References | Pediatric Ingestions: Emergency Department Management

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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study are included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Burt AJ, Ballesteros MF, Budnitz DS. Nonfatal, unintentional medication exposures among young children – United States, 2001– 2003. MMWR Morb Mortal Wkly Rep.2006; 55:1- 5. (Database review)

  2. Mowry JB, Spyker DA, Cantilena LR Jr, et al. 2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th annual report. Clin Toxicol (Phila). 2013;51(10):949-1229. (Database review)

  3. Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr. 2012;160(2):265- 270. (Database review)

  4. Bar-Oz B, Levichek Z, Koren G. Medications that can be fatal for a toddler with one tablet or teaspoonful: a 2004 update. Paediatr Drugs. 2004;6(2):123-126. (Review)

  5. Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990-2009. Pediatrics. 2012;129(6):1111-1117. (Database review)

  6. United States Consumer Product Safety Commission. Poison prevention packaging: a guide for healthcare professionals. 2005. (Guidelines)

  7. Rodgers GB. The safety effects of child-resistant packaging for oral prescription drugs. Two decades of experience. JAMA. 1996;275(21):1661-1665. (Population study)

  8. Tuuri RE, Wright JL, He J, et al. Does prearrival communication from a poison center to an emergency department decrease time to activated charcoal for pediatric poisoning? Pediatr Emerg Care. 2011;27(11):1045-1051. (Retrospective study; 351 patients)

  9. Tuuri RE, Ryan LM, He J, et al. Does emergency medical services transport for pediatric ingestion decrease time to activated charcoal? Prehosp Emerg Care. 2009;13(3):295-303. (Retrospective study; 351 patients)

  10. Crockett R, Krishel SJ, Manoguerra A, et al. Prehospital use of activated charcoal: a pilot study. J Emerg Med. 1996;14(3):335-338. (Retrospective study; 36 patients)

  11. Spiller HA, Rodgers GC Jr. Evaluation of administration of activated charcoal in the home. Pediatrics. 2001;108(6):E100. (Prospective study; 138 patients)

  12. Doe-Simkins M, Walley AY, Epstein A, et al. Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health. 2009;99(5):788-791. (Prospective study; 385 subjects)

  13. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Pediatrics. 2006;117(5):e1005- e1028. (Guidelines)

  14. Cowan D, Ho B, Sykes KJ, et al. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325-1328. (Retrospective study; 75 subjects) 

  15. Lheureux PE, Zahir S, Gris M, et al. Bench-to-bedside review: hyperinsulinaemia/euglycaemia therapy in the management of overdose of calcium-channel blockers. Crit Care. 2006;10(3):212. (Review)

  16. Wang GS, Deakyne S, Bajaj L, et al. The limited utility of screening laboratory tests and electrocardiograms in the management of unintentional asymptomatic pediatric ingestions. J Emerg Med. 2013;45(1):34-38. (Retrospective chart review; 595 pediatric patients)

  17. Gandhi SG, Gilbert WM, McElvy SS, et al. Maternal and neonatal outcomes after attempted suicide. Obstet Gynecol. 2006;107(5):984-990. (Retrospective study; 4,833,286 patients)

  18. Finkelstein Y, Hutson JR, Freedman SB, et al. Drug-induced seizures in children and adolescents presenting for emergency care: current and emerging trends. Clin Toxicol (Phila). 2013;51(8):761-766. (Retrospective study; 142 patients)

  19. Chabali R. Diagnostic use of anion and osmolal gaps in pediatric emergency medicine. Pediatr Emerg Care. 1997;13(3):204- 210. (Review and case reports, 2 patients)

  20. Sporer KA, Khayam-Bashi H. Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. Am J Emerg Med. 1996;14(5):443-446. (Retrospective study; 1820 subjects)

  21. Doyon S, Klein-Schwartz W, Lee S, et al. Fatalities involving acetaminophen combination products reported to United States poison centers. Clin Toxicol (Phila). 2013;51(10):941-948. (Retrospective study; 337 patients)

  22. Wu AH, McKay C, Broussard LA, et al. National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Clin Chem. 2003;49(3):357-379. (Guidelines)

