You are on page 1of 80

Dr

_F

American Academy of Pediatrics

aq

PREP 2014

eh

i

Item 15
A 2-year-old boy is brought to the emergency department by ambulance. Thirty minutes
ago, his mother discovered him eating pills from a pillbox at his grandparents' house and
called 911. The boy's mother states that the pillbox contained a 1-week supply of his
grandparents' daily medications. She did not count how many tablets remained in the box
before the ambulance arrived, but she states, "I think only a couple were missing:' Both
grandparents take "blood pressure medicine" and that the grandfather takes "a pill for his
nerves"
The boy is well-appearing and playful. His vital signs are normal for his age, and you
note no abnormalities on physical examination. The mother states that she now feels
"silly for panicking over nothing. ' She asks you how soon she can take her son home.
Of the following, the BEST next step in managing this patient is
A.
B.
C.
D.
E.

administration of activated charcoal at 1 g/kg
administration of intravenous normal saline at 20 mL/kg
discharge the boy after educating his mother about signs and symptoms to
observe for at home
observe the boy in the emergency department for development of symptoms
over the next 6 hours
perform gastric lavage to remove ingested pill fragments from the stomach

American academy of pediatrics

1

Dr

_F

American Academy of Pediatrics

aq

PREP 2014

eh

Item 15
S
Preferred Response: A
The child described in this vignette was seen ingesting the contents of a pillbox thought
to contain an antihypertensive agent and an antidepressant, therefore, administration of
activated charcoal is warranted to decrease absorption of these toxins. Activated charcoal
minimizes absorption of drugs by binding them onto its surface; it has become the
gastrointestinal (GI) decontamination strategy of choice in pediatric patients and is most
effective when administered within the first hour after a toxic ingestion. The dose of
activated charcoal is 1 g/kg. Activated charcoal is contraindicated in patients with an
unprotected airway, patients with a disrupted GI tract, or patients in whom charcoal
therapy may increase the risk and severity of aspiration, such as in those ingesting a
hydrocarbon. Substances that are poorly adsorbed by activated charcoal include common
electrolytes, heavy metals such as iron, alcohols, cyanide, most solvents, and most waterinsoluble compounds. For the asymptomatic boy described in the vignette, no
contraindications for activated charcoal administration exist.
Poisoning represents one of the most common medical emergencies encountered by
young children and is responsible for a significant proportion of emergency department
visits in the adolescent population. More than 2 million toxic exposures are reported to
the American Association of Poi-son Control Centers Toxic Exposure Surveillance
System each year. Two-thirds of these exposures occur in individuals younger than 20
years of age, with half occurring in children younger than 6 years. All physicians caring
for children must be familiar with the evaluation and management of poisoning. While
poisonings in young children are usually unintentional, poisonings in adolescents and
young adults generally result from substance abuse, experimental risk-taking behaviors,
and depression or suicidal intent.
Numerous factors place young children at risk for unintentional poisonings. Between 1
and 2 years of age, most children learn to walk and develop the dexterity to use a pincer
grasp; a common way that children within this age group explore their environments is by
placing objects in their mouths. Young children like to mimic actions that they have seen
their family members perform, such as using household products and taking medications.
Furthermore, a number of household products and medications are brightly colored and
may even resemble candy, making them particularly attractive to children.
Most substances that young children are exposed to within their home environments,
such as cosmetics and personal care items, are nontoxic. Even among the significant
percentage of toxic exposures involving drugs, small quantities of most agents ingested
by a child require little treatment beyond reassurance. A few medications, however, can
be lethal to small children in quantities of only 1 or 2 pills or teaspoon-sized swallows.
Pediatric practitioners need to be familiar with the drug classes from which "one pill can
kill" when ingested by a toddler. These classes include cardio-vascular drugs (eg, blockers and calcium-channel antagonists), antidepressants, antipsychotics,
anticonvulsants, antiarrhythmic agents, salicylates, oral hypoglycemics, and opioids, all
of which are widely prescribed for adults. When drugs from these classes are involved,

American academy of pediatrics

2

i

Dr

_F

American Academy of Pediatrics

aq

PREP 2014

eh

i

proper evaluation and intervention are essential for preventing severe toxic effects and
even death in small children.
The first priority in managing any child who has ingested a toxic substance is to ensure
stability of the airway and take any necessary steps to maintain adequate ventilation and
circulation. The asymptomatic child who may have ingested only a few pills or swallows
of an unknown toxin presents a clinical dilemma. A careful history, physical
examination, and laboratory findings may narrow the differential diag-nosis and facilitate
an educated assessment of the potential severity of the exposure. In situations in which a
child may have ingested a medication with potentially lethal effects, the most appropriate
course of management is to decontaminate the child if no contraindications exist and to
monitor closely for a period of time, depending on the poison that may have been
ingested.
The boy described in the vignette is asymptomatic with normal vital signs; therefore,
administration of intravenous normal saline is not warranted. Since, he may have ingested
drugs with the potential to produce significant toxic effects within a few hours, GI
decontamination and a period of observation are required before discharge. Although
observation of the child for a period of several hours is warranted in this case,
administration of activated charcoal would be the best initial step in management because
activated char-coal is most efficacious within the first hour after ingestion. The clinical
benefit of gastric lavage has not been confirmed in controlled studies, and its routine use
in the management of poisoned patients is no longer recommended.
PREP Pearls

Pediatric practitioners must recognize the drug classes from which "one pill
can kill" when ingested by a toddler.

The first priority in managing a possible toxic ingestion is to ensure stability
of the airway and maintenance of adequate ventilation and circulation.

Activated charcoal is the GI decontamination strategy of choice in pediatric
patients with possible toxic ingestions and should be given as soon as possible
provided there are no contraindications.

American academy of pediatrics

3

Dr

_F

American Academy of Pediatrics

aq

PREP 2014

eh

i

American Board of Pediatrics Content Specification(s):

Understand the management of childhood poisonings

Understand the management of poisonings by an unknown agent or by
multiple agents
Suggested Reading:
 Braitberg G, Oakley E. Small dose ... big poison. Aust Fam Physician.
2010;39:826-833
 Osterhoudt KC. The toxic toddler: drugs that can kill in small doses. Contemp
Pediatr. 2000;17:73
 Osterhoudt KC, Ewald MB, Shannon M, Henretig FM. Toxicologic emergencies.
In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1171-1223
 Velez LI, Shepherd JG, Goto CS. Approach to the child with occult toxic
exposure. UpToDate. Available online only for subscription

American academy of pediatrics

4

the boy has complained of severe throat pain. Of the following. difficulty swallowing. toilet bowl cleaner (sodium hydroxide) E. The father tells you that his son is drooling and that he can see a few white "sores" on his tongue and the roof of his mouth. burning pain in his chest. The boy was working in the family garage when he drank an unknown substance out of a plastic bottle that he mistakenly thought contained water. the MOST likely substance to cause the boy's symptoms and physical findings is A. weed killer (glycophosphate) American academy of pediatrics 5 . furniture polish (hydrocarbon) C. Since swallowing some of the substance. insecticide (organophosphate) D. and nausea. antifreeze (ethylene glycol) B.Dr _F American Academy of Pediatrics aq PREP 2014 eh i Item 33 You are taking weekend telephone calls for your practice when the father of a 12-yearold boy calls to let you know he is driving his son to the local hospital.

and batteries. acids carry a lower risk of esophageal perforation but are still capable of producing serious corrosive injury. or chest. a child's caregivers seek medical attention when symptoms indicate toxic effects from exposure to an unknown product. Many are ingredients found within common household products. and burns on the face. floor cleaners. as experienced by the adolescent in the vignette. Because of accumulation of the toxic metabolites glycolaldehyde. garden chemicals. Because the primary mode of injury from contact with these toxins is direct tissue corrosion. drooling. where toxic household products are often readily available. Significant burns to the eyes may occur with any ocular exposure. dyspnea. Acidic substances tend to cause injury via coagulation necrosis. oven cleaners. Apart from distress due to pain. the toxic ingredient in antifreeze. with nausea and vomiting as common associated symptoms. alkaline. Often. intraoral burns. hoarseness. as in the vignette. glycolic acid. The most pressing clinical concern after a caustic ingestion is the potential for airway or esophageal injury. Evaluation of the esophagus by upper endoscopy is indicated in patients who have intraoral burns. rust removers. or rust remover. laundry detergents. stain and mildew removers. a corrosive product. Ethylene glycol. rather than liquefaction necrosis. and automotive products carry the risk of significant toxic effects if ingested. furniture polishes. Many household cleaners. or oxidizing agents.Dr _F American Academy of Pediatrics aq PREP 2014 eh Item 33 S Preferred Response: D The adolescent boy described in the vignette is symptomatic after unintentional ingestion of an unknown household product that was improperly stored in an unlabeled container. other symptoms related to the ingestion. hands. Of the substances listed. Corrosives are concentrated acid. In asymptomatic patients in whom caustic ingestion is uncertain. swimming pool products. Most unintentional ingestions in pediatric patients occur in their homes. mental status is usually normal in affected children. including toilet bowl cleaners. and hemodynamic instability generally does not occur. Recognition of the typical signs and symptoms related to specific toxic exposures is critical to intervening appropriately and for providing appropriate anticipatory guidance. Early airway visualization and protection are indicated in any patient presenting with stridor or respiratory distress. can result in serious penetrating injuries to mucosal and skin surfaces by liquefaction necrosis. and oxalic acid. the need for endoscopy is controversial. phenol-based disinfectants. The Centers for Disease Control and Prevention estimate that more than a half million children are treated emergently each year for acute poisoning with corrosives. systemic symptoms are rare. is most likely responsible for his symptoms. thus. Ingestion of even small amounts of a corrosive alkaline substance. or a history strongly suggesting ingestion of a corrosive product. or ulcerations. such as toilet bowl cleaner. respiratory difficulty with stridor or wheezing. drain cleaners. Patients ingesting corrosive substances typically present with odynophagia. retrosternal chest pain. sodium hydroxide. Additional findings may include vomiting with hematemesis. Depressed mental status is the initial manifestation. dysphagia. produced by the metabolism American academy of pediatrics 6 i . presents with a clinical syndrome typical of all alcohols.

