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covered in detail in Chapter 7 A General Approach to the Ill or Injured Child . In
the context of the poisoned child, a few points deserve special emphasis. In
addition to the usual signs of airway obstruction, pay special attention to evidence
of disturbed airway protective reflexes, or to signs of airway injury as with a
caustic ingestion. Many poisoned patients will vomit, and some may be
administered charcoal, which poses an aspiration risk. Elective endotracheal
intubation (Chapter 8 Airway ) may thus be indicated at a lower threshold in this
context than in another child with comparable central nervous system (CNS)
depression.
Anticipate imminent respiratory failure in the deeply comatose poisoned child.
Cyanosis and overt apnea are late findings with progressive drug-induced
medullary depression. Thus, clinical or laboratory assessment of early ventilatory
insufficiency is critical in such patients to avoid the chaos of a precipitous
respiratory arrest; continuously monitor the patient with end-tidal CO2 and pulse
oximetry. Likewise, it is far easier to establish intravenous (IV) access in a child
with normal circulatory status than in a child in shock, so establish an IV line
early.
After securing the airway, ensuring effective breathing, and supporting
circulation (ABCs), evaluate the poisoned patient for neurologic “d isability,” and
the need for empiric “d rug” treatment, and emergent “d econtamination.” Level
of consciousness may be assessed rapidly and repeatedly with a semiquantitative
scale such as the Glasgow Coma Scale or the AVPU (spontaneously a lert,
response to v erbal stimulation or p ain, or u nresponsive) scale. Pupillary size and
reactivity may be quickly noted. Rapid changes in mental status are common in
serious intoxications and may herald precipitous cardiorespiratory failure.