Toxicology – a crash course in accidental overdoses

Cite this article as:
Tessa Davis. Toxicology – a crash course in accidental overdoses, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17991

Matthew (18 months) is brought into ED by his mum. He was found playing in his grandma’s handbag with what looked to be a pill in his mouth. Grandma has loads of meds in that handbag and it’s impossible for them to work out what is missing. What do you do?

Non-Toxic Exposures

Cite this article as:
Joe Rotella. Non-Toxic Exposures, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16453

Mary had a little taste…

Common non-toxic exposures (and what to expect)

As clinicians, we will occasionally come across someone with a case of Toxicophobia – the fear of being poisoned. In paediatrics, this usually presents in the parents of a little one who has explored their way into something they shouldn’t have. Whilst developmentally normal, it can be hard to tell what to be worried about (and given the last post, there are definitely things to be worried about!). It may seem that something will surely happen (you can blame television for that feeling), but in many cases, a patient is going to be just fine.

Before looking further into the various substances that can cause problems for our young patients, I thought it would be interesting and a bit of fun to talk about some of the non-toxic exposures the Poison Information Centre receives calls about – sometimes on a daily basis. In the instances where patients and their parents find themselves in front of you, it’s useful to know a little about what you needn’t worry about. Or in some cases, only worry about a little…

 

Topical antiseptics  and hand sanitisers

With all this talk about hand hygiene and killing germs, it’s not surprising that someone would worry about someone getting into one of these.

From a Toxicology perspective, there are two ingredients in these products that can be problematic – the first are quaternary ammonium compounds. A prime example is benzalkonium chloride, found in products such as Dettol. The concentrations for most household products are low (less than 7.5%) and likely to cause GI irritation at best with perhaps a vomit and some diarrhoea so supportive treatment will suffice.

Not surprisingly, deliberate overdoses can be clinically more significant with sequelae including corrosive injury, hypotension, renal injury and aspiration. Hand sanitisers containing alcohol, typically ethanol, and can cause intoxication if a large amount is ingested. In scenarios, where a child has had a taste, lick or swallow, significant toxicity is very unlikely

In the end, Paracelsus still holds true – the dose makes the poison and in the vast majority of these cases, it will not be a problem.

 

Silica gel packets

Containing sodium silicate to prevent excess moisture build-up and food spoilage, these little white packets are everywhere you look in the pantry. It is not surprising people get worried when they read the warning ‘DO NOT EAT’ all over the packet. Fortunately, silica is non-toxic however; it can be a choking hazard so a medical assessment is recommended if there are any signs suggestive of inhalation (e.g. cough, wheeze).

 

Dish-washing detergents

Dishwashing detergents contain soaps to help get rid of dirt and grease but luckily not people. Like other household products, they only cause mild GI upset, a ‘scratchy’ throat and aspiration if vomiting occurs.

 

Toilet bowl cleaners

The usual suspects are the toilet discs (see below). Given their job is to help clean yucky organic matter from the inside of a toilet; these are rather pretty in appearance.

As a parent, I do not know what would horrify me more – my child putting his finger into a disc or into the toilet! Maybe the latter…

These discs contain detergent and perfume but the method of exposure is usually a ‘finger dip’ so minimal exposure occurs. If anything, mild GI upset may occur with a larger ingestion. Important advice for parents is that the next poo might be a more psychedelic colour than usual.  

 

Glow sticks

I suspect the majority of calls come around New Year’s or Moomba (if you live in Melbourne). Glow sticks glow thanks to an ester called cyalume, which luminesces when mixed with hydrogen peroxide. Some products have a plastic casing that contains an inner glass capsule that when broken allows the cyalume (in the glass capsule) to mix with the hydrogen peroxide (surrounding the capsule). An accidental chew will lead to a bitter taste, a dry mouth and perhaps a vomit with some nausea, but not much else.

 

Creams and Lotions

Whilst they keep your skin looking healthy and young, eating these will not do much to your insides apart from a GI upset. Some of these contain small amounts of ethanol but normally not enough to cause clinically significant toxicity.

 

Perfumes, colognes and after-shaves

Similar to creams and lotions, these products are often in reach of little hands. Little people often do not drink much, if any, due to their strong odour and taste. Small ingestions are irritant in nature but larger ingestions can result in ethanol intoxication. However a lot of these products can be 60-80% ethanol and given the taste, it would be a very rare event for a child to swallow enough to become intoxicated.

