Poisoning -management of childhood
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- Unintentional poisoning is most common in the 12 to 36 month age group.
- Most small children will only take 2 to 3 tablets or one mouthful of substance.
- Serious sequelae are rare.
- Supportive care and observation are the mainstays of treatment.
- Beware of causing harm - a risk assessment is essential before considering decontamination or treatment.
- Small ingestions of some substances can cause very serious injury in a small child.
One or two tablets that can be lethal to a 10kg toddler
Small volumes of non-pharmaceuticals than can result in severe toxicity
Poisoning should be considered in the child with unexplained abnormal vital signs, altered neurology or metabolic disturbance.
Consider non accidental injury (NAI) in non-ambulatory children, older children or large ingestions.
Older children/adolescents may present with deliberate self harm (intentional poisoning).
Approach to Paediatric Toxicology
- Risk assessment
- Supportive care
- Enhanced elimination
Resuscitation takes priority over decontamination and administration of antidotes (unless necessary for resuscitation e.g. NaHCO3)
Intubation likely to be indicated in the following situations:
- Cardio-respiratory arrest
- Airway injury
- Corrosive ingestion
- Decreased level of consciousness (GCS<8) or anticipated decrease in GCS
- Prolonged seizures
- Severe agitation or to facilitate treatment/investigations
Oxygen/ventilation if required
- Support perfusion as needed
- IV fluids (20ml/kg 0.9% NaCl if shocked) (see Shock guideline)
- Treatment of hypertension (see Hypertension
- Beta-blockers should be avoided in sympathomimetic toxicity
- NaHCO3 (1mmol/kg repeated as necessary) if sodium channel blocker ingested (Suspect if prolonged QRS, large R wave in aVR)
- Generally poor response to defibrillation in poisoning
|Examples of sodium channel blockers|
Class 1A and 1C antiarrhthmics
First generation antihistamines
- Sedation (benzodiazepines are the mainstay)
- Midazolam (0.1-0.2mg/kg) is most commonly used
- Seizure control (note - NOT conventional treatment)
- Repeat doses of Midazolam (0.15mg/kg IV)
- Phenobarbitone (20mg/kg IV) as second line
- Phenytoin should NOT be used - Prolongs sodium channel blockade
- Treatment of hypoglycaemia
- Maintain normothermia
- Management of hyperthermia
- Physical cooling
- May require intubation and paralysis
Risk assessment is a distinct cognitive process through which the clinician attempts to predict the likely clinical course and potential complications for the individual patient at that particular presentation.
Risk assessment should be quantitative and take into account agent, dose, time of ingestion, current clinical status and individual patient factors (for example, weight and co-morbidities).
The risk assessment is essential to determine the course of the poisoning and will guide treatment, investigations, period of observation and disposition.
Attempt to elucidate and clearly document:
- What substance(s) have been ingested?
- How much of each substance has been ingested - including a calculation of amount of substance per kg?
- What time the ingestion occurred?
- What clinical features have occurred thus far?
- What other relevant patient factors (patient weight, other medical problems etc) are present?
Then discuss with senior staff and/or consult poisons
If the ingestant is unknown:
Consider all possible medications or toxins accessible in the house
- All family members medications
- Non-pharmaceutical agents
- Drugs of abuse
Conduct tablet counts of missing medication
Consider the worst case scenario, including:
- That all the missing tablets were taken
- That the ingestion time is the latest time possible
- That there has not been significant spillage
- That one child has ingested all of the missing poison.
Focused clinical examination
- Especially important if ingestant is unknown
No tests are routine. These will be determined by risk assessment and may include:
- Blood sugar level
- Paracetamol level
- Should be requested in all children/young people following any intentional ingestion
- Other screening tests should be guided by risk assessment
- Other drug levels
- Blood gases
For most children the only treatment required is good supportive care:
- Treatment of
This is rarely required and must not distract from resuscitation and supportive care
Wash off with soapy water
Irrigate with 0.9% NaCl until pH is <8.0
- Dilution with milk/water is generally not recommended
- Emesis should never be induced
- Gastric lavage - is not recommended as no demonstrated benefit compared to a single dose of activated charcoal.
- Activated charcoal (AC)
Is rarely indicated in paediatric poisoning
The use of AC carries a risk of aspiration and subsequent chemical pneumonitis
Indicated only if ALL of the following are true:
- Presentation within 1 hour of Ingestion
- Toxin is adsorbed by AC
- Patient is currently maintaining own airway and risk assessment determines that their GCS will remain normal
- Otherwise only give if airway is protected
- The substance has significant toxicity and is not easily treatable
Dose = 1g/kg
Can be made more palatable by mixing with ice-cream
Toxins not adsorbed by activated charcoal
- Whole bowel irrigation (WBI)
Is very rarely performed
- Ingestion of a slow release or extended release substance or a substance not bound to AC and
- Presentation prior to symptom onset and
- Ingestion is likely to result in significant toxicity despite supportive care or antidote therapy
- Polyethylene glycol (Golytely) - 30ml/kg/h until effluent runs clear)
Possible indications for WBI
Iron (>60mg/kg elemental iron ingested)
This is very rarely required and must not distract from resuscitation and supportive care
Multidose activated charcoal
- Can interrupt enterohepatic circulation and promote gut dialysis
- May be indicated with large ingestions of Carbemazepine, Dapsone, Phenobarbital, Quinine, Theophylline
- 1g/kg activated charcoal q4h
- Alkalinisation promotes ionization of highly acidic drugs, therefore prevents reabsorbtion across tubule and increases renal excretion.
