Evaluation and Management

of a poisoned child

Professor Dr. Hassan Elkinany.

Faculty of Medicine, Alexandria University.
Pediatric department ( PICU )
Can you imagine or predict …
The number of poisons the we are subjected
to ?

They are innumerable …!!!

Do you know.. ?

Poisoned patients constitute a substantial

number of cases that you would meet
during the initial days you will practice
your career as a caring physician in the ER
(may be the first day)
 Objectives of the lecture :
 To know a global view as regards the
epidemiology, routes and the circumstances that
accompany the intake of poisons.
 To learn how can you diagnose or suspect the
“poisoning state”.
 To be able to deal with and manage a poisoned
or a suspected poisoned child initially in the ER
The detailed information about the clinical
picture of the so many poisons as well as
their ultimate management is not among
the objectives of this lecture.
 Epidemiology
 In 2007, the ER department of El-Shatby
Alexandria University Children Hospital
received 967cases with poisoning.
 Of these, 21 cases needed admission to
PICU
 In USA, the AAPCC reports an annual
number ranging from 2.1-2.8 million
( 1998-2005 ).
Routes of poison intake :
 Oral
 Parenteral
 Inhalation
 Trough skin or eyes
Circumstances of poisoning :

 Accidental : Mainly in toddlers.

 Suicidal : Mainly in adolescents.
 Homicidal : Consider “child abuse”.
 Drug abuse : B2 agonists, tranquilizers..
 Iatrogenic : Lomotil, digoxin…
Diagnosis or Suspicion of
the diagnosis :
In practice you will be confronted with two situations :
1. Frank history :
Here you will need to have answers for the following
questions :
a. When ?
b. How much ?
c. Symptoms and signs.
d. Actions done by the parents.

Remember, you should match the clinical findings with

the name of the poison given
2. Denied or suspected poisoning :
In this situation you may ask some questions as :
Drugs given at home
Open bottles
The usual habits and life style
Visit or visited by somebody
Special odors
Symptoms and signs
Diagnostic tips :
 Poisoning should be highly suspected in any
previously healthy child who presents with acute
deterioration of 3 major organ/systems :
1. CNS
2. Liver
3. Lungs
 Poisoning is ruled out in the presence of
lateralsing or focal neurological signs.
 Management
Remember that:
 the proper management requires a skilled
teamwork and an easy access to a poison center, a
handbook and/or a computer or internet facility
(information store or reservoir).

 The initial skilled and rapid interventions are the

most determinant factors that predict the outcome
and prognosis of a poisoned child.
Situation 1 : Frank history
Management accordingly…..
 Apply what you know about the basics of
life support measures ..(if needed)
 Give an antidote if there is…
 Try to minimize toxin absorption
 Assess organs and systems…and…
 Monitor……….
Situation 2 : Denied or suspected
poisoning
Evaluation of organs and systems (Which
are the most important ? )
 Initially and…..
 Continuously i.e. monitoring
 And manage accordingly
“You might reach the diagnosis later on”
 You can get very valuable information
through the careful examination of :
Vital signs
Eyes
Skin
NB. Revise and keep in close contact to you a
table which demonstrates the correlation
between some clinical signs and certain poisons.
 Diagnostic clues
Signs Drugs

Tachypnoea Aspirin, theophylline, CO, cyanide

Bradypnoea Opiates, barbiturates, sedatives, ethanol

Metabolic acidosis CO, ethanol, ethylene glycol

Tachycardia TCA, sympathomimetics, amphetamines, cocaine..

Bradycardia B-blockers, digoxin, clonidine

Hypotension Barbiturates, benzodiazepines, B-blockers, calcium channel blockers, opiates, iron,

TCA...

Hypertension Amphetamines, cocaine, sympathomimetics..

Small pupils Opiates, OPC, phenothiazines

Large pupils Amphetamines, atropine, cannabis, cocaine, TCA, quinine..

Hypothermia Barbiturates, ethanol, phenothiazines, opiates

Hyperthermia Amphetamines, cocaine, salicylates, phenothiazines, anti-cholinergics..

Convulsions OPC, TCA, phenothiazines

Tremors Hg, arsenic, lithium..

Focal neurologic signs Rule out poisoning

 Management tips
“if poisoning is denied or suspected”
 In the conscious child : you can send him home if he
remains asymptomatic for 6 hours in the ER,
provided that he can easily return to hospital if
necessary. (Why and what is the value of this
concept ?? )
 The exception is if there is a documented or
suspected intake of a drug whose onset of action is
delayed (anticoagulants or sustained release
medications).
 In the unconscious child : Give Naloxone 0.1-0.2
mg/kg rapid IV. ( What is the idea ?, What is the
coma cocktail ? )
 Methods to diminish toxin
absorption :
These measures are only done if the time lapsed after
poison ingestion is not more than 2 hours.
 
1. Ipecac syrup: 10-15 ml followed by water. It must not be
used in children with depressed level of consciousness. It
better be given within the first 30 minutes of the drug
intake and it is of limited value if given after 1 hour.
2. Gastric lavage: using saline in infants and water in older
children. Only effective if given within 1 hour of the
poison intake. The lavage tube can be used thereafter as a
route for a specific antidote or activated charcoal.
( contraindications ?? )
 3. Activated charcoal: It has a surface area of 1000 m2/g and is
capable of adsorbing nearly all drugs (except alcohol and
iron). Now it is available as colored granules, and is given in a
dose of 1-2 g/kg mixed with a chocolate milk or any sweet
drink. Repeated doses (at 2-hourly interval) are useful in some
drugs as they promote drug reabsorption from the circulation
back to the bowel and interrupt enterohepatic cycling
(aspirin, barbiturates and theophylline).

 It can be given through a NGT or the stomach lavage tube

after the washout.

 In the unconscious child it should be given after airway

protection as it can cause severe lung damage.
 4.Cathartics “As magnesium citrate and
sorbitol” : They are used only in older
children

 Whole bowel irrigation : using a

polyethylene glycol (Colyte ) ???

 Others….(diuretics, dialysis,
hemoperfusiom..)
 Toxidromes
The term refers to a group of related signs
and symptoms that can occur with a group
of poisons. EXAMPLES :
Cholinergic toxidrome : diminished
level of consciousness, salivation,
lacrimation, bronchorrhea, bradycardia, pin
point pupil and incontinence.
Drugs/poisons : OPC, Nicotine
 Anti-cholinergic toxidrome : agitation,
salivation, sweating, mydriasis, hyperpyrexia,
tachycardia and urine retention.
Drugs/poisons : Anticholinergics, antihistamines,
tricyclic antidepressants..

Opiates toxidrome : sensorium, hypothermia,

hypotention and pin point pupil.
Drugs/poisons : Heroin, morphine, fentanyl,
lomotil…
 Please Remember
 All that surround us could be a poison.
 Child abuse….
 Unexplained deterioration of 3 systems greatly
arouse the possibility of poisoning (what are
them?).
 Focal neurological signs rules out poisoning.
 Basic life support measures .. AND…
continuous monitoring…
 In an asymptomatic child with suspected history
you can send him home after…..hours.
 In an unconscious child without a clear cause it is
a good policy to add……by rapid IV infusion to
the coma cocktail.
 Induction of emesis and stomach lavage are not
needed if……hours lapsed after poison intake.
 Be sure of an easy contact with an information
store.
List of drugs and toxins in the
curriculum
 Tricyclic antidepressants (TCA)
 OPC
 Paracetamol
 Aspirin
 Theophylline
 Iron
 For MD curriculum
 Digoxin

 Opiates

 Lead, Mercury and arsenic

 Food poisoning
Thank you