Pediatric Annals

from the guest editor 

THIS ISSUE: Managing Emergencies Part 2

Mark E Ralston, MD, MPH

Abstract

In 2003, approximately twothirds of the 2,395,582 calls to the American Association of Poison Control Centers (AAPCC) involved pediatrie toxicologie exposures.1 Pediatrie poisonings are indeed common, and it is safe to say that poison control centers are probably underused in their service to the general public and medical professionals in the management of toxicologie exposures in children and adolescents.2 Now the 62 AAPCC-certified poison control centers in the United States share the same 24-hour phone number, 1800-222-1222, for routing of calls to the appropriate regional center based on the caller's area code and exchange.3 Sixty percent of exposures involve children younger than 6.3 The vast majority of these can be handled safely at home,3 making the current services of US poison control centers cost-effective.

The value of the regional poison control center recently was recognized by the Institute of Medicine (IOM) Committee on Poison Prevention and Control in its 2004 report2'4 However, the current system needs updating, to include the sharing of data and resources among centers and with federal and state agencies and the nation's public health system.2

While most pediatrie poisonings are inconsequential, the primary care practitioner occasionally is confronted with a child or adolescent who is critically ill from poisoning or overdose. In 2003, the AAPCC Toxic Exposure Surveillance System (TESS) database recorded 106 deaths in patients 19 and younger.1 For the majority of exposures physicians encounter, diagnosis is uncomplicated, and management has been streamlined. However, in many cases diagnosis and management decisions are not simple, related to many factors, including a wide variety of new drugs and diagnostic tests.

Treatment recommendations are undergoing rapid and dramatic changes. Considerable data are needed to drive appropriate treatment decisions. The articles in this issue are presented to shed light on the data that have driven management recommendations for a number of complex toxicologie emergencies in children and adolescents.

INTHISISSUE

In his article "Diagnosis and Management of the Poisoned Child," Dr. Barry introduces the concept of "toxic triage," which is the process of sorting poisoned patients according to risk based on history, physical examination, and directed laboratory studies. Ultimately, the goal of toxic triage is to focus on the uncommon significant exposure to institute effective intervention rapidly while avoiding unnecessary management and treatment in the majority of children who have insignificant exposures. Dr. Barry gives helpful advice regarding priorities for laboratory testing in the setting of an acute toxicologie exposure, distinguishing between the "safety net" of tests that are obtained universally and the "probing set" that may be indicated to investigate specific toxins. Dr. Barry also critically evaluates the paucity of data to support many methods of gastric decontamination, not the least of which is syrup of ipecac. He concludes with a discussion of antidotes and the critical roles of supportive care and poison prevention.

Drs. Bebarta, Kostic, and Gonzalez, in their article, "Managing Adverse Reactions to Psychotropic Medications," discuss a topic relevant to pediatrie practitioners and emergency physicians who increasingly manage the side effects of psychotropic medications prescribed to children and adolescents. Among the topics in the review, the authors mention two recent controversies, one surrounding the association between suicide risk and serotonin selective reuptake inhibitor use for treatment of depression, the other pertaining to the association between use of an extended-release mixed amphetamine salts medication and sudden death in patients diagnosed with attentiondeficit/hyperactivity disorder.

In "Adolescent Substance Abuse: A SimplifiedApproachTo Drug Testing," Drs. Ahrendt and Miller discuss recent trends in drug use among adolescents and the risk factors underlying substance abuse in this populatioa The authors offer a rational strategy for the use of laboratory drug tests in…

In 2003, approximately twothirds of the 2,395,582 calls to the American Association of Poison Control Centers (AAPCC) involved pediatrie toxicologie exposures.1 Pediatrie poisonings are indeed common, and it is safe to say that poison control centers are probably underused in their service to the general public and medical professionals in the management of toxicologie exposures in children and adolescents.2 Now the 62 AAPCC-certified poison control centers in the United States share the same 24-hour phone number, 1800-222-1222, for routing of calls to the appropriate regional center based on the caller's area code and exchange.3 Sixty percent of exposures involve children younger than 6.3 The vast majority of these can be handled safely at home,3 making the current services of US poison control centers cost-effective.

The value of the regional poison control center recently was recognized by the Institute of Medicine (IOM) Committee on Poison Prevention and Control in its 2004 report2'4 However, the current system needs updating, to include the sharing of data and resources among centers and with federal and state agencies and the nation's public health system.2

While most pediatrie poisonings are inconsequential, the primary care practitioner occasionally is confronted with a child or adolescent who is critically ill from poisoning or overdose. In 2003, the AAPCC Toxic Exposure Surveillance System (TESS) database recorded 106 deaths in patients 19 and younger.1 For the majority of exposures physicians encounter, diagnosis is uncomplicated, and management has been streamlined. However, in many cases diagnosis and management decisions are not simple, related to many factors, including a wide variety of new drugs and diagnostic tests.

