Epidemiología y Tratamiento general de las intoxicaciones.

XV Congreso Chileno Medicina Familiar. X Congreso Nacional Médicos Atención Primaria. Dr.Enrique Paris M. Director Centro Información Toxicológica Pontificia Universidad Católica de Chile CITUC.

The price of life

Acute respiratory infection 18%

Other24%

Diarrhoea 15%

Malaria 11%

Measles 5%

Human Immunodeficiency Virus (HIV) 4%

Perinatal diseases(within 7 days of birth) 23%

Deaths associated with malnutrition:

54% Annual expenditure on pet food in North America and Europe

1998

Annual cost of scaling-up vaccination, malaria prevention and

essential treatment to reach every child in the developing world

2001

US$ 7.5 billion

US$ 17 billionAUSTRALIA

REP.KOREA

DPRKOREA

TIMOR-LESTE

MICRONESIA,FED. STATES OF

ANTIGUA & BARBUDA

BARBADOSST LUCIA

TRINIDAD & TOBAGO

PALAU

ST KITTS & NEVIS

ST VINCENT & GRENADINES

BAHAMAS

ZIMBABWE

UGANDA

TURKMENISTAN

UZBEKISTAN

TAJIKISTAN

KYRGYZSTANGEORGIAAZERBAIJAN

ARMENIA

MADAGASCAR

SRI LANKA

JAMAICA

CUBA

DOMINICANREP.

BRUNEI DAR.

M A L A Y S I A

SAUDI ARABIA

C H I N A

M O N G O L I A

VIET NAM

CAMBODIA

LAOPDR

THAILAND

I N D I A

BHUTAN

BANGLADESH

ISL . REP .IRAN

PAKISTAN

AFGHANISTAN

T U R K E Y

IRAQ

CYPRUS SYRIAN ARAB REPUBLIC

LEBANONISRAEL JORDAN

BAHRAIN

QATAR

UAE

OMAN

KUWAIT

YEMEN

NEPAL

K A Z A K H S T A N

U S A

C A N A D A

ALGERIA

NIGER CHADS U D A N

NIGERIACENTRAL AFRICAN

REPUBLIC

DEM. REP.CONGO

ETHIOPIA

ANGOLA

E G Y P T

MOROCCO

LIBYANARAB

JAMAHIRIYA

MAURITANIA

SENEGALGAMBIA

CAPE VERDE

SAO TOME & PRINCIPE

GUINEA-BISSAUGUINEA

LIBERIA

CÔTE D’IVOIRE

BURKINA FASO

GH

AN

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BEN

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CAMEROONEQUATORIALGUINEA

GABON

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NAMIBIABOTSWANA

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UNITED REP.TANZANIA

BURUNDI

RWANDAKENYA

DJIBOUTI

SOMALIA

TOG

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SIERRA LEONE

SWAZILAND

MALI

LESOTHO

ERITREAGUATEMALA

EL SALVADOR

MEXICO

HAITI

BOLIVIA

PARAGUAY

B R A Z I L

VENEZUELA

COLOMBIA

HONDURAS

NICARAGUA

COSTA RICA

PANAMA

ECUADOR

PERU

GUYANASURINAME

BELIZE

ARGENTINA

URUGUAY

CHILE

PHILIPPINES

NEW

ZEALAND

PAPUANEW

GUINEAI N D O N E S I A

JAPAN

R U S S I A N F E D E R A T I O N

MAURITIUS

MALDIVES

COMOROS

SEYCHELLES

SINGAPORE

DOMINICA

GRENADA

MYANMAR

SOLOMONISLANDS

TUVALU

MARSHALL ISLANDS

NAURU

TONGA

SAMOA

NIUE

COOKISLANDS

KIRIBATI

FIJIVANUATU

TUNISIA

CROATIAITALY

REP.MOLDOVA

UKRAINE

FYR MACEDONIA

LITHUANIA

LATVIA

ESTONIA

ALBANIA

AUSTRIA HUNGARY

BULGARIA

ROMANIA

GREECE

SERBIA &MONTENEGRO

POLAND

SLOVENIA

BELARUS

RUSSIANFED.UNITED

KINGDOM

IRELAND

DENMARK

FRANCE

SPAIN

ANDORRA

S. MARINO

PORTUGAL

GERMANY

SWITZ.

