Pediatric Toxicology 2007

Overview of Pediatric Toxicology Unknown Exposures Trivial Ingestions Sometimes Severe Morbidity/Mortality Michael Wahl MD, FACEP, FACMT Emergency Physician, Evanston Northwestern Healthcare Medical Director, Illinois Poison Center

Pediatric Cases in Toxicology Why are Pediatric Ingestions so common? Pediatric Poisoning: Developmental Milestones Epidemiology of Pediatric Poisoning Poison Center Exposure Data Toxic vs. Non-toxic Exposures Trends Significance Management issues Cases

Poisoning is a matter of dose Paracelsus (1493-1551) Third Defense “ What is there that is not poison? All things are poison and nothing without poison. Solely, the dose determines that a thing is not a poison”

Pediatric Development 6-9 months: creep, crawl, and pick up objects

Pediatric Development 9-12 months: pick up a pellet and put it in a hand

Pediatric Development 15 months: walking; pick up a pellet and put it in a bottle

Pediatric Development 18 months: able to consciously dump pellet from bottle (e.g. Tylenol, aspirin, vitamins, adult prescription medications)

California Study: 3 month age intervals of injury related hospitalization or death from 0 to 3 years of Age 0-6 months ABUSE Overall: FALLS

Pediatric Poisoning #2 leading reason for injury-related hospitalization in children 0 to 3 years of age behind falls

Pediatric Poisoning #1 reason for hospitalization or death in children 18 months to 3 years of age

The #1 reason for injury-related hospitalization between 18 and 35 months is poisoning

Pediatric Poisoning Admission In Illinois Illinois Poison Center Data:

Pediatric Poisoning: Lots of exposures, small number admitted Pediatric Exposure calls to IPC under 6 years of age 1.3% of exposures admitted for observation Less than one death reported per year (and those are usually pre-hospital)

Assessment of Pediatric Ingestion History Who What Where When Why How The scene?

Difficulty with Pediatric History: Did they actually ingest the substance? Toxic Alcohol Evaluation of Pediatric Patients is often Incomplete DesLauriers C, Mazor S, Metz J, Mycyk M 2 year retrospective review 33 pediatric cases of Toxic Alcohol Ingestion 21 with levels drawn 5/21 with measurable levels (24% of cases)

Pediatric Exposures Reported to AAPCC (National Data)

Pediatric Deaths Reported to AAPCC (National Data) ~ 2/100,000 pediatric exposures result in death. Adult Fatalities >500 times more prevalent due to intentional nature of exposures

Unpublished Data from National Benchmarking committee (22 centers) 95% of all pediatric calls to a poison center are managed at home without referral to a poison center. 86% of pediatric exposures that present to an ED without calling a poison center first are discharged from the ED 66% of pediatric exposures that are referred to ED are discharged from the ED

Pediatric Exposures AAPCC Data Most Common Exposures Cosmetics and personal care products Cleaning substances Analgesics Tylenol >200 mg/kg ASA >150 mg/kg Codiene >2 mg/kg Propoxyphen >10 mg/kg Plants

Most Common Pediatric Exposures Cough and cold preparations Bropheneramine >2 mg/kg Chlorpheneramine >1.4 mg/kg Phenylephrine >4 mg/kg Pseudoephedrine >16 mg/kg Dextromethorphan >10 mg/kg Hydrocarbons Hormones/hormone antagonist

Pediatric Exposures AAPCC Data Most Common Exposures Foreign bodies Topicals Pesticides and Rodenticides Antimicrobials Vitamins Gastrointestinal preparations Arts/crafts/office supplies

Pediatric Exposures Determination of non-toxic exposures Call the Poison Center is easiest It is what poison center staff person does 30 times a day

Pediatric Exposures General guidelines for categorizing a non-toxic exposure for poison center staff The product must be absolutely identified Only a single product can be involved in the exposure The exposure must be unintentional The Consumer Product Safety Commission words CAUTION, WARNING, DANGER are not on label Route of exposure is accurately assessed No symptoms are noted Follow-up must be possible

Management of Pediatric Exposures Decontamination Enhanced elimination Antidotal Therapy Supportive Care

Decontamination Elimination from the gut and/or decreasing absorption Emetic Agents (Syrup of Ipecac) Cathartics (sorbitol, magnesium citrate) Gastric Lavage Whole Bowel Irrigation Charcoal

Decontamination All decontamination measures were started before the advent of evidence medicine. No improvement in outcomes has been shown for any of the modalities. Re-examination of practices are slowly removing them from practice.

