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Poisoning Key Feature 2: In intentional poisonings (overdose) think about multi-toxin ingestion. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: When assessing a patient with a potentially toxic ingestion, take a careful history about the timing and nature of the ingestion. Skill: Clinical Reasoning Phase: History Key Feature 4: When assessing a patient with a potential poisoning, do a focused physical examination to look for the signs of toxidromes. Skill: Clinical Reasoning Phase: Physical Key Feature 5: When assessing a patient exposed (contact or ingestion) to a substance, clarify the consequences of the exposure (ex: don’t assume it is non-toxic, call poison control). Skill: Clinical Reasoning Phase: Hypothesis generation, Treatment Key Feature 6: When managing a toxic ingestion, utilize poison control protocols that are current. Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 7a: When managing a patient with a poisoning: Assess ABCs. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 7b: When managing a patient with a poisoning: Manage ABC's Skill: Clinical Reasoning Phase: Treatment Key Feature 7c: When managing a patient with a poisoning: Regularly reassess the patient’s ABC’s (i.e., do not focus on antidotes and decontamination while ignoring the effect of the poisoning on the patient). Skill: Clinical Reasoning Phase: Hypothesis generation, Treatment Substance Abuse Key Feature 3: In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Suicide Key Feature 4: In suicidal patients presenting at the emergency department with a suspected drug overdose, always screen for acetylsalicylic acid and acetaminophen overdoses, as these are common, dangerous, and frequently overlooked. Skill: Clinical Reasoning Phase: Investigation Working in a subacute nursery, as I am currently, I am helping to provide care for neonates with the neonatal abstinence syndrome, a consequence of maternal opioid use during pregnancy. I am not used to thinking about poisoning in this way. My experience is usually more in the domain of opioid overdose and other illicit substance intoxication in the adult population. When it comes to pediatrics, the first thing that comes to mind when I think about poisoning is accidental ingestion of household chemicals and medications by young children. In adolescents and adult patients with suicidal behaviour, I think about this in terms of any types of pills, sometimes with alcohol. In any of these cases, it is important to understand that if poisoning from one substance is possible, it is certainly possible that poisoning from more than one substance is the reality. The neonate whose mom recently injected street drugs may have been exposed to more than opioids via a contaminated substance mom had injected. If a child managed to get their hands on and ingest one non-food substance, whose to say they didn't ingest multiple poisons. And in the acutely suicidal patient, it would not be uncommon to try to mix various drugs in order to make the ingestion more lethal. In intentional but arguably unintentional poisonings as well, it is always important to thing about multi-toxin ingestion. Part of the reason it's important to keep an open mind regarding what was ingested is because of the uncertainty when relying on obtaining an accurate history in these circumstances. The patient using illicit substances may wish to avoid having health care workers find out what they took to prevent judgement or persecution (although disclosing specific substance use to police authorities would generally go against the physician's code of ethics). The patient with the suicide attempt may not want to say what they ingested so that access to those pills for a future attempt is not taken from them, or because they took someone else's medications and don't want them to know, etc. And of course, a child may not be able to communicate what they took. So, even if a patient is coherent enough to provide information after a toxic ingestion, it is always important to obtain as much collateral as possible to best piece together the story. One important point to try to nail down is the timing of contact with the substance, be it by ingestion, intravenous injection, inhaled, absorption through the skin, etc., as this directly affects the choice of interventions in managing the overdose. If the substance was ingested by mouth within the preceding hour or so, activated charcoal may be administered to bind to a substance still sitting in the stomach. Gastric lavage, or "stomach pumping" as it is colloquially known, can be done as another way to get rid of an acute ingestion, although its effectiveness is debatable and so it is done less frequently than in the past. Skin or mucous membrane contact may warrant thorough flushing of the exposed site with water or saline. Other than for the possible use of decontamination procedures, it is also important to try to estimate when a substance was ingested to predict where in the course of the ingestion the patient is with respect to the impact the substance has on their body. For example, one of the few highly effective antidotes is N-acetylcysteine, given in the setting of acetaminophen overdose. Being able to look at the level of acetaminophen in the blood based on a nomogram is how one knows whether or not N-acetylcysteine is helpful if administered. Another substance to think about the setting of suspected suicide attempt is acetylsalicylic acid (aka Aspirin), another easy to access over the counter medication that can be life-threatening and for which we can intervene to improve morbidity and mortality. In a setting of suspected poisoning, it is always important to check the serum salicylate along with the serum acetaminophen.  Being unable to rely big-time on the history in the setting of an overdose, the physical examination becomes key in terms of figuring out what sorts of ingestions took place, although there is a lot of overlap between the effects of different substances and the possibility of mixed ingestions certainly can confuse the matter. UpToDate provides a helpful table of the signs to look for with the ingestion of various classes of substances, and it is important for the physician responding to possible ingestions to have a sense of the signs on examination that suggest certain substances were ingested rather than others. Apart from considering co-ingestions, it is also important to think about the presentation as a possible withdrawal rather than acute ingestion from a substance, with withdrawal symptoms occurring because of longstanding use of the substance, and with effects that are generally the opposite of the effects of the substance. (For example, in the patient who has been using opioids regularly, which tends to cause constipation among many other effects, if they are in withdrawal, they commonly will have diarrhea.) There are often institutional protocols for the acute management of substance withdrawal (ex: CIWA protocol for alcohol withdrawal), and patients should be referred to a setting in which they will have the necessary supportive care depending on the severity of their presentation. These patients can derive significant benefit from community supports beyond the acute withdrawal phase, and consideration should be given to long-term therapy (ex: opioid agonist therapy for opioid use disorder). The above list is something I found when reading up on substance intoxication. But there are far more substances that can poison, particularly when you consider the number of day to day household chemicals a young child could potentially ingest. If you aren't at all sure that the substance is safe, in general but also at high doses if a large exposure was possible, call your local poison control centre for confirmation and/or guidance. The World Health Organization has a list online of all of the poison control centres worldwide here. As well, at least for the provincial poison control centre where I am located in Vancouver, they have a part of their webpage devoted to the suggested management of some more toxic ingestions. I looked up the ingestion of crayons, which although are supposed to be "non-toxic" can actually have some heavy metal contamination, more so if you've gotten them outside of Canada and the US. And even if they don't, they can have an apparent laxative effect from the wax. The poison control centre advises to rinse out the mouth and then drink a small glass of water or milk. Whether using their website or calling their centre, which I think is more advisable for ingestions you have not managed before, especially if they are out of the ordinary, like, say, crayons from Cambodia, it is important to approach poisonings with the most up to date protocol, as approaches here can change with time. It is also always only a phone call away, 24 hours a day. As part of my well child visits with young children, I advise parents to keep this number handy in the case of accidental ingestions, per the Rourke Baby Record.
