Evaluation and Management of

Common Childhood Poisonings

 Substance Ingestion in Children
 initial assessment bahan yang diduga terlibat
 Mengenali tanda dan gejala keracunan yang penting
 Rapid triage  airway, respiration, and circulation stabilization
 Segera memulai tx suportif dan spesifik
 Gastric decontamination (activated charcoal and gastric lavage)  tidak lagi rutin
direkomendasikan
 Ipecac tidak rutin
 Gejala ringan  dipulangkan
 Obat long-acting  efek toksin lambat  pengamatan jangka panjang
 Sebagian besar kasus keracunan merupakan oral ingestion
 93% terjadi di rumah
 80% tidak sengaja
 REKOMENDASI Level Evidence

Pasien yang diduga terminum racun dan mengalami C

gangguan respiratori, sirkulasi atau gejala neurologi  IGD
terdekat

Riwayat pasien dugaan terminum racun  usia, jenis C

kelamin, waktu dan kemungkinan jenis racun

Asymptomatic  mungkin aksi lambat C

Gastric lavage hanya direkomendasikan dalam 1 jam C

pertama

activated charcoal juga dalam 1 jam C

Syrup ipecac tidak lagi direkomendasi C

Evaluasi kasus terpapar racun pada
anak
 Triage dan penilaian awal
 Stabilisasi
 Stabil: anamnesis meliputi usia, jenis kelamin, waktu eksposur, tipe bahan
dan cara paparan (kontak kulit, inhalasi, atau tertelan)
 Cara paparan  deteksi abuse atau bunuh diri (remaja)
 Tempat/wadah, obat bebas atau resep yang bisa diakses pasien di rumah,
termasuk yang dibawa tamu
Stabilisasi emergensi

 ABC
 Kondisi pasien bisa berubah cepat  reasses
 Dextrose atau ECG bisa diperlukan
 GDA  pada peurunan kesadaran, diduga menelan obat hipoglikemik
atau alkohol
 Tanda hipoglikemia (kulit dingin basah, gangguan kesadaran) dengan
atau tanpa GDA rendah  pasang infus yang mengandung dextrose
 ECG  diduga menelan bahan kardiotoksik
 Penurunan kesadaran  akibat racun atau trauma kapitis
INDICATION MEDICATION INFANTS CHILDREN
Hypoglycemia, altered Dextrose* 5 mL per kg at 10 4 mL per kg at 25
mental status percent percent

Suspected opioid Naloxone (Narcan; 0.1 mg per kg (for 0.1 to 0.8 mg per kg
overdose; long-term brand no longer children five years and
or multiple-drug available in the United younger)
ingestion States)
Commonly Ingested Substances

 Bayi atau anak yang tidak banyak bergerak  bahan dalam jangkauan 
kosmetik, sabun
 Toksisitas signifikan  pikirkan child abuse
 Sebagian besar kasus keracunan pada anak usia <6 tahun  adanya
akses ke bahan beracun (penyimpanan yang kurang aman)
Racun yang paling sering terminum
usia < 6 tahun
 Kosmetik dan produk perawatan  Vitamin
 Bahan pembersih  Antihistamin
 Analgetik  Antibiotik
 Obat batuk pilek  Preparat hormon
 Benda asing  Peralatan melukis, seni, kerajinan
 Tanaman  Mineral dan elektrolit
 Pestisida
 Toksisitas tinggi
NON FARMAKOLOGIK
Alkohol Beverage ethanol, ethylene glycol (antifreeze), methanol
(windshield wiper fluid)
Caustic agents Acids (antirust compounds, toilet cleaners), alkalis (Clinitest tablets,
drain or oven cleaner, perm relaxers), cleaning agents
Food-flavoring additives Methyl salicylate (wintergreen oil)*
Hydrocarbons Kerosene, lamp oil, mineral seal oil (furniture polish), mineral spirits
(paint thinner), naphtha (lighter fluid)

Industrial chemicals Methylene chloride (paint thinner), selenious acid (gun bluing), zinc
chloride (soldering fluid)

