Badrinath Narayan, PEM Fellow
Pediatric AHD, Aug 5th 2014
PEDIATRIC TOXICOLOGY
 Objectives
 Provide a general approach to the poisoned patient

History, physical, investigations
 Introduce types of decontamination with
indications/complications
 List “Pills that Kill”
Poisoning
 Poisoning
 One of the most common medical emergencies
 Exploratory behaviour
 Child abuse
 Environmental exposures
 Suicide attempts
 In utero toxicants
 Pediatricians have a role in advocacy
 Modes of exposure:
 Ingestion, ocular exposure, topical exposure, envenomation,
inhalation and transplacental exposure.
Approach
 Brief window of opportunity to make critical
diagnostic and management decisions
 Prioritize critical assessment and simultaneous
management interventions
14 year old female found unconscious in
a park by friends
The patient is brought into the trauma
bay at BCCH ED
What would you do?
Primary Survey ABCDEFG
Apply monitors - O2, HR, RR, cycling BP
Obtain vitals: HR, RR, BP, O2 sat
A – Maintain patency, assess reflexes, note GCS, have airway
equipment ready
B - Apply O2, consider ETCO2, ABG
C – Assess perfusion, Get two large bore Ivs
Disability (GCS, pupil size and reactivity), ? Signs of trauma
Decontamination
Drug Treatment – dextrose, oxygen, narcan
Bedside Glucose
Primary Survey
 Pay special attention to:
 Evidence of impaired airway protective reflexes
 Many poisoned patients will vomit
 Elective endotracheal intubation may be indicated at a
lower threshold
 Anticipate imminent respiratory failure
 Cyanosis/apnea are late findings
Case
 The patient has been stabilized
 What would you ask?
History – known
intoxicant
Take standard AMPLE history plus:
What was ingested, How much, When,
Why?
Obtain prescription bottles when possible,
and be sure that bottles contain med listed
Talk to patient’s family and friends in
ED/contact home
Ensure belongings are looked at to identify
paraphernalia
In a toddler think single pills, in an adolescent
think co-ingestions!!
When to suspect?
 Suspected but unknown intoxicant:
 Acute onset of illness
 Pica-prone age (1-5)
 History of pica, ingestions
 Current household “stress”
 Significantly altered mental status
 Family medications/recent illnesses
 Social: grandparents visiting, holiday parties, other
events
Case
 On exam what things might you see to suggest a
toxicological cause for the child’s presentation?
Physical
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Vitals
GCS/mental status
Pupils, EOM, fundi
Mouth: corrosive lesions, odors, secretions
Respiratory: rate, chest excursion, air entry
CVS: rate, rhythm, perfusion
GI: motility, corrosive effects
Skin colour, burns, diaphorsis, piloerection, track
marks
 Bladder size
Odours
Removal of toxic
substance
Decontamination:
Removal of a substance prior to entry
into the circulation
Elimination:
Removal of a substance by enhanced
excretion once it has entered the
circulation
Approach to
decontamination
Get help -- Poison control centre
24-hour Line: 604-682-5050 or 1-800567-8911
Healthcare professionals only line:
604-707-2787 or 1-866-298-5909
(outside the Lower Mainland)
Monday to Friday from 9 am - 4 pm
Forms of
Decontamination
Topical
flush aggressively (ocular or skin), remove
contaminated clothing
Dilution
Ipecac (no longer recommended; AAP
statement against it)
Activated Charcoal
Gastric Lavage – also fallen out of favour
Whole Bowel Irrigation
Dilution
 Indicated if toxin produces only simple irritation
 Controversial for caustic agents
 May be used in first few minutes
 NOT for drugs – may increase absorption
 Not if upper airway compromise
 Water or milk
 E.g. dish soap
Activated Charcoal
 “Activation” increases surface area of particles
 Toxins adsorb to activated charcoal decreasing amount
adsorbed by the body
 Some toxins are not well adsorbed – most small
molecules

Iron, the alcohols, lithium, strong acids and alkali, sodium,
chloride.
 Dose: 10:1 charcoal to drug ratio.
 For unknown ingestions dosing is based on ability to
tolerate the agent: Children - 1 gram/kg of body weight.
Activated Charcoal
 Timing
 If not contraindicated there does not seem to be a
reasonable time that is too late to give AC, especially
with SR or DR products
 Dogma used to be an hour but studies with respect to
delayed gastric emptying have challenged this data
Multiple-dose activated charcoal
sustained-release products
useful with drugs with low Vd, low protein binding,
long half-life
Activated Charcoal
Activated charcoal not useful with:
P esticides
H ydrocarbons
A cids, Alkali, Alcohols
I ron
L ithium, Liquids
S olvents
Activated Charcoal
Contraindications
absent gut motility or perforation
if endoscopic visualization is required (e.g.
caustic ingestions)
loss of protective airway reflexes
Complications
fatal aspiration
small bowel obstruction
Gastric Lavage
Orogastric lavage with a large bore tube (36-40 F for adult; no smaller than 22-24 F
for children)
RARELY recommended – not been demonstrated to
improve outcome, several risks
Might be considered: VERY early or after very
dangerous ingestions (colchicine, arsenic)
Ensure airway protected
Place patient in left lateral decubitus position with the
head down
Have suction available for secretions
Place tube (tragus-nose-xyphoid) and confirm position
Lavage until fluids clear
Whole Bowel
Irrigation
Whole bowel irrigation of the entire GI
tract by instillation of large volumes of
fluid
Usually takes hours
Has been used safely in children
Most useful for substances with delayed
absorption ( i.e. extended release ), not
amenable to activated charcoal and with
body stuffers/packers
Whole Bowel
Irrigation
Accomplished by orally taking (or through
NG) large volumes of Nulytely (approved
for children and adults), Colyte, or
Golytely
Adolescents: mininum of 1.5-2 L/hour
Children: 25 mL/kg/h
Give until rectal effluent is clear.
Whole Bowel
Irrigation
Contraindications:
absent bowel sounds
bowel obstruction or perforation
unprotected compromised airway
hemodynamic instability
Forms of Elimination
Urine alkalinization
- promotes excretion of salicylate,
enhances clearance of some drugs
Dialysis
Charcoal Hemoperfusion
Dialysis
Consider nephrology consult with dialysis if:
S alicylates
T heophylline
U remia
M ethanol
B arbiturates
L ithium
E thylene Glycol
Antidotes
Poison
Antidote
Acetaminophen
N-acetylcysteine
Anticholinergics
Physostigmine
Cholinergics
Atropine
Benzodiazepines
Flumazenil
Carbon monoxide
Oxygen
Cyanide
Amyl nitrite, sodium
nitrite, sodium
thiosulfate,
hydroxycobalamin
Digoxin
Ethylene glycol

