14.3 Toxic Ingestion, Inhalation & Exposure

The Pediatric Toxicology Landscape

Children under five commonly ingest household products, button batteries, magnets, iron supplements, and caregivers' medications because of exploratory behavior. Adolescents more often present with intentional overdose, recreational substances, or inhalant abuse. The CCRN Pediatric nurse must stabilize first, then identify the agent class, because many stems withhold a confirmed toxin and instead describe a toxidrome.

Always ask: What was available at home? How much is missing? When was the last seen well time? Was ingestion witnessed? Any co-ingestants, ethanol, or extended-release preparations? Bring containers to the ED when possible. Contact a poison control center early — their recommendations are the clinical standard of care and appear in exam rationales.

Initial Stabilization Before the Antidote

Airway protection is paramount. Declining consciousness, loss of gag, heavy secretions, or caustic airway burns may require intubation by an experienced clinician. Support breathing and treat shock. Check point-of-care glucose immediately — hypoglycemia mimics toxins and is itself life-threatening in infants. Obtain ECG early for agents that prolong QRS/QTc or trigger dysrhythmias (tricyclics, some antihistamines, diphenhydramine in large doses, etc.). Seizures are treated with benzodiazepines first-line in most toxicologic seizures; investigate metabolic causes concurrently.

Do not delay resuscitation to wait for a comprehensive drug panel. Many lethal pediatric toxins are not on standard urine immunoassays.

Decontamination Concepts

Decontamination reduces ongoing absorption but is never more important than ABCs.

Activated charcoal may be considered for selected recent ingestions of adsorbable substances when the airway is protected or the child is awake and cooperative. It is not used for metals (iron, lithium), alcohols, or corrosives in the usual sense, and timing matters — benefit declines as time from ingestion increases. Aspiration of charcoal is catastrophic; never force charcoal into an unprotected airway.

Gastric lavage is rarely indicated and reserved for life-threatening recent ingestions under airway control in specialized settings. Whole-bowel irrigation may be discussed for sustained-release products or body packing per toxicologist guidance.

For dermal exposures (pesticides, hydrocarbons), remove contaminated clothing and irrigate skin with soap and water while protecting staff. For ocular caustic exposure, immediate copious irrigation takes priority over waiting for ophthalmology arrival. For inhalational exposures (CO, smoke, irritant gases), remove from the source, give high-flow oxygen, and monitor for delayed pulmonary edema.

Button batteries lodged in the esophagus are a surgical/endoscopic emergency — tissue necrosis can occur within hours. Do not induce vomiting.

Toxidromes Nurses Must Recognize

"Mad as a hatter, blind as a bat, dry as a bone, red as a beet, hot as a hare" remains a useful anticholinergic memory aid — map it to nursing assessment, not folklore.

High-Yield Specific Exposures

Acetaminophen: Initially quiet, then hepatic injury. Time since ingestion determines whether N-acetylcysteine (NAC) is indicated using the Rumack-Matthew nomogram for single acute ingestions with known time. When time is unknown or ingestion is staggered, poison center guidance and empiric NAC may be warranted. Monitor AST/ALT, INR, and mental status for fulminant failure.

Salicylates: Tachypnea (respiratory alkalosis then mixed disorder), tinnitus, fever, altered mentation. Alkalinization of serum/urine and consider hemodialysis for severe cases — nursing role includes serial blood gases, glucose, and fluid/electrolyte vigilance.

Iron: Gastrointestinal toxicity phases, then latent period, then shock and hepatic failure. Abdominal radiographs may show tablets. Deferoxamine is the chelator when indicated.

Sulfonylureas: Delayed and prolonged hypoglycemia in toddlers after even one tablet. Admit for glucose monitoring; octreotide may be used for recurrent hypoglycemia.

Cardiac glycosides / calcium-channel blockers / beta-blockers: Bradycardia and hypotension dominate; antidotes and high-dose insulin euglycemia therapy appear in advanced toxicology pathways — nurses prepare glucose, insulin drips, and pacing/vasopressor support as ordered.

Hydrocarbons: Aspiration risk exceeds systemic absorption for many household hydrocarbons; avoid emesis; observe for pneumonitis.

Carbon monoxide: High-flow oxygen; consider hyperbaric consultation for severe neurologic findings or pregnancy in older adolescents per protocol.

ICU Monitoring and Family Care

Continuous pulse oximetry, capnography when sedated, cardiac monitoring, and frequent neuro checks catch delayed deterioration. Document exact medication administration times for antidotes with short half-lives (naloxone). Maintain staff safety with PPE during organophosphate or unknown powder exposures.

Psychosocial care includes nonjudgmental history taking for adolescent self-harm, immediate safety planning, and psychiatry involvement. For unintentional toddler ingestions, provide prevention teaching (lock boxes, safe storage) at a teachable moment after stabilization. Mandated reporting applies when neglect or factitious injury is suspected.

Exam traps: treating the tox screen instead of the patient; giving charcoal down an unprotected airway; missing hypoglycemia; discharging a sulfonylurea-exposed toddler too early; delaying oxygen in CO exposure while waiting for a level.