BELGIUM

LUX.

NETH.

ICELAND

NORWAY

FINLAND

SWEDEN

SLOVAKIACZECHREPUBLIC

MALTA

MONACO

BOSNIA & HERZEGOVINA

Under-five mortality rate per 1000 live births2000

Beacons of hope

greatest improvement in child mortality rate 1970–2000

over 175

101 – 175

26 – 100

11 – 25

10 and under

no data

Child mortality rate

Main causes of child mortality 2002

The biggest killers of children under five

Produced by M

yriad Editions

O

The World’s Forgotten Children

ver 10 million children under five die every year –

98 per cent of them in developing countries. Widespread malnutrition hampers children’s growth and development, opening the door to the biggest killers of children under five: perinatal diseases, pneumonia, diarrhoea, and malaria. This presents a sharp contrast to the situation in the industrialized world, where junk food and a sedentary lifestyle have triggered an unprecedented epidemic of obesity in children, leading to diabetes and heart disease in adult life.

The last three decades have witnessed an impressive decline in child mortality, from 17 million a year in the 1970s. Yet these gains have not been enjoyed everywhere. In some countries of sub-Saharan Africa, child mortality is rising as wars and the ravage of the AIDS epidemic undermine the medical, social and economic structures of society.

At the turn of the century, the world joined together in the fight against poverty, and committed itself to the Millennium Development Goals, adopted by the United Nations in 2000. “To reduce by two-thirds the under-five mortality rate between 1990 and 2015” may be the most ambitious of these goals.

Aiko is safely delivered in Kumamoto, Japan, and can expect to live about 85 years. At the same time, Mariam comes

into this world in one of the poorest areas of Freetown, Sierra Leone. She is

underweight and vitamin-deficient, and has a 30% chance of dying before her

fifth birthday.

Today, 35% of Africa’s children are at higher risk of death than they were ten years ago.

From Inheriting the World: The Atlas of Children's Health and the Environment © WHO

World Health Organization

"It is not enough to prepare our children for the world;

we must also prepare the world for our children.”

Luis J. Rodriguez (1954– )

Niños y Medio Ambiente.

A U S T R A L I A

REP.KOREA

DPRKOREA

TIMOR-LESTE

MICRONESIA,FED. STATES OF

ANTIGUA & BARBUDA

BARBADOSST LUCIA

TRINIDAD & TOBAGO

PALAU

ST KITTS & NEVIS

ST VINCENT & GRENADINES

DOMINICA

BAHAMAS

ZIMBABWE

UGANDA

TURKMENISTAN

UZBEKISTAN

TAJIKISTAN

KYRGYZSTANGEORGIAAZERBAIJAN

ARMENIA

MADAGASCAR

SRI LANKA

JAMAICACUBA DOMINICAN

REP.

BRUNEI DAR.

