Clinical Commander

Back to dossier
peds.toxic-ingestions.v1PRODUCTION
peds.toxic-ingestions.v1

Pediatric toxic ingestions (acute)

pediatricsacutepediatric
Hard-required inputs
0 / 14
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm ingestion (substance, time, dose, co-ingestants); differentiate from medical illness (DKA, sepsis, meningitis, intussusception, head trauma)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Ingestion confirmed + Poison Control contacted (1-800-222-1222 in US)

Patient inputs (17)

Toddler exploratory vs adolescent intentional changes risk profile + disposition (AAP/AAPCC)

All antidote dosing weight-based (AAP Red Book 2024-2027, Lexicomp Peds)

Combined toxicity (e.g., alcohol + APAP raises hepatotoxicity); affects monitoring

Identify toxin + magnitude — drives antidote selection (Poison Control)

Charcoal window <1-2 h; APAP nomogram requires 4 h timing (Rumack-Matthew)

Sulfonylurea ingestion + reversible cause of altered MS (AAP)

Gap acidosis flags salicylate, iron, methanol, ethylene glycol (AAP)

Baseline hepatotoxicity (APAP); trend q12 h while on NAC (Heard NEJM 2008)

QRS >100 ms = TCA Na-channel blockade; QTc prolongation; brady from CCB/BB/digoxin (ACMT)

Shock detection for CCB/BB/TCA; affects HIE + bicarbonate decisions (ACMT)

Bradycardia (BB/CCB/digoxin) vs tachycardia (TCA/sympathomimetic/anticholinergic)

Hypoventilation (opioid/sedative) vs hyperventilation (salicylate)

Hypoxemia or normal SpO2 with cyanosis (methemoglobinemia)

Airway protection decision; severity (AAP)

Iron tablets, lead, heavy metals are radiopaque — visualize pill burden (AAP)

APAP level at 4 h post-ingestion drives Rumack-Matthew nomogram (Heard NEJM 2008 PMID 18635433)

Mandatory in any intentional overdose; can be occult precipitant of acidosis (AAP)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningtca_overdose_with_qrs_widening
    TCA overdose with QRS >100 ms on 12-lead ECG (ACMT TCA-toxicity guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningccb_or_bb_toxic_shock
    CCB or BB overdose with refractory shock not responding to first-line resuscitation (ACMT HIE position statement)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningiron_ingestion_stage_3_to_5
    Iron ingestion with shock, acidosis, hepatic dysfunction, OR iron level >500 mcg/dL — Smith stages 2-5 (ACMT iron-toxicity guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningopioid_overdose_respiratory_depression
    Opioid overdose with respiratory depression (RR below age-appropriate threshold OR apnea OR cyanosis) — pediatric exploratory ingestion or adolescent intentional (AAP Red Book 2024-2027)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsalicylate_toxicity_severe
    Salicylate level >100 mg/dL (acute) OR >60 mg/dL with altered MS/acidosis OR any chronic salicylate with toxicity (ACMT salicylate position statement)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcyanide_toxicity_smoke_inhalation
    Known cyanide ingestion OR smoke inhalation with altered MS + lactate >8 + hypotension (ACMT cyanide-toxicity guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdigoxin_toxicity_severe
    Digoxin overdose with K+ >5, ventricular arrhythmia, shock, acute ingestion >4 mg, or chronic level >4 ng/mL (ACMT digoxin-toxicity guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereapap_above_treatment_line
    APAP level above 4-h treatment line on Rumack-Matthew nomogram OR staggered overdose OR time unknown with elevated LFT (Heard NEJM 2008 PMID 18635433)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremethemoglobinemia_with_symptoms
    Methemoglobinemia with symptoms (cyanosis, altered MS, chest pain) OR methemoglobin >25-30% (ACMT methemoglobinemia position statement)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresulfonylurea_hypoglycemia
    Sulfonylurea ingestion with hypoglycemia (any glipizide/glyburide exposure in toddler is potentially life-threatening) (Lexicomp Peds; ACMT)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereintentional_adolescent_overdose
    Adolescent intentional self-harm overdose with any toxin (AAP/AAPCC)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPrequiredDrives severity classification
Loading…

