Approach to the child with occult toxic exposure
- Larissa I Velez, MD
Larissa I Velez, MD
- Professor of Emergency Medicine
- 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 and Emergency Medicine
- 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)
- Clinical 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. Medical 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)".)
Examples of medical child abuse by poisoning include:
- Current annual report. National Poison Data System. The American Association of Poison Control. http://www.aapcc.org/ (Accessed on August 20, 2014).
- Osterhoudt KC, Burns Ewald M, Shannon M, Henretig FM. Toxicologic emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2000. p.951.
- Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am 2003; 21:101.
- Mofenson HC, Greensher J. The unknown poison. Pediatrics 1974; 54:336.
- Friedman EM. Caustic ingestions and foreign body aspirations: an overlooked form of child abuse. Ann Otol Rhinol Laryngol 1987; 96:709.
- Dine MS, McGovern ME. Intentional poisoning of children--an overlooked category of child abuse: report of seven cases and review of the literature. Pediatrics 1982; 70:32.
- Cohle SD, Trestrail JD 3rd, Graham MA, et al. Fatal pepper aspiration. Am J Dis Child 1988; 142:633.
- Henretig FM, Paschall R, Donaruma-Kwoh MM. Child abuse by poisoning. In: Child Abuse Medical Diagnosis & Management, 3rd ed, Reece R, Christian C (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.549.
- Siew LT, Auerbach M, Baum CR, et al. Respiratory failure caused by a suspicious white powder: a case report of intentional methadone poisoning in an infant. Pediatr Emerg Care 2012; 28:918.
- Arieff AI, Kronlund BA. Fatal child abuse by forced water intoxication. Pediatrics 1999; 103:1292.
- Meadow R. Non-accidental salt poisoning. Arch Dis Child 1993; 68:448.
- Goldfrank LR, Flomenbaum NE, Lewin NA, et al. Principles of managing the poisoned or overdosed patient: An overview. In: Goldfrank's Toxicologic Emergencies, 6th ed, Goldfrank L (Ed), Appleton and Lange, Stamford 1998. p.31.
- Clinical policy for the initial approach to patients presenting with acute toxic ingestion or dermal or inhalation exposure. American College of Emergency Physicians. Ann Emerg Med 1995; 25:570.
- Linden CH. General considerations in the evaluation and treatment of poisoning. In: Intensive Care Medicine, Rippe JM, Irwin RS, Fink MP, Cerra FB. (Eds), Little Brown and Company, Boston 1996. p.1455.
- Clancy C. Electrophysiologic and electrocardiographic principles. In: Goldfrank's Toxicologic Emergencies, 9th ed, Nelson L et al (Ed), McGraw Hill, Stamford 2011. p.314.
- Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med 1985; 313:474.
- Kirk M, Pace S. Pearls, pitfalls, and updates in toxicology. Emerg Med Clin North Am 1997; 15:427.
- Albertson TE, Dawson A, de Latorre F, et al. TOX-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med 2001; 37:S78.
- Clinical policy for the initial approach to patients presenting with acute toxic ingestion or dermal or inhalation exposure. Ann Emerg Med 1999; 33:735.
- Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness. Controversies in the use of a 'coma cocktail'. JAMA 1995; 274:562.
- Dart RC, Borron SW, Caravati EM, et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med 2009; 54:386.
- Sivilotti ML. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428.
- Goldfrank L, Weisman RS, Errick JK, Lo MW. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med 1986; 15:566.
- Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med 1991; 20:246.
- Tate JR, Nixon PF. Measurement of Michaelis constant for human erythrocyte transketolase and thiamin diphosphate. Anal Biochem 1987; 160:78.
- Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med 2012; 42:488.
- Emery, D, Singer J. Highly toxic ingestions for toddlers: when a pill can kill. Pediatr Emerg Med Rep 1998; 3:111.
- Osterhoudt, KC. The toxic toddler: drugs that can kill in small doses. Contemp Pediatr 2000;17:73.
- Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful: a 2004 update. Paediatr Drugs 2004; 6:123.
- Matteucci MJ. One pill can kill: assessing the potential for fatal poisonings in children. Pediatr Ann 2005; 34:964.
- Chomchai C, Sirisamut T, Silpasupagornwong U. Pediatric fatality from gun bluing solution: the need for a chemical equivalent of the one-pill-can-kill list. J Med Assoc Thai 2012; 95:821.
- Sutter ME, Gerona RR, Davis MT, et al. Fatal Fentanyl: One Pill Can Kill. Acad Emerg Med 2017; 24:106.
- Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, et al. 2001 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2002; 20:391.
- Shannon M. Ingestion of toxic substances by children. N Engl J Med 2000; 342:186.
- Woolf AD. Poisoning by unknown agents. Pediatr Rev 1999; 20:166.
- Brayden RM, MacLean WE Jr, Bonfiglio JF, Altemeier W. Behavioral antecedents of pediatric poisonings. Clin Pediatr (Phila) 1993; 32:30.
- Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2002 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2003; 21:353.
- Soslow AR. Acute drug overdose: one hospital's experience. Ann Emerg Med 1981; 10:18.
- Wright N. An assessment of the unreliability of the history given by self-poisoned patients. Clin Toxicol 1980; 16:381.
- Woolf A, Alpert HR, Garg A, Lesko S. Adolescent occupational toxic exposures: a national study. Arch Pediatr Adolesc Med 2001; 155:704.
- Ratnapalan S, Potylitsina Y, Tan LH, et al. Measuring a toddler's mouthful: toxicologic considerations. J Pediatr 2003; 142:729.
- Havlik DM, Nolte KB. Fatal "crack" cocaine ingestion in an infant. Am J Forensic Med Pathol 2000; 21:245.
- Boros CA, Parsons DW, Zoanetti GD, et al. Cannabis cookies: a cause of coma. J Paediatr Child Health 1996; 32:194.
- Winter ML, Ellis MD, Snodgrass WR. Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. Ann Emerg Med 1990; 19:663.
- Fulop M. Flow diagrams for the diagnosis of acid-base disorders. J Emerg Med 1998; 16:97.
- Rutecki GW, Whittier FC. An approach to clinical acid-base problem solving. Compr Ther 1998; 24:553.
- Gabow PA. Disorders associated with an altered anion gap. Kidney Int 1985; 27:472.
- Emmett M, Narins RG. Clinical use of the anion gap. Medicine (Baltimore) 1977; 56:38.
- Hoffman RS. Fluid, electrolyte, and acid-base principles. In: Goldfrank's Toxicologic Emergencies, 6th ed, Goldfrank L, et al (Eds), Appleton and Lange, Stamford 1998. p.243.
- Jurado RL, del Rio C, Nassar G, et al. Low anion gap. South Med J 1998; 91:624.
- Steinhart B. Case report: severe ethylene glycol intoxication with normal osmolal gap--"a chilling thought". J Emerg Med 1990; 8:583.
- Glaser DS. Utility of the serum osmol gap in the diagnosis of methanol or ethylene glycol ingestion. Ann Emerg Med 1996; 27:343.
- Eisen TF, Lacouture PG, Woolf A. Serum osmolality in alcohol ingestions: differences in availability among laboratories of teaching hospital, nonteaching hospital, and commercial facilities. Am J Emerg Med 1989; 7:256.
- Hoffman RS, Smilkstein MJ, Howland MA, Goldfrank LR. Osmol gaps revisited: normal values and limitations. J Toxicol Clin Toxicol 1993; 31:81.
- Wallace KL, Suchard JR, Curry SC, Reagan C. Diagnostic use of physicians' detection of urine fluorescence in a simulated ingestion of sodium fluorescein-containing antifreeze. Ann Emerg Med 2001; 38:49.
- Casavant MJ, Shah MN, Battels R. Does fluorescent urine indicate antifreeze ingestion by children? Pediatrics 2001; 107:113.
- Osterloh JD, Snyder JW. Laboratory principles and techniques to evaluate the poisoned or overdosed patient. In: Goldfrank's Toxicologic Emergencies, 6th ed, Goldfrank L, et al (Eds), Appleton and Lange, Stamford 1998. p.64.
- Wiley JF 2nd. Difficult diagnoses in toxicology. Poisons not detected by the comprehensive drug screen. Pediatr Clin North Am 1991; 38:725.
- Osterloh JD. Utility and reliability of emergency toxicologic testing. Emerg Med Clin North Am 1990; 8:693.
- Litovitz TL, Klein-Schwartz W, Dyer KS, et al. 1997 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1998; 16:443.
- Ashbourne JF, Olson KR, Khayam-Bashi H. Value of rapid screening for acetaminophen in all patients with intentional drug overdose. Ann Emerg Med 1989; 18:1035.
- Sporer KA, Khayam-Bashi H. Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. Am J Emerg Med 1996; 14:443.
- Belson MG, Simon HK. Utility of comprehensive toxicologic screens in children. Am J Emerg Med 1999; 17:221.
- Brett AS. Implications of discordance between clinical impression and toxicology analysis in drug overdose. Arch Intern Med 1988; 148:437.
- Kellermann AL, Fihn SD, LoGerfo JP, Copass MK. Impact of drug screening in suspected overdose. Ann Emerg Med 1987; 16:1206.
- Schwartz DT. Diagnostic imaging. In: Goldfrank's Toxicologic Emergencies, 9th ed, Nelson L et al (Ed), McGraw Hill, Stamford 2011. p.45.
- Florez MV, Evans JM, Daly TR. The radiodensity of medications seen on x-ray films. Mayo Clin Proc 1998; 73:516.
- Roy TM, Ossorio MA, Cipolla LM, et al. Pulmonary complications after tricyclic antidepressant overdose. Chest 1989; 96:852.
- Tran TP, Panacek EA, Rhee KJ, Foulke GE. Response to dopamine vs norepinephrine in tricyclic antidepressant-induced hypotension. Acad Emerg Med 1997; 4:864.
- Buchman AL, Dauer J, Geiderman J. The use of vasoactive agents in the treatment of refractory hypotension seen in tricyclic antidepressant overdose. J Clin Psychopharmacol 1990; 10:409.
- Hollander JE. The management of cocaine-associated myocardial ischemia. N Engl J Med 1995; 333:1267.
- Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med 1990; 112:897.
- Yuan TH, Kerns WP 2nd, Tomaszewski CA, et al. Insulin-glucose as adjunctive therapy for severe calcium channel antagonist poisoning. J Toxicol Clin Toxicol 1999; 37:463.
- Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther 1993; 267:744.
- Kerns W 2nd, Schroeder D, Williams C, et al. Insulin improves survival in a canine model of acute beta-blocker toxicity. Ann Emerg Med 1997; 29:748.
- Blake KV, Massey KL, Hendeles L, et al. Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline-induced seizures in mice. Ann Emerg Med 1988; 17:1024.
- Shepherd G. Treatment of poisoning caused by beta-adrenergic and calcium-channel blockers. Am J Health Syst Pharm 2006; 63:1828.
- Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med 1997; 15:335.
- Burns MJ, Linden CH, Graudins A, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med 2000; 35:374.
- CLINICAL PRESENTATION
- OVERVIEW OF APPROACH
- INITIAL EVALUATION AND STABILIZATION
- Altered mental status
- Other considerations
- DIAGNOSIS OF POISONING
- Physical examination
- Ancillary studies
- - Rapid blood glucose
- - Blood gas
- - Electrolytes
- - Serum osmolality
- - Urinalysis
- - Electrocardiogram
- - Toxicology screens
- - Radiologic evaluation
- Supportive care
- - Diagnostic trial
- Enhanced elimination
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS