The Poisoned Pediatric Patient.

Abstract

1. Michael S. Toce, MD, MS* 2. Michele M. Burns, MD, MPH*,† 1. *Harvard Medical Toxicology Program and 2. †Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Boston, MA * Abbreviations: AGMA: : anion gap metabolic acidosis ALT: : alanine aminotransferase APAP: : acetaminophen ASA: : acetylsalicylic acid AST: : aspartate aminotransferase Cl-: : chloride ECG: : electrocardiogram GI: : gastrointestinal GSH: : glutathione HCO3−: : bicarbonate IV: : intravenous K+: : potassium NAC: : N-acetylcysteine NAPQI: : N-acetyl-p-benzoquinoneimine NPDS: : National Poison Data System PO: : oral Poisonings remain a frequent source of morbidity and mortality in the pediatric age group. All pediatricians, whether in training or in practice, encounter these patients, yet toxicologic training is lacking in most pediatric residencies. After completing this article, readers should be able to: 1. Understand the epidemiology of pediatric poisonings and explain how developmental milestones influence behavior that may lead to a poisoning exposure. 2. Perform a focused toxicologic physical examination and describe the various toxidromes. 3. Explain the primary acid-base disturbance in salicylate toxicity. 4. Determine which patient requires treatment after acute acetaminophen ingestion. 5. Provide the differential diagnosis of an anion gap metabolic acidosis. 6. Identify which drugs can lead to QRS and QTc prolongation and the treatment for each abnormality. 7. Describe the toxicologic differential diagnosis for hypoglycemia and explain the physiologic reasons why pediatric patients are at increased risk for complications. This review focuses on the epidemiology and initial evaluation and treatment of the poisoned pediatric patient. We emphasize the diagnosis and treatment of acetaminophen and aspirin toxicity, identifying and treating prolonged QRS/QTc, and developing a differential diagnosis for an anion gap metabolic acidosis (AGMA) and hypoglycemia (Table 1). View this table: Table 1. Introduction to the Poisoned Patient Pediatric exposures and poisonings continue to be a significant cause of morbidity and mortality. According to the 2014 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS), 1,326,789 toxic exposures occurred in children younger than age 20 years in 2014, representing 1,595 exposures per 100,000 …