Nail products Acetonitrile (sculptured nail remover), methacrylic acid (artificial nail
primer), nitromethane (artificial nail remover)
Pesticides and insecticides Lindane,* organophosphates, paraquat
 Pharmacologic agents
Antidepressants and antipsychotics Phenothiazines,* tricyclic antidepressants*
Antimalaria medications Chloroquine* (Aralen), quinidine,* quinine* (Qualaquin)
Cardiovascular agents Beta blockers,* calcium channel blockers,* clonidine*
(Catapres)
Opioids Cough syrups, diphenoxylate/atropine* (Lomotil), methadone,*
oxycodone* (Oxycontin)
Oral hypoglycemic agents Metformin (Glucophage), sulfonylureas*
Topical agents Benzocaine* (Americaine), lindane,* methyl salicylate
(wintergreen oil),* podophyllum resin 25%* (Podocon), tea tree
oil*
Other agents Isoniazid (Nydrazid), phenylpropanolamine (no longer
available in the United States),* theophylline*
Toksin dengan efek lambat

Absorbsi lambat: Mekanisme lambat:

 Carbamazepin  Antikoagulan
 Aspirin, theofilin  Monoamin oxidase inhibitor
 Atropin  Sulfonilurea
 Obat2 Enteric-coated atau lepas  Hormon tyroid
lambat
 Jamur beracun
Metabolit toksik:
 Acetaminophen, Dapsone
 Alkohol toksik (methanol, ethylene
glycol
 Bahan Untuk membersihkan lambung
AGENT DOSE RISKS CONTRAINDICATIONS
Activated 1 to 2 g per kg (maximum of 50 Aspiration, Unlikely to benefit patients who
charcoal*† to 60 g) constipation, vomiting ingested alcohols, strong acids
or bases, minerals, iron, lithium,
or hydrocarbon
Gastric lavage*† 10 to 15 mL per kg saline Esophageal/laryngeal Unprotected airway, ingestion of
instilled via large-bore trauma, aspiration, hydrocarbons or corrosives, risk
orogastric tube, repeated until nausea/vomiting, of perforation or hemorrhage
aspirates clear impaired level of
consciousness
Polyethylene 500 mL per hour for children Vomiting, cramping Unprotected airway, intractable
glycol (used with nine months to five years of vomiting, gastrointestinal
whole bowel age1,000 mL per hour for hemorrhage, ileus, perforation,
irrigation) children six to 12 years of age obstruction
Sorbitol (used 1 to 2 g per kg Hypernatremia, Obstruction, perforation, ileus
with activated dehydration
charcoal)

*Tidak bermanfaat setelah 1 jam

†Tidak rutin
Bilas lambung/kumbah lambung/gastric lavage

 Mengeluarkan racun dari lambung

 Normal saline  NGT besar  memacu muntah, pemasangan tidak
mudah
 Makin lama racun tertelan  efek kumbah lambung makin kurang
bermanfaat
 The American Academy of Clinical Toxicology (AACT) and European
Association of Poison Centres dan Clinical Toxicologists (EAPCCT)  tidak
merekomendasi kumbah lambung rutin di IGD  kecuali oleh tenaga
terlatih dalam waktu kurang dari 1 jam paska tertelan racun
Activated charcoal

 Mengurangi absorbsi
 Anak menelan carbamazepine, dapsone, phenobarbital, quinine
(Qualaquin), theophylline, salicylates, phenytoin, or valproic acid
(Depakene).
 Menghambat resirkulasi enterohepatic and enteroenteric
 Limted krn rasa tidak enak  memacu muntah
 Tidak bisa digunakan utnuk semua bahan
 Dalam 1 jam setelah paparan
CATHARTICS AND WHOLE BOWEL IRRIGATION

 Semacam pencahar, PER atau sorbitol

 Resiko: electrolyte imbalances and dehydration
 Nyeri, kram perut
 Menelan logam berat atau obat2 lepas lambat
 Pada anak  evidence masih kurang
HEMODIALYSIS AND URINE ALKALINIZATION

 lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, atau as.

Valproat
 Konsultasi dengan nefrologi
 Alkalinisasi urin menggunakan sodium bicarbonate  pada salisilat,
tricyclic antidepressants, phenobarbital, chlorpropamide, chlorophenoxy
herbicides, atau methotrexate
Sirup Ipecac