  23. Kolecki PF, Curry SC. Poisoning by sodium channel blocking agents. Crit Care Clin. 1997;13(4):829-848. (Review)

  24. Harrigan RA, Brady WJ. ECG abnormalities in tricyclic antidepressant ingestion. Am J Emerg Med. 1999;17(4):387-393. (Review)

  25. Foulke GE, Albertson TE. QRS interval in tricyclic antidepressant overdosage: inaccuracy as a toxicity indicator in emergency settings. Ann Emerg Med. 1987;16(2):160-163. (Retrospective study; 102 patients)

  26. Berkovitch M, Matsui D, Fogelman R, et al. Assessment of the terminal 40-millisecond QRS vector in children with a history of tricyclic antidepressant ingestion. Pediatr Emerg Care. 1995;11(2):75-77. (Retrospective study; 35 patients)

  27. Saps M, Rosen JM, Ecanow J. X-ray detection of ingested non-metallic foreign bodies. World J Clin Pediatr. 2014;3(2):14- 18. (Observational study)

  28. Savitt DL, Hawkins HH, Roberts JR. The radiopacity of ingested medications. Ann Emerg Med. 1987;16(3):331-339. (Observational study)

  29. Agbo C, Lee L, Chiang V, et al. Magnet-related injury rates in children: a single hospital experience. J Pediatr Gastroenterol Nutr. 2013;57(1):14-17. (Retrospective study; 112 patients)

  30. Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177. (Database review)

  31. Clifton JC 2nd, Sigg T, Burda AM, et al. Acute pediatric lead poisoning: combined whole bowel irrigation, succimer therapy, and endoscopic removal of ingested lead pellets. Pediatr Emerg Care. 2002;18(3):200-202. (Case report)

  32. George S, Braithwaite RA. A preliminary evaluation of five rapid detection kits for on site drugs of abuse screening. Addiction. 1995;90(2):227-232. (Observational study)

  33. Winter ML, Ellis MD, Snodgrass WR. Urine fluorescence using a Wood’s lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. Ann Emerg Med. 1990;19(6):663-667. (Observational study; 12 samples)

  34. Wallace KL, Suchard JR, Curry SC, et al. Diagnostic use of physicians’ detection of urine fluorescence in a simulated ingestion of sodium fluorescein-containing antifreeze. Ann Emerg Med. 2001;38(1):49-54. (Observational study; 30 samples)

  35. Brett AS. Implications of discordance between clinical impression and toxicology analysis in drug overdose. Arch Intern Med. 1988;148(2):437-441. (Retrospective study; 209 patients)

  36. Flanagan RJ, Huggett A, Saynor DA, et al. Value of toxicological investigation in the diagnosis of acute drug poisoning in children. Lancet. 1981;2(8248):682-685. (Retrospective study; 287 patients)

  37. Belson MG, Simon HK. Utility of comprehensive toxicologic screens in children. Am J Emerg Med. 1999;17(3):221-224. (Retrospective study; 463 subjects)

  38. Wahbeh G, Wyllie R, Kay M. Foreign body ingestion in infants and children: location, location, location. Clin Pediatr (Phila). 2002;41(9):633-640. (Review)

  39. Benson BE, Hoppu K, Troutman WG, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):140-146. (Guidelines)

  40. Kornberg AE, Dolgin J. Pediatric ingestions: charcoal alone versus ipecac and charcoal. Ann Emerg Med. 1991;20(6):648- 651. (Randomized controlled trial; 70 patients)

  41. Krenzelok EP, McGuigan M, Lheur P. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):699-709. (Guidelines)

  42. Hojer J, Troutman WG, Hoppu K, et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013;51(3):134-139. (Systematic literature review)

  43. Olson KR. Activated charcoal for acute poisoning: one toxicologist’s journey. J Med Toxicol. 2010;6(2):190-198. (Review)

  44. Chyka PA, Seger D, Krenzelok EP, et al. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61- 87. (Guidelines)

  45. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999;37(6):731-751. (Guidelines)

  46. Sato RL, Wong JJ, Sumida SM, et al. Efficacy of superactivated charcoal administered late (3 hours) after acetaminophen overdose. Am J Emerg Med. 2003;21(3):189-191. (Randomized controlled trial; 46 patients)

  47. Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015;53(1):5-12. (Guidelines)

