Poisoning - Acute Guidelines For Initial Management

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

Poisons information/Toxicology/Toxinology Resources

For 24 hour advice, contact Victorian Poisons Information Centre 13 11 26

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

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)
Resuscitation and risk assessment are described below, and may need to be performed concurrently. Most treatment is supportive
In any patient whose developmental age is inconsistent with accidental poisoning, a non-accidental poisoning should be considered
Admission should be considered for all adolescent patients with an intentional overdose
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 (25 mg) - coma Camphor - rapid decrease in conscious state, seizures, hypotension Carbamazepine (400 mg) - coma Centrally acting alpha adrenergic agonists eg clonidine - like opiate but more hypotension and bradycardia Clozapine 100mg/ 200 mg - coma Colchicine Corrosives - strong alkali or acid - Gastroesophageal injury Dextropropoxyphene 100 mg - Ventricular Tachycardia Opiates eg buprenorphine (8 g sublingual or film absorbs in <5 min), 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 150 mg - 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 13 11 26. 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 <4 mmol/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
Organophosphates	Pralidoxime
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 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.

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

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines