Approach to the child with occult toxic exposure
- Larissa I Velez, MD
Larissa I Velez, MD
- Associate Professor
- University of Texas Southwestern Medical Center
- J Greene Shepherd, PharmD
J Greene Shepherd, PharmD
- Professor of Clinical Pharmacy
- University of North Carolina - Eshelman School of Pharmacy
- Collin S Goto, MD
Collin S Goto, MD
- Associate Professor of Pediatrics
- University of Texas Southwestern Medical Center at Dallas
- Section Editor
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The general approach and initial management of the child who is suspected to have ingested or inhaled an unknown poison is reviewed here. Specific issues relating to management of common drug overdoses are discussed separately. (Refer to appropriate topic reviews).
Toxic exposures occur frequently in children throughout the world. Common patterns of pediatric poisoning consist of exploratory ingestions in children younger than six years of age and intentional ingestions and recreational drug use in older children and adolescents . In many instances, the toxic agent is readily identified. However, in an important minority of exposures, a history of poisoning is not provided.
The clinical presentation of occult ingestion varies depending upon the ingested substance and can range from asymptomatic to critically ill. Occult toxic exposure should be considered in the differential diagnosis of children who present with acute onset of multiorgan system dysfunction, altered mental status, respiratory or cardiac compromise, unexplained metabolic acidosis, seizures, or a puzzling clinical picture [2,3]. The index of suspicion should be raised if the child is in the "at risk" age group (one to four years of age) and/or has a previous history of ingestion .
Intentional etiologies for occult poisonings, including suicide attempts in older children and adolescents, and child abuse via forced ingestion in young children, particularly those who are younger than one year of age, must not be overlooked . (See "Suicidal behavior in children and adolescents: Epidemiology and risk factors" and "Medical child abuse (Munchausen syndrome by proxy)".)
Forced ingestion or intentional poisoning of children is a form of child abuse that overlaps with Munchausen syndrome by proxy. A variety of substances, including water, salt, pepper, and various drugs (prescription and illicit), may be used [5-9]. (See "Medical child abuse (Munchausen syndrome by proxy)".)
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- CLINICAL PRESENTATION
- OVERVIEW OF APPROACH
- INITIAL EVALUATION AND STABILIZATION
- Altered mental status
- Other considerations
- DIAGNOSIS OF POISONING
- Physical examination
- Ancillary studies
- - Blood gas
- - Electrolytes
- - Serum osmolality
- - Urinalysis
- - Electrocardiogram
- - Toxicology screens
- - Radiologic evaluation
- Supportive care
- - Diagnostic trial
- Enhanced elimination
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS