Paediatric Clinical Guideline
Emergency: 1.3 Ingestions and Accidental Poisoning
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Ingestions and Accidental Poisoning
Guideline for the assessment and management of a ingestions and accidental poisoning in children and young people
June 2005
This guideline applies to all children and young people under the age of 19 years.
Dr Damian Wood, Consultant Paediatrician Ext 64041
Revision Date June 2008
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Ingestions and accidental poisonings are a common cause of hospital attendance and admission. Severe toxicity is uncommon, with the majority of admitted children requiring observation only, however some require intensive care, and nationally there are a small number of deaths each year.
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Resuscitation and stabilisation o Determine the exact nature and timing of the poisoning o Prevent and treat toxicity o Eliminate the poison o Deliver specific antidote if available
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Monitor for late effects and complications
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Determine if poisoning was accidental, intentional or deliberate (see below) o Accidental (typically toddler / pre school age group) o Intentional (common in young people) o Deliberate (by "carer"; rare)
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Prevention of future episodes/protection from future harm
Call the paediatric registrar if resuscitation required. Paediatric registrar to ensure stabilisation and safe transfer to ward/PICU as appropriate.
Airway – Depression of the CNS is a common symptom of poisoning and treatments may necessitate airway protection
Breathing - Consider naloxone if respiratory depression secondary to narcotic
Circulation - Expand circulatory volume (20ml/kg normal saline) if shock present. Inotropes and invasive monitoring may be required if poor response to initial fluid resuscitation.
Poisonings are a common cause of arrhythmias – see management of arrhythmias below
Damian Wood Page 1 of 5 June 2005

Paediatric Clinical Guideline
Emergency: 1.3 Ingestions and Accidental Poisoning
Disability - Assess conscious level (intubation likely to be ne eded if GCS ≤ 8) and pupillary size and response
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Which agent ? o Tablets/medicines
 Examine the packaging and estimate how much remains
 What prescriptions (new and old are in the house?) o Plants / berries may be identifiable from charts / books
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What dose ?
(assume maximum possible) – calculate dose/kg body weight
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When ?
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Look for evidence of specific poisons e.g. mouth ulceration from corrosive substance, if pupils dilated/sweatiness consider tricyclic antidepressants
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Is it possible that other children may have been involved?
What are the adverse effects of the ingested substance?
Upto date information regarding risk of toxicity, elimination of poisons and specific antidotes as well as monitoring for specific poisons is available from:
National Poisons
Information Service
24 hour poisons enquiries
TOXBASE www.spib@luht.scot.nhs.uk
Nottingham University
Hospitals
Drug Information
0870 600 6266
Access available at all workstations in the emergency department.
Departmental user name and password can be obtained from nurse in charge
Queen’s Medical Centre
(0115 924 9924)
Ext 64185
Can absorption be prevented?
Activated charcoal
Dose : 1g/kg (up to 50g maximum) Repeated doses (4 hrly) for severe poisoning with theophylline, digoxin, carbamazepine, barbiturates and salicylate. Obtain expert advice
Indications: If moderate to severe toxicity predicted
Substances where repeat doses of activated charcoal may prove useful:
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Carbamazepine
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Barbiturates
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Dapsone
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Quinine
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Theophylline
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Salicylates
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Death cap mushroom (Amanita phalloides)
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Slow release preparations
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Digoxin and digitoxin
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Phenylbutazone
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Phenytoin
Damian Wood Page 2 of 5 June 2005

