don’t Just Do Something,
Sit There
the Child with Occult Toxic Ingestion

TOXICOLOGY TALK
JANUARY 21 2014
PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
EMERGENCY MANAGEMENT
(ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY...
PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
EMERGENCY MANAGEMENT
(ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY...
2012

2008
2012
2011
VILKE 2011
age & Gender Distribution of Human Exposures

BRONSTEIN 2011
FRANKLIN 2008
distribution of reason for exposure by age

BRONSTEIN 2011
VILKE 2011
medical outcome of human exposure cases by patient age

97% NO EFFECT, MINOR EFFECT, NO FOLLOW UP. UNRELATED EFFECT
BRONST...
VILKE 2011
distribution of age and gender fatalities

BRONSTEIN 2011
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 EME...
micro journal club

intro
methods
results
limitations
take home
intro
MOST INGESTIONS ARE:
!

UNINTENTIONAL
!

INVOLVE A SINGLE SUBSTANCE
!

DON’T PRODUCE SIGNIFICANT CLINICAL EFFECTS
intro
MORTALITY RATE IN PEDS POISONINGS IS
<.0004%

(BRONSTEIN 2010; CDC)
intro
INGESTIONS IN ADOLESCENTS SIMILAR TO ADULTS:
!

SIGNIFICANT DOSES
!

MULTIPLE MEDS
!

INTENTIONAL
intro
POINT OF THE STUDY:
!

ASSESS THE UTILITY OF screening labs/ekg
!

IN THE MANAGEMENT OF
!

UNINTENTIONAL asymptomati...
methods
RETROSPECTIVE CHART REVIEW
!

PEDIATRIC PATIENTS <12 YO
!

PRESENTING TO CHILDREN’S ED (~60,OOO VISITS/YEAR)
!

EV...
APPROXIMATELY 90 INGESTION VISITS PER YEAR
= 7.5/month
!

= 1 every other shift (15 shifts/month)
methods
WHAT DATA DID THEY GRAB?
!

AGE, SEX, DATE OF VISIT
!

TYPE OF INGESTION
!

INTENTIONALITY
!

VITAL SIGNS, EXAM, M...
methods
WHAT 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 LEXICOM...
methods
NORMAL EKG= NSR
!

NOT NORMAL BUT OK (I)
MILD ABNORMALITY (I; NO CARDS F/U)= SINUS DYSRHYTHMIA, ATRIAL
ENLARGEMENT...
methods
DEFINITION OF “CHANGED MANAGEMENT”
RESULT REQUIRING INTERVENTION/TX
!

NON POISON CENTER SUBSPECIALTY CONSULT
!

P...
results
595 KIDS <12 YO EVAL IN ED FOR UNINTENTIONAL INGESTION
!

47 BUTTON-BATTERY INGESTIONS
!

MEDIAN AGE 2.6 YEARS (56...
WANG 2013
WANG 2013
results
AT LEAST 1 LAB OR EKG OBTAINED IN 233 (39%) PATIENTS
!

73 (12%) PATIENTS RECEIVED EKG
!

3 PATIENTS HAD CLASS II ...
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...
results
51 (9%) ADMITTED= 23 (45%) INPATIENT + 28 (55%) PICU
!

11 (2%) TO OR (10 BUTTON BATTERY REMOVAL + 1 CAUSTIC INGES...
limitations
RETROSPECTIVE CHART REVIEW
IN A SINGLE TERTIARY CARE CHILDREN’S HOSPITAL
= NOT GENERALIZABLE
!

SINGLE CHART R...
take home
SCREENING TESTS ONLY HELPFUL IN KIDS WHO WERE SYMPTOMATIC
WITHOUT AN INGESTION HISTORY
KIDS <12 YO WITH UNINTENT...
pediatric pathophysiologic considerations

HIGHER BODY SURFACE AREA/WEIGHT RATIO
!

DERMAL ABSORPTION INCREASED
!

AT GREA...
pediatric pathophysiologic considerations

INCREASED RR AND MINUTE VENTILATION=
HIGHER DOSE IN SHORTER TIME FOR AIRBORNE T...
pediatric pathophysiologic considerations

INCREASED RELIANCE ON DIAPHRAGM + LIMITED CAPACITY OF ACCESSORY
MUSCLES + HIGHE...
pediatric pathophysiologic considerations

RELATIVE LACK OF GLYCOGEN STORES
!

INCREASES LIKELIHOOD OF HYPOGLYCEMIA FROM
E...
pediatric pathophysiologic considerations

LIMITED CARDIOVASCULAR RESERVE
!

CARDIAC OUTPUT HEAVILY RELIANT ON HR
!

ADREN...
pediatric pathophysiologic considerations

KIDS ARE MORE SENSITIVE TO SPECIFIC DRUGS
!

OPIOID RECEPTOR AGONISTS CAN CAUSE...
Don't just do something, sit there: the asymptomatic child with suspected ingestion
Upcoming SlideShare
Loading in …5
×

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

715 views

Published on

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

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
715
On SlideShare
0
From Embeds
0
Number of Embeds
253
Actions
Shares
0
Downloads
5
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

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

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

×