Paediatric ECAT protocol

Poisoning (suspected or confirmed)

P6.2 Published: December 2023 Printed on 19 May 2024

Get the latest version

Any person, 4 weeks to 15 years, presenting with confirmed or suspected toxic exposure.

If there is a concern for ingestion of a button battery or other high-risk object, switch to inhalation or ingestion of a foreign body protocol.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

Consider staff safety and hazmat requirements.

Complete clinical assessment rapidly and contact the Poisons Information Centre 13 11 26 or local clinical toxicology service for advice.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting complaint
Type of agent, drug or substance, including name and formulation, i.e. immediate or modified release
Total dose or worst-case scenario
Time of exposure
Route of exposure, e.g. ingested, inhaled, topical, ocular or other
Co-ingestants or exposure to other agents
Reason for exposure, e.g. accidental or intentional
Relevant medical history, including deliberate self-harm or previous overdoses
Potential access to high-risk drugs or chemicals, e.g. methadone, alcohol, illicit drugs or household chemicals
Known drug or alcohol use
Pre-hospital treatment
Past admissions
Medical and surgical history
Current medications
Known allergies
Immunisation status
Current weight and height

Signs and symptoms

Signs and symptoms will be specific to substance and exposure.

Confusion
Drowsiness
Hypotension or hypertension
Bradycardia or tachycardia
Bradypnea or tachypnoea
Respiratory distress, e.g. wheeze or cough
Diarrhoea or vomiting
Seizures
Delirium

Note: patient may present before the onset of symptoms

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Exposure to a high-risk substance. See precautions and notes section
Signs of non-accidental injury:
- inconsistency in history
- mechanism of injury not consistent with developmental age

Clinical

Airway compromise
Altered consciousness
Ataxia
Slurred speech
Hypotension or hypertension
Bradycardia or tachycardia
Bradypnea or tachypnoea

Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort
Decreased consciousness	Position supine or recovery position

Airway

Assessment	Intervention
Patency of airway Colour of lips Blisters to lips or mucous membranes	Maintain airway patency Consider airway opening manoeuvres and positioning Note oral secretions and/or odour

Assessment

Intervention

Patency of airway

Colour of lips

Blisters to lips or mucous membranes

Maintain airway patency

Consider airway opening manoeuvres and positioning

Note oral secretions and/or odour

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO₂)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO₂ over 93% If concerned for inhalation poisoning or hypoventilation, apply high flow oxygen If hypoxic or signs of hypoventilation, i.e. difficult to rouse, consider opiate overdose
Suspected opiate overdose, e.g. hypoventilation and difficult to rouse	Escalate as per local CERS protocol and give naloxone 10 microg/kg IV/IM, maximum dose 400 microg. Repeat dose if required, every 2 minutes, until the patient is more awake and breathing adequately. Maximum total dose 2 mg If no response, consider non-opiate cause or fentanyl analogue

Assessment

Intervention

Respiratory rate and work of breathing

Consider auscultation of chest (breath sounds)

Oxygen saturation (SpO₂)

Assist ventilation as clinically indicated

Apply oxygen to maintain SpO₂ over 93%

If concerned for inhalation poisoning or hypoventilation, apply high flow oxygen

If hypoxic or signs of hypoventilation, i.e. difficult to rouse, consider opiate overdose

Suspected opiate overdose, e.g. hypoventilation and difficult to rouse

Escalate as per local CERS protocol

and give naloxone 10 microg/kg IV/IM, maximum dose 400 microg. Repeat dose if required, every 2 minutes, until the patient is more awake and breathing adequately. Maximum total dose 2 mg

If no response, consider non-opiate cause or fentanyl analogue

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG
IVC and/or pathology	Follow advice from the Poisons Information Centre 13 11 26 Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Assessment

Intervention

Perfusion (capillary refill, skin warmth and colour)

Heart rate

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

Consider 12 lead ECG

IVC and/or pathology

Follow advice from the Poisons Information Centre 13 11 26

Insert IV cannula, if trained and clinically indicated

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Seizure activity	Measure BGL. See glucose section for management Note: give a maximum of 2 doses of benzodiazepines in any seizure episode, inclusive of out of hospital treatment Select: IV access No IV access IV access Give midazolam 0.15 mg/kg IV, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg No IV access Give: midazolam 0.15 mg/kg IM once only. Maximum dose 10 mg or midazolam 0.3 mg/kg intranasal/buccal, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg Escalate as per local CERS protocol for second-line seizure management
Pain	Assess pain. If severe pain present, escalate as per local CERS protocol

