Accidental Poisoning Causes

Aka: Accidental Poisoning Causes, Poisoning Causes, Poisoning Causes in Children, Medication Overdose Causes, One Pill Can Kill, KIDs List, Key Potentially Inappropriate Drugs in Pediatrics, Pediatric Toxicology, Medication Dosing Errors in Children

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II. Epidemiology: Incidence of specific agents in childhood Poisonings

  1. Most common: Cosmetics, personal care products, cleaning agents
  2. Moderately common: Analgesics, topicals, Cold Preparations
  3. Other: Plants, Pesticides, Vitamins, Antihistamines, Antibiotics, arts and craft supplies
  4. Most common cause of pediatric lethal Overdose (even single doses may be lethal to a toddler)
    1. Sedative-Hypnotics (esp. Benzodiazepine Overdose)
    2. Antipsychotics
    3. Oral Hypoglycemic agents (esp. Sulfonylurea Overdose such as Glipizide 5 mg)
    4. Cardiovascular agents (e.g. Calcium Channel Blockers such as Verapamil 240 mg)
    5. Analgesics (e.g. Acetaminophen Overdose, Opioids such as Methadone 20 mg)
  5. References
    1. (2014) Presc Lett 21(3)
    2. Watson (2005) Am J Emerg Med 23(5): 589-666 [PubMed]

III. Causes: Important Poisonings in Children

  1. Heavy Metal Poisonings
    1. Iron Poisoning
    2. Lead Poisoning
  2. Plant Ingestions and Insecticide Exposures
    1. Herbal Toxicity (Toxic Plant)
    2. Lead-Containing Herbal
    3. Mushroom Poisoning
    4. Organophosphate Poisoning Management (Insectides)
  3. Household substance ingestions
    1. Medications in Children
      1. Fluoride Poisoning
      2. Acetaminophen
        1. See Acetaminophen Overdose
        2. Accurately dosed and measured in less than one third of pediatric patients
          1. Simon (1997) Arch Pediatr Adolesc Med 151:654-6 [PubMed]
    2. Parental medications (See "One Pill Can Kill" list as below)
      1. Anticoagulant Overdose
      2. Atypical Antipsychotic Overdose
      3. Beta Blocker Overdose
      4. Calcium Channel Blocker Overdose
      5. Cardiac Glycoside Overdose
      6. Dextromethorphan Overdose
      7. Insulin Overdose
      8. Lithium Poisoning
      9. Salicylate Poisoning
      10. SSRI Overdose
      11. Sulfonylurea Overdose
      12. Tricyclic Antidepressant Overdose
    3. Drugs of Abuse (Accidental Ingestion in young children, intentional use in teens)
      1. Hallucinogen (e.g. Lysergic Acid, Phencyclidine)
      2. Cannabinoids
      3. Stimulant Overdose (Amphetamines, Methamphetamine, MDMA, cathinones, Cocaine)
      4. Sedative-Hypnotics (e.g. Benzodiazepine Overdose)
      5. Opioid Overdose
      6. Volatile Inhalant
      7. Alcohol Intoxication
      8. Toxic Alcohol ingestion (Ethylene Glycol Poisoning, Isopropyl Alcohol Poisoning, Methanol Poisoning)
    4. Cleaning solutions and other substances
      1. See Caustic Ingestion (Acid Ingestion, Base Ingestion)

IV. Causes: Lethal agents to small children (<10 kg) in small doses ("One Pill Can Kill")

  1. Benzocaine
  2. Benzonatate Overdose (Tessalon)
  3. Beta Blocker Overdose
  4. Calcium Channel Blocker Overdose
  5. Chloroquine
  6. Clonidine Overdose
  7. Iron preparations
    1. See Iron Poisoning
    2. One of the most toxic agents in Overdose for small children
    3. Morris (2000) South Med J 93(4): 352-8 [PubMed]
  8. Lindane
  9. Methyl Salicylate (oil of wintergreen - even in small amounts)
  10. Opioid Overdose
    1. Lomotil
    2. Methadone
    3. Oxycodone
  11. Oxymetolazoline (Afrin) - see below
  12. Phenothiazines
  13. Phenylpropanolamine
  14. Podophyllum
  15. Quinine
  16. Quinidine
  17. Sulfonylurea Overdose
  18. Tea Tree Oil
  19. Theophylline
  20. Tricyclic Antidepressant Overdose
  21. Bar-Oz (2004) Paediatr Drugs 6(2): 123-6 [PubMed]

