POISONING

Dr. Sasan L. Hanna

• Environmental Hazards Diseases are caused by environmental
factors that are not transmitted genetically or by infection.
• Children are more vulnerable than adults to environmental
risks because of a number of factors:
1. Children are constantly growing. They breathe more air, consume
more food, and drink more water than adults do, in proportion to their
weight (note: When a child ingests something poisonous, they wont stop
and probably ingest a lot more than would an adult)
2. Children's central nervous, immune, reproductive, and digestive
systems are still developing.
3. Young children crawl on the ground where they can be exposed to dust
and chemicals that accumulate on floors and soils.
4. Children have little control over their environment (Note: A child may
also not know that something is hazardous, such as a heater or crossing a
road)
Note: Infants tend to mouth objects, and this may continue up to 1.5 years.
Algorithm of Environmental Hazards

Note: here, commonly

kerosene
Acid, base,
oxidizing agents
Case
A 2 year child comes with attack of generalized convulsion for 10 minutes,
and after that becomes conscious and there Is no fever. He was completely
normal playing in the garage and after that suddenly complained of
abdominal pain and followed by convulsion. They have no any chronic
disease in the family except his mother has some psychiatric disease and she
is on regular treatment; on examination, the child is unconscious, with dilated
pupil and ECG shows multiple ventricular ectopics.

What is your provisional diagnosis? TCA poisoning (affects the CNS and heart)

What is your line of management?

 Risk of Environmental
Hazards are Increased by
1. Poverty
2. Poor Quality, Overcrowded Homes
3. Lack of a Safe Environment for Play (note: e.g.,
playing on streets on which cars pass)
4. Poor Parenting Skills, which may be due to
parental psychiatric illness, drug and alcohol abuse,
violent temperament, poor education.

Children need a safe, healthy and nurturing

environment to achieve their full potential.
 Etiology
• The most common agents ingested by young children include
family members' medications (note: Acetaminophen,
multivitamins, contraceptive), cleaning or polishing solutions,
plants, and cosmetics.
• The most common poisonings that lead to hospitalization are
due to Acetaminophen, Lead (note: not common here, more
common in the US), and Antidepressant Medications.
 Routes of Administration of
the Poisons