Exposure

Assessment	Intervention
Skin	Use full PPE Remove contaminated clothes Rinse skin with copious low-pressure water for 10–15 minutes until skin pH 6–7 Check the pH of affected areas with an appropriate pH indicator paper after 20 minutes, and repeat irrigation if abnormal
Eyes	Ensure the face and other exposed areas are thoroughly washed with water Instil one drop of oxybuprocaine 0.4% or tetracaine (amethocaine) hydrochloride 0.5% or 1% into the affected eyes. Block lacrimal sac at medial canthus during and for one minute after drop Drops may need to be re-instilled every 10 minutes during irrigation, maximum 3 doses If a small amount of superficial dust or organic matter is present, gently remove it with a cotton bud that is moistened with sodium chloride 0.9%. Do not apply pressure to the eye, only use a flicking or sweeping motion Gently irrigate the affected eyes with sodium chloride 0.9% via giving set, for a minimum of 15–20 minutes regardless of pH Wait 5 minutes after ceasing the irrigation fluid, then check the pH in both eyes using the appropriate pH indicator paper Irrigate until pH is neutral Severe burns may require over 30 minutes of irrigation
Temperature	Measure temperature If abnormal, consider clinical causes, including malignant hyperthermia, neuroleptic malignant syndrome and other toxidromes If hyperthermic, provide active cooling, do not use antipyretics
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	Do not induce vomiting
NBM	NBM may be required for specific poisonings. Follow advice from the Poisons Information Centre

Glucose

Assessment	Intervention
BGL	Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing

If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):

give quick-acting carbohydrate:
- Up to 12 months: milk feed and/or 40% glucose gel, buccal
- 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal
reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L

If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:

give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access
escalate as per local CERS protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Consider a secondary survey.

Obtain the following information in consultation with the Poisons Information Centre 13 11 26:

Agent: type of agent, drug or poisonous substance. Obtain name and formulation. Be wary of more than one agent.
Dose: the amount of substance ingested or exposed to, which includes dose per kilogram. The maximum dosage of potential ingestion in a worst-case scenario, determined by what is absent.
Route: route of exposure, e.g. ingested, inhaled, injected, dermal contact, bite or sting, intranasal, aural, vaginal, rectal, buccal or sublingual.
Time: the elapsed time since ingestion and the length of exposure, whether through inhalation or contact with chemicals. Consider whether the substance was consumed simultaneously or in staggered intervals.
Patient factors: weight, age, height. Determine previous medical or psychiatric history and current medications.
Intent of ingestions: accidental, deliberate self-harm attempt, suspected non-accidental injury or recreational.
Environmental factors: determine the method of agent access, geographical location, exposure location, e.g. house, school, or work, and the presence of known illicit drug use in the household.
Current clinical features: signs and symptoms.

Precautions and notes

A number of agents are highly toxic in a dose of just 1–2 tablets in the toddler age group.
Consider non-accidental poisoning if the developmental age is inconsistent with accidental poisoning.
The following lists are not exhaustive. Contact the Poisons Information Centre 13 11 26 for advice.