  48. Lo JC, Ubaldo C, Cantrell FL. A retrospective review of whole bowel irrigation in pediatric patients. Clin Toxicol. 2012;50(5):414-417. (Retrospective study; 176 patients)

  49. Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal techniques for the poisoned patient: a review for the intensivist. J Intensive Care Med. 2010;25(3):139-148. (Review)

  50. Holubek WJ, Hoffman RS, Goldfarb DS, et al. Use of hemodialysis and hemoperfusion in poisoned patients. Kidney Int. 2008;74(10):1327-1334. (Retrospective study; 19,351 patients)

  51. Prescott LF. Hepatotoxicity of mild analgesics. Br J Clin Pharmacol. 1980;10 Suppl 2:373S-379S. (Review)

  52. Rivera-Penera T, Gugig R, Davis J, et al. Outcome of acetaminophen overdose in pediatric patients and factors contributing to hepatotoxicity. J Pediatr. 1997;130(2):300-304. (Retrospective study; 73 patients)

  53. Burillo-Putze G, Mintegui S, Munne P. Changes in pediatric toxic dose of acetaminophen. Am J Emerg Med. 2004;22(4):323. (Editorial)

  54. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975;55(6):871-876. (Review)

  55. Froberg BA, King KJ, Kurera TD, et al. Negative predictive value of acetaminophen concentrations within four hours of ingestion. Acad Emerg Med. 2013;20(10):1072-1075. (Prospective study; 83 patients)

  56. Harrison PM, Wendon JA, Gimson AE, et al. Improvement by acetylcysteine of hemodynamics and oxygen transport in fulminant hepatic failure. N Engl J Med. 1991;324(26):1852- 1857. (Case series; 12 patients)

  57. Keays R, Harrison PM, Wendon JA, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial. BMJ. 1991;303(6809):1026-1029. (Prospective randomized controlled trial; 50 patients)

  58. Smilkstein MJ, Knapp GL, Kulig KW, et al. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med. 1988;319(24):1557-1562. (Retrospective study; 2540 subjects)

  59. Prescott LF, Illingworth RN, Critchley JA, et al. Intravenous N-acetylcystine: the treatment of choice for paracetamol poisoning. Br Med J. 1979;2(6198):1097-1100. (Retrospective study; 100 patients)

  60. Pizon AF, Jang DH, Wang HE. The in vitro effect of N-acetylcysteine on prothrombin time in plasma samples from healthy subjects. Acad Emerg Med. 2011;18(4):351-354. (In vitro study)

  61. Wang GS, Monte A, Bagdure D, et al. Hepatic failure despite early acetylcysteine following large acetaminophen-diphenhydramine overdose. Pediatrics. 2011;127(4):e1077-e1080. (Case report)

  62. Slaughter RJ, Mason RW, Beasley DM, et al. Isopropanol poisoning. Clin Toxicol (Phila). 2014;52(5):470-478. (Review)

  63. White ML, Liebelt EL. Update on antidotes for pediatric poisoning. Pediatr Emerg Care. 2006;22(11):740-746. (Review)

  64. Baud FJ, Galliot M, Astier A, et al. Treatment of ethylene glycol poisoning with intravenous 4-methylpyrazole. N Engl J Med. 1988;319(2):97-100. (Case report)

  65. Darracq MA, Cantrell FL. Hemodialysis and extracorporeal removal after pediatric and adolescent poisoning reported to a state poison center. J Emerg Med. 2013;44(6):1101-1107. (Database study; 90 patients)

  66. Frascogna N. Physostigmine: is there a role for this antidote in pediatric poisonings? Curr Opin Pediatr. 2007;19(2):201- 205. (Review)

  67. Shannon M. Toxicology reviews: physostigmine. Pediatr Emerg Care. 1998;14(3):224-226. (Review)

  68. Lifshitz M, Zucker N, Zalzstein E. Acute dilated cardiomyopathy and central nervous system toxicity following propranolol intoxication. Pediatr Emerg Care. 1999;15(4):262- 263. (Case report)

  69. Shepherd G. Treatment of poisoning caused by beta-adrenergic and calcium-channel blockers. Am J Health Syst Pharm. 2006;63(19):1828-1835. (Review)

