Ingestion Injury
Despite the success of various preventive public health programs,
poisoning in the pediatric population continues to be a common occurrence. Fortunately,
the vast majority of presumed poisonings in young children can be managed at home
by telephone consultation with a regional poison control center. In one study, acute
poisoning accounted for approximately 5% of all medical admissions to a PICU.[359]
In this study, approximately half were accidental ingestions and half were suicidal
overdoses. The median age for the accidental group was 2 years, and for the suicidal
group it was 15 years. Although many different toxic substances are ingested by
children and adolescents, the approach to therapy is routine. Management has three
main goals: (1) identifying, decontaminating, and eliminating the toxic agents[360]
;
(2) minimizing the toxic effects on the host; and (3) providing close observation
and organ system support until detoxification is complete. Procedures for drug elimination
include emesis, gastric lavage, activated charcoal, and magnesium citrate. Toxic
effects can be minimized with specific antidotes when available, with hemodialysis,
or with charcoal hemoperfusion. Examples of specific antidotes are deferoxamine
for iron ingestion, ethanol infusion for methanol ingestion, naloxone for narcotic
overdose, and N-acetylcysteine for acetaminophen
ingestion. Because many ingestions, particularly the suicidal ones, include multiple
drugs, specific antidote therapy is only occasionally successful. Organ system surveillance
and support usually include airway protection and mechanical ventilation, intravenous
fluids, cardiovascular monitoring for arrhythmias and myocardial depression, and
anticonvulsive therapy when seizures occur. Consultation with clinical pharmacologists
or with the regional poison control center and contacting a social worker or psychiatrist
are essential aspects of the care of an acutely toxic child. Common complications
of ingestions and their therapy include aspiration pneumonia from hydrocarbon ingestion
or loss of glottic function, sepsis, respiratory depression, myocardial depression,
arrhythmias, seizures, and coma. Although it is important to treat the specific
ingestion, the psychosocial environment that allowed or precipitated the ingestion
must also be considered. Families should be counseled about proper supervision and
"childproofing" their home. Psychiatric intervention should be introduced early;
unsuccessful suicide attempts are often repeated.
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