(note: iatrogenic)
 Clinical Manifestations
• Unless the ingested drug is revealed, poisoning is often
a diagnosis of exclusion.
• On presentation, assessment of the ABCs is followed by careful
examination for evidence of ingestion.
• A comatose child should be considered to have ingested a
poison until proved otherwise.
• Note: The parents may even lie so them saying the child has
not ingested anything doesn’t necessarily exclude poisoning.
INITIAL
PATIENT
EVALUATION
 Patient History
The following information should be obtained during
the initial assessment.
1. Description of Toxins
2. Magnitude of Exposure. It is better to overestimate
than to underestimate.
3. Time of Exposure
4. Progression of Symptoms
Note: examples on description of and
magnitude of exposure
Drugs, such as:
• Acetaminophen: dosage is important; there is a poisonous
dose for acetaminophen (In children, 150 mg/kg/day for 2 or
more days is believed to be the threshold level that will
produce toxicity[1]), though of course the exposure amount
described may not be accurate or truthful
• Multivitamins: particularly focus on iron content, as iron
overload is serious and can cause hepatotoxicity
Physical Examination
1. Vital Signs is necessary.
2. For many agents, the Level of Consciousness,
3. Pupillary Size,
4. Muscle Fasciculations.
5. Bowel and Bladder Activity
6. Cardiac Arrhythmia
7. Seizures
8. Hypothermia.
Initial patient evaluation
1. Certain Complexes of Symptoms and Signs are
relatively specific to a given class of drugs (toxidrome).
2. Evaluation of the Lungs may reveal pulmonary edema,
which can be caused by cyclic antidepressants,
organophosphates
3. The Patient’s Breath Odor may provide valuable clues
to potential ingestions.
 Complications
A poisoned child can exhibit any one of six basic
clinical patterns:
1. Coma
2. Toxicity
3. Metabolic Acidosis
4. Heart Rhythm Aberrations
5. Gastrointestinal Symptoms
6. Seizures
1. Coma
• Is perhaps the most striking symptom of a poison
ingestion.
• A careful history and clinical examination are needed to
distinguish among other causes.
• Pinpoint Pupils suggest either a pontine lesion or toxic
ingestion of opiates, organophosphates (note: found in
Pesticides, e.g., in rural areas used in farming), phenothiazines.
• Dilated Pupils often are associated with cyclic
antidepressants or atropine-like agents.
• Note: poisonous until proven otherwise
2. Systemic and Pulmonary Toxicity
• Hydrocarbon (e.g., kerosene) Ingestion occasionally may
result in systemic toxicity, but more often in pulmonary
toxicity.
• Note: Superadded pneumonia can also occur.
3. Metabolic Acidosis
• A poisoned child also may have metabolic acidosis,
which is assessed easily by measuring arterial blood
gases, serum electrolyte levels, and urine pH.
4. Dysrhythmias
• Dysrhythmias may be prominent signs of a variety of
toxic ingestions, although ventricular arrhythmias
are rare.
• Prolonged Q-T intervals may suggest phenothiazine
or antihistamine ingestion, and widened QRS
complexes are seen with ingestions of cyclic anti-
depressants and quinidine. (Note: TCAs can also
cause ventricular ectopics)
5. Gastrointestinal Symptoms
• Gastrointestinal symptoms of poisoning include
emesis, nausea, abdominal cramps, and diarrhea.
• These symptoms may be the result of direct toxic
effects on the intestinal mucosa or of systemic toxicity
after absorption (note: e.g., acetaminophen)
6. Seizures
• Poisoning is an uncommon cause of afebrile seizures.
• When seizures do occur with intoxication, they
may be life-threatening and require aggressive
therapeutic intervention.
 Laboratory and Imaging
Studies
1. Specific Toxin-Drug Assays
2. Measurement of Arterial Blood Gases and
Electrolytes and Glucose.
3. A full 12-lead ECG should be part of the
initial evaluation.
4. Urine Screens for Drugs of Abuse or to confirm
suspected ingestion of Medications.
 TYPES OF
POISONING
 Acetaminophen Poisoning
• Acetaminophen is the most widely used analgesic and
antipyretic in pediatrics, available in multiple formulations,
strengths, and combinations.
• Consequently, acetaminophen is commonly available in the home,
where it can be unintentionally ingested by young children.
• Initial Treatment should focus on the ABCs and consideration
of decontamination with activated charcoal in patients who
present within 1-2 hours of ingestion.
• The Antidote for acetaminophen poisoning is N-Acetyl Cysteine.
NAC therapy is most effective when initiated within 8 hours of
ingestion.
• Note: divided into 4 stages. In stage 3, the patient either dies or
goes to stage 4, where they recover.
 Classic stages in the clinical
course of acetaminophen toxicity
Stage Time after ingestion Characteristics
I 0.5-24 hours • Anorexia, nausea, vomiting, malaise, pallor,
diaphoresis
• Labs typically normal, except for acetaminophen
level
II 24-48 hours • Resolution of earlier symptoms, right upper
quadrant abdominal pain, and tenderness
• Elevated bilirubin, prothrombin time, and hepatic
enzymes
• Oliguria
III 72-95 hours • Peak liver function abnormalities
• Fulminant hepatic failure
• Multisystem organ failure
• Potential death
IV 4 days-2 weeks • Resolution of liver function abnormalities
• Clinical recovery precedes histologic recovery
 Caustic Poisoning
Caustics include Acids and Alkalis as well as a few common Oxidizing
Agents, such as bleach.
Note: an example of an acid here is H2CO3, used in the making of ‫ترشیات‬.
Alkalis are more common, and can be found in cleaning agents.
Pathophysiology
• Acids coagulate proteins, causing local tissue necrosis.
• Alkalis digest and dissolve proteins, producing transmural liquefaction
necrosis, with the risk of perforation if the injury is located in the intestinal
tract.
• The severity of the chemical burn produced depends on the pH, the
concentration of the agent, and the length of contact time.
• Agents with a pH of <2 or >12 are most likely to produce significant
injury.
 Note: Liquid vs powder
• These agents may come in liquid or powder forms. The
former is more dangerous, as it’s more easily ingested.
• Solid products tend to leave particles that stick to and burn
tissues, discouraging further ingestion and causing
localized damage.
• Because liquid preparations do not stick, larger quantities
are easily ingested, and damage may be widespread.
Liquids may also be aspirated, leading to upper airway
injury.
Clinical Manifestations
• Ingestion of caustic materials may produce oral
burns, visualized as reddened areas or whitish
plaques.
• Symptoms include pain, drooling, vomiting, and
difficulty swallowing or refusal to swallow.
• Circumferential burns of the esophagus are likely
to cause strictures on healing, which may require
repeated dilation (note: endoscopic) or surgical
correction.
• Caustics on the skin or in the eye can cause
significant tissue damage.
Treatment
1. Initial treatment of caustic exposure includes
thorough removal of the product from the skin or
eye by flushing with water.
2. Contaminated clothing should also be removed.
3. Ingested agents should be rinsed from the oral
cavity.
4. Emesis and Lavage are contraindicated.
Activated charcoal should NOT be used (note:
not beneficial)
5. Endoscopy should be performed in symptomatic
patients or those in whom injury is suspected on
the basis of history.
6. The use of Corticosteroids and Esophageal Stents
(note: to prevent strictures) is controversial.
7. Prophylactic Antibiotics do NOT improve
 Hydrocarbons Poisoning
Aspiration of hydrocarbons into the lung can lead to serious, even
life-threatening toxicity.
Pathophysiology
• The most important adverse effect of hydrocarbons is Aspiration
Pneumonitis
• Aspiration usually occurs at the time of ingestion, when coughing and
gagging are common, but can also be secondary to vomiting, which
commonly occurs after ingestion. (note: Parents tend to put fingers in
the child’s throat to make them vomit the substance out but as
mentioned this is actually counter-productive and make things worse)
• Gasoline and Kerosene are poorly absorbed, but often cause
considerable Gastrointestinal Mucosal Irritation as they pass through
the intestines.
• Several Chlorinated Solvents, most notably, Carbon
Tetrachloride, can produce Hepatic Toxicity.
• A few hydrocarbons have also been associated
with Renal and Bone Marrow Toxicity.
• Benzene is known to cause Cancer in humans after
long-term exposure.

