Poisoning and animal bites

ผศ.นพ.วรพนธ เกรยงสนทรกจ กมารเวชศาสตรผ ปวยนอก

ภาควชากมารเวชศาสตร คณะแพทยศาสตรศรราชพยาบาล

Toxicology

“All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a

remedy.” Paracelsus, early 1500s

Scope of talk

•Common drugs and chemical agents in the house

•Lead exposure

•Snake bite

•How to prevent chemical and drugs poisoning

•First aid for poisoning and snake bite

Poisoning in children

•Toddlers and young children are explorers and have much hand-mouth activity

•Incidence of poisoning increases after 9-month old

•Over 90% of poisoning exposures occur in homes

•Unintentional exposure: young children (less than 6 yr)> older children

Rate of human poison exposures by age group

Acute poisoning surveillance in Thailand: the current state of affairs and a vision for the future, Emergency Medicine, 2013

Iron supplement

• Almost 16,000 iron exposures/ year: reported in children < 6 years of age in the US

• Serious toxicity: adult preparation > chewable vitamins with iron

• Prenatal and postnatal iron supplement: increase risk of poisoning in older sibling

• 4-time increase in the risk of iron poisoning to the older sibling of a newborn during the first postpartum month.

Iron poisoning in young children: association with the birth of a sibling. CMAJ. 2003;168:1539–1542.

Clinical presentation

• Gastrointestinal (GI) phase: 30 minutes to 6 hours after ingestion

• Latent, or relative stability, phase: 6 to 24 hours after ingestion

• Shock and metabolic acidosis: 6 to 72 hours after ingestion

• Hepatotoxicity/hepatic necrosis: 12 to 96 hours after ingestion

• Bowel obstruction: 2 to 8 weeks after ingestion

Iron supplement

Salicylate

•Aspirin

•Salicylic acid (topical keratolytic agent)

•Oil of Wintergreen (น ามนมวย), น ามนระก า •Analgesic balm

•ยาธาตน าขาว active ingredient (salol, phenyl salicylate)

Toxic dose of aspirin

•Mild intoxication: 150-200 mg/kg

•Severe intoxication: 300-500 mg/kg

Salicylate

1 teaspoon (oil of wintergreen) = 5 g of methyl salicylate or 7.5 g of aspirin

Mechanism of action

•Inhibition of cyclooxygenase results in decreased synthesis of prostaglandins, prostacyclin, and thromboxanes

•Stimulation of the chemoreceptor trigger zone in the medulla causes nausea and vomiting

•Direct activation of the respiratory center

•Uncouple oxidative phosphorylation

Hydrocarbons

•Gases: methane, propane

•Liquid: toluene, xylene, kerosene, turpentine, benzene, gasoline

• semisolid: petroleum jelly

Pesticides

•Oragnophosphates

•Carbamates

•Pyrethrin/ pyrethroid

•Paraquart/ diquart

•Rodenticides

Oxymethazoline

•ยาหยอดจมกเพอลดอาการคดจมก

Mechanism of action

Sulfonylurea

•Prolonged duration of action

•Metabolized by the liver

•Excreted by the kidneys as an active metabolite

Mechanism of action

Gun blue (Selenious acid)

Use of gun blue

•Change the color of steel from silver-grey to blue-grey

•Chemical darkening and patination of copper, brass and bronze

•Reagent for alkaloids, as an oxidizing agent and as an isotope for labelling radiopharmaceutical compounds.

Patination of copper, brass and bronze

Toxicity

•Inhibition of activity of sulfhydryl-containing enzymes

•Corrosive effect, PH 1.5

•In fatal ingestion: •Hepatoxicity •Nephrotoxicity •Discoloration of the skin and viscera

Diphynoxylate-atropine

Diphynoxylate-atropine toxicity

•The first phase (anticholinergic toxidrome) • Last for 2-3 hr

•Opioid phase • Much longer than 1st phase • Miosis, lethargy, apnea, and respiratory

depression (13-24 hr after ingestion)

The Journal of Emergency Medicine, Vol. 34, No. 1, pp. 71–75, 2008

Calcium channel blockers

1. Phenylalkylamines: verapamil, gallopamil

2. Benzothiazepines: diltiazem

3. dihydropyridines (nifedipine, amlodipine, aranidipine, azelnidipine, barnidipine, benidipine, cilnidipine,clevidipine, efonidipine, felodipine, lacidipine, lercanidipine, manidipine, nicardipine, nilvadipine, nimodipine, nisoldipine, nitrendipine, and pranidipine)

Pharmacology

•Dihydropyridines: selectively to vascular smooth muscle calcium channels > cardiac calcium channels

•Non-dihydropyridines: cardiac calcium channels > vascular smooth muscle calcium channels

Blood lead level after leaded gasoline removal in Thailand

Place/ Year Age group Number of population

author BLL (mcg/dL)

