Poisoning

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Last modified 06/06/2015

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9 Poisoning

Poisoning is one of the most common medical emergencies in young children and adolescents. Children are exposed to toxic substances more than any other age group. According to the American Association of Poison Control Centers (AAPCC), there were almost 2.5 million total human exposures in 2007, of which 65% were in children younger than 21 years old. Of these exposures, approximately 10% to 15% were intentional and include suicide attempts, and 80% to 85% of them were unintentional and occurred through exploratory behavior, environmental exposure, or neonatal exposure.

Etiology and Pathogenesis

The cause of childhood poisoning can vary dramatically from one case to another, but the most frequent causes are ingestions of readily accessible household products such as cosmetics, hair products, cleaning substances, and analgesics. The most lethal or potentially lethal poisonings, however, are most commonly related to pharmaceuticals, including antimalarials, β-blockers, calcium channel blockers, camphor, antidiarrheals, salicylates, opioids, and tricyclic antidepressants (TCAs).

The mechanism of toxicity varies from one agent to another, yet there are some classic presentations that can be seen with particular ingestions (Table 9-1). Ingestions that can be lethal in small doses are reviewed in more depth here.

Table 9-1 Clinical Manifestations of Selected Toxic Ingestions

Ingestion Clinical Findings
Acetaminophen Nausea, vomiting, anorexia early in course; late findings of jaundice and liver failure
Antihistamines Initially CNS depression but stimulation in higher doses (hyperactivity, tremors, hallucinations, seizures)
Aspirin Tachypnea, respiratory alkalosis, metabolic acidosis, tinnitus, coagulopathy, slurred speech, seizures
β-Blockers Bradycardia, hypotension, coma or convulsions, hypoglycemia, bronchospasm
Calcium channel blockers Bradycardia, hypotension, junctional arrhythmias, hyperglycemia, metabolic acidosis
Caustics Coagulation necrosis (acid) or liquefaction necrosis (alkali), scarring, strictures, burning, dysphagia, glottic edema
Digoxin Nausea, vomiting, visual disturbances, lethargy, electrolyte disturbances, hyperkalemia, prolonged AV dissociation and heart block, arrhythmias
Disc batteries Corrosive when in contact mucosal surfaces
Ethanol Nausea, vomiting, stupor, anorexia; late toxicity: triad of coma, hypothermia, hypoglycemia
Lethal (cardiorespiratory depression) if >400-500 mg/dL (life-threatening hypoglycemia may occur at much lower levels in young children)
Ethylene glycol CNS depression, metabolic acidosis, convulsions and coma, hypocalcemia, renal failure
Laboratory findings: anion gap metabolic acidosis, osmolal gap, urine oxalate crystals
Hypoglycemic agents Hypoglycemia, coma, seizures
Iron Hemorrhagic necrosis of GI mucosa, hypotension, hepatotoxicity, metabolic acidosis, coma, seizure, shock
Isopropyl alcohol Altered mental status, gastritis, hypotension
Laboratory findings: elevated osmolal gap, ketonuria (no metabolic acidosis or hypoglycemia)
Lead Abdominal pain, constipation, anorexia, listlessness, encephalopathy (peripheral neuropathy; rare in children), microcytic anemia
Methanol CNS depression, delayed metabolic acidosis, optic disturbances
Laboratory findings: anion gap metabolic acidosis, osmolal gap
Tricyclic antidepressants Lethargy, disorientation, ataxia, urinary retention, decreased GI motility, coma, seizures
Cardiovascular alterations: sinus tachycardia, widened QRS complex; may progress to hypotension, ventricular dysrhythmias, cardiovascular collapse

AV, atrioventricular; CNS, central nervous systeml; GI, gastrointestinal.

Compiled from Eldridge DL, Van Eyk J, Kornegay C: Pediatric toxicology. Emerg Med Clin North AM 15:283-308, 2007 and Osterhoudt K, Shannon M, Burns Ewald M, Henretig F: Toxicologic emergencies. In Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, ed 6. Philadelphia, Lippincott Williams & Wilkins, 2010, pp 1171-1223.

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