 Tidak ada evidence

 AACT, EAPCCT tidak merekomendasi meski segera setelah paparan
 The American Academy of Pediatrics (AAP) tidak lagi merekomendasi sirup
ipecac untuk penanganan di rumah pada anak
 Terapi Spesifik
TYPE OF
AGENTS TOXIDROMES/TOXIC SYMPTOMS ANTIDOTES
POISONINGÇ
Acetaminophen Acetaminophen Abdominal pain, nausea/vomiting, N-acetylcysteine
elevated aspartate transaminase level (Acetadote)
(greater than 1,000 IU per L after 24
hours), jaundice, confusion, somnolence,
coma, disorientation
Anticholinergic Antihistamines, atropine Tachycardia, hyperthermia, mydriasis, —
(Atreza), belladonna warm and dry skin, urinary retention,
alkaloids, toxic ileus, delirium
mushrooms, psychoactive
drugs
Anticoagulant Warfarin (Coumadin), Ecchymoses, bleeding, prolonged Vitamin K
rodenticides prothrombin and bleeding times
 TYPE OF
AGENTS TOXIDROMES/TOXIC SYMPTOMS ANTIDOTES
POISONING
Cardiac Calcium channel blockers, beta Bradycardia, arrhythmias, Calcium chloride,
medication blockers, digoxin hypotension, dizziness, heart block, glucagons
nausea, vomiting (Glucagen), digoxin
immune fab
(Digibind)
Cholinergic, Carbamates, some mushrooms, Salivation, lacrimation, urination, Atropine/pralidoxime
muscarinic organophosphates, diarrhea, bronchorrea, wheezing, (not available in the
physostigmine, pilocarpine bradycardia, vomiting United States)
(Isopto Carpine), pyridostigmine
Cholinergic, Black widow spider bites, Tachycardia, hypertension, Atropine/pralidoxime
nicotinic carbamates, insecticides, fasciculations, gastrointestinal (not available in the
nicotine cramps, emesis, miosis United States)
 Terapi Spesifik
TYPE OF
AGENTS TOXIDROMES/TOXIC SYMPTOMS ANTIDOTES
POISONINGÇ
Cyanide Cyanide Syncope, cyanosis, hypotension, Sodium nitrite 3%, sodium
psychosis thiosulfate 25%
Ethylene glycol, Antifreeze, rubbing Central nervous system depression, Ethanol 10% or fomepizole
methanol alcohol respiratory depression, seizures,
hypotension, hypoglycemia
Iron Iron-containing Dyspepsia, nausea, vomiting, Deferoxamine
products diarrhea, dark stools
Opioid Opioids (e.g., Hypoventilation, hypotension, miosis, Short-acting naloxone,
morphine, sedation, hypothermia, ileus monitor closely for withdrawal
hydrocodone symptoms and relapsing
[Hycodan], sedation
methadone)
 Terapi Spesifik
TYPE OF TOXIDROMES/TOXIC
AGENTS ANTIDOTES
POISONING SYMPTOMS
Tinnitus, nausea, vomiting, fever, —
Aspirin products disorientation, lethargy, tachypnea
Sulfonylurea Sulfonylurea Hypoglycemia, tachycardia, Octreotide
diaphoresis, clammy skin, (Sandostatin)
mental status changes, coma
Sympatho- Amphetamines, caffeine, cocaine, Tachycardia, hypertension, —
mimetic ephedrine, 3,4- mydriasis, agitation, seizures,
methylenedioxymethamphetamine (also diaphoresis, psychosis,
called Ecstasy), phenylpropanolamine hyperthermia
(no longer available in the United States),
theophylline, diphenoxylate/atropine
(Lomotil)
PEDIATRIC SHOCK
Definition and Pathophysiology

 A life-threatening state t
 oxygen and nutrient delivery are insufficient to meet tissue metabolic
demands
 Disease compromises any of the factors that contribute to oxygen and
nutrient delivery
 Familiarity with a few simple equations
 understanding the myriad factors that may contribute to shock
 understanding how the body attempts to compensate
 how the clinician may intervene to reverse shock.
 Oxygen delivery (DO2) is determined by cardiac output (CO) and the
arterial content of oxygen (Cao2):

DO2 (mL/min)=CO (L/min)×Cao2 (mL/L)

 Cardiac output is the product of stroke volume (SV) and HR:

CO (L/min)=SV (L)×HR/min
Stroke volume is determined by:
 Preload: the amount of filling of the ventricle at end-diastole
 Afterload: the force against which the ventricle must work to eject blood
during systole
 Contractility: the force generated by the ventricle during systole
 Lusitropy: the degree of myocardial relaxation during diastole
 Heart rate variability relies on an intact autonomic nervous system and a
healthy cardiac conduction system.
 Arterial oxygen content also dictates oxygen delivery and is determined by
hemoglobin (Hgb), oxygen saturation (SaO2), and the partial pressure of
oxygen (Pao2), as follows:

Cao2 (ml/L)={[Hgb (g/dL)×1.34 (mL O2/g Hgb) ×(SaO2/100)]

+(Pao2×0.003 mL O2/mm Hg/dL)}×10 dL/L
 Shock

 early, compensated shock to irreversible, terminal shock.

