Paediatric Toxicology

1. Paediatric Toxicology:
Ingestions &
Smoke Inhalation

2. Objectives
Explain the general management
principles for ingestions and toxic
exposures.
Identify methods used to minimize drug
absorption.
Discuss the steps in evaluation and
management of a patient exposed to
smoke and carbon monoxide.

3. Key points
Most toddler ingestions are insignificant;
however, a number of agents are highly toxic in
a dose of 1-2 tablets in this age group.
Resuscitation and risk assessment may need
to be performed concurrently.
Most treatment is supportive.
Poisons Information Centre may provide useful
information about product ingredients and
potential toxicity & specific clinical advice.

4. Key points
In any patient whose developmental age
is inconsistent with accidental poisoning,
a non-accidental poisoning should be
considered.
Admission should be considered for all
adolescent patients with an intentional
overdose.
Always check for Medic alert bracelet in
any unconscious patient, or any other
signs of underlying medical condition.

5. Potentially harmful 1-3 tablet
ingestions/ small exposures
Anticholinesterase inhibitors e.g. organophosphates -
cholinergic syndrome, seizures, LOC
Baclofen (25 mg) - coma
Camphor - rapid decrease in conscious state, seizures,
hypotension
Carbamazepine (400 mg) - coma
Centrally acting alpha adrenergic agonists e.g.,
clonidine - like opiate but more hypotension and
bradycardia
Clozapine 100mg/ 200 mg – coma
Colchicine
Corrosives - strong alkali or acid - Gastroesophageal
injury

6. Potentially harmful 1-3 tablet
ingestions/ small exposures
 Dextropropoxyphene 100 mg - Ventricular Tachycardia
 Opiates e.g. buprenorphine (8 g sublingual or film absorbs in <5 min), codeine,
methadone, fentanyl
 Hydrocarbon solvents/ kerosene / essential oils - decreased level of consciousness,
seizures, aspiration pneumonia
 Illicit/street drugs, e.g. amphetamine.
 Loperamide and diphenoxylate
 Naphthalene - 1 mothball (but most mothballs aren't naphthalene) -
methaemoglobinaemia, haemolysis
 Podophyllin
 Paraquat - esophageal burns, multi-organ failure
 Salicylates
 Strychnine - muscle spasm and respiratory arrest
 Venlafaxine 150 mg - seizures.

7. Potentially lethal 1-3 tablet ingestions
Beta blockers e.g., propranolol - coma, seizures, Ventricular
Tachycardia, hypoglycaemia
Calcium channel blockers - delayed onset bradycardia,
hypotension, conduction defects
Chloroquine / hydroxychloroquine - rapid onset coma, seizures,
cardiovascular collapse
Ecstasy and other amphetamines - agitation, hypertension,
hyperthermia
Oral hypoglycemics e.g., sulphonylureas - Hypoglycaemia may be
delayed 8 hours
Tricyclic antidepressants - coma, seizures, hypotension, VT
Theophylline - seizures, Supraventricular Tachycardia,
tachycardia, vomiting

9. Emergency Management
ABCs
A. Airway
Inability to protect airway may be with >GCS8 in
poisonings. AVPU may be a more useful descriptor
of conscious state.
Caustic ingestions
B. Breathing
C. Circulation
Dysrhythmias are frequently due to sodium channel
blockade and may be treated with Sodium
Bicarbonate.
Alternately they may be caused by potassium
channel blockade - treated with magnesium sulphate
(MgS04)

10. Emergency Management
D1. Disability
Check glucose level: treat if glucose <4 mmol/L
Seizures - those due to poisoning are always
generalized. Usually respond to
benzodiazepines with barbiturates second line.
Phenytoin is not recommended (as this is
usually ineffective).
Consideration should be given to drug induced
syndromes
malignant hyperthermia, serotonin syndrome and
neuroleptic malignant syndrome

11. Emergency Management
D2. Decontamination
Eye
Copious irrigation with saline.
Instillation of local anaesthetic eye
drops and sedation may be required
Skin
Remove clothes, rinse with copious
water, then soap and water

