Acute iron ingestion

Objective : Intoxication is one of the most common causes of admissions to emergency department in pediatric age group. Incidence of iron poisoning gradually increased because of wide spread use of iron containing drugs.Method : In this report, we present five cases of iron ingestion who were admitted to our emergency department within a year.Result : Whole bowel irrigation in addition to gastric lavage with an iron dose of over 50mg/kg as well as deferoxamine treatment for patients in whom clinical and laboratory indications are present.Conclusion : The prompt recognition and treatment of children with acute iron poisoning is the single and the most critical point for decreasing the morbidity and mortality associated with iron containing products.     

Hydrocarbon poisoning: a review

This article reviews the mechanisms of pulmonary injury associated with hydrocarbon poisoning. The evolution of clinical and radiographic changes is discussed, along with appropriate treatment. Preventing aspiration in the emergency department is the most effective therapy for these children in the first few hours after ingestion.     

Carbamate poisoning: the 'other' insecticide

A 16-month-old child who ingested rat poison, according to her parents, was noted to have signs of cholinergic poisoning. In the emergency department, the child was intubated and given atropine via the endotracheal tube until venous access was established. Phytonadione (vitamin K) and pralidoxime (2-PAM) were also administered. The child recovered after an uneventful hospital course. The toxic agent was determined to be a carbamate insecticide, for which treatment with pralidoxime is considered controversial. Treatment of cholinergic poisoning due to unknown or mixed agents and poisoning caused by known carbamate insecticides are discussed.     

Iron: not a benign therapeutic drug

PURPOSE OF REVIEW: This article reviews the pathophysiology and clinical presentation of iron poisoning. Recently proposed guidelines for triage of children with iron ingestion will be discussed as well as diagnostic and treatment modalities. Finally, the potential impact of unit-dose packaging as a primary preventative measure will be discussed. RECENT FINDINGS: Carbonyl iron has a greater safety margin than the iron salts. There have been no published reports of serious or fatal poisoning from the ingestion of carbonyl iron products. Evidence-based consensus guidelines have determined that the threshold for referral to a healthcare facility is 40 mg/kg of elemental iron in the form of adult iron formulations. Unit-dose packaging of iron preparations appeared to decrease the number of exposures to iron and deaths in the United States during the period they were instituted. SUMMARY: Iron poisoning remains primarily a clinical diagnosis, although certain laboratory and radiological testing may provide helpful evidence to guide evaluation and management. Primary prevention is the best modality for decreasing morbidity and mortality for all poisonings including iron.     

Controversies in rapid sequence intubation in children

PURPOSE OF REVIEW: Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children. RECENT FINDINGS: The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics: The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients. Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation. Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure. Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine. SUMMARY: Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.     

Acute Poisoning in Children; Data of a Pediatric Emergency Unit

Objective

Acute Poisoning in children is still an important public health problem and represents a frequent cause of admission in emergency units. The epidemiological surveillance specific for each country is necessary to determine the extent and characteristics of the problem, according to which related preventive measures can be taken.

Methods

The present retrospective study describes the epidemiology of accidental and suicidal poisonings in a pediatric population admitted to the Pediatric Emergency Department of Eskisehir Osmangazi University Hospital during the year 2009.

Findings

Two hundred eighteen children were reffered to the emergency department due to acute poisoning. 48.4% of patients were boys and 51.6% were girls. The majority of cases were due to accidental poisoning (73.3% of all patients). Drugs were the most common agent causing the poisoning (48.3%), followed by ingestion of corrosive substance (23.1%) and carbon monoxide (CO) intoxication (12.5%). Tricyclic antidepressant was the most common drug (11.7%). Methylphenidate poisoning, the second common drug. 262 patients were discharged from hospital within 48 hours.

Conclusion

Preventable accidental poisonings are still a significant cause of morbidity among children in developing countries. Drugs and corrosive agents are the most frequent agents causing poisoning.     

Acute Poisoning in Children; a Population Study in Isfahan,Iran, 2008-2010

Objective

Acute accidental poisoning in children is still an important public health problem. The epidemiological investigation specific for each country is necessary to determine the extent and characteristics of the problem. The aim of our study was to elucidate the current pattern of acute poisoning among children.

Methods

The present retrospective study describes the epidemiology of acute accidental poisoning in children (less than 10 years old) admitted to the Emergency Department of two teaching hospitals during a period of two years.