Clinical and Laboratory Manifestations

• Transient, Mild CNS depression is common after
hydrocarbon ingestion.
• Aspiration is characterized by Coughing, which
usually is the first clinical finding. Cough usually
begins immediately or within 2–5 min of the aspiration,
and persists.
• Whenever possible, Chest Radiograph should be delayed until 6 hours
or longer after the hydrocarbon exposure, as they may be Normal for
as long as 8–12 hours after aspiration, but more often will be Positive
after 6 hours or longer from the time of exposure.
• Respiratory Symptoms may remain mild or may progress rapidly.
• Patient symptoms often correlate very poorly with abnormalities observed
on chest radiograph, underscoring the importance of close clinical
monitoring of the patient's respiratory status. (note: Treat the patient, not
the x-ray. Both clinical status and radiography should be relied upon for
patient assessment)
• Fever occurs and may persist for as long as 10 days after aspiration.
• Accompanying leukocytosis may be misleading because, in most cases of
aspiration pneumonitis, no bacteria are present in the lungs (note: the
fever and leukocytosis may mislead the doctor into thinking there is
pneumonia)
• Chest Radiographs may remain abnormal long after the patient is
clinically normal, and they should NOT be used to guide acute treatment.
Perihilar Opacity Bi-basal Infiltration
Treatment
• Emesis is Contraindicated because of the risk of
aspiration.
• Likewise, Gastric Lavage is Contraindicated, except
under special circumstances of ingestion of highly
toxic hydrocarbons (Carbon Tetrachloride), because
of the risk of vomiting and aspiration.
• If gastric lavage is to be performed, the patient
should be intubated with a cuffed tube to protect the
airway from further aspiration.
• Activated Charcoal also is NOT useful because it
does not bind the common hydrocarbons.
• If hydrocarbon-induced pneumonitis
develops, Respiratory Treatment is Supportive
• Corticosteroids should be Avoided because they are
not effective and may increase the risk of infection.
• Prophylactic Antibiotics should NOT be given
because bacterial pneumonia occurs in only a very
small percentage of cases.
• Respiratory Failure has been successfully treated both
with Standard Ventilation and with Extracorporeal
Membrane Oxygenation
Carbon Monoxide Poisoning
Carbon Monoxide Poisoning results from inhalation of fire smoke, automobile exhaust,
fumes from faulty gas stoves and ingestion of paint and varnish removers (note: and
electricity generators)
Note: common here, particularly in the winter
Note: fire normally produces CO2. Carbon monoxide gas is produced when fossil fuel
burns incompletely because of insufficient oxygen; intoxication can occur when these
devices are being used in closed spaces without adequate ventilation.
Clinical Manifestations include:
1. Headache
2. Nausea
3. Shortness of Breath
4. Cyanosis
5. Convulsions
6. Loss of Consciousness
7. Coma
Treatment:
• Patients are administered 100% oxygen.
• If carboxyhemoglobin levels are above 40%,
Hyperbaric Oxygen Therapy is considered.
• Note: CO has a very high affinity for
hemoglobin, not allowing O2 to bind. 100%
normobaric and hyperbaric oxygen therapy
remove CO at a faster rate from the blood by
increasing the partial pressure of oxygen,
which increases the dissociation rate of CO
from Hb.
TREATMENT
 Supportive Care
• Prompt attention must be given to protecting
and maintaining the Airway, establishing
effective Breathing, and supporting the
Circulation.
• If the level of consciousness is depressed, and a
toxic substance is suspected, glucose (1 g/kg IV),
100% oxygen, and naloxone should be
administered.
 Gastric Decontamination
• To Prevent the poisoning.
• Gastric Emptying, through administration of syrup of ipecac (note: emetic
agent, no longer used) or orogastric lavage, is used when life- threatening
ingestions present early (≤60 minutes), and the airway is protected. (note:
activated charcoal is another method of gastric decontamination)
• It is contraindicated if:
1. The ingestion is minimally toxic.
2. There has been prior vomiting.
3. The airway is unprotected.
4. The ingested substance is caustic, a hydrocarbon, or foreign body.
• Note: contraindicated with hydrocarbon aspiration because of high
aspiration potential, with caustic agents for the risk of re-exposure to the
corrosive agent and additional injury to the esophagus (e.g., perforation,
stricture, etc.), and with foreign bodies as it’s ineffective.
• Note: activated charcoal is also contraindicated in these cases as it cannot
bind to these agents.
 Activated Charcoal
• Is the Mainstay for Decontamination.
• By binding with toxins, charcoal may prevent the toxin
from being absorbed by the intestinal tract (note: the
toxin then passes through the gastrointestinal tract to
be eliminated in the stool as a sticky black substance)
• Charcoal has been used as a single-dose (25 to 50 g for
small children; 50 to 100 g for children >12 years old)
and multiple-dose intervention for poisonings.
• Note: not useful after 60 minutes [Dr. Sasan][1]
 Whole Bowel Irrigation
• Whole bowel irrigation is advocated for
gastrointestinal decontamination.
• It involves the use of polyethylene glycol
(GoLYTELY) as a nonabsorbable cathartic (note:
purgative agent) and may be effective for toxic
ingestion of sustained-release or enteric-coated
drugs. (note: The rationale behind whole-bowel
irrigation is to prevent absorption of ingested matter in
the small intestine (mostly) by inducing a liquid stool)
• Note: can be used after 60 minutes [Dr. Sasan]
• Note: after 8 hours, dialysis is used to remove the
toxin from the blood stream [?? Dr. Sasan]
 Subsequent Care of a Child
With a Significant Ingestion
1. Providing continued supportive care
2. Using specific antidotes where available
3. Actively removing the toxin from the bloodstream
Active Removal (Hemoperfusion
or Dialysis)
Should be undertaken only:
1. For toxins that may cause tissue damage.
2. For toxins that have been ingested by a patient
already exhibiting confounding medical problems.
3. To avoid prolonged supportive care.
Common Antidotes for
Poisoning
1. N-Acetyl Cysteine (Acetodote)  Acetaminophen
2. Atropine  Organophosphate and Carbamate
Pesticides
3. Deferoxamine (Desferal)  Iron (note: also
used in transfusion-dependent thalassemic
patients)
4. Diphenhydramine (Benadryl)  Extrapyramidal
Symptoms (note: e.g., with Metoclopramide
[Plasil])
5. Flumazenil (Romazicon)  Benzodiazepines
6. Glucagon β Blockers  Calcium Channel
Blockers and Hypoglycemic Agents
7. Methylene Blue  Methemoglobinemia
8. Naloxone (Narcan)  Narcotics
9. Oxygen  Carbon Monoxide
10.Vitamin K  Warfarin (note: found in
rodenticides)
11.Sodium Bicarbonate Sodium Channel Blockade
 Tricyclic Antidepressants and Type-1
Antiarrhythmics
 Prognosi
s
• Mortality from poisoning is rare (0.002%)
(note: the numbers are likely less encouraging
in our country)
• The most common exposures resulting in death
include Carbon Monoxide, Hydrocarbons, and
Opioids.
 Prevention
• Most ingestions occur in the home, and the toxins involved are
common household medications, household cleaning and work
solutions, or vitamins (note: So these things should be kept out
of the reach of children and placed and stored properly)
• Note: A poisoning in a case > 5 years old should be
considered a suicidal attempt or intentional poisoning by a
family member until proven otherwise [Dr. Sasan]
(ingestions should be considered intentional in any affected
child older than age 5 years, but suicidal ideation should
particularly be considered in adolescent patients[1])
• Unintentional poisonings are more frequent in children younger
than 5 years old, in boys, in families of low socioeconomic status,
and during times of family disorganization (note: e.g., moving
houses, taking things in and out of storage as seasons change).
 Summary
• A poisoned child can exhibit any one of six basic clinical
patterns: coma, toxicity, metabolic acidosis, heart rhythm
aberrations, gastrointestinal symptoms, and seizures.
• Activated charcoal is the mainstay for decontamination.
• A comatose child should be considered to have ingested a
poison until proved otherwise; poisoning is often a
diagnosis of exclusion.
• The severity of the chemical burn produced depends on
the pH, the concentration of the agent, and the length of
contact time. Emesis and lavage are contraindicated.
Activated charcoal should not be used
• The most important adverse effect of hydrocarbons
is aspiration pneumonitis. Emesis is contraindicated because
of the risk of aspiration. Likewise, gastric lavage is
contraindicated.
SUMMARIES
for Diagnosis and Approach