12. Emergency Management
D2. Decontamination
Gastrointestinal
A variety of methods may be considered
and should be discussed with a
toxicologist before commencement as all
require a risk / benefit analysis. Paediatric
deaths have occurred from activated
charcoal.
Emesis has no role in the hospital setting

13. Emergency Management
D2. Decontamination
Activated Charcoal has a very limited role in treatment
and should not be used without consultation with a
toxicologist, unless presents less than 1 hour after a
potentially toxic ingestion with normal conscious state.
Contraindications:
Patients with altered conscious state
Ethanol/glycols
Alkalis / corrosives
Metals - including Lithium, Iron compounds, potassium
Fluoride
Cyanide
Hydrocarbons
Mineral acids - Boric acid

14. Emergency Management
D2. Decontamination
Gastric Lavage has a very limited role in treatment. It
requires intubation for airway protection and should not
be used without consultation.
Whole Bowel Irrigation has a limited role in treatment of
life-threatening ingestions of some slow-release
preparations and agents that do not bind to activated
charcoal.

15. Emergency Management
D3 Drug antidotes
Specific antidotes may be available as
part of a management plan. Serum drug
concentrations may help in treatment
decisions.

16. Emergency Management
D3 Drug antidotes
Poisoning Antidote
Anticholinergic syndrome Physostigmine
Benzodiazepines Flumazenil
Beta Blocker Glucagon
Calcium channel blocker Calcium
Insulin/ glucose
Intralipid®
Cyanide Hydroxocobalamin
Dicobalt edetate
Sodium thiosulphate
Digoxin Digoxin immune Fab (Digibind)
Ethylene glycol Ethanol
Pyridoxine

17. Emergency Management
D3 Drug antidotes
Poisoning Antidote
Iron Desferrioxamine
Isoniazid Pyridoxine
Local anaesthetics Intralipid®
Methaemoglobinaemia Methylene Blue
Methanol Ethanol
Opiates Naloxone
Oral hypoglycaemics Octreotide
Organophosphate Atropine
Paracetamol N-Acetyl Cysteine
Organophosphates Pralidoxime
Quinine induced hypoglycaemia Octreotide
Tricyclic antidepressants Sodium bicarbonate
Warfarin, long-acting rodenticide
anticoagulant
Vitamin K

18. E ECG, Exposure & Enhanced
elimination
E1 ECG
E2 Exposure
Hyper/ hypothermia - >38.5°C requires urgent
cooling
E3 Enhanced elimination
Urinary alkalization
Useful for salicylate toxicity if performed
meticulously
Multi dose activated charcoal
Whilst there is evidence of a pharmacokinetic effect,
it is not evident that it improves clinical outcome

19. E ECG, Exposure & Enhanced
elimination
Dialysis
Intermittent High flux haemodialysis removes small water-soluble
toxins
 salicylate,
 toxic alcohols
 lithium
 theophylline
 valproate
 barbiturates
 methotrexate
Continuous renal replacement such as veno-veno haemofiltration
has a low clearance rate and is only suitable where haemodialysis
is not tolerated. Other methods such as peritoneal dialysis,
charcoal haemoperfusion, exchange transfusion and
plasmapheresis are less effective.

20. Risk Assessment
The aim is to determine if the ingestion/ contact is
potentially harmful and to develop a management plan.
The Poisons Information Centre may provide useful
information about product ingredients and potential
toxicity.
Agent: (drug / substance, name and formulation -
immediate or modified release)
Beware of the possibility of mixed overdose
Route - ingested, inhaled, topical exposure
Time of incident
Dose/ kg

21. Risk Assessment
Maximum amount of ingestion (include all
medication that was potentially in the bottle or
packet when calculating).
Beware of the possibility of inaccurate dose
reporting on history taking.
Weight of child
Symptoms
Signs
If mixed or undetermined ingestion
paracetamol level should be done.

22. Perform a good examination
Vital signs.
Assess and note the GCS.
Do a neurological exam with the rest of
your systems exam.
Look specifically at the eyes. skin, urine
stools – think of specific toxidromes
Consider other potential causes of any
symptoms described.

