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peds.toxic-ingestions.v1

Pediatric toxic ingestions (acute)

pediatricsacutepediatricacuteinpatient
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NEW pediatric dossier (lane-D 2026-05-26). Manifest authored at prisma/seed/manifests/peds.toxic-ingestions.v1.ts. All RxCUIs RxNav-verified (forward + reverse) on 2026-05-26: acetylcysteine 197, deferoxamine 3131, octreotide 7617, glucagon 4832, sodium bicarbonate 36676, naloxone 7242, methylene blue 6878, hydroxocobalamin 5514, activated charcoal 272, insulin regular 253182, glucose (dextrose) 4850, mannitol 6628. Digoxin-Fab listed as non_pharm composite (no single RxCUI; package-insert dosing). PMIDs verified via PubMed MCP: 18635433 Heard 2008 NEJM NAC for APAP; 26900382 Glauser AES 2016 status epilepticus cross-reference; 19403508 Christian 2009 abusive head trauma cross-reference. Workup IDs omitted as not in registry: toxic_ingestion, opioid_overdose, methemoglobinemia, organophosphate — orchestrator may add later. Used safe registry workups: workup.encephalopathy, workup.first_seizure, workup.pediatric_fever. Calculator gaps: Rumack-Matthew nomogram, iron Smith stages, Wedge index for digoxin not in registry — used calc.anion_gap (resolves) for initial gap-acidosis flagging. Scope: representative antidotes for common life-threatening pediatric ingestions; dedicated per-toxin sibling engines (e.g. peds.acetaminophen-overdose.v1, peds.iron-poisoning.v1, peds.organophosphate-poisoning.v1) are deferred follow-up builds.

Entry points (5)

  • history
    Caregiver-reported or witnessed ingestion of medication/household substance in a child (AAP/AAPCC NPDS pathway)
    witnessed_or_suspected_ingestion_child
  • history
    Found-pill-bottle scenario in toddler with unknown amount missing — exploratory ingestion (AAP/AAPCC)
    found_pill_bottle_unknown_amount
  • symptom
    Altered mental status with toxidrome features (anticholinergic / opioid / sympathomimetic / sedative-hypnotic / cholinergic) in a child
    toxidrome_altered_mental_status_child
  • lab_abnormality
    Unexplained hypoglycemia in a child — sulfonylurea or insulin ingestion until proven otherwise
    unexplained_hypoglycemia_in_child
  • lab_abnormality
    Unexplained high anion-gap acidosis in a child — toxic ingestion differential (salicylate, methanol, ethylene glycol, iron)
    unexplained_high_anion_gap_acidosis_child

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Toddler exploratory vs adolescent intentional changes risk profile + disposition (AAP/AAPCC)
  • weightrequired
    demographic • used at CONTEXT
    All antidote dosing weight-based (AAP Red Book 2024-2027, Lexicomp Peds)
  • substance_ingested_and_doserequired
    history • used at FRAME
    Identify toxin + magnitude — drives antidote selection (Poison Control)
  • time_of_ingestionrequired
    history • used at FRAME
    Charcoal window <1-2 h; APAP nomogram requires 4 h timing (Rumack-Matthew)
  • co_ingestantsrequired
    history • used at CONTEXT
    Combined toxicity (e.g., alcohol + APAP raises hepatotoxicity); affects monitoring
  • sbprequired
    vital • used at RED_FLAGS
    Shock detection for CCB/BB/TCA; affects HIE + bicarbonate decisions (ACMT)
  • hrrequired
    vital • used at RED_FLAGS
    Bradycardia (BB/CCB/digoxin) vs tachycardia (TCA/sympathomimetic/anticholinergic)
  • rrrequired
    vital • used at RED_FLAGS
    Hypoventilation (opioid/sedative) vs hyperventilation (salicylate)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia or normal SpO2 with cyanosis (methemoglobinemia)
  • gcsrequired
    vital • used at RED_FLAGS
    Airway protection decision; severity (AAP)
  • glucose_fingerstickrequired
    lab • used at INITIAL_WORKUP
    Sulfonylurea ingestion + reversible cause of altered MS (AAP)
  • acetaminophen_level_4h
    lab • used at INITIAL_WORKUP
    APAP level at 4 h post-ingestion drives Rumack-Matthew nomogram (Heard NEJM 2008 PMID 18635433)
  • salicylate_level
    lab • used at INITIAL_WORKUP
    Mandatory in any intentional overdose; can be occult precipitant of acidosis (AAP)
  • bmp_anion_gaprequired
    lab • used at INITIAL_WORKUP
    Gap acidosis flags salicylate, iron, methanol, ethylene glycol (AAP)
  • lft_inrrequired
    lab • used at INITIAL_WORKUP
    Baseline hepatotoxicity (APAP); trend q12 h while on NAC (Heard NEJM 2008)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    QRS >100 ms = TCA Na-channel blockade; QTc prolongation; brady from CCB/BB/digoxin (ACMT)
  • abdominal_xr_for_radiopaque
    imaging • used at BRANCHING_WORKUP
    Iron tablets, lead, heavy metals are radiopaque — visualize pill burden (AAP)

