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eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Deadly in a Single Dose

Cynthia L Morris-Kukoski, PharmD, Clinical Assistant Professor, Department of Pharmacy and Occupational Medicine, Medical College of Virginia
Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center

Updated: Apr 23, 2009

Introduction

Background

A wide variety of medications and substances can kill a toddler who ingests just a single dose. More than 1 million children ingest toxins in the United States every year, and more than 85% of the ingestions are unintentional. Most of the children are younger than 6 years.

The intent of this article is not to guide treatment of poisoned children but rather to report toxic ingestions that proved fatal in small doses. The article addresses some types of toxic ingestions and those that may cause serious illness or injury, even in small quantities.

Many of the involved toxins are common in the home or in household products. Ingestion of relatively small amounts of commonly used perfumes, cosmetics, cleaning solutions, alcoholic beverages, and other products may cause serious injury or death. Medications also are a common source of toxic ingestions in small quantities. Without taking prior precautions, visits to the homes of friends or relatives (even grandparents) or visits from guests who bring medications into the home may result in tragedy.

Pathophysiology

Pathophysiology varies according to the ingested substance. Children are particularly susceptible to injury from ingestion of small doses for the following reasons:

  • The low body mass of children means that a single ingested dose of a substance may easily be toxic.
  • While exploring their surroundings, younger children, especially toddlers, may ingest substances with objectionable tastes or odors that would be rejected by older children and adults.
  • The metabolic pathways of young children, particularly infants, are less developed and use sulfonation rather than glucuronidation to process some toxins.

Frequency

United States

Most ingestions by children involve nontoxic substances. More than 1 million ingestions are believed to occur annually, most involving children younger than 7 years.

Mortality/Morbidity

Mortality and morbidity depend on the substance or drug ingested and the quantity relative to body weight (ie, mg/kg/dose).

Race

Race and frequency of toxic ingestions appear to have no correlation.

Age

Toxic ingestions from a single dose occur most often as unintentional ingestions by young children aged 1-6 years.

Clinical

History

Most cases of deadly single-dose toxicity involve a history or suspicion of ingestion based on circumstances surrounding the child's illness. Some patients may present before developing significant symptoms. Patients may present in an obtunded state and without a clear history of ingestion. Elicit the following information:

  • What substance was ingested? If the substance was a medication, obtain the name and dosage. Specific identification may require retrieving the pill bottle or product container.
  • What are the ingredients of the ingested substance? Learning the product name or finding the container helps determine the specific ingredients and concentrations.
  • When was the substance ingested?
  • When did the patient last eat?
  • What is the patient's medical history?
  • Did anyone observe the ingestion? If so, ask to speak with the person who saw the incident because this may help determine the amount ingested.
  • Is the ingestion consistent with the history provided? If the history is inconsistent, the suspicion of abuse or neglect is raised, and the incident must be reported.

Physical

Physical examination results may range from normal to patients who present in an obtunded state or even in cardiopulmonary arrest. Some examination results may offer subtle specific clues regarding the type of ingestion.

  • Begin the examination by evaluating the patient's ABCs. Initiate appropriate interventions for any abnormalities.
  • Perform a complete physical examination, and record all vital signs.
  • Search for evidence of specific toxidromes.
  • Pay particular attention to neurologic examination results and changes, since this is a primary means of monitoring patients with toxic ingestions.

Causes

Ingestion of numerous common substances and drugs may be fatal in small doses. Many of the case reports listed below specify quantities; however, a significant number of young children have died from ingesting unknown quantities of a substance.

The Gosselin system classifies agents as extremely toxic when the probable lethal oral dose is 5-50 mg/kg and as supertoxic when the probable lethal oral dose is less than 5 mg/kg. The following list includes drugs and chemical agents classified as either extremely toxic or supertoxic, the quantities of each that are potentially fatal to children, and selected case studies.

