General Measures in the Emergency Department for Pediatric Patients Poisoned
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Jan 24, 2012
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Abstract
Introduction: Exposure to toxic substances is common in pediatrics. In Colombia in between the 2006 and 2008 there were 40 061 cases of poisoning, of which 19 723 were in younger than 14 years old. In 2009 there were a total of 187 deaths which corresponds to a mortality rate of 0.6 cases per 100000 inhabitants, and a fatality rate of 9.48 per 100 000 cases of poisoned patients.
Objective: Evaluate in the literature the role of general measures for treatment in pediatric patients intoxicated and determine which are the measures that have proven safe and effective.
Method: Selection articles (in English and Spanish, from Medline, PubMed, Academic Search Complete, Science Direct, and SciELO) and data extraction (focused on the implementation of general measures in the management of poisoned patients in the emergency department).
Conclusions: Knowledge of the mechanism of action of different techniques to decrease absorption or enhance elimination of toxic substances, the indications and contraindications for use are important to provide adequate and effective treatment in the emergency department.
Keywords
acute poisoning, emergencies, toxicology, pediatrics, overdose, toxicología, envenenamiento, sobredosis, urgencias, pediatría,
References
1. Watson WA, Litovitz TL, Rodgers GC, Jr., Klein-Schwartz W, Reid N, Youniss J et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2005 Sep;23(5):589-666.
2. Abella JJ, Salgado M, Sánchez F, Sáenz MA, Urrego J. Informe intoxicaciones por sustancias químicas: periodo epidemiológico XIII. Actualización de casos a abril de 2010. Bogotá: Sivigila-Instituto Nacional de Salud; 2010.
3. Albertson TE, Dawson A, Latorre F de, Hoffman RS, Hollander JE, Jaeger A et al. TO X-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med. 2001 Apr;37(4 Suppl):S78-90.
4. Nogué S, Echarte JL, Puiguriguer J, Miró Ó. Acerca de la epidemiología de las intoxicaciones. Rev Clín Esp. 2009;209(10):525.
5. Mintegui Raso S, Benito Fernández J, Vázquez Ronco MA, Fernández Landaluce A, Gortazar Arias P, Grau Bolado G. Emergency department visits for poisoning: epidemiological changes in the last 10 years. An Esp Pediatr. 2002 Jan;56(1):23-9.
6. Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am. 2007 May;25(2):249-81.
7. Hanhan UA. The poisoned child in the pediatric intensive care unit. Pediatr Clin North Am. 2008 Jun;55(3):669-86.
8. Eldridge DL, Van Eyk J, Kornegay C. Pediatric toxicology. Emerg Med Clin North Am. 2007 May;25(2):283-308.
9. Callaham M, Schumaker H, Pentel P. Phenytoin prophylaxis of cardiotoxicity in experimental amitriptyline poisoning. J Pharmacol Exp Ther. 1988 Apr;245(1):216-20.
10. Hanhan UA, Fiallos MR, Orlowski JP. Status epilepticus. Pediatr Clin North Am. 2001 Jun;48(3):683-94.
11. Doyon S. Anticonvulsants. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Goldfrank’s toxicologic emergencies. New York: McGraw-Hill; 2006. p. 732-45.
12. Bond GR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Ann Emerg Med. 2002;39:273-86.
13. Amigo M, Nogue S, Sanjurjo E, Faro J, Ferro I, Miro O. Efficacy and safety of gut decontamination in patients with acute therapeutic drug overdose. Med Clin (Barc). 2004 Apr 10;122(13):487-92.
14. Ardagh M, Flood D, Tait C. Limiting the use of gastrointestinal decontamination does not worsen the outcome from deliberate self-poisoning. N Z Med J. 2001 Sep 28;114(1140):423-5.
15. Wolsey BA, McKinney PE. Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose? Ann Emerg Med. 2000 Jun;35(6):579-84.
16. Heyerdahl F, Hovda KE, Bjornaas MA, Nore AK, Figueiredo JC, Ekeberg O et al. Pre-hospital treatment of acute poisonings in Oslo. BMC Emerg Med. 2008 Nov 24;8:15.
17. Wax PM, Cobaugh DJ. Prehospital gastrointestinal decontamination of toxic ingestions: a missed opportunity. Am J Emerg Med. 1998 Mar;16(2):114-6.
18. Vale JA, Kulig K, American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position paper: gastric lavage. J Toxicol Clin Toxicol. 2004;42(7):933-43.
19. Barry JD. Diagnosis and management of the poisoned child. Pediatr Ann. 2005 Dec;34(12):937-46.
20. Tucker JR. Indications for, techniques of, complications of, and efficacy of gastric lavage in the treatment of the poisoned child. Curr Opin Pediatr. 2000 Apr;12(2):163-5.