  70. Love JN, Howell JM, Klein-Schwartz W, et al. Lack of toxicity from pediatric beta-blocker exposures. Hum Exp Toxicol. 2006;25(6):341-346. (Prospective cohort study; 208 patients)

  71. Smith RC, Wilkinson J, Hull RL. Glucagon for propranolol overdose. JAMA. 1985;254(17):2412. (Case report)

  72. Bindon MJ, Barlotta K. Glucagon treatment for bradycardia and a junctional rhythm caused by excessive beta-blockade. Resuscitation. 2009;80(11):1327. (Case report)

  73. Love JN, Howell JM. Glucagon therapy in the treatment of symptomatic bradycardia. Ann Emerg Med. 1997;29(1):181- 183. (Case series)

  74. Engebretsen KM, Kaczmarek KM, Morgan J, et al. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol (Phila). 2011;49(4):277-283. (Review)

  75. Ramoska EA, Spiller HA, Myers A. Calcium channel blocker toxicity. Ann Emerg Med. 1990;19(6):649-653. (Retrospective, study; 91 patients)

  76. Truitt CA, Brooks DE, Dommer P, et al. Outcomes of unintentional beta-blocker or calcium channel blocker overdoses: a retrospective review of poison center data. J Med Toxicol. 2012;8(2):135-139. (Database study)

  77. Belson MG, Gorman SE, Sullivan K, et al. Calcium channel blocker ingestions in children. Am J Emerg Med. 2000;18(5):581-586. (Retrospective review)

  78. Levine M, Boyer EW, Pozner CN, et al. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil. Crit Care Med. 2007;35(9):2071-2075. (Retrospective study, 40 patients)

  79. Jokanovic M. Medical treatment of acute poisoning with organophosphorus and carbamate pesticides. Toxicol Lett. 2009;190(2):107-115. (Review)

  80. Saadeh AM, Farsakh NA, al-Ali MK. Cardiac manifestations of acute carbamate and organophosphate poisoning. Heart. 1997;77(5):461-464. (Retrospective study; 46 patients)

  81. Thacker D, Sharma J. Digoxin toxicity. Clin Pediatr (Phila). 2007;46(3):276-279. (Review)

  82. Woolf AD, Wenger TL, Smith TW, et al. Results of multicenter studies of digoxin-specific antibody fragments in managing digitalis intoxication in the pediatric population. Am J Emerg Med. 1991;9(2 Suppl 1):16-20. (Retrospective study; 57 patients)

  83. Fazio A. Fab fragments in the treatment of digoxin overdose: pediatric considerations. South Med J. 1987;80(12):1553-1556. (Review)

  84. Jang DH, Spyres MB, Fox L, et al. Toxin-induced cardiovascular failure. Emerg Med Clin N Am. 2014;32(1):79-102. (Review)

  85. Woolf AD, Wenger T, Smith TW, et al. The use of digoxin-specific Fab fragments for severe digitalis intoxication in children. N Engl J Med. 1992;326(26):1739-1744. (Retrospective study; 29 patients)

  86. Kaufman J, Leikin J, Kendzierski D, et al. Use of digoxin Fab immune fragments in a seven-day-old infant. Pediatr Emerg Care. 1990;6(2):118-121. (Case report)

  87. Reynolds LG. Diagnosis and management of acute iron poisoning. Baillieres Clin Haematol. 1989;2(2):423-433. (Review)

  88. Sankar J, Shukla A, Khurana R, et al. Near fatal iron intoxication managed conservatively. BMJ Case Rep. 2013;2013. (Case report)

  89. Chang TP, Rangan C. Iron poisoning: a literature-based review of epidemiology, diagnosis, and management. Pediatr Emerg Care. 2011;27(10):978-985. (Review)

  90. Madiwale T, Liebelt E. Iron: not a benign therapeutic drug. Curr Opin Pediatr. 2006;18(2):174-179. (Review)

  91. Geib AJ, Babu K, Ewald MB, et al. Adverse effects in children after unintentional buprenorphine exposure. Pediatrics. 2006;118(4):1746-1751. (Case series; 5 patients)

  92. Goldfrank L, Weisman RS, Errick JK, et al. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med. 1986;15(5):566-570. (Prospective study; 11 patients)