  • Antidepressant drugs
    • Tricyclic antidepressants: A dose of 15-20 mg/kg is fatal.1,2,3
    • Desipramine: Two 75-mg tablets may be fatal.
      • A 3-year-old boy on long-term therapy using desipramine 100-mg tablets died within 47 hours postingestion after obtaining 2 or 3 extra tablets either from his own or a 6-year-old sibling's prescription.4
      • A 2-year-old boy ingested 1 desipramine 50-mg tablet and died a few hours postingestion.5
    • Imipramine: One 150-mg tablet can be fatal.
    • Monoamine oxidase inhibitors: Fatal ingestions have occurred with 4-mg/kg to 6-mg/kg doses.6 .
    • Amitriptyline: A 9-month-old girl was administered half of a 100-mg tablet to induce sleep. She arrived unresponsive at the emergency department (ED) 2-3 hours postingestion and died a few hours after admission.7
    • Amoxapine: The minimum fatal dose is 250 mg in children.8,9
  • Antimalarial drugs
    • Chloroquine: One 500-mg tablet can be fatal.
      • A 24-month-old boy was found with a single tablet in his hand. His respiratory system became compromised, and he required cardiopulmonary resuscitation (CPR) shortly thereafter. Life support was withdrawn 8 days postingestion.10
      • A 12-month-old boy who ingested 1 g was unresponsive 30 minutes postingestion and died within 3 days.11
    • Chloroquine phospate and primaquine (Aralen): A 12-month-old child was pronounced brain dead approximately 24 hours after ingesting 1 Aralen tablet and sucking the coating of 12 tablets.12
    • RTS,S/AS malaria vaccine: This is currently under investigation.13
  • Antipsychotic drugs
    • Thioridazine: One 200-mg tablet can be fatal.
    • Chlorpromazine: A 1-year-old child went into coma and respiratory arrest after ingesting 200 mg.14
    • Clozaril: A 2-year-old girl who weighed 10.5 kg was found chewing a single 100-mg clozapine tablet. She was brought to the ED an hour later after becoming ataxic. The girl died 16 days after ingestion from cardiac arrest secondary to respiratory failure.15
  • Cardiovascular drugs
    • Clonidine: Ingestion of 0.1 mg/kg may cause bradycardia, hypotension, respiratory depression, and apnea.
    • Lorcainide: Approximately 50 mg/kg can be fatal.16
    • Quinidine: Two 300-mg tablets can be fatal.
    • Verapamil: One or two 240-mg tablets can be fatal.
      • A 4-year-old boy who ingested 6-10 sustained-release tablets and 2-4 cold capsules (acetaminophen, chlorpheniramine, pseudoephedrine, dextromethorphan) went into cardiac arrest approximately 5 hours postingestion and died within 24 hours of admission.17
      • A 7-day-old boy inadvertently ingested 25 mg and died 20 hours postingestion.18
    • Disopyramide: A 2-year-old child ingested 600 mg and died 12 hours postingestion.19
    • Lidocaine: Ingestion of 1 oz of 2% viscous lidocaine solution was almost fatal in a 20-month-old girl.20
    • Nifedipine
      • A 14-month-old girl who ingested a single 10-mg capsule died 3 hours postingestion.21
      • An 11-month-old boy ingested four 10-mg capsules and died 2 days postingestion.22
      • A 14-month-old child ingested a single 10-mg capsule and died 4 hours postingestion.23
  • Drugs of abuse
    • Ibogaine: Approximately 29 mg/kg can be fatal.24
    • Lysergic acid diethylamide (more commonly known as LSD): A dose of 0.2 mg/kg is potentially fatal.9
    • p -Methoxyamphetamine: Ingestion of a single tablet is potentially fatal.
    • Nicotine: Ingestion of a single whole cigarette can be fatal. An 11-month-old girl was found dead at home. Autopsy revealed 5 undigested cigarettes and 1 tablet of diazepam.25
  • Miscellaneous drugs
    • Amantadine: Ingestion of more than approximately 30 mg/kg is potentially fatal.26
    • Colchicine: Ingestion of more than approximately 0.8 mg/kg is potentially fatal.9 An adult reportedly died after ingestion of a 0.31 mg/kg dose.27
    • Hypoglycemic agents
      • Sulfonylureas - Two 5-mg tablets of glyburide
      • Theophylline - A dose of 40-50 mg/kg or a single 500-mg tablet (may be fatal)
    • Albuterol: A 2-month-old child who received 6 times the recommended oral dose had a postmortem concentration of 31 mcg/L.19
    • Chloral hydrate
      • A 3-year-old girl received 10 mL (250 mg/5 mL) chloral hydrate for sedation prior to CT scanning. She arrived in the ED 45 minutes postingestion in cardiorespiratory arrest and died 45 minutes later.22
      • A 2-year-old child had a near fatal exposure after ingesting 250 mg.28
  • Opioid analgesic agents
    • Codeine may be fatal to a toddler who ingests three 60-mg tablets.29
    • Fentanyl patches have caused death in opioid-naive patients who have chewed or sucked on the patches or in those for whom the patches have been prescribed for acute pain.
    • Five or six tablets of diphenoxylate at 2.5 mg and atropine at 0.025 mg (Lomotil) may cause coma or respiratory depression.30
    • Methadone poisoning has been reported as follows:31
      • A 2-year-old boy who ingested approximately 12 mL (ie, 10 mg/mL) of his mother's methadone died within 3 days of presentation.25
      • A 5-year-old girl given a single 10-mg tablet to stop coughing died 6.5 hours postingestion.17
      • A 12-month-old boy who drank 1.5 oz of a bottle containing 35 mg of methadone in 8 oz of formula died approximately 24 hours postingestion.32
