Management of Pediatric Toxic Ingestions in the Emergency Department (Pharmacology CME)

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Publication Date: December 2023 (Volume 20, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 12/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Pediatric ingestions present a common challenge for emergency clinicians. While findings and information from the physical examination, electrocardiographic, laboratory, and radiologic testing may suggest a specific ingestion, timely identification of many substances is not always possible. In addition to diagnostic challenges, the management of many ingested substances is controversial and recommendations are evolving. This issue reviews the initial resuscitation, diagnosis, and treatment of common pediatric ingestions. Also discussed are current recommendations for decontamination and administration of antidotes for specific toxins.

Case Presentations

An 18-month-old girl is brought in by ambulance after her grandmother was unable to wake her from an unusually long nap...

• The grandmother reports that the child had not been ill that morning. After repeated questioning, the grandmother admits that the child was found earlier in the day holding her pillbox. She does not have the pillbox with her and does not remember the names of all of her medications.
• On examination, the child is breathing shallowly. In response to painful stimuli, the girl moans and withdraws but does not open her eyes. The remainder of her physical examination is normal, without fever or evidence of trauma.
• As the team applies monitor leads, obtains IV access, and administers oxygen to this lethargic toddler, you order a STAT ECG and glucose level. As you prepare for possible intubation, you consider medications that could be fatal in a small dose, such as opioids, sedatives, cardiac medications, and hypoglycemic agents. Could ingestion of a small amount of the grandmother’s medication be fatal in this toddler? Is it appropriate to give activated charcoal at this time?

A 15-year-old adolescent girl is brought in by her family for a possible suicide attempt...

• The patient’s friend received a text in which the patient reported taking “a whole bottle of pain pills.” The family reports that an old bottle of acetaminophen with hydrocodone that was in the bathroom cabinet is now empty. The patient says she does not know exactly how many pills she took or at what time but says that it was just after sending that text, which you see from her phone was 4 hours ago.
• The girl is tearful and tired, but she answers questions appropriately. Her vital signs and physical examination are normal.
• Are there any specific drug levels that should be checked and, if so, when? Should you give naloxone, activated charcoal, or N-acetylcysteine? When can the patient be medically cleared for transfer to a psychiatric facility?

A mother rushes her 9-month-old boy into the ED after applying oil of wintergreen ointment...

• The boy had been coughing, so she wanted to help soothe his symptoms by applying some oil of wintergreen ointment on his chest. She then looked at the bottle and realized a safety warning regarding toxicity in children and came right to the ED.
• The boy is acting and breathing normally, with normal vital signs and a normal physical examination.
• What amount of exposure, if any, could be toxic to this child? What diagnostic tests or treatment(s) are indicated while the child is asymptomatic?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.