TABLE 102.4 GENERAL APPROACH TO THE KNOWN OR SUSPECTED INTOXICATION Initial life support phase Airway: Maintain patency, assess protective reflexes Breathing: Adequate tidal volume? ABG or ETCO2 ? Circulation: Secure IV access, assess perfusion Disability: Level of consciousness (AVPU or GCS) Pupillary size, reactivity Drugs: Dextrose (rapid bedside test) Oxygen Naloxone (Other ALS medications) Decontamination: Ocular—copious saline lavage Skin—copious water, then soap and water GI—consider options Evaluation and detoxification phase History —Brief, focused Known toxicant: Estimate amount Elapsed time Early symptoms Home treatment Significant underlying conditions Suspected but unknown toxicant—consider poisoning if: Patient: Acute onset of illness Pica-prone age History of pica, ingestions Current household “stress” Multiorgan system dysfunction Significantly altered mental status Puzzling clinical picture Family: Medications at home Recent illness (under treatment) Social: Grandparents visiting Holiday parties, other events, new baby Physical examination Vital signs Level of consciousness, neuromuscular tone, reflexes Eyes—pupil size/reactivity, extraocular movements, fundi, nystagmus Mouth—corrosive lesions, odors Cardiovascular—rate, rhythm, perfusion Respiratory—rate, chest excursion, air entry GI—motility, corrosive effects Skin—color, bullae or burns, diaphoresis, piloerection Odors Laboratory (individualize) CBC, co-oximetry ABG, serum osmolarity EKG/cardiac monitor Chest radiograph, abdominal radiograph Electrolytes, BUN/creatinine, glucose, calcium, liver function panel Urinalysis Urine screen for common drugs (amphetamine, benzodiazepines, barbiturates, cocaine, marijuana, opiates, phencyclidine) Quantitative toxicology tests (including acetaminophen, aspirin, ethanol) Assessment of severity/diagnosis Clinical findings Laboratory abnormalities (with consideration of anion, osmolar gaps) Toxidromes ( Table 102.6 ) Specific detoxification Reassess ABCDs Institute appropriate GI decontamination (if not already under way) Urgent antidotal therapy Consider excretion enhancement Continue supportive care ABG, arterial blood gas; ETCO2 , end-tidal carbon dioxide; AVPU, A lert, V erbal, P ain, U nresponsive; GCS, Glasgow Coma Scale; ALS, advanced life support; GI, gastrointestinal; CBC, complete blood cell count; EKG, electrocardiogram; BUN, blood urea nitrogen Empiric drug treatment is warranted for most symptomatic poisoned children with altered mental status Administer humidified oxygen and monitor blood oxyhemoglobin saturation by pulse oximetry Assess ventilatory effort by auscultation and continuously by end-tidal CO2 , if available If rapid bedside glucose testing is not available, a trial dosage of 0.25 to g/kg glucose as 10% to 25% solution should be infused It should be noted that drug- or toxicant-induced hypoglycemia does not present uniformly with coma or seizures Almost any neuropsychiatric sequelae of hypoglycemia may predominate, including aphasia, slurred or dysarthric speech, and focal neurologic signs Adrenergic signs, such as diaphoresis and tachycardia, are not uniformly present Hypoglycemia is a complication seen in ingestions of ethanol, oral hypoglycemics, β-blockers (BBs), salicylates, and, of course, insulin injection As basic as this intervention seems, in our experience, it is still one of the most often delayed critical treatments in the management of the poisoned patient Empiric naloxone therapy is as important in potentially poisoned toddlers with altered mental status as it is in adults As opioid prescriptions in the adult population have increased in recent years, so too has the availability of these agents to young children Many households contain a variety of oral opioid analgesic agents, as well as cough medicines (codeine, dextromethorphan), antidiarrheal agents (loperamide, diphenoxylate), and partially naloxone-responsive antihypertensive agents such as clonidine In addition, the possibility of exploratory ingestion of a “stash” of illicit opioids does exist Thus, naloxone should be used as a therapeutic/diagnostic trial when there is a reasonable possibility that altered mental status is drug induced Previous recommendations have based dosing on weight (e.g., 0.01 to 0.1 mg/kg); however, several sources now prefer a unified pediatric dose of to mg for acute overdose patients of all ages (outside the neonatal period) Such an approach conceptualizes naloxone dosing as based on total narcotic load and number of opioid receptors that require competition for binding sites In general, this latter approach is easier to remember and has not been associated with complication in the ED Adolescent patients with a strong clinical picture for opioid intoxication (without habituation) may receive 2-mg bolus doses every minutes, up to a total dose of to 10 mg, because several congeners of morphine (e.g., propoxyphene, illicit fentanyl derivatives, pentazocine, oxycodone, methadone) may require these higher doses If chronic abuse is suspected, lower initial doses (0.04 mg) are warranted Empiric administration of flumazenil after an unknown drug overdose is not recommended as it may precipitate seizures and life-threatening benzodiazepine withdrawal (see “Central Nervous System Sedative-Hypnotics” section) Lastly, thiamine (100 mg IV), although routinely administered to adult overdose patients who receive hypertonic glucose to obviate precipitating Wernicke encephalopathy, is not generally necessary in the pediatric population Perhaps it should be considered in adolescent patients who may be ... young children Many households contain a variety of oral opioid analgesic agents, as well as cough medicines (codeine, dextromethorphan), antidiarrheal agents (loperamide, diphenoxylate), and partially... based dosing on weight (e.g., 0.01 to 0.1 mg/kg); however, several sources now prefer a unified pediatric dose of to mg for acute overdose patients of all ages (outside the neonatal period) Such... hypertonic glucose to obviate precipitating Wernicke encephalopathy, is not generally necessary in the pediatric population Perhaps it should be considered in adolescent patients who may be