Pediatric Toxicology 2007

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Illinois Poison Center Pediatric Toxicology Presentation

Transcript of Pediatric Toxicology 2007

  • 1. 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

2. 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

3. 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

4. Pediatric Development

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

5. Pediatric Development

  • 9-12 months: pick upa pellet and put itin a hand

6. Pediatric Development

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

7. Pediatric Development

  • 18 months: able to
  • consciouslydump
  • pellet from bottle
  • (e.g. Tylenol, aspirin, vitamins, adult prescription medications)

8. 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

9. Pediatric Poisoning

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

10. Pediatric Poisoning

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

11. The #1 reason for injury-related hospitalization between 18 and 35 months is poisoning 12. 13. Pediatric Poisoning Admission In Illinois

  • Illinois Poison Center Data:

14. 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)

15. Assessment of Pediatric Ingestion

  • History
    • Who
    • What
    • Where
    • When
    • Why
    • How
    • The scene?

16. 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)

17. Pediatric Exposures Reported to AAPCC (National Data) 18. 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

19. 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

20. 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

21. 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

22. Pediatric Exposures

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

23. 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

24. 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

25. Management of Pediatric Exposures

  • Decontamination
  • Enhanced elimination
  • Antidotal Therapy
  • Supportive Care

26. Decontamination

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

27. 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.

28. Ipecac 29. Ipecac 30. Syrup of Ipecac 31. Syrup of Ipecac

  • Use of Ipecac promoted in the 1960s 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