    • A 6-year-old girl on long-term imipramine therapy for attention deficit disorder was found dead in her home after her mother had given the child 15-20 mg to induce sleep.25
  • Nonprescription medications
    • Iron: Ten adult tablets is fatal in children.
    • Aspirin: A 3-year-old girl weighing 4.3 kg who ingested a total of 2400 mg died 12 days postingestion.18
    • Pseudoephedrine: A 2-year-old child was found dead after ingesting approximately seven 60-mg tablets.19
  • Topical preparations
    • Benzocaine - Two milliliters of 10% solution are fatal.
    • Camphor: Five milliliters (ie, 1 tsp) of 20% camphor oil or more than 50 mg/kg is a potentially lethal dose.9 A 19-month-old child ingested 5 mL of camphorated oil and died 5 days postingestion.33
    • Lindane: Two teaspoons (ie, 10 mL) or 6 mg/kg are fatal.34
    • Dibucaine poisoning has been reported as follows:
      • An 18-month-old girl who ingested approximately half of a 30-g tube (ie, 150 mg = 15 mg/kg) died 7 hours postingestion.15
      • A 17-month-old girl ingested approximately 22.5 g of ointment, developed cardiorespiratory arrest, and died approximately 4 hours postingestion.18
    • Less than 5 mL (ie, 1 tsp) of oil of wintergreen is a potentially fatal dose. Case reports of fatal ingestions of oil of wintergreen include a 2-year-old boy who ingested 7.5 mL,35 a 2-year-old girl who ingested 15 mL,5 and another 2-year-old girl who ingested 10 mL.17
  • Alcohols
    • Methanol - 15 mL of 40% solution9
    • Ethylene glycol - 1-1.5 mL/kg9
    • Isopropyl alcohol - 2-4 mL/kg of 70% solution9
    • Ethanol -1-2 oz of cologne9,36
  • Other chemical agents
    • Aniline: A 4.5-year-old child developed a blood methemoglobin (metHb) level of 77% at 13 hours after ingesting 5 mL of aniline. Although the child was treated successfully with an exchange transfusion, metHb levels exceeding 60% are considered life threatening.37
    • Arsenic: Two hundred milligrams may be deadly.38
    • Boric acid: A dose of 2-3 g may be deadly.39,40
    • Chloroform: Ten milliliters may be deadly.19
    • Hydrogen cyanide: Fifty milligrams may be deadly.38
    • Dimethylnitrosamine: A dose of 30 mg/kg may be deadly.41
    • Diquat: Ingestion of 20 mL of a 20% solution was fatal in a 2-year-old child.42
    • Methylene iodide: A 20-month-old girl who ingested 10-15 mL developed acute hepatic failure within 2 days and died 9 days postingestion.18
    • Elemental yellow phosphorus: A dose of 1 mg/kg is deadly.9
    • Sodium monofluoroacetate (Compound 1080): Three to 7 mg/kg is a potentially fatal dose. Thirteen to 14 mg/kg of Compound 1081 is a potentially fatal dose.9
    • Sodium fluoroacetate: A dose of 2-10 mg/kg is deadly.38
    • Paraldehyde: A single fatality has been reported with a 25-mL dose.9
    • Paraquat: A dose of 25-50 mg/kg is deadly.9
    • Pentachlorophenol: A 2-g dose is potentially fatal in adults.9,19
    • Selenious acid (a component of gun bluing with copper sulfate and nitric acid): A single swallow may be fatal.
      • A 22-month-old boy ingested 15 mL of gun-bluing solution. He was unresponsive upon arrival at an ED 3 hours after ingestion and died after lengthy unsuccessful CPR.43
      • A 30-month-old boy who ingested less than 1 oz of gun-bluing solution was unconscious when the ambulance arrived 10 minutes postingestion. He died less than 90 minutes after arrival at an ED.17
    • Strychnine: A dose of 5-8 mg/kg is deadly.38,9
    • Tetrachlorodibenzo -p- dioxin: A dose of 0.1 mcg/kg is potentially fatal.9
    • Thallium: A dose of 12-15 mg/kg is deadly.38,9
    • Pyriminyl (Vacor): A dose of 5 mg/kg is deadly.9
    • Xylene: A dose of 15 mL can be deadly.19
    • Zinc phosphide: A dose of 10 mg/kg is deadly.9
  • Hydrocarbons
    • Kerosene and gasoline: A single mouthful may be fatal if aspirated.
    • Aliphatic hydrocarbon: An 18-month-old boy who ingested/aspirated a mouthful of saddle dressing died 20 days postingestion.18
    • Lighter fluid: A 14-month-old boy ingested/aspirated a mouthful of lamp oil and died.44
    • Motor oil: A 15-month-old boy who ingested/aspirated one swallow of motor oil died 51 days postingestion.44
    • Mineral oil and mineral spirits: A 2-year-old girl ingested/aspirated 15-30 mL of hair weaving remover (ie, 20% mineral oil, 30% mineral spirits) and died 2 days postingestion.22 A 3-year-old boy who ingested/aspirated "a couple of swallows" of fabric protector containing mineral spirits died 19 days postingestion.5
  • Plants and natural toxins
    • Amatoxin (ie, mushroom): A dose of 0.1 mg/kg is potentially fatal.9
    • Amygdalin is a cyanogenic glycoside (toxicity or death occurs secondary to cyanide ingestion): In separate case reports, 2 of 945 and 1 of 846 intoxicated children died after eating apricot seeds.
    • Botulism toxin: Fifty nanograms or 0.1 mL of contaminated food can be fatal.38
    • Castor beans (ie, ricin): One milligram per kilogram or approximately 8 seeds can be fatal.9
    • Pennyroyal: A 12-week-old boy with a history of rhinorrhea and mild cough was administered 4 oz of tea made from 3-4 pennyroyal leaves. The child developed fulminant hepatotoxicity and died within 2.5 days postingestion.4