23. Toxidromes

24. Case 1

25. Case Study 1:
“Unresponsive”
Unresponsive 2-year-old boy presents to
the ED.
He was found by his parents in the
bathroom with pills and empty bottles
scattered over the floor.
His breathing is shallow and slow, and
skin color is pink.

26. Initial Assessment (1 of 2)
PAT:
Abnormal appearance, abnormal breathing,
normal circulation
Vital signs:
Heart rate 70/min
Respiratory rate 8/min
Blood pressure 80/40 mm hg
Temperature 37.1˚c
Weight 12 kg

27. Initial Assessment (2 of 2)
A: No evidence of obstruction
B: Slow and shallow, breath is minty
C: Cool, pink skin; strong pulses
D: Unresponsive, no focal findings,
pupils 4 mm and reactive
E: No signs of injury

28. Key Question
What is your general impression of this
patient?

29. General Impression
Respiratory failure
CNS dysfunction due to toxin
What are your initial management
priorities?

30. Management Priorities
Begin bag-mask ventilation.
Obtain IV access and give 20 mL/kg of
normal saline.
Obtain blood for laboratory studies.
Rapid glucose level is 20 mg/dL.
Give 2 mL/kg of 25% dextrose IV push.

31. Case Discussion (1 of 4)
After dextrose he is alert with a
respiratory rate of 24/min and bag-mask
ventilation is discontinued.
He is given oxygen by partial
nonrebreather mask.
What drugs/toxins could cause this
child’s symptoms?

32. Case Discussion (2 of 4)
Slow respirations: sedative hypnotics,
alcohol, opioids, weed (marijuana)
Low glucose level: alcohol, sulfonylureas
Minty breath: methylsalicylate, flavorings

33. Case Discussion (3 of 4)
Because he is now awake, he is given
charcoal via a nasogastric tube.
His minty breath is concerning because it
may indicate methyl salicylate ingestion.

34. Case Discussion (4 of 4)
Baseline laboratory study results are normal,
urine toxicology screen result is negative, and
serum levels for acetaminophen, iron, and ASA
are negative. Serum ethanol level is 100
mg/dL.
Parents remember that there was a full bottle of
mint mouthwash in the cabinet, and it was on
the floor next to the child.

35. Differential Diagnosis: What Else?
Ethanol
Methanol
Ethylene glycol
Isopropanol

36. Case Progression/Outcome
Child is admitted to PICU; he requires
additional glucose and fluids but recovers
uneventfully.
His parents buy a child-proof door and
cabinet locks to prevent this from
happening again.

37. Background
Ethanol-containing items:
beer, wine, liquor, cologne,
perfumes, mouthwashes
Blood level of 100 mg/dL
causes intoxication.
Due to low hepatic glycogen
stores, children are prone to
hypoglycemia.

38. “One Pill/Teaspoon Can Kill”
Methyl salicylate (<1 tsp)
Camphor (1 tsp)
Chloroquine
Benzocaine
Lomotil
Sulfonylureas
Imidazoline decongestants

39. Case 2

40. Case Study 2: “Belly Pain”
4-year-old boy ingested mother’s
prenatal vitamins, thinking they were
M&Ms.
Toddler is awake but stating that his
“tummy hurts.” He has vomited once.
He has no increased work of breathing,
and his color is pink.

41. Initial Assessment (1 of 2)
PAT:
Normal appearance, normal breathing,
normal circulation
Vital signs:
Heart rate 110/min
respiratory rate 22/min
blood pressure 96/68 mm Hg
temperature 37˚C
weight 18 kg

42. Initial Assessment (2 of 2)
A: Patent, no pill fragments seen
B: Unlabored
C: Pulse strong, skin is warm and dry
D: Awake, holding belly
E: Ingestion 30 minutes ago

43. Key Questions
What is your general impression of this
patient?
Is this a potentially toxic ingestion?

44. General Impression
Stable
Although this toddler is stable now, he is showing
signs of the gastrointestinal stage of iron toxicity,
including vomiting and abdominal pain.
What are your initial management priorities?
What additional information do you need?

