Patients less than 17 years of age account for 66 percent of reported exposures and 9 percent of all fatalities from poisoning. Medications, including iron, alcohol, hydrocarbons, and carbon monoxide are some of the most common and serious agents; the kitchen and the bathroom are the locations where most ingestion in children occur.

Patients present an average of 68 minutes after the ingestion.

• First and foremost is the evaluation and management of the ABCs (airway, breathing, and circulation).

• History: Agent, time, and amount ingested, any symptoms, medical history, if unknown: consider occupation, search of location.

• Physical Exam: Vital signs, mental status, pupillary signs, skin, odor.

If the patient has a depressed mental status

• Dextrose 0.5-1.0 g/kg, 2-4 cc/kg D 25 for a child or 50cc D 50 for a teenager; may repeat boluses or infusion, or give glucagon 1 mg IM if no IV access.

• Naloxone 2mg (1mg/cc), can repeat Q2-5min to total 10mg; lasts 20-30 min; may need repeat boluses.

• The differential diagnosis for depressed mental status includes sepsis, meningitis, trauma, seizures, hypo/hyperthermia, central nervous system (CNS) mass lesions, and metabolic derangement.

Dextrostix, serum glucose, electrolytes, monitor/EKG, toxicology of blood/serum/vomitus, arterial blood gas (ABG), abdominal films. Especially look for arrhythmias, metabolic acidosis, seizures, and GI disturbance.

Traditional methods of lavage, catharsis, and activated charcoal are undergoing reassessment; each has benefits and risks that apply to individual cases. Before choosing an intervention, the physician must determine:

• Is gastric emptying indicated? The substance may be either nontoxic or potentially lethal, or there may be a contraindication to emptying (acid/alkali).

• Is the substance still present in the stomach and is decontamination likely to work? The substance may be rapidly absorbed, may decrease GI motility, or the patient may already have vomited.

Clinical studies to compare efficacy of techniques are limited. Syrup of Ipecac and lavage are considered to have generally equal efficacy in clearing the stomach; activated charcoal is the most frequently used and the most effective decontamination agent. Certain patients can be treated appropriately without gastric emptying and with activated charcoal only.

This should not be used routinely. Dose: 6-12months, 10 cc; 1-10years of age, 30cc; follow with water; induces emesis within 20-60 minutes.

Disadvantages:

• Patient must be conscious, have a good gag, and no potential for decrease in mental status (this rules out many serious ingestions).

• Must use within 1 hour of ingestion.

• Protracted emesis delays giving activated charcoal.

• Avoid with caustics or hydrocarbons.

Advantages:

• May occasionally be helpful immediately after ingestion at home.

• May be helpful in a small child who can't tolerate a large bore tube.

Lavage 36-40 F orogastric tube.

Can use in any patient with a potentially toxic ingestion, in whom toxin may still be present, where procedure can be done safely. If the mental status is depressed, you must intubate first to prevent aspiration.

Activated Charcoal

• When: Recommended after ingestion of an agent that may be absorbed (not iron, lithium, and heavy metals).

• Avoid if GI obstruction is present or suspected, or if endoscopy may be necessary (acid and alkali ingestions).

• Complications include vomiting, diarrhea, and aspiration. Remember to intubate first if the mental status is depressed.

• Dose: 1-2 g/kg, made as a slurry with H2O or sorbitol to 25%; aim for charcoal: poison ratio of 10:1.

Multiple dose regimen: Can increase adsorptive capacity, prevent reabsorption of poison in enterohepatic circulation, and enhance elimination with gut dialysis (creates concentration gradient):

• Repeat 1 g/kg every 2-4 hours; may use smaller doses more frequently and antiemetics if necessary.

• Avoid sorbitol in repeat doses (electrolyte instability).

• Very useful especially for theophylline, aspirin, Tegretol, phenobarbitol, and tricyclics.

Acetaminophen overdose. Although charcoal may bind N-acetylcysteine (NAC), there is no evidence that activated charcoal inhibits efficacy. Activated charcoal can be alternated Q2 hr with NAC, each at its own 4-hr interval. Treatment with NAC has priority over treatment with activated charcoal in a patient with a toxic acetaminophen level.

Used safely in surgical preps, e.g., Golytely, Colyte; 0.5L/hr for a small child, 2 L/hr for a teen, until clear (4-6 L per hr). This treatment can be considered for patients who ingest a substance that is absorbed by charcoal; massive ingestion; or patients who don't tolerate charcoal.

Pediatric poisoning treatment algorithm

Specific Toxins and Antidotes

Remember

• Contact a local/national poison control center; document their advice for treatment of the patient.

• Know the substances tested by the lab's drug and toxicologic screens, and the time it takes to run them.