Poisoning

Ali Alhaboo Assisstant Professor of

Pediatrics

PICU consultant

Overview of pediatric
poisoning, diagnosis and
treatment
Summary of the most
encountered poisoning

Epidemiology

Most of the toxic exposures have only

minor or no effect on the child
85% - 90% of pediatric poisoning
occurs in < 5 yrs of age (accidental)
usually single agent
10% - 15% in older age, mainly
adolescents (intensional) usually
several agents
3-4% of PICU admission are because of
toxic exposures

ED referral recommendations

Serious exposures
Younger than 6 months
History of previous toxic ingestion
Questionable or unreliable history

Routes of exposures in
children

Ingestion
Inhalation
Skin exposure

Common agents

Cosmetics and personal

care product
Cleaning substance:
flash is more serious than Clorox
because it melts the esophagus
and destroys it.

Plants
Analgesics: Paracetamol is
the commonest cause of
poisoning in children ( high
doses more than 200 mg/kg)

Less common but

serious

causing severe
hypoglycemia and LOC.

Anti-hypertensive.
Pesticides:
organophosphates.

Note: OCPs are not harmful.

Fe supplements:
2nd most common
in females.
Antidepressants
Anti-diabetics:

Hydrocarbon

History

Identification of the toxic agent

Age of the child.
What has been done to the child.
The time elapsed and the dose taken (if it was unknown consider it
serious).
The route of exposure
Underlying medical problems
The clinical effect (with few exceptions rapidity of symptoms
progression correlates with severity of poisoning.e.g.,
acetaminophen)
? Trauma in addition to ingestion (change in LOC).

Physical Exam

Weight (determine ? mg/kg ingested)

Vital signs
Check odors from the breath, skin, hair,
clothing
Thorough exam for any abnormal finding

General presentations suggestive

of poisoning

Severe vomiting,
diarrhea
Acutely disturbed
consciousness
Abnormal behavior
Seizure
unusual odor

Shock
Arrhythmias
Metabolic acidosis
Cyanosis
Respiratory distress

Clinical clues to the diagnosis

of unknown poisoning

Odor
Skin
Mucous
membranes
Temperature
Blood pressure

Pulse rate
Respiration
Pulmonary
edema
CNS
GI system

Odor
Signs or symptom

Poison

Bitter almond
Acetone

Oil of
wintergreen
Garlic

Alcohol
Petroleum

Cyanide
Isopropyl alcohol, methanol,
acetylsalicylic acid
Methyl salicylate
Arsenic, phosphorous, thallium,
organophosphates
Ethanol, methanol
Petroleum distillates

Skin
Sign or symptom

Cyanosis

Red flush

Poison

Sweating

Dry

Methemoglobinemia secondary to
nitrates, nitrites, phenacetin,
benzocaine
Carbon monoxide, cyanide, boric
acid, anticholenergics
Amphetamines, LSD,
organophosphates, cocaine,
barbiturates
Anticholenergics

Mucous membranes
Signs or symptoms

Dry

Salvation

Oral lesions

Lacrimation

Poison
Anticholenergics
Organophosphates,
carbamates
Corrosives, paraquat
Caustics, organophosphates,
irritant gases

Temperature
Signs or symptoms

Hypothermia

Hyperthermia

Poison
Sedatives hypnotics, ethanol,
carbon monoxide, clonidine,
phenothiazines, TCAs
Anticholenergics, salicylates,
phenothiazines, cocaine,
TCAs, amphetamines,
theophylline

Blood Pressure
Signs or symptoms

Hypertension

Hypotension

Poison

Sympathomimitics (especially
phenylpropanolamine in overthe-counter cold remedies),
organophosphates,
amphetamine, phencyclidine,
cocaine
Antihypertensives,
barbiturates, benzodiazepines,
beta blockers, Ca++ channel
blockers, clonidine, TCAs

Pulse rate
Signs or symptoms

Bradycardia

Tachycardia

Arrhythmias

Poison

Digitalis, sedatives hypnotics,

beta blockers, ethchlorvynol,
opioids
Antichlonergics,
sympathomimetics,
amphetamines, alcohol, aspirin,
theophylline, cocaine, TCAs
Anticholenergics, TCAs,
organophosphates, digoxin,
phenothiazines, betablockers,
carbon monoxide, cyanide

Respirations
Signs or symptoms

Depressed

Tachypnea

Kussmauls sign
Wheezing
Pneumonia
Pulmonary
edema

Poisoning

Alcohol, opioids, barbiturates,

sedatives/hypnotics, TCAs, paralytic
shelfish poisoning
Salicylates, amphetamines, carbon
monoxide
Methanol, ethylene glycol, salicylates
Organophosphates
Hydrocarbons
Aspiration, salicylates, opioids,
sympathomimetics