- Salicylates (however if severe toxicity this should not detract from urgent haemodialysis)
- 1-2 mmol/kg NaHCO3 stat then titrate (can infuse further doses over 1-2 hours)
- Aim for urinary pH >7.5
Extracorporeal elimination (haemodialysis)
- Haemodialysis is effective if toxin is water soluble, low
molecular weight, not protein bound and has a small volume of
- e.g. alcohols, lithium, chloral hydrate, amphetamine, camphor, heavy metals, salicylates, theophylline, valproate or carbamazepine
- Indications are based on drug levels, biochemistry and clinical symptoms.
- Intensive care required
- Pharmacological antagonists and chelating agents
- Only useful in a small minority of poisonings
- Administered when the potential therapeutic effect outweighs the adverse effects
Examples of some available antidotes
|Paracetamol||N-acetylcysteine - see guideline|
|Sodium channel blockers||NaHCO3|
|Digoxin||Digoxin fab-fragments (Digi-bind)|
|Beta blockers, Ca2+ channel blockers||Insulin/dextrose euglycaemic therapy|
For further information see Toxicology Handbook (Murray et al). Elsevier. 2007
- Should be directed by risk assessment
- Some children can be safely discharged after brief or no observation.
- Others may require admission for ongoing observation and treatment
- Assume worst case scenario - a potentially lethal ingestion
- Observe for a minimum of 12 hours
- Monitor cardio-respiratory status and neurology
- Cardiac monitoring if any evidence of abnormal vital signs
- IV access can be deferred unless evidence of toxicity present
- BSL at presentation and discharge
- Discharge only in daylight hours
- Child safety and parental education
- Safe storage of toxins
- Social work review might be indicated
- Consider non-accidental injury
- Discharge instructions
Deliberate self harm
Psychiatric review is mandatory prior to discharge
- The prevention of unintentional poisoning should be promoted throughout the community.
- Child resistant packaging and safe storage has been shown to decrease the incidence of childhood poisoning.
- Other measures include:
- Smaller volume prescribing
- Child resistant lids
- Education about safe storage of medications, out of reach of children
- Store in cupboards with child resistant latches
- Home visits to target this advice
|Anticholinergic||Delirium + peripheral effects
Mad as a hatter
Confusion, hallucinations, seizures, coma
Red as a beet
Blind as a bat
Hot as a hare
Dry as a bone
Dry skin, urinary retention, ileus
1st generation antihistamines
Diarrhoea (& abdo cramps)
M Miosis (or mydriasis)
Chemical warfare agents
- Ricin, Tabun, Soman, VX
Agents used for myasthenia gravis
- Phenylephrine, OTC cold preps
- Salbutamol, Theophylline, Caffeine
Alpha and beta
- Amphetamine, Cocaine,
Pseudo/ephedrine, OTC cold preps,MDMA (ecstasy)
Opioids and barbiturates
- Anxiety, agitation, hallucinations, seizures, coma
- Hyper-reflexia and clonus (LL>UL)
- SSRIs, SSNRIs, MAOIs, TCADs
- Tramadol, Pethidine, Fentanyl
Drugs of abuse
- Amphetamine, MDMA (ecstasy), LSD
- St John's Wort, Ginseng
- Magic mushroom - Psilocybin species
Information for Families
Safekids information on poisoning prevention.
Poisons information centre 0800POISON
Toxins database (http://www.toxinz.co.nz/)
- This is an extensive database of most toxins
- Information is generally accurate but generic at times (particularly with regard to decontamination). Consider each case on its merits. If in doubt discuss with ED consultant.
Toxicology Handbook (Murray, Daly, Little, Cadogen). Elsevier.
- An excellent reference guide with a very sensible approach to poisoning
A risk assessment based approach to the management of acute poisoning. Daly FFS, Little M, Murray L. Emerg Med J 2006;23:396-399
Poisonous plants in New Zealand. http://www.landcareresearch.co.nz/publications/factsheets/poisonous-plants
Safefkids New Zealand - Excellent resource for prevention
Did you find this information helpful?
- Date last published: 01 September 2013
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department
- Author(s): Mike Shepherd, E Batistich
- Owner: Mike Shepherd
- Editor: Greg Williams
- Review frequency: 2 years
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