Most toxic exposures occur in the pediatric population Occult toxic exposure should always be considered in the differential diagnosis when a child presents w/ a. Acute onset of multiorgan dysfunction b. AMS c. resp. or cardiac compromise, d. unexplained metabolic acidosis or e. Seizures. Index of suspicion should particularly be raised if the child is in the at risk group which is age 1 to 4 years old and/or has a previous hx of ingestion. Approach begins w/ evaluation and stabilization: This includes first and foremost CAB (Circulation, Airway, Breathing) followed by attempts to identify the agent involved as well as the severity of intoxication. Initial assessment should involve evaluation of the 3 most common parameters: 1. Vital signs 2. Mental status and 3. Pupils. This initial approach helps to direct your plan of care as well as provide a clue to the etiologic agent since many agents, even ones in different classes tend to mimic each others physiologic features. For example Sympathomimetic agents and Anticholinergics share many clinical features while Opioids, Sedative hypnotics and cholinergics tend to share many clinical features. Of all the possible clinical signs that an agent in each one of these categories may induce, Sympathomimetics and Anticholinergics tend to usually if not always cause a dilated pupil along with other hypersympathetic symptoms while Opiods, Sedative Hypnotics and Cholinergics tend to cause pupillary constriction along with other hyper-Parasympathetic symptoms such as hypothermia, bradycardia, and bradypnea. Do not forget the hallucinogens which tend to present with a more a unique set of signs and symptoms which include hallucinations, perceptual distortions, and Nystagmus along with other non-specific signs such as dilated pupils, tachycardia and agitation. Many agents also tend to cause Hypoxemia and/or hypoglycemia which are two common causes of AMS in the poisoned patient. These two presenting signs require prompt identification and correction with Oxygen supplementation and Dextrose administration. In the event that a concomitant Thiamine deficiency is suspected, Thiamine must also be administered. And the notion that Thiamine must be given before Dextrose to avoid precipitating Wernickes encephalopathy is largely unsupported because uptake of Thiamine into cells is slower than that of dextrose and withholding Dextrose until Thiamine administration is complete may prove detrimental to those with actual hypoglycemia Once you have narrowed down your list of possible etiologic agents to a specific group; either CNS Stimulants AKA sympathomimetics, CNS depressants, or hallucinogens, a confirmatory test is usually required to correctly identify the specific agent. Confirmatory tests may include 1. UDS 2. Serum levels of a particular substance OR Both. Next step in care involves one or more of 4 possible management modalities must be initiated: These include in order of importance 1. Supportive care 2. Decontamination (e.g Activated Charcoal, or Whole Bowel Irrigation) 3. Antidotes or 4. Enhanced elimination. ****KEEP IN MIND THAT CLINICAL BENEFITS OF GASTRIC LAVAGE HAVE NOT BEEN CONFIRMED AND ITS ROUTINE USE IS NO LONGER RECOMMENDED****. Goals of supportive therapy are primarily stabilization of ABCs followed by Seizure treatment and/or prophylaxis and symptomatic relief where feasible such as the use of Antipsychotics for psychosis or Benzos for agitation, etc. Often patients require telemetric as well as pulse oximetry monitoring during the course of their care. Administration of an Antidote follows next and these are some of the examples that are commonly used: NACAcetaminophen AtropineOrganophosphate DeferoxamineIron DimercaprolArsenic, Lead (w/Encephalopathy) Ethanol or FomepizoleMethanol and Ethylene glycol NaloxoneAcute opioid PyridoxineINH Sodium BicarbTCAs, Cocaine, Salicylates *****KEEP IN MIND THE USE OF FLUMAZENIL TO REVERSE BZP INGESTION IS NOT ROUTINELY RECOMMENDED B/C OF POTENTIAL PRECIPITATION OF SEIZURES***** Then comes Elimination enhancement which typically is done by either Alkanizing or Acidofying the urine or Chelating a particular substance The last step of patient management usually involves Disposition. It is imperative as well as a requirement in almost all states to refer ALL PATIENTS WITH INTENTIONAL OVERDOSE FOR PSYCHIATRIC EVALUATION PRIOR TO DISCHARGE. As a side note: It is of paramount importance that clinicians consider the potential psychosocial consequences that an underlying Substance abuse or addiction may have on an individuals future. Often Substance abuse problems carry with them an underlying psychosocial precipitant such as Abuse of different shapes and forms, unstable family dynamics, and even hereditary factors. Effectively treating substance abuse is merely impossible without addressing a possible underlying precipitant and our discretionary measures and acting with an unbiased empathy is extremely important to a childs future.