these calcium oxylate crystals may be deposited in all organs of the body.1542/pir. doi:10. cyanosis. Ludwig S. 6th ed. defecation or diarrhea.  The most pressing clinical concern after a caustic ingestion is the potential for airway or esophageal injury.Dr _F American Academy of Pediatrics aq PREP 2014 eh of ethyl-ene glycol. Toxicologic emergencies. Physical examination findings may include fever. eds. Ewald MB. or even coma. Philadelphia. Caustic esophageal injury in children. Available online only for subscription  33-3 Osterhoudt. patients typically progress to renal failure. and emesis. tachypnea. In: Fleisher GR. or ulcerations. Direct central nervous system effects of the hydrocarbon may lead to lethargy. and hemodialysis may be warranted. Pupillary constriction is a classic finding with organophosphate toxicity. UptoDate. The classic features of cholinergic toxicity can be recalled using the mnemonic SLUDGE: salivation. Seizure and coma may manifest within a few hours after a significant ingestion. Shannon M. These products are not corrosive and generally do not cause mucosal injury. Crystalluria in patients with ethylene glycol poisoning is a late finding.27-4-154  Ferry GD. Corrosive ingestions. Ingestion of hydrocarbon -based products. gastrointestinal upset. primarily causes respiratory distress due to pulmonary aspiration. such as furniture polish. Affected patients may progress to frank coma and cardiopulmonary failure. gagging. Savage RR. 2010:11711223 American academy of pediatrics 7 i . dysphagia. Among the expected vital sign abnormalities are tachypnea and bradycardia. resulting from the formation of calcium oxalate crystals by toxic metabolites. PREP Pearls  Ingestion of even small amounts of a corrosive alkaline substance can result in serious penetrating mucosal and skin injuries. seizure. Patients present with acute coughing. cough with inhalation. Textbook of Pediatric Emergency Medicine. PA: Lippincott Williams & Wilkins. lacrimation. and choking. KC. and vomiting after ingestion. American Board of Pediatrics Content Specification(s):  Know the common household sources of acids and alkali Suggested Reading:  Brunnie C. and abnormal lung sounds. Glycophosphate-containing weed killers are irritants that may cause chemical conjunctivitis.  All household chemical products should be stored in their original labeled containers and kept out of the reach of children. Approximately 24 to 72 hours after ingestion.  Patients ingesting corrosive substances typically present with odynophagia. urination. intraoral burns. drooling. 2006. Hypocalcemia is another common finding. Toxicity from insect repellants that contain organophosphate is marked by clinical signs and symptoms related to the overactivation of cholinergic receptors by excess acetylcholine. Henretig FM.27:154-155. Pediatr Rev. Fishman DS. severe metabolic acidosis ensues after ingestion. which may include crackles and wheezing.

right axis deviation. E. An electrocardiogram demonstrates a QRS duration of 110 milliseconds. the MOST likely medication ingested by the patient is A. During the first hour of being monitored in the ED. D. the boy becomes increasingly lethargic and develops mydriasis and a dry mouth. C. B. Of the following. You notice on the cardiopulmonary monitor that his heart rate is 130 beats/min and he now appears to have a prolonged QRS duration.Dr _F American Academy of Pediatrics aq PREP 2014 eh i Item 77 A 3-year-old boy is brought to the emergency department (ED) 30 minutes after ingesting one of his grandmother's medications. and prolonged PR and QT intervals. The boy's mother reports that the grandmother takes medications for depression and hypertension. amitriptyline clonidine fluoxetine labetalol nicardipine American academy of pediatrics 8 .

pinpoint pupils. is associated with less toxicity compared to TCAs. Overdoses of TCAs can produce other more serious side effects. β-blocker overdoses. Dysrhythmias seen can include ventricular tachycardia and asystole. such as nicardipine. coma. Clonidine overdoses are also of significant pediatric toxicology concern. such as that caused by labetalol. and cardiac dysrhythmias. and seizures). The anticholinergic and central nervous symptoms that are seen with TCA overdose are not seen in calcium channel poisoning. the characteristic anticholinergic symptoms and signs of TCA overdose would not be present. American academy of pediatrics 9 i . Central nervous system depression. ventricular tachycardia. A QRS duration greater than 100 milliseconds and right axis deviation appear to be the strongest predictors of cardiac toxicity. chronic pain. dizziness. and muscle rigidity may be seen. their siblings. tachycardia. hyperthermia. Sinus tachycardia is the most common rhythm but more serious cardiac complications such as bradydysrhythmias.Dr _F American Academy of Pediatrics aq PREP 2014 eh Item 77 S Preferred Response: A Tricyclic antidepressants (TCAs). respiratory depression. lethargy. such as amitriptyline and imipramine are widely used for treating depression. and seizures) as well as electrocardiographic changes. hypotension. The electrocardiographic changes seen in the patient in the vignette are not consistent with a clonidine overdose. delirium. and attention-deficit disorders. cause myocardial depression and cardiac conduction changes. hypotension. urinary retention. Ingestion of selective serotonin reuptake inhibitors (SSRIs). or an adult relative's medications. including a widening of the QRS interval and prolongation of the PR interval. However. right axis deviation. These changes may persist for days. bradydysrhythmias. including PR interval prolongation and bradydysrhythmias. supraventricular tachycardia. Electrocardiographic changes (secondary to sodium channel blockade) are usually seen within 6 hours of ingestion and include widened QRS interval. and ventricular fibrillation may occur within 24 hours of ingestion. Pediatric patients can be exposed to potential accidental or intentional ingestions of their own. including central nervous system abnormalities (irritability. Agitation. tachycardia. Overdoses of calcium channel blockers. constipation. and vomiting. or atrioventricular block. Symptoms may occur as early as 30 minutes and are usually seen within 6 hours of ingestion. can produce both central nervous system changes (lethargy. Tricyclic antidepressants have strong anticholinergic activity and can produce symptoms such as dry mouth. coma. abnormal T waves and ST segments. prolonged PR interval (first-degree heart block). and respiratory depression are characteristic findings. but again the electrocardiographic changes exhibited by the patient in the vignette are not consistent with an SSRI overdose. such as fluoxetine. blurred vision.

American Board of Pediatrics Content Specification(s): • Understand that a danger of tricyclic antidepressant treatment is accidental ingestion by siblings • Understand that cardiac dysrhythmias may occur late after ingestion of tricyclic antidepressants Suggested Reading:  O'Donnell KA. their siblings'. • An electrocardiogram demonstrating a QRS duration greater than 100 milliseconds and right axis deviation appears to be the strongest predictor of cardiac toxicity in TCA overdoses. Poisonings. In: Kliegman RM. Tricyclic antidepressant poisoning. UptoDate. respiratory depression. Nelson Textbook of Pediatrics. Stanton BMD. eds. Philadelphia. and cardiac dysrhythmias. Available online only for subscription American academy of pediatrics 10 . Schor N. 19th ed. St Geme J.Dr _F American Academy of Pediatrics aq PREP 2014 eh i PREP Pearls • Pediatric patients can be exposed to accidental ingestions of their own. 2011: 264  Traub SJ. hypotension. • Overdoses of tricyclic antidepressants (TCAs) can cause central nervous system abnormalities. or an adult relative's medications. Behrman RE. PA: Elsevier Saunders. Ewald MB.

C. B. E. D. You are working with a group of medical students who ask you what symptoms the patient may exhibit. hyperglycemia hypertension seizures tachycardia tachypnea American academy of pediatrics 11 . the MOST likely symptom that would be seen is A.Dr _F American Academy of Pediatrics aq PREP 2014 eh i Item 165 A 3-year-old girl is seen in the emergency department 30 minutes after ingesting a large amount of her father's propranolol that was prescribed for the treatment of hypertension. Of the following.

Cardiac side effects that can be seen at therapeutic doses are hypotension. patients with a known or suspected ingestion of an overdose should be observed for 6 hours (24 hours for a sustained-release formulation). ischemic heart disease. migraine headaches. heart block. and thyrotoxicosis. sinus bradycardia. Philadelphia. these findings may be accompanied by respiratory depression and changes in mental status. • Symptoms of (β -blocker overdose are almost always seen by 6 hours unless the drug is a sustained-release formulation. Behrman RE. Major side effects of beta blockers. hypoglycemia. Ewald MB. In: Kliegman RM. respiratory depression. and seizures. Barrueto F. The onset of symptoms generally is within 2 hours of ingestion and almost always within . eds. Poisonings. UptoDate. As a result.6 hours unless the drug is a sustained-release formulation. 19th ed. Stanton BMD. Schor N. delirium. American Board of Pediatrics Content Specification(s): • Recognize common side effects of beta-blocking drugs Suggested Reading: • Lemkin E. and seizures. • β -blocker overdose can produce changes in mental status. including hypertension. sinus bradycardia. Symptoms vary depending on the β-blocker ingested. Available online only for subscription • O'Donnell KA. UptoDate. dysrhythmias. or heart block. propranolol is particularly likely to cause central nervous system symptoms including seizures.Dr _F American Academy of Pediatrics aq PREP 2014 eh Item 165 Preferred Response: C Beta-blocking agents are used to treat various adult and pediatric medical conditions. St Geme J. including coma. Noncardiac effects can include increased airway resistance. 2011: 261 • Podrid PJ. Especially in pediatric patients. PREP Pearls • β -blocker overdose can cause hypotension. including coma. increased airway resistance. Beta blocker poisoning. heart failure. Nelson Textbook of Pediatrics. Symptomatic patients should be admitted to an intensive care unit for monitoring and treatment. and hyperkalemia. delirium. Available online only for subscription American academy of pediatrics 12 i . hypoglycemia. and hyperkalemia. PA: Elsevier Saunders.

refer her to the emergency department for urine toxicology testing Copyright 2013 © American Academy of Pediatrics 1 i . although there is some spillage on his shirt. the MOST appropriate next step is to A.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM Question: 40 The mother of a 2-year-old boy calls you because she just found her son in the bathroom holding an empty bottle of liquid acetaminophen. provide reassurance that no further evaluation is necessary B. He has had no vomiting and is behaving normally. recommend that she call 911 for emergent transport to the emergency department D. She reports that she put him in bed for a nap about 90 minutes ago and does not know when he may have consumed the acetaminophen. refer her to the emergency department for serum acetaminophen level testing E. Of the following. The bottle had been full and she suspects he drank all of it. recommend that she administer ipecac at home C.

