Don't just do something, sit there: the asymptomatic child with suspected ingestion

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

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

BOND 2012

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

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

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


INCREASED RR AND MINUTE VENTILATION= HIGHER DOSE IN SHORTER TIME FOR AIRBORNE TOXINS

(CARBON MONOXIDE POISONING)


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)


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


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)


*

**

**** MEGARBANE 2013, BAMSHAD 1990, KIM 2012, MCCARRON 1991,

** TOBIN 2008*** LAER 2005

Don't just do something, sit there: the asymptomatic child with suspected ingestion

Health & Medicine

Transcript of Don't just do something, sit there: the asymptomatic child with suspected ingestion