Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XIV.9. Toxicology
Alson S. Inaba, MD
March 2003

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Case 1: A 2 year old boy reportedly ate 12 grape flavored chewable acetaminophen tablets that he found in the bathroom two hours ago. He already has had two episodes of vomiting. His mother calls the pediatrician and asks for advice. She states that her son is now playful and "looks fine." If you were this child's pediatrician, what recommendations would you give to his mother? In this case, the majority of the details regarding the ingestion are known yielding some data upon which treatment and management decisions can be made.

Case 2: A 15 year old girl reportedly took a whole box of diphenhydramine (Benadryl) tablets after she got into an argument with her boyfriend. She is brought to the emergency department by her parents who claim that she is "not acting right." She is slightly sleepy in appearance but seems to answer questions appropriately. She denies taking any other medications, alcohol or illicit drugs. She does not remember exactly when she took the diphenhydramine tablets. Her vital signs reveal HR 160, RR 18, BP 160/90, RA O2 sat 99%. Her physical examination is unrevealing. If you were the emergency department physician caring for this girl, what would be your assessment and plan of action? This case involves an intentional overdose situation involving a teenager which is a more difficult scenario to assess because the history that is provided is often incomplete and/or inaccurate/unreliable. For example, did she really ingest an entire box of diphenhydramine tablets as was reported? Is there the possibility that she ingested other substances in addition to the diphenhydramine? When did the reported overdose occur and is her degree of tachycardia and hypertension consistent with the medication that was allegedly ingested? Is it possible that this adolescent female is pregnant and if so, are any of your therapeutic interventions contraindicated in a pregnant female?

Case 3: A 3 year old boy is brought to the emergency department by the paramedics in status epilepticus. The father found his son seizing and immediately called 911. The child has never had prior episodes of seizures but he has had two days of low grade fevers along with a slight cough. He is not on any medications and his father denies any possibility of head trauma preceding the seizure. He requires IV anticonvulsants to terminate the seizure activity. Although you are contemplating the possibilities of meningitis and febrile seizures in your differential diagnosis, should the possibility of a toxic ingestion/exposure also be considered in the differential diagnosis in this case? This case illustrates how one must consider the possibility of a toxic exposure in the differential diagnosis of a patient who presents to the emergency department with severe, life threatening signs and symptoms (e.g., status epilepticus, coma, respiratory distress, cardiovascular shock, altered mental status, etc.).

Each year approximately two million poisoning cases are reported to poison control centers through the United States. Based on the 2000 Annual Report of the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System, there were 2.1 million human exposure cases reported throughout the country last year (1). Keep in mind that the actual number of poisoning cases that occur each year is considerably higher than this since all poisoning cases that occur are not actually reported to a poison control center. The majority (75%) of these poisoning cases that are reported to the poison control centers each year are safely and effectively managed at home with phone advice from the poison control center's poison information specialists. Therefore only 25% of the callers are actually referred to emergency departments for further assessment and treatment.

Roughly 50% of the reported poisoning cases involve children under six years of age. Within the group of children that are <6 years of age, the largest group is the 18 month to 3 year age group. Therefore healthcare providers who deal with the pediatric population must be extremely knowledgeable in the assessment and management of poisonings. The substances that were most frequently reported involving poisoning in children under six years of age in the 2000 annual report are listed as follows: Cosmetics & personal care products (13%), cleaning substances (11%), analgesics (7%), foreign bodies (7%), plants (7%), topicals (6%), cough & cold preparations (5%), insecticides & pesticides (4%), vitamins (4%) (1).

Poisonings can occur through a variety of different routes of exposure, but the most common route of exposure is via oral ingestions. Each year approximately 75% of all poisoning cases are due to ingestions. Other routes are dermal (8%), inhalation (6%), ocular (5%) and bites/stings (4%).

