Peds 24

Question 1

Madelyn is a previously healthy 2-year-old female who presents with acutely altered mental status and suspected accidental ingestion. She initially presented with hypoglycemia, hypotension, tachycardia, and hypoxemia. She has slightly improved with initial treatment, but mental status is still not at baseline. Exam is significant for agitation, tachycardia, mydriasis, decreased bowel sounds, and warm, flushed skin.

What kind of toxin did this child most likely ingest?

Answer 1

Anticholinergic

Question 2

What are some examples of anticholinergic toxins?

Answer 2

• Diphenhydramine (Benadryl)
• Tricyclic antidepressants
• Pseudoephedrine (decongestant)

Question 3

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. Her father suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested?

A. Iron
B. Amitriptyline
C. Insecticides
D. Hydromorphone

Answer 3

D. Hydromorphone

Question 4

A 2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion?

A. Pseudoephedrine
B. Codeine
C. Iron pill
D. Acetaminophen
E. Propranolol

Answer 4

A. Pseudoephedrine

Question 5

You are working in the pediatric ED when a 3-year-old female, Jenny, presents with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after Jenny started acting agitated and “looking very sick.” The mother reports “she feels so warm, I think she has a fever and has become dehydrated.” On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested one of her mother’s medications. An overdose of which of the following medications could cause Jenny’s symptoms?

A. Tricyclic antidepressant
B. SSRI
C. Decongestant
D. Acetaminophen
E. ACE inhibitor

Answer 5

A. Tricyclic antidepressant

Question 6

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His heart rate is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms?

A. Organophosphates
B. Tricyclic antidepressant
C. Barbiturates
D. Codeine
E. Pseudoephedrine

Answer 6

A. Organophosphates

Question 7

What are s/s of sympathomimetic toxidrome poisoning?

Answer 7

Mydriasis
Fever
Diaphoresis
Tachycardia
Agitation
Seizures

Question 8

What are some examples of sympathomimetic toxins?

Antidote?

Answer 8

Cocaine, amphetamines, pseudoephedrine

None

Question 9

What are s/s of cholinergic toxidrome poisoning?

Answer 9

SLUDGE (salivation, lacrimation, urination, defecation, GI motility, emesis)

DUMBELS (diarrhea/diaphoresis, urination, miosis, bradycardia, emesis, lacrimation, salivation)

wet and slow

Question 10

What are some examples of cholinergic toxins?

Antidote?

Answer 10

Organophosphates (pesticides, nerve agents)

Atropine

Question 11

What are s/s of anticholinergic toxidrome poisoning?

Answer 11

Hyperthermia (HOT)
Tachycardia/HTN
Red, hot, dry skin (DRY, RED)
Mydriasis (BLIND)
Absent bowel sounds
Urinary retention
Confusion/hallucinations (MAD)

Question 12

What are some examples of anticholinergic toxins?

Antidote?

Answer 12

Antihistamines (Benadryl)
Antipsychotics
Atropine/scopolamine
Tricyclic antidepressants
Skeletal muscle relaxants

Physostigmine

Question 13

What are s/s of opioid toxidrome poisoning?

Answer 13

Miosis, respiratory depression, CNS depression (bradycardia, hypotension, hypothermia), depressed mental state (sedation, confusion, coma)

Question 14

What are examples of sedative-hypnotic toxins?

Antidote?

Answer 14

Benzodiazepines, barbiturates

Flumanezil

Question 15

What are s/s of sedative-hypnotic toxidrome poisoning?

Answer 15

Miosis/blurry vision
Hypotension
Apnea and bradycardia
Hypothermia
Sedation
Confusion
Delirium
Coma

Question 16

On initial assessment, you note the patient is tachycardia, hypotensive, hypoxic, and hypoglycemic. What are your initial steps to stabilize the patient? What do you do after stabilization?

Answer 16

STABILIZE:
Bolus NS 20 mL/kg for tachycardia and hypotension
Bolus of D10 or D25 for hypoglycemia
Administration of O2 for hypoxia

AFTER:
IV fluids & order labs depending on differential diagnoses

Question 17

What 4 medication classes could cause mydriasis?

Answer 17

Antidepressant, antihistamine, decongestant, sedative-hypnotic

Question 18

An EKG is performed on a patient who you suspect has ingested an unknown substance. The EKG results come back with these findings: P waves not distinctly seen, wide QRS, prolonged QT interval. What substance do you suspect the patient ingested?

Answer 18

Tricyclic antidepressants