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Common Toxicology in Pediatrics :skull_and_crossbones: (:silhouette: PE …
Common Toxicology in Pediatrics :skull_and_crossbones:
:goal_net:
Objectives
Dx
&
General approach
of pt with Drug overdose & poisoning
:leaves:
Decontamination
— eg. GI decon (Lavage), Skin decon (water มาล้าง), Toxic gas decon (normal Fresh air aka move out of scene)
:dizzy:
Common drug overdose & poisoning
in children &
antidotes
:tada:
Def
All things are poison — just dose doesn’t make a thing not a poison
:books:
Hx taking
Ages
< 6 yr
:
99% fr unintentional
exposure
Adolescent
: 44% unintentional &
50% intentional exposure
Household products
Details: brand, specific ingredients, concentrations
All medications
in the environment (parents’, relatives’ and visitors’ med)
Where’s the child was found?
Amount & time of exposure
:silhouette:
PE
approach like Emergency
A
: Airway
esp upper airway cuz Stridor & obstruction can happen
B
: Breathing better? O2 sat? Any lung signs?
C
: Circulation — Full pulses? BP?
D
: Disability, Drugs, Decontamination
V/S
Mental status
Pupil size
Skin, bowel sound, odor
Common odors caused by toxins & drugs
:grapes:
:leaves:
Decontamination
:black_circle:
Activated charcoal (AC)
aka ผงถ่านกัมมันต์
Doses
AC : Drug = 10:1 (1 g/kg/dose)
Multiple dose AC (MDAC
)
1g/kg
then
0.5 g/kg/dose
q 4-6 hr until clinical improves (1-3 doses)
Mechanism
Interrupts enterohepatic circulation
GI dialysis
Pharmacobezoar
Mechanism
Extensive network of pores
Van der Waals force
Bind substances excreted in the bile ➯
interrupts enterohepatic circulation
Effective within a hr of ingestion
Airway must be intact & protected
:cry: AC hv no taste and dull ➯ may added soda, chocolate milk or ice cream to :arrow_up: palatability
:warning:
Caution
Do not give AC with
ยาระบาย
cuz no evidence support that it’s better than AC alone
:poodle:
AC poorly absorbed substances
Alcohols
Acids & Alkali
Cyanide
Heavy metals — eg lead, iron, lithium
Hydrocarbons
:warning:
Complications
Aspiration
Gut obstruction (bezoar :bread:)
:no_entry:
C/I
(relative)
Acid, base, hydrocarbon, corrosive agents, caustic agents
Alternation of consciousness (AOC)
GI obstruction, ileus, perforation
:bread:
Pharmacobezoar
Is
I/C to do Whole bowel irrigation
Film X-ray or CT finds Radiolucent
Common meds
in Bezoar formation
Aspirin
Extended release products: Nifedipine, Procanamide, Verapamil
Cabamazepine
Lithium
:large_blue_circle:
Whole Bowel Irrigation (WBI)
Doses
Polyethylene glycol (PEG) via NG tube
Children: 35 ml/kg/hr
Adolescents: 1-2 L/hr
Combine
with use of
AC
0.5-1 g/kg
q 2-3 hr
:busstop: Stops when
No rectal effluent after 8-10 L (150-200 ml/kg in children)
Clear rectal effluent
:green_book:
I/C of WBI
Massive
ingestion of
Sustained-release
or
Enteric coated preparations
Substances that
not well absorbed by Charcoal
(lithium, iron)
Body packer
or
Body stuffer
:closed_book:
C/I of WBI
similar to AC C/I
Ileus, Gut obstruction
Obtunded, comatose or convulsing pt
unless the airway is protected
Gastric placement
:green_heart:
I/C for gastric tube placement
To administer AC & WBI
Remove ingested Liquid & Solid drugs
(effective if initiate within 30-60 min)
:<3:
C/I for gastric lavage
Ingest corrosive agents, hydrocarbon
Obtunded, Comatose, or Convulsing pts
:dizzy:
Common toxidromes
Sympathomimetic toxidrome
:silhouette:
Agents
: Amphetamine, Cocaine
:checkered_flag:
Common findings
: Psychomotor agitations, Mydriasis,
Diaphoresis
, Tachycardia, HT, Hyperthermia
:black_flag:
Other S&S
: Seizures, Rhabdomyolysis, MI
:skull_and_crossbones:
Death fr
: Seizures, Cardiac arrest, Hyperthermia
Def: Toxin + Syndrome = Clinical that allow us to regconize Drug group (regconized pattern)
Opioid
:silhouette:
Agents
: Heroine, Morphine
:checkered_flag:
Common findings
:
CNS depression, Miosis, Respiratory depression
:black_flag:
Other S&S
: Hypothermia, Bradycardia
:skull_and_crossbones:
Death fr
: Respiratory arrest, Acute lung injury
Anticholinergic
:silhouette:
Agents
: Diphenhydramine (Anti-histamine), Atropine**, Scopolamine, TCA
:checkered_flag:
Common findings
: Altered mental status, Mydriasis,
Dry flushed skin
, Urinary retention, :arrow_down:Bowel sounds, Hyperthermia, Dry mucous membranes
:black_flag:
Other S&S
: Seizures, Dysrhythmias, Rhabdomyolysis
:skull_and_crossbones:
Death fr
: Hyperthermia & Dysrhythmias
Cholinergic
:silhouette:
Agents
: Organophosphate, Carbamate
:checkered_flag:
Common findings
:skier:
Muscarinic effects
—
SLUDGE 3Bs
: Salivation, Lacrimation, Urination, Defecation, GI motility :arrow_down:, Emesis, Bronchorrhea, Bronchospasm,
Bradycardia*
:skier:
Nicotinic effects
: Muscle fasciculations & weakness
:black_flag:
Other S&S
: Bradycardia, Miosis/Mydriasis, Seizures, Respiratory failures, Paralysis
:skull_and_crossbones:
Death fr
: Respiratory arrest fr paralysis, Bronchorrhea, Seizures
Serotonin
:silhouette:
Agents
:
SSRIs
, Meperidine, MAOI, TCA,
Amphetamines
,
a variety drug interactions with !Dextromethorphan!
:checkered_flag:
Common findings
: Altered mental status, :arrow_up:
muscle tone esp. Lower extremities
, Hyperthermia,
:crown: pathog=myoclonus & hyperreflexia
:black_flag:
Other S&S
: intermittent whole body tremor
:skull_and_crossbones:
Death fr
Hyperthermia
Extrapyramidal
:silhouette:
Agents
: Haloperidol,
Phenothiazines, Risperidone, Olanzapine,
Metoclopramide, Domperidone
:checkered_flag:
Common findings
:
Dystocia, Torticollis, Tremor, Muscle rigidity
:black_flag:
Other S&S
: Choreoathetosis, Hyperreflexia, Seizures
:skull_and_crossbones:
Death fr
-
EPS Spectrum
Acute
- dystonia
Subacute
- Neuroleptic malignant syndrome
Chronic
- Tardive dyskinesia
irreversible
:cry:
Sedative-hypnotic
:silhouette:
Agents
: Barbiturate, BZD
:checkered_flag:
Common findings
: Depressed lvl of consciousness, Slurred speech, Ataxia
:black_flag:
Other S&S
: Stupor to coma, Depressed respirations, Apnea, Bradycardia
:skull_and_crossbones:
Death fr
?