Paediatric Poisoning &
Done by: Dr. Abed Alhalim Shamout
General management principles for ingestions and
The principles of gastric decontamination.
The substances of low toxicity in pediatrics
The use of specific therapies for poisonings caused
Epidemiology - More than 2 million incidents of
poisoning and toxic ingestions occur in the United
States each year, accounting for 12,000 deaths.
Most episodes of accidental ingestion reported to
poison control centers are for children under the age
of 5 years.
Poisoning can be caused by either accidental or
intentional exposure to toxic agents;accidental
ingestion is responsible for approximately 85% of
episodes in younger children.
Nonpharmaceutical agents account for 60% of the
childhood poisonings that occur under age 6 years.
The most commonly ingested substances in this age
group are plants, household cleaners, over-the-
counter medications, and cosmetics.
The vast majority of childhood poisonings occur
around the house, ingestion of prescription
medications, either in the home of the child’s or
that of a relative (such as a grandparent).
Types of Poisoning
Mainly young children aged 1-3 years
Mainly drugs or household products
More common in household with recent
May be an indicator of maternal depression
Usually ingestion of drugs
Usually result of calculation error
Most frequently fatal drug: digoxin
Munchhausen syndrome by proxy
May present as an unusual illness rather than
Mainly environmantal hazards
Commonest: Lead poisoning
Identification of the poison
1. Determine the product ingested,the amount
the time of ingestion,the childs present
2. In determining therapy, assume the largest
3. Physical Examination.
A. Asymptomatic child
The asymptomatic child may have been exposed to, or
ingested, a lethal dose of apoison, yet not have any
manifestations of toxicity. Therefore, it is important to:
1) Quickly assess the potential danger.
A. If the toxin is known, the potential danger can be
assessed by consulting acomputerized information
Risk assessment will generally take into account the
1. the dose ingested (mg/kg)
2. the time interval since ingestion
3. the presence of any clinical signs
The goal of gastric decontamination is to minimize
exposure of the toxin by removing it from the GI
tract, or by binding it to a non-absorbable agent.
At the present time, there is considerable
controversy regarding the role of syrup of ipecac-
induced emesis, gastric lavage, and activated
charcoal in achieving gastric decontamination.
There is little evidence to support the use of
induced emesis or gastric lavage, especially if
performed 60minutes or longer after ingestion.
Ipecac-induced emesis - Syrup of ipecac may be of
some value if given within a few minutes after
ingestion. It may prove to have a useful role in
home management of pediatric ingestions.
Gastric lavage - In studies, gastric lavaage appears
to be slightly more effective than induced emesis.
Gastric lavage, especially in the pediatric patient,
does not allow removal of undissolved pills or pill
fragments too large to pass through the diameter of
the lavage tube. Gastric lavage is not necessary for
small to moderate ingestions if activated charcoal is
available for administration.
Activated charcoal - Recent studies indicate
that the administration of charcoal alone may
be as effective as emesis or gastric lavage,
and may prove to be the mainstay of gastric
Observe the Child/Provide Parent Education/Perform a
a. Observe the asymptomatic child for an appropriate
interval (usually 4-6 hours).
b. Consider evaluation of the home situation, especially in
accidental ingestions in children < 14-16 months or > 5
years of age.
c. Intentional ingestions in adolescents, especially girls,
raises the possibility of unwanted pregnancy, or sexual
or physical abuse; these children require careful
psychiatric evaluation for suicide risk.
d. Because repeat ingestions occur, all parents require
instructions about poisonprevention techniques.
Management is based on four general
a. Supportive care
b. Preventing or minimizing absorption
c. Enhancement of excretion
d. Administration of antagonists
Attention to the ABCs is always the first
Treat the patient, not the poison!!!
Ongoing assessment and serial vital signs
are particularly important,as they may help
to pinpoint the responsible agent and
indicate the subtle signs of impending
Establish and maintain a patent airway by
positioning, suctioning and, ifneeded, endotrachal
b. Provide supplemental oxygen and assist
ventilations, if needed.
c. Monitor the circulation by assessing the pulse,
blood pressure and perfusion.
1. Establish a large-bore IV line and draw labs
(CBC with platelets, basic metabolic profile, serum
CO2, toxicology screen, and specific drug levels if
Monitor for variations in blood pressure.
a) Hypotension results from venodilation, arteriole
dilation, depressed cardiac contractility, or a
combination of causes.
Regardless of the etiology, most hypotensive
children respond to volume therapy of 10-20 cc/kg
boluses of Ringer's Lactate or Normal Saline and
rarely need pharmacologic treatment.
Hypertension should be treated if systolic pressure
is > 160-170 mmHg or diastolic pressure is > 100-
105 mmHG, in order to prevent intracranial
hemorrhage or hypertensive encephalopathy.
