Pediatric Toxicology
Jana Stockwell, MD
Epidemiology
2 million calls
 52% of poison center calls <6years
 Peak ages: 18 months - 3 years
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Epidemiology
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Unintentional (1-2 years)
– Exploratory
– Boys > girls
– Unable to discriminate safe from unsafe liquid
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Intentional (adolescent)
– Purposeful
– Girls > boys
Epidemiology
Around meal time
 Grandparents home
 Kerosene or gasoline in a soda bottle
 Older sibling can pharmaceutically treat
younger sibling

Most often reported
Cleaning products
 Analgesics
 Cosmetics
 Cough & cold preparation
 Insecticides

10%
10%
9%
5%
4%
PICU Admission
Tricyclic antidepressants (TCA)
 Anticonvulsants
 Digoxin
 Opiates
 Hydrocarbon-based household products
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Toxic Exposures  Death
Analgesics
 Sedative-hypnotics
 Alcohols
 Gases & fumes
 Cleaning substances
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“Fatal Sip”
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Camphor (Vick’s VapoRub)
– (100mg/kg)
Methyl salicylate (wintergreen)
– (200 mg/kg)
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Benzocaine (OraGel)
– 2 mL
– Met-hemoglobinemia
– Seizure
1000 mg/5 ml
1400 mg/ml
“Malignant Swallow”
Chloroquine
 Theophylline
 Imipramine
 Chlorpromazine
 Clonidine

– Bradycardia
– CNS depression
(20 mg/kg)
(8.4 mg/kg)
(15 mg/kg)
(25 mg/kg)
(0.3 mg tablet)
Other Highly Toxic
Acetonitrile - nail tip remover  MetHgb
 Ammonium fluoride – hub cap cleaner
(ArmorAll)  sz, arrhythmias, acidosis
 Pennyroyal Oil – some herbal teas
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Look-Alike, Sound-A-Like
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Albuterol
Celebrex
Oruvail
Lamictal
Lotrimin
Plendil
Hydralazine
Hydrocodone
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Atenolol
Cerebrex
Elavil
Lomotil
Lotensin
Pindolol
Hydroxyzine
Hydrocortisone
Poison plants
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Digitalis effects
– Lily-of-the-valley,
Foxglove,
Oleander, Yew
Nicotinic effects
– Poison hemlock
Atropinic effects
– Jimson weed
Non-Toxic Products
Ball point ink
 Bubble bath
soaps
 Chalk
 Cigarettes (< 3
butts)
 Crayons
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Deodorants
 Lipstick
 Pencil (graphite)
 Toothpaste
 Water colors
 Candle wax (but
candle oil is!)

Evaluation
History of poisoning
 Physical examination
 Laboratory studies
 Gastrointestinal decontamination

History
What?
 When?
 How much?
 Reliability…
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What ?
Medication
 Illicit drug
 Hazardous chemical
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What form?
Pill
 Solid
 Liquid
 Gaseous

