Chloral hydrate, calcium carbonate
Heavy metals (lead, zinc, barium, arsenic, lithium, bismuth as in
Play-Doh, potassium chloride
KUB, Kidney-ureter-bladder radiograph. *Indicates hyperosmolar condition.
Seizures are the sixth major mode of presentation for children with toxic ingestions, but poisoning is an uncommon cause of afebrile seizures. When seizures do occur with intoxication, they may be life-threatening and require aggressive therapeutic intervention.
Laboratory studies helpful in initial management include specific toxin-drug assays; measurement of arterial blood gases and electrolytes, osmoles, and glucose; and calculation of the
Drugs Associated with Major Modes of Presentation
Amphetamine Antiarrhythmics Anticholinergics Antihistamines Arsenic Carbon monoxide Chloral hydrate Cocaine Cyanide Cyclic antidepressants Digitalis Freon Phenothiazines Physostigmine Propranolol Quinine, quinidine Theophylline *Causes of methemoglobinemia: amyl nitrite, aniline dyes, benzocaine, bismuth subnitrate, dapsone, primaquine, quinones, spinach, sulfonamides.
anion or osmolar gap. A full 12-lead electrocardiogram should be part of the initial evaluation in all patients suspected of ingesting toxic substances. Urine screens for drugs of abuse or to confirm suspected ingestion of medications in the home may be revealing.
Quantitative toxicology assays are important for some agents (Table 45-5), not only for identifying the specific drug, but also for providing guidance for therapy, anticipating complications, and estimating the prognosis.
The four foci of treatment for poisonings are supportive care, decontamination, enhanced elimination, and specific antidotes.
Supportive care is the mainstay of treatment in most cases. Prompt attention must be given to protecting and maintaining the airway, establishing effective breathing, and supporting the circulation. This management sequence takes precedence over other diagnostic or therapeutic procedures. If the level of consciousness is depressed, and a toxic substance is suspected, glucose (1 g/kg intravenously), 100% oxygen, and naloxone should be administered.
The intent of gastrointestinal decontamination is to prevent the absorption of a potentially toxic ingested substance and, in theory, to prevent the poisoning. There has been great controversy about which methods are the safest and most efficacious. Recommendations from the American Academy of Clinical Toxicology (AACT) and the European Association of Poison Centres and Clinical Toxicologists (EAPCCT) follow. Syrup of ipecac should not be administered routinely to poisoned patients because of potential complications and lack of evidence that it improves outcome. Likewise, gastric lavageshould not be used routinely, if ever, in the management of poisoned patients because of lack of efficacy and potential complications. Single-dose activated charcoal decreases drug absorption when used within 1 hour of ingestion; however, it has not been shown to improve outcome. Thus, it should
Acetaminophen N-Acetylcysteine 140 mg/kg PO initial dose, then 70 mg/kg Most effective within 16 h of ingestion PO q4hr × 17 doses 150 mg/kg IV over 1 hr, followed by 50 mg/ kg IV over 4 hr, followed by 100 mg/kg IV over 16 hr
Benzodiazepine Flumazenil 0.2 mg IV, may repeat to 1 mg max Possible seizures, arrhythmias, DO NOT USE FOR UNKNOWN INGESTIONS β-Blocking agents Glucagon 0.15 mg/kg IV, followed by infusion of 0.05–0.15 mg/kg/hr