The majority of the human exposure cases each year involve accidental exposures as compared to intentional overdoses. In 2000, 86% of the reported two million human exposure cases involved unintentional/accidental exposures, while only 11% involved intentional exposures (with the majority of the intentional overdoses involving adults) (1). Up to 90% of the poisoning cases each year occur in the victim's own home, while only 1% occur at schools.

The majority of the poisoning related fatalities each year involve adults. However each year approximately 20-35 of the annual fatalities unfortunately involve children under six years of age. In 2000, the substances that were responsible for these pediatric fatalities were: methanol, crotalid snake bite, pine oil cleaner, carbon monoxide/smoke, hair oil/conditioner, kitty litter (aspiration), lead, kerosene, aluminum phosphide pesticide, paraquat pesticide, acetaminophen, methadone, morphine, amitriptyline, diphenhydramine, norfloxacin, and diphenoxylate/atropine (antidiarrheal) (1).

The three clinical cases listed at the beginning of this chapter illustrate the wide spectrum of how poisoning cases may present to healthcare providers. Because it would be virtually impossible to cover every possible type of poisoning scenario that you may encounter in your career, a systematic and logical overall approach to poisonings will be emphasized throughout this chapter. Since 75% of all toxic exposures involve ingestions, this chapter will primarily focus on the assessment and management of toxic ingestions. Decontamination from ocular or dermal exposures basically involves copious washing/irrigation of the eyes or skin to prevent further absorption of the toxin.

The key points in the general approach to the poisoned child that will be covered in this chapter include the following:
. . . . . 1. Initial stabilization priorities
. . . . . 2. History (the What, When and How much of poisonings)
. . . . . 3. Decoding of the vital signs and the toxicologic physical examination
. . . . . 4. Toxidromes
. . . . . 5. Gastrointestinal decontamination and enhanced drug elimination
. . . . . 6. Laboratory studies
. . . . . 7. Antidotes and ongoing care
. . . . . 8. Patient disposition from the emergency department
. . . . . 9. Helpful poison prevention tips

The initial management of any poisoning case must first address the assessment and stabilization of the standard "A-B-C's" of emergency medicine. Regardless of what substance may have been ingested, the physician must assure that the child's airway, breathing and circulation have been assessed and stabilized first, before addressing other issues such as gastrointestinal decontamination and laboratory evaluations. If the patient is unable to maintain and protect his or her own airway or has a diminished gag reflex, one may need to first consider endotracheal intubation prior to performing any type of gastrointestinal decontamination in order to protect the airway from aspiration. One must also be ready to address and stabilize any seizures that the patient may be experiencing due to the toxic exposure. If a child develops hypoglycemic seizures secondary to a toxic ingestion, the child will require IV dextrose in addition to the standard anticonvulsant medications in order to eradicate the seizures. A rapid method to remember exactly how much IV dextrose to administer in these types of situations is my "Hawaii Five-O" rule (2).

An IV bolus of 0.5 gm/kg of dextrose will raise the patient's serum glucose level by approximately 60-100 mg/dL. Various concentrations of IV dextrose solutions (i.e., D5W, D10W, D25W or D50W) may be used to correct symptomatic hypoglycemia. A quick and easy method that I have devised to calculate how many "cc/kg" of any dextrose solution to draw up in order to administer 0.5 gm/kg of dextrose can be remembered by the following:

[dextrose concentration] x [?? cc/kg] = "50"
. . . . . D5% 10 cc/kg
. . . . . D10% 5 cc/kg
. . . . . D25% 2 cc/kg
. . . . . D50% 1 cc/kg

Therefore for a child with a hypoglycemic seizure, 5 cc/kg of a D10W solution would provide enough IV dextrose (0.5 gm/kg) to raise the child's serum glucose level by 60-100 mg/dL.

The three key questions that must be addressed in all poisoning cases are:
. . . . . 1) WHAT substance(s) was ingested?
. . . . . 2) WHEN did the ingestion occur?
. . . . . 3) HOW MUCH was ingested?

