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PHARMACOLOGY FOR EMS

PROFESSIONALS PART 2:
PEDIATRIC
TOXICOLOGY
 Photo and cover photo: Aaron Webster

SERIOUS LIFE
THREATS IN
CHILDREN
Curious young minds get into everything—and this can
spell serious hazards to their health. EMS providers
called to a scene of a “sick kid” never know quite what
to expect and must play detective by questioning dis-
traught parents and young children who may not be
able to communicate what’s wrong or what they were
doing prior to falling ill.

This e-book is a compendium of EMS World columns

authored by Blair Bigham, MD, MSc, EMT-P. After a
decade working as a helicopter paramedic, Bigham
completed medical school in Ontario, Canada, where
he is now a resident physician in the emergency depart-
ment. He has authored over 30 scientific articles,
led major national projects to advance prehospital
research and participated in multiple collaboratives,
including the Resuscitation Outcomes Consortium.

CONTENTS
PEDIATRIC MARIJUANA POISONING
Most paramedics have treated adults impaired by
marijuana—but pediatric poisonings are on the rise
as potent edibles become more common
Page 3

WARFARIN INGESTION
Serious complications are rare, but the frequency with
which young children consume rat poisons has raised
red flags for years
Page 5

THE DANGERS OF BUTTON BATTERIES

A real-life case contains lessons for prehospital
providers
Page 7
PEDIATRIC TOXICOLOGY: MARIJUANA POISONING

PEDIATRIC MARIJUANA
POISONING
Most paramedics have treated adults
impaired by marijuana—but pediatric
poisonings are on the rise as potent
edibles become more common
Photo: Kyle Gaines,
SCCAD

M
ost paramedics have treated
adults impaired by marijua-
na—whether because they
crashed their car, thought
they were having a heart attack, or mixed
their weed with other drugs. But pediatric
poisonings are on the rise as potent edibles
become more common. Often in the form
of brownies or gummy candies, marijuana
edibles can be potent for small children,
who may eat more than even an adult dose
by mistaking the drugs for regular candy.
Delta-9-tetrahydrocannabinol, or THC,
is the psychoactive substance in marijuana
responsible for most symptoms seen after
its use. The potency of THC has increased
over the years, and the actual dose of THC
in homemade foods is difficult to know.
When consumed orally THC can affect
the brain for longer than inhaled forms.
THC affects cannabinoid receptors in the

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PEDIATRIC TOXICOLOGY: MARIJUANA POISONING
central nervous system, which can affect
GABA, an inhibitory neurotransmitter, and
dopamine, which affects movement.1
Symptoms of toxicity include decreased
level of consciousness, wobbly walking,
and respiratory depression.
While most adults who call 9-1-1 for help
will know they’ve consumed a product
containing THC, children who accidentally
consume marijuana might not. Have a high
index of suspicion for unwitnessed ingestion
and ask if children had access to any edibles.
A Word on Pediatric
Poisoning
Accidents don’t happen in poisoning.
Every time a child is poisoned, preven-
tion failed. Many practitioners prefer the
term incident to accident.2 Paramedics
have a responsibly to advocate for young
patients who are poisoned to build better
safeguards and prevent these incidents.
A lack of regulations for child-resis-
tant packaging is partly to blame for the
increase in pediatric poisonings called in to
poison control lines across North America.
Cannabis should be treated like any other
medication or household toxin: locked up
and out of reach of children.
Teens are also a group to watch. In Col-
orado, which legalized medical marijuana
in 2010 and recreational marijuana in 2014,
surveys show only 7% of teens used mar-
ijuana in 2015, the same rate as before it
was legal, but cannabis-related emergen-
cy-room visits by adolescents quadrupled
to 639 between 2009 and 2014, meaning
five of every 1,000 emergency visits were
associated with marijuana. The number of
children under age 10 with unintentional
cannabis poisoning went from one in 2009
to 16 in 2015.
Finally, an August study in the jour-
nal Pediatrics found THC in human
breast milk at significant concentra-
tions.3 Other studies have shown THC
is found in the stool of breastfeed-
ing infants whose mothers consume
VERIZON.COM/FRONTLINE | EMSWORLD.COM | 2022
cannabis, suggesting babies metabolize
THC, which has been shown to delay
psychomotor development. Breast-
feeding mothers should refrain from
using cannabis.
R E FE R E N CE S
1. Prabhu E. Pediatric Marijuana Expo-
sures. American College of Emergency
Physicians, www.acep.org/how-we-
serve/sections/toxicology/news/
march-2016/pediatric-marijuana-
exposures/.
2. Bigham BL, Harding A, Goldfrank LR.
Unintentional use of the word “acci-
dent”? Letter to the Editor, Clinical
Toxicology, 2018 Jul 13; http://blair-
bigham.com/?p=1072.
3. 
B ertrand KA, Hanan NJ, Honer-
kamp-Smith G, et al. Marijuana Use
by Breastfeeding Mothers and Can-
nabinoid Concentrations in Breast
Milk. Pediatrics, 2018 Sep; 142(3):
e20181076.
4
PEDIATRIC TOXICOLOGY: WARFARIN INGESTION