Only if You Want to be Awa’il!!!

Management of a poisoned child or young person

Outline of Management
Question parents, child, or young person
Identify the agent Clinical symptoms and signs may help where
history is unclear (Table 7.3)

Consider:
• intrinsic toxicity (use poisons information service)
• reported dose ingested
Determine toxicity of agent
• presence of symptoms
• time since ingestion

Activated charcoal:
• high surface area leads to adsorption of many
drugs
• can be effective in reducing absorption of toxic
Is reduction of absorption
possible/indicated? agent if administered within 1 h of ingestion
• ineffective for iron, hydrocarbons, and pesticides
Gastric lavage and induced vomiting no longer
recommended

• General blood tests (e.g. full blood count, renal

Are investigations indicated?
and liver function) dependent on mechanism
and likelihood of toxicity
• ECG for drugs with cardiovascular toxicity
• Specific blood concentrations only helpful for
paracetamol, iron, salicylates, and alcohol
• Urine toxicology screen not helpful in the
acute
situation but may help to confirm diagnosis

Mainly determined by toxicity of agent:

• specific management including antidote as
directed by poisons information service
• assessment of circumstances of ingestion
Clinical management important to prevent future recurrence
• assessment by child and adolescent psychiatrist
or mental health services in cases of deliberate
self-harm

Figure Outline of management of poisoning.

