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Paediatrics - SCHP Oral Viva > Poisoned Child > Flashcards

Poisoned Child Flashcards

1
Q

What is special about childhood poisoning?

A
  • Not usually deliberate self-harm
  • History difficult
  • Different types of material ingested
  • Usually small amounts and not very toxic
  • Small amounts of certain substances are potentially lethal: “one pill can kill”
  • Smaller oesophagus and stomach can limit effectiveness of decontamination techniques.
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2
Q

What are the different causes for poisoning in the context of psychosocial problems?

A

Poisoning is a manifestation of an underlying psychosocial problem

  • Adults
    • Psychiatric
    • Social
    • Drug & Alcohol
    • Environmental
    • Workplace
  • Children
  • NAI
    • Infants
      • External force
    • Toddlers
      • Behavioural
    • Children
      • Behavioural
      • Environmental
    • Adolescents
      • Similar to adults
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3
Q

What kind of poison is the most common exposure for children under 5?

A
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4
Q

What is the most common disposition poisons calls for children?

A
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5
Q

List examples of non-toxic ingestions?

A
  • Antacids
  • Antibiotics
  • Inks
  • Bath oil
  • Candles
  • Mostdetergents- except “concentrated powerballs”
  • Chalk
  • Cigarettes
  • Colognes & perfumes
  • Corticosteroids
  • Cosmetics
  • Fertiliser
  • Glues
  • Hair products
  • Hand lotions
  • Incense
  • Laxatives
  • Lipstick
  • Matches
  • Newsprint
  • Oral contraceptives
  • Paint
  • Shampoo
  • Shavingcream
  • Shoe polish
  • Silica–dessicantin boxes
  • Soap
  • Suntanlotions
  • Thermometermercury
  • Vaseline
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6
Q

List some examples of potentially lethal “1 pill can kill” substances?

A
  • Amphetamines
  • Betablockers
  • Calcium Channel Blockers
  • Digoxin
  • Opioids
  • Sulphonylureas
  • Tricyclic antidepressants
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7
Q

What are some non-pharmaceuticals that are potentially lethal?

A
  • Pesticides
    • Paraquat 1 mouthful
    • organophosphates
  • Hydrocarbons
    • Kerosene
    • Essential oils Eucalyptus
  • Household products
    • camphor
    • napthalene
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8
Q

What are important points to remember when taking a history for suspected poisoning?

A
  • Unreliable
    • Ingestion is only a SUSPICION
    • Time of ingestion unknown
  • Calculate maximal possible ingestion on mg/kg basis
  • If >1 child found with poison, need to assume that each child ingested all the poison
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9
Q

What are the principles of management for paediatric poisoning?

A
  • Resuscitation ABC’s
  • History & Examination
  • Risk Assessment
  • Poisons information: 13 11 26
  • Ongoing management
    • Supportive care and monitoring
  • D-E-A-D
    • Decontamination
    • Enhanced elimination - Multi-dose charcoal and urine alkalinisation
    • Antidotes
    • Disposition
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10
Q

What are your aims on physical examination for suspected poisoning of a child?

A
  • Identify and treat immediate threats to life
  • Establish baseline clinical status
  • Corroborate history- does it match?
  • Identify toxidromes
  • Look for alternative diagnoses “Tox vs Non Tox”
  • Identify complications of poisoning
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11
Q

Describe initial assessment and stabilisation for a poisoned child

A
  • Airway
  • Breathing
    • RR
    • O2 saturation
  • Circulation
    • Pulse
    • BP
    • Cardiac Rhythm
  • Level of Consciousness AVPU
  • Presence of Seizure Activity
  • Glucose
  • Temperature
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12
Q

What factors do you consider when conducting risk assessment of poisoning?

A
  • Substance/dose/time
  • weight
  • Clinical features
  • Investigations incl. ECG/paracetamol
  • This enables you to assess the likely severity and outcome
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13
Q

What will complete your examination when the poisoned child is stable?

A
  • Full neurological examination
    • Mental Status
    • Pupil size
    • Tone/reflexes
    • Clonus
    • Focal signs
  • Evidence of trauma
  • Skin
    • colour
    • sweating
  • Bowel sounds
  • Urine- retention?
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14
Q

What are the differentials for coma/altered mental status?

A
  • Non-Tox vs Tox
  • Head Injury
  • CNS infections
  • Metabolic
    • hypo/hyperglycaemia
    • hypo/hypernatraemia
    • acute renal failure
  • Hypo/hyperthermia
  • Ictal and post-ictal states
  • Drugs
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15
Q

What are some important secondary complications of poisoning?

A
  • Pulmonary aspiration- vomit
  • Rhabdomyolysis- long lie
  • Acute renal failure
  • Pressure areas
  • Hypoxic brain injury
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16
Q

What are some helpful drug levels in the context of drug overdose?

A
  • 4hr paracetamol level for any deliberate self poisoning
  • Others only if clinically indicated:
    • Anticonvulsants
      • Phenytoin,carbamazepine,valproate,phenobarbitone
    • Digoxin, aspirin, Li, Fe
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17
Q

Which drug levels are NOT helpful in drug overdose?

A
  • Central Nervous System
    • antidepressants
    • benzodiazepines
    • benztropine
    • cocaine
    • antipsychotics
    • opiates
    • phenothiazines
    • THC
  • Cardiovascular System
    • ACE inhibitors
    • beta blockers
    • calcium channel blockers
    • clonidine
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18
Q

Give examples of some common toxidromes

A
  • Sympathomimetic
  • Opioid
  • Anti-cholinergic: “Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.”
  • Cholinergic: central, muscarinic, nicotinic (secretions)
  • Serotonin toxicity
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19
Q

What symptoms do you get with a sympathomimetic toxidrome and list examples of substances

A
  • Symptoms
    • Hypertension
    • Tachycardia
    • Dilated pupils
    • Agitation
    • Sweating
    • Hyperthermia (urgent attention)
    • Treatment: benzodiazepines
  • Examples
    • Cocaine
    • (met)Amphetamines
    • Ecstasy/MDMA
    • Khat
    • Cathinones
    • “Bath salts”
    • Synthetic Cannabinoid Rc Agonists “synthetic marijuana”
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20
Q

What are some symptoms of an opioid toxidrome and what is the treatment?

A
  • Symptoms
    • Respiratory depression
    • Sedation
    • Pinpoint pupils
  • Naloxone is antidote mainly for respiratory depression rather than GCS
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21
Q

What are some symptoms of an anti-cholinergic toxidrome, some common causes and treatment?

A
  • Symptoms
    • Think “anti-muscarinic”
    • Agitated delirium-plants
    • Pills usually partially sedate
    • Visual hallucinations
    • Tachycardia
    • Hyperthermia
    • Dilated pupils
    • Dry flushed skin
    • Urinary retention- IDC can benefit
    • Ileus
  • Treatment: benzo’s /physostigmine
  • Common causes
    • Anti-histamines
    • Tricyclic antidepressants
    • Phenothiazines
    • Plant poisonings Datura, Brugmansia
    • Benztropine (given for dystonia !)
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22
Q

What are some symptoms from a cholinergic toxidrome, examples of causes and treatment?

A
  • DUMBBELS
    • Diarrhoea
    • Urination
    • Miosis
    • Bronchorrea, bradycardia- “Killer B’s”
    • Emesis
    • Lacrimation
    • Salivation
  • Nicotinic effects: weakness, fasciculations
  • Central effects: coma, seizures
  • Treatment:
    • Intubate
    • ATROPINE
    • wash patient
  • Examples
    • organophosphates
    • Carbamates
    • Chemical attack
    • VX
23
Q

What are some symptoms of serotonin toxicity, examples of substances and treatment?

A
  • Neuromuscular exam is key
    • – hyperreflexia, clonus (ankle)
  • Can also find:
    • Altered sensorium
    • confusion,agitation
    • Autonomic changes
    • Dilated pupils
    • Sweating
    • Hypertension
  • Treatment: benzo’s /cyproheptadine
  • Examples
    • SSRIs/SNRIs
    • MAOIs
    • TCAs
    • Amphetamines/MDMA
    • Tramadol
    • Opiates
    • Usually combinations
24
Q

What is a part of supportive care of poisoned patients?