Digoxin-specific
Antibodies
Ethanol/fomepizole,
thiamine and
pyridoxine
Poison
Antidote
Heavy metals
Dimercaprol
(BAL), EDTA,
penicillamine
Hypoglycemic
agents
Dextrose,
sucrose,
octreotide
Iron
Deferoxamine
mesylate
Isoniazid
Pyridoxine
Methanol
Ethanol/fomepiz
ole, folic acid
Methemoglobin Methylene blue
emia
Opioids
Naloxone
Organophospha Atropine,
tes
pralidoxamine
Avoid physostigmine if TCA ingestion present - has potential to worsen ventricular
conduction defects and to lower seizure threshold.
Investigations
Select tests only
Help confirm diagnosis
Help monitor
Help identify “silent” killers
Tox screens not useful in acute
management
Investigations
All symptomatic patients with unknown ingestion should get
electrolytes, glucose, osmolarity, acetaminophen/ASA levels,
blood gas, EKG
All suicidal patients should get acetaminophen level (~1:500
patients without a history of APAP ingestion will have a
potentially toxic blood level - NYPCC) and ASA level
Other tests based on history, physical, level of suspicion
CBC
Specific drug levels
Urinanalysis
BHCG
Calcium, liver function panel
Increased anion gap metabolic acidosis
(Na – (Cl + HCO3)
M ethanol (hx of alcohol abuse, methanol level),
metformin
U remia (BUN)
D KA, AKA, SKA (hx; urine ketones)
P araldehyde (distinctive odor)
I soniazid (seizure; lactate level)
L actic acidosis
E thylene glycol (level)
S alicylates/solvents (level)
Increased Osmolar gap (serum –
calculated)
“Two salts and a sticky BUN”
M annitol
A lcohols
D ye
G lycerol
A cetone
S orbitol
Pitfalls of osmolar gap
 Cannot distinguish between type of toxic alcohol
 Insensitive in late presentations
 Not sufficiently sensitive to exclude small ingestion
 Cannot rule out ingestion based on a normal OG
Radio-opaque drugs
 Chloral Hydrate
 Opioid packets (latex)
 Iron and other heavy metals
 Neuroleptics
 Sustained release tablets/Salicylates
ECG
 Findings include:
 Toxicologic tachcyardia/bradycardia
 QRS widening
 Prolonged QT (www.qtdrugs.org)
 Findings can develop late so obtain serial ECGs
Case
 A 2 year old girl is found playing with his
grandmother’s pill box. Some pills may be missing
and a powder residue is found in the child’s mouth.
 What medications would most concern you if this
child ate “just one pill”?
ONE PILL KILLERS
Small dose toxins
Substance
Major symptom
Symptom onset
Beta-adrenergic antagonists(sustained
release)
Bradycardia, hypotension
Delayed, up to 24 hours
Buproprion(sustained release)
Seizure, cardiovascular collapse
Delayed up to 24 hours
CCB (sustained release)
Bradycardia, hypotension
dElayed, up to 24 hours
Clonidine
Apnea, bradycardia, hypotension
1-2 hours
Lomotil (Diphenoxylate/Atropine)
Apnea
Delayed, up to 24 hours
Methylsalicylate (oil of wintergreen)
Metabolic acidosis, pulmonary/cerebral
edema
1-6 hours
Opioids: extended release preparations
Apnea
Delayed, up to 24 hours
Medications
Methadone
1 – 2 hours
Sulfonylureas
Hypoglycemia
Delayed, up to 24 hours
Theophylline
Seizure, hypotension
Delayed, up to 24 hours
Camphor
Seizure
Minutes to hours
Pesticides
SLUDGE
Minutes to hours
Toxic alcohols
Blindness, renal failure, metabolic acidosis
3 – 8 hours (ethylene glycol)
3 – 18 hours( methanol)
Other agents
Case
 A 3 yo male presents to the ED comatose with a GCS of
6. He was found on the bathroom floor. Following
stabilization, what is the most immediate course of
action?
 A. Head CT
 B. ECG
 C. Tox screen
 D. Broad spectrum Abx