POISONING

POISONING IN CHILDREN
Poison is a substance that causes harm if it gets into the body. The poisoning in children could occur due to diverse causes and could be classified as

accidental, homicidal or suicidal.

Erroneous administration of over dosage of drugs by the parents or by the medical staff is also frequent.

Acute exposure is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less. Chronic exposure is contact that lasts for many days, months or years. A poison may get into the body through ingestion, inhalation (gas, vapors, dust, fumes, smoke, spray), skin contact (pesticides), or injection (bites and stings, drug injection Accidental poisoning in children is a global problem. The relative importance of poisoning as a cause of childhood morbidity and mortality increases when malnutrition and infections are brought under control. Accidental poisoning is the twelfth leading cause of admissions in pediatric wards in India and accounts for about one percent of the hospitalized patients. Most cases of accidental poisoning are preventable. Continuing morbidity and mortality due to accidental poisoning is serious challenge to the pediatricians and public health officials.

Pattern of poisoning:
Chemical products, most often swallowed by children include household cleaners (bleach, detergents) fuel (kerosene, paraffin), cosmetics, medicines, paints and products for household repairs and household pesticides. Bites and stings of animals and insects, and ingestion of poisonous plants and seeds also considerably account for outdoor poisoning in children.

 Carbon monoxide poisoning can happen when fires, stoves, heaters or ovens are used in rooms, huts which do not have proper ventilation to let the gas out. Environment: Lead poisoning is common in children living in areas were there are workshops for automobile, lead storage batteries or for manufacture of lead typesets for printing presses. Caustic soda poisoning used to be observed frequently in children of families, which prepared washing soap for domestic or commercial purposes in their own houses. Insecticides, medicines, naphthalene balls and kerosene are common household things which are potential hazards.

Rural or Urban areas:

The pattern of poisoning varies in rural and urban areas due to exposures to different types of potential poisons. Snakebites are more common in those wandering in fields.Also pesticides are more common in rural set up. The poor are driven by starvation to experiment on roots and fruits thus leading to poisoning.

Classification of poisons:
Based on the chief symptoms they produce

Corrosives- strong acids, strong alkalis, metallic salts. Irritants- organic, inorganic. Systemic- cerebral, spinal, peripheral, CVS, asphyxiants. Miscellaneous- food poisoning & botulism. Non toxic common household agents Shampoos, toothpaste, lipstick, creams, shaving cream, toilet soaps, cosmetics, hair dye/oil. Antacids, house lizards, non nitrate fertilizers, newspaper, adhesives, water colors, chalk, ink Important causes of child poisoning: Kerosene and other hydro carbons(8-55%) Household products-insecticides, rodenticides, phenol, alkalis, turpentine, camphor, Drugs- iron salts, barbiturates, anticonvulsants, antihypertensives, aspirin, antiseptics(16-30%).
naphthalene, neem oil, alcohol(14-30%). (ball point/ fountain pen), candles.

 Plant and plant products- Dhatura, castor seeds(6-32%). Food poisoning(7-15%). Venomous bites & stings(7-11%).
History taking

What poison was ingested. Time since ingestion. Total amount of poison ingested. Route of exposure. Progression of signs and symptoms since ingestion. Family history of epilepsy, mental sub normality, bleeding disorder. Whether the patient is receiving other medications which may interact with the poison.

General signs and symptoms

Symptoms-odor, sweating, fever, delirium, convulsions, burns of mouth, blindness, GI symptoms, abnormal movements, coma. Signs- miosis, mydriasis, blindness, facial twitching, dull & mask like expression, pallor, cyanosis, hypothermia, sweating, respiratory symptoms, CVS symptoms, CNS symptoms.

Poisoning severity Grades

None(0)- no symptoms or signs/vague symptoms judged not to be related to poisoning. Minor(1)- Mild, transient & spontaneously resolving symptoms. Moderate(2)- pronounced or prolonged symptoms. Severe(3)- severe or life threatening symptoms.

Diagnosis of Poisoning

Cardiac arrythmias. Tricyclic antidepressants, amphetamine, aluminium phosphide, digitalis, theophylline, arsenic, cyanide, chloroquin. Metabolic acidosis. Isoniazid, methanol, salicylates, phenformin, iron, cyanide. GIT disturbances. Organophosphorus, arsenic, iron, lithium, mercury. Cyanosis. Nitrobenzene compounds, aniline dyes, and dapsone.

Basic Management of a poisoned patient

Antidotes are available for very few commonly encountered poisons, and treatment is usually nonspecific and symptomatic. In such cases management consists of emergency first aid and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counseling.