21. Christophersen AB. Techniques used to prevent gastrointestinal absorption of toxic compounds. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Gold-frank’s toxicologic emergencies. New York: McGraw-Hill; 2006;109-23.
22. Gómez HF, McClafferty HH, Flory D, Brent J, Dart RC. Prevention of gastrointestinal iron absorption by chelation from an orally administered premixed deferoxamine/charcoal slurry. Ann Emerg Med. 1997 Nov;30(5):587-92.
23. Amigó M et al. Carbón activado en 575 casos de intoxicaciones agudas: seguridad y factores asociados a las reacciones adversas. Med Clin (Barc). 2010;135(6):243-9.
24. Christophersen AB, Levin D, Hoegberg LC, Angelo HR, Kampmann JP. Activated charcoal alone or after gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol. 2002 Mar;53(3):312-7.
25. Olson KR. Activated charcoal for acute poisoning: one toxicologist’s journey. J Med Toxicol. 2010 Jun;6(2):190-8.
26. Herranz M, Clerigue N. Poisoning in children: methaemoglobinaemia. An Sist Sanit Navar. 2003;26 Suppl 1:209-23.
27. Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust. 1995 Oct 2;163(7):345-9.
28. Scharman EJ. Use of ondansetron and other antiemetics in the management of toxic acetaminophen ingestions. J Toxicol Clin Toxicol. 1998;36(1-2):19-25.
29. Sabga E, Dick A, Lertzman M, Tenenbein M. Direct administration of charcoal into the lung and pleural cavity. Ann Emerg Med. 1997 Nov;30(5):695-7.
30. Mariani PJ, Pook N. Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage. Ann Emerg Med. 1993 Mar;22(3):606-9.
31. Position paper: whole bowel irrigation. J Toxicol Clin Toxicol. 2004;42(6):843-54.
32. Chyka PA, Seger D. Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):721-41.
33. Bradberry SM, Vale JA. Multiple-dose activated charcoal: a review of relevant clinical studies. J Toxicol Clin Toxicol. 1995;33(5):407-16.
34. Buckley NA, Karalliedde L, Dawson A, Senanayake N, Eddleston M. Where is the evidence for treatments used in pesticide poisoning? Is clinical toxicology fiddling while the developing world burns? J Toxicol Clin Toxicol. 2004;42(1):113-6.
35. Mohamed F, Sooriyarachchi MR, Senarathna L, Azhar S, Sheriff MH, Buckley NA et al. Compliance for single and multiple dose regimens of superactivated charcoal: a prospective study of patients in a clinical trial. Clin Toxicol (Phila). 2007;45(2):132-5.
36. Ansari R, Khah A. Activated charcoal: preparation, characterization and applications: a review article. Int J Chem Tech Res. 2009;1(4):859-64.
37. 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):731-51.
38. Brahmi N, Kouraichi N, Thabet H, Amamou
M. Influence of activated charcoal on the pharmacokinetics and the clinical features of carbamazepine poisoning. Am
J Emerg Med. 2006 Jul;24(4):440-3.
39. June R, Aks SE, Keys N, Wahl M. Medical outcome of cocaine bodystuffers. J Emerg Med. 2000 Feb;18(2):221-4.
40. Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal techniques for the poisoned patient: a review for the intensivist. J Intensive Care Med. 2010 May-Jun;25(3):139-48.
41. Goldfarb DS. Principles and techniques applied to enhance the elimination of toxic compounds. En: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Goldfrank’s toxicologic emergencies. New York: McGraw-Hill. 2006;160-81.
42. Davies JG, Kingswood JC, Sharpstone P, Street MK. Drug removal in continuous haemofiltration and haemodialysis. Br J Hosp Med. 1995 Nov 15-Dec 12;54(10):524-8.
43. Proudfoot AT , Krenzelok EP, Vale JA. Position Paper on urine alkalinization. J Toxicol Clin Toxicol. 2004;42(1):1-26.
44. Vree TB, Van Ewijk-Beneken Kolmer EW, Verwey-Van Wissen CP, Hekster YA. Effect of urinary pH on the pharmacokinetics of salicylic acid, with its glycine and glucuronide conjugates in human. Int J Clin Pharmacol Ther. 1994 Oct;32(10):550-8.
45. Patel R, Connor G. A review of thirty cases of rhabdomyolysis-associated acute renal failure among phencyclidine users. J Toxicol Clin Toxicol. 1985-1986;23(7-8):547-56.
46. Van Bommel EF, Kalmeijer MD, Ponssen HH. Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration. Am J Nephrol. 2000 Sep-Oct;20(5):408-11.
47. Fertel BS, Nelson LS, Goldfarb DS. The underutilization of hemodialysis in patients with salicylate poisoning. Kidney Int. 2009 Jun;75(12):1349-53.
