The editors and current authors would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2002 first edition, Dr. Alson Inaba. This current third edition chapter is a revision and update of the original author’s work.
Case 1: A 2-year-old boy ingested approximately 12 grape-flavored chewable acetaminophen tablets that he found in the bathroom two hours ago. He has had two episodes of vomiting. His mother calls the pediatrician and asks for advice. She states that her son is now playful and looks fine. As the child's pediatrician, what recommendations would you give to his mother? What additional data do you need to appropriately answer her question?
Case 2: A 15-year-old girl ingested an entire box of diphenhydramine (Benadryl) tablets after she got into an argument with her boyfriend. She is brought to the emergency department (ED) by her parents, who state that she is "not acting right." She is sleepy but answering questions appropriately. She denies taking any other medications, alcohol, or illicit drugs. She does not remember exactly when she took the diphenhydramine tablets. Her vital signs are T37, HR 160, RR 18, BP 160/90, and oxygen saturation was 99% on room air. Her physical examination is normal. As the ED provider caring for this girl, what is your assessment and plan of action? Is the report of the amount ingested a reliable estimate? Could there be other substances in addition to the diphenhydramine that she ingested? Is her degree of tachycardia and hypertension consistent with the medication taken and the timing of the ingestion? Could the patient be pregnant, and if so, would this change any of your therapeutic interventions? Because this is an intentional overdose involving a teenager, there are additional considerations.
Case 3: A 3-year-old boy is brought to the ED by paramedics in status epilepticus. The father found his son seizing and immediately called 911. The child has never had prior episodes of seizures, but he has had two days of low-grade fevers along with a slight cough. He is not on any medications, and his father denies any possibility of head trauma preceding the seizure. He requires IV anticonvulsants to terminate the seizure activity. Although you are considering meningitis and febrile seizures in your differential diagnosis, should you include the possibility of a toxic ingestion/exposure in this case? The provider should consider the possibility of toxic exposure in the differential diagnosis of a patient who presents to the ED with severe, life-threatening signs and symptoms (e.g., status epilepticus, coma, respiratory distress, cardiovascular shock, altered mental status, among others).
Based on the 2022 Annual Report of the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System, there were over 2 million human exposure cases reported throughout the country in 2022 (1). The actual number of poisoning cases was likely higher due to under-reporting. The majority of these poisoning cases that were reported to poison control centers were managed on site where the exposure occurred with phone advice from the poison control center's poison information specialists. Only 30% of the callers were referred to a health care facility for further assessment and treatment. (1)
Forty percent of the reported poisoning cases involved children under six years of age. However, older children had increased morbidity when being treated for poisoning. While only 2.42 % of poisonings for ages 0-5 were coded as "moderate effect" or higher, 20.7 % were coded as such for ages 13-19 (1). Healthcare providers who care for the pediatric population must be prepared to quickly and effectively evaluate potential poisonings for all pediatric age ranges.
