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Poisoning and Animal Bites Poisoning and animal bites ผศ.นพ.วรพันธ์ เกรียงสุนทรกิจ กุมารเวชศาสตร์ผู้ป่วยนอก ภาควิชากุมารเวชศาสตร์ คณะแพทยศาสตร์ศิริราชพยาบาล Toxicology “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy.” Paracelsus, early 1500s Scope of talk •Common drugs and chemical agents in the house •Lead exposure •Snake bite •How to prevent chemical and drugs poisoning •First aid for poisoning and snake bite Poisoning in children •Toddlers and young children are explorers and have much hand-mouth activity •Incidence of poisoning increases after 9- month old •Over 90% of poisoning exposures occur in homes •Unintentional exposure: young children (less than 6 yr)> older children Rate of human poison exposures by age group Acute poisoning surveillance in Thailand: the current state of affairs and a vision for the future, Emergency Medicine, 2013 Iron supplement • Almost 16,000 iron exposures/ year: reported in children < 6 years of age in the US • Serious toxicity: adult preparation > chewable vitamins with iron • Prenatal and postnatal iron supplement: increase risk of poisoning in older sibling • 4-time increase in the risk of iron poisoning to the older sibling of a newborn during the first postpartum month. Iron poisoning in young children: association with the birth of a sibling. CMAJ. 2003;168:1539–1542. Clinical presentation • Gastrointestinal (GI) phase: 30 minutes to 6 hours after ingestion • Latent, or relative stability, phase: 6 to 24 hours after ingestion • Shock and metabolic acidosis: 6 to 72 hours after ingestion • Hepatotoxicity/hepatic necrosis: 12 to 96 hours after ingestion • Bowel obstruction: 2 to 8 weeks after ingestion Iron supplement Salicylate •Aspirin •Salicylic acid (topical keratolytic agent) •Oil of Wintergreen (น ้ามันมวย), น ้ามันระก า •Analgesic balm •ยาธาตุน ้าขาว active ingredient (salol, phenyl salicylate) Toxic dose of aspirin •Mild intoxication: 150-200 mg/kg •Severe intoxication: 300-500 mg/kg Salicylate 1 teaspoon (oil of wintergreen) = 5 g of methyl salicylate or 7.5 g of aspirin Mechanism of action •Inhibition of cyclooxygenase results in decreased synthesis of prostaglandins, prostacyclin, and thromboxanes •Stimulation of the chemoreceptor trigger zone in the medulla causes nausea and vomiting •Direct activation of the respiratory center •Uncouple oxidative phosphorylation Hydrocarbons •Gases: methane, propane •Liquid: toluene, xylene, kerosene, turpentine, benzene, gasoline • semisolid: petroleum jelly Pesticides •Oragnophosphates •Carbamates •Pyrethrin/ pyrethroid •Paraquart/ diquart •Rodenticides Oxymethazoline •ยาหยอดจมูกเพื่อลดอาการคัดจมูก Mechanism of action Sulfonylurea •Prolonged duration of action •Metabolized by the liver •Excreted by the kidneys as an active metabolite Mechanism of action Gun blue (Selenious acid) Use of gun blue •Change the color of steel from silver- grey to blue-grey •Chemical darkening and patination of copper, brass and bronze •Reagent for alkaloids, as an oxidizing agent and as an isotope for labelling radiopharmaceutical compounds. Patination of copper, brass and bronze Toxicity •Inhibition of activity of sulfhydryl- containing enzymes •Corrosive effect, PH 1.5 •In fatal ingestion: •Hepatoxicity •Nephrotoxicity •Discoloration of the skin and viscera Diphynoxylate-atropine Diphynoxylate-atropine toxicity •The first phase (anticholinergic toxidrome) • Last for 2-3 hr •Opioid phase • Much longer than 1st phase • Miosis, lethargy, apnea, and respiratory depression (13-24 hr after ingestion) The Journal of Emergency Medicine, Vol. 34, No. 1, pp. 71–75, 2008 Calcium channel blockers 1. Phenylalkylamines: verapamil, gallopamil 2. Benzothiazepines: diltiazem 3. dihydropyridines (nifedipine, amlodipine, aranidipine, azelnidipine, barnidipine, benidipine, cilnidipine,clevidipine, efonidipine, felodipine, lacidipine, lercanidipine, manidipine, nicardipine, nilvadipine, nimodipine, nisoldipine, nitrendipine, and pranidipine) Pharmacology •Dihydropyridines: selectively to vascular smooth muscle calcium channels > cardiac calcium channels •Non-dihydropyridines: cardiac calcium channels > vascular smooth muscle calcium channels Blood lead level after leaded gasoline removal in Thailand Place/ Year Age group Number of author BLL BLL> 10 population (mcg/dL) mcg/dL Chiangmai/ 6Mo - 6Yr 1,000 - 4.97 +/- 3.17 4.4% 1995-1997 - / 2005 6Mo – 4Yr 269 Chomchai C 5.65 +/- 3.65 8% Tak/ 2010 3-7 Yr 220 QSNICH, - 26% Bureau of Occupational and Environmental Diseases Sources of lead • lead containing paint/pigment • Soil/dust near lead industries • Glaze pottery, ceramic wear, Benjarong • Plumbing leachate • lead solder • Battery recycling Lead poisoning •Level of action: 5 mcg/dL •Level of concern: 10 mcg/dL Sources of lead Blood lead levels considered toxic Before 1971 ≥60 mcg/dL 1972-1975 ≥40 mcg/dL 1975-1985 ≥30 mcg/dL 1985-1991 ≥25 mcg/dL 1991-2012 ≥10 mcg/dL 2012-present Any detected level Lead toxicokinetics Elimination Absorption Distribution Renal T1/2 • Ingestion • Blood Children 40-50% 25 days (adult) Adult 10-15% RBC: plasma = 99:1 10 months • Inhalation • Soft tissue (liver, (children) 30-40% 40 days • Increase absorption kidney, brain, bone Fe, Ca, Zn deficiency marrow) Fasting 10-20 years Malnutrition • Bone (children 70%, • Skin 0.06% adult 95%) Hum Toxicol. 