1 Procrc<.lingS.Z.P.G.M.I vol: 9(a- I> I !1rl'l, pp. 52-57. II Editorial Review 1 Poisoning in Children Aysha Maqbool, Huma Maqbool, Sajid Maqbool Department of Paediatrics, Shaikh Zayed Postgraduate Medical Institute, Lahore
INTRODUCTION their specific treatment modalities. Treatment generally involves 3 aspects; omes have always been considered as fo1tresses Hof protection and safety, but these same havens 1) Removal of the poison of safety may become menacing danger fields for the 2) Supportive therapy in fulminantcases young inquisitive toddlers, containing within them 3) Life-sustaining measures unassuming, hidden and sometimes fatal traps. Unattended for a minute, children especially Removal of Poison between the ages of 1-5 yr are attracted by anything Stomach emptying is the first line of action in that catches their eye, and they fall easy prey to case of an ingestion. Unless contraindicated emesis is brightly coloured tablets or cleaning agents lying induced immediately, in the emergency room at about the house. home or even in the doctors office. Contraindications Thus poisonings in children are generally a are coma, corrosive ingestion and petroleum result of ingestion of household products or drugs; ingestion. where failure to put such agents in a safe place is a common error and parental neglect contributory. a) Emesis: Simple gagging can be induced by Hence prevention should be the key word in any making the child drink a glass of water or milk discussion. and · then inducing emesis by stroking the The following are some pertinent warnings for posterior pharngeal wall. 10-15 ml syrup Ipecac a safe child-proof home. can be given to a child with oral fluids. This can be repeated again after 15-30 min if the first 1) Keep all drugs, pesticides, household chemicals dose is ineffective. Remember > 30ml Ipecac out of sight and out of reach of children should not be left in the stomach. Being a 2) Do not store poisons etc in food containers, soft cardiotoxin, it can cause atrial fibrillation. drink or juice bottles. 3) Lock up all dangerous substances. b) Gastic lavage: If vomiting cannot be induced 4) Do notjtell children medicine is candy. then a gastic lavage is reso1ted to. It is indicated in ingestion of toxic drugs < 3 hour ago, if the Once ! child begins crawling, he begins to poison was enteric coated, or the drug is ve1y explore his environment, and begins putting slowly absorbed, e.g. tricyclic antidepressants. anything he can hold in his mouth. Hence from It is contraindicated in petroleum and distillate about 9 months to about 4 yrs children are in an ingestion, coma; decreased cough reflex and in exploratory phase where diligent supervision is strong corrosives ingestion though if the patient necessa1y. arrives within 1 hr of the ingestion of During this age all effo1ts should be made by corrosives, a lavage may be tried. parents to keep all agents capable of pathological A urina1y catheter lubricated with water and toxicity, away from children. marked at the nasoxiphoid distance can be Household chemicals should be kept under lock passed in children and infants perorally. A glass and key. No drug, however trivial should be left syringe is attached and the gastric contents are lying around the house. And homes, should indeed aspirated. Then isotonic saline is used for be made havens of protection and safety for these lavage, and the procedure is continued 10-12 youngsters. times till the aspirate is clear. N eve1theless, once a toxic agent is ingested, every effo1t should f:>e made to identify it. This a1ticle c) Antidotes: These can be given via the tube and deals with various common household poisons and allowed to remain in the stomach. Tannie acid
52 Poisoning in Children
