PEDIATRIC EM er G E N C Y Medici N E PRACTICE AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE s EBMEDICINE.net March 2010 An Evidence-Based Review Of Volume 7, Number 3 Single Pills And Swallows That Authors David L. Eldridge, MD Assistant Professor, Department of Pediatrics, Brody School of Can Kill A Child Medicine, East Carolina University, Greenville, NC Katherine W. Mutter, MD Department of Emergency Medicine, University of Virginia School Just as you start your shift, a toddler is brought into the pediatric ED. An of Medicine, Charlottesville, VA hour earlier he had ingested a single tablet of his grandmother’s glipizide. Christopher P. Holstege, MD, FAAEM, FACEP, FACMT Director, Division of Medical Toxicology; Associate Professor, The child is asymptomatic, shows no signs of distress, and is playful. On Departments of Emergency Medicine and Pediatrics, University initial fingerstick his blood glucose is 95 mg/dL. The nursing staff reminds of Virginia School of Medicine, Charlottesville, VA you that you have a full waiting room, the hospital has no beds, and the Peer Reviewers mother is eager to leave because the boy’s older sibling will be getting home Denis R. Pauze, MD from school within the hour. Physician, Inova Fairfax Hospital, Falls Church, Virginia; Clinical Assistant Professor, The George Washington University Medical Center, Washington, DC n the ED, clinicians routinely manage children with potential Ghazala Sharieff, MD Ipoisoning. Despite the frequency of such presentations, research Division Director/Clinical Professor Rady Children’s Hospital pertaining to the management of children exposed to distinct toxins is Emergency Care Center/University of California, San Diego; Director of Pediatric Emergency Medicine, California Emergency limited. Numerous agents pose significant risks, even when a child in- Physicians, San Diego, CA 1-3 gests small amounts, such as a single pill or swallow. (Table 1, page CME Objectives 2). Since it is beyond the scope of this article to address all of these Upon completing this article, you should be able to: agents individually, we will review a select number of common toxins 1. Identify specific drugs and chemicals that can be deadly to a child with a single swallow. and discuss their respective treatments. 2. Discuss the proper management of children who ingest substances that are potentially deadly with a single swallow, including length of observation time. Critical Appraisal Of The Literature 3. Recognize the pathophysiology of specific deadly toxins commonly encountered in pediatric patients. The medical literature contains a paucity of research pertaining to 4. Identify the limitations of basic urine drug screens. Date of original release: March 1, 2010 pediatric poisonings, and the majority of studies are retrospective, Date of most recent review: February 10, 2010 with cases series and case reports being the predominant type of re- Termination date: March 1, 2013 Medium: Print and Online view. Management of the poisoned child must be based on these re- Method of participation: Print or online answer form and ports as well as data from relevant studies in adults, isolated animal evaluation Prior to beginning this activity, see “Physician CME Information” studies, and laboratory bench research. Since such scant evidence on the back page. AAP Sponsor Michael J. Gerardi, MD, FAAP, Alson S. Inaba, MD, FAAP, Attending Physician, Emergency Gary R. Strange, MD, MA, FACEP FACEP PALS-NF Medicine Specialists of Orange Professor and Head, Department Martin I. Herman, MD, FAAP, FACEP Clinical Assistant Professor of Pediatric Emergency Medicine County and Children’s Hospital of of Emergency Medicine, University Professor of Pediatrics, UT Medicine, University of Medicine Attending Physician, Kapiolani Orange County, Orange, CA of Illinois, Chicago, IL College of Medicine, Assistant and Dentistry of New Jersey; Medical Center for Women & Director of Emergency Services, Brent R. King, MD, FACEP, FAAP, Christopher Strother, MD Director, Pediatric Emergency Children; Associate Professor of FAAEM Assistant Professor,Director, Lebonheur Children’s Medical Medicine, Children’s Medical Pediatrics, University of Hawaii Center, Memphis, TN Professor of Emergency Medicine Undergraduate and Emergency Center, Atlantic Health System; John A. Burns School of Medicine, and Pediatrics; Chairman, Simulation, Mount Sinai School of Editorial Board Department of Emergency Honolulu, HI; Pediatric Advanced Department of Emergency Medicine, Medicine, New York, NY Medicine, Morristown Memorial Life Support National Faculty The University