17.3 Acute Pediatric Toxicological Ingestions & Antidotes (Acetaminophen, Opioids, Iron, Toxic Alcohols)

Acute Pediatric Toxicological Ingestions & Antidotes

Quick Answer: Support airway, breathing and circulation, check glucose, and contact the poison center while identifying the agent and formulation. Give assisted ventilation and naloxone for suspected opioid respiratory arrest with a pulse. Start CPR if pulseless. Select decontamination for the agent and the child's stability. Use the time-specific acetaminophen treatment line for eligible exposures. For suspected ethylene glycol or methanol poisoning, start alcohol dehydrogenase blockade promptly and assess toxin-specific dialysis indications. In severe iron poisoning, treat shock and arrange chelation before considering whole-bowel irrigation. An esophageal button battery requires immediate removal.

Recognize the pattern and stabilize the child

Determine the product, formulation, maximum possible dose, time of exposure and co-ingestants. Obtain the package or a photo when possible. Use pulse oximetry, cardiorespiratory monitoring, glucose and a 12-lead ECG when appropriate. Pupils, skin moisture, ventilation, bowel activity and muscle findings help prioritize treatment. Mixed exposures and hypoxia may obscure the pattern. In suspected deliberate poisoning, evaluate for occult co-ingestion and arrange a safety assessment after stabilization. AHA 2025 poisoning guidance · Royal Children's Hospital initial poisoning guideline

A child with dry skin, delirium and a wide QRS after an antihistamine or tricyclic overdose may also have sodium-channel blockade. A wide QRS with hemodynamic compromise changes the treatment priority to IV sodium bicarbonate with toxicology support. For a child with suspected opioid overdose and a definite pulse but inadequate breathing, give rescue breaths or bag-mask ventilation immediately. Naloxone can be given in parallel. For example, the U.S. injection label gives 0.01 mg/kg IV initially for pediatric overdose and 0.1 mg/kg if the initial response is inadequate. Use the local resuscitation protocol and available formulation. Community nasal products have product-specific instructions. If the child is pulseless or a pulse cannot be confirmed promptly, start CPR with breaths and follow pediatric arrest care. In suspected opioid cardiac arrest, naloxone may be given if it does not interrupt standard resuscitation. After reversal, monitor until consciousness and vital signs have normalized and recurrent respiratory depression is unlikely. Recurrent depression may require repeat naloxone and continued respiratory support. AHA 2025 poisoning guidance · U.S. naloxone injection label · Utah Poison Control Center antimuscarinic guidance

Select gastrointestinal decontamination

• Activated charcoal may help after selected potentially serious exposures to an adsorbable drug. Expected benefit depends on the drug, formulation, time and evidence of ongoing absorption. Some exposures warrant treatment beyond one hour. Avoid charcoal with an unprotected airway, suspected obstruction or perforation. It has no useful role for iron, lithium or toxic alcohols and should be avoided for caustics and aspiration-prone hydrocarbons.
• Whole-bowel irrigation with polyethylene glycol electrolyte solution may be considered after a substantial iron, lithium or potassium ingestion, certain sustained-release or enteric-coated ingestions, or body packing. Consult toxicology. Avoid it with shock or other hemodynamic instability, an unprotected airway, obstruction, ileus or perforation. Retained tablets support consideration after stabilization. They do not outweigh contraindications.
• Emesis and gastric lavage have no routine role. Inducing vomiting adds aspiration risk. Any exceptional consideration of lavage for a life-threatening exposure requires expert review, trained staff and airway protection.

2026 activated charcoal recommendations · AACT/EAPCCT whole-bowel irrigation position update · AACT/EAPCCT gastric lavage position update

Acetaminophen toxicity and acetylcysteine

Most therapeutic acetaminophen undergoes conjugation. In overdose, more of the reactive metabolite NAPQI can accumulate, deplete glutathione and injure hepatocytes. Early symptoms may be absent or limited to nausea and vomiting. Aminotransferases and INR can rise over the next days, with later hypoglycemia, encephalopathy, acidosis and AKI in severe poisoning. Reassess clinical and laboratory trends even when initial symptoms are mild. Acetylcysteine (NAC) replenishes glutathione precursors and is most effective when given early. U.S./Canada consensus · U.S. ACETADOTE label

