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Age-specific features of acute poisoning treatment

 
, medical expert
Last reviewed: 07.07.2025
 
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Features of intensive care of acute poisoning in children

The peculiarities of resuscitation and intensive care in children are associated with quantitative and qualitative differences between the adult and child organism. These differences are most obvious in early childhood (up to 5 years) and are due to significant features of metabolic processes (in particular, water-salt metabolism), increased membrane permeability (BBB and endothelium of blood vessels), nervous and humoral regulation of the functions of the cardiovascular system and excretory organs (liver, kidneys).

The common opinion about the "imperfection" of the child's body and its low tolerance to poisons as the cause of a more severe clinical course of poisoning in childhood is fundamentally wrong. The influence of the age factor on the resistance and adaptive capabilities of the body in acute poisoning has not been sufficiently studied at present. Nevertheless, based on clinical toxicometry data, when comparing the main hemodynamic parameters (stroke volume, minute volume, total peripheral vascular resistance) in children aged 1-3 years and adults with the same concentration of barbiturates in the blood, children were noted to have greater resistance of the cardiovascular system to the action of the toxic substance than adults. A study of the autonomic nervous system in the same groups of patients showed that adults and children have unidirectional changes in autonomic homeostasis in the form of pronounced hypersympathicotonia caused by an increase in the activity of the sympathetic division of the autonomic nervous system and the suppression of the parasympathetic. However, in children, the degree of tension of compensatory-adaptive mechanisms was less pronounced than in adults. This phenomenon can be explained by the anatomical and physiological characteristics of the cardiovascular and autonomic nervous system of young children.

It is well known that the body has increased tolerance in the early neonatal period to the effects of many poisons that have a stimulating effect on the central nervous system (strychnine) or that acquire toxicity as a result of "lethal synthesis" due to the insufficient development of certain enzyme systems in children (organophosphorus substances, methyl alcohol, ethylene glycol, etc.). It is known that children have higher renal clearance of most water-soluble poisons.

The opinion about the more severe course of poisoning in children is based on a number of circumstances. Firstly, 60-73% of all poisonings in children are caused by drugs, more than half of which are psychotropic substances that have a depressing effect on the vegetative functions of the central nervous system, tolerance to which is significantly reduced in young children. Children are usually deprived of the specific and non-specific tolerance to narcotic substances (alcohol, drugs, etc.) acquired by adults, and therefore the clinical picture of poisoning develops much faster with a predominance of the state of stupor and coma.

Secondly, it is necessary to take into account the more intense nature of somatogenic reactions to “chemical trauma”, which depend on the increased reactivity of the child’s body and the more rapid development of some complications, such as toxic cerebral edema.

The nature of treatment measures for acute poisoning in children does not differ fundamentally from the complex method of combating poisoning in adults. The main attention of the doctor, as a rule, is directed at the fastest and most effective removal of the toxicant from the body using methods of enhancing natural detoxification, artificial detoxification, as well as specific therapy using antidotes and therapy for dysfunction of vital organs and systems.

In foreign literature, there are discussions about the preference of using ipecac or apomorphine to artificially induce vomiting in children. In our country, these substances are not used due to the obvious danger of aspiration complications. In addition, apomorphine suppresses the respiratory center in small children. Therefore, among the methods of cleansing the gastrointestinal tract, the most popular is gastric lavage. Gastric lavage is considered appropriate if the child has clinical manifestations of poisoning characteristic of the toxicogenic phase.

Young children must be immobilized (swaddled) before lavage. In children with suppressed pharyngeal reflexes and in a comatose state, the procedure is performed after preliminary tracheal intubation.

To wash out the stomach, use drinking water at room temperature.

In case of poisoning with caustic liquids, gastric lavage through a tube is mandatory in the first hours after ingestion of the poison. The presence of blood in the lavage waters does not serve as a contraindication for this procedure. In these cases, the tube is generously lubricated (along its entire length) with vaseline oil before insertion into the stomach, 0.1 ml per year of life of a 1% solution of trimeperidine or omnopon is administered subcutaneously. Neutralization of acid in the stomach with an alkali solution is not effective, and the use of sodium bicarbonate for this purpose significantly worsens the child's condition due to significant expansion of the stomach by the formed carbon dioxide. Laxatives are not administered in case of poisoning with caustic poisons, vegetable oil is given orally 4-5 times a day (children under 3 years old - 1 teaspoon, from 3 to 7 years old - a dessert spoon, over 7 years old - a tablespoon).

