Pediatric Ingestion Dose Thresholds for ED Referral
Pediatric Ingestion Dose Thresholds for Emergency Department Referral
Clinical Toxicology has published guidelines for out-of-hospital management of 16 distinct overdoses and their dose thresholds, above which, pediatric patients should be referred to the Emergency Department for evaluation. Clinical Toxicology is the official journal of the American Academy of Clinical Toxicology (AACT, @AACTinfo), the American Association of Poison Control Centers (AAPCC, @AAPCC), and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT).
There are 2 caveats to be aware of regarding these guidelines
- They were developed between 2005 and 2007. New medications have been approved since that time and there may be more recent data available.
- As with any poisoning, the dose is only one factor when determining disposition. Consideration should also be given to intent, underlying medical conditions, co-ingestion of other medications, presence of symptoms, and drug formulation.
This ALiEM Card summarizes the pediatric ingestion dose thresholds for referral to an Emergency Department.
| Acronym | Meaning |
|---|---|
| RSTI | Repeated supratherapeutic ingestion |
| IR | Immediate release |
| SR | Sustained release |
| MR | Modified release |
NOTES:
- Whenever 2 values are noted, the lesser one should be utilized.
- Symptomatic patients always warrant ED evaluation.
Acetaminophen
Age <6 years (Acute & RSTI)
- ≥ 200 mg/kg
- ≥ 200mg/kg over 24 hours, or
- ≥ 150 mg/kg per 24 hours x 2 days, or
- ≥ 100 mg/kg per 24 hours x 3 days
Age >6 years (Acute & RSTI)
- ≥ 10 g or ≥ 200 mg/kg
- ≥ 10 g or ≥ 200 mg/kg over 24 hour, or
- ≥ 6 g or ≥ 150 mg/kg per 24 hours x 2 days
Atypical Antipsychotics
Age <12 years
| Drug | Dose |
|---|---|
| Ariprazole | > 15 mg |
| Clozapine | > 50 mg |
| Olanzapine | > 10 mg |
| Quetiapine | > 100 mg |
| Risperidone | > 1 mg |
| Ziprasidone | > 80 mg |
Age >12 years
| Drug | Dose |
|---|---|
| Ariprazole | > 50 mg |
| Clozapine | > 62.5 mg |
| Olanzapine | > 25 mg |
| Quetiapine | > 125 mg |
| Risperidone | > 5 mg |
| Ziprasidone | > 100 mg |
Anticoagulant Rodenticides
≥1 mg
Beta Blockers
Ingestion of any excess beta blocker in combination with a calcium channel blocker warrants referral to an ED.
| Drug | Dose |
|---|---|
| Acebutolol | > 12 mg/kg |
| Atenolol | > 2 mg/kg |
| Carvedilol | > 0.5 mg/kg |
| Labetalol | > 20 mg/kg |
| Metoprolol IR | > 2.5 mg/kg |
| Metoprolol SR | > 5 mg/kg |
| Nadalol | > 2.5 mg/kg |
| Propanolol IR | > 4 mg/kg |
| Propanolol SR | > 5 mg/kg |
| Sotalol | > 4 mg/kg |
| Timolol | No safe dose |
Calcium Channel Blockers
Ingestion of any excess beta blocker in combination with a calcium channel blocker warrants referral to an ED.
| Drug | Dose |
|---|---|
| Amlodipine | ≥ 0.3 mg/kg or ≥ 30 mg |
| Diltiazem | ≥ 1 mg/kg |
| Felodipine | ≥ 0.3 mg/kg |
| Isradipine | ≥ 0.1 mg/kg |
| Nifedipine IR | ≥ 1 mg/kg |
| Verapamil IR | ≥ 2.5 mg/kg |
Camphor
>30 mg/kg
Dextromethorphan
>7.5 mg/kg
Diphenhydramine & Dimenhydrinate
- Age <6 years: >7.5 mg/kg
- Age ≥6 years: >7.5 mg/kg or 300 mg
Ethylene Glycol
More than witnessed taste/lick or unknown amount
Iron (Elemental)
≥40 mg/kg of adult ferrous sulfate formulation
Mercury (Elemental)
>1 household fever thermometer
Methylphenidate
| Drug | Dose |
|---|---|
| IR or chewed MR | >2 mg/kg or 60 mg |
| MR (intact) | >4 mg/kg or 120 mg |
Salicylate
Aspirin equivalent: >150 mg/kg or 6.5 g
Oil of Wintergreen:
- Age < 6 years: More than a taste/lick
- Age ≥ 6 years: More than 4 mL
Selective Serotonin Reuptake Inhibitors
| Drug | Dose |
|---|---|
| Citalopram | > 100 mg |
| Escitalopram | > 50 mg |
| Fluoxetine | > 100 mg |
| Fluvoxamine | > 250 mg |
| Paroxetine | > 100 mg |
| Sertraline | > 250 mg |
Tricyclic Antidepressants (TCA)
| Drug | Dose |
|---|---|
| Desipramine | > 2.5 mg/kg |
| Nortriptyline | > 2.5 mg/kg |
| Trimipramine | > 2.5 mg/kg |
| Protriptyline | > 1 mg/kg |
| All Others | > 5 mg/kg |
Valproic Acid
≥50 mg/kg
References
- Wax P, Erdman A, Chyka P, et al. beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(3):131-146. PubMed [PubMed]
- Caravati E, Erdman A, Christianson G, et al. Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(5):327-345. PubMed [PubMed]
- Manoguerra A, Erdman A, Booze L, et al. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(6):553-570. PubMed [PubMed]
- Olson K, Erdman A, Woolf A, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(7):797-822. PubMed [PubMed]
- Dart R, Erdman A, Olson K, et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(1):1-18. PubMed [PubMed]
- Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(3):205-223. PubMed [PubMed]
- Manoguerra A, Erdman A, Wax P, et al. Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(4):357-370. PubMed [PubMed]
- Caravati E, Erdman A, Scharman E, et al. Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(1):1-22. PubMed [PubMed]
- Chyka P, Erdman A, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. PubMed [PubMed]
- Woolf A, Erdman A, Nelson L, et al. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(3):203-233. PubMed [PubMed]
- Nelson L, Erdman A, Booze L, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(4):315-332. PubMed [PubMed]
- Chyka P, Erdman A, Manoguerra A, et al. Dextromethorphan poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(6):662-677. PubMed [PubMed]
- Scharman E, Erdman A, Cobaugh D, et al. Methylphenidate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(7):737-752. PubMed [PubMed]
- Cobaugh D, Erdman A, Booze L, et al. Atypical antipsychotic medication poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(8):918-942. PubMed [PubMed]
- Caravati E, Erdman A, Christianson G, et al. Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(1):1-21. PubMed [PubMed]
- Manoguerra A, Erdman A, Woolf A, et al. Valproic acid poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(7):661-676. PubMed [PubMed]
