History

Risk assessment is a specific and cognitive step taken in the assessment of all patients with possible ingestions. It involves a detailed history around the likely agent, the amount and timing of ingestion, and any current symptoms.

Some patients may present before developing significant symptoms. Other patients may present in an obtunded state and without a clear history of ingestion. Obtain collateral history from patients, family, paramedics, doctor, or pharmacist.

Elicit the following information:

What substance was ingested? If the substance was a medication, obtain the name, dosage strength, and preparation type (immediate verses sustained release).
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?
Did anyone observe the ingestion? If so, ask to speak with the person who saw the incident, because this may help determine the amount and timing of ingestion.
Is the patient exhibiting any clinical features of ingestion?
What is the patient's medical history?
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.

Always assume a worst-case scenario. Assume all unaccounted for tablets have been taken. Do not account for spillage. Place the timing of ingestion at latest possible. If two children are involved, presume all the missing tablets were consumed by either child.

Physical Examination

Physical examination findings are variable and depend on the specific agent and amount ingested. Findings may range from normal to obtundation or even cardiopulmonary arrest. Some examination results may offer subtle but specific clues regarding the type of ingestion. The recommended process is as follows:

Begin the examination by evaluating the patient's airway, breathing, and circulation (ABCs). Initiate appropriate interventions for any abnormalities.
Perform a complete physical examination, and record all vital signs.
Search for evidence of specific toxidromes (sedatives, hypnotics, sympathomimetics, serotonin toxicity, anticholinergic syndrome)
Perform a neurologic examination, checking for level of consciousness, pupils, tone, reflexes, ocular clonus, and lower limb clonus.

