Pediatric Paraquat Poisoning Management
Immediate Oxygen Management - Critical First Priority
The most critical intervention in pediatric paraquat poisoning is restrictive oxygen therapy: avoid supplemental oxygen unless SpO2 falls below 85%, and target oxygen saturation of 85-88% only. 1, 2 This is uniquely important in paraquat toxicity because oxygen dramatically accelerates paraquat-induced lung injury through increased free radical production. 2 High oxygen concentrations worsen the pulmonary fibrosis that is the primary cause of death in paraquat poisoning. 2, 3
Oxygen Protocol
- Do not provide liberal supplemental oxygen - this is the single most harmful intervention you can make in paraquat poisoning 2
- Only initiate oxygen if SpO2 drops below 85% 1, 2
- If oxygen is required, target SpO2 of 85-88% and reduce or stop oxygen if saturation rises above 88% 1, 2
- This restrictive approach directly contradicts standard pediatric resuscitation but is essential for paraquat cases 1, 2
Gastrointestinal Decontamination
After securing the airway and achieving hemodynamic stability, administer multiple-dose activated charcoal (15-20g every 6 hours) rather than gastric lavage. 2 The American College of Medical Toxicology recommends against routine gastric lavage for paraquat poisoning. 2
Decontamination Algorithm
- First priority: Remove all contaminated clothing immediately and thoroughly wash exposed skin to prevent continued dermal absorption 2
- Second priority: Secure airway protection before any gastrointestinal decontamination due to significant aspiration risk 2
- Third priority: Administer activated charcoal or Fuller's earth (preferred agents) which work through adsorption rather than mechanical removal 2, 3
- Multiple-dose activated charcoal: 15-20g every 6 hours after airway is secured 2
- Fuller's earth is an alternative adsorbent agent 2, 3
Common Pitfall
Never delay airway protection to perform gastrointestinal decontamination - aspiration risk is substantial and will worsen outcomes. 2
Standard Detoxification Protocol
Based on the largest pediatric case series, aggressive treatment includes: 4
- Gastric lavage (only if presenting within 1-2 hours and airway is secured) 4
- Activated charcoal administration 4
- Charcoal hemoperfusion for systemic removal 4, 5
- Cyclophosphamide and steroid pulse therapy (immunosuppressive treatment) 4, 5
However, evidence for hemofiltration and immunosuppression improving survival is conflicting - one study found no survival benefit 6, while another institutional protocol includes these interventions 5.
Clinical Monitoring and Prognosis
High-Risk Features in Children
- Intentional ingestion (32.5-69.6% of pediatric cases) has worse prognosis than accidental exposure 4, 7, 6
- Positive urine paraquat test indicates significantly higher mortality (47.4% vs 15.2% for negative results) 6
- Delay from exposure to hospital admission worsens outcomes 6
- Respiratory failure is the primary cause of death 7, 3
Expected Complications
Children with paraquat poisoning develop: 4
- Shock (50%) 4
- Hypoxemia and respiratory failure (33.3%) 4
- Acute respiratory distress syndrome 4
- Hepatitis (66.7%) 4
- Gastrointestinal bleeding (33.3%) 4
- Acute renal failure (33.3%) 4
- Multiple-organ failure 4, 5
- Secondary infections common: sepsis (33.3%), pneumonia (33.3%), urinary tract infection (50%) 4
Mortality Data
Pediatric mortality rates range from 33.3% to higher depending on dose and time to treatment. 4, 5 Death typically occurs within 2 days of ingesting 50 mg/kg, but may be delayed several weeks at lower doses. 3 Even with prompt diagnosis and immediate detoxification protocol, outcomes remain poor. 4
Supportive Care Essentials
- ICU admission for all symptomatic patients 5
- Prepare for mechanical ventilation - respiratory failure develops rapidly in children due to respiratory muscle weakness 5, 3
- Fluid resuscitation - children dehydrate more quickly from vomiting and diarrhea 1
- Renal replacement therapy may be needed for acute renal failure, though renal excretion decreases rapidly once tubular necrosis occurs 3
Contact Resources
Immediately contact poison control centers (1-800-222-1222) for expert guidance and coordination with local, state, and federal agencies. 1 Poison centers are staffed by certified specialists in poison information backed by medical toxicologists who can provide real-time consultation. 1
Pediatric-Specific Vulnerabilities
Children are at higher risk than adults because: 1
- Less fluid reserves and more rapid dehydration from vomiting/diarrhea 1
- Higher minute ventilation leads to greater exposure to aerosolized paraquat 1
- Cardiac output is rate-dependent 1
- Smaller physical size makes airway management and IV access more challenging 1