Accidental poisonings

Introduction, Defination, Scenario of Poisoining worldwide, Risk Factors, Ecology of Poisoining, Presenting features of common poisonings, Basic management of a poisoned patient, Emergency stabilization measures, Identification of poison, Removal of toxin, Eye/Dermai/Gut/Gastric lavage/ adsorbent administration/Catharsis, Specific antidotal therapy, Promotion of excretion of toxin, supportive therapy, prevention of poisoining, some specific poisons and antidotes-OP poisoining/Hydrocarbon poisoining/Barbiturate poisoining/Iron poisoining

1. Accidental Poisoning Presented by: Shalini Mehta Department of Child Health Nursing BPKIHS, Dharan

2. Introduction Children are curious and explore their world with all their senses, including taste. As a result, the home and its surroundings can be a dangerous place when poisonous substances are inadvertently ingested Acute exposure is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less.

3. Introduction… Chronic exposure is contact that lasts for many days, months or years. Most of the poisonings in children is accidental in nature . Accidental poisoning in children is a global problem. It is one of the leading causes of death in children. 10/20/2020 Shalini Mehta 3

4. Defination Poisoning is when cells are injured or destroyed by the inhalation, ingestion, injection or absorption of a toxic substance . Key factors that predict the severity and outcome of poisoning are the nature, dose, formulation and route of exposure of the poison; co-exposure to other poisons; state of nutrition of the child or (fasting status); age and pre-existing health conditions.

5. Scale of the problem Mortality In 2004, acute poisoning caused more than 45 000 deaths in children and youth under 20 years of age – 13% of all fatal accidental poisonings worldwide. In 16 high-income and middle-income countries, poisoning is the fourth biggest cause of unintentional injury after road traffic injuries, fires and drowning.

6. Scale of the problem… The rate of fatal poisoning is highest for children under one year, with another slight peak around 15 years. Fatal poisoning rates in low-income and middle-income countries are four times that of high-income countries. Africa and low-income and middle-income countries in Europe and the Western Pacific Regions have the highest rates.

7. Scale of the problem… Common poisoning agents in high-income countries include pharmaceuticals, household products (e.g. bleach, cleaning agents), pesticides, poisonous plants and bites from insects and animals. Common poisoning agents in low-income and middle income countries are fuels such as paraffin and kerosene, pharmaceuticals and cleaning agents.

8. Research Article Title : Pattern of acute poisoning in children in a tertiary care hospital in eastern Nepal By : Satish Yadav, Shankar Prasad Yadav, Jyoti Agrawal, Gaurishankar Shah in 2 July 2016 . Results : A total number of 64 children (36 males & 28 females) were admitted with acute poisoning. It constituted 3.4% of the total admissions and 4.4% of the total deaths. The maximum number of children 25 (39.1%) was of the age group 1 to 5 years . 10/20/2020 Shalini Mehta 8

9. Results… Fifty-one (79.7%) were admitted in Ward and 13 (20.3%) in Pediatric Intensive Care Unit (PICU) among which 4 (6.25%) patients were put in mechanical ventilation. The most common poison involved was organo - phosphorus compounds 24 (37.5%) followed by mushroom 16 (25%) and kerosene 11 (17.2%). Mean time interval between ingestion and admission to hospital was 6.87 ±8.33 hours. 10/20/2020 Shalini Mehta 9

10. Results… The majority of the poisoning 28 (44%) occurred between 2pm to 7 pm. Forty-nine (76.6%) of the poisonings were non-intentional and 14 (21.6%) were intentional. Average duration of hospital stay was 4.14±1.94 days and vomiting was the commonest clinical manifestation . Of all the patients, 28 (43.8%) received pre-referral treatment, 44 (68.8%) antidotes and 22 (34.4%) gastric lavage. 10/20/2020 Shalini Mehta 10

11. Conclusions : In our study, most of the poisoning was non-intentional and 1 to 5 years old children were at greater risk for poisoning . The main substance was organophosphorus . 10/20/2020 Shalini Mehta 11

12. Risk factors Young children are particularly susceptible to the ingestion of poisons, especially liquids, because they are very inquisitive, put most items in their mouths and are unaware of consequences. Adolescents , on the other hand, are more aware of the consequences of their actions but peer pressure and risk taking behaviour can lead them to misuse alcohol or illicit drugs, leading to a fatality rate higher than in younger children.

