Dont just do something sit there. Pediatric Toxicology
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

Dont just do something sit there. Pediatric Toxicology

on

  • 180 views

Investigating the minimalist approach to the asymptomatic child presenting to the ER with suspected toxic ingestion

Investigating the minimalist approach to the asymptomatic child presenting to the ER with suspected toxic ingestion

Statistics

Views

Total Views
180
Views on SlideShare
180
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Dont just do something sit there. Pediatric Toxicology Presentation Transcript

  • 1. don’t Just Do Something, Sit There the Child with Occult Toxic Ingestion TOXICOLOGY TALK JANUARY 21 2014
  • 2. PEDIATRIC TOXICOLOGY EPIDEMIOLOGY AND PREVENTION EMERGENCY MANAGEMENT (ABCS, DECONTAMINATION, TOXIDROMES ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE) WELL APPEARING CHILD WITH POISON EXPOSURE PEDIATRIC PATHOPHYSIOLOGIC CONSIDERATIONS DEADLY IN SMALL DOSES
  • 3. PEDIATRIC TOXICOLOGY EPIDEMIOLOGY AND PREVENTION EMERGENCY MANAGEMENT (ABCS, DECONTAMINATION, TOXIDROMES ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE) WELL APPEARING CHILD WITH POISON EXPOSURE PEDIATRIC PATHOPHYSIOLOGIC CONSIDERATIONS DEADLY IN SMALL DOSES
  • 4. 2012 2008 2012 2011
  • 5. VILKE 2011
  • 6. age & Gender Distribution of Human Exposures BRONSTEIN 2011
  • 7. FRANKLIN 2008
  • 8. distribution of reason for exposure by age BRONSTEIN 2011
  • 9. VILKE 2011
  • 10. medical outcome of human exposure cases by patient age 97% NO EFFECT, MINOR EFFECT, NO FOLLOW UP. UNRELATED EFFECT BRONSTEIN 2011
  • 11. VILKE 2011
  • 12. distribution of age and gender fatalities BRONSTEIN 2011
  • 13. BOND 2012
  • 14. FRANKLIN 2008
  • 15. BRONSTEIN 2011
  • 16. BRONSTEIN 2011
  • 17. BOND 2012
  • 18. BRONSTEIN 2011
  • 19. BRONSTEIN 2011
  • 20. BRONSTEIN 2011
  • 21. BRONSTEIN 2011
  • 22. BRONSTEIN 2011
  • 23. pediatric poisoning trends vs population change from 2001 baseline BOND 2012
  • 24. limited utility of screening labs and ekg in unintentional asymptomatic pediatric ingestions WANG GS ET AL. JOURNAL OF EMERGENCY MEDICINE. 2013 + =
  • 25. micro journal club intro methods results limitations take home
  • 26. intro MOST INGESTIONS ARE: ! UNINTENTIONAL ! INVOLVE A SINGLE SUBSTANCE ! DON’T PRODUCE SIGNIFICANT CLINICAL EFFECTS
  • 27. intro MORTALITY RATE IN PEDS POISONINGS IS <.0004% (BRONSTEIN 2010; CDC)
  • 28. intro INGESTIONS IN ADOLESCENTS SIMILAR TO ADULTS: ! SIGNIFICANT DOSES ! MULTIPLE MEDS ! INTENTIONAL
  • 29. intro POINT 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
  • 30. methods RETROSPECTIVE 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
  • 31. APPROXIMATELY 90 INGESTION VISITS PER YEAR = 7.5/month ! = 1 every other shift (15 shifts/month)
  • 32. methods WHAT 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
  • 33. methods WHAT LABS? ! CBC ! BMP/CMP ! BLOOD GAS ! SALICYLATE/ACETAMINOPHEN ! URINE TOX
  • 34. methods CRITERIA FOR screening LAB/TEST IN THIS STUDY: ! ABNORMALITIES NOT LISTED UNDER POTENTIAL SIDE EFFECTS IN LEXICOMP
  • 35. methods NORMAL 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
  • 36. methods DEFINITION OF “CHANGED MANAGEMENT” RESULT REQUIRING INTERVENTION/TX ! NON POISON CENTER SUBSPECIALTY CONSULT ! PROLONGED ED STAY
  • 37. results 595 KIDS <12 YO EVAL IN ED FOR UNINTENTIONAL INGESTION ! 47 BUTTON-BATTERY INGESTIONS ! MEDIAN AGE 2.6 YEARS (56% MALE)
  • 38. WANG 2013
  • 39. WANG 2013
  • 40. results AT 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
  • 41. WANG 2013
  • 42. WANG 2013
  • 43. WANG 2013
  • 44. WANG 2013
  • 45. WANG 2013
  • 46. WANG 2013
  • 47. results OVERALL: ! 224 (38%) DISCHARGED IMMEDIATELY + 309 (52%) OBSERVED IN ED THEN DISCHARGED 533 (~90%) DISCHARGED FROM ED
  • 48. 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
  • 49. 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
  • 50. take home SCREENING 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
  • 51. pediatric pathophysiologic considerations HIGHER BODY SURFACE AREA/WEIGHT RATIO ! DERMAL ABSORPTION INCREASED ! AT GREATER RISK FOR DEHYDRATION AND INSENSIBLE LOSSES
  • 52. pediatric pathophysiologic considerations INCREASED RR AND MINUTE VENTILATION= HIGHER DOSE IN SHORTER TIME FOR AIRBORNE TOXINS (CARBON MONOXIDE POISONING)
  • 53. 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)
  • 54. pediatric pathophysiologic considerations RELATIVE LACK OF GLYCOGEN STORES ! INCREASES LIKELIHOOD OF HYPOGLYCEMIA FROM ETHANOL AND BETA BLOCKER INGESTION
  • 55. pediatric pathophysiologic considerations 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
  • 56. 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)*** * MEGARBANE 2013, BAMSHAD 1990, KIM 2012, MCCARRON 1991, ** TOBIN 2008 *** LAER 2005