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The utility of toxicologic analysis in children with suspected ingestions
M G Belson1, H K Simon, K Sullivan
1Department of Pediatrics, Georgia Poison Center, Emory University School of Medicine, Atlanta, USA. Marty_Belson@oz.ped.emory.edu
Insights
Toxicologic studies in children with suspected ingestions are useful, especially serum drug levels for overdose evaluations. However, urine drug screens offer limited value, with unexpected findings rarely altering management.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Toxicology
Background:
- Suspected ingestions are common in children presenting to emergency departments.
- The utility of toxicologic studies in guiding management decisions for these patients requires evaluation.
Purpose of the Study:
- To assess the usefulness of toxicologic studies in managing pediatric patients with suspected ingestions.
- To determine how drug analysis impacts clinical decision-making and patient outcomes.
Main Methods:
- A prospective, consecutive case series was conducted in two tertiary care children's hospitals.
- Pediatric emergency physicians completed questionnaires on patient demographics, symptoms, and toxicology testing performed.
- Physicians rated the utility of tests pre- and post-analysis and reported management changes.
Main Results:
- Drug analysis was performed in 72% of 220 children, most commonly for acetaminophen and cold preparations.
- Toxicology tests affected patient management in 34% of cases, with unsuspected findings influencing management in only 3%.
- Serum assays showed significant utility, while qualitative urine drug screens provided minimal useful information, rarely altering management.
Conclusions:
- Toxicologic analysis, particularly serum drug levels, is valuable in managing pediatric ingestions, especially in overdose cases.
- Qualitative urine drug screens have limited utility and infrequently lead to changes in patient management.
- Unexpected findings on toxicology screens are uncommon and rarely alter clinical decisions.
Objective:
To evaluate the usefulness of toxicologic studies on the management of children with suspected ingestions.
Design:
Prospective, consecutive case series.
Setting:
Two tertiary care children's hospital emergency departments.
Patients:
All children < or =18 years of age presenting with a suspected ingestion.
Study Design:
Pediatric emergency physicians completed a 14-point questionnaire on each identified patient that included demographics, signs, and symptoms, and if applicable, the extent of drug analysis performed. Pre-test and post-test utility values were determined by the ordering physician using an 11-point scale (0 = least valuable, 10 = most valuable). Physicians also assessed how positive or negative drug analyses affected patient management.
Results:
Two hundred twenty patients met study criteria. Median age was 5 years, with males making up 53% of patients. Drug analysis was ordered in 72% (158/220) of cases, with 59% of these tests obtained for a history of ingestion and 27% obtained for altered mental status (AMS). The most common suspected ingestions were acetaminophen and cold preparations. Seventy-eight of 158 (49%) patients had positive toxicology tests, with 17 unsuspected findings. Patient management was affected in 53/158 (34%; 95% CI, 27-41%) cases. Unsuspected findings affecting management were found in only 4/158 (3%; 95% CI, 1-6%) cases. Significant differences in pre-test and post-test utility values occurred for serum assays (mean difference +0.4, P = 0.008), patients presenting with AMS (mean difference -0.8, P = 0.005), and patients having a negative drug test (mean difference -0.5, P = 0.003). Although negative drug analysis gave the physician reassurance in 39/80 (49%; 95% CI, 38-60%) cases, patient management was altered in only 8/80 (10%; 95% CI, 5-18%) cases.
Conclusions:
Seventy-two percent of children presenting with suspected drug ingestions had toxicologic analysis performed as part of their evaluation. Analysis was most valuable to physicians when evaluation of overdoses required serum drug levels. Qualitative urine drug screens provided minimal useful information. Unexpected findings on urine drug screening leading to changes in management were uncommon.