 Clinical
Agent Mechanism Management
Symptoms
Risk Assessed by
measuring plasma
Early: Initial gastric irritation
paracetamol
• Abdominal pain Toxic metabolite
concentration
• Vomiting
Paracetamol (NAPQI) produced by
Treat with intravenous
Later (12-24 hrs): saturation of liver
acetylcysteine if
• Liver failure metabolism
concentration is high or
liver function abnormal

X-ray of chest and

abdomen to confirm
ingestion and identify
position
Corrosion of gut wall
Button •
•
Abdominal pain
Gut perforation and
due to electrical circuit Endoscopic removal is
Batteries stricture formation
production of caustic
hydroxide
recommended if in the
oesophagus, the object
fails to pass, or
symptoms are present
(e.g. abdominal pain or
melaena)
 Clinical
Agent Mechanism Management
Symptoms

Early:
High-flow oxygen to
• Headache
hasten dissociation of
• Nausea
Carbon carbon monoxide
Binds to haemoglobin
Monoxide Later: causing tissue hypoxia The role of hyperbaric
• Confusion
oxygen therapy is
• Drowsiness
unclear
• Leading to coma

Plasma salicylate
concentration 2–4 h
Early: after ingestion helps to
• Vomiting Direct stimulation of estimate toxicity
• Tinnitus respiratory centre
Salicylates (e.g.
Alkalinization of urine
aspirin, oil of Later: Uncouples oxidative increases excretion of
• Respiratory phosphorylation leading
wintergreen) Alkalosis to metabolic acidosis
salicylates
• Followed by and hypoglycaemia Haemodialysis also
Metabolic Acidosis
effectively removes
salicylate
 Clinical
Agent Mechanism Management
Symptoms

Early:
• Tachycardia
• Drowsiness Anti-cholinergic effects Treatment of
Tricyclic • Dry Mouth
Interference with
arrhythmias with
Sodium Bicarbonate
Antidepressant Later: cardiac conduction
• Arrhythmias pathways Support breathing
• Seizures

Fomepizole inhibits the

production of toxic
Early: metabolites
• Intoxication
Production of toxic
Ethylene metabolites that
Alcohol may also be
Later: used but has more
Glycol • Tachycardia
interfere with
adverse effects
intracellular energy
(anti- • Metabolic Acidosis
production
leading to Renal Haemodialysis to
freeze) Failure remove toxic
metabolites in severe
cases
 Clinical
Agent Mechanism Management
Symptoms
Monitor blood glucose
Alcohol Direct inhibitory effect on:
and correct if necessary.
• Hypoglycaemia
(accidental or • Coma
• Glycolysis in the liver Support ventilation
experimenting by • Neurotransmission if required
• Respiratory failure
in the Brain
older children) Blood alcohol levels
may help to predict
severity
Initial:
• Vomiting
• Diarrhoea Serious toxicity if
• Haematemesis >75 mg/kg elemental
• Melaena Local corrosive effect on iron ingested
• Acute gastric ulceration gut mucosa
Serum iron level 4 h
6–12 hours later: Disruption of after ingestion is the best
Iron • Drowsiness
• Coma
oxidative
phosphorylation in
laboratory measure of
severity
• Shock mitochondria leads t:
• Liver failure with • Free radical Intravenous deferoxamine
hypoglycaemia production chelates iron and should be
• Convulsions • Lipid peroxidation administered in cases of
• Metabolic moderate-to-severe
Long Term: Acidosis toxicity
• Gut strictures
 Clinical
Agent Mechanism Management
Symptoms

Low viscosity and high

volatility facilitates
Hydrocarbons aspiration, resulting in
No specific antidote –
• Pneumonitis direct lung toxicity
(e.g. paraffin, • Coma
supportive treatment
only
kerosene) Direct inhibitory effect
on neurotransmission in
the Brain

