Makindo Medical Notes

Acute Care

Drug overdose in children requires prompt and thorough assessment to ensure appropriate management. The initial assessment focuses on the stabilization of the child, identification of the substance ingested, and addressing any life-threatening complications. Below are key steps for conducting the initial assessment.

Stabilization of ABCs (Airway, Breathing, Circulation)

• Airway: Ensure the child has a patent airway. Assess for any signs of airway obstruction. If the child is unresponsive or has respiratory depression, consider airway adjuncts or endotracheal intubation.
• Breathing: Monitor the respiratory rate and oxygen saturation. If hypoxia or respiratory depression is present, provide supplemental oxygen. Use bag-mask ventilation or mechanical ventilation if necessary.
• Circulation: Check for signs of shock such as tachycardia, hypotension, or poor perfusion. Establish IV access and administer IV fluids to maintain blood pressure and ensure proper hydration.

Quick History Taking

• Gather as much information as possible from the patient, family, or caregivers. Key points to ask about include:
• Substance: Identify the drug or substance ingested, if possible. Look for medication bottles, packaging, or ask the caregivers what was available in the home.
• Amount: Estimate the amount ingested based on the remaining volume of the drug or packaging information.
• Timing: Determine the time of ingestion, as this will guide management decisions, particularly regarding decontamination (e.g., activated charcoal) and antidotes.
• Co-Ingestions: Ask about the potential use of multiple substances or medications, including alcohol, over-the-counter medications, or household products.
• Intentional or Accidental: Ascertain whether the overdose was accidental or intentional, especially in older children or adolescents where mental health concerns may be present.

Initial Physical Examination

• Conduct a focused physical examination to assess the child’s overall condition and to look for signs of toxicity. Key areas of focus include:
• Level of Consciousness: Use the Glasgow Coma Scale (GCS) to assess the child’s level of consciousness. Look for signs of drowsiness, confusion, or unresponsiveness.
• Pupils: Assess for pupil size and reactivity. Pinpoint pupils may indicate opioid overdose, while dilated pupils may suggest anticholinergic or stimulant toxicity.
• Vital Signs: Record the heart rate, respiratory rate, blood pressure, and temperature. Bradycardia, tachycardia, hypotension, or hyperthermia can provide clues to the type of drug ingested.
• Skin: Check for signs of cyanosis, diaphoresis, or flushing. Dry, flushed skin may indicate anticholinergic toxicity, while cool, clammy skin may be a sign of shock.
• Neurological Exam: Look for signs of seizure activity, tremors, or muscle rigidity. Certain drugs, such as tricyclic antidepressants or stimulants, can induce seizures.

Specific Toxic Syndromes (Toxidromes)

• Opioid Toxidrome: Characterized by respiratory depression, pinpoint pupils, and decreased level of consciousness. May require naloxone for reversal.
• Anticholinergic Toxidrome: Presents with dilated pupils, dry skin, tachycardia, urinary retention, and confusion. Drugs like antihistamines or tricyclic antidepressants can cause this.
• Sympathomimetic Toxidrome: Characterized by agitation, tachycardia, hypertension, hyperthermia, and dilated pupils. Seen in stimulant overdose (e.g., amphetamines, cocaine).
• Cholinergic Toxidrome: Presents with salivation, lacrimation, urination, diarrhoea, bronchorrhea, and bradycardia. Typically seen in organophosphate poisoning.

Laboratory and Diagnostic Tests

• Blood Glucose: Check for hypoglycemia, particularly in children with altered mental status. Administer dextrose if needed.
• U&E: Monitor sodium, potassium, chloride, and bicarbonate levels, especially in overdoses that can cause metabolic derangements (e.g., salicylates, tricyclic antidepressants).
• Arterial Blood Gases (ABGs): Evaluate acid-base status and oxygenation, particularly in children with respiratory depression or metabolic acidosis.
• Toxicology Screen: Urine or blood toxicology screening for common drugs of abuse and therapeutic drugs.
• ECG: Obtain an ECG to check for arrhythmias or QT prolongation, especially in cases of tricyclic antidepressant or antipsychotic overdose.

Decontamination: If the ingestion is recent (< 1 hour), consider

• Activated Charcoal: Administer if the child is alert and has ingested a drug that can be absorbed by charcoal (e.g., acetaminophen, salicylates, or antidepressants).
• Gastric Lavage: Consider only in life-threatening ingestions if performed within 1 hour, but it is rarely used in pediatric patients.
• Whole Bowel Irrigation: Consider in cases of iron or sustained-release drug overdose.

Antidotes

• Naloxone: For opioid overdose, administer to reverse respiratory depression and altered mental status.
• N-Acetylcysteine (NAC): For acetaminophen overdose, initiate based on serum levels and timing of ingestion.
• Flumazenil: Consider for benzodiazepine overdose, though it is used cautiously due to the risk of seizures in mixed overdoses.
• Sodium Bicarbonate: For tricyclic antidepressant overdose or to treat metabolic acidosis and prolonged QRS complex on ECG.

