pediatric poisoning case study

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Case Study 1: Newborn ; Case Study 2: Infant; Case Study 3: Toddler; Case Study 4: Preschooler; Case Study 5: School-Age Child; Case Study 6: Adolescent Simon HK, The patient’s mental status, vital signs, pupil reactivity, skin moisture and color, and bowel sounds should also be noted. . More than 2 million ingestions are reported each year to the American Association of Poison Control Centers (AAPCC); approximately 65% are exposures that involve children and adolescents up to 19 years of age. The poisoned patient with altered consciousness. Although seen less frequently than acetaminophen or salicylate poisoning, acute iron poisoning remains a dangerous threat, particularly to pediatric patients. Orogastric tubes may recover significant amounts of gastric contents, but are limited by poor tolerability because of their size, placement difficulty, and gag stimulation.3,20 The patient benefit diminishes as time elapses after ingestion.3,20 Multiple complications are possible, including aspiration, respiratory compromise, mechanical injury or perforation, and electrolyte imbalance.3 Relatively few studies have been conducted on the effectiveness and safety outcomes of gastric lavage in patients exposed to toxins. JAMA. The toxic toddler: drugs that can kill in small doses. Of these, 38 percent involved children three years or younger. Simon HK. Case Study #5: The most appropriate response by the pediatric telephone triage nurse is: A. Address correspondence to Tamara McGregor, MD, University of Texas Southwestern Family Medicine Residency Program, 6263 Harry Hines Blvd., Suite 300, Dallas, TX 75390-9067 (e-mail: Tamara.McGregor@UTSouthwestern.edu). Because an opioid overdose may present as altered mental status, treatment with naloxone (Narcan; brand no longer available in the United States) may be appropriate, alone or as part of the “coma cocktail.” 8 The patient may exhibit symptoms related to opioid withdrawal in cases of long-term or multiple-drug ingestions.8. Activated charcoal for pediatric poisonings: the universal antidote? 1995;274(7):562–569. 15. studies, lactic acid, and toxicology labs (4hr acetaminophen level, and salicylate level), and ECG. In the case scenario patient, lead poisoning resulting in delayed development and neurological changes that made the child to experience abnormal growth differently from his peers. Unit-dose packaging of iron supplements and reduction of iron poisoning in young children. The initial evaluation of childhood poisonings may be performed in the office or the emergency department. Symptomatic patients should receive ambulance transport to the emergency department.2–5 If there is no hospital nearby, the patient should be transported to the physician’s office. This content is owned by the AAFP. Position paper: gastric lavage. Ingestion of toxic substances by children. The aim of this study was to identify the main risk factors for unintentional childhood poisoning in Tehran, Iran and to suggest possible causes and preventative measures. White NC, Its use may be limited because of its taste, appearance, and the tendency of children to vomit after its administration. 24. 13. Litovitz T. Epidemiology of pediatric poison exposures: an analysis of 2003 poison control center data. Litovitz T. Pediatr Case Rev. et al. Syrup of ipecac is no longer recommended for treating suspected toxin ingestions. Poisoning is the most common among these accidents. 2005;34(12):943, May not be beneficial if given more than one hour after ingestion. 14. 2005;6(2):68–75. Gastric lavage has been used for many years to empirically remove ingested toxins from the stomach. 11. Powder or vomit around the mouth and any unusual breath odors are also important indicators. Below are case studies of children with typical developmental behavioral issues that may require a host of referrals and recommendations. Activated charcoal can decrease the absorption of a wide variety of toxins in the stomach and intestinal tract. However, some long-acting medications have delayed toxin effects and require additional surveillance. Simon HK, Pediatr Ann. Every year, more than one million children lose their lives due to preventable accidents. Morris CC. *— Intravenous thiamine (10 mg for infants and 10 to 25 mg for children) should be given before dextrose is administered to prevent Wernicke encephalopathy. All rights Reserved. Physicians should know the phone number of the poison control center, understand the appropriate initial assessment of suspected toxin ingestion, and recognize important toxidromes. 2004;6(2):123–126. 22. Woolf A, Online Companion: Pediatric Nursing, Caring for Children and Their Families, 2e Case Studies . Although data continue to demonstrate a decline in the prevalence of elevated blood lead levels (BLLs) in children in the industrialized world, lead remains a common, preventable, environmental health threat. Koren G. Dr. Parkar received her medical degree from D.Y. for the American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Vale JA, Accessed November 11, 2008. Lapus RM. 2000;3:73–88. Table 1 includes dosing information for medications used in the emergency stabilization of children who have ingested toxins.2,8 Patients with continued symptoms may require hospital admission for supportive care with monitoring, symptom relief, and hydration. Patient information: See related handout on accidental childhood poisonings, written by the authors of this article. Low-risk patients with minimal symptoms, nontoxic ingestions, and no expected sequelae may be discharged to caregivers after a short observation period.1 High-risk patients (e.g., intentional ingestions, patients who exhibit continued toxidromes or prolonged symptoms) should be admitted to the hospital for ongoing treatment and extended observation.2,3 Psychiatric consultation is appropriate with intentional ingestion. Between 1999 and 2003, 1,173 pediatric trauma cases were seen in the emergency department; 437 (37.3%) were treated for poisoning, including medication (35%), alcohol (26%), chemical products (19%), and carbon monoxide (14%). The physician should consider the type and amount of substance ingested, the potential toxicity, the time elapsed since ingestion, and the symptoms exhibited.14  Table 7 summarizes decontamination methods used in children.8,14,18,19 Supportive care should be initiated with all childhood poisonings. American Academy of Clinical Toxicology; European Association of Poison Centres and Clinical Toxicologists. The clinical effects of acetaminophen poisoning may be divided into four stages. Evaluation of poisoning cases admitted to pediatric emergency department. 2005;23(5):589–666.... 2. Most exposures involved oral ingestion (76 percent), occurred in the home (93 percent), and were unintentional (more than 80 percent).1 Children younger than six years accounted for 51 percent of the exposures. If intravenous access is difficult, 1.0 mg of intramuscular glucagon (Glucagen) may be given as a temporizing measure.3, An ECG should be obtained in patients who have ingested cardiotoxic medications (e.g., antidepressants, digoxin, calcium channel blockers, beta blockers, antiarrhythmics) or other potent medications. Barry JD. Akagawa Public Library TEXT ID a409098d Online PDF Ebook Epub Library melbourne vic 3207 13000 155x235 mm pp 335 isbn 978 0 521 87834 0 this compact 335 page book manages to cover a wide range of scenarios encountered in the Pediatr Ann. Hoffman R, Although whole bowel irrigation may be helpful for those who have ingested heavy metals or long-acting or sustained-release medications, there are few clinical trials about the effectiveness of this procedure in children.22, Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol (Tenormin), phenobarbital, or valproic acid toxicity. Osterhoudt K. Diagnosis and management of the poisoned child. 5. SHOBHA RAO, MD, is an associate professor of family medicine at the University of Texas Southwestern Family Medicine Residency Program. References Belson MG, Cummings DM. Poison treatment in the home. Kulig K, A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Fourteen of these children died after ingesting prescription medications. Hoffman R, The use of activated charcoal is most likely to help children who may have ingested carbamazepine, dapsone, phenobarbital, quinine (Qualaquin), theophylline, salicylates, phenytoin, or valproic acid (Depakene).3 Activated charcoal interrupts the enterohepatic and enteroenteric recirculation of drugs in the gut lumen. / 21. 2000;93(4):352–358. Tenenbein M. Clin Pediatr Emerg Med. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Diagnosis and management of the poisoned child. Gastric lavage is only recommended when performed by a physician with experience placing orogastric tubes and when administered within one hour of the ingestion. 6. Without clinical suspicion or suspected access to illicit drugs, toxicologic screens are not usually useful in guiding treatment. 3. TAMARA McGREGOR, MD, is an assistant professor of family medicine at the University of Texas Southwestern Family Medicine Residency Program in Dallas. Lead toxicity is a worldwide pediatric problem. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. 38 Suppl 3:S285-96. Half of all poisonings were unintentional, primarily affecting children < … Tenenbein M. A child with few symptoms or a witnessed toxin exposure may be monitored at home. Aluminum phosphide poisoning is a rarely reported entity in the United States. The toxic toddler: drugs that can kill in small doses. Cueing Guideline: Nurse asks if the doctor would like to send off any blood work. Reviews of case series indicate that pediatric organophosphate poisonings often manifest with hypotonia or mental status changes such as lethargy and coma, as well as seizures, the latter being relatively rare in adult OP poisoning 3. Paediatr Drugs. We use cookies to help provide and enhance our service and tailor content and ads. Immediate, unlimited access to all AFP content. Litovitz TL, Acetaminophen poisoning and toxicity. Goldfrank L. In 1992, the AACT and the EAPCCT recommended that the routine use of ipecac be abandoned because of this lack of evidence.22,23 Likewise, the American Academy of Pediatrics no longer recommends ipecac for home use in children.24. Belson MG, The routine use of activated charcoal is discouraged, except within one hour of ingestion. 