Pediatric Ingestions: Emergency Department Management (Pharmacology CME)

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Initial Stabilization
   2. History
   3. Initial Testing
   4. Physical Examination
9. Diagnostic Studies
   1. Chemistry And Osmolality
   2. Specific Medication/Substance Levels
      1. Acetaminophen
      2. Salicylate
      3. Other Substances
   3. Electrocardiography
   4. Radiographic Studies
   5. Urine Toxicology Screen
10. Treatment For Pediatric Ingestions
    1. Foreign Body Removal
    2. Decontamination
       1. Gastric Lavage
       2. Ipecac
       3. Activated Charcoal
       4. Whole-Bowel Irrigation
       5. Hemodialysis
    3. Treatment Of Specific Toxic Ingestions
       1. Acetaminophen
       2. Alcohols
       3. Anticholinergic Agents
       4. Beta Blockers
       5. Calcium-Channel Blockers
       6. Cholinergic Agents
       7. Digoxin
       8. Iron
       9. Opioids
       10. Salicylates
       11. Sedative-Hypnotics
       12. Sulfonylureas
11. Special Populations
12. Controversies And Cutting Edge
    1. Marijuana Exposure
    2. Intravenous Lipid Emulsion Therapy
13. Disposition
14. Summary
15. Risk Management Pitfalls In Management Of Ingestions In Pediatric Patients
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway For Management Of Battery Ingestions In Pediatric Patients
19. Tables and Figures
    1. Table 1. Medications Known For A High Risk Of Fatality
    2. Table 2. Resources Available To Clinicians For Management Of Overdose
    3. Table 3. Differential Diagnosis For Common Toxidromes
    4. Table 4. Anion Gap And Osmolal Gap Calculation
    5. Table 5. Emergency Medications For Overdose
    6. Figure 1. Ingested Button Battery With Double Rim At Thoracic Inlet
    7. Figure 2. 1981 Rumack-Matthew Nomogram
20. References

Abstract

Pediatric ingestions present a common challenge for emergency clinicians. Each year, more than 50,000 children aged < 5 years present to emergency departments with concern for unintentional medication exposure, and nearly half of all calls to poison centers are for children aged < 6 years. Ingestion of magnetic objects and button batteries has also become an increasing source of morbidity and mortality. Although fatal pediatric ingestions are rare, the prescription medications most responsible for injury and fatality in children include opioids, sedative/hypnotics, and cardiovascular drugs. Evidence regarding the evaluation and management of common pediatric ingestions is comprised largely of case reports and retrospective studies. This issue provides a review of these studies as well as consensus guidelines addressing the initial resuscitation, diagnosis, and treatment of common pediatric ingestions. Also discussed are current recommendations for decontamination, administration of antidotes for specific toxins, and management of ingested foreign bodies.

Case Presentation

An 18-month-old girl is brought in to the ED by ambulance after her grandmother was unable to wake her from an unusually long nap. The grandmother reports that the child had not been ill that morning. After repeated questioning, she admits that the child was found earlier in the day holding her pillbox. She does not have the pillbox with her and does not remember the names of all of her medications. On examination, the child is breathing shallowly. In response to painful stimuli, the girl moans and withdraws, but does not open her eyes. The remainder of her physical examination is normal, without fever or evidence of trauma. The resident physician asks what initial testing should be performed. As the team applies monitor leads, obtains intravenous access, and administers oxygen to this lethargic toddler, you order a stat ECG and glucose level. As you prepare for possible intubation, you consider medications that could be fatal in a small dose, such as opioids, sedatives, cardiac drugs, and hypoglycemic agents. Could ingestion of a small amount of the grand-mother’s medication be fatal in this toddler? Is it appropriate to give activated charcoal at this time?

A 3-year-old boy is referred to the ED by his pediatrician. He arrives with an x-ray that was taken earlier in the day. The parents state that the child came to them holding his throat and saying that he had swallowed something, although they are not sure what it was. Soon afterward, he refused to eat and they took him to his doctor. On examination, the patient is afebrile, with normal vital signs, and no respiratory distress. His oropharynx and lungs are clear. You wonder what you should look for on the previous imaging. Should you obtain further radiographic studies? Is a surgical consultation indicated? Can he be safely discharged for observation at home?

A 15-year-old adolescent girl is brought in by her family for a possible suicide attempt. The patient’s friend received a text in which the patient reported taking “a whole bottle of pain pills.” The family reports that an old bottle of acetaminophen with hydrocodone that was in the bathroom cabinet is now empty. The patient does not know exactly how many pills she took or at what time, but says that it was just after sending that text, which you see from her phone, was 4 hours ago. She is tearful and tired, but answers questions appropriately, and her physical examination is normal. Are there any specific drug levels that should be checked and, if so, when? Should you give naloxone, activated charcoal, or N-acetylcysteine? When can the patient be medically cleared for transfer to a psychiatric facility?

