Paediatric Acute care Guidelines PMH Emergency Department

This guideline provides an outline of the general approach to poisoning. Specific information about poisoning presentations can be obtained from Poisons Information: 131126 or refer to the Toxicology Handbook. 

Background

  • The vast majority of morbidity and mortality in toxicology arises from complication of the poisoning not the poisoning itself, particularly
    • Aspiration due to sedation
    • Urinary retention
  • Good supportive care is the best way to prevent this
  • Poisonings follow a highly predictable path 
  • Risk assessment is an essential cognitive step during assessment that outlines ongoing care
  • If information is unclear always base the risk assessment upon a “worse case scenario”
  • Know your list of “2 pills can kill” in a toddler. 
    • Most accidental paediatric ingestions are only 1-2 tablets and a risk assessment will be low. Nevertheless, there are some toxins which can kill a young child with a very small exposure. These should be aggressively managed with early senior advice and/or Toxicology service input. 
  • The general approach to all poisonings should follow the “RRSIDEAD” format

R Resuscitation 
R Risk Assessment
S Supportive Care
I Investigations
D Decontamination
E Enhanced Elimination
A Antidotes
D Disposition 

Management

Resuscitation

Follow traditional ABC approach with modification

  • Airway 
  • Breathing
  • Circulation
  • Control/Correct
    • Seizures with midazolam (phenytoin contraindicated)
    • Hypothermia
    • Hyperthermia
      • Temperature > 38.5º requires core monitoring
      • Temperature > 39.5° is an indication for intubation, ventilation and paralysis

Risk Assessment

The following five factors will provide an accurate prediction of clinical course, potential complications and time coarse of poisoning to direct management. 

  • Agent/s
  • Dose
  • Time of ingestion
    • Use the latest possible time if uncertain
  • Patient factors
    • Weight
    • Comorbidities that may affect prognosis, for example:
      • Heart disease complicating calcium channel overdose
      • Morbid obesity affecting airway patency
  • Clinical status (features and progress)
    • Agents commonly affect the autonomic, CNS and neuromuscular systems and may produce a recognisable “toxidrome”
    • Does the clinical presentation of the patient fit with the predictable profile of the overdose?
    Anticholinergic Sympathomimetic Serotonergic
Examples  

Antihistamines
Antidepressants
Antipsychotics
Oxybutinin

Street amphetamines
Dexamphetamine
Methylphenidate

SSRIs/SNRIs
TCAs
MAOi
MNDA

Autonomic

Vital Signs Elevated Elevated Elevated

 

Temperature Elevated Elevated Elevated

 

Pupils Dilated Dilated Dilated

 

Skin/Mucous Membranes Flushed, Dry Flushed, Sweaty Flushed, Sweaty

CNS

Mental Status Agitated delirium Euphoria, Agitated Agitated, Coma

 

Seizures Rarely Yes Yes

Neuromuscular

Tone Normal Increased/Rigidity Increased/Rigidity

 

Reflexes Normal Hyperreflexic  Hyperreflexic/clonus

Complications

  Urinary retention
Hyperthermia
Rhabdomyolysis
Injury to self

Severe hypertension
Dysrhythmias
Myocardial infarction
Pulmonary edema
Rhabdomyolysis
Hyponatreamia
SAH

Hyperthermia
Rhabdomyolysis

Supportive Care and Monitoring

  • Supportive care is tailored to the risk assessment and may involve:
    • IV hydration
    • Control of agitation and seizures with titrated benzodiazepines
    • Ensuring normoglycaemia
    • Bladder care (especially monitoring for urinary retention)

Investigations 

Investigations are done for either specific purposes, to identify occult overdoses, or specific tests to determine the presence or level of a known ingestant

Screening

  • 12 lead ECG
    • Wide QRS  (sodium channel blockade)
    • Long QT (potassium channel blockade, anti-psychotic overdose)
    • Heart blocks (calcium channel and beta blockers/calcium channel poisoning
  • Serum Paracetamol level (4 hours)
  • Blood glucose level (BGL)

Specific  

  • Drug levels
    • Paracetamol (in known ingestion)
    • Iron
    • Alcohols
    • Lithium
    • Salicylate
    • Theophylline
    • Anti-epileptics
    • Others

Other adjunctive tests as indicated:  

  • Blood gas:
    • High anion gap metabolic acidosis
      • TCA
      • Salicylates (late)
      • Iron
      • Toxic alcohol
      • Metformin
    • Respiratory alkalosis
      • Salicylates
    • Respiratory acidosis
      • Sedatives
  • Abdominal X-Ray: 
    • Confirmation of iron or other heavy metal ingestion
  • Blood tests:
    • LFT (delayed paracetamol) 
    • UEC
    • INR (Warfarin, delayed paracetamol) 

Decontamination

  • Consider but rarely required
    • Activated charcoal
      • Will not bind to hydrocarbons or alcohol, corrosives and metals
      • Reserved for life threatening intoxications in which other measures are not expected to result in a good outcome
      • Contraindicated in un-intubated patient if decreased conscious level, vomiting or seizures are expected
      • Can be considered where the toxin is likely to remain in the gastrointestinal tract (generally within the first hour post ingestion for most agents) 
    • Other methods: e.g. whole bowel irrigation – should not be instigated in the ED and should only be commenced on advice of Poisons Information

