SYMPOSIUM: ACCIDENTS AND POISONING
A practical approach to
the intoxicated child
Daniel Murrell
Damian Roland
Abstract
Suspected intoxication causes a range of clinical challenges in the
Children’s Emergency Department. The majority of ingestions, espe-
cially in younger children are unintentional, occurring mainly in the
home environment. Adolescence alcohol intoxication is often part of
risk-taking behaviour and experimentation; however, clinicians need
to be wary of deliberate co-ingestion of other poisons with alcohol
in acute mental health crisis. Anatomical and physiological differences
in ages effect the way drugs are absorbed and eliminated in the body,
effecting clinical features. A good knowledge base of the clinical man-
ifestations of certain drugs can help predict and manage side effects.
The management of toxic ingestion is mainly supportive, as side ef-
fects may take to become apparent. Investigation is determined by
suspected drug ingested, however bedside blood glucose measure-
ment and ECG should be the first consideration. The main life-
threatening complications of alcohol intoxication are respiratory
depression and hypoglycaemia. Other complications include hypovo-
laemia, hypothermia and alcoholic ketoacidosis. Any professional with
safeguarding responsibility for children should take action to recog-
nise and treat any addiction as well as identify specific social vulnera-
bilities. Children presenting with signs alcohol dependence, alcohol
withdrawal, organ dysfunction or with self-harm should be referred
for specialist care.
Keywords alcohol; child health; paediatrics; poisoning; toxicology
Introduction
About 40,000 Emergency Department (ED) attendances each
year in England and Wales are as a result of suspected poisoning;
of which approximately 50% are admitted for further manage-
ment. Alcohol related attendance accounts for a significant
amount of ED workload. In the United Kingdom up to 15% of all
ED attendances are alcohol related.1 Alcohol consumption
among young people in the United Kingdom is higher than the
European average. In 2014/15 in the U.K there were over 4000
Daniel Murrell BMBS FRCEM Subspecialty Registrar in Paediatric
Emergency Medicine, Paediatric Emergency Medicine Leicester
Academic (PEMLA) Group, Paediatric Emergency Department,
Leicester Royal Infirmary, Leicester, UK. Conflicts of interest: none
declared.
Damian Roland BMedSci BMBS FRCPCH PhD Honorary Associate
Professor and Consultant in Paediatric Emergency Medicine,
Paediatric Emergency Medicine Leicester Academic (PEMLA) Group,
Paediatric Emergency Department, Leicester Royal Infirmary and
SAPPHIRE Group, Health Sciences, Leicester University, Leicester,
UK. Conflicts of interest: none declared.
PAEDIATRICS AND CHILD HEALTH 31:10
alcohol related admissions in under 18 year olds, with females
being more likely to be admitted.1 Management of these patients
is often challenging due to vague histories, uncooperative pa-
tients and difficult social circumstances with related safeguarding
concerns.
In this article will discuss the approach to the intoxicated
child, as alcohol cannot be presumed as the cause, and the
important considerations when investigating and managing these
children.
Background
The majority of paediatric ingestions involve accidental unin-
tentional exposure to products from within the home that are
minimally toxic. The incidence of poisoning is determined
mainly by availability of household products especially in chil-
dren under the age of six, and particularly toddlers. These chil-
dren often ingest drugs or poisons as part of their exploratory
behaviour, especially when left unattended and often imitating
parents taking medications or beverages.2
Deliberate self-poisoning general involves adolescents. In the
UK a quarter of adolescents report one episode of self-harm. One
in ten report repeated episodes of self-harm. These children and
young people (CYP) have similar self-harm patterns to adults.
These include mixing of poisons and co-ingestion with alcohol.
These behaviours require input from age-appropriate psychiatric
and social teams.
In England and Wales 40% of poisoning in children under the
age of 15 is related to ingestion of a pharmaceutical preparation.
Paracetamol, iron, tricyclic antidepressants, benzodiazepines
and oral contraceptive pills are the most frequently encountered.