M A L A Y S I A

SAUDI ARABIA

C H I N A

M O N G O L I A

VIET NAM

CAMBODIA

LAOPDR

THAILAND

I N D I A

BHUTAN

BANGLADESH

ISL . REP .IRAN

PAKISTAN

AFGHANISTAN

T U R K E Y

IRAQ

CYPRUS SYRIAN ARAB REPUBLICLEBANON

ISRAEL

JORDAN

BAHRAINQATAR

UAE

OMAN

KUWAIT

YEMEN

NEPAL

K A Z A K H S T A N

U S A

C A N A D A

ALGERIA

NIGER

CHAD S U D A N

NIGERIA

CENTRALAFRICAN REPUBLIC

DEM. REP.CONGO

ETHIOPIA

ANGOLA

E G Y P T

MOROCCO

LIBYANARAB

JAMAHIRIYA

MAURITANIA

SENEGALGAMBIA

CAPE VERDE

SAO TOME & PRINCIPE

GUINEA-BISSAU GUINEA

LIBERIA

CÔTE D’IVOIRE

BURKINAFASO

GHAN

A

BENIN

CAMEROONEQUATORIAL

GUINEA

GABON

CONGO

NAMIBIABOTSWANA

SOUTH AFRICA

MOZAMBIQUE

MALAWIZAMBIA

UNITED REP.TANZANIA

BURUNDI

RWANDAKENYA

DJIBOUTI

SOMALIA

TOGOSIERRA LEONE

SWAZILAND

MALI

LESOTHO

ERITREAGUATEMALA

EL SALVADOR

MEXICO

HAITI

BOLIVIA

PARAGUAY

B R A Z I L

VENEZUELA

COLOMBIA

HONDURAS

NICARAGUA

COSTA RICA

PANAMA

ECUADOR

PERU

GUYANA

SURINAME

BELIZE

ARGENTINA

URUGUAY

CHILE

PHILIPPINES

NEW

ZEALAND

PAPUANEW

GUINEAI N D O N E S I A

JAPAN

R U S S I A N F E D E R A T I O N

MAURITIUS

MALDIVES

COMOROS

SEYCHELLES

SINGAPORE

GRENADA

MYANMAR

SOLOMONISLANDS

WEST BANK AND GAZA

TUVALU

MARSHALL ISLANDS

NAURU

TONGA

TOKELAU

SAMOANIUE

COOKISLANDS

KIRIBATI

FIJI

VANUATU

TUNISIA

CROATIA

ITALY

REP.MOLDOVA

UKRAINE

FYR MACEDONIA

LITHUANIA

LATVIA

ESTONIA

ALBANIA

AUSTRIA HUNGARY

BULGARIA

ROMANIA

GREECE

SERBIA &MONTENEGRO

POLAND

SLOVENIAB-H

BELARUS

RUSSIANFED.UNITED

KINGDOM

IRELAND

DENMARK

FRANCE

SPAINPORTUGAL

GERMANY

SWITZ.

BELGIUM

LUX.

NETH.

ICELAND

NORWAY

FINLAND

SWEDEN

SLOVAKIACZECHREPUBLIC

MALTA

How children are injured

Causes of deaths worldwide due to unintentional injuries for children under 15 years 2002

Road traffic accidents boys girls

Poisoningsboys girls

Falls boys girls

111 559

71 261

19 818 15 79722 294

14 713

Fires boys girls

34 23839 969

Drowningboys girls

89 955

55 104

Deaths due to road traffic accidents of children aged 0–14 years per 100 000 2002by WHO sub-region

20.0 and over

10.0 – 19.9

5.0 – 9.9

2.5 – 4.9

under 2.5

no data

Dying on the roads

Produced by Myriad Editions

Child Injuries are Preventable

rowning is the most common cause of injuries

for infants, killing approximately 60 000 children under five every year and leaving roughly the same number permanently disabled. Children also suffer burns from open fires and kerosene stoves, and are injured in falls at home, at school and at playgrounds.

In older children, however, the overriding cause of injuries is road traffic accidents, killing approximately 180 000 children under 15 each year. Children are rarely the cause of road traffic accidents but suffer as pedestrians, cyclists and passengers. Boys, often given greater freedom to roam, are more likely to be injured than girls.

Injuries are unnecessary and avoidable. The use of seatbelts and child car seats, and the wearing of helmets are essential to prevent the death of child passengers or cyclists. Traffic measures such as checking vehicle roadworthiness, enforcing speed limits and prosecuting drunk drivers are particularly important in developing countries, where roads tend to be poorly maintained and the number of vehicles is growing rapidly.

Injuries from road traffic accidents already cost developing countries US$ 65 billion a year – more than the annual amount of development assistance they receive.

D

Emeka slipped while drawing water from the river near her village in Nigeria and

did not return home . . .

From Inheriting the World: The Atlas of Children's Health and the Environment © WHO

World Health Organization

Deaths from road accidents are projected to rise by 65%

by 2020, mostly in developing countries.

LIFETIME EXPOSURES

Birth 6 m 1 yr 5 yr 16 yr 45 yr 65yr

Intrauterine

Breastfeeding Occupational exposure

“Normal” food

Soil: ingestion

Soil: dermal

Domestic environments

Drinking water

Air

www.cituc.cl

EPIDEMIOLOGIA

EPIDEMIOLOGIA

EPIDEMIOLOGIA

EPIDEMIOLOGIA

Intoxicaciones.

