Acute poisoning guidelines for initial management

ACUTE POISONING
GUIDELINES FOR INITIAL
MANAGEMENT
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@yahoo.com

INTRODUCTION
• The majority of poisonings are
accidental, especially in the under-5
age group
• Intentional overdoses and substance
abuse are seen in older children
http://emedicine.medscape.com/pediatrics_general/
6/30/2013 Acute poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital

CONT.
• Deaths in children from poisoning are
becoming increasingly rare
• Factors responsible for this decline
include:
1. Introduction of child-resistant
containers
2. Reducing the pack sizes of aspirin and
acetaminophen
3. More effective management

HOW CHILDREN DIFFER FROM ADULTS
• Pediatric patients may be particularly
vulnerable to certain toxins at specific
stages of childhood.
• Breast fed infants may be exposed to
drugs or toxins excreted in breast milk;
neonates have immature metabolic
capabilities

CONT.
• Toddlers, as they develop exploratory
hand-to-mouth activity, may be
exposed to a wide range of potential
hazards

GENERAL PRINCIPLES
Assess:
Type of ingestion (drug, preparation)
Time of incident
Amount of ingestion (include all medication
that was potentially in the bottle or packet
when calculating)
Weight of child
http://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Management/

GENERAL PRINCIPLES
Cont.
Is the ingestion potentially harmful?
Beware of the possibility of mixed overdose
Beware of the possibility of inaccurate dose
reporting on history taking
If mixed or undetermined ingestion
Paracetamol level should be done
Management/

GENERAL PRINCIPLES
Management
Airway
Breathing
Circulation
Removal of poison (if necessary)
Emesis
 No role in the hospital setting
Management/

GENERAL PRINCIPLES
Cont.
 Activated Charcoal
The treatment of choice for most ingestions.
Most effective when given within first hour.
Management/

GENERAL PRINCIPLES
Cont.
Management/
Activated Charcoal Contraindications:
•Patients with altered conscious state
•The following agents:
6.Potassium and other metallic ions1.Ethanol/glycols
7.Fluoride2.Alkalis
8.Cyanide3.Boric acid
9.Hydrocarbons4.Lithium
10.Mineral acids5.Iron compounds

GENERAL PRINCIPLES
Cont.
 Whole Bowel Irrigation has a limited role
in treatment of some slow release
preparations
Gastric Lavage has a very limited role in
treatment and should not be used without
consultation.
Specific antidotes may be available and
serum drug levels may help in treatment
decisions
Management/

GENERAL PRINCIPLES
Cont.
 All acts of deliberate self harm must be
taken extremely seriously.
All intentional self poisonings in
adolescents require admission
If unexplained symptoms exist a urinary
drug screen may be indicated
Management/

INITIAL ASSESSMENT AND MANAGEMENT
The initial priority in treating poisoned
children is the standard ABC
(airway, breathing, and circulation)
resuscitation approach

A: ASSESS AIRWAY PATENCY
By looking, listening, and feeling for
air movement.
 If there is no air movement, try to open
the airway with simple maneuvers such
as the jaw thrust or the use of airway
adjuncts.

CONT.
Certain ingested agents may predispose
to airway edema and
obstruction, including caustic
agents, angiotensin-converting enzyme
inhibitors, and plants containing
calcium oxalate crystals
(e.g. Dieffenbachia and
Philodendron house plants)

B: ASSESS THE ADEQUACY OF BREATHING
It is important to remember that
succinylcholine may cause prolonged
block in children who have a reduced
cholinesterase concentration due to
exposure to cocaine or
organophosphate compounds:
prolonged apneas of up to 7 h have
been described.

CONT.
Observing ventilatory frequency, use of
accessory muscles, breath sounds, and
oxygen saturations.
 Reduced respiratory effort may require
bag-valve-mask ventilation until a
definitive airway can be secured

C: ASSESS THE CIRCULATION
In terms of cardiovascular status (heart
rate, arterial pressure, and capillary
refill) and the effect of circulatory
inadequacy on other organs (mental
state, urine output, skin
temperature, and colour).

