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Investigating the minimalist approach to the asymptomatic child presenting the ER with suspected ingestion
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don’t Just Do Something, Sit There
the Child with Occult Toxic Ingestion
TOXICOLOGY TALK JANUARY 21 2014
PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
PEDIATRIC PATHOPHYSIOLOGIC CONSIDERATIONS
EMERGENCY MANAGEMENT (ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE)
WELL APPEARING CHILD WITH POISON EXPOSURE
DEADLY IN SMALL DOSES
PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
PEDIATRIC PATHOPHYSIOLOGIC CONSIDERATIONS
EMERGENCY MANAGEMENT (ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE)
WELL APPEARING CHILD WITH POISON EXPOSURE
DEADLY IN SMALL DOSES
2012
2012
2008
2011
VILKE 2011
BRONSTEIN 2011
age & Gender Distribution of Human Exposures
FRANKLIN 2008
BRONSTEIN 2011
distribution of reason for exposure by age
VILKE 2011
BRONSTEIN 2011
medical outcome of human exposure cases by patient age
97% NO EFFECT, MINOR EFFECT, NO FOLLOW UP. UNRELATED EFFECT
VILKE 2011
BRONSTEIN 2011
distribution of age and gender fatalities
BOND 2012
FRANKLIN 2008
BRONSTEIN 2011
BRONSTEIN 2011
BOND 2012
BRONSTEIN 2011
BRONSTEIN 2011
BRONSTEIN 2011
BRONSTEIN 2011
BRONSTEIN 2011
pediatric poisoning trends vs population change from 2001 baseline
BOND 2012
limited utility of screening labs and ekg in unintentional asymptomatic pediatric ingestions
WANG GS ET AL. JOURNAL OF EMERGENCY MEDICINE. 2013
+ =
micro journal club
intro
methods
results
take home
limitations
introMOST INGESTIONS ARE:
!UNINTENTIONAL
!INVOLVE A SINGLE SUBSTANCE
!DON’T PRODUCE SIGNIFICANT CLINICAL EFFECTS
intro
MORTALITY RATE IN PEDS POISONINGS IS
<.0004%
(BRONSTEIN 2010; CDC)
introINGESTIONS IN ADOLESCENTS SIMILAR TO ADULTS:
!
SIGNIFICANT DOSES !
MULTIPLE MEDS !
INTENTIONAL
introPOINT OF THE STUDY:
!
ASSESS THE UTILITY OF screening labs/ekg !
IN THE MANAGEMENT OF !
UNINTENTIONAL asymptomatic INGESTIONS BY CHILDREN YOUNGER THAN 12 YO
WHO PRESENT TO ED
methodsRETROSPECTIVE CHART REVIEW
!
PEDIATRIC PATIENTS <12 YO !
PRESENTING TO CHILDREN’S ED (~60,OOO VISITS/YEAR) !
EVALUATION OF INGESTION !
FROM JAN 2005 THROUGH DEC 2008 !
CASES IDENTIFIED BY ICD 9 CODE
APPROXIMATELY 90 INGESTION VISITS PER YEAR
= 7.5/month !
= 1 every other shift (15 shifts/month)
methodsWHAT DATA DID THEY GRAB?
!AGE, SEX, DATE OF VISIT
!TYPE OF INGESTION
!INTENTIONALITY
!VITAL SIGNS, EXAM, MENTAL STATUS
!USE OF LABS/TESTS AND RESULTS
!USE OF REGIONAL POISON CENTER
!UNSCHEDULED RETURNED VISITS/DISPOSITION
methodsWHAT LABS?
!CBC !
BMP/CMP !
BLOOD GAS !
SALICYLATE/ACETAMINOPHEN !
URINE TOX
methods
CRITERIA FOR screening LAB/TEST IN THIS STUDY:
!
ABNORMALITIES NOT LISTED UNDER POTENTIAL SIDE EFFECTS IN LEXICOMP
methodsNORMAL EKG= NSR
!NOT NORMAL BUT OK (I)
MILD ABNORMALITY (I; NO CARDS F/U)= SINUS DYSRHYTHMIA, ATRIAL ENLARGEMENT, SINUS BRADYCARDIA, 1ST DEGREE AV BLOCK
!ABNORMAL (II, III)
MODERATE ABNORMALITY (II; YES CARDS F/U)= RIGHT OR LEFT BBB, BIVENTRICULAR HYPERTROPHY, WPW, PROLONGED QTC
!
SIGNIFICANT ABNORMALITY (III; CARDS C/S NOW!)= COMPLETE AV BLOCK, A FIB, PACING WITH LOSS OF CAPTURE, ATRIAL TACH
methods
DEFINITION OF “CHANGED MANAGEMENT”
RESULT REQUIRING INTERVENTION/TX !
NON POISON CENTER SUBSPECIALTY CONSULT !