48. Pilapil M, Petersen J. Efficacy of hemodialysis and charcoal hemoperfusion in carbamazepine overdose. Clin Toxicol (Phila). 2008 Apr;46(4):342-3.
49. Barrueto F, Meggs WJ, Barchman MJ. Clearance of metformin by hemofiltration in overdose. J Toxicol Clin Toxicol. 2002;40(2):177-80.
50. O’Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46.
2. Abella JJ, Salgado M, Sánchez F, Sáenz MA, Urrego J. Informe intoxicaciones por sustancias químicas: periodo epidemiológico XIII. Actualización de casos a abril de 2010. Bogotá: Sivigila-Instituto Nacional de Salud; 2010.
3. Albertson TE, Dawson A, Latorre F de, Hoffman RS, Hollander JE, Jaeger A et al. TO X-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med. 2001 Apr;37(4 Suppl):S78-90.
4. Nogué S, Echarte JL, Puiguriguer J, Miró Ó. Acerca de la epidemiología de las intoxicaciones. Rev Clín Esp. 2009;209(10):525.
5. Mintegui Raso S, Benito Fernández J, Vázquez Ronco MA, Fernández Landaluce A, Gortazar Arias P, Grau Bolado G. Emergency department visits for poisoning: epidemiological changes in the last 10 years. An Esp Pediatr. 2002 Jan;56(1):23-9.
6. Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am. 2007 May;25(2):249-81.
7. Hanhan UA. The poisoned child in the pediatric intensive care unit. Pediatr Clin North Am. 2008 Jun;55(3):669-86.
8. Eldridge DL, Van Eyk J, Kornegay C. Pediatric toxicology. Emerg Med Clin North Am. 2007 May;25(2):283-308.
9. Callaham M, Schumaker H, Pentel P. Phenytoin prophylaxis of cardiotoxicity in experimental amitriptyline poisoning. J Pharmacol Exp Ther. 1988 Apr;245(1):216-20.
10. Hanhan UA, Fiallos MR, Orlowski JP. Status epilepticus. Pediatr Clin North Am. 2001 Jun;48(3):683-94.
11. Doyon S. Anticonvulsants. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Goldfrank’s toxicologic emergencies. New York: McGraw-Hill; 2006. p. 732-45.
12. Bond GR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Ann Emerg Med. 2002;39:273-86.
13. Amigo M, Nogue S, Sanjurjo E, Faro J, Ferro I, Miro O. Efficacy and safety of gut decontamination in patients with acute therapeutic drug overdose. Med Clin (Barc). 2004 Apr 10;122(13):487-92.
14. Ardagh M, Flood D, Tait C. Limiting the use of gastrointestinal decontamination does not worsen the outcome from deliberate self-poisoning. N Z Med J. 2001 Sep 28;114(1140):423-5.
15. Wolsey BA, McKinney PE. Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose? Ann Emerg Med. 2000 Jun;35(6):579-84.
16. Heyerdahl F, Hovda KE, Bjornaas MA, Nore AK, Figueiredo JC, Ekeberg O et al. Pre-hospital treatment of acute poisonings in Oslo. BMC Emerg Med. 2008 Nov 24;8:15.
17. Wax PM, Cobaugh DJ. Prehospital gastrointestinal decontamination of toxic ingestions: a missed opportunity. Am J Emerg Med. 1998 Mar;16(2):114-6.
18. Vale JA, Kulig K, American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. Position paper: gastric lavage. J Toxicol Clin Toxicol. 2004;42(7):933-43.
19. Barry JD. Diagnosis and management of the poisoned child. Pediatr Ann. 2005 Dec;34(12):937-46.
20. Tucker JR. Indications for, techniques of, complications of, and efficacy of gastric lavage in the treatment of the poisoned child. Curr Opin Pediatr. 2000 Apr;12(2):163-5.
21. Christophersen AB. Techniques used to prevent gastrointestinal absorption of toxic compounds. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Gold-frank’s toxicologic emergencies. New York: McGraw-Hill; 2006;109-23.
22. Gómez HF, McClafferty HH, Flory D, Brent J, Dart RC. Prevention of gastrointestinal iron absorption by chelation from an orally administered premixed deferoxamine/charcoal slurry. Ann Emerg Med. 1997 Nov;30(5):587-92.
23. Amigó M et al. Carbón activado en 575 casos de intoxicaciones agudas: seguridad y factores asociados a las reacciones adversas. Med Clin (Barc). 2010;135(6):243-9.
24. Christophersen AB, Levin D, Hoegberg LC, Angelo HR, Kampmann JP. Activated charcoal alone or after gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol. 2002 Mar;53(3):312-7.