CNS
Sings or symptoms

Seizures

Fasciculation
Hypertonus
Myoclonus,
rigidity

Poison
Camphor, carbon monoxide,
cocaine, amphetamines,
sympathomimetics,
anticholenergic, aspirin,
pesticides, organophosphates,
lead, PCP, phenothiazines, INH,
lithium, theophylline, TCAs
Organophosphates
Anticholenergics, phenothiazines
Anticholenergics, phenothiazines,
haloperidol

CNS
Sings or symptoms

Poison

Delirium/psychosis Anticholenergics,
phenothiazines,
sympathomimetics, alcohol,
PCP, LSD, marijuana, cocaine,
heroin, heavy metals
Coma
Alcohol, anticholenergics,
sedative hypnotics, opioids,
carbon monoxide, TCAs,
salicylates, organophosphates
Organophosphates,
Weakness,
paralysis
carbamates, heavy metals

EYE
Signs or symptoms

Miosis

Mydriasis

Blindness
Nystagmus

Poison

Opioids, phenothiazines,
organophosphates, benzodiazepines,
barbiturates, mushrooms, PCP
Antichlenergics, sympathomimitics
(cocaine, amphetamines, LSD, PCP),
TCA, methanol, glutethimide
Methanol
Diphenylydantoin, barbiturates,
carbamazepine, PCP,carbon
monoxide, glutethimide, ethanol

GI
Sings or symptoms

Vomiting,
diarrhea

Poison

Iron, phosphorous, heavy

metals, lithium, mushroom,
fluoride, organophosphates

Toxidromes of Common Pediatric

Poisonings
Toxin

Anticholenergi
cs (atropine,
scopolamine,
TCAs,
antihistamines,
mushrooms)
Cholenergics
(organophospha
tes and
carbamate
insecticides)

Signs or symptoms

Fever, flushed, warm, dry skin,

dry mouth, mydriasis,
tachycardia, arrhythmias,
agitation, hallucinations, coma
Salivation, lacrimation, sweating,
bronchorrhea, emesis, diarrhea,
miosis, bradycardia,
bronchospasm with wheezing,
confusion, weakness,
fasciculations, coma

Toxidromes of Common Pediatric

Poisonings
Toxin

Opiates

Narcotic
withdrawal

Signs or symptoms

Hypothermia,
hypoventilation, hypotension,
bradycardia, miosis, coma
Nausea, vomiting, diarrhea,
abdominal pain, lacrimation,
diaphoresis, mydriasis,
tremor, irritability, delirium,
seizure

Toxidromes of Common Pediatric

Poisonings
Toxin

Sedative/
hypnotics

TCAs

Phenothiazines

Signs or symptoms

Hypothermia, hypoventilation,
hypotension, tachycardia, coma
Coma, convulsions, arrhythmias,
anticholenergic manifestations
Hypotension, tachycardia,
dystonia syndrome, oculogyric
crisis, trismus, ataxia, coma,
anticholenergic manifestations

Toxidromes of Common Pediatric

Poisonings

Toxin
Salicylates

Iron

Sympathomimetics
(amphetamines,
phenylpropanolamie,
ephedrine, caffeine,
cocaine,
aminophylline)

Signs or symptoms

Fever, hyperpnea, vomiting,

tinnitus, acidosis, seizure,
lethargy, coma
Hyperglycemia, shock,
hemorrhagic diarrhea
Tachycardia, arrhythmias,
psychosis, hallucinations,
nausea, vomiting,
abdominal pain

Laboratory
tests
Qualitative toxicology screening is rarely as helpful as Hx and

PE in determining the cause

Best done on urine and gastric aspirate samples
Quantitative serum level of known drug is indicated when it can
enable prediction of toxicity or determination of treatment
ABGs with respiratory symptoms and to assess acid-base
balance
Blood glucose from 1st sample
Liver and kidney function (metabolism&excretion)
Serum electrolytes (anion gap, renal function)
Serum osmolar gap
CBC (anemia, hemolysis)
DIC panel when suspected

Routine Laboratory Tests That Can

Suggest Poisoning
- Decreased hemoglobin
saturation with normal
or increased PO2
- Elevated anion gap
metabolic acidosis
- Elevated osmolar gap
- Hyperglycemia
- Hypoglycemia
- Hypocalcemia

