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Ten Key Tips for Pediatric Poisoning

Sean Boley MD

pediatric, respiration, respiratory, airway, ventilation, bag valve mask, BVM

EMS Reference editor's note: This article is co-authored by JoAn Laes, MD.

 

Introduction

The following are some of the key tips you need to know about the assessment and immediate management of the pediatric poisoned patient and how to recognize toxidromes.

 

1. Exposure

As with all patients, EMS providers need to provide basic life support first and foremost. The pediatric patient’s airway, breathing, and circulation (ABCs) should be addressed. Given the relatively high metabolic demands and low respiratory reserve, pediatric patients can become hypoxic and unstable very quickly.

Pediatric patients can also become hypoglycemic quickly given low glycogen stores. Therefore, a point-of-care blood sugar should be assessed quickly and addressed if necessary.

It’s important to consider the following questions about what was ingested and/or what toxins are accessible to the child:

  • How much?
  • When?
  • Why?
  • Has the patient vomited?
  • Have any treatments been administered?

It's also important to consider the following exam findings:

 

2. Prevalence

These are the most common poisonings, listed in order of decreasing prevalence: 

  • Cosmetics/personal care items
  • Analgesics
  • Household cleaners
  • Foreign bodies
  • Topical preparations
  • Vitamins
  • Antihistamines.1

 

3. One-Pill Killers

The following substances can be fatal in children—even with a low dose, in some cases as little as a single pill: 

Opioids: Such as buprenorphine (Suboxone), oxycodone, diphenoxylate/atropine (antidiarrheal), etc. Opioids can cause fatal respiratory depression and sedation in children.

Camphor: Due to the highly aromatic odor, this substance (often found in over-the-counter topical cold remedies) can be appealing to children and lethal in small amounts due to central nervous system (CNS) depression and seizure. Fortunately, there is increasingly limited availability due to federal regulations that restrict the concentration of camphor in products to less than 11%.2

Sulfonylureas: These common diabetic medications, such as glipizide or glyburide, can cause severe hypoglycemia even in doses as little as 2 mg. Due to pharmacologic properties of the drugs, clinical effects can be delayed up to 18 hours.3

Methyl salicylate: Products containing this include oil of wintergreen. One teaspoon of 98% oil of wintergreen contains 7,000 grams of salicylate. Other products that may contain salicylates are muscle pain relief creams and wart removers.

Beta blockers and calcium channel blockers: Beta blockers, such as metoprolol and propranolol and calcium channel blockers, such as amlodipine and diltiazem, can cause severe bradycardia and hypotension in children even with small doses.

Tricyclic antidepressants: These medications, such as nortriptyline and amitriptyline, have the potential to cause serious morbidity in toddlers, such as seizures and dysrhythmias, who have ingested a few tablets. 

 

4. Gastric Decon

In 2003, the American Academy of Pediatrics (AAP) ceased to recommend the use of syrup of ipecac. Syrup of ipecac has no routine role in the care of poisoned patients.4 The last manufacturer of the product discontinued it in 2010.5

Activated charcoal may be effective in early gastrointestinal (GI) decontamination for certain toxins by adherence of toxin to charcoal surface. There are no set guidelines regarding routine use of prehospital activated charcoal. However, due to potential for aspiration, EMS should have the ability to intubate if administering charcoa, and charcoal should not be given to the child who is exhibiting symptoms from their ingestion or signs that they may be at increased risk for aspiration, such as decreased mentation or inability to manage secretions. To be most effective, it should be given within 60 minutes and is recommended in doses of 0.5-1 gram/kilogram for children 12 and under.6

 

5. Sulfonylurea

Sulfonylureas are common diabetic medications that can cause severe hypoglycemia even in doses as little as 2 mg, by increasing insulin release. Common sulfonylureas include glipizide and glyburide. Look for symptoms that may include dizziness, agitation, lethargy, CNS depression, or seizure. Due to the pharmacokinetic properties of the drugs, hypoglycemia may be delayed and may be recurrent following initial episodes despite treatment with glucose.

Prophylactic treatment with IV dextrose in the asymptomatic, euglycemic patient is not indicated, however hospital observation for 24 hours is necessary.7 Blood glucose levels should be checked frequently, including with any change in mental status.

 

6. Antihypertensive

Common medications in this category include atenolol, metoprolol, carvedilol, verapamil, and amlodipine. Look for physical findings that may include hypotension and bradycardia.

Your initial management of toxicity should be aimed at correction of the bradycardia and hypotension.

Supportive interventions include airway management (if needed), IV fluids, and atropine for bradycardia. If glucagon is available, this may be considered as a temporizing measure in calcium channel blockers and beta blockers. Glucagon side effects include nausea and vomiting, which can compromise the airway.8

 

7. Opiates and Opioids

Physical findings may include drowsiness, CNS depression, decreased respirations, and pinpoint pupils.

The mainstay of treatment is airway support and naloxone for opiate reversal. The standard naloxone dose in children up to the age of 5 is 0.1 mg/kg.9 After that, adult dosing is recommended.

Naloxone can be used via several different routes, including intramuscularly, inhaled via nebulizer, insufflated via nasal spray, intravenously, or subcutaneously.10–12

You should attempt to identify the opiate or opioid so that you can alert hospital providers to the possibility of acetaminophen toxicity, given that most pediatric ingestions involve combination opioid-acetaminophen products.13

 

8. Methyl Salicylate

Methyl salicylate, also called oil of wintergreen, can cause salicylate toxicity (e.g., the syndrome of poisoning seen after aspirin overdose). The symptoms of toxicity are nausea, vomiting, tinnitus, abdominal pain, lethargy, and seizures.14

Prehospital treatment is supportive, including airway monitoring and fluid resuscitation.