Differential Diagnoses

Acidosis, Metabolic
Toxicity, Ethanol
Alkalosis, Metabolic
Toxicity, Hydrocarbons
Child Abuse & Neglect: Physical Abuse
Toxicity, Isoniazid
Shock
Toxicity, Oral Hypoglycemic Agents
Toxicity, Calcium Channel Blocker
Toxicity, Theophylline
Toxicity, Carbamazepine
Toxicity, Tricyclic Antidepressant
Toxicity, Carbon Monoxide
Toxicity, Digitalis

Workup

Laboratory Studies

  • Order laboratory studies directed to the specific ingestion.
  • Consider specific symptoms related to the ingestion or to the patient's preexisting medical conditions, if any.

Imaging Studies

  • Radiography may help in specific ingestion cases. For example, in iron ingestion, radiopaque tablets may be visible in the GI tract. Other radiopaque substances include heavy metals, iodine, phenothiazines, enteric-coated tablets, and chloral hydrate.

Other Tests

  • Perform an electrocardiogram in patients with known or suspected tricyclic antidepressant ingestion to look for a prolongation of the QRS interval of greater than 100 milliseconds.

Treatment

Medical Care

Immediate care should include the ABCs, plus 2 D 's: disability (ie, neurologic examination) and decontamination (ie, gastric decontamination). ABC procedures should follow standard Pediatric Advanced Life Support (PALS) and Advanced Pediatric Life Support (APLS) guidelines.

Perform gastric decontamination for all serious ingestions.

  • Perform gastric lavage in patients with life-threatening ingestions who present early (ie, generally, <1 h following ingestion). Beyond 1 hour, much of the toxin has already passed into the small intestine. Take special care to protect the patient's airway during gastric lavage. Protective measures may include intubation, particularly in comatose patients and patients with a decreased or absent gag reflex.
  • Gastric decontamination with activated charcoal is highly recommended. The dosage is 1 g/kg of body weight. Charcoal may be administered mixed with juice or soda if the child can drink from a cup. Administration often requires placing a nasogastric tube because the charcoal's gritty texture is not palatable to most children.
  • Whole bowel irrigation is effective in patients with certain ingestions who present too late for effective gastric lavage.