Findings

Three hundred and forty four children under 10 years old were admitted to emergency department of two teaching hospitals due to acute accidental poisoning. Drugs were the most common agents causing the poisoning (58.1%), followed by Hydrocarbons (13.1%), and opioids (9.3%). Common signs were neurological (42.6%) with lethargy being the most common (39.1%). 50.6% of cases were discharged from hospital within 6-12 hours, 91.6% of them without any complication.

Conclusion

Accidental poisonings are still a significant cause of morbidity among children in developing countries. Regarding the high prevalence of pharmaceutical drug poisoning and because lethargic was the most frequent neurological sign, comprehensive toxicology screen tests should be included as part of the routine evaluation of children presenting to an ED with an apparent life-threatening event.     

Angel trumpet lily poisoning in five adolescents: clinical findings and management

OBJECTIVE: To describe clinical features and management of Angel trumpet lily poisoning in adolescents. METHODOLOGY: Case notes of five adolescent males who presented to the emergency department of a teaching hospital were reviewed. RESULTS: All five boys ingested a mixture of coca-cola and a brew prepared by boiling the leaves and flowers of the plant. They presented to the emergency department with various degrees of agitation and confusion and specific clinical signs. All were treated with charcoal and cathartics and discharged after 36 h. CONCLUSIONS: Due to its hallucinogenic effects, abuse of Angel trumpet lily is not uncommon and should be suspected in adolescents presenting with altered mental state and hallucinations in conjunction with other anticholinergic symptoms and signs.     

Injury surveillance in an accident and emergency department: a year in the life of CHIRPP.

BACKGROUND: The design of childhood injury prevention programmes is hindered by a dearth of valid and reliable information on injury frequency, cause, and outcome. A number of local injury surveillance systems have been developed to address this issue. One example is CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program), which has been imported into the accident and emergency department at the Royal Hospital for Sick Children, Glasgow. This paper examines a year of CHIRPP data. METHODS: A CHIRPP questionnaire was completed for 7940 children presenting in 1996 to the accident and emergency department with an injury or poisoning. The first part of the questionnaire was completed by the parent or accompanying adult, the second part by the clinician. These data were computerised and analysed using SPSSPC for Windows. RESULTS: Injuries commonly occurred in the child's own home, particularly in children aged 0-4 years. These children commonly presented with bruising, ingestions, and foreign bodies. With increasing age, higher proportions of children presented with injuries occurring outside the home. These were most commonly fractures, sprains, strains, and inflammation/oedema. Seasonal variations were evident, with presentations peaking in the summer. CONCLUSIONS: There are several limitations to the current CHIRPP system in Glasgow: it is not population based, only injuries presented to the accident and emergency department are included, and injury severity is not recorded. Nevertheless, CHIRPP is a valuable source of information on patterns of childhood injury. It offers local professionals a comprehensive dataset that may be used to develop, implement, and evaluate child injury prevention activities.     

Do not get burned: preventing iatrogenic fires and burns in the emergency department

Burns are a common emergency in children but are rarely sustained in the emergency department. While iatrogenic burns in the operating room have been detailed in the medical literature, there is little or no information on iatrogenic burns in the emergency department. We present 2 cases of patients who sustained burns in the emergency department and review the most common mechanisms for this to happen. It is not always evident that certain procedures can cause unexpected burns to our patients. A survey of pediatric emergency medicine fellowship programs indicates that most programs have no training about these dangers. Recommendations are made to help prevent and control iatrogenic fires in the emergency department.     

Child abuse by intentional iron poisoning presenting as shock and persistent acidosis

A case of intentional iron poisoning presented to our hospital. The patient's persistent acidosis and the team's observation of maternal indifference indicated the diagnosis. This case should alert physicians to a potential source for intentional poisoning that is present in most homes with young infants.     

Improving Management of Severe Asthma: BiPAP and Beyond

Acute severe asthma exacerbations present unique challenges in the pediatric emergency department. While most children presenting to the emergency department respond to standard asthma therapy including inhaled β₂-agonists, ipratropium, and systemic corticosteroids, some children remain refractory to these treatments and require adjunct therapies. Here we provide a review of the most recent National Asthma Education and Prevention Program guidelines, Global Initiative for Asthma guidelines, as well as recent evidence guiding the management of severe asthma exacerbations in the pediatric emergency department.     

