Poisoning - Acute Guidelines For Initial Management


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Poisons information/Toxicology/Toxinology Resources

    For 24 hour advice, contact Victorian Poisons Information Centre 131126

    • Clinicians Health Channel
    • TOXINZ ( Australian and New Zealand Poisons information and Toxicology)
    • Therapeutic guidelines - Toxicology and Wilderness
    • Snake Bite Management In Victorian Emergency Departments
    • POISINDEX (MICROMEDEX)
    • Victorian Therapeutics Advisory Group (VicTAG)
    • Register of emergency and lifesaving drugs and their location within Victoria
    • Toxnet

    Key Points

    1. Most toddler ingestions are insignificant, however a number of agents are highly toxic in a dose of 1-2 tablets in this age group (see table below).
    2. Resuscitation and risk assessment are described below, and may need to be performed concurrently. Most treatment is supportive.
    3. In any patient whose developmental age is inconsistent with accidental poisoning, a non-accidental poisoning should be considered.
    4. Admission should be considered for all adolescent patients with an intentional overdose.
    5. Always check for Medicalert bracelet in any unconscious patient, or any other signs of underlying medical condition (fingerprick marks etc)​.

    Background

    All acts of deliberate self-harm must be taken extremely seriously. All intentional self-poisonings in adolescents require screening for paracetamol ingestion and admission. If unexplained symptoms exist a urinary drug screen may be indicated, though they are rarely of use in the short term.

    NAI or neglect should be considered particularly where accidental poisoning is not consistent with the developmental age of the child, the history is inconsistent, there is a past history of poisoning, illicit drugs or unusual poisoning from household substances. Infants under 1 do not self-administer medicines.

    Children are more susceptible to poisonings from exposure to some agents than adults. For example increased absorption from dermal exposure due to thin skin and higher surface area to weight ratio, and to inhaled toxins due to increased respiratory rate.

      Potentially harmful 1-3 tablet ingestions/ small exposures
    • Anticholinesterase inhibitors eg organophosphates - cholinergic syndrome, seizures, LOC
    • Baclofen (25mg)  - coma
    • Camphor - rapid decrease in conscious state, seizures, hypotension
    • Carbamazepine (400mg) - coma
    • Centrally acting alpha adrenergic agonists eg clonidine - like opiate but more hypotension and bradycardia
    • Clozapine 100mg/ 200mg - coma
    • Colchicine
    • Corrosives - strong alkali or acid - Gastroesophageal injury
    • Dextropropoxyphene 100mg - Ventricular Tachycardia
    • Opiates eg buprenorphine (8g sublingual or film absorbs in <5min), codeine, methadone, fentanyl
    • Hydrocarbon solvents/ kerosene / essential oils - decreased level of consciousness, seizures, aspiration pneumonia
    • Illicit/street drugs, eg amphetamine.
    • Loperamide and diphenoxylate
    • Naphthalene - 1 mothball (but most mothballs aren't naphthalene) - methaemoglobinaemia, haemolysis
    • Podophyllin
    • Paraquat - oesophageal burns, multi-organ failure
    • Salicylates
    • Strychnine - muscle spasm and respiratory arrest
    • Venlafaxine 150mg - seizures. 

    Potentially lethal 1-3 tablet ingestions

    • Beta blockers eg propranolol - coma, seizures, Ventricular Tachycardia, hypoglycaemia
    • Calcium channel blockers - delayed onset bradycardia, hypotension, conduction defects
    • Chloroquine / hydroxychloroquine - rapid onset coma, seizures, cardiovascular collapse
    • Ecstasy and other amphetamines - agitation, hypertension, hyperthermia
    • Oral hypoglycaemics eg sulphonylureas - hypoglycaemia may be delayed 8 hours
    • Tricyclic antidepressants - coma, seizures, hypotension, VT
    • Theophylline - seizures, Supraventricular Tachycardia, tachycardia, vomiting
     

    Risk Assessment

    The aim is to determine if the ingestion/ contact is potentially harmful and to develop a management plan.

    The Poisons Information Centre may provide useful information about product ingredients and potential toxicity. Phone 131126. Toxicologists are available 24/7 to provide specific clinical advice, and require the following clinical information:

    • Agent: (drug / substance, name and formulation - immediate or modified release)
    • Beware of the possibility of mixed overdose
    • Route - ingested, inhaled, topical exposure
    • Time of incident
    • Dose/ kg
    • Maximum amount of ingestion (include all medication that was potentially in the bottle or packet when calculating).
    • Beware of the possibility of inaccurate dose reporting on history taking.
    • Weight of child
    • Symptoms
    • Signs
    • If mixed or undetermined ingestion paracetamol level should be done.

