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When faced with a patient who has been a victim of poisoning, whether accidental or intentional, think ahead! This is a simpler task when faced with a patient who presents with a classic toxidrome (remember “mad as a hatter, dry as a bone”), but it is equally important when faced with a child who simply presents with a diagnostic dilemma.
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When drawing blood during the acute phase of illness, always secure extra samples when possible. Collect whatever samples you deem necessary in the context of the patient’s signs and symptoms; blood and urine (and occasionally vomit or feces) may be helpful.
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Include poisoning in the differential diagnosis.
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Poison control centers can be an excellent source of information.
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The National Capital Poison Center can be reached at 1-800-222-1222.
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Accidental ingestions are rare in this age group due to limited developmental capabilities.
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Instead, consider:
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Misuse of a medication (e.g., administering a medication prescribed for another household member to an infant)
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Inappropriate dosing (concentration or measurement error) of a prescription or over-the-counter medication
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Toddlers have a potentially deadly developmental combination of independent mobility, evolving manual dexterity, and impulsivity.
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According to the 2013 Annual Report of the American Association of Poison Centers’ National Poison Data, 35.5% of all exposures occurred in children younger than 3 years of age.
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There is a male predominance for ingestions in children <13 years of age.
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Children in this age group with normal developmental achievement do not typically ingest toxic substances unless they are improperly stored (e.g., antifreeze stored in a soda container).
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Female predominance of ingestions in teens and adults.
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Intentional poisonings are more commonly recognized in this age group.
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Suicide attempts
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Recreational ingestion for amusement/altered perception/intoxication leading to unintentional overdose
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More severe clinical effects of toxin due to higher volume ingestion
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Higher associated morbidity and mortality with intentional poisonings (suicide attempts or deliberate poisonings) in all age ranges
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Often minimal or no history available due to altered mental status or impaired consciousness
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The number one chief complaint of poisoning victims is altered mental status.
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Secure the available timeline of progression of symptoms.
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Presence of a prodrome
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Treatments/medications administered for symptoms prior to arrival
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Recent introduction of a new compound into the environment
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This is particularly important with toddlers (e.g., the household car’s brake fluid was just changed and the container left accessible in the driveway).
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Holidays may increase availability of alcohol-containing beverages within a child’s reach.
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New caretaker
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Possible lower level of attentiveness to child’s activity
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New household members, such as elderly relatives taking prescription medications that may be accidentally stored within arm’s reach of a small child
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Home environment
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More than 90% of poisonings occur in the home.
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The most common poisons in accidental ingestions include cosmetics, cleaning products, and over-the-counter products like analgesics, topical creams, antihistamines, vitamins, and cough and cold preparations.
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Prescription medications are another common culprit.
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They are available to all household members: child-resistant caps are not childproof.
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Anticipatory guidance must include keeping all prescription and over-the-counter medications, as well as potentially toxic products, in their original containers and securing these products with the use of a lock or latch.
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A repeat visit with a chief complaint of ingestion is a concern. These patients are more likely to be chemically abused children. One of the following is likely true:
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The home environment is unsafe (e.g., methamphetamine “lab”).
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Caretakers practice neglectful supervision.
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The child was intentionally administered a toxic substance.
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Plants
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Common backyard plants of concern are listed in Table 5-1.
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Mushrooms are also common in pediatric ingestions.
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Mushrooms from backyards are unlikely to be poisonous, whereas those found in woody areas are more concerning and may be pale or have a white underside.
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Child protective services can help assess the home environment to confirm the details of the history by conducting a home inspection.
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TABLE 5-1 Backyard Plants of Interest | ||||||||||||||||||||||||||||||||||||||||
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Sodium
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Salt loading resulting in hypernatremia may be distinguished from hypernatremic dehydration by a measurement of the patient’s fractional excretion of sodium (FENa).
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A child who has a high-sodium burden is expected to have a high FENa (>2%) as the body attempts to achieve equilibrium.
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Conversely, a child with hypernatremia as a result of dehydration still has an avid renal response of water resorption facilitated by sodium resorption, and therefore, the FENa should be low (<1%).
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FENa equation:[UrineNa × Plasmacreatinine/PlasmaNa × Urinecreatinine] × 100
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Bicarbonate
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