Unless the local emergency medical services can administer activated charcoal in the field. A serum level should then be obtained between 4 and 24 hours and the patients level should be plotted on the Rumack-Matthew nomogram to determine the likelihood of hepatotoxicity. Certain patients are at increased risk of serious adverse effects after acetaminophen overdose. singleagent. during which patients who have not succumbed will clinically improve. Ipecac syrup is no longer recommended for the treatment of toxic ingestions because of lack of efficacy. On examination. NAC should be administered within 10 hours of ingestion and should be started before levels are available in unknown or suspected large ingestions. patients who have ingested repeated excessive doses. symptoms. patients may have hepatomegaly and right upper quadrant tenderness. including patients over 5 years of age. the patient should be given activated charcoal as a decontaminant. N-acetylcysteine (NAC). a glutathione precursor. if there are any. increasing the availability of glutathione decreases the production of the toxic metabolites and limits liver injury. Ideally. The most important adverse effect is acute liver failure. evidence of hepatotoxicity becomes apparent with abnormalities in liver synthetic function and transaminase increases. Urine toxicologic testing is not helpful in a known. an acetaminophen level should be obtained before reassurance can be given that there will be no adverse effects. If the serum level suggests possible or probable hepatotoxicity. there is no likely benefit from emergency transport to the emergency department in this otherwise asymptomatic patient. are frequently vague and nonspecific. Evaluation and management of these ingestions begins with quantifying the ingested dose if possible. and multiorgan failure develop and worsen between 72 and 96 hours. The clinical course after an acetaminophen overdose has 4 phases. and malaise are most often reported. Liver failure. vomiting. Because the liver injury is caused by acetaminophen metabolites produced in the absence of glutathione. with most of the deaths occurring during this phase. While toddlers who ingest acetaminophen rarely consume harmful quantities. If the amount is unknown or greater than 150 mg/kg and if fewer than 4 hours have elapsed since the ingestion. the risk of serious sequelae from toxic overdoses is significant. Twenty-four to 72 hours later. single acute doses of less than 150 mg/kg are generally not associated with toxicity. renal failure. In the first 24 hours after ingestion. The final phase is the recovery period. is responsible for more overdoses and overdose deaths than any other medication. Liver transplantation in this phase can prevent mortality. the patient should be treated with NAC.Dr _F aq eh American Academy of Pediatrics 2013 PREP SA on CD-ROM Critique: 40 Preferred Response: D The child in the vignette has likely ingested an unknown quantity of acetaminophen. such as anticonvulsants and antituberculous drugs. In patients without other risk factors. Nausea. The drug can be Copyright 2013 © American Academy of Pediatrics 2 i . can prevent morbidity and mortality. as a result of its ready availability in most households. Acetaminophen is the most commonly used antipyretic and analgesic in the United States and. patients with Gilbert syndrome. For this reason and because clinical signs and symptoms of a dangerous overdose are often absent. Timely recognition of a toxic ingestion and administration of the antidote. acetaminophen ingestion because the drug is not excreted in the urine. which leads to approximately 250 deaths per year. and patients taking drugs that induce cytochrome P450 2E1 (CYP2E1) enzymes. although laboratory abnormalities and liver histology may not normalize for several months.

com/contents/acetaminophen-paracetamol-poisoning-in-children-andadolescents?source=search_result&search=acetaminophen+poisoning&selectedTitle=3%7E41 Wolf SJ.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM intravenously and discontinued if the level suggests no or low risk of hepatotoxicity. http://www.2007.1016/j. American College of Emergency Physicians.uptodate. Heard K. Sloan EP.annemergmed. 2007. Consultation with the local poison control center is advised in these situations. Acetaminophen (paracetamol) poisoning in children and adolescents. Ann Emerg Med.50(3):292-313. Clinical policy: critical issues in the management of patients presenting to the emergency department with acetaminophen overdose. doi:10. Jagoda AS. It is not possible to use the nomogram to predict hepatotoxicity in chronic overdoses or ingestions of sustained-release products.06.014 Copyright 2013 © American Academy of Pediatrics 3 i . UptoDate Online. SUGGESTED READING: Dyer KS.

he has a generalized tonic-clonic seizure. he is poorly responsive and moans to painful stimuli.1°C. a respiratory rate of 36 breaths/min. and a temperature of 38.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM Question: 125 A 2 year-old boy is brought to the emergency department after he was found in the bathroom with multiple open bottles scattered around him. She is unable to provide a list of the medications. He has a heart rate of 140 beats/min. nasal spray containing oxymetazoline Copyright 2013 © American Academy of Pediatrics 4 i . His mother reports that there were pills and liquids spilled all over the floor. blood pressure of 90/60 mm Hg. mouthwash E. fever reducer containing acetaminophen D. His pupils are midsized and sluggishly reactive. While you are examining him. cold medication containing dextromethorphan C. antidiarrheal medication containing bismuth subsalicylate B. Of the following. the over-the-counter product MOST likely responsible for this childs symptoms is A. On physical examination.

com/contents/dextromethorphan-poisoningepidemiology-pharmacology-and-clinical-features?source=search_result&search=over-thecounter+medication+toxicity&selectedTitle=10%7E150 Schillie SF.49(10):910-941. pharmacology and clinical features. Acute overdoses of acetaminophen may cause nausea and vomiting. Dextromethorphan poisoning: epidemiology. analgesics (9%). especially to small children. Cantilena LR. http://www. Boyer EW. Anticipatory guidance around poisoning prevention should include safe storage recommendations for OTC products. the American Association of Poison Control Centers (AAPCC) reported that almost 35% of calls related to exposures in children less than 5 years old were due to OTC products. Pediatr Rev. bradypnea. 2007. Salicylate poisoning in children and adolescents UptoDate Online. and hypertension. Shehab N. 2011. Alcohol. Over-the-counter cold medications typically contain stimulants like phenylephrine and lead to agitation. many of which are commonly found in most households.28-4-153 Rosenbaum C.28(4):153-155. Nasal and ocular drops containing oxymetazoline can lead to coma and seizures. doi:10.Dr _F aq eh American Academy of Pediatrics 2013 PREP SA on CD-ROM Critique: 125 Preferred Response: A The over-the-counter (OTC) product most likely to have produced this childs symptoms is an antidiarrheal medication containing bismuth subsalicylate.uptodate. and cough or cold preparations (5%). Acute salicylism is characterized by several signs and symptoms exhibited by the patient. Spyker DA. and hypotension. and tachycardia. If the product contains dextromethorphan. and hypotension. Rumack BH. including altered mental status ranging from lethargy to coma. respiratory depression. Parents often assume that medications obtained without a prescription are nontoxic and are unaware that OTC products and medications may contain substances that can be harmful (Item C125). Clin Toxicol (Phila).uptodate. such as lethargy. topical preparations (7%). Dart RC. seizures.635149 Legano L. Budnitz DS. bradycardia.1542/pir.3109/15563650. tachycardia.2011. some did result in morbidity and mortality. Boyer EW. Thomas KE. In 2010. the boys' pupils would be miotic secondary to opioid effects produced by a toxic dose of this medication. While most of these exposures were not serious. Medication overdoses leading to emergency Copyright 2013 © American Academy of Pediatrics 5 i . tachypnea or hyperpnea.com/contents/salicylate-poisoning-in-children-andadolescents?source=search_result&search=salicylate+toxicity&selectedTitle=2%7E57 Bronstein AC. hyperpyrexia. Mouthwashes typically contain ethanol. SUGGESTED READING: Barnett AK. http://www. which would cause sedative-hypnotic adverse effects. 2010 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 28th annual report. Green JL. doi:10. but most patients remain asymptomatic. UptoDate Online. These included cosmetics and personal care items (13%).

2009. Am J Prev Med.amepre.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM department visits among children.05.37(3):181-187. doi:10.1016/j. 2009.018 Copyright 2013 © American Academy of Pediatrics 6 i .

Dr _F aq eh i .

a heart rate of 130 beats/min. and her blood pressure is 90/60 mm Hg.0°C. Her oxygen saturation by pulse oximetry is 97% on 100% oxygen administered by non-rebreather mask.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM Question: 166 You are called to the emergency department to evaluate a 3-year-old girl who was rescued by paramedics from a house fire. airway edema C. On arrival at the emergency department. the MOST likely cause of her depressed neurologic condition is A. Of the following. She has no obvious external burns although there is soot around her nares. She was found unconscious at the scene. and her breath sounds are clear bilaterally. a respiratory rate of 24 breaths/min. carbon monoxide exposure D. she is difficult to arouse but is in no respiratory distress. shock Copyright 2013 © American Academy of Pediatrics 8 i . acute respiratory distress syndrome B. methemoglobinemia E. She has a temperature of 37.

as compared with 4 to 6 hours without therapy.Dr _F aq eh American Academy of Pediatrics 2013 PREP SA on CD-ROM Critique: 166 Preferred Response: C The child described in the vignette has been rescued from a house fire and therefore is at high risk of carbon monoxide poisoning. eds. If carbon monoxide exposure is suspected. seizures. and exposure can result in impaired oxygen transport and release and subsequent tissue hypoxia. Chest radiography and electrocardiography also should be performed. Jenson HB. 2003. Poisonings: toxic gases. Behrman RE. direct measurement of a blood carboxyhemoglobin concentration should be performed using co-oximetry. fatigue. PA: Saunders Elsevier. or persistent symptoms after 4 to 6 hours after treatment with normobaric oxygen. myocardial depression with hypotension. as evidenced by her altered level of consciousness and soot around the nares. Carbon monoxide is the leading cause of death by accidental poisoning in the United States. and headache. Endotracheal intubation should be performed in patients who are unable to protect their airway because of significantly depressed neurologic symptoms or in patients who have evidence of significant thermal injury of the respiratory tract.31(12):2794-2801 Copyright 2013 © American Academy of Pediatrics 9 i . and dysrhythmia. 2011:269-270 Zimmerman JL. she shows no signs of respiratory distress or impaired perfusion. Methemoglobinemia after fire exposure is rare but has been reported. In: Kliegman RM. Crit Care Med. carboxyhemoglobin levels greater than 25% (or >15% if pregnant). and shock are unlikely causes of her depressed neurologic condition. Nelson Textbook of Pediatrics. it is unreliable in testing for carbon monoxide poisoning. Philadelphia. confusion. Ewald MB. 19th ed. Patients generally present with intense cyanosis and respiratory distress in addition to a depressed neurologic state. therefore. Stanton BF. Hyperbaric oxygen therapy further shortens the half-life to 15 to 30 minutes. therapy should be guided by symptoms. with over 500 fatalities each year. acute respiratory distress syndrome. The resultant hypoxia from the impaired oxygen transport and release can lead to coma. not levels. Initial symptoms after exposure include nausea. Administration of 100% oxygen via a non-rebreathing mask should be administered while confirming the diagnosis because 100% oxygen shortens the half-life of carboxyhemoglobin to 40 to 80 minutes. SUGGESTED READING: ODonnell KA. Although she is tachycardic. Carbon monoxide has extremely high affinity for hemoglobin. Poisonings and overdoses in the intensive care unit: general and specific management issues. Indications for its use include altered mental status. airway edema. cardiac ischemia or dysrhythmias. Because pulse oximetry is unable to distinguish oxyhemoglobin and carboxyhemoglobin. Although symptoms increase in severity as systemic carboxyhemoglobin levels increase.