As these are volatile products, off gassing of fumes can occur and causes a chemical pneumonitis in larger ingestions but the taste and smell of these is such that this is a rare occurrence.

 

Pens/Ink

Suddenly I find myself back in high school, swinging from my chair in the back row whilst chatting with friends. The typical patient is a young teenager sucking on a pen. The anticipated adverse effects include discoloration of the tongue, faeces and clothing often with a sense of embarrassment but nothing more.

 

Bubbles

Whilst we ask you not to forget about the bubbles, I’m happy to add ‘Don’t worry about the bubbles’.  These often contain a soap or mild detergent to produce these clear spheres of pure delight so a drink from a container will result only in GI upset and perhaps some irritation if other parts of the body make contact (e.g. eyes). Not to be confused with the champagne variety.

 

Don’t forget to check out the other posts in this series…

Special thanks to Jeff Robinson for his review and input

 

References

Hammond, K., Graybill, T., Spiess, S. E., Lu, J., & Leikin, J. B. (2009). A complicated hospitalization following dilute ammonium chloride ingestion. Journal of Medical Toxicology, 5(4), 218–222. https://doi.org/10.1007/BF03178271

Joseph, M. M., Zeretzke, C., Reader, S., & Sollee, D. R. (2011). Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school. World Journal of Emergency Medicine, 2(3), 232–233. https://doi.org/10.5847/wjem.j.1920-8642.2011.03.014

https://en.wikipedia.org/wiki/Glow_stick

Disclaimer: The information published in this post is for medical education only and does not constitute formal Toxicology advice. The information is current at the time of writing and may change with emerging evidence over time. If you have concerns about an individual who may be poisoned, please call your local Poisons Information Centre (13 11 26 for Australia).

Preventing Poisonings in the Home

Cite this article as:
Joe Rotella. Preventing Poisonings in the Home, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16269

You’ve just seen a young lady who managed to swallow a tablet out of Grandma’s handbag, whilst she was over for a visit. Luckily, it was a 20 mg esomeprazole tablet so she’s going to be ok. You go in and reassure her worried family that nothing further will occur. Feeling your job is done, you turn to leave but then her mother asks you ‘How can we prevent this happening in future?’.

What would you say?

Blue Ringed Octopus

Cite this article as:
Andrew Tagg. Blue Ringed Octopus, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.10977

One of the highlights of the holiday season, here in Australia, is being able to go to the beach (please don’t try this in the north). Victoria is one of the safer states when it comes to dangerous critters but the local news has reported sightings of another of the ‘world’s deadliest creatures’ at my local beach. I thought it about time to revise the dangers of the Blue Ringed Octopus.

Munchausen by Proxy : Fabricated & Induced Illness

Cite this article as:
Henry Goldstein. Munchausen by Proxy : Fabricated & Induced Illness, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9772

I recently attended a superbly insightful presentation by Dr Sue Wilson, the psychiatrist for our Consultation Liaison team here at Queensland Children’s Hospital. Some years ago, I was involved with a case of FII / Munchausen’s syndrome by Proxy, and – as is often the case – the case continues to resonate and evoke strong feelings. She has kindly offered her source material for this post.

Theoretical conceptualizations

Fabrication and Induction of Illness (FII) tends to be conceptualized as a rare/severe form of child abuse. The term Munchausen’s syndrome by proxy is used less in clinical practice, as it places an emphasis on the abuser rather than the victim. We’ll mostly use FII hereafter in this post, although there’s a short explainer about Munchausen himself later on.

An alternative view is that fabricated illness occurs along a broad spectrum that ranges from exaggerated reporting of symptoms by very anxious parents to the actual production of symptoms, with varying degrees of risk. This broader definition includes a far wider range of motivations and behaviours that represent clinical reality.

Here’s a 5 point summary:

  1. MBP/FII is a rare and severe form of child abuse. The behaviours may be considered on a spectrum of induced symptoms.
  2. Focus needs to be on caring for the child, not diagnosing the carer.
  3. Consider FII whenever you come across a perplexing presentation – it’s more common than some of the other, very rare, diagnoses we chase.
  4. A key differentiator is the parental response to a proposed medical change of direction.
  5. If you are even considering FII as a differential diagnosis, make early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion.

Important to remember


The line between volitional and non-volitional processes in the caregiver is difficult to identify. To be clear, volitional means the cognitive process whereby a person decides on and commits to a particular course of action. The harmful effects on the child are very similar, irrespective of the parent’s actions and motivations.

