More effort needed to prevent pediatric poisonings

Early recognition improves outcomes for toxic ingestion.

More effort needed to prevent pediatric poisonings
More effort needed to prevent pediatric poisonings

BOSTON -- The proportion of pediatric poisonings due to toxic ingestion has remained static for the past decade, but clinicians can educate parents about prevention and know which signs to look for to expedite treatment, according to a speaker at the 2014 National Association of Pediatric Nurse Practitioners Annual Conference.

More than one million poisonings occur each year in children aged 5 years and younger each year, said Cathy Haut DNP, CPNP, CCR, director of the advanced pediatrics nurse practitioner program at the University of Maryland School of Nursing in Baltimore.

In 2012, more than 65,000 children were treated in the ED for toxic ingestion – a 30% increase from 2002 -- and 30 died, a 2013 National Poison Data system report indicated.

“Earlier recognition can support management in toxic ingestion cases,” Haut said. “The challenge is to identify children who are at risk for severe or life-threatening adverse events.”

Clinicians can avoid unnecessary and costly work-ups by recognizing common characteristics in poisoning cases and understanding which physiologic changes are associated with different types of substances.

It is important clinicians understand many parents and caregivers are unaware that toxic ingestion is the cause of a child's symptoms. Most times a child is brought in for medical attention due to altered consciousness.

“Patient history can give you good information, but a physical exam is better,” Haut said. She added that it's not easy for parents to admit that their child may have gotten into the medicine cabinet, or that they may not always be telling you the real story.

Looking at neurologic and cardiovascular function, as well as the presence or absence of metabolic derangement and the patient's temperature can assist in diagnosis. Paying close attention to a patients vital signs may provide clues as to what type of toxin was ingested.

Vital Signs and Toxic Ingestion

Symptom
Ingestion
Hypothermia
Opioids, sedatives, alcohol
Hyperthermia Salicylate, anticholinergic, amphetamines
Tachycardia Anticholinergics, antihistamines, sympathomimetics and tricyclic, antidepressants
Bradycardia Beta-blockers, calcium channel blockers and clonidine
Tachypnea Direct pulmonary insult or noncardiogenic pulmonary edema or as a compensatory mechanism in the setting of metabolic acidosis
Respiratory depression Clonidine, opiate or sedative‐hypnotic ingestion, especially in young children
Hypertension Cocaine, sympathomimetics, anticholinergics
Hypotension Tricyclic antidepressants, beta-blockers, calcium channel blocker

“Perform irrigation and hydration if you're unsure of what a child has ingested,” Haut said. “Oral hydration can help until you get to the next step. Fresh air can help with hallucinations.”

Because of safety concerns with administering charcoal, Haut advises to call poison control for guidance with gastrointestinal decontamination.

Top 10 Pediatric Toxic Substance Exposures in 2013

Cosmetics, personal care products
Analgesics
Cleaning substances
Foreign bodies/toys
Topical preparations
Vitamins
Antihistamines
Pesticides
Antimicrobials

When a toxin is unknown use a step-wise, “ABC approach” to differential diagnosis. After physical exam, perform lab evaluations to assess methemoglobinemia, arterial blood gases, electrolyte levels and osmolarity or gap, Haut advised. Clinicians may also consider performing urinalysis or a toxicology screen.  

“Remember that prevention of toxic exposures is really the key,” Haut said. “No matter where you work --  primary care or the hospital setting -- always advise parents not to buy toxic substances that they don't need and to get rid of any medications left over from previous treatments.”

References

  1. Haut C. #316. “Terrible Toxic Tales: 2013 and Beyond.” Presented at: 2014 National Association of Pediatric Nurse Practitioners Annual Conference. March 11-14, 2014; Boston.
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