Identification of Poison
Identify the poison by careful history and helpful clues. Determine what, when and how much of the poison was ingested or inhaled. Find the supporting evidence for your diagnosis from the nature of the symptoms and physical signs. Some common toxidromes based on certain signs and symptoms :

Principles of Management

Removal of the patient from the site of poisoning. Initial resuscitation and stabilization. Symptomatic and supportive measures. Removal of unabsorbed poisons- from GI tract or from skin, eye. Hastening the elimination of absorbed poisons. Use of specific antidote if available Disposition of the patient with advice for prevention.

Emergency Stablization Measures:

The unconscious patient should be transported in the headdown semiprone position to minimize the risk of inhalation of gastric contents. A clear airway is established and ventilation is maintained. Potentially serious abnormalities such as metabolic acidosis, hyperkalemia and hypoglcymia may require correction as a matter of urgency. Neurological assessment is made by calculating the Glasgow Coma Score (GCS).

Initial resuscitation stabilization:

Includes airway- proper positioning head tilt and chin lift, suction of secretions from oropharynx, falling back of tongue is prevented by suitable airway tube. Breathing- oxygen via a mask, when gag/cough reflects is absent- ET tube inserted. if necessary positive pressure ventilation with ABG monitoring, respiratory stimulants for severe respiratory depression. Circulation- proper IV access, maintenance of fluid & electrolyte balance, IV drugs for treatment.

Symptomatic & supportive Management:

Hemodynamic support- elevation of foot end of the bed, oxygen administration, IV fluids, blood products. Cardiac dysrrhythmias- correction of hypoxia, acidosis, hypokalemia, ECG, treatment with antiarrhythmic drugs. Convulsions- correction of hypoglycemia/hypocalcemia/hypoxia/cerebral edema and other metabolic defects, anticonvulsant therapy. Management of hypothermia- cover with a blanket, thermo neutral environment maintenance, pre warmed IV fluids and inspired gases. Management of pulmonary edema- administer 100% oxygen, intermittent positive pressure ventilation, IV aminophylline(5-8mg/kg), IV frusemide(1-2 mg/kg). Management of stress ulcers- NG intubation, cold saline wash, administration of antacids, H2receptor antagonists.

Management of pain- analgesics (preferably- narcotics).

Removal of Toxin
The aim of decontamination procedures is to reduce the absorption of poison. It can be achieved by:

Eye decontamination. Ocular exposure to solvents, e.g., hydrocarbons, detergents, and alcohol, or corrosive agents, e.g., acid or alkalis require immediate local decontamination. This is achieved by copious irrigation with neutralizing solution (e.g., normal saline or water) for at least 30 minutes. Do not use acid or alkaline irrigating solution. Dermal decontamination. Absorption of organophosphorus and related compounds through cutaneous route can prove to be a fatal as oral route absorption. Cutaneous absorption depends on several factors such as lipid solubility, skin condition, location, caustic effect, physical conditions

Remove all contaminated clothes and irrigate the whole body including nail, groin, skinfolds with water or saline as soon as possible after exposure and continue irrigating for at least 15 minutes. Water should not be used to decontaminate skin in exposures to sodium and phosphorus. In certain cases, specific agents may be indicated for skin decontamination (e.g., mineral oil for elemental sodium, Neosporin for super glue and calcium gluconate for hydrofluoric acid). Gut decontamination. This includes (i) gastric evacuation; (ii) adsorbent administration; and (iii) decontamination. catharsis. Emesis is the preferred method of emptying the stomach in conscious children. Vomiting can be induced by (a) tickling the fauces with a finger, feather or a leafy twig of a tree; (b) administration of copious draughts of warm water; (c) gurgling with non-detergent soap; or (d) saline emetics in warm water. To prevent aspiration in small children, the head should be kept low. Syrup of ipecac may be used for inducing emesis in children older than 6 months in a single dose of 10 mL for 6-12 months age, and 15 mL for children above 1 year of age. The dose may be repeated in 20 minutes for those more than 1 year of age. Induction of vomiting is contraindicatied in corrosive or kerosene poisoning and in comatose patients or those with absent gag reflex.

Gastric Lavage. If the vomiting does not occur quickly, gastric lavage should be done promptly to remove the poison. In a symptomatic but alert patient with minor ingestion, activated charcoal alone by mouth is sufficient for gastrointestinal decontamination Gastric lavage should not be performed in children with poor gag reflex or corrosive ingestion. In kerosene poisoning, lavage may be done very cautiously if the child has consumed a large gulp of kerosene and is brought quickly to the hospital, otherwise it is better to avoid stomach wash.

Adsorbent administration
An agent capable of binding to a toxic agent in the GIT is known as adsorbent. Activated charcoal is the most widely used adsorbent. It is created by subjecting carbonaceous material e.g., wood, coal etc. to steam at 600-900 degree Celsius and acid.

