In an asymptomatic child presenting to the ED soon after an ingestion the physical examination is likely to be unremarkable but it may provide valuable information as to the nature of an unknown toxin.

As with any sick child, APLS principles [1] should be followed and a systematic ABCDE approach taken, paying special attention to the points below:

Carefully assess the vital signs

Take seriously observations that lie outside the normal range for the age of the child. Don’t forget to measure the temperature (hyperpyrexia is associated with ingestion of ecstasy, cocaine and salicylates, whilst hypothermia suggests poisoning with ethanol or barbiturates).

Observe the mental status

There is a lack of supporting evidence to suggest the use of the Glasgow Coma Scale (GCS) in the prognosis or management of poisoned patients. In general the AVPU score is used in children.

Perform a thorough neurological examination

Neurological signs affecting one side of the body must not be attributed to a poisoning. Look for external signs of head injury or other evidence of non-accidental injury.

Examine the eyes, mucous membranes, skin, bowels and bladder

This information may be used to suggest a class of poisons that has been ingested to produce a specific toxidrome (or collection of signs and symptoms that class of toxins is known to cause). It must be noted however that often more than one substance has been ingested and rarely are the toxidromes so clear cut.

Exclude alternative causes

In addition, by examining the child the Emergency physician needs to exclude other organic conditions that may present in a similar fashion to poisonings. The reverse is true and the clinician should have a low threshold for considering a toxicological cause for a child’s presentation if a medical cause cannot be found.

Learning bite

Significant toxidromes include opiate, sympathomimetic, salicylism, serotinergic, anticholinergic (tricyclic antidepressants, antihistamines, plant ingestions – deadly nightshade) and cholinergic (organophosphorous and carbamate compounds). More details can be found in the Toxidrome module.