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TOXICOLOGY*

*The authors acknowledge the special contributions of Ronak R. Shah, MD, Mae De La Calzada-Jeanlouie, MD and Rachel S. Weiselberg, MD to the prior edition.

THE EVALUATION AND MANAGEMENT OF POISONING IN CHILDREN: GENERAL APPROACH AND GI DECONTAMINATION

Clinical Summary

The incidence of pediatric poisoning follows a biphasic curve, with about 90% of cases occurring in children age 1 to 6 years and a second smaller peak of 10% to 15% of cases occurring in adolescents. Most ingestions in children are of a single agent (frequently nontoxic household products) and unintentional/accidental. The most frequently reported pharmaceutical exposures in children <6 years of age include analgesics, cough and cold preparations, cardiovascular agents, topical preparations, sedative hypnotic agents, and antidepressants. Adolescent toxic ingestions are more likely to be multiple pharmaceutical agents and intentional.

The most important factor in successfully treating a patient with a toxicologic exposure is to recognize a toxicologic etiology in the patient who presents with undifferentiated symptoms. Poisoning must be considered in the differential diagnosis of multiple conditions, especially when a patient presents with cyanosis, shock, vomiting, diarrhea, hypothermia or hyperthermia, abnormal behavior, or altered mental status. A thorough history must be obtained with a focus on the identification of the toxin, timing, dosage, route, intent of ingestion, and symptom development since ingestion.

The patient and/or care providers may be able to directly identify the involved toxin because of a known exposure (eg, medications taken, intentional overdose attempt, substance abuse, exposure to occupational chemicals). Determining whether the exposure was intentional or not may aid in assessing the reliability of the history given by the patient. Regardless of intent, patients may or may not report accurate amounts, and it may be necessary to search through medication containers and count the number of remaining pills or measure approximate quantities of liquid.

FIGURE 17.1

Household Products Frequently Ingested by Young Children. Household cleaners, cosmetics, and plants are among the leading nonpharmaceutical agents ingested by children. Some of these products contain potential toxic substances including sodium hydroxide, alcohol, methyl salicylate (eg, Listerine), and sodium hypochlorite (eg, bleach). (Photo contributor: Ronak R. Shah, MD.)

FIGURE 17.2

Medications and Poisons Frequently Ingested by Adolescents. Pharmaceutical agents and other substances that are intentionally ingested in the context of a suicide attempt by adolescents include analgesics, sedative-hypnotics, cyclic antidepressants, antihistamines, ethylene glycol, and windshield washer fluid (methanol). (Photo contributor: Ronak R. Shah, MD.)

Prehospital health care workers may aid in identification of the toxin and information about dosage/route at the time of arrival in the ED with findings of containers or other evidence of possible toxins and can provide information on any treatment and attempts at decontamination prior to hospital arrival.

Coingestions or multiple agents should be ...

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