Poisoning in Pediatrics

Practical Guide

The initial management of any poisoned pediatric patient follows the pediatric advanced life support (PALS/APLS) sequence. The goal is to stabilize the patient before identifying the specific toxicant.

  • A (Airway): Ensure airway patency. Consider the need for aspiration of secretions or orotracheal intubation if there is compromised state of consciousness (Glasgow < 8), respiratory failure or risk of aspiration.
  • B (Breathing): Assess respiratory rate, effort, auscultation, and pulse oximetry. Administer supplemental oxygen. Be alert for signs of respiratory depression (opioids, benzodiazepines) or hyperventilation (salicylates, metabolic toxins).
  • C (Circulation): Assess heart rate, pulse, blood pressure, and peripheral perfusion. Obtain intravenous access. Initiate fluid resuscitation with crystalloids if there are signs of hypoperfusion. Perform a 12-lead electrocardiogram (ECG) to look for arrhythmias, QRS widening, or QT prolongation.
  • D (Disability): Perform a rapid neurological evaluation: Glasgow Coma Scale, pupil size and reactivity, and level of consciousness. Measure capillary blood glucose in all patients with altered mental status.
  • E (Exposure): Completely undress the patient to look for transdermal patches, signs of trauma, skin lesions, or contamination. Monitor temperature to detect hyperthermia or hypothermia.

Once the patient is stabilized, the history and physical examination are crucial. The toxidromes They are sets of signs and symptoms that suggest a specific class of toxicant.

Key anamnesis: What?, How much?, When?, How?, Why? (accidental vs. intentional). Check history, usual medication and look for empty containers.

Display of Common Toxidromes

Sign cholinergic Anticholinergic Opioid Sympathomimetic
FurDiaphoreticdry, redNormalDiaphoretic
PupilsMiosisMydriasisMiosisMydriasis
Intest noises.HyperactiveHypoactiveHypoactiveHyperactive
FC/TABradycardiaTachycardiaBradycardiaTachycardia, HTN
CNSConfusion, comaAgitation, deliriumCNS depressionAgitation, psychosis

Gastrointestinal Decontamination

Its use is selective and increasingly restricted. The decision must be individualized.

  • Activated Charcoal (Single Dose): 1 g/kg (max 50 g). More effective if administered in the first hour after ingestion. It binds to many substances, preventing their absorption.
    Contraindications: Unprotected airway, ingestion of caustics, hydrocarbons, heavy metals (iron, lithium), alcohols, or if endoscopy or use of oral antidotes (N-acetylcysteine) is planned.
  • Gastric lavage: Rarely indicated. Consider only in the first hour of a potentially lethal ingestion of a substance not absorbable by activated charcoal.
    Risks: Aspiration pneumonitis, esophageal/gastric perforation, hypoxia, arrhythmias.
  • Total Intestinal Irrigation: With polyethylene glycol. For massive intakes of iron, lithium, "body packers" or sustained release drugs.

External Decontamination

  • Dermal: Remove all contaminated clothing. Irrigate the skin with plenty of soap and water. Health personnel must use protective equipment.
  • Ocular: Irrigate the affected eye with saline or water for at least 15-20 minutes, ensuring the eyelids open.

The use of antidotes is specific for certain toxins. Knowing the indications and dosage is essential.

Toxic Antidote Key Pediatric Indication/Dose
Paracetamol/Acetaminophen N-Acetylcysteine ​​(NAC) IV loading dose: 150 mg/kg in 1 hour. Follow 9pm protocol.
Opioids Naloxone 0.1 mg/kg/dose IV/IM (max 2 mg). Repeat according to answer.
Benzodiazepines Flumazenil Controversial use. Risk of seizures! 0.01 mg/kg IV (max 0.2 mg).
Iron Deferoxamine Shock, metabolic acidosis, lethargy. 15 mg/kg/h IV.
Methanol / Ethylene Glycol Fomepizole or Ethanol Fomepizole: Load 15 mg/kg, then 10 mg/kg every 12 hours.
Anticholinergics Physostigmine Arrhythmias or severe agitation. 0.02 mg/kg slow IV (max 0.5 mg).
Digoxin Anti-digoxin Fab antibodies Lethal arrhythmias, severe hyperkalemia. Dosage according to intake or levels.

It is one of the most common and potentially serious poisonings due to its hepatotoxicity. The acute toxic dose is >150 mg/kg.

Clinical Phases

  • Phase I (0-24h): Asymptomatic or mild symptoms (nausea, vomiting).
  • Phase II (24-72h): Apparent improvement. Elevation of transaminases begins. Pain in right hypochondrium.
  • Phase III (72-96h): Peak hepatotoxicity. Jaundice, coagulopathy, encephalopathy, liver failure.
  • Phase IV (>96h): Recovery or progression to transplant/death.

Management

The key is the use of for acute intakes. Paracetamol levels should be measured at 4 hours post-ingestion (or as soon as possible after 4 hours).

If the plasma level is above the treatment line, it is indicated to start the antidote: N-Acetylcysteine ​​(NAC). Start NAC empirically if there is doubt about the time of intake, if it is massive, or if levels will not be available in time.

Key point! The nomogram is NOT useful for repeated/chronic or extended-release ingestions. In these cases, NAC is indicated if levels are >10 mcg/mL or there is evidence of hepatotoxicity.

1. A 3-year-old patient arrives at the emergency room with miosis, bradycardia, diaphoresis and wheezing. Which toxidrome is most likely?

2. What is the main contraindication for administering activated charcoal?

3. From what time after acute paracetamol ingestion is the Rumack-Matthew nomogram useful?

4. The antidote for opioid poisoning is:

5. What measure is essential in the management of a comatose patient (Glasgow < 8) due to poisoning?

  • American Academy of Pediatrics. Pediatric Education for Prehospital Professionals (PEPP), 4th Edition. Jones & Bartlett Learning; 2021.
  • Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, PA: Saunders Elsevier; 2007.
  • Protocols of the Spanish Association of Pediatrics (AEPED). Intoxications. Accessible at: www.aeped.es/protocolos/.
  • Nelson LS, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. Goldfrank's Toxicologic Emergencies, 11th Edition. McGraw-Hill Education; 2019.
  • Yarema M, Green JP, Wax P, et al. The Toxicology Investigators Consortium (ToxIC): A decade of progress. J Med Toxicol. 2021;17(4):341-354.
  • Meehan TJ. Approach to the poisoned child. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on June 2025).