Chapter 18 Emergency Management

1
Chapter 18Emergency Management
2
Poisoning in Children

• Definition of Poisoning
• Exposure to a chemical or other agent that
  adversely affects functioning of an organism.
• Circumstances of Exposure can be accidental,
  environmental, medicinal or recreational.
• Routes of exposure can be ingestion, injection,
  inhalation and others.

3

• Ingestion of a harmful substance is among the
  most common causes of injury to children less
  than six years of age
• Toxicology is the science that studies the
  harmful effects of drugs, environmental
  contaminants, and naturally occurring substances
  found in food, water, air and soil.
• Poisoning maybe a medical emergency depending on
  the substance involved.

4
Poisoning in ChildrenImportant history points

• What toxic agent/medications were found near the
  patient?
• What medications are in the home?
• How much was available before the ingestion?
• How much remained after the ingestion?
• When did the ingestion occur ?
• Were there any characteristic odors at the scene
  of the ingestion?
• Was the patient alert on discovery?
• Has the patient remained alert since the
  ingestion?
• How has the patient behaved since the ingestion?
• Does the patient have a history of substance
  abuse?

5

• Clinical manifestations
• GIT symptoms anorexia, abdominal pain, nausea,
  vomiting, and diarrhea
• ? CNS symptoms convulsions (CNS stimulants),
  coma (CNS depressants) as alcohol and
  barbiturates, dilated pupils common in nicotine,
  cocaine and ephedrine poisoning or pinpoint
  pupils due to opiates or organophosphorus
  poisoning.
• ? Skin symptoms rashes, burn, eye inflammation,
  skin irritation and cyanosis (cyanide).
• ? Cardiopulmonary symptoms dyspnea,
  cardiopulmonary arrest.

6
Emergency treatment

• General measures
• Quick assessment triage
• Identify the criminal.
• Limit absorption
• Vomiting
• Lavage
• Activated charcoal instillation

7

• Specific
• ABCs of Toxicology
• Airway
• Breathing
• Circulation
• Drugs
• Resuscitation medications if needed
• Universal antidotes
• Draw blood
• chemistry, coagulation, blood gases, drug levels
• Decontaminate (Clean)
• Expose / Examine
• Full vitals / Foley / Monitoring
• Give specific antidotes / treatment

8

• Terminate exposure
• ? Empty mouth of pills, plant part or other
  material.
• ? Flush eyes continuously for 15-20 minutes.
• ? Flush skin and wash with soap and a soft cloth,
  remove contaminated clothes, especially if a
  pesticide, acid, alkali or hydrocarbon is
  involved.
• ? Bring victim of an inhalation poisoning into
  fresh air.
• ? Give water to dilute ingested poison.

9

• 3. identify the poison
• ? Ask the victim and witnesses.
• ? Save all evidence of poison ?empty bottle,
  opened container, vomitus and urine.
• ? Be alert to signs and symptoms of potential
  poisoning in absence of other evidence.

10

• 4. Remove poison and prevent absorption
• a. Induce vomiting
• ? Administer ipecac if ordered.
• ? 6-12 months 10 ml doesnt repeat.
• ? 1-12 years 30 ml.
• ? Give 10-20 ml/kg of clear fluids after ipecac.
• b. Dont induce vomiting if
• ? Victim is comatose, in severe shock or
  convulsing or has lost the gag reflex.
• ? Poison is or low-viscosity hydrocarbon, strong
  acid or alkali.
• c. Place the child in side lying or sitting
  position with head below chest to prevent
  aspiration.
• d. Administer activated charcoal (1g/kg) 30-60 m.
  after vomiting from ipecac if ordered.

11
1. Corrosives substances strong acids or alkali

• toilet cleanness, detergents, etc.
• Clinical manifestation
• ? Severe burning pain in mouth, throats and
  stomach.
• ? White swollen mucous membranes.
• ? Edema of lips and tongue and pharynx
  (respiratory obstruction).
• ? Violent vomiting and drooling and inability to
  clear secretions.
• ? Anxiety and agitation and signs of shock

12
Treatment

• ? Inducing vomiting is contraindicated ?vomitus
  will re-damage the mucosa.
• ? Dilute corrosive with water not milk unless
  vomiting occurs.
• ? Provide patent air way if needed.
• ? Administer analgesics and dont allow oral
  intake

13

• Hydrocarbons e.g. Kerosene, Lamp oil, Turpentine
  and paint remover.
• Clinical manifestations
• ? Gagging, choking and coughing.
• ? Nausea, vomiting, lethargy and weakness.
• ? Respiratory symptoms (tachypnea, cyanosis and
  grunting).
• N.B. Immediate danger is aspiration lead to
  chemical pneumonia.

14

• Treatment
• ? Inducing vomiting is generally contraindicated.
  
