Pediatric emergency medicine trisk 3139 3139

drug but may identify it by a street name. Although drug terminology tables are
often available in pharmacology or toxicology texts or on the internet, temporal
and regional changes in street drug terminology generally make such tables of
limited value. Additionally, the true substances in the products may not match the
substances that the patient believed they were using. Your regional poison center
can be a useful source of current substance use patterns and regional trends.
As with any potentially poisoned patient, primary attention is initially paid
toward assessment of vital signs and life support as needed to provide a patent,
secure airway; to ensure adequate respiratory function; and to treat seizures,
shock, or cardiorespiratory arrest. Do not overlook temperature. Hyperpyrexia is
both a poor prognostic indicator for many ingestions and a management target, so
accurate measurement with a core temperature is important.
In the agitated patient, chemical and/or physical restraint may be necessary to
both assess the patient and to ensure safety of both the patient and the treating
staff. Chemical restraint should be used liberally to prevent patients from harming
themselves or others. Benzodiazepines are the preferred class of agents for most
patients. The duration of the sedative effects of midazolam are shorter than the
other benzodiazepines, allowing for reassessment within an hour. Haloperidol
may be effective but not be the best first-line agent because it can reduce heatdissipating capability and may lower the seizure threshold.
Management must also include consideration of the need for GI
decontamination. With many substances of abuse, several distinct routes of
exposure are possible (e.g., ingestion, inhalation, injection, and/or nasal
insufflation). Therefore, GI decontamination is not always necessary or
appropriate. Decontamination should be considered using the same guiding
principles regarding toxin and patient characteristics detailed earlier in this
chapter. If the practitioner is considering decontamination, carefully assess mental
status and gag reflex. If the potential benefits of decontamination outweigh the
risks in a patient with obtundation or a diminished gag reflex, protect the airway
by endotracheal intubation before initiating GI decontamination.
Additional toxin-specific management strategies are discussed in the section
that follows.

Clinical Indications for Discharge or Admission
The decision to admit the patient depends on both the clinical severity of the
presentation and the anticipated pharmacokinetics of the suspected substance(s).
After initial assessment and medical stabilization, subsequent evaluation of any
patient presenting in the setting of intentional substance use must include an
estimation of the severity of the drug use problem and the risk of suicide or other