Approach Considerations

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

Have a low threshold for obtaining a electrocardiogram (ECG) in patients who have bradycardia, tachycardia, or other arrhythmias, or those who may have ingested any toxin associated with sodium channel or potassium channel blockade or any cardiac medication, such as the following:

Calcium channel blocker
Beta-blocker
Digoxin
Clonidine

Laboratory Studies

Assessing acid-base status, electrolytes, renal and hepatic function, and effects of substances on bone marrow can help identify potential toxins and guide treatment decisions. Recognizing specific laboratory abnormalities (such as falsely elevated creatinine in nitromethane poisoning)^[87]can give clues to substances ingested and avoid inappropriate treatment.

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 the following:

Heavy metals
Iodine
Phenothiazines
Enteric-coated tablets
Chloral hydrate

Electrocardiography

ECG changes in sodium channel blocker toxicity include widened QRS and right axis deviation of the terminal QRS. Sodium channel blockers include the following:

Tricyclic antidepressants (TCAs)
Class 1A and C antidysrhythmics
Local anesthetics
Phenothiazines
Chloroquine and Hydroxychloroquine/Chloroquine

ECG changes in potassium channel toxicity include prolongation of the QT interval; plot the QT interval on a QT nomogram to identify patients at risk of developing torsade de pointes.Potassium channel blockers include the following:

Antipsychotics
Class IA and IC antidysrhythmics
Class III Antidysrhythmics
TCAs
Other antidepressants
Antihistamines
Chloroquine/Hydroxychloroquine.

ECG changes from calcium channel blocker and beta-blocker toxicity include the following:

Sinus bradycardia
Decreased atrioventricular (AV) node conduction
Intraventricular conduction defects

Treatment & Management

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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.