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

Table of Contents

 

About This Issue

Pediatric ingestions present a common clinical challenge for emergency clinicians. This issue presents an evidence-based approach to common pediatric ingestions, with a focus on initial emergency department (ED) stabilization, diagnosis, and management of a selection of the most common and hazardous ingestions. In this issue, you will learn:

Medications known for a high risk for fatality

Resources available to clinicians for management of an overdose

The differential diagnosis for common toxidromes

Recommendations for prehospital management of suspected dangerous ingestions in children

Guidance for initial stabilization in the ED

Key aspects of the history and physical examination that can help narrow the differential diagnosis

Recommendations for initial testing as well as additional testing when specific medications/substances are suspected

Which patients should have an electrocardiogram, radiographic testing, or a urine toxicology screen

Methods that are recommended for decontamination and which methods are no longer recommended

Treatment recommendations for pediatric patients who have ingested specific toxins

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
   3. Physical Examination
10. Diagnostic Studies
    1. Initial Testing
    2. Chemistry and Osmolarity
    3. Specific Medication/Substance Levels
       1. Acetaminophen
       2. Salicylate
       3. Testing for Other Substances
    4. Electrocardiography
    5. Radiographic Studies
    6. Urine Toxicology Screen
11. Treatment
    1. Decontamination
       1. Recommended Method for Decontamination
          • Hemodialysis
       2. Methods That Are No Longer Recommended for Decontamination
          • Activated Charcoal
          • Whole-Bowel Irrigation
          • Gastric Lavage
          • Ipecac
    2. Treatment of Specific Toxic Ingestions
       1. Acetaminophen
       2. Alcohols
       3. Anticholinergic Agents
       4. Beta Blockers
       5. Calcium-Channel Blockers
       6. Cholinergic Agents
       7. Digoxin
       8. Iron
       9. Opioids
       10. Salicylates
       11. Sedative-Hypnotics
       12. Sulfonylureas
12. Special Populations
13. Controversies and Cutting Edge
    1. Cannabis Exposure
    2. Intravenous Lipid Emulsion Therapy
    3. Laundry Detergent Pod Exposures
    4. Recreational Street Drugs
       1. Fentanyl
       2. Xylazine
       3. Ketamine
       4. Other Street Drugs
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. 5 Things That Will Change Your Practice
18. Risk Management Pitfalls for Toxic Ingestions in Pediatric Patients
19. Case Conclusions
20. Tables and Figures
21. References

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?

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Risk Management Pitfalls for Toxic Ingestions in Pediatric Patients

3. “The parents didn’t mention giving aspirin to their febrile child, so I didn’t consider it.” Symptoms of a toxic ingestion may be nonspecific, and an elevated temperature may be due to ingestion of salicylates, anticholinergic agents, or sympathomimetic agents, in addition to an infectious process. Always ask about use of over-the-counter medications and their ingredients.

4. “The urine toxicology screen was negative, so ingestion was ruled out.” Urine toxicology screen interpretations are limited by which drugs are included and at what threshold levels, in addition to false-negative and false-positive results.

7. “We gave dextrose to prevent hypoglycemia after suspected sulfonylurea ingestion.” Prophylactic dextrose will mask and possibly delay effects of sulfonylurea ingestion, confusing further management. Dextrose should be administered only as needed.

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful: a 2004 update. Paediatr Drugs. 2004;6(2):123-126. (Review) DOI: 10.2165/00148581-200406020-00005

5. US Consumer Product Safety Commission. Poison prevention packaging - a guide for healthcare professionals. 2005. Accessed November 1, 2023. (Guidelines)

11. * American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Poison treatment in the home. Pediatrics. 2003;112(5):1182-1185. (Guidelines) DOI: 10.1542/peds.112.5.1182

14. American Academy of Pediatrics. Decontamination: disaster management resources. Patient Care. 2021. Accessed November 1, 2023. (Guidelines)

23. Adam H. Petechiae and purpura. Pediatr Care Online. 2021. Accessed November 1, 2023. (Quick reference) DOI: 10.1542/aap.ppcqr.396100

30. * Wu AH, McKay C, Broussard LA, et al. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem. 2003;49(3):357-379. (Guidelines) DOI: 10.1373/49.3.357

51. * American Academy of Clinical Toxicology European Association of Poisons Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999;37(6):731-751. (Guidelines) DOI: 10.1081/clt-100102451

57. * Benson BE, Hoppu K, Troutman WG, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):140-146. (Guidelines) DOI: 10.3109/15563650.2013.770154

58. * Krenzelok EP, McGuigan M, Lheur P. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):699-709. (Guidelines) DOI: 10.3109/15563659709162567

135. American Association of Poison Control Centers. Track emerging hazards; laundry detergent packets. 2020. Accessed November 1, 2023. (Case report)

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Keywords: pediatric toxic ingestion, pediatric toxicology, poison control, Poison Control Center, toxidrome, urine drug screen, urine toxicology screen, ipecac, activated charcoal, whole-bowel irrigation, hemodialysis, acetaminophen, salicylates, anticholinergics, cholinergic agents, alcohol, digoxin, calcium-channel blocker, beta blocker, iron, opioids, sedative hypnotics, sulfonylureas, intravenous lipid emulsion, ILE, anion gap, osmolar gap, decontamination, hemodialysis, cannabis exposure, laundry detergent pod exposure, recreational street drugs