Elliot Melendez, MD
Objectives
Discuss Principles of Toxin Assessment
and Screening
 Discuss toxidromes and their management
 Discuss specific toxins

I will try not talk about decontamination or
elimination of toxins
 I will not follow Fuhrman word-for-word

 You should have read the 2 chapters (98,99)
Epidemiology

> 2 million calls to poison control centers per
year
 ~ 66% involve < 20 years
 ~ 52% < 6 years

Only 25% require referral to a health care
facility
 1 of 8 require critical care admission

Mortality
 2.1% < 6 years
 8.1% < 20 years
Epidemiology

Highest incidence in 1-3 year olds
(accidental)
 Boys > girls
 Children with developmental delay or pica

Second peak in adolescents
 suicide attempt or experimentation
 Females >>> males
 Anorexia and psychiatric conditions risk
factors
Epidemiology
Most occur when parents distracted at
home
 2nd most common site is at grandparents’
homes


91% occur in the home

Many involve household products or meds
that are left open and being used at the
time
Pediatric Ingestions (< 6 yrs)
Cosmetics
Cleaning
Analgesics
Plants
FB
Cough/cold
Topicals
13.3%
11.0%
7.6%
7.1%
6.3%
5.5%
5.4%
Insecticides
Vitamins
Antimicrobials
GI preps
Arts/crafts
*Hydrocarbons
Antihistamines
3.9%
3.3%
3.1%
3.0%
2.5%
2.2%
1.9%
Epidemiology

Agents involved known in most cases
 In unknown cases, recognition of a toxic
syndrome may help in management

Common toxic agents leading to
hospitalization
 Caustics
 Rx Meds (antidepressants)
 Analgesics (acetaminophen)
 Heavy metals (lead)
Agents Leading to ICU

Rx meds
 TCA
 Anticonvulsants
 Digitalis
 Opiates
Alcohol
 Hydrocarbon household products

Pediatric Pitfalls
Suspicious if:
 Altered mental status
 Multiple organ dysfunction
 New onset, afebrile sz
 Acute onset of presenting sx
 Hx of previous ingestions
 Current household stress/pregnancy/visitors
Pediatric Pitfalls
Difficult Hx:
 Uncooperative/preverbal patient
 Abuse
 Fear of parental discipline

Get the bottle!
Assessment of Poisoned Patient
An accurate history is vitally important.
 Parents usually minimize the child’s
exposure to a toxin in order to deny
threat of injury or assuage guilt
 However, frequently, the precise time
and toxin are accurately known.

Evaluating for the Unknown
Substance
History
Obtain ingredients in suspected toxins
 Ask to see containers
 Assume the worst possible scenario in
calculating max dose

 Use max amt of missing tablets or liquid
 Concentration of drug or chemical
 Child’s weight
Priorities

Assess for medical stability
 A, B, C, D’s

Airway/Breathing – Consider intubation?
 Upper airway obstruction
 Excessive bronchial secretions
 Loss of airway reflexes
 Respiratory failure
Priorities

Circulation
 Assess and treat hypertension and tachycardia
○ Typically if patient is agitated, use sedatives first
○ Avoid non-selective blockers
 Treat hypotension with fluids first, and if needed,
use direct agonists

Disability
 Protect patient from self-harm
 Treat seizures and protect airway
Diagnosis via Toxidromes

Why don’t they work?
 Memorization?
 Not all clinical criteria may be present
 Polysubstance ingestion complicates clinical
signs and symptoms
What Works?
Exam

And what poison control wants to hear!
 Vital signs: Temp, HR, BP, RR, Sats
 Pupil size
 Skin (dry or wet)
 Level of Consciousness/Mental status
Let’s Work this Through
Temperature

Fever
 Sympathomimetics/Anticholinergics
 ASA
 Neuroleptic malignant syndrome, MH

Hypothermia
 Depressants
 Alcohol
 Barbiturates
Let’s Work this Through
Heart Rate

Tachycardia
– Sympathomimetics/Anticholinergics
– Antihistamines
– TCA
–
Bradycardia
 Ca channel and beta blocker, pure alpha
agonists
 Digoxin
 Opiates/Sedative hypnotics
 Clonidine
 Cholinergics/Organophosphates
Let’s Work this Through
Blood Pressure

Hypertension
– Clonidine?
– Sympathomimetics/Anticholinergics
– Trauma, CNS bleed from adrenergics
 Hypotension
 Ca channel and beta blocker
 Barbiturates
 Opiates
 Sympatholytics - clonidine
 Vasodilators/Diuretics
Let’s Work this Through
RR and O2 sats

Respiratory Depression
 Opiates
 Barbiturates

Respiratory distress
 ASA (metabolic acidosis)
– Sympathomimetics/Anticholinergics
– Organophosphates
Let’s Work this Through
Pupil Size

Pupils Small (Miosis)
 Cholinergics
 Opiates
 Clonidine
 Organophosphates
 Sedatives/Barbiturates