Syrup of Ipecac Use of Ipecac promoted in the 1960’s on clinical opinion AAP recommendation to no longer use ipecac in the home because of a lack of proven benefit. Does lack of proven benefit equal lack of efficacy? Prior to this, use decreased to less than <1% of poisonings.

Charcoal Effective at binding a variety of toxins, most beneficial if given within 60 minutes Dose 1 gm/kg, up to 100 gm in a single dose

Charcoal Bond, Annals of EM, 2002

Charcoal Not proven to change outcome Every year 5 to 10 deaths in poison center data from charcoal aspiration Always with drugs that cause decreased consciousness, vomiting or seizures Hundreds of thousands of doses given, small number of measurable deaths, unable to measure benefit Risk Benefit Ratio?

Cathartics Use promoted because of clinical opinion Most commonly used in ED is sorbitol or magnesium citrate Intended to decrease absorption by increasing expulsion from the GI tract Dosing Sorbitol 70 % 2 cc/kg per kg in adults Sorbitol 35 % 4 cc/kg per kg in children Mag citrate 4 cc/kg in children/adults

Cathartics Indications -- No proven benefit. By convention it is usually given with the first dose, not used for multiple dose therapy The IPC recently stopped recommending it routinely due to guideline recommendations

Gastric Lavage Bond, Annals of EM, 2002

Gastric Lavage Indications -- Ingestion of a potentially life-threatening amount of a poison and the procedure can be done within 60 minutes of exposure contraindications -- depressed level of consciousness (airway), corrosives, hydrocarbons, patients at risk for GI trauma or bleeding

Gastric Lavage Adults 36-40 french tube (children 24-28 French) 20 degrees trendelenburg, left lateral position 200-300 cc aliquots of water or saline (10 ml/kg chidren, saline)

Whole Bowel Irrigation Co-Lav Colovage Colyte Colyte-flavored Colyte with Flavor Packs Go-Evac GoLYTELY NuLYTELY NuLYTELY, Cherry Flavor

Whole Bowel Irrigation No proven efficacy Potential to reduce drug absorption by rapidly cleansing the GI tract dosing 9 mo - 6 yo 500 ml/hr 6 yr - 12 yo 1000 ml/hr Adolescents/adults 1500-2000 ml/hr

Whole Bowel Irrigation Indications sustained release or enteric coated drugs Illicit drug packages Drugs not well absorbed by Charcoal

Whole Bowel Irrigation 18% of IPC cases documented at recommended rate of administration and an endpoint of clear rectal effluent Difficult to accomplish Time consuming Can be messy Inexperience and uncomfortable for staff

General Approach ENHANCED ELIMINATION Hemodialysis/Hemoperfusion MDAC Urinary Alkalinization

Enhanced Elimination Water soluble Small molecular weight Not highly protein bound Small Volume of distribution (<1 L/kg)

Dialysis I sopropyl S alicylates T heophylline U remia M ethanol B arbiturates (long-acting) L ithium E thylene Glycol

MDAC Dialyzable Enterohepatic recirculation A (Theophylline) B (Phenobarbital) C (Carbamazepine) D (Dapsone) Q (Quinine)

Antidotal Therapy Acetaminophen NAC Arsenic, mercury, gold BAL Atropine Physostigmine CO Oxygen CN CN antidote kit Ethylene glycol, methanol Ethanol, 4-MP Iron Deferoxamine Nitrites Methylene blue Opiates Naloxone Lead EDTA, BAL, Succimer Organophosphates Atropine, Pralidoxime

Review of Select 2005 Pediatric Death Cases Reported to AAPCC Already you know the outcome is going to be bad The discussion of risk of exposure, treatment and outcomes is what important