• ? Gastric lavage may be used.
• ? Symptomatic treatment of chemical pneumonia as
  oxygen therapy, humidification and hydration.
• ? Antibiotic for secondary infection

15
3. Acetaminophen

• Clinical manifestations occur in 4 stages
• 1. Initial period (2-4 hours after ingestion)
  nausea, vomiting, sweating and pallor.
• 2. Latent period (24-36 hours), patient improves.
  
• 3. Hepatic involvement (last up to 7 days), pain
  in right upper quadrant, jaundice, confusion
  stupor, coagulation abnormalities. Patient who
  doesnt die in hepatic stage gradually recover.

16

• Treatment
• ? Emesis, lavage and activated charcoal.
• ? Antidote N-acetylcystine given by N.G. tube or
  I.V. because of its offensive odor ?rotten eggs.

17
4. Aspirin

• Clinical manifestations
• ? Acute poisoning nausea, vomiting,
  disorientation, dehydration, diaphoreses,
  hyperpnea, hyperpyrexia, oliguria, tinnitus, coma
  and convulsions.
• ? Chronic poisoning as mention above and
  bleeding tendencies.
• ? Acute ingestion toxic dose 300-500 mg/kg and
  chronic ingestion toxic dose 100 mg/kg for 2 or
  more days.

18

• Treatment
• ? Home use of ipecac for moderate toxicity and
  hospitalization for severe toxicity.
• ? Emesis, lavage, activated charcoal, sodium
  bicarbonate to overcome metabolic acidosis.
• ? Diazepam for seizures.
• ? Oxygen and ventilation for respiratory
  depression.
• ? Vit. K. for bleeding.
• ? Dialysis for severest toxicity.

19
5. Organophosphorus Poisoning Parathion poisoning

• Clinical manifestations
• ? Miosis (constriction of pupils), salivation,
  lacrimation, urinary and stool incontinent.
• Pathology it have three actions
• 1. Muscarinic action (Acetylcholine receptors)
• ? Bronchospasm, dyspnea, cough, cyanosis,
  increase bronchial secretions and frothy
  secretions from mouth.

20

• 2. Nicotinic action
• ? Muscle spasm (cramps), weakness, hypertension,
  weak intercostal muscle that can cause
  respiratory failure and death.
• 3. CNS action
• ? Confusion, restlessness, drowsiness,
  convulsions, general weakness, coma and/or
  cardiopulmonary failure.

21

• Diagnosis
• ? History and physical examination ?clinical
  manifestations?.
• ? Atropine test.
• Treatment
• ? Remove clothes and wash skin ? Remove poisonous
  by gastric lavage.

22
Give specific antidote

• a. Atropine sulfate block muscarinic action and
  CNS action BUT not nicotinic action. 0.02 mg-0.04
  mg/kg dose every 10 minutes until signs of
  atropinization appear ?(dilated pupil, flush face
  and dry mouth).
• b. In severe cases Toxoguanin 5-8 mg/kg I.V. will
  be given to activate acetylcholinestrase enzyme
  in order to block nicotinic action of parathion
  poisoning.

23
(No Transcript)
24
(No Transcript)
25
Communicable Diseases and Vaccination ? Normal
functioning of the immune system protects the
body against the invasion of outside
microorganisms referred to as a pathogen. Two of
the most common pathogens are bacteria and
viruses. An infection occurs when there is a
successful invasion of the host by a pathogen
(antigen). However, for this to happen, each link
in the chain of infection must be intact.
26
Chain of Infection

• ? The chain of infection describes the elements
  that must be in place for the infection to occur.
  These elements are
• 1. Pathogen Sufficient number of microorganisms
  strong enough to enter and survive the body.
• 2. Reservoir the proper environment within the
  body to thrive must include oxygen water, food,
  and the best pH balance and temperature.
• 3. Portal of exit the pathogen must be able to
  exit its existing environment. For example, the
  pathogen must be able to leave the respiratory
  tract, gastrointestinal (GI) tract, or skin of
  its present host to infect another host.

27

• Mode of transmission There must be a way for the
  pathogen to move from one host to another such as
  by air droplets, water, or contact.
• 5. Portal of entry The pathogen must be able to
  enter the new host such as through a break in the
  skin or via the respiratory tract.
• 6. Susceptible host The hosts immune system
  must be weak and unable to define against the
  invading pathogen. A person who is very young or
  very old or who has a low white blood cell count
  or is taking anti-inflammatory medication
  typically has a weakened immune system.

28
Staging of Infection

• The infectious process begins once the pathogen
  has successfully invaded the host. There are four
  stages of the infectious process
• 1. Incubation period This is the interval
  between the invasion and when the first symptoms
  appear.
• 2. Prodromal This is the interval between the
  appearance of nonspecific symptoms (e.g., I feel
  like Im coming down with something) to when
  specific symptoms appear (e.g., starting to feel
  warm and having a headache).
• 3. Illness This is when symptoms for a specific
  type of infection occur (e.g., fever, chills,
  headache, running nose).
• 4. Convalescence This is the interval when the
  specific systems abate (i.e., starting to feel
  better but not yet back to normal).