Unintentional ingestion of brimonidine antiglaucoma drops: a case report and review of the literature

A previously healthy, 1-year 7-month-old boy was brought to the emergency department after having unintentionally ingested topical brimonidine antiglaucoma drops. He was pale and lethargic and had brief periods of apnea and bradycardia. Activated charcoal was administered, and supportive measures were initiated, achieving complete resolution of the symptoms 4 hours after admission. Brimonidine poisoning is very rare, and a high index of suspicion is necessary to identify its signs and symptoms in the pediatric emergency department. To our knowledge, only 1 case of brimonidine poisoning after oral ingestion of this topical drug has been previously reported in the literature.     

Unit-dose packaging of iron supplements and reduction of iron poisoning in young children

BACKGROUND: Iron poisoning is a major cause of unintentional poisoning death in young children. The US Food and Drug Administration proclaimed a regulation for unit-dose packaging of iron supplements in 1997. OBJECTIVE: To determine whether the requirement for unit-dose packaging of iron supplements decreases the incidence of iron ingestion and the incidence of deaths due to iron poisoning in children younger than 6 years. METHODS: This is a preintervention-postintervention study of the US federally mandated requirement for unit-dose packaging of iron supplements. The 10 years prior to the intervention were compared with the 5 years after its promulgation. The incidences of iron ingestion and of iron poisoning deaths for children younger than 6 years were obtained from the annual reports of the American Association of Poison Control Centers (Washington, DC). RESULTS: The average number of iron ingestion calls per 1000 of all calls to poison control centers regarding children younger than 6 years decreased from 2.99 per 1000 to 1.91 per 1000 (odds ratio, 1.29 [95% confidence interval, 1.27-1.32]; P<.001). The number of deaths decreased from 29 to 1 (odds ratio, 13.56 [95% confidence interval, 1.85-99.52]; P = .03). CONCLUSIONS: These are the first data that show a decrease in the incidence of nonintentional ingestion of a specific drug by young children and a decrease in mortality from poisoning by this drug after the introduction of unit-dose packaging. There was a decrease in the incidence of iron ingestion and a dramatic decrease in the number of deaths due to iron poisoning. This validates unit-dose packaging as an effective strategy for the prevention of iron poisoning and iron poisoning deaths in young children. This highly effective intervention should be considered for other medications with a high hazard for morbidity and mortality when taken as an overdose.     

Carbamate and organophosphate poisoning in young children

OBJECTIVE: Retrospective evaluation of the clinical course of carbamate and organophosphate poisoning in young children. DESIGN: The records of 36 children intoxicated with carbamate and 16 children intoxicated with organophosphate (age range: 2 to 8 years, median: 2.8 years) were examined retrospectively. The carbamate agents were identified as methomyl or aldicarb, and the organophosphate as parathion, fenthion, malathion, and diazinon. The causes of poisoning were accidental ingestion in 46 children and inhalation in six children. CLINICAL SETTING: Pediatric Intensive Care Unit of a teaching hospital. INTERVENTIONS: Gastric lavage was performed, and activated charcoal was administered to all children who had ingested poisonous pesticides. Atropine sulphate was administered intravenously in repeated doses to all children with bradycardia, diarrhea, salivation, and miosis. Obidoxime chloride was administered to patients with organophosphate poisoning and to those in whom the ingested material was unidentified on admission. RESULTS: Predominant symptoms were related to central nervous system depression and severe hypotonia. Other clinical signs such as miosis, diarrhea, salivation, bradycardia, and fasciculation were less frequent, while tearing and diaphoresis were not observed. Pulmonary edema developed in six patients with organophosphte poisoning. Three children required mechanical ventilation for several hours. One child (organophosphate poisoning) died shortly after arrival at the emergency department. All other children recovered completely. CONCLUSION: Based on a relatively large group of young pediatric patients with carbamate and organophosphate poisoning, it is concluded that the clinical presentation differed from those described in adults. Absence of classic muscarinic effects does not exclude the possibility of cholinesterase inhibitor agents poisoning in young children with central nervous system depression.     