Agents causing methemoglobin (nitrates,

nitrites, benzocaine)
Methanol, ethanol, isopropyl alcohol,
ethylene glycol, salicylates, isoniazid,
paraldehyde, toluene, iron, phenformin,
CO, cyanide
Ethanol, methanol, isopropyl alcohol,
ethylene glycol
Salicylates, isoniazid,
organophosphates, iron
Insulin, ethanol, isopropyl alcohol,
isoniazid, phenfomin, acetaminophen,
salicylates, oral hypoglycemic agents
Ethylene glycol, methanol

- Oxalic acid crystalluria Ethylene glycol

- Ketonuria

Isopropyl alcohol, ethanol, salicylates

Drugs with clinically useful serum

level quantitation

Acetaminophen
Anticonvulsants
Carbon
monoxide
Cholinesterase
Digoxin
Ethanol
Ethylene glycol
Heavy metals

Iron
Isopropanol
Lead
Lithium
Methanol
Methemoglobin
Salicylate
Theophylline

Radiography indications

If head trauma cannot be excluded

(skull and cervical spine film, head CT if
physical findings are suggestive)
If child abuse is suspected
(skeletal survey)
If patient is having respiratory distress
(CXRay)
If radiopaque substance is suspected

Common substances that are

radiopaque (CHIPES)

Chloral hydrate
Heavy metals
Iodine
Phenothiazine
Enteric coated and extended
release medication
Salt tablets
(in Fe ingestion, serial films indicate movement and elemination)

Steps of management

First you have to start with ABC, if hypotensive repeat ABCs.

Check the O2 saturation
Glucocheck for hypoglycemia. If hypoglycemic give 5-10% dextrose (not higher
than that because it might harm the vessel). Dose: 2-5 ml/Kg.
Do toxicology screen.
LFT, U/E, RFT, coagulation profile (PT is the first to be affected, if it was elevated
give FFP or vitamin K) and albumin.
Give antidote as early as possible if available. (N-acetylcesteine is the antidote for
paracetamol. Desfuroxemine is the antidote for iron.
Transfer the patient to the ICU, if there is no bed keep him in the ER.

Treatment

Airway: patency and protective mechanisms (if absent, use

nonspecific antidote of D10W 2cc/kg and Naloxone
0.1mg/kg; if no response intubate.

Breathing: clear secretions, give O2, continuous O2

saturation, ABGs, CXRay, treat wheezing and stridor, early
controlled intubation prefered

Circulation: frequent VS, continuous CR monitor, fluids for

low BP, do baseline ECG, watch for arrythmias, PALS
guidelines

Neurologic status: frequent assessments, the most

common cause to admit intoxication to PICU, use
nonspecific antidotes, watch for seizures, rule out metabolic
causes of seizure

GI decontamination

Emesis-Syrup of Ipecac

Therapy

Dosage in < 1 yr 10 ml
Young children 15 ml
Adolescents,
adults
30 ml
may repeat once

Contraindications

Petroleum distillates
Caustic agents
Impaired
consciousness,
seizures
Rapid coma-inducing
agents (e.g.,
propoxyphene, TCAs)

We use lavage when the patient presents

early and is stable.
If late presentation where the drug has
already passed to the duodenum use the
activated charcoal( through a NG tube)
where up to 1 million particles can adsorb
to the medication.

GI decontamination
Therapy

Lavage

Large bore orogastric hose (28 Fr for

young children, 36-40 Fr for
adolescents)
Left recumbent Trendelenburgs
position to reduce the risk of aspiration
Lavage with saline or 1/2 NS until return
is clear
Most successful for toxins that delay
gastric emptying (aspirin, iron,
anticholinergics) and for those forming
concretions (iron, salicylates,
meprobamate)

Contraindications

Corrosive
caustic agents
Controversial in
petroleum
distillates
ingestion
Stupor or coma
unless airway is
protected

GI decontamination
Therapy

Activated Charcoal

Contraindications

Administer in all
cases after
emesis. It should
be only given for
conscious
patients.
Dosage:
- Children 1 g/kg
- Adults 50-100 g

Corrosive agents:
charcoal interfers
with GI endoscopy

Most feared complication

is aspiration leading to
severe pneumonitis and
ARDS

GI decontamination
Therapy

Cathartics

MgSO4 250 mg/kg/dose

P.O.(max dose 30 g) in
10%-20% solution
Sorbitol magnesium
citrate
Repeat above doses
every 2-4 hrs until
passage of charcoal
stained stools

Contraindications
Avoid MgSO4 in
renal failure

Enhanced elimination

Forced diuresis by administering 2-3 times the

maintenance fluid to achieve U.O = 2-5 cc/kg/hr
(contraindicated in pulmonary or cerebral edema and
renal failure)