What route ?
Ingestion
 Inhalation
 Topical
 Intravenous
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When ?
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Elapsed time
How much ?
Estimate amount
 Concentration
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“Clues”
Bradycardia
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Calcium channel blockers
Digoxin
Narcotics
Organophosphates
Carbon monoxide
Beta-blockers
Clonidine
Tachycardia
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Amphetamine (Ritalin)
Atropine
TCA’s
Theophylline
Salicylates (aspirin)
Iron
Cocaine
PCP
Synthroid
Slow Respiration
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Alcohol
Narcotics
Clonidine
Sedatives
Tachypnea
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Amphetamines
Salicylates
Carbon monoxide
Ethylene glycol
(anti-freeze)
Hypotension
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Calcium channel blockers
Carbon monoxide
Cyanide
Iron
Narcotics
Anti-hypertensives
Met-hemoglobin
Hypertension
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OTC cold remedies
Amphetamine
PCP
TCA
Cocaine
Diet pills
V Tach
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Amphetamines
Carbamzepine (Tegretol)
Chloral hydrate
Cocaine
Digitalis
Theophylline
Torsades de Pointes
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Chloral hydrate
Cisapride
Organophosphates
Terfenadine
Phenothiazines
Hypoglycemia (HOBBIES)
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Hypoglycemia
Oral hypoglycemic agents
Beta-Blockers
Insulin
Ethanol
Salicylates
Hypothermia
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Ethanol
Narcotics
Carbon monoxide
Clonidine
Hyperpyrexia
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Atropine
Salicylates
Theophylline
Cocaine
TCA
CNS - Coma
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Narcotic
Anti-cholinergics
Carbon monoxide
CNS - Delirium / Psychosis
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Alcohol
PCP / marijuana
LSD
CNS - Seizure
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Cocaine
Amphetamine
Lead
Salicylate
Isoniazid
Theophylline
Pupils - Miosis (COPS)
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Cholinergics, Clonidine
Opiates, Organophosphates
Phenothiazine, Pilocarpine
Sedatives (barbiturates, ethanol)
Pupils - Mydriasis (AAAS)
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Anti-histamine
Anti-depressant
Anticholinergics (atropine)
Sympathomimetics
– amphetamine, cocaine, PCP
Caution!
Polydrug overdoses with opposite
pupillary actions
 Non-toxin diagnoses
– Head trauma
– CNS hemorrhage
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Cyanosis
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MetHgb
– Unresponsive to O2
Aniline dyes
Nitrites
Benzocaine
Dapsone
Dry Skin
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Anticholinergic
Breath Odors
Arsenic
 Camphor
 Cyanide
 Methyl salicylate
 Paraldehyde
 Hemlock
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Garlic
Mothballs
Bitter almond
Wintergreen
Pears
Carrots
Cholinergic
“DUMBBELS”
 “SLUDGE”
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Example –
Organophosphates
Nerve agents
DUMBBELS
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Diarrhea, diaphoresis
Urination
Miosis, muscle fasiculation
Bradycardia
Bronchospasm
Emesis
Lacrimation
Salivation
SLUDGE
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Salivation
Lacrimation
Urination
Diarrhea
GI complaint
Emesis
Anti-cholinergic syndrome
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Dry mouth
Flushed appearance
Dilated pupils
Fever
Ileus
Urinary retention
Disorientation
Examples –
Anti-histamines
Jimson weed
Lomotil
TCA
Carbamazepine
Glycopyrrolate
Atropine
Anti-cholinergic
Hot as a hare
 Blind as a bat
 Dry as a bone
 Red as a beet
 Mad as a hatter
 Full as a flask
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Narcotic
Pinpoint pupils
 Coma
 Respiratory depression
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Salicylates
Fever
 Tachypnea & hyperpnea
 Lethargy
 Metabolic acidosis
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Theophylline
Protracted Vomiting
 Tremors
 Tachycardia
 Seizures
 Hypotension
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Isoniazid
Seizures
 Metabolic acidosis
 Hyperglycemia
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Phencyclidine (4 Cs)
Combative
 Catatonia
 Convulsion
 Coma
 Nystagmus
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TCA
Metabolic acidosis
 Prolonged QRS
 Seizures
 Dilated pupils
 Dysrhythmia
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Cyanide
Feeling of impending doom
 Sudden coma
 Metabolic acidosis
 Hypotension
 Bitter almond odor
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Carbon monoxide
Headache
 Lethargy
 Dizziness
 Influenza like syndrome
 Coma
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Ethanol
Hypoglycemia
 Lethargy
 Ataxia
 Seizure
 Characteristic breath odor
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Methanol
Severe metabolic acidosis
 Sluggish pupils
 Hyperemic retina
 Blurred vision
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Ethylene Glycol
Lethargy or coma
 Metabolic acidosis
 Urinary sediment
 Crystalluria
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Clonidine
Hypothermia
 Bradycardia
 Miosis
 Respiratory depression
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Elevated anion gap
Methanol
 Paraldehyde & phenformin
 Iron & isoniazid
 Ethylene glycol & ethanol
 Salicylate
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ABC’s
Airway
 Breathing
 Circulation
 Disability
 Decontamination
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Consciousness
A: Alert
 V: Responsive to verbal stimuli
 P: Responsive to pain
 U: Unresponsive
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Drugs
Dextrose
 Oxygen
 Naloxone
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Decontamination
Ocular- copious saline lavage
 Skin- copious water
 GI-consider options
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Lab Evaluation
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No “tox panel” that is uniformly
helpful
Urine Screen
Marijuana
 Amphetamines
 Barbiturates
 Cocaine
 Opiates
 PCP
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5-10 days
48 hours
24 h-2 wks
2-4 days
2 days
8 days
EKG
All suspected ingestion
 Tricyclics
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Pulse oximetry
Measure of oxygen saturation of
normal hemoglobin
 Does NOT differentiate CO-Hgb
from oxyHgb
 Falsely low sats

– Nail polish
– Methylene blue
– Poor perfusion
Other tests
CXR - hydrocarbons
 ABG - salicylates
 Esophagoscopy - Caustics
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Drug levels
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Acetaminophen
Salicylates
Methanol
Ethylene glycol
Iron
Theophylline
Carbon monoxide (co-ox blood gas)
Lithium
Radiopaque (CHIPS)
Chloral hydrate
 Heavy metals
 Iron
 Phenothiazine (laxatives)
 Slow release
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GI tract decontamination
Syrup of Ipecac (not used in hospital)
 Gastric lavage – 1st hour
 Activated charcoal
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– Inert
– Reduces bioavailability of drug
– Not w/ HC or corrosives
Cathartics – decrease transit time
 WBI (whole bowel irrigation)…till clear
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Urine alkalinization
Salicylates
 Phenobarbital
 Chlorpropamide
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Extracorporeal methods
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Hemodialysis
– Severe poisoning
– Renal failure
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Hemoperfusion
– Perferred in some toxic ingestions
Antidotes
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Oxygen - carbon monoxide
Naloxone – opioids
Methylene blue – MetHgb
Sodium nitrite - cyanide
Deferoxamine – iron
Acetoaminophen – N-acetylcysteine
Anti-cholinergics – physostigmine
Organophosphates – atropine, pralidoxime
Benzodiazepines – flumazenil
B-blockers – glucagon
TCA – bicarb
Coumadin – Vitamin K
Fomepizole (Antizol) – ethylene glycol