The answers to these questions will provide valuable information about:
. . . . . a) The severity of the ingestion.
. . . . . b) The potential benefits/efficacy of gastrointestinal decontamination.
. . . . . c) Whether or not therapeutic interventions will be potentially necessary.
. . . . . d) Accurate interpretation of specific drug levels.
. . . . . e) Disposition of the patient (i.e., can the patient be safely discharged from the emergency department and after what period of time, or does the patient need to be admitted for further observation and treatment?)

When determining what substance(s) was ingested, one must be very specific. For example, many of the over-the-counter (OTC) medications frequently have various preparations with many different active ingredients. The exact milligram amount of the suspected ingested medication or liquid/syrup should also be confirmed since many medications (both OTC as well as prescription medications) are available in multiple milligram dosages and concentrations. If at all possible have a family member bring the bottle, box or container of the suspected toxin to the emergency department so that you yourself can verify the specific product and active ingredients. Local poison control centers have computerized data bases of over a million substances, which can be accessed via a specific product name or via the individual active ingredients. If the suspected ingestion involved a plant, have a family member bring in as much of the actual plant for identification.

If the time from the ingestion to the time of arrival to the emergency department is within 1-2 hours, gastric lavage may be beneficial. In general, gastric lavage is not very effective if performed more than two hours post-ingestion. Knowing the time of the ingestion is also necessary when attempting to interpret specific drug levels. For example, an acetaminophen level of 100 mcg/ml cannot be interpreted and plotted on the nomogram unless the time of ingestion as well as the time of the blood draw are known. The level of 100 mcg/ml may not be toxic if it was obtained two hours post-ingestion, whereas the very same level would be considered toxic if it was obtained 20 hours post-ingestion.

Often, the most difficult aspect of the toxicologic history for the parents to answer is regarding the exact amount of the toxin or drug that may have been ingested. When confronted with this dilemma, the physician should always assume the worst case scenario rather than minimizing the amount that may have been potentially ingested.

The physician must be a medical detective in some aspects when attempting to estimate how much the child may have ingested. For example, if a child presents to the emergency department after potentially ingesting some tablets, questions which could be asked include the following (3):
. . . . . a) Was the medication just recently purchased, and if so was the bottle completely full prior to the child getting to the pills?
. . . . . b) If the bottle was not brand new or recently purchased, then how many pills were in the bottle before the child got to it?
. . . . . c) If the medication was a prescribed medication, how many pills were originally prescribed, when was the medication prescribed and how many pills were already taken prior to the child getting to the bottle?
. . . . . d) How many pills did the parents find remaining in the bottle?
. . . . . e) How many pills did the parents find around the area where they found the child playing with the opened medication bottle?
. . . . . f) How many pills did the parents find in the child's mouth?

Once the total milligrams of the potential ingestion has been determined, then one must calculate how much was ingested in mg/kg to determine severity potential. If more than one child may have been involved in an ingestion scenario, perform your mg/kg calculations for each child (based on each child's individual weight) assuming that all of the potentially ingested medication may have been consumed only by one child.

Although the majority of the substances that are typically ingested by children are either nontoxic or mildly toxic, there are a few substances that can potentially be fatal even when ingested in very small amounts. Some of these highly toxic substances with the corresponding amounts which could potentially be lethal for a 10 kg child are: amanita phalloides (one mushroom), amphetamines, antimalarials (one chloroquine tablet), calcium channel blockers (one nifedipine tablet), camphor (one teaspoon), clonidine (one 0.1 mg tablet), cocaine, cyclic antidepressants (one 150 mg imipramine tablet), ethylene glycol (one teaspoon), methylsalicylates (one teaspoon), narcotic medications, phenothiazines, theophylline (one 500 mg tablet) (4).