Differential Diagnoses

Zed PJ, Haughn C, Black KJ, Fitzpatrick EA, Ackroyd-Stolarz S, Murphy NG, et al. Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review. J Pediatr. 2013 Aug. 163(2):477-83. [QxMD MEDLINE Link].
Frithsen IL, Simpson WM Jr. Recognition and management of acute medication poisoning. Am Fam Physician. 2010 Feb 1. 81(3):316-23. [QxMD MEDLINE Link].
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, et al. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec. 59 (12):1282-1501. [QxMD MEDLINE Link]. [Full Text].
Linakis JG. Amoxapine. Clin Toxicol Rev. 1988. 10.
Manoguerra AS. Tricyclic antidepressants. Crit Care Quarterly. 1982. 43-51.
Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J. 2001 Jul. 18 (4):236-41. [QxMD MEDLINE Link]. [Full Text].
Rosenbaum TG, Kou M. Are One or Two Dangerous? Tricyclic Antidepressants Exposure in Toddlers. The Journal of Emergency Medicine. 2005. 28 (2):169-174. [QxMD MEDLINE Link].
Litovitz TL, Felberg L, White S, Klein-Schwartz W. 1995 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1996 Sep. 14(5):487-537. [QxMD MEDLINE Link].
Litovitz TL, Holm KC, Bailey KM, Schmitz BF. 1991 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1992 Sep. 10(5):452-505. [QxMD MEDLINE Link].
Cronin AJ, Khalil R, Little TM. Poisoning with Tricyclic Antidepressants: an Avoidable Cause of Childhood Deaths. British Medical Journal. 1971. 1:722. [QxMD MEDLINE Link].
Hon KL, Fung CK, Lee VW, Cheung KL, Wong W, Leung AK. Neurologic and Cardiovascular Complications in Pediatric Life Threatening Imipramine Poisoning. Curr Drug Saf. 2015. 10 (3):261-5. [QxMD MEDLINE Link].
Litovitz TL, Klein-Schwartz W, Dyer KS, et al. 1997 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1998 Sep. 16(5):443-97. [QxMD MEDLINE Link].
Olgun H, Yildirim ZK, Karacan M, Ceviz N. Clinical, electrocardiographic, and laboratory findings in children with amitriptyline intoxication. Pediatr Emerg Care. 2009 Mar. 25(3):170-3. [QxMD MEDLINE Link].
Shepard FM. Amoxapine intoxication in an infant: seizures arrested with diazepam. South Med J. 1983 Apr. 76(4):543-4. [QxMD MEDLINE Link].
Ellenhorn MJ, Barceloux DG. Medical Toxicology: Diagnosis and Treatment of Human Poisoning. New York, NY: Elsevier Science; 1988.
Linden CH, Rumack BH, Strehlke C. Monoamine oxidase inhibitor overdose. Ann Emerg Med. 1984 Dec. 13(12):1137-44. [QxMD MEDLINE Link].
Murray L, Daly F, Little M, Cadogan M. Monoamine Oxidase Inhibitors (MAOIs). Toxicology Handbook. Second. Australia: Churchill Livingstone; 2011. 280-282.
Smith ER, Klein-Schwartz W. Are 1-2 Dangerous? Chloroquine and Hydroxychloroquine Exposure in Toddlers. The Journal of Emergency Medicine. 2005. 28 (4):437-443. [QxMD MEDLINE Link].
McCarthy VP, Swabe GL. Chloroquine poisoning in a child. Pediatr Emerg Care. 1996 Jun. 12(3):207-9. [QxMD MEDLINE Link].
Litovitz TL, Martin TG, Schmitz B. 1986 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1987 Sep. 5(5):405-45. [QxMD MEDLINE Link].
Kelly JC, Wasserman GS, Bernard WD, et al. Chloroquine poisoning in a child. Ann Emerg Med. 1990 Jan. 19(1):47-50. [QxMD MEDLINE Link].
Cann HM, Verhulst HL. Fatal Acute Chloroquine Poisoning in Children. Pediatrics. 1961. 27 (1):95-102. [QxMD MEDLINE Link].
McCarthy VP, Swabe GL. Chloroquine Poisoning in a Child. Pediatric Emergency Care. 1996. 12:207-9. [QxMD MEDLINE Link].
Ranniger C, Roche C. Are One or Two Dangerous? Calcium Channel Blocker Exposure in Toddlers. The Journal of Emergency Medicine. 2007. 33 (2):145-154. [QxMD MEDLINE Link].
Litovitz TL, Bailey KM, Schmitz BF, et al. 1990 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1991 Sep. 9(5):461-509. [QxMD MEDLINE Link].
