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Common Toxicology in pediatrics 2:skull_and_crossbones: (:cookie: Iron…
Common Toxicology in pediatrics 2: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
:doughnut:
Paracetamol
overdose
(UK/Australia/Europe)
Aka Acetaminophen (US) or N-acetyl-p-aminophenol(APAP — scientific name)
Metabolism
:grapes:
:snake:
Toxic dose
Acute single
ingestion
Children > 150-200 mg/kg
Adult 6-7 g
Chronic
toxicity
200 mg/kg/day for within 1 day
150 mg/kg/day for 2 days ติดกัน
100 mg/kg/day for 3 days ติดกัน
:warning:
High risks
Co-ingestion with Cytochrome P450 inducer (eg Isoniazid)
Alcoholism (as LFT baseline is low + low glutathione storage)
:arrow_down: Glutathione states (malnutrition, liver ds)
:frame_with_picture:
Clinical presentation
depends on Time after ingestion
Early (first 24 hr)
Asymptomatic
N/V
Massive overdose: Altered mental status, Metabolic acidosis
After 24-48 hr
Jaundice: transaminitis, hepatic necrosis, fulminant hepatic failure
Rising AST > ALT, PT/INR
Encephalopathy, Metabolic acidosis, Renal failure
:male-scientist::skin-tone-4:
Labs
:seedling:
Paracetamol lvl
(APAP lvl)
Chronic
or
Repeated
ingestion — not applicable
Acute single
ingestion
Level
before 4 hrs
do not interpret
& if it’s undetectable ➯ less likely to be toxic
:star: only
acute single
can use
Rumack Matthew normogram
Level @ 4 hr value is borderline or delayed absorption ➯ Obtain Second level @ 8 hrs
‘Level @ 4 hrs post-ingestion’ can predicts likelihood of toxicity so its helpful
Level @ 4 hrs after ingestion ➯
possible hepatic toxicity line
(150µg/ml) ➯ Start NAC
Level is
not available
➯
NAC initiation
for Rx
based on
Dose of ingestion
Type of ingestion: acute, chronic
Type of APAP
LFT
:warning: co-ingestion with
opioids or anticholinergic
➯ peak lvl might be delayed
Other useful lab studies
: Elytes, Glucose, BUN/Cr, AST, ALT, PT/INR
:green_heart:
Antidote
: NAC (N-acetylcysteine)
Effects
:smiley:
Act as Sulfhydryl group donor (Glutathione precursor)
Enhance :arrow_down: of NAPQI
Prevent Paracetamol induced liver injury (given within 8-10 hr)
Mucolytic agent
Doses
:pill:
IV
: 150mg/kg in 15 min ➯ 50mg/kg in 4 hrs ➯ 100mg/kg in 16 hrs
Oral
: loading 140 mg/kg ➯ 70 mg/kg q 4 hrs
Timing
:timer_clock:
Should given
8-10 hrs after ingestion
for
maximal benefit
Starts when
Paracetamol
lvl > value of probable toxicity line
(4th hr post-ingestion APAP lvl > 150µg/ml )
Even late presenter at 24 hr up ➯ still indicate
ADR
:frowning_face:
GI -
N/V*
Anaphylactoid reaction (10-20%)
: hypotension, wheezing, ตาบวมปากบวม, rash
Obesity
Asthma
High rate of infusion
Labs after NAC Rx 20 hrs
:male-scientist::skin-tone-4:
Paracetamol lvl
PT/INR, TB
AST/ALT
Continuation/Discontinuation
:fireworks:
Continue NAC
until LFTs r improving
Discontinuation of NAC
Paracetamol lvl
undetectable
PT/INR, TB/DB
normal
AST/ALT
peak & trending down
:cookie:
Iron poisonings
PathoPSO
:gear:
Direct corrosive effect on mucosal tissue
Unbound iron -> cellular dysfunc -> lactic acidosis -> multi organs failure
Causes
Potential
lethal
ingestion (unintentional in children)
Prenatal vitamins
(bright color, sugar coated) ➯ serious toxicity
Chewable vitamins
: no fatality reported
Mechanism of toxicity
:gear:
Local corrosive effects on GI tract: fluid & blood loss
Oxidative stress
:eight_pointed_black_star:
Stages of Iron poisoning & PathoPSO
:grapes:
Toxic dose
:snake:
Less than 20 mg/kg: Less likely toxic
20-30 mg/kg: self limited vomiting, abd. pain, diarrhea
40 mg/kg: potentially serious
60 mg/kg: potentially
lethal
Dx
:cheese_wedge:
Hx — medicine disappear
Acute clinical presentation: vomiting, diarrhea, shock
Lab: :star::
WBC>15,000 , blood glucose > 150mg/dL
Abdominal X-ray:
radiopaque
pills
Labs
:male-scientist::skin-tone-3:
Serum iron conc (free form)
Timings
@
4-6 hrs after
ingestion (รอ distribution into circulation)
repeated
@ 8-12 hr: ingestion of sustained release tablets & co-ingestion with drugs :arrow_down: GI motility
(Opioid, BZD, Anticholinergic)
Levels
Mild to Moderate GI symptoms when >
450-500
mcg/dL
Severe poisoning when
>800-1000
mcg/dL
TIBC - no use
Treatment
:palm_tree:
:rosette:
Emergency & supportive measures
Maintain open airway & ventilation
Rx of hypovolemic shock: IV fluid, blood component
Rx of coma & Metabolic acidosis
Supportive Rx: monitor, IV fluid, O2, position, เช็ดตัวลดไข้, Antiemetic drugs
:rosette:
Decontamination
:warning:
ห้ามให้ charcoal
as Iron is metallic (metallic is C/I in Charcoal decon)
Types
of ingested products?
Liquid formulation or Chewed tablets ➯ Gastric lavage (ไม่น่าออก tho)
:stars: Tablets ➯ :star:
Whole bowel irrigation
:star:
(Iron tablets seen as
radioopaque
in Abd Xray)
:rosette:
Specific treatment
Deferoxamine
(iron chelator)
Doses
IV
dose: 10-15 mg/kg/hr (max 35 mg/kg/hr)
prefer in
serious
toxicity
IM dose: 90 mg/kg q 8 hr
:check:
I/C
Acidosis (eg. Wide gap anion)
Radioopaque tablets visible in GI X-ray
Serum iron > 500-600 mcg/dL
:no_entry:
Can't
use in Iron overdose เยอะๆ
Not quite good efficacy ➯
needs
to eat continuous everyday for it to slowly chelate
➯ chelating iron cause
vin rose urine
:rose: ➯
stops
when urine color returns to normal
or
serum iron decrease to normal ranges
usu. given to Thalassemia who got blood transfusion
:frowning_face:
SEs
Pulmonary edema
Eucemia sepsis
:rosette:
Enhance elimination
Hemodialysis
not effective
for iron
Mayb needed for Desferoxamine-iron complex in
Renal failur
e
Exchange tranfusion
Questionable efficacy
:battery:
Button battery
Film AP & Lateral
of Neck
Double contour
:leaves:
Mx
got 2 values to consider
Diameter if > 2 cm ➯ scope can't get it out
(Note: scope can only go to 1st part of duo)
Length
Objects length > 5 cm
or
Diameter > 1.5-2 cm ➯ less likely to pass Duodenum
Esophagogastroscopy & Laryngoscopy
Coin cell battery - removed fr Proximal eso
Lithium battery - fr Remote control with unwitnessed ingestion
S&S
Hematochezia, melena, acute abdomen