Treat hypertension with sodium nitroprusside
(continuous infusion: begin with 1.0 mg/kg/minute;
range is 0.5-10.0 mg/kg/minute) with or without
esmolol or propranolol;
Do not use beta-blockers alone as this may
worsen the hypertension, particularly that resulting
from cocaine toxicity.
Place the child on a cardiorespiratory monitor to assess
a) Arrhythmias are often caused by hypoxia or
1) For ventricular tachycardias use lidocaine
2) For sympathomimetic-induced tachycardias, use
esmolol 25-100 mg/kg/min IV and titrate to heart rate.
3) For wide complex tachycardias resulting from TCA
administer 1-2 mEq/kg of NaHCO3 in repeated boluses
until the QRS interval narrows to 0.12 seconds, or the
serum pH exceeds 7.7.
Assess the child's mental status. Use the Glasgow
The most common cause of death in the comatose
child is respiratory failure.
Respiratory failure may occur abruptly and can be
complicated by aspiration, especially if the child is
seizing or develops an altered level of
consciousness after receiving ipecac.
In all comatose or convulsing children, check blood
glucose and administer 2-4 cc/kg D25W if needed.
Although a specific benzodiazepine receptor
antagonist (flumazenil) is available, its use may be
complicated by seizures; most benzodiazepine
ingestions are best managed conservatively with
When indicated, flumazenil can be given in a dose
of 0.2 mg over 30 seconds. If there is no response
in 30 seconds, repeat with 0.3 mg, and then 0.5 mg,
up to a cumulative dose of 3 mg.
Naloxone, 0.4-2 mg IV, should be used if there is
any possibility of narcotic ingestion in a patient
with a decreased level of consciousness.
Before giving medication for seizures, rule out
other causes (such as hypoglycemia or metabolic
Seizures are usually controlled with
benzodiazepines and phenobarbital.
1. Hyperthermia may be caused by a variety of
drugs or toxins.
Treat it aggressively with skin cooling.
If necessary, intubate and chemically paralyzethe
patient; monitor for ongoing seizure activity.
Hypothermia - Hypothermia may result from
particular agents (ethanol,barbiturates, narcotics) or
be related to environmental exposure.
Hypothermia may cause, or aggravate,hypotension.
Assessment of adequate perfusion is difficult in the
hypothermic child. Gradual warming,with warm
blankets, devices such as “bear huggers”, and
warmed IV fluids utilizing devices such as the
“HotLine” is usually successful in managing
1. Observe for adequate (_ 1 cc/kg/hour) urine output as
well as changes in the color/clarity of the urine.
2. Send urine specimens to the lab for urinalysis,
Toxicology screens may take several days to be
completed and are often not helpful in the acute clinical
1. Chest – Evaluate for infiltrates, possible aspiration,
and pulmonary edema.
2. Abdominal - Look for radiopaque materials, such as
iron and enteric-coated pills.
Some rapid screening tests are also helpful in
pinpointing a diagnosis:
Ferric chloride test - turns the urine a burgundy
color in the presence of salicylates and purplish-
green in the presence of phenothiazines.
Osmolar gap - To calculate the osmolar gap
subtract the measured serum osmolality from the
calculated serum osmolarity
[Calculated osmolality =2(Na) + glucose/18 +
An elevated osmolar gap (> 10 mosm/L)can indicate
ethanol, isopropyl alcohol, methanol, or ethylene glycol
A wide osmolar gap will be seen with sorbitol and
mannitol when administered therapeutically.
Anion gap [Na - (Cl+HCO3)].
lactic acid= iron, INH, salicylate ingestion.
production of other acids (methanol, ethylene and other
Causes of a wide anion gap is
1. Methanol, Uremia, Diabetic ketoacidosis,
Phenformin ,Paraldehyde, Iron
Isoniazid, Lactic acidosis, Ethanol
Ethylen glycol, and Salicylates.
The second phase of management is to prevent or
minimize absorption of the toxin.
In the case of symptomatic children, consider
gastric lavage to prevent further absorption.
Intubate prior to lavage if the child is unable to
protect his/her airway.
1.In the home, syrup of ipecac may be used to
induce emesis in the conscious,alert child. It is
ideally administered within 30 minutes of ingestion.
In theED ipecac is rarely used, since its efficacy is
diminished if administered 60minutes or more after
2. Gastric lavage can be used when vomiting is
contraindicated. Such include the child with a
depressed level of consciousness,seizures,
compromised gag reflex, respiratory distress, or
ingestion of apetroleum distillate.
A. Overdose or Ingestion
within 1 hour
B. Specific overdose Laryngospasm.
after 1 hour Hypoxia and hypercapnia.