25. Olson KR. Activated charcoal for acute poisoning: one toxicologist’s journey. J Med Toxicol. 2010 Jun;6(2):190-8.
26. Herranz M, Clerigue N. Poisoning in children: methaemoglobinaemia. An Sist Sanit Navar. 2003;26 Suppl 1:209-23.
27. Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomised controlled trial. Med J Aust. 1995 Oct 2;163(7):345-9.
28. Scharman EJ. Use of ondansetron and other antiemetics in the management of toxic acetaminophen ingestions. J Toxicol Clin Toxicol. 1998;36(1-2):19-25.
29. Sabga E, Dick A, Lertzman M, Tenenbein M. Direct administration of charcoal into the lung and pleural cavity. Ann Emerg Med. 1997 Nov;30(5):695-7.
30. Mariani PJ, Pook N. Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage. Ann Emerg Med. 1993 Mar;22(3):606-9.
31. Position paper: whole bowel irrigation. J Toxicol Clin Toxicol. 2004;42(6):843-54.
32. Chyka PA, Seger D. Position statement: single-dose activated charcoal. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35(7):721-41.
33. Bradberry SM, Vale JA. Multiple-dose activated charcoal: a review of relevant clinical studies. J Toxicol Clin Toxicol. 1995;33(5):407-16.
34. Buckley NA, Karalliedde L, Dawson A, Senanayake N, Eddleston M. Where is the evidence for treatments used in pesticide poisoning? Is clinical toxicology fiddling while the developing world burns? J Toxicol Clin Toxicol. 2004;42(1):113-6.
35. Mohamed F, Sooriyarachchi MR, Senarathna L, Azhar S, Sheriff MH, Buckley NA et al. Compliance for single and multiple dose regimens of superactivated charcoal: a prospective study of patients in a clinical trial. Clin Toxicol (Phila). 2007;45(2):132-5.
36. Ansari R, Khah A. Activated charcoal: preparation, characterization and applications: a review article. Int J Chem Tech Res. 2009;1(4):859-64.
37. 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):731-51.
38. Brahmi N, Kouraichi N, Thabet H, Amamou
M. Influence of activated charcoal on the pharmacokinetics and the clinical features of carbamazepine poisoning. Am
J Emerg Med. 2006 Jul;24(4):440-3.
39. June R, Aks SE, Keys N, Wahl M. Medical outcome of cocaine bodystuffers. J Emerg Med. 2000 Feb;18(2):221-4.
40. Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal techniques for the poisoned patient: a review for the intensivist. J Intensive Care Med. 2010 May-Jun;25(3):139-48.
41. Goldfarb DS. Principles and techniques applied to enhance the elimination of toxic compounds. En: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, editores. Goldfrank’s toxicologic emergencies. New York: McGraw-Hill. 2006;160-81.
42. Davies JG, Kingswood JC, Sharpstone P, Street MK. Drug removal in continuous haemofiltration and haemodialysis. Br J Hosp Med. 1995 Nov 15-Dec 12;54(10):524-8.
43. Proudfoot AT , Krenzelok EP, Vale JA. Position Paper on urine alkalinization. J Toxicol Clin Toxicol. 2004;42(1):1-26.
44. Vree TB, Van Ewijk-Beneken Kolmer EW, Verwey-Van Wissen CP, Hekster YA. Effect of urinary pH on the pharmacokinetics of salicylic acid, with its glycine and glucuronide conjugates in human. Int J Clin Pharmacol Ther. 1994 Oct;32(10):550-8.
45. Patel R, Connor G. A review of thirty cases of rhabdomyolysis-associated acute renal failure among phencyclidine users. J Toxicol Clin Toxicol. 1985-1986;23(7-8):547-56.
46. Van Bommel EF, Kalmeijer MD, Ponssen HH. Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration. Am J Nephrol. 2000 Sep-Oct;20(5):408-11.
47. Fertel BS, Nelson LS, Goldfarb DS. The underutilization of hemodialysis in patients with salicylate poisoning. Kidney Int. 2009 Jun;75(12):1349-53.
48. Pilapil M, Petersen J. Efficacy of hemodialysis and charcoal hemoperfusion in carbamazepine overdose. Clin Toxicol (Phila). 2008 Apr;46(4):342-3.
49. Barrueto F, Meggs WJ, Barchman MJ. Clearance of metformin by hemofiltration in overdose. J Toxicol Clin Toxicol. 2002;40(2):177-80.
50. O’Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46.
How to Cite
Ávila Álvarez, A. A., & Moreno Carrillo, A. (2012). General Measures in the Emergency Department for Pediatric Patients Poisoned. Universitas Medica, 53(2), 154–165. https://doi.org/10.11144/Javeriana.umed53-2.mgsu
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