unknown exposures trivial ingestions sometimes severe
TRANSCRIPT
Overview of Pediatric Toxicology
Unknown Exposures Trivial Ingestions
Sometimes Severe Morbidity/Mortality
Michael Wahl MD, FACEP, FACMT Medical Director, Illinois Poison Center Emergency Physician, Northshore University Healthsystems
Pediatric Cases in Toxicology
• Why are Pediatric Ingestions so common? – Pediatric Poisoning: Developmental Milestones
• Epidemiology of Pediatric Poisoning – Poison Center Exposure Data – Toxic vs. Non-toxic Exposures – Trends – Significance
• Management issues • Cases
Poisoning is a matter of dose
Paracelsus (1493-1551) Third Defense
“What is there that is not poison? All things are poison and nothing without poison. Solely, the dose determines that a thing is not a poison”
Pediatric Development
6-9 months: creep, crawl, and pick up objects
Pediatric Development
9-12 months: pick up a pellet and put it in a hand
Pediatric Development
15 months: walking; pick up a pellet and put it in a bottle
Pediatric Development
18 months: able to consciously dump pellet from bottle (e.g. Tylenol, aspirin,
vitamins, adult prescription medications)
California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years
of Age • 0-6 months ABUSE • Overall: FALLS
Pediatric Poisoning • #2 leading reason for injury-related
hospitalization in children 0 to 3 years of age behind falls
The #1 reason for injury-related hospitalization and death between 18 and 35 months is
poisoning
Pediatric Susceptibility to Poisoning
• Small size: less ingested to get to a toxic mg/kg ratio
• Large surface to body ratio for relative increased in dermal absorption (e.g. oil of wintergreen products, alcohols, etc.)
• Thinner skin for increased dermal absorption • Faster minute ventilation for increased
inhalation absorption
Assessment of Pediatric Ingestion
• History – Who – What – Where – When – Why – How – The scene?
Difficulty with Pediatric History: Did they actually ingest the substance?
Toxic Alcohol Evaluation of Pediatric Patients is often Incomplete DesLauriers C, Mazor S, Metz J, Mycyk M
2 year retrospective review 33 pediatric cases of Toxic Alcohol Ingestion 21 with levels drawn 5/21 with measurable levels (24% of cases)
Pediatric exposures 5 years and under reported to AAPCC (National Data)
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2000 2003 2006 2009 2012
PediatricExposures
Pediatric Deaths Reported to AAPCC (National Data)
~ 4/100,000 pediatric exposures in PCC database result in death.
Adult Fatalities >500 times more prevalent due to intentional nature of exposures
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10
20
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2000 2003 2006 2009 2012
PediatricDeaths
Selection bias in numbers as poison centers get calls on the living, not those that are deceased on scene
Unpublished Data from National Benchmarking committee (22 centers)
95% of all pediatric calls to a poison center are managed at home without referral to a poison center.
86% of pediatric exposures that present to an ED without
calling a poison center first are discharged from the ED 66% of pediatric exposures that are referred to ED are
discharged from the ED
Analgesics
• Double Dose • Unintentional
Overdose
Tylenol >200 mg/kg ASA >150 mg/kg OPIATES
AAPCC Data Most Common Exposures (2013)
Cosmetics and personal care products:
Cleaning Substances
Foreign bodies
Most Common Pediatric Exposures
– Topical Preparations – Cough and cold preparations
• Bropheneramine >2 mg/kg • Chlorpheneramine >1.4 mg/kg • Phenylephrine >4 mg/kg • Pseudoephedrine >16 mg/kg • Dextromethorphan >10 mg/kg
– Hydrocarbons – Hormones/hormone antagonist
Topical Preparations
Pediatric Exposures • AAPCC Data Most Common Exposures (6-10)
– Vitamin – Antihistamines – Pesticides and Rodenticides – Plants – GI Preparations (e.g. simethicone)
Pediatric Exposures
• Determination of non-toxic exposures – Call the Poison Center is easiest
• It is what poison center staff person does over 30 times a day
– My Child Ate Web Content
• www.illinoispoisoncenter.org • 14,000 visits to clinical content in June, 2014
Management of Pediatric Exposures
• Decontamination • Enhanced elimination • Antidotal Therapy • Supportive Care
Decontamination
• Elimination from the gut and/or decreasing absorption – Emetic Agents (Syrup of Ipecac) – Cathartics (sorbitol, magnesium citrate) – Gastric Lavage – Whole Bowel Irrigation – Charcoal
Decontamination
All decontamination measures were started before the advent of evidence-based medicine.
No improvement in outcomes has been shown for
any of the modalities. Re-examination of practices are slowly removing
them from practice.
Ipecac
Ipecac
Ipecac
Family Guy Video:
Charcoal
• Effective at binding a variety of toxins, most beneficial if given within 60 minutes
• Dose 1 gm/kg, up to 100 gm in a single dose
Charcoal Bond, Annals of EM, 2002
Charcoal
Charcoal
Charcoal
Charcoal • Not proven to change outcome • Every year 5 to 10 deaths in poison center data from
charcoal aspiration – Always with drugs that cause decreased consciousness,
vomiting or seizures
Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit
– Risk Benefit Ratio?
