What are the symptoms and treatment for acute poisoning in a child?

Acute Poisoning in Children: Symptoms and Treatment

Immediate Life-Threatening Signs Requiring Emergency Activation

If a child exhibits altered mental status, seizures, difficulty breathing, or vomiting after poison exposure, activate emergency medical services immediately. 1

• Sleepiness or lethargy indicates potential central nervous system depression 1
• Seizures suggest severe toxicity requiring urgent intervention 1
• Respiratory difficulty may progress to respiratory failure 1
• Persistent vomiting increases aspiration risk and indicates significant toxicity 1

Contact Poison Control Center First

Call the Poison Help hotline (1-800-222-1222 in the United States) immediately for all suspected poisonings, as they provide expert guidance on specific toxin management. 1, 2

• Poison control centers have extensive experience in diagnosis and treatment planning 3
• They can help determine if emergency department evaluation is necessary 1
• Maintain continuous contact for evolving recommendations 4

Common Clinical Presentations by System

Gastrointestinal Symptoms

• Nausea and vomiting are the most common presenting symptoms (23.8% of cases) 5
• Abdominal pain and diarrhea may occur 6
• Corrosive burns to mouth and throat occur with caustic ingestions 1, 6

Neurological Symptoms

• Altered mental status and confusion (23.8% of cases) 5
• Lethargy progressing to coma in severe cases 6
• Seizures indicate severe toxicity 5, 6
• Dizziness and syncope 1

Cardiovascular Symptoms

• Tachycardia or bradycardia 6
• Hypotension and shock in severe poisoning 6
• Dysrhythmias 6
• Cool peripheries and prolonged capillary refill time (≥2 seconds) 2

Respiratory Symptoms

• Respiratory tract irritation 6
• Dyspnea and polypnea 1
• Respiratory depression in severe cases 1

Dermal Manifestations

• Skin burns or irritation from topical exposure 6
• Sweating 6

Critical "Do Not" Actions

Do not administer anything by mouth (water, milk, or activated charcoal) unless specifically instructed by poison control center, as this may cause vomiting and aspiration. 1, 2

• Do not induce vomiting with ipecac syrup—it is contraindicated and causes harm without benefit 1, 2
• Do not attempt dilution with water or milk—no human studies show clinical benefit and it may worsen outcomes 1, 2
• Do not delay emergency activation while attempting home interventions 2

Decontamination Based on Exposure Route

Dermal Exposure

• Remove all contaminated clothing and jewelry immediately to prevent continued absorption 1, 2
• Brush off any powdered chemicals with a gloved hand or cloth before washing 1, 2
• Immediately irrigate affected skin with copious amounts of water 1, 2
• Use warmed water in pediatric patients to prevent hypothermia 2
• Apply lower pressure during washing to prevent additional skin damage in children 2
• Use heat lamps and blankets to maintain body temperature during decontamination 2

Eye Exposure

• Rinse eyes immediately with copious amounts of water for at least 15 minutes 1, 7, 2
• Continue irrigation even during transport to hospital 1

Inhalation Exposure

• Remove child from contaminated environment 1
• Administer 100% oxygen if indicated (see specific toxin considerations below) 1

Ingestion

• Do not perform gastric lavage routinely—it is not recommended for most poisonings 1, 4
• Activated charcoal administration should only occur if advised by poison control center and after airway protection 1, 4
• Never attempt decontamination without first ensuring airway protection due to significant aspiration risk 4

Pediatric-Specific Vulnerabilities

Children are more susceptible to toxic effects than adults due to physiological differences that require heightened vigilance. 1

• Higher minute ventilation leads to greater exposure to inhaled toxins 1
• Lower body mass index increases toxin concentration per kilogram 1
• Less fluid reserves and more rapid dehydration from vomiting/diarrhea 1
• Rate-dependent cardiac output requires continuous hemodynamic monitoring 1, 2
• Higher incidence of seizures from organophosphate poisoning compared to adults 1

Specific Toxin Considerations

Carbon Monoxide Poisoning (from smoke inhalation)

• Administer 100% oxygen immediately via high-concentration mask 1
• Continue oxygen for 6-12 hours if mechanically ventilated 1
• All children with CO poisoning showing impaired consciousness, neurological, cardiac, respiratory, or psychological symptoms should receive hyperbaric oxygen therapy regardless of carboxyhemoglobin level 1

Cyanide Poisoning (from smoke inhalation)

• Children are more vulnerable than adults due to higher alveolar ventilation 1
• Administer hydroxocobalamin (70 mg/kg, maximum 5 g) for moderate poisoning signs: GCS score ≤13, confusion, stridor, hoarse voice, dyspnea, soot in airways 1
• Administer hydroxocobalamin for severe poisoning signs: GCS score ≤8, seizures, coma, mydriasis, severe hemodynamic disorders, respiratory depression 1
• Plasma lactate >8 mmol/L suggests cyanide poisoning 1

Organophosphate/Nerve Agent Poisoning

• Atropine doses in children are relatively higher than standard resuscitation doses (0.02 mg/kg) 1
• Doses of 0.05 mg/kg are minimally effective; doses up to 0.1 mg/kg may be needed 1
• Titrate atropine until complete resolution of cholinergic crisis 1
• Do not stop atropine for tachycardia—repeated boluses do not cause arrhythmias in children unlike adults 1
• Administer obidoxime or pralidoxime chloride slowly IV to minimize side effects 1
• Give diazepam (0.2 mg/kg) or midazolam (0.1 mg/kg) repetitively until seizures cease 1

Acetaminophen Poisoning

• N-acetylcysteine is the antidote for acetaminophen overdose 8
• Delaying treatment increases risk of hepatotoxicity and mortality 8
• Acetaminophen doses ≥150 mg/kg are associated with hepatotoxicity 8
• Safety and effectiveness in pediatric patients ≥5 kg is based on clinical practice 8

Caustic Substance Ingestion (acids/alkalis)

• There is insufficient evidence for or against administering diluents 1
• Do not administer anything by mouth unless advised by poison control 1, 2
• Immediately irrigate skin or eye exposure with copious water 1, 2

Paraquat Poisoning

• Avoid supplemental oxygen unless SpO2 falls below 85%—target oxygen saturation of 85-88% because oxygen dramatically worsens paraquat toxicity through increased free radical production. 4
• Remove contaminated clothing immediately and wash exposed skin thoroughly 4
• Consider multiple-dose activated charcoal (15-20g every 6 hours) only after airway protection and hemodynamic stabilization 4
• Do not delay airway protection to perform gastrointestinal decontamination 4

Severity Assessment and Disposition

Mild Toxicity (31.1% of cases)

• Minimal symptoms 5
• May be discharged home with poison control follow-up 5

Moderate to Severe Toxicity (31.1% of cases)

• Multi-organ involvement 2, 5
• Requires general ward admission (16.5% of cases) or intensive care unit admission (13.9% of cases) 5
• May require intubation (34.4% of cases) 5
• IV fluid resuscitation needed (27.8% of cases) 5

Laboratory Monitoring

• Blood tests indicated in 67% of cases 5
• Elevated AST/IUL correlates with complicated cases (75.5 vs. 20.08 in non-complicated) 5
• Systolic blood pressure correlates positively with age in children 5

Common Pitfalls to Avoid

• Do not assume all asymptomatic children are safe—70.9% were asymptomatic at presentation but some developed severe toxicity 5
• Do not overlook hypothermia risk during prolonged decontamination in pediatric patients 2
• Do not contaminate yourself while removing contaminated clothing or during decontamination 2
• Do not provide liberal supplemental oxygen in paraquat poisoning—this is uniquely harmful 4
• Do not use gastric lavage routinely when activated charcoal is the evidence-based alternative 4

Epidemiological Context

• Peak incidence occurs in children aged 1 to <6 years (86% of cases) 9
• Highest incidence occurs between 12 a.m. and 6 a.m. (35.4% of cases) 9
• Pharmaceutical ingestion causes 67.1% of poisonings, with analgesics being most common (26.4%) 9
• Chemical ingestion causes 32.9% of poisonings, with cleaning agents most common (48.1%) 9
• Accidental poisoning accounts for 83% of cases 5
• Most poisonings (69.7%) occur at home 5
• Oral ingestion is the most common route (82.8%) 5