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The poisoned child. Evolving concepts in care
1Division of Emergency Medicine, University of Virginia, Charlottesville, USA.
Insights
Pediatric poisonings are common, but most children are not harmed. Emergency physicians should focus on identifying at-risk children and providing targeted treatment, reserving aggressive interventions for severe cases.
Area of Science:
- Pediatric Emergency Medicine
- Toxicology
- Clinical Management
Background:
- Over 1 million children in the US experience poison ingestions annually.
- Most pediatric poisonings result in minimal or no harm.
- Emergency physicians must differentiate between at-risk and low-risk pediatric ingestions.
Purpose of the Study:
- To outline the appropriate evaluation and management of pediatric poisoning cases.
- To guide emergency physicians in selecting appropriate decontamination and treatment strategies.
- To emphasize judicious use of laboratory testing and specific therapies.
Main Methods:
- Review of current practices in pediatric toxicology and emergency medicine.
- Discussion of diagnostic approaches, including toxic differential diagnosis.
- Evaluation of gastrointestinal decontamination techniques (activated charcoal, gastric emptying, whole bowel irrigation).
Main Results:
- Activated charcoal is the preferred agent for gastrointestinal decontamination when indicated and effective.
- Gastric emptying is reserved for specific scenarios (e.g., non-charcoal-binding substances, rapid presentation with CNS depression).
- Laboratory testing should be targeted, avoiding broad "drug screens" unless clinically justified.
Conclusions:
- Basic supportive care and careful patient assessment are crucial in managing pediatric poisonings.
- Specific therapies like antidotes and enhanced elimination should be used judiciously, with clear benefit outweighing risk.
- Management strategies for pediatric ingestions may differ from adult protocols.
Abstract:
More than 1 million children in the United States ingest poisons each year. The vast majority of these exposures result in no harm to the child. The task of the emergency physician is to discern which children are at risk and treat those children with appropriately aggressive therapy while minimizing intervention for the rest. In pediatric exposure cases, the toxin is usually identified. A careful toxic differential diagnosis will lead to a list of likely poisons in symptomatic patients without an identified exposure. The cornerstone of treatment remains the evaluation of the ingestion episode, careful assessment of the patient, and the application of basic supportive medical care. In the ED, when it has been determined that gastrointestinal decontamination is indicated on the basis of the substance and quantity ingested, activated charcoal is the decontamination agent of choice if the substance ingested is absorbed by activated charcoal. Gastric emptying should be restricted to those circumstances when the substance ingested is not bound to activated charcoal or the rare event when a child presents to the ED within 1 hour of ingestion with significant CNS depression. Whole bowel irrigation is a recently described technique to enhance the passage of drugs already beyond the pylorus. The indications for its use are poorly defined. Laboratory tests are generally overordered after pediatric ingestions. Appropriate use of the laboratory includes an assessment of basic serum chemistry studies in symptomatic patients, confirmation of suspected toxins, and the determination of the need for specific antidotal therapy. General "drug screens" are expensive and rarely contribute to patient care. Use of specific therapies, including antidotes and enhanced elimination techniques, should be limited to those cases when expectation that a defined benefit outweighs the risk of the procedure is reasonable. The indications for the use of these interventions in children may be different from those for adults.