Lead Poisoning in Children: Emergency Department Recognition and Management (Pharmacology CME) -
Publication Date: April 2022 (Volume 19, Number 4)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 04/01/2025.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits, subject to your state and institutional approval.
Ariella Nadler, MD
Assistant Professor of Clinical Pediatrics and Clinical Emergency Medicine, New York-Presbyterian/Weill Cornell Medical College, New York, NY
Sing-Yi Feng, MD, FAAP
Associate Professor, Division of Emergency Medicine/Department of Pediatrics, Division of Medical Toxicology/Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
Michael Levine, MD
Associate Professor of Emergency Medicine; Director of Toxicology, University of California, Los Angeles, Los Angeles, CA
Millions of children continue to be at risk for lead exposure despite a dramatic decline over the past 4 decades, and hundreds present annually to emergency departments with lead poisoning. These patients can be challenging to identify due to their nonspecific presentation and frequent lack of known exposure. This issue will prepare the emergency clinician to identify and care for the lead-poisoned patient, focusing on: (1) identifying key historical features, signs, and symptoms at presentation; (2) the medical management of lead poisoning; and (3) formulation of a safe discharge plan.
A 4-year-old boy with a history of autism spectrum disorder presents to the ED with a chief complaint of abdominal pain...
The patient is nonverbal, but his mom states that he is intermittently holding his abdomen and crying. He has not had fever or emesis. He has not stooled in 10 days. The mom tells you that he has been constipated “since he was a baby,” and it has been managed with polyethylene glycol, but he has never gone this long without stooling. The patient has a decreased appetite, but his urine output has been normal. On further questioning, the mom says that her son has pica behaviors and that their apartment was recently renovated.
On physical examination, you note that the patient appears comfortable, but has a slightly distended abdomen with generalized tenderness, without rebound or guarding. You discuss with the mom your concern that his symptoms may be due to lead poisoning. You relay the plan to obtain a blood lead level.
What risk factors for lead poisoning does this patient have? What other tests should you consider as part of your initial workup? How much of this workup needs to be done in the ED? How will you determine whether the patient needs to be admitted?
A 15-month-old previously healthy girl presents to the ED after swallowing her grandmother’s heirloom necklace...
Earlier today, the girl’s grandmother was looking for her necklace, and the patient’s 8-year-old sister said that she saw the patient swallow it. The sister says that last week, the patient was playing with the necklace and started chewing on it. The patient then coughed for a few minutes and swallowed the necklace. As soon as the parents heard about this, they immediately rushed their daughter to the ED.
On arrival, the patient appears comfortable, with normal vital signs and no respiratory distress. The remainder of the physical examination is normal. The mom is particularly concerned because the grandmother mentioned that the necklace is made from lead, and she remembers their pediatrician talking to her about the risks of lead exposure.
In addition to obtaining imaging studies to assess the location of the foreign body, what other workup should you consider? Can the patient become lead-poisoned from this foreign body? What is your management plan?
A 13-year-old girl presents to the ED with chronic abdominal pain...
The patient’s pain started 5 months ago, at which time she was diagnosed with appendicitis and underwent an appendectomy. The pain has persisted, and she has developed anorexia and constipation. She has been afebrile, with some nausea but no vomiting or diarrhea. Two months ago, she was diagnosed with iron deficiency anemia. Her mother also mentions that the girl has been increasingly irritable and depressed, which the family has attributed to frustration with her prolonged abdominal pain.
On examination, the patient has a blood pressure of 150/90 mm Hg and is noted to be pale. Her abdomen is soft, with generalized tenderness. You obtain laboratory tests, which are significant for microcytic anemia but show a normal WBC count and inflammatory markers. An abdominal ultrasound looking for abscess is normal. While talking to one of the nurses, the patient mentions that she spends a lot of time working in her family’s pottery shop. On further questioning, her mother reveals that the patient’s uncle had lead poisoning 2 years ago.
You are concerned for lead poisoning and send a blood lead level. Could this patient have become lead-poisoned from being around lead, without ingesting it? Is her irritability and depression related to her underlying diagnosis? What is your next management step?
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