- There are approximately 2.4 million cases of ingestion or toxin exposure annually in the US. Half are in children younger than 6 yr, with a peak incidence at age 1–2 yr. Two-thirds are in patients younger than age 20 yr.
- Leading fatal agents of ingestion (all ages): Analgesics, antidepressants, cardiovascular drugs, street drugs.
- Leading agents of ingestion (adolescents): Acetaminophen, barbiturates, stimulants, antidepressants, alcohol.
- Majority of poisonings occur at home, and ∼10% involve two or more substances.
- Adolescents: 50% intentional; 50% unintentional.
- Poisonous substance storage precautions should be discussed at every 6-month well-child visit.
- Child-resistant closures have decreased the mortality of unintentional ingestions by 45%.
- One to two tablets or 1 to 2 tsp (standard pediatric “swallow” ∼5–10 cc) of the standard-strength preparations of the following medications are potentially fatal to a 10-kg child:
- Antiarrhythmics, antimalarials (chloroquine, hydroxychloroquine), benzocaine, β-blockers, CCBs, camphor, clonidine, Lomotil (diphenoxylate/atropine), lindane, methyl salicylate, opioids (codeine, morphine, pentazocine), phenothiazines (thioridazine, chlorpromazine), quinine, theophylline, TCAs (imipramine, desipramine)
- Nontoxic pharmaceuticals: Antacids, antibiotics, corticosteroids, contraceptives, laxatives, mineral oil, ACE inhibitors
- Nontoxic household products: Cosmetics, deodorants, dehumidifying (silica gel) packets, matches, candles
Cosmetics or personal care substances | 13.4% |
Cleaning products | 9.8% |
Analgesics | 8.2% |
Foreign bodies | 7.4% |
Topicals | 7.2% |
Cough and cold medicines | 5.7% |
Plants | 4.0% |
Pesticides | 4.0% |
Vitamins | 3.9% |
Antihistamines | 2.9% |
- History Should address the questions what?, when?, how?, how much?, what symptoms?, and why?: Timing of ingestion, substance(s) taken, amount taken (pill count or volume quantification, if bottle available), location of ingestion (kitchen vs bedroom vs other), reason or circumstances of exposure or ingestion, symptoms before arrival, other substances in the home (possible co-ingestions), concomitant illness or trauma (possible supratherapeutic or chronic dosing of acetaminophen or aspirin), history of depression or prior suicide attempts (in adolescents), history of street drug use.
Marijuana: Acapulco gold, bhang, doobie, ganja, grass, joint, Mary Jane, pot, rope, reefer Amphetamines: Black beauties, crank, crystals, cat (methcathinone), ice, ecstasy, meth, pep pills, smart drug (Ritalin), speed, uppers Ecstasy: Adam, E, lollies, love drug, smarties, vitamin E, XTC Heroin: Boy, China white, dust, Harry, horse, junk, monkey, smack, speed ball (with cocaine), atom bomb (with marijuana) | PCP: Angel dust, goon, horse tranquilizer, hog, Sherman, tank, wickie stick (with marijuana) δ-hydroxybutyrate (GHB): Bioski, Georgia home boy, grievous bodily harm, liquid G, liquid ecstasy, somatomax, cow growth hormone Cocaine: All-American drug, coke, crack, girl, mother of pearl, nose candy, Peruvian powder, snow, toot, white lady LSD: Acid, blotters, microdots, paper acid, pyramids, window pane, Zen |
- Anticipate: Seizures, altered mental status, multi-organ dysfunction, respiratory failure, cardiac failure, arrhythmias, or unexplained metabolic acidosis.
- Primary survey: See Figure 27-1.
- Secondary survey, laboratory investigation: More detailed history and physical exam (including possible abnormal odors), including pulse oximetry and cardiac monitoring, laboratory testing (glucose, electrolytes, anion gap, osmolar gap, baseline CBC and liver panel, urinalysis for hemoglobinuria or myoglobinuria, urine pregnancy test), blood gas (with carboxyhemoglobin if carbon monoxide toxicity is possible), urine drug screen (detects limited number of agents; rarely, color of urine may be helpful), serum drug levels (only to guide therapy or predict toxicity, eg, acetaminophen, salicylates, theophylline, lithium, lead, iron, methemoglobin, toxic alcohols, anticonvulsants, digoxin), chest radiography (if respiratory symptoms present, may identify selected radiopaque objects), baseline ECG (evaluate QRS duration for TCA, β-blocker, CCB toxicity).