1. Ingested drug slows Mechanical injury to the
peristalsis throat, esophagus, and
a. Anticholinergics stomach.
b. Opioids (Narcotics) Fluid and electrolyte
1. Ingested drug of: imbalance.
Recent studies indicate that administration of
activated charcoal is the most effective
gastric decontamination procedure.
Many toxicologists recommend charcoal be
administered if the patient presents with 1-2
hours after ingestion.
Indications Substances for which
A. Patient presents within charcoal is
60 minutes of ingestion ineffective
1. Antidepressants A. Pesticides
2. Aspirin B. Hydrocarbons
3. Aminophylline C. Alcohols
8. Dapsone G. Lithium
Many children will not drink the needed dose; therefore, it
may be necessary to administer activated charcoal via NG
tube. This increases the risk of emesis, with subsequent
A cathartic mixed with charcoal shortens the transit time in
The cathartic sorbitol is recommended in the pediatric age
group, since magnesium citrate may cause symptomatic
hypermagnesemia in children under the age of 2 years.
Recommended dose: 1 gm/kg with sorbitol.
Repeat dose charcoal is useful in the management of
theophylline, phenobarbital, phenytoin, salicylates, and
Types: Sorbitol 2ml/kg,Mg citrate 4-8ml/kg
Used only with Activated Charcoal.
Hasten intestinal transit of GIT contents so it
decrease systemic absorption.
1.Absent bowel sounds 2. Recent abdominal
surgery or trauma
3.Intestinal Obstruction 4. Dehydration
B.Poison ingestion of corrosive substance
C.Poison ingestion with Diarrheal adverse effects
1.Organophosphate 2. Carbamate 3.Heavy metal
Whole bowel irrigation
uses polyethylene glycol solution (Golytely, Colyte) in
large volumes at rapid rates to mechanically cleanse the
Whole bowel irrigation results in negligible fluid and
electrolyte losses; it can be used when charcoal is
ineffective (iron, lithium), when there is ingestion of a
large volume of toxic substance (cocaine swallowed in
packages), or for ingestion of sustained-release drugs.
Whole bowel irrigation requires large volumes (1-2
L/hour in adolescents and 25 cc/kg/hour in children).
If the child is not able todrink the polyethylene glycol
solution, an NG tube is necessary for administration.
Forced diuresis: increases GFR and
enhancines elimination of drugs excreted
mainly by the kidneys(eg.lithium).
IV isotonic fluids at twice at maintance rate
should sustain diuresis at 2-3 times normal.
Clinically, this method has been shown to
have little benefit.
Urinary alkalinization - Administering sodium
bicarborate intravenously results in an alkaline urine.
Many drugs will diffuse more readily from the blood
stream into alkaline urine.
urinary PH 7.5-9.0 .
promotes excreation of weak acid .
for salicylates, phenobarbital poisoning .
NaHco3 50-100 mEq + 1 liter DS …..250-
500ml/hour for the first 1-2 hours
Maintain urine output 2-3ml/kg/h
Hemodialysis - Renal dialysis effectively
removes select drugs (these must be low in
molecular weight, water soluble, have
small volumes of distribution, and exhibit
low protein binding).
Dialysis is most commonly used for
alcohols, theophylline, salicylates, and
a. severe Methemoglobinemia b.Hemolysis
No treatment required Remove if large amount
Ballpoint inks Afterchave lotion
Bathtub floating toys Body conditioners
Battery (Dry cell) Colognes
Bublle bath soap
Chalk Fabric softeners
Crayons Hair dyes
Detergents (anionic) Hair sprays
Fishbowl additives Hair tonic
Hand lotion and creams Matches(+20wooden
Pencils (lead and coloring) Oral cotraceptives.
Shaving creams and lotions
Shoe polish(occasionaly aniline dyes) Toilet water
Striking surface materials of matchboxes
Potent Pediatric Poisons
Benzocaine 2ml of 10%gel
Chloriquine One 500mg tablet
Codiene Three 60mg tab
Hydrocarbones. One swallow if aspirated
Hypoglycemic sulfonylureas Two 5mg glyburide tab
Imipramine One 150 mg tab
Iron Ten adult strength tab
Lindane Two teaspoons 10ml
Methyl salicylate Less than 5ml oil of witergreen
Theophylline One 500mg tablet
Thioridazine One 200mg tab
verapamil One –two 240mg tab
Tricyclic Antidepressants (TCA) -
Organophosphorus (Cholinergic Insecticides).
Thanks for listening
To be continued in part II
ما كان مه تىفيق فمه اللــً وحـدي , وما كان مه
خطأ أو سهـى أو وسيــان فمىـي ومه الشيــطان .
واللــً ولـي التىفيــق