Consultations

  • Always consult the regional poison control center.
    • Locate the nearest US poison control center by contacting the American Association of Poison Control Centers at 1-800-222-1222.
    • In addition to providing advice on management and specific treatment or antidotes, poison control centers have on-call toxicologists available for physician consultations.
    • Data on toxic ingestions are compiled through reports to the poison control centers; these data improve treatment of future patients with similar ingestions.
  • The need for additional medical consultation depends on the nature of the ingestion and the toxicity of the substance.

Medication

  • Medical therapy is directed to the specific ingestion. Certain antidotes are well described for ingestion of a number of toxic substances.
  • Provide supportive therapy for patients with other ingestions, based on symptoms. (Specific antidotes for each of the previously mentioned toxic substances are beyond the scope of this article.)

Follow-up

Further Inpatient Care

  • Tailor inpatient treatment to the patient's condition.

Transfer

  • Transfer may be required for patients whose needs exceed the capability of the hospital providing initial treatment (eg, a patient who needs hemodialysis).

Deterrence/Prevention

  • Public education about the potentially fatal hazards posed by chemicals, medications, and common cleaning compounds is the key to prevention. Basic steps include the following:
    • Keep hazardous and toxic substances in their original containers. Containers should be appropriately marked.
    • Never store food near toxic substances.
    • Keep hazardous and toxic compounds in a secure place out of the reach of children.
  • Parents and the public should know how to contact the regional poison control center for suspected toxic ingestions.

Complications

  • Complications depend on the substance ingested and may include death or permanent neurologic disability.

Prognosis

  • Prognosis depends on the ingested substance and the amount of time between ingestion and initiation of medical care.

Patient Education

  • See Deterrence/Prevention.
  • For excellent patient education resources, visit eMedicine's Substance Abuse Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning, Drug Overdose, Activated Charcoal, and Poison Proofing Your Home.

Miscellaneous

Medicolegal Pitfalls

  • Be aware that even small ingestions may be deadly.
  • Report all suspected cases of nonaccidental toxic ingestions.47

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Keywords

deadly in a single dose, accidental poisoning, toxic ingestions, medication overdose, drug overdose, fatal poisoning, overdose, single-dose poisoning, poisoning, ingestion, cosmetics, cleaning solutions, alcoholic beverages, unintentional ingestion, toxic ingestion, antidepressant ingestion, tricyclic antidepressant poisoning, desipramine poisoning, imipramine poisoning, monoamine oxidase inhibitor poisoning, amitriptyline poisoning, amoxapine poisoning, antimalarial drug poisoning, chloroquine poisoning, thioridazine poisoning, chlorpromazine poisoning, Clozaril poisoning

clonidine poisoning, lorcainide poisoning, quinidine poisoning, verapamil poisoning, disopyramide poisoning, lidocaine poisoning, nifedipine poisoning, ibogaine poisoning, LSD poisoning, nicotine poisoning, amantadine poisoning, colchicine poisoning, hypoglycemic agent poisoning, albuterol poisoning, chloral hydrate poisoning, codeine poisoning, methadone poisoning, iron poisoning, aspirin poisoning, pseudoephedrine poisoning, benzocaine poisoning, camphor poisoning, lindane poisoning, methanol poisoning, ethanol poisoning

Contributor Information and Disclosures

Author

Cynthia L Morris-Kukoski, PharmD, Clinical Assistant Professor, Department of Pharmacy and Occupational Medicine, Medical College of Virginia
Cynthia L Morris-Kukoski, PharmD is a member of the following medical societies: American Academy of Clinical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William T Zempsky, MD, Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Maureen Strafford, MD is a member of the following medical societies: American Medical Women's Association, American Pain Society, American Society of Anesthesiologists, International Anesthesia Research Society, Society for Education in Anesthesia, Society for Pediatric Anesthesia, and Society of Cardiovascular Anesthesiologists
Disclosure: Nothing to disclose.

Further Reading

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  • Toxicity, Oral Hypoglycemic Agents
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  • Toxicity, Tricyclic Antidepressant

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