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Chapter 27. Toxicology

  • There are approximately 2.4 million cases of ingestion or toxin exposure annually in the US. Half are in children younger than 6 yr, with a peak incidence at age 1–2 yr. Two-thirds are in patients younger than age 20 yr.
  • Leading fatal agents of ingestion (all ages): Analgesics, antidepressants, cardiovascular drugs, street drugs.
  • Leading agents of ingestion (adolescents): Acetaminophen, barbiturates, stimulants, antidepressants, alcohol.
  • Majority of poisonings occur at home, and ∼10% involve two or more substances.
  • Adolescents: 50% intentional; 50% unintentional.
  • Poisonous substance storage precautions should be discussed at every 6-month well-child visit.
  • Child-resistant closures have decreased the mortality of unintentional ingestions by 45%.
  • One to two tablets or 1 to 2 tsp (standard pediatric “swallow” ∼5–10 cc) of the standard-strength preparations of the following medications are potentially fatal to a 10-kg child:
    • Antiarrhythmics, antimalarials (chloroquine, hydroxychloroquine), benzocaine, β-blockers, CCBs, camphor, clonidine, Lomotil (diphenoxylate/atropine), lindane, methyl salicylate, opioids (codeine, morphine, pentazocine), phenothiazines (thioridazine, chlorpromazine), quinine, theophylline, TCAs (imipramine, desipramine)
  • Nontoxic pharmaceuticals: Antacids, antibiotics, corticosteroids, contraceptives, laxatives, mineral oil, ACE inhibitors
  • Nontoxic household products: Cosmetics, deodorants, dehumidifying (silica gel) packets, matches, candles

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Cosmetics or personal care substances

13.4%

Cleaning products

9.8%

Analgesics

8.2%

Foreign bodies

7.4%

Topicals

7.2%

Cough and cold medicines

5.7%

Plants

4.0%

Pesticides

4.0%

Vitamins

3.9%

Antihistamines

2.9%

Data from Clin Toxicol. 2006;44:803.

(Emerg Med Clin North Am 2007;25:249)

  • History Should address the questions what?, when?, how?, how much?, what symptoms?, and why?: Timing of ingestion, substance(s) taken, amount taken (pill count or volume quantification, if bottle available), location of ingestion (kitchen vs bedroom vs other), reason or circumstances of exposure or ingestion, symptoms before arrival, other substances in the home (possible co-ingestions), concomitant illness or trauma (possible supratherapeutic or chronic dosing of acetaminophen or aspirin), history of depression or prior suicide attempts (in adolescents), history of street drug use.

eFigure 27-1.
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Simultaneous diagnostic and treatment approach to a poisoned patient. (Adapted from Emerg Med Clin North Am 2007;25:249)

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Marijuana: Acapulco gold, bhang, doobie, ganja, grass, joint, Mary Jane, pot, rope, reefer

Amphetamines: Black beauties, crank, crystals, cat (methcathinone), ice, ecstasy, meth, pep pills, smart drug (Ritalin), speed, uppers

Ecstasy: Adam, E, lollies, love drug, smarties, vitamin E, XTC

Heroin: Boy, China white, dust, Harry, horse, junk, monkey, smack, speed ball (with cocaine), atom bomb (with marijuana)

PCP: Angel dust, goon, horse tranquilizer, hog, Sherman, tank, wickie stick (with marijuana)

δ-hydroxybutyrate (GHB): Bioski, Georgia home boy, grievous bodily harm, liquid G, liquid ecstasy, somatomax, cow growth hormone

Cocaine: All-American drug, coke, crack, girl, mother of pearl, nose candy, Peruvian powder, snow, toot, white lady

LSD: Acid, blotters, microdots, paper acid, pyramids, window pane, Zen

  • Anticipate: Seizures, altered mental status, multi-organ dysfunction, respiratory failure, cardiac failure, arrhythmias, or unexplained metabolic ...

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