CONT.
Hypotension should initially be treated
with a 20 ml/ kg crystalloid
bolus, remembering that if it is caused
by specific toxins such as β-
blockers, the specific antidote should
also be given, for example, glucagon

CONT.
Arrhythmias associated with poisoning
are best treated by:
i. Correcting precipitating factors (e.g.
hyperkalaemia and acidosis)
ii. Administering the appropriate
antidote;

CONT.
Children in cardiac arrest should be
treated according to standard guidelines
(e.g. The Advanced Cardiac Life
Support protocol), although it is
important to address the need for a
specific antidote, for example, sodium
bicarbonate for tricyclic antidepressant
(TCA) poisoning

SALICYLATES POISONING

Assessment
Management/
Symptoms
SeizuresTinnitus
HyperthermiaVomiting
DehydrationHyperventilation
HypoglycemiaLethargy
Non cardiogenic pulmonary edemaComa

Cont.
• Initial respiratory alkalosis (may be
transient), followed by paradoxical
aciduria (pH <6), then metabolic
acidosis & Hypokalemia (± ongoing
respiratory alkalosis).
Management/

Patients Requiring Treatment
Acute ingestion ≥ 150mg/kg
All symptomatic patients
Ingestion of unknown quantity
Management/

 Investigations
 Serum salicylate level at presentation (on
patients requiring treatment), and 2 hrly if
symptomatic or enteric coated preparation.
(Need to call the RCH lab to get test run
urgently as it is sent to RMH for analysis)
Urea & electrolytes, creatinine, acid-
base, glucose
Management/

 Management
 Asymptomatic
 Charcoal 1g/kg (if <1 hour since ingestion unless
enteric coated preparation)
 Observe 6 hours & discharge if still asymptomatic
 If enteric coated preparations, serial salicylate levels
(2 hourly)
 Admit if levels have not plateaued at 6 hours post
ingestion
 I.V. bicarbonate infusion 1mmol/kg/hr to correct any
acidosis (pH <7.3)
Management/

Cont.
 Symptomatic
 All symptomatic patients require urgent medical
assessment and investigations as above.
 Charcoal 1g/kg unless altered conscious state
(protect airway first)
 I.V. fluid resuscitation to correct dehydration (use
N. Saline)
Management/

Symptomatic (Cont.)
 I.V. bicarbonate infusion 1mmol/kg/hr, after
initial slow bolus of 2mmol/kg, (keep urine pH
>7.5)
 Potassium replacement as required
 Worsening symptoms, convulsion, coma, contact
I.C.U. for respiratory support hemodialysis
 Salicylate level >7mmol/l following an acute
poisoning contact I.C.U. for consideration of
hemodialysis.
Management/

PARACETAMOL POISONING

 Patients Requiring Management
1. Acute ingestion of > 200 mg/kg
2. Ingestion of unknown quantity
3. Repeated supratherapeutic ingestion of
> 100mg/kg/day
Management/

Assessment
Consider the possibility of co
ingestions, either accidental or deliberate
Management/

Management
Activated charcoal is not useful in liquid
ingestions due to rapid absorption
Activated charcoal 1 g/kg may be considered
in a cooperative patient seen within 1 hour of
tablet or capsule ingestion.
Serum paracetamol level at (or as soon as
possible after) 4 hours post ingestion
determines the need for N-acetyl cysteine
(NAC) administration. (see nomogram)
Management/

There is no benefit in measuring
paracetamol level earlier than 4 hours
It is safe to wait for the paracetamol level to
decide on the need for NAC in all cases that
present within 8 hours of ingestion.
Management/

Cont.
 Patients who present > 8 hours after a toxic
ingestion / symptoms of toxicity (RUQ pain or
tenderness, nausea, vomiting) should be
commenced on NAC immediately.
 The decision to continue or cease NAC is then
based on the paracetamol level.
 Delaying NAC administration beyond 8 hours is
associated with a progressive increased risk of
liver injury.
Management/