Toxic ingestions in children typically present to an emergency department in one of two scenarios. The first is that of a child who presents with a witnessed or suspected ingestion. The second scenario is that of a child who presents with a constellation of signs and symptoms which may include the possibility of a toxic ingestion within the working differential diagnosis. For example if a previously healthy 2 year old child presents to the emergency department after experiencing a brief afebrile seizure, the possibility of a toxic ingestion must be included within the differential diagnosis in addition to head trauma and other various etiologies for the child's afebrile seizure.

Every element of a child's vital signs must be carefully analyzed in any potential poisoning case scenario, which may give the physician a clue as to what the ingested substance might have been in the case of the unknown ingestion. The following is my quick and easy to remember method of simplified pediatric vital signs (5).

Heart rate
Respiratory rate
Newborn to 1 year old
1 to 4 years old
4 to 12 years old
>12 years old

The key elements of a toxicologic physical examination include the following elements (3):
. . . . . a) Eyes: pupillary size, symmetry and response to light presence of nystagmus (vertical or horizontal).
. . . . . b) Oropharynx: moist or dry mucus membranes, presence/absence of the gag reflex, presence of any particular or distinctive odors.
. . . . . c) Abdomen: presence/absence and quality of bowel sounds.
. . . . . d) Skin: warm/dry, warm/sweaty or cool.
. . . . . e) Neurologic: level of consciousness and mental status, presence of tremors, seizures or other movement disorders, presence/absence and quality of deep tendon reflexes.

Toxidromes refer to a specific constellation of signs and symptoms which one may expect to see with a specific class or type of toxic substance. Toxidromes are based on the patient's vital signs as well as on the physical examination findings. The five distinct toxidromes and the common toxins of each of the toxidromal classes are listed below (3):

1. Anticholinergics (e.g., atropine, antihistamines, cyclic antidepressants, etc.): Tachycardia, hypertension, tachypnea, mydriasis, agitation, hallucinations/delirium, seizures, hypoactive bowel sounds, warm/dry skin, dry mouth.

2. Sympathomimetics (e.g., cocaine, amphetamines, PCP, decongestants, beta-agonists, theophylline, etc.): Tachycardia, hypertension, tachypnea, mydriasis, agitation, hallucinations, delirium, seizures, hypoactive bowel sounds, warm/sweaty skin.

3. Cholinergics (e.g., organophosphate and carbamate insecticides): "D-U-M-B3-E-L-S": Defecation, Urinary incontinence, Miosis, Bradycardia/Bronchospasm/Bronchorrhea, Emesis, Lacrimation, Salivation.

4. Opioids (e.g., codeine, morphine, meperidine, heroin, etc.): Bradycardia, hypotension, bradypnea, hypothermia, hyporeflexia, pinpoint, pupils.

5. Sedative-hypnotics (e.g., ethanol, benzodiazepines, barbiturates, etc.): Bradycardia, hypotension, bradypnea, hypothermia, hyporeflexia, miosis.

In 1985 ipecac administration was recommended in 15% of the poisoning cases handled throughout the country by the American Association of Poison Control Centers. However the recommended use of ipecac in the home has continually declined over the past several years to only 0.8% of poisoning cases reported in the year 2000 (1). Because of this, the American Academy of Pediatrics Committee on Injury and Poison Prevention is currently recommending that syrup of ipecac no longer be used as a poison treatment intervention in the home setting. The AAP is also recommending that pediatricians and other health care professionals advise parents to safely dispose of the ipecac syrup that they may currently have within their homes (6).

Gastric lavage has several clinical advantages over ipecac induced emesis. Gastric lavage provides a quicker, more controlled and safer route of gastric emptying than ipecac. The typical method of performing gastric lavage is to perform lavage with saline until the retrieved gastric contents are clear, then activated charcoal with sorbitol is instilled down the lavage tube.

