This is Janice Zimmerman, and this presentation is on evaluation and management of the poison child. I'll first review some of the epidemiology of poisonings in the pediatric population, and then outline the initial evaluation and management of the poison child. At the end, I'll review some poisonings that are related to product changes in the marketplace. More information on specific toxins and interventions is covered in a separate presentation. I have no conflict of interest to relate to this presentation. Data on poisonings comes from an annual report from 55 poison control centers in the United States. In the 2020 report, pediatric poisonings accounted for 56% of all exposures, but thankfully only a small percentage of fatalities, about 6.7%. About 88% of pediatric poisonings are unintentional. There are some differences in poisoning by the age group. In the age group under five years, this accounts for 75% of all pediatric exposures, and it is male predominant. About 30% have no or minor clinical effects, and this group accounts for about 22% of all pediatric fatalities. This age group, the toddler age group, poisonings are usually the result of exploratory ingestions. They see something, they grab it, and put it in their mouth. It usually involves only one substance. They're often non-toxic substances, and the ingestion is a small amount. And since they're often picked up very quickly, they present soon after ingestion. However, this age group is also at risk for therapeutic errors in dosing of medications by caregivers. Children age six to 12 account for 10% of all pediatric poisoning exposures. We still see a male predominance in this age group, but this age group has the lowest frequency of pediatric deaths, only 7% of all pediatric deaths. Now when we get to adolescence, we see some changes. This age group accounts for about 14% pediatric exposures, but here it's female predominant. About 62% are female. The intentionality also changes with almost two-thirds of the exposures being intentional, and this group accounts for the largest percentage of pediatric deaths, 71%. There is also a concerning trend in this adolescent age group. The percent of suspected suicides for all intentional exposures has been increasing since 2010. The agents involved in pediatric fatalities also varies by age group. You can see the agents listed here, and they're in order of the most frequent to the least frequent. So in the under five age group, analgesics are there, but most of these substances, such as fumes, which is carbon monoxide. Then we have batteries, chemicals, pesticides, and cold and cough medicines that can be found in the environment. There aren't that many deaths in the age group of six to 12, but you also still see here carbon monoxide. You see antidepressants, but chemicals, analgesics, and pesticides. The adolescent age group begins to look more like adults. You see analgesics at the top of the list, antidepressants, stimulants, and street drugs, and then cardiovascular drugs, and then hormones are hormone antagonists. Let's turn now to the evaluation and management of the poison child. And this always begins with resuscitating and stabilizing the patient. That involves the ABCs that you're very familiar with, but also keep in mind the D, which is for depressed level of consciousness. In patients with depressed level of consciousness, you need to consider whether concentrated glucose is appropriate. Thiamine may need to be administered. And then always remember naloxone. And we'll talk more about the opioid crisis in children, but we are seeing more poisoned children with opioids. So naloxone is an important part of this approach to the patient with depressed level of consciousness. Before we talk about diagnosis, let's look at this question. A 14-year-old agitated patient presents after two seizures with the following exam. Heart rate is 130, respiratory rate is 20, blood pressure 140 over 88 with a temperature of 100.8. Pupils are 5 millimeters and reactive. So the question is, which one of the following is the most likely toxin? Is it a cholinergic drug, an antihypertensive drug, an opioid, a sedative, or sympathomimetic? Well, hopefully you thought that the correct answer was a sympathomimetic drug. And I think when you look at the vital signs and also the presence of seizures as well as these dilated pupils, this would be the obvious answer. And this is really a sympathomimetic toxidrome that we'll talk more about. In trying to establish the toxin involved in a poisoning, you're going to rely on the history, physical examination, and laboratory data. When approaching the history, you want, of course, to know the substance and quantity, although sometimes this information is not available or it may not be accurate. You would like to try to establish the time of ingestion or exposure so that you can anticipate the onset of toxicity or the duration of toxicity. There are many sustained-release medications in use today, and it's important to determine whether the ingestion was a regular release or a sustained-release form of medication. Toxicity will be more prolonged with sustained-release medications. You also want to know if the patient is chronically taking the agent that they overdosed on or was this a single, acute, grab-a-handful-of-pills-and-stuff-them-in-the-mouth type of exposure. In general, patients who chronically take medications are more likely to develop toxicity and an overdose. Of course, with pediatric patients, you have to consider the possibility of abuse and neglect. You're going to do a thorough physical examination, but I would suggest that you concentrate on the vital signs and neurologic findings, as this will help you maybe not identify the exact drug, but at least guide you to a category of drugs. For vital signs, you'll find patterns. Things that tend to increase the temperature, blood pressure, and heart rate fall into anticholinergic and sympathomimetic drugs, and of course, this includes the illicit drugs such as amphetamines and cocaine. On