Case #1 18 month old child thought to have a respiratory infection (cough and vomiting) by family comes to ED for evaluaton. CXR shows FB in esophagus and stomach

Button Batteries Fatal in rare cases Ingestion of cylindrical and button batteries: an analysis of 2382 cases Litovitz et al, Pediatrics April 1992 2320 button batteries: no deaths 2 in esophagus with severe burns

Button Battery Ingestion Severe esophageal damage due to button battery ingestion: Can it be prevented? Yardeni et al, Pediatric Surgery International 2004 July State 19 cases reported in literature from 1979 to 2004 Brief Literature search showed multiple nasal and ear canal damage/reconstruction due to button battery insertion

Button Battery Ingestion Size <15 mm unlikely to become lodged in esophagus >20 mm likely to cause burns Locate the battery Esophagus – immediate removal Stomach/Intestine – expectant management with serial x-rays if not detected in stool

Button Battery Case Time delay in transfer to appropriate facility Both batteries removed endoscopically Admitted for 4 days. Barium swallow with undefined esophageal deviation Discharged with fever on abx and medication for acid reflux 4 days later found cyanotic and in shock Death Certificate with aorto-esophageal ulcer/fistula

Hydrocarbons 15 month old female found vomiting, cyanotic and in respiratory distress in the garage. The odor of gasoline was on the child 2 yo child ingested unknown amount of cigarette lighter fluid (Zippo) 18 month old child brought to ED after ingestion of pyrethrin insecticide that was 99% mineral spirits

Hydrocarbons 17,685 exposures reported to AAPCC 3 deaths – all respiratory Unknown number admitted with significant sequelae

Hydrocarbons Important History: When How much (often unreliable) Coughing Vomiting (increases aspiration potential) Behavior changes (lethargy, drowsiness)

Hydrocarbon Important signs and diagnostic exam results Mental status Respiratory status Cough Tachypnea Grunting/Flaring/Retractions Fever Pulse ox CXR

Hydrocarbons 15 mo female: Taken to community hospital. Arrested and expired before helicopter transport 2 yo male with cigarette lighter fluid: Died in ED 18 mo female in 99% mineral spirit ingestion: Lethargic and vomiting, died soon after arriving at tertiary care center

Calcium Channel Blockers 19 month old male found with mother’s Nifedipine 90 mg SR tablets. By pill count may have ingested 5 pills.

Calcium Channel Blockers AAPCC data with 22,082 pediatric exposures to “cardiac medications” No breakdown of Ca Channel blockers Illinois Data 1,611 cardiac medications: 158 Calcium Channel Blockers (9.8%) Extropolating to national data: over 2100 pediatric calcium channel blocker exposures Are they all true exposures?

Calcium Channel blocker Triage Criteria Proposed by AAPCC, ACMT, AACT (Triage amounts in mg/kg so small, may not be clinically useful)

Calcium Channel Blockers Hyperglycemia Calcium Channel blockers in the pancreatic B islet cells Decreased release of insulin Can lead to HYPERGLYCEMIA

Calcium Channel blockers 2 yo male with ingestion of up to 450 mg sustained release nifedipine Unremarkable vitals initially. Glucose 253 Upon arrival to tertiary care center, resting tachycardia 150 to 170. Patient monitored, tachycardic, hyperglycemic for up to 24 hours. Arrested the day after admission to tertiary care center, unable to resuscitate

Opiates 5 deaths in 2005 (9 in 2005) 3 deaths from Methadone Two from morphine/MS Contin Deaths were pre-hospital or secondary to anoxic brain injury

Opiates Not tracked historically (AAPCC database created 1983) rapid increase of opiate use and abuse somewhat recent phenomena A concerted effort to monitor and publish pediatric exposure data not yet established

Pediatric Toxicology Summary Pediatric Poisoning Exposure is a common occurrence Determining the dose is important, but frequently can be unreliable Death is rare as a percentage

Final Keys Know where to get knowledge about the substances involved Know where to get information on the clinical course and treatment

Pediatric Toxicology 2007

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