Urinary alkalinization to eleiminate weak

acids(salicylates, barbiturates and methotrexate), can be
achieved by adding NaHCO3 to the IV fluids, the goal is
urine pH of 7-8

Serum alkalinization in TCAs toxicity

Hemodialysis in low molecular weight substances with
low volume of distribution and low binding to plasma
proteins

Hemoperfusion, protein binding is not a limitation

Antidotal Therapy

Only a small proportion of

poisoned patients are amenable to
antidotal therapy
Only a few poisoning is antidotal
therapy urgent (e.g., CO, cyanide,
organophosphate and opioid
intoxication)

Specific Intoxications and Their Antidotes

Poison

Antidote

Indications

Acetaminophen

N-Acetylcysteine
(Mucomyst)

Serum level in probable

hepatotoxic range

Anticholenergics

Physostigmine

SVT with hemodynamic

compromise

Beta blockers

Glucagon
Isopreterenol,
dopamine,
epinephrine
Flumazenil

Bradycardia
Bradycardia

Benzodiazepines

Symptomatic intoxication

Carbon monoxide O2

Level > 5-10%

Cyanide

Amyl nitrite,
sodium nitrite,
sodium thiosulfate

Symptomatic intoxication

Digitalis

Specific Fab
antibodies

Specific Intoxications and Their Antidotes

Poison

Antidote

Indications

Ethylene glycol

Ethanol

Osmolar gap and metabolic acidosis or

Serum level >20 mg/dl regardless of
symptomatology

Iron salts

Desferoxamine

Symptomatic patients
Serum iron > 350 g/ml or > TIBC
Positive deferoxamine challenge test

Isoniazid

Pyridoxine
(vit B6)

Methanol

Ethanol

Metabolic acidosis and elevated

osmolar gap regardless of symptoms

Methemoglobinemi Methylene blue

a producing agents

Symptomatic poisoning
Methemoglobin level > 30-40 %

Narcotics

Naloxane

Symptomatic intoxication

Organophosphate
insecticides

Atropine
Pralidoxime

Cholenergic crisis
Fasciculation and weakness

Phenothiazines

Diphenhydramine Symptomatic intoxication (oculogyric

crisis)

Acetaminophen
(paracetamol) poisoning

Nausea, vomiting and malaise for 24 hrs

Improvement for 24-48 hrs
Hepatic dysfunction after 72 hrs (AST is the
earliest and most sensitive)
Death may occur from fulminant hepatic failue
Toxicity likely with ingestion of > 150 mg/kg
Rumack-Matthew nomogram defines the risk of
hepatic damage in acute intoxication (level at 4
hrs post ingestion)

Acetaminophen (paracetamol)
poisoning management

GI decontamination
Activated charcoal within 4 hrs of ingestion
Antidote N-acetylcysteine is most effective if
given within 8 hrs of ingestion, total of 17
doses, P.O or IV (However, NAC should be
given even with > 24hrs presentation)
NAC should be given if serum acetaminophen
level is either in the possible or probable
hepatotoxic range

Salicylate toxicity
Clinical manifestations
Common

Fever
Sweating
Nausea
Vomiting
Dehydration
Hyperpnea
Tinnitus
Seizures
Coma
Coagulopathy

Uncommon

Respiratory
depression
Pulmonary
edema
SIADH
Hemolysis
Renal failure
Hepatotoxicity
Cerebral edema

Laboratory findings in salicylate

toxicity

Metabolic acidosis
Respiratory alkalosis
Mixed (resp alkalosis
&metabolic acidosis)
Hyperglycemia,
Hypoglycemia

Hypernatremia,
hyponatremia
Hypokalemia
Hypocalcemia
Prolonged PT
Ketouria

Prediction of acute salicylate

toxicity

Ingested dose can predict the severity

< 150 mg/kg
toxicity not expected
(asymptomatic)
150-300 mg/kg
toxicity mild to moderate
(mild to moderate hyperpnea,
lethargy or excitability)
300-500 mg/kg
severe toxicity
(severe hyperpnea, coma
or semicoma, sometimes
with convulsions)

Management of salicylate toxicity

GI decontamination
Correct dehydration and force diuresis
Urine alkalinization and acidosis correction with IV
NaHCO3
Monitor electrolytes, glucose, calcium
Vit K for hemorrhagic diathesis
Decrease fever with external cooling
Hemodialysis for severe intoxication (Dome nomogram),
severe acidosis unresponsive to NaHCO3, renal failure,
pulmonary edema and severe CNS manifestation