Treatment recommendations are undergoing rapid and dramatic changes. Considerable data are needed to drive appropriate treatment decisions. The articles in this issue are presented to shed light on the data that have driven management recommendations for a number of complex toxicologie emergencies in children and adolescents.

INTHISISSUE

In his article "Diagnosis and Management of the Poisoned Child," Dr. Barry introduces the concept of "toxic triage," which is the process of sorting poisoned patients according to risk based on history, physical examination, and directed laboratory studies. Ultimately, the goal of toxic triage is to focus on the uncommon significant exposure to institute effective intervention rapidly while avoiding unnecessary management and treatment in the majority of children who have insignificant exposures. Dr. Barry gives helpful advice regarding priorities for laboratory testing in the setting of an acute toxicologie exposure, distinguishing between the "safety net" of tests that are obtained universally and the "probing set" that may be indicated to investigate specific toxins. Dr. Barry also critically evaluates the paucity of data to support many methods of gastric decontamination, not the least of which is syrup of ipecac. He concludes with a discussion of antidotes and the critical roles of supportive care and poison prevention.

Drs. Bebarta, Kostic, and Gonzalez, in their article, "Managing Adverse Reactions to Psychotropic Medications," discuss a topic relevant to pediatrie practitioners and emergency physicians who increasingly manage the side effects of psychotropic medications prescribed to children and adolescents. Among the topics in the review, the authors mention two recent controversies, one surrounding the association between suicide risk and serotonin selective reuptake inhibitor use for treatment of depression, the other pertaining to the association between use of an extended-release mixed amphetamine salts medication and sudden death in patients diagnosed with attentiondeficit/hyperactivity disorder.

In "Adolescent Substance Abuse: A SimplifiedApproachTo Drug Testing," Drs. Ahrendt and Miller discuss recent trends in drug use among adolescents and the risk factors underlying substance abuse in this populatioa The authors offer a rational strategy for the use of laboratory drug tests in the emergency evaluation of substance abuse in adolescents.

In his article "One PiU Can Kill: Assessing the Potential for Fatal Poisonings in Children" Dr. Matteucci discusses the clinical presentation and management of five kinds of ingestions that are potentially fatal to small children even in small doses: antimalarials, camphor, clonidine, methyl salicylates, and sulfonylureas. The pharmacology, clinical presentation, and treatment of methemoglobinemia, rattlesnake envenomation, and acetaminophen overdose in children are discussed by Drs. Carstairs and Tañen in their article, "Case Studies in Pediatrie Toxicology."

In the concluding article, "Understanding Poison Control and Protecting its Future," Drs. Kostic, Rose, and Bebarta present the story of US poison control centers, past and prèsent, as well as a glimpse into the future of these centers in light of the recent recommendations for updating and improved funding by the IOM Committee on Poison Prevention and Control. Community service, healthcare professional service, and health care expenditure reduction are identified as the primary roles of a poison control center.

SUMMARY

Pediatrie toxicologie exposures are common, and the primary care pediatrie practitioner must be prepared to handle emergencies related to poisoning and overdose in children and adolescents. Fortunately, many poisonings in children are unintentional, preventable, and benign. For both simple and complex cases, help is available to medical professionals 24/7 from multiple sources, including an improved toxic exposure database, new research, the network of Certified Specialists in Poison Information at our nation's regional poison control centers, and backup medical and clinical lexicologists.

The US system of AAPCC-certified poison control centers has been appropriately labeled "a national safety net" serving the public and medical practitioners in the management of pediatrie toxicologie exposures.2 Increased funding to this system will be critical to update its services for the future, including preparation to detect the increasing threat of new public health emergencies such as chemical and biological terrorist attacks.

REFERENCES

1. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am JEmergMed. 2004; 22(5): 335-404.

2. American Academy of Pediatrics. IOM Report: Poison control centers undervalued, underused. AAP News. August 2004:63.

3. American Association of Poison Control Centers. Poison Prevention and Education and Prevention Tips. Available at: http://www.aapcc.org. Accessed November 14, 2005.

4. Institute of Medicine. Forging a Poison Prevention and Control System. Washington, DC: National Academies Press; 2004.

10.3928/0090-4481-20051201-04

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