The substances that were most frequently reported involving poisoning in children under six years of age in 2022 were: household cleaning substances (11%), cosmetics and personal care products (10%), analgesics (9%), foreign bodies (7%), dietary supplements (7%), antihistamines (5%), vitamins (5%), topical preparations (4%), pesticides (4%), plants (3%), gastrointestinal preparations (3%), and cough & cold preparations (2%). (1)
Poisonings can occur through a variety of different routes of exposure, but the most common was via oral ingestion. In 2022, approximately 83% of all poisoning cases were due to ingestion. Other routes were inhalation (7.6%), dermal (6.9%), ocular (4.1%), and bites/stings (1.5%). Up to 93% of the poisoning cases in 2022 occurred at home, while only 1.5% occurred at school. (1)
While unintentional exposures generally outnumbered intentional exposures, the 13–19-year-old population was a notable exception, with 64% of exposures attributed to intentional exposures. While suicide attempt was the most common cause of intentional exposure and fatalities, substance misuse and abuse accounted for 20% of intentional exposures and 15% of all fatalities. (1)
Although most exposure-related fatalities involved adults, 118 patients aged 0-19 died due to exposures. Twenty-seven of these were children aged 0-5 years old. Analgesics and vapor inhalation were the most implicated substances in pediatric deaths. Substances that continue to demonstrate the greatest rate of exposure increase over the last 10 years are the four A's - analgesics, antidepressants, antihistamines, and alcohols. (1)
The three cases at the start of this chapter illustrate the wide spectrum of how poisoning cases present. Since it would be impossible to cover every possible poisoning scenario, this chapter will focus on a systematic approach to general poisonings. Since over 80% of all toxic exposures involve ingestions, this chapter will primarily focus on the assessment and management of toxic ingestions, including initial stabilization, decontamination, enhanced elimination techniques, and detoxification. Toxidromes and specific antidotes for some common ingestions will be discussed, as well as the interpretation of common laboratory studies and calculations.
It is emphasized that the Poison Control Center employs specially trained healthcare providers to assist front-line providers. Their 24-hour national hotline at (800)222-1222 can be contacted immediately following initial stabilization measures in all cases of suspected or confirmed toxic exposures, where their specialists may assist in various aspects of patient care.
The initial management of any poisoning case must first address the assessment and stabilization of the standard "A-B-C's" of emergency medicine. Regardless of the exposure or substance ingested, the provider must assure that the child's airway, breathing, and circulation have been assessed and stabilized first before addressing other issues, such as gastrointestinal decontamination and laboratory evaluation. If the patient is unable to maintain and protect his or her airway or has a diminished gag reflex, one must first consider endotracheal intubation prior to performing any type of gastrointestinal decontamination in order to protect the airway from aspiration. Breathing should be evaluated with both observing (chest rise) and listening (auscultate over all lung fields). Respiratory rate most closely correlates to breathing, while pulse oximetry correlates well with both breathing and circulation. Bag mask ventilation (BMV) should be the primary intervention for patients with an intact airway but impaired respiratory drive. Circulation should be evaluated by assessing heart rate, blood pressure, brachial and femoral pulses, and central capillary refill.
In pediatric toxicology, a helpful mnemonic to continue this initial evaluation and aid in management is (A, B, C) D, D, D, D, E. The first "D" stands for Disability which relates to mental status. Glasgow Coma Score and pupils should be evaluated at this time to aid with prognostic and diagnostic evaluation.
The next "D" stands for Dextrose and can be related to pediatric disability. Hypoglycemia can lead to somnolence, obtundation, stupor, seizure, and death and is, therefore, a priority for prompt identification and treatment. Current guidelines for correcting hypoglycemia in the pediatric population include an initial IV bolus of 200 to 250 mg/kg followed by 10% dextrose at a maintenance rate of 5-8 mg/kg/min in an infant and about 3-5 mg/kg/min in an older child. (2)
The third "D" stands for Decontamination. Decontamination may be indicated regardless of the specific agent ingested. Simple dilution, while not often performed in the ED, may be an initial step at home for parents in the management of toxic ingestion. Ingestion of large volumes of inert liquids, most commonly milk, may simply dilute the offending agent to harmless concentrations. Other decontamination methods include osmotic cathartics, such as sorbitol or magnesium citrate, which limit the absorption of the offending agent by reducing bowel transit time. Whole bowel irrigation (WBI) may be considered for a late presentation (>2 hours after ingestion) of sustained-release drugs such as iron, lithium, and potassium. For WBI, polyethylene glycol (bowel prep solution) is irrigated directly into the bowel at a rate of 500 mL/hr for toddlers and 2L/hr for adolescents until the drainage is the same color as the irrigation fluid. (3)
Activated charcoal is often touted for its potentially detoxifying properties, but clinical usage is limited by several factors. Activated charcoal shows next to no benefit if administered >1 hour post-ingestion (4). Aspirating any amount of activated charcoal carries a significant risk of developing pneumonitis and mediastinitis. Charcoal does not bind all toxins. Weighing its limited effectiveness against the risk of aspiration pneumonitis, charcoal may not necessarily be the best or first choice for decontamination.