precipitates a large number of organic and alkalis. House hold bleach and home made sooi inorganic compounds. However, due to contain mild alkalis. Children experienC\. r hepatotoxicity it should be used . with care. burning f om mouth to stomach whereh� Potassium permanganate coYers a wide range of swallowing becomes progressively difficult toxic organic compounds especially Nicotine, Mucus membranes are brown and tilceratt-d: Physostigmine and Quinine. It is diluted bloody mucoid vomitus may he present. And a generously (1:10,000) in solution to prevent patient may collapse with deteriorating vital gastric mucosa] irritation by Potassium signs. Large quantities of milk or water can be Permanganate directly. Magnesium oxide is given immediately. A lavage or ernesis is not used in asprin and oxalic acid poisonings. done. Cort1costeriods are gi\·en to pren'nt esophageal stenosis in upto 4 yrs of age. Activated charcoal is a potent aclsorbent if given Predinsolone is started at 60mg/kg in 4 di\·iciPd promptly. It is effective for by farthe largest number doses ancl is tapered to a11cl maintainer] al of organic ancl inorganic compounds. The list 20mg/kg for :3 \\'CPks or rn1til the esophagt-al includes drugs like Atropine, Morphine, Penicillin, lesion is hL'alt'd. Salicylates, Darbitmates and so on 1-2 tablespoon in 240 ml 9fwater are given orally, usually post emesis. Table I: Common household Supportive Thernpy <·ornpounds An emergency airway is established ifrequired, and circulation is maintained. Parent ral fluids are Hous,·1>1,/d ,�gent ('h,·11111·n! started to maintain urine output. and electrolyte balance and vital signs are monitored and stabilized. I Toil,•t ,1ml Till' clPanl'r HyrlrnchloncaC'1cl :l. Floor d,•,ull'r S11iph11ric aC'1d Life Sustaining Measures 3. Hou'>Phold d,•an<•r An1n11nia 1. Bleach<'" S11cl111111 H_,rln>,rrl1• a) Hemodialysis is used for circulatory poisons or ;;. Toill't Cl,·anPr Ph11,phonC' al'!d tissue or colloid- binding poisons e.g lJahituates, 0. MatchP�. rnr!Pntic1df' Plw,plioru, salicylates. Contraindications include GI 7. Bleach Oxal11· aC'id 1· "l11-1111 Jl.,pochon1,• bleedings or inexperienced personnel. ______s _,_ �8-.-B-IP -a-ch_ ___ b) Peritoneal dialysis may also he used, though J contraindicated in peritoneal ca\'ity infections. c) Exchange transfusions can be done in < 1 yr infants with salicylate or harbituate poisoning. Toilet Bowl cleaners contain Sodinm Acid Forced duiresis and urine alkalinization is also sulfate, an acid corrosive that cauSL'S superficial increasingly effective. skin destruction. With production of initial gases e.g. chlorine, ammonia, cough clyspnea, Specific Poisons and Their Management respiratory tract irritation and pulmonary 1. Disinfectants, Bleaches: edema may be a presenting scenario. Treatment Oxalic Acid is present in disinfectants and includes administering oxygen and aitifical bleaching agents. Children usually present with respiration if needed. Fmther symptomatic and GI upset, dysphagia, hematmesis, oral mucus suppmtiYe treatment is given as required. membrane lesions, hypocalcemia and dilated pupils. Treatment includes oral magnesium 2. Barbiturates: hydroxide, calcium bicarbonate, and chalk and Barbituates are another sonrC'c' of childh,,od water. Emesis is contraindicated though laYage poisonings. Excitement, hallucinations. mental can be done if oral and esophageal erosions are depression, deteriorating Yital signs leading to mild. 10% calcium gluconate is given shock is seen. Lavage is uselt'ss clue to rapid intravenously. Symptomatic and supportive absorption of barhituates. ActiYi11·d charcoal is treatment is giYen as required. administered. Forced diuresis and urine Washing powder, Clinitest tablets Paint alkalinization is also done. Airway is established removers, and Drain cleaners con t.ai n strong if required and suppo1tive therapy provided. Afut1hoo/ <'f al.