The focus must be on the outcomes or the impact on the child’s health and development and not initially on attempts to diagnose the parent or carer.

Detailed descriptions of the impact of the carer’s behaviour on the child are more useful than diagnostic labels which may distract from the central issue of harm to the child. Recognition of the carer’s difficulties is neither necessary nor sufficient for the diagnosis of FII.

So, who was Munchausen?

Munchausen refers to a satirical character based loosely on Hieronymus Karl Friedrich von Münchhausen, a German nobleman born in 1720. He gained notoriety in German aristocratic society after returning from a number of foreign wars with literally unbelievable stories. An author, so inspired by the Baron’s tales, expanded them into satire and farce and published them widely, much to the rage of Munchausen himself. This last point, to me, serves to reinforce the point above about volition versus non-volitional processes – I’m sure the original Baron von Munchausen did not intend to leave this kind of legacy! The satirical Munchausen features in a number of books and movies, most recently in a 2012 TV movie.

munchausen

Right then, back to it…

Perplexing presentations vs FII

FII are one sub-group within the category of perplexing presentations – FII should be considered as a differential diagnosis when some of the other indicators are present. Think to yourself, “What doesn’t make sense about this child’s presentation? ” What differentiates perplexing presentations from FII is the parental response to a proposed medical change of direction – from investigation to rehabilitation. That is, some parents persist in seeking medical opinions and investigations and decline or do not participate in the rehab process. They find difficulty in enabling their child to function and cope better.

Indicators which should alert professionals to the possibility of FII


Several indicators can give clues to an FII presentation. These include a carer reporting symptoms and signs which are not explained by any known medical condition, physical examination and investigations that do not explain reported symptoms and signs, inexplicably poor response to medication or other treatment, or intolerance of treatment or acute symptoms that are exclusively observed by/in the presence of the carer.

Additionally, on resolution of the presenting problems, the carer may report new symptoms or symptoms in different children.

The child’s daily life and activities may be limited beyond what is expected due to any disorder from which the child is known to suffer e.g, poor or no school attendance; use of seemingly unnecessary special aids.

Occasionally there is objective evidence of fabrication – history from different observers in conflict or being biologically implausible; test results (toxicology or blood typing); covert video surveillance (this is a minefield and we heavily caution against this course of action, even if you loved The Sixth Sense!!).
Sometimes a carer expressing concern that they are under suspicion of FII or relatives raising concerns about FII may be an indicator, as is a carer seeking multiple opinions inappropriately.

Characteristics


Characteristics of parents who fabricate or induce illness in their children should be applied with caution – many of them are also true of many parents. Additionally, they should not be used to confirm or deny the existence of FII and ultimately the identification of characteristics consistent with parents or carers fabricating or inducing illness in children may add to suspicions during the investigation process but do not constitute a profile. Nonetheless, we know;

  • Typically carried out by women, specifically mothers (95%)
  • Usually the child’s primary carer
  • Often present initially as “good” carers

(Yes, the three above points are also true of a very, very high proportion of carers…)

  • Usually accomplished liars and manipulators
  • Usually the only ones consistently present or associated with the onset of the child’s symptoms (when the carers are absent, symptoms or illnesses are not reported or may begin to improve)
  • They may have a history of self-induced symptoms/illness exaggeration, falsification or induction
  • They may have mental health evaluations indicating they are “normal” – psychiatric disturbance may be well-concealed from the observer
  • They may have no prior involvement with child protection services
  • They may appear to be overanxious, overprotective, mistaken or deluded
  • They may have a background in the health profession (14-30%) or an unusual degree of knowledge about health
  • They may seek publicity or attention from a variety of people

These parents or carers do not necessarily stop their behaviour towards the child when under suspicion or caught, but change tactics by:

  • Changing health professionals.
  • Denying all or part of what they have done, even in the face of overwhelming evidence.
  • Accusing their accusers, and shifting blame onto those who are aware of their behaviour. 