 The earliest stage of shock, vital organ function is maintained by a
number of compensatory mechanisms  rapid intervention can reverse
the process.
 If unrecognized or undertreated  compensated shock 
decompensated shock
 tissue ischemia
 damage at the cellular and subcellular levels
 Inadequate treatment  terminal shock  irreversible organ damage
 Hypovolemic Shock

 most common
 Diarrheal illnesses, bleeding, thermal injury, and inappropriate diuretic use.
 Signs and symptoms
 tachycardia, tachypnea, and signs of poor perfusion 9cool extremities, weak
peripheral pulses, sluggish capillary refill, skin tenting, and dry mucous membranes0
 End organ damage: weak central pulses, poor urine output, mental status changes,
and metabolic acidosis.
Cardiogenic shock

 failure of the heart as a pump  decreased cardiac output

 depressed myocardial contractility, arrhythmias, volume overload, or
diastolic dysfunction.
 Depressed myocardial contractility  primary neuromuscular disorders or
acquired such as infection, following exposure to a toxin, or when a patient
suffers a metabolic derangement such as severe hypocalcemia or
hyperkalemia.
 Myocardial ischemia due to inadequate coronary perfusion  congenital
cardiac lesions  dysrhythmias
Cardiogenic Shock

 lethargy, poor feeding, tachycardia, and tachypnea

 Pale, cold extremities and barely palpable pulses
 cardiogenic shock or septic shock?
 Cardiogenic shock: a gallop rhythm, rales, jugular venous distension, and
hepatomegaly.
 Chest radiography: cardiomegaly and pulmonary venous congestion
 CVP is elevated above 10 cm H2O
 empiric treatment for possible septic or cardiogenic shock should not be
delayed.
noncardiac conditions
 bilateral pneumothoraces
 cardiac tamponade

 Both prevent diastolic filling of the heart  decreased SV and poor

CO.
Distributive or Neurogenic Shock

 derangements in vascular tone  end-organ hypoperfusion

 anaphylaxis, an immunoglobulin E-mediated hypersensitivity reaction
 mast cells and basophils release histamine  vasodilator poten
 massive production of other potent vasodilators (prostaglandins and
leukotrienes)
 Spinal cord trauma and spinal or epidural anesthesia
 hypotension without reflex tachycardia
 Septic Shock
 The host response to infection
 Endotoxin released by gram-negative  inflammatory cascade  activation of
lymphocytes and the release of proinflammatory cytokines  overproduction 
imbalance pro- and anti-inflammatory factors  unchecked inflammation and
septic shock.
 “Cold” shock: low CO and high SVR (tachycardia, mottled skin, cool extremities
with prolonged capillary refill, and diminished peripheral pulses). BP may be
normal
 “warm” shock: high cardiac output and low SVR (tachycardia, plethora, warm
extremities with flash capillary refill, bounding pulses, and a widened pulse
pressure)
 Patterns may interchange in the same patient
 neonates  persistent pulmonary hypertension with right ventricular failure.
Manajemen

 Airways
 Rapid vascular access
 Sedatives and Analgesics
 Fluid therapy:
 initial rapid bolus of 20 mL/kg of isotonic fluid  reassessment  titration
 Goals: normal BP and perfusion
 Antibiotic, in an hour when sepsis is suspected
 Inotropic agent
 Corticosteroid in distributive shock caused by anaphylaxis or spinal trauma
 Glycemic control
 Septic Shock

Phoebe Yager, and Natan Noviski Pediatrics in Review

2010;31:311-319
 Fluid resuscitation in infants and children who have cardiogenic
shock
 approached carefully
 May be hypo-, hyper-, or euvolemic.
 euvolemic or hypervolemic patient, volume loading the failing
heart may exacerbate pump failure and contribute to
pulmonary congestion
 Frequent clinical assessment is required
 Ideally, a central venous line should be placed to monitor CVP
and to assist in adjusting therapy.
TERIMA KASIH