    Resuscitation/Emergency Management

    A. Airway
    • Inability to protect airway may be with >GCS8 in poisonings. AVPU may be a more useful descriptor of conscious state.
    • Caustic ingestions

    B. Breathing

    C. Circulation

    • Dysrhythmias are frequently due to sodium channel blockade and may be treated with Sodium Bicarbonate. Alternately they may be caused by potassium channel blockade - treated with magnesium sulphate (MgS04)

    D1. Disability

    • Seizures - those due to poisoning are always generalized. Usually respond to benzodiazepines with barbiturates second line. Phenytoin is not recommended (as this is usually ineffective).
    • Consideration should be given to drug induced syndromes - malignant hyperthermia, serotonin syndrome and neuroleptic malignant syndrome
    • Check glucose level: treat if glucose <4mmol/L (link hypoglycaemia)

    D2. Decontamination

        Eye

    • Copious irrigation with saline. Instillation of local anaesthetic eye drops and sedation may be required.

        Skin  

    • Remove clothes, rinse with copious water, then soap and water

    Gastrointestinal

    A variety of methods may be considered and should be discussed with a toxicologist before commencement as all require a risk / benefit analysis. Paediatric deaths have occurred from activated charcoal.

    • Emesis has no role in the hospital setting
    • Activated Charcoal has a very limited role in treatment and should not be used without consultation with a toxicologist, unless presents less than 1 hour after a potentially toxic ingestion with normal conscious state.

    Contraindications:

    • Patients with altered conscious state 
    • Ethanol/glycols
    • Alkalis / corrosives
    • Metals - including Lithium, Iron compounds, potassium
    • Fluoride
    • Cyanide
    • Hydrocarbons
    • Mineral acids - Boric acid
    • Gastric Lavage has a very limited role in treatment. It requires intubation for airway protection and should not be used without consultation.
    • Whole Bowel Irrigation has a limited role in treatment of life-threatening ingestions of some slow release preparations and agents that do not bind to activated charcoal.

    D3 Drug antidotes see specific guidelines

         Specific antidotes may be available as part of a management plan. Serum drug concentrations may help in treatment decisions.

    Poisoning

    Antidote

    Anticholinergic syndrome

    Physostigmine

    Benzodiazepines

    Flumazenil

    Beta Blocker

    Glucagon

    Calcium channel blocker

    Calcium
    Insulin/ glucose
    Intralipid®

    Cyanide

    Hydroxocobalamin
    Dicobalt  edetate
    Sodium thiosulphate

    Digoxin

    Digoxin immune Fab (Digibind)

    Ethylene glycol

    Ethanol
    Pyridoxine

    Iron

    Desferrioxamine

    Isoniazid

    Pyridoxine

    Local anaesthetics

    Intralipid®

    Methaemoglobinaemia

    Methylene Blue

    Methanol

    Ethanol

    Opiates

    Naloxone

    Oral hypoglycaemics

    Octreotide

    Organophosphate

    Atropine

    Paracetamol

    N-Acetyl Cysteine

    Pralidoxime

    Organophosphates

    Quinine induced hypoglycaemia

    Octreotide

    Tricyclic antidepressants

    Sodium bicarbonate

    Warfarin, long acting rodenticide anticoagulant

    Vitamin K

    E1 ECG E2 Exposure

    • Hyper/ hypothermia - >38.5°C requires urgent cooling

    E3 Enhanced elimination 

    • Urinary alkalization

                Useful for salicylate toxicity if performed meticulously 

    • Multi dose activated charcoal

    Whilst there is evidence of a pharmacokinetic effect, it is not evident that it improves clinical outcome. 

    • Dialysis

    Intermittent High flux haemodialysis removes small water-soluble toxins

    • salicylate,
    • toxic alcohols
    • lithium
    • theophylline
    • valproate
    • barbiturates
    • methotrexate 

    Continuous renal replacement such as veno-veno haemofiltration has a low clearance rate and is only suitable where haemodialysis is not tolerated. Other methods such as peritoneal dialysis, charcoal haemoperfusion, exchange transfusion and plasmapheresis are less effective.  

    Contact Victorian Poisons Information Centre 131126 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. 

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

    Parent information 

    Accidental ingestion: Parent information sheet from Victorian Poisons Information centre on the prevention of poisoning

    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

     Last updated August 2017