History and exam
Key diagnostic factors
common
medication error in infants
In children who are immobile and not yet crawling or walking, the ingestion is usually an accidental medication error by a carer. The carer is usually aware of the error.
witnessed ingestion or child found with empty bottle or pill
Medications that look like sweets or familiar objects may be ingested when the carer is distracted for a brief period.
Children may ingest objects found in a family member's handbag, behind the couch, or other places within the home. Older children can climb and find medications that are put up high, or accidentally ingest substances that have been placed in their non-original containers (e.g., chemicals in soda bottles).
Medical help is usually sought immediately if the ingestion was witnessed, involved a chemical ingestant (which causes crying and physical clues), or the child was found with the bottle or a pill in his or her mouth.
history of deliberate ingestion
This is usually as a cry for help, and the child will tell a friend or supervisory adult and present immediately. Girls are more likely than boys to consider self-harm.[11]
The substance is usually easier to identify from the history and is most likely to be a medication that is either present in the house or that can be easily purchased without a prescription. A readily available chemical in the garage, attic, or store may also be ingested.
history of substance misuse
Substance misuse should be suspected if the following features are present: a child who comes home late, has been partying, or is with friends that parents do not know or parents are uncomfortable with; a recent deterioration in school work; forgetfulness or secretive behaviour, or a sudden change of friends; absent-minded behaviour on returning home; somnolence, or hallucinations; talking about substances that are unknown to the parent, or 'pharm parties', 'bowl parties', and 'trail mix'.
sympathomimetic toxidrome
Symptoms include metabolic overdrive with hypertension, tachycardia, tachypnoea, hyperthermia, agitation, seizures, and mydriasis.
The presence of this toxidrome suggests ingestion of alpha agonists, beta agonists, amfetamines/psychostimulants, tricyclic antidepressants, or monoamine oxidase inhibitors (MAOIs).
antimuscarinic toxidrome
Symptoms include hypertension (not as marked as sympathomimetic toxidrome), tachycardia, hyperthermia, mydriasis, flushed red skin, urinary retention, absent bowel sounds, loss of sweating, agitation to sedation, and seizures.
Suggests ingestion of an antimuscarinic agent such as diphenhydramine.
opioid toxidrome
Symptoms include miosis, bradypnoea and hypopnoea, absent bowel sounds, and coma. Bradycardia and hypotension may also be present.
sedative-hypnotic toxidrome
Patients have coma or depressed mental status with relatively normal vital signs, and tend to be poikilothermic and become mildly hypothermic.
Suggests ingestion of a benzodiazepine, barbiturate, or ethanol.
cholinergic toxidrome
Features are predominantly due to muscarinic stimulation with increased secretions (oral, bronchial, tears, vomiting, diarrhoea), bradycardia, hypotension, small pupils, and mental status changes.
Nicotinic stimulation may also occur, producing tachycardia, hypertension, respiratory depression and paralysis, muscle fasciculations, or seizures.
Some children may not show many muscarinic findings but be floppy and limp with an altered mental status.
Suggests anticholinesterase toxicity (e.g., organophosphate poisoning).
Other diagnostic factors
common
nausea, vomiting, or diarrhoea
Non-specific symptoms that may be present with many toxic ingestions. Most plant and mushroom ingestions also produce these symptoms.
If the ingestion is not witnessed or the child does not tell anyone about the poison ingested or overdose, they may not present until symptoms appear, which may be presumed to be due to other illnesses. Toxic ingestions should therefore be considered in the differential of these symptoms.
altered mental status
A non-specific symptom that may be present with any toxic ingestion that affects the central nervous system, either directly or indirectly.
If the ingestion is not witnessed or the child does not tell anyone about the poison ingested or overdose, they may not present until symptoms appear, which may be presumed to be due to other illnesses. Toxic ingestions should therefore be considered in the differential of altered mental status.
fever or hyperthermia
A non-specific symptom that may be present with any toxic ingestion that leads to rigidity or muscular hyperactivity. Generally regarded as a poor prognostic sign.