In case of poisoning with KMnO4 crystals, a 1% solution of ascorbic acid is used to cleanse the mucous membranes of the lips, oral cavity, and tongue from brown-black plaque.

In case of poisoning with gasoline, kerosene and other petroleum products, before rinsing the stomach, it is necessary to introduce 20-50 ml of Vaseline oil (or 3 ml per 1 kg of the child’s body weight), and then rinse according to the usual scheme.

To adsorb substances in the gastrointestinal tract before and after gastric lavage, activated carbon (or other adsorbents) is used at a rate of 1 g/kg of body weight for children under 5 years of age and 0.5 g/kg for children over 5 years of age.

Cleansing the intestines is of great importance in treating poisoning in children. For this purpose, laxatives are used - saline in a dose of 0.5 g / kg or, in case of poisoning with fat-soluble substances, vaseline oil (3 ml / kg). In addition, cleansing enemas are used to empty the intestines.

The method of forced diuresis is widely used to remove toxic substances from the bloodstream in children. As in adult patients, this method is indicated for most cases of poisoning with water-soluble poisons, when their elimination is carried out mainly by the kidneys.

Depending on the severity of the condition, forced diuresis is presented in the form of an oral water load or intravenous administration of solutions.

In case of mild poisoning, the oral water load in children is carried out at the rate of 5-6 ml/(kg h). In case of moderate poisoning, the amount of liquid is increased to 7.5 ml/(kg h). The water load is carried out during the toxicogenic stage of poisoning. For this, 5-10% glucose solutions, electrolytes, as well as drinking water, juice, mineral water, etc. are used. If the child refuses to take liquid, reacts negatively to the staff, etc., the water load is carried out through a tube. To do this, a thin tube is inserted into the stomach, secured with adhesive tape and the required amount of liquid is administered in small portions (30-50 ml). If the patient is admitted in a serious condition, forced diuresis is carried out in the form of intravenous infusions at a rate of 8-10 (up to 12) ml/(kg h). Short-acting hemodilutants are used (0.9% isotonic sodium chloride solution, Ringer's solution, 5-10% glucose solutions). The ratio of administered non-electrolytes and electrolytes in children under 1 year is 3:1, from 1 year to 5 years - 2:1, and over 5 years - 11. If the applied hemodilution does not provide a sufficient increase in diuresis, then diuretics are used - furosemide 1-3 mg / kg, mannitol - 1-2 g of dry matter per 1 kg of body weight. In this case, it is necessary to monitor the electrolyte content and constantly administer an intravenous electrolyte solution in an amount equal to hourly diuresis.

In the treatment of acute poisoning with barbiturates, salicylates and other chemicals whose solutions have an acidic reaction, as well as in the treatment of poisoning with hemolytic poisons, alkalization of plasma in combination with forced diuresis is indicated.

Taking a large amount of the drug, a rapid increase in symptoms of poisoning, as well as the lack of a positive effect from methods of enhancing natural detoxification processes serve as an indication for the use of artificial detoxification methods in children.

Blood replacement surgery (BRS) is one of the simplest, but least effective detoxification methods used in pediatric practice.

Indications for the use of OZK in children are mainly poisoning with substances that cause toxic damage to the blood - the formation of methemoglobin and massive hemolysis, as well as severe poisoning with drugs in the absence of the possibility of using more intensive detoxification methods - hemosorption and HD.

For blood replacement, single-group Rh-compatible individually selected donor blood is used. A positive effect is observed after replacement of 25% of the BCC (BCC = 70-75 ml x kilogram of body weight).

Optimally, 1 BCC is replaced. The speed of the operation should be 25-30% of the BCC per hour. When using donor blood containing sodium citrate, 10 ml of 4% sodium bicarbonate solution and 1-2 ml of 10% calcium gluconate solution are administered intravenously for every 100 ml of transfused blood. Antihistamines, hormones, and oxygen inhalations are prescribed as indicated. Among the methods of artificial detoxification, the most effective is hemosorption, which is widely used in the treatment of many types of poisoning in children. The main contraindications for hemosorption in children are decreased blood pressure, especially with a decrease in total peripheral resistance.

