Is your care of pediatric poisonings outdated?

Knowing the correct interventions can save lives

When a child presents with assessment findings that just don’t add up, poisoning often can explain the situation, says Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, emergency, trauma, and neurological clinical nurse specialist at Oregon Health and Sciences University in Portland.

"Why does this child have a profound metabolic acidosis? Why is this boy seizing? What is a 3-year-old doing in V-fib?" she asks. "Think toxicology!"

To dramatically improve care of this group, take the following steps:

Find out the details about the ingestion.

Try to discover specific information about the time of ingestion, actual amount, substance or substances involved, and any home or pre-hospital interventions, says Criddle. Answer the following three questions, she says: What is the child’s current status? Has it changed post-ingestion? Is it changing quickly?

"Any ingestion that produces seizures, extreme lethargy/coma, or cardiac or respiratory alterations is serious and can progress quickly," warns Criddle.

Although exposures are very common, it is unusual for a child to have a severe reaction to common household substances such as cosmetics, cleaning solutions, or plants, says Criddle.

"Most serious poisonings in children occur in adolescents who deliberately ingest a substance with recreational or suicidal intent," she notes. "The other pediatric group who really get into trouble is the small child who ingests potent pharmaceutical agents such as cardiac meds."

Know risks of ingesting multiple substances.

The percentage of people who die after ingesting a single agent is extremely low, says Criddle. "The vast majority of fatal poisonings occur when two or more substances are involved," she says. "The presence of polypharmacy should always be a big red flag."

Know current treatments.

Syrup of ipecac is no longer considered appropriate to treat most poisonings, and there is a lack of evidence to support the use of gastric lavage, says Criddle.

Activated charcoal is the single most effective agent in the treatment of ingested toxins, Criddle says. "It works for a wide variety of common poisonings," she says. "However, it is important to note that it is ineffective for alcohol, iron, heavy metal, acid, or alkali ingestions."

Understand side effects of antidotes.

While textbooks contain an impressive list of antidotes, many are expensive, rarely used, or carry significant side effects, says Criddle.

Antidotes such as naloxone, oxygen, D50, sodium bicarbonate, calcium chloride, and N-acetylcysteine are cheap, safe, and effective, she says. "Fab fragments, fomepizol, flumazenil, and glucagon are effective but expensive," she says. "Physostigmine can cause as many problems as it is designed to cure."

Make sure that lab levels are measured the same way as the referring facility.

When a child had overdosed on acetaminophen and showed very high acetaminophen levels, plasmaphoresis was ordered based on those labs, recalls Barbara Coffel, RN, MSN, clinical nurse specialist for the neonatal pediatric critical care transport team at Riley Children’s Hospital in Indianapolis.

"It turned out that we were looking at deciliters per liter, and the lab that did the values reported the levels in a different manner," says Coffel. This problem can occur when a child has elevated drug levels done at a referring facility, and treatment is begun immediately because of critical lab values, she explains.

Fortunately, the discrepancy was caught in the nick of time, says Coffel. Otherwise, the child would have had a dialysis-grade catheter placed and unnecessary aggressive treatment including administration of heparin with potential side effects, she explains.

"To be certain that the labs are reporting like information, it would be worth the time involved to repeat values before initiating aggressive treatment," says Coffel. "Be certain that you are comparing apples and apples, not apple and oranges."

Do a toxicology screen for abuse cases.

You may be treating head injuries for a suspected nonaccidental trauma, but this same child may have ingested or been given a toxic substance, says Coffel. "So as a part of a workup on abuse cases, we do a toxicology screen," she says. "If toxicology issues are undetected, this can really skew the neuro assessment that you get."

Resources

For more information on pediatric poisonings, contact:

Barbara Coffel, RN, MSN, Clinical Nurse Specialist, Riley Neonatal Pediatric Critical Care Transport Team, Riley Children’s Hospital, 702 Barnhill Drive, Room 1960, Indianapolis, IN 46202-5210. Telephone: (317) 274-4386. Fax: (317) 274-4354. E-mail: BCoffel@clarian.org.

Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, Emergency, Trauma, and Neurological Clinical Nurse Specialist, Oregon Health and Sciences University, Mail Code UHS8Q, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201. Telephone: (503) 494-1350. Fax: (503) 494-7441. E-mail: criddlel@ohsu.edu.