Pediatric Toxicology

Severe camphor poisoning, a seven-year observational study

In a retrospective case series from 2007 to 2014, we searched for any accidental/intentional, and recreational cases of pure camphor poisoning through hospital records. Epidemiological data, as well as factors correlated with seizure, were evaluated. Thirty cases including 29 males were recruited with a median age of 18 years (range; 0.2-87). Patient's reported ingestion rate of camphor was 1.5-15 grams. Almost all of the patients (96.7%) were conscious on arrival time and the ingestion to the presentation time ratio was 7±5h. It was observed that in a majority of the cases (53.4%), decreasing libido was the main intent of Camphor ingestion. Nausea and vomiting occurred in 22 (73.3%) cases and tonic-clonic seizure was seen in 12 (40%) patients. Mean presentation time was significantly longer in patients who experienced seizure (9.1±6.1h vs. 5.2±2.8h, p=0.05). No correlation was found between the amount of ingested camphor (grams or mg/kg) and vital signs along with the bio-chemistry results. Not only did all of our cases survive but also they exclusively received supportive care.

Severity scores and their associated factors among orally poisoned toddlers: a cross sectional single poison center study

Background

One of the most unfortunate events toddlers may encounter during their early years of curiosity and experimentation is substance poisoning. The aim of the study was to evaluate the poison severity score and its associated factors among toddlers with orally ingested substances at a pediatrics emergency department (ED), central Saudi Arabia.

Methods

A cross-sectional, poisoning report review between 2009&2011 was conducted. Exposures were patient characteristics (sex, age, body mass index, medical history) and incident characteristics (substance type, amount, form, witnessed or not, home remedy, arrival time to ED). Outcome was Poison Severity Score (PSS) that rates signs/symptoms of 11 body aspects on scale 0–4 (none, minor, moderate, severe, fatal). Inclusion criteria: age (1–3 years), previously healthy and oral exposure route. Bivariate analysis and multi-linear regression were conducted. Significance at p < 0.05.

Results

Eligible cases were 165/315(52 %). Males (58 %) and females (42 %) had normal BMI (70 %). Substances ingested were medications (60 %) and chemicals (40 %). Almost 85 % were witnessed incidents and 27 % received a home remedy (water, juices, dairy products, salt/sugar solutes, and/or manually induced vomiting). Delayed arrival (≥1 hour) was observed in 57 %. Composite mean PSS of total was (0.16 ± 0.21), and was highest at the gastrointestinal (GI) aspect (0.39 ± 0.63), metabolic balance (0.35 ± 0.60), and respiratory aspect (0.30 ± 0.61). Significantly associated factors with higher severity scores were: home remedies at the composite mean PSS (adj.p = 0.048), chemical poisoning at two aspects respiratory (adj.p = 0.047) and muscular (adj.p = 0.009) compared to medication poisoning. Unwitnessed incidents at the muscular aspect (adj.p = 0.026) compared to witnessed incidents; delayed arrival time to ED at three aspects GI (adj.p = 0.001), nervous system (adj.p = 0.014) and kidney (adj.p < 0.001).

Conclusions

Parents are not recommended to provide any home remedy to their orally poisoned toddlers, but rather directly visit the ED. Physicians are expected to observe more severe clinical outcomes among toddlers with chemical poisoning, unwitnessed incidents, and delayed arrival times especially at the respiratory, GI, muscular, nervous and kidney aspects.

The Comparison of Accidental Poisonings Between Pharmaceuticals and Nonpharmaceuticals in Children Younger than 3 Years

INTRODUCTION

The management of pediatric poisoning is dependent on the type of toxicant ingested; however, little information has been published regarding the difference in poisoning by pharmaceuticals and nonpharmaceuticals in children. We compared the accidental poisoning of children younger than 3 years who had ingested pharmaceuticals or nonpharmaceuticals using emergency medical information center data.

METHODS

We retrospectively reviewed the records of the poisonings of children younger than 3 years who were evaluated by the Seoul Emergency Medical Information Center in 2011. The demographic data and detailed information regarding the poisonings were investigated. The substances that caused the poisonings were divided into the following 2 groups: pharmaceuticals and nonpharmaceuticals, and their characteristics and the differences between the 2 types of poisonings were investigated.

RESULTS

A total of 1279 cases were collected, most of which involved children who were 13 to 24 months old. Boys (51.3%) were involved more than girls. Exposure to nonpharmaceuticals (60.7%) was more common than exposure to pharmaceuticals. Personal care products and respiratory agents were the most commonly implicated substances. There were several significant differences between the pharmaceutical and nonpharmaceutical groups. Poisoning by pharmaceuticals occurred more frequently in older children and more frequently at night. Although the exact exposure of the children in the pharmaceutical group was known and they required more treatment in the emergency department, they were not given extra immediate first aid than the children in the nonpharmaceutical group.