Gastric lavage by itself is only effective at removing toxins that are still within the stomach. Lavage is not capable of removing any toxins that have already passed into the small intestines. Thus, if more than 1-2 hours have already elapsed prior to the patient's arrival in the emergency department, gastric lavage would probably not be very effective at preventing toxin absorption since the majority of the ingested substance has already probably passed out of the stomach and into the small intestines. In order to perform effective lavage, the internal diameter of the tube must be large enough to accommodate the pill fragments that are in the child's stomach. Thus, because large orogastric lavage tubes cannot always be safely placed in children, the option of gastric lavage may not be feasible and/or effective in smaller children. However, when the ingested substance is a liquid preparation, then a smaller sized tube would be sufficient, although it must be performed much sooner in order to be effective since liquid preparations are more quickly absorbed than pills or tablets.

Activated charcoal is very effective at adsorbing many ingested toxins and thereby prevents systemic toxicity. The majority of activated charcoal preparations currently available have adsorptive surface areas of 1,000 square meters per gram of charcoal. Some of the newer "super" adsorptive activated charcoal preparations reportedly have up to 2,000 square meters of adsorptive surface area per gram of charcoal. Because activated charcoal is able to prevent systemic toxicity by effectively binding so many different ingested toxins, many poison control centers have been recently recommending the administration of activated charcoal alone (without first performing gastric lavage) for ingestion cases of mild to moderate severity.

Although activated charcoal has been sometimes referred to as the "universal antidote" because it adsorbs so many different toxins, there are nine scenarios in which activated charcoal may not be clinically effective. My mnemonic to remember these nine scenarios is "C-H-E-M-I Ca-L Cam-P" (Cyanide, Hydrocarbons, Ethanol (and other alcohols), Metals, Iron, CAustics, Lithium, CAMphor, Potassium) (7). Even though charcoal has a very low affinity for cyanide, it may still be effective in preventing systemic cyanide toxicity if the amount of cyanide ingested is within the 100-500 mg range. Although charcoal is not necessary for ingestions of plain hydrocarbons, it should be considered if the ingested hydrocarbon contains systemic toxins (i.e., aromatic and halogenated hydrocarbons). If the ingested hydrocarbon does not pose any risk in terms of systemic toxic effects, charcoal administration should be avoided because the charcoal may predispose the patient to vomiting, which will definitely worsen the aspiration toxicity of the hydrocarbon. Although charcoal is very effective at adsorbing camphor, the administered charcoal may not be very effective depending on the time that the child presents to the emergency department. Because the majority of camphor containing products are typically found in liquid preparations, by the time the child presents to the emergency department, most of the liquid camphor has already been completely absorbed from the stomach and therefore there will be nothing left for the activated charcoal to adsorb. However if the child presents to the emergency department with 30 minutes after ingesting a potentially toxic amount of camphor, gastric lavage should probably be attempted in order to prevent systemic toxicity (e.g., camphor induced seizures). Multiple doses of activated charcoal (without cathartics) are sometimes used as a method of "gastrointestinal dialysis" for certain drugs that undergo enterohepatic circulation (e.g., theophylline, carbamazepine, cyclic antidepressants, phenobarbital, digoxin).

In the year 2000, activated charcoal was administered in 6.7% of the poisonings reported throughout the country (1). Although there have been a few studies that have looked at the efficacy of home administration of activated charcoal, the AAP does not currently recommend the routine use of activated charcoal as a poison treatment intervention in the home scenario at this time until their have been more studies which further investigate the risks and benefits of activated charcoal administration within the home (6).

Cathartic agents by themselves are not a very effective method of gastrointestinal decontamination. The main role of cathartics is to more quickly eliminate the charcoal bound toxin complex from the intestines before the toxins have the opportunity to dissociate from the activated charcoal. Sorbitol is the most commonly used of the cathartics because of its rapid gastrointestinal transit time. Sorbitol also comes premixed with activated charcoal ranging from 27-48 grams of sorbitol per 120 milliliter bottle of activated charcoal. Sorbitol can be safely used in children as long as it is administered only once per 24 hours and the stool output and the cardiovascular and hydration status are closely monitored.