13. Risk factors … Younger children are more susceptible to poisoning because of their smaller size and less well-developed physiology, particularly as the toxicity of most substances relates to dose per kilogram of bodyweight. Most common agents involved in childhood poisoning: Over-the-counter preparations such as paracetamol, cough/ cold remedies, vitamins and iron tablets, antihistamines and anti inflammatory drugs.

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15. Risk factors … Prescription medications such as antidepressants, narcotics, analgesics and illicit drugs. Household products such as bleach, disinfectants, detergents, cleaning agents, cosmetics, vinegar. Paraffin/kerosene. 10/20/2020 Shalini Mehta 15

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18. Risk factors … Pesticides , including insecticides, rodenticides and herbicides. Poisonous plants. Animal or insect bites. Boys have higher rates of poisoning than girls in all regions of the world, probably because of differences in socialization.

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22. Risk factors … Fatal and non-fatal poisonings are strongly associated with lower socioeconomic status, between and within countries. The prevalence and types of poisoning vary in different parts of the world.

23. Risk factors … They depend on industrial development, agricultural activities, cultural practices relating to supervision of children and local beliefs and customs. For example, medicinal drugs are the leading cause of non-fatal poisoning in children in middle income to high-income countries, and ingestion of fuels such as kerosene is a common cause in low-income countries. 10/20/2020 Shalini Mehta 23

24. Risk factors … Other risk factors for poisoning include those related to the poisoning agent itself, including toxicity, nature, physical appearance and storage; season and weather conditions; policies, standards and laws governing the manufacture, labelling, distribution, storage and disposal of poisoning agents; and access to quality health care for treatment.

25. Ecology of poisoning Age: About 40 percent of all cases of accidental poisoning in children are reported in the second year of life; about 12 percent of the cases occur in the first and 20 percent in the third years. Large families: In large families, there may be carelessness in storage of potentially poisonous household substances. 10/20/2020 Shalini Mehta 25

26. Ecology of poisoning… Small accommodation: In smaller houses, there is little storage facility. Poisonous substances may be stored in easily accessible places. Environment: Lead poisoning is common in children living in areas where there are workshops for repair of old automobile lead storage batteries or for manufacture of lead typesets for printing presses . Rural or urban areas 10/20/2020 Shalini Mehta 26

27. Presenting features of common poisonings Seizures: Organochlorines, chlorinated hydrocarbons, cocaine, isoniazid, phenothiazine, carbon monoxide, theophylline Respiratory embarrassment: Narcotics, organophosphates, barbiturates, benzodiazepines Cardiac arrhythmias: Tricyclic antidepressants, amphetamine, aluminium phosphide, digitalis, theophylline, arsenic, cyanide, chloroquine. 10/20/2020 Shalini Mehta 27

28. features of common poisonings… Metabolic acidosis: Isoniazid, methanol, salicylates, phenformin, iron, cyanide. GIT disturbances: Organophosphorus, arsenic, iron, lithium, mercury. Cyanosis: Nitrobenzene compounds, aniline dyes, and dapsone. 10/20/2020 Shalini Mehta 28

29. Basic management of a poisoned patient: Antidotes are available for very few commonly encountered poisons, and treatment is usually non-specific and symptomatic. In such cases management consists of emergency first aid and stabilization measures, appropriate treatment to reduce absorption, measures to enhance life support followed by psychiatric counseling. 10/20/2020 Shalini Mehta 29

30. Emergency stabilization measures The unconscious patient should be transported in the head-down semi prone position to minimize the risk of inhalation of gastric contents. A clear airway is established and ventilation is maintained. Potentially serious abnormalities such as metabolic acidosis, hyperkalemia and hypoglycemia may require correction as a matter of urgency. Neurological assessment is made by calculating the Glasgow Coma Score (GCS). 10/20/2020 Shalini Mehta 30

31. Emergency stabilization measures… Many drugs and poisons can cause grand malconvulsions, which, if repeated, should be controlled with intravenous diazepam. Hypotension with peripheral circulatory failure is treated first by correction of hypoxia and acidosis, and by elevation of foot end of the bed. 10/20/2020 Shalini Mehta 31