the opposite side, agents that tend to decrease temperature, blood pressure, and heart rate include the antihypertensives, the opioids, and sedative hypnotics. For the neurologic examination, it's important to focus on the level of consciousness and the pupillary size. Agitation suggests sympathomimetic or anticholinergic drugs. Less level of consciousness suggests opioids or sedatives. Dilated pupils, sympathomimetics and anticholinergics. Small pupils are classic for opioids, but also remember that could be a cholinergic poisoning. Although a lot of medications can cause seizures, this is still a helpful tool to help you narrow down to a category of drugs. Now, if you take these signs and symptoms, you can often classify the patient into a clinical syndrome of poisoning, which has been called a toxidrome. The sympathomimetic toxidrome includes high blood pressure, tachycardia, seizures, dilated pupils, agitation, and diaphoresis. The classic narcotic or opioid toxidrome is respiratory depression, small pupils, depressed level of consciousness, and often hypotension. And this is very similar to sedative and hypnotics, where you see the same depressed level of consciousness, respiratory depression, and more frequently you'll see hypotension, and you also see hyporeflexia. The anticholinergic toxidrome can look a lot like sympathomimetic, but they usually have a higher elevation of temperature, or tachycardic with dilated pupils, but they have dry skin rather than diaphoresis, and of course they have delirium and agitation. Now, the least common toxidrome is a cholinergic toxidrome, which is often called the hypersecretory toxidrome. You see salivation, lacrimation, urination, defecation, GI upset, emesis, and meiosis, which is characterized by the acronym SLUDGE. Respiratory data may be helpful in identifying a toxin, but it also helps you determine the effects of a toxin. Glucose should usually always be checked, and arterial blood gas may be helpful in the more severely ill patients to help you assess acid-base status and ventilation. Electrolytes are important for acid-base status, and renal function is important to determine if you have problems with excretion of certain toxins. Osmolality is usually measured only when you're expecting a toxic alcohol. Electrocardiograms should be indicated in those who have cardiovascular instability or have ingested a potential cardiotoxin. A pregnancy test, particularly in the adolescent patient, is not going to change your management but may be important for counseling after they recover. And then we come to the toxicology tests themselves. There are two types, qualitative and quantitative. The most commonly used is that qualitative urine tox screen. These tests may help you confirm a clinical diagnosis, but they are limited to only a few categories of drugs. Test results may have social implications, as they may often help you identify drugs that are out on the streets or in the environment. What may be more helpful in some patients are quantitative tests. And this is where you can assess the severity of exposure, such as, is it a toxic level? And you may also use this data to determine the need for a specific antidote, such as with acetaminophen poisoning. Now, other more advanced techniques, such as liquid chromatography and mass spectrometry are reserved for forensic analysis. And also, these types of results are not available in a short period of time. Let's look at another question. You have a four-year-old who ingested 20 ibuprofen, 200 milligrams, three hours before arrival to the hospital. Which one of the following is the most appropriate intervention? EpiCac, gastric lavage, and charcoal? Charcoal, whole bowel irrigation, or no intervention? Well, I would suggest that the best answer is no intervention in this patient. Over the last two decades, our use of gastrointestinal decontamination interventions has really changed. When you're considering whether to employ an intervention, take into account the type of substance that you're dealing with and the amount that was ingested, the toxicity of the substance, how long it's been since it was ingested, and also the symptoms that the patient is having. Here's a list of gastrointestinal decontamination techniques, and we'll talk a little bit more about some of these. But EpiCac has been gone since about 2003. Gastric lavage, we'll talk more about, but there really are no specific indications. Cathartics, there's really no evidence ever that they are of any benefit. The role of whole bowel irrigation is still not clear. And then, of course, we have activated charcoal, which is the most commonly employed gastrointestinal decontamination technique at present. Gastric lavage can be performed with normal saline or water, but as I mentioned, there's no definite indications. It may be considered within one hour of ingestion of a life-threatening substance. However, you have to weigh this against some of the complications, which can be severe, which is aspiration pneumonitis, esophageal perforation, and water intoxication causing hyponatremia. Whole bowel irrigation was actually first described in the pediatric population. And this is where you try to increase transit through the GI tract by using a polyethylene glycol solution to cleanse the bowel. I can tell you that the patient and the nursing staff do not appreciate this type of intervention. There's actually no definite indications for using whole bowel irrigation, but it has been suggested that it might have benefit with ingestions not absorbed by charcoal, such as iron and lithium, or with sustained release drugs and terracotta drugs or illicit drug packets. However, the evidence for any benefit is not there at the current time. Activated charcoal is actually administered in less than 1% of pediatric exposures. So although it's still the most common, it's not commonly used. The dose is one gram per kilogram, but if you're going to use this, it should be given within one to two hours of ingestion, unless you think there is really