don't just do something, sit there: the asymptomatic child with suspected ingestion
DESCRIPTION
Investigating the minimalist approach to the asymptomatic child presenting the ER with suspected ingestionTRANSCRIPT
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don’t Just Do Something, Sit There
the Child with Occult Toxic Ingestion
TOXICOLOGY TALK JANUARY 21 2014
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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
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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
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2012
2012
2008
2011
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VILKE 2011
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BRONSTEIN 2011
age & Gender Distribution of Human Exposures
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FRANKLIN 2008
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BRONSTEIN 2011
distribution of reason for exposure by age
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VILKE 2011
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BRONSTEIN 2011
medical outcome of human exposure cases by patient age
97% NO EFFECT, MINOR EFFECT, NO FOLLOW UP. UNRELATED EFFECT
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VILKE 2011
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BRONSTEIN 2011
distribution of age and gender fatalities
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BOND 2012
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FRANKLIN 2008
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BRONSTEIN 2011
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BRONSTEIN 2011
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BOND 2012
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BRONSTEIN 2011
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BRONSTEIN 2011
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BRONSTEIN 2011
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BRONSTEIN 2011
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BRONSTEIN 2011
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pediatric poisoning trends vs population change from 2001 baseline
BOND 2012
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limited utility of screening labs and ekg in unintentional asymptomatic pediatric ingestions
WANG GS ET AL. JOURNAL OF EMERGENCY MEDICINE. 2013
+ =
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micro journal club
intro
methods
results
take home
limitations
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introMOST INGESTIONS ARE:
!UNINTENTIONAL
!INVOLVE A SINGLE SUBSTANCE
!DON’T PRODUCE SIGNIFICANT CLINICAL EFFECTS
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intro
MORTALITY RATE IN PEDS POISONINGS IS
<.0004%
(BRONSTEIN 2010; CDC)
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introINGESTIONS IN ADOLESCENTS SIMILAR TO ADULTS:
!
SIGNIFICANT DOSES !
MULTIPLE MEDS !
INTENTIONAL
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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
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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
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APPROXIMATELY 90 INGESTION VISITS PER YEAR
= 7.5/month !
= 1 every other shift (15 shifts/month)
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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
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methodsWHAT LABS?
!CBC !
BMP/CMP !
BLOOD GAS !
SALICYLATE/ACETAMINOPHEN !
URINE TOX
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methods
CRITERIA FOR screening LAB/TEST IN THIS STUDY:
!
ABNORMALITIES NOT LISTED UNDER POTENTIAL SIDE EFFECTS IN LEXICOMP
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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
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methods
DEFINITION OF “CHANGED MANAGEMENT”
RESULT REQUIRING INTERVENTION/TX !
NON POISON CENTER SUBSPECIALTY CONSULT !
PROLONGED ED STAY
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results
595 KIDS <12 YO EVAL IN ED FOR UNINTENTIONAL INGESTION !
47 BUTTON-BATTERY INGESTIONS !
MEDIAN AGE 2.6 YEARS (56% MALE)
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WANG 2013
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WANG 2013
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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
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WANG 2013
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WANG 2013
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WANG 2013
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WANG 2013
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WANG 2013
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WANG 2013
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results
OVERALL: !
224 (38%) DISCHARGED IMMEDIATELY 309 (52%) OBSERVED IN ED THEN DISCHARGED+
533 (~90%) DISCHARGED FROM ED
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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
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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
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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
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pediatric pathophysiologic considerations
HIGHER BODY SURFACE AREA/WEIGHT RATIO !
DERMAL ABSORPTION INCREASED !
AT GREATER RISK FOR DEHYDRATION AND INSENSIBLE LOSSES
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pediatric pathophysiologic considerations
INCREASED RR AND MINUTE VENTILATION= HIGHER DOSE IN SHORTER TIME FOR AIRBORNE TOXINS
(CARBON MONOXIDE POISONING)
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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)
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pediatric pathophysiologic considerations
RELATIVE LACK OF GLYCOGEN STORES !
INCREASES LIKELIHOOD OF HYPOGLYCEMIA FROM ETHANOL AND BETA BLOCKER INGESTION
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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
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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