CONCLUSIONS

Because there were several significant differences in the characteristics of accidental pediatric poisonings between the pharmaceutical and nonpharmaceutical groups, preventive strategies and educational programs should be implemented on the basis of the causative agent.

Seizures due to high dose camphor ingestion

Camphor is a cyclic ketone of the hydro aromatic terpene group. Today it is frequently used as a prescription or non-prescription topical antitussive, analgesic, anesthetic and antipruritic agent. Camphor which is considered an innocent drug by parents and physicians is a common household item which can lead to severe poisoning in children even when taken in small amounts. Neurotoxicity in the form of seizures can ocur soon after ingestion. A two-year old female patient who presented with a complaint of generalized tonic-clonic seizures after oral ingestion of camphor is presented.

Comparative outcome analysis of home-initiated non-medical interventions among toddlers with orally ingested substances

Background

Poison management guidelines recommend contacting or visiting poison centers directly after exposure. However, some parents initiated non-medical interventions on their children before visiting these centers. Aim was to evaluate the clinical and hospital outcomes of such practices among toddlers with orally ingested medication or chemical substances at a tertiary care facility.

Methods

Retrospective cohort, based on four-arm outcome analysis. Exposures were gender, age, body mass index, arrival time to facility (hours) presented in Median [Interquartile range]. Clinical outcomes were vital signs, physical examination, diagnostic tests; Hospital outcomes were in-hospital admission, length of hospital stay (hours) presented in Median [Interquartile range], hospital cost ($US). Bivariate analysis (nonparametric tests), binary logistic/linear regression were conducted. Significance at p < 0.05.

Results

Between 2009–2011, 165 (all previously healthy) toddlers were (Males = 58 %, females = 42 %) and had normal weights in 70 %. Witnessed incidents were in 85 %. Two control groups [Medication (control) = 72, Chemical (control) = 48] directly visited the facility after incident, while two intervention groups [Medication (intervention) = 27, Chemical (intervention) = 18] received orally administered water, salt/sugar solutes, milk/yogurt, lemon juice and/or manually induced vomiting before the visit. Abnormal clinical outcomes in total were in vital signs = 15 %, physical examination = 42 % and diagnostic tests = 26 %; hospital outcomes were admission = 16 %, length of stay range (2 hours–7.5 days), cost range (667–11,500). Bivariate analysis: Length of stay in Medication (intervention) = 9[5.4–12.0] hours significantly higher than Medication (control) = 5[2.7–7.5] hours, p = 0.003; abnormal physical examination in Chemical (intervention) = 77.8 % significantly higher than Chemical (control) = 37.5 %, p = 0.004. In regression: intervention significantly increased length of stay (t = 0.213, adj. P = 0.035); lower weight toddlers were at higher risk of admission (Beta = -0.51, adj. P = 0.018); delayed arrival time significantly increased abnormal physical examination (Beta = 0.29, adj. P = 0.003). No significant control/intervention group differences regarding abnormal vital signs (adj. P = 0.148), physical examination (adj. P = 0.781), diagnostic tests (adj. P = 0.285), admission (adj. P = 0.499), and cost (adj. P = 0.102).

Conclusion

Home-initiated non-medical interventions didn't improve the clinical and hospital outcomes. It has delayed the arrival time to emergency department, which added the risk of encountering abnormal physical examination, and in return increased the average length of hospital stay.

Drug-induced acid-base disorders

The incidence of acid-base disorders (ABDs) is high, especially in hospitalized patients. ABDs are often indicators for severe systemic disorders. In everyday clinical practice, analysis of ABDs must be performed in a standardized manner. Highly sensitive diagnostic tools to distinguish the various ABDs include the anion gap and the serum osmolar gap. Drug-induced ABDs can be classified into five different categories in terms of their pathophysiology: (1) metabolic acidosis caused by acid overload, which may occur through accumulation of acids by endogenous (e.g., lactic acidosis by biguanides, propofol-related syndrome) or exogenous (e.g., glycol-dependant drugs, such as diazepam or salicylates) mechanisms or by decreased renal acid excretion (e.g., distal renal tubular acidosis by amphotericin B, nonsteroidal anti-inflammatory drugs, vitamin D); (2) base loss: proximal renal tubular acidosis by drugs (e.g., ifosfamide, aminoglycosides, carbonic anhydrase inhibitors, antiretrovirals, oxaliplatin or cisplatin) in the context of Fanconi syndrome; (3) alkalosis resulting from acid and/or chloride loss by renal (e.g., diuretics, penicillins, aminoglycosides) or extrarenal (e.g., laxative drugs) mechanisms; (4) exogenous bicarbonate loads: milk-alkali syndrome, overshoot alkalosis after bicarbonate therapy or citrate administration; and (5) respiratory acidosis or alkalosis resulting from drug-induced depression of the respiratory center or neuromuscular impairment (e.g., anesthetics, sedatives) or hyperventilation (e.g., salicylates, epinephrine, nicotine).