Infective endocarditis: experience of a paediatric emergency department

OBJECTIVES: To determine the clinical features at presentation of children with infective endocarditis to a tertiary centre and review the role of the emergency department in these cases. The subsequent course and outcomes are briefly discussed. METHODS: Retrospective audit of children with endocarditis presenting to a tertiary children's hospital over a 16-year period. RESULTS: Twenty-three cases of infective endocarditis were identified. Initial presentation via the paediatric emergency department occurred in 78% of cases and was associated with the least delay to commencement of appropriate treatment. The average duration of illness at the time of presentation was 6 days. Prior medical care had been sought in 65% of the cases, with antibiotics prescribed for an alternate diagnosis in 73%. Children with and without cardiac anomalies were equally represented. Of the group with normal cardiac anatomy, 45% presented without a murmur. Staphylococcus aureus was the most frequent causative organism (43%) and accounted for 64% of cases in children with no pre-existing cardiac abnormalities. Permanent sequelae were more likely to occur with S. aureus. The overall mortality rate was 9%. CONCLUSIONS: Infective endocarditis is a rare illness in children and represents a diagnostic challenge. The majority of cases will present via the paediatric emergency department with a non-specific febrile illness, having frequently commenced antibiotics for an alternate diagnosis. Specific expertise in paediatric emergency care can assist in early diagnosis and management. Morbidity remains significant, particularly in cases caused by S. aureus.     

High incidence of lead poisoning revealed by erythrocyte protoporphyrin (EPP) screening in Arabian children

The measurement of erythrocyte protoporphyrin (EPP) has been used in screening infants for undue exposure to lead. The infants were from a high risk area, Al Jahra in Kuwait, and were selected from those attending the emergency department of Al Jahra District Hospital. Dried spots of blood on Guthrie filter paper were mailed to the Central Laboratory of the Children's Hospital in Buffalo, New York. Elevated EPP values (greater than 50 micrograms/dl) were present in 63 (66%) out of 96 tests. Forty-four of the infants with elevated values were investigated further: 16 had blood lead levels above 30 micrograms/dl (1.45 mmol/l) and 12 had evidence of iron deficiency anaemia. Five infants with blood lead levels above 80 micrograms/dl (3.9 mmol/l) needed urgent chelation and in addition an 8-month-old infant with the highest EPP value (478 micrograms/dl) died of acute lead encephalopathy. We conclude that lead poisoning is a serious problem in Al Jahra, Kuwait, and that a comprehensive programme for screening and health education are urgently needed to avoid the irreversible effects of lead toxicity.     

Office management of acute pediatric poisonings

Over the past five years, the role of the office practitioner in diagnosis and management of acute poisoning has developed into an important first line of defense in preventing serious morbidity and mortality associated with these exposures. The prime role of the practitioner is to accurately identify and quantify a poisoning exposure, to institute appropriate initial stabilization and management, and to recognize individuals who require further treatment and transfer to hospital settings. Beyond the obvious importance of initial stabilization of severely poisoned patients, the most important step in approaching the acute overdose is to identify what was taken, how much was taken, and when it was taken. To ensure appropriate treatment, the practitioner must use all the resources possible to obtain accurate identification and quantification of these exposures. Nontoxic exposures judged by the product (see Table 5) or by the quantity ingested (see Table 4) may safely be discharged with follow-up care. With toxic exposures, all attempts must focus on terminating the exposure by gastrointestinal decontamination with oral poisonings, adequate aeration with inhalational poisonings, and copious washing with topical and/or ocular exposures. The skillful approach of the office practitioner will provide the most effective initial management of the poisoned child. Appropriate referral to an emergency department for further evaluation and treatment may then be considered.     

A panorama of medical history of acute iron poisoning (author's transl)]

The paper describes briefly the fatal course taken by some of the 720 acute cases of poisoning with iron compounds as documented in literature between 1826 and the present time. The various concomitant conditions and the genesis, as well as the fatal disease pattern, are communicated. The various pathogenetic factors and nosological variants of acute iron poisoning, as well as the epidemiology of juvenile iron poisoning, are discussed. Finally, the paper points to numerous deficiencies in the exact diagnosis of acute cases of iron poisoning.     

Sturge-Weber syndrome presenting as an acute life-threatening event

Young infants may present to an emergency department after an acute life-threatening event. The differential diagnosis for an acute life-threatening event is quite extensive. Fortunately, most will have benign or treatable causes. A case of Sturge-Weber syndrome is described in a 2-day old who presented to the emergency department after an acute life-threatening event. A thorough history and detailed physical examination are generally helpful in discerning the etiology for most acute life-threatening events and may at times reveal unusual diseases such as Sturge-Weber syndrome.