Therefore, activated charcoal should be considered if the following criteria are met: 1) Administering activated charcoal would not delay definitive care, such as administering a specific antidote. 2) The ingested substance was taken less than 1 hour prior to charcoal administration. 3) The patient has an intact or protected airway, including confirmation of a correctly placed endotracheal tube. 4) Confirm that charcoal adsorbs the ingested toxin. Charcoal has no adsorption efficacy for the following substances: Acids and alakalis, corrosives, cyanide, alcohols, eucalyptus oil, essential oils, fluoride, hydrocarbons, metals (lithium, iron, potassium lead), mineral acids (boric acid). Consultation with a toxicologist is recommended. 5) Activated charcoal must not be given forcibly due to the risk of pneumonitis. If given by nasogastric tube, correct placement of the tube within the stomach should be confirmed. Activated charcoal, therefore, has a limited role in toxic ingestions. When used, activated charcoal should be administered concomitantly with cathartics to quickly eliminate the toxin-bound charcoal to reduce the chance of dissociation and subsequent absorption. (4)
Historically, other decontamination methods included gastric lavage and forced vomiting with syrup of ipecac. These methods are now obsolete and have nearly no clinical benefit. Gastric lavage, commonly referred to as having the "stomach pumped", demonstrates very little benefit unless performed <10 minutes after ingestion and requires a very large bore nasogastric tube placement, which carries a risk of esophageal tear and mediastinitis (5). Syrup of ipecac was a drug developed in the 1960s and was used to induce vomiting for the purpose of gastric emptying; however, ipecac presents a small risk of overdose (being a mild poison itself) and a major risk for esophagitis and aspiration. Currently, syrup of ipecac is not available and is not recommended since its risks outweigh its benefits in nearly all cases (2).
The fourth "D" stands for Detoxification which is removal or pharmacological management of the toxic substance. Specific antidotal strategies should be considered, as well as enhanced elimination techniques. These are discussed in further detail below.
"E" stands for Exposure/Environment which includes safely removing any clothing or topical substances that may be continuing to expose the patient to the toxic substance and getting a core temperature since some toxidromes are accompanied by abnormal elevations in temperature.
History and physical examination are important for the previous steps of managing toxic ingestion. Initial stabilization and rapid initiation of decontamination techniques are concomitantly performed while obtaining a history to determine the toxic substance and the specific detoxification steps that must be taken for each individual case.
The three key questions that must be addressed in all poisoning cases are: 1) WHAT substance(s) was ingested? 2) WHEN did the ingestion occur? 3) HOW MUCH was ingested?
The answers to these questions will provide valuable information about the following: 1) The severity of the ingestion. 2) The potential benefits/efficacy of gastrointestinal decontamination. 3) Whether or not therapeutic interventions will be necessary. 4) Accurate interpretation of specific drug levels. 5) Disposition of the patient (i.e., can the patient be safely discharged from the ED and after what period of time, or does the patient need to be admitted to the inpatient service for further observation and treatment?).
When determining what substance(s) was ingested, one must be very specific. For example, many of over-the-counter (OTC) medications and household items frequently have various preparations with many different active ingredients. Some examples of this are: 1) The trade name Dramamine could be meclizine or dimenhydrinate. 2) The trade name Clorox could be household bleach or many other products that carry this trade name. Other household products are similar in that a given brand name is used for a family of different products that carry the same trade name. 3) The trade name Excedrin could contain various combinations of acetaminophen, ibuprofen, aspirin, and/or caffeine. The exact milligram amount of the suspected ingested medication or liquid/syrup should also be confirmed since many medications (both OTC as well as prescription medications) are available in multiple milligram dosages and concentrations. It is best to see the actual packaging of the product to confirm the actual ingredients. Local poison control centers have computerized databases of over a million substances, which can be accessed via a specific product name or via individual active ingredients; however, this still results in uncertainty because a product manufactured in 2022 could have different substances in 2024 even though they have exactly the same label name. If the suspected ingestion involved a plant, have a family member bring in as much of the actual plant for identification. A photograph of the full plant can be helpful as well.