Paediatric Clinical Guideline
Emergency: 1.3 Ingestions and Accidental Poisoning
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Sotalol
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Piroxicam
Administration
Give via oral or nasogastric route within 1 hour of ingestion. (May be effective > 1hr for sustained release preparations and drugs delaying gastric emptying)
Patient must be fully conscious or have airway protected – “aspiration can be fatal”
Contraindications : Avoid following ingestion of acid / alkali
Cautions: Not effective for iron, lithium, mercury, lead, ethanol, organic solvents, bleach, essential oils or petrochemicals.
In a small number of poisoning scenarios gastric lavage or whole bowel irrigation may be indicated. If the advice from TOXBASE is that either gastric lavage or WBI is indicated please seek advice from the a senior doctor in the emergency department.
Does the child/young person need a specific antidote?
Specific antidotes are available for a number of substances. Detailed advice should be sought from TOXBASE or the NPIS.
Substance Specific Antidote
Benzodiazepines
Beta-blockers
Carbon monoxide
Carbon tetrachloride
Flumazenil
Adrenaline infusion, glucagons
Oxygen
N-acetylcyseine
Digoxin
Iron
Isoniazid
Lithium
Methaemoglobinaemia
Methanol
Ethylene glycol
Digoxin antibodies
Desferrioxamine
Pyridoxine, Sodium bicarbonate
Sodium replacement, low dose dopamine
Methylene blue
Ethanol, alcohol dehydrogenase inhibitor
(fomepizole)
Ethanol, alcohol dehydrogenase inhibitor
(fomepizole)
Metoclopramide
Opiates
Procyclidine
Naloxone
Organophosphate insecticides
Paracetamol
Atropine. Pralidoxime
N-acetylcysteine
Thyroxine Propranolol
Does the child young person need admission?
Guidelines on admission and period of observation can be obtained from TOXBASE.
Admission is generally required if
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Child/young person is symptomatic or requiring treatment
Damian Wood Page 3 of 5 June 2005

Paediatric Clinical Guideline
Emergency: 1.3 Ingestions and Accidental Poisoning
 the ingested substance is liable to produce delayed symptoms
 if there was deliberate poisoning (see child protection guidelines) or intentional self harm (see self harm guideline)
If a child with poisoning is admitted please attach a copy of the printed TOXBASE advice sheet to the casenotes so that monitoring and management may continue on the ward/PICU.
What monitoring does the child/young person require?
Make a plan for monitoring based on the advice provided by TOXBASE/NPIS. Ensure this is communicated clearly to the team responsible for ongoing care as the timings of investigations are very important in acute poisoning.
Consider
 what physiological monitoring is required (TPR, blood pressure, ECG, electrolytes etc) and how often?
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What specific investigations (eg serum or urine drug levels) are required and when?
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Accidental ingestions: Health visitor referral (for patients not admitted this occurs via
A&E through the paediatric liaison health visitor, in cases where admission occurs the health visitor is contacted by ward nursing staff)
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Self-harm : Admit all children and young people with self harm and refer to Child &
Adolescent Self Harm Team
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Intentional Poisoning : if this is suspected the child should be admitted, and the consultant on-call informed. Child safeguarding procedures should be followed with referral to social services and the police. Early discussion with the clinical chemistry oncall is also advisable.
Advice on specific agents can be obtained from Toxbase or the NPIS Information Line
Paracetamol Poisoning
For specific advice please consult TOXBASE
Paracetamol poisoning should now be managed according to the 2007 guidelines agreed by the National Poisons Information Service. These are available either through TOXBASE or on a wallchart in PA&E and in E37 doctor’s office.
IT IS IMPORTANT TO CALCULATE THE MAXIMUM POSSIBLE DOSE INGESTED
It is also important to consider:
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Was the overdose staggered or is this a late presentation?
Does the child/young person fall into a high risk group?
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Is there an indication for commencing (N-acetylcysteine) Parvolex immediately whilst awaiting blood results?
After treatment has been given consider:
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Are there any biochemical/haematological markers of acute hepatotoxicity?
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Are there any symptoms of acute hepatotoxicity such as abdo pain and vomiting?
Damian Wood Page 4 of 5 June 2005

Paediatric Clinical Guideline
Emergency: 1.3 Ingestions and Accidental Poisoning
Guidelines for the Management of Acute Paracetamol Overdosage, National Poison
Information Service (NPIS), 2007
Poisoning In Children Series Archives of Disease in Childhood 2002;87(8):392-410
Jones AL, Dargan PI What’s New in Toxicology Current Paediatrics 2001; 11:409-13
Title
Poisoning and Ingestions
Distribution
All wards QMC and CHN
Guideline Number
1.3
Author
Version
Final
Dr Damian Wood
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician
First Issued Latest Version Date
June 2005
Ratified By
Paediatric Clinical Guidelines Meeting
Audit
Management of paracetamol poisoning
Induction Programme
Document Derivation
Review Date
June 2008
Date
June 2005
Amendments
Damian Wood Page 5 of 5 June 2005