A
  • Airway: intubation
  • Breathing: supplemental oxygen, ventilation
  • Circulation
    • defibrillation, antiarrhythmics, pacing
    • intravenous fluids, inotropes
    • control of hypertension
    • cardiopulmonary bypass
  • Metabolic
    • glucose
    • control of pH
  • Sedation
    • IV benzodiazepines
  • Seizures
    • IV benzodiazepines
    • Do not load with phenytoin (a Na Channel blocker)
  • Body temperature
    • warming
    • Cooling- control quickly
  • Renal function
    • hydration
    • haemodialysis
25
Q

What is the rationale for GI decontamination and some methods?

A

“If a poisonous substance can be removed from the gastrointestinal tract before it is absorbed, then it will be unable to exert its toxic effect.”

  • Gastric Emptying-historical only
    • Induced emesis
    • Gastric lavage
  • Adsorbent administration
    • Activated Charcoal
  • Whole Bowel Irrigation-Colonic Prep/Polyethylene glycol for slow release meds
  • Endoscopy
26
Q

What are some complications of ipecac (dried root that causes emesis)?

A
  • Protracted vomiting
  • Oesophageal/Mallory Weiss tears
  • Pneumomediastinum
  • Gastric rupture
  • Intracranial Haemorrhage
27
Q

What is activated charcoal?

A
  • Produced by superheating charcoal to remove impurities and produce small porous particles.
  • 1g/kg
  • Mixed with water to form a suspension OR ICECREAM OR COLA!
  • Given orally or via a nasogastric tube after CXR confirmation
  • Effectiveness of preventing drug absorption decreases rapidly with time, the greatest benefit is within 1 hour of ingestion.
  • Decreases Drug Concentration in some overdoses
  • Clinical outcome studies – no studies to show that AC improves clinical outcome.
28
Q

What are the complications of activated charcoal?

A
  • Vomiting
  • Charcoal aspiration/pneumonitis
  • Adsorption of oral antidotes
  • Messy
  • Bowel obstruction/ileus
29
Q

What are the indications for activated charcoal?

A
  • Risk Assessment suggests that drug ingested is expected to lead to toxicity
  • Charcoal can be administered within 1 hour of ingestion, longer if SR or massive amount
  • Co-operative patient
  • Patient is alert or airway protected
30
Q

What are some contraindications to activated charcoal?

A
  • NOT for metals (Li, K), alcohols, hydrocarbons, corrosives “MACH”
  • Low GCS
  • Seizure risk
  • Ileus
31
Q

When do you consider whole bowel irrigation and how do you prepare?

A
  • WBI may be considered for potentially toxic ingestions of:
    • Slow Release or Enteric Coated drugs: CCB
    • Metals: K, Fe
    • Body packers
  • Similar to preparing bowel for colonoscopy- drinking bowel prep or via NG tube
32
Q

What are contraindications to whole bowel irrigation?

A
  • bowel obstruction,
  • perforation,
  • ileus,
  • unprotected airway
33
Q

What is enhanced elimination?

A
  • Increasing elimination of drugs already absorbed
  • Multi dose activated charcoal- enterohepatic circulation
    • carbamazepine, mushrooms,
  • Urinary alkalinisation- only for salicylates, “ion trapping” of drug in urine
  • Haemodialysis/CVVHD/Haemoperfusion
34
Q

What pharmacokinetic properties are suitable for haemodialysis?

A
  • Drug must have particular pharmacokinetic properties
    • low molecular weight
    • low protein-binding
    • Water soluble
    • small volume of distribution, ie: drug mostly in the blood, not in tissues
35
Q

What substances are suited for haemodialysis?

A
  • Indicated for severe poisoning by
    • Toxic alcohols-methanol, anti-freeze (PEG)
    • Lithium
    • Salicylates-severe only
    • Theophylline
    • Valproic acid-severe
    • Carbamazepine -severe
36
Q

What is considered as toxic ingestion of paracetamol and how do you use a nomogram?

A
  • Toxic ingestion >200mg/kg
  • Nomogram:
    • Single ingestion
    • Known time of ingestion
    • Level after 4hr to ensure post- peak
    • If above line, start IV N-acetylcysteine antidote
  • For chronic paracetamol and slow release -> consult guidelines or a toxocologist
37
Q

What are some symptoms with clonidine overdose?