32. Emergency stabilization measures… If adequate perfusion is not restored by these measures, the circulating volume should be increased by administration of plasma expander intravenously. Cardiac arrhythmias are often improved or abolished by correction of hypoxia, acidosis and electrolyte imbalance. 10/20/2020 Shalini Mehta 32

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34. Identification of poison Identify the poison by careful history and helpful clues. Determine what, when and how much of the poison was ingested or inhaled. Find the supporting evidence for your diagnosis from the nature of the symptoms and physical signs. 10/20/2020 Shalini Mehta 34

35. Removal of toxin The aim of decontamination procedures is to reduce the absorption of poison. It can be achieved by: Eye decontamination Ocular exposure to solvents, e.g. hydrocarbons, detergents and alcohol, or corrosive agents, e.g. acid or alkalis require immediate local decontamination. 10/20/2020 Shalini Mehta 35

36. Eye decontamination… This is achieved by copious irrigation with neutralizing solution (e.g. normal saline or water) for at least 30 minutes. Do not use acid or alkaline irrigating solution. 10/20/2020 Shalini Mehta 36

37. Dermal decontamination Absorption of organophosphorous and related compounds through cutaneous route can prove to be as fatal as oral route absorption. Remove all decontaminated clothes and irrigate the whole body including nail, groin, skinfolds with water or saline as soon as possible after exposure and continue irrigating for at least 15 minutes. Water should not be used to decontaminate skin in exposures to sodium and phosphorus. 10/20/2020 Shalini Mehta 37

38. Gut decontamination This includes gastric evacuation, adsorbent administration and catharsis. Emesis is the preferred method of emptying the stomach in conscious children. Induction of vomiting is contraindicated in corrosive or kerosene poisoning and in comatose patients or those with absent gag reflex. 10/20/2020 Shalini Mehta 38

39. Gastric lavage If the vomiting does not occur quickly, gastric lavage should be done promptly to remove the poison. In a symptomatic but alert child with minor ingestion, activated charcoal alone by mouth is sufficient for gastrointestinal decontamination. 10/20/2020 Shalini Mehta 39

40. Adsorbent administration An agent capable of binding to a toxic agent in the GIT is known as adsorbent. Activated charcoal is the most widely used adsorbent. For the comatosed child with potentially serious overdose, gastric lavage is followed by administration of activated charcoal via an orogastric or nasogastric tube within 1-2 hours of ingestion. Dose of activated charcoal administered should be at least 10 times the dose of ingested toxic material. 10/20/2020 Shalini Mehta 40

41. Catharsis Laxative and purgatives may be given in poisoning with substances which do not cause corrosive action on gastrointestinal mucosa. Increased motility of may reduce absorption. Commonly used cathartics include sorbitol and mannitol (1-2 g/kg), and magnesium or sodium sulfate (200-300 mg/kg). Do not give magnesium salt cathartics in cases with renal failure. 10/20/2020 Shalini Mehta 41

42. Specific antidotal therapy Specific antidotes may be lifesaving but unfortunately they are not often available and are effective for less than 5% of poisoning cases. Chemical antidotes combine with the poison and render it innocuous. 10/20/2020 Shalini Mehta 42

43. Promotion of excretion of toxin Forced diuresis Diuresis alone has relatively little effect on drug elimination because at best the renal clearance is only proportional to the urine flow rate. In the cases of drugs which are weak organic acids and bases, a much greater effect on clearance can be obtained by manipulation of the urine pH. 10/20/2020 Shalini Mehta 43

44. Supportive therapy Keep the airway open, give oxygen for inhalation and be prepared for intermittent positive pressure respiration. Fluid and electrolyte balance is maintained. Circulatory failure should be managed to sustain life. 10/20/2020 Shalini Mehta 44

45. Supportive therapy… Anemia is treated with packed cell transfusion. Severe convulsions and status epilepticus are treated with diazepam or midazolam. Renal failure is managed as per standard protocol; dialysis may be needed . Infections are treated with antibiotics. Fever and pain are relieved with antipyretics and analgesics. 10/20/2020 Shalini Mehta 45

46. Prevention of poisoning Protection of the child from the poisonous substances. Education of parents about the potential household poisons. Need for parental supervision. 10/20/2020 Shalini Mehta 46

