Joe Rotella. The Toxicological Risk Assessment, Don't Forget the Bubbles, 2018. Available at:
Hello and welcome to Twinkle Twinkle Little Tox, a new section for Don’t Forget the Bubbles on Paediatric Toxicology!
I’m humbled and honoured to have the opportunity to contribute to this amazing site and join a team of dedicated medical educators. A special thanks to Andy Tagg for the chance and to Shaun Greene and Jeff Robinson from the Victorian Poisons Information Centre for their support in producing these blog posts.
Clinical Toxicology is the study of poisoning. This includes accidental, intentional and sometimes (thankfully rarely) malicious poisoning. Toxicologists utilize the risk assessment to decide a) is this bad? b) how bad is it? c) what treatments do we need to administer and in what order and d) where is the best place for the patient to be treated?
Jack and Jill took which pill?
In paediatrics, toxicology faces similar challenges to other aspects of medicine in that the patients may not be able to fully participate in a history or clinical examination (or may not want to!) and there is the added factor of their care-givers. Obtaining a collateral history and assuming the worse case scenario are important parts of ensuring a safe assessment is made.
Some nuances in paediatrics:
- Ingestions in young children are accidental however in adolescents, they are often intentional
- Weight is an important component in risk assessment. In the words of Paracelsus, the dose makes the poison
- One tablet can be harmful in paediatric patients (the aptly named ‘one pill kills’ will be discussed in a future post)
- Young children will often tell their parents what they think they should say. So, an answer of ‘yes’ is by no means confirmation of ingestion. Conversely, an appropriate period of observation ensures that the assumption made is a safe one
As a clinician, one will invariably look after someone with a toxicological problem. Whilst more commonplace in the ED or General Practice, it could also occur during ICU, Psychiatry or General Medicine. Similar to other presentations, you will often need to seek out expert advice, namely a toxicologist.
If your hospital doesn’t have an super awesome in-house Toxicology service, then a Poisons Information Centre (or Poisons Control Centre depending on where you are) can connect you with an on-call toxicologist if the receiving specialist in poisons information (or SPI) determines their input is required. In Australia, that number is 13 11 26 and it works anywhere in the country, 24/7.
A few years ago, when working as a Toxicology Registrar, I reflected on a few nervous referrals I received (we were all junior once!) and constructed the mnemonic DR TOXIC (in the spirit of ISBAR) as a way of guiding junior doctors in making Toxicology referrals.
A little more detail…
This refers to the patient’s name, age, gender and hospital identification or record number. The first and last ones are important because toxicologists often follow-up calls and it helps to have one or ideally, both. Don’t forget weight!
This refers to the patient’s relevant medical (e.g. cardiac disease in someone who has taken a potentially cardiotoxic drug) and psychiatric history (previous overdoses, history of other self-harm)
Time, type and total
This refers to time of ingestion, type of drug/s ingested, and the amounts. These can be hard to establish for various reasons. Sometimes you don’t get a name or number from the patient, a relative or the ambulance paramedic and other times you have to assume a maximum amount of drug/s ingested from empty packets. Consider access to other people’s medications.
Self-explanatory. GCS (although not validated in toxicology, the motor score is useful) or AVPU if more appropriate, A description of what the patient is doing and what they can’t do is far more useful to the toxicologist on the phone. Heart rate, blood pressure and oxygen saturations are also useful.
Similarly, this is self-explanatory but there a few extra things that can be useful. For example, presence of ptosis in someone who may have been bitten by a snake or clonus in someone presenting with possible serotonergic toxicity
At a SMACC conference several years ago, clinical toxicologist and emergency physician Mark Little gave a great talk on an approach to toxicology patients. When it comes to investigations, he kept it simple- an ECG, a paracetamol level (as paracetamol poisoning can be asymptomatic) and a BSL (remember hypoglycaemia can cause altered conscious state and it’s an easy fix!)
This is really important for doctors outside of tertiary hospitals. Where is the patient now? Are there HDU or ICU capabilities at your hospital? Many emergency departments can look after a broad group of toxicology patients without question however it is important to think about whether that management can continue beyond the ED’s doors. If not, then you need to consider whether to transfer the patient elsewhere on clinical grounds
In addition, there’s a few other important considerations
- Time of Day – don’t send children home at night after a significant ingestion, the sun is a much better companion on their journey home
- Accident or non-accident? Sad as it may, non-accidental injury using toxins is possible and any suspicion of NAI needs to be explored as per standard convention
- If in doubt, observe – time heals all toxicology (more or less!)
Till next time!