This handout is for pediatric toxic ingestions (acute). Your care team identified this based on: caregiver-reported or witnessed ingestion of medication/household substance in a child (aap/aapcc npds pathway).
Other reasons your team may use this plan: found-pill-bottle scenario in toddler with unknown amount missing — exploratory ingestion (aap/aapcc); altered mental status with toxidrome features (anticholinergic / opioid / sympathomimetic / sedative-hypnotic / cholinergic) in a child; unexplained hypoglycemia in a child — sulfonylurea or insulin ingestion until proven otherwise.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| activated charcoal | 1 g/kg PO/NG (max 50 g single dose) | PO/NG | single dose if within 1-2 h of ingestion + airway protected | AAP/AAPCC + AACT/EAPCCT position statements — single-dose charcoal effective only within 1-2 h; AVOID if airway not protected, caustic ingestion, or hydrocarbon (aspiration risk) (AACT/EAPCCT activated-charcoal position statement) |
| acetylcysteine | IV Prescott protocol: 150 mg/kg over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h (total 300 mg/kg over 21 h) | IV | single 3-phase protocol | Heard NEJM 2008 PMID 18635433 — IV N-acetylcysteine indicated when APAP level above 4-h treatment line on Rumack-Matthew nomogram; alternative PO 140 mg/kg load then 70 mg/kg q4h x 17 doses (Heard NEJM 2008) |
| deferoxamine | 15 mg/kg/h IV continuous infusion | IV | continuous | ACMT/AAPCC iron-toxicity guidance — chelate free iron in stage 2-4 toxicity; urine "vin rose" color indicates active chelation (AAP Red Book 2024-2027, Lexicomp Peds) |
| octreotide | 1-1.5 mcg/kg SC q6h | SC/IV | q6h x at least 24 h | Inhibits insulin release; mandatory adjunct to dextrose for sulfonylurea ingestion (children: low single-bite high-dose exposure to second-generation sulfonylureas like glyburide/glipizide); continue at least 24 h (Lexicomp Peds, ACMT toxic-ingestion guidance) |
| glucagon | 50 mcg/kg IV bolus then 0.05-0.15 mg/kg/h IV infusion | IV | bolus then continuous | Bypasses beta-adrenergic blockade via direct cAMP stimulation; first-line for symptomatic BB overdose; add HIE if refractory (ACMT position statement on BB toxicity; AAP Red Book 2024-2027) |
| insulin, regular, human | 1 U/kg IV bolus then 0.5-1 U/kg/h infusion with D10W titrated to euglycemia | IV | bolus then continuous | ACMT/AAPCC HIE guidance for CCB/BB toxic shock — improves myocardial contractility; mandatory D10W co-infusion + frequent glucose monitoring + K+ monitoring (ACMT high-dose-insulin position statement) |
| sodium bicarbonate | 1-2 mEq/kg IV bolus then continuous infusion (150 mEq in 1 L D5W) titrated to serum pH 7.45-7.55 and urine pH 7.5-8.0 | IV | bolus then continuous as needed | Reverses Na-channel blockade in TCA (QRS narrowing); enhances renal salicylate elimination via ion trapping; AVOID in pH >7.55 (ACMT TCA + salicylate guidance; AAP Red Book 2024-2027) |
| naloxone | 0.01-0.1 mg/kg IV/IM/IN/SC q2-3 min PRN; titrate to respiratory drive not full alertness | IV/IM/IN | q2-3 min PRN until respiratory drive restored | Reverses opioid-induced respiratory depression; short half-life so anticipate re-narcotization (especially methadone, buprenorphine, fentanyl analogs) — infusion 2/3 of waking dose per h if needed (AAP Red Book 2024-2027, Lexicomp Peds) |
| methylene blue | 1-2 mg/kg IV over 5 min | IV | single dose; may repeat in 1 h if methemoglobin remains >30% or symptomatic | Reduces methemoglobin via NADPH-methemoglobin reductase; CONTRAINDICATED in G6PD deficiency (paradoxical hemolysis); offending agents include benzocaine, dapsone, nitrites, sulfonamides, local anesthetics (ACMT methemoglobinemia position statement; AAP Red Book 2024-2027) |
| hydroxocobalamin | 70 mg/kg IV over 15 min | IV | single dose; may repeat 70 mg/kg if persistent toxicity | Binds cyanide to form cyanocobalamin (excreted renally); first-line in suspected smoke inhalation with cyanide features (lactate >8, altered MS, hypotension); avoid nitrites in concurrent CO toxicity (ACMT/AACT hydroxocobalamin position statement; AAP Red Book 2024-2027) |
| digoxin-specific antibody fragments (DigiFab) | Per package insert: 1 vial neutralizes 0.5 mg digoxin; calculate from ingested dose, serum level, or empiric (10 vials acute / 6 vials chronic; pediatric per weight); reconstitute and infuse over 30 min | IV | single dose calculated per Fab vials needed | DigiFab dose by package insert formula; non_pharm composite (no single RxCUI); indicated for life-threatening digoxin toxicity with K+ >5, ventricular arrhythmia, or shock (ACMT digoxin-toxicity guidance; AAP Red Book 2024-2027) |
| glucose | D25W 2-4 mL/kg IV for hypoglycemia <60 mg/dL infant or <70 mg/dL child; D10W maintenance infusion at GIR 6-8 mg/kg/min | IV | bolus then continuous for sulfonylurea | Reverses hypoglycemia from sulfonylurea / insulin / salicylate / ethanol / quinine; pair with octreotide for sulfonylurea (Lexicomp Peds; ACMT) |
| mannitol | 0.5-1 g/kg IV over 20 min | IV | single, may repeat in 30 min | Cerebral edema rescue when toxic ingestion causes acute liver failure with encephalopathy (e.g., severe APAP toxicity); cross-reference peds.reye-syndrome.v1 (AAP Red Book 2024-2027; Heard NEJM 2008) |
Plan: Pediatric toxic ingestions — decontamination + per-toxin antidotes (Poison Control mandatory)
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: AAP / AAPCC NPDS Poison Center Pathway + ACMT position statements (HIE, methylene blue, hydroxocobalamin, deferoxamine, digoxin-Fab) + AAP Red Book 2024-2027 + Lexicomp Peds + Heard NEJM 2008 (NAC for APAP)