Paediatric poisonings are complicated by the anatomical,
physiological and developmental differences between ages that
can influence their presentations. Body weight and nutritional
status vary considerably with age. Therefore, the amount of
poison need to cause serious harm or amount of antidote
required to treat a patient vary considerably. The anatomical and
physiological differences seen in CYP are summarised in
Table 1.2,3
Size matters. For some medications a single pill dose can be
lethal in a child under 10 kg (see Figure 1). These include tri-
cyclic antidepressants, chloroquine, calcium channel blockers,
opioids, amphetamines, propranolol, theophylline, and sulpho-
nylureas. Other household agents that can be legal in small doses
include camphor (present in VixVapoRub and Tiger balm),
alcohol, iron supplements and essential oils.4
Alcohol
Adolescents commonly ingest alcoholic beverages as part of risk-
taking behaviours and experimentation. Binge drinking in all age
groups is associated with increased risks of violent activity,
sexual assault, self-harm, and unplanned pregnancy.
The UK has a large per capita alcohol intake compared to
many countries. In the UK alcohol related attendances in the ED
peak on Friday and Saturday evenings.1 Whilst most ingested
alcohol is found in beverages, it is also found in some household
products such as vanilla extract, mouthwash, hand sanitiser and
perfume. Infants and toddlers may ingest these forms of alcohol,
but these often only result in minor symptoms.3
376 Ó 2021 Published by Elsevier Ltd.
 SYMPOSIUM: ACCIDENTS AND POISONING

Summary of anatomical and physiological differences that complicate management of poisoning in children and place
them at higher risk
Body Difference

Total body water As children get older proportionally have greater total body water causing variation in volumes of distribution
Body surface area Smaller children have a bigger body surface area
Skin Infants and smaller children have immature keratinised and thin epithelium making them more susceptible to agents
absorbed though skin
Airway Smaller diameter having a significant impact to airflow in the presence of bronchoconstriction, and secretions
Ventilation Younger children have a greater minute volume making them more susceptible to gases vapours and aerosolised agents.
Renal Immature renal function impairs ability to elimination toxins
Hepatic Immature liver function impairs ability to eliminate toxins
Lower level of glycogen stored in the liver predisposes to early hypoglycaemia
Breast feeding Some drugs such as aspirin, cocaine and lithium can be transferred in breast milk to infants

Table 1

Ethanol is a selective central nervous system depressant. At
high doses there can be a loss of protective reflexes, coma and
increase risk of death from respiratory depression. Ethanol is
absorbed rapidly across the gastric mucosa, peak concentrations
in serum occur within 90 minutes. High alcohol consumption is
associated with pylorospasm and delayed gastric emptying.
However, after 1e2 hours there will be little alcohol left
unabsorbed.
Once it has been absorbed alcohol elimination follow zero
order pharmacokinetics (it is eliminated from the body at the
same rate no matter what the plasma concentration is). The rate
that blood alcohol levels fall is therefore fixed but the speed of
decrease varies between individuals. Intoxication generally oc-
curs when blood alcohol concentration reaches between 0.08 and
0.12% (120e150 mg/dL). At this point gait and balance are
frequently disturbed (see Table 2). Most adults will eliminate
alcohol at rates of between 0.01% and 0.02% per hour through a
process of metabolism and elimination in urine.5 A small amount
is eliminated in the breath, and this route of elimination forms
the basis of alcohol breath tests.
Clinically ethanol has multiple affects. Dose related central
nervous system ranging from decrease inhibition and diminished
fine motor coordination to coma and respiratory depression,
summarised in Table 2.5 Other effects include hypotension,
tachycardia and hypothermia secondary to ethanol-induced pe-
ripheral vasodilation and volume loss, and hypoglycaemia.
Assessment
History
Although often challenging, history from either the patient or a
responsible caregiver is vital. It may give an indication of how
much alcohol has been ingested. This can allow clinicians to
determine the likely dangers, anticipate potential complications,
and can guide subsequent investigations and management.
However, an intoxicated patient is often an unreliable witness.
Friends and even adults may be scared to fully disclose the de-
tails of how much, or what else has been taken. Caution and
clinical correlation are required.
Important questions include what was ingested, time of
ingestion, staggering of ingestion, maximum possible quantity of
substance taken, what other toxins maybe available and symp-
toms. It is vital to ask what medication, including prescription,
over the counter medicines, vitamins, and household products
are available in the home environment.