Risk factors of mothers for creating Abnormal Illness Behaviour in children

Remote or longstanding risks include;

  • Loss or separation from parent
  • Abuse/neglect
  • Foster care
  • History of lying in adolescence
  • History of self-harm

Recent or acute risks include;

  • Current somatoform disorder
  • Current factitious disorder
  • In receipt of disability living allowance
  • Child missing school
  • Frequent visits to doctors (symptoms unexplained)
  • Frequent moves of house and GP
  • Parent requests disability living allowance for child

Psychopathology of Fabricators

There is no clear relationship between any mental disorder and abusive behaviour towards children.  Many mothers with Borderline Personality Disorder (BPD) or history of abuse do not abuse their children in this way. Such a history may be a trigger to look more closely but doesn’t constitute proof; it’s important to remember that FII is a behaviour to be identified, not a medical or psychiatric diagnosis.

There are a number of associated conditions for those parents/caregivers whom fabricate;

72% somatoform disorders
55% self harmed

21% misused alcohol &/or drugs
89% personality disorder especially Borderline (by interview)
23% personality disorder (by self-rating scale)

Additionally, symptoms of depression and anxiety are common, as well as a high prevalence of somatising and factitious disorder. It’s worth noting that Factitious disorder and FII in children can co-occur; Somatoform disorder in the mother indicates some abnormality of illness behaviour and relationships with health professionals. Detection of factitious disorder in a mother of young children should provoke a search for FII in her offspring.

Fabricators are classically highly persuasive and have a tendency to split between staff (the idealisation of some, whilst devaluing others). FII involves all social classes (not just Barons). There may be a history of significant lying behaviours and deception dating back to childhood. One study notes 1 in 4 abusing carers had a history of being victims of child abuse, whilst another found high rates of deprivation, childhood abuse, significant loss or bereavement in the mothers, however FII is not necessarily associated with young, inexperienced parents or deprivation.

Possible explanatory mechanisms and motivations


The motivations of FII are complex and vary from case to case. However, it can be noted that extreme anxiety leading to exaggeration of symptoms and signs to encourage the doctor to rule out or identify any treatable disorder may play a roles. As can the need to confirm (false) beliefs about the child’s health (e.g, developmental disorder, food allergy) including beliefs held by caregivers with ASD and rarely with a delusional disorder. There may also be a wish for attention or deflection of blame for the child’s (usually behavioural) difficulties. FII also maintains closeness to the child and may invoke a material gain e.g. carer’s benefit. There may be an underlying hostility to doctor or even the child themselves.

In one study motivation for the induced illness in children was unclear in 2/3 of cases.

Intergenerational transmission of abnormal illness behaviours


There appears a common theme amongst caregivers that there is a past use of illness behaviours in relationships with other individuals, including health professionals. FII may at times represent extensions and distortions of childhood patterns of behaviour whose function was to obtain comfort and protection from others, with clinicians now placed in the caregiving role.

This adaptive use of deception develops early in life, and becomes entrenched over time and further distorted by subsequent losses and traumas. From early childhood some caregivers report feigning symptoms in order to avoid beatings or to prevent contact visits with abusive parents/carers. This makes sense if “playing sick” saves you from physical or other abuse.

When parents have been exposed to significant loss and trauma their behaviour is likely to be motivated by trauma-related triggers in situations where they feel threatened or perceive their children to be threatened; it’s worth noting that these ways of thinking and behaving are not always accessible to conscious reflection.

Disturbed attachment

 It may be more useful to see FII as a function of a disturbed mother-child attachment bond, influenced by mother’s own attachment experiences; insecure attachment is associated with higher levels of somatisation. Indeed, a study of attachment models in mothers who fabricated or induced illness found high levels of insecure attachment and unresolved bereavement. This may, in turn, sensitise individuals to see others as more sick than they really are.

Mother-child relationship

Remember, the mother may appear to have a close and caring relationship with the child (may not be so), with presence of separation anxiety and over protectiveness noted.
FII has been described as a “symbiotic bond”, although symbiotic infers mutually beneficial, and in FII it’s pretty hard to see any benefits for the child.  However, illness is the way for this child to maintain a relationship with his/her parent and perhaps preserve the parent’s mental equilibrium.


Consequences

Half of the patients suffer psychological harm including emotional and behavioural problems, school non-attendance and concentration difficulties, whilst a high percentage are affected by other forms of maltreatment or neglect or a repetition of FII. There are usually  compromised attachment relationships as a result.