Catharsis
Laxative and purgatives may be given in poisoning with substances which do not cause corrosive action on gastrointestinal mucosa. Increased motility of the gut may reduce absorption. Commonly used cathartics include sorbitol and mannitol (1-2 g/kg), and magnesium or sodium sulfate (200-300 mg/kg). Do not give magnesium salt cathartics in cases with renal failure. Specific Antidotal Therapy

The antidotes may be physiological, chemical or physical. Chemical antidotes combine with the poison and render it innocuous. Physiological antidotes counteract the effects of the poison on the metabolism and physiological functions of the body and thus prevent its harmful effects. Physical antidotes prevent the contact of the poisonous substance with the target organ or adsorb the toxic components, thus preventing their toxicity. Specific antidotes may be life saving but unfortunately they are not often available and are effective for less than 5% of poisoning cases. When obtainable, they must be given without delay for maximum protective action. Antidotes now considered obsolete include universal antidote for ingested poisons, acetazolamide for modification of urinary pH, ascorbic acid for methemoglobinemia, castor oil as cathartic, nalorphine for opiates, sodium chloride for emesis and tannins for alkaloids. Hemodialysis, hemo-perfusion and peritoneal dialysis. Drugs which can be removed reasonably effectively by hemoperfusion and haemodialysis include barbiturates, carbamazepine, salicylates, theophylline, dapsone, most antibiotics, lithium, chloral hydrate, methanol and ethylene glycol. In general, hemoperfusion with coated charcoal or exchange resins is more preferred for simultaneous correction of acid-base and electrolyte balance (e.g., in salicylate poisoning). Hemodialysis is also the method of choice for removal of methanol, ethylene glycol and lithium.

Peritoneal dialysis is much less effective and it is used rarely. It has the advantage that is does not require special facilities but may be complicated by fluid and electrolyte abnormalities, perforations, peritonitis and adhesions.

Supportive Therapy

Keep the airway open, give oxygen for inhalation and be prepared for intermittent positive pressure respiration. Fluid and electrolyte balance is maintained. Circulatory failure should be managed to sustain life. Anemia is treated with packed cell transfusion. Severe convulsions and status epilepticus are treated with diazepam or midazolam. Renal failure is managed as per standard protocol; dialysis may be needed. Infections are treated with antibiotics. Fever and pain are relived with antipyretics and analgesics.

Some Specific Poisons and Antidotes

KEROSENE POISONING

Clinical features Age 1 to 3 years more than 70% symptomatic within

10 hours

SYMPTOMS
RS breathlessness, cough CNS convulsions, coma GPE fever, restlessness, cyanosis GI vomiting, diarrhea Lab Investigations Blood Leukocytosis X Ray changes Changes appear within one hour - commonly right basal infiltrates - emphysema - pleural effusion - pneumatocoeles

Management

 Avoid emetics Avoid gastric lavage In case of massive amount use a cuffed endotracheal tube After lavage leave magnesium or sodium sulphate in the stomach Oxygen may be useful Assisted Ventilation Antibiotics - Penicillin G 50000/Kg/24 hrs IV qid Kanamycin 10-15mg/Kg/24 hrs - IM bd Steroids Not helpful
Complications

Pneumothorax Pneumatocoeles Pleural effusion Bronchopneumonia Coma

Organophosphorus (insecticides and pesticides) Poisoning:

Organic phosphate insecticides cause irreversible inhibition of the enzyme cholinesterase. As result acetylcholine accumulates in various tissues. Excessive parasympathetic activity occurs. These agents are absorbed by all routes including skin and mucosa. Symptoms manifest quickly usually within a few hours and include weakness, blurred vision, headache, giddiness, nausea, and pain in chest. These patients have excessive secretion in the lungs and they sweat profusely. Salivation is marked. Pupils are constricted and papilledema may occur. Muscle twitching, convulsions and coma occur in severe cases. Reflexes are absent and sphincter control is lost.

Treatment

If the insecticide was in contact with skin or eyes, these are thoroughly washed. Stomach wash is done.

Atropine sulphate: 0.03 to 0.04 mg/kg IV (atropine sulphate is usually available in ampules 1 in 1,000 or 1 mg/mL). Other strengths may also be available. Repeat half the dose in 15 minutes and if necessary every hour (until signs of toxicity appear), subject to a maximum of 1 mg/kg in 24 hours. Pralidoxime (PAM) is given in dose of 25-50 mg/kg IM or IV over 30 min infusion. The dose may be repeated in 1-2 hours, then at 6-12 hour intervals as needed. Monitor for hypertension. Never inject morphine, theophylline, aminophylline or chlorpromazine. Intravenous fluids should only be given with caution. No oral tranquilizers are administered. Artificial respiration may be necessary to sustain life.

