Intensive Care of Acute Poisoning - A. V. Hovenko 2010

Emergency Care and Intensive Care of Acute Poisoning
Specifics of Intensive Care of Acute Poisoning in Children

The Specific features of intensive care in children are due to the Qualitative and quantitative differences between the adult and child Organism.

Early childhood is characterized by certain peculiarities of metabolic processes; Water and Electrolyte METABOLISM; increased permeability of membranes, the Blood-Brain barrier, and blood vessel endothelium; as well as specific features in the neural and humoral Regulation of cardiovascular and excretory system Functions.

The more severe course of poisoning in children is caused by the following factors:

1. More than 90% of all poisonings in childhood are caused by psychotropic drugs that suppress the autonomic Functions of the Central Nervous system, to which tolerance in infants and young children is markedly reduced. Children lack specific and non-specific tolerance to narcotic poisons (barbiturates, alcohol, drugs, etc.). Consequently, lethargy dominates the clinical picture, and a comatose state develops much more rapidly.

2. Poisonings in children are very often accidental, occurring unnoticed by parents, which delays hospitalization. Therapeutic measures are initiated with a significant spatial and temporal delay.

3. Somatogenic reactions to chemical trauma are more pronounced in children due to the heightened reactivity of the child's organism and the accelerated development of severe complications, such as toxic cerebral edema and endogenous catecholamine Intoxication syndrome.

The Skin in children has higher permeability to various chemical and biological substances. In addition, it is looser and more hydrated. The relative amount of adipose tissue in newborns is 5 times greater than in adults. This ratio equalizes only by the age of 7, and sometimes even by 10 years. The predominance of Unsaturated Fatty acids in adipose tissue increases its depot-forming capacity.

When a poison enters a child's bloodstream, the binding of toxicants to Plasma Proteins is less stable in young children than in older children. Therefore, toxicants are released from protein bonds and displaced by certain endogenous substances. During stress, Hypoxia, or acidosis, the bound fraction of toxic substances may increase, which enhances intoxication, but on the other hand, accelerates their elimination from the body.

Furthermore, in children with Liver or Kidney pathology, Rickets, or hypotrophy, plasma protein levels are lower than in healthy children; hence, a greater amount of the toxic substance can be found in a free state, causing even more severe chemical trauma.

During the first year of life, The amount of adipose and Muscle tissue capable of sequestering toxicants is significantly smaller than in adults or older children. Consequently, the deposition of various toxicants in young children occurs less efficiently and in smaller quantities. This shortens their persistence time within the child's body.

Therapeutic measures in children do not fundamentally differ from the comprehensive management of poisoning in adults. The main focus should be on the rapid and effective removal of the poison from the body via Gastrointestinal Decontamination and artificial detoxification (hemodialysis, hemoperfusion, etc.).

Specifics of gastric lavage in children. Among gastrointestinal decontamination Methods, gastric tube lavage is considered the most popular. Gastric lavage is indicated if the child presents clinical signs characteristic of the toxigenic phase.

Young children should be swaddled before gastric lavage. If the child has suppressed pharyngeal Reflexes or is in a coma, gastric lavage is performed only after prior endotracheal intubation.

Drinking water at room Temperature is used for gastric lavage. The volume of water required for a single-stage and complete gastric lavage in children of various ages is given in Table 3.1.

Class="center">Table 3.1 Volume of water used for gastric lavage in children depending on age

In cases of poisoning with caustic liquids, gastric lavage is mandatory within the first few hours after ingestion. The presence of blood in the washout fluid is not a contraindication for this Procedure; in such cases, the tube should be thoroughly lubricated (along its entire length) with petrolatum jelly prior to insertion, and a 1% promedol solution should be administered subcutaneously at a dose of 0.1 mL per year of life.

Acid solutions swallowed into The Stomach must never be neutralized with alkali solutions. The Use of sodium bicarbonate for this purpose can significantly worsen the child's condition due to acute gastric distension (gastric rupture is even possible) caused by the generated carbon dioxide.