Drag the table right to view more columns or turn your phone to landscape

Potentially lethal 1–3 tablet ingestions or small exposures	Potentially harmful 1–3 tablet ingestions or small exposures
Beta-blockers, e.g. propranolol: coma, seizures, ventricular tachycardia and hypoglycaemia Calcium channel blockers: delayed onset bradycardia, hypotension and conduction defects Chloroquine/hydroxychloroquine: rapid onset coma, seizures and cardiovascular collapse Ecstasy and other amphetamines: agitation, hypertension and hyperthermia Oral hypoglycaemics, e.g. sulfonylureas: hypoglycaemia, which may be delayed 8 hours Tricyclic antidepressants: coma, seizures, hypotension and ventricular tachycardia Theophylline: seizures, supraventricular tachycardia, tachycardia and vomiting Toxic alcohols	Anticholinesterase inhibitors, e.g. organophosphates and carbamates: cholinergic syndrome, seizures or loss of consciousness Baclofen, 25 mg: coma Camphor: rapid decrease in conscious state, seizures and hypotension Carbamazepine, 400 mg: coma Carbon monoxide inhalation Centrally acting alpha-adrenergic agonists, e.g. clonidine: similar to opioids but with more hypotension and bradycardia Clozapine 100 mg/200 mg: coma Colchicine Corrosive, e.g. strong alkali or acid: gastroesophageal injury Opioids, e.g. buprenorphine (8 mg sublingual or film absorbs in less than 5 minutes), codeine, methadone or fentanyl Hydrocarbon solvents, kerosene, or essential oils: decreased level of consciousness, seizure and aspiration pneumonia Illicit or street drugs, e.g. amphetamine Diphenoxylate Naphthalene, 1 mothball (but most mothballs aren't naphthalene): methaemoglobinaemia and haemolysis Podophyllin Paraquat: oesophageal burns and multi-organ failure Salicylates Strychnine: muscle spasm and respiratory arrest Venlafaxine 150 mg: seizures Marijuana, synthetic cannabinoids, nicotine or vape liquids

Potentially lethal 1–3 tablet ingestions or small exposures

Potentially harmful 1–3 tablet ingestions or small exposures

Beta-blockers, e.g. propranolol: coma, seizures, ventricular tachycardia and hypoglycaemia
Calcium channel blockers: delayed onset bradycardia, hypotension and conduction defects
Chloroquine/hydroxychloroquine: rapid onset coma, seizures and cardiovascular collapse
Ecstasy and other amphetamines: agitation, hypertension and hyperthermia
Oral hypoglycaemics, e.g. sulfonylureas: hypoglycaemia, which may be delayed 8 hours
Tricyclic antidepressants: coma, seizures, hypotension and ventricular tachycardia
Theophylline: seizures, supraventricular tachycardia, tachycardia and vomiting
Toxic alcohols

Anticholinesterase inhibitors, e.g. organophosphates and carbamates: cholinergic syndrome, seizures or loss of consciousness
Baclofen, 25 mg: coma
Camphor: rapid decrease in conscious state, seizures and hypotension
Carbamazepine, 400 mg: coma
Carbon monoxide inhalation
Centrally acting alpha-adrenergic agonists, e.g. clonidine: similar to opioids but with more hypotension and bradycardia
Clozapine 100 mg/200 mg: coma
Colchicine
Corrosive, e.g. strong alkali or acid: gastroesophageal injury
Opioids, e.g. buprenorphine (8 mg sublingual or film absorbs in less than 5 minutes), codeine, methadone or fentanyl
Hydrocarbon solvents, kerosene, or essential oils: decreased level of consciousness, seizure and aspiration pneumonia
Illicit or street drugs, e.g. amphetamine
Diphenoxylate
Naphthalene, 1 mothball (but most mothballs aren't naphthalene): methaemoglobinaemia and haemolysis
Podophyllin
Paraquat: oesophageal burns and multi-organ failure
Salicylates
Strychnine: muscle spasm and respiratory arrest
Venlafaxine 150 mg: seizures
Marijuana, synthetic cannabinoids, nicotine or vape liquids

Interventions and diagnostics

Specific treatment

Specific antidotes may be available as part of a management plan.
Treatment is specific to the agent.
Contact the Poisons Information Centre 13 11 26 for advice.

Radiology

Not usually indicated initially unless recommended by the Poisons Information Centre.

If the patient has swallowed a radio-opaque agent such as iron tablets, lead sinker or button batteries, switch to inhalation or ingestion of a foreign body (suspected) protocol.

Pathology

If suspected drug ingestion, escalate as per local CERS protocol for drug-level testing.

