Last reviewed: 9 Apr 2021
Last updated: 16 Mar 2021



History and exam

Key diagnostic factors

  • medication error in infants
  • witnessed ingestion or child found with empty bottle or pill
  • history of deliberate ingestion
  • history of substance abuse
  • sympathomimetic toxidrome
  • antimuscarinic toxidrome
  • opioid toxidrome
  • sedative-hypnotic toxidrome
  • cholinergic toxidrome

Other diagnostic factors

  • nausea, vomiting, or diarrhea
  • altered mental status
  • fever or hyperthermia
  • staining or burns of the mouth and oropharynx
  • hypertension or hypotension
  • hyperventilation or hypoventilation
  • seizures
  • blindness or reduced vision
  • reduced hearing or tinnitus
  • reddened skin coloration
  • symptoms and signs of hypoglycemia
  • jaundice
  • hyperreflexia and myoclonus
  • muscle rigidity
  • nystagmus
  • ataxia
  • stridor

Risk factors

  • presence of medications in the household
  • easy access to medications or household chemicals
  • young age
  • pica
  • emotional stress
  • history of depression or other mental illness
  • female sex
  • family history of alcohol use disorder

Diagnostic investigations

1st investigations to order

  • serum electrolytes
  • serum BUN
  • serum creatinine
  • fingerstick or serum glucose
  • capillary blood gas or ABG
  • anion gap
  • serum lactate
  • serum ketones or acetone
  • INR
  • LFTs
  • serum acetaminophen levels
  • serum salicylate levels
  • urine drug screen
  • urinalysis
  • ECG
  • pregnancy test
  • serum creatine kinase
  • abdominal x-ray
  • chest x-ray

Investigations to consider

  • ethanol level
  • serum methanol or ethylene glycol
  • serum digoxin level
  • serum anticonvulsant levels
  • serum iron levels
  • serum lithium, theophylline, or whole blood heavy metal levels
  • comprehensive urine drug screen
  • therapeutic trial of naloxone
  • therapeutic trial of sodium bicarbonate
  • therapeutic trial of atropine and pralidoxime
  • therapeutic trial of flumazenil
  • therapeutic trial of octreotide
  • therapeutic trial of physostigmine

Treatment algorithm


Associate Professor

Clerkship Director

Department of Pediatrics

Brody School of Medicine at East Carolina University




DLE has received research grants and been a site investigator for an ongoing clinical trial from GlaxoSmithKline and a closed clinical trial from Cempra Pharmaceuticals. DLE is an author of one reference cited in this topic.

Associate Professor of Pediatrics

Vice Chair of Pediatrics

Co-Medical Director, Maynard Children’s Hospital, Vidant Medical Center

Division Chief, Division of Pediatric Critical Care and Hospital Medicine

Department of Pediatrics

Brody School of Medicine at East Carolina University




MRL declares that he has no competing interests.

Dr David Eldridge and Dr Matthew Ledoux would like to gratefully acknowledge Dr Cynthia K. Aaron and Dr Keenan M. Bora, previous contributors to this topic.


CKA and KMB declare that they have no competing interests.

Peer reviewersVIEW ALL

Emeritus Professor of Clinical Pharmacology

Faculty of Medicine

University of Edinburgh




LP declares that he has no competing interests.

Consultant in Pediatric Emergency Medicine

Assistant Professor of Pediatric and Adolescent Medicine

Mayo Clinic College of Medicine




MM declares that he has no competing interests.


European Journal of Emergency Medicine

Professor of Emergency Medicine

Chinese University of Hong Kong

Hong Kong

People's Republic of China


CAG is the editor of the European Journal of Emergency Medicine and receives an annual honorarium from Wolters Kluwer Health, the journal's publishers.

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