Poisoned Child Flashcards
(54 cards)
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.
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
- Infants
3
Q
What kind of poison is the most common exposure for children under 5?
A
4
Q
What is the most common disposition poisons calls for children?
A
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
6
Q
List some examples of potentially lethal “1 pill can kill” substances?
A
- Amphetamines
- Betablockers
- Calcium Channel Blockers
- Digoxin
- Opioids
- Sulphonylureas
- Tricyclic antidepressants
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
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
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
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
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
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
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?
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
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
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
- Anticonvulsants
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
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
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”
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
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 !)
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
What is the rationale for GI decontamination and some methods?
“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
What are some complications of ipecac (dried root that causes emesis)?
* Protracted vomiting
* Oesophageal/Mallory Weiss tears
* Pneumomediastinum
* Gastric rupture
* Intracranial Haemorrhage
27
What is activated charcoal?
* 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
What are the complications of activated charcoal?
* Vomiting
* Charcoal aspiration/pneumonitis
* Adsorption of oral antidotes
* Messy
* Bowel obstruction/ileus
29
What are the indications for activated charcoal?
* 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
What are some contraindications to activated charcoal?
* NOT for metals (Li, K), alcohols, hydrocarbons, corrosives “MACH”
* Low GCS
* Seizure risk
* Ileus
31
When do you consider whole bowel irrigation and how do you prepare?
* 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
What are contraindications to whole bowel irrigation?
* bowel obstruction,
* perforation,
* ileus,
* unprotected airway
33
What is enhanced elimination?
* 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
What pharmacokinetic properties are suitable for haemodialysis?
* 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
What substances are suited for haemodialysis?
* Indicated for severe poisoning by
* Toxic alcohols-methanol, anti-freeze (PEG)
* Lithium
* Salicylates-severe only
* Theophylline
* Valproic acid-severe
* Carbamazepine -severe
36
What is considered as toxic ingestion of paracetamol and how do you use a nomogram?
* 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
What are some symptoms with clonidine overdose?
* 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
Symptoms of red back spider bite and how to treat?
* 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
What are some symptoms of a bite from funnel-web spider/big black spider?
* 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
How do you manage a bite from funnel-web spider/big black spider?
* Pressure Bandage Immobilisation
* ResuscitationwithABC
* Large bore IV access
* Anti-Venom if signs of systemic envenomation
* Consult with Clinical Toxicologist (PIC)
* Admit to ICU
41
What are some symptoms of a brown snake bite?
* Collapse-cardiotoxins
* Venom Induced Consumptive coagulopathy
* Low fibrinogen
42
What are some symptoms from a bite from the black snake group?
* RBBS, BBBS
* Local & systemic symptoms
* Mulga & Collett’s snakes
* Myotoxic
* Rhabdomyolysis
* Renal failure
43
What are some symptoms from tiger snakes and taipans?
* Neurotoxic (pre-synaptic)
* EYES: Ptosis and opthalmoplegia
* VICC coagulopathy
44
What are some symptoms from a death adder snake bite?
* Neurotoxicity (post-synaptic)
45
What are some do's and don'ts for snake bites?
* 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
What are some indications for pressure immobilisation bandages?
* All Australian snake bites (incl. sea snake)
* Funnel web spider bite
* Blue-ringed octopus
* Cone shell sting
47
Describe the technique for pressure immobilisation bandages?
* 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
How do you diagnose snake envenomation?
* Clinical diagnosis based on
* Geography
* Circumstances of the bite
* Symptoms & signs
* Laboratory results
49
How do you use a snake venom detection kit?
* 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
How do you give snake antivenom?
* 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
What is a complication from box jelly fish envenomation?
Cardiac arrest in a few minutes
52
How do you treat a box jelly fish sting?
* Remove tentacles
* Vinegar
* Anti-venom available
53
How do you treat bluebottle stings?
* Painful- responds to heat
* Put other limb in hot water too as a control to avoid burns
54
