24 th Oct 2012
Dr. Julia Ng
Emergency Physician

• Most children age 1-2 y.o
• Most harmless substance
• Most do not need hospital care
• Death or serious harm is exceptionally rare
• Small list of 1-2 tablets can kill children

•
•
• Resuscitation ABCDE
• D detect and correct 1) seizure using benzo benzo and benzo, no phenytoin
2) hypoglycemia
3) hyper or hypothermia eg serotonin
•
• E emergency antidote - naloxone sodium bicar
• Risk assessment
• Agent eg carbamazepine 50mg/kg
•
• Dose
• Time since ingestion
• Clinical features and progress
• Patient factors eg weight, comorbidities
• Supportive
• Investigation
• Decontamination
• Enhanced elimination
• Antidote
• Disposition

• Dose- response in mg/kg is usually the same as for adults
• Children rarely ingested > 2-3 tablets
• Exact dose and time may be difficult to estimate
• May need to resort to a ' worst case scenario '
• Assume the time of ingestion is the latest possible
• Assume all missing tablets have been ingested
• Do not attempt to account for spillage
• If more than one child is involved, assume each child ingested the amount
• Consider NAI in large and repeated dose

• Routine investigation :
• Paracetamol and ECG for cardio toxicity
• Paracetamol can be occult

• Amphetamine
• Clonidine
• Calcium channel
• Chloroquine hydrochloride
• Dextroproxyphine -VT
• Propranolol
• Opioids
• Sulphonyureas
• Theophylline
• TCA

• Admit 12hours for unknown pills
• Ability to ETT/BVM
• No IVC if alert and running
•
• If flop check BSL
• Monitor for level of consciousness and vital signs

• 2 y.o old was brought to triage by mother, ate
1-2 pellets

• Long acting warfarin - up to 6-8 months
• Kids ingested 1 packet to have significant poison
• Adults 3 packets to be toxic
• Discharged home from triage, no need for blood test

• Check INR first
• no vitamins K
• if toxic may need 100mg vit K for 3-6 months
• Serial INR check
• If INR> 2-3, intervene

• 2 y.o brought into ED :
• Drowsy
• RR 8
• Pinpoint pupil
• What is the toxidrome ?

• Check undisturbed RR
• If < 10 , need intervention : naloxone
• Dose ?
• Alternative vital ETCO
• If need a second dose of naloxone , start an infusion at 2/3 of reversal dose.
• Especially if it is overnight

• 2.y.o has been playing , possibly ingested grandmother’s antihypertensive medication in a dosette box.
• Grandmother is on a beta blcoker.
• Is this dangerous ?

• Atenolol and metoprolol in kids usualy cause slight lower BP and reduced PR
• Settled with fluid
• But propranolol and sotalol the worst :
• Propranolol – CNS and class I sodium channel blockade
• Sotalol – K channel blockade, QT prolongation

• 2 y.o girl was brought to ED ingested 5mg glipizide.
• Is this a concern ?

• Up to 8 hours course of hypoglycaemia
• Dextrose 10% only in adult due to high volume infusion
• Used octretide – stop release of insulin and safe
• Dose ?

• 2 y.o boy has ingested 2 lomotil tablets 1 hour ago presented to triage.
• Triage nurse thought it only causes constipation as a result but come to ask you if she can discharge the child and maybe suggest some laxative if constipated.
• What do you do ?

• Has anticholinergic ( atropine 23 mcg ) and opioid ( diphenoxylate 2.5mg )
• Symptom onset within 4 hours

• 2 children , siblings, had been playing with a bottle of 100% eucalyptus oil and ? ingestion

• First sign : coughing
• Implies pneumonitis
• Within 2 hour drowsy
• Then seizure and coma usually short lived
• If asymptomatic by 4-6 hours, safe for discharge

• 2 y.o ingested grandfather’s digoxin.
• Is this dangerous ?

• Toxic lethal dose 4mg for child
• Sign of vomiting within 4 hours

• 2 y.o ingested unknown amount of iron tablet
Is this a concern ?

• If < 40mg/kg elemental iron, no vomiting
• AXR to count the tablets to work out dose per kg
• Progressive lowering of Bicarbonate level
• Treatment is to maintain HCO > 18

• 2 y.o ingested grandfather ‘s colchicine

• Vomiting early within 2 hours
• Lethal dose 0.5mg/kg -0.8mg/kg