Doyon S, Klein-Schwartz W, Lee S, Beuhler MC. Fatalities involving acetaminophen combination products reported to United States poison centers. Clin Toxicol (Phila). 2013 Dec. 51(10):941-8. [QxMD MEDLINE Link].
Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1989 Sep. 7(5):495-545. [QxMD MEDLINE Link].
Lee DC, Greene T, Dougherty T, Pearigen P. Fatal nifedipine ingestions in children. J Emerg Med. 2000 Nov. 19(4):359-61. [QxMD MEDLINE Link].
Litovitz TL, Holm KC, Clancy C, et al. 1992 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1993 Sep. 11(5):494-555. [QxMD MEDLINE Link].
Pearigen PD. Death from accidental nifedipine ingestion in a toddler. Vet Hum Toxicol. 1993. 35:345.
Love JN, Sikka N. Are 1-2 Tablets Dangerous? Beta-Blocker Exposure in Toddlers. The Journal of Emergency Medicine. 2004. 26 (3):309-314. [QxMD MEDLINE Link].
Hesse B, Pedersen JT. Hypoglycaemia after propranolol in children. Acta Medica Scandinavica. 1973. 193 (6):551-552. [QxMD MEDLINE Link].
Murray L, Daly F, little M, Cadogan M. Beta-Blockers. Toxicology Handbook. Second. Australia: Churchill Livingstone; 2011. 168-170.
Wang GS, Le Lait MC, Heard K. Unintentional Pediatric Exposures to Central Alpha-2 Agonists Reported to the National Poison Data System. The Journal of Pediatrics. 2014 - Jan. 164 (1):149-152. [QxMD MEDLINE Link].
Evers J, Buttner-Belz U. Fatal lorcainide poisoning. J Toxicol Clin Toxicol. 1995. 33(2):157-9. [QxMD MEDLINE Link].
Baselt RC. Disposition of Toxic Drugs and Chemicals in Man. 5th ed. Foster City, CA: Chemical Toxicology Inst; 2000.
Garrettson LK, McGee EB. Rapid onset of seizures following aspiration of viscous lidocaine. J Toxicol Clin Toxicol. 1992. 30(3):413-22. [QxMD MEDLINE Link].
Sachdeva DK, Stadnyk JM. Are One or Two Dangerous? Opioid Exposure in Toddlers. The Journal of Emergency Medicine. 2005. 29 (1):77-84. [QxMD MEDLINE Link].
Litovitz TL, Schmitz BF, Matyunas N, Martin TG. 1987 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1988 Sep. 6(5):479-515. [QxMD MEDLINE Link].
Nurse gives fatal overdose of codeine to child. Nurs Law Regan Rep. 2008 Aug. 49(3):2. [QxMD MEDLINE Link].
Fentanyl Patch Can Be Deadly to Children. U.S. Food & Drug Administration. Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm300803.htm. September 23, 2012; Accessed: December 23, 2020.
Parekh D, Miller M, Borys D, Patel P, Levsky ME. Transdermal Patch Medication Delivery Systems and Pediatric Poisonings, 2002 - 2006. Clinical Pediatrics. 2008 Sept. 47 (7):659-663. [QxMD MEDLINE Link].
Teske J, Weller JP, Larsch K, Troger HD, Karst M. Fatal Outcome in a Child after Ingestion of a Transdermal Fentanyl Patch. International Journal of Legal Medicine. 2007. 121:147-151. [QxMD MEDLINE Link].
Rumack BH, Temple AR. Lomotil poisoning. Pediatrics. 1974 Apr. 53(4):495-500. [QxMD MEDLINE Link].
Kim HK, Smiddy M, Hoffman RS, Nelson LS. Buprenorphine May Not be as Safe as You Think. A Pediatric Fatality from Unintentional Exposure. Pediatrics. 2012 November. 130 (6):e1700-1703. [QxMD MEDLINE Link].
Little GL, Boniface KS. Are One or Two Dangerous? Sulfonylurea Exposure in Toddlers. The Journal of Emergency Medicine. 2005. 28 (3):305310. [QxMD MEDLINE Link].
Murray L, Daly F, Little M, Cadogan M. Sulfonylureas. Toxicology Handbook. Second. Churchill Livingstone; 2011. 346-348.
Riordan M, Rylance G, Berry K. Poisoning in Children 3: Common Medicines. Achives if disease in Childhood. 2002. 87:400-402. [QxMD MEDLINE Link].
Murray L, Daly F, Little M, Cadogan M. Theophylline. Toxicology Handbook. Second. Australia: Churchill Livingstone; 2011. 348-350.
Buchanan N, Wainwright L, De Villiers F. Theophylline Poisoning in an Infant. A Case Report. South African Medical Journal. 1979. 56:811-812. [QxMD MEDLINE Link].