The parents report the boy has had several episodes of emesis since the ingestion. The childs temperature is 37. bleach B.0°C.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM Question: 250 You are working in the emergency department and evaluating a 2-year-old boy who was brought by his parents because of ingestion several hours ago of an unknown liquid that was being stored in the garage. ethylene glycol C. kerosene D. the toxin MOST likely to produce this boys symptoms is A. Of the following. respiratory rate is 30 breaths/min. methanol E. his pupils are 2 mm and mildly reactive and he is drooling. Physical examination reveals the boy to be sleepy and diaphoretic. His abdomen is tender to palpation and there are hyperactive bowel sounds. His oxygen saturation by pulse oximetry is 95% on oxygen administered at 2 L/min via nasal cannulae. and blood pressure is 78/45 mm Hg. organophosphates Copyright 2013 © American Academy of Pediatrics 10 i . heart rate is 100 beats/min.

carbamates do not penetrate the central nervous system. bradycardia. such as the 1995 Tokyo subway attacks. intubation (succinylcholine. 2-PAM is most effective if given within 24 to 48 hours because of the “aging” of the acetylcholinesterase-organophosphate binding that becomes irreversible with time. In addition.000 deaths. and coma. bronchospasm. Symptoms caused by these agents result from the accumulation of acetylcholine at both the nicotinic and the muscarinic receptors. Atropine and 2-PAM are usually given as a loading dose and followed by continuous infusion. is contraindicated) and mechanical ventilation. Muscarinic symptoms include tearing. Decontamination consists of washing the skin while avoiding hypothermia. hypertension. drooling. Worldwide. injectors with proper pediatric dosing do not exist. but it is important to remember that children often present with central nervous system and nicotinic effects and therefore pose a diagnostic challenge. and neuropathy target esterase. and tachycardia. supportive care. plasma cholinesterase (pseudocholinesterase). Activated charcoal administered within 1 hour of ingestion has been recommended. seizures. diaphoresis. these compounds are nerve agents that have been used in warfare and terrorist activities. and seizure control (benzodiazepines are the treatment of choice). appropriate clinical suspicion is critical for diagnosis and initiation of treatment. a depolarizing neuromuscular blocker. while in the United States there are 8. Precautions should be made to protect healthcare personnel from exposure during the decontamination. 2PAM is generally not indicated in carbamate poisonings because the compound-enzyme bond will degrade spontaneously. delirium. Specific treatment consists of atropine to counteract the actions of the excess acetylcholine and an oxime (eg. Organophosphates and carbamates prevent the breakdown of acetylcholine through the inhibition of cholinesterases. They present a significant pediatric toxicology problem because of accidental ingestion of improperly stored products. Unlike organophosphates that form permanent bonds with cholinesterases. produce symptoms that are less severe and of shorter duration. however. but gastric lavage is generally avoided because of the risk of aspiration in the setting of concurrent respiratory distress and altered neurologic status. Results from laboratory studies are normal. pralidoxime [2-PAM]) to reactivate cholinesterases. including red blood cell acetylcholinesterase. emesis. miosis. as a result. Two common mnemonics (Item C250) are used to recall the muscarinic symptoms. carbamates form temporary bonds and. vasopressors. Both medications are critical components of the United States Strategic National Stockpile and similar storage programs in other countries. Recovery can be Copyright 2013 © American Academy of Pediatrics 11 i . They exist in the form of auto-injectors for potential terrorist attacks. Supportive care may include intravenous fluids. fasciculations. Treatment of organophosphate and carbamate poisonings consists of decontamination. as a result. Central nervous symptoms include confusion. serial measurements of red blood cell cholinesterase activity (but not serum cholinesterase) can be used to assess the severity of exposure and guide therapy. If readily available. and antidote treatment advised by a toxicologist.000 cases with fewer than 15 deaths per year. Repeat doses of atropine are indicated as long as muscarinic symptoms persist. In addition. Nicotinic symptoms include weakness.Dr _F aq eh American Academy of Pediatrics 2013 PREP SA on CD-ROM Critique: 250 Preferred Response: E Organophosphates and carbamates are commonly used insecticides. Levels of serum or red blood cell cholinesterase activity can confirm the diagnosis but are often not available in a timely fashion and. urinary and fecal incontinence. and hypotension. there are an estimated 3 million cases yearly with 300.

Huang YH. lacrimation and miosis (mydriasis is the more common finding). eds. Gundacaram A. 2005:26(7):263-270. are atypical. PA: Saunders Elsevier. Nelson Textbook of Pediatrics.26-7-263 ODonnell KA. Philadelphia. drooling.Dr _F American Academy of Pediatrics aq eh 2013 PREP SA on CD-ROM organophosphate poisoning with persistent neurotoxicity. Organophosphate poisonings may be difficult to diagnose because the symptoms mimic those of mushroom. and opioid poisonings. In addition. 19th ed. Ingestion of bleach or other caustic chemicals produces oral or esophageal burns associated with gagging.1542/pir. SUGGESTED READING: Bird S. These symptoms were not exhibited by the boy in the vignette. Poisonings: cholinesterase-inhibiting insecticides. gagging is typically observed after hydrocarbon ingestion. seizures. polyneuropathies. vomiting. as exhibited by the boy in the vignette. respiratory failure. muscular weakness. UpToDate Online. St Geme JW III. Pediatr Rev. However. In: Kliegman RM. 2011:266-267 Copyright 2013 © American Academy of Pediatrics 12 i . In both ingestions.com/contents/organophosphate-and-carbamatepoisoning?source=search_result&search=organophosphates&selectedTitle=1%7E16 Fox J. coma. and respiratory failure. http://www. doi:10. and vomiting. nicotine. Ewald MB. Woods SK. Stanton BF. Index of suspicion. Behrman RE. Organphosphate and carbamate poisoning. Kerosene ingestion can produce respiratory and abdominal symptoms but miosis is not present. and refusal to swallow. Varma SK. laboratory studies will show a marked metabolic acidosis with a serum osmolar gap. including hypotension. Wong KS. Methanol and ethylene glycol can cause cardiorespiratory and central nervous system symptoms. nausea.uptodate. Schor NF.

Dr _F aq eh i .

lesions in multiple stages on the same part of the body E. One of the students asks you to describe how to differentiate varicella from smallpox in a child presenting with a vesicular rash. superficial nature of the skin vesicles Copyright 2012 © American Academy of Pediatrics eh 1 . involvement of the palms and soles with rash D. the clinical feature MOST suggestive of smallpox is A. Of the following.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 12 You are precepting a group of medical students and leading a discussion on vaccine-preventable diseases. abrupt onset of rash in a previously well child B. centripetal spread of the skin lesions C.

SUGGESTED READING: American Academy of Pediatrics. 2002.346:13001308. Baker CJ. Henderson DA. Finally. Smallpox (variola).nejm.int/mediacentre/factsheets/smallpox/en/index. 28th ed. N Engl J Med.org/doi/full/10. Red Book: 2009 Report of the Committee on Infectious Diseases. Emergency Preparedness & Response.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 12 Preferred Response: C aq i Although smallpox has been eradicated since 1977 through successful implementation of worldwide control and vaccine programs. In: Pickering LK. Although lesions in varicella appear in multiple stages of development on the same part of the body (Item C12B). Elk Grove Village. smallpox lesions are deeper into the skin compared to the superficial "dew drop on a rose petal" appearance in varicella.1056/NEJMra020025 Centers for Disease Control and Prevention. The lesions of smallpox spread centrifugally. 2007. eds. 2007. Clinical features of smallpox and comparison to varicella are summarized (Item C12A).to 5-day prodrome of fever and malaise. Long SS. IL: American Academy of Pediatrics. Kimberlin DW. Accessed January 2011 at: http://www.who. Smallpox infections typically are characterized by a 4.gov/agent/smallpox/diagnosis/riskalgorithm/ World Health Organization. Media Centre. 2009:596-598 Breman JG. In contrast to varicella. and the infected individual appears very ill at the time of rash presentation.bt. Diagnosis and management of smallpox. Accessed January 2011 at: http://www.html Copyright 2012 © American Academy of Pediatrics eh 2 . the rash in smallpox involves the palms and soles.cdc. smallpox lesions are homogenous (Item C12C). concern has been raised for the virus being a potential bioterrorism agent. Smallpox Fact Sheet. Evaluating a Rash Illness Suspicious for Smallpox. Accessed January 2011 at: http://www.

Dr _F aq eh i .

Dr _F aq eh i .

