Pediatric emergency medicine trisk 3089 3089
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levels higher than 90 to 100 mg/dL after acute ingestion or 60 mg/dL or higher
after chronic salicylism. Specific indications for hemodialysis include (i) severe
acidosis or other electrolyte disturbance, (ii) renal failure, (iii) persistent
neurologic dysfunction, (iv) pulmonary edema, and/or (v) progressive clinical
deterioration despite standard treatment.
Criteria for Admission or Discharge: Patients who are clinically asymptomatic
with either undetectable or downtrending serial salicylate levels <30 mg/dL are
candidates for discharge as long as also cleared from a psychiatric and/or social
standpoint. Clinically symptomatic patients and those needing treatment with IV
sodium bicarbonate should be admitted, and providers should consider admission
to a higher level of care for these patients given the need for frequent laboratory
and clinical monitoring and meticulous fluid and electrolyte management.
Miscellaneous Toxins
Antihistamines
Current Evidence. Antihistamines are used to treat children with allergic diseases,
as sedatives and antinauseants, and to prevent motion sickness. They are present
in many cough syrups, available both over the counter (OTC) and by prescription.
Antihistamines may also be found in combination with analgesics,
sympathomimetic amines, and caffeine for the symptomatic relief of the common
cold. They are combined with analgesics, such as salicylamide, and an
anticholinergic drug, such as scopolamine, for use as a nonprescription sleep
medication. Finally, they are included in some liquid cough and cold preparations
that may also contain ethanol as the solvent.
Clinical Considerations. Antihistamines may depress or stimulate the CNS. Used
therapeutically, CNS depression is most commonly seen as drowsiness or
dizziness. With increasing doses, stimulation results in insomnia, nervousness,
and restlessness. In antihistamine overdose, the CNS stimulatory effects of the
drug predominate. In children, CNS stimulation causes excitement, tremors,
hyperactivity, hallucinations, and with higher dosages, tonic–clonic convulsions.
Children are also more likely to have signs and symptoms of anticholinergic
poisoning: flushed skin, fever, tachycardia, and fixed dilated pupils. The
nonsedating antihistamines terfenadine and astemizole (both no longer available
in the United States) have caused cardiac arrhythmia after overdose and as a
result of drug–drug interactions. Cetirizine, loratadine, and fexofenadine have not
produced this complication. Death from antihistamine ingestion in children is
