 1-2g/kg max of 100g
– Purgatives and enemas
• Magnesium sulphate
• Milk of magnesium
• Kaolin
• Oil purgatives(castor oil, mineral oil) should not be used to
avoid aspiration pneumonia
• Raw eggs
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Removal of the poison by (cont)
– Increase urinary excretion by
• Forced diuresis with fluid intake using IV mannitol or IV
lasix
• Urine may be alkalinized or acidified to increase
excretion of poisons.
• Acidic poison are remove by alkaline diuresis while
alkaline poison are remove by acidic diuresis.
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Removal of the poison by (cont)
–Acidic drugs
»Sulphonamides
»Barbiturates
»Salicylates
–Basic drugs
»Chloroquine
»Ephedrine
»Pethidine
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Removal of the poison by (cont)
– Dialysis
– Exchange blood transfusion
• Administration of antidote – these are of two
types:
– Chemical agents which, by direct combination make
the poison harmless or unabsorbable
– Agents which counteract the action of the poison
after it had been absorbed
Not every poison has an antidote.
GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
Poison Antidote

Atropine Organophosphates

Naloxone Opoids

Desferoxamine Iron

Na/Ca EDTA Lead

Dimercaprol Gold; mercury; arsenic

Alkali Acids

Paracetamol Methionine or acetylcysteine

Table 2: Heavy metal chelators
Chelator Indication

Dimercaprol, BAL Acute poisoning of As, Pb, Hg

Succimer (Dimercaptosuccinic acid, DMSA) Acute As, Pb poisoning (Cd?)

Ethylenediaminetetraaceticacid (EDTA) Chelation of Pb, Zn, Mn, radionucleotides (Cd?)

Unithiol (Dimercaptopropanesulfonic acid, DMPS) Enhances Hg, As, Pb excretion

Penicillamine (D-dimethylcysteine) Cu (also enhances Pb, Hg excretion)

Deferoxamine Fe poisoning
 Antidote Poison Special considerations
Acetylcysteine Paracetamol P.o or i.v, give within 8-10h
Atropine Anticholinesterases, Given i.v. and therapeutic end-
organophosphates, carbamates point is decreased secretions
Sodium bicarbonate Antidepressants, quinidine Given as i.v. bolus, avoid in heart
failure
Calcium Calcium channel blockers, ----------
fluoride
Deferoxamine Fe salts 100mg deferoxamine binds 8.5mg
of Fe
Digoxin antibodies Digoxin & related cardiac ---------
glycosides
Ethanol, fomepizole Methanol, ethylene glycol ---------
Flumazenil Benzodiazepines Given i.v., do not give to seizure
and benzodiazepine dependent
patients
Glucagon β-blockers May cause vomiting
Naloxone Narcotics, opioid derivatives i.v, i.m., s.c.
Oxygen Carbon monoxide Give 100% continously
Physostigmine Antimuscarinics Given i.v., have atropine ready to
reverse excess effects
Pralidoxime Organophosphate cholinesterase Given i.v.
 GENERAL MANAGEMENT OF CHILDHOOD
POISONING (CONT)
• Supportive treatment – depends on poison involved
– Those which depress the nervous systems → give
stimulant
– Those with stimulant nervous system → give depressant
– Respiratory failure
• Artificial respiration
• Give respiratory stimulants
– Shock
• General measures to alleviate shock
– Electrolyte imbalance should be corrected
– Correct temperature abnormality present
 KEROSINE POISONING

• Commonest cause of poisoning in our

enviroment
• May be mistaken for water
• May be asymptomatic when small quantities
are ingested
• Features resulted from:
– Systemic toxicity
– Aspiration hazard
 KEROSINE POISONING (CONT)
• Systemic toxicity
– CNS(depression)
• Irritability
• Lethargy
• Seizure or coma
– CVS
• Arrhythmia
– Renal
• Haematuria
• Proteinuria
– GIT
• Hepatic damage
– Degenerative changes
– Hypoglycaemia
 KEROSINE POISONING (CONT)

