Exposições tóxicas agudas em crianças: um panorama

0021-7557/05/81-05-Suppl/S212 Jornal de Pediatria Copyright © 2005 by Sociedade Brasileira de Pediatria REVIEW ARTICLE Acute toxic exposure in children: an overview Fábio Bucaretchi,1 Emílio C. E. Baracat2 Abstract Objective: To review the literature on acute toxic exposure in children, excluding envenomations. Sources of data: MEDLINE review (emphasis on the past decade), including the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists’ position statements and position papers (peer-reviewed information based on scientific evidence and broad consensus) on gastrointestinal decontamination, multiple-dose activated charcoal and urine alkalinization. Summary of the findings: Acute toxic exposure in children is a common event, mainly in children under six years of age. Death is rare. Although widely employed, there is no evidence that gastrointestinal decontamination and multiple-dose activated charcoal improve the outcome of poisoned patients. Very few efficient antidotes are used on a consistent basis, and some of them are very expensive and not available in Brazil. Conclusions: Ipecac syrup and cathartics should not be administered on a routine basis in acute toxic exposures in outpatient treatment. Excluding the contraindications, single-dose activated charcoal and gastric lavage may be considered within one hour of ingestion if a patient ingested a potentially toxic amount or a potentially lethal amount, respectively. Whole bowel irrigation, multiple-dose activated charcoal and urine alkalinization may be considered in a few situations. Fomepizole and octreotide are safe and efficient antidotes, which can be used in the treatment of alcohol (methanol and ethylene glycol) and sulfonylureas poisoning, respectively. J Pediatr (Rio J). 2005;81(5 Suppl):S212-S222: Poisoning, gastrointestinal decontamination, charcoal, antidotes, children. Introduction Exposure to toxic substances (pharmaceutical or not) is a common event in pediatrics.1-10 According to the 2003 American Association of Poison Control Centers’ Toxic Exposures Surveillance System data, which provide a wide coverage of the U.S. territory, there are approximately 2.4 million exposures, and 93 and 52% of them occurs in the household and in children younger than six years, respectively. 1 Most exposures in this age group are unintentional (99.4%), with less morbidity and mortality if compared to other pediatric age groups; however, among adolescents, 45.9% of the exposures were intentional.1 In the 1940s, approximately 500 children died in the USA every year, due to toxic exposures. Current data show important prophylactic (active and passive) measures established in order to reverse this situation, including mainly the mandatory use of child-resistant packaging, permanent public education and the creation of poison control centers. 1-4,9,11-12 Poison control centers are a very good example of this, with an excellent cost-benefit ratio, significantly reducing the number of unnecessary referrals to emergency rooms and the number of invasive procedures, by providing, in most cases, specialized guidance and telephone follow-up with remarkable success.1-4,9,11-12 Moreover, poison control centers act as “surveillance tools,” and the analysis of the information, collected in a uniform and systematic manner, has helped to devise adequate public policies for toxic exposure surveillance.1 1. PhD. Assistant professor, Department of Pediatrics, Medicine School, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil. Centro de Controle de Intoxicações, UNICAMP. 2. PhD. Assistant professor, Department of Pediatrics, Medicine School, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil. Suggested citation: Bucaretchi F, Baracat EC. Acute toxic exposure in children: an overview. J Pediatr (Rio J). 2005;81(5 Suppl):S212-S222. S212 Jornal de Pediatria - Vol. 81, No.5(Suppl), 2005 S213 Acute toxic exposure – Bucaretchi F & Baracat ECE In Brazil, 25 of 33 regional centers, each with its own characteristics, fed the Brazilian National System of Toxic and Pharmacological Information (SINITOX) in 2002, according to which there were 75,212 exposures (25.4% in children younger than five years) and 375 deaths (31 in children younger than five years).10 The major agents, classified according to age group, are listed in Table 1, including mainly medicines, household products, and venomous animals. In terms of lethality, pesticides (organophosphorates), medicines and rat poisons whose use is not authorized (aldicarb) are the major agents that victimize children (Table 2). Accidents involving venomous animals are also of great importance, but they are not within the scope of the present study. By analyzing Brazilian data, we may speculate that there is a large number of understatements, and that nearly 1% of the population has some kind of exposure every year.1 Most cases treated by poison control centers are referred from health centers; in other words, poison control centers are not as much sought after by laypersons in Brazil as they are in industrialized countries.1 An important measure has been recently taken by the Brazilian National Health Surveillance Agency (ANVISA, 2005): the creation of the National Network of Information and Poison Control Centers (CIATs), which is in charge of approving the guidelines for the qualification of the centers in operation. Among the first measures is the availability of a hotline (0800) for all CIATs in the Brazilian territory, with an automatic regional search. Table 1 - General approach Whenever possible, the following should be determined: the product involved (pharmaceutical, non-pharmaceutical, or illicit drug); route of exposure (in most cases, a single product is ingested); the estimated dose (toxic or nontoxic); whether the exposure was unintentional or intentional (more serious), where it took place [at home, at the neighbor’s house, in a vacant lot, at parties (raves) ...] and who was in charge of the child (assess the possibility of maltreatment or Munchausen’s syndrome by proxy); how long ago exposure occurred (less or more than one hour ago); what measures were taken (induced vomiting; gastric lavage, often unnecessary, is performed and then the poison control center is contacted either during or after the procedure); patient health status (with or without clinical signs and symptoms); whether referral to an emergency room is necessary; whether the use of gastrointestinal decontamination is indicated in order to expedite poison elimination and whether the use of antidotes is recommended; whether it is necessary to carry out toxicological screening or specific blood tests which may help to establish the diagnosis and treatment.4,9 Qualitative toxicological lab tests are restricted to the clinical management of patients, but they should be considered for a possible identification of illicit (...truncated)