Poisoning in Children
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Direct answer
Kerosene stored in a soft-drink bottle is the prototype of Indian childhood poisoning — a boy under five, a household hydrocarbon, and two forbidden treatments: no induced vomiting, no gastric lavage, because reflux into the lungs causes the pneumonitis that actually kills. Airway, breathing, circulation and glucose come first in every ingestion; activated charcoal 1 g/kg helps only within about an hour and only for drugs it binds (it fails for hydrocarbons, corrosives, iron, lithium and alcohols). The antidote shelf earns its marks: atropine and pralidoxime for organophosphates, deferoxamine for iron, N-acetylcysteine for paracetamol, and 100 per cent oxygen for carbon monoxide — while aluminium phosphide, the grain-tablet poison of rural India, has no antidote and a grim mortality managed supportively.
What you must remember
- Epidemiology pattern: boys under five, at home, oral route; Indian series lead with kerosene and hydrocarbons, then medicines (iron, paracetamol), pesticides, naphthalene and corrosives — the container travels with the child.
- Decontamination doctrine: activated charcoal 1 g/kg once within the first hour for bound drugs; gastric lavage only within an hour, for potentially lethal ingestions, with a protected airway — contraindicated for hydrocarbons, corrosives and the convulsing child.
- Kerosene/hydrocarbon protocol: observe for tachypnoea, cyanosis, fever; chest radiograph even if asymptomatic (infiltrates, typically right lower and mid-zone, lag hours); no prophylactic steroids or antibiotics.
- Organophosphate poisoning: muscarinic DUMBBELS (diarrhoea, urination, miosis, bronchorrhoea, bradycardia, excess secretions, lacrimation) plus nicotinic fasciculations and weakness; atropine 0.02-0.05 mg/kg intravenously every five minutes until secretions dry (pupils and tachycardia are not endpoints), then infusion; pralidoxime 25-50 mg/kg slow loading then infusion for nicotinic features; watch the intermediate syndrome of respiratory weakness at 24-96 hours.
- Iron: four-stage illness (gastrointestinal, quiescent, shock/acidosis, obstructive) — serum iron above roughly 350-500 micrograms/dL or symptoms warrant deferoxamine 15 mg/kg/hour intravenously; tablets are radiopaque on abdominal radiograph.
- Paracetamol: N-acetylcysteine is nearly completely protective within 8-10 hours of ingestion; use the four-hour level with the Rumack-Matthew nomogram — intravenous 150 mg/kg over one hour, then 50 mg/kg over four, then 100 mg/kg over sixteen.
- Corrosives (acids and alkali): dilute with water or milk, never neutralise (exothermic injury), no lavage, no emesis; endoscopy within 6-24 hours grades injury — alkali liquefaction causes deep oesophageal necrosis with later strictures.
- Others worth one mark each: aluminium phosphide (garlicky breath, refractory shock, no antidote — magnesium sulphate and supportive care); naphthalene haemolysis in G6PD deficiency; oesophageal button battery — endoscopic emergency; multiple magnets — perforation risk; lead (surma, paint) chelated with DMSA or CaNa2EDTA; carbon monoxide — 100 per cent oxygen.
The toddler and the blue bottle
An 18-month-old is found coughing beside an open kerosene bottle; he smells of the solvent and vomited once spontaneously. Resist the reflex to "wash the stomach". Examine: rate 42, saturation 95 per cent, mild recession. Order the radiograph despite wellness, observe 24 hours, and treat falling saturation with oxygen — steroids and prophylactic antibiotics are not indicated. Counsel on storage — locked, high, never in drink bottles. The same hour, a farmer's child arrives dusky, drooling, with pinpoint pupils, bradycardia and crackles — organophosphate until proven otherwise: suction, oxygen, atropine 0.05 mg/kg intravenously immediately and five-minutely until the chest dries, pralidoxime slowly, then monitoring for the intermediate syndrome, with clothes bagged and skin washed to protect staff.
Where students slip
The reflex punished hardest is "empty the stomach" — modern toxicology decontaminates rarely, and late lavage for hydrocarbons or corrosives converts a survivable ingestion into aspiration or perforation. Second slip: atropine endpoints — dosing to pupil dilation or heart rate causes atropine toxicity; the endpoints are drying of secretions and improved ventilation. Third: charcoal omniscience — charcoal does not bind iron, hydrocarbons, alcohols, acids or alkalis, and the question plants a kerosene or iron ingestion with a "give charcoal" option. Fourth: timing nihilism with paracetamol — the nomogram needs a four-hour level, and N-acetylcysteine still works, less perfectly, started late.
Frequently asked questions
Why is gastric emptying contraindicated in kerosene ingestion?
Kerosene has low systemic toxicity but high aspiration potential — vomiting or lavage risks chemical pneumonitis, the actual killer, so care is observation, radiography and respiratory support.
What is the dosing of activated charcoal and when is it useless?
One gram per kilogram as a single dose within about an hour of ingestion; useless for hydrocarbons, corrosives, iron, lithium and alcohols, which charcoal does not adsorb.
How is organophosphate poisoning treated?
Airway and suction first; atropine 0.02-0.05 mg/kg every five minutes titrated to dry secretions (not pupil size), then infusion, plus pralidoxime 25-50 mg/kg slow loading then infusion — watching for the intermediate syndrome.
When is deferoxamine given in iron poisoning?
With symptomatic poisoning, serial levels above roughly 350-500 micrograms/dL, metabolic acidosis or radiopaque tablets — 15 mg/kg/hour intravenously, producing the vin rose urine when iron-chelate is excreted.
What is the antidote and timing window for paracetamol poisoning?
N-acetylcysteine, virtually fully protective within 8-10 hours of ingestion, dosed by weight intravenously over 21 hours in three sequential infusions, guided by the four-hour Rumack-Matthew level.