Time from ingestion is vital for determining treatment options and for interpreting drug levels. As discussed previously, activated charcoal offers benefits only if given in a specific timeframe. Interpreting nomograms requires knowledge of ingestion time which guides specific treatment and prognosis. Nomogram interpretation and utility will be further explored below, with acetaminophen overdose.
Often the most difficult aspect of the pediatric toxicologic history for the parents to answer is the exact amount of the toxin or drug that may have been ingested. When confronted with this dilemma, the provider should always assume the highest possible ingested dose rather than minimizing the amount that may have been potentially ingested.
The provider must be a medical detective in some respects when attempting to estimate how much the child may have ingested. For example, if a child presents to the ED after potentially ingesting some tablets, questions which could be asked include: a) Was the medication just recently purchased, and if so was the bottle completely full prior to the child getting into it? b) If the bottle was not brand new or recently purchased, then how many pills were in the bottle before the child got to it? c) If the medication was a prescribed medication, how many pills were originally prescribed, when was the medication prescribed and how many pills were already taken prior to the child getting to the bottle? d) How many pills did the parents find remaining in the bottle? e) How many pills did the parents find in the area where they found the child playing with the opened medication bottle? f) How many pills did the parents find in the child's mouth?
Once the total milligram total of the potential ingestion has been determined, then one must calculate how much was ingested in mg/kg to determine severity potential. If more than one child may have been involved in an ingestion scenario, perform your mg/kg calculations for each child (based on each child's individual weight) assuming that all the potentially ingested medication may have been consumed by only one child.
Although the majority of the substances that are typically ingested by children are either nontoxic or mildly toxic, there are a few substances that can potentially be fatal even when ingested in very small amounts, termed "one-pill killers", that providers should be familiar with and ask about specifically. Some of these highly toxic substances that could potentially be lethal for a 10 kg child are: amanita phalloides (one mushroom), amphetamines, antimalarials (one chloroquine tablet), calcium channel blockers (one nifedipine tablet), camphor (one teaspoon), clonidine (one 0.1 mg tablet), cocaine, cyclic antidepressants (one 150 mg imipramine tablet), ethylene glycol (one teaspoon), methylsalicylates (one teaspoon), narcotic medications, phenothiazines, theophylline (one 500 mg tablet). Methylsalicylates deserve special consideration due to their unregulated inclusion in massage oils, a substance parents may leave available to their children without understanding their danger. (6)
The key elements of a toxicologic physical examination include the following elements: a) Eyes: pupillary size, symmetry, and response to light, presence of nystagmus (vertical or horizontal). b) Oropharynx: moist or dry mucus membranes, presence/absence of the gag reflex, presence of any particular or distinctive odors. c) Abdomen: presence/absence and quality of bowel sounds. d) Skin: warm/dry, warm/sweaty or cool. e) Neurologic: level of consciousness and mental status, presence of tremors, seizures or other movement disorders, presence/absence and quality of deep tendon reflexes.