1985;4(4):401 Environ Health Perspect. 1990;89:75 Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine (CSEM): Lead Toxicity Cover Page 2008 www.atsdr.cdc.gov/csem/lead/pbcover_page2.html Neurocognitive development • 4.6-point decrement in IQ for each 10-μg/dL increase in BLL (children age 3-5 yr) • 7.4 point loss, for the subset of children in the 1 to 10 μg/dL BLL range • Loss 1 to 2 IQ points for chronic BLL increases from 10 to 20 μg/dL N Engl J Med. 2003;348:1517-1526 CDC. Interpreting and managing blood lead levels <10 μg/dL in children and reducing childhood exposures to lead, 2007 Screening questions for lead poisoning •อยู่ในเขตอุตสาหกรรมที่เกี่ยวข้องกับสารตะกั่ว •มีสมาชิกในครอบครัวท างาน: ซ่อมและยาเรือ, ท าเครื่องประดับ, ก่อสร้างหรือรื้อถอนอาคาร, ช่างประปา, สี, หม้อน ้ารถยนต์, หลอม ตะกั่ว, แบตเตอรี่รถยนต์, เบ็ดตกปลา, อวนหาปลา •สีหลุดลอก, ใช้สีน ้ามันทาภายในบ้าน •ใช้แบตเตอรี่เติมไฟในบ้าน •คนในบ้าน ชุมชน โรงเรียน ศูนย์เด็กเล็ก เป็นโรคพิษจากสารตะกั่ว หรือ สัมผัสตะกั่ว Clinical presentation Primary prevention for lead exposure ปัจจัยเสี่ยง กลยุทธ์ 1 สิ่งแวดล้อม สี แนะน าให้ใช้สีไร้สารตะกั่วส าหรับทาภายใน ฝุ่น ท าความสะอาดโดยการเช็ดถูด้วยน ้า (wet mop) แทนการ กวาด, ล้างมือบ่อยๆ ดิน ให้เล่นในบ้าน หรือ ล้างมือบ่อยๆ น ้าดื่ม ใช้ภาชนะและท่อประปาที่ไม่ใช่โลหะเคลือบตะกั่ว, เซรามิค หรือ ฟิวเตอร์, ให้เปิดน ้าประปาทิ้งในช่วง 2 นาทีแรก 2 ผู้ปกครองที่มีอาชีพเกี่ยวข้องกับตะกั่ว เปลี่ยนเสื้อผ้าและอาบน ้าเมื่อกลับถึงบ้าน 3 เด็ก Hand-mouth ล้างมือบ่อยๆ behaviors โภชนาการ แนะน าให้กินอาหารที่มีธาตุเหล็กและแคลเซียมสูง ไขมันต ่า พัฒนาการช้า ให้ตรวจระดับตะกั่วในเลือด Toilet cleaners, caustic agents HF Button battery •Toys •Hearing aid •Watch Chest X-ray Double-ring shadow A coil lodged in esophagus Mechanism of toxicity •Pressure necrosis •Local electrical current •Leak of alkali solutions and heavy metals (lithium, mercury) rare EsophagoGastroDuodenoscopy Button Battery CR2032 Lithium, diameter 20 mm, height 3.2 mm Battery identification • Button batteries range in diameter from 6 to 25 mm • Lithium batteries: common (lasting, higher voltage, lighter) • Batteries that are larger than 12 mm in diameter are most likely to become lodged in the esophagus, especially in young children • The chemical content identification • L: Manganese dioxide • S: Silver oxide • P: Oxygen • C: Manganese dioxide • B: Carbon monofluoride • G: Copper oxide • LR (or AG): Alkaline • SR: Silver oxide • CR: Lithium/manganese dioxide • BR: Lithium carbon monofluoride International electrotechnical Commission. www.iec.ch/ (Accessed on June 02, 2010) Battery identification Li, diameter 20 mm, height 3.2 mm Li, diameter 20 mm, height 2.5 mm Li, diameter 16 mm, height 3.2 mm Prevention Medicines •Only take prescription medications that are prescribed to you by a healthcare professional.. •Never take larger or more frequent doses of your medications •Never share or sell your prescription drugs •Take your prescribed medicine as direction of the label •Read all warning labels Medicines •Some medicines are not safe when you take with medicines or drink alcohol. •Turn on a light when you give or take medicines at night so that you know you have the correct amount of the right medicine. •Keep medicines in their original bottles or containers. •Monitor the use of medicines prescribed for children and teenagers, such as medicines for attention deficit hyperactivity disorder, Medicines and household products •Keep in a locked cabinet where a child cannot reach them •Do not put your medicines on the table or anywhere children can reach them •Child safe cap •After use, put them away and out of sight in a locked cabinet where child cannot reach them Medicines and household products •Be aware of any legal or illegal drugs that guests may bring into your home. •Ask guests to store drugs where children cannot find them. •Pillboxes, purses, backpacks, or coat pockets are not the safe places •Do not call medicine "candy" What to do if poison occurs ? •Remain calm. •Call 1669 if you have a poison emergency and the victim has collapsed or is not breathing. •If the victim is awake and alert, dial 02- 4197007 or 1367 What to do if poison occurs ? •Try to have this information ready: •
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