Odor | Agent |
|---|---|
Wintergreen | Methyl salicylate |
Garlic | Arsenic, DMSO, organophosphate insecticides, selenium |
Rotten eggs | Hydrogen sulfide, sulfur dioxide |
Fresh hay | Phosgene |
Mothballs | Camphor, naphthalene, paradichlorobenzene |
Bitter almond† | Cyanide |
Pears | Chloral hydrate, paraldehyde |
Fruity | Isopropyl alcohol, ketones (diabetic ketoacidosis), phenol |
Carrots | Water hemlock (cicutoxin) |
Drug | Duration of Urine Detectability | Drugs Causing False-Positive Preliminary Results |
|---|---|---|
Amphetamines | 2–3 d | Amantadine, bupropion, chlorpromazine, desipramine, ephedrine, phenylephrine, pseudoephedrine, ranitidine, selegiline, trazodone |
Cocaine | 2–3 d | Topical anesthetics containing cocaine-like structure |
Marijuana | 1–7 d (light use); 1 mo with chronic moderate to heavy use | Dronabinol, efavirenz, hemp seed oil, ibuprofen, naproxen |
Opiates | 1–3 d | Fluoroquinolones, poppy seeds, quinine (tonic water), rifampin |
Phencyclidine | 7–14 d | Dextromethorphan, ketamine |
Color | Substance Responsible |
Orange to red-orange | Deferoxamine, hydroxocobalamin, lead (chronic poisoning), mercury, phenazopyridine, rifampin |
Pink | Ampicillin, cephalosporins |
Brown | Carbon tetrachloride, chloroquine |
Blue-green | Copper sulfate, methylene blue |
Chloral hydrate Calcium Opiate or cocaine packets | Iron and other heavy metals Neuroleptic agents Sustained-release or enteric-coated agents |
Symptoms | Intoxications | Withdrawals |
|---|---|---|
Tachycardia | Anticholinergics, sympathomimetics, theophylline, levothyroxine, TCAs | Barbiturates, benzodiazepines, ethanol |
Bradycardia | β-blockers, CCBs, cholinergics, cholinesterase inhibitors, clonidine, digoxin, ethanol,* opiates | |
Tachypnea | Alcohols, hydrocarbons (chemical pneumonitis), nerve agents, PCP, phosgene, salicylates | |
Bradypnea | Barbiturates, benzodiazepines, ethanol,* marijuana, opioids | |
Pulmonary edema (noncardiogenic) | Meprobamate, methadone, opioids, paraquat, phenobarbital, phosgene, propoxyphene, salicylates | |
Hypoxia | Benzocaine (secondary to methemoglobinemia), carbon monoxide, opioids, sedative–hypnotics | |
Hypertension | Anticholinergics, caffeine, nicotine, PCP, sympathomimetics, levothyroxine | Ethanol |
Hypotension | Antihypertensives, barbiturates, benzodiazepines, ethanol,* iron, opioids, rodenticides (containing arsenic, cyanide), TCAs | Barbiturates, benzodiazepines, ethanol |
Miosis | Cholinergics, clonidine, organophosphates, opioids, oxymetazoline, phenothiazines, pilocarpine | |
Mydriasis | Anticholinergics, antihistamines, marijuana, sympathomimetics, TCAs | Opioid |
Hyperthermia | Amphetamines, anticholinergics, cocaine, MAOIs, neuroleptic malignant syndrome, PCP, salicylates, serotonin syndrome | Ethanol |
Hypothermia | Barbiturates, benzodiazepines, carbon monoxide, clonidine, ethanol, opioids, oral hypoglycemics, phenothiazines, TCAs | |
Seizures | Amphetamines, anticholinergics, atropine, bupropion, caffeine, camphor, carbon monoxide, chlorinated hydrocarbons (lindane), cocaine, cyanide, INH, inhalants, insulin, lead, lidocaine, lithium, methanol*, mushrooms, nicotine, oral hypoglycemics, organophosphates, PCP, salicylates, strychnine, TCAs, theophylline | Barbiturates, benzodiazepines, ethanol |
Anion gap metabolic acidosis (see Fluid, Electrolyte, and Acid–Base Balance, Chapter 15, for more detail) | Alcohols* (ethanol,* ethylene glycol,* methanol*), carbon monoxide, cyanide, ibuprofen, INH, iron, metformin, salicylates | |
Hypoglycemia | Alcohols,* β-blockers, insulin, oral hypoglycemics, salicylates | |
Acute ataxia or nystagmus | Alcohols,* anticonvulsants, (especially phenytoin) antihistamines, barbiturates, carbon monoxide, organic solvents, PCP (rotary nystagmus, versus vertical nystagmus of brainstem lesion) | |
Emesis, severe | Boric acid, corrosives, fluoride, iron, salicylates, theophylline | Opioids |
Renal failure | Carbon tetrachloride, ethylene glycol,* methanol,* mushrooms, oxalates | |
Skin Color | Red: Anticholinergics, boric acid, carbon monoxide, cyanide Blue: Methemoglobinemia | |
Diaphoresis | Organophosphates, PCP, salicylates, sympathomimetics | Opioids |
Altered mental status | Anticonvulsants, antihistamines, antipsychotics (risperdone), benzodiazepines (Rohypnol), carbon monoxide, clonidine, cyanide, GHB, ethanol,* ethylene glycol,* heavy metals (lead), hemlock, INH, insulin, lithium, opioids, oral hypoglycemics, TCAs, thallium, toluene, toxin-induced hepatic encephalopathy | Ethanol |
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