There is little evidence to guide management
in repeated supratherapeutic doses. Potential
toxicity should be assessed when:
 > 200 mg/kg (or 10g) ingested over a 24
hour period
 > 150 mg/kg/day (or 6 g) ingested over a 48
hour period
 > 100 mg/kg/day ingested over a 72 hour
period
Management/

Management/

N- Acetyl cysteine (NAC) Infusion
Instructions
The standard administration of NAC is a 3
stage infusion giving a total dose of 300
mg/kg:
1. 150 mg/kg over the first hour
2. 50 mg/kg over the next 4 hours
3. 100mg/kg over the next 16 hours
Management/

Cont.
For patients > 110 kg, calculate the dose based
on 110 kg body weight.
NAC may be diluted in 5% dextrose or 0.9%
saline (normal saline).
 It can also be diluted in combination dextrose-
saline solutions not exceeding these
concentrations including 0.45% saline in 5%
dextrose, and 0.9% saline in 5% dextrose.
Management/

For adolescent / adult:
1. 150 mg/kg in 250 or 500 ml over 1
hour
2. 50 mg/kg in 500 ml over 4 hours
3. 100 mg/kg in 1000 ml over 16 hours
Management/

IRON POISONING

IRON POISONING
Background
Iron is found in several different forms in
different medicines.
The important ingestion is the amount of
elemental iron not the iron salt.
Management/

IRON POISONING
Management/
Table: Iron Medications

IRON POISONING
Management/
Percentage elemental iron:
• Ferrous fumarate 33%
• Ferrous chloride 28%
• Ferrous sulfate 20%
• Ferrous chloride 28%
• Ferrous gluconate 12%
Iron is also found in plant fertilizers
(e.g. sulphate of iron -20% elemental iron).

ASSESSMENT
Patients Requiring Assessment
1. Ingestion of > 40 mg/kg elemental iron.
(approximately > ½ tablet/kg or 6.5 ml
syrup/kg)
2. Ingestion of an unknown quantity.
3. Any symptomatic patients
Management/

HISTORY AND EXAMINATION
Initial symptoms:
 Usually occur within 20 minutes
 Nausea, vomiting, diarrhea, abdominal
pain, hypotension, Hematemesis, fever
 Gastrointestinal symptoms related to the corrosive
nature of iron may occur without systemic
toxicity, however any symptoms require iron levels.
 Lack of symptoms within the first 6 hours makes
significant toxicity unlikely.
Management/

Latent period:
There is often 6-24 hour latent period when
initial symptoms resolve, before overt
systemic toxicity
Thus improvement over this time may be a
result of improvement or deterioration
Management/

Other symptoms:
Usually appear at 6-24 hours and last 12-24
Tachycardia, vasoconstriction, hypotension
and shock
Metabolic acidosis can occur.
These are related to fluid shifts from
intravascular to extravascular compartments
and cellular hypoxia
Management/

Multiple organ failure:
Occurs 12-48 hours after ingestion
Particularly hepatic failure
Management/

Management
ABC
Supportive therapy to maintain adequate
blood pressure and electrolyte balance is
essential
I.V. fluid resuscitation 20 ml/kg
Potassium and glucose administration as
necessary.
Management/
IRON POISONING

Investigations
Asymptomatic patients:
If tablet ingestion do AXR and if negative -
does not need further investigation or
observation
If unknown amount or >60mg/kg ingested
need serum iron levels 4 hourly until falling
Management/
IRON POISONING

 All symptomatic patients should have the
following investigations:
 AXR if tablet ingestion
 ABG/CBG (acidosis)
 Glucose (hyperglycaemia)
Management/
IRON POISONING

Cont.
 Serum iron
 Peak levels are usually seen at 4 hours.
 Levels taken after four hours may underestimate
toxicity because the subject iron may have either been
distributed into tissues or be bound to ferritin.
 In the case of slow release or enteric coated
tablets, levels should be repeated at six to eight hours as
absorption may be erratic.
 Once desferroxamine is commenced, iron levels are not
accurate at most labs using automated methods
(including RCH)
Management/
IRON POISONING