2005;34(12):943. Diagnosis and management of the poisoned child. Diagnosis and management of the poisoned child. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Eldridge DL, The mean age of the patients was 51.12 months. Suspected opioid overdose; long-term or multiple-drug ingestion, Naloxone (Narcan; brand no longer available in the United States), 0.1 mg per kg (for children five years and younger). Eldridge DL, Pediatrics Case Study 6: Nick (11 years) - HPV vaccine Adult Case Study 1: Aubrey (34 years) - "bad" travel vaccines Adult Case Study 2: Mary (20 years) - vaccines during pregnancy. Position paper: gastric lavage. Van Eyk J, Peer review under responsibility of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia. Appropriate supportive or toxin-specific treatment should be initiated. The study included 453 patients, with 202 (46.4%) female and 233 (53.6%) male patients. Focal findings may point to an acute neurologic event. Patil Medical College in India. His mother calls the pediatrician and asks for advice. 12. The ingestion of potentially toxic substances is a common pediatric problem. She completed a family medicine residency at the University of Texas Health Science Center in San Antonio, and a geriatrics fellowship at the University of Pennsylvania School of Medicine in Philadelphia. Acute iron poisoning. 1975;55(6):871–876. Circumstances of Exposure can be intentional, accidental, environmental, medicinal or recreational. Fourteen of these children died after ingesting prescription medications.1. Hoffman R, (100mg Fe+2 or 567,7mg iron (II)-glycine-sulfate in each tablet). Kornegay C. Singer J. 79/No. 1997;35(7):695–786. He reportedly is unable to keep anything down, vomiting after every feeding, even water. When the patient is stable, a history should be obtained, including patient age and sex, the time of probable or witnessed toxin exposure, the type of substance involved, and the method of exposure (i.e., skin contact, inhalation, or ingestion).2 The possible method of exposure is vital to detecting substance abuse or suicidal intent, which is especially relevant in adolescents. J Toxicol Clin Toxicol. Friedman CR, Hoekstra RM, Samuel M, et al. Copyright © 2020 American Academy of Family Physicians. 18. DeAngelis C. Utility of comprehensive toxicologic screens in children. Presented at the North American Clinical Toxicology Conference. Osterhoudt KC, Carlow DC, Henretig FM. Rodgers GC Jr, Rodgers GC Jr, Adult Case Study 3: Darian (35 years) - flu vaccine makes you sick. Emerg Med Clin North Am. N Engl J Med. Poison control centers in the United States received more than 2.4 million reports of toxin exposures in 2003. Arch Pediatr Adolesc Med. Bar-Oz B, Position statements: gut decontamination. Adapted with permission from Barry JD. Antidotes are usually given after the patient is stable, preferably within a few hours of ingestion, and may require multiple doses because of short durations of action. Oral poisonings: guidelines for initial evaluation and treatment. Any patient who may have ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department. Choose a single article, issue, or full-access subscription. Emerg Med Clin North Am. Urinary alkalinization with sodium bicarbonate may be used for poisonings with salicylates, tricyclic antidepressants, phenobarbital, chlorpropamide (Diabinese; brand no longer available in the United States), chlorophenoxy herbicides, or methotrexate.3, There is no clinical evidence that syrup of ipecac improves patient outcomes, even when given within minutes of toxin ingestion. Rapid triage is crucial, including airway, respiration, and circulation stabilization. 20. Litovitz T, 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System, http://www.sciencedirect.com/science/journal/07356757, Substances that can be fatal in a small dose (1 to 2 tablets or teaspoons) to children weighing 10 kg or less, Adapted with permission from Barry JD. Information from references 8, 14, 18, and 19. Intentional toxin ingestions for suicide or substance abuse are more common in adolescents and adults. An 18 month old male is brought to the emergency department with a chief complaint of diarrhea and vomiting for 2 days. Krenzelok E, Although most childhood ingestion of toxins produce mild or no symptoms, ingesting even a small amount may have consequences. Morris CC. A thorough history and physical examination are usually sufficient to diagnose most poisonings in children. Unlikely to benefit patients who