Interpret the concentration in its time window

For acute oral exposure with reliable timing, plot a concentration drawn 4–24 hours after ingestion began on the revised Rumack–Matthew nomogram. The U.S./Canada consensus defines an acute ingestion period as less than 24 hours. An earlier sample cannot be plotted. The treatment line falls with elapsed time and begins at 150 µg/mL at hour four. Begin NAC when a concentration is on or above the treatment line. The separate high-risk line begins at 300 µg/mL at four hours. Consider poison-center consultation and additional measures for a high-risk concentration or a reported dose of at least 30 g. The chart provides reference points rather than a replacement for the time-specific nomogram.

• Example. For 190 µg/mL measured 4.5 hours after the start of a timed acute ingestion, the approximate treatment threshold is $150\times2^{-(4.5-4)/4}\approx138\ \mu\text{g/mL}$. The measured value is above the treatment line. Start NAC even when early liver tests are normal.
• Delayed absorption. Extended-release products can still be assessed with the acute nomogram. With extended release, repeat the level in four to six hours if an initial level drawn four to 12 hours after ingestion is below the treatment line but above 10 µg/mL. With opioid or anticholinergic co-ingestion, repeat in four to six hours if those clinical effects are present and a 4–24 hour level is above 10 µg/mL but below the treatment line. Consider activated charcoal selectively for ongoing absorption and a protected airway with poison-center input.
• Unknown timing, repeated exposure or late presentation. Use separate clinical and laboratory pathways with toxicology input. For an unreliable or unknown time, the U.S./Canada consensus uses a concentration above 10 µg/mL or AST/ALT elevated above baseline. For repeated supratherapeutic exposure spanning more than 24 hours, its Figure 4 uses a concentration of at least 20 µg/mL or AST/ALT above baseline. Start NAC promptly for suspected acetaminophen-associated liver injury. Start NAC while awaiting the concentration if the reported dose is at least 30 g. With strong concern for a toxic acute ingestion, such as a dose above 200 mg/kg or 10 g, also start NAC if waiting for testing would delay treatment beyond eight hours. U.S./Canada consensus and nomogram

Prescribe and monitor NAC

The U.S. ACETADOTE label gives a three-bag IV regimen of 150 mg/kg over one hour, 50 mg/kg over four hours, and 100 mg/kg over 16 hours (300 mg/kg total). Use label and pharmacy guidance for weight-based diluent and fluid restrictions. The U.S./Canada consensus caps the dosing weight at 100 kg. The label uses the three-bag regimen for 5–40 kg. At 41 kg or more, the label also offers 200 mg/kg over four hours followed by 100 mg/kg over 16 hours. It favors considering three bags for early severe liver injury or a large exposure. Discuss dosing in smaller infants, major overdoses or extracorporeal treatment with toxicology. Monitor for hypersensitivity during infusion. For a serious reaction, stop the infusion and treat immediately, including epinephrine if anaphylaxis is present. Discuss cautious restart after acute symptoms resolve. Recurrent or worsening hypersensitivity requires stopping that infusion and arranging alternative management. U.S. ACETADOTE label · U.S. anaphylaxis practice parameter

Near completion, reassess acetaminophen, aminotransferases, INR and the clinical course. The 2026 ACMT stopping criteria require acetaminophen below 10 µg/mL, AST/ALT at baseline or falling 25–50% from peak if elevated, INR below 2.0, and improving relevant prognostic markers such as creatinine, lactate, pH and phosphate. If criteria are unmet, consult toxicology about continuing therapy. The final three-bag infusion rate is 6.25 mg/kg/h. In rare massive early poisoning, the U.S./Canada consensus recommends hemodialysis in addition to NAC when the level is at least 900 µg/mL with acidosis or altered consciousness caused by acetaminophen. The IV NAC rate during hemodialysis should be at least 12.5 mg/kg/h under toxicology guidance. Progressive liver failure calls for early transplant-center involvement. ACMT 2026 practice statement · 2026 pediatric transplant evaluation guideline

Salicylate poisoning

Vomiting, tinnitus, tachypnea, fever and altered mental status can follow salicylate overdose. A respiratory alkalosis and a high anion gap metabolic acidosis may coexist. Children can present with prominent acidosis. A near-normal pH can mask the mixed disorder. Check serial concentrations and blood gases, including after an initially low level when delayed absorption is possible. A falling concentration during a fall in pH or clinical decline can reflect movement of salicylate into tissues.