A
  • Centrally acting alpha 2-agonist
    • Common because of ADD
  • Symptoms
    • CNS depression and bradycardia >24 hours
    • Transient initial hypertension
  • Treatments
    • Generally responds to IV fluid bolus and IV atropine
    • Naloxone controversial
38
Q

Symptoms of red back spider bite and how to treat?

A
  • Commonest spider-bite in ED
  • 10-20% envenomation risk
  • Local Fx:
    • Pain, redness
    • Piloerection, sweating
  • Systemic Fx:
    • Regional pain
    • Diaphoresis, hypertension
  • Antivenom:
    • Current controversy about efficacy, not often used now.
    • Generous analgesia is usually all that is needed.
    • No bandage needed
39
Q

What are some symptoms of a bite from funnel-web spider/big black spider?

A
  • Neuromuscular excitation
    • Fasciculations (tongue!), tremor, paraesthesia (lips!)
  • Autonomic storm
    • Excessive secretions, pilo-erection
    • Tachycardia, hypertension & cardiac arrhythmias
  • Other effects
    • N/V & abdo pain
    • Non-cardiogenic pulmonary oedema
40
Q

How do you manage a bite from funnel-web spider/big black spider?

A
  • Pressure Bandage Immobilisation
  • ResuscitationwithABC
  • Large bore IV access
  • Anti-Venom if signs of systemic envenomation
  • Consult with Clinical Toxicologist (PIC)
  • Admit to ICU
41
Q

What are some symptoms of a brown snake bite?

A
  • Collapse-cardiotoxins
  • Venom Induced Consumptive coagulopathy
    • Low fibrinogen
42
Q

What are some symptoms from a bite from the black snake group?

A
  • RBBS, BBBS
    • Local & systemic symptoms
  • Mulga & Collett’s snakes
    • Myotoxic
    • Rhabdomyolysis
    • Renal failure
43
Q

What are some symptoms from tiger snakes and taipans?

A
  • Neurotoxic (pre-synaptic)
  • EYES: Ptosis and opthalmoplegia
  • VICC coagulopathy
44
Q

What are some symptoms from a death adder snake bite?

A
  • Neurotoxicity (post-synaptic)
45
Q

What are some do’s and don’ts for snake bites?

A
  • Do:
    • Remove from danger
    • Keep still
    • Apply pressure bandage
    • Immobilise entire limb
  • Don’t:
    • Panic or run
    • Attempt to catch snake
    • Apply tourniquet
    • Wash, suck or cut bite site
    • Remove pressure immobilisation bandage until adequate facilities and antivenom available
46
Q

What are some indications for pressure immobilisation bandages?

A
  • All Australian snake bites (incl. sea snake)
  • Funnel web spider bite
  • Blue-ringed octopus
  • Cone shell sting
47
Q

Describe the technique for pressure immobilisation bandages?

A
  • Firm bandage to bitten area
  • Bandage entire limb
  • Immobilise with splint
  • Instructions
    • Apply bandage over the bite site as for sprain
    • Extend bandage to cover rest of limb, from distal to proximal, including fingers/toes
    • Keep limb still using splint
48
Q

How do you diagnose snake envenomation?

A
  • Clinical diagnosis based on
    • Geography
    • Circumstances of the bite
    • Symptoms & signs
    • Laboratory results
49
Q

How do you use a snake venom detection kit?

A
  • Detects the presence of venom from:
    • Bitesite
    • Urine
    • Snake fangs
    • NOT blood
  • Preferably done by lab technician NOT you!
  • Does NOT tell you about:
    • envenomation
    • When to give AV
    • How much AV to give
50
Q

How do you give snake antivenom?

A
  • Horse-derived blood product
  • Given IV over 30min (diluted in 100mL N/S)
  • Pre-treatment with steroids/antihistamines is NOT used in most cases
  • Same dose for adults and children
  • Adverse reactions
    • Anaphylaxis can occur
    • Serum sickness (delayed)- outpatient steroids if occurs
51
Q

What is a complication from box jelly fish envenomation?

A

Cardiac arrest in a few minutes

52
Q

How do you treat a box jelly fish sting?

A
  • Remove tentacles
  • Vinegar
  • Anti-venom available
53
Q

How do you treat bluebottle stings?

A
  • Painful- responds to heat
  • Put other limb in hot water too as a control to avoid burns
54
Q
A

Paediatrics - SCHP Oral Viva (14 decks)

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