47. Prevention of poisoning… Safety regulations by the state should be enforced. Establishment of the poison control centers to collect, compile and disseminate information on poisons and their management. These should promote research on prevention and treatment. 10/20/2020 Shalini Mehta 47

48. Some specific poisons and antidotes 10/20/2020 Shalini Mehta 48

49. ORGANOPHOSPHOROUS COMPOUNDS AND CARBAMATES Organophosphorus compounds and Carbamates are used as insecticides in agriculture and in domestic usage. Some of the commonly used compounds are Organophosphosohates: Tetraethyl pyrophosphate (TEPP), Ethyl parathion, Dichlorofos, Fenthion (Baytex), Malathion, Temephos (Abate), Endosulphan (Endrin) Carbamates: Methocarb (Nudrin), Propoxur (Baygon), Carbaryl (Sevin) 10/20/2020 Shalini Mehta 49

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54. Clinical Features Muscarinic effect: This is characterized by excess salivation, lacrimation, urination and diarrhea. The pupils are pinpoint and there is marked bradycardia. GI symptoms consist of nausea, vomiting, pain abdomen and diarrhea. Tightness of chest , bronchospasm, wheezing and pulmonary edema may occur. 10/20/2020 Shalini Mehta 54

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56. Clinical Features… Nicotinic effects: These are seen in severe poisoning chiefly causing muscle twitching, fasciculation, and cramps followed by muscle weakness and paralysis particularly of the respiratory muscles. 10/20/2020 Shalini Mehta 56

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58. Clinical Features… Central effects: These are seen in severe cases and include restlessness, confusion, headache, slurred speech, ataxia, seizures and coma. The signs and symptoms of Carbamates are similar except that they are milder and of short duration. 10/20/2020 Shalini Mehta 58

59. Diagnosis History and typical clinical findings. The RBC cholinesterase level is less than 50% in cases where exposure has occurred and less than 20% in case symptoms are present. X-ray chest may be required to document the presence of pulmonary edema. 10/20/2020 Shalini Mehta 59

60. Management Further exposure to the insecticide must be avoided by moving to a safer environment. The clothes to be removed and skin to be washed with adequate amount of soap and water. If ingested, gastric decontamination should be done. If conscious, by vomiting followed by lavage, and if unconconcious by lavage after protecting the airway with a ET tube. 10/20/2020 Shalini Mehta 60

61. Management… Activated charcoal slurry can be left in the stomach after lavage. Atropine is the specific antidote which neutralizes the CNS and Muscarinic effect but not the Nicotinic effect. It is given in a loading dose of 0.02-0.05mg/Kg followed by maintenance dose of the same dose every 10-30 min. Child should be watched for signs of Atropinisation in the form of dryness of mouth, dry skin, decrease in bronchial secretions, pupillary dilatation and tachycardia. 10/20/2020 Shalini Mehta 61

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63. Management… The patient is kept Atropinised till the enzymes regenerates or is reactivated. Pralidoxime, a cholinesterase enzyme reactivator is a specific antidote for Organophosphorus compounds. Enzyme activation occurs most rapidly at the neuromuscular junction with rapid restoration of skeletal muscle response. The Muscarinic or central effects are not significantly reversed with this drug and hence concomitant use of atropine is essential. 10/20/2020 Shalini Mehta 63

64. Management… The dose of Pralidoxime is 25-50 mg/Kg for a child less than 12 years and for children above 12 years adult dose of 1-2 gm is given over 15 to 30 min IV followed by repeat dose after 1-2 hours. Following recovery the child should be observed closely for 24 to 48 hours to ensure that cholinergic signs do not recur as Pralidoxime and Atropine effects wear off. 10/20/2020 Shalini Mehta 64

65. Management… Intermediate syndrome can develop 24 to 96 hours after Organophosphorus poisoning which is characterized by weakness in the proximal motor muscles, motor cranial nerves, neck flexors and respiratory muscles. A combination of pre-synaptic and post synaptic impairment of neuromuscular transmission probably causes this syndrome. Enzyme activation has no role in Carbamates poisoning and may be harmful. 10/20/2020 Shalini Mehta 65