Cann HM, Verhulst HL. Accidental ingestion and overdosage involving psychopharmacologic drugs. New Engl J Med. 1960. 263:719-24.
Litovitz TL, Felberg L, Soloway RA, et al. 1994 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1995 Sep. 13(5):551-97. [QxMD MEDLINE Link].
Ozedmir R, Bayrakci B, Teksam O. Fatal poisoning in children: acute colchicine intoxication and new treatment approaches. Clinical Toxicology (Philadelphia). 2011 October. 49 (8):739-743. [QxMD MEDLINE Link].
Litovitz T, Manoguerra A. Comparison of Pediatric Poisoning Hazards: An Analysis of 3.8 Million Exposure Incidents a Report from the American Association of Poison Control Centers. Pediatrics. 1992. 89:999-1006. [QxMD MEDLINE Link].
MacCready RA. Methyl salicylate poisoning: a report of five cases. New Engl J Med. 1943. 228:155.
Smith AG, Margolis G. Camphor poisoning. Am J Path. 1954. 30:857-69.
Wong LC, Heimbach MD, et al. Boric acid poisoning: report of 11 cases. Can Med Assoc J. 1964. 90:1018-23.
Connolly GN, Richter P, Aleguas A, Pechacek TF, Stanfill SB, Alpert HR. Unintentional Child Poisonings Through Ingestion of Conventional and Novel Tobacco Products. Pediatrics. May 2010. 125(5):896-899. [QxMD MEDLINE Link].
Lowry JA. Electronic Cigarettes: Another Pediatric Toxic Hazard in the Home?. Clinical Toxicology (Philadelphia). 2014 June. 52(5):449-450. [QxMD MEDLINE Link].
Matteucci M, Auten J, Crowley B, Combs D, Clark R. Methamphetamine Exposures in Young Children. Pediatric Emergency Care. 2007 September. 23 (9):638-640. [QxMD MEDLINE Link].
Bedford Russell AR, Schwartz RH, Dawling S. Accidental Ingestion of 'Ecstasy' (3,4-methylenedioxymethylamphetamine). Archives of Disease in Childhood. 1992. 67:1114-1115. [QxMD MEDLINE Link].
Montesdeoca-Melian A, Burillo-Putze G, Gonzalez Campo C, Gonzalez Padron A, Ormazabal Ramos C. Accidental Ecstasy Poisoning in a toddler. Pediatric Emergency Care. 2004 August. 20 (8):534-535. [QxMD MEDLINE Link].
Chang YJ, Lai MW, Kong MS, Chao HC. Accidental Ingestion of Ecstasy in a Toddler. Journal of Formosan Medical Association. 2005 December. 104 (12):946-7. [QxMD MEDLINE Link].
Nicol JJ, Yarema MC, Jones GR, Martz W, Purssell RA, MacDonald JC, et al. Deaths from exposure to paramethoxymethamphetamine in Alberta and British Columbia, Canada: a case series. CMAJ Open. 2015 Jan-Mar. 3 (1):E83-90. [QxMD MEDLINE Link].
Klys M, Wozniak K, Rojek S, Rzepecka-Wozniak E, Kowalski P. Ethanol-related death of a child: an unusual case report. Forensic Sci Int. 2008 Jul 18. 179(1):e1-4. [QxMD MEDLINE Link].
Pond SM, Powell D, Allen TB. Fatal pontine infarction in a child who ingested diquat. Vet Hum Toxicol. 1983. 25 (suppl 1):41-3.
Duan Y, Wang Z. To explore the characteristics of fatality in children poisoned by paraquat - with analysis of 146 cases. Int J Artif Organs. 2016 Feb 29. [QxMD MEDLINE Link].
McDonagh BJ, Martin J. Paraquat Poisoning in Children. Archives of Disease in Children. 1970 June. 45 (241):425-427. [QxMD MEDLINE Link].
Falk W, Hinrich R. Jacutin poisoning in childhood. Med Klin Wschr. 1957. 42:1837.
Trestrail JH. Criminal Poisonings: Investigational Guide for Law Enforcement, Toxicologists, Forensic Scientists, and Attorneys. Totowa, NJ: Humana Press; 2000.
Nordt SP, Chew G. Acute Lindane Poisoning in Three Children. The Journal of Emergency Medicine. 2000. 18 (1):51-53. [QxMD MEDLINE Link].
Mier RJ. Treatment of aniline poisoning with exchange transfusion. J Toxicol Clin Toxicol. 1988. 26(5-6):357-64. [QxMD MEDLINE Link].
Veltri JC, Litovitz TL. 1983 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. 1984 Sep. 2(5):420-43. [QxMD MEDLINE Link].