of Texas Houston Jeffrey R. Avner, MD, FAAP Hospital, Morristown, NJ Representative, American Heart Adam Vella, MD, FAAP Professor of Clinical Pediatrics Medical School, Houston, TX Assistant Professor of Emergency Ran D. Goldman MD Association, Hawaii and Pacific and Chief of Pediatric Emergency , Robert Luten, MD Medicine, Pediatric EM Fellowship Island Region Medicine, Albert Einstein College Associate Professor, Department Professor, Pediatrics and Director, Mount Sinai School of Andy Jagoda, MD, FACEP of Medicine, Children’s Hospital at of Pediatrics, University of Toronto; Emergency Medicine, University of Medicine, New York, NY Montefiore, Bronx, NY Division of Pediatric Emergency Professor and Vice-Chair of Florida, Jacksonville, FL Medicine and Clinical Pharmacology Academic Affairs, Department Michael Witt, MD, MPH, FACEP, T. Kent Denmark, MD, FAAP, and Toxicology, The Hospital for Sick of Emergency Medicine, Mount Ghazala Q. Sharieff, MD, FAAP, FAAP FACEP Children, Toronto, ON Sinai School of Medicine; Medical FACEP Medical Director, Pediatric Medical Director, Medical Simulation Division Director and Clinical Emergency Medicine, Elliot Hospital Mark A. Hostetler, MD MPH Director, Emergency Medicine Center; Associate Professor of , Clinical Professor, Rady Children’s Manchester, NH Professor of Pediatrics and Department, Mount Sinai Hospital, Emergency Medicine and Pediatrics, New York, NY Hospital Emergency Care Center Loma Linda University Medical Emergency Medicine, University and University of California, Research Editor of Arizona Children’s Hospital Tommy Y. Kim, MD, FAAP Center and Children’s Hospital, San Diego; Director of Pediatric V. Matt Laurich, MD Loma Linda, CA Division of Emergency Medicine, Assistant Professor of Emergency Emergency Medicine, California Phoenix, AZ Medicine and Pediatrics, Loma Fellow, Pediatric Emergency Emergency Physicians, San Diego, Medicine, Mt. Sinai School of Linda Medical Center and CA Children’s Hospital, Loma Linda; Medicine, New York, NY Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Eldridge, Dr. Mutter, Dr. Holstege, Dr. Pauze, Dr. Sharieff, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive commercial support. makes it difficult for health care providers to make and their lack of awareness about what constitutes a decisions regarding potentially poisoned children, true toxic ingestion. Childhood exposures are largely the clinician must err on the side of caution when preventable if one recognizes the toxic potential of managing such cases. medications, household products, cosmetics, herbal products, and plants and keeps these agents out of Epidemiology, Etiology, And Pathophysiology the reach of children. Predicting the pathophysiology of childhood Poisonings in childhood are a common occurrence. poisoning is extremely difficult, since the toxicoki- In 2007, the American Association of Poison Control netics of an overdose cannot be predicted based on Centers reported 2,482,041 toxic exposures and 1239 the pharmacokinetics of standard doses. Drug ab- resultant fatalities.4 Mortality associated with these sorption is commonly delayed in toxic ingestions. In overdoses was less than 1%. Of these total expo- addition, the time to peak effect may be prolonged, sures, 588,262 children were managed in a health and metabolic pathways may be saturated. There- care facility and 88,417 were admitted to a critical fore, it is imperative that children be monitored for care unit (23.7% vs 3.6%). Poisonings are among the a sufficient length of time following exposure to cer- most preventable public health problems. The ma- tain agents. In addition, drugs taken inappropriately jority of exposures are accidental (83.2%) and occur may display different pharmacologic effects from in children under 6 years of age (51.2%). Children 18 those seen when the drug is administered by the to 36 months of age are at the greatest risk owing to appropriate routes and in the proper doses. For ex- excessive hand-to-mouth behavior and extensive ex- ample, when imidazoline decongestants are sprayed ploration of the surrounding environment. Contrib- into the nose, they exhibit alpha-2-agonist activity uting to this risk are poor supervision by caretakers and cause peripheral vasoconstriction; however, when ingested and absorbed systemically, these agents can cause central alpha-2-agonist activity that results in central nervous system (CNS) depression, Table 1. Examples Of Single Pills And hypotension, and bradycardia. Swallows That Can Kill A Child Differential Diagnosis Alcohols Hydrocarbons Ethylene glycol Differentiating