The exact laboratory tests to obtain in a poisoning case will depend upon the specifics of each individual case as well as the overall severity of the case. Although blood and urine toxicologic screens and specific drug levels may be obtained, the results of these studies typically are not available for hours. Therefore, the initial stabilization and management of every poisoning case is clinically determined by the patient's presenting signs, symptoms, and vital signs. For intentional overdose cases, a standard order set may contain an EKG (to quickly assess for any conduction abnormalities and/or dysrhythmias), acetaminophen levels, salicylate levels, and a pregnancy test in females of childbearing age. An electrolyte panel may be helpful in assessing for metabolic acidosis. Once the results of the electrolyte panel are known, one can also calculate the anion gap, which may provide helpful clues to the potential toxin in cases of unknown or suspected ingestion. The anion gap can be calculated via the formula: Na - [Cl + CO2]
The calculated anion gap should normally be equal to 8-12 mEq/L. Toxins that typically produce an increased anion gap metabolic acidosis may be remembered by the "M-U-D-P-I-L-E-S" mnemonic (methanol, uremia, diabetic ketoacidosis (DKA), paraldehyde, iron/ibuprofen/isoniazid, lactic acidosis (e.g., carbon monoxide, cyanide and various other etiologies of lactic acidosis), ethanol/ethylene glycol, salicylates).
Another very useful laboratory study is the measured serum osmolality and the calculated serum osmolarity which yields the osmolar gap. A patient's serum osmolality can be calculated via the formula:
2 X [Na] +[BUN/2.8] + [glucose/18]
Based on this calculated formula, the only three elements in the serum which are accounted for are sodium, BUN, and glucose. In contrast to this calculated formula, the actual measured serum osmolality includes other substances in the patient's blood that adds to the serum osmolality. Substances that classically elevate the measured serum osmolality (which are not part of the calculated osmolality) are the alcohols (i.e., ethanol, methanol, ethylene glycol, and isopropyl alcohol). Thus, a patient who has ingested one of the alcohols will typically exhibit an elevated measured serum osmolality despite a normal calculated serum osmolality.
The serum osmolar gap (measured serum osmolarity minus the calculated serum osmolarity) should be <5-10 mOsm/L. The calculated osmolar gap is also valuable in that it can also be used to predict a patient's blood ethanol level via the formula:
[serum osmolar gap] X [4.6] = blood ethanol level in units of mg/dL
The 4.6 is a constant based on the molecular weight ethanol (46 grams per mole = 46 grams per Osm = 0.046 gm per mOsm = 4.6 mg/mOsm. If the osmolar gap is 12, the ethanol concentration is 55 mg/dL = 0.055% (gm/dL). This factor will differ for different alcohols such as ethylene glycol or methanol.
Detoxification, Extracorporeal Elimination Techniques, and Toxidromes
Once the provider obtains an adequate history and acquires appropriate data to determine the specifics and severity of the patient's profile, detoxification with extracorporeal elimination techniques (EETs) may be considered in severe cases (7,8). EETs seek to reduce tissue damage of exogenous chemicals by more rapidly eliminating them from the bloodstream. The effectiveness of hemodialysis and hemoperfusion (if available) increases with high water solubility, low molecular weight, low volume of distribution, and low protein binding, and is, therefore, most effective in treating severe cases of toxins listed in Table 3. Urinary alkalinization via the IV administration of sodium bicarbonate is another common detoxification method that can be used to enhance the urinary excretion of certain toxins. Table 3 details specific toxins whose clearance can be enhanced with EETs.
Table 3: Enhanced elimination techniques and efficacy for increasing clearance of corresponding toxins. (8)
| Toxins with increased clearance via hemodialysis | Toxins with increased clearance via urinary alkalinization |
|---|---|
| salicylates
phenobarbital theophylline methanol ethylene glycol lithium diethylene glycol propylene glycol isopropyl alcohol valproic acid carbamazepine | salicylates
chlorpropamide 2,4-dichlorophenoxyacetic acid diflunisal fluoride mecoprop (MCPP, a chlorphenoxy herbicide) methotrexate phenobarbital |
Toxidromes refer to a specific constellation of signs and symptoms which one may expect to see with a specific class or type of toxic substance. Toxidromes are based on the patient's vital signs as well as on the physical examination findings. The five distinct toxidromes and the common toxins are listed below (9):
The table below lists other common ingestions with their specific antidotes. Note that these antidotes are often used in conjunction with the general principles of decontamination described above.