WARFARIN INGESTION
Serious complications are rare, but
the frequency with which young
children consume rat poisons
has raised red flags for years

W
arfarin has been used
as a pesticide for more
than 50 years. Concerns
around warfarin resis-
tance led to the creation of superwarfa-
rins, which work similarly but last much
longer—months instead of hours. This
drug class includes brodifacoum, bro-
madiolone, difenacoum, and flocoumafen
and makes up the great majority of rat
poisons on the domestic market.1
These drugs are vitamin K antagonists
and prevent vitamin K from activating
dependent clotting factors. Without vitamin
K, the body can’t get thrombin, and without
thrombin, there is no stable clot. Rats bleed
to death. (Other less common rat poisons
contain red squill, which is a digoxin sub-
stance, strychnine, and phosphorus.)
But very few children have severe toxic-
ity, especially when only a small amount
of poison is consumed. In a 2006 study
of 68,000 children under 6 years old who
consumed rat poisons, more than one-third
visited a healthcare facility, but only 302
were hospitalized and 219 admitted to an
intensive care unit.2
In a registry study of poison control cen-
ters, 10,762 pediatric cases of unintentional
ingestions of brodifacoum were reviewed;
67 patients reported coagulopathy, but
no major effects or deaths occurred.3 In a
study of 545 children who ingested rat poi-
son, none had significant coagulopathy on
blood work; two had non-life-threatening
nosebleeds.4 The authors concluded that
ingestions of less than one box (and most
are only a pellet or two) need no treatment
or follow-up.
Large toxicities are another matter. In
a case report, a 25-year-old attempted

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PEDIATRIC TOXICOLOGY: WARFARIN INGESTION

suicide by ingesting four boxes of superwar-

farin, each 42 g of bait (0.005% brodi-
facoum).5 Nine days later he presented to
an emergency room after syncope and had
hematochezia, gross hematuria, epistaxis,
anemia, and severe coagulopathy; imaging
revealed pleural, pericardial, and medias-
tinal bleeding.
He was given vitamin K and fresh frozen
plasma, which contains clotting factors,
and discharged on oral vitamin K. Fifteen
weeks later he returned with a history of
additional ingestion. Neurologic status was
initially normal, but he became comatose
after induction of vomiting with ipecac. He
died of subarachnoid hemorrhage.

The Bottom Line

Serious complications and death from
superwarfarin are very rare and dose-de-
pendent. Prehospital providers should rest
assured that small ingestions of rat poison
are not dangerous.
Expert counseling and follow-up can PUBLIC HEALTH
be offered by emergency doctors, family VS. PUBLIC HEALTH
doctors, pediatricians, and poison-con-
Unintentional rat poison ingestions are preventable, but doing away with rat
trol centers. Reassurance and referral to
poison altogether causes additional concerns. To be sure,
experts who can guide in watching for signs
rat infestations are bad. Public health officials work
of serious toxicity in the days that follow
hard to control rats, as they, and the insects that
the ingestion are all that is required for
live on them, can spread diseases like bubonic
small overdoses.
plague,6 hemorrhagic fever, leptospirosis, sal-
Signs that would warrant expert atten-
monellosis, and rat bite fever.
tion include bruising and bleeding in stool,
urine, or gumlines. Large overdoses will
But the frequency with which young children
often prompt blood work in the emergen-
consume rat poisons has raised red flags for years,
cy department, with observation lengths
particularly at the Environmental Protection Agency.
varying with coagulation studies.
The EPA has been monitoring human ingestions of rat
R E FE R E N CE S poisons since the 1970s and believes they are four times as common as
reported to poison centers. In 1998 the EPA declared that rat poisons must
1. 
Kanabar D, Volans G. Accidental
taste bitter and be dyed bright colors so their consumption would be obvi-
superwarfarin poisoning in chil-
ous. Yet legislative tug-of-wars went on for over a decade, and those recom-
dren—less treatment is better. Lancet,
mendations didn’t always stick. A Scientific American investigation found
2002 Sep 28; www.thelancet.com/
the issue has never fully been resolved.2
journals/lancet/article/PIIS0140-
6736(02)11120-2/fulltext.
2. 
McClure R. Rat Poisons Endanger
10,000 Children Every Year in the U.S. Care, 2002 Jun; 18(3): 174–8. cide poisoning with brodifacoum. Ann
Scientific American, 2010 Dec 14; www. 4. Ingels M, Lai C, Tai W, et al. A prospec- Emerg Med, 1992 Mar; 21(3): 331–6.
scientificamerican.com/article/rat-poi- tive study of acute, unintentional, 6. Bigham B. Plague: Four Things You
sons-endanger-10000-children/. pediatric superwarfarin ingestions Need to Know. EMS World, 2017 Nov
3. Shepherd G, Klein-Schwartz W, Ander- managed without decontamination. 3; www.hmpgloballearningnetwork.
son BD. Acute, unintentional pediatric Ann Emerg Med, 2002 Jul; 40(1): 73–8. com/site/emsworld/article/219160/
brodifacoum ingestions. Pediatr Emerg 5. Kruse JA, Carlson RW. Fatal rodenti- plague-four-things-you-need-know.