V. Causes: Key Potentially Inappropriate Drugs in Pediatrics (KIDs List)

  1. Background
    1. Examples are listed below
    2. Remainder of this page overlaps many of the drugs on KIDs List
  2. Antiemetics
    1. Dopamine blockers (Prochlorperazine, Promethazine)
      1. Risk of respiratory depression and Dyskinesia
      2. Avoid under age 2 years, and Exercise caution in children over age 2 years
    2. Alternative agents that are preferred
      1. Ondansetron (Zofran)
  3. Analgesics
    1. Codeine and Tramadol
      1. Avoid in all children
      2. Some children are CYP2D6 ultra-metabolizers
      3. Risk of erratic blood levels that spike and result in respiratory depression and death
    2. Oxycodone and Hydrocodone
      1. Exercise caution as these agents are also metabolized by CYP2D6
      2. Has not been associated with pediatric toxicity as seen with Codeine and Tramadol
    3. Alternative agents that are preferred
      1. Acetaminophen
      2. Ibuprofen
      3. If Opioid is needed, consider short-acting oral Morphine
  4. Topical Anesthetics
    1. Benzocaine
      1. Avoid in all children (previously used for Teething)
      2. Risk of Methemoglobinemia
    2. Alternative agents that are preferred
      1. See Teething
  5. Gastrointestinal Agents
    1. Loperamide (Imodium)
      1. Avoid in all children (despite FDA approval over age 6 years)
      2. Risk of ileus, Somnolence, death (especially age <3 years)
    2. Alternative agents
      1. See Diarrhea Management in Children
  6. Topical Corticosteroids
    1. Limit to low potency steroids if possible (due to systemic absorption risk)
  7. References
    1. (2020) Presc Lett 27(8): 45
    2. Meyers (2020) J Pediatr Pharmacol Ther 25(3): 175-91 +PMID:32265601 [PubMed]

VI. Causes: Medications with Higher Toxicity

  1. Beta Blocker Overdose
  2. Calcium Channel Blocker Overdose
  3. Chloroquine
  4. Clonidine
  5. Glucophage
  6. Iron preparations
  7. Isoniazid
  8. Lomotil
  9. Methadone
  10. Oxycodone
  11. Phenothiazines
  12. Phenylpropanolamine
  13. Quinine
  14. Quinidine
  15. Sulfonylureas
  16. Theophylline
  17. Tricyclic Antidepressant Overdose

VII. Causes: Non-Medications or Topical Agents with Higher Toxicity

  1. Alcohols (Ethanol, Methanol, Ethylene Glycol)
    1. Hand sanitizer contains >60% Alcohol
    2. Even a small amount can result in Alcohol Poisoning in a young child
  2. Benzocaine
  3. Bleach (sodium Hypochlorite)
    1. Commercial concentrations that exceed that found in household bleech (3-6%) have greater toxicity
    2. Esophageal inflammation or pulmonary aspiration if ingested; Inhalation Injury in higher concentrations
    3. Highly toxic when Bleach is combined with ammonia
      1. Results in chloramine gas release, which has resulted in fatalities
  4. Caustics (e.g. toilet cleaners, drain cleaners)
  5. Hydrocarbons (Kerosene, furniture polish, paint thinner, lighter fluid)
  6. Laundry Pods (contain Ethylene Glycol and ethoxylated Alcohols)
    1. Have resulted in deaths and life threatening Poisonings
    2. Esophageal Thermal Burns may occur
    3. Observe for 3-4 hours while trialing oral liquids
    4. Swadron and Nordt in Herbert (2016) EM:Rap 16(11): 16-7
  7. Lindane
  8. Methyl Salicylate (oil of wintergreen)
  9. Nail products (acetonitrile, methacrylic acid, nitromethane)
  10. Organophosphates
  11. Oxymetolazoline (Afrin)
    1. Even 1 ml may be lethal due to central alpha-2 Agonist, Clonidine-like CNS depression)
    2. If a nasal Decongestant is used in children, Neo-Synephrine (Phenylephrine) is preferred
  12. Paraquat Poisoning
  13. Podophyllum
  14. Tea Tree Oil

VIII. Causes: Toxins with Delayed Effects in Overdose

  1. Acetaminophen Overdose
  2. Acetonitrile
  3. Anticoagulants (e.g. Warfarin)
  4. Aspirin or Salicylate Overdose
  5. Carbamazepine (Tegretol)
  6. Dapsone
  7. Enteric-coated or sustained release medications
  8. Ethylene Glycol (also in laundry pods)
  9. Iron
  10. Lithium
  11. Lomotil
  12. Meprobamate
  13. Methanol
  14. Monoamine Oxidase Inhibitors
  15. Sulfonylureas
  16. Theophylline
  17. Thyroid Hormones
  18. Toxic Mushrooms
  19. Barry (2005) Pediatr Ann 34(12):937-46 [PubMed]

IX. Prevention

  1. See Prescription Safety

X. References

  1. Tagliaferro (2023) Crit Dec Emerg Med 37(1): 21-9

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