Cont.
 FBE (leukocytosis)
 U&E & Cr
 X-match
 Clotting (reversible early coagulopathy and late
coagulopathy secondary to hepatic injury)
 LFTs
 AXR may be helpful in evaluating gastrointestinal
decontamination after treatment if tablets have been
ingested.
Management/
IRON POISONING

Cont.
 Decontamination
 Charcoal is of no benefit.
 Decontamination of choice is whole bowel irrigation
(WBI) with naso-gastric colonic lavage solution
30ml/kg/hr until rectal effluent clear (contraindicated if
there are signs of bowel obstruction or haemorrhage).
 WBI is indicated:
 If AXR reveals tablets, or capsules ingested
 In symptomatic patients
Management/
IRON POISONING

Antidote:
Desferroxamine is a chelating agent which
forms a water soluble desferroxamine-iron
complex.
Management/
IRON POISONING

Consider desferroxamine in:
 Serum iron levels > 90 micromol/l
 Level 60 - 90 micromol/l and tablets visible on
XRay or symptomatic
(nausea, vomiting, diarrhea, abdominal
pain, haematemesis, fever)
 Any patient with significant symptoms of altered
conscious
state, hypotension, tachycardia, tachypnea, or
worsening symptoms irrespective of ingested dose
or serum iron level.
 Do not wait for iron level if altered conscious
state, shock, severe acidosis (pH <7.1), or
worsening symptoms but commence
Desferroxamine without delay.
Management/
IRON POISONING

 Dose: Desferroxamine 15 mg/kg/hr I.V. The rate
is reduced after four to six hours so that the total
intravenous dose in general does not exceed 80
mg/kg/24 hours.
 Desferroxamine -iron complex is renally excreted.
 If oliguria or anuria develop, peritoneal dialysis
or hemodialysis may become necessary to remove
ferrioxamine.
Management/
IRON POISONING

It is difficult to determine the endpoint for
chelation therapy.
Significant poisoning usually requires 12 -
16 hours,
Management/
IRON POISONING

Cont.
It is recommended to continue desferroxamine
until:
 Patient is asymptomatic.
 decontamination complete
 anion-gap acidosis resolved
 Iron level (if measurable) is <54 micromol/L
 Desferroxamine has been associated with
pulmonary toxicity and should be used with
caution if indications persist >24 hours.
Management/
IRON POISONING

HYDROCARBON POISONING

Hydrocarbons Include:
 Petrol
 Kerosene
 Lighter Fluid
 Mineral Turpentine
 Paraffin Oil
 Lubricating Oil
 Furniture Polishes
 2 Stroke Fuel
 Diesel Fuel
 White Spirit
Management/

Assessment
 Main complication is Aspiration Pneumonitis
 C.N.S. toxicity can be evident (either depression or
excitement)
Management/

Symptoms:
Coughing, choking, respiratory distress
ataxia, drowsiness, coma, convulsions
persistent burping (particularly seen after
petrol ingestion
Management/

Keep nil orally charcoal is contraindicated.
Asymptomatic
 Observe 6hours
 Discharge if remains asymptomatic
 Arrange review by LMO the following day
Management/
MANAGEMENT

 Symptomatic
 If develops respiratory symptoms
(aspiration), do CXR & O2 saturation
 Give O2 to maintain saturation > 94%
 If stable, admit to general medical ward
 If increasing O2 requirements or increased
respiratory distress contact I.C.U.
 If altered conscious state at any time contact
I.C.U.
Management/
MANAGEMENT (CONT.)

ALKALIS POISONING

Alkalis include:
Drain cleaners, Oven cleaners
Automatic dish washing liquids & powders
Laundry detergents, Ammonia
Portland cement
Management/
ALKALIS POISONING

pH of >11.5 is likely to cause significant GI
ulceration
Attempt to obtain container to check
contents and strength of substance.
Management/
ALKALIS POISONING

 Corrosive potential varies with concentration of
specific ingredients and preparations, ie liquid
preparations are more likely to cause esophageal
burns than powders.
 Check preparations with Poisons Information Centre
to determine whether ingested substance is
weak, strong, irritant or corrosive in nature.
Management/
ALKALIS POISONING(CONT.)