Bertinelli A, Hamill J, Mahadevan M, Miles F. Serious injuries from dishwasher powder ingestions in small children. Journal of Paediatrics and Child Health. March 2006. 42(3):129-133. [QxMD MEDLINE Link].
Vakkalanka JP, Hardison LS Jr, Holstege CP. Epidemiological Trends in Electronic Cigarette Exposures Reported to U.S. Poison Centers. Clinical Toxicology (Philidelphia). June 2014. 52 (5):542-548. [QxMD MEDLINE Link].
Beuhler MC, Gala PK, Wolfe HA, Meaney PA, Henretig FM. Laundry detergent "pod" ingestions: a case series and discussion of recent literature. Pediatric Emergency Care. June 2013. 29 (6):743-747. [QxMD MEDLINE Link].
Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 1997 Sep. 15(5):447-500. [QxMD MEDLINE Link].
Tibballs J. Clinical effects and management of eucalyptus oil ingestion in infants and young children. Medical Journal of Australia. April 1995. 163(4):177-180. [QxMD MEDLINE Link].
[Guideline] American Academy of Clinical Toxicology. Position Statements: Topic: Gastric Decontamination. AACT. Available at https://www.clintox.org/resources/position-statements. Accessed: February 8, 2019.
[Guideline] Chyka PA, Seger D, Krenzelok EP, Vale JA, 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. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Höjer J, Troutman WG, Hoppu K, Erdman A, Benson BE, Mégarbane B, et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar. 51 (3):134-9. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Benson BE, Hoppu K, Troutman WG, Bedry R, Erdman A, Höjer J, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar. 51 (3):140-6. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Thanacoody R, Caravati EM, Troutman B, Höjer J, Benson B, Hoppu K, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015 Jan. 53 (1):5-12. [QxMD MEDLINE Link]. [Full Text].
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older. FDA.GOV. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-labeling-changes-prescription-opioid-cough-and-cold. 2018 Jan11; Accessed: January 17, 2022.
Bagazgoitia L, Torrelo A, Gutiérrez JC, Hernández-Martín A, Luna P, Gutiérrez M, et al. Propranolol for infantile hemangiomas. Pediatr Dermatol. 2011 Mar-Apr. 28 (2):108-14. [QxMD MEDLINE Link].
Vohra R, Huntington S, Koike J, Le K, Geller RJ. Pediatric Exposures to Topical Benzocaine Preparations Reported to a Statewide Poison Control System. West J Emerg Med. 2017 Aug. 18 (5):923-927. [QxMD MEDLINE Link].
Mullins ME, Hammett-Stabler CA. Intoxication with nitromethane-containing fuels: don't be "fueled" by the creatinine. J Toxicol Clin Toxicol. 1998. 36 (4):315-20. [QxMD MEDLINE Link].
Lindmark J, Verive M. Salicylate Toxicity in an Adolescent Presenting as Chest Pain. CHEST. [Full Text].

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Author

Michael J Verive, MD, FAAP Pediatrician, UP Health System Portage

Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Received salary from Merck for employment.

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.

Chip Gresham, MD, FACEM † Emergency Medicine Physician, Medical Toxicologist, and Intensive Care Consultant, Department of Emergency Medicine, Clinical Director of Medication Safety, Middlemore Hospital; Consultant Toxicologist, National Poisons Centre; Director, Auckland Regional Toxicology Service; Senior Lecturer, Auckland University Medical School, New Zealand

Chip Gresham, MD, FACEM is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, Australasian College for Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sarah J Buller, MBChB, FACEM Consulting Physician, Department of Emergency Medicine, Auckland City Hospital, New Zealand

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.