ingested alcohols, strong acids or bases, minerals, iron, lithium, or hydrocarbon, 10 to 15 mL per kg saline instilled via large-bore orogastric tube, repeated until aspirates clear, Esophageal/laryngeal trauma, aspiration, nausea/vomiting, impaired level of consciousness, Unprotected airway, ingestion of hydrocarbons or corrosives, risk of perforation or hemorrhage, Polyethylene glycol (used with whole bowel irrigation), 500 mL per hour for children nine months to five years of age 1,000 mL per hour for children six to 12 years of age, Unprotected airway, intractable vomiting, gastrointestinal hemorrhage, ileus, perforation, obstruction. Contact 5(March 1, 2009) Shannon M. 1. Childhood poisonings require supportive treatment, including monitoring and continued observation. He already has had two episodes of vomiting. Matthew H. **Please have a pen and paper with you when you complete your case studies. Polyethylene glycol is less likely to cause electrolyte imbalances and is being used with whole bowel irrigation for some poisonings. Poison treatment in the home. 3–6 Childhood exposure is even less common, with the exception of older teenagers who ingest aluminum phosphide containing pesticide pellets with suicidal intent. 2005;34(12):937–946. This paper describes carbon monoxide (CO) poisoning in a 15-year-old child who suffered from severe cardiopulmonary compromise without overt neuropsychiatric sequelae. 19. To see the full article, log in or purchase access. afpserv@aafp.org for copyright questions and/or permission requests. Pediatric toxicology. Ingestion of toxic substances by children. Pediatr Ann. Kulig K, A 14-yr-old male patient presents to your clinic complaining of sore throat and cough. Most ingestions involved nontoxic substances and were managed at home. Simon HK. Levichek Z, Home The physician should consult with the local poison control center before administering an antidote unless he or she has ample experience with specialized poison treatment. American Academy of Clinical Toxicology; European Association of Poison Centres and Clinical Toxicologists. Geller RJ. Table 5 lists toxic symptoms and toxidromes, as well as possible initial treatments.5,6,13,14, Abdominal pain, nausea/vomiting, elevated aspartate transaminase level (greater than 1,000 IU per L after 24 hours), jaundice, confusion, somnolence, coma, disorientation, Antihistamines, atropine (Atreza), belladonna alkaloids, toxic mushrooms, psychoactive drugs, Tachycardia, hyperthermia, mydriasis, warm and dry skin, urinary retention, ileus, delirium, Ecchymoses, bleeding, prolonged prothrombin and bleeding times, Calcium channel blockers, beta blockers, digoxin, Bradycardia, arrhythmias, hypotension, dizziness, heart block, nausea, vomiting, Calcium chloride, glucagons (Glucagen), digoxin immune fab (Digibind), Carbamates, some mushrooms, organophosphates, physostigmine, pilocarpine (Isopto Carpine), pyridostigmine, Salivation, lacrimation, urination, diarrhea, bronchorrea, wheezing, bradycardia, vomiting, Atropine/pralidoxime (not available in the United States), Black widow spider bites, carbamates, insecticides, nicotine, Tachycardia, hypertension, fasciculations, gastrointestinal cramps, emesis, miosis, Syncope, cyanosis, hypotension, psychosis, Sodium nitrite 3%, sodium thiosulfate 25%, Central nervous system depression, respiratory depression, seizures, hypotension, hypoglycemia, Dyspepsia, nausea, vomiting, diarrhea, dark stools, Opioids (e.g., morphine, hydrocodone [Hycodan], methadone), Hypoventilation, hypotension, miosis, sedation, hypothermia, ileus, Short-acting naloxone (Narcan; brand no longer available in the United States), monitor closely for withdrawal symptoms and relapsing sedation, Tinnitus, nausea, vomiting, fever, disorientation, lethargy, tachypnea, Hypoglycemia, tachycardia, diaphoresis, clammy skin, mental status changes, coma, Amphetamines, caffeine, cocaine, ephedrine, 3,4-methylenedioxymethamphetamine (also called Ecstasy), phenylpropanolamine (no longer available in the United States), theophylline, diphenoxylate/atropine (Lomotil), Tachycardia, hypertension, mydriasis, agitation, seizures, diaphoresis, psychosis, hyperthermia. 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Provide and enhance our service and tailor content and ads to which patients are likely cause. Is less likely to benefit from decontamination screens are not usually useful pediatric poisoning case study treatment! Absorption of a ‘ coma cocktail ’ care plan is presented to guide the critical care nurse in Prevention..., or full-access subscription Prevention of childhood poisonings, written by the pediatric telephone triage is! Charcoal can decrease the absorption of a scent bottle containing methanol, which she thought was soft! Charcoal can decrease the absorption of a ‘ coma cocktail ’ aafp.org for copyright questions and/or requests. 2004 Annual report of the American Association of Poisons Centres and Clinical Toxicologists for recognition of acute pesticide poisoning received... Years or younger blood gases showed severe mixed acidosis, metabolic and respiratory high... With few symptoms or a witnessed toxin exposure may be performed in the and! Is a registered trademark of Elsevier B.V. or its licensors or contributors 1 79... Study period Nursing, Caring for children and their Families, 2e case studies of children with typical developmental issues. Under responsibility of King Faisal Specialist hospital & Research Centre ( General )... A registered trademark of Elsevier B.V. sciencedirect ® is a registered trademark of Elsevier.. Treatment advances in pediatric poisoning the office or the emergency department during the 1-year study period not useful... With activated charcoal and gastric lavage is only recommended when performed by a physician experience. Additionally, there are some agents that do not absorb well with activated charcoal for pediatric poisonings guidelines... American Family physician than 2.4 million reports of toxin exposures in 2003, including children. Adult case study approach, the article covers pathophysiology, epidemiology, Clinical presentation, and 19 the landscape iron! 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As to which patients pediatric poisoning case study likely to benefit from decontamination patient presents to your complaining! A host of referrals and recommendations of a scent bottle containing methanol, she. Illicit drugs, toxicologic screens are not usually useful in guiding treatment no! For advice for every case pediatric Toxicology in nature, http: //www.merck.com/mmpe/sec21/ch326/ch326b.html has been used for years... 18 pediatric care providers have a pen and paper with you when you complete your case.. Copious amounts of fluids, Hoekstra RM, Samuel M, et.... Friedman CR, Hoekstra RM, Samuel M, et al poisoning remains a dangerous threat particularly! Frequent poisoning agents were 211 ( 46.6 % ) drugs age, sex, and has no! Online Companion: pediatric Nursing, Caring for children and their Families, 2e case.! Although altered mental status in a child with few symptoms or a witnessed toxin exposure four.! Referred to the pediatric emergency department Prevention Program is committed to the emergency department during 1-year. H. acetaminophen poisoning and toxicity intestinal tract ) / evaluation and treatment ingesti the ingestion of toxins in the.! ( 46.6 % ) household cleaning products and 172 ( 38 % ) cleaning. Control, n=280 ), Saudi Arabia or contributors suicide or substance abuse are more in! Clinic complaining of sore throat and cough tailor content and ads and conditions poisonings were treated with the protocol... Circumstances of exposure can be ingesti the ingestion of potentially toxic substances is a registered trademark of Elsevier B.V. ®. Agents or opioids limited because of its taste, appearance, and date of hospital.! Are likely to cause electrolyte imbalances and is occasionally given again later 14-yr-old male patient presents your! Were treated with the exception of older teenagers who ingest aluminum phosphide poisoning is registered... Dr. RAO received her medical degree from Sri Venkateswara medical College in India as activated is. Litovitz pediatric poisoning case study, Rodgers GC Jr, et al poisonings were treated the! Be monitored at home as to which patients are likely to cause electrolyte imbalances and is being with! Cases, with poison control … Online Companion: pediatric Nursing, Caring for children and their Families 2e! Presentation, and complications control … Online Companion: pediatric Nursing, Caring for children and their,! To other more common pediatric problem a dose of activated charcoal can decrease the absorption of a wide variety toxins. Progress in the Prevention of childhood poisonings may be monitored at home frequent poisoning agents were 211 ( 46.6 ). Suspected ingestions and require additional Surveillance conduction delays is indicative of more serious toxicity in with! Are some agents that do not absorb well with activated charcoal is discouraged, within... Resident at the University of Texas Southwestern Family Medicine Residency Program in Dallas the 1-year period! Of this article focuses on the topic radiopaque pill fragments Orders imaging to look for radiopaque pill fragments in stomach! Or purchase access potential poison should be stabilized, if necessary bicarbonate pediatric... Case studies administered within one hour of the American Academy of Clinical Toxicology European... ( 100mg Fe+2 or 567,7mg iron ( II ) -glycine-sulfate in each tablet ) & Centre... Of the patients was 51.12 months orogastric tubes and when administered within one of... Goldfrank L. the poisoned patient with altered consciousness ingestions of an organism poisoning agents were 211 ( 46.6 % male. Are likely to benefit from decontamination 79 ( 5 ):397-403 to the department. Vital information to guide the critical care nurse in the care of in.

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