Cathartics
• Use initially promoted because of clinical opinion • Most commonly used in ED is sorbitol or
magnesium citrate • Intended to decrease absorption by increasing
expulsion from the GI tract • Dosing
– Sorbitol 70 % 2 cc/kg per kg in adults – Sorbitol 35 % 4 cc/kg per kg in children – Mag citrate 4 cc/kg in children/adults
Cathartics
• Indications -- No proven benefit. By convention it was usually given with the first dose, not used for multiple dose therapy
• No longer recommending it routinely due to guideline recommendations
Gastric Lavage
Gastric Lavage Bond, Annals of EM, 2002
Gastric Lavage
• Indications -- Ingestion of a potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure
• contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding
Gastric Lavage
• Adults 36-40 french tube (children 24-28 French)
• 20 degrees trendelenburg, left lateral position • 200-300 cc aliquots of water or saline (10
ml/kg chidren, saline)
Whole Bowel Irrigation • Co-Lav • Colovage • Colyte • Colyte-flavored • Colyte with Flavor Packs • Go-Evac • GoLYTELY • NuLYTELY • NuLYTELY, Cherry Flavor
Whole Bowel Irrigation
• No proven clinical efficacy in changing outcomes • Potential to reduce drug absorption by rapidly
cleansing the GI tract • dosing
– 9 mo - 6 yo 500 ml/hr – 6 yr - 12 yo 1000 ml/hr – Adolescents/adults 1500-2000 ml/hr
Whole Bowel Irrigation
= + =
Whole Bowel Irrigation
• Indications – sustained release or enteric coated drugs – Illicit drug packages – Drugs or compounds not well absorbed by
Charcoal (e.g. iron, lead, lithium)
Whole Bowel Irrigation • 18% of IPC cases documented at
recommended rate of administration and an endpoint of clear rectal effluent – Difficult to accomplish – Time consuming – Can be messy – Inexperience and is uncomfortable for staff
General Approach
• ENHANCED ELIMINATION – Hemodialysis/Hemoperfusion – MDAC – Urinary Alkalinization
Enhanced Elimination Hemodialysis
• Water soluble • Small molecular weight • Not highly protein bound • Small Volume of distribution (<1 L/kg)
Review of Select Pediatric Cases Reported to AAPCC
• Outcome is going to be bad • Discussion of risk of exposure, treatment and
outcomes
Case #1 (Christmas Tox)
• 18 month old child thought to have a respiratory infection (cough and vomiting) by family comes to ED for evaluaton.
• CXR shows FB in esophagus and stomach
Button Battery Case #1
• Time delay in transfer to appropriate facility • Both batteries removed endoscopically • Admitted for 4 days. Barium swallow with undefined
esophageal deviation • Discharged with fever on abx and medication for acid
reflux • 4 days later found cyanotic and in shock • Death Certificate with aorto-esophageal ulcer/fistula
Button Battery # 2 • 4 yo female found pulseless and apneic with
blood around mouth and nares • Initially thought to be trauma • CXR with button battery in esophagus • Taken to operating room • Unable to resuscitate • Intra-operative finding?
Button Battery Case #3 • 4 yo cough for over a week. May have been
treated with acetaminophen. • CXR showed a 20 mm disc in esophagus • Transferred to tertiary care center, removed
endoscopically • Admitted to ICU • Developed massive GI bleed, liver failure,
renal failure • Child arrested during exploratory laparoscopy
Button Batteries • Fatal in rare cases • Over 5,500 ED visits in 2009 • Larger, newer batteries most often implicated • Burns can occur in 2 to 2.5 hours
Three hours of Hotdog vs. Button Battery
Hydrocarbons (Garage and Kitchen Sink Tox)
• 15 month old female found vomiting, cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child
• 2 yo child ingested unknown amount of cigarette lighter fluid (Zippo)
• 18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits
Hydrocarbons
• 2 yo female with Trisomy-21, swallowing problem, fed through g-tube entire life, found mineral oil bottle and thought to have ingested 5 – 10 ml.
• 15 mo male ingested and aspirated tiki torch oil at home
Hydrocarbons
• 33,000 exposures reported to AAPCC (2013) • 10,000 involved children • Low rate of admission and death
Hydrocarbons
• Important History: – When – How much (often unreliable) – Coughing – Vomiting (increases aspiration potential) – Behavior changes (lethargy, drowsiness)
Hydrocarbons
• Important signs and diagnostic exam results – Mental status – Respiratory status
• Cough • Tachypnea • Grunting/Flaring/Retractions • Fever • Pulse ox • CXR
Hydrocarbons
• 15 mo female: Taken to community hospital. Arrested and expired before helicopter transport
• 2 yo male with cigarette lighter fluid: Died in ED
• 18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center
Hydrocarbons
• 2 yo female with Down’s syndrome, rocky, long complicated course in ICU complicated by cardiac arrest, hypothermia, abdominal compartment syndrome (day 44) and expired on hospital day 45
• 15 mo male, intubated in ER, transferred to tertiary care center for ECMO, aggressive treatment for 4 days – 4th day declared brain dead
Garage Tox • Grandmother gave child an unmarked bottle
she thought was water. It was actually tire/wheel cleaner (HF)
• Child complained of pain and brought to ER drooling
• Child arrested 3 hours after presentation. Resuscitated with calcium and magnesium
• Transferred to tertiary care center, terminal arrest 7 hours after ingestion
Rattle Tox • Parents gave a bottle of Aspirin 325 mg to an
11 m/o child to play with. Unknown amount ingested, 7 tablets unaccounted for.
