Paediatric Toxicology
SSEM Sept 2012 by Dr. Mark Little
24th Oct 2012
Dr. Julia Ng
Emergency Physician
Take Home Message
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Most children age 1-2 y.o
Most harmless substance
Most do not need hospital care
Death or serious harm is exceptionally rare
Small list of 1-2 tablets can kill children
Management
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Resuscitation ABCDE
D detect and correct 1) seizure using benzo benzo and benzo, no phenytoin
2) hypoglycemia
3) hyper or hypothermia eg serotonin
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E emergency antidote - naloxone sodium bicar
Risk assessment
Agent eg carbamazepine 50mg/kg
Dose
Time since ingestion
Clinical features and progress
Patient factors eg weight, comorbidities
Supportive
Investigation
Decontamination
Enhanced elimination
Antidote
Disposition
Risk assessment in children
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Dose- response in mg/kg is usually the same as for adults
Children rarely ingested > 2-3 tablets
Exact dose and time may be difficult to estimate
May need to resort to a ' worst case scenario '
Assume the time of ingestion is the latest possible
Assume all missing tablets have been ingested
Do not attempt to account for spillage
If more than one child is involved, assume each child
ingested the amount
• Consider NAI in large and repeated dose
Investigation
• Routine investigation :
• Paracetamol and ECG for cardio toxicity
• Paracetamol can be occult
List of 1-2 tablets lethal in children !
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Amphetamine
Clonidine
Calcium channel
Chloroquine hydrochloride
Dextroproxyphine -VT
Propranolol
Opioids
Sulphonyureas
Theophylline
TCA
Unknown pill
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Admit 12hours for unknown pills
Ability to ETT/BVM
No IVC if alert and running
If flop check BSL
Monitor for level of consciousness and vital
signs
Case 1
• 2 y.o old was brought to triage by mother, ate
1-2 pellets
Ratsak
• Long acting warfarin - up to 6-8 months
• Kids ingested 1 packet to have significant poison
• Adults 3 packets to be toxic
• Discharged home from triage, no need for blood
test
If delibrated self harm,
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Check INR first
no vitamins K
if toxic may need 100mg vit K for 3-6 months
Serial INR check
If INR> 2-3, intervene
Case 2
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2 y.o brought into ED :
Drowsy
RR 8
Pinpoint pupil
• What is the toxidrome ?
opioid
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Check undisturbed RR
If < 10 , need intervention : naloxone
Dose ?
Alternative vital ETCO
If need a second dose of naloxone , start an
infusion at 2/3 of reversal dose.
• Especially if it is overnight
Case 3
• 2.y.o has been playing , possibly ingested
grandmother’s antihypertensive medication in
a dosette box.
• Grandmother is on a beta blcoker.
• Is this dangerous ?
Case 3
• Atenolol and metoprolol in kids usualy cause
slight lower BP and reduced PR
• Settled with fluid
• But propranolol and sotalol the worst :
• Propranolol – CNS and class I sodium channel
blockade
• Sotalol – K channel blockade, QT prolongation
Case 4
• 2 y.o girl was brought to ED ingested 5mg
glipizide.
• Is this a concern ?
Case 4
• Up to 8 hours course of hypoglycaemia
• Dextrose 10% only in adult due to high volume
infusion
• Used octretide – stop release of insulin and
safe
• Dose ?
Case 5
• 2 y.o boy has ingested 2 lomotil tablets 1 hour
ago presented to triage.
• Triage nurse thought it only causes
constipation as a result but come to ask you if
she can discharge the child and maybe suggest
some laxative if constipated.
• What do you do ?
Case 5
• Has anticholinergic ( atropine 23 mcg ) and
opioid ( diphenoxylate 2.5mg )
• Symptom onset within 4 hours
Case 6
• 2 children , siblings, had been playing with a
bottle of 100% eucalyptus oil and ? ingestion
Case 6
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First sign : coughing
Implies pneumonitis
Within 2 hour drowsy
Then seizure and coma usually short lived
If asymptomatic by 4-6 hours, safe for
discharge
Case 7
• 2 y.o ingested grandfather’s digoxin.
• Is this dangerous ?
• Toxic lethal dose 4mg for child
• Sign of vomiting within 4 hours
Case 8
• 2 y.o ingested unknown amount of iron tablet
Is this a concern ?
Case 8
• If < 40mg/kg elemental iron, no vomiting
• AXR to count the tablets to work out dose per
kg
• Progressive lowering of Bicarbonate level
• Treatment is to maintain HCO > 18
Case 9
• 2 y.o ingested grandfather ‘s colchicine
Case 9
• Vomiting early within 2 hours
• Lethal dose 0.5mg/kg -0.8mg/kg