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Poisoning in Children

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Poisoning in Children ARTICLE IN PRESS Current Paediatrics (2005) 15, 563–568 www.elsevier.com/locate/cupe Poisoning in children Fiona JepsenÃ, Mary Ryan Emergency Medicine, Royal Liverpool Children’s NHS Trust, Alder Hey, Liverpool L12 2AP, UK KEYWORDS Summary Poisoning accounts for about 7% of all accidents in children under 5 Poisoning; years and is implicated in about 2% of all childhood deaths in the developed world, Child; and over 5% in the developing world (National Poisons Information Service). In Accidents; considering this topic, however, it is important to differentiate accidental overdose Home (common in the younger age groups) and deliberate overdose (more common in young adults). Although initial assessment and treatment of these groups may not differ significantly, the social issues and ongoing follow-up of these children will be totally different and the treating physician must remain aware of this difference. The initial identification and treatment of these children remains the mainstay of management, and many ingested substances do not have a specific antidote. Supportive treatment must be planned and the potential for delayed or long-term effects noted. The specific presentation and treatment of some of the commonly ingested substances will be addressed in this article, and guidance given on when to contact expert help. & 2005 Elsevier Ltd. All rights reserved. Introduction such as bleaches, detergents and turpentine sub- stitutes. More than 100 000 individuals are admitted to Toxic compounds may be ingested or inhaled hospital in England and Wales annually due to either accidentally or deliberately. Accidental poisoning, accounting for 10% of all acute admis- poisoning can occur at any age, but is much more 1 sions.1 However, the true incidence of acute common in children. Peak incidence is around the poisoning may be 2–3 times greater.1 age of 2 years and boys are at more risk than girls. In England and Wales, analgesics account for Most incidents (80–85%) occur in the child’s home 20% of all cases of poisoning in children aged and in many cases the substances involved have not 14 years or less, with a further 40% ingesting been stored in their usual place or have been put 1 other pharmaceutical preparations. The remaining into a different container. 40% are poisoned by a variety of household products Household products are more commonly ingested than drugs by children and seasonal variability has ÃCorresponding author. Tel.: +44 151 2933623; been described. Pesticides and weed killers are fax: +44 151 2525088. more commonly ingested in the spring, berry E-mail address: [email protected] (F. Jepsen). poisoning occurs in the autumn, and cough and 0957-5839/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.cupe.2005.08.006 ARTICLE IN PRESS 564 F. Jepsen, M. Ryan cold remedies are more commonly ingested in the of body weight should be identified as accurately as winter. possible.2 Deliberate poisoning is more common in adults, In cases where poisoning is suspected, but cannot but is increasing in the teenage population; the be confirmed by clinical history, a detailed physical incidence of analgesic ingestion has particularly examination, including a full neurological assess- increased. Depression and deliberate self-harm are ment is an essential part of substance identifica- often found concurrently with analgesic overdose, tion.2 Initially, assessment and treatment of the and the particular needs of this population differs airway, breathing and circulation is mandatory. from adults. Treatment should first focus on supportive mea- Poisoning accounts for a very small proportion of sures, including use of high-flow oxygen and deaths in children under 10 years of age. This intravenous fluids. Depression of the nervous declining proportion of deaths in children may be system can occur and fitting should be treated with attributable to the widespread introduction of child- intravenous benzodiazepines. resistant closures on containers. However, other There is no place for the use of emetics in the factors, including greater emphasis on safety in the modern treatment of poisoning.3 The use of home, improved access to information on poisons and activated charcoal for reducing drug absorption improved treatment may also contribute to reducing should be considered if a patient presents within mortality. In England and Wales, carbon monoxide 1 h of taking the substance. A single dose of 1 g/kg remains the most common cause of childhood death body weight for children can be given by mouth or due to poisoning. Tricyclic antidepressant ingestion via naso-gastric tube up to 1 h after ingestion of a remains a significant contributor to mortality, potentially toxic amount