Of course, if a patient presents with a possible life-threatening ingestion, it is always important for physicians to prioritize the assessment, immediate management, and ongoing reassessment of the ABCs of life-sustaining emergency medical care over looking for an antidote to the suspected poisons(s). Antidotes can still be a very important part of the care provided to the patient, and as I mentioned previously, some ingestions do have antidotes that, if given early, can potentially save a life. The patient just needs to be able to breathe and circulate blood to their brain and body while you get on the phone with your nearest poison control centre.
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By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Learning (Patients) Key Feature 1: As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties. Skill: Clinical Reasoning Phase: History Newborn Key Feature 6: In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (ex: hips, heart, hearing). Skill: Clinical Reasoning Phase: Follow-up, Physical Key Feature 7a: When discharging a newborn from hospital: Advise parent(s) of warning signs of serious or impending illness. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Key Feature 7b: When discharging a newborn from hospital: Develop a plan with them to access appropriate care should a concern arise. Skill: Clinical Reasoning, Patient Centered Phase: Follow-up Obesity Key Feature 7: As part of preventing childhood obesity, advise parents of healthy activity levels for their children. Skill: Clinical Reasoning Phase: Treatment Poisoning Key Feature 1: As part of well-child care, discuss preventing and treating poisoning with parents (ex: “child-proofing”, poison control number). Skill: Communication, Clinical Reasoning Phase: Treatment Well-baby Care Key Feature 1: Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record. Skill: Clinical Reasoning, Psychomotor, Skills/Procedure Skills Phase: Physical Key Feature 4: At each assessment, provide parents with anticipatory advice on pertinent issues (ex: feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues). Skill: Clinical Reasoning Phase: Treatment Key Feature 5: Ask about family adjustment to the child (ex: sibling interaction, changing roles of both parents, involvement of extended family). Skill: Patient Centered Phase: History Key Feature 8: Even when children are growing and developing appropriately, evaluate their nutritional intake (ex: type, quality, and quantity of foods) to prevent future problems (ex: anemia, tooth decay), especially in at-risk populations (ex: the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations). Skill: Clinical Reasoning Phase: History, Treatment A well baby is always a good thing! And having an easy and trustworthy method of knowing whether a baby is well is a double good thing. In medical school we were taught we needed to memorise the extensive list of childhood developmental milestones and remember just how many ounces of formula per kg of weight infants need. We were taught to always perform a comprehensive physical examination during a well child checkup, but one that included only the relevant manoeuvres, which tended to change as quickly as you went from one preceptor to the next. BUT THERE IS A BETTER, MORE EVIDENCE-INFORMED, MORE EFFICIENT, AND LESS STRESSFUL WAY. The Rourke Baby Record is an evidence-based pediatric flow sheet that assists physicians in assessing and documenting the routine well-child checkup. It is based on age and can be integrated into electronic medical records. It is my friend, and it's got my back with its guide to interpretation of what is considered within normal limits. The website has links to the WHO growth charts as well, if it wasn't already schmoozing me enough. Furthermore, it provides a template* for the entire encounter, prompting information gathering and anticipatory guidance as relevant to the child's age. With handouts for parents and a list of relevant resources for different-age related concerns (including for the initial discharge from hospital after delivery), along with evidence-informed recommendations for all of the anticipatory guidance you could dream of, no wonder these kids as displayed on their website are as happy as I am!  *Being a template for a generic encounter, it is important for the clinician to be astute in modifying the encounter as needed. For example, one of the prompts for information gathering in the first month of life is inquiry into siblings. I consider this to be a prompt to assess how others in the family in general, including but not limited to siblings, are adjusting to the new family member. This may include how parental roles are being affected, and who in the extended family is offering support. The RBR is a stimulus for a conversation, but should not be considered a literal and exhaustive encounter script. And, when it comes to physical exam maneuvers that aren't as enjoyable, like measuring head circumference or length, or assessing hip stability, I perform these opportunistically or else altogether at the end of the visit so that I disturb the child as little as possible. The template ensures you obtain the important clinical information, but I can choose how to acquire the most information and with more rather than less tact.
Once children are older than 5 years old, switch out your RBR for the Greig Health Record and you can continue on your merry way until a child has reached adulthood. |
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