Table 4: Toxic ingestions and specific antidotes for reference of common toxic ingestions that require specific antidotes for effective treatment. Note that antidotes often require the coadministration of detoxification techniques for optimal efficacy (14).
| Toxic ingestion | Specific antidote |
|---|---|
| acetaminophen | N-acetylcysteine |
| carbon monoxide | oxygen |
| cyanide | hydroxocobalamin (Cyanokit) |
| digoxin | digoxin immune Fab antibodies |
| ethylene glycol or methanol | fomepizole |
| iron | deferoxamine |
| methemoglobinemia | methylene blue |
| phenothiazine induced dystonic reactions | diphenhydramine |
| salicylates | sodium bicarbonate |
Analgesic ingestions, including acetaminophen and salicylates, accounted for the majority of fatal pediatric ingestions in 2022, and are therefore, a particular concern among healthcare providers (1). Parents may have "fever phobia", leading them to intentionally overmedicate without realizing the potential harm or simply misunderstand dosing labeling. Acetaminophen overdose is initially clinically silent for 12-24 hours. Nonspecific gastrointestinal symptoms, such as vomiting and abdominal pain, follow. Hepatic injury, the primary mechanism for mortality and morbidity, presents 3-5 days after ingestion. Treatment with the antidote N-acetylcysteine (NAC) inhibits cytochrome P-450 to reduce the production of the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI). NAC must be administered prior to the onset of hepatic injury to have any effect. Acetaminophen toxicity is described in further detail in chapter XIV. Acetaminophen Overdose.
Salicylates are also sold over-the-counter and also represent mortality risk in the pediatric population. The acutely toxic dose of acetylsalicylic acid (ASA, also known as aspirin) is generally considered to be greater than 150 mg per kg of body mass (15). Assuming a pediatric patient accesses adult aspirin doses of 325 mg/pill, they would still have to ingest multiple pills to achieve toxic serum concentrations. However, methylsalicylates, which can be thought of as the liquid version of aspirin, can have concentrations of 7000 mg/5mL (but more typically 1500 mg/5mL), and are found in a variety of over-the-counter topical products, with a wintergreen odor, that are used for muscle aches. Pure oil of wintergreen has much higher concentrations. For children under 6 years old, one lick of a solution containing concentrated methylsalicylates can achieve the toxic dose (16).
Classically, salicylate poisoning initially presents as a primary respiratory alkalosis as compensation for a metabolic acidosis. Other symptoms include tachypnea, dyspnea, hyperpnea, pulmonary edema, fever, tinnitus, deafness, vomiting, lethargy, confusion, and even seizures and shock. While serum values are helpful for the management of salicylate toxicity, treatment decisions are not as clearly defined as with acetaminophen toxicity. Clinical picture, including acid-base status, electrolytes, volume status, and respiratory status, guide supportive treatment more than simply salicylate levels in the blood. Ultimately though, enhancing elimination is the primary method for detoxification. Administration of sodium bicarbonate alkalinizes urine to facilitate urinary excretion. Sodium bicarbonate should be titrated to urinary pH of 7.5-8.0, and fluids should be administered to maintain a urine output of 2-3 mL/kg/hr. Severely poisoned patients may be placed on hemodialysis for further detoxification. (16,17)
Ibuprofen and other NSAIDs are the last of the analgesics commonly seen in overdoses. Fortunately, NSAIDs (apart from salicylates) are among the safest analgesics, with adverse effects occurring after many years of chronic abuse rather than with acute overdose. However, life-threatening toxicity can occur with doses exceeding 400mg/kg. This is very uncommon in children but case reports exist of both suicide attempts and therapeutic error in adolescents. The patients may present with acute renal injury, and while there is no antidote, they should be treated with standard acute toxicity decontamination and acute kidney injury (AKI) protocols (18).