When poisoned with KMnO₄ crystals, lavage is performed According to the same protocol (Table 3.1). A 1% ascorbic acid solution is used to clean the brown-black coating from the Lips, Oral Cavity, and Tongue.

In cases of poisoning with gasoline, kerosene, or other petroleum products, 20-50 mL of liquid petrolatum (or 3 mL per 1 kg of the child's body weight) must be introduced into the stomach before lavage, followed by standard washing Procedures.

In severe forms of poisoning in unconscious children (e.g., sleeping pill overdose), gastric lavage must be repeated 2-3 times during the first 24 hours due to severely delayed resorption.

To adsorb substances remaining in the gastrointestinal tract, activated charcoal (or other sorbents) is administered after gastric lavage at a dosage of 1 g/kg of body weight for children under 5 years old and 0.5 g/kg for children over 5 years old.

Performing Forced diuresis in children. To eliminate toxic substances from the bloodstream in children, the forced diuresis technique is employed. As in adults, this method is indicated for most poisonings involving water-soluble toxins whose elimination occurs primarily via the Kidneys.

Protocol for forced diuresis in children

Phase 1 involves preliminary fluid loading to compensate for hypovolemia in children, which can be achieved via oral rehydration or intravenous infusion. In mild poisoning without vomiting, diuresis is enhanced by prescribing large volumes of oral fluids (alkalinized water, fruit drinks, mildly brewed tea), totaling 1-2 L (Table 3.2). Beverages should be consumed as follows: the hourly dose is divided into 2-3 portions and given every 20-30 minutes. Polyuria develops within 20-40 minutes. This method can be used in older children. In infants and young children, solutions are administered into the stomach via a tube.

In cases of severe intoxication, Hydration is administered intravenously (via an intravenous drip). This involves the use of a 5% glucose solution (accounting for 1/2 of the total fluid volume administered), Ringer's solution (1/4 of the total fluid volume), an isotonic sodium chloride solution (1/4 of the total fluid volume), and a 4% sodium bicarbonate solution (10% of the total volume). These solutions are administered sequentially. The required total fluid volume is determined by the child's age and is presented in Table 3.2.

Table 3.2 Total fluid volume administered to a child during forced diuresis

Phase 2 - diuresis stimulation: slow intravenous administration (2-3 mL per minute) of a 15-20% mannitol solution at a dosage of 0.5-1.5 g/kg per day, or 5 mL/kg of solution. To enhance diuresis, a 2.4% aminophylline solution at a dosage of 0.1-0.15 mL/kg and furosemide at 1 mg/kg can be administered intravenously at the same time.

Phase 3 - electrolyte replacement infusion.

During hydration therapy, it is essential to closely monitor renal excretion function (ensuring diuresis corresponds to the fluid load). To record the amount of urine output, an indwelling urinary catheter is placed in the bladder. A balance must be maintained between the volume of fluid administered and hourly diuresis. The drip rate in the infusion set should match The rate of urine droplet formation.

Artificial detoxification in children. Among artificial detoxification methods, extracorporeal hemosorption (HS) is recognized as the most effective. Currently, HS is widely used in the Treatment of various types of severe poisonings in children. The main contraindications for performing HS in children include a drop in blood pressure, particularly when accompanied by a decrease in total peripheral vascular resistance.

For the treatment of poisonings caused by dialyzable substances in children, hemodialysis (HD) using an artificial kidney machine is most commonly performed.

Pharmacotherapy. The pharmacotherapy of acute poisonings in children follows the same principles as in adults—it is individualized, depending on the stage and severity of the poisoning, with strict adherence to age-appropriate drug dosages.

Other supportive medical measures have no specific features, other than adjustments for the patient's age and body weight.

Specific antidote therapy in children is based on generally accepted indications, adhering strictly to age-appropriate drug dosages.