University of Pennsylvania ScholarlyCommons Miscellaneous Papers Miscellaneous Papers 1-1-2001 Critical Care Nursing of Infants and Children Martha A. Q. Curley University of Pennsylvania, [email protected] Patricia A. Moloney-Harmon The Children's Hospital at Sinai Copyright by the author. Reprinted from Critical Care Nursing of Infants and Children, Martha A.Q. Curley and Patricia A. Moloney-Harmon (Editors), (Philadelphia: W.B. Saunders Co., 2001), 1,128 pages. NOTE: At the time of publication, the author, Martha Curley was affiliated with the Children's Hospital of Boston. Currently, she is a faculty member in the School of Nursing at the University of Pennsylvania. This paper is posted at ScholarlyCommons. http://repository.upenn.edu/miscellaneous_papers/4 For more information, please contact [email protected]. Please Note: The full version of this book and all of its chapters (below) can be found on ScholarlyCommons (from the University of Pennsylvania) at http://repository.upenn.edu/miscellaneous_papers/4/ Information page in ScholarlyCommons Full book front.pdf - Front Matter, Contributors, Forward, Preface, Acknowledgements, and Contents Chapter 1.pdf - The Essence of Pediatric Critical Care Nursing Chapter 2.pdf - Caring Practices: Providing Developmentally Supportive Care Chapter_3.pdf - Caring Practices: The Impact of the Critical Care Experience on the Family Chapter_4.pdf - Leadership in Pediatric Critical Care Chapter 5.pdf - Facilitation of Learning Chapter_6.pdf - Advocacy and Moral Agency: A Road Map for Navigating Ethical Issues in Pediatric Critical Care Chapter_7.pdf - Tissue Perfusion Chapter 8.pdf - Oxygenation and Ventilation Chapter_9.pdf - Acid Base Balance Chapter 10.pdf - Intracranial Dynamics Chapter 11.pdf - Fluid and Electrolyte Regulation Chapter 12.pdf - Nutrition Support Chapter 13.pdf - Clinical Pharmacology Chapter_14.pdf - Thermal Regulation Chapter_15.pdf - Host Defenses Chapter 16.pdf - Skin Integrity Chapter_17.pdf - Caring Practices: Providing Comfort Chapter 18.pdf - Cardiovascular Critical Care Problems Chapter 19.pdf - Pulmonary Critical Care Problems Chapter 20.pdf - Neurologic Critical Care Problems Chapter 21.pdf - Renal Critical Care Problems Chapter 22.pdf - Gastrointestinal Critical Care Problems Chapter_23.pdf - Endocrine Critical Care Problems Chapter_24.pdf - Hematologic Critical Care Problems Chapter_25.pdf - Oncologic Critical Care Problems Chapter_26.pdf - Organ Transplantation Chapter 27.pdf - Shock Chapter_28.pdf - Trauma Chapter_29.pdf - Thermal Injury Chapter 30.pdf - Toxic Ingestions Chapter_31.pdf - Resuscitation and Transport of Infants and Children back.pdf - Appendices and Index Toxic Ingestions Maureen A. Madden oisoning continues to be a significant cause of pediatric COMMON PRINCIPLES OF EMERGENCY AND CRITICAL Pinjury. Five percent of all accidental childhood deaths CARE MANAGEMENT are related to poisoning. Methods of exposure to toxic Toxidromes agents vary, with ingestions accounting for the majority of Identification of Toxin exposures. I The 1998 Annual Report of the American Association of Poison Control Centers Toxic Exposure The Unknown Toxin Surveillance System reported more than 2 miUion human Gastrointestinal Decontamination exposures to toxins that year. Fifty-three percent of the cases PHARMACEUTICAL TOXINS involved children younger than 6 years of age. Males Acetaminophen predominated in the ingestions under age 13, whereas teenage cases involved more females. I The majority of Barbiturates the 755 fatalities were associated with ingestion and Carbamazepine inhalation exposures. Children younger than 6 years ac­ Clonidine counted for 2.1 % of the fatalities, whereas adolescents Iron accounted for 5.9%. Theophylline The substances involved most often in human exposure Cyclic (Tricyclic) Antidepressants are not the most toxic but the most readily accessible. Some of the more common agents involved in pediatric exposures NONPHARMACEUTICAL TOXINS-THE ALCOHOLS are cosmetics, cleaning fluids, analgesics, plants, and cough AND DRUGS OF ABUSE and cold preparations. Toxic effects do not often occur with Methanol these substances because children usually do not ingest Ethylene Glycol amounts sufficient to produce toxicity. Isopropanol Other agents ingested less often but that do not require large exposures to produce toxic effects are barbiturates, Ethanol clonidine, iron, theophylline, antidepressants, alcohols, co­ Cocaine caine, and caustics. The ingestion ofthese substances causes Heroin the greatest percentage of hospitalizations, intensive care Methadone unit (rCU) admissions, and fatalities in pediatric poisonings. Phencyclidine Table 30-1 compares the most common with the most toxic substances ingested. HOUSEHOLD TOXINS Characteristics