29

• Good Defense
• 1. Natural immunity the immune system recognizes
  the pathogen as a foreign cell that attacks and
  destroys the pathogen using nonpathogen-specific
  phagocytic action.
• 2. Naturally acquired active immunity The immune
  system develops antibodies to a pathogen once the
  pathogen infected the host previously. Antibodies
  then attack and destroy subsequent invasion by
  the pathogen.
• 3. Naturally acquired passive immunity passed
  from mother to fetus
• 4. Artificially acquired active immunity A low
  potent or dead portion of the pathogen is
  introduced to the host in a vaccine causing the
  immune system to develop antibodies against

30

• 5. Artificially acquired passive immunity The
  host is administered antibodies from a different
  host in the form of immunoglobulin such as
  gammaglobulin or convalescent serum globulin.
  Artificially acquired passive immunity provides
  short-term protection.

31

• The Defender
• Lymphocytes divided into B cells and T cells.
• B cells Provide a humoral immune response
  because they produce an antigen-specific
  antibody.
• T cells Provide a cellular immune response.
  Mature T cells are composed of CD4 and CD8 cells.
  
• CD4 cells, known as helper T cells, stimulate
  immune functions, such as B cells and
  macrophages.
• A macrophage is a cell whose functions include
  ingesting foreign or cells
• CD8 cells are responsible for destroying foreign
  and viral inhabited cells, and they suppress
  immunologic functions

32
Vaccinations

• There are three types of vaccinations
• 1. Live, attenuated This vaccination contains a
  weakened pathogen.
• 2. Inactivated This vaccination contains
  portions of a dead pathogen
• 3. Toxoids Amicroorganism itself might not cause
  an infection, but toxin released by the
  microorganism might cause the infection. Toxoids
  are vaccines that are a defense against the toxin
  

33
Immunization

• The recommended age for beginning primary
  immunization for infants is 2 month, except for
  types of vaccination e.g. tuberculosis vaccine
  and hepatitis B vaccine.
• Types of immunization-
• 1. B.C.G. (Bacillus Calmette Guerin) vaccine
  offers protection against tuberculosis

34

• Frequency the vaccine is given by intradermal
  injection (0.1 ml).
• dose at birth during the first month of life.
• 2. Hepatitis B vaccine (HBV)- affords protection
  against hepatitis B virus.
• Frequency 3 doses, given intramuscular
  injections of separate site.
• 1st dose within the first 12 hours after birth.
• 2nd dose at one month of age.
• 3 rd. dose at 6 month of age.

35

• Diphtheria, tetanus, pertussis vaccine (DPT)
  afford protection against diphtheria, tetanus and
  pertussis. (0.5 ml) toxoids vaccine mixtures,
  given I.M deeply, don't repeat the injection at
  the same site.
• Frequency
• The first dose at 2 months of age.
• The second dose 4 months of age.
• The third dose at 6 months of age.
• The first booster 18 months of age.
• The second booster at 4 - 6 years.
• The third booster at 14 - 16 years DT only.

36

• Contraindication-
• Febrile illness.
• History of nervous system disease.
• For Pertussis- C.N.S disturbances.

37

• Oral poliovirus vaccine (OPV) offered for
  protection of poliomyelitis, vaccine is alive
  virus - 2 - 3 drops given orally.
• Frequency
• ? 1st dose at 2 months.
• ? 2nd dose at 4 months.
• ? 3rd dose at 6 months.
• ? 4th dose at 18 months booster.
• ? 5th dose at 2.5 years booster.
• Precautions ask mother not to feed the infant
  for 2 hours after the vaccine is given.

38

• Contraindication-
• ? Febrile illness.
• ? Gastro enteritis.
• ? Immunologic disease e.g. Leukemia.

39

• 5. Measles, mumps and rubella vaccine (MMR)
  affords for protection against measles, mumps and
  rubella. Attenuated virus vaccine given S.C. at
  15 month of age. Storage at 2 - 8 c. and protect
  from light, expired date 8 hours. Check
  temperature before giving the vaccine.
• Rubella (German measles) Given to children from
  12 month or older. Unimmunized Prepupertal
  children and adolescence female.
• Measles given for children at 15 month of age
  repeated at 4 - 6 years.
• Mumps given for children over 12 months of age
  given at 15 mon

40

• Reaction
• Measles- anorexia, malaise, rush, fever 5 - 7
  days after immunization.
• Rubella- mild rashes lasts 1 - 2 days after
  vaccination, arthralgia, arthritis.
• Mumps- mild fever
• Contraindication
• Febrile illness.
• Pregnancy.
• Food allergy such as eggs.

41
Thank you

• DR Areefa Albahri