Short-term effects include;

  • Self-image of self as sick or disabled
  • School absences
  • Miss normal developmental opportunities
  • Impact on peer relationships
  • Only way to achieve nurture or interaction with parent may be via the sick role
  • Impact of possible collusion in older child
  • Following confirmation, must consider child’s developmental stage, level of attachment, effect of separation from sibs and others

Long-term effects include

  • Impairment of overall development
  • Risk of psychological harm
  • Long term implications for child’s mental health including risks of Factitious disorder
  • Long term implications for attachment – effect on trust
  • Relationships and caring mediated through illness
  • Little research on harm from verbal fabrication

Role of mental health

Since no psychiatric diagnosis is pathognomonic of a perpetrator of this type of abuse, psychiatric assessment should not be used to determine whether FII has occurred, however there is a role for mental health after the behaviour has been confirmed, by way of;
  – assessment: parents, family dynamics, parenting skills, child
  – treatment planning: opinions re possibility of family intervention

The Mental Health team may be asked to assess parents who have a history of psychiatric disorder, especially if it seems that parental anxiety or misinterpretation may be contributing to the presentation. The main role for mental health is providing support for the team behind the scenes and taking part in case discussions; this process can be very stressful for all members of the team!

Given the early life experiences of caregivers, they tend to draw clinicians into close relationships in which boundaries can become blurred; this may be a red flag as well as an issue that can be explored in staff support meetings. There is also the potential to cause splitting in the team and arouse strong feelings (including around diagnosis and methods of investigation).

This is particularly challenging as medical & nursing staff must balance the need to remain engaged with the family as clinicians, whilst also being involved in observation and complex case discussions about the family; the period of growing suspicion and investigation is often the most difficult.

Areas of uncertainty

 FII is an area that has some intrinsic uncertainty, often as cases evolve over time. It’s important to always come back to impact on the child. Additionally, consider is this just an overanxious parent, perhaps exaggerating symptoms? Is there something medical being missed?  How much medical investigation is enough? For the parent?  For the treating team? Could it be conversion or somatoform disorder in the child rather than FII?


In older children, there is also a potential for coaching and collusion.


Plus, it is possible that a child may actually experience symptoms of a psychological nature (e.g. headache) which parent insists must have a medical cause.

Management

 Pragmatically, it is essential to notify your local child safety/child protection organisation. In some jurisdictions, including Australia, this is mandatory for health practitioners. One key message from Dr Wilson’s presentation was that if you are beginning to suspect FII, then making early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion – can facilitate the diagnosis and subsequent management. Generally speaking, psychological treatment is not indicated for individuals who cannot admit their behaviour.

In some cases, reunification is possible eg specialist unit in UK.  Better outcomes are associated with:

  • Acknowledgment of fabrication
  • Less severe abuse
  • Improvement in parent’s psychological functioning and empathy for the child
  • Improved parent-child relationship and child attachment behaviour
  • Change in the family system
  • Therapeutic alliance with the partner and extended family – safety network

Training for Paediatricians

So, how can Paediatricians & Paediatric trainees improve, with the above in mind? Clinical skills in consultations are always  being sharpened; with experience clinicians, become increasingly aware that parents need to be listened to but not always agreed with. Additionally, the skills of managing the potential conflict in the doctor-patient relationship also develop with time. In FII, there is a shift in emphasis so that the child truly becomes the primary client.

In the case of perplexing presentations, exploration of childcare perspective of children’s problems in addition to medical disease model, as well as identification of behavioural and interactional cues may assist in the recognition of FII.

Be mindful of obstacles which stand in the way of paediatricians recognising FII:
  – discomfort with not believing a parent, on whose history paediatricians rely
  – discomfort with not understanding the child’s presentation
  – concern about missing a treatable condition
  – concern about litigation or complaints.

References:

Jureidini JN, Shafer AT, Donald TG.”Munchausen by proxy syndrome”: not only pathological parenting but also problematic doctoring? Med J Aust. 2003 Feb 3;178(3):130-2.

Proops & Sibert (Eds), Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians. RCPCH, 2009. (Dr Wilson also referenced the 2002 edition of this publication in her talk.)

Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet. 2014 Apr 19;383(9926):1412-21.

Kozlowska K, Foley S, Savage B.Fabricated illness: working within the family system to find a pathway to health. Fam Process. 2012 Dec;51(4):570-87.

Kozlowska K.When the lie is the truth: grounded theory analysis of an online support group for factitious disorder. Psychiatry Res. 2014 Dec 30;220(3):1176-7.

Bass C, Jones D.Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011 Aug;199(2):113-8.

Bools CN, Neale BA, Meadow SR.Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Arch Dis Child. 1993 Dec;69(6):625-30.

Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. 2005 Oct;187:328-33.

Adshead G, Bluglass K. A vicious circle: transgenerational attachment representations in a case of factitious illness by proxy. Attach Hum Dev. 2001 Apr;3(1):77-95.

Fish E, Bromfield L and Higgins D. A new name for Munchausen Syndrome by Proxy: Defining Fabricated or Induced Illness by Carers. Australian Institute of Family Studies. 2005; 23.

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Paracetamol poisoning in children

Cite this article as:
Andrew Tagg. Paracetamol poisoning in children, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7530

Earlier this month the MJA published the latest consensus guidelines for the management of paracetamol (acetominophen) poisoning.  Whilst there is very little that is new for those of us used to dealing with this problem in adults, the document now makes some recommendations regarding the management of paracetamol overdose in children.

Spider Bites

Cite this article as:
Andrew Tagg. Spider Bites, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5502

6 year old Charlotte is carried into  your emergency department by her father. She had been helping him tidy up the garage and she thought she had scratched herself on an old box of toys.  An hour later she was inconsolable and refusing to walk.

Bottom line

  • Redback spider bites, though painful, don’t kill you.
  • They classically present as delayed onset intense pain associated with local autonomic symptoms and signs.
  • Redback spider antivenom may resolve the symptoms within a day 85% of the time but this should be weighed against the risk of an acute hypersensitivity reaction.
  • Funnel web spider bites, however, can be deadly.
  • Australia is a dangerous place to live.

 

How do Redback spider bites classically present?

Image courtesy - WikiWill - Flickr

Redbacks (Latrodectus hasselti) can be found throughout Australia with their kissing cousins, the Katipo (Latrodectus katipo) more common in New Zealand.  They thrive in urban environments and are one of the reasons this author refuses to use outdoor toilets.

Their bites are not immediately painful and  can often be mistaken for a scratch but within about 30 minutes there is intense regional pain  accompanied by sweating and piloerection.  Their venom contains alpha-latrotoxin which causes neurotransmitter release at nerve terminals in the sympathetic nervous system. Whilst children are often bitten on the leg the pain can radiate to the leg that has not been chomped on. This triad of intense pain, sweating and piloerection is the classic presentation of lactrodectism.

Systemic envenomation is occurs in about a third of cases and is characterised by both autonomic features (e.g. sweating) and more general features such as nausea, vomiting and headaches.

Be aware though that Redback bites have been known to present in atypical ways and have been confused with appendicitis, intussussception and meningitis so they should be on the differential for any inconsolable child with irritability and diaphoresis.  The autonomic effects have even been known to cause priapism in young boys.

 

How should they be treated?

If the bite is left untreated symptoms should resolve in three to four days.

Simple first aid measures that can be applied at home include applying an ice pack to the bite and using simple analgesia to help mitigate the pain.  There is no evidence that pressure immobilisation bandages are effective in the treatment of Redback bites.

Once in hospital the child should be given reassured and given appropriate analgesia.  Often they  need  titrated doses of opiates.  They may also be offered antivenom.

 

If there is an antivenom, shouldn’t we give it?

CSL Redback Spider antivenom is indicated for severe local pain that does not respond to simple analgesics.  The standard dose is 2 vials undiluted IM or 2 vials diluted in 100mls normal saline IV over 30 minutes. Interestingly the RAVE trial found detectable levels of antivenom only in patients given intravenous therapy  compared to via the intramuscular route but with no appreciable clinical difference between the two groups at two hours.  Doubt has now been cast on its utility. When one considers that up to 5% of patients undergo an immediate hypersensivity reaction 16 % of recipients of the antivenom develop serum sickness within two weeks a shared decision needs to be made with the patient/parents as to whether or not to give it. Because of these risks it should be given in a monitored environment.

Redback anti-venom can also be used to treat the bite of a cupboard spider.

 

How about funnel-web spiders?  Are they more dangerous?

Image courtesy Wikimedia Commons

Funnel-web spiders belong to the famous BBS, or Big Black Spider, group of Australian nasties.  They can be found around 120km radius of Sydney.  Their venom, a potent neurotoxin, can be lethal if untreated.  Because of the  speed of onset of venom action the pain is immediate with systemic symptoms occurring just half an hour after envenomation. Effects will be felt within two hours of the bite.

