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Certain underlying medical conditions may be relevant (e.g., glucose-6-phosphate
dehydrogenase [G6PD] deficiency for mothball ingestions); thus, any significant
medical history should be noted.
Often, children who are poisoned do not come to the ED with a clear history of
exposure followed by onset of symptoms. Rather, they develop signs and
symptoms that mimic other diseases and give no history of toxic exposure. Thus,
the ED staff must always consider the possibility of ingestion when treating
young children.
General historical features that suggest the possibility of poisoning include (i)
acute onset; (ii) age range of 1 to 5 years or adolescence; (iii) history of pica or
known exposure to a potential toxicant; (iv) substantial environmental stress,
either acute (e.g., arrival of a new baby, serious illness in a parent) or chronic
(e.g., marital conflict, parental disability); (v) multiple organ system involvement;
(vi) significant alteration in level of consciousness; and (vii) a clinical picture that
seems especially puzzling.
Certain family and social history variables are also important. Medications
used by other household members, particularly new medications introduced into
the home environment by virtue of recent illnesses, or visits from/to grandparents
and other relatives, are a common source of ingested drugs. Changes in routine
and large family gatherings (e.g., holiday parties, moving to a new home) are
particularly risky occasions for decreased parental supervision or less carefully
guarded potentially toxic medications or household products. Although often
difficult to obtain, the history of illicit drug use, manufacture, or distribution in
the child’s environment (the “drug-endangered child”) significantly increases the
risk of serious outcomes from a poison exposure as well.
Physical Examination
The focused physical examination should begin with a reassessment of vital
functions and complete recording of vital signs, including core temperature. After
securing the airway and ensuring adequate cardiorespiratory function, focus on
the central and autonomic nervous systems, eye findings, changes in the skin
and/or oral and gastrointestinal (GI) mucous membranes, and odors (see Chapter

50 Odor: Unusual ) on the breath or clothing of the patient. These features
represent those areas most likely affected in toxic syndromes and, when taken
together, often form a constellation of signs and symptoms referred to as
toxidromes ( Tables 102.5 and 102.6 ). Such toxidromes may be so characteristic
as to provide guidance for early therapeutic management before precise historical
or laboratory confirmation of a specific exposure is available.