Whole bowel irrigation (WBI) is a method of gastrointestinal decontamination that utilizes high volumes of iso-osmotic fluids to basically flush pills and other toxins out of the gastrointestinal tract. One advantage of WBI is that unlike gastric lavage, this method of decontamination will eliminate pills and toxins from the entire gastrointestinal tract and not just from the stomach. The second advantage WBI is that it can be utilized in those scenarios in which activated charcoal would not be very effective. The most common indication for WBI is an overdose of iron tablets.

The two iso-osmotic solutions which are currently utilized for WBI are GoLytely and CoLytely. Adults and teenagers can be given 1-2 liters of GoLytely per hour via a nasogastric tube until the ingested toxin is completely eliminated per rectum and the rectal effluent is clear in color. Typically the duration of WBI that is required to achieve this end point is roughly 4-6 hours. The recommended rate of WBI in children is 25 ml/kg/hour (up to a maximum 500 ml/hour). Any child undergoing WBI must also be carefully monitored for the risk of aspiration since high volumes of fluid may be required during this process.

Although there are multiple methods available to enhance the elimination of specific toxins from the body, the majority of pediatric poisoning cases can be treated with one or more of the decontamination methods mentioned above. The urinary pH can be manipulated in order to enhance the urinary excretion of certain drugs and toxins. The prime example is urinary alkalinization via the IV administration of sodium bicarbonate in order to enhance the urinary excretion of salicylates. Other more complex methods of enhanced elimination techniques include peritoneal dialysis, hemodialysis and hemoperfusion.

The exact laboratory tests which one would obtain in a poisoning case will depend upon the specifics of each individual case as well as the overall severity of the case. Although blood and urine toxicologic screens and specific drug levels may be obtained, the results of these studies typically are not available for several hours. Therefore, the initial stabilization and management of every poisoning case is clinically determined by the patient's presenting signs, symptoms, and vital signs. For intentional overdose cases, I would recommend an EKG rhythm strip (to quickly assess for any conduction abnormalities and/or dysrhythmias), acetaminophen levels, salicylate levels and a pregnancy test in females of child bearing age. An electrolyte panel may also be helpful to assess for metabolic acidosis. Once the results of the electrolyte panel are known, one can also calculate the anion gap, which may provide helpful clues to the potential toxin in cases of the unknown or suspected ingestion. The anion gap can be calculated via the formula: Na - [Cl + CO2]

The calculated anion gap should normally be equal to 8-12 mEq/liter. Toxins that typically produce an increased anion gap metabolic acidosis may be remembered by the "M-U-D-P-I-L-E-S" mnemonic (Methanol, Uremia, DKA, Paraldehyde, Iron/Ibuprofen/INH, Lactic acidosis (e.g., carbon monoxide, cyanide and various other etiologies of lactic acidosis), Ethanol/Ethylene glycol, Salicylates).

Another very useful laboratory study is the measured serum osmolality and the serum osmolar gap. A patient's serum osmolality can be calculated via the formula:

2 x [Na] +[BUN/2.8] + [glucose/18]

Based on this calculated formula, the only three elements in the serum which are accounted for are the sodium, BUN and glucose. In contrast to this calculated formula, the actual measured serum osmolality also takes into account other substances in the patient's blood which could also affect the serum osmolality. Substances that classically elevate the measured serum osmolality (which are not part of the calculated osmolality) include the alcohols (i.e., ethanol, methanol, ethylene glycol and isopropyl alcohol). Thus a patient who has ingested one of the alcohols will typically exhibit an elevated measured serum osmolality despite a normal calculated serum osmolality.

The serum osmolar gap (measured serum osmolarity minus the calculated serum osmolarity) should be <5-10 mosm/Liter. The calculated osmolar gap is also valuable in that it can also be used to predict a patient's blood ethanol level via the formula:

[serum osmolar gap] x [4.6] = blood ethanol level in units of mg/dL

The 4.6 is a constant based on the density of ethanol. This factor will differ if the alcohol involved is something else such as ethylene glycol or methanol.