If the history is unclear and the patient was brought to hos-
pital the pre-hospital team e.g. paramedic crew, may be able to
provide useful information including the time any emergency call
was made, where the patient was found and in what circum-
stances. The state of the home, presence of empty drug packets,
bottles or recreational drug paraphernalia are important clues. If
the patient is unconscious it is useful to check available medical
records for prescribed drugs and previous drug overdoses. It is
also important to consider whether there was any sign of trauma
that the patient suffered either prior to, or after the drug
ingestion.
Safeguarding
The clinician must always consider potential of safeguarding
concerns. Accidental ingestion is commonly a result of inappro-
priate supervision and providing prevention advice and educa-
tion to these patients is vital in preventing further episodes.
Without additional support and education recurrence is com-
mon, but not inevitable. Up to 30% of children under the age of
six who present to the ED with an episode of accidental ingestion
will re-present with a further episode.4
Inconsistent history or stories that do not fit the develop-
mental capabilities of the child should raise concerns noting that
deliberate poisoning is more likely in children under the age of
one. Concern about deliberate poisoning or safeguarding issues
should be managed according to local safeguarding policies.
Resources
There are several helpful resources available to help guide the
management of the intoxicated child. Toxbase is the UK National
Poison’s information service (NPIS) database on clinical toxi-
cology. It contains information on a broad range on toxins,
including dugs, household products, plants, and industrial
agents. It is freely accessible to NHS professionals and hospitals
in Ireland and the 24-hour telephone service provides more
specific advice about seriously poisoned patients including spe-
cific investigations and how to source specific antidotes.

PAEDIATRICS AND CHILD HEALTH 31:10 377 Ó 2021 Published by Elsevier Ltd.
 SYMPOSIUM: ACCIDENTS AND POISONING
Figure 1 One pill kills. Reproduced with the kind permission of Tessa
Davis.
To aid the identification of agents using descriptions or sam-
ples brought by relatives there are various web-based resources
such as Martindale (https://about.medicinescomplete.com) and
talk to frank (https://www.talktofrank.com/).
NPIS also has access to TICTAC a computer-aided tablet and
capsule identification system (https://www.tictac.org.uk/) as
well as links to royal botanic gardens, Kew to help identify un-
known plants.
Examination
Most children presenting to the ED soon after any ingestion will
be asymptomatic or may have non-specific symptoms. As with
PAEDIATRICS AND CHILD HEALTH 31:10
Clinical effect of blood alcohol concentrations5
Blood alcohol Clinical signs
concentration
0.02e0.05% Decrease inhibition, diminished fine motor
co-ordination
0.05e0.10% Impaired judgement, and co-ordination
0.10e0.15% Difficulty with gait and balance
0.15e0.25% Lethargy; difficulty with sitting upright
without assistance
0.30% Coma in the non-habituated drinker
0.40% Respiratory depression
Table 2
any acutely sick child, Advanced Paediatric Life Support (APLS)
principles should be followed and a systemic ABCDE approach
should be taken. Common errors made during assessment
include, ignoring observations that lie outside normal range,
especially with temperature measurement. Hyperpyrexia is
associated with ingestions of ecstasy, cocaine and salicylates,
while hypothermia is associated with ethanol and barbiturate
ingestion.3,4
Often clinical features are typically progressive, and a period
observation is required to see whether symptoms evolve over
time. Regular reassessment allows prompt treatment of
complications.
Knowledge of the clinical features of particular poisons or
otherwise known as toxidromes is useful and assessment of eyes,
mucous membranes, skin, bowel and bladder function is needed.
Features of particular toxidromes are summarised in Table 3.
However interpretation is difficult when more than one sub-
stance has been ingested and toxidromes are rarely clear cut in
person. Alternative diagnoses such infection, trauma or meta-
bolic disease need to excluded, especially in the context of the
unconscious patient.3,6
Investigations
Clinical investigations of the poisoned child will often be deter-
mined by what the suspected ingestion is. Bedside blood sugar
measurement should be a first consideration as exclude a meta-
bolic cause or a common complication of poison. This is
mandatory in CYP with an altered mental status.
An electrocardiogram (ECG) should be undertaken in sub-
stances known to cause cardiac arrhythmias, or where there is a
significant possibility of their ingestion.
