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Chapter 18 Emergency Management


Title: Poisoning in Children Author: Norah Last modified by: home Created Date: 2/1/2008 11:01:26 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Chapter 18 Emergency Management

Chapter 18Emergency Management
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.

  • 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.

Poisoning in ChildrenImportant history points
  • What toxic agent/medications were found near the
  • 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
  • How has the patient behaved since the ingestion?
  • Does the patient have a history of substance

  • 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
  • ? Skin symptoms rashes, burn, eye inflammation,
    skin irritation and cyanosis (cyanide).
  • ? Cardiopulmonary symptoms dyspnea,
    cardiopulmonary arrest.

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

  • 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

  • Terminate exposure
  • ? Empty mouth of pills, plant part or other
  • ? 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
  • ? Bring victim of an inhalation poisoning into
    fresh air.
  • ? Give water to dilute ingested poison.

  • 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.

  • 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
  • d. Administer activated charcoal (1g/kg) 30-60 m.
    after vomiting from ipecac if ordered.

1. Corrosives substances strong acids or alkali
  • toilet cleanness, detergents, etc.
  • Clinical manifestation
  • ? Severe burning pain in mouth, throats and
  • ? 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

  • ? 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

  • 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
  • N.B. Immediate danger is aspiration lead to
    chemical pneumonia.

  • 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

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.

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

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.

  • 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
  • ? Vit. K. for bleeding.
  • ? Dialysis for severest toxicity.

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.

  • 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.

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

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

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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.
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.

  • 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.

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
  • 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).

  • 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

  • 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.

  • The Defender
  • Lymphocytes divided into B cells and T cells.
  • B cells Provide a humoral immune response
    because they produce an antigen-specific
  • 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
  • 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

  • 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

  • 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

  • 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.

  • 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.

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

  • 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.

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

  • 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

  • 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.

Thank you
  • DR Areefa Albahri
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