66. Symptoms : Muscarinic - Skin, Resp., Pupils, GIT, Urinary Nicotinic - Skeletal muscles, Resp. muscles CNS- Confusion, coma Management : Decontamination of Surface and GIT Atropinisation, Pralidoxime 10/20/2020 Shalini Mehta 66

67. Management of OP Poisoning in Children (BPKIHS) Inj. atropine 0.05mg/kg IV every 5-10 minutes till full atropinization (the best sign of atropinization is chest devoid of any secretions , detected by chest auscultation. i.e. end point of atroponization is clear chest on auscultation ). Once patient is atropinized give the maintenance dose at 0.08mg/kg/hour. Decrease the dose of atropine by 0.02 mg/kg every 12-24 hours till it reaches 0.02 mg/kg/hr. (Range of atropine infusion: 0.02-0.08mg/kg/ hr ). Once the infusion reaches 0.02mg/kg/ hr then stop atropine infusion. Also pralidoxime should be given. 10/20/2020 Shalini Mehta 67

68. Hydrocarbon poisoning 10/20/2020 Shalini Mehta 68 SOURCES Petrol Kerosene Lighter Fluid Paraffin Oil 2 Stroke Fuel Diesel Fuel Solvents White Spirit Lubricating Oil Furniture Polishes Essential oils Mineral Turpentine

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71. Risk Assessment History   Was exposure intentional or accidental?   Dose: Type of compound Quantity ingested Duration of exposure in inhalation Co- ingestants (eg paracetamol) 10/20/2020 Shalini Mehta 71

72. Examination Respiratory Coughing / gagging / choking indicates aspiration Wheeze, tachypnoea, hypoxia, hemoptysis and pulmonary edema are signs of evolving chemical pneumonitis . Cardiovascular Dysrhythmias occur early in exposure 10/20/2020 Shalini Mehta 72

73. CNS CNS depression, coma and seizures may occur with large acute exposures. Onset is usually within 2 hours GIT Nausea, vomiting and diarrhoea Excessive burping, heartburn, epigastric pain 10/20/2020 Shalini Mehta 73

74. Acute Management 1 . Resuscitation Standard procedures and supportive care  Intubate early for progressive CNS depression Ventricular dysrhythmias: Commence advance life support Intubate , hyperventilate, correct hypoxia Correct electrolyte disturbances Withhold catecholamine inotropes if possible  10/20/2020 Shalini Mehta 74

75. Seizures – Benzodiazepines remain standard first line treatment. Chemical pneumonitis is managed supportively (Oxygen & bronchodilators – may require non invasive ventilation or intubation if severe).  Fever is common following aspiration with pneumonitis – antibiotics should be withheld until there is objective evidence of bacterial infection 10/20/2020 Shalini Mehta 75

76. 2. Decontamination Activated charcoal is  specifically contraindicated  in hydrocarbon poisoning as they do not bind hydrocarbons and increase the risk of hydrocarbon aspiration. Ongoing care and monitoring Asymptomatic children with normal vital signs should be observed for 6 hours post exposure before discharge Patients with milder respiratory or CNS symptoms should be admitted for a longer period of observation +/- supportive care. 10/20/2020 Shalini Mehta 76

77. BARBITURATE Poisoning is likely to occur in children who suffer from epilepsy or where a family member is on such medication. Ingestion of over 1 gm of any barbiturate should be viewed with concern and over 3 gm is potentially lethal. 10/20/2020 Shalini Mehta 77

78. Clinical Features The clinical features are characterized by CNS depression. The respiration may be shallow and progress to respiratory arrest. Hypotension occurs with severe poisoning and the pupils are constricted but later dilate. There is loss of light and corneal reflex. The bullous lesions on the skin are more due to pressure effects on the skin rather than toxicity due to the drug. 10/20/2020 Shalini Mehta 78

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80. Clinical Features… On recovery there is headache, dizziness, diplopia, ptosis and ataxia. Cause of death in barbiturate poisoning is due to respiratory arrest. Serum levels of barbiturate are useful in confirming toxicity with levels more than 10 mg/dl for long acting, 7 mg for intermediate acting and more than 3 mg for short acting drugs considered to be in the toxic range. EEG changes correlate with severity with fast activity in mild poisoning to slowing and progressing to flat EEG with severe poisoning. 10/20/2020 Shalini Mehta 80

