Chapter 97 Pediatric Poisonings (Case 54)
Patient Care
Clinical Thinking
• Airway: If the airway is patent, should the airway be secured now before there is progressive loss of airway maintenance?
• Circulation: Do the vital signs seem to imply impending hemodynamic instability? Have I secured vascular access? Do I need to administer volume or vasopressor support?
• Decontamination: Is there continued exposure to toxic substance from the skin or the clothes? Have I been careful to wear personal protective equipment? What, if any, method of decontamination should be used? What was the time of the exposure/ingestion? Will decontamination be successful and safe?
• Exposure: Have I exposed the body to look for other signs of injury or clues to a diagnosis? Have I checked a temperature?
• Electrocardiogram (ECG): Is the patient on a monitor, and have I ordered an ECG to identify arrhythmias and specific toxidromes?
• Does this patient have a recognizable toxidrome? Does this particular ingestion have an antidote? Are there recommended support measures? Is the substance something that can and should be removed with hemodialysis?
History
• What medications are kept in the home (over-the-counter medications, prescription medications, cultural remedies)?
• Knowing medical conditions of others in the home provides clues to what medications are in the home.
• Find out the exact time of ingestion to correlate expected symptoms and the current patient status.
Physical Examination
• Tachycardia does not necessarily reflect intravascular volume depletion, which can occur if the ingestion causes excessive vomiting. Tachycardia may be due to the anticholinergic properties or impending hemodynamic collapse or may be a sign of autonomic stimulation. Bradycardia may represent direct cardiac effects or generalized autonomic depression.
• Tachypnea with respiratory alkalosis classically presents in early aspirin toxicity. Tachypnea may be present if a substance was aspirated. Bradypnea can occur with generalized autonomic depression.
• Hyperthermia can be seen in aspirin toxicity and may lead the clinician to incorrectly diagnose the patient with an infection.
• An age-appropriate mental status examination can be performed quickly. Caregivers are the best resource to identify if the child is at baseline activity and level of consciousness. Children may be appropriately somnolent if it is past their usual bedtime.
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