Chapter 112

#### High-Yield Facts

• The cardinal principle of the management of the poisoned patient is meticulous supportive care.

• Gastrointestinal decontamination plays a limited role in the management of poisoned patients and is indicated in only a few of them.

• Ipecac induced emesis, gastric lavage and cathartics should not be considered.

• Activated charcoal or whole bowel irrigation (WBI) are potential intervention in a limited number of patients.

• Antidotes are available for a limited number of poisonings.

#### Epidemiology

Over the past several decades, fatalities associated with pediatric poisoning have fallen steadily, from 450 deaths in 1960 to just 42 in 2011.1 Interventions such as child-resistant packages, poison-education programs designed to increase household awareness of potential toxins, and improved intervention at both the poison center and hospital levels have all contributed to this decrease in pediatric mortality to just 1.5% of all poisoning deaths.1

However, pediatric exposures account for nearly two-thirds of all poisonings reported to the nation's poison control centers, as noted by the most recent annual report from the American Association of Poison Control Centers.1 Furthermore, this report also shows that 80% of all pediatric exposures occurred in patients 5 years of age or younger. Fortunately, most ingestions in this age group tend to be unintentional ingestions of small doses and thus result in minimal toxicity. However, most adolescent and adult poison exposures are purposeful involving larger doses and thus resulting in greater morbidity and mortality. These intentional exposures include suicide gestures, recreational substance use and Munchausen syndrome by proxy.2

#### History and Physical Examination

It is often difficult to obtain an accurate history. In children who are either too young to provide specific details, or who have an altered level of consciousness from their ingestion, alternative sources of information should be considered. Essential historical points include: the specific identification of the substance, when it was ingested, the amount ingested, and what other medications or poisons are available in the home. If possible, sending a family member back to the home to collect pill bottles, including over-the-counter and herbal supplements/vitamins, can be very informative. Overall, it is prudent to assume the worst-case scenario until proven otherwise.24

The physical examination may provide valuable information regarding the ingestion or exposure. Specific focus upon vital signs and level of consciousness is paramount in assessing the degree of toxicity. Many drugs and toxic agents have specific effects on the heart rate, respiratory rate, blood pressure, and temperature; as such, vital sign monitoring is of the utmost importance (Table 112-1). The level of consciousness, pupil size, and the presence of coma or seizures may provide clues regarding the identity of the ingested poison (Tables 112-2 and 112-3). Other diagnostic clues may be obtained from examination of the skin (Table 112-4) and breath odor (Table 112-5). Several groups ...

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