Recommended regimen

Pediatric toxic ingestions — decontamination + per-toxin antidotes (Poison Control mandatory)
axis: peds_tox_decontamination_and_antidotes
Selected axis "Pediatric toxic ingestions — decontamination + per-toxin antidotes (Poison Control mandatory)" by default fallback (first axis)
  • activated charcoal
    first line
    GI_adsorbent
    1 g/kg PO/NG (max 50 g single dose) • PO/NG • single dose if within 1-2 h of ingestion + airway protected (max: max 50 g single dose)
    triggers: within_1_to_2_h_ingestion, airway_protected_or_intubated, no_caustic_or_hydrocarbon
    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)
    rxcui 272
  • acetylcysteine
    first line
    antidote_glutathione_precursor
    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 (max: max single-bag concentration per Lexicomp Peds (typically max 150 mg/kg per loading dose capped at adult-equivalent of 15 g))
    triggers: acetaminophen_level_above_treatment_line_on_Rumack_Matthew_nomogram, staggered_overdose, time_unknown_with_elevated_LFT
    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)
    rxcui 197
  • deferoxamine
    first line
    iron_chelator
    15 mg/kg/h IV continuous infusion • IV • continuous (max: max 6 g/day, max 35 mg/kg/h short-term)
    triggers: iron_ingestion_with_shock_acidosis_or_iron_level_above_500_mcg_per_dL
    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)
    rxcui 3131
  • octreotide
    first line
    somatostatin_analog
    1-1.5 mcg/kg SC q6h • SC/IV • q6h x at least 24 h (max: max 50 mcg per dose)
    triggers: sulfonylurea_induced_hypoglycemia_recurrent_after_dextrose
    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)
    rxcui 7617
  • glucagon
    first line
    pancreatic_hormone_antidote
    50 mcg/kg IV bolus then 0.05-0.15 mg/kg/h IV infusion • IV • bolus then continuous (max: max bolus 10 mg single dose, infusion titrate to HR/BP response)
    triggers: beta_blocker_overdose_with_bradycardia_or_hypotension
    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)
    rxcui 4832
  • insulin, regular, human
    first line
    high_dose_insulin_euglycemia_HIE
    1 U/kg IV bolus then 0.5-1 U/kg/h infusion with D10W titrated to euglycemia • IV • bolus then continuous (max: max infusion typically 10 U/kg/h in refractory CCB shock per ACMT; titrate to inotropy not glucose)
    triggers: CCB_or_BB_toxic_shock_refractory_to_first_line_resuscitation
    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)
    rxcui 253182
  • sodium bicarbonate
    first line
    alkalinizing_agent
    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 (max: max bolus 50 mEq single dose per Lexicomp; titrate infusion to pH endpoints)
    triggers: TCA_overdose_with_QRS_above_100_ms, salicylate_overdose_with_acidosis_or_level_above_30_mg_per_dL, phenobarbital_overdose
    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)
    rxcui 36676
  • naloxone
    first line
    opioid_antagonist
    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 (max: max 2 mg single dose; if no response after 10 mg total, reconsider opioid as the toxin)
    triggers: opioid_overdose_with_respiratory_depression_RR_below_age_appropriate_threshold
    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)
    rxcui 7242
  • methylene blue
    first line
    methemoglobinemia_antidote
    1-2 mg/kg IV over 5 min • IV • single dose; may repeat in 1 h if methemoglobin remains >30% or symptomatic (max: max 7 mg/kg cumulative)
    triggers: methemoglobinemia_with_symptoms_or_methemoglobin_above_25_to_30_percent
    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)
    rxcui 6878
  • hydroxocobalamin
    first line
    cyanide_antidote
    70 mg/kg IV over 15 min • IV • single dose; may repeat 70 mg/kg if persistent toxicity (max: max 5 g single dose (adult-equivalent cap))
    triggers: known_or_suspected_cyanide_toxicity_smoke_inhalation_with_altered_MS_or_lactate_above_8
    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)
    rxcui 5514
  • digoxin-specific antibody fragments (DigiFab)
    first line
    digoxin_antidote
    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
    triggers: digoxin_overdose_with_arrhythmia_K_above_5_or_acute_ingestion_above_4_mg_or_chronic_level_above_4_ng_per_mL
    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
    rescue
    simple_sugar
    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 (max: use D10W for peripheral infusion; D25/D50 only via central or via large IV with caution)
    triggers: hypoglycemia_at_any_point_in_toxic_ingestion_workup
    Reverses hypoglycemia from sulfonylurea / insulin / salicylate / ethanol / quinine; pair with octreotide for sulfonylurea (Lexicomp Peds; ACMT)
    rxcui 4850
  • mannitol
    rescue
    osmotic_diuretic
    0.5-1 g/kg IV over 20 min • IV • single, may repeat in 30 min (max: max 4 g/kg/day cumulative)
    triggers: cerebral_edema_from_toxin_induced_hepatic_failure_with_grade_3_4_encephalopathy
    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)
    rxcui 6628

ed playbook — drug actions (5)

