BNF for Children 2011-2012

BNFC 2011–2012 Emergency treatment of poisoning 33Side-effects nausea, diarrhoea, abdominal pain, painat site of injection, thrombophlebitis if given toorapidly, renal damage particularly in overdosage;hypotension, lacrimation, myalgia, nasal congestion,sneezing, malaise, thirst, fever, chills, headache andzinc depletion also reportedLicensed use licensed for use in children (age rangenot specified by manufacturer)Indication and doseLead poisoning. By intravenous infusionChild 1 month–18 years 40 mg/kg twice daily forup to 5 days; if necessary a second course can begiven at least 7 days after the first course, and athird course can be given at least 7 days after thesecond courseAdministration for intravenous infusion, dilute to aconcentration of not more 30 mg/mL with Glucose5% or Sodium Chloride 0.9%; give over at least 1 hourLedclair c (Durbin) AInjection, sodium calcium edetate 200 mg/mL, netprice 5-mL amp = £7.29Noxious gasesCarbon monoxideCarbon monoxide poisoning isusually due to inhalation of smoke, car exhaust, orfumes caused by blocked flues or incomplete combustionof fuel gases in confined spaces.Immediate treatment of carbon monoxide poisoning isessential. The child should be moved to fresh air, theairway cleared, and high-flow oxygen 100% administeredas soon as available. Artificial respiration shouldbe given as necessary and continued until adequatespontaneous breathing starts, or stopped only afterpersistent and efficient treatment of cardiac arrest hasfailed. The child should be admitted to hospital becausecomplications may arise after a delay of hours or days.Cerebral oedema may occur in severe poisoning and istreated with an intravenous infusion of mannitol (section2.2.5). Referral for hyperbaric oxygen treatmentshould be discussed with the National Poisons InformationService if the patient is pregnant or in cases ofsevere poisoning such as if the child is or has beenunconscious, or has psychiatric or neurological featuresother than a headache or has myocardial ischaemia oran arrhythmia, or has a blood carboxyhaemoglobinconcentration of more than 20%.Sulphur dioxide, chlorine, phosgene, ammoniaAll of these gases can cause upper respiratory tract andconjunctival irritation. Pulmonary oedema, with severebreathlessness and cyanosis may develop suddenly upto 36 hours after exposure. Death may occur. Childrenare kept under observation and those who developpulmonary oedema are given oxygen. Assisted ventilationmay be necessary in the most serious cases.CS SprayCS spray, which is used for riot control, irritates the eyes(hence ‘tear gas’) and the respiratory tract; symptomsnormally settle spontaneously within 15 minutes. Ifsymptoms persist, the patient should be removed to awell-ventilated area, and the exposed skin washed withsoap and water after removal of contaminated clothing.Contact lenses should be removed and rigid oneswashed (soft ones should be discarded). Eye symptomsshould be treated by irrigating the eyes with physiologicalsaline (or water if saline is not available) andadvice sought from an ophthalmologist. Patients withfeatures of severe poisoning, particularly respiratorycomplications, should be admitted to hospital for symptomatictreatment.Nerve agentsTreatment of nerve agent poisoning is similar to organophosphorusinsecticide poisoning (see below), butadvice must be sought from the National Poisons InformationService. The risk of cross-contamination is significant;adequate decontamination and protectiveclothing for healthcare personnel are essential. In emergenciesinvolving the release of nerve agents, kits(‘NAAS pods’) containing pralidoxime can be obtainedthrough the Ambulance Service from the National BloodService (or the Welsh Blood Service in South Wales ordesignated hospital pharmacies in Northern Ireland andScotland—see TOXBASE for list of designated centres).The National Poisons Information Service (Tel:0844 892 0111) will provide specialist advice on allaspects of poisoning day and nightPesticidesOrganophosphorus insecticides Organophosphorusinsecticides are usually supplied as powders ordissolved in organic solvents. All are absorbed throughthe bronchi and intact skin as well as through the gutand inhibit cholinesterase activity, thereby prolongingand intensifying the effects of acetylcholine. Toxicitybetween different compounds varies considerably, andonset may be delayed after skin exposure.Anxiety, restlessness, dizziness, headache, miosis,nausea, hypersalivation, vomiting, abdominal colic,diarrhoea, bradycardia, and sweating are common featuresof organophosphorus poisoning. Muscle weaknessand fasciculation may develop and progress to generalisedflaccid paralysis, including the ocular and respiratorymuscles. Convulsions, coma, pulmonary oedemawith copious bronchial secretions, hypoxia, and arrhythmiasoccur in severe cases. Hyperglycaemia andglycosuria without ketonuria may also be present.Further absorption of the organophosphorus insecticideshould be prevented by moving the child to fresh air,removing soiled clothing, and washing contaminatedskin. In severe poisoning it is vital to ensure a clearairway, frequent removal of bronchial secretions, andadequate ventilation and oxygenation; gastric lavagemay be considered provided that the airway is protected.Atropine will reverse the muscarinic effects ofacetylcholine and is given by intravenous injection in adose of 20 micrograms/kg (max. 2 mg) as atropine sulphateevery 5 to 10 minutes (according to the severity ofpoisoning) until the skin becomes flushed and dry, thepupils dilate, and bradycardia is abolished.Pralidoxime chloride, a cholinesterase reactivator, isused as an adjunct to atropine in moderate or severepoisoning. It improves muscle tone within 30 minutes ofEmergency treatment of poisoning