There are a long list of poisons that result in significant dis-
tubances in acid-base balance. Where there is evidence of
deliberate poisoning, or in suspected aspirin or iron poisoning
then blood gas analysis should be undertaken.2,4
In infants and younger children, when the identification and
quality of a drug is uncertain, X-rays could be considered in those
drugs that are radio-opaque. These include chloral hydrate, cal-
cium, opiates, iron and other metals, neuroleptic agents and
sustained released or enteric coated preparations.2,4
In the UK, a urine toxicology screen will identify certain
drugs, such as opioids, cannabis, amphetamines, and benzodi-
azepines. However, as most accidental poisons will not involve
378 Ó 2021 Published by Elsevier Ltd.
 SYMPOSIUM: ACCIDENTS AND POISONING

Activated charcoal given within one hour of ingestion reduces

Clinical features of toxidromes and related drugs6 the absorption of therapeutic doses of many drugs. For many
Toxidrome Features Drug examples drugs there is little evidence of benefit if given after this time
frame. However, in specific drugs that undergo enterohepatic
Anticholingeric Confusion Tricyclic antidepressants recycling such as carbamazepine, dapsone, phenobarbital, qui-
Tachycardia Atropine nine, theophylline and sustained release medications charcoal
Dry skin and skin Mandrake Juice can reduce reabsorption and therefore shorten the biological half-
Flushing Jimson Weed life.
Mydriasis The use of charcoal is not without risk. Charcoal is messy to
Hyperthermia administer, unpleasant to taste and often causes vomiting. If
Urinary retention aspirated can cause fatal pneumonitis. Vomiting may reduce the
Cholingeric Confusion Organophosphate efficacy of charcoal treatment and should be promptly treated
Defecation Nerve Agents with antiemetic or in cases of intolerance, reduced doses and
Urination increase frequency. Charcoal is contra-indicated in drugs that do
Miosis not bind to it such as heavy metals i.e., iron and lithium, cyanide,
Bronchospasm ethanol, ethylene glycol, methanol and organophosphates.3,6
Emesis Gastric lavage is only indicated in life threatening ingestions
Lacrimation that cannot be effectively be removed by other means for
Salivation example iron or lithium. It should be carried out only if there is
Stimulants Euphoria Amphentamines adequate airway protection and is contra-indicated in corrosive
Aggression MDMA substance or petroleum distillate ingestion.3,6
Paranoia Cocaine Whole bowel irrigation is used in situations where modified
Tachycardia release or enteric-coated formulations have been ingested or se-
Mydriasis vere poisoning with iron or lithium salts. Other indications
Sweating include illicit drugs carried in the gastrointestinal tract or “body-
Hyperreflexia packing”.
Serotonin/ Hyperthermia Antidepressants, Antidotes to specific poison aim to increase the elimination of
neuroleptic Sweating especially monoamine the toxin from the body. Though antidotes for a few specific
malignancy Hyperreflexia oxidase inhibitors drugs and poisons are available, shown in Table 4, the provision
syndrome Clonus Antipsychotics of supportive care is essential in acute intoxication. Not all an-
Rigity Co-ingestion tidotes are necessary to administer and specialist advice should
Hypotension with tramadol be sort either from an online database such as Toxbase or from
Depressants Confusion Benzodiazepines contact specialist centres especially in the context of complex or
Listlessness Alcohol rare ingestions.3,6
Hypotonia Opiates/Opioids Other techniques intended to enhance the elimination of
Hypotension poisons after absorption are only suitable for a small number of
Miosis severely poisoned patients and only apply to a limited number of
Apnoea
Nicotinic Diplopia Botulism
(neuromuscular Ptosis Snake and spider bites Common drug antidotes3,6
junction) Fasciculation
Poison Antidote
Paralysis
Coma Beta-blockers Glucagon, atropine, insulin therapy
Carbon monoxide Oxygen, hyperbaric therapy
Table 3
Cyanide Hydroxocobalamin
drugs found in urine toxicology screen its role in assessment is Digoxin Digoxin antibodies (Digiband)
often limited. Furthermore, patients who are experimenting with Ethylene glycol Ethanol, fomepizole
recreational drugs, such as adolescents, a toxicology screen has Iron Deferoxamine
shown not to improve outcomes or change management. How- Local anaesthetics Lipid emulsion (Intralipid)
ever, in certain contexts such as suspicion of deliberate poisoning Methanol Ethanol, fomepizole
and safeguarding concerns serum, urine, or gastric sampling Opioids Naloxone
maybe be required for qualitative toxicology analysis.2,4 Organophosphates Atropine, Pralidoxime
Paracetamol N-Acetylcysteine, methionine
Management Sulphonylureas Glucose, Octreotide
Tricyclic antidepressants Sodium bicarbonate
Reducing drug absorption, antidotes and increasing Warfarin Vitamin K, prothrombin complex
drug elimination (Beriplex, Octaplex)
The mainstay of poison treatment is organ support while
reducing drug absorption and increasing drug elimination. Table 4

PAEDIATRICS AND CHILD HEALTH 31:10 379 Ó 2021 Published by Elsevier Ltd.