Fever may be present in a range of poisonings. Hyperthermia indicates poisoning with sympathomimetics, antimuscarinics, or agents that affect cellular respiration, such as salicylates. It may also be seen in serotonin syndrome or neuroleptic malignant syndrome.
staining or burns of the mouth and oropharynx
Suggests ingestion of a chemical. Burns suggest ingestion of an acid or alkali. Odours may also be present.
hypertension or hypotension
Hypertension suggests poisoning with sympathomimetics or antimuscarinics.
Hypotension with bradycardia suggests poisoning with beta-blockers, calcium-channel blockers, alpha-2 agonists, or digoxin. Calcium-channel blockers produce peripheral vasodilation and warm extremities, whereas beta-blockers produce peripheral vasoconstriction with cold extremities.
hyperventilation or hypoventilation
Hypoventilation suggests poisoning with opioids or alpha-2 agonists.
Hyperventilation suggests poisoning with salicylates, uncouplers of oxidative phosphorylation (e.g., cyanide), or substances that cause metabolic acidosis (e.g., salicylates or toxic alcohols). The changes in respiratory rate and depth that suggest salicylate intoxication are often subtle and easily missed.
uncommon
seizures
May be caused by a range of drugs, including sympathomimetics, antimuscarinics, antidepressants, cholinergics (including cholinesterase inhibitors), propranolol, isoniazid, theophylline, or some opioids such as tramadol or pethidine.
May also be caused by Gyromitra mushroom ingestion.
blindness or reduced vision
Suggests poisoning with methanol, quinine, chloroquine, or hydroxychloroquine.
reduced hearing or tinnitus
Suggests poisoning with salicylates, loop diuretics, aminoglycosides, opioids, vancomycin, quinine, hydroxychloroquine, or chloroquine.
reddened skin coloration
Suggests poisoning with cyanide. Can also be seen following administration of hydroxycobalamin.
symptoms and signs of hypoglycaemia
Include nausea, confusion, tremor, sweating, palpitations, and hunger, and may indicate poisoning with insulin, sulfonylureas, beta-blockers, or severe salicylate poisoning.
jaundice
A late sign of paracetamol toxicity.
May also be present in obstructive jaundice due to therapeutic use of antibiotics or oral contraceptives.
hyperreflexia and myoclonus
Suggest serotonin syndrome. Causative agents include antidepressants (selective serotonin-reuptake inhibitors, venlafaxine, clomipramine, imipramine), opioids (pethidine, tramadol, fentanyl, dextromethorphan), MAOIs, amfetamines, lithium, and tryptophan.
muscle rigidity
Suggests poisoning with phenothiazines, atypical antipsychotics, antiemetics, or Parkinson's disease medications.
nystagmus
Suggests poisoning with dextromethorphan, ethanol, monoamine oxidase inhibitors, or selective serotonin-reuptake inhibitors.
ataxia
Suggests poisoning with any sedative hypnotic, antipsychotics, or anticonvulsants.
stridor
May occur in severe cases of chemical ingestion, due to swelling of the oropharynx.
Risk factors
strong
presence of medications in the household
A detailed history of all medications that might be present in the house should be obtained. Occasionally, a toxic ingestion may also occur from places a child visits, or if the child encounters spillages of medications taken by another household member on the carpet or floor.
easy access to medications or household chemicals
A toxic ingestion is more likely if medications or toxins are within easy reach and/or not in childproof containers.
Chemicals should be stored out of reach of children. Liquid chemicals should be stored in their original containers, because there are several beverages that may appear similar to toxic liquids (e.g., torch fuel and apple juice, ethylene glycol and neon-green drinks). Medications should be stored in a lockable box or behind a locked cabinet.
young age
Children between 12 months and 3 years old are in the exploratory phase and tend to put objects in their mouths. They also have a reduced capacity to distinguish medications and chemicals from beverages, food, or sweets.
pica
Pica is a medical disorder in which children develop an appetite for non-nutritive substances, which increases the risk of a toxic ingestion.
emotional stress
Many deliberate ingestions in children represent a cry for help prompted by what is perceived as an intolerable situation.
weak
history of depression or other mental illness
Rarely, suicidal ideation is present due to an underlying psychiatric condition.
female sex
Girls are more likely than boys to consider self-harm.[11]
family history of alcohol use disorder
Children of people with alcohol use disorder are more likely to abuse ethanol. It is unclear whether a similar trend exists for substance misuse.
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