Neobook — clinical reference

Poison Information Centre Contact Details

Description

Diagnostic criteria

Treatment

Referral

Secondary prevention

For advice contact:

POISON INFORMATION CENTRES
Poisons Information Helpline (National service)	24 hours/day, every day for poisons queries	0861 555777
Red Cross War Memorial Children’s Hospital Poisons Information Centre Email: poisonsinformation @uct.ac.za http://www.paediatrics .uct.ac.za/ poisons-information-centre	Office Hours	(021) 6585308
Tygerberg Poison Information Centre Email: toxicology@sun.ac.za http://www.sun.ac.za/poisoncentre	Office Hours	(021) 9389596
University of the Free State Poison Control and Medicine Information Centre	24 hours/day	082 4910160

The Afritox poisons information database is available free of charge to public hospitals in South Africa: see www.afritox.co.za for information on how to access it.

DESCRIPTION

Frequently encountered poisonings in children include:

analgesics,
hydrocarbons,
pesticides,
plant material,
vitamins and minerals,
anticonvulsants,
antipsychotics,
sedatives and antidepressants,
household cleaning products.

Suspect intentional ingestion in older children and adolescents.

DIAGNOSTIC CRITERIA

Clinical

Can be divided into ‘toxidromes’:

Cholinergic, e.g. organophosphates:

salivation,
lacrimation,
urination,
pinpoint pupils,
diarrhoea,
vomiting,
bronchorrhoea,
bradycardia.

Salicylism, e.g. aspirin:

tachypnoea,
metabolic acidosis,
seizures.
agitation,
coma,

Anticholinergic, e.g. antihistamines, amanita pantherina, atropine:

fever,
ileus,
flushing,
tachycardia,
urinary retention,
dry/warm skin,
blurred vision,
dilated pupils,
coma,
hallucinations and seizures.

Sedative-hypnotic, e.g. alcohol, benzodiazepines:

Obtundation or coma.

Opiates, e.g. morphine:

pinpoint,
respiratory depression,
bradycardia,
hypotension.
decreased bowel sounds,
hypothermia,
altered (decreased) mental status,

Dystonic reaction, e.g. haloperidol, antihistamines, anti-emetics:

torticollis,
opisthotonus,
intermittent spasms and tongue thrusting.

Sympathomimetic, e.g. cocaine, amphetamines:

hypertension,
agitation,
tachycardia,
sweating,
hyperthermia,
dilated pupils.

Sympathomimetic toxidrome resembles anticholinergic toxidrome, i.e. fight, flight and fright response, however, the sympathomimetic toxic patient is sweaty as opposed to hot, dry skin seen with anticholinergic toxicity.

Toxic alcohols, e.g. ethylene glycol, methanol:

metabolic acidosis,
increased osmolar gap,
increased anion gap,
visual disturbances (methanol),
hypoglycaemia,
convulsions,
renal failure (ethylene glycol),
depressed level of consciousness.

TREATMENT

If the ingestion has definitely occurred: establish whether toxicity is expected and act accordingly.
If the possibility of ingestion was remote: only observation is necessary.

Principles of treatment

Stabilise patient if necessary.
Decontaminate the patient if indicated (see below) and contra-indications are not present.
Give antidote if available. There are a limited number of antidotes for poisoning by certain substances, e.g. N-acetylcysteine for paracetamol, naloxone for opioids. Each antidote has specific criteria and indications for use.
Enhance elimination if possible.
Monitor hydration status carefully.

Decontamination:

1. Gastric lavage

Gastric lavage is seldom indicated and may cause more harm than benefit. If indicated, it should only be performed by experienced staff and within 60 minutes of ingestion. Indicated only if patient:

has ingested a potentially life-threatening poison,
has a protected airway, i.e. fully awake and cooperative or intubated with a depressed level of consciousness.

Gastric lavage is contraindicated after ingestion of corrosive substances and volatile hydrocarbons such as paraffin.

Technique:

Place patient in left lateral head down position.
Insert orogastric tube if possible, with largest bore and rounded tip.
Insert 200 mL warmed water or normal saline, and aspirate.

Continue until recovered solution is clear of particulate matter.

2. Activated charcoal

May reduce systemic absorption of a variety of poisonous substances. The greatest benefit is achieved if activated charcoal is given within one hour after ingestion; however, where gastric emptying is delayed by certain substances, there may be a longer period of time in which it is effective.

Activated charcoal must only be given in cases where the airway is protected, i.e. fully awake and cooperative patient or intubated with a depressed level of consciousness.

Repeated doses of activated charcoal every 4 hours are effective in enhancing elimination of substances that undergo enterohepatic circulation, e.g. carbamazepine, dapsone, phenobarbital, quinine or theophylline overdose.

Activated charcoal, oral, given as a slurry:
- If < 6 years of age: 1 g/kg in 50–100 mL water.
- If > 6 years of age: 20–50 g in 100–300 mL water.

LoE III¹

Note:
In the intubated patient with a protected airway, the activated charcoal can be administered via a nasogastric tube (the slurry is thick and requires administration to be pushed through a syringe).

Contra-indications:

If patient is unconscious and the airway is not protected.

Poisons where charcoal is ineffective and should not be given	Charcoal may be useful if these poisons are taken in toxic doses
- ethanol - methanol - brake fluid - petrol or paraffin - iron salts - lithium - bleach and caustic alkalis - boric acid	- carbamazepine, barbiturates, phenytoin - dapsone, quinine » theophylline - salicylates - mushroom poisoning (Amanita phalloides) - slow-release preparations - digoxin - beta-blockers - NSAIDs

3. Whole bowel irrigation

Whole bowel irrigation can be done for potentially toxic ingestions of substances that are:

not absorbed by activated charcoal (e.g. iron and lithium),
sustained-release and enteric-coated products, or
for removal of illicit drugs in body packers.

Patients must have a protected airway, i.e. fully awake and cooperative or intubated with a depressed level of consciousness.

Polyethylene glycol (PEG) balanced electrolyte solution, NGT:
- Child (9 months to 6 years): 500 ml per hr
- Child (6 to 12 years): 1000 ml per hr
- Continue until rectal effluent is clear.

LoE III²

REFERRAL

Severely ill patient for ventilatory/circulatory support.
If relevant diagnostic testing is not available, e.g. paracetamol levels.
If relevant medication/antidotes are not available.
If dialysis/haemoperfusion is required.
For psychiatric evaluation where deliberate self-harm is suspected.

SECONDARY PREVENTION

All cases of accidental poisoning require an assessment of home circumstances. The opportunity must be taken to educate childcare providers on safe storage practices, particularly of medications and household products.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 18: Poisoning, 18.1 Poisoning

Click here for Anticholinergic Poisoning

Click here for Anticoagulant Poisoning

Click here for Tricyclic Antidepressant Poisoning

Click here for Ingestion of Caustic or Corrosive Agents

Click here for Volatile Solvents

Click here for Ethanol Poisoning

Click here for Iron Poisoning

Click here for Neuroleptic Poisoning

Click here for Organophosphate Poisoning

Click here for Opioid Poisoning