Summary
Definition
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 misuse
- 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 tests
1st tests 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
Tests to avoid
- hair or nail testing
Tests 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
asymptomatic
symptomatic and/or high-risk ingestion and/or elevated drug levels
Contributors
Authors
David L. Eldridge, MD
Associate Professor of Pediatrics
Senior Associate Dean of Academic Affairs
Brody School of Medicine at East Carolina University
Greenville
NC
Disclosures
DLE has received research grants and been a site investigator for a closed clinical trial from GlaxoSmithKline and a closed clinical trial from Cempra Pharmaceuticals. DLE is an author of two of the references cited in this topic.
Matthew R. Ledoux, MD
Chair, Department of Pediatrics
Pediatrician in Chief Maynard Children's Hospital
Associate Professor of Pediatrics
Maynard Distinguished Scholar of Pediatrics
Brody School of Medicine at East Carolina University
ECU Health
Greenville
NC
Divulgaciones
MRL declares that he has no competing interests.
Agradecimientos
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.
Divulgaciones
CKA and KMB declare that they have no competing interests.
Revisores por pares
Laurie Prescott, MD, FRCP
Emeritus Professor of Clinical Pharmacology
Faculty of Medicine
University of Edinburgh
Edinburgh
UK
Divulgaciones
LP declares that he has no competing interests.
Mark Mannenbach, MD
Consultant in Pediatric Emergency Medicine
Assistant Professor of Pediatric and Adolescent Medicine
Mayo Clinic College of Medicine
Rochester
MN
Divulgaciones
MM declares that he has no competing interests.
Colin A. Graham, MBChB, MPH, MD, FRCSEd, FRCSGlasg, FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM
Editor
European Journal of Emergency Medicine
Professor of Emergency Medicine
Chinese University of Hong Kong
Hong Kong
People's Republic of China
Divulgaciones
CAG is the editor of the European Journal of Emergency Medicine and receives an annual honorarium from Wolters Kluwer Health, the journal's publishers.
Agradecimiento de los revisores por pares
Los temas de BMJ Best Practice se actualizan de forma continua de acuerdo con los desarrollos en la evidencia y en las guías. Los revisores por pares listados aquí han revisado el contenido al menos una vez durante la historia del tema.
Divulgaciones
Las afiliaciones y divulgaciones de los revisores por pares se refieren al momento de la revisión.
Referencias
Artículos principales
Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. N Engl J Med. 2020 Apr 30;382(18):1739-48.
McKay C. Can the laboratory help me? Toxicology laboratory testing in the possibly poisoned pediatric patient. Clin Pedi EM. 2005;6:116-22.
Dart RC, Goldfrank LR, Erstad BL, et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018 Mar;71(3):314-25.e1.Texto completo Resumen
Royal College of Emergency Medicine. College of Emergency Medicine and National Poisons Information Service guideline on antidote availability for emergency departments, 2021 update. Dec 2021 [internet publication].Texto completo
American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position paper: single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61-87.Texto completo Resumen
Artículos de referencia
Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.
Diferenciales
- Nontoxic causes of wide complex tachycardia
- Nontoxic causes of status epilepticus
- Nontoxic causes of anion gap metabolic acidosis
Más DiferencialesGuías de práctica clínica
- Expert consensus for a national essential antidote list: e-Delphi method
- Guideline on antidote availability for emergency departments
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