Paediatric Clinical Guideline

Emergency: 1.3 Ingestions and Accidental Poisoning

Short Title: / Ingestions and Accidental Poisoning
Full Title: / Guideline for the assessment and management of a ingestions and accidental poisoning in children and young people
Date of production/Last revision: / June 2005
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 19 years.
Name of contact author / Dr Damian Wood, Consultant Paediatrician Ext 64041
Revision Date / June 2008
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Ingestions and Accidental Poisoning

Introduction

Ingestions and accidental poisonings are a common cause of hospital attendance and admission. Severe toxicity is uncommon, with the majority of admitted children requiring observation only, however some require intensive care, and nationally there are a small number of deaths each year.

Important Management Principles

·  Resuscitation and stabilisation

o  Determine the exact nature and timing of the poisoning

o  Prevent and treat toxicity

o  Eliminate the poison

o  Deliver specific antidote if available

·  Monitor for late effects and complications

·  Determine if poisoning was accidental, intentional or deliberate (see below)

o  Accidental (typically toddler / pre school age group)

o  Intentional (common in young people)

o  Deliberate (by "carer"; rare)

·  Prevention of future episodes/protection from future harm

Resuscitation

Call the paediatric registrar if resuscitation required. Paediatric registrar to ensure stabilisation and safe transfer to ward/PICU as appropriate.

Airway – Depression of the CNS is a common symptom of poisoning and treatments may necessitate airway protection

Breathing - Consider naloxone if respiratory depression secondary to narcotic

Circulation - Expand circulatory volume (20ml/kg normal saline) if shock present. Inotropes and invasive monitoring may be required if poor response to initial fluid resuscitation. Poisonings are a common cause of arrhythmias – see management of arrhythmias below

Disability - Assess conscious level (intubation likely to be needed if GCS ≤ 8) and pupillary size and response

Determine the exact nature and timing of the poisoning

·  Which agent ?

o  Tablets/medicines

§  Examine the packaging and estimate how much remains

§  What prescriptions (new and old are in the house?)

o  Plants / berries may be identifiable from charts / books

·  What dose ? (assume maximum possible) – calculate dose/kg body weight

·  When ?

·  Look for evidence of specific poisons e.g. mouth ulceration from corrosive substance, if pupils dilated/sweatiness consider tricyclic antidepressants

·  Is it possible that other children may have been involved?

Prevent and treat toxicity

What are the adverse effects of the ingested substance?

Upto date information regarding risk of toxicity, elimination of poisons and specific antidotes as well as monitoring for specific poisons is available from:

National Poisons Information Service
24 hour poisons enquiries / TOXBASE
/ Nottingham University Hospitals
Drug Information
0870 600 6266 / Access available at all workstations in the emergency department. Departmental user name and password can be obtained from nurse in charge / Queen’s Medical Centre
(0115 924 9924)
Ext 64185

Can absorption be prevented?

Activated charcoal

Dose : 1g/kg (up to 50g maximum) Repeated doses (4 hrly) for severe poisoning with theophylline, digoxin, carbamazepine, barbiturates and salicylate. Obtain expert advice

Indications: If moderate to severe toxicity predicted

Substances where repeat doses of activated charcoal may prove useful:

·  Carbamazepine

·  Barbiturates

·  Dapsone

·  Quinine

·  Theophylline

·  Salicylates

·  Death cap mushroom (Amanita phalloides)

·  Slow release preparations

·  Digoxin and digitoxin

·  Phenylbutazone

·  Phenytoin

·  Sotalol

·  Piroxicam

Administration

Give via oral or nasogastric route within 1 hour of ingestion. (May be effective > 1hr for sustained release preparations and drugs delaying gastric emptying)

Patient must be fully conscious or have airway protected – “aspiration can be fatal”

Contraindications: Avoid following ingestion of acid / alkali

Cautions: Not effective for iron, lithium, mercury, lead, ethanol, organic solvents, bleach,

essential oils or petrochemicals.

In a small number of poisoning scenarios gastric lavage or whole bowel irrigation may be indicated. If the advice from TOXBASE is that either gastric lavage or WBI is indicated please seek advice from the a senior doctor in the emergency department.