Dr _F aq eh i .

aspirin ingestion B. but none of the bottles were opened. lisinopril ingestion D. His mother reports that earlier in the day she found him in his grandmother's room playing with her medicine bottles. sepsis Copyright 2012 © American Academy of Pediatrics eh 6 . and his pupils are midsized and reactive. heart rate is 130 beats/min. metoprolol ingestion E. intracranial hemorrhage C. Of the following. respiratory rate is 56 breaths/min.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 16 An 18-month-old boy is brought to the office because he has been difficult to arouse for the past hour.6°C. the MOST likely explanation for this child's symptoms is A. and blood pressure is 90/60 mm Hg. The remainder of his physical examination findings are normal. His temperature is 38." The child is somnolent and responsive only to pain. The mother explains that the grandmother takes "pills for her heart.

but intubation and mechanical ventilation are reserved for those patients who have respiratory failure. hemodialysis is indicated. Because acidosis promotes diffusion of salicylic acid into the central nervous system. The increases in minute ventilation seen in salicylate-poisoned patients contribute significantly to maintenance of alkalemia. renal failure. Serum pH measurements should be maintained between 7. SUGGESTED Copyright 2012 © American Academy of Pediatrics eh 7 . pulmonary edema. which should be administered every 4 hours until the patient is asymptomatic and the salicylate concentration is less than 30 mg/dL. Salicylic acid is eliminated in the urine and such elimination is maximized if the urine is alkaline. Early/mild signs and symptoms include fever/hyperpyrexia. In severe poisoning associated with significant neurologic signs. Oxygen should be provided as needed. and focal neurologic signs. Although salicylate poisoning is not seen as commonly as before the introduction of childproof packaging and other nonsalicylate antipyretics/analgesics. acute iron poisoning. an obtunded patient who has sepsis is likely to exhibit hypotension and other findings consistent with septic shock or meningitis.6 during therapy. hypoglycemia. The recommended use of low-dose aspirin as primary prevention for cardiovascular disease in adults means that aspirin is readily available and potentially accessible to children in many households. nausea. Tachypnea/hyperpnea. Hypovolemia and potassium deficits should be corrected. hypertension.000 reported cases to United States poison control centers annually. Finally. and elimination. and seizures are commonly seen in more severe poisonings. rehydration.5 and 7. altered mental status (lethargy to coma). or plasma salicylate concentrations greater than 100 mg/dL. diarrhea. The clinical findings of acute salicylism can be explained by the many cellular and systemic effects of the drugs (Item C16) and are related to ingested dose. hypotension predominates.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 16 Preferred Response: A aq i The child described in the vignette is exhibiting signs and symptoms consistent with salicylate poisoning. with bradycardia seen additionally with a beta-blocker overdose. and ethylene glycol toxicity. those of greater than 300 mg/kg lead to moderate toxicity and greater than 500 mg/kg lead to death. Initial stabilization should focus on airway maintenance. decontamination. and attempts to normalize ventilation by eliminating the patient's own hyperpnea have resulted in death from severe acidosis. Mild symptoms are typically seen in ingestions of 300 mg/kg or less. tachycardia. metabolic acidosis with an elevated anion gap. and tinnitus. and correction of electrolyte abnormalities. with all aspects of therapy directed at maintaining serum alkalemia. Decontamination is accomplished using multiple doses of activated charcoal. The management phases of acute salicylate poisoning encompass stabilization. unresponsive metabolic acidosis. Such clinical findings can overlap with a number of equally serious conditions. vomiting. The patient who has intracranial hemorrhage is likely to exhibit bradycardia. including diabetic ketoacidosis. intoxication with aspirin and other salicylates is responsible for more than 20. life-threatening neurologic symptoms can be avoided with aggressive alkalization. In lisinopril and metoprolol ingestions. Intravenous fluids should contain both potassium and sodium bicarbonate to replete potassium stores and maintain alkalemia.

Nelson LS.15532712.com/online/content/topic.aspx?id=9905 O'Donnell KA. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients.150:396-404.3. eds. Accessed January 2011 at: http://www. UpToDate Online 18.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i READING: Barnett AK.2008.2008. Salicylate poisoning in children and adolescents. Schor NF.S. Accessed January 2011 at: http://onlinelibrary. Philadelphia.15532712.do?topicKey=ped_tox/8460 Chyka PA. 2007.wiley.annals.org/content/150/6/396.long Copyright 2012 © American Academy of Pediatrics eh 8 . et al. 2011:250-270 Stolbach AI.45:95-131. St. 19th ed.x/full US Preventive Services Task Force. Clin Toxicol (Phila). 2009. Hoffman RS. PA: Saunders Elsevier. Accessed January 2010 at: http://www.uptodate.x. Acad Emerg Med 2008. Stanton BF.15:866-869.1111/j. Preventive Services Task Force recommendation statement.gov/content. In: Kliegman RM. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Burns Ewald M. Pediatric drug therapy: poisonings.00205. Christianson G. Ann Intern Med.1111/j. Traub SJ. and Behrman RE. Nelson Textbook of Pediatrics. Geme JW III. Boyer EW. 2010. Erdman AR. DOI: 10. Accessed January 2011 at: http://www. Aspirin for the prevention of cardiovascular disease: U.guideline.00205.com/doi/10.

Dr _F aq eh i .

0°C. the awake and alert child's temperature is 37.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 34 A father brings his 2-year-old son to the emergency department after they had spent several hours in the garage while the father worked on the car. His shirt is saturated with lighter fluid. and oxygen saturation is 98%. Of the following. heart rate is 120 beats/min. perform gastric lavage D. The father reports that approximately 30 minutes ago he heard the child coughing and found him with an open bottle of charcoal lighter fluid in his hands. You remove the boy's shirt and decontaminate his skin. reassure the father and discharge the patient Copyright 2012 © American Academy of Pediatrics eh 10 . respiratory rate is 24 breaths/min. the MOST appropriate next step is to A. On physical examination. obtain a STAT chest radiograph B. obtain a urine toxicology screen C. blood pressure is 90/60 mm Hg. place the child under observation E.

PA: Copyright 2012 © American Academy of Pediatrics eh 11 .Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 34 Preferred Response: D aq i The boy described in the vignette has ingested a hydrocarbon-containing substance. Hydrocarbon poisoning. Antibiotics and corticosteroids are not indicated. 2009. Evaluation of symptomatic patients should include assessment of oxygen saturation or arterial blood gasses and chest radiography. A chest radiograph (Item C34) should be obtained acutely in a symptomatic patient. The asymptomatic patient who has had a hydrocarbon exposure should be observed for the development of signs or symptoms for a minimum of 6 hours.do?topicKey=ped_tox/11453 O'Donnell KA. he or she may be safely discharged. Emergency Medicine. Accessed January 2011 at: emedicine. and gasoline. The resulting damage leads to chemical pneumonitis. and Behrman RE. Highly volatile hydrocarbons may diffuse rapidly into the central nervous system.uptodate. Schor NF. eds. Aspiration risk is highest with low-viscosity. Greshem C III. mineral spirits. Gastric lavage is contraindicated because it has the potential to cause further aspiration. Hydrocarbon ingestion does not often lead to systemic toxicity unless other toxic substances such as camphor or pesticides are admixed with the hydrocarbon.1. the radiograph should be repeated in 4 to 6 hours if it appears initially normal. Urine toxicology screening is not routinely helpful unless an illicit coingestant is suspected. Burns Ewald M. but because radiographic findings often lag behind clinical findings. Pediatric drug therapy: poisonings. stupor. Stanton BF. and intubation/mechanical ventilation for respiratory failure. St. Aleguas A Jr. furniture polish. aspiration during the swallowing event deposits the hydrocarbon in the pulmonary tree. 2010. eMedicine Specialties. wheezing. management does not typically involve decontamination or elimination but focuses on respiratory stabilization and observation. or coma. or hypoxemia. Nelson Textbook of Pediatrics. UpToDate Online 18. 19th ed. Geme JW III. Rather. Supportive care should be provided. somnolence. Hydrocarbons are a large family of compounds that most commonly cause toxic effects in the pulmonary and central nervous systems when ingested. In contrast to most other toxic ingestions. Philadelphia. SUGGESTED READING: Levine MD. high-volatility hydrocarbons such as kerosene. If the radiograph is normal and the patient does not develop any symptoms during the observation period. beta-agonist treatment for wheezing. hydrocarbons. Patients who have any respiratory signs or symptoms on presentation should be observed for 24 to 48 hours for disease progression. leading to ataxia. including oxygen therapy. Toxicology.com/article/821143-overview Lewander WJ. Toxicity. A chest radiograph should be obtained 4 to 6 hours after exposure. In: Kleigman RM. where it directly injures the respiratory mucosa. Accessed January 2011 at: http://www.com/online/content/topic. Clinical suspicion should be high for an aspiration event in any child who presents following a hydrocarbon exposure with a history of coughing/gagging or respiratory signs and symptoms such as tachypnea.medscape.

2011:250-270 Copyright 2012 © American Academy of Pediatrics eh 12 .Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Saunders Elsevier.

Dr _F aq eh i .

The remainder of his physical examination findings are normal. allopurinol C.0°C. acetaminophen B. simvastatin E. The sleepy but arousable child has a temperature of 37. heart rate of 160 beats/min. simvastatin.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 86 An 18-month-old boy is brought to the emergency department after being found in his grandfather's room with several open pill bottles. The family reports that they removed two unidentifiable tablets from his mouth and found 23 more scattered on the floor. respiratory rate of 24 breaths/min. the medication that is MOST likely to be the cause of this child's clinical findings is A. acetaminophen. aspirin. and allopurinol. terazosin Copyright 2012 © American Academy of Pediatrics eh 14 . The medications include terazosin. aspirin D. and blood pressure of 66/34 mm Hg. Of the following.

do?topicKey=ped_tox/3023 Copyright 2012 © American Academy of Pediatrics eh 15 . A patient who is hypotensive following an unknown ingestion should be treated initially with fluid resuscitation.3. Hypotension following an ingestion can be an important clue to the identity of the ingested agent (Item C86). 19th ed. skin. Shepherd JG. UpToDate Online 18. Accessed by subscription January 2011 at: http://www. Electrocardiography and bedside glucose measurement also should be obtained to determine if the hypotension is related to a cardiac dysrhythmia or hypoglycemia. Pediatric drug therapy: poisonings. 2011:250-270 Velez LI. may be found in a child's environment and ingested accidentally. vasopressor agents such as dopamine or dobutamine should be considered. St. Of the medications listed. Nelson Textbook of Pediatrics. and often not specific to the actual agent. with careful reassessment following each bolus. not the poison" reminds the clinician that the treatment of patients who have ingested toxic substances is primarily supportive.com/online/content/topic. reactive. it is important to collect information that will help in identifying agents that may cause life-threatening symptoms or complications and have specific treatments or antidotes. causes hypotension. PA: Saunders Elsevier. In: Kliegman RM. Fluid boluses of 20 mL/kg 0. Philadelphia. 2010. When evaluating a child following an unknown ingestion. More importantly. eds.9% saline should be administered rapidly. and neurologic status can provide useful clues.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 86 Preferred Response: E aq i The boy described in the vignette is lethargic and hypotensive. pupil size. and Behrman RE. If the patient's blood pressure does not normalize after three boluses. only terazosin. Assessment of vital signs. Burns Ewald M. from hypertension to insomnia. an alpha-blocker used to treat symptoms associated with prostatic hypertrophy.uptodate. presumably due to a toxic ingestion. however. Stanton BF. Geme JW III. The adage "treat the patient. Many medications commonly used to treat various of conditions in adults. Schor NF. Goto CS. is initial stabilization of the patient and correction of any vital sign derangements. Approach to the child with occult toxic exposure. SUGGESTED READING: O'Donnell KA.