45. Management Priorities
Child’s airway and breathing are stable at this
time.
Venous access is established and IV fluids
started at 20 mL/kg.
Laboratory studies are performed: Iron level,
CBC, electrolytes, glucose, BUN, creatinine,
and LFTs
Abdominal radiography, 3 views

46. Key Information for
Iron Ingestion
Determine how much iron was ingested.
Determine type of iron salt (different
amounts of elemental iron: ferrous
sulfate, 20%; ferrous fumarate, 32%;
ferrous gluconate, 10%).
Coated tablet (delayed absorption)
Significant ingestion (>60 mg/kg)

47. Management Issues (1 of 3)
This toddler ingested approximately 150
tablets containing 29 mg of ferrous
fumarate, for a total of 1,392 mg
elemental iron, or 75 mg/kg.
Significant and potentially toxic dose

48. Management Issues (2 of 3)
Should this patient receive ipecac, gastric
lavage, or another method to minimize
absorption in the ED?

49. Management Issues (3 of 3)
Gastric lavage: No, it would not obtain
pill fragments with small (pediatric size)
tube.
Charcoal: No, it does not absorb iron.
Whole bowel irrigation is the technique of
choice for large ingestions.

50. Case Discussion/Outcome
Radiograph shows a large amount of iron
tablets, so whole bowel irrigation is
begun.
His iron level returns to 390 mcg/dL.
Chelation with IV deferoxamine is begun,
and patient is admitted.

51. Iron Ingestion
Mortality has decreased since child-proof
caps.
Lethal dose is 200 to 250 mg/kg, but GI
symptoms occur at 15 to 30 mg/kg.
Serum iron levels often correlate with
symptoms.
Four phases of iron ingestion: GI, relative
stability, shock, hepatotoxicity

52. Iron Ingestion Management
IV fluids for those with early symptoms
Initial laboratory studies: Iron level, CBC,
chemistries, BUN, creatinine, glucose, LFTs.
ABG, and type and cross match as needed
If acidotic, need sodium bicarbonate
Chelation with IV deferoxamine: “Vin rose”
color of urine due to available free iron

53. Differential Diagnosis: What Else?
Other medications visible on radiograph:
Choral hydrate, cocaine packets
Opium packets
Iron and other heavy metals (lead, arsenic,
mercury)
Neuroleptic agents (phenothiazines)
Sustained-release or enteric-coated agents

54. Case 3

55. Case Study 3:
“Unresponsive”
15-year-old girl passed out on her bed, is found
by mother
Note is found saying she “didn’t want to live”
because she and her boyfriend broke up.
Mother drives her to the ED.
She is unconscious and breathing slowly, with
sonorous respirations, and her color is pale.

56. Initial Assessment (1 of 2)
PAT:
Abnormal appearance, abnormal breathing,
abnormal circulation
Vital signs:
Heart rate 62/min
respiratory rate 8/min
blood pressure 80/40 mm Hg
temperature 39˚C
oxygen saturation 91%
weight 50 kg

57. Initial Assessment (2 of 2)
A: Sonorous, no secretions
B: Slow, hypoxic
C: Warm, dry, pale skin; capillary refill
of 4 seconds
D: Unresponsive to painful stimuli,
pupils 6 mm and reactive
E: No bruises or hematomas

58. Key Question
What is your general impression of this
patient?

59. General Impression
Cardiopulmonary failure
Patient with suicide note implies probable
toxic ingestion.
What are your initial management
priorities?

60. Management Priorities
A: Position airway.
B: Begin bag-mask ventilation with
100% oxygen: Consider intubation.
C: Obtain venous access and begin fluid
resuscitation with 20 mL/kg of normal
saline.
Reassess.

61. Case Discussion
Are there clues to the specific ingestion?
What are key questions to ask her
mother?
What laboratory tests are needed?