Because the majority of pediatric nonintentional ingestions typically do not involve highly toxic substances and/or large amounts, the majority of children who present to the ED with an accidental overdose can be safely discharged after a thorough assessment and an adequate period of observation. Hospitalization should be considered for the following situations: a) Severe signs and symptoms upon presentation to the ED. b) Unstable or abnormal vital signs. c) A potentially severe ingestion based on the identity or potential toxic dose of the ingested substance. d) Intentional overdoses.
Since prevention is the best method of reducing accidental poisoning in children, providers should routinely incorporate poison prevention guidelines/tips into their healthcare maintenance discussions with their parents. Some of these points are: a) Store all medications and household products out of reach and out of sight (and preferably locked up). b) Never refer to medicines as candy. c) Child resistant caps should be closed properly, and remember that these types of caps are only child resistant and not "child proof". d) Avoid transferring/storing household cleaning products, pesticides, and automotive fluids in unmarked bottles or containers, which could be mistaken for a beverage and consumed by an unsuspecting child. e) Keep the phone number of the national poison control center near the telephone. The nationwide number is (800) 222-1222. f) If a parent suspects poisoning, instruct them to call the poison control center immediately for advice rather than waiting for the child to develop signs and symptoms of toxicity. g) If a parent suspects a poisoning, never induce vomiting. Call the poison control center immediately for advice.
Pediatric toxic exposures are a common reason for presentation to the ED, and providers should thus be familiar with general concepts of stabilization and treatment using the mnemonic ABCDDDDE (airway, breathing, cardiac, disability, dextrose, decontamination, detoxification, and extracorporeal elimination techniques). Providers must be vigilant for ingestions of particularly deadly substances and be prepared to ask specific questions regarding them. It is helpful to quickly recognize toxidromes from multiple medication classes and be familiar with specific treatments.
This chapter contains generalizations and is not exhaustive of the multitude of possible toxic exposures, thus the Poison Control Center national hotline (800) 222-1222 should be contacted immediately after emergency stabilization to receive guidance from specially trained nurses and toxicologists, even if the exposure may seem mild or easily managed.
Questions
1. The majority of accidental ingestions in the pediatric population occur in which age group?
a. Infants (under 12 months of age)
b. Under 6 years of age
c. 6 to 12 years years of age
d. 13 to 18 years of age
2. The most common route of toxic exposures is via:
a. Inhalation
b. Dermal contact
c. Bites and stings
d. Ingestion
e. Ocular contact
3. A mother of a 2-year-old boy calls you because she suspects that her son may have eaten a few of his grandmother's "heart pills". She claims that her son seems fine and that the possible ingestion may have occurred 30 minutes ago. What is the best action for you to take as the child's pediatrician?
a. Have the mother induce vomiting immediately by sticking her finger in the child's mouth.
b. Have her administer ipecac syrup immediately in order to induce vomiting.
c. Advise no interventions at the present time, but also advise her that if the child should begin to develop any symptoms to go to the ED for further treatment.
d. Call the national poison control hotline immediately for advice.
4. A child with suspected ingestion presents to the ED with delirium, tachycardia, mydriasis, dry mucus membranes, and warm/dry skin. This child exhibits signs and symptoms of which toxidrome?
a. Anticholinergic
b. Sympathomimetic
c. Cholinergic
d. Opioid
e. Sedative hypnotic
5. A parent suspects her 4-year-old child may have ingested a small amount of her massage oil (that smells minty) though she is not sure when. She initially assumed there would be no harm, but her child is experiencing symptoms of diaphoresis, apparent shortness of breath, and has vomited once. Workup shows primary respiratory alkalosis. What is the primary method of treatment for the most likely etiology of toxicity?
a. Sodium Bicarbonate
b. Activated charcoal
c. N-acetylcysteine
d. Hydroxocobalamin
e. Benzodiazepines
References
1. Gummin DD, Mowry JB, Beuhler MC, et al. 2022 Annual Report of the National Poison Data System® (NPDS) from America's Poison Centers®: 40th Annual Report. Clin Toxicol (Phila). 2023;61(10):717-939. doi: 10.1080/15563650.2023.2268981.