BLL> 10 mcg/dL

Chiangmai/ 1995-1997

6Mo - 6Yr 1,000 - 4.97 +/- 3.17 4.4%

- / 2005 6Mo – 4Yr 269 Chomchai C 5.65 +/- 3.65 8%

Tak/ 2010 3-7 Yr 220 QSNICH, Bureau of Occupational and Environmental Diseases

- 26%

Sources of lead

• lead containing paint/pigment

• Soil/dust near lead industries

• Glaze pottery, ceramic wear, Benjarong

• Plumbing leachate

• lead solder

• Battery recycling

Lead poisoning

•Level of action: 5 mcg/dL

•Level of concern: 10 mcg/dL

Sources of lead

Blood lead levels considered toxic

Before 1971 ≥60 mcg/dL

1972-1975 ≥40 mcg/dL

1975-1985 ≥30 mcg/dL

1985-1991 ≥25 mcg/dL

1991-2012 ≥10 mcg/dL

2012-present Any detected level

Lead toxicokinetics

Absorption • Ingestion

Children 40-50% Adult 10-15%

• Inhalation 30-40%

• Increase absorption Fe, Ca, Zn deficiency Fasting Malnutrition

• Skin 0.06%

Distribution

• Blood RBC: plasma = 99:1

• Soft tissue (liver,

kidney, brain, bone marrow)

• Bone (children 70%,

adult 95%)

Elimination Renal T1/2

25 days (adult) 10 months (children) 40 days 10-20 years

Hum Toxicol. 1985;4(4):401

Environ Health Perspect. 1990;89:75

Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine (CSEM): Lead Toxicity Cover Page 2008

www.atsdr.cdc.gov/csem/lead/pbcover_page2.html

Neurocognitive development

• 4.6-point decrement in IQ for each 10-μg/dL increase in BLL (children age 3-5 yr)

• 7.4 point loss, for the subset of children in the 1 to 10 μg/dL BLL range

• Loss 1 to 2 IQ points for chronic BLL increases from 10 to 20 μg/dL

N Engl J Med. 2003;348:1517-1526

CDC. Interpreting and managing blood lead levels <10 μg/dL in children and reducing childhood exposures to lead, 2007

Screening questions for lead poisoning

•อยในเขตอตสาหกรรมทเกยวของกบสารตะกว • มสมาชกในครอบครวท างาน: ซอมและยาเรอ, ท าเครองประดบ, กอสรางหรอรอถอนอาคาร, ชางประปา, ส, หมอน ารถยนต, หลอมตะกว, แบตเตอรรถยนต, เบดตกปลา, อวนหาปลา

•สหลดลอก, ใชสน ามนทาภายในบาน •ใชแบตเตอรเตมไฟในบาน •คนในบาน ชมชน โรงเรยน ศนยเดกเลก เปนโรคพษจากสารตะกว หรอ สมผสตะกว

Clinical presentation

Primary prevention for lead exposure

ปจจยเสยง กลยทธ

1 สงแวดลอม ส แนะน าใหใชสไรสารตะกวส าหรบทาภายใน

ฝ น ท าความสะอาดโดยการเชดถดวยน า (wet mop) แทนการกวาด, ลางมอบอยๆ

ดน ใหเลนในบาน หรอ ลางมอบอยๆ

น าดม ใชภาชนะและทอประปาทไมใชโลหะเคลอบตะกว, เซรามค หรอ ฟวเตอร, ใหเปดน าประปาทงในชวง 2 นาทแรก

2 ผปกครองทมอาชพเกยวของกบตะกว เปลยนเสอผาและอาบน าเมอกลบถงบาน

3 เดก Hand-mouth behaviors

ลางมอบอยๆ

โภชนาการ แนะน าใหกนอาหารทมธาตเหลกและแคลเซยมสง ไขมนต า

พฒนาการชา ใหตรวจระดบตะกวในเลอด

Toilet cleaners, caustic agents

HF

Button battery

•Toys

•Hearing aid

•Watch

Chest X-ray

Double-ring shadow

A coil lodged in esophagus

Mechanism of toxicity

•Pressure necrosis

•Local electrical current

•Leak of alkali solutions and heavy metals (lithium, mercury) rare

EsophagoGastroDuodenoscopy

Button Battery

CR2032

Lithium, diameter 20 mm, height 3.2 mm

Battery identification • Button batteries range in diameter from 6 to 25 mm

• Lithium batteries: common (lasting, higher voltage, lighter)

• Batteries that are larger than 12 mm in diameter are most likely to become lodged in the esophagus, especially in young children

• The chemical content identification • L: Manganese dioxide

• S: Silver oxide

• P: Oxygen

• C: Manganese dioxide

• B: Carbon monofluoride

• G: Copper oxide

• LR (or AG): Alkaline

• SR: Silver oxide

• CR: Lithium/manganese dioxide

• BR: Lithium carbon monofluoride

International electrotechnical Commission. www.iec.ch/ (Accessed on June 02, 2010)

Battery identification

Li, diameter 20 mm, height 3.2 mm

Li, diameter 20 mm, height 2.5 mm

Li, diameter 16 mm, height 3.2 mm

Prevention

Medicines

•Only take prescription medications that are prescribed to you by a healthcare professional..