12-phase flow (12)

  1. 1FRAME
    Confirm ingestion (substance, time, dose, co-ingestants); differentiate from medical illness (DKA, sepsis, meningitis, intussusception, head trauma)
    inputs: substance_ingested_and_dose, time_of_ingestion
    advance: Ingestion confirmed + Poison Control contacted (1-800-222-1222 in US)
  2. 2ENTRY
    Caregiver-reported ingestion, found pill bottle, toxidrome on exam, unexplained hypoglycemia or acidosis (AAP/AAPCC)
    inputs: age
    advance: Entry trigger captured
  3. 3CONTEXT
    Weight (all dosing), age, time of ingestion, household medications, prior medical illnesses, co-ingestants, ED arrival vitals + GCS (AAP)
    inputs: weight, co_ingestants
    advance: Context complete + Poison Control consulted
  4. 4RED_FLAGS
    Coma/airway compromise, refractory shock, ventricular arrhythmia, severe acidosis, seizure, severe hypoglycemia, methemoglobinemia (chocolate-brown blood, cyanosis unresponsive to O2), QRS >100 ms (ACMT)
    inputs: sbp, hr, rr, spo2, gcs
    advance: Life-threatening features identified + airway/breathing/circulation addressed
  5. 5INITIAL_WORKUP
    Fingerstick glucose; iSTAT (BMP, lactate, ABG/VBG); APAP level at 4 h; salicylate level; ethanol; LFTs + INR + ammonia (APAP); 12-lead ECG; UA + urine pregnancy in adolescent; urine drug screen (limited utility)
    inputs: glucose_fingerstick, bmp_anion_gap, lft_inr, ecg_12_lead
    actions: panel.metabolic, panel.cbc, panel.renal, panel.lft, panel.abg
    advance: Baseline labs returned + Poison Control input documented
  6. 6BRANCHING_WORKUP
    Specific levels (iron level + abdominal XR for radiopaque, digoxin level, lithium, sulfonylurea sequencing); repeat APAP at 4-8 h for extended-release; CT head if focal neuro; LP if febrile + altered (AAP)
    inputs: abdominal_xr_for_radiopaque
    advance: Toxin-specific workup initiated
  7. 7DIFFERENTIAL
    Primary toxidrome categorization (sympathomimetic, anticholinergic, cholinergic, opioid, sedative-hypnotic, hallucinogenic, serotonergic, NMS); differential to medical mimics (DKA, sepsis, meningoencephalitis, intussusception in toddler with altered MS, head trauma)
    advance: Differential narrowed; toxidrome assigned
  8. 8RISK_STRATIFICATION
    Rumack-Matthew nomogram for APAP; QRS >100 ms with TCA = severe; iron stages 1-5 (Smith); Wedge index for digoxin; AGE-2/3 features (ACMT)
    inputs: ecg_12_lead
    advance: Severity tier + antidote indication documented
  9. 9TREATMENT
    Step 1: ABC + airway protection + supportive care + IV access; Step 2: gastric decontamination (activated charcoal 1 g/kg PO/NG within 1-2 h if airway protected); Step 3: per-toxin antidote (NAC for APAP, deferoxamine for iron, octreotide for sulfonylurea, glucagon for BB, HIE for CCB/BB toxic shock, sodium bicarbonate for TCA QRS widening or salicylate alkalinization, naloxone for opioid, methylene blue for methemoglobinemia, hydroxocobalamin for cyanide, digoxin-Fab for digoxin); Step 4: extracorporeal removal (HD for salicylate >100, lithium >4, severe ethylene glycol/methanol)
    inputs: weight, glucose_fingerstick
    advance: Antidote initiated + Poison Control plan documented
  10. 10DISPOSITION
    PICU for any antidote infusion requiring titration, severe toxicity, intubated, ECMO consideration; ward for observation/monitoring once stable; psychiatric admission for intentional adolescent overdose after medical clearance (AAP)
    advance: Disposition + level of care set
  11. 11MONITORING
    Toxin-specific: APAP LFTs/INR q12 h; iron stages 1-5 over 48 h; ECG continuous for TCA/digoxin; glucose q1 h for sulfonylurea ingestion x 24 h minimum; methemoglobin level for methylene blue
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Pediatrician + household safe-storage counseling + AAPCC poison-prevention education for accidental; psychiatry + outpatient mental health + safety planning for intentional adolescent overdose (AAP/AAPCC; AAP Bright Futures)
    advance: Follow-up + prevention plan documented