PROLONGED ED STAY
results
595 KIDS <12 YO EVAL IN ED FOR UNINTENTIONAL INGESTION !
47 BUTTON-BATTERY INGESTIONS !
MEDIAN AGE 2.6 YEARS (56% MALE)
WANG 2013
WANG 2013
resultsAT LEAST 1 LAB OR EKG OBTAINED IN 233 (39%) PATIENTS
!73 (12%) PATIENTS RECEIVED EKG
!3 PATIENTS HAD CLASS II EKG ABNORMALITIES
(ALL UNRELATED TO INGESTION CARDS CONSULTED BUT NO IMMEDIATE INTERVENTION)
!NONE OF THE 24 SCREENING EKGS WERE ABNORMAL
WANG 2013
WANG 2013
WANG 2013
WANG 2013
WANG 2013
WANG 2013
results
OVERALL: !
224 (38%) DISCHARGED IMMEDIATELY 309 (52%) OBSERVED IN ED THEN DISCHARGED+
533 (~90%) DISCHARGED FROM ED
results
51 (9%) ADMITTED= 23 (45%) INPATIENT + 28 (55%) PICU !
11 (2%) TO OR (10 BUTTON BATTERY REMOVAL + 1 CAUSTIC INGESTION) !
1 DEATH (HEMATEMESIS, BUTTON BATTERY IN STOMACH, UNSUCCESSFUL RESUSCITATION IN OR
limitations
RETROSPECTIVE CHART REVIEW IN A SINGLE TERTIARY CARE CHILDREN’S HOSPITAL
= NOT GENERALIZABLE !
SINGLE CHART REVIEWER NOT BLINDED TO STUDY QUESTION
= POSSIBLE/PROBABLE BIAS
take homeSCREENING TESTS ONLY HELPFUL IN KIDS WHO WERE SYMPTOMATIC
WITHOUT AN INGESTION HISTORY
KIDS <12 YO WITH UNINTENTIONAL INGESTIONS WITH NORMAL VITALS AND MENTAL STATUS HAD NO POSITIVE SCREENING TESTS
THE ONLY SCREENING TESTS THAT CHANGED MANAGEMENT: KIDS WITH MULTIPLE SX OR ALTERED MENTAL STATUS WITHOUT AN INGESTION
HISTORY
pediatric pathophysiologic considerations
HIGHER BODY SURFACE AREA/WEIGHT RATIO !
DERMAL ABSORPTION INCREASED !
AT GREATER RISK FOR DEHYDRATION AND INSENSIBLE LOSSES
pediatric pathophysiologic considerations
INCREASED RR AND MINUTE VENTILATION= HIGHER DOSE IN SHORTER TIME FOR AIRBORNE TOXINS
(CARBON MONOXIDE POISONING)
pediatric pathophysiologic considerations
INCREASED RELIANCE ON DIAPHRAGM + LIMITED CAPACITY OF ACCESSORY MUSCLES + HIGHER METABOLIC RATE + DECREASED RESERVE
!HIGHER LIKELIHOOD OF HYPOXIA AND RESPIRATORY FAILURE
!POOR RESPONSE TO DIRECT RESPIRATORY TOXIN (THINK HYDROCARBON ASPIRATION) AND POOR COMPENSATION FOR ACID-BASE DISTURBANCES
(SALICYLATE OR TOXIC ALCOHOL POISONING)
pediatric pathophysiologic considerations
RELATIVE LACK OF GLYCOGEN STORES !
INCREASES LIKELIHOOD OF HYPOGLYCEMIA FROM ETHANOL AND BETA BLOCKER INGESTION
LIMITED CARDIOVASCULAR RESERVE !
CARDIAC OUTPUT HEAVILY RELIANT ON HR !
ADRENERGIC TONE ALLOWS FOR BP TO REMAIN STABLE UNTIL ADVANCED SHOCK
!DRUGS CAUSING BRADYCARDIA (CA CHANNEL BLOCKERS, PESTICIDES)
CAN PRECIPITATE CIRCULATORY ARREST IN SMALL DOSES
pediatric pathophysiologic considerations
KIDS ARE MORE SENSITIVE TO SPECIFIC DRUGS !
OPIOID RECEPTOR AGONISTS CAN CAUSE ENHANCED CNS AND RESPIRATORY DEPRESSION
(DEXTROMETHORPHAN COUGH SYRUPS, CLONIDINE, CODEINE) !
MORE PRONE TO PARADOXICAL REACTIONS TO BENZODIAZEPINES !
INCREASED TENDENCY TO QTC PROLONGATION (BETA BLOCKERS, ANTIDYSRHYTHMIC DRUGS)
pediatric pathophysiologic considerations
*
**
**** MEGARBANE 2013, BAMSHAD 1990, KIM 2012, MCCARRON 1991,
** TOBIN 2008*** LAER 2005
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