Kiddy Tox

Fortunately for us, younger kids are less dedicated in their efforts to harm themselves with a variety of poisons… On the other hand, their sneaky inventiveness knows no bounds, when it comes to getting hold of something that they shouldn’t.

The principles of Clinical Toxicology are similar in kids and adults, but there are a few additional aspects to consider. Join us on a sketch of assessment and management of the poisoned child… or the potentially poisoned child.

Paeds Tox PEMcast: Outline

[cp] Welcome, intro, disclaimer
80,000 calls to Australian Poisons Information Centre per year regarding paediatric unintentional exposures

[sf] Pharmacokinetic / Toxicokinetic differences in kids:
Different body composition – affects volume of distribution
Higher metabolic rate
Immature liver enzymes (& not induced by alcohol and other recreational substances)
However same mg/kg toxic effects for most agents
Actual agent involved is probably most important factor
Remember that venomous animals do not respect size of their victim…

[KH] 2 types of poisoning in kids:
Toddlers: exploratory, unaware of risks,
usually spit out pills (unpleasant taste) or only sip / mouthful of liquid agent
Teenagers: deliberate self-poisoning, serious intent

[sf] Household exposures – call poisons info centre
Most household exposures non-toxic, including:

• thermometer mercury
• Oral Contraceptive Pill
• cosmetic products
• paint
• matches
• cigarette butts (?nicotine)

[cp] ‘One pill can kill’ list:
Airway & Breathing (CNS, RS, muscles):
opiates
paraquat

Circulation (CVS):
calcium channel blockers (SR)
propranolol
dextropropoxyphene
TCAs

Disability (CNS):
(hydroxy) chloroquine
theophylline
organophosphate & carbamate insecticides
hydrcarbons (solvents, eucalyptus oil, kerosene)
camphor

Metabolic / other:
amphetamines
sulphonylureas
naphthalene

[KH] Agents NOT on this list (but can still cause toxicity in sufficient dose):

• paracetamol
• iron
• colchicine
• anticoagulant rat poison

[sf] Adolescent Deliberate Self-Poisoning
Intent vs lethality (not always congruent)
Common agents – OTC medications (Paracetamol), own meds, Parents meds (FHx of psychiatric illness, nature & nurture)

[cp] Acute Management template: “R RSI DEAD”
Resuscitation:
A, B, C
Sugar, seizures, shivering:
hypoglycaemia 5ml/kg of 10% dextrose
seizures: benzodiazepines
hyperthermia – intubation & paralysis; hypothermia: external warming
(emergency antidotes) eg bicarb for TCA, naloxone for opiates

[KH] Risk assessment:
“ADT CP”
Agent(s)
Dose
Timing
Clinical effects & evolving features
Patient factors (co-morbidities, weight)
Hampered by incomplete history (unwitnessed ingestions/exposure) and different range of medications in children

[sf] Tips for Tox Detectives:
Agent: Include all agents in the house, and at grandparents, other places where child has been; contact GP, pharmacy for parents’ meds; Ambos (counting empty packets), proprietary pharmaceutical product indexes (pill colours, shape, inscriptions)
Dose: assume maximum dose (taken by both/all siblings)
Timing: assume worst-case scenario based on possible earliest & latest times

[cp] Acute Management template: “R RSI DEAD”
Resuscitation
Risk assessment
Supportive care & monitoring
Investigations:

• blood sugar
• ECG
• paracetamol level

[cp/KH both]:
Decontamination (induced emesis, gastric lavage, activated charcoal, whole bowel irrigation)
Enhanced elimination (repeat-dose activated charcoal, dialysis/filtration, urinary alkalinisation – specific agents for each) charcoal heamoperfusion
Antidotes – small role
Disposition (medical and psychosocial)

[sf] Toddler Mystery Pill Ingestion management:
Admit & observe 12 hrs +
Monitor vital signs, GCS, blood sugar, specific signs depending on agent
IV access if & when toxicity manifests
Cardiac monitoring depending on agent
Home in daylight hours only

[KH] Risk Assessment over a Thousand Miles?

[KH] Agents where treatment different from adults:
Paracetamol
Benzodiazepines
Agents causing bradycardia

[all] Summary

Shout-outs to:
Perth Toxicologists a-plenty…
LITFL Crew @sandnsurf @antidoped
TPR – The Poison Review @poisonreview

References:

Toxicology Handbook – Lindsay Murray, Frank Daly, Mark Little, Mike Cadogan
2nd Edition (esp Chapter 1 and pg 120-125)

Australian Poisons Information Centre: Freecall 13 11 26 (Australia)