Toxicity
Exposure may lead to severe burns of
GIT, especially esophagus
Absence of mouth or pharyngeal ulcers does
not preclude gastro- oesophageal lesions
Symptoms: May be minimal
Pain
Nausea & vomiting, drooling or refusing to eat
and drink
Stridor, respiratory distress
Management/
ASSESSMENT

Activated charcoal is contraindicated
If asymptomatic treat with fluid dilution:
10ml/kg of water (max 250ml)
If asymptomatic after 4 hours and able to
eat and drink the patient can be safely
discharged
If any symptoms, contact surgical
registrar, & admit for oesophagoscopy
Management/
MANAGEMENT

ANTICONVULSANT POISONING

 CARBAMAZEPINE, PHENYTOIN, SODIUM
VALPROATE, PHENOBARBITONE
Assessment
 CNS
 Ataxia, drowsiness, coma, convulsions
 GIT
 Nausea & Vomiting
 CVS
 Hypotension, Arrhythmias
 Drug levels are available for some anticonvulsants e.g.
carbamazepine, phenytoin, phenobarbitone
Management/
ANTICONVULSANT POISONING

Acute ingestion of unknown quantity
Carbamazepine ingestion of >20mg/kg (for
patients not on maintenance treatment) or
the greater of more than twice the daily
dose or 20mg/kg for patients on
maintenance treatment
Management/
PATIENTS REQUIRING TREATMENT

 Charcoal 1g/kg unless altered conscious state (protect
airway first)
 Mild symptoms (e.g. ataxia, blurred vision)
 observe 4 hours, discharge if symptom free
 Moderate or persistent symptoms (after 4 hours of
observation)
 Admit for observation
 Severe symptoms
 Depressed conscious state or cardiac arrhythmias
contact I.C.U. .
Management/
MANAGEMENT

TRICYCLIC OVERDOSE

Assessment
Symptoms
 Anticholinergic
 vomiting, blurred vision, ataxia, tachycardia, urinary retention
 Antiadrenergic
 vasodilatation
 Sodium Channel blockade
 widened QRS (>0.12 ms)
 QT prolongation
 reduced cardiac contractility & hypotension
 CNS Depression
 drowsiness, coma, convulsions
 Symptomatic patients require urgent medical assessment
Management/
TRICYCLIC OVERDOSE

 Charcoal 1g/kg unless altered conscious state (protect
airway first)
 Require ECG, cardiac monitoring
 Asymptomatic: observe for 6 hours post ingestion and
discharge if have a normal ECG just prior to discharge
 All symptomatic patients should be admitted
 If widened QRS on ECG commence Sodium Bicarbonate
infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg
 If altered conscious state, widened QRS or arrhythmia
contact I.C.U. & protect airway
Management/
MANAGEMENT

Assessment
Symptoms
CNS depression, drowsiness, coma
Respiratory depression
Hypotension
Beware additive toxicity with other CNS &
Respiratory depressants
Management/
BENZODIAZEPINE POISONING

Ingestion of ≥3 times recommended dose
for age
Management/
PATIENTS REQUIRING OBSERVATION

Charcoal is not usually of benefit (due to
low order of toxicity)
If depressed state of consciousness, protect
airway and contact ICU
Antidote available - Flumazenil, not
indicated for ingestions and should only be
used after discussion with consultant staff.
Management/
MANAGEMENT

THEOPHYLLINE POISONING

Assessment
CNS
 Agitation, hyperventilation, headache, convu
lsions
Cardiovascular
 Arrhythmias
GIT
 nausea & vomiting (may be
intractable), thirst, diarrhea
Management/
THEOPHYLLINE POISONING