Cholinergic Effects:
• Salivation
• Lacrimation Supportive care
• Urination
• Diarrhoea Inhibition of
• Vomiting acetylcholinesterase Atropine (often in large
• Muscle Weakness resulting in doses) as an
Organophosphorus • Cramps
accumulation of anticholinergic agent
• Paralysis
Pesticides • Bradycardia acetylcholine
• Hypotension throughout the nervous Pralidoxime to
Central Nervous System system reactivate
Effects: acetylcholinesterase
• Seizures
• Coma
QUESTIONS
Poisoning
Q1. A 2-year-old boy is brought to the emergency
department by ambulance. Thirty minutes ago, his
mother discovered him eating pills from a pillbox at his
grandparents' house and called for ambulance. The boy's
mother states that the pillbox contained a 1-week supply
of his grandparents' daily medications. She did not count
how many tablets remained in the box before the
ambulance arrived, but she states, "I think only a couple
were missing:' Both grandparents take "blood pressure
medicine" and that the grandfather takes "a pill for his
nerves"
The boy is well-appearing and playful. His vital signs are
normal for his age, and you note no abnormalities on
physical examination. The mother states that she now
feels "silly for panicking over nothing. ' She asks you how
soon she can take her son home.
Of the following, the BEST next step in managing
this patient is:
A. Administration of activated charcoal at 1 g/kg
B. Perform gastric lavage to remove ingested
pill fragments from the stomach
C. Discharge the boy after educating his mother
about
signs and symptoms to observe for at home
D. Observe the boy in the emergency department for
development of symptoms over the next 6 hours
E. Administration of intravenous normal saline at
20 mL/kg
Answer: A
Q2. A 3 years old child come to emergency department
suffering of vomiting, difficulty in swallowing with pain
in his oral cavity and drooling, the child was completely
normal. On examination there is oral burns, history
revealed that he ingest a cleaning solution.
A. 1st action is to remove contaminated clothes and
washing the skin and eyes by water
B. Activated charcoal is a 2nd line of management
C. All cases should receive antibiotic to avoided
super added infection
D. Gastric lavage should not be delayed
E. The main complication is aspiration pneumonitis

Answer: A
Q3. Regarding drug poisoning;
A. The most common agents ingested are relative medications
B. Aspirin are the commonest drug poisoning
C. Fatal poisoning occur by carbon monoxide
D. About 20% of poisoning occur in the home
E. Inhalation is the commonest route of poisoning

Ans. C or A?
Notes:
• More than 90% of poisonings occur in the home, and half of those involve
children younger than the age 6.
• Ingestion is the most common route of exposure to toxic chemicals.
• Despite its excellent safety profile when properly dispensed, acetaminophen is
cited as one of the drugs that is most often ingested in childhood poisonings.
 Q4. Hydrocarbon Poisoning;
A. Gastric Complications are the most serious
complication
B. Aspiration can occur at the time of ingestion
when gagging and coughing are common.
C. Low viscosity slowly spread across surface of the
lung
D. Gasoline and kerosene are highly absorbed from
intestinal mucosa
E. Chest X-ray should be done as soon as possible

Ans: B
Note: Hydrocarbon liquids with low viscosity, such as gasoline and
mineral spirits, can spread rapidly over large surface areas
Q5. Regarding carbon monoxide poisoning, all are true EXCEPT;
A. Normal blood may contain up to 5% of carboxy
haemoglobin
B. The outcome of severe poisoning may be complete recovery
C. More severe in infant
D. Headache is one of the prominent early features of poisoning
E. None of the Above
Ans. E

Notes:
• Normal blood may contain up to 5% carboxyhemoglobin (10% in smokers).
• Newborn infants are more vulnerable to carbon monoxide poisoning
because of the persistence of fetal hemoglobin.
• The most prominent early symptom is headache.
• The outcome of severe poisoning may be complete recovery, vegetative
state, or any degree of mental injury between these extremes.
Q6. A child took Kerosene, and the father removed
their clothes. What do you do next?
A. Observe at the hospital for 24 hours

Q7. A child was left alone in a room with a box of

their grandmothers (heart drugs). They presented to
the
emergency department… What is the most likely
cause?
A. Aspirin Toxicity

Q8. A child used their mothers paracetamol medications

and presented to the emergency department with… What
is the most likely complication?
A. Hepatic Toxicity
B. Metabolic Acidosis