Poisoning - Paracetamol in Children

Pediatric emergencies

Clinicals - History

Fact Explanation
Asymptomatic Patient can be asymptomatic for the 1st 24 hours. Asymptomatic
Patient can be asymptomatic for the 1st 24 hours.
Nausea and or vomiting This is commonly seen within half an hour to 24hours. Commonly accompanied by fatigue and malaise. Nausea and or vomiting
This is commonly seen within half an hour to 24hours. Commonly accompanied by fatigue and malaise.
Diaphoresis Seen during the initial 24hours period. Diaphoresis
Seen during the initial 24hours period.
Symptoms of dehydration This may occur secondary to severe vomiting. Children often complain of thirst. Young children have reduced urine output and lethargy. Symptoms of dehydration
This may occur secondary to severe vomiting. Children often complain of thirst. Young children have reduced urine output and lethargy.
Right upper quadrant abdominal pain Children complain of right upper quadrant abdominal pain after 24 hours of ingestion and it may persist up to about 72 hours. Right upper quadrant abdominal pain
Children complain of right upper quadrant abdominal pain after 24 hours of ingestion and it may persist up to about 72 hours.
Bleeding manifestations Coagulopathy occurs between 3 days to 5 days of intoxication. Bleeding manifestations
Coagulopathy occurs between 3 days to 5 days of intoxication.
Confusion and coma Children may develop confusion which might progress to coma within 3 to 5 days of intoxication. Confusion and coma
Children may develop confusion which might progress to coma within 3 to 5 days of intoxication.
History of accidental ingestion Young children may swallow the tablets if the paracitamol tablets are kept within children’s reach. History of accidental ingestion
Young children may swallow the tablets if the paracitamol tablets are kept within children’s reach.
Therapeutic misadventure Often parents give their children supra-therapeutic doses of paracitamol expecting a therapeutic benefit. This is commonly seen in infants. Therapeutic misadventure
Often parents give their children supra-therapeutic doses of paracitamol expecting a therapeutic benefit. This is commonly seen in infants.
History of attempted suicide Older children may use high doses of paracitamol as a method of suicide. History of attempted suicide
Older children may use high doses of paracitamol as a method of suicide.
Symptoms of liver failure Paracitamol is hepatotoxic and symptoms of liver failure may develop after about 4 to 6 days of use. Both acute and long term intoxication can cause hepatotoxicity, however the cumulative dose of intoxication is important in predicting the degree of liver damage. Symptoms of liver failure
Paracitamol is hepatotoxic and symptoms of liver failure may develop after about 4 to 6 days of use. Both acute and long term intoxication can cause hepatotoxicity, however the cumulative dose of intoxication is important in predicting the degree of liver damage.
Presence of risk factors of suicide Children with depression, or facing sudden stressful life events are at risk of deliberate self-harm and suicide. Presence of risk factors of suicide
Children with depression, or facing sudden stressful life events are at risk of deliberate self-harm and suicide.

Clinicals - Examination

Fact Explanation
Signs during the stage 1 From half an hour of ingestion up to 24 hours is considered as the stage 1. During this period children may have insignificant examination findings. Some children may have evidence of dehydration due to recurrent vomiting. Signs during the stage 1
From half an hour of ingestion up to 24 hours is considered as the stage 1. During this period children may have insignificant examination findings. Some children may have evidence of dehydration due to recurrent vomiting.
Stage 2 (24 to 72 hours) During the stage 2 of the paracitamol intoxication, children develop tenderness in the right hypochondrium. Hepatomegaly can also be detected. Tachycardia and hypotension are also seen during the second stage. Stage 2 (24 to 72 hours)
During the stage 2 of the paracitamol intoxication, children develop tenderness in the right hypochondrium. Hepatomegaly can also be detected. Tachycardia and hypotension are also seen during the second stage.
Stage 3 (3 to 5 days) In the third stage, children develop jaundice, confusion and may progress to coma. Subcutaneous bleeding and mucosal bleeding are seen during the third stage of intoxication. Stage 3 (3 to 5 days)
In the third stage, children develop jaundice, confusion and may progress to coma. Subcutaneous bleeding and mucosal bleeding are seen during the third stage of intoxication.
Stage 4 (5 to 7 days) Children begin to recover during this stage. Often all the abnormal examination findings are returning to normal during this stage. Stage 4 (5 to 7 days)
Children begin to recover during this stage. Often all the abnormal examination findings are returning to normal during this stage.

Investigations - Diagnosis

Fact Explanation
Serum paracitamol levels This is helpful in diagnosing acute intoxication and should be done within 4 to 6 hours of ingestion. Serum paracitamol levels
This is helpful in diagnosing acute intoxication and should be done within 4 to 6 hours of ingestion.