  1. 1. ABC + oxygen + IV access
    as needed • inhaled/IV • continuous
    trigger: All toxic ingestions
    ABC first; intubate for airway protection if GCS ≤ 8 or expected deterioration
  2. 2. activated charcoal 1 g/kg PO/NG
    1 g/kg (max 50 g) • PO/NG • single
    trigger: Within 1-2 h ingestion + airway protected + no caustic/hydrocarbon
    AACT/EAPCCT charcoal position statement
  3. 3. antidote per toxin
    per axis • IV • per axis
    trigger: Toxin-specific (NAC, deferoxamine, octreotide, glucagon, HIE, bicarbonate, naloxone, methylene blue, hydroxocobalamin, digoxin-Fab)
    Per Poison Control + ACMT position statements + Heard NEJM 2008 PMID 18635433
  4. 4. supportive: IV fluids + pressors + dextrose PRN
    per protocol • IV • continuous
    trigger: Shock, hypoglycemia, dehydration
    Supportive care often as important as antidote (ACMT)
  5. 5. seizure abortive (lorazepam 0.1 mg/kg IV max 4 mg)
    0.1 mg/kg IV max 4 mg per dose • IV • q5 min x 2
    trigger: Toxin-induced seizure (TCA, isoniazid, bupropion, tramadol)
    Routes to peds.status_epilepticus.v1 if refractory; AVOID phenytoin in TCA seizures (worsens cardiotoxicity)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Caregiver-reported or witnessed ingestion of medication/household substance in a child (AAP/AAPCC NPDS pathway); 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric toxic ingestions (acute)** (peds.toxic-ingestions.v1).
Phenotype framing: 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)
Scope: Confirm ingestion (substance, time, dose, co-ingestants); differentiate from medical illness (DKA, sepsis, meningitis, intussusception, head trauma)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric toxic ingestions — decontamination + per-toxin antidotes (Poison Control mandatory)**.
1. 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 (GI_adsorbent, first line) — 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)
2. 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 (antidote_glutathione_precursor, first line) — 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)
3. deferoxamine 15 mg/kg/h IV continuous infusion IV continuous (iron_chelator, first line) — 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)
4. octreotide 1-1.5 mcg/kg SC q6h SC/IV q6h x at least 24 h (somatostatin_analog, first line) — 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)
5. glucagon 50 mcg/kg IV bolus then 0.05-0.15 mg/kg/h IV infusion IV bolus then continuous (pancreatic_hormone_antidote, first line) — 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)
6. 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 (high_dose_insulin_euglycemia_HIE, first line) — 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)
7. 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 (alkalinizing_agent, first line) — 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)
8. 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 (opioid_antagonist, first line) — 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)
9. methylene blue 1-2 mg/kg IV over 5 min IV single dose; may repeat in 1 h if methemoglobin remains >30% or symptomatic (methemoglobinemia_antidote, first line) — 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)
10. hydroxocobalamin 70 mg/kg IV over 15 min IV single dose; may repeat 70 mg/kg if persistent toxicity (cyanide_antidote, first line) — 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)
11. 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 (digoxin_antidote, first line) — 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)
12. 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 (simple_sugar, rescue) — Reverses hypoglycemia from sulfonylurea / insulin / salicylate / ethanol / quinine; pair with octreotide for sulfonylurea (Lexicomp Peds; ACMT)
13. mannitol 0.5-1 g/kg IV over 20 min IV single, may repeat in 30 min (osmotic_diuretic, rescue) — 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)

Setting playbook (ed) — ABC + identify toxin + contact Poison Control + initiate gastric decontamination if appropriate + antidote per toxin + decide PICU vs ward
14. ABC + oxygen + IV access as needed inhaled/IV continuous — All toxic ingestions (ABC first; intubate for airway protection if GCS ≤ 8 or expected deterioration)
15. activated charcoal 1 g/kg PO/NG 1 g/kg (max 50 g) PO/NG single — Within 1-2 h ingestion + airway protected + no caustic/hydrocarbon (AACT/EAPCCT charcoal position statement)
16. antidote per toxin per axis IV per axis — Toxin-specific (NAC, deferoxamine, octreotide, glucagon, HIE, bicarbonate, naloxone, methylene blue, hydroxocobalamin, digoxin-Fab) (Per Poison Control + ACMT position statements + Heard NEJM 2008 PMID 18635433)
17. supportive: IV fluids + pressors + dextrose PRN per protocol IV continuous — Shock, hypoglycemia, dehydration (Supportive care often as important as antidote (ACMT))
18. seizure abortive (lorazepam 0.1 mg/kg IV max 4 mg) 0.1 mg/kg IV max 4 mg per dose IV q5 min x 2 — Toxin-induced seizure (TCA, isoniazid, bupropion, tramadol) (Routes to peds.status_epilepticus.v1 if refractory; AVOID phenytoin in TCA seizures (worsens cardiotoxicity))