Correct volume depletion and potassium deficits, monitor glucose, and start IV bicarbonate for significant poisoning with toxicology guidance. If renal function permits, aim for urine pH 7.5–8 while monitoring blood pH, potassium and fluid balance. Hypokalemia impedes urinary alkalinization. If intubation is unavoidable, minimize apnea and maintain the child's compensatory minute ventilation and mild alkalemia to limit CNS entry of salicylate. Continue alkalinization while mobilizing dialysis as tolerated. EXTRIP recommends extracorporeal treatment for altered mental status, new hypoxemia requiring supplemental oxygen, failure of standard therapy, or an acute concentration above 100 mg/dL (above 90 mg/dL with impaired kidney function). It also suggests treatment for systemic pH at or below 7.20. Clinical deterioration can warrant dialysis at lower concentrations. Intermittent hemodialysis is preferred. ACMT salicylate guidance · EXTRIP salicylates

Ethylene glycol and methanol

Check the product label. Ethylene glycol is found in some antifreezes and methanol in some windshield washer products. Alcohol dehydrogenase converts the parent compounds to metabolites. Glycolate drives much of ethylene glycol's acidosis. Oxalate can bind calcium and contribute to kidney injury. Methanol's formate can cause acidosis and optic or other CNS injury.

• Osmolal gap is measured minus calculated osmolality. A common calculation before accounting for any ethanol is $2[Na] + glucose/18 + BUN/2.8$, using sodium in mEq/L and glucose and BUN in mg/dL. If ethanol is present, use the laboratory's ethanol correction. Parent alcohol may raise the osmolal gap early. The gap can narrow as acidic metabolites accumulate and the anion gap rises. A normal result for either gap at a single time does not exclude exposure.
• Anion gap is often reported as $Na-(Cl+HCO_3)$ without potassium. EXTRIP uses $Na+K-(Cl+HCO_3)$ for ethylene glycol and the potassium-free formula for methanol. Use the specified formula before applying a threshold.
• Supporting findings include calcium oxalate crystalluria in ethylene glycol poisoning and visual complaints in methanol poisoning. Either can be absent. Neither a product's color nor urine fluorescence under a Wood's lamp is reliable diagnostic evidence. Obtain specific concentrations where available. With credible exposure and compatible findings, begin treatment while awaiting confirmation.

CDC/ATSDR ethylene glycol laboratory guidance · Wood's lamp diagnostic study · EXTRIP ethylene glycol · EXTRIP methanol

Block metabolism and assess dialysis

With toxicology and pharmacy support, give fomepizole promptly for strongly suspected poisoning. The U.S. label regimen starts at 15 mg/kg IV over 30 minutes, then 10 mg/kg every 12 hours for four doses, then 15 mg/kg every 12 hours until the level is undetectable or below 20 mg/dL and the patient is asymptomatic with normal pH. Safety and effectiveness in children are not established in the U.S. label. Pediatric use is specialist-directed. Intermittent hemodialysis removes fomepizole, so shorten the interval to every four hours during dialysis and check timing at dialysis initiation and completion. Ethanol is a specialist-directed alternative if fomepizole is unavailable. Folate or folinic acid can be an adjunct in methanol poisoning. U.S. fomepizole label · Pediatric fomepizole case report · EXTRIP methanol

Intermittent hemodialysis is preferred when available. Start antidotal treatment while arranging dialysis. Use the toxin-specific criteria and reassess acid–base status, organ injury and concentrations with toxicology and nephrology. EXTRIP ethylene glycol · EXTRIP methanol