Investigations - Management

Fact Explanation
Liver function tests During the stage 4 children begin to recover. Hepatic transaminases gradually decrease. Serum bilirubin, and coagulation profile also normalize during this stage. Liver function tests
During the stage 4 children begin to recover. Hepatic transaminases gradually decrease. Serum bilirubin, and coagulation profile also normalize during this stage.
Renal function test Renal functions should be monitored till it normalizes. Renal function test
Renal functions should be monitored till it normalizes.
Hepatic transaminases Hepatic transaminases are slightly elevated during the first 12hours, which becomes marked thereafter. Transaminases begin to normalize after about 5 days of intoxication. Hepatic transaminases
Hepatic transaminases are slightly elevated during the first 12hours, which becomes marked thereafter. Transaminases begin to normalize after about 5 days of intoxication.
Prothrombin time Elevated after first 24 hours. Prothrombin time
Elevated after first 24 hours.
Serum bilirubin Elevated after first 24 hours. Direct bilirubin levels are elevated commonly. Serum bilirubin
Elevated after first 24 hours. Direct bilirubin levels are elevated commonly.
Blood urea and nitrogen Elevated after first 24 hours. Blood urea and nitrogen
Elevated after first 24 hours.
Serum electrolytes Assesses the renal function. Serum electrolytes
Assesses the renal function.
Serum creatinine Elevated after first 24 hours. This may be due to either direct renal damage or may be secondary to hepato-renal syndrome. Serum creatinine
Elevated after first 24 hours. This may be due to either direct renal damage or may be secondary to hepato-renal syndrome.
Random blood sugar Hypoglycemia can occur with liver failure and usually present within 3 to 5 days of intoxication. Random blood sugar
Hypoglycemia can occur with liver failure and usually present within 3 to 5 days of intoxication.
Serum ammonia Becomes elevated within 3 to 5 days of intoxication. Serum ammonia
Becomes elevated within 3 to 5 days of intoxication.

Management - Supportive

Fact Explanation
Health education Parents should be educated about the importance of adherence to recommended doses. The maximum dose of paracitamol is 10 to 15 mg/kg every 4 to 6 hours. If it is used as an over-the-counter medication, instructions written on the product information leaflet should be read carefully. Parents should be advised to use a pediatric preparation rather adult preparation of paracitamol. Health education
Parents should be educated about the importance of adherence to recommended doses. The maximum dose of paracitamol is 10 to 15 mg/kg every 4 to 6 hours. If it is used as an over-the-counter medication, instructions written on the product information leaflet should be read carefully. Parents should be advised to use a pediatric preparation rather adult preparation of paracitamol.
Basic life support Assessment of the airway, breathing and circulation should be done first. Patency of the airway should be maintained and oxygen should be delivered if necessary. A nasogastric tube will help to prevent aspiration if vomiting is present. Circulatory support is provided with adequate fluid resuscitation. Basic life support
Assessment of the airway, breathing and circulation should be done first. Patency of the airway should be maintained and oxygen should be delivered if necessary. A nasogastric tube will help to prevent aspiration if vomiting is present. Circulatory support is provided with adequate fluid resuscitation.
Anti-emetics Anti-emetics prevent vomiting, secondary to paracitamol intoxication. NAC causes vomiting as a side effect. Anti-emetics are helpful in preventing this as well. Anti-emetics
Anti-emetics prevent vomiting, secondary to paracitamol intoxication. NAC causes vomiting as a side effect. Anti-emetics are helpful in preventing this as well.

Management - Specific

Fact Explanation
Activated charcoal Administration of activated charcoal (1g/kg body weight) orally, will reduce the absorption of paracitamol. This is effective within 2 to 4 hours of ingestion. Activated charcoal
Administration of activated charcoal (1g/kg body weight) orally, will reduce the absorption of paracitamol. This is effective within 2 to 4 hours of ingestion.
N-acetyl cysteine (NAC) NAC should be administered in all patients with history of staggered paracitamol overdose irrespective of serum paracitamol levels. According to the Rumack-Matthew nomogram plasma acetaminophen levels greater than 150 µg/mL after 4 hours of ingestion indicate possible toxicity and need of NAC. NAC is effective only up to 24hours of ingestion.
A loading dose of 140 mg/kg is administered first. Thereafter 70 mg/kg NAC is administered 17 times, in 4 hours intervals. If the child vomits within 4 hours of administration of oral NAC, the dose should be re-administered.
N-acetyl cysteine (NAC)
NAC should be administered in all patients with history of staggered paracitamol overdose irrespective of serum paracitamol levels. According to the Rumack-Matthew nomogram plasma acetaminophen levels greater than 150 µg/mL after 4 hours of ingestion indicate possible toxicity and need of NAC. NAC is effective only up to 24hours of ingestion.
A loading dose of 140 mg/kg is administered first. Thereafter 70 mg/kg NAC is administered 17 times, in 4 hours intervals. If the child vomits within 4 hours of administration of oral NAC, the dose should be re-administered.
Liver transplantation This is helpful in children with significant liver damage. Liver transplantation
This is helpful in children with significant liver damage.

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