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Stabilization and Hospitalization of the Poisoned Child

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BACKGROUND

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Over 2 million poisoning exposures are reported to the American Association of Poison Control Centers’ National Poison Data System each year.1 Nearly half of all reported exposures involve children aged 5 years or younger, and two-thirds can be considered “pediatric” exposures. Seventy percent of poisoning exposures reported to poison centers are managed at home, with less than 10% of exposures leading to hospitalization. In 2004, the federally commissioned Institute of Medicine determined that poisoning was the second leading cause of injury-related death in the United States, with costs exceeding $12.6 billion each year.2 Recently, poisoning has surpassed motor vehicle collisions as the leading cause of death due to injury in the United States.

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The epidemiology of pediatric poisoning is bimodal: young, curiosity-driven children encounter toxicants through normal exploration of their environment, whereas adolescents become poisoned through substance abuse, experimentation, and intentional self-harm. Hospitalization rates, morbidity, and mortality are higher among the older group. Both groups are appropriate targets for preventive education in the hospital setting.

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Poisoned children are frequently encountered by pediatric hospitalists. Typically, the poisoning scenario has been identified before inpatient hospitalization; however, pediatric poisoning may occasionally present as a diagnostic dilemma. The families of all children admitted to the hospital should be queried with regard to medication use; use of vitamins, herbs, or ethnic remedies; recreational drug abuse; occupational drug and chemical exposure; and environmental drug and chemical exposure. Several features of childhood illnesses that should raise the suspicion for poisoning are detailed in Table 165-1.

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TABLE 165-1Features That Suggest a Diagnosis of Poisoning
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INITIAL STABILIZATION

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Respiratory arrest, shock, cardiac arrhythmia, and neurological injury are the most acute threats to life from poisoning. A standardized approach to initial life support is recommended (Table 165-2). Central nervous system depression due to poisoning may be most effectively assessed and communicated using the “AVPU” system (A, alert; V, opens eyes to verbal stimuli; P, opens eyes to painful stimuli; U, unresponsive). The Glasgow Coma Scale (GCS) was developed for trauma evaluation, and its prognostic properties do not apply to acute poisoning. It is important to identify hypoglycemia or hypoxia as a cause of altered mentation early in the resuscitative process.

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