Note that salicylate toxicity can be associated with CNS hypoglycemia even if serum glucose levels are normal, and dextrose is recommended when the child's mental status is altered.15 Activated charcoal and bicarbonate infusions are also potential treatments in the prehospital setting.16,17

 

9. Hydrocarbon Aspiration

Hydrocarbons are easily aspirated by young children during swallowing due to the physical properties of the liquids. Examples of these liquids include lamp oil, tiki torch oil, and gasoline.

Symptoms can rapidly progress and include vomiting, coughing, dyspnea, and respiratory failure.

Prehospital management should focus on airway support and early intubation may be considered if symptoms progress.18

 

10. Household Toxins

Some examples of common toxic household products are hydrocarbons, toxic alcohols, and caustics. Examples of hydrocarbons are lamp oil, tiki torch oil, and furniture polish. Common household toxic alcohols are windshield wiper fluid, antifreeze, and brake fluid.

Caustics can be broken down into alkalis and acidics. Examples of alkalines and their corresponding products include:

  • Ammonia: as glass cleaners;
  • Sodium hydroxide, such as detergents and oven cleaners, and
  • Sodium hypochlorite, such as bleach.

Common household acidics include:

  • Hydrochloric acid like toilet bowl cleaners;
  • Sulfuric acid, such as drain cleaners, and
  • Hydrofluoric acid, such as wheel cleaners and rust removers.

 

Conclusion

These tips are meant to be used as practical guide for the focused assessment and acute management of the pediatric poisoned patient. The American Association of Poison Control Centers supports poison centers nationwide that are available for assistance 24 hours a day, seven days a week. They are able to assist with determining the severity and acuity of potential ingestions, identifying what may have been ingested based on symptoms, and advise on basic management. The national poison center hotline phone number is (800) 222-1222.

 

References

  1. Calello DP, Henretig FM. Pediatric toxicology. Emerg Med Clin North Am. 2014;32(1):29–52. doi:10.1016/j.emc.2013.09.008.
  2. Love JN, Sammon M, Smereck J. Are one or two dangerous? Camphor exposure in toddlers. J Emerg Med. 2004;27(1):49–54. doi:10.1016/j.jemermed.2004.02.010.
  3. Davis JE. Are one or two dangerous? Methyl salicylate exposure in toddlers. J Emerg Med. 2007;32(1):63-69. doi:10.1016/j.jemermed.2006.08.009.
  4. Little GL, Boniface KS. Are one or two dangerous? Sulfonylurea exposure in toddlers. J Emerg Med. 2005;28(3):305–310. doi:10.1016/j.jemermed.2004.09.012.
  5. Manoguerra AS, Cobaugh DJ. Guidelines for the management of poisoning consensus panel. Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons. Clin Toxicol Phila Pa. 2005;43(1):1–10.
  6. American Society of Health-System Pharmacists: Ipecac syrup. Am Soc Health-Syst Pharm Bethesda, Md. 2010. Available at: http://www.ashp.org/Import/PRACTICEANDPOLICY/PracticeReso urceCenters/DrugShortages/GettingStarted/CurrentShortages /Bulletin.aspx?id=468.
  7. Lowry JA. Use of activated charcoal in pediatric populations. 2008. Available at: http://cdrwww.who.int/entity/selection_medicines/committees/subcommittee.... Accessed December 31, 2013.
  8. Glatstein M, Scolnik D, Bentur Y. Octreotide for the treatment of sulfonylurea poisoning. Clin Toxicol Phila Pa. 2012;50(9):795–804. doi:10.3109/15563650.2012.734626.
  9. Bailey B. Glucagon in β-blocker and calcium channel blocker overdoses: A systematic review. Clin Toxicol. 2003;41(5):595–602.
  10. American Academy of Pediatrics Committee on Drugs: Naloxone dosage and route of administration for infants and children: Addendum to emergency drug doses for infants and children. Pediatrics. 1990;86(3):484–485.
  11. Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012;16(2):289–292. doi:10.3109/10903127.2011.640763.
  12. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med. 1998;5(4):293–299. doi:10.1111/j.1553-2712.1998.tb02707.x.
  13. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care. 2009;13(4):512–515. doi:10.1080/10903120903144866.
  14. Flomenbaum NE, Goldfrank LR. Goldfrank’s toxicologic emergencies. New York, N.Y., [etc.]: McGraw-Hill; 2006.
  15. O’Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007;25(2):333–346. doi:10.1016/j.emc.2007.02.012.
  16. Calkins T, Chan TC, Clark RF, Stepanski B, Vilke GM. Review of prehospital sodium bicarbonate use for cyclic antidepressant overdose. Emerg Med J. 2003;20(5):483–486.
  17. Greene SL, Kerins M, O’Connor N. Prehospital activated charcoal: The way forward. Emerg Med J. 2005;22(10):734–737. doi:10.1136/emj.2005.024968.
  18. Evans B. Know how to treat hydrocarbon poisoning. JEMS.com. Available at: http://www.jems.com/article/patient-care/know-how-treat-hydrocarbon-poi. Accessed January 6, 2014.

 

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Published: May 14, 2014
Revised: November 27, 2015