seminar

1. Approach To A Case Of
Poisoning
Dr. Arif Khan
Department of Pediatrics

2. • INTRODUCTION
• COMMON POISONING IN CHILDREN AND
ADOLESCENTS
• HISTORY
• GENERAL PHYSICAL EXAMINATION
• GENERAL MANAGEMENT
• SPECIFIC POISONING AND THEIR MANAGEMENT
CONTENT

3. Poisoning
• Poisoning represents one of the most common medical
emergency encountered in young children and adolescents.
• Children <11 years usually have accidental poisoning of
single substance while adolescents ingest voluntarily large
amount of one or more substance.
• Pattern of sign and symptom of ingestion or exposure to a
toxin is called Toxidrome.

4. • Poison is any agent of self-injury absorbed into the body
through epithelial surfaces like skin or gut.
• Toxins are poisons produced by a biological process in
nature.
• Venoms are toxins that are injected by a bite or sting to
cause their effect.

5. Common Poisoning in Children
and Adolescents
• Kerosine and other Hydrocarbons
• Household Products: Insecticides, Rodenticides, Phenol,
Caustic Soda, Neem Oil, Camphor, Alcohol, Copper Sulphate
• Pharmaceutical Products: Paracetamol, Iron Opiates,
Phenothiazines, Barbiturates, Aspirin, Anticonvulsants,
Antihypertensives

6. • Plants and Plant Products: Datura, Yellow Oleander,
White Oleander, Caster Seeds
• Environmental Poisoning: Elapidae(Cobra,Krait),
Viperdae(Russel Viper, Saw-scaled Viper,
Scorpion/Bee/Wasp Stings, Insect bite

7. • What was ingested?
• Time since ingestion
• How much amount ingested? check the container or
remaining no. of tablets
• Route of ingestion; skin or mucosa, iv or im
• In which form (gas,solid or liquid) the poison ingested
History

8. History
• Circumstance(location and intent) of exposure
• Time, nature and severity of symptoms
• Timing of first aid measures
• Family history of diseases and drug therapy

9. General Physical Examination
• Assess general condition
• Level of consciousness(GCS) and Pupillary size-
constricted or dilated, reactive or non reactive
• Vitals- heart rate, blood pressure, temperature,
peripheral perfusion, respiratory rate, SpO2

10. • General signs and symptoms
• Identifying toxidromes
General Physical Examination

11. General sign and symptoms
• Miosis: cholinergics, barbiturates, nicotine, opium,
morphine, parasympathomimetics
• Mydriasis: cocaine, datura, thallium, cyanide, carbon
monoxide, benzene, sympathomimetics
• Partial or Total blindness: methyl alcohol
• Blurring of vision: cholinergics, datura, alcohol,
digitalis

12. • Alopecia: thallium, arsenic, ergot, lead
• Facial twitching: lead, mercury, phenothiazines
• Pallor: aniline derivatives, symathomimetics, insulin,
pilocarpine
• Cyanosis: carbon monoxide, morphine, sulphonamide
• Yellow discolouration: paracetamol, carbon
tetrachloride
• Sweating: physostigmine, cholinergics, nicotine,
pilocarpine

13. • Dry hot skin: datura, botulism
• Flushed skin: carbon monoxide, cyanide
• Diaphoresis: organophosphates, salicylates
• Seizures: carbon monoxide, mushroom, cyanide,
salicylates, nicotine, lead, cholinergics, datura, cocaine
• Coma: salicylates, mushroom, cholinergics, carbon
monoxide, cyanide, lead, barbiturates, morphine, nicotine

14. • Bradycardia: digitalis, organophosphates, beta-blockers,
opioids
• Tachycardia: atropine, salicylate, amphetamine
• Tachypnoea: salicylate, ethylene glycol
• Apnoea: barbiturates, alcohol, opioids
• Hypertension: anticholinergics, phenylpropanolamine
• Paralysis: botulism, heavy metals
• Characteristic smell: kerosine, alcohol,
organophosphates and arsenic (garlic odour),
metanol(acetone), cyanide( bitter almonds)

15. Initial Assessment
• Assess GCS, Pupils and skin colour
• Airway:-
• check for patency of airway
• proper positioning- head tilt and chin lift
• suction of vomitus, secretions from oropharynx
• removal of obstructing objects, if any
• falling back of tongue is prevented by suitable airway tube

16. • Breathing:-
• O2 by mask: if spontaneous respiration
• Insert endotracheal tube if gag or cough reflex absent
• Intermittent positive pressure ventilation with proper
monitoring when ventilation remains inadequate by above
measures
• Respiratory stimulants like nikethamide or doxapram are
used for severe respiratory depression. doxapram is most
effective.