♦ Primeros Centros Toxicológicos 60’. ♦ Formados por Pediatras. ♦ Campañas Masivas. ♦ Semana de la Prevención. ♦ Uso Responsable del Medicamento.

Intoxicaciones.

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Intoxicaciones. ♦ Personal y Base de Datos CITUC. ♦ 1 Secretaria. ♦ 5 Enfermeras. ♦ 4 Químicos Farmaceúticos.1 Dr. Tox. ♦ 16 Internos de Medicina y QF. ♦ 1 Médico Intensivista Pedíatra. ♦ 1 Médico Laboratorio. ♦ Micromedex. Intox.

Intoxicaciones.

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EPIDEMIOLOGIA

EPIDEMIOLOGIA

EPIDEMIOLOGIA

EPIDEMIOLOGIA

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Medicamentos

Prod. Ind. Y Químicos

Productos Aseo

Fitosanitarios

Animales

Plaguicidas domésticos

Cosméticos

Metales

Cuerpo Extraño

Alimentos Gases

Plantas

Otro

SUSTANCIAS MAS FRECUENTES

Llamadas

0 1000 2000 3000 4000

Sistema Nervioso Central

AINES

Sistema Respiratorio

Antibióticos Sist. Hormonal

Sist. Nervioso Autónomo

Sistema Cardiovascular Vitaminas/Minerales

Antisépticos/desinfectantes

Agentes gastrointestinales

Otros

MEDICAMENTOS MAS FRECUENTES

LLAMADAS

GRUPO MAS FRECUENTE SNC

0 200 400 600 800 1000

BENZODIAZEPINAS

ANTIDEPRESIVOS

FENOTIAZINAS Y DROGAS RELACIONADAS

ANTICONVULSIVANTES

ANFETAMINAS

OTRAS DROGAS SNC

LLAMADAS

PRODUCTOS DE ASEO

0 200 400 600 800 1000

CLORO

DETERGENTES

LAVALOZAS

OTROS AGENTES

LIMPIADORES

LLAMADAS

PRODUCTOS INDUSTRIALES

0 200 400 600 800 1000 1200

HIDROCARBUROS

ALCOHOLES

ACIDOS/ALKALIS

PEGAMENTOS

OTROS

LLAMADAS

OTRO 10%

ANTICOAGU-LANTE 35%

PIRETROIDES 25%

ORGANOFOSFORADOS 30%

PLAGUICIDAS DE USO DOMESTICO

Figure  1.  A  21-­‐year-­‐old  dental  assistant  a1empted  suicide  by  injec8ng  10  ml  (135  g)  of  elemental  mercury  (quicksilver)  intravenously.  She  presented  to  the  emergency  room  with  tachypnea,  a  dry  cough,  and  bloody  sputum.  While  breathing  room  air,  she  had  a  par8al  pressure  of  oxygen  of  86  mm  Hg.  A  chest  radiograph  showed  that  the  mercury  was  distributed  in  the  lungs  in  a  vascular  pa1ern  that  was  more  pronounced  at  the  bases.  The  pa8ent  was  discharged  aNer  one  week,  with  improvement  in  her  pulmonary  symptoms.  Oral  chela8on  therapy  with  dimercaprol  was  given  for  nine  months,  un8l  the  pa8ent  stopped  the  treatment;    

Intoxicaciones.

♦ Diagnóstico.

♦ - Sospechar el Diagnóstico. ♦ - Anamnesis. ♦ - Examen Físico . Sindromes Tóxicos. ♦ - Examenes de Laboratorio.

Intoxicaciones.

♦ Sindromes Tóxicos.

♦ - Sindrome Anticolinérgico. ♦ - Sindrome Colinérgico. ♦ - Sindrome Opiode Alcohólico. ♦ - Sindrome Catecolaminérgico.

Intoxicaciones. Síndromes Tóxicos. Síndrome Anticolinérgico. Causas. Antihistamínicos, antidepresivos tricíclicos

antiespasmódicos, chamico, atropina.CBZ. Sintomatología. Taquicardia, vasodilatación, retención

urinaria, silencio abdominal, alucinaciones y convulsiones.Midriasis.Mucosas secas.