81. Treatment Gastric lavage is useful if done within 6 hours of ingestion. Activated charcoal adsorbs barbiturates and is used as slurry after the lavage. Supportive treatment for respiratory failure, hypotension and hypothermia is to be provided. Forced alkaline diuresis enhances drug excretion. 10/20/2020 Shalini Mehta 81

82. IRON Iron is an important toxicological hazard because of easy availability and bright coloured formulations. Ingestion up to 25 mg/Kg of elemental iron does not cause any problem. Higher ingestions are potentially serious. 10/20/2020 Shalini Mehta 82

83. Clinical Features The earliest symptoms of Iron ingestion are nausea, vomiting and diarrhea with onset within 30 min and up to 6 hrs post ingestion. Following this is a quiescent phase. Subsequently, GI losses due to increased capillary permeability and systemic effect in tissues causing metabolic acidosis and myocardial dysfunction lead to circulatory failure characterized by shock. 10/20/2020 Shalini Mehta 83

84. Clinical Features… Thrombocytopenia and hypoprothrombinemia may also occur. Hepatocellular necrosis leading to hepatic failure is a significant cause of mortality. The corrosive effect of iron leads to gastric scarring causing outlet obstruction as a late feature of the poisoning. 10/20/2020 Shalini Mehta 84

85. Toxic dose: More than 25 mg/Kg or serum levels above 300 mcg/dl Symptoms: GI symptoms (Vomiting & diarrhea), shock, hepatic failure Management: General measures-lavage, bowel wash, IV fluids, Inotropes Antidote: Desferroxamine 10/20/2020 Shalini Mehta 85

86. Lab Investigations Serum level of iron greater than 300 mcg/dl are associated with toxicity and levels greater than 500 mcg/ dl are considered severe poisoning and levels above 1000 mcg/dl are invariably fetal. Blood glucose may be elevated and liver functions may be derranged. X-ray abdomen may be valuable prior to and after lavage to see the quantum of radio opaque tablets if ingested. 10/20/2020 Shalini Mehta 86

87. Treatment Ingestion up to 25 mg/Kg of elemental iron need not be treated. Children if symptomatic or with serum levels above 300 mcg/dl may be managed with specific antidote. All other children should receive general measures of poison management. Lavage is indicated even if emesis has occurred though the iron tablets may have become a gel in the acid medium of the stomach and not likely to be fully removed even with lavage. 10/20/2020 Shalini Mehta 87

88. Treatment… 100 ml of Milk of Magnesia or 100 ml of Soda bi carb may be left in the stomach after lavage. Bowel irrigation with Polyethylene glycol may be useful in Iron elimination from the GI tract. The excretion of free circulating iron can be enhanced by chelating with Desferroxamine, the complex of Desferroxamine-Iron being more water soluble gets excreted by the kidney. 10/20/2020 Shalini Mehta 88

89. Treatment… Desferroxamine is added to normal saline and infused at the rate of 15 mg/Kg/hr. The Desferroxamine-iron complex colours the urine a distinct pink(vin-rose) hue to the urine. The infusion is continued for a period of 24 hrs after the urine becomes clear or the serum Iron level is below 300 mcg/dl. 10/20/2020 Shalini Mehta 89

90. Treatment… The child may require supportive therapy in the form of IV fluids, inotropic support, maintaining glucose levels and correction of the metabolic acidosis. Gastrostomy may be required if radiological visualization confirms persistence of large number of radio opaque shadows even after lavage . Hemodialysis is not useful unless associated renal failure is present. 10/20/2020 Shalini Mehta 90

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92. Title: Hospital Based Study of Poisoning Among Children, 1 to 18 Years of Age in Eastern Nepal By: Rimal HS et al; May 2017 Birat Journal of Health Sciences Introduction: The poisoning among children had been a major cause of hospital admission and also a significant global health problem throughout the world including Nepal. There are various studies suggestive of incidence rate of poisoning in children ranging from 0.74% to 3%. In older children, poisoning is usually intentional where as in infants and younger children it is accidental in nature. There are few studies done in Nepal and they are mainly from Kathmandu valley, this study will add more information from eastern region of Nepal. 10/20/2020 Shalini Mehta 92