of a well charcoal- although it is relatively infrequently ingested. adsorbed poison, and perhaps beyond an hour in cases involving sustained or modified-release drug preparation. A list of poisons for which activated charcoal has been proven to be ineffective is found in Table 1. The use of repeated doses of activated Initial approach, investigation and charcoal to remove toxins undergoing enterohepa- treatment tic circulation is one of the simplest active elimination techniques.5 Table 1 lists the sub- The diagnosis of acute poisoning may be apparent stances for which this technique may be useful. from the clinical history. However, it should also be Gastric lavage is not recommended by The considered in patients who present with altered American Academy of Clinical Toxicology or the consciousness, those unable to give a history and European Association of Poisons Centres and Clin- those who present with an episode of deliberate ical Toxicologists unless a patient has ingested a self-harm. Wherever possible the constituents of potentially life-threatening amount of a poison and the substance ingested and its dosage per kilogram the procedure can be undertaken within 1 h of Table 1 Poisons for which activated charcoal has been proven to be ineffective and substances for which the use of repeated doses of activated charcoal may prove useful. Poisons for which activated charcoal has been proven Substances where repeat doses of activated charcoal to be ineffective may prove useful in enhancing clearance Cyanide Carbamazepine DDT Theophylline Essential oils Digoxin Organic solvents Barbiturates Iron Salicylates Lead Phenylbutazone Mercury Dapsone Lithium Amanita phalloides Bleach Phenytoin Alkalis Quinine Alcohols (i.e., methanol, ethanol, ethylene glycol) Slow-release preparations Sotalol Piroxicam ARTICLE IN PRESS Poisoning in children 565 ingestion.4 They also advise against the use of have taken very large overdoses, particularly of a emetics, and conclude that there is no evidence long-acting agent such as dihydrocodeine and from clinical studies that ipecacuanha improves the methadone, may need further doses of naloxone to outcome of poisoned patients.3 competitively antagonise the opioid agonist, and Urinary alkalinisation can be used to enhance the continuous intravenous infusion of naloxone, to- excretion of weakly acidic drugs.2 Dialysis, haemo- gether with intensive monitoring may be necessary perfusion and haemofiltration have all been used to in some cases. The use of flumazenil is not actively enhance toxin excretion.2 recommended in the suspected overdose of benzo- diazepines because of the risk of fitting with co- ingestion of tricyclic antidepressants. Laboratory investigations A careful history may obviate the need for blood 2 tests. Standard haematological investigations are Specific poisons rarely diagnostically helpful, although the pro- thrombin time may be prolonged after ingestion Paracetamol of anticoagulants or in case of hepatic damage (e.g. in paracetamol poisoning). Blood glucose estima- Children are more resistant to paracetamol-in- tion should be performed in all cases, as hypogly- duced liver damage than adults.8 The volume and caemia is typically caused by an overdose of insulin paracetamol concentration of the formulation or oral hypoglycaemic agents and complicates should be established from the packaging and the ethanol intoxication, particularly in children. Blood volume remaining should be measured.9 The max- gas analysis should be undertaken in any patient imum possible ingestion should be assumed. If the with respiratory insufficiency, hyperventilation or dose of paracetamol consumed is known with when metabolic acid–base disturbance is sus- absolute certainty to be below 150 mg/kg no pected.6 Hypokalaemia has been described as a further action is required.9 However, it is recom- complication of acute poisoning and electrolyte mended that paracetamol levels should be investi- estimation may be useful. gated at least 4 h after the time of ingestion in any Routine measurement of plasma paracetamol patient who has deliberately taken an overdose in should be performed in older children presenting order to commit deliberate self-harm. Samples with any deliberate ingestion. In one study, authors taken before this may be unreliable. found one in 500 adult overdose patients not Paracetamol levels should be compared with the suspected of having taken paracetamol had levels standard adult normogram to determine the need above the treatment threshold.7 The routine for treatment with N-acetylcysteine (NAC). This measurement of salicylate is controversial, and may overestimate treatment required in children although done in practice, is only necessary when but there is at present no normogram available for symptoms become obvious. It
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