Intoxicaciones. Síndromes Tóxicos. Síndrome Colinérgico. Causas. Hongos, carbamatos, órganofosforados,

fisostigmina. Sintomatología. Depresión SNC, hipotonía, salivación,

lagrimación, incontinencia urinaria y fecal, bradicardia y convulsiones.Miosis.

Intoxicaciones. Síndromes Tóxicos. Síndrome Opioide alcohólico. Causas. Codeína, morfina, barbitúricos, BDZ,

etanol, clonidina. Sintomatología. Coma, depresión respiratoria, hipotensión,

miosis, bradicardia, hipotermia, edema pulmonar, shock distributivo.

Intoxicaciones. Síndromes Tóxicos. Síndrome Catecolaminergico. Causas. Cocaína, amfetaminas, efedrina, cafeína,

pseudoefedrina, fenilpropanolamina. Sintomatología. Taquicardia, hipertensión, hipertermia,

diaforesis, midriasis, convulsiones y arritmias.Dolor anginoso.

Intoxicaciones.

♦ Tratamiento . ♦ Siempre tratar primero al Paciente: ♦  ABC de la Reanimación. ♦ Después tratar al Tóxico. ♦  “ABC” de la Intoxicación.

Intoxicaciones.

♦ Tratamiento . ♦ Siempre tratar primero al Paciente: ♦  ABC de la Reanimación. Via Aerea Permeable.Oxigenar. Asegurar una buena ventilacion. Dos vias venosas gruesas. Monitoreo Cardíaco. Saturación.

Intoxicaciones.

♦ “ABC” de la Intoxicación.

♦  - evitar la absorción. ♦  - favorecer la adsorción. ♦  - favorecer la eliminación. ♦  - antagonizar al tóxico.

Intoxicaciones.

♦ Evitar absorción : Lavado Gástrico. Solo en la primera hora post ingestión. Proteger la vía aerea si existe compromiso de

Conciencia. Indicado principalmente en Tóxicos que

comprometen gravemente la vida del paciente. Contraindicado en Caústicos e Hidrocarburos.

Intoxicaciones.

♦ Favorecer adsorción :Carbón Activado. Muy Importante. Dosis Unica. 2 a 3 gr /kg Niños. Dosis Secuenciales. 0,5 a 1 gr/ kg c/4, 6 u 8 hrs. Contraindicado en Caústicos y Obst.Intestinal Inutil en Litio y Fierro.

Intoxicaciones.

♦ Carbón Activado. Concomitantemente usar Lactulosa. 10 a 15 ml con cada dosis de Carbón.

Intoxicaciones.

♦ Favorecer la Eliminación. Ventilación del lugar del accidente. Forzar diuresis. Alcalinizar o Acidificar

orina. Lavado Gastrointestinal total. Solución de

Colon. Oxigenar . Cámara Hiperbárica.

Intoxicaciones.

♦ Antagonizar al Tóxico.

Usar un Antagonista no es la Panacea. Lo importante es Tratar al Paciente.

Intoxicaciones.

♦ Paradoja. Uso de flumazenil en Intoxicación Mixta de BDZ y Antidepresivos Tricíclicos. ¿ se debe usar flumazenil ?

Intoxicaciones. Antídotos. ♦ N-Acetilcisteína. ♦ Atropina. ♦ Benztropina. ♦ Difenhidramina. ♦ Digibind. ♦ Etanol. ♦ Fitomenadiona ♦ Glucagón.

♦ Flumazenil. ♦ Glucosa. ♦ Naloxona. ♦ Obidoxima. ♦ Oxígeno. ♦ Piridoxina. ♦ Succimer. ♦ Fomepizol.

Intoxicaciones.

♦ Prevención. ♦ - Educación a toda la Familia. ♦  almacenar correctamente los tóxicos. ♦ - Uso correcto del Medicamento. ♦ - Promover el Envase Seguro. ♦ - Promover los Centros de Información.

Intoxicaciones.

♦  Gracias !