Steps

Rationale/Points of Emphasis

1 Determine whether the child has a pulse and is breathing. Be prepared to initiate cardiopulmonary resuscitation and/or assist with intubation (see Chapter 25 and Chapter 58 ). Assess mental status.

Cardiac arrest may occur as a result of respiratory compromise. Compromised airway/respiratory depression and altered mental status are common with certain exposures.

2 Obtain intravenous access, if necessary.

Enables immediate administration of fluids and necessary medication.

3 Have appropriate antidote or reversal agent ready to administer on healthcare prescriber’s order. Examples include

• Naloxone (Narcan) to children with respiratory depression

• Thiamine to malnourished children

• Glucose to any child with an altered mental status

Have available to treat or reverse effects of the poison. Naloxone is an opioid antagonist. Thiamine helps control energy metabolism and a deficiency may impair glucose utilization. Administration of glucose excludes hypoglycemia as the cause of altered mental status.

4 Look for evidence of pill fragments, poison plant matter, or odors in or near mouth. Inspect clothing for the presence of possible toxic substances.

May aid in verification of toxic substance, which will aid in delivery of an appropriate treatment.

Steps

Rationale/Points of Emphasis

1 Obtain child’s demographic information:

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  Weight

  
  
• 
  

  Age

  
  
• 
  

  Sex

The ability to metabolize a drug changes with age and dose; toxicity often relates to the size of the child. Information on gender is obtained for epidemiological tracking.

2 Obtain exposure information:

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  Name of the product

  
  
• 
  

  Amount of product to which the patient was exposed (if known)

  
  
• 
  

  Route of exposure

  
  
• 
  

  Time of exposure

  
  
• 
  

  Reason for exposure (intentional or unintentional)

There are many types of medications on the market with varying ingredients and amounts; the route and time of exposure may predict the level of toxicity and outcome. Intentional overdoses often involve large amounts and multiple ingestions. Amount of product can predict the effects. Many poisonings and medication overdoses involve more than one agent, resulting in compounding of effects.

3 Obtain symptom history:

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  Onset

  
  
• 
  

  Duration

  
  
• 
  

  Progression

Determining whether the symptoms have started, continued, lessened, or worsened helps determine the outcome. Sustained-release or extended-release products have the potential to create prolonged or delayed clinical effects.

4 Obtain medical/medication history:

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  Medications that the patient is currently taking

  
  
• 
  

  Medications that are available in the household including over-the-counter products and nutritional supplements.

Helps to form a more complete differential diagnosis.

Steps

Rationale/Points of Emphasis

1 Perform hand hygiene.

Reduces transmission of microorganisms.

2 Determine respiratory rate. Note the depth, pattern, and effort. Place pulse oximeter for continuous readings.

Changes in respiratory rate are affected by direct effects on the respiratory center, either suppression or stimulation; increased metabolic requirements; or acid-base disorders. Tachypnea is seen with aspirin, cocaine, and amphetamines, among other substances. Bradypnea is associated with agents that cause overall depressed central nervous system effects (e.g., barbiturates, clonidine, opioids, and ethanol).

3 Obtain pulse rate, and provide continuous electrocardiogram monitoring.

Many drugs and toxic exposures cause a change in heart rate and conduction. Bradycardia is seen with antidysrhythmics, clonidine, and opioids. Prolongation of the QRS complex can be seen with tricyclic antidepressants and selective serotonin reuptake inhibitors. Agents such as cocaine, theophylline, amphetamines, and organophosphates may cause tachycardia. Respiratory depression may result in hypoxia, causing dysrhythmias.

4 Obtain blood pressure.

Hypotension is noted in β-blockers, calcium channel blockers, methanol, and tricyclic antidepressants, among others. The most common reason hypotension develops in poisoned patients is intravascular volume depletion. Hypertension may develop because of increased release of norepinephrine. Some agents that may cause this effect include epinephrine, phenylephrine (Neo-Synephrine), and ergotamines that constrict blood vessels in the brain, and are used for migraine headaches.

5 If weight is unknown, weigh child or use length-based resuscitation tape to estimate weight.

The length-based resuscitation tape is a rapid noninvasive method that converts the child’s length into a probable weight range.

6 Obtain rectal temperature.

Slight variations in temperature are noteworthy in poison exposures. Rectal temperature is the preferred method because it reflects the core temperature.

Steps

Rationale/Points of Emphasis

1 Assess neurological status:

• Evaluate the child’s level of consciousness (orientation to people, place, and time) as age appropriate.

Level of consciousness changes can range from lethargy to coma. Agents that produce this effect include benzodiazepines, phenothiazine, sedative-hypnotics, and certain household products.

• If the child is comatose, determine whether the child responds to painful stimuli.

Indicates depth of coma.

• Determine pupil size and reactivity to light. Note any variation in symmetry, color, or movement of pupils, iris, or sclera.

Mydriasis occurs with tricyclic antidepressants, anticholinergics, cocaine, amphetamines, and drug withdrawal, whereas miosis occurs with opioids, and sedating agents; effects of organophosphates include both miosis and mydriasis. Nystagmus is seen with phencyclidine, carbamazepine, and other drugs.

• Observe for signs of visual or auditory hallucinations and seizures. If seizures occur, determine the type of seizure. Maintain seizure precautions.

Reduces the chance of injury if seizure occurs.

2 Perform abdominal assessment specific for distention and bowel sounds.

Hyperactive bowel sounds are associated with cholinergic crisis, as with organophosphates (dermal and oral exposures), and diminished bowel sounds are associated with anticholinergic effects. Drugs that cause a decrease in gastrointestinal motility include diphenhydramine and tricyclic antidepressants.

Determining the presence of bowel sounds is essential before the administration of activated charcoal. If the bowel is not active, activated charcoal will not have the intended effect and may cause further problems if it accumulates.

3 Evaluate the skin for moisture, turgor, and edema.

Agents that have anticholinergic effects, such as diphenhydramine and tricyclic antidepressants, cause skin to become warm, red, and dry. Anticholinergic agents such as tricyclic antidepressants and diphenhydramine, which blocks the action of acetylcholine, so causes anticholinergic effects, cause the skin to become warm, red, and dry. Organophosphates produce a cholinergic crisis, which manifests with diaphoresis.