Iron poisoning

Calculate dose using elemental iron per tablet from the product label. For a 12-kg child who ingests 30 tablets containing 65 mg elemental iron each, the estimated dose is $30\times65/12=162.5\text{ mg/kg}$. The 325 mg on a ferrous sulfate label refers to the salt. The U.S. out-of-hospital consensus recommends referral for at least 40 mg/kg from adult ferrous-salt formulations or for severe or persistent symptoms. The Royal Children’s Hospital acute-care guideline identifies 60–120 mg/kg as a range with potential systemic toxicity and above 120 mg/kg as potentially lethal. This child exceeds that latter threshold. The estimated dose helps triage. Shock, altered consciousness and acidosis drive urgent treatment even when the dose is uncertain. U.S. poison-center triage consensus · U.S. product label example · Royal Children's Hospital iron guideline

Early abdominal pain, vomiting and gastrointestinal bleeding can be followed by apparent improvement over 6–24 hours before acidosis, shock or liver injury emerges. Severe cases can later develop hepatic failure or gastrointestinal scarring. Check serum iron, acid–base status, glucose, renal and liver function and coagulation. In significant tablet ingestions, obtain radiography for retained tablets. A negative film does not exclude ingestion. In consultation with toxicology, assess iron near four hours and repeat when delayed absorption is possible, especially with sustained-release or enteric-coated products. Late concentrations can underestimate severity after tissue uptake, and assays may be unreliable after chelation.

In a child with shock, support airway and circulation and arrange urgent IV deferoxamine with the poison center or toxicologist. Severe symptoms warrant action before the serum iron result. Retained tablets may justify later whole-bowel irrigation if the child stabilizes, the airway can be protected and gastrointestinal bleeding or other bowel contraindications are absent. Charcoal does not adsorb iron. The U.S. Desferal label caps the initial slow IV rate in cardiovascular collapse at 15 mg/kg/h and provides regimen-specific limits. U.S. safety and effectiveness are not established under age three. A life-threatening exposure in a younger child needs immediate expert-directed chelation rather than delaying for tests or decontamination. Monitor blood pressure and renal function during treatment. Prolonged infusion can cause pulmonary toxicity. Reddish urine can occur during chelation and is an unreliable marker of severity or treatment completion. Follow clinical recovery, acid–base status, removal of retained tablets when relevant, and toxicologist-interpreted iron measurements. U.S. Desferal label · Royal Children's Hospital iron guideline · AACT/EAPCCT irrigation contraindications

Caustic chemicals and button batteries

After a caustic ingestion, stridor, drooling, dysphagia, pain or hematemesis suggest significant injury. Assess early for progressive airway edema. The mouth may look normal despite esophageal injury. Keep symptomatic children NPO after initial assessment, involve GI and relevant airway or surgical teams, and plan endoscopy after stabilization, generally within 24 hours when indicated. A completely asymptomatic child may follow a specialist-directed observation pathway based on the exposure and reliability of the history. Avoid emesis, chemical neutralization, lavage, charcoal and blind nasogastric placement. ESGE/ESPGHAN pediatric endoscopy guideline · Royal Children's Hospital caustic guideline

A suspected esophageal button battery is a separate emergency. Obtain prompt radiographs covering the neck through the abdomen, with AP and lateral views when a battery is in the esophagus. Look for a double rim on AP and a step-off on lateral. A very thin battery can lack an obvious step-off. Electrical current through moist tissue generates hydroxide at the battery’s negative pole. Serious burns can occur within two hours. Mobilize immediate removal when an esophageal battery is identified. Injury can progress after removal, with delayed bleeding, airway injury or fistula requiring specialist surveillance.

Under the U.S. National Capital Poison Center protocol, give 10 mL of honey by mouth every 10 minutes for up to six doses en route if it is immediately available, a lithium coin cell could have been swallowed within 12 hours, and the child is at least 12 months old and can swallow. With an unknown battery type, the U.S. protocol assumes lithium unless it is a hearing aid battery. In hospital, after X-ray confirms an esophageal battery, a child able to swallow may receive 10 mL of sucralfate suspension (1 g/10 mL) every 10 minutes for up to three doses before sedation when the battery may have been in place for no more than 12 hours. Neither measure nor recent food intake should delay emergency evaluation or removal. National Capital Poison Center button battery guideline · Battery injury mechanism study · Battery injury mitigation study