Urinalysis:
- Patient who can void in the toilet: mid-stream urine
- Patient who is not toilet trained: clean catch or catheter urine
- If positive for nitrites and/or leucocytes send for MC&S based on clinical presentation. If uncertain, keep the sample refrigerated and seek advice.
Blood pathology as per advice from Poisons Information Centre: FBC, UEC, LFT, VBG
Post-menarche: urine βHCG

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug	Dose	Route	Frequency
Glucose 40% gel (0.4 g/mL)	4 weeks–1 year: 200 mg/kg (=0.5 mL/kg) 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g	Buccal	Repeat after 15 minutes if required
Midazolam	0.15 mg/kg Maximum single dose 10 mg Maximum total dose 20 mg	IV	Repeat once if required after 5 minutes
	OR
	0.15 mg/kg Maximum dose 10 mg	IM	Once only
	OR
	0.3 mg/kg Maximum single dose 10 mg Maximum total dose 20 mg	Buccal/intranasal	Repeat once if required after 5 minutes
Naloxone	10 microg/kg Maximum single dose 400 microg Maximum total dose 2 mg	IV/IM	Repeat dose if required every 2 minutes, until the patient is more awake and breathing adequately
Oxybuprocaine 0.4% eye drops	Instil 1 drop into affected eyes	Topical	For local anaesthesia: Once only For local anaesthesia during irrigation: Every 10 minutes as required, maximum 3 doses
Oxygen	0.25–15 L/min, device dependent	Inhalation	Continuous
Sodium chloride 0.9%	20 mL/kg Maximum dose 1000 mL	IV/intraosseous	Bolus Once only
Tetracaine (amethocaine) hydrochloride 0.5% or 1% eye drops	Instil 1 drop into affected eyes	Topical	For local anaesthesia: Once only For local anaesthesia during irrigation: Every 10 minutes as required, maximum 3 doses

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

Show

Australian Resuscitation Council. ANZCOR Guideline 12.4 – Paediatric resuscitation in special circumstances. Australia: Australian Resuscitation Council; 2021 [cited 1 Mar 2023]. Available from: https://resus.org.au/download/anzcor-guideline-12-4-paediatric-resuscitation-in-special-circumstances-november-2021-0-3-mib/?wpdmdl=13780&masterkey
Bore M. Emergency management: chemical burns. Community Eye Health. 2018;31(103):72.
Brady CJ. How To Irrigate the Eye and Do Eyelid Eversion. United States: Merck and Co Inc.; 2023 [cited 1 Mar 2023]. Available from: https://www.msdmanuals.com/en-au/professional/eye-disorders/how-to-do-eye-procedures/how-to-irrigate-the-eye-and-do-eyelid-eversion
Centre NPI. NSW Poisons Resources. Australia: The Children's Hospital at Westmead; 2023 [cited 7 March 2023]. Available from: https://www.poisonsinfo.nsw.gov.au/
Chiew AL, Gluud C, Brok J, et al. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database of Systematic Reviews. 2018 (2):1-71.
Chiew AL, Reith D, Pomerleau A, et al. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Medical Journal of Australia. 2020;212(4):175-83.
Group NTA. The NSW TAG Life Saving Drugs Register. Australia: NSW TAG; 2023 [cited 7 March 2023]. Available from: https://www.nswtag.org.au/life-saving-drugs-register/
NSW Health. Infants and Children: Acute Management of Seizures. Sydney, Australia: NSW Government; 2014 [cited 28 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/pages/doc.aspx?dn=GL2016_005
Australian Medicines Handbook. Adelaide: AMH; c2023 [cited 28 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Australian Medicines Handbook Children's Dosing Companion. Adelaide: AMH; c2023 [cited 03 May 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/
The Royal Children's Hospital Melbourne. Clinical practice guidelines: Poisoning - Acute Guidelines For Initial Management. Melbourne: Victoria Health; 2017 [cited 28 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Poisoning_-_Acute_Guidelines_For_Initial_Management/
The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
Therapeutic Guidelines Limited. Poisoning in children. Australia: Therapeutic Guidelines Limited; 2020 [cited 1 Mar 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?etgAccess=true&guidelinePage=Toxicology%20and%20Toxinology&topicfile=poisoning-in-children
Velez LI, Shepherd JG, Goto CS. Approach to the child with occult toxic exposure. UpToDate ONLINE. The Netherlands: Wolters Kluwer; 2022 [cited 1 Mar 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/approach-to-the-child-with-occult-toxic-exposure

Hide references

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/poisoning

Poisoning (suspected or confirmed)

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Circulation

Disability

IV access

No IV access

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Specific treatment

Radiology

Pathology

Medications

References