2. Thornton PS, Stanley CA, De Leon DD, et al, Pediatric Endocrine Society. Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children. J Pediatr. 2015 Aug;167(2):238-45. doi: 10.1016/j.jpeds.2015.03.057.
3. Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol. 2015;53(1):5-12. doi:10.3109/15563650.2014.989326
4. Chyka PA, Seger D, Krenzelok EP, Vale JA; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position Paper: Single-Dose Activated Charcoal. Clin Toxicol (Phila). 2005;43(2):61-87. doi: 10.1081/clt-200051867
5. Benson BE, Hoppu K, Troutman WG, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):140-146. doi:10.3109/15563650.2013.770154
6. Vroman R. Pediatric toxicology: Part 3. What EMS providers need to know about “one-pill killers.” EMS Mag. 2008;37(6):61-68.
7. Proudfoot AT, Krenzelok EP, Vale JA. Position Paper on Urine Alkalinization. J Toxicol Clin Toxicol. 2004;42(1):1-26. doi:10.1081/CLT-120028740
8. Levine M, Brooks D E, Truitt C A, et al. Toxicology in the ICU: Part 1: general overview and approach to treatment. Chest 2011;140(3):795-806. DOI: 10.1378/chest.10-2548
9. Calello DP, Henretig FM. Pediatric toxicology: specialized approach to the poisoned child. Emerg Med Clin North Am. 2014;32(1):29-52. doi:10.1016/j.emc.2013.09.008
10. Body R, Bartram T, Azam F, Mackway-Jones K. Guidelines in Emergency Medicine Network (GEMNet): guideline for the management of tricyclic antidepressant overdose. Emerg Med J. 2011;28(4):347-368. doi:10.1136/emj.2010.091553
11. Goldstein S, Richards JR. Sympathomimetic Toxicity. In: StatPearls. StatPearls Publishing; 2022. Accessed May 13, 2022. http://www.ncbi.nlm.nih.gov/books/NBK430757/
12. Lott EL, Jones EB. Cholinergic Toxicity. In: StatPearls. StatPearls Publishing; 2022. Accessed May 13, 2022. http://www.ncbi.nlm.nih.gov/books/NBK539783/
13. Simone CG, Bobrin BD. Anxiolytics and Sedative-Hypnotics Toxicity. In: StatPearls. StatPearls Publishing; 2022. Accessed May 13, 2022. http://www.ncbi.nlm.nih.gov/books/NBK562309/
14. Hon KL, Hui WF, Leung AK. Antidotes for childhood toxidromes. Drugs Context. 2021(10):2020-11-4. doi: 10.7573/dic.2020-11-4.
15. Chyka PA, Erdman AR, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(2):95-131. doi:10.1080/15563650600907140.
16. Muniandy RK, Sinnathamby V. Salicylate toxicity from ingestion of traditional massage oil. BMJ Case Rep. 2012;2012:bcr2012006562. doi:10.1136/bcr-2012-006562
17. Espírito Santo R, Vaz S, Jalles F, et al. Salicylate Intoxication in an Infant: A Case Report. Drug Saf Case Rep. 2017;4:23. doi:10.1007/s40800-017-0065-9
18. Mboma O, Wirth S, Aydin M. The Risk of Nonsteroidal Anti-Inflammatory Drugs in Pediatric Medicine: Listen Carefully to Children with Pain. Children. 2021;8(11):1048. doi:10.3390/children8111048
Answers to questions
1.b, 2.d, 3.d, 4.a, 5.a