•Never take larger or more frequent doses of your medications

•Never share or sell your prescription drugs

•Take your prescribed medicine as direction of the label

•Read all warning labels

Medicines •Some medicines are not safe when you take with medicines or drink alcohol.

•Turn on a light when you give or take medicines at night so that you know you have the correct amount of the right medicine.

•Keep medicines in their original bottles or containers.

•Monitor the use of medicines prescribed for children and teenagers, such as medicines for attention deficit hyperactivity disorder,

Medicines and household products

•Keep in a locked cabinet where a child cannot reach them

•Do not put your medicines on the table or anywhere children can reach them

•Child safe cap

•After use, put them away and out of sight in a locked cabinet where child cannot reach them

Medicines and household products

•Be aware of any legal or illegal drugs that guests may bring into your home.

•Ask guests to store drugs where children cannot find them.

•Pillboxes, purses, backpacks, or coat pockets are not the safe places

•Do not call medicine "candy"

What to do if poison occurs ?

•Remain calm.

•Call 1669 if you have a poison emergency and the victim has collapsed or is not breathing.

•If the victim is awake and alert, dial 02-4197007 or 1367

What to do if poison occurs ?

•Try to have this information ready: • the victim’s age and weight • the container of the poison if available • the time of the poison exposure • the address where the poisoning occurred

•Stay on the phone and follow the instructions from poison control center.

งเหา (Cobra)

•พบไดทง ใน และ นอกแหลงชมชน และ ในปา •แผแมเบยไดและมดอกจน

งจงอาง (king cobra)

•พบไดในปาทวทกภาคของประเทศ • แผแมเบย แต ไมมดอกจน

งสามเหลยม (banded krait)

•พบได ทราบลมใกลแหลงน า ปาชายเลน และทงนา ทวประเทศ

งทบสมงคลา (Malayan krait)

•พบได ทราบลมใกลแหลงน า ปาชายเลน และทงนา ทวประเทศ

งแมวเซา (Russell’s viper) •พบได ทดอนแหง ทงนา บรเวณภาคกลางและ ภาคตะวนออก ขดตวนอนตามโพรงดน ซอกหน หรอ พงหญารก

งกะปะ (Malayan pitviper)

•พบได ตามซอกหน ใตใบไมรวง ในสวนยางพารา พบบรเวณทลมในปาชนทวทกภาคของประเทศ

งเขยวหางไหม (Green pitviper)

•พบไดตามพมไม หรอบนตนไมใกลแหลงชมชน ทวทกภาคของประเทศไทย

Snake bite prevention

•Immediately call the animal control agency

•Be aware of snakes that may be swimming in the water or hiding under debris or other objects.

•If someone are bitten, try to see and remember the color and shape of the snake.

•Do not pick up a snake or try to trap it.

Areas that might be related to specific snake bite

Area Specific snake bite

กรงเทพมหานคร งเขยวหางไหม งเหา บนตนไม งเขยวหางไหม สวนยางพารา งกะปะ ในบาน เวลากลางคน ขณะนอนหลบ

งทบสมงคลา

ในทะเล หรอ รมทะเล งทะเล

แนวทางการดแลผ ปวยถกงกดและไดรบพษจากสตว , สภากาชาดไทย 2555

What TO DO if You or Someone Else is Bitten by a Snake ?

• Try to see and remember the color and shape of the snake,

• Keep the bitten person still and calm. This can slow down the spread of venom if the snake is poisonous.

• Seek medical attention as soon as possible.

• Dial 1669 for Emergency Medical Services (EMS).

• Apply first aid if you cannot get the person to the hospital right away.

• Lay or sit the person down with the bite below the level of the heart.

• Tell him/her to stay calm and still.

• Cover the bite with a clean, dry dressing

• Pressure immobilization

What not to do if you or someone else bitten by a snake ?

• Do not pick up the snake or try to trap it (this may put you or someone else at risk for a bite).

• Do not apply a tourniquet.

• Do not slash the wound with a knife.

• Do not suck out the venom.

• Do not apply ice or immerse the wound in water.

• Do not drink alcohol as a pain killer.

• Do not drink caffeinated beverages.

Pressure immobilization

Take home message

• เมอเดกเรมหยบของชนเลกๆได (pincer grasp) อบตการณของ poisoning and overdose เพมขน

• เกบสารเคมและยาใหอยนอกสายตาเดก และอยในต ทลอคกญแจ •อยาเกบสารเคมทเหลอ หรอ แบงเกบไวในภาชนะอาหารหรอเครองดม

•“One pill or one swallow can kill” •Screening questions: lead poisoning •จดเบอรโทรฉกเฉน 1669, 1367, 02-419-7007 •จดจ าลกษณะของง, pressure immobilisation

Siriraj Poison Control Center

Hot line: 02-419-7007