Acute ingestion of ≥ 10mg/kg
Any ingestion while on maintenance
theophylline
Management/
PATIENTS REQUIRING TREATMENT

 Theophylline levels should be determined on all patients
requiring charcoal
 Serial levels are required at 2 hours then every 2 hours
until peak reached or decline demonstrated.
 If slow release preparation has been taken:
admit, continue levels at 4 hourly intervals after decline or
plateau to ensure detection of secondary peak
 Seizures are common at levels >330 micromol/L
 Haemoperfusion commonly needed at levels > 550
micromol/L.
 U&E, Cr and Glucose on all patients.
Management/
INVESTIGATIONS

Asymptomatic
 Charcoal 1g/kg
 Observe 4 hours. If no
symptoms, discharge if not slow release
medication.
 If ingestion of slow release
preparation, admit for observation and
serial drug levelshttp://www.rch.org.au/clinicalguide/guideline_index/Acute_Poisoning_Guidelines_For_Initial_
Management/
MANAGEMENT

Symptomatic
 Charcoal 1g/kg initially unless altered conscious state
(protect airway first) then 0.5g/kg 4 hourly, and whole
bowel irrigation with colonic lavage solution 30ml/kg/hr.
 Cardiac monitoring
 I.V. fluid resuscitation & maintenance of adequate hydration
is vital
 If depressed conscious state, arrhythmias or intractable
vomiting contact I.C.U. as likely to need intubation
 Severe intoxication may require haemoperfusion
 If agitated, may need sedation with a benzodiazepine or
phenobarbitone.
Management/
MANAGEMENT(CONT.)

Management/
ETHANOL POISONING

Ethanol Containing Preparations
 Light beer 2% Beer 5%
 Cider 5%
 Wine 10%
 Wine coolers 5%
 Fortified wine 20%
 Spirits 45%
 Liqueurs 30%
 Perfumes& colognes >60%
 Aftershaves 80%
 Mouth washes (some) 25%
 Methylated spirit 95% (does not contain methanol)
Management/
ETHANOL POISONING

 Fatalities generally occur with blood levels > 86.8mmol/L
(breath alcohol >0.4)
Assessment
Symptoms
 Nausea, vomiting, abdominal pain
 Hypoglycemia
 Ataxia, lethargy, coma, convulsions
 Respiratory depression
Management/
ETHANOL POISONING

 Hypothermia
 Hypokalemia, metabolic acidosis
 Unexplained drowsiness, hypothermia or hypoglycemia in
adolescents may be ethanol induced. In adolescents ethanol
ingestion often accompanies ingestion of other drugs.
Patients Requiring Treatment
 symptomatic patients
Management/
ETHANOL POISONING(CONT.)

 Charcoal is of no benefit
 Check blood glucose in younger children
 Asymptomatic or Mild Symptoms (decreased
inhibition, slight incoordination)
 Observe for 2 hours
 Give frequent carbohydrate containing drinks
 Breath alcohol if possible
 If remains symptomatic or symptoms worsen
admit
Management/
MANAGEMENT

Symptomatic (more than just mild symptoms or
continued symptoms after 2 hours)
 Blood ethanol measurement, U& E, Glucose
 I.V. fluid
 Temperature regulation
 Admit.
 If unconscious or convulsions contact I.C.U.
Management/
MANAGEMENT(CONT.)

 American Association of Poison Control Centers:
http://www.aapcc.org/dnn/Home.aspx
 American Academy of Clinical Toxicology:
http://www.clintox.org/index.cfm
 Centers for Disease Control and Prevention,
Section on Environmental health:
http://www.cdc.gov/Environmental
Management/
REFERENCES

THANK YOU

Acute poisoning guidelines for initial management

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (6)

Similaire à Acute poisoning guidelines for initial management

Similaire à Acute poisoning guidelines for initial management (20)

Plus de Dr. Saad Saleh Al Ani

Plus de Dr. Saad Saleh Al Ani (20)

Dernier

Dernier (20)

Acute poisoning guidelines for initial management