Non-pharmacologic actions:
- Poison Control consultation MANDATORY (1-800-222-1222 US) (AAP/AAPCC)
- Cardiopulmonary monitoring (AAP)
- Psychiatric / social work consult for intentional adolescent overdose after medical clearance (AAP)
- Skeletal survey if non-accidental trauma concern (AAP 2009 Christian PMID 19403508)
- Notify Child Protective Services if abuse or grossly negligent storage suspected (AAP)

AVOID / contraindication checks:
- No_activated_charcoal_for_caustic_or_hydrocarbon_ingestion (AACT/EAPCCT position statement)
- No_charcoal_if_airway_not_protected_unintubated_with_altered_MS (AACT/EAPCCT)
- Methylene_blue_contraindicated_in_G6PD_deficiency (ACMT methemoglobinemia)
- Do_not_titrate_HIE_insulin_to_glucose_titrate_to_inotropy (ACMT HIE)
- Digoxin_Fab_lab_levels_unreliable_after_administration (ACMT)
- Naloxone_short_half_life_anticipate_re_narcotization (Lexicomp Peds)
- NAC_anaphylactoid_reaction_risk_with_IV_route_slow_first_dose (Heard NEJM 2008 PMID 18635433)
- Bicarbonate_avoid_pH_above_7_55_paradoxical_alkalosis (ACMT)

Monitoring

Regimen monitoring:
- Poison Control consultation MANDATORY (1-800-222-1222 US) (AAP/AAPCC)
- Continuous cardiac + SpO2 + ETCO2 monitoring (AAP)
- APAP: LFTs + INR q12 h until trend favorable (Heard NEJM 2008)
- Iron: stages 1-5 over 48 h + GI bleeding monitoring (ACMT)
- Sulfonylurea: glucose q1h x 24 h minimum after last hypoglycemic episode (Lexicomp Peds)
- Methemoglobinemia: serial methemoglobin level + cooximetry; SpO2 unreliable (ACMT)
- HIE: glucose q15-30 min during titration, K+ q1 h (ACMT)

Setting (ed) monitoring:
- Continuous cardiac + SpO2 + ETCO2 (AAP)
- Repeat ECG q1-2 h for TCA/digoxin/QTc-prolonging toxins (ACMT)
- Glucose q1 h for sulfonylurea (Lexicomp Peds)
- Methemoglobin level + cooximetry for methemoglobinemia (ACMT)
- Serial APAP + LFTs for APAP toxicity (Heard NEJM 2008)

Follow-up plan: 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)
- Close-out criterion: Follow-up + prevention plan documented

Monitoring phase: 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

Disposition

Current setting: ed — ABC + identify toxin + contact Poison Control + initiate gastric decontamination if appropriate + antidote per toxin + decide PICU vs ward

Disposition criteria:
- PICU: any antidote infusion requiring titration (NAC IV, HIE, deferoxamine, octreotide infusion, hydroxocobalamin), intubated, severe toxicity, refractory shock, severe arrhythmia (AAP)
- Ward + telemetry: stable post-ED management, no infusion required, mild-moderate toxicity (AAP)
- Discharge: asymptomatic at 4-6 h after non-toxic exploratory ingestion + Poison Control clearance + safe disposition (AAP/AAPCC)
- Psychiatric admission: intentional adolescent overdose after medical clearance (AAP)

Escalation triggers (move to higher acuity):
- Refractory shock → HIE + pressors + PICU (ACMT)
- QRS >100 ms with TCA → sodium bicarbonate 1-2 mEq/kg IV bolus + PICU (ACMT)
- Severe acidosis or salicylate >100 → HD + PICU (ACMT)
- Status epilepticus → route to peds.status_epilepticus.v1 (AES 2016 PMID 26900382)
- Coma or rapidly worsening GCS → intubate + PICU

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] TCA overdose with QRS >100 ms on 12-lead ECG (ACMT TCA-toxicity guidance)
- [LIFE_THREATENING] CCB or BB overdose with refractory shock not responding to first-line resuscitation (ACMT HIE position statement)
- [LIFE_THREATENING] Iron ingestion with shock, acidosis, hepatic dysfunction, OR iron level >500 mcg/dL — Smith stages 2-5 (ACMT iron-toxicity guidance)

Citations

- 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) [PMID:18635433](https://pubmed.ncbi.nlm.nih.gov/18635433/)
- Cited evidence (PMID 26900382) [PMID:26900382](https://pubmed.ncbi.nlm.nih.gov/26900382/)
- Cited evidence (PMID 19403508) [PMID:19403508](https://pubmed.ncbi.nlm.nih.gov/19403508/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 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) — PMID:18635433
  • Cited evidence (PMID 26900382) — PMID:26900382
  • Cited evidence (PMID 19403508) — PMID:19403508