covered in detail in Chapter A General Approach to the Ill or Injured Child In the context of the poisoned child, a few points deserve special emphasis In addition to the usual signs of airway obstruction, pay special attention to evidence of disturbed airway protective reflexes, or to signs of airway injury as with a caustic ingestion Many poisoned patients will vomit, and some may be administered charcoal, which poses an aspiration risk Elective endotracheal intubation (Chapter Airway ) may thus be indicated at a lower threshold in this context than in another child with comparable central nervous system (CNS) depression Anticipate imminent respiratory failure in the deeply comatose poisoned child Cyanosis and overt apnea are late findings with progressive drug-induced medullary depression Thus, clinical or laboratory assessment of early ventilatory insufficiency is critical in such patients to avoid the chaos of a precipitous respiratory arrest; continuously monitor the patient with end-tidal CO2 and pulse oximetry Likewise, it is far easier to establish intravenous (IV) access in a child with normal circulatory status than in a child in shock, so establish an IV line early After securing the airway, ensuring effective breathing, and supporting circulation (ABCs), evaluate the poisoned patient for neurologic “d isability,” and the need for empiric “d rug” treatment, and emergent “d econtamination.” Level of consciousness may be assessed rapidly and repeatedly with a semiquantitative scale such as the Glasgow Coma Scale or the AVPU (spontaneously a lert, response to v erbal stimulation or p ain, or u nresponsive) scale Pupillary size and reactivity may be quickly noted Rapid changes in mental status are common in serious intoxications and may herald precipitous cardiorespiratory failure