that place children at risk of inges­ Caustics tions differ for various age groups. Toddlers are newly Hydrocarbons mobile, curious, and anxious to explore their environ­ ment through reaching, climbing, and tasting. They are SUMMARY without suicidal intent. Usually only one substance is 999 1000 Part V Multisystem Problems COMMON PRINCIPLES OF EMERGENCY TABLE 30-1 Most Common Versus Most AND CRITICAL CARE MANAGEMENT Toxic Agents Ingested Initial evaluation of the patient in whom a toxic ingestion is known or suspected includes establishing a patent airway, MostToxict rost Common" effective ventilatory pattern, and adequate perfusion. Pri­ ~osmetics Analgesics mary measures to stabilize the patient's condition are based "._ '-leaning substances Antidepressants on the priorities of resuscitation. In the secondary phase of fi\nalgesics Stimulants/street drugs evaluation, clinical signs that identify the toxin are ob­ ~Iants Cardiovascular drugs served, and appropriate treatment is initiated. Fig. 30-1 IFforeign bodies SedativeslHypnotics provides an algorithm for management of the patient with a "Cough/cold preparations Alcohols known or suspected toxic ingestion. ~:.ropicals Chemicals , esticides/lnsecticides Gases and fumes ~ tamins Cleaning substances Toxidromes "'. timicrobials Anticonvulsants After initial evaluation and stabilization, the examination I[GI preparations Asthma therapies focuses on the assessment of the central and autonomic l s/Crafts/Oftice supplies Antihistamines nervous system; eye findings; changes in skin, oral, and :'" "ydrocarbons Hydrocarbons if.: .. gastrointestinal (GI) mucosa; and odors. These areas repre­ ~nlJhlstanunes Automotive products sent the ones most likely affected in toxic syndromes. The !Hormones and hormone Hormones/Hormone clinical syndromes, called toxidromes, comprise a constel­ ,ll:-antagonists antagonists tl~- lation of signs and symptoms that suggest a specific class of InsecticideslPesticides \1; poisoning, Toxidromes help identify the toxin so that ,from Lilovitz TL, Klein-Schwartz W, Caravali EM el al: 1998 appropriate treatment can be initiated in a timely manner. ~ual Report of Ihe American Association of Poison Control The most common toxidromes are sympathomimetic, the­ ?~.'.:•.'.".'.'.,nlers Toxic Exposure Surveillance Syslem, Am J Emerg Med ophylline, sedati ve/hypnotic, opiate, anticholinergic, and ,1,7:435-487, 1999. 3 4 r~ost common in pediatric exposures for younger than 6 years cholinergic. - Table 30-2 presents the toxidromes with 'tot age. associated symptoms and causative agents. I':~Listed in order of frequency in human exposures. Identification of Toxin The goal of identification is to determine which patients are involved, and the amount ingested tends to be small and at risk for toxic effects. An additional goal is to minimize nontoxic. Toddlers often present for evaluation soon after intervention for children not at risk for toxic effects because ingestion, the majority of pediatric ingestions result in no harm to the An increasing number of significant pediatric exposures child.5 For the vast majority of patients, the clinical in children younger than 6 years of age involve ingestion of condition rather than the specific ingredients of the ingestion a grandparent's or other elderly caretaker's medicine. These directs the management. This approach does not preclude agents, often in sustained-release dosage forms, tend to be treating specific toxins or toxidromes, but rather enforces more toxic to children. the concept of basic clinical management and resuscitation Most adolescent ingestions occur in the home and are techniques.6 intentional rather than accidental. They are associated with A thorough history is obtained, including type and academic difficulties, social adjustment problems, failed amount of ingestion if known; the possibility of multiple romances, family issues, or the death of a loved one. agents; time of ingestion; time of presentation; any history Adolescent ingestions commonly involve multiple sub­ of vomiting, choking. coughing, or alteration in mental stances, they are a result of either suicide attempts or status; and any interventions performed before presentation substance abuse, and commonly a delay occurs between at the medical facility, Regardless of the history of the ingestion and when medical attention is sought. substance ingested by a child or adolescent, serum and urine At present, 65 poison control centers serve 257.5 toxicology screens may be necessary to rule out the million of the estimated 270.3 million people living in possibility of unknown ingestants, Appropriate laboratory the United States. I Poison control centers have streamlined studies include basic serum chemistry studies in symptom­