See also

Poisoning - Acute Guidelines For Initial Management 
Burns / management of burn wounds
Acute pain management 
Foreign body ingestion

Key points

1. Alkali ingestion can often be asymptomatic early and this does not exclude serious injury
2. Absence of mouth or pharyngeal ulcers does not preclude gastro-oesophageal lesion
3. Nasogastric insertion should only be performed by an endoscopist
4. If threatened airway, consider early intubation
5. If inhalational exposure, respiratory symptoms can be delayed 
   

Background

Children requiring assessment

All patients with deliberate self-poisoning or significant accidental ingestion 
Any symptomatic patient 
Any patient whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be considered.

Risk Assessment

History

Intentional overdose or accidental

Dose: 
Stated or likely dose taken
Find the following information (where possible)

• Obtain container to check contents and strength of substance/photos
• Check preparations with the Victorian Poisons Information Centre (13 11 26) to determine the corrosive potential of the product with severe toxicity.
  

Co-ingestants eg paracetamol

Examination

Symptoms      

• May be minimal and / or delayed
  
• Pain, nausea & vomiting, drooling or refusing to eat and drink
  
• Stridor, respiratory distress
  
• Splash burns (skin / eyes)
  
• Systemic features – circulatory collapse and / or multi-organ failure

Investigations (if symptomatic)

• Blood tests may be required if systemic features
• CXR
•  Endoscopy (best method for assessing GI injury within 12 - 24 hours) in symptomatic patients and is required in spite of a normal chest x-ray and lab investigations
  

Pathology

Paracetamol concentration in all intentional overdoses

Acute Management

Depends on type of injury

Ingestion / Inhalational

Decontamination: Activated charcoal / GI decontamination / neutralisation procedures are contraindicated

Standard resuscitation may be required in severe poisoning

If asymptomatic – observe, trial of oral intake at 4 hours after exposure, earlier if low suspicion or likely benign ingestion after discussion with Poisons Information Centre

If any symptoms admit for oesophagoscopy (within 24 hours) (PIPER, local paed surg)

• Keep NBM
• Commence intravenous PPI 

Analgesia – see Acute pain management. If opiate or parenteral analgesia required, please consult local pain management service.

Dermal

Remove clothing / particulate matter. 
Copious low pressure water for minimum 10-15 minutes, or until pH of skin is normal (pH 6 – 7 in children). 
Recheck pH of affected areas after a period of 15-20 minutes and repeat irrigation if abnormal (several hours may be required). 
Then treat as per thermal injury (see Burns CPG)

Eye

Alkaline exposure is an ophthalmic emergency.

Remove contact lenses if present. Use topical anaesthetic (if available), immediate irrigation with 1L normal saline (via a giving set) for minimum 10-15 minutes regardless of pH. 
This procedure may require sedation to ensure prompt management.
Aim for a final conjunctival pH of 7.5 - 8.0; or similar to other eye if unaffected. 
The conjunctivae may be tested with indicator paper. 
Retest 20 minutes after irrigation; repetitive irrigation may be necessary.
Record Visual Acuity (if possible) and assess presence of corneal damage with fluorescein uptake.
Prompt referral to ophthalmology services.

Consider consultation with local paediatric team when

• All symptomatic patients
• Admission should be considered for all children and young people with an intentional overdose
  

Consult Contact Victorian Poisons Information Centre 13 11 26 for advice

When to consider transfer to a tertiary centre

• Patients requiring escalation of care beyond the comfort of the hospital and local paediatric team. 
• Any patient requiring intensive care

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Consider discharge when

If asymptomatic after 4 hours and able to eat and drink the patient can be safely discharged.
Suspected non-accidental injury / mental health concerns may independently warrant admission and need to be addressed. 
For deliberate ingestion a risk assessment should indicate that the patient is at low risk of further self-harm in the discharge setting.

Discharge information and follow-up

Poisoning prevention for children Parent information

Victorian Poisons Information Centre: 13 11 26 www.austin.org.au/poisons

Intentional self –harm: Referral to local mental health services eg Orygen Youth Health: 1800 888 320 

Recreational poisoning: Referral to YoDAA, Victoria's Youth Drug and Alcohol Advice service: 1800 458 685