A nationwide survey of poison control centers comparing 1999 to 1998 triage and management of asymptomatic children who ingested tricyclic antidepressant.

Triage of asymptomatic, unintentional pediatric (< 6y) tricyclic antidepressant (TCA) exposures has been based upon single cases or small studies involving large dose, symptomatic ingestions. This study evaluated patterns of triage for asymptomatic pediatric TCA exposures as practiced nationally by regional centers and compared them to 1998 patterns. It also evaluated the role of activated charcoal in the management of these exposures. Surveys were sent to the 30 certified regional Poison Control Centers that responded to our 1998 survey. Twenty-two centers responded (73%). Fourteen (63%) referred to a health care facility based upon mg/kg, compared to 6 (20%) in 1998. Of the 14, 6 referred at doses >5 mg/kg compared to 2 (6.6%) in 1998. If referred to an emergency department, 18 (82%) recommended activated charcoal compared to 1 (3.3%) in 1998. The lowest toxic dose reported in the literature is 6.7 mg/kg. This is consistent with poison control data during the past 6y where no child became toxic at doses < 5 mg/kg. This survey demonstrated significant changes in triage patterns for asymptomatic pediatric TCA exposures.

Selected tricyclic antidepressant ingestions involving children 6 years old or less.

OBJECTIVE: According to the annual report of the American Association of Poison Control Centers, tricyclic antidepressant (TCA) ingestions accounted for 15,708 exposures in 1998, of which 70% (all age groups) were treated at health care facilities (HCFs), with an estimated 2,022 children less than 6 years of age exposed. The study objective was to evaluate the manifestations, referral patterns, HCF management, and medical outcomes in pediatric patients 6 years old or less with TCA ingestions reported to a regional poison control center. METHODS: All TCA (amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline) ingestions from January 1, 1993, to December 31, 1997, involving patients aged 6 years or less managed by the poison control center were evaluated for dose, symptoms, treatments, disposition, and outcome. RESULTS: Forty-four of 48 patients (92%) were asymptomatic. All were single-drug exposures. Forty-three patients (90%) ingested a TCA dose that was less than the normally prescribed pediatric dose (5 mg/kg). Of the five children ingesting >5 mg/kg (range 5-9.4 mg/kg), only one (5.3 mg/kg) was mildly symptomatic (drowsy) prior to admission. Thirty-one of the 48 (65%) were sent to the emergency department (dose range 0.59-9.4 mg/kg). Fourteen of the 31 were admitted for 12-24-hour observation and none subsequently developed symptoms. Twenty-three (74%) received activated charcoal (AC). There was no difference in outcome between the children who did and did not receive AC. CONCLUSIONS: No case of significant toxicity occurred in the children who experienced unintentional TCA ingestions in this study population. None of the children in the study had toxicity at doses <5 mg/kg. Further study is necessary to develop clinical guidelines for the appropriate referral of unintentional ingestions of TCA involving children.

Evaluation of blood lead proficiency testing: comparison of open and blind paradigms.

BACKGROUND: Most proficiency testing (PT) programs operate with an open design in which clearly identified performance samples are distributed directly to participating laboratories on a shipping schedule announced in advance. In this study, we examine the effectiveness of assessing clinical laboratory performance for blood lead with an open PT by comparing its results with a double-blinded testing protocol. METHODS: Aliquots from up to 72 blood lead performance pools from the New York State Department of Health and the Wisconsin State Laboratory of Hygiene were disguised as routine patient specimens and submitted in two phases to up to 42 certified clinical laboratories for blood lead analysis. These 42 laboratories also received aliquots of the same performance samples for blood lead analysis directly from the "open" PT program provider. RESULTS: Data reported under blind and open strategies were scored against acceptable target ranges using the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) criteria established for blood lead, i.e., +/- 0.19 micromol/L (+/- 4 microg/dL) or +/- 10%, whichever is greater. Performance differences between the strategies were also assessed. We found that 17.7% of all blind PT results were classified as unacceptable compared with only 4.5% of open PT results (P <0.001). In phase 1, 13 of 22 laboratories (60%) exhibited a statistically significant difference (P <0.05) between their blind and open PT performances, although for 6 laboratories the poorer blind performance may not necessarily have led to unsuccessful PT participation under CLIA '88 criteria. Seven (32%) laboratories had unsuccessful aggregate performance (<80%) under blind testing while maintaining successful performance in open testing. Of these seven, two had gross discrepancies motivating further investigation. CONCLUSIONS: The data suggest that although approximately 60% of clinical laboratories make special efforts to improve analytical performance on open PT samples relative to performance achieved for routine patient specimens, in most cases the differences are clinically insignificant and would not likely affect cumulative PT performance. Occasional use of blind PT may deter the inclination to treat performance samples more carefully.

A nationwide survey of the management of unintentional-low dose tricyclic antidepressant ingestions involving asymptomatic children: implications for the development of an evidence-based clinical guideline.