Dr _F aq eh i .

administer syrup of ipecac C. He is drooling slightly. and his vital signs are normal.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 122 A 2-year-old boy is brought to the emergency department after his mother found him with an open bottle of toilet bowl cleaner. but examination of his oropharynx reveals no lesions. perform gastric lavage D. refer the boy to a gastroenterologist for urgent endoscopy Copyright 2012 © American Academy of Pediatrics eh 17 . the MOST appropriate next step is to A. provide no further treatment E. She reports that he had spilled some on his shirt and had some on his face. but she does not know if he drank any of it. administer activated charcoal B. The child is awake and alert. Of the following.

PA: Saunders Elsevier. gastric lavage carries the risk of esophageal perforation. odynophagia. 19th ed. As many as 45% of patients who do not have oral burns and 12% of asymptomatic patients have findings on endoscopy. The need for endoscopy in the asymptomatic patient in whom a significant caustic ingestion is questionable is controversial. SUGGESTED READING: Ferry GD. 2011:250-270 Copyright 2012 © American Academy of Pediatrics eh 18 .Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 122 Preferred Response: E aq i Ingestion of a caustic substance causes injury to mucosal and skin surfaces by liquefaction necrosis in alkali exposures and by protein coagulation in acid exposures. In addition. In: Kleigman RM. Toxicity.uptodate. such as the boy in the vignette. Toxicity.medscape. Pediatric drug therapy: poisonings.com/article/813772-overview O'Donnell KA. eMedicine Specialties. or late stricture formation also may result from significant ingestions. intraoral burns. Further. Stanton BF. Severe gastritis.com/online/content/topic. Nelson Textbook of Pediatrics. Early airway visualization and protection are indicated in any patient who presents with stridor or respiratory distress. hands.3. should be considered endoscopy candidates. Emergency Medicine. In addition. 2010 Accessed January 2011 at: http://www. Caustic esophageal injury in children UpToDate Online 18. 2010. Substances at the extremes of the pH scale (<2 and >12) are especially damaging. and evaluation of the esophagus by upper endoscopy is indicated in patients who have intraoral burns or other symptoms. Patients typically present with drooling. Philadelphia. respiratory distress with stridor or wheezing. they may have vomiting with hematemesis. based on history or other clinical concerns. Burns Ewald M. Geme JW III. perforation. Use of activated charcoal is not indicated because it can make subsequent endoscopic evaluation of the esophagus difficult. or chest. decontamination of patients following caustic ingestions is focused on washing the skin and flushing the eyes. caustic ingestions. The major clinical concerns with a caustic ingestion are airway or esophageal injury. Schor NF. eds. and Behrman RE. Accessed January 2011 at: http://emedicine. Syrup of ipecac and gastric lavage are contraindicated because of potential aspiration risk.do?topicKey=pedigast/11441 Kardon EM. and burns on the face. some asymptomatic patients. St. dysphagia. Because the primary mode of injury is direct tissue corrosion and systemic symptoms are rare. if indicated. and in many cases.

dry mouth. he develops lethargy. Over the ensuing hour of observation in the emergency department. Within 3 hours of ingestion. irritability. discharge home without further evaluation C.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 162 A 5-year-old boy presents to the emergency department 30 minutes after he ingested some of his mother's tricyclic antidepressant. Of the following. these symptoms have resolved. chest radiography and arterial blood gas B. serum electrolytes assessment E. electrocardiography and continuous cardiac monitoring D. and autonomic nervous system findings of mydriasis. tricyclic serum drug concentration assessment and discharge home Copyright 2012 © American Academy of Pediatrics eh 19 . the MOST appropriate next step in management is A. and urinary retention.

Often. protein binding increases and bioavailability decreases. constipation. and seizures. Accessed January 2011 at: http://www.gov/pmc/articles/PMC1725608/?tool=pubmed Copyright 2012 © American Academy of Pediatrics eh 20 . tricyclic antidepressant toxicity does not directly affect serum electrolyte concentrations or renal function. blurred vision. Discharging the boy after 3 hours of observation in the emergency department is not appropriate. instead requiring cardiac support with extracorporeal membrane oxygenation or some other form of ventricular assist device. and prolongation of the PR interval (first-degree heart block) is common. dizziness. SUGGESTED READING: Kerr GW. As toxic effects on the myocardium worsen.4.nih. Wilkie S.nlm. Ventricular tachyarrhythmias are a common late finding. Two mechanisms are postulated for its therapeutic effect.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 162 Preferred Response: C aq i An overdose of any of the tricyclic antidepressant drugs may result in a fatal cardiac dysrhythmia. DOI: 10.ncbi. Emerg Med J. urinary retention. and if present. but such findings alone should not lend reassurance when early noncardiac symptoms are present. Electromechanical dissociation (EMD) can result. The cardiac toxicity associated with this class of agents most often manifests as a prolongation of the QRS complex on electrocardiographic monitoring. 2001.236. the boy described in the vignette should receive electrocardiography and continuous cardiac monitoring. Such earlier features may include lethargy. leading to the need for urgent cardiopulmonary resuscitation. Treatment is otherwise supportive. If there is metabolic acidosis. anticholinergic effects upon the autonomic nervous system associated with sympathetic nervous system dysfunction. Respiratory depression can result from the central nervous system sedative properties of these agents. Therefore. By reversing the acidosis. irritability. infusion of sodium bicarbonate is appropriate. and vomiting. Tricyclic antidepressants are protein-bound and become less bound in more acidic conditions. In this situation. Although serum electrolyte imbalance could exacerbate any ventricular dysrhythmia.1136/emj. these findings do not appear late. However. Tricyclic antidepressant overdose: a review.18. further inpatient monitoring is always indicated. Measuring serum concentrations of the tricyclic antidepressants may be useful in assessing the potential for toxicity. given the potential for late cardiac effects. Anticholinergic effects of tricyclic antidepressants include dry mouth. tachycardia. and this boy has no indication of respiratory compromise. The tricyclic antidepressants are highly metabolized by the cytochrome P450 hepatic enzymes. EMD does not respond to electrical cardioversion. loss of cardiac mechanical activity and severely widened QRS complexes occur simultaneously. McGuffie AC. warrants careful laboratory and clinical observation.18:236-241. An alternative explanation is that the sodium load helps to reverse the sodium channel-blocking effects of the tricyclic antidepressants. the effect on the heart is delayed. In addition. presentation to the emergency department with various signs and symptoms may precede the cardiac findings. atrioventricular block can occur. The QRS complex prolongation is caused by delayed conduction through a poisoned myocardium.

9:75-79. Abstract accessed January 2011 at: http://www. Serial electrocardiographic changes as a predictor of cardiovascular toxicity in acute tricyclic antidepressant overdose. Singh KH. Khan IA. 2002. DOI: 10.nlm.2004. Abstract accessed January 2011 at: http://www.08. 2005. Kou M. J Emerg Med.28:169-174.018.ncbi.ncbi.gov/pubmed/15707813 Singh N.gov/pubmed/11782822 Copyright 2012 © American Academy of Pediatrics eh 21 .nih.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Rosenbaum T.nih.1016/j. Am J Ther.nlm.jemermed. Are one or two dangerous? Tricyclic antidepressant exposure in toddlers.

filtered tap water E. boiled tap water B. Of the following. tap water Copyright 2012 © American Academy of Pediatrics eh 22 . you are MOST likely to advise them to use A.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 179 A couple who is new to the community comes to you for a prenatal visit. bottled drinking water D. bottled distilled water C. They live in a home with a private well and have questions about the safety of providing well water to their newborn.

for most chemical contaminants such as hydrocarbons.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 179 Preferred Response: A aq i In the United States. community wells. the source of their water is important to discuss. or agricultural departments or private well installation and service firms. and private wells equipped with modern purification systems are generally believed to safeguard the water supply for drinking. and perchlorates. and Giardia lamblia. but they are meant for water that is already processed through a municipal water supply and are not intended to detoxify heavily contaminated water. reservoirs. Annual testing for fecal coliforms is recommended. Because the family's water supply is from their own private well. as do some child care centers and schools in suburban and rural areas. is expensive and may not contain fluoride. and parents should be made aware of other potential ground water contaminants that may have long-term effects on health for both children and adults. For the family described in the vignette. Although infections in children caused by drinking water that is contaminated by fecal coliforms or parasites (especially Cryptosporidium) may be identified by gastrointestinal symptoms such as diarrhea and vomiting. Use of bottled water. These agents have been linked to both low birthweight and birth defects. including the recommended periodicity and costs of routine testing of well water. testing should be performed every 3 to 5 years. Risks for children from drinking contaminated water are greater than for adults. including distilled. health. The Environmental Protection Agency regulates water safety in municipal water supplies and community wells but not in private wells. and surveillance of wells to provide a safe drinking water supply. including arsenic. used as degreasers and aerosolized solvents. bottled water may contain chemical contaminants from the plastic that could confer long-term health risks for the family. SUGGESTED Copyright 2012 © American Academy of Pediatrics eh 23 . Up to one sixth of the homes in the United States have water supplied by private wells. The American Academy of Pediatrics has published a policy statement that may assist practitioners in providing advice to families about proper construction. There is evidence that industrial hydrocarbons such as trichloroethylenes. they need to evaluate the water supply to determine if it is safe. they should use boiled water. municipal water supplies. More frequent testing may be indicated if there are outbreaks of intestinal disease in the community. in many cases due to the dose response and dose per body weight of both microorganisms and chemical contaminants. methyl tertiary butyl ester. Meanwhile. Families who have private wells should be advised to engage the services of a professional well monitoring technician available through local water. chronic ingestion of chemical contaminants may result in "silent intoxication" or more vague symptom complexes. Infant formula should not be prepared with well water containing high concentrations of nitrates (>10 mg/dL). maintenance. which may lead to some risks. In addition. Filtered tap water (via faucet or pitcher/carafe-mounted filters) may reduce the presence of lead. and the water supply. Cryptosporidium. can seep into groundwater. Those who choose to self-monitor and maintain wells may find resources for acceptable levels of fecal coliform contaminants and instructions for decontamination (using household bleach) from local health departments.