17. • Circulation:-
• Shock is initially managed with fluid boluses
• Dopamine is vasopressor of choice if shock remains
unresponsive
• Maintenance of fluid and electrolyte balance
• Administrating iv drugs for treatment

18. Prevention of further
absorption of Poison
• Dilution
• Gastric Emptying- Emesis, Gastric Lavage
• Binding Agents- Activated Charcoal, Bentonite, Fuller’s
Earth, Kaolin and Pectin
• Cathartics
• Whole Bowel Irrigation
• Enhancing Excretion- Diuresis, Dialysis and
Hemoperfusion

19. Dilution
• Dilution Agents:- water and milk
• Indication: when toxin causes local irritation in oral,
esophageal or gastric mucosa like acids, alkalis and
household cleansing agents
• Contraindication- medicinal toxin like tablets or
capsules as it increases the dissolution

20. Emesis
• Emetic:-syrup ipecac dose@30ml for
adolescents,15ml for children and 10ml for infants
• Contraindication:-Hydrocarbon
ingestion,corrosive,comatose or those with absent
gag reflex
• Not used now

21. Gastric Lavage
• Gastric Lavage is preferred in patients presented early in
hospital, <6 months age, impaired level of
consciousness and mercury poisoning
• In comatose it should be done after intubation with
cuffed endotracheal tube
• 36 French tube used in adolescents and 22-24 French
tube in children
• Lavage with NS @15ml/kg until clear fluid drained
• Contraindicated in hydrocarbon and corrosive poisoning

22. Activated Charcoal
• Most appropriate agent to decontaminate GI tract
• Single dose is sufficient with greatest effect within 1hr of
ingestion
• Adsorbs toxin in gut lumen
• Benefits include capability to decontaminate without requiring
invasive procedures
• Dose 1-2g/kg (400mg tablet should be crushed before
administration) through oral or nasogastric tube
• Contraindicated in iron poisoning, cyanide poisoning and oral
antidotes

23. Multi-Dose Charcoal
• One dose usually sufficient
• Indications for multi-dose activated charcoal:
ingestion of large doses, slow release toxins, toxins
that slow gut function, toxins with enterohepatic
circulation like cyclic
antidepressants,diazepam,carbamazepine
• Repeat dose is 0.25-0.5 g/kg

24. Whole-Bowel Irrigation
• It removes the unabsorbed drug from entire gut and possibly
partially absorbed poison from gastrointestinal mucosa
• Polyethylene glycol is used for whole bowel irrigation
• Common indications: Heavy metals, Iron, Lithium, Sustained
or enteric coated preparations
• Dose is 30ml/kg/hr in children, 2 litres/hr in adolescents by
nasogastric tube or through oral route upto 4 to 6 hours
• Contraindication: Intestinal obstruction and Gastro-intestinal
perforation

25. Urinary Alkalization
• It is useful in salicylate and barbiturate intoxication
• Alkalization achieved by IV dose of sodium
bicarbonate at 1-2 mEq/kg, followed by intermittent
boluses or continuous bicarbonate infusion for target
urine pH >8.0

26. Hemodialysis/Hemoperfusi
on
• Dialysis reserved for specific toxins: salicylates,
methanol, ethylene glycol, lithium, theophylline
• Benefits: removal of toxins already absorbed, ability
to remove parent compound and active metabolite

27. Investigations
• Complete blood count
• Urine:- Routine and Microscopy
• Chest Xray PA View
• RBS
• ABG
• ECG
• LFT
• KFT
• Serum Electrolytes

28. Kerosine Poisoning
• Kerosine poisoning is common in communities where
kerosine is a major household fuel.
• The circumstance is usually accidental ingestion (mistaken
for water).
• Ingestion of 30ml of kerosine is lethal.

29. • The earliest sign with kerosene ingestion may be
choking,coughing and gasping respiration.
• Respiratory distress occur in the form of tachypnea,
nasal flaring,grunting and chest retractions.children
who are asymptomatic for 6 hrs are less likely to
develop pneumonia later.
Clinical features

30. • Convulsion or Coma.
• Gastrointestinal symptoms like
nausea,vomiting,abdominal pain and diarrhoea may
occur.
• Fever may occur and can persist for 10 days.
• Renal injury is uncommon but may manifest as
tubular necrosis,hematuria,proteinuria and
glomerulonephritis.

31. Perihilar opacity Bilateral basal infiltration
• Initially the chest radiograph may be normal but
positive findings develop over the first few hours
after ingestion of kerosine. Common findings
include perihilar opacities and bilateral basal
infiltration.

32. Management of Kerosine
Poisoning
• Maintenance of airway, breathing and circulation.
• Symptomatic treatment and preservation of the airway is
always the first priority of treatment.
• Gastric lavage and induction of emesis ( e.g. use of
Ipecac) should not be considered in the management of
kerosene poisoning as these may cause aspiration and
worsens the condition.Gastric lavage is indicated when
amount of hydrocarbon exceeds 1ml/kg.

33. Paracetamol Poisoning
• Very common, often asymptomatic
• Hepatotoxicity may occur when a dose of more than
150mg/kg is ingested.
• Hepatic damage occur due to increased formation of
highly reactive intermediate(N-acetyl-p-
benzoquinonimine) which is produced by its metabolism
through p-450 cytochrome oxidase. N-acetyl-p-
benzoquinonimine is normally detoxified by endogenous
glutathione,but the increased production induced by
paracetamol overdose deplete glutathione stores
• Death may occur within 2 to 7 days.

