Investigating the minimalist approach to the asymptomatic child presenting the ER with suspected ingestion

1. don’t Just Do Something,
Sit There
the Child with Occult Toxic Ingestion
TOXICOLOGY TALK
JANUARY 21 2014

2. PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
EMERGENCY MANAGEMENT
(ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE)
WELL APPEARING CHILD WITH POISON EXPOSURE
PEDIATRIC PATHOPHYSIOLOGIC
CONSIDERATIONS
DEADLY IN SMALL DOSES

3. PEDIATRIC TOXICOLOGY
EPIDEMIOLOGY AND PREVENTION
EMERGENCY MANAGEMENT
(ABCS, DECONTAMINATION, TOXIDROMES
ANTIDOTAL THERAPY, LABS/EKG, SUPPORTIVE CARE)
WELL APPEARING CHILD WITH POISON EXPOSURE
PEDIATRIC PATHOPHYSIOLOGIC
CONSIDERATIONS
DEADLY IN SMALL DOSES

4. 2012
2008
2012
2011

5. VILKE 2011

6. age & Gender Distribution of Human Exposures
BRONSTEIN 2011

7. FRANKLIN 2008

8. distribution of reason for exposure by age
BRONSTEIN 2011

9. VILKE 2011

10. medical outcome of human exposure cases by patient age
97% NO EFFECT, MINOR EFFECT, NO FOLLOW UP. UNRELATED EFFECT
BRONSTEIN 2011

11. VILKE 2011

12. distribution of age and gender fatalities
BRONSTEIN 2011

13. BOND 2012

14. FRANKLIN 2008

15. BRONSTEIN 2011

16. BRONSTEIN 2011

17. BOND 2012

18. BRONSTEIN 2011

19. BRONSTEIN 2011

20. BRONSTEIN 2011

21. BRONSTEIN 2011

22. BRONSTEIN 2011

23. pediatric poisoning trends vs population change from 2001 baseline
BOND 2012

25. limited utility of screening labs and ekg in
unintentional asymptomatic pediatric ingestions
WANG GS ET AL. JOURNAL OF EMERGENCY MEDICINE. 2013
+
=

26. micro journal club
intro
methods
results
limitations
take home

27. intro
MOST INGESTIONS ARE:
!
UNINTENTIONAL
!
INVOLVE A SINGLE SUBSTANCE
!
DON’T PRODUCE SIGNIFICANT CLINICAL EFFECTS

28. intro
MORTALITY RATE IN PEDS POISONINGS IS
<.0004%
(BRONSTEIN 2010; CDC)

29. intro
INGESTIONS IN ADOLESCENTS SIMILAR TO ADULTS:
!
SIGNIFICANT DOSES
!
MULTIPLE MEDS
!
INTENTIONAL

30. intro
POINT 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

31. methods
RETROSPECTIVE 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

32. APPROXIMATELY 90 INGESTION VISITS PER YEAR
= 7.5/month
!
= 1 every other shift (15 shifts/month)

33. methods
WHAT 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

34. methods
WHAT LABS?
!
CBC
!
BMP/CMP
!
BLOOD GAS
!
SALICYLATE/ACETAMINOPHEN
!
URINE TOX

35. methods
CRITERIA FOR screening LAB/TEST
IN THIS STUDY:
!
ABNORMALITIES NOT LISTED UNDER
POTENTIAL SIDE EFFECTS IN LEXICOMP

36. methods
NORMAL 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

37. methods
DEFINITION OF “CHANGED MANAGEMENT”
RESULT REQUIRING INTERVENTION/TX
!
NON POISON CENTER SUBSPECIALTY CONSULT
!
PROLONGED ED STAY

38. results
595 KIDS <12 YO EVAL IN ED FOR UNINTENTIONAL INGESTION
!
47 BUTTON-BATTERY INGESTIONS
!
MEDIAN AGE 2.6 YEARS (56% MALE)

39. WANG 2013

40. WANG 2013

41. results
AT 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

42. WANG 2013

43. WANG 2013

44. WANG 2013

45. WANG 2013

46. WANG 2013

47. WANG 2013

48. results
OVERALL:
!
224 (38%) DISCHARGED IMMEDIATELY
+ 309 (52%) OBSERVED IN ED THEN DISCHARGED
533 (~90%) DISCHARGED FROM ED

49. 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

50. 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

51. take home
SCREENING 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

52. pediatric pathophysiologic considerations
HIGHER BODY SURFACE AREA/WEIGHT RATIO
!
DERMAL ABSORPTION INCREASED
!
AT GREATER RISK FOR DEHYDRATION AND
INSENSIBLE LOSSES

53. pediatric pathophysiologic considerations
INCREASED RR AND MINUTE VENTILATION=
HIGHER DOSE IN SHORTER TIME FOR AIRBORNE TOXINS
(CARBON MONOXIDE POISONING)

54. 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)

55. pediatric pathophysiologic considerations
RELATIVE LACK OF GLYCOGEN STORES
!
INCREASES LIKELIHOOD OF HYPOGLYCEMIA FROM
ETHANOL AND BETA BLOCKER INGESTION

56. pediatric pathophysiologic considerations
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

57. pediatric pathophysiologic considerations
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)***
* MEGARBANE 2013, BAMSHAD 1990, KIM 2012, MCCARRON 1991,
** TOBIN 2008
*** LAER 2005