Iron Intoxication
Ingestion of a number of tablets of ferrous sulphate may cause acute poisoning. Lethal dose is 300 mg/kg of iron. Severe vomiting and diarrhea occur. These may contain blood due to extensive gastrointestinal bleeding. The child may go into severe shock, hepatic and renal failure within a few hours or after a latent period of 1 to 2 days

Treatment
Vomiting should be induced and stomach should be washed with sodium bicarbonate solution. Shock is corrected by infusion of fluids parenterally. Three mL of 7.5 percent sodium bicarbonate solution per kg of body weight are diluted with 3 times its volume of 5 percent glucose solution and injected intravenously for treatment of acidosis. This dose may be repeated after an hour if acidosis is persisting.

Acetaminophen (paracetamol)
It is safe in pharmacological doses. Overdosage may cause hepatic damage. Acetaminophen overdosage is treated with ACETYLCYSTEIN to be used orally within 16 hours after ingestion in a loading dosage of 140 mg/kg diluted to 5 percent solution orally followed by 70 mg/kg q 4h for another 16 doses.

Hydrocarbon Poisoning

These may be divided into aliphatic or aromatic compounds. Aliphatic hydrocarbons include kerosene, turpentine, lubricating oils, tar and have greatest risk of aspiration and pulmonary symptoms. Aromatic compounds have mainly neurological and hepatic toxicity and include benzene compounds. Induced emesis or gastric lavage is contraindicated for kerosene oil poisoning. It is done only when large quantities of turpentine have been ingested or the hydrocarbons product contains

benzene, toluene, halogenated hydrocarbons, heavy metals, pesticides or aniline dyes. Other specific modalities including steroids and antibiotics are not efficacious.

Carbon Monoxide Poisoning

Carbon monoxide poisoning results from inhalation of fire smoke, automobile exhaust, fumes from faulty gas stoves and ingestion of paint and varnish removers. Clinical manifestations include headache, cyanosis, convulsions, and coma. Patients are administered 100 percent oxygen and if carboxyhemoglobin levels are above 40 percent, hyperbaric oxygen therapy is considered.

Lead Poisoning
Chronic lead intoxication occurs usually in children who eat non-edible substances (pica) and manifests as pain in abdomen and resistant anemia. Lead is deposited in the bones. Acute infections may mobilize lead from storage areas in bones and cause acute lead poisoning leading to acute lead encephalopathy.

Treatment
In symptomatic children, therapy is usually started with dimercapol (BAL) (75 mg/m2 every 4 hourly IM). BAL may be stopped after 48 hours, while calcium disodium edetate is used for another 3 days but at a lower dosage of 50 mg/kg or 1000 mg/M2 per 24 hours by continuous IV infusion.

Barbiturate Poisoning

Clinical features include hypoxia, depression of respiration, pulmonary complications and kidney failure. Peripheral vascular bed is dilated; shock which may sometimes be delayed may occur

Treatment

Hypoxia is managed by oxygen inhalation and maintenance of open air way. Circulatory collapse is treated with fluids and plasma. Patients do not respond to epinephrine. Urine is alkalinized to facilitate excretion of barbiturates. Mannitol is given. This causes osmotic diuresis. In severe cases peritoneal dialysis may be necessary to remove barbiturates.

Cyanide Poisoning
Sodium nitrite 2.5 to 5 mL of 3.5 percent solution is given IV every minute followed by sodium thiosulfate 2.5 mL of 25 percent solution every minute subject to a maximum of 50 mL. Amylnitrite capsules (10mg/kg) may be inhaled.

Opium (Morphine) Poisoning

Respiratory depression occurs and pupils are constricted; patients are excessively drowsy. Treatment:- Stomach wash is done. Specific antidote for opium poisoning is naloxone given IV in a dose of 0.03 mg/kg/dose. If there is no response in 2 minutes the same dose may be repeated. Naloxone can also be given by continuous infusion (20-40 microgram/kg/h). Analeptics may be used and oxygen is administered by inhalation.

Prevention

Parental education Keep away from reach of children Properly capped containers Avoid storage in beverage bottles or colorful containers which attract children Immediately seek medical care

Laws on poison

The Drugs and Cosmetics act, 1940.

ingredients contained in it. The Pharmacy Act-1948

To control the quality, purity & strength of drugs. Any patent/proprietary medicine should display on the label or container & the list of The object of this act is to allow only the registered pharmacists to prepare, mix or dispense any
medicine on prescription of a medical practitioner.

Prepared By: Dr. Naseem Zaman Dr. Asif Dr. Maheen Dr. Sadia