Enhanced Elimination

  • Consider but rarely required
    • Techniques include: multiple dose activated charcoal, urinary alkalinisation, haemodialysis, haemofiltration, charcoal haemoperfusion

Antidotes

  • The risk assessment should determine if the potential benefit outweighs the possible adverse effects of the antidote
Antidote  Poison
N-acetylcysteine Paracetamol
Naloxone Opiates
Flumazenil Benzodiazepines
Desferrioxamine Iron
Sodium Bicarbonate TCAs

Disposition

  • The disposition will be determined by:
    • The clinical risk assessment of the overdose
    • The psychiatric safety of the patient (for deliberate overdoses)
    • Other safety factors (parental neglect or drug use, domestic issues)
  • Children should not be discharged home at night unless the risk assessment determines that the overdose is trivial and not requiring any form of observation 

Discharge home with parental supervision:

  • Trivial overdose with no requirement for observation
  • Ensure safety issues such as accessibility to tablets are addressed and provide parents with Kidsafe WA Poisoning Fact Sheet
  • Low risk overdose with minimal potential for deterioration during day-time hours
  • Parents must be able to return to ED in the event of deterioration

Emergency observation ward

  • Stable patient with low-risk overdose requiring observation
  • Low risk overdose with minimal potential for deterioration during night hours

Medical ward

  • Stable patient requiring medical or antidote therapy
  • Any suspicion of NAI

PICU

  • Unstable or intubated patient

Psychiatric Ward 

  • Medically cleared patient deemed at risk of deliberate self harm 

 Nursing 

  • Baseline observations include heart rate, respiratory rate, oxygen saturation, blood pressure and neurological observations
  • Minimum of hourly observations should be recorded whilst in the emergency department
    • Any significant changes should be reported immediately to the medical team
  • Nursing care specific to the presentation
Two Tablets – Potentially Lethal to a 10kg Child 2
Agent  Principle Features of Severe Toxicity

Amphetamines 

  • Amphetamine
  • Metamphetamine
  • MDMA (ecstacy)

Agitation
Confusion
Hypertension
Hyperthermia

Baclofen 

Coma

Calcium Channel Blockers

  • Diltiazem CD 
  • Verapamil SR 

Delayed onset of bradycardia
Hypotension
Conduction defects
Refractory shock 

Chloroquine 
Hydrochloroquine 

Rapid onset of coma
Seizures
Cardiovascular collapse 

Dextropropoxyphene Ventricular tachycardia 

Opioids

  • Oxycodone
  • Methadone
  • Morphine Sulphate
  • Diphenoxylate/Atropine 

Coma, respiratory arrest 
Note: May be delayed with diphenoxylate/atropine and controlled release morphine

 Propranolol  Coma
Seizures
Ventricular tachycardia
Hypoglycaemia

Sulfonylureas

  • Glibenclamide
  • Glibenclamide/Metformin
  • Gliclazide
  • Glimepiride

Hypoglycaemia
Note: Onset may be delayed up to eight hours. 

Theophylline Seizures
Supraventricular tachycardia
Vomiting

Tricyclic antidepressants

  • Dothiepin

Coma
Seizures
Hypotension
Ventricular tachycardia

Venlafaxine XR

Seizures

 

Non-pharmaceutical agents considered potentially lethal to children 2
Agent  Dose of concern for a 10kg child Clinical Effects
Organophosphate and carbamate insecticides Single sip Cholinergic symptoms
Seizures
Depressed level of consciousness
Paraquat/Diquat  Sip Oro-pharyngeal burns
Multiple organ failure
Pulmonary fibrosis

Hydrocarbons

  • Solvents
  • Eucalyptus oil
  • Kerosene

Sip

Rapid depressed level of consciousness
Seizures
Aspiration pneumonia

Camphor 5mL of 100% Rapid depressed level of consciousness
Seizures
Hypotension

Corrosives

  • Sodium hydroxide
  • Strong acids
  Gastro-oesophageal injury including perforation 
Naphthalene

One mothball

NB: Most mothballs contain paradichlorbenzene, which is non-toxic after a single accidental ingestion 

Methaemoglobinaemia
Haemolysis
Strychnine   Rapid onset of generalised muscle spasm
Death by respiratory failure

References

  1. Murray L, Daly F, Little M, Cadogan M (2011) Toxicology Handbook, 2nd Edition, Elsevier Australia
  2. Murray L, Little M, Pascu O and Hoggett KA (2015) Chapter 2.23 Poisoning in Children, Toxicology Handbook, 3rd Edition, Elsevier Ltd
  3. McCoubrie D, Murray L, Daly FFS and Little M. Toxicology case of the month: ingestion of two unidentified tablets by a toddler. Emerg Medicine J 2006; 23: 718-720.  
  4. Bar-Oz B, Levichek Z and Koren G. Medications That Can Be Fatal For a toddler with One Tablet or Teaspoon. Paediatric Drugs 2004; 6 (2): 123-126

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