Toxic Ingestion (Pediatric)

Key considerations: Lethal in one pill/dose: calcium channel blockers, beta-blockers, opioids, sulfonylureas, TCAs, clonidine, Button battery ingestion, Iron toxicity

Cannot miss

Lethal in one pill/dose: calcium channel blockers, beta-blockers, opioids, sulfonylureas, TCAs, clonidine
Button battery ingestion
Iron toxicity

Likely diagnoses

Accidental ingestion (most common <5yr)
Intentional ingestion (adolescent)
Medication error

Red flags

Altered mental status
Seizures
Arrhythmia
Respiratory depression
Metabolic acidosis

Workup

history: What, when, how much, any coingestants, time of ingestion, pill count; exam: Vital signs, pupil exam, mental status, toxidromes; labs: Glucose, BMP, VBG/ABG, acetaminophen level, salicylate level, ECG; Specific levels as indicated (iron, lithium, digoxin, etc.); imaging: KUB for iron, lead, or enteric-coated tablets; bedside: Continuous monitoring, ECG

Management

immediate: ABCs — secure airway if altered mental status; Activated charcoal if within 1 hour and intact airway (NOT for caustics, metals, hydrocarbons); Specific antidotes: NAC (acetaminophen), naloxone (opioids), atropine (organophosphates); general: Poison control consultation: 1-800-222-1222; Whole bowel irrigation for iron, sustained release, or body packers; Observation time depends on agent — some have delayed toxicity

Disposition

admit: Any symptomatic ingestion, high-risk agent, suicidal intent; Observation: minimum 4-6 hours for most agents, 24hr for sustained release; discharge: Asymptomatic after appropriate observation period with poison control guidance; consults: Poison control, toxicology, psychiatry if intentional

Clinical pearls

One pill can kill a toddler: calcium channel blockers, opioids, sulfonylureas, TCAs, clonidine, camphor
Button battery in esophagus = surgical emergency (tissue necrosis within 2 hours)
Always get acetaminophen and salicylate levels in ANY intentional ingestion — they are common co-ingestants

Source and review

AAP Poison Prevention 2023. Last reviewed: 2024-11-01