Pediatric Ingestions: Acetaminophen, Salicylates, Iron, Opioids, Beta Blockers, Calcium Channel Blockers, Digoxin, Sulphonylureas, Battery, Magnet | EB Medicine
0
TOC Will Appear Here

Pediatric Ingestions: Emergency Department Management (Pharmacology CME)

3,638 views
Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.
Table of Contents
 
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

 

Table 2. Resources Available To Clinicians For Management Of Overdose

 

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

 Table 1. Medications Known For A High Risk Of Fatality

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.

  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)
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Publication Information
Authors

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

Publication Date

April 2, 2016

CME Expiration Date

May 3, 2019

Get Permission

Content You Might Be Interested In

Toxic Alcohol Ingestion: Prompt Recognition and Management in the Emergency Department (Critical Care Topic and Pharmacology CME)

Allergy And Anaphylaxis: Principles Of Acute Emergency Management

Best Practices In The Emergency Department Management Of Children With Special Needs

Emergency Department Evaluation And Management Of Patients With Upper Gastrointestinal Bleeding

Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.