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.
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.
Include poisoning in the differential diagnosis.
Poison control centers can be an excellent source of information.
The National Capital Poison Center can be reached at 1-800-222-1222.
Accidental ingestions are rare in this age group due to limited developmental capabilities.
Instead, consider:
Misuse of a medication (e.g., administering a medication prescribed for another household member to an infant)
Inappropriate dosing (concentration or measurement error) of a prescription or over-the-counter medication
Toddlers have a potentially deadly developmental combination of independent mobility, evolving manual dexterity, and impulsivity.
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.
There is a male predominance for ingestions in children <13 years of age.
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).
Female predominance of ingestions in teens and adults.
Intentional poisonings are more commonly recognized in this age group.
Suicide attempts
Recreational ingestion for amusement/altered perception/intoxication leading to unintentional overdose
More severe clinical effects of toxin due to higher volume ingestion
Higher associated morbidity and mortality with intentional poisonings (suicide attempts or deliberate poisonings) in all age ranges
Often minimal or no history available due to altered mental status or impaired consciousness
The number one chief complaint of poisoning victims is altered mental status.
Secure the available timeline of progression of symptoms.
Presence of a prodrome
Treatments/medications administered for symptoms prior to arrival
Recent introduction of a new compound into the environment
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).
Holidays may increase availability of alcohol-containing beverages within a child’s reach.
New caretaker
Possible lower level of attentiveness to child’s activity
New household members, such as elderly relatives taking prescription medications that may be accidentally stored within arm’s reach of a small child
Home environment
More than 90% of poisonings occur in the home.
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.
Prescription medications are another common culprit.
They are available to all household members: child-resistant caps are not childproof.
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.
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:
The home environment is unsafe (e.g., methamphetamine “lab”).
Caretakers practice neglectful supervision.
The child was intentionally administered a toxic substance.
Plants
Common backyard plants of concern are listed in Table 5-1.
Mushrooms are also common in pediatric ingestions.
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.
Child protective services can help assess the home environment to confirm the details of the history by conducting a home inspection.
TABLE 5-1 Backyard Plants of Interest | ||||||||||||||||||||||||||||||||||||||||
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Sodium
Salt loading resulting in hypernatremia may be distinguished from hypernatremic dehydration by a measurement of the patient’s fractional excretion of sodium (FENa).
A child who has a high-sodium burden is expected to have a high FENa (>2%) as the body attempts to achieve equilibrium.
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%).
FENa equation:
[UrineNa × Plasmacreatinine/PlasmaNa × Urinecreatinine] × 100
Bicarbonate