General features of funnel-web envenomation include headache, listlessness and nausea but these rapidly progress to life threatening cardiovascular, respiratory and neurological compromise.  In the late stages of envenomation the child may become bradycardic and hypotensive (or hypertensive due to autonomic overactivity) and develop acute pulmonary oedema.  They may complain of perioral paraesthesia and may have visible muscle fasciculations. These all herald impending doom and potential cardiorespiratory arrest.

 

How should they be treated?

The spider is big enough to be seen and leave visible fang marks so there is often no doubt as to what has happened. The victim needs to be transported to a centre capable of dealing with such an envenomation as quickly as possible. In cases of funnel-web envenomation proper application of a pressure immobilisation bandage LINK may be life saving.

Once in hospital the ABC’s should be managed in the usual fashion with priority given to the provision of antivenom. Two vials should be given immediately though there are case reports of four vials being given peri-arrest. Funnel-web anti-venom can also be used to treat the bite of the mouse spider.

 

Any other scary spiders I should know about?

Image courtesy Wikimedia Commons

Australia has a lot of scary looking creepy crawlies.  One common reason for visits to the ED is the White Tail.  These spiders can be found throughout Australia. Like most arachnids their bites can be painful for a couple of hours but they very rarely cause systemic envenomation.  Unlike their North American cousins, the Brown Recluse spider, they have not been shown to cause necrotic skin ulcers. Generally they cause local pain and may leave a red mark for a day or two but there is no evidence of skin break down. There is no role for prophylactic antibiotics.

 

Outcome

Charlotte is treated initially with intranasal fentanyl and oral adjunctive therapy.  After discussion with her father you elect not to give Redback anti venom on the proviso that they return should the pain be uncontrollable.
 

References

Craven, John A. “An Irritable Infant and the Runaway Redback: An Instructive Case.” Case reports in emergency medicine 2011 (2011) 

Isbister, G. K., et al. “A randomised controlled trial of intramuscular vs. intravenous antivenom for latrodectism—the RAVE study.” QJM 101.7 (2008): 557-565

Isbister, Geoffrey K. “Antivenom efficacy or effectiveness: the Australian experience.” Toxicology 268.3 (2010): 148-154.

Isbister, Geoffrey K., and Hui Wen Fan. “Spider bite.” The Lancet 378.9808 (2011): 2039-2047.

Isbister, GK. Safety of IV administration of redback spider antivenom. Internal Medicine Journal 37 (2007) 820-822

Daly, Frank, Mike Cadogan, and Mark Little. Toxicology handbook. Elsevier Australia, 2011.

Carbon Monoxide Poisoning

Cite this article as:
Andrew Tagg. Carbon Monoxide Poisoning, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5361

4 year old Mariska is brought in by ambulance with her mother after being rescued from a house fire.  Neither appear to have sustained any significant injuries as they were woken by the screech of the smoke detector but your resident is worried about possible carbon monoxide poisoning and wants to do an arterial blood gas to rule it out.

Bottom line

  • Carbon monoxide (CO) is an odourless, colourless, tasteless gas that preferentially binds to haemoglobin rendering it unavailable for oxygen transport.
  • CO poisoning in children manifests in a similar fashion as it does in adults but occurs sooner.
  • Capillary blood gases are a lot kinder than arterial blood gases.
  • There is a lack of hard evidence on the best way to treat mild to moderate CO poisoning and no data on long term effects.
  • Prevention is better than cure – fit a CO detector in your home.

How common is paediatric carbon monoxide poisoning?

Every year the newspapers publish heartbreaking headlines about children who have died as a result of carbon monoxide poisoning.   Fortunately these tragic cases are rare. Approximately 450 adults die in the US every year as a result of accidental poisoning but there is no data on the actual number of cases in the paediatric population. There is also little data on the number of cases of exposure and any figure is liable to be a gross underestimate.  It’s a problem that’s rarely on our list of differential diagnoses.

How does CO poisoning manifest in children?

Symptoms can be very subtle and nondescript

  • Headaches
  • Weakness or clumsiness
  • Nausea or vomiting
  • Blurry vision
  • Shortness of breath
  • Flu-like illness

or more serious.

  • Seizures
  • Coma
  • Cardiac arrest

This retrospective case series from Ankara suggested that, as in adults, severity of symptoms relates to degree of exposure, with the worst symptoms to be found with levels greater than 25%.  These affected kids were much more likely to present with neurological symptoms such as headache, syncope or seizures compared to children with lower levels of carboxyhaemoglobin. Because infants and children have a higher basal metabolic rate than adults they are likely to become symptomatic earlier than their parents.  Fortunately this also means they are likely to recover more quickly.

