Drug overdose children (NICE compliant)

Drug overdose in children requires rapid ABC stabilisation, identification of the substance, and targeted treatment. Both accidental ingestions (toddlers) and intentional overdoses (adolescents) must be considered. Refer to UK poisons information services (e.g., TOXBASE) for substance‑specific management. :contentReference[oaicite:1]{index=1}

🫁 Stabilisation of ABCs

• Airway: Ensure patency; airway adjuncts or intubation if GCS decreases.
• Breathing: Monitor RR & O₂ sats; provide supplemental oxygen or ventilation if needed.
• Circulation: Assess for shock; obtain IV access and initiate IV fluids if hypotensive.

🕵️ Quick History

• 📦 Substance: Identify drug/packaging if possible.
• ⚖️ Amount: Estimate ingestion dose.
• ⏰ Timing: Time since ingestion informs decontamination/antidote decisions.
• ➕ Co‑ingestions: Alcohol, OTC meds, household products.
• 🧠 Intent: Accidental vs deliberate (especially in adolescents; self‑harm pathways per NICE self‑harm guidance NG225).

👩‍⚕️ Initial Exam & Observations

• GCS for level of consciousness.
• Pupils: pinpoint (opioids) vs dilated (anticholinergics, stimulants).
• Vital signs: bradycardia/tachycardia, hypo/hypertension, temperature abnormalities.
• Skin: dry/flushed (anticholinergic), sweaty (sympathomimetic), clammy (shock).
• Neuro: seizures, tremors, rigidity (TCAs, stimulants).

🧩 Classic Toxidromes

• 💊 Opioid: Pinpoint pupils, ↓RR, ↓GCS → Naloxone where indicated.
• 🌿 Anticholinergic: Dilated pupils, dry hot skin, tachycardia, agitation.
• ⚡ Sympathomimetic: Agitation, tachycardia, hypertension, dilated pupils.
• 💧 Cholinergic: SLUDGE signs (salivation, lacrimation, urination, diarrhoea) with bradycardia.

🧪 Investigations

• Point‑of‑care glucose (exclude hypoglycaemia).
• U&E, LFTs (metabolic derangements).
• ABG (acidosis/hypoxia).
• ECG (arrhythmias, QRS/QT prolongation in TCA or sodium channel blocker toxicity).
• Toxicology screen (urine/blood) and substance levels if available.

🧴 Decontamination & Elimination

• Activated charcoal within 1 hr if appropriate and airway protected.
• Whole bowel irrigation for iron, lithium, or sustained‑release tablets in specific cases.
• Gastric lavage only in rare, life‑threatening ingestions early after ingestion.

💉 Key Antidotes & Targeted Therapy

• 🔑 Naloxone: For opioid toxicity with respiratory depression.
• 🧪 N‑Acetylcysteine (NAC): For paracetamol overdose; follow local paediatric protocols.
• 💤 Flumazenil: For benzodiazepine overdose only in select cases (seizure risk).
• 🧂 Sodium bicarbonate: For TCA toxicity and significant QRS prolongation.
• 🧲 Deferoxamine: For iron toxicity when levels/clinical signs indicate.
• 💉 Glucagon/Calcium/High‑dose Insulin: For β‑blocker and Ca‑channel blocker overdose (specialist care).

🧭 Substance‑Specific Pointers

• 🌡️ Paracetamol: NAC and monitoring of LFTs/INR as per UK paediatric regimens.
• 💊 Salicylates: Alkalinisation with sodium bicarbonate; haemodialysis if severe.
• 💉 Opioids: Titrate naloxone and support airway/ventilation.
• 😴 Benzodiazepines: Supportive care; flumazenil rarely appropriate due to seizure risk.
• 🧲 Iron: Consider whole bowel irrigation and deferoxamine with high levels.
• ❤️ TCAs: Sodium bicarbonate for arrhythmias; benzos for seizures.

🧠 Post‑Recovery Care & Safeguarding

After stabilisation, address psychosocial factors. Adolescents with intentional overdose require formal assessment under NICE self‑harm guidance (e.g., NICE NG225: Self‑harm). Child maltreatment considerations should be applied if the child could not access the substance independently or explanations are inconsistent, per safeguarding guidance. :contentReference[oaicite:2]{index=2}

👪 Family & Social Dynamics

• Assess family conflict, parental mental health/substance misuse.
• Bullying, social isolation, peer pressure.

🧾 Ongoing Support

• Referral to paediatric/psychiatric services (CAMHS) where indicated.
• CBT, family therapy, school support, safety planning.
• Secure storage of medications.

💡 Exam Tip: Structure your approach: Stabilise → Identify substance → Recognise toxidrome → Targeted investigations/antidotes → Psychosocial assessment.

📚 NICE & UK Resources

• NICE NG225: Self‑harm (assessment & management)
• NICE Topic: Poisoning and toxicology (overview)
• NICE CG89: Child maltreatment considerations (poisoning context)
• NHS Specialist Pharmacy Service: Poisoning & toxicity resources