• Aspiration hazard → lipoid pneumonia

– Cough
– Respiratory distress
– ± rhonchi
– ± creps
– Cyanosis
– Chemical pnuemonitis
 KEROSINE POISONING (CONT)
• Investigations
– CXR
• Patchy areas of collapse
• Consolidations
• Pulmonary oedema
• Treatment
– Admit observe for 6hrs if not symptomatic discharge
– Oxygen
– Steroids
– Antibiotics (procaine penicillin 3oo ooounits
– Treat heart failure if present
– Do not perform emesis or gastric lavage
– Liquid paraffin(mineral oil) by mouth will delay
absorption
 SALICYLATES POISONING
• Ingestion of > 200mg/kg is toxic.
• Clinical manifestations
– Over breathing
• Earliest clinical features
• Due to direct stimulant action of the
salicylate on the respiratory centre
– Vomiting
– Diarrhea
 SALICYLATES POISONING (CONT)
• Clinical manifestations (cont)
– Hyperpyrexia
• Results from the action of salicylates in
increasing heat production
– Sweating
• Occurs at first but stops once dehydration
develops
– Hyperglycaemia and glycosuria
• Results from disturbance of carbohydrate
metabolism
• Increase glycogen breakdown i.e.uncoupling
of oxidative phosphorylation
 SALICYLATES POISONING (CONT)
• Clinical manifestations (cont)
– Ketosis
• Results from increase rate of fat
metabolism and disturbance of
carbohydrate metabolism
– Hypernatraemia
– Hypokalaemia ← alkalosis
– Hypoprothrombinaemia ] cause
– Platelet dysfunction ] bleeding
 SALICYLATES POISONING (CONT)

• Urinary finding
– Positive test for reducing substance because
of their conjugation with glycine or
glucuronic acid
– Glycosuria
– Ketones
– Positive ferric chloride
 SALICYLATES POISONING (CONT)
• Investigations
– Urine testing
• Ferric chloride test(purple colour indicates
positive test)
• Phenistix test – colour change is purple
• Urinary salicylate level
– Serum salicylate level
• Level below 40mg/100ml rarely causes symptoms
• <50mg/100ml = mild
• 50 -80mg/100ml = moderate
• >100mg/100ml = severe
– Acid-base balance
– E/U/Cr
– Blood sugar
 SALICYLATES POISONING (CONT)

• Treatment
– Admit
– Induce vomiting btwb8-12 hrs of ingestion
– Gastric lavage “
– Alkaline diuresis
– If unconscious
• Dialysis or
• EBT
 PARACETAMOL POISONING

• Cause hepatic damage

• Is a life threatening complications of over dosage
• A single, acute acetaminophen ingestion of
>140mg/kg is potentially toxic.
• Clinical manifestations
– Vomiting
– GIT haemorrhage
– hyper- or hypoglycaemia
– renal tubular damage
– cerebral oedema may occur.
 PARACETAMOL POISONING (CONT)

• Treatment
– Admit
– Emesis or lavage
– Estimate plasma paracetamol level 4hrs after
ingestion
– N-acetylcysteine by infusion
• It is very effective when given up to 8hrs
after overdose. Thereafter its efficacy
declines progressively.
• It is no longer of value by 15 – 24hrs and if
given at that stage it may be harmful.
 IBUPROFEN POISONING
• Ingestion of >100mg/kmg is potentially toxic.
• Clinical manifestations
– abdominal pain
– Vomiting
– Drowsiness
– lethargy.
– In rare cases
• apnea (especially in young children)
• Seizures
• metabolic acidosis
• CNS depression leading to coma have
occurred.
 IBUPROFEN POISONING (CONT)

• Treatment
– Dilution with water or milk may be
necessary to minimize the gastrointestinal
upset
– Induce vomiting
– Gastric lavage
 ALCOHOL POISONING