62. Clinical Features:
Your First Clue (1 of 2)
Elevated temperature, dry skin, and large
pupils suggest an anticholinergic
(antihistamine, TCAs).
Slow heart rate and blood pressure suggests
clonidine, calcium channel blockers, or -
blockers.
Slow heart rate and breathing suggests alcohol
(liquor), opiates, or sedative-hypnotics.

63. Clinical Features:
Your First Clue (2 of 2)
Low blood pressure and slow
respirations suggest sedative-hypnotic or
opiates.
Large pupils suggest antihistamines or
antidepressants.
A mixed picture: Clinical picture doesn’t
fit a single toxidrome. Think multiple drug
ingestion.

64. Case Discussion
Her mother says prescription medicines
at home include propranolol, alprazolam
(Xanax), hydrocodone and
acetaminophen (Norco), doxepin
(Sinequan), and sildenafil (Viagra).
Other items at home include ibuprofen,
aspirin, hard liquor, wine, and beer.

65. Diagnostic Studies
ECG and cardiac monitoring: Look at
QRS interval: >100 milliseconds risk for
dysrhythmia
Laboratory studies: CBC, electrolytes,
calcium, glucose, acetaminophen,
ethanol, and ABG
Urine drug screen for drugs of abuse

66. Management Issues
Gastric lavage: Too late and only if airway
secured (ETT)
Charcoal: Yes, via nasogastric tube (secure
airway!); can use cathartic
Ion trapping: Alkalinize urine?
Multiple-dose charcoal?
Antidotes?

67. Management Issues:
Antidotes
Naloxone: Yes
Glucagon?
Bicarbonate?
Flumazenil: NO!

68. Case Progression
Patient is given naloxone with no response;
she is intubated.
Repeat vital signs: Heart rate 74/min,
respiratory rate via ETT 20/min, blood pressure
96/50 mm Hg, temperature 38.8˚C
ECG shows QRS interval of 120 milliseconds;
sodium bicarbonate is given to get blood pH to
7.45 to 7.55.
Charcoal/sorbitol are given by nasogastric
tube.

69. Case Progression/Outcome
Urine toxicology screen result is positive for
benzodiazepines, opiates, and TCAs.
Acetaminophen level is 20 mcg/mL (nontoxic),
Ca level is 10.5 mg/dL, ethanol level is 60
mg/dL.
She is admitted to the PICU.
Admits to taking Xanax, Norco, Sinequan, and
vodka.

70. Background: Ingestions
Age Ingestion Reason
Children
<5 years
Single item:
Often nontoxic
Unintentional
Adolescents
13-19 years
Multiple, often
with alcohol
Intentional:
Suicide, abuse

71. Case 4

72. Case Study 4:
“A Night to Forget”
17-year-old girl went to a party. She tried an
energy drink, then felt very tired.
Her friends were concerned because she was
“falling all over and not making sense,” so they
drove her to the ED.
She is hard to arouse, breathing is slow but not
labored, and her color is pink.

73. Initial Assessment (1 of 2)
PAT:
Abnormal appearance, abnormal breathing,
normal circulation
Vital signs:
Heart rate 70/min
respiratory rate 8/min
blood pressure 110/70 mm Hg
temperature 37.9C
oxygen saturation 89%

74. Initial Assessment (2 of 2)
A: Patent, no stridor
B: Shallow, hypoxic, no retractions or wheezes
C: Pulse strong and regular
D: When stimulated, becomes agitated, then
returns to drowsy state, pupils 3 mm and
reactive
E: No injuries, bruises

75. Key Question
What is your initial impression of this
patient?

76. General Impression
Respiratory failure, probably due to CNS
dysfunction
What are your initial management
priorities?

77. Management Priorities
Provide 100% oxygen by bag-mask
ventilation and prepare for intubation.
Obtain vascular access.
Measure bedside glucose level.
Consider naloxone.

78. Case Discussion
Are their clues to the specific ingestion(s)?
What other tests would be helpful?

79. Toxidrome Clues
Respiratory depression, decreased level
of consciousness, small pupils: Opiates,
sedative-hypnotics, benzodiazepines,
clonidine
Low heart rate: Calcium channel
blockers, β-blockers
Don’t forget ethanol.