a slow GI transit. Keep in mind that charcoal will not absorb iron, lithium, alcohols, cyanide, hydrocarbons, or acids or alkalis. The toxicity of ingested drugs could also be potentially minimized by enhancing elimination. Multiple doses of charcoal take advantage of the enterohepatic circulation of some drugs to enhance hepatic clearance. The exact dose to give for subsequent doses is not clearly defined, but it's usually recommended is not less than 12.5 grams per hour. These doses of charcoal should not be combined with a cathartic, and you must assess to see if there's adequate gastric emptying before giving another dose. This may be a potential benefit with poisonings involving barbiturates, dapsone, carbamazepine, theophylline, or quinine. However, it is very uncommon to see poisonings with these drugs. Forced diuresis does not work, so you can forget about that. Alkaline diuresis does enhance the renal clearance of salicylates and barbiturates, but when alkalinizing the urine, you have to be careful and monitor for hypokalemia. Now, in many more seriously ill patients, hemodialysis or hemoperfusion may be used to enhance elimination of toxins. In some institutions, the charcoal cartridges are no longer available for hemoperfusion, but hemodialysis can always be used. Continuous dialysis techniques have been described, but we have much more experience with intermittent hemodialysis. In the pediatric population, you'll also find some case reports of using exchange transfusion, but that experience is very limited. A lot of the care for a poisoned patient is supportive. Supporting the respiratory mechanisms, monitoring for cardiovascular toxicity, and then controlling either the agitation or sedation. And of course, after recovery, counseling and intervention. Let's finish by talking about some poisonings that are related to products that come on the market and might have an appeal to the pediatric population. Laundry detergent packets, of course, are marketed to adults, but they are very attractive, particularly to young children. Most exposures have occurred in children under the age of six. Although exposures have decreased since 2015, more than 10,000 exposures were reported in 2020. A newer trend has been intentional exposures in the older age group. And of course, these children can circumvent the safety mechanisms on the containers. There's a wide variety of toxicities that can be seen. Nausea and vomiting, coma, respiratory depression, as well as pneumonitis, even cardiac arrest. The anti-gap acidosis is often associated with an elevated lactate. Ocular injuries usually occur from release of the liquid from these packets entering the eye. Management is primarily supportive. Of course, the e-cigarette trend continues, and this is popular with the adolescents. And reports of exposure started coming in around 2014, when the first death in a child was actually reported in 2014. Most exposures are in the age group under five, and most involve e-liquid refills, as you can see in the photo here. They're often flavored, like bubblegum, blueberry, or watermelon. So it's very easy to see a small child thinking this is something they can drink. The nicotine can be absorbed through the skin or through contact with the mucous membranes. The toxicity is a cholinergic poisoning. You can see nausea and vomiting, athercardia and arrhythmias, and even seizures and death. Management, again, is primarily supportive. Keep in mind that there are actually even very large quantities of nicotine that are out there that can come in contact with children. Of course, the new trend has been marijuana exposure. There has been an increase in exposures and emergency department visits in children after legalization of marijuana in various states in the United States and also in Canada. The Poison Control Center looked at exposures to marijuana from 2017 to 2019. They found that children are more likely to be exposed to manufactured products than the plant products. And it varies a little bit with age groups. So under the age of 10, they're more likely to be exposed to the edibles. And as you can imagine, there's cookies, there's candy that has these marijuana extracts in them. They're less likely to come in contact with the concentrate or the vaping liquids. But when you get into the adolescence, you still see exposure to the edibles, but more exposure to the concentrate and vaping. The manifestations that have been seen and described in the literature include lethargy, coma and ataxia, respiratory failure and seizures. And of course, these are types of toxicities that wind up having the patient admitted to the ICU. It's important to keep in mind because these patients often may not have a known exposure to marijuana. So this is a good reason to use a urine tox screen to see if this is playing a role in your patient's presentation. And also be aware that marijuana is actually concentrated in breast milk. So you can potentially see exposure in breastfeeding infants as well. As you would expect, care is primarily supportive in these patients. The last poisoning I'm gonna talk about is from energy drinks or basically caffeine toxicity. Although adults regularly consume these, it's been estimated that about 30% of teens regularly consume energy drinks. And there's a variety out there. And these are often combined with alcohol. There's even a product called AeroShot, which advertises breathable energy anytime, any place with one shot equaling one cup of coffee. Again, these are related, toxicities related to caffeine or Guadana. And Guadana, of course, is a caffeine product. And you get toxicities such as arrhythmias, particularly supraventricular, but you can also see ventricular arrhythmias. You may also see seizures. And in older individuals, you'll see stroke, but cardiac arrest can occur at any age. If these patients present, care is usually supportive. Thank you very much for your attention.

pediatric poisonings

evaluation

management

toxidromes

gastrointestinal decontamination

supportive care