The mainstay to the treatment of the majority of poisoning cases involves supportive care and continued reassessment of the patient's airway, breathing and circulatory status. Although the majority of poisoning cases do not require any specific antidotes, some of the common toxins with antidotes are: acetaminophen (N-acetylcysteine), benzodiazepines (flumazenil), calcium channel blockers (calcium chloride), carbon monoxide (oxygen), cholinergics (atropine +/- pralidoxime), cyanide (cyanide antidote kit), cyclic antidepressants (sodium bicarbonate), digoxin (digoxin immune Fab antibodies), ethylene glycol or methanol (fomepizole), iron (deferoxamine), methemoglobinemia (methylene blue), opiates (naloxone), phenothiazine induced dystonic reactions (diphenhydramine), salicylates (sodium bicarbonate).

Because the majority of pediatric nonintentional ingestions typically do not involve highly toxic substances and/or large amounts, the majority of children who present to the emergency department with an accidental overdose can be safely discharged after a thorough assessment and an adequate period of observation. Hospitalization should be considered for the following situations:
. . . . . a) Severe signs and symptoms upon presentation to the emergency department.
. . . . . b) Unstable or abnormal vital signs.
. . . . . c) A potentially severe ingestion based on the identity or potential toxic dose of the ingested substance.
. . . . . d) Intentional overdoses.

Since prevention is the best method of reducing accidental poisoning in children, physicians should routinely incorporate poison prevention guidelines/tips into their healthcare maintenance discussions with their parents. Some of these points are listed below:
. . . . . a) Keep the phone number of your local poison control center near the telephone.
. . . . . b) If you suspect a poisoning, call the poison control center immediately for advice rather than waiting for your child to develop signs and symptoms of toxicity.
. . . . . c) If you suspect a poisoning, never induce vomiting. Call the poison control center immediately for advice.
. . . . . d) Store all medications and household products out of reach and out of sight (and preferably locked up).
. . . . . e) Never refer to medicines as "candy," since a child may then try to eat more of the "candy," when you are least expecting them to.
. . . . . f) Child resistant caps should be closed properly and remember that these types of caps are only child resistant and not "child proof".
. . . . . g) Avoid transferring/storing household cleaning products, pesticides and automotive fluids in unmarked bottles or containers which could be mistaken for a beverage and consumed by unsuspecting child.


1. The majority of accidental ingestions in the pediatric population occur in which age group?
. . . . . a. 6 months to 1 year of age.
. . . . . b. 18 months to 3 years of age.
. . . . . c. 4 years to 6 years of age.
. . . . . d. 8 years to 12 years of age.

2. The most common route of toxic exposures is via:
. . . . . a. Inhalation.
. . . . . b. Dermal contact.
. . . . . c. Bites and stings.
. . . . . d. Ingestion.
. . . . . e. Ocular contact.

3. A mother of a 2 year old boy calls you because she suspects that her son may have eaten a few of his grandmother's "heart pills." She claims that her son seems fine and that the possible ingestion may have occurred 30 minutes ago. What is the best action for you to take as the child's pediatrician?
. . . . . a. Have the mother induce vomiting immediately by sticking her finger in the child's mouth.
. . . . . b. Immediately give the child eight ounces of water or milk to dilute the concentration of pills in his stomach.
. . . . . c. Have her administer ipecac syrup immediately in order to induce vomiting.
. . . . . d. Advise no interventions at the present time, but also advise her that if the child should begin to develop any symptoms to go to the emergency department for further treatment.
. . . . . e. Call you local poison control center immediately for advice.

4. The gastrointestinal decontamination method of choice for a child who presents to the emergency department with multiple episodes of vomiting two hours after ingesting a toxic amount of iron is:
. . . . . a. Syrup of ipecac.
. . . . . b. Orogastric lavage.
. . . . . c. Activated charcoal with sorbitol.
. . . . . d. Multiple doses of activated charcoal.
. . . . . e. Whole bowel irrigation.