There is also some evidence that poisoning can lead to potential long-term neuropsychiatric sequelae such as subtle personality changes and memory impairment but again paediatric data is lacking.

What's the basic pathophysiology behind CO poisoning?

Carbon monoxide is a byproduct of the incomplete burning of carbon containing fuel.  In most cases of domestic CO poisoning this is as a result of poor or unventilated space heaters that use kerosene or natural gas.

Carbon monoxide exerts its toxic effects via three mechanisms. It preferentially binds to haemoglobin reducing its oxygen binding capacity, it shifts the oxygen dissociation curve to the left thus inhibiting the release of bound oxygen in the periphery and it acts as a direct cellular toxin by impairing aerobic metabolism.

Remember that fetal haemoglobin has a greater affinity for carbon monoxide than adult haemoglobin and so neonates are particularly susceptible.

How is it detected?

Oxygen saturation monitors can be falsely reassuring in the setting of CO poisoning. Carboxyhameoglobin (CoHb) levels may be detected directly from either an arterial or venous blood gas sample with a high degree of correlation between results. A capillary gas is equally as effective and a lot less painful.  Although high levels may give you a diagnosis, partially treated cases may already have low levels.

Small, portable transcutaneous devices also exist but are not readily available in most EDs.

How is it treated?

Whilst immediate first aid involves removing the child from the source, high flow oxygen is the mainstay of treatment.  The half-life of COHb is 320 minutes whilst breathing room air and about 30-90 minutes with an FiO2 of 1.0. With hyperbaric oxygen therapy reduces this time even further to only about 15 minutes  (at 2.5 ATM and 100% O2) though there is controversy over its utility.  We can only extrapolate from adult data as age less than 18 has been an exclusion criteria in all of the major trials.  Whilst there have been positive and negative results the 2011 Cochrane review summarised the results nicely – there’s not enough evidence either way to determine whether HBO reduces the incidence of delayed neuropsychiatric damage.  In the case of moderate to severe poisoning it would be worth consulting your local hyperbaric service.

 

What can you do to make your home safe?

The two basic principles are avoiding it happening in the first place and detecting leaks early. The former can be done by using properly serviced heaters in well ventilated rooms.  The latter can be done by fitting a ceiling mounted carbon monoxide detector.  This device, similar to a smoke detector, emits an ear-piercing shriek if higher than expected levels of carbon monoxide are detected.

Outcome

You convince your resident that although it is possible that Mariska had an elevated CO level when she was rescued, the investigation that they want to do is likely to be more harmful than helpful. You persuade them to do a capillary gas instead and are satisfied with an undetectable CO level.

HT to Charlotte Davies (@OneLongPlait) for the idea behind this post.

 

References
Kurt F, Bektaş Ö, Kalkan G, Öncel MY, Yakut HI, Kocabaş CN. Does age affect presenting symptoms in children with carbon monoxide poisoning? Pediatr Emerg Care. 2013 Aug;29(8):916-21

Vieregge P, Klostermann W, Blumm RG, Borgis KJ. Carbon monoxide poisoning: clinical, neurophysiological, and brain imaging observations in acute disease and follow-up. J Neurol 1989;236:478–81

Suner S, Partridge R, Sucov A, et al. Non-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity. J Emerg Med. May 2008;34(4):441-50

Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr 13;(4)

Life in the Fast Lane Critical Care Companion – Carbon Monoxide poisoning (accessed 1/4/2014)

Weaver LK, Hopkins RO, Chan KJ et al.  Hyperbaric oxygen for acute carbon monoxide poisoning. New England Journal of Medicine 2002; 347(14):1057–1067

Scheinkestel CD, Bailey M, Myles PS et al. Hyperbaric or normobaric oxygen for acute carbon monoxide posioning: a randomised controlled clinical trial. Medical Journal of Australia 1999; 170:203–210

Touger, Michael, E. John Gallagher, and Jim Tyrell. “Relationship between venous and arterial carboxyhemoglobin levels in patients with suspected carbon monoxide poisoning.” Annals of emergency medicine 25.4 (1995): 481-483.

Heidari, Kamran, et al. “Correlation between capillary and arterial blood gas parameters in an ED.” The American journal of emergency medicine 31.2 (2013): 326-329.