Tranquilizers cause de('p sleep, d('(Tt>asi11g \"ital acet.aminoph0n may ensue. Within 7-8 days signs anci tonic donic rnnn1lsions anci rnma. If hepatic necrosis and renal failure can set it. the child is sle('ping, then aciminister i, \" fluids only. l\orqJinephrine is gin1 n for shock and Mortality results due to hepatic necrosis. barhituatcs may be administered carefnlly for Greater than 5 gm ingestion is taken as toxic terminating tonic clonic com'11lsions. dose. an
problem. Chemical pneumonitis, massive poisoned by diapers stamped with aniline dye pulmonary edema and pulmona1y shock are products. They become apathic, dyspneic and some modes of presentation. Hemoptysis occurs may develop convulsions. Circulatory and in younger children who may be sicker. respiratory failure may ensue. Cyanosis sometimes developes very quickly due in pa1t to the displacement of alveolar gas by 12. Lead hydrocarbon vapours� Chemical pneumonitis is Chronic lead poisoning by inhalation and typically bilateral and generally involves ingestion of water from old lead pipes is another 9 10 multiple lobes, most severely the lower lobes • . serious form of poisoning. Hypochromic Aspiration on occasion may not be recognised microcytic anemia, GI upsets, cranial nerve due to depressed cough and choking response. palsies and unexplained hypertension are some Lavage is not indicated. Emesis may be tried in presentations. Lead greater than 0.08mg/100ml an ale1t patient with a large amount of in blood is indicative of toxicity. For immediate ingestion. Ipecac can also be used. poisoning, lavage is indicated. Later lead is removed by edetate disodium calcuim (EDTA) 9. C::arbon Monoxide I/V or I/M for 5 days. Carbon monoxide is a relatively frequent source of poisoning usually seen in incomplete 13. Mercury combustion, especially of coal. Headaches, Metallic mercu1y as present in thermometei} is vomiting, bounding pulses, dusky skin and a common source of ingestion in children \)'Ut it convulsions are typical presentations, Coma is nontoxic as it is not absorbed. signifies fatal intoxication. A1tifical respiration 14. Insecticides with pure oxygen is instituted immediately to Insecticides consist of two groups, reduce the carboxy hemoglobin. a) chlorinated hydrocarbons and b) organophosphates. 10. Alcohols Ethyl alcohol and methylalcohol intoxication is a) Chlorinated hydrocarbons: include DDT In inf1�quent in children. Gastric lavage and co-ordination, muscle spasm, GI upsets, sodium bicarbonate is given in ethyl alcohol respiratory collapse and tonic clonic whilst in methanol toxicity ethanol can be convulsions can occur leading to death. administered. It is imp01tant to recognise and Lavage and epsom salts are used. Skin is treat acidosis as well. washed if it had come in cont.act with the toxin. Although infrequently, significant 11. Naphthalene (Moth Balls) dermal absorption can occur if the skin and Naphthalene is not very soluble in water and clothing become contaminated by a liquid remains in garments for long periods of time. formulation16 Convulsions are controlled by Interesting to note, it is soluble in oil and may barbituates and if required ai1way is be absorbed through the skin. The most maintained. significant toxicity is hemolytic. It involves a Heinz Body hemolytic anemia leading to a b) Phosphorus: Organo phosphates can also be sharp fall in hemoglobin Hct and red blood cell absorbed through the skin and severe count11, 12. Ingestion of mothballs can cause intoxication can follow spillage of the abdominal cramps, dyspnea brown black urine compound on the body17 ·1'1• Organophos and convulsions. The brown or black urine phates cause GI upsets, salivation, pinpoint occurs due to hemoglobinuria or methemo pupils and if severe cause pulmonary edema, globinemia 13· 1 4· 1 5. Emesis and lavage is done coma and death. After lavage, atropine can immediately. Catha1tics are administered next. be given I/V or I/M l-2mg eve1y 15min till Alkalinization of urine and forced diuresis also improvement. Ai1way is maintained and the helps prevent renal tubular damage. patient stabilized. Pralidoxime iodide, the · specific antidote to organo posphate Interesting to note is that newborns have been poisoning is used as an adjunct to atropine.
