Use these tips to assess and treat ingestions

By Theresa Cromling, RN
Advanced Clinical Staff Nurse
Emergency Department
Duke University Medical Center, Durham, NC
Coordinator, The National Safe Kids Campaign, Durham County, NC

One busy afternoon in the ED, a mother brought her 3-year-old daughter to triage after an ingestion of an unknown quantity of the brother’s clonidine tablets. The mother stated that the daughter could have ingested up to 10 pills, since the mother kept extra pills in a bag in her purse.

The child was lethargic and pale, and her respirations at triage were 10. She was placed on cardiac and oxygen saturation monitors, which showed a tachycardic rate of 136, blood pressure of 136/64, oxygen saturation at 96%, and respirations of 16 to 18. Intravenous access was initiated with a No. 22 gauge catheter in her right hand, and she was given an initial bolus of normal saline at 20 cc/kg.

A No. 12 French nasogastric tube and 200-cc warm normal saline were used to irrigate her stomach contents and evacuate many pill fragments.

Within nine minutes of arrival at triage, she had been stabilized and the charcoal administration was completed. Her blood pressure dropped to 80/44 due to the mode of action of clonidine, which has a central sympatholytic, down-regulating effect. As we stimulated her, her mental status, pulse, and respiratory rate increased, but she continued to be somnolent.

Since clonidine ingestions resemble narcotic overdoses, she was given 1 mg of naloxone, and her altered mental status lightened for a short time, but her respiratory status was unchanged. She was admitted to the pediatric intensive care unit for observation, because the half-life of clonidine is 12-16 hours.

Rapid assessment and initiation of interventions are paramount in having desirable outcomes after toxic ingestions in children. Because children are smaller and have faster metabolic rates than adults, they are at a significantly greater risk of being harmed from the exposure.

Initial assessment of the child that has been exposed to a toxin consists of an evaluation of the ABCs: airway, breathing, and circulation.

The secondary survey must include a history of the event. This can be the best way to identify the toxin. Where was the child: in the garage, in the yard, or the kitchen? What products are available in these areas? When was the last time the caregiver saw the child acting normally?

Physical assessment also may help to identify the toxin. The child may be displaying a toxidrome — a cluster of signs and symptoms that can suggest a specific toxin or type of product — with treatment initiated accordingly. For example, the toxidrome for anticholinergic medicines such as antihistamines and tricyclic antidepressants is "red as a beet" (flushing), "dry as a bone" (dry mucus membranes), "hot as a hare" (febrile), and "mad as a hatter" (delirium). These symptoms may be caused by some plants, also.

Specific interventions depend on the toxin, and poison control centers are the best reference for parents as well as health care professionals. Syrup of ipecac should be administered only at the direction of a physician or the poison control center, because emesis is contraindicated with some toxins such as corrosives, and vomiting delays the use of charcoal.

Activated charcoal is administered as 1 gm/kg in children and 50-100 g in adults, and it is administered orally or through a nasogastric tube. The charcoal binds with the toxin and prohibits the absorption in the stomach and small intestine. Remember that charcoal stains whatever it touches, and that includes the patient’s teeth and the nurses’ scrubs!

There are some agents that do not bind with the charcoal. You can remember those toxins with the pneumonic "PHAILS": pesticides, hydrocarbons, acids/alkalis, iron, lithium, and solvents. Multiple doses of activated charcoal may be necessary for drugs such as phenobarbital, theophylline, and carbamazepine.

Overzealous administration should be avoided to prevent iatrogenic complications such as aspiration and bowel obstruction. A cathartic such as sorbitol may be given to older teens and adults, but it should be avoided in children and the elderly because of the potential for disrupting electrolytes with diarrhea.

An important point to keep in mind during evaluation is that the patient’s status may change and you must be prepared. Have a working monitor and suction equipment at the bedside, and assess your patient frequently. Know the normal vital sign parameters for the child’s age group.

Some medications have a very long half-life, so symptoms may persist for a prolonged time. The child with altered mental status has a high risk for falling, choking on secretions or charcoal, having a seizure, or experiencing respiratory difficulties so you must take the appropriate precautions.

[Editor’s note: The National Safe Kids Campaign is a Washington, DC-based nonprofit organization for the prevention of unintentional childhood injury. Cromling can be reached at Duke University Medical Center, Box 3869, Durham, NC 27705. Telephone: (919) 416-8202. Fax: (919) 286-9219. E-mail: croml001@mc.duke.edu.]