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Intentional Versus Unintentional Child Toxicity at National Center of Environmental and Clinical Research of Toxicology (Nectr)

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Intentional Versus Unintentional Child Toxicity at National Center of Environmental and Clinical Research of Toxicology (Nectr) INTENTIONAL VERSUS UNINTENTIONAL CHILD TOXICITY AT NATIONAL CENTER OF ENVIRONMENTAL AND CLINICAL RESEARCH OF TOXICOLOGY (NECTR) Thesis Submitted for partial fulfillment of Master Degree (M.Sc.) in FORENSIC MEDICINE & CLINICAL TOXICOLOGY By RANIA MOHSEN ABDEL RAHEEM (M.B., B.CH.) Demonstrator of Forensic Medicine and Clinical Toxicology Faculty of Medicine, Cairo University Under Supervision of PROF. DR. DINA ALI SHOKRY Professor and Head of Forensic Medicine & Clinical Toxicology Department Faculty of Medicine – Cairo University PROF. DR. HODA ABD ELMAGIED EL GHAMRY Professor of Forensic Medicine & Clinical Toxicology Faculty of Medicine – Cairo University DR. MARWA ISSAK MOHAMED Lecturer of Forensic Medicine & Clinical Toxicology Faculty of Medicine – Cairo University Faculty of Medicine Cairo University 2018 ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ II ACKNOWLEDGEMENT First and foremost, all praises to ALLAH, who gave me the strength to accomplish this achievement and gifted me with people who tried to help all-through. It is a great honor to me to express my deepest gratitude to Prof. Dr. Dina Ali Shokry, Professor and Head of Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Cairo University, for her unlimited support, valuable guidance and sincere supervision that were the most driving forces in the initiation and progress of this work. She performed much effort and consumed much of her time in guiding me through this thesis. No words can fulfill my infinite thanks and appreciation to Prof. Dr. Hoda Abd Elmagied El Ghamry, Professor of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, for her continuous encouragement, meticulous supervision and great-unlimited help through this work. I wish to express my deepest thanks to Dr. Marwa Isshk Mohamed, Assistant Lecturer of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, for her great support, precious advices, and valuable guidance. Also I am deeply grateful to my professors and my colleagues in the Department of Forensic Medicine & Clinical Toxicology, Faculty of Medicine - Cairo University for their help and support. III DEDICATION Dedication To my father who taught me the meaning of responsibility To my mother who believed in me and taught me to trust in Allah and believe in hard working. I owe her everything To my husband, my daughters and my brothers for their endless love, care, and support and for being always by my side VI CONTENTS CONTENTS PAGE ABSTRACT …………………………………………...……….… VII LIST OF TABLES ……………………………………………..... VIII LIST OF FIGURES …………………………………..……………. X LIST OF ABBREVIATIONS ……………………….………..… XII INTRODUCTION …………………………………………………. 1 AIM OF THE WORK ……….……………………………………... 3 REVIEW OF LITERATURE .……………………………………... 4 o Chapter 1: Pediatric Toxicokinetics and Toxicodynamics …….. 4 Toxicokinetics (absorption) ………………..………………………… 4 Distribution …………………………..……………………….…….. 8 Metabolism (bio-transformation) ….………..………………….. 11 Excretion …………………………………………………………... 16 Toxicodynamics …………………………….……………………... 18 o Chapter 2: Common Poisons in Pediatric Toxicity ……………… 21 Household products ……….……….…………………………….. 21 Corrosives ………………………….…….………………………... 21 Kerosene …………..……………………..……………………….. .25 Pesticides ……………………………..…………………………… 28 Organophosphorus ………………………………………….. .… 29 Carbamates …………………………………………….…… ……34 Drug of abuse (cannabis) ……………………….…………..…. 36 Tramadol ………………………………………………...……….. 38 Medications ……………………………………………………... 43 Paracetamol ………….………………………………… …….... 43 Theophylline ……………….………….……………………….... 48 o Chapter 3: Manner of Pediatric Toxicity and Other Medicolegal Aspects ……………………………….…………………………. 52 Unintentional child toxicity …………………………… ………… 52 Intentional (suicidal toxicity )……………..…………..…………… 53 Intentional (homicidal toxicity )..……………………..……….….. 54 Important medicolegal concept …………………………………... 55 Medical aspect ….…………………………….……………….……… 55 Legal aspect ……………………….………….………..……….…….. 63 V CONTENTS SUBJECTS AND METHODS …..……………………………… 65 RESULTS …………………………………………………………. 71 DISCUSSION …………………………………...…………..…... 131 CONCLUSION & RECOMMENDATIONS …………………. 156 SUMMARY …………………………………………………… 161 REFERENCES ……………………………………………….. 168 APPENDICES …………………………………………………. 