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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Ingestions

There are about 4 to 5 million cases of poisoning per year in the United States. Children less than 17-years of age account for most poisoning exposures but account for only about 10% of fatalities. About 4% of fatalities occur in children under the age of 6. Poisoning peaks at 10 months and between 2- and 4-years old. Childhood poisoning is usually accidental and is usually associated with a low morbidity and mortality.

Poison Control Center is staffed 24 hours a day. Their number is 1-800-848-6946. Calls from family members regarding ingestions should always be referred to poison control. They also have a toxicologist on call that can help with our management of poisonings.

  1. Initial life support phase
    1. airway: maintain patency, assess protective reflexes
    2. breathing: adequate tidal volume? ABG?
    3. circulation: obtain IV access, assess perfusion
    4. disability: level of conciousness (AVPU or GCS), pupils
    5. decontamination: ocular-copious saline lavage; skin-copious water, then soap and water; GI-consider options (see below)
  2. History
    1. substance ingested; product name, ingredients, strength of medication; POISINDEX® can be helpful in indentifying ingredients in household products
    2. amount ingested
    3. route of exposure
    4. time of ingestion
    5. symptoms
    6. treatment prior to ED
    7. medical history
  3. Physical Exam
    1. vital signs
    2. mental status, neuromuscular status
    3. eyes: pupils, EOMs, fundi
    4. mouth: corrosive lesions, odors, moistness
    5. cardiovascular: rate, rhythm, perfusion
    6. respiratory: rate, chest excursion, air entry
    7. GI: motility, corrosive effects
    8. skin: color, bullae or burns, diaphoresis, piloerection
    9. odors
    10. toxidromes
  4. Tests (individualize)
    1. glucose (always with altered mental status), CBC, ABG, serum osmolarity, lytes, BUN/creatinine, calcium, LFTs, urinalysis
    2. urine pregnancy test (consider in ANY teenage girl with an ingestion)
    3. urine tox screen
    4. quantitative toxicology tests (acetaminophen, aspirin, ethanol)
    5. ECG/cardiac monitor
    6. CXR/KUB
  5. GI decontamination: in short, consider charcoal in some ingestions of potentially toxic amounts of poisons. It is ineffective in iron, alcohols, cyanide, most solvents, mineral acids or bases, and hydrocarbons.

    1. Activated Charcoal: "Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within one hour of ingestion. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to one hour previously; there are insufficient data to support or exclude its use after one hour of ingestion."
    2. Ipecac: "Syrup of ipecac should not be administered routinely in the management of poisoned patients. In experimental studies, the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned."
    3. Gastric Lavage: "Gastric lavage should not be employed routinely in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. There is no certain evidence that its use improves clinical outcome and it may cause significant morbidity. Gastric lavage should not be considered unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion. Even then, clinical benefit has not been confirmed in controlled studies."
    4. Cathartics: "The administration of a cathartic alone has no role in the management of the poisoned patient and is not recommended as a method of gut decontamination. Based on available data, the routine use of a cathartic in combination with activated charcoal is not endorsed."
    5. Whole-Bowel Irrigation: Whole bowel irrigation (WBI) should not be used routinely in the management of poisoned patients. Although some volunteer studies have shown substantial decreases in the bioavailability of ingested drugs, no controlled clinical trials have been performed and there is no conclusive evidence that WBI improves the outcome of poisoned patients. Based on volunteer studies WBI may be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs. There are insufficient data to support or exclude the use of WBI for potentially toxic ingestions of iron, lead, zinc or packets of illicit drugs; WBI remains a theoretical option for these ingestions."
Frequently Useful Quantitative Toxicology Tests in Pediatric Patients
 Drug/Toxin
Optimal Time After Ingestion
  Acetaminophen
4 hr

  Carbamazepine

2 - 4 hr

  Carboxyhemoglobin

Immediate

  Digoxin

4 - 6 hr

  Ethanol

1/2 - 1 hr

  Ethylene Glycol

1/2 - 1 hr

  Iron

4 hr

  Lithium

2 - 4 hr*

  Methanol

1/2 - 1 hr

  Methomoglobin

Immediate

  Phenobarbital

1 - 2 hr

  Phenytoin

1 - 2 hr

  Salicylates

2 - 4 hr*

  Theophylline

1 - 2 hr*
Modified with permission from Weisman, PS, Howland MA, Flomünbaum, NE. The Toxicology Laboratory, In: Goldfrank, LR, Flomenbaum NE, Lowin NA, Weisman RS, Howland MA, eds. Tolicologic Emergencies. Norwalk, CT: Appleton & Lange, 1990.

*Repeat levels over 6 - 12 hours may be necessary with sustained-release preparation.

Toxidromes
Note: this file opens in a new window.

Summary of Antidotes
Poison
Antidotes
  Acetaminophen
N-Acetylcysteine (Mucomyst) initial dose of 140 mg/kg PO in water, fruit juice, or soda; then, 70 mg/kg every 4 hr for 17 doses

  Anticholinergics

Physostigmine (adult, 2 mg; child 0.5 mg) IV; may repeat in 15 minutes until desired effect is acheived; subsequent doses every 2 - 3 hr PRN (Caution: May cause seizures, asystole, cholinergic crisis)

  Anticholine-
  sterases

Atropine, 2 - 5 mg (adults); 0.05 - 0.1 mg/kg (children) IM or IV repeated every 10 - 15 minutes until atropinization is evident.