Introduction

Each year in the United States, more than 50,000 children aged < 5 years present to emergency departments (EDs) with concern for unintentional medication exposure.¹ In 2013, United States poison control centers received reports of 1,341,862 exposures in patients aged < 20 years, which accounted for 61.33% of all exposures.² Pediatric exposures demonstrate a bimodal pattern, with unintentional exposures in young children and exposures that are more likely to be intentional in adolescents.² Although the number of pediatric exposures is large, fatal pediatric ingestions are rare. Children aged < 6 years account for only 1.8% of all toxicologic fatalities reported to United States poison control centers, and patients aged < 20 years account for 6.1%.² According to the most recent annual report of the American Association of Poison Control Centers, the most common pediatric ingestions reported to the National Poison Data System include cosmetics/personal care products (13.8%), household cleaning substances (10.4%), analgesics (9.8%), foreign bodies/ toys/miscellaneous (6.9%), and topical preparations (6.1%).² Prescription medications most responsible for injury and fatality in children are opioids, sedative/hypnotics, and cardiovascular drugs.³ Certain medications and household substances are known for a high risk of fatality upon ingestion, even if only a small amount is ingested by a small child.⁴ (See Table 1.) In addition, ingestions of magnetic objects and button batteries have become an increasing source of morbidity and mortality.⁵

Ingestion cases pose several challenges to the emergency clinician. Even when a potentially toxic ingestion has been reported, the exact agent, formulation, quantity, or time of ingestion may be unknown. More often, occult ingestion is only one item on an extensive list of differential diagnoses for a critically ill child who presents with altered mental status, respiratory distress, cardiovascular instability, or metabolic derangement. Although physical examination findings and information gleaned by electrocardiographic, laboratory, and radiologic testing may suggest a specific ingestion, timely identification of many substances remains unavailable. In addition to these diagnostic challenges, the management of many ingested agents is controversial and remains the subject of further study and evolving recommendations. Fortunately, many resources are available to clinicians, providing general guidelines as well as individual recommendations. (See Table 2.)

This review presents an evidence-based approach to common pediatric ingestions, with a focus on initial ED stabilization, diagnosis, and management of a selection of the most common and hazardous ingestions, including foreign bodies and medications that may be fatal to children in small doses.

Critical Appraisal Of The Literature

A literature search was performed in PubMed using the search terms pediatric toxicology epidemiology, poison control, prehospital, toxidrome, electrocardiography, urine drug screen, ipecac, activated charcoal, whole-bowel irrigation, hemodialysis, magnet, battery, acetaminophen, salicylate, anticholinergic, cholinergic, alcohol, digoxin, calcium-channel blocker, beta blocker, and lipid emulsion. A search of the Cochrane Library for pediatric ingestion resulted in 5 relevant randomized controlled trials. References cited in review articles were further evaluated. A total of 304 articles were reviewed, 112 of which have been included here. Guidelines released by the American Academy of Pediatrics (AAP), the American Academy of Clinical Toxicology (AACT), and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) were reviewed.

Literature regarding pediatric ingestions is largely comprised of case reports, case series, and retrospective studies. Several large retrospective studies have compared treatment modalities for safety and efficacy, and a few randomized controlled trials have evaluated newer treatment modalities. Clinical guidelines are based on expert consensus as well as the available literature, and many have been updated recently to reflect greater emphasis on evidence-based medicine. Data are available through the National Poison Data System, a repository of all calls to United States poison control centers, and the National Electronic Injury Surveillance System, a United States Consumer Product Safety Commission database of ED visits.⁶

Risk Management Pitfalls In Management Of Ingestions In Pediatric Patients

1. “I didn’t think the poison control center would be helpful.”
   The American Association of Poison Control Centers provides recommendations from tremendous resources and experience. In addition to the benefits of better patient care and clinician education, the data you provide will be included in the National Poison Data System to further knowledge in the field.


2. “I give activated charcoal to all patients with ingestions.”
   Activated charcoal increases the risk of aspiration pneumonitis and is unlikely to be of benefit once the toxin has been absorbed. Routine use is no longer recommended unless a toxin shown to be bound by activated charcoal was ingested in the past hour by a patient to whom charcoal may be safely administered.


3. “The parents didn’t mention giving aspirin to their febrile child, so I didn’t consider it.”
   Symptoms of a toxic ingestion may be nonspecific, and an elevated temperature may be due to ingestion of salicylates, anticholinergic agents, or sympathomimetic agents, in addition to an infectious process. Always ask about use of over-the-counter medications and their ingredients.


4. “The urine toxicology screen was negative, so ingestion is ruled out.”
   Urine toxicology screen interpretations are limited by which drugs are included and at what threshold levels, in addition to false-negative and false-positive results.


5. “He attempted suicide by taking ibuprofen. Why would we check for acetaminophen?”
   Polypharmacy is common in suicidal ingestions, and acetaminophen overdose may present without symptoms and lead to fulminant hepatic failure.
6. “The ingested battery can wait until the surgi¬cal department opens in the morning.”
   A battery lodged in the esophagus may cause necrotic damage within 2 hours and should be removed immediately to prevent perforation and fistula formation.


7. “We’ll give dextrose to prevent hypoglycemia after suspected sulfonylurea ingestion.”
   Prophylactic dextrose will mask and possibly delay effects of sulfonylurea ingestion, confusing further management. Dextrose should only be administered as needed.


8. “Naloxone reversed the effect of methadone ingestion, so the child can be discharged.”
   Naloxone’s half-life is less than that of methadone, and clinicians may expect recrudescence of central nervous system and respiratory depression, requiring additional antidote administration.


9. “She became apneic after receiving lorazepam for her seizure, so we gave flumazenil.”
   Flumazenil administration in a patient with seizure disorder or chronic benzodiazepine use may precipitate intractable seizures and is contraindicated.


10. “The mother said that her 7-month-old baby got into this medication herself.”
    Although most ingestions by young children are due to normal exploratory behavior, home safety and the possibility of abuse should be addressed by clinicians, especially in cases with an implausible history.

Tables And Figures

References

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.

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