What is the management approach for paraquat poisoning in pediatric patients?

Management of Paraquat Poisoning in Pediatric Patients

Immediate decontamination with activated charcoal or Fuller's earth after airway protection, strict oxygen restriction (target SpO2 85-88%), and early poison control consultation form the cornerstone of pediatric paraquat poisoning management, though mortality remains high (33%) even with aggressive treatment. 1, 2, 3

Immediate Rescuer and Healthcare Worker Safety

• Don personal protective equipment (gloves, protective clothing) before any patient contact to prevent secondary exposure from contaminated skin, clothing, or body fluids 2, 4
• Remove all contaminated clothing and jewelry immediately 2, 4
• Thoroughly wash all exposed skin areas with soap and water 5, 4

Critical Initial Management Steps

Airway and Hemodynamic Stabilization FIRST

• Secure the airway and achieve hemodynamic stability BEFORE attempting any gastrointestinal decontamination 1, 4
• Treat hypotension and dysrhythmias according to standard protocols 2
• Administer benzodiazepines for seizures or severe agitation if they occur 2

Immediate Poison Control Contact

• Contact poison control centers (1-800-222-1222) immediately for expert guidance and maintain continuous contact for evolving recommendations 5, 2, 4

Decontamination Protocol

Preferred Method: Activated Charcoal

• Administer multiple-dose activated charcoal (15-20g every 6 hours) ONLY after airway protection and hemodynamic stabilization 1, 4
• Activated charcoal or Fuller's earth are preferred over gastric lavage as they work through adsorption rather than physical removal 1
• The American College of Medical Toxicology recommends against routine gastric lavage for paraquat poisoning 1

When Gastric Lavage May Be Considered

• Consider gastric lavage only in the earliest phases of presentation (within 0.5-2 hours), though this is not standard practice 1, 3
• Most pediatric patients in case series were referred within 0.5-2 hours of exposure 3

Oxygen Management: UNIQUELY CRITICAL IN PARAQUAT

Restrictive Oxygen Strategy

• Avoid supplemental oxygen unless SpO2 falls below 85% 1, 2, 4
• Target oxygen saturation of 85-88%, significantly lower than typical pediatric critical care targets 1, 2, 4
• Reduce or stop oxygen therapy if saturation rises above 88% 1, 2, 4

Rationale for Oxygen Restriction

• Paraquat toxicity is dramatically worsened by high oxygen concentrations through increased free radical production 1, 4
• Oxygen accelerates paraquat-induced lung injury 1, 4
• This represents a critical departure from standard pediatric resuscitation protocols

Pediatric-Specific Considerations

Age-Related Patterns

• The 0-2.9 year age group has the largest number of accidental exposures (30% of cases) 6
• Younger children typically have accidental ingestion, while older children and adolescents more commonly have intentional ingestion 3, 6
• Mean age in pediatric case series is approximately 8-9 years 3

Pediatric Decontamination Modifications

• Use warmed shower water at lower pressure to prevent hypothermia and additional skin damage 5
• In cold climates, use heat lamps and blankets to prevent hypothermia during decontamination 5

Expected Complications and Monitoring

Common Severe Complications in Pediatric Patients

• Acute respiratory distress syndrome and respiratory failure (33%) 3
• Multiple organ failure 3, 7
• Shock (50%) 3
• Acute renal failure (33%) 3
• Hepatitis (67%) 3
• Gastrointestinal bleeding (33%) 3
• Seizures (17%) 3

Secondary Infections

• Monitor for sepsis (33%), pneumonia (33%), and urinary tract infections (50%) after hospitalization 3
• These are common complications following aggressive treatment protocols 3

Advanced Treatment Protocols

Institutional Protocol Components

• Standard detoxification protocol includes gastric lavage (if very early), activated charcoal, charcoal hemoperfusion, and cyclophosphamide/steroid pulse therapies 3, 7
• Some centers propose immunosuppressive and antioxidant treatments with systemic removal techniques 7
• Note: Evidence for hemofiltration and immunosuppression improving survival is lacking 8

Prognostic Indicators

Poor Prognostic Factors

• Intentional exposure (versus accidental) 8
• Positive urine paraquat test (47% mortality vs 15% with negative test) 8
• Delay from exposure to hospital admission 8
• Development of respiratory failure 9, 8

Expected Mortality

• Pediatric mortality rate is approximately 33% despite aggressive treatment 3
• Death typically occurs from respiratory failure and multiple organ failure within days to a month after exposure 8

Critical Pitfalls to Avoid

• Do NOT delay airway protection to perform gastrointestinal decontamination 1
• Do NOT provide supplemental oxygen liberally—this is uniquely harmful in paraquat toxicity 1, 2, 4
• Do NOT use gastric lavage routinely when activated charcoal is the evidence-based alternative 1
• Do NOT assume standard pediatric oxygen saturation targets (>94%) apply—target 85-88% instead 1, 2, 4

Diagnostic Considerations

Clinical Presentation

• Suspect paraquat poisoning in children with skin and mucous membrane burns, gastrointestinal symptoms, acute kidney injury, and respiratory failure, even without clear ingestion history 9
• Nonspecific symptoms and storage in inappropriate containers can delay diagnosis 9
• Most exposures in rural areas involve "left-behind children" (88% in one series) 6