Drinking Water Contaminants: National Primary Drinking Water Regulations. Howard WB. Accessed January 2011 at: http://water.aappublications.2005.013.2009-0752. DeSesso JM.org/cgi/content/full/123/6/e1123 United States Environmental Protection Agency.gov/pubmed/16181768 Copyright 2012 © American Academy of Pediatrics eh 24 . 2009. Red Book: 2009 Report of the Committee on Infectious Diseases.21:117-147.gov/drink/contaminants/index.123: e1123-e1137. DOI: 10. the Committee on Environmental Health. Baker CJ. eds.reprotox. IL: American Academy of Pediatrics.1016/j. Kimberlin DW. Cryptosporidiosis. and the Committee on Infectious Diseases.nih. 2006.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i READING: American Academy of Pediatrics. 2010.1542/peds. Accessed January 2011 at: http://aapredbook.nlm.ncbi. Reprod Toxicol.07.cfm Watson RE. Trichloroethylene-contaminated drinking water and congenital heart defects: a critical analysis of the literature. Drinking water from private wells and risks to children.org/cgi/content/full/2009/1/3. Williams AL. 2009:272-273. Accessed January 2011 at:: http://pediatrics. In: Pickering LK. Pediatrics. Elk Grove Village. Brady MT.32 Rogan WJ. Long SS. Abstract accessed January 2011 at: http://www. Jacobson CF. 28th ed.epa. DOI: 10.aappublications.

the MOST likely cause of this child's symptoms is A. intussusception D. Complete blood count.Dr American Academy of Pediatrics _F aq 2012 PREP SA on CD-ROM i Question: 246 A 16-month-old girl is brought to the emergency department because of persistent crying for several hours. She has no underlying medical conditions and no exposures. Electrocardiography shows sinus tachycardia. and cerebrospinal fluid studies yield normal results. Physical examination reveals an agitated. has vomited twice.8°C. reaction to cold and cough medicine Copyright 2012 © American Academy of Pediatrics eh 25 . and an undocumented fever for 3 days. early meningitis C. The remainder of physical examination findings are normal. blood pressure is 122/78 mm Hg. and has had no diarrhea. Current medications include acetaminophen and an over-the-counter cough and cold medicine. who is inconsolable. electrolytes. Of the following. respiratory rate is 36 breaths/min. cough. myocarditis E. crying child. She has had clear rhinorrhea. Her temperature is 37. heart rate is 192 beats/min. She has had adequate oral intake. urinalysis. acetaminophen overdose B. and oxygen saturation is 98%.

hallucinations. or cough suppressant effects. Although it does not have the addictive or analgesic properties of other opiates. and pruritus. even at an early stage. and carbinoxamine can lead to central nervous system agitation or depression. such as meningitis. Multiple studies have shown that these medications have little or no efficacy in the treatment of upper respiratory tract infections in children compared with placebo. it is prudent to measure the serum concentration of acetaminophen for this patient. and urinary retention. coma. The most common decongestant in cold and cough preparations is pseudoephedrine. ranging from trauma to infection to metabolic conditions to toxicologic issues. gastrointestinal distress. codeine can lead to somnolence. Although experts further recommended that the products be eliminated for children younger than 6 years of age. but usual electrocardiographic findings. further strengthening the argument against their use. intussusception may present with lethargy.and dextromethorphan-containing cough remedies in children. the use of cold and cough preparations has been implicated in the deaths of a number of infants and children. and rarely seizures. Intussusception causes episodes of crying in children. major manufacturers pulled from production products marketed for children younger than 2 years of age and added a label warning against using the medications for sedative purposes. chlorpheniramine. it can cause euphoria. including decreased precordial voltages. usually with decongestant. Recently. It does have abuse potential because of the euphoric effects it may produce. In fact. Dextromethorphan is derived from opiates and acts at the central nervous system level to inhibit cough. dysrhythmias.Dr _F American Academy of Pediatrics 2012 PREP SA on CD-ROM Critique: 246 Preferred Response: E aq i The differential diagnosis for an irritable and crying child. her history and abnormal vital signs suggest a likely cause: toxic effects from cough and cold medication. Alternatively. is generally well tolerated but may cause mild gastrointestinal discomfort. it leads to depressed mental status and respiratory depression. arrhythmia. Antihistamines such as diphenhydramine. lethargy. which may have sympathomimetic effects. hypertension. antihistamine. the most commonly used expectorant. Because some cold and cough preparations may contain analgesics. Since 1997. drowsiness. seizures. however. The absence of abnormalities in the cerebrospinal fluid of this girl makes meningitis very unlikely. the United States Food and Drug Administration (FDA) was petitioned and convened a meeting in 2007 to review the safety of these products. ataxia. such as tachycardia. In lower doses. For this reason. respiratory depression. Over-the-counter cough and cold medications may contain one or more components. but such efficacy is not noted for children. Guaifenesin. are absent in this patient. central nervous system stimulation. brompheniramine. Myocarditis may result in tachycardia out of proportion to fever. but agitation. in higher doses. Before the meeting. Dextromethorphan and codeine are the most widely used cough suppressants and appear to have efficacy greater than placebo in adults. tachycardia. ataxia. continuous agitation is not typical. is broad. but they are typically intermittent rather than continuous. This girl's evaluation has ruled out many of the serious entities in the differential diagnosis. hypertension. expectorant. the American Academy of Pediatrics has recommended against the use of codeine. nausea. nystagmus. dizziness. such as the girl described in the vignette. a pharmaceutical trade group subsequently voluntarily changed labeling to warn about their use in children younger than 4 years. and hypertension are not characteristic of Copyright 2012 © American Academy of Pediatrics eh 26 . and in extreme cases.

Dr

American Academy of Pediatrics

_F

aq

2012 PREP SA on CD-ROM

i

acetaminophen overdose.
SUGGESTED READING:
Carr BC. Efficacy, abuse, and toxicity of over-the-counter cough and cold medicines in the pediatric
population. Curr Opin Pediatr. 2006;18:184-188. DOI: 10.1097/01.mop.0000193274.54742.a1. Abstract
accessed January 2011 at: http://www.ncbi.nlm.nih.gov/pubmed/16601501
Committee on Drugs. American Academy of Pediatrics. Use of codeine- and dextromethorphancontaining cough remedies in children. Pediatrics. 1997;99:918-920. DOI: 10.1542/peds.99.6.918.
Accessed January 2011 at: http://pediatrics.aappublications.org/cgi/content/full/99/6/918
Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter cough and cold medications.
Pediatrics. 2001;108:e52. Accessed January 2011 at:
http://pediatrics.aappublications.org/cgi/content/full/108/3/e52
Kuehn BM. Debate continues over the safety of cold and cough medicines for children. JAMA.
2008;300:2354-2356
Rimsza ME, Newberry S. Unexpected infant deaths associated with use of cough and cold
medications. Pediatrics. 2008;122:e318-e322. DOI: 10.1542/peds.2007-3813. Accessed January 2011
at:: http://pediatrics.aappublications.org/cgi/content/full/122/2/e318
Sharfstein JM, North M, Serwint JR. Over the counter but no longer under the radar - pediatric cough
and cold medications. N Engl J Med. 2007;357:2321-2324. Accessed January 2011 at:
http://www.nejm.org/doi/full/10.1056/NEJMp0707400

Copyright 2012 © American Academy of Pediatrics

eh

27

Dr

_F

aq

eh

i

2011 PREP SA on CD-ROM
Question: 161

You receive a call from the emergency department at 11:00 pm on New Year’s Eve. Five patients
have presented with foreign body ingestions.
Of the following, the foreign body that is MOST appropriate to be removed first is a

A. 1999 penny in the stomach of an 18-month-old
B. AAA battery in the stomach of a 4-year-old
C. button battery in the mid-esophagus of a 2-year-old
D. quarter in the esophagus of a 3-year-old who vomited twice and is refusing solids
E. toothbrush in the stomach of an asymptomatic 16-year-old, which she swallowed 2 hours ago

Copyright © 2010 by the American Academy of Pediatrics

page 1

Dr

_F

aq

eh

i

2011 PREP SA on CD-ROM
Critique: 161

Preferred Response: C

Management of ingested foreign bodies depends on the item ingested, its anatomic location,
and the presence of symptoms. In most cases, gastric foreign bodies may be managed
conservatively, but esophageal impactions require urgent removal. Button batteries present a
unique problem because they contain toxic heavy metals as well as alkaline compounds (eg,
sodium and potassium hydroxide) that are caustic to esophageal mucosa. Significant
esophageal injury (including perforation) has been reported from button batteries lodged in the
esophagus for as few as 6 hours. Most complications are caused by larger batteries (20 to 23
mm diameter), although significant esophageal injury has been reported with batteries as small
as 8 mm in diameter. Symptoms of dysphagia (including feeding refusal, excessive drooling,
difficulty swallowing) or emesis suggest esophageal impaction.
Regardless of the presence or absence of symptoms, a radiograph of the neck, chest, and
abdomen should be obtained in all patients who present with a history of possible battery
ingestion (Item C161A). Button batteries lodged in the esophagus must be removed
endoscopically as soon as possible after detection. Batteries (both button and cylindrical)
detected in the stomach usually traverse the gastrointestinal tract without incident, with more
than 80% passing within 48 hours. In asymptomatic patients, battery location should be
assessed radiographically at that time, and if the object has not passed the pylorus, removal is
recommended. In symptomatic patients, urgent endoscopic removal is indicated.
In the United States, foreign body ingestions are primarily a pediatric problem, with more
than 80% of reported cases occurring in children. The exception is esophageal meat impaction,
which is the most common foreign body ingestion-related problem in adults who do not have
underlying psychiatric disturbances. Although the precise incidence is unknown, more than
100,000 cases of foreign body ingestion in children were reported to the American Association
of Poison Control Centers toxic exposure surveillance system in 2000. Of these, 98% were
unintentional. Coins are the most commonly reported foreign bodies, and most traverse the
gastrointestinal tract without difficulty. Toy parts, sharp objects (needles, pins), batteries,
chicken or fish bones, and food impactions are other frequently reported items.
A coin lodged in the esophagus must be removed emergently if the patient is unable to
handle secretions (Item C161B). Otherwise, endoscopy may be carried out within 12 to 24
hours, by which time up to 30% of coins (mostly those in the distal third of the esophagus) will
have passed into the stomach. In all instances of esophageal and gastric foreign bodies, a chest
radiograph should be performed immediately prior to endoscopy to confirm location and
determine whether the object has passed the lower esophageal sphincter or the pyloric outlet.
Coins in the stomach require no immediate therapy in asymptomatic patients. Parents should be
instructed to examine stools for coin passage, and if the coin is not retrieved, a follow-up
radiograph may be obtained in 2 to 3 weeks. Only then, if the coin is retained in the stomach,
should removal be considered. Of note, the composition of pennies changed from copper to
predominantly zinc in 1982. Although corrosion by gastric acid may release absorbable zinc
chloride, no difference in the management of ingested pennies is recommended in asymptomatic
patients. Toothbrushes and other long objects (eg, tongue depressors) have been reported as
unintentional ingestions in adolescents who have bulimia. The objects are swallowed while
using them to induce vomiting and require endoscopic removal.