  93. O’Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007;25(2):333-346. (Review)

  94. Bogacz K, Caldron P. Enteric-coated aspirin bezoar: elevation of serum salicylate level by barium study. Case report and review of medical management. Am J Med. 1987;83(4):783- 786. (Case report and in vitro study)

  95. Proudfoot AT, Krenzelok EP, Vale JA. Position paper on urine alkalinization. J Toxicol Clin Toxicol. 2004;42(1):1-26. (Guidelines)

  96. Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med. 2008;15(9):866-869. (Retrospective study; 7 patients)

  97. Wiley CC, Wiley JF 2nd. Pediatric benzodiazepine ingestion resulting in hospitalization. J Toxicol Clin Toxicol. 1998;36(3):227-231. (Retrospective study; 46 patients)

  98. Kreshak AA, Tomaszewski CA, Clark RF, et al. Flumazenil administration in poisoned pediatric patients. Pediatr Emerg Care. 2012;28(5):448-450. (Retrospective study; 83 patients)

  99. Harrigan RA, Nathan MS, Beattie P. Oral agents for the treatment of type 2 diabetes mellitus: pharmacology, toxicity, and treatment. Ann Emerg Med. 2001;38(1):68-78. (Review)

  100. Calello DP, Kelly A, Osterhoudt KC. Case files of the Medical Toxicology Fellowship Training Program at the Children’s Hospital of Philadelphia: a pediatric exploratory sulfonylurea ingestion. J Med Toxicol. 2006;2(1):19-24. (Case report)

  101. Glatstein M, Garcia-Bournissen F, Scolnik D, et al. Sulfonylurea intoxication at a tertiary care paediatric hospital. Can J Clin Pharmacol. 2010;17(1):e51-56. (Case series; 10 patients)

  102. Pollack CV Jr. Utility of glucagon in the emergency department. J Emerg Med. 1993;11(2):195-205. (Review)

  103. Levine M, Ruha AM, Lovecchio F, et al. Hypoglycemia after accidental pediatric sulfonylurea ingestions. Pediatr Emerg Care. 2011;27(9):846-849. (Retrospective case series; 93 patients)

  104. Glatstein M, Scolnik D, Bentur Y. Octreotide for the treatment of sulfonylurea poisoning. Clin Toxicol (Phila). 2012;50(9):795-804. (Meta-analysis)

  105. Hickson GB, Altemeier WA, Martin ED, et al. Parental administration of chemical agents: a cause of apparent life-threatening events. Pediatrics. 1989;83(5):772-776. (Case series; 9 patients)

  106. Pitetti RD, Whitman E, Zaylor A. Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants. Pediatrics. 2008;122(2):e359-e362. (Prospective study; 596 patients)

  107. Macnab A, Anderson E, Susak L. Ingestion of cannabis: a cause of coma in children. Pediatr Emerg Care. 1989;5(4):238- 239. (Case series; 6 patients)

  108. Wang GS, Roosevelt G, Le Lait MC, et al. Association of unintentional pediatric exposures with decriminalization of marijuana in the United States. Ann Emerg Med. 2014;63(6):684-689. (Retrospective study; 985 patients)

  109. Lokajova J, Holopainen JM, Wiedmer SK. Comparison of lipid sinks in sequestering common intoxicating drugs. J Sep Sci. 2012;35(22):3106-3112. (In vitro study)

  110. French D, Armenian P, Ruan W, et al. Serum verapamil concentrations before and after Intralipid(R) therapy during treatment of an overdose. Clin Toxicol (Phila). 2011;49(4):340- 344. (Case report)

  111. Rodriguez B, Wilhelm A, Kokko KE. Lipid emulsion use precluding renal replacement therapy. J Emerg Med. 2014;47(6):635-637. (Case report)

  112. Kearney TE, Olson KR, Bero LA, et al. Health care cost effects of public use of a regional poison control center. West J Med. 1995;162(6):499-504. (Cost-effectiveness analysis)

  113. Harrison DL, Draugalis JR, Slack MK, et al. Cost-effectiveness of regional poison control centers. Arch Intern Med. 1996;156(22):2601-2608. (Cost-effectiveness analysis)
Publication Information

Stacy M. Tarango, MD; Deborah R. Liu, MD;

Publication Date

April 2, 2016

CME Expiration Date

May 2, 2019

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