5. A child with a suspected ingestion presents to the emergency department with delirium, tachycardia, mydriasis, dry mucus membranes and warm/dry skin. This child exhibits signs and symptoms of which toxidrome?
. . . . . a. Anticholinergic.
. . . . . b. Sympathomimetic.
. . . . . c. Cholinergic.
. . . . . d. Opioid.
. . . . . e. Sedative hypnotic.

6. A parent suspects that her 18 month old son may have accidentally ingested a few pellets of rat poison. The mother should:
. . . . . a. Not panic and simply wait to see if her son develops any signs and symptoms of toxicity before calling her pediatrician.
. . . . . b. Call 911 immediately since this may be a medical emergency.
. . . . . c. Call her local poison control center immediately for advice, rather than waiting to see if her son will develop signs and symptoms of toxicity.
. . . . . d. Induce vomiting by giving her son a teaspoon of ipecac syrup.
. . . . . e. Rush her son to the nearest emergency department for immediate gastric lavage and activated charcoal.

7. Activated charcoal would NOT be an effective method of gastrointestinal decontamination for which one of the following ingestions?
. . . . . a. Albuterol.
. . . . . b. Ferrous sulfate.
. . . . . c. Amoxicillin.
. . . . . d. Carbamazepine.
. . . . . e. Phenobarbital.


1. Litovitz TL, Klein-Schwartz W, White S, et al. 2000 annual report of the American Association of Poison Control Centers Toxic Surveillance System. Am J Emerg Med 2001;9(5):337-395.

2. Inaba AS: The "Hawaii Five-O" rule for IV dextrose. Contemp Pediatr 1999;16(10):189.

3. Inaba AS. Clinical pearls in pediatric toxicology: A systematic approach to the poisoned child. Hawaii Med J 1998;57:445-449.

4. Emery D, Singer JI. Highly toxic ingestions for toddlers: When a pill can kill. Pediatr Emerg Med Report 1998;3(12):111-122.

5. Inaba AS. Vital signs. Emerg Med 2001;33(5):76.

6. Poison treatment in the home. Abstract from the American Academy of Pediatrics Committee on Injury and Poison Prevention, July 2001.

7. Inaba AS. "CHEMICaL CamP." Emerg Med 1992;24(4):191.

8. Inaba AS. "Toxicologic teasers:" Testing your knowledge of clinical toxicology. Hawaii Med J 1998;57:471-473.

9. Liebelt EL, De Angelis CD. Evolving trends and treatment advances in pediatric poisoning. JAMA 1999;282:1113-1115.

10. McGuigan MA. Activated charcoal in the home. Clin Pediatr Emerg Med 2000;1:191-194.

11. Erickson TB, Aks SE, et al. Toxicology updates: A rational approach to managing the poisoned patient. Emerg Med Practice 2001;3(8):1-28.

12. Kulig KW, Barkin RA. Chapter 54 - Poisoning and Overdose: Management Principles. In: Barkin RA, Rosen P (eds). Emergency Pediatrics: A Guide to Ambulatory Care, fifth edition. 1994, St. Louis: Mosby, pp. 347-361.

13. Dart RC. The 5 Minute Toxicology Consult. 2000, Philadelphia: Lippincott Williams & Wilkins.

14. Olson KR. Poison & Drug Overdose, third edition. 1999, Stamford: Appleton & Lange.

15. Goldfrank LR. Toxicologic Emergencies, fifth edition. 1994, Norwalk: Appleton & Lange.

16. Bryson PD. Comprehensive Review in Toxicology for Emergency Clinicians, third edition. 1996, Washington DC: Taylor & Francis.

Answers to questions 1.b, 2.d, 3.e, 4.e, 5.a, 6.c, 7.b

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