34. • Stage 1 (6-24hrs): anorexia, nausea, vomiting, pallor and
excessive sweating with cold skin
• Stage 2 (24-48hrs): hepatorenal injury, jaundice, tender
hepatomegaly, elevated liver enzymes, prolong
prothrombin time, oliguria, raised serum urea and serum
creatinine
Stages of Paracetamol Toxicity

35. Stages of Paracetamol Toxicity
• Stage 3(48-96hrs): stage 1 symptoms reappear,
hepatic coma
• Stage 4(4 days-2 weeks): after supportive and
specific therapy recovery starts with return of
consciousness with improvement in liver function
tests.

36. Management of Paracetamol
Poisoning
• Specific antidote: N-acetyl cysteine(NAC)
• Supportive treatment: correct hypoglycaemia,
maintenance of hydration, electrolyte balance,
treatment of coagulopathy, hemodialysis for acute
renal failure and management of fulminant hepatic
failure

37. N-acetyl cysteine(NAC)
• Most effective within 8 hours of ingestion
• Precursor for glutathione production
• Can cause anaphylactic reactions
• Dose:-Loading dose 140mg/kg followed by 70mg/kg
every 4hrs for 68 hrs(17 doses) as oral solution
mixed with fruit juice

38. Organophosphorus (insecticides and
pesticides) Poisoning
• Organic phosphate 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.

39. Clinical features
• Symptoms manifest quickly usually within a few hours
are weakness, blurred vision, headache, giddiness,
nausea and pain in chest.
• These patients have excessive secretion in the lungs
and they sweat profusely.
• Salivation, lacrimation, urination and diarrhoea are
present.

40. • Pupils are constricted and papilledema may occur.
• Muscle twitching, convulsions and coma occur in
severe cases. Reflexes are absent and sphincter
control is lost.
• Death occurs usually due to respiratory failure.

41. Management of
Organophosphates
• If the insecticide was in contact with skin or eyes, these
are thoroughly washed. Stomach wash is done.
• Atropine sulphate: 0.05 mg/kg IV. Repeat half the
dose in 15 minutes and then after every hour (until
signs of toxicity appear), subject to a maximum of 1
mg/kg in 24 hours.

42. Management of
Organophosphates
• Pralidoxime Aldoxime Methiodide (PAM) is given in
dose of 25-50 mg/kg IM or IV over 30 min infusion,
then at 6-12 hour intervals as needed. Monitor for
hypertension.

43. Iron Intoxication
• Ingestion of tablets of ferrous sulphate causes acute
poisoning.
• Iron is an essential mineral but in excess it acts as
metabolic poison in body.
• Acute iron intoxication exerts its primary effect on git,
liver and cardiovascular system.
• Fatal dose is 10 tablets of iron i.e. 650mg of elemental
iron. absorption of 60mg/kg causes significant iron
poisoning.

44. • Gastrointestinal tract- nausea, vomiting, diarrhoea,
abdominal pain, hematemesis and blood mixed stool.
• Then circulatory shock with metabolic acidosis and
myocardial dysfunction.
• Hepatic fibrosis and gastric scarring is longterm effect.
Clinical features

45. Management of Iron
Poisoning
• Gastric lavage should be done with sodium
bicarbonate.
• IV sodium bicarbonate @ 3ml/kg diluted twice with 5%
dextrose is given for acidosis.
• Deferoxamine is a chelating agent used iv @
15mg/kg/hr until the total serum iron falls to less than
300μg/dl.

46. • Atropine
• Indication- organophosphate poisoning
• Dose- @0.05mg/kg iv; repeat dose until atropinisation
• N-acetyl cysteine
• Indication- paracetamol poisoning
• Dose- loading dose @140mg/kg followed by
maintenance dose @70mg/kg every 4 hourly for 17
Antidotes

47. • Deferoxamine
• Indication- iron poisoning
• Dose- @15mg/kg/hr iv until the serum iron is
<300μg/dl or until 24 hr after the child has stopped
passing ‘vine rose’ colour urine.
• Physostigmine
• Indication- anticholinergics like datura poisoning
• Dose- @0.02mg/kg slow iv

48. • Pralidoxime aldoxime methiodide (PAM)
• Indication- organophosphate poisoning
• Dose- @25-50 mg/kg im or iv over 30 minutes, then
repeat after 6-12 hourly
• Naloxone
• Indication- opioid poisoning
• Dose- 0.1mg/kg iv (upto 2mg) repeat every 2 minute till
reversal ( upto 10mg)

49. • Sodium bicarbonate
• Indication- salicylate poisoning
• Dose- @ 150 mEq/l + 40 mEq KCl/l of 5% dextrose
• Digoxin immune antibody fragment
• Indication- digoxin (digitalis) poisoning
• Dose- 10-20 vials iv bolus

50. Thank You