BACKGROUND: The triage of unintentional tricyclic and cyclic antidepressant ingestions involving children <6 years seems based on single cases or small studies. Walsh, in describing 2 cases involving 15-20 mg/kg ingestions, recommended hospitalizing all children ingesting tricyclic and cyclic antidepressants. OBJECTIVE: To evaluate the patterns of triage for pediatric tricyclic and cyclic antidepressants practiced by regional poison control centers nationwide, and to determine the amount ingested (mg/kg) that resulted in referral to the emergency department, including the recommended duration of observation time for asymptomatic children. Second, to analyze the cost implications, as well as the need for a practice guideline based on severity stratification. METHODS: We sent a survey to 44 major regional poison control centers. We reviewed Health Care Financing Administration's tricyclic and cyclic antidepressants management related costs. RESULTS: Thirty centers responded (68%). Eighty-seven percent of all centers send children, regardless of dose ingested, to the emergency department. Four out of the 30 recommended observation based on dose in mg/ kg ingested (range >1.5-5). Recommended observation times in the emergency department varied between 6-24 hours. Twenty-seven (90%) Poison Control Centers recommended 6 hours (although one recommended doing so only after administering activated charcoal). One recommended 6-12 hours of observation and 2 Poison Control Centers recommended 24-hour observation. Only 1 center recommended obtaining tricyclic and cyclic antidepressant plasma levels. DISCUSSION: In our review of the literature, the lowest toxic dose reported was 6.7 mg/kg. This is consistent with our Poison Control Center data over the past 5 years where no child was toxic at doses <5 mg/kg. While only 13% of the centers surveyed utilize a stratification strategy to triage pediatric tricyclic and cyclic antidepressant ingestions, the current referral patterns support evaluation based on pharmacokinetics, not worst case incidents. CONCLUSION: This survey demonstrates that most children with tricyclic and cyclic antidepressant ingestions will be sent to the emergency department, regardless of the amount ingested. A prospective study is needed to determine the probable dose of tricyclic and cyclic antidepressant ingestions that requires observation at a health care facility.

Hydrogen peroxide 3% exposures.

OBJECTIVE: To present a child who developed gastric ulcers and duodenal erosions after ingestion of hydrogen peroxide 3% and delineate the epidemiology, medical outcomes, and toxicity of exposures to this agent managed by a poison control center. METHODS: A retrospective chart review of exposures to hydrogen peroxide 3% reported to the Long Island Regional Poison Control Center from January 1992 to April 1995 was conducted. Data extracted included age, route of exposure, amount of agent, symptoms, therapy, and medical outcome. RESULTS: There were 670 exposures to hydrogen peroxide 3% of 81,126 total exposures reported during the 40 months. Most exposures were by oral route (77%), occurred in children < 17 years old (67%), and were asymptomatic (85.6%). All but one exposure resulted in a benign outcome. One child, who presented with bloody emesis, developed multiple gastric ulcers and duodenal erosions after ingestion of hydrogen peroxide 2-4 oz. CONCLUSIONS: Exposure to hydrogen peroxide 3% is usually benign, however, severe gastric injury may occur following small ingestions in children. Patients who report persistent vomiting or bloody emesis require medical evaluation and consideration of endoscopy to evaluate gastrointestinal injury.

Severe lead poisoning from an imported clothing accessory: "watch" out for lead.

CASE REPORT: A case of severe lead poisoning following ingestion of an imported clothing accessory is reported. The child presented with abdominal pain, vomiting, and anemia but did not develop encephalopathy. RESULTS: Prompt removal of the object in conjunction with whole bowel irrigation and chelation therapy led to a favorable outcome.

The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction.

STUDY OBJECTIVE: It is often taught that acetaminophen-induced liver dysfunction occurs only after a latent period of 24 to 48 hours. This study was designed to evaluate the temporal profile of transaminase levels in patients with acetaminophen-induced hepatotoxicity. DESIGN: Prospective data collection using standard poison control center data sheets. PARTICIPANTS: Hospitalized patients with acetaminophen exposure who were reported to the Long Island Poison Control Center between January 1993 and June 1994. Patients who presented within 24 hours of ingestion and in whom increased aspartate aminotransferase (AST) levels developed during hospitalization were included in the data analysis. Patients who presented more than 24 hours after ingestion, who had ingested another potentially hepatotoxic agent, or who had ingested acetaminophen over a period of more than 2 hours were excluded. RESULTS: Of 1,825 patients with reported acetaminophen exposure, 779 had potentially toxic ingestions and were examined in an emergency department. Of 291 patients with toxic acetaminophen levels who were admitted, 36 (12%) had increased levels of AST at some point during hospitalization. All received oral N-acetylcysteine within 2.5 hours of presentation. In 11 of 19 patients who met all inclusion criteria (58%), AST levels were noted to be increased in the 24 hours after ingestion. The median peak AST level was 422 IU/L (range, 74 to 8,538 IU/L). AST levels peaked within 48 hours in 4 patients (21%) and within 72 hours in 18 patients (95%). Six of eight patients with peak AST levels greater than 1,000 IU/L had increased transaminase levels during the 24 hours after acetaminophen ingestion. CONCLUSION: Acetaminophen poisoning may cause the serum transaminase level to increase during the 24 hours after ingestion.

Alcohol intoxication in young children.

This article presents two cases of severe ethyl alcohol intoxication in pediatric patients, with one of these cases resulting in the death of a child. A review of the current literature is provided along with a comparison of our regional poison control centers and the national intoxication statistics regarding pediatric alcohol ingestion. Medical evaluation is recommended for all symptomatic children; hourly observations x 6 h are recommended for asymptomatic children.

Mercuric chloride poisoning due to ingestion of a stool fixative.

We present a case of ingestion of a commonly used stool fixative containing 675 mg of mercuric chloride per 15 mL vial. Early chelator therapy with dimercaprol and aggressive hydration were initiated and the patient remained asymptomatic. Safety packaging of this product is recommended.