55 Maqbool et al.
Guide to specific antibote therapy
Antidote Dose Poison Reaction (to antidote) & comments
Acid�, weak JOO to 200ml alkali, caustic c di�ten�ion from
Magnesium oxide liLPr) �odium hypochloritc libPratrd CO (from use Ammonium acN.ate 5 ml in fiOO ml watPr formaldPhyde (formalin) forms rPlalivrlv harm for lavagr less methrnam"inP Ammonium hydroxide• 0.2'il !--olution, f'or lavagr AtropinP !-,UlfatP 1 lo 2 mg l Mand organic phosphate estrrs: atropinization n·prat in :�o min for gluthion, malathion, para organic phosphatr; thion, mu!>hroom, tPtrarthyl l'�trrs: O.fi mg for othrr pyrophosphate, trithion, etc; cholinPstPra�r inhibitor� BAL (dimPn;aproll SP\'Prr intoxication: dav antimonv, ar�C"nic, !1u!,hingmyalgia, 1: :� mg/kg Pvrry l hr· bi!-,muth.gold, mPrcury nausea and vomting (G injrctions); day 2: (acrod.'11ia), nickel, ncphrotoxic rfTC'cts, 2 mg/kg t'vPryday 3: !rad (combinrd Lhrrapy hypotension, pulmonary :-1 mg/kg every G hr with rdrtic acid for edema, salivation and ( 1 injPctinns); days rnc<'phalitis); contra Jacrimation, fPvcr 2 mg/kg C'vrry day :-1; inclicatPd for iron (or until rrcovPry); a mg/kg p,·pry 12 hr (2 injrctions) mild intoxication: day l: 2.fimg/kg e,·rry l hr (G inj<'ctionsl; day 2: samp; day :i: 2.fi mg/kgg rvery 12 hr; days l to 13 (or until rccovi•ry): 2.fi mg/ kg daily ( I injrction) Bromobc\1Z('nP adult: lg �rlPnium EDTA Child: 0.2fi g (in lavagp solution) Calcium lactate 10'1, !,o}ution (in lavage ch lorinat<'d hvdrocarbons !,o}utionl nuoridr, oxal�LPS ChlorpromazinP 0.5-1 mg/kg Pvrry 30 min amplwtaminr drowsiness, hypotrnsion nruromuscular (parkin sonianl PfT<'cl� Copprr sulf'atP 0.2fi to :i gin gla!-,!-, of" pho�phorus forms insolubl!' copper watpr phosphide• um nitrite in 2 to I min, and Sodium thiosulfatP 2:i<;; !--olution (nOmll in iodinr sodium lhiosulfatr used 10 min through !,UmP alonr for iodinl'; forms nrPdlP and vrin; rrprat harmlC'ss �odium iodide with 1/2 do<,('S if nt•cpssary 56 l'o1so11111g in Children 1979: 15. Nicotine l",1"'111in1-"- Prwd C"/111 NA 26: 1<27-:l(i Childhood nicotine poisoning ocrnrs accidently F.rvis :\1E. PPtrol,·um rl1qilla1<•, and lllrJl<'nt1n,· C'luw·alrhaplPI' where chilrlren bite and swallo\\' cigarettes. 77 Ill' eds. Haddad LM. winC'hestn ,JF. ,\fwl fi4· 17(i�-{i:l It'\\ i(i Half"y TJ 9RO, .•J3. Rl'I of th,· toxiC'olol!:'· of paraquat C/111 T,,., w"l 14. 1- Hi. Common poisons and their anti dotE>s 17 Feldman H,J, M aihad1 JI I. P<'l'C'ttla111·1111� p1·111·tratio11 111" -�om<'Plwrmu,·icr JJ<'',\t('i Sajicl Maqh11ol Pnif""""r & H,·ad REFERENCES D,·partnll'nt. ol' Pa,•cliat nc·,. Shaikh Zayt•cl P11-..tgraclual<' 11<-cli('al !11,t1lut1·. N J r 1993; J. Hill, JB. Sali('ylatf' intoxiration f:11J!l ,\f d 288: Lahore. �. 1110-J:t Pearson HA. Comparntiv<· <·fl'c•('ts of A,prin and Ac:Ptaminoph<'n on lwmo'-lali�. Pwc/ialrir·s 1978; 62: !12(i- Address for Correspondence: 2!) :�. S,�jirl Maqbool Cooney DO. Efl'Pc:l or typ<' and amount ofv _ Profh,or & HPad ('arhoxyml'lhyic<'llttl