Drug overdose children

Drug overdose in children requires rapid ABC stabilization, identification of the substance, and targeted treatment. Both accidental ingestions (toddlers) and intentional overdoses (adolescents) must be considered.

🫁 Stabilization of ABCs

• Airway: Ensure patency; consider airway adjuncts or intubation if GCS ↓.
• Breathing: Monitor RR & O₂ sats; provide supplemental oxygen, BVM or ventilation if needed.
• Circulation: Check for shock (tachycardia, hypotension); gain IV access, give IV fluids.

🕵️ Quick History

• 📦 Substance: Identify drug/packaging.
• ⚖️ Amount: Estimate ingestion.
• ⏰ Timing: Time since ingestion determines role of charcoal/antidotes.
• ➕ Co-ingestions: Ask about alcohol, OTC meds, household products.
• 🧠 Intent: Accidental vs deliberate (esp. adolescents).

👩‍⚕️ Initial Examination

• GCS for consciousness.
• Pupils: pinpoint (opioids) vs dilated (anticholinergics, stimulants).
• Vital signs: bradycardia, tachycardia, hypo/hypertension, fever clues toxidrome.
• Skin: flushed/dry (anticholinergic), sweaty (sympathomimetic), clammy (shock).
• Neuro: seizures, tremors, rigidity (TCAs, stimulants).

🧩 Classic Toxidromes

• 💊 Opioid: Pinpoint pupils, ↓RR, ↓GCS → Naloxone.
• 🌿 Anticholinergic: Dilated pupils, dry hot skin, tachy, confusion.
• ⚡ Sympathomimetic: Agitation, tachy, hypertension, fever, dilated pupils.
• 💧 Cholinergic: SLUDGE (salivation, lacrimation, urination, diarrhoea, bronchorrhoea, bradycardia).

🧪 Investigations

• Glucose (exclude hypoglycaemia).
• U&E (for metabolic derangements).
• ABG (for acidosis/hypoxia).
• ECG (arrhythmias, QRS/QT prolongation).
• Toxicology screen (urine/blood, drug levels).

🧴 Decontamination

• Activated charcoal within 1 hr if safe + appropriate substance.
• Whole bowel irrigation for iron / sustained-release tablets.
• Gastric lavage only if life-threatening & within 1 hr (rare in paeds).

💉 Key Antidotes

• 🔑 Naloxone: Opioids.
• 🧪 N-Acetylcysteine (NAC): Paracetamol.
• 💤 Flumazenil: Benzodiazepines (use cautiously – seizure risk).
• 🧂 Sodium Bicarbonate: TCA toxicity, metabolic acidosis, prolonged QRS.
• 🧲 Deferoxamine: Iron overdose.
• 💉 Glucagon / Calcium / High-dose insulin: β-blocker & Ca-channel blocker overdose.

🧭 Substance-Specific Pointers

• 🌡️ Paracetamol: NAC, monitor LFTs/INR.
• 💊 Salicylates: Sodium bicarb for alkalinisation, haemodialysis if severe.
• 💉 Opioids: Naloxone titrated, airway support.
• 😴 Benzodiazepines: Supportive, Flumazenil in select cases.
• 🧲 Iron: Whole bowel irrigation, deferoxamine, monitor iron levels.
• 🌼 Antihistamines: Supportive, benzos for agitation, sodium bicarb for arrhythmias.
• ❤️ TCAs: Sodium bicarb for arrhythmias, benzos for seizures.

🧠 Post-Recovery Care

After stabilization, address psychosocial factors. Many overdoses in adolescents reflect intentional self-harm.

🧠 Mental Health Assessment

• Depression, anxiety, trauma history.
• Suicide risk assessment: ideation, plans, past attempts, access to means.
• Behavioural/impulsivity issues.

👪 Family & Social Dynamics

• Family conflict, parental MH/substance misuse.
• Bullying, social isolation, peer pressure.

🧾 Ongoing Support

• Referral to CAMHS / psychiatry.
• CBT, family therapy, school support.
• Safety planning & secure storage of medications.

💡 Exam Tip: In OSCEs, structure your approach as: Stabilize → Identify substance → Look for toxidrome → Targeted investigations → Antidote/supportive care → Psychosocial assessment.