No. Agent 1 Paracetamol 2 Detergents 3 Household cleaning agents 4 Dessicants (e.g. silica gel) 5 Ibuprofen 6 Cough & cold preparations 7 Rodenticides 8 Light sticks/glow toys 9 Zinc-containing barrier creams 10 Bleach (containing hypochlorite)

Diagnosis

As opposed to overdose in the adult population, exposures in children are nearly always accidental or unintentional. The circumstances around the exposure or ingestion are often unknown or difficult to elucidate. Parents and carers are usually uncertain about time of exposure or dosage of drug ingested. As such, the clear history required to make an accurate risk assessment is difficult or sometimes impossible. Regardless of whether the entire history and circumstances surrounding the exposure are available, it is prudent to plan for a ‘worst-case scenario’, assuming maximal exposure.

Important elements of the focused history include:

• age and gender of child;

• agent involved – drug, chemical or plant;

• approximate time of exposure;

• dose ingested, including maximum possible ingestion;

• circumstances around exposure;

• symptoms, in particular vomiting;

• first aid and pre-hospital management.

Deliberate self-poisoning in adolescents warrants further enquiry into previous ingestions, pre-existing psychiatric illness and management, drug use and social circumstances. In cases of unknown drug exposure, it is important to explore the availability of pharmaceuticals and/or chemicals to which the child may have had access. Plant and mushroom ingestion is common in children and needs to be considered in the acutely unwell child who has been outdoors.

Non-accidental (or deliberate) poisoning of a child requires mandatory reporting to child protection authorities in all jurisdictions within Australia. The index of suspicion is higher in children under the age of 1 year, or where the circumstances of the exposure do not fit the capabilities of the child in question. Rare cases of Munchausen’s syndrome by proxy are also reported in the literature, involving deliberate poisoning of children by their parent/carer.

Physical examination of the potentially poisoned child is usually unremarkable, particularly in asymptomatic children or in the early stage of ED presentation. However, in children presenting with symptoms or patients with altered level of consciousness, a thorough physical examination is vital. Key elements of the toxicological examination include:

• vital signs: heart rate, blood pressure, temperature, respiratory rate, oxygen saturation;

• odour suggesting intoxication or poisoning;

• airway patency and adequacy of ventilation;

• cardiovascular status and end-organ perfusion;

• level of consciousness or altered mental status, presence of delirium or psychosis (including blood glucose level);

• neurological signs: abnormal tone, reflexes, clonus, seizures;

• external signs of trauma, bruising, bite marks;

• saliva or vomitus, pill fragments.

Children may also present with a cluster of symptoms and signs suggestive of poisoning, i.e. a toxidrome. Although most cases do not manifest the full spectrum of signs and symptoms, pattern recognition amongst clinicians may provide a clue to diagnosis. Toxidromes and corresponding causative agents commonly seen in children are listed in Table 21.1.2.

Toxidrome Agents Clinical features Sympathomimetic Amphetamines
Pseudoephedrine
Caffeine Tachycardia
Hypertension
Mydriasis
Sweating
Agitation
Delirium
Fever Anticholinergic Atropine
Hyoscine
Antihistamines
Plants
Mushrooms Tachycardia
Mydriasis
Loss of visual accommodation
Flushed skin
Dry skin/mouth/eyes
Fever
Delirium Opiate Opiates
Tramadol
Clonidine Sedation
Respiratory depression
Hypotension
Miosis Cholinergic Organophosphates
Carbamates Delirium
Coma
Seizures
Excess secretions (DUMBELS)
Weakness
Fasciculations Serotonergic SSRIs
Cyclic antidepressants
Opiates
Tramadol
Lithium
MDMA (ecstasy) Delirium/agitation
Hyperreflexia
Hypertonia
Tremor
Clonus
Diaphoresis
Fever

SSRI, selective serotonin reuptake inhibitor.