• Alcohol exists in the form of methanol,

ethanol and iso-propanol.
• Ethanol is the most frequently abused.
• Household source of ethanol are: local gin,
brandy, whisky, wines, perfumes, aftershaves.
• Ethanol is rapidly absorbed from the stomach
and the intestine.
• Ethanol metabolism takes place in the liver
(→CO2 + H2O).
• Lethal dose is > 3mg/kg.
 ALCOHOL POISONING

• Clinical manifestations
– Incoordination
– Drowsiness
– Slurred speech
– Blurred vision
– Coma
– Convulsion ← hypoglycaemia
– Signs of intoxication appear in children when
the blood concentration of 50mg/dl is
achieved.
 ALCOHOL POISONING

• Treatment
– Gastric lavage
• Useful if done within 30minutes of the
ingestion
– Activated charcoal
– Management of hypoglycaemia
 IRON POISONING

• Many of the tablets are highly coloured and

look like sweats.
• The ingestion of > 20mg/kg of elemental iron
is potentially toxic.
• Gluconate 12%
• Sulphate 20%
• Fumarate 33%
 IRON POISONING (CONT)
• Clinical manifestations
– Immediate effect is its corrosive action on the
gastric mucosa which may be sufficient to
perforate the stomach
– Vomiting – vomitus appear rusty(coffee grounds)
and has a characteristic metallic smell
– Abdominal pain
– Melaena stool may also be present
– ± shock
– ± severe acidosis
– ± coma
– If the child survives, pyloric stenosis may develop
from scarring
– ± death
 IRON POISONING (CONT)

• Investigations
– Presence of ferrous salts in the vomitus can
be confirmed by the Prussian
blue(ferricyanide) test
– The serum iron is raised but doses not
correlate well with the severity of
intoxication
 IRON POISONING (CONT)
• Treatments
– Admit
– Induce vomiting
– Gastric lavage
• With a phosphate solution(e.g.sodium
dihydrogen phosphate) to form insoluble iron
salts
• 1% sodium bicarbonate solution can also be used
– Correct acidosis
– antidotes
• IM/IV/oral desferoxamine or 2g/l of warm water
• IV calciumdisodium EDTA(less powerful
chealating agent)
 CAUSTIC INGESTION

• Present in:
– Clinitest tablets(contain NaOH)
– Caustic soda
– Paint removers
– Dye
– Some water softners
– Bleeches
 CAUSTIC INGESTION (CONT)
• Clinical manifestations
– Initially
• Burns in the mouth, pharynx and oesophagus
• The mucosa looks soapy white, later becoming brown,
oedematous and ulcerated
– Later
• Perforation of the oesophagus → retrosternal or neck
pain
• Respiratory obstruction from laryngeal oedema
• Inability to swallow secretions → drooling of saliva
• Oesophageal stricture may develop after recovery
 CAUSTIC INGESTION (CONT)

• Treatment
– Do not perform emesis or gastric lavage
– Wash mouth with water
– Attempts to neutralize or dilute the alkali with
milk, or water
– Orange juice are usually unhelpful as the burns is
immediate.
– Manage as for corrosive oesophagitis
 PREVENTION

– Parents/guardian health education

– Sales of toxic substance restriction
– Use of containers with cap
– Prompt diagnosis and early treatment
– Insist on packages with safety closures and learn how to
use them properly.
– Keep household cleaning supplies, medicines, garage
products, and insecticides out of the reach and sight of
your child. Lock them up whenever possible.
– Never store food and cleaning products together. Store
medicine and chemicals in original containers and never in
food or beverage containers.
– Avoid taking medicine in your child's presence. Children
love to imitate. Never suggest that medicine is candy—
especially aspirin and children's vitamins.
 CONCLUSION
Poisoning is one of the leading cause of death
amongs the children and can be prevented.