  Organophos-
  phates

Pralidoxime chloride 1 - 2 g (adults); 25 - 50 mg/kg (children) IV: repeat dose in 1 hr pm, then every 6 - 8 hr for 24 - 48 hr (consider also constant infusion)

  Carbamates

Atropine, as above: pralidoxime for severe causes

  Benzodiazepines

Flumazenil, 0.01 mg/kg IV (estimated pediatric dose)

  Beta-adrenorgic
  blockers

Glucagon, 50 mg/kg IV
  Calcium channel
  blockers
Calcium chloride 10%, 30 mL (adult); 0.2 mL/kg (pediatric) IV
                                          OR
  Calcium gluconate 10%, 30 mL (adult); 0.6 mL/kg (pediatric) IV
  Glucagon, 50 µg/kg IV
  Carbon
  monoxide
Oxygen 100% inhalation, consider hyperbaric for severe cases 
  CyanideAdult: Amyl nitrite inhalation (inhale for 15 - 30 sec every 60 sec)pending administration of 300 mg sodium nitrite (10 mL of a 3% solution) IV slowly (over 2 - 4 min); follow immediately with 12.5 g sodium thiosulfate (2.5 - 5 mL/min of 25% solution) IV

Children: (No nitrite should exceed recommended dose because fatal methemoglobinemia may result):


Hemoglobin
Initial Dose 3%
Na Nitrite IV
Initial Dose 25%
Na Thiosulfate IV
8 g
0.22 mL (6.6 mg)/kg
1.10 mL/kg
10 g
0.27 mL (8.7mg)/kg
1.35 mL/kg
12 g (normal)
0.33 mL (10 mg)/kg
1.65 mL/kg
14 g
0.39 mL (11.6 mg)/kg
1.95 mL/kg
  DigitalisFab antibodies (Digibind): dose based on amount ingested and/or digoxin level (see text, package insert)
  Ethylene glycol4-Methylpyrazole: Load 15 mg/kg; maintenance 10 mg/kg q 12h thereafter Ilittle experience in children) (see Methanol)
  FluorideCalcium gluconate: 10%, 0.6 mL/kg slowly until symptoms abate, serum calcium normalizes; repeat PRN
  Heavy metals/
  usual chelators
  • Arsenic/BAL
  • Lead/BAL, EDTA, penicillamine, DMSA
  • Mercury/BAL, DMSA
BAL, (dimorcaprof): 3 - 5 mg/kg/dose deep IM every 4 hr for 2 days, every 4 - 6 hrfor an additional 2 days, then every 4 - 12 hr for upto 7 additional days

EDTA: 50 - 75 mg/kg/24 hr deep IM or slow IV infusion given in 3 - 6 divided doses for up to 5 days; may be repeated for a second course after a minimum of 2 days: each course should not exceed a total of 500 mg/kg body weight

Penicillamine: 100 mg/kg/day (max 1 g) PO in divided doses for up to 5 days; for lon term therapy do not exceed 40 mg/kg/day

DMSA (succimer): 350 mg/m (10 mg/kg) PO every 8 hr for 5 days, followed by 350 mg/m (10 mg/kg) PO every 12 hr for 14 days
  IronDeferoxamine: 5 - 15 mg/kg/hr IV; use higher dosage for severe symptoms and decrease as patient recovers
  IsoniazidPyridoxine 5 - 10%, 1 g per gram of INH ingested (70 mg/kg up to 5 g if dose unknown) IV slowly over 30 - 50 min
  Methanol (and
  ethylene glycol)
Ethanol loading dose: 0.75 g/kg infused over 1 hr

Maintenance: 0.1 - 0.2 g/kg/hr infusion; adjust as needed with target level 100 mg/dL

Folate 1 mg/kg IV every 6 hr (methanol)
  Methemoglo-
  binemic agents
Methylene blue 1%, 1- 2 mg/kg (o.1 - 0.2 ml/kg) IV slowly over 5 - 10 min if cyanosis is severe or methemoglobin level >40%
  OpioidsNaloxone 1 - 2 mg IV, IM, sublingual or by ETT; may repeat up to total 8 - 10 mg in adolescent/adult
  Phenothiazines
  (dystonic reaction)
Diphenhydramine, 1 - 2 mg/kg IM or IV; or

Benztropine, 1 - 2 mg IM or IV (adolescents)
  Tricyclic
  antidepressants
Sodium bicarbonate, 1 - 2 mEg/kg IV
  Warfarin (and
   superwarfarin rat
   poisons)
Vitamin K, 10 mg (adult); 1 - 5 mg (pediatric) IV, IM, suboutaneous, PO

  * See package insert for dosage information.


References:

Tenenbein M: Recent Advancements in Pediatric Toxicology. Pediatric Clinics of North America 1999;46(6):1179-88.

American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. J. Toxicol Clin Toxicol 1997;35:699-762.

Fleisher GR, Ludwig S, eds. Toxicologic Emergencies, in Textbook of Pediatric Emergency Medicine, Fourth Edition 2000:887-942.

For additional reading on ingestions, visit MDconsult.com and search for article, "Recent Advancements in Pediatric Toxicology" by Milton Tenenbein, MD, Department of Pediatrics and Pharmacology, University of Manitoba, Children's Hospital, Winnipeg, Manitoba, Canada.

"Pesticides in Children" by J. Routt Reigart, MD and James R. Roberts, MD, MPH, Children's Environmental Health, Volume 48, Number 5, October 2001.


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