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MNJ17-001
A 2-year-old boy brought in by neighbor after grandmother stated he was "not acting right". Grandmother is on antihypertensive medication. Examination shows a lethargic toddler with no other physical findings; pupils, 1 to 2 mm. Vital signs: HR: 70; RR: 20; BP: 80/palpable; T: 37°C; weight: 13 kg:

  1. What is the likely substance ingested by this toddler?
  2. What is the treatment of respiratory depression induced by this agent?

Answer

  1. Likely substance: Clonidine (Central-acting antihypertensive: stimulation of α2A receptors in medulla → decreased sympathetic outflow).
  2. Treatment of respiratory depression: Naloxone may reverse the respiratory depression.

MNJ17-002
A 4-year-old child has accidentally swallowed his grandfather's low dose aspirin tablets. A couple of partly used strips were found near him but parents are unsure how many tablets were ingested. You admit the child for observation.

  1. What is the pathophysiology?
  2. What are the toxic effects on the body?
  3. What is the therapeutic and toxic dose?
  4. What are the further steps of management?

Answer

  1. Pathophysiology: Uncoupling of oxidative phosphorylation.
  2. Toxic effects:
    • Direct stimulation of respiratory centre causing hyperventilation and respiratory alkalosis
    • Metabolic acidosis and dehydration
    • Hyperglycemia/hypoglycemia and hyperpyrexia
    • Hepatotoxicity
  3. Doses:
    • Therapeutic dose = 10 to 15 mg/kg
    • Toxic dose = >150 mg/kg
  4. Management:
    • Serial serum salicylate concentrations (>70 mg/dL: life-threatening; >90 mg/dL: hemodialysis)
    • Monitor urine output with urine pH (maintain pH 7.0–7.5)
    • Monitor plasma pH, plasma glucose, electrolytes, LFT, and clotting studies
    • Treatment: Multiple-dose activated charcoal, urinary alkalinization (IV sodium bicarbonate), hemodialysis for severe toxicity.

MNJ17-003
Mention 3 poisonings (for each drug), for which the following drug can be used as antidote:

  1. Glucagon
  2. Pyridoxine
  3. N-Acetylcysteine
  4. EDTA (disodium calcium edetate)
  5. Dimercaptosuccinic acid (DMSA)

Answer

  1. Glucagon: β-blockers, Calcium channel blockers (CCBs), Oral hypoglycemic agents.
  2. Pyridoxine: Isoniazid (INH), Gyromitra mushrooms, Ethylene glycol.
  3. N-Acetylcysteine (NAC): Acetaminophen (Paracetamol), Carbon tetrachloride (CCl4), Chloroform.
  4. EDTA: Lead (Pb), Manganese (Mn), Nickel (Ni), Zinc (Zn), Chromium (Cr).
  5. DMSA: Lead (Pb), Mercury (Hg), Arsenic (As), other heavy metals.

MNJ17-004
A 7-year-old child was prescribed imipramine for nocturnal enuresis. Accidentally he consumed more tablets than was prescribed:

  1. What clinical features will you look for?
  2. How will you manage?

Answer

  1. Clinical features:
    • CNS anticholinergic effects: Agitation, delirium, mydriasis, dry mucous membranes, fever, urinary retention, decreased bowel sounds.
    • Cardiovascular/Arrhythmias: Tachycardia/bradycardia, wide QRS complex, prolonged PR/QT intervals, depressed ST segments, hypotension, ventricular arrhythmias.
  2. Management:
    • Gastric lavage (even several hours after ingestion because reduced gastric motility delays gastric emptying) followed by activated charcoal.
    • NaHCO3 (mainstay of treatment): Alkalinize serum to maintain pH 7.45 to 7.55 (increases protein binding of TCA, decreasing free drug levels and stabilizing myocardial membranes).
    • Lidocaine, phenytoin, or magnesium for refractory ventricular arrhythmias (avoid class IA and IC antiarrhythmics).

MNJ17-005
A 4-year-old deaf girl swallowed a disc battery from her hearing aid, which she informed to her mother immediately:

  1. What is its toxic effect?
  2. How will you manage?

Answer

  1. Toxic effect:
    • Disc batteries contain potentially toxic substances like mercury, lithium, and potassium hydroxide.
    • They generate electrical currents and produce local hydroxide ions causing severe liquefactive necrosis and corrosive mucosal burns, which can lead to perforation (e.g., tracheoesophageal fistula or aortoesophageal fistula).
  2. Management:
    • Urgent chest and abdominal X-ray.
    • If lodged in the esophagus: Emergency endoscopic removal immediately.
    • If in the stomach or beyond: Follow by repeat abdominal X-ray every 2–3 days to ensure passage and spontaneous evacuation.
    • If it remains lodged in one position for >7 days or symptoms develop: Surgical or endoscopic removal.

MNJ17-006
A 2-year-old child swallowed some amount of kerosene:

  1. Kerosene belongs to which type of poisoning agents?
  2. What symptomatology will you expect?
  3. How will you manage?

Answer

  1. Type of agent: Aliphatic hydrocarbon with high volatility, low surface tension, and low viscosity.
  2. Symptomatology:
    • Gastrointestinal irritation: Nausea, vomiting, abdominal pain.
    • Pulmonary injury (due to aspiration): Cough, choking, tachypnea, cyanosis, dyspnea, chemical pneumonitis, pulmonary edema.
    • CNS depression: Drowsiness, lethargy, coma (with large ingestions).
  3. Management:
    • No emesis and no routine gastric lavage due to high risk of aspiration.
    • Lavage only if massive toxic co-ingestion (e.g., organophosphates or CCl4) after securing airway with a cuffed endotracheal tube.
    • Supportive care: Humidified oxygen, monitor SpO2, maintain fluid and electrolyte balance.
    • Chest X-ray (at baseline and repeat at 4–6 hours).
    • Antibiotics only if secondary bacterial infection develops (indicated by fever and leukocytosis); corticosteroids are avoided.

MNJ17-007
A 2-year-old male child is admitted with ingestion of dishwasher detergent solution:

  1. What type of agent is it?
  2. What will be the signs and symptoms?
  3. How will you manage?

Answer

  1. Type of agent: Caustic/corrosive alkali (or acid) substance.
  2. Signs and symptoms:
    • Oropharyngeal burns, oral and retrosternal pain, excessive salivation/drooling, dysphagia/odynophagia.
    • Nausea, vomiting (sometimes bloody/hematemesis), abdominal pain, diarrhea.
    • Late complications: Esophageal and gastric ulceration, necrosis, perforation, mediastinitis, peritonitis, esophageal stricture formation.
  3. Management:
    • Hospitalize for observation.
    • Maintain airway, breathing, and circulation (ABC).
    • Baseline investigations: CBC, electrolytes, CPK, chest and abdominal X-rays; check vomitus/stool for occult blood.
    • Contraindicated: Do not induce emesis, do not perform gastric lavage, do not give activated charcoal or cathartics, and do NOT attempt neutralization (causes exothermic reaction worsening tissue damage).
    • Rinse external/skin burns with copious amounts of water.
    • Supportive IV fluids, analgesia, and NPO.
    • Endoscopic evaluation (esophagoduodenoscopy) ideally within 12–24 hours to assess extent of mucosal injury.
    • Prophylactic antibiotics and surgical consultation if perforation is suspected.