Pupils Dilated (Mydriasis)
 Sympathomimetics/Anticholinergics
 Antidepressants (SSRI, TCA)
Let’s Work this Through
Skin

Wet
– Sympathomimetics
– Organophosphates
– Cholinergics

Dry
 Anticholinergics
Let’s Work this Through
Mental Status

Agitated/Confused/Seizures
 Sympathomimetics/Anticholinergics
 Withdrawal syndromes

Depressed
 Alcohols
 Opiates/Barbiturates
 Sedatives/Hypnotics
 TCA
Laboratory Studies

Chem 10
 Calculate serum anion gap

Pregnancy test
EKG

Sosm

 Calculate osmolar gap if alcohol suspect




LFTs, Coags
Blood gas
Urine pH
X-rays
Laboratory Studies

Blood levels useful to assess risk
 ASA, Tylenol, anticonvulsants, alcohol

Tox Screens
 Only occasionally reveals an unanticipated
toxin
 Most commonly confirms what is suspected
from history and exam.
Tox Screens

Know you institutions screens and their
limitations
Suboxone, methadone, and
dextromethorphan do not show up on
urine tox
 Benadryl, Tegretol cross-react with TCA
screen

ICU Management



Mostly Supportive
Very few antidotes
Consider “Coma” Cocktail
 Naloxone
 Glucose
 Thiamine
 Flumazenil
 Physostigmine

Consult with local poison control
Specific Cases

16 y/o girl with history of anorexia is
brought to ED for confusion, agitation

What do you want to know?
Case #1
Temp 100.3
 HR 130
 BP 150/90
 RR 20
 O2 sat 99% RA


What else?
Case #1

Pupils dilated, poorly reactive

Skin: Dry

Mental Status
 Agitated
 Paranoid
 Picking things from air
Case #1

Diagnosis?
Case #1

Anticholinergic syndrome

Drugs:
 TCA
 Antihistamines
 Belladona
 Others
Labs?
Labs


Chem 7 normal
CBC normal


Urine tox negative
Serum tox negative
 Tylenol, ASA, TCA, EtOH

EKG normal

Mother asks, “Could this be from her new
appetite stimulant medication.”
Management

Treat agitation with sedatives as needed

Diagnostic test?
Diagnostic Test?

Physostigmine
 Ach-ase inhibitor, transient
 Risks:
○ Seizures
○ Asystole
○ Have atropine available!!!!
Case #2

16 y/o girl just broke up with her
boyfriend, presents with seizure.

What do you want to know?
Case #2
Temp 100.3
 HR 130
 BP 150/90
 RR 20
 O2 sat 99% RA
 Seizing


What else?
Case 2

What do you mean what else?

Treat the seizure!!!
 Ativan, Ativan  seizure stops

Okay, now what else?
Case #2

Pupils dilated, poorly reactive

Skin: Dry

Mental Status
 Depressed, intermittent agitation
Labs?
Labs
Chem 7 normal
 CBC normal
 Tox screens sent


EKG with QRS 0.12

Mother states no meds in home other
than her migraine meds
Case #2

What do you do next?
Case #2
Management
Depression
 ? Migraine medication

Seizure
 Anticholinergic syndrome
 Tachycardia with QRS >0.1

Case #2

TCA = Tachycardia, Convulsions,
Anticholinergic

Treatment?
Case #2
Treatment

Alkalinize the serum!!!
 NOT THE URINE

NaHCO3 IVP until QRS < 0.1
 How much?
 As much as if takes!!!

If this symptomatic, start NaHCO3 drip once
QRS narrowed, goal pH 7.45-7.55.

If nonsymptomatic, NS infusion at 1.5
maintenance, with NaHCO3 at bedside
Case #2

Seizes again

Ativan doesn’t stop seizures after 2
doses.

Next?
Case #2
Still Seizing

DO NOT GIVE PHENYTOIN
 Na channel blocker, which is what TCA’s do
and can make things worse

Continue NaHCO3 push and Ativan,
consider pentobarbital, Propofol
TCA Toxicity

TCAs block Na channels leading to effects
 Seizures correlated with QRS > 0.1
 Arrhythmias with QRS > 0.16
 Rarely, prolonged QTc (but not without QRS
widening)

You don’t have TCA toxicity without
tachycardia.

If initially asymptomatic, and no symptoms by
6 hrs of ingestion, PICU monitoring not
needed.
Other Notable Ingestions

Serotonin Syndrome
 Altered MS, Increased muscle activity, clonus,
autonomic instability
 Seen with SSRI overdoses, combination of
ingestions leading to serotonin increase

ASA




Metabolic acidosis, but respiratory alkalosis
Alkalinize urine!!!
If tinnitus, level > 30.
Think of sources other than ASA
○ Bismuth, oil of wintergreen, topical acne meds
Summary

VS, Pupils, Skin, MS should give you a
clue to agent

Tox screens rarely helpful

Look at AG and Sosm when appropriate