Poisoning necessitating pediatric ICU admissions: size of pupils does matter

Childhood poisonings are common, but usually trivial, and infrequently necessitate intensive care unit (ICU) admissions.

A retrospective record review was conducted to analyze the pattern of severe poisoning-associated ICU admissions at a teaching hospital between May 2002 and December 2007.

Six cases (4 boys and 2 girls, aged 2 months to 11 years) of drug poisoning-associated ICU admissions were identified. Methadone was the culprit in 3 boys and 1 girl, resulting in respiratory failure, depressed conscious state and pinpoint pupils. As relevant exposure history was not immediately apparent, diagnosis at the emergency department was only made correctly in 2 patients. Phenobarbitone overdose occurred in 1 girl with past history of phenobarbitone overdose as a clue. She was also considered to have pinpoint pupils that were unresponsive to naloxone. Features consistent with cholinergic toxidrome, including small pupils, and increased secretion occurred in an infant fed with milk prepared with an herbal broth suspected to have been adulterated with a pesticide. Atropine as an antidote was used when the child was in the pediatric ICU. All children made an uneventful recovery following their short ICU stay.

Life-threatening poisonings requiring ICU support can pose diagnostic difficulties and challenges to frontline medical officers at the emergency department. Children from all age groups can be affected. Prompt diagnosis is based on relevant history, careful clinical examination and a high index of suspicion in patients known to be at risk. The pupillary size and its reaction following treatment serves as an important diagnostic clue.