Drug Type / Substance	Management
General Management of All Overdoses	Stabilize ABCs: Airway, Breathing, and Circulation should be stabilized immediately. Decontamination: Activated charcoal (within 1 hour of ingestion) for non-caustic substances to prevent absorption. IV Fluids: For hypotension and to maintain hydration. Seizure Management: Benzodiazepines (e.g., diazepam or lorazepam) for any seizure activity. Monitor Vital Signs: Continuous monitoring of heart rate, respiratory rate, blood pressure, oxygen saturation, and mental status. Toxicology Screen: Obtain blood/urine samples for toxicology and drug levels.
Paracetamol Overdose	Activated Charcoal: If within 1 hour of ingestion. N-Acetylcysteine (NAC): Administer orally or IV if ingestion is >150 mg/kg or if toxic levels on serum testing. Monitor: LFTs and INR for hepatotoxicity and Paracetamol levels. Supportive Care: Monitor hydration and treat any liver failure complications.
Salicylates (Aspirin) Overdose	Activated Charcoal: Administer if within 1 hour of ingestion. Alkalinization: IV sodium bicarbonate may be used to help elimination and correct acidosis. Haemodialysis: For severe cases with high salicylate levels or severe acidosis. Monitor: Blood salicylate levels, electrolytes, and acid-base status.
Opioid Overdose	Airway Management: ABC and administer oxygen if needed. Naloxone (Narcan): Administer IV or intranasally to reverse opioid toxicity (dose titrated based on response). Monitor: Respiratory rate and oxygen saturation continuously. Supportive Care: IV fluids and treat respiratory depression.
Benzodiazepine Overdose	Airway Management: Ensure respiratory support if needed. Flumazenil: Consider for severe CNS depression. Risk of seizures, especially in mixed overdoses. Supportive Care: Monitor for resp depression and provide IV fluids if hypotension is present.
Iron Overdose	Whole Bowel Irrigation: Consider in cases of significant ingestion of iron tablets. Deferoxamine: Chelating agent used if serum iron levels are elevated or in cases of severe toxicity. Monitor: Serum iron levels, abdominal X-rays to detect undissolved tablets, and signs of shock or metabolic acidosis.
Antihistamine (Diphenhydramine) Overdose	Activated Charcoal: If within 1 hour of ingestion. Supportive Care: IV fluids and benzodiazepines for agitation or seizures. Sodium Bicarbonate: For prolonged QRS or arrhythmias on ECG.
Tricyclic Antidepressant (TCA) Overdose	Activated Charcoal: If within 1 hour of ingestion. Sodium Bicarbonate: To treat arrhythmias and widen QRS complex, and correct acidosis. Seizure Management: Benzodiazepines for any seizures. Supportive Care: IV fluids, cardiac monitoring, and respiratory support as needed.
Beta-Blocker or Calcium Channel Blocker Overdose	Activated Charcoal: Administer if within 1 hour of ingestion. IV Glucagon: First-line antidote to reverse beta-blocker effects. IV Calcium: For calcium channel blocker overdose. High-Dose Insulin and Glucose: For refractory hypotension or bradycardia. Vasopressors: If needed for hypotension unresponsive to fluids.

Post recovery

Many cases of drug overdose in children, particularly in adolescents, may involve intentional self-harm or accidental ingestion. A thorough psychological evaluation is essential to assess the underlying mental health conditions, such as:

Assessment

• Depression: A common factor in intentional overdoses, particularly in adolescents. It is crucial to evaluate the child's mood, sleep patterns, and any history of hopelessness or suicidal ideation.
• Anxiety Disorders: Anxiety may contribute to impulsive behaviors, such as substance misuse. Addressing ongoing anxiety can help prevent future overdose episodes.
• Impulsivity or Conduct Disorders: Children with behavioral issues may engage in risk-taking behaviors, including substance misuse.
• History of Trauma: Exposure to traumatic experiences may increase the likelihood of drug misuse. Assessment of trauma history is essential in formulating a comprehensive care plan.

Suicide Risk Assessment

• In cases of suspected intentional overdose, a suicide risk assessment is critical:
• Assess for Suicidal Ideation: Ask about recent thoughts of self-harm or suicide. Direct questioning about these thoughts is necessary, as children may not volunteer this information.
• Previous Attempts: A history of previous suicide attempts increases the risk of further attempts. This information is important when determining the level of care and monitoring.
• Access to Lethal Means: Determine whether the child has access to other medications, weapons, or harmful substances at home.

Family and Social Dynamics: family and social dynamics are key

• Family Stressors: Factors such as family conflict, parental mental health issues, or substance misuse in the home environment may increase the risk of overdose.
• Bullying or Social Isolation: Social difficulties, such as bullying or exclusion from peers, may drive the child to substance misuse or intentional overdose.
• Peer Influence: Adolescents may be influenced by peers to engage in risky behaviors, including the misuse of medications or drugs.

Ongoing Mental Health Referrals and Counseling

• Psychiatric Evaluation: A referral to a child and adolescent psychiatrist or psychologist for a full mental health assessment and treatment plan.
• Cognitive Behavioral Therapy (CBT): For managing underlying depression, anxiety, or impulsive behaviors that may have contributed to the overdose.
• Family Therapy: Engaging the family in therapy can help address underlying family dynamics contributing to the child's mental health challenges.
• School-Based Support: Involving school counselors or support staff to ensure that the child receives mental health and academic support in their school environment.

Prevention of Future Overdoses

• Safety Planning: Develop a clear safety plan with the child and family, outlining steps to take if suicidal thoughts or self-harm urges arise.
• Medication Storage: Ensure that all medications, especially those with overdose potential, are stored securely and out of the child’s reach.
• Follow-Up Care: Schedule regular mental health follow-up appointments to monitor progress and adjust treatment as necessary.