80. Diagnostic Studies
Bedside glucose level is 85 mg/dL
ECG shows normal sinus rhythm, and the QRS
interval is <100 milliseconds.
No response to naloxone
Serum ethanol level is 60 mg/dL
Drug screen result for drugs of abuse: Negative

81. Case Progression
Friends deny any illicit drugs at the party.
Patient is intubated but gradually regains
full consciousness, and ETT is removed.
Patient is discharged to parents.

82. Keys Points: Ingestions
Manage ABCs.
Look for clinical features/toxidromes.
Diagnostic studies: ECG, serum electrolytes,
serum osmolality, ABG.
Calculate anion gap, osmolar gap
Toxicology screens: Urine (drugs of abuse),
specific drugs (ASA, acetaminophen, ethanol,
digoxin, iron, lead, lithium, theophylline)

83. Keys Points: Treat the Patient
Not the Poison
Provide ABCs.
Prevent or minimize absorption:
Gastric lavage, charcoal, whole bowel irrigation
Enhance excretion:
Ion trapping, diuresis, multidose charcoal,
hemodialysis, charcoal hemoperfusion
Administer antidotes.

84. Case 5

85. Case Study 5: “House Fire”
8-year-old girl found unconscious in house fire
Paramedics began advanced life support care.
Patient is intubated and receiving 100% oxygen
with IV fluids.
Has burns to face and chest, is immobilized on
backboard, and has cervical collar applied

86. Initial Assessment (1 of 2)
PAT:
Abnormal appearance, abnormal breathing, normal
circulation
Vital signs:
Heart rate 110/min
respiratory rate 18/min (bagging)
blood pressure 100/60 mm Hg
temperature 37˚C
oxygen saturation 99% with 100% oxygen
weight 25 kg

87. Initial Assessment (2 of 2)
A: Soot around lips, nose
B: Ventilated at 18/min, wheezes
C: Warm, capillary refill of 3 seconds
D: Unresponsive, pupils 5 mm and reactive
E: Second-degree burns to face and chest,
approximately 25% BSA, no other injuries
noted

88. Key Question
What is your general impression of this
patient?

89. General Impression
Respiratory failure
What are your initial management
priorities?

90. Management Priorities
Confirm ETT position and give 100% oxygen
and bronchodilator.
Provide IV fluids (20 mL/kg).
Perform laboratory studies: ABG, COHb,
electrolytes, BUN, creatinine, CBC, LFTs,
urinalysis
Obtain chest and c-spine radiographs.
Perform ECG.

91. Case Progression/Outcome
Wheezing clears after
albuterol.
COHb level is 10%.
Consult with
hyperbaric chamber.
Patient is admitted to
PICU/burn unit.

92. Case Discussion:
Carbon Monoxide Poisoning
Assess and treat abnormalities in ABCs.
Provide 100% oxygen.
Determine COHb level.
Provide hyperbaric oxygen for COHb >25%,
pregnant women, neurologic symptoms
Half-life COHb: 15 to 30 minutes at 3 atm and
60 to 90 minutes at 100% oxygen

93. Other Considerations
Interface with EMS/transport team
Transport: Need PICU, burn center
Documentation
Carbonaceous sputum on intubation
Interfacility agreements
Have agreements with hyperbaric facility for
secondary transport if needed
Prevention
Smoke detectors

94. The Bottom Line:
Smoke Inhalation
Maintain ABCs.
Consider inhalation injury in any exposure to
fire or severe burns.
Heat, asphyxiants (carbon monoxide),
particulate matter, and irritants damage airway.
Provide 100% oxygen.
Consider hyperbaric oxygen.

95. The Bottom Line: Ingestions
Consider toxins as cause for sudden changes
in mental status.
Management begins with assessment and
treatment of abnormalities in ABCs.
Use poison control center.
Identify toxin, decrease absorption, enhance
elimination, and administer antidote if available.