In recent years, HD using an "artificial kidney" apparatus has become more common in the treatment of poisoning with dialysis agents in children. Indications for its use are no different from those for adults. In addition, an absolute indication for HD is the anuric phase of acute renal failure resulting from poisoning.

To enhance the overall effect of detoxification, it is possible to use the above methods in combination.

In the treatment regimen for acute drug poisoning in children, specific antidote pharmacotherapy is carried out according to the same rules as in adults, namely, differentiated depending on the stage and severity of the disease. In the toxicogenic stage of poisoning, antidote therapy is based on generally accepted indications with strict adherence to the age-appropriate dosage of drugs.

Infusion therapy and other symptomatic measures also have no characteristic features, except for obvious adjustments for the patient's age and body weight. Treatment of children with acute poisoning should be carried out in pediatric intensive care units.

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Features of intensive care of acute poisoning in the elderly

In old and senile age, due to a decrease in the body's adaptive capacity, the clinical course of poisoning acquires certain features that have a noticeable impact on the outcome of the disease and the nature of the intensive therapy.

Slow and sluggish development of the main pathological syndromes of acute poisoning, frequent addition of intercurrent diseases and exacerbation of chronic ones are typical for elderly and senile patients. For example, pneumonia in such patients is observed 2 times more often than in young patients, and acute cardiovascular failure in the somatogenic stage of poisoning ("secondary somatogenic collapse") - more than 3 times more often. Accordingly, the recovery period is slower, and the transition to a chronic course of the disease is more often observed (with chemical burns of the esophagus and stomach, toxic liver dystrophy and nephropathy).

At the same time, in elderly and senile individuals, acute stress conditions in response to chemical trauma occur less frequently and at a later time. For example, the development of exotoxic shock in case of poisoning with caustic liquids is noted only in 10.2% of elderly patients (compared to 17.6% in young patients).

Particular attention should be paid to the reduction of tolerance of elderly patients to various toxic substances, as evidenced by the sharp decrease in critical and irreversible levels of toxic substances in the blood, to such an extent that at the age of over 70 years they decrease by 10 or more times, and the threshold levels of concentration in the blood of many poisons are already little different from critical.

Therefore, the choice of treatment methods for these patients requires a strictly individual approach. First of all, this concerns the volume of infusion therapy. Fluid overload of the cardiovascular system in elderly patients is very dangerous due to the rapid development of hyperhydration, OL, cavitary and peripheral edema and other signs of circulatory failure. This is caused by a decrease in the contractility of the myocardium, a decrease in the filtration function of the kidneys, etc. As a result, they need to conduct more careful monitoring of the main indicators of central and peripheral hemodynamics, acid-base and osmotic state, the content of basic electrolytes in plasma, hourly diuresis and body weight.

Infusion therapy in the first 2-3 hours after poisoning is carried out at a rate of 5-6 ml/min, then, with an increase in diuresis and a decrease in CVP, it can be increased to 15-20 ml/min so that CVP remains within 80-90 mm H2O.

When choosing diuretics, preference is given to furosemide, which is administered in fractional doses of 50-80 mg 3-4 times with an interval of 1 hour, which allows maintaining a stable hourly (300-500 ml/h) and daily diuresis (4-5 l). The composition of the electrolyte solution used must include a glucose-potassium mixture and potassium and magnesium aspartate.

Of the methods of extrarenal body cleansing in elderly people, the most acceptable are intestinal lavage, veno-venous GF, and PD, which does not cause noticeable hemodynamic disturbances if performed correctly. The volume of dialysate simultaneously introduced into the abdominal cavity should not exceed 1.0-1.5 l, and patients in a comatose state must undergo artificial respiration throughout the entire period of the operation. To prevent fluid retention in the abdominal cavity, the glucose content in the dialysate is increased (by 20-30%).

All other types of artificial detoxification are used as methods of choice when the concentration of poisons in the blood is significantly lower (approximately 10 times lower).

Conducting drug therapy in elderly patients requires special care and consideration of individual drug tolerance.

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