Pediatric Poisonings (Case 54)

Chapter 97 Pediatric Poisonings (Case 54)

Jannet Lee-Jayaram, MD , Christopher J. Haines, DO, FAAP, FACEP

Case

A 13-month-old boy is brought into the emergency department (ED) because he is “not acting right.” He vomits and then starts to have a generalized tonic-clonic seizure. Eventually, his family brings in an empty jar that smells strongly of the medicinal odor that was noted on the child on arrival.

Differential Diagnosis

Camphor Salicylates Hydrocarbons

Speaking Intelligently

When I suspect a patient has ingested a toxic substance, I start with the ABCDEs (see Clinical Thinking). Simultaneously, I obtain a focused history and perform a physical examination while trying to fit the information into a particular toxidrome. A toxidrome is a pattern of signs and symptoms that are consistent with a specific toxic exposure. I consider the potential manifestations of the toxidrome and what problems may progress to become urgent/emergent. My decision to observe in the emergency department (ED), discharge home, or admit to the hospital is based on recognition of the specific ingestion and the patient’s clinical status. If ingestion is suspected, I often consult with the poison control center. The number 1-800-222-1222 is used throughout the United States to speak with a poison control center.

Patient Care

Clinical Thinking

• Airway: If the airway is patent, should the airway be secured now before there is progressive loss of airway maintenance?
• Breathing: How is the breathing, and does it need support?
• 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?
• Disability: What is the patient’s mental status, and do I expect further deterioration?
• 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?
• Dextrose: Have I checked a bedside serum glucose level?
• 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?
• Is the patient a teenager with intentional ingestion with multiple substances?
• Is the patient pregnant?

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.
• Ask for the bottle of the ingested substance to estimate the dose in mg/kg.
• Find out the exact time of ingestion to correlate expected symptoms and the current patient status.
• Separate the teenager from the caregiver to promote open communication and honesty and facilitate patient-doctor communication.

Physical Examination

• Initial assessments starts with the ABCDEs as above.
• 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.
• Hypotension is a late sign of shock in children.
• 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.

Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Physical Abuse (Case 53)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Pediatric Poisonings (Case 54)

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