The poisoned child. Evolving concepts in care.

More than 1 million children in the United States ingest poisons each year. The vast majority of these exposures result in no harm to the child. The task of the emergency physician is to discern which children are at risk and treat those children with appropriately aggressive therapy while minimizing intervention for the rest. In pediatric exposure cases, the toxin is usually identified. A careful toxic differential diagnosis will lead to a list of likely poisons in symptomatic patients without an identified exposure. The cornerstone of treatment remains the evaluation of the ingestion episode, careful assessment of the patient, and the application of basic supportive medical care. In the ED, when it has been determined that gastrointestinal decontamination is indicated on the basis of the substance and quantity ingested, activated charcoal is the decontamination agent of choice if the substance ingested is absorbed by activated charcoal. Gastric emptying should be restricted to those circumstances when the substance ingested is not bound to activated charcoal or the rare event when a child presents to the ED within 1 hour of ingestion with significant CNS depression. Whole bowel irrigation is a recently described technique to enhance the passage of drugs already beyond the pylorus. The indications for its use are poorly defined. Laboratory tests are generally overordered after pediatric ingestions. Appropriate use of the laboratory includes an assessment of basic serum chemistry studies in symptomatic patients, confirmation of suspected toxins, and the determination of the need for specific antidotal therapy. General "drug screens" are expensive and rarely contribute to patient care. Use of specific therapies, including antidotes and enhanced elimination techniques, should be limited to those cases when expectation that a defined benefit outweighs the risk of the procedure is reasonable. The indications for the use of these interventions in children may be different from those for adults.