Does the child/young person need a specific antidote?

Specific antidotes are available for a number of substances. Detailed advice should be sought from TOXBASE or the NPIS.

Substance / Specific Antidote
Benzodiazepines / Flumazenil
Beta-blockers / Adrenaline infusion, glucagons
Carbon monoxide / Oxygen
Carbon tetrachloride / N-acetylcyseine
Digoxin / Digoxin antibodies
Iron / Desferrioxamine
Isoniazid / Pyridoxine, Sodium bicarbonate
Lithium / Sodium replacement, low dose dopamine
Methaemoglobinaemia / Methylene blue
Methanol / Ethanol, alcohol dehydrogenase inhibitor (fomepizole)
Ethylene glycol / Ethanol, alcohol dehydrogenase inhibitor (fomepizole)
Metoclopramide / Procyclidine
Opiates / Naloxone
Organophosphate insecticides / Atropine. Pralidoxime
Paracetamol / N-acetylcysteine
Thyroxine / Propranolol

Does the child young person need admission?

Guidelines on admission and period of observation can be obtained from TOXBASE. Admission is generally required if

·  Child/young person is symptomatic or requiring treatment

·  the ingested substance is liable to produce delayed symptoms

·  if there was deliberate poisoning (see child protection guidelines) or intentional self harm (see self harm guideline)

If a child with poisoning is admitted please attach a copy of the printed TOXBASE advice sheet to the casenotes so that monitoring and management may continue on the ward/PICU.

What monitoring does the child/young person require?

Make a plan for monitoring based on the advice provided by TOXBASE/NPIS. Ensure this is communicated clearly to the team responsible for ongoing care as the timings of investigations are very important in acute poisoning.

Consider

·  what physiological monitoring is required (TPR, blood pressure, ECG, electrolytes etc) and how often?

·  What specific investigations (eg serum or urine drug levels) are required and when?

Follow-up

·  Accidental ingestions: Health visitor referral (for patients not admitted this occurs via A&E through the paediatric liaison health visitor, in cases where admission occurs the health visitor is contacted by ward nursing staff)

·  Self-harm: Admit all children and young people with self harm and refer to Child & Adolescent Self Harm Team

·  Intentional Poisoning: if this is suspected the child should be admitted, and the consultant on-call informed. Child safeguarding procedures should be followed with referral to social services and the police. Early discussion with the clinical chemistry on-call is also advisable.

Specific Agents

Advice on specific agents can be obtained from Toxbase or the NPIS Information Line

Paracetamol Poisoning

For specific advice please consult TOXBASE

Paracetamol poisoning should now be managed according to the 2007 guidelines agreed by the National Poisons Information Service. These are available either through TOXBASE or on a wallchart in PA&E and in E37 doctor’s office.

IT IS IMPORTANT TO CALCULATE THE MAXIMUM POSSIBLE DOSE INGESTED

It is also important to consider:

·  Was the overdose staggered or is this a late presentation?

·  Does the child/young person fall into a high risk group?

·  Is there an indication for commencing (N-acetylcysteine) Parvolex immediately whilst awaiting blood results?

After treatment has been given consider:

·  Are there any biochemical/haematological markers of acute hepatotoxicity?

·  Are there any symptoms of acute hepatotoxicity such as abdo pain and vomiting?

References

Guidelines for the Management of Acute Paracetamol Overdosage, National Poison Information Service (NPIS), 2007

Poisoning In Children Series Archives of Disease in Childhood 2002;87(8):392-410

Jones AL, Dargan PI What’s New in Toxicology Current Paediatrics 2001; 11:409-13

Title
Poisoning and Ingestions
Guideline Number / Version / Distribution
1.3 / Final / All wards QMC and CHN
Author / Document Derivation
Dr Damian Wood
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician
First Issued / Latest Version Date / Review Date
June 2005 / June 2008
Ratified By / Date
Paediatric Clinical Guidelines Meeting / June 2005
Audit / Induction Programme / Amendments
Management of paracetamol poisoning

Damian Wood Page 1 of 5 June 2005