93. Objective: This study aimed to find out the type of poisoning among children and adolescents, manner of poisoning and its outcomes . 10/20/2020 Shalini Mehta 93

94. Methodology: This was a retrospective study carried out at Nobel Medical College Teaching Hospital over a period of one year starting from 1 August 2014 to 31July 2015 . This study included all the children and adolescents of 1 to 18 years of age admitted to pediatric ward and ICU for the management of poisoning . The information including name of poisons, manner of poisoning, socio-economic and demographic factors related to poisoning, geographical distribution of sample population, durations of hospital stay and outcome of treatment were retrieved from the records. The data was analyzed using SPSS. 10/20/2020 Shalini Mehta 94

95. Results: A total of 64 cases were studied. It included almost the same number of males (n=31) and females (n=33). The age group of 13-18 years had the largest prevalence of poisoning (n=22). Organo-phosphorus (n=25) was the commonest poison. 10/20/2020 Shalini Mehta 95

96. Results… As the study was conducted in a tertiary care center of eastern Nepal located at Biratnagar, Morang district, a majority of the cases (39) were from Morang. A total of 41% children required hospital stay for more than 7 days where as 37% of them required 5-7 days of hospital stay and only 22% children stayed for 1-4 days in the hospital. No mortality was noted. 10/20/2020 Shalini Mehta 96

97. Conclusion: The pediatric poisoning in eastern Nepal is a significant public health issue and nature of poisoning was accidental followed by suicidal. The commonest age group involved is adolescence, which highlights the need for education and implementation of suicidal prevention program in this region. The higher prevalence of accidental poisoning in first two year of life necessitates the need of child safety and injury prevention program in the community 10/20/2020 Shalini Mehta 97

98. 10/20/2020 Shalini Mehta 98 Any Query?

99. References Ghai, O.P., Ghai Essential Pediatrics, 6 th edition, CBS Publishers and distributors; 2007 Gupta, Piyush, Textbook of Pediatrics, 1st edition, CBS publishers, New Delhi, 2013 Mayo Clinic. 2020.  Poisoning: First Aid . [online] Available at: <https://www.mayoclinic.org/first-aid/first-aid-poisoning/basics/art-20056657> [Accessed 17 October 2020 ].   Who.int. 2020.  WHO | Poisoning . [online] Available at: <https://www.who.int/environmental_health_emergencies/poisoning/en/> [Accessed 17 October 2020]. 10/20/2020 Shalini Mehta 99

100. Melbourne, T., 2020.  Clinical Practice Guidelines : Poisoning - Acute Guidelines For Initial Management . [online] Rch.org.au. Available at: <https://www.rch.org.au/clinicalguide/guideline_index/Poisoning_-_Acute_Guidelines_For_Initial_Management/> [Accessed 18 October 2020 ]. Rwimal, H., Tiwari, U., Ghimire , K. and Thapa , M., 2017. Hospital Based Study of Poisoning Among Children, 1 to 18 Years of Age in Eastern Nepal.  Birat Journal of Health Sciences , [online] 2(1), pp.138-141. Available at: <https://www.researchgate.net/publication/316840255_Hospital_Based_Study_of_Poisoning_Among_Children_1_to_18_Years_of_Age_in_Eastern_Nepal> [Accessed 15 October 2020]. 10/20/2020 Shalini Mehta 100

101. References… Dhakal , A., Shrestha, D., Shakya , A., Shah, S. and Shakya , H., 2014. Clinical Profile of Acute Poisoning in Children at a Teaching Hospital in Lalitpur.  Journal of Nepal Paediatric Society , [online] 34(2), pp.100-103. Available at: <https://www.researchgate.net/publication/267927778_Clinical_Profile_of_Acute_Poisoning_in_Children_at_a_Teaching_Hospital_in_Lalitpur> [Accessed 15 October 2020 ]. Yadav, S., Yadav, S., Agrawal, J. and Shah, G., 2016. Pattern of acute poisoning in children in a tertiary care hospital in eastern Nepal.  International Journal of Contemporary Pediatrics , [online] pp.1001-1005. Available at: <https://www.ijpediatrics.com/index.php/ijcp/article/view/61> [Accessed 15 October 2020]. 10/20/2020 Shalini Mehta 101

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