• Thoughts? • How to approach
Rattle Tox
• 6 hour salicylate level 107 mg/dl. Peaked at 123 mg/dl
• Labs drawn, given charcoal, started on sodium bicarbonate drip.
• In PICU became tachycardic to 220, tachypneic (50) and hyperthermic
• Patient intubated and set up for transfer to tertiary care center for dialysis and died.
Teething Tox
• 13 mo old twin A cared for by 16 yo sibling while parents went to PICU to see ill twin B.
• Brother called 911 for Twin A who developed sz (and subsequent cardiac arrest)
• Taken to ED, intubated and then patient became bradycardic and then pulseless
• 90 minute PALS care unable to resuscitate patient
Teething Tox
• Police went home and found 2% viscous lidocaine on the dining room table
• Surviving twin B with elevated lidocaine levels on blood test
• Post mortem on twin A with elevated lidocaine levels
16 yo brother had been putting lidocaine in bottles to relieve teething pain
Calcium Channel Blockers (Medicine Cabinet Or Purse Tox Or
Visiting Grandparents Tox)
• 19 month old male found with mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills.
Calcium Channel Blockers • AAPCC data with 22,082 pediatric exposures to
“cardiac medications” – No breakdown of Ca Channel blockers
• Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%)
• Extropolating to national data: over 2100 pediatric calcium channel blocker exposures – Are they all true exposures?
Calcium Channel Blockers
Calcium Channel Blockers
• Hyperglycemia • Calcium Channel blockers in the pancreatic B
islet cells • Decreased release of insulin • Can lead to HYPERGLYCEMIA
Calcium Channel blockers
• 2 yo male with ingestion of up to 450 mg sustained release nifedipine
• Unremarkable vitals initially. Glucose 253 • Upon arrival to tertiary care center, resting
tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours.
• Arrested the day after admission to tertiary care center, unable to resuscitate
Toy Tox
• 19 mo old male with complaints for vomiting and diarrhea. Discharged home
• Found unresponsive the next morning, 911 called and CPR started
• EMS and police found insecticide in room and toys
Toy Tox
• Child expired in ER • Skeletal survey done in ER to look for signs of
abuse showed portal venous gas, pneumatosis and 7 spherical bodes in the left abdomen
• Autopsy: ischemic bowel with pressure necrosis from magnets
Laundry Detergent Unit Doses (Pods)
Laundry Tox
• 7 mo male bit a laundry pod. Crying, cough and then became somnolent
• Vomiting en route to ED (vomiting and somnolence)
• Had seizure in ED • Intubated • Arrested 3 hours post exposure • Significant Right sided pulmonary congestion
and cerebral edema
Pediatrics December 2014 Evaluated poison center data for 2012 – 2013 17,000 exposures • Vomiting: 56% • Lethargy: 8% • Cough/choke: 15% • Intubation (0.6%) 1:170
Opiate Tox
• 2 yo female found with bottle of atropine/diphenoxylate (lomotil). 16 tablets removed from mouth, unknown how many ingested
• Went to ER, normal after 4 hours observation and discharged
Thoughts?
Opiate Tox • Found next morning unresponsive with
frothing at mouth and yellow secretions. • Called pediatrician and then brought to ER
when child would not awaken after 2 hours of trying to get her awake
Complicated course with aspiration pneumonia, cerebral infarction and anoxic injury, eventual herniation and death
Methadone Tox
• 9 yo had trouble sleeping. Family usually gave him benadryl, but ran out. Gave some of mom’s methadone instead.
• 2 yo drank juice then said her tongue felt funny. Went to take a nap and found cold and limp. At ER intubated and transferred to Tertiary care hospital. Drug screen came back + for methadone.
Opiate Tox
• 13 mo male given bottle of suboxone (buprenorphine and naloxone) to play with as a rattle
• Parents noted that the bottle was open and pill fragments in mouth.
• Fed child and put him to bed • Next morning child found cold and
unresponsive (Declared upon arrival to ED)
Pediatric Toxicology Summary
• Pediatric Poisoning Exposure is a common occurrence (1,000,000 + calls to PCC annually)
• Determining the dose is important, but frequently can be unreliable – Exposure does not necessarily mean poisoning – Calling poison center can help with triage decisions in
unintentional pediatric exposures
• Death is rare as a percentage of total exposed
Questions?