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PEDIATRIC TOXICOLOGY: BUTTON BATTERIES
THE DANGERS OF
BUTTON BATTERIES
A real-life case contains lessons
for prehospital providers
K
ids put the darnedest things in their mouths. It’s part of
the natural human learning and development process:
pica. Pica starts at around age 2 and involves exploring
the environment by putting objects into the mouth.
Ingestions aren’t part of pica; it’s like window shopping with your
mouth—taste but don’t swallow.
This is different from intentionally eating things, which kids also
do; think of those colorful vape nicotine packages or coated medi-
cation tablets that are sweet. But pica is different—there is nothing
tasty about a Lego or a battery (though accidents do happen).
Most objects swallowed by children are nontoxic and will not
obstruct the esophagus or intestinal tract unless they are long
and sharp. Those that do get stuck, like coins, often pass after a
few hours. But one object has received a lot of attention over the
years, and for good reason: button batteries.
Button batteries come in various sizes, similar to a nickel or
quarter. They often get stuck in children’s esophagi, rarely affecting
the airway. Rather than producing stridor, as happens with vari-
ous foreign-body aspirations, button batteries get lodged at the
narrowing of the cricopharyngeous muscle, at narrowings caused
by the aortic arch or bronchi or at the sphincter that separates the
esophagus from the stomach.
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PEDIATRIC TOXICOLOGY: BUTTON BATTERIES

Coins, which can readily be differentiated from button batteries

on x-ray by identifying the “double density” that makes up but-
ton batteries, pass with time and tend not to need endoscopic CHILDPROOFING THE HOME
extraction. Button batteries often do too, but we aren’t willing Is your home button-battery proof? Can you educate
to wait. parents and caregivers about the threat? Here’s a list
from poison.org about where you might find button
Case Study batteries:
A 3-year-old child presents in the emergency department drool- • Remote controls (the worst offenders!)
ing and unable to swallow water. An x-ray confirms the elicited • Garage door openers
history of a swallowed coin. The child is sent home. Five hours • Keyless entry fobs
later an ambulance is called for hematemesis. • Bathroom scales
On arrival paramedics find the • Parking transponders
child without vital signs in a pool • Toys
of blood. Despite rapid transport to • Cameras
a local pediatric emergency depart- • Watches
ment, the child dies. An autopsy • PDAs
shows a button battery lodged in • Calculators
the esophagus, which eroded into • Digital thermometers
the aorta, leading to a fistula that • Hearing aids
allowed arterial blood to enter the • Singing greeting
esophagus. The cause of death was cards
exsanguination. On case review the • Talking books
x-ray was deemed to clearly show • Portable stereos
the double density of the button • Handheld video
battery. games
This is not a fictitious case. More • Cell phones
than 3,500 button battery inges- • Home medical
tions are reported to U.S. poison equipment/meters
control centers annually; there • Flash- and penlights
were 14 deaths between 1995– • Flashing shoes
2010 according to the CDC,1 and • Toothbrushes, bedwetting monitors
an additional 11 deaths of children aged 7 months to 3 years were • Keychains
recorded in a six-year period following 2010 in the United States. • Flashing or lighted jewelry or attire
How does a button battery produce so much damage? There • Any powered household item
are multiple mechanisms that interact to cause the deadly com-
Here’s a great resource: the National Battery Ingestion
plication of esophageal erosion. Most button batteries are lithium
Hotline at 800/498-8666.
ion batteries. Saliva causes the positive and negative ends of the
battery to create an electrical circuit. The constant current causes
hydrolysis, where water is broken down into hydroxide, an alkali,
which burns the friable tissue that makes up the esophagus. lifelong morbidity in the forms of strictures, increased cancer risk,
The physical pressure of the battery in a tight space speeds and trouble swallowing.
erosion of the tissue (leaking battery contents are not usually the The bottom line is that any child who may have swallowed
culprit). Most button batteries large enough to get stuck (over 20 a button battery needs an emergent x-ray. If a battery is seen,
mm) produce 3 volts, which is more than double what it takes to emergent endoscopic removal is mandatory. Damage can begin
cause hydrolysis. This erosion can cause the esophagus to leak as quickly as two hours after ingestion. Do not allow the child to
into the mediastinum, leading to contamination. eat or drink until assessed in the ER, and do not induce vomiting.
This causes a severe form of sepsis called mediastinitis that is If the airway is compromised, laryngoscopy with Magill forceps
often fatal. In the worst-case scenario, the battery erodes through may be appropriate.
the esophagus and the aorta, causing essentially an aortic rupture
R E FE R E N CE
into the esophagus that cannot be tamponaded. Blood freely flows
down into the stomach and up into the mouth, where it can be 1.  Sharpe SJ, Rochette LM, Smith GA. Pediatric Battery-Related
aspirated. Death can be from asphyxia or exsanguination. Emergency Department Visits in the United States, 1990–
Even if the esophagus doesn’t break open, burning can lead to 2009. Pediatrics, 2012 Jun; 129(6): 1,111–7.

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