Transporting children with toxicological emergencies

OBJECTIVE

Each year, the Newborn and Paediatric Emergency Transport Service (NETS) receives over 3600 calls from health professionals regarding the management and transportation of critically ill children across New South Wales, with toxicological emergencies making up 1.5% of these calls. The aim of the present study is to describe the characteristics of patients transported for toxicological emergencies and their retrieval management.

METHODS

A retrospective review of patients referred for management of a toxicological emergency between 2007 and 2011. Extracted data included patient demographics, substances involved, consultation with toxicological expertise, interventions performed and major adverse outcomes.

RESULTS

Two hundred and thirty patients, with 307 toxicological exposures, were referred to NETS, of whom 169 (73.5%) were subsequently transported. Pharmaceutical poisonings (223, 72.6%) were the most common, followed by non-pharmaceutical poisonings (61, 19.9%) and envenomation (23, 7.5%). Psychotropics, analgesics and chemicals were the most frequently ingested substances. The most common source of accidentally ingested pharmaceuticals was a family member. The most frequently given therapies were specific antidotes, in particular naloxone and N-acetylcysteine. Nearly half (43.2%) of transported children required only non-invasive monitoring. There was one death during the retrieval process.

CONCLUSIONS

Many children with toxicological emergencies require only non-invasive monitoring, which could be provided by trained ambulance crews in select scenarios. Involvement of a toxicologist in the initial consultation to identify these patients might reduce retrieval numbers and costs. Children on regular medication and those living with family members on psychotropic or cardiac drugs were identified as high-risk groups that should be targeted for medication safety education.

Utilization of a pediatric observation unit for toxicologic ingestions

OBJECTIVES

The objectives of this study were to evaluate the efficacy and utilization of an observation unit (OU) for admission of pediatric patients after a toxicologic ingestion; compare the characteristics and outcomes of patients admitted to the pediatric OU, inpatient (IP) service, and intensive care unit (ICU) after ingestions using retrospective chart review; and attempt to identify factors associated with unplanned IP admission after an OU admission.

METHODS

This was a retrospective chart review of children seen in the emergency department (ED) after potentially toxic suspected ingestions and then admitted to the OU, IP service, or ICU from June 2003 to September 2007.

RESULTS

One thousand twenty-three children were seen in the ED for ingestions: 18% were admitted to the OU, 15% to the IP service service, and 6% to the ICU. Observation unit patients had less mental status changes reported and were less frequently given medications while in the ED. Eighty-one percent of OU patients were admitted with poison center recommendation. Ninety-four percent of OU patients were discharged within 24 hours, and less than half of IP service/ICU patients were discharged that quickly. No significant associations were found between specific historical and physical examination or laboratory characteristics in the ED and the need for unplanned IP admission.

CONCLUSIONS

Observation unit patients admitted after ingestions were young, typically ingested substances found in the home, and required observation according to poison center recommendations. Ninety-four percent were able to be discharged home within 24 hours even after ingesting some of the most concerning substances such as central nervous system depressants, cardiac/antihypertension medications, hypoglycemics, and opiates. All OU patients did well without any adverse events reported. Many patients requiring prolonged observation after an ingestion, and who do not require ICU care, may be appropriate for OU management. This study suggests a potential underutilization of observation units in this setting.

Toxicology in the emergency department: a review for the advanced practice nurse

General assessment, resuscitation strategies, and risk assessment of the poisoned patient are explored in this article, including specific interventions for unresponsive patients and seizures. Sympathomimetic and anticholinergic toxidromes are described in terms of clinical presentation and treatment strategies and are compared with other common toxidromes. Controversies in gastric decontamination are also outlined, including consensus panel and national organizational recommendations. Despite available methods for toxin elimination, advances in medicine, and pharmacotherapy options, the cornerstone of toxicology remains supportive care. The purpose of this article is to equip the advanced practice nurse in the emergency setting with baseline knowledge to provide initial care of the poisoned patient.

Toddler with seizures due to ingesting camphor at an Indian celebration

We report a 3-year-old girl who presented to the emergency department with seizures. Earlier in the evening, the patient was with her parents at an Indian celebration where she vomited once and then became hyperactive. Fifteen minutes later, she became unresponsive and had an episode characterized by eye blinking, teeth grinding, and posturing that lasted 2 to 3 minutes. To our knowledge, this is the first report of seizure after ingestion of ceremonial camphor tablets at an Indian ceremony. Given the inadequate packaging and use of many grams of camphor at these ceremonies, the pediatric population specifically is at risk for camphor toxicity from this source. Health care professionals should be aware of this unique and culturally specific source of potential camphor toxicity.

Pharmaceutical and chemical pediatric poisoning in Kuwait: a retrospective survey

Past studies of pediatric poisoning in Kuwait have suggested differences at hospital level which could impact on the implementation of public health interventions. The objective was to compare pediatric poisoning admissions at general hospitals in Kuwait.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .