Management of Unknown Tablet Ingestion in Children
Immediately contact Poison Control (1-800-222-1222) for expert guidance while simultaneously assessing the child's airway, breathing, and circulation. 1, 2
Immediate Assessment and Stabilization
Establish and maintain an open airway as the absolute first priority. 1, 3 If respiratory compromise is present, provide bag-mask ventilation followed by endotracheal intubation when appropriate. 1, 3
Critical Information to Obtain
- Exact time of ingestion (determines decontamination window and need for serum levels) 4, 5
- Maximum possible number of tablets ingested (even one or two tablets of certain medications can be fatal in toddlers) 6, 4
- Any identifying characteristics of the tablet (color, shape, markings, packaging) 4
- Presence of symptoms (onset may be delayed for some agents) 4
- Child's weight (essential for calculating toxic doses and antidote dosing) 1, 2
Risk Stratification
A small number of pharmaceuticals can produce life-threatening toxicity in children from just one or two tablets. 6, 4 High-risk medications include:
- Opioids (most common cause of fatal pediatric poisoning) 5, 7
- Sedative/hypnotics and benzodiazepines 5
- Cardiovascular drugs (beta blockers, calcium channel blockers, antidysrhythmics) 5, 7
- Camphor, topical imidazolines, diphenoxylate-atropine (as little as 1/4 teaspoon or 1/2 tablet can be fatal) 6
- Tricyclic antidepressants 7
All unknown ingestions warrant referral to an emergency department given the potential for serious or fatal consequences. 6, 4
Decontamination Strategy
What NOT to Do
Do NOT administer ipecac syrup—it should never be used as first aid treatment for acute poisoning. 1 This represents a critical change from older practices. 1
Activated Charcoal Administration
Activated charcoal is the decontamination method of choice if the child can be treated within 1-2 hours of ingestion. 2, 8
Dosing by age: 2
- 0-10 years: 1-3 heaping tablespoons (10-25g) mixed in minimum 8 ounces of liquid
- 10-12 years: 3-6 tablespoons (25-50g) mixed in minimum 8 ounces of liquid
- >12 years: 3-12 tablespoons (25-100g) mixed in minimum 8 ounces of liquid
Mix well and have the child drink the entire mixture. 2 Repeat the dose immediately if possible. 2
Important Contraindications
Do NOT give activated charcoal if: 6
- Significant camphor ingestion (risk of seizures)
- Topical imidazoline ingestion (risk of CNS depression)
- Diphenoxylate-atropine (Lomotil) ingestion (risk of respiratory depression)
- Child cannot protect airway
Specific Antidote Considerations
For Respiratory Depression
If combined opioid and benzodiazepine poisoning is suspected, administer naloxone FIRST before considering other antidotes. 1, 3
- Naloxone dose: 0.1 mg/kg IV/IO/IM 1
- Titrate to reversal of respiratory depression and restoration of protective airway reflexes (not full consciousness) 1
For Pure Benzodiazepine Overdose
Flumazenil may be considered in select patients with respiratory depression from pure benzodiazepine poisoning, but has significant contraindications. 3
DO NOT use flumazenil if: 3
- Benzodiazepine dependence suspected
- History of seizure disorders
- Suspected co-ingestion of tricyclic/tetracyclic antidepressants
- Co-ingestion of other seizure-threshold lowering drugs
- Hypoxia present
Pediatric flumazenil dose: 0.01 mg/kg IV 3
Monitoring and Observation
Asymptomatic children require careful monitoring as onset of toxicity may be delayed for some agents. 4 The child in the case report was observed overnight despite being asymptomatic. 4
Key Monitoring Parameters
- Vital signs (heart rate, blood pressure, respiratory rate, temperature) 7
- Mental status changes 7
- Cardiovascular abnormalities (obtain ECG for suspected beta blocker, tricyclic antidepressant, or antidysrhythmic ingestion) 7
- Seizure activity 7
- Gastrointestinal symptoms 7
Laboratory Testing
Consider obtaining: 7
- Electrolytes, serum creatinine, serum bicarbonate
- Anion gap calculation
- Specific drug levels if substance identified (e.g., acetaminophen, salicylates)
Special Considerations for Preventing Hypothermia
If decontamination is needed, use warm shower water at lower pressure to prevent hypothermia and additional skin damage. 1 In cold climates, use heat lamps and blankets during decontamination. 1
Common Pitfalls to Avoid
- Failing to recognize that even 1-2 tablets can be fatal in young children for certain medications 6, 4
- Assuming the child is safe because they are asymptomatic (toxicity may be delayed) 4
- Administering flumazenil without ruling out contraindications (can precipitate seizures or dysrhythmias) 3
- Using ipecac (contraindicated in modern practice) 1
- Delaying Poison Control contact (should be immediate) 1, 2
- Failing to provide adequate respiratory support while focusing on pharmacological interventions 3