 SYMPOSIUM: ACCIDENTS AND POISONING
poisons. Examples include haemodialysis for ethylene glycol,
lithium, methanol, phenobarbital, salicylates, and sodium val-
proate and alkalinisation of the urine for salicylates.3,6
Agitated patients
Angry and aggressive patients, even CYP, present a hazard not
only to themselves but other members of the clinical team.
Autonomic dysfunction is often seen in acute behaviour distur-
bance and is associated with sudden death in up to 10% of all
patient groups.
The Royal College of Emergency Medicine (RCEM) in their
rapid tranquillisation policy advocates initial use of verbal
calming and de-escalation techniques, such as negotiating and
visual aids to communicate. Physical restriction is rarely required
but may be necessary to facilitate initial management; however it
must be proportional, justifiable and minimal.
Pharmaceutical restraints or sedation can be administered via
oral, intramuscular or intravenous depending on safety of staff
and patient factors. Intravenous administration has often the
fastest onset but requires intravenous access which may be
impossible or unsafe in the agitated patient. Intramuscular
administration is quicker and often easier in these circumstances,
especially in an uncooperative patient; however absorption if
often unpredictable and doses of sedative drug will need to be
altered.
Common sedative agents used include benzodiazepine, anti-
psychotics and ketamine. Clinicians should be aware of what
agents are available in their healthcare setting and potential side
effects of each agent. Many emergency departments have a rapid
tranquillisation policy and clinicians should use sedative agents
that they are familiar with to avoid complications.
Acute management of alcohol intoxication
The acute management of alcohol intoxication is supportive with
key interventions to aim to treat hypoglycaemia, hypovolaemia,
hypothermia, decreased consciousness, and respiratory depression.
The main life-threatening respiratory consequence of intoxi-
cation is respiratory depression. CYP with alcohol intoxication
should have regular monitoring of vital signs and be nursed in
high visible area, with early consideration of intubation and
ventilation. Intoxicated patients often have decreased airway
sensitivity to foreign bodies, decrease ciliary clearance, and
delayed gastric emptying and are therefore at higher risk for
aspiration.3,6
The obtunded intoxicated CYP should be placed in the lateral
position to reduce the risk of aspiration. Altered level of con-
sciousness should prompt consideration of whether the patient
has suffered any trauma while intoxicated. Subsequent appro-
priate imaging as clinical condition dictates should be initiated.3,6
There is no evidence to support the use of intravenous fluid
therapy to hasten recovery from alcohol intoxication, but should
be considered in CYP with signs of dehydration, or those with
electrolyte abnormalities, hypotension or presence of metabolic
acidosis. Hypoglycaemia is a common complication of alcohol
intoxication and infants and young children are prone to pro-
found hypoglycaemia. All patients should have bedside blood
glucose measure done on presentation and repeated sampling in
the event of clinical deterioration.3,6
PAEDIATRICS AND CHILD HEALTH 31:10
CYP may have also taking other recreation drugs or have
other substances involved, including deliberate overdose of
medications. In these circumstances, clinicians need to consider
checking levels of paracetamol and salicylates.6
The hypothermic CYP should be passively rewarmed with
simple measures, such as removing wet clothing, blanket, and
head covering. Active external rewarming with heat pack, heat
lamps, and forced-air patient warming devices (e.g. Bair
HuggerÔ) should also be considered. Active rewarming should
be considered in cases of moderate to severe hypothermia with
altered physiological signs such as bradycardia, stupor, and
respiratory depression.3,6
Alcoholic ketoacidosis is a rare complication which occurs
after cessation of alcohol consumption following either a period
of prolonged alcohol usage or "binge" drinking.
It occurs through three different pathways
1. Depletion of NAD due to ethanol metabolism resulting in
elevated NADH/NAD ratio
2. Increased catecholamine and cortisol levels due to volume
depletion
3. Decrease glycogen stores from starvation
These derangements create a catabolic state causing
decreased insulin levels, increased glycogen levels, lipolysis and
ketone production. Patients frequently present with nausea,
vomiting, anorexia, and abdominal pain. Blood gas analysis will
demonstrate increased anion gap metabolic acidosis, hypo-
glycaemia, raised ketones and often electrolyte abnormalities
such as hypokalaemia. Treatment is rehydration with 5%
dextrose and thiamine supplementation.3,6
Management of alcohol dependence
Any professional with safeguarding responsibility for children
should take action to treat any potential alcohol addiction. In all
circumstances, consider the significance of alcohol intake in each
individual and referral to alcohol addiction services such as
counselling. Assess ability to consent to alcohol related activity
should also be assessed.
National Institute of Clinical Excellence (NICE) guidance
recommends children who present to the ED with symptoms of
acute alcohol withdrawal such as hand tremors, sweating,
nausea, visual hallucinations and seizures or who are at high risk
of alcohol withdrawal seizure or delirium tremens should be
offered admission for physical, such as medically assisted alcohol
withdrawal and psychosocial assessment. Medical withdrawal
treatment consists of benzodiazepines for treatment of delirium
tremors and of thiamine replacement for prevention of a Wer-
nicke’s-Korsakoff encephalopathy.
Obtaining a detailed history of their alcohol intake using an
assessment tool is essential. NICE recommends the common
assessment framework. Other factors such as family problems,
under-achievement at school, and instances of child abuse
should be explored. During assessment clinicians need to be
sensitive to the patients ability to understand what is involved,
their emotional maturity, faith and beliefs.
Patients who should be referred for speciality treatment
include those who show signs of moderate or severe alcohol
dependence, have previous failed structured advice, wish to
receive further treatment, show signs of severe alcohol related
380 Ó 2021 Published by Elsevier Ltd.
 SYMPOSIUM: ACCIDENTS AND POISONING

impairment or have alcohol related co-morbid condition, such as National Institute for Health and Care Excellence. Alcohol-use disor-
liver disease. ders: diagnosis, assessment and management of harmful drinking
Those at risk of self-harm should be referred to the acute child (high-risk drinking) and alcohol dependence [CG115]. 2011. Avail-
and adolescent mental health service. Children at high risk of able at: https://www.nice.org.uk/guidance/cg11 (accessed 19
alcohol related self-harm include; Recent accident or minor February 2021).
injury, regularly attend a Gentiourinary Medicine (GUM) clinic, NHS Digital. Statistics on alcohol. 2020. Available at: https://digital.
involved with crime or antisocial behaviour, absences from nhs.uk/data-and-information/publications/statistical/statistics-on-
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publishing.service.gov.uk/government/uploads/system/uploads/
The management of paediatric poisoning and alcohol intoxica-
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children_self-harm.pdf (accessed 17 February 2021).
department. Having a working knowledge of toxidromes, being
open-minded as to ingested agents and always ensuring safe
guarding issues are addressed are critical to safe management.A
Practice points
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FURTHER READING
Davis T. Toxicology e a crash course in accidental overdoses, Don’t
C Respiratory depression, hypoglycaemia, hypovolaemia, and
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hypothermia are seen in severe alcohol intoxication.
DFTB.17991 (accessed 17 February 2021).
Though the management is mainly supportive patients
Gillings M, Grundlingh J, Aw-Yong M. Guidelines for the management
should be observed in a suitable area to deal with these
of excited delirium/Acute Behavioural Disturbance (ABD); Royal
complications rapidly. Patients presenting with complica-
College of Emergency Medicine. 2016. Available at: https://www.
tions of alcohol use or at risk of alcohol dependence should
rcem.ac.uk/docs/College%20Guidelines/5p.%20RCEM%
be referred for specialist treatment.
20guidelines%20for%20management%20of%20Acute%
C Clinicians should evaluate patients for safeguarding con-
20Behavioural%20Disturbance%20(May%202016).pdf (accessed
cerns and take appropriate action according to local
17 February 2021).
policies.

PAEDIATRICS AND CHILD HEALTH 31:10 381 Ó 2021 Published by Elsevier Ltd.