195 ARABIC Summary …………………………………………… 1-7 VI ABSTRACT ABSTRACT Background: Poisoning is an important emergency as well as major problem in pediatric age groups throughout the world. Most of the poisoning in children is accidental. Unfortunately, the incidence of deliberate poisoning among adolescents is increasing due to changing familial and social conditions in our society. The causes and types of poisoning vary in different parts of the world and within the country also depending upon factors such as education, demography, socioeconomic factors, customs and local belief. Aim of the work: The purpose of this study was to Identify the common manner of toxicity and rate of child toxicity in Egypt. Also, it aimed to elucidate the precipitating factors for child poisoning and the common complication. Subjects and Methods: The current study was conducted on 152 of Egyptian participant of both sexes in age blew 18 years old at NECTR; 96 females and 56 males. They were classified into 4 age groups; toddlers (1-<3 yrs), early childhood (3-<9 yrs), late childhood (9-<13 yrs) and adolescent (13-<18 yrs). Data were analyzed with respect to demographic data of the patients: age, sex, residence, level of education and family status, and data of toxicity: manner of toxicity, type of poison, its availability to the child, place of exposure, amount and form of poison, duration between exposure and presentation, the first aid that may be done to the patient, associated morbidity, history of medications and Severity and mortality rate of each poisons detected by poison severity scoring (PSS) and the acute physiology and chronic health evaluation (APACHE II). Results: Accidental toxicity (58.6%) is still common than intentional toxicity (41.4%), toddlers and males were the most common age group in accidental, while negligence was the most probable cause of accidental toxicity. On other hand adolescent and females were common age group in suicidal, while family problems were the most probable cause of suicidal toxicity. There were multiple significant relations between demographic data (age, sex, residence, level of education and family status) and type of poison, its availability, location of exposure, most probable cause of exposure, manner of toxicity. There were significant relations between PSS and type and amount of poison, vital signs and CNS manifestations, period of admission and hours of delay. There were significant relations and positive correlation between APACHE II and type and amount of poison, vital signs and CNS manifestations, period of admission and hours of delay. Conclusion and Recommendations: The present study proved that accidental toxicity is still common manner among pediatric age group but there is increasing in incidence of suicidal toxicity among them. Further attention from parent is needed and proper care to children in different age group to prevent and reduce the toxicity in pediatric age group. Keywords: Pediatric toxicity, Manner of toxicity, Probable cause, Poison severity scoring and APACHE II. VII LIST OF TABLES LIST OF TABLES No. TITLE PAGE 1 Factors affecting absorption in neonates and infants 7 2 Age-related changes in body composition. 11 3 Household agents classified according to their chemical natures 21 4 Grading system for corrosive burns of the alimentary tract with 23 endoscopy. 5 Major pesticide classes and selected examples 28 6 Clinical Stages of Acetaminophen Toxicity 46 7 Indications for hemodialysis/hemoperfusion With Theophylline 51 8 methods used to analysis different poisons in different samples 56 9 ACHE II scoring system according to acute physiology and chronic 67 health diseases. 10 Poison scoring system (PSS) according to signs and symptoms 68 11 Distribution of cases according to age and manner of toxicity. 73 12 Relation between age in group 1 and type of poison and its amount. 74 13 Relation between age in group 2 and type of poison and its amount 75 14 Relation between age in group 1 and availability of poison. 76 15 Relation between age in group 2 and availability of poison. 77 16 Relation between age in group 1 and the most probable cause. 78 17 Relation between age in group 2 and the most probable cause. 78 18 Relation between age in group 1 and (location of exposure and 79 previous attempts). 19 Relation between age in group 2 and (location of exposure and 79 previous attempts). 20 Relation between sex and (type of poison and its amount). 81 21 Relation between sex and most probable cause. 82 22 Relation between sex and previous attempts 82 23 Relation between residence and type of poison. 84 24 Relation between residence and 1st aid. 84 25 Relation between residence and availability of poison. 85 26 Relation between residence and the most probable cause of toxicity. 86 27 Relation between residence and hours of delay. 86 VII LIST OF TABLES No. TITLE PAGE 28 Relation between educational level and type of poison. 89 29 Relation between educational level and amount of poison. 90 30 Relation between educational level and the most probable cause of 91 toxicity. 31 Relation between mother work and education and the availability of 95 poison 32 Relation father work and education and (previous attempts) 97 33 Relation mother work and education and (previous
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