BNF for Children 2011-2012

34 Emergency treatment of poisoning BNFC 2011–2012Emergency treatment of poisoningadministration. Pralidoxime chloride is continued untilthe patient has not required atropine for 12 hours.Pralidoxime chloride can be obtained from designatedcentres, the names of which are held by the NationalPoisons Information Service (see p. 24).The National Poisons Information Service (Tel:0844 892 0111) will provide specialist advice on allaspects of poisoning day and nightPRALIDOXIME CHLORIDECautions myasthenia gravisContra-indications poisoning with carbamates ororganophosphorus compounds without anticholinesteraseactivityRenal impairment use with cautionSide-effects drowsiness, dizziness, disturbances ofvision, nausea, tachycardia, headache, hyperventilation,and muscular weaknessLicensed use licensed for use in children (age rangenot specified by manufacturer)Indication and doseAdjunct to atropine in the treatment of poisoningby organophosphorus insecticide ornerve agent. By intravenous infusion over 20 minutesChild under 18 years initially 30 mg/kg, followedby 8 mg/kg/hour; usual max. 12 g in 24 hoursNote The loading dose may be administered by intravenousinjection (diluted to a concentration of 50 mg/mL with water for injections) over at least 5 minutes ifpulmonary oedema is present or if it is not practical toadminister an intravenous infusion; pralidoxime chloridedoses may differ from those in product literature1Pralidoxime chloride AInjection, powder for reconstitution pralidoximechloride 1 g/vialAvailable as Protopam c (from designated centres for organophosphorusinsecticide poisoning or from the National BloodService (or Welsh Ambulance Services for Mid West and SouthEast Wales)—see TOXBASE for list of designated centres)1. A restriction does not apply where administration is forsaving life in emergencySnake bites and animal stingsSnake bites Envenoming from snake bite is uncommonin the UK. Many exotic snakes are kept, someillegally, but the only indigenous venomous snake is theadder (Vipera berus). The bite may cause local andsystemic effects. Local effects include pain, swelling,bruising, and tender enlargement of regional lymphnodes. Systemic effects include early anaphylacticsymptoms (transient hypotension with syncope, angioedema,urticaria, abdominal colic, diarrhoea, and vomiting),with later persistent or recurrent hypotension,ECG abnormalities, spontaneous systemic bleeding,coagulopathy, adult respiratory distress syndrome, andacute renal failure. Fatal envenoming is rare but thepotential for severe envenoming must not be underestimated.Early anaphylactic symptoms should be treated withadrenaline (epinephrine) (section 3.4.3). Indicationsfor antivenom treatment include systemic envenoming,especially hypotension (see above), ECG abnormalities,vomiting, haemostatic abnormalities, and marked localenvenoming such that after bites on the hand or foot,swelling extends beyond the wrist or ankle within 4hours of the bite. The contents of one vial (10 mL) ofEuropean viper venom antiserum (available fromMovianto) is given by intravenous injection over 10–15 minutes or by intravenous infusion over 30 minutesafter diluting in sodium chloride intravenous infusion0.9% (use 5 mL diluent/kg body-weight). The samedose should be used for adults and children. Thedose can be repeated after 1–2 hours if symptoms ofsystemic envenoming persist. However, for those childrenwho present with clinical features of severe envenoming(e.g. shock, ECG abnormalities, or local swellingthat has advanced from the foot to above the knee orfrom the hand to above the elbow within 2 hours of thebite), an initial dose of 2 vials (20 mL) of the antiserum isrecommended; if symptoms of systemic envenomingpersist contact the National Poisons Information Service.Adrenaline (epinephrine) injection must be immediatelyto hand for treatment of anaphylactic reactionsto the antivenom (for the management of anaphylaxissee section 3.4.3).Antivenom is available for bites by certain foreignsnakes and spiders, stings by scorpions and fish. Forinformation on identification, management, and forsupply in an emergency, telephone the National PoisonsInformation Service. Whenever possible the TOXBASEentry should be read, and relevant information collected,before telephoning the National Poisons InformationService (see p. 24).Insect stings Stings from ants, wasps, hornets, andbees cause local pain and swelling but seldom causesevere direct toxicity unless many stings are inflicted atthe same time. If the sting is in the mouth or on thetongue local swelling may threaten the upper airway.The stings from these insects are usually treated bycleaning the area with a topical antiseptic. Bee stingsshould be removed as quickly as possible. Anaphylacticreactions require immediate treatment with intramuscularadrenaline (epinephrine); self-administered (oradministered by a carer) intramuscular adrenaline (e.g.EpiPen c ) is the best first-aid treatment for children withsevere hypersensitivity. An inhaled bronchodilatorshould be used for asthmatic reactions. For themanagement of anaphylaxis, see section 3.4.3. A shortcourse of an oral antihistamine or a topical corticosteroidmay help to reduce inflammation and relieveitching. A vaccine containing extracts of bee and waspvenom can be used to reduce the risk of severeanaphylaxis and systemic reactions in children withsystemic hypersensitivity to bee or wasp stings (section3.4.2).Marine stings The severe pain of weeverfish (Trachinusvipera) and Portuguese man-o’-war stings can berelieved by immersing the stung area immediately inuncomfortably hot, but not scalding, water (not morethan 458 C). Children stung by jellyfish and Portugueseman-o’-war around the UK coast should be removedfrom the sea as soon as possible. Adherent tentaclesshould be lifted off carefully (wearing gloves or usingtweezers) or washed off with seawater. Alcoholic solutions,including suntan lotions, should not be appliedbecause they can cause further discharge of stinginghairs. Ice packs can be used to reduce pain.