Copyright © 2010 by the American Academy of Pediatrics

page 2

Dr

_F

aq

eh

i

2011 PREP SA on CD-ROM

Suggested reading:
Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in
childhood and review of the literature. Eur J Pediatr. 2001;160:468-472. DOI:
10.1007/s004310100788. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/11548183
Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases.
Pediatrics. 1992;89: 747-757. Abstract available at:
http://pediatrics.aappublications.org/cgi/content/abstract/89/4/747
Mas E, Olives J-P. Toxic and traumatic injury of the esophagus. In: Kleinman RE, Goulet O, MieliVergani G, Sanderson I, Sherman P, Shneider B, eds. Walker’s Pediatric Gastrointestinal
Disease. 5th ed. Hamilton, Ontario, Canada: BC Decker; 2008:105-116
Rebhandl W, Steffan I, Schramel P, et al. Release of toxic metals from button batteries retained in
the stomach: an in vitro study. J Pediatr Surg. 2002;37:87-92. DOI: 10.1053/jpsu.2002.29435.
Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/11781994
Yardeni D, Yardeni H, Coran AG, Golladay ES. Severe esophageal damage due to button battery
ingestion: can it be prevented? Pediatr Surg Int. 2004;20:496-501. DOI: 10.1007/s00383-0041223-6. Available at: http://springerlink.metapress.com/content/rdrxu127rlw6twgb/fulltext.html

Copyright © 2010 by the American Academy of Pediatrics

page 3

Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 161 (Courtesy of D Mulvihill) A 2-year-old child who ingested a watch battery that is now located in mid esophagus. the more radio-opaque peripheral rim is not a feature of coins. Copyright © 2010 by the American Academy of Pediatrics page 4 . Although the foreign body resembles a coin.

Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 161 (Courtesy of D Mulvihill) Coin in the upper esophagus of a child who had been coughing for weeks. Copyright © 2010 by the American Academy of Pediatrics page 5 . There is widening of the esophageal wall.

Dr _F aq eh i 2011 PREP SA on CD-ROM Question: 177 The father of a 4-year-old boy calls you from the emergency department near the family’s vacation home in another state. a follow-up abdominal radiograph in 2 weeks B. you are MOST likely to recommend A. endoscopic removal of the coin D. a short course of metoclopramide C. Of the following. His son just swallowed a quarter. polyethylene glycol 3550 as an osmotic cathartic Copyright © 2010 by the American Academy of Pediatrics page 6 . no further follow-up because the coin will pass unaided E. and an abdominal film shows it to be in the gastric fundus.

and the use of cathartics have not proved to be effective. eosinophilic esophagitis). or a sensation of something in the chest.Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 177 Preferred Response: A Coins are the most common foreign bodies ingested by children in the United States and are responsible for approximately 25.000 emergency department visits annually. because many coin ingestions are not witnessed and most are asymptomatic. Patients who present with or develop symptoms should undergo endoscopy within 12 to 24 hours. up to 40% of excreted coins are missed by parents. Because the composition of pennies changed from copper to predominantly zinc in 1982. Most swallowed coins traverse the gastrointestinal tract unaided and without incident. feeding refusal. indicating the need for urgent endoscopic removal. retained esophageal foreign bodies are responsible for significant morbidity. may not precipitate acute symptoms. For an asymptomatic child who has an ingested coin located in the stomach (or small bowel). especially in toddlers. However. However. treatment with prokinetic agents to enhance gastrointestinal motility. Drinking carbonated beverages to dilate the esophagus and facilitate passage of esophageal coins (previously studied in adult subjects). previous surgery. the necessity of an initial radiograph has been questioned. a radiograph is recommended in all cases. including esophageal ulceration and perforation. and follow-up radiographs are negative. Smaller coins also may remain in the stomach. no difference in the management of ingested pennies from that of other coins currently is recommended in asymptomatic patients. if nothing is recovered. Alternate or adjunct therapeutic options following coin ingestion are not recommended. a significant number likely are unreported. Nevertheless. as described for the boy in the vignette. it can be removed safely via endoscopy after a few weeks if a followup radiograph indicates gastric retention. concerns have been raised about the potential toxicity of zinc chloride released from the corrosive action of gastric acid following penny ingestion. particularly when multiple coins are ingested and among patients who have underlying motility disturbances or a history of prior surgery for pyloric stenosis. However. some coins may lodge in the esophagus (Item C177). esophageal stricture. and abdomen to confirm the coin ingestion and estimate its size and location. In the absence of symptoms. fundoplication. Parents should be instructed to examine the child’s stools because most coins pass within 4 to 6 days. chest. However. dysphagia. parenteral administration of glucagon. a quarter may be retained in the stomach. a follow-up radiograph at 2 weeks should confirm coin passage versus retention and guide further therapy. and others may be managed at home. Coins located in the distal third of the esophagus. Despite the fact that most patients do not present with symptoms. no further immediate management is required. Because most ingested coins pass spontaneously and are not associated with symptoms. Accordingly. however. Interestingly. Suggested reading: Copyright © 2010 by the American Academy of Pediatrics page 7 . A coin also is more likely to lodge in the esophagus of a patient who has underlying esophageal pathology (eg. a radiograph should be taken of the neck. Most esophageal foreign bodies cause immediate problems with handling of secretions. Because of its size.

1542/peds.nlm. Vandenplas Y. Hauser B.aappublications. Foreign body ingestion in infants and children: location.ncbi.41:633-640 Copyright © 2010 by the American Academy of Pediatrics page 8 . Clin Pediatr (Phila). DOI: 10.116:752-753. Pediatrics. location.160:468-472.Dr _F aq eh i 2011 PREP SA on CD-ROM Arana A. Abstract available at: http://www. Available at: http://pediatrics. Hachimi-Idrissi S.1007/s004310100788.2005-0062. 2005. Management of asymptomatic coin ingestion. DOI: 10.gov/pubmed/11548183 Conners GP. 2001. Management of ingested foreign bodies in childhood and review of the literature. Wyllie R.org/cgi/content/full/116/3/752 Wahbeh G. Eur J Pediatr. 2002. location. Kay M.nih.

Copyright © 2010 by the American Academy of Pediatrics page 9 .Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 177 (Courtesy of M Wright) Coin in the upper esophagus of a child who had been coughing for weeks.

His lips are erythematous and edematous. On physical examination. the boy is alert and screaming. spilled container of granular drain cleaner beside him. Of the following. upper gastrointestinal endoscopy Copyright © 2010 by the American Academy of Pediatrics page 10 . the MOST appropriate next step is A. but he can handle his secretions without difficulty. observation in the hospital for 24 hours E. His parents found him crying on the kitchen floor with an open. barium swallow study D. administration of broad-spectrum antibiotics B.Dr _F aq eh i 2011 PREP SA on CD-ROM Question: 193 You are called to the emergency department to see a 2 1/2-year-old boy at 9 pm on New Year's Eve. administration of intravenous corticosteroids C.

endoscopic evaluation is indicated following the ingestion of known caustic agents irrespective of the degree of symptoms. bleaches (30% to 40%) and laundry detergents (10% to 20%) comprise the remainder. and delay of endoscopy more than 24 hours after the incident can increase the risk of esophageal perforation. alkalis are ingested more commonly than acids and account for most postingestion complications. therefore. any patient who has signs of oral injury or symptoms of odynophagia/dysphagia (drooling. thus limiting the quantity of ingestion. and early symptoms may be absent. In fact. Endoscopy undertaken before 12 hours after the incident may fail to identify the severity and extent of injury. where the caustic injury is most severe. This agent contains 5% sodium hypochlorite buffered to a pH of less than 11. The granular drain cleaner to which the toddler described in the vignette has been exposed typically is formulated as a strong base (often sodium hydroxide) with a pH of greater than 11. Despite evidence of oral burns (erythematous.Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 193 Preferred Response: E More than 200. Acids and alkalis. cause immediate oral pain and have a bitter taste. and patients rarely require a diagnostic evaluation or specific therapy following exposure. and granular products cause a higher rate of injury compared with liquids. As a consequence. Products that have a pH greater than 11 (drain cleaner typically has a pH of greater than 11. in whom the ingestion most often represents a suicide attempt. and drain cleaners. choking. even after several swallows. solid food refusal) following a known or suspected caustic ingestion should undergo upper gastrointestinal endoscopy within 12 to 24 hours. toilet bowl. because of the use of childproof containers and the enactment of laws to limit the concentration of household cleaning products. and the degree of injury is related to both the amount and concentration of the material ingested. Alkalis usually are odorless and tasteless. the boy apparently can handle secretions without difficulty. Fortunately. the ingested product may be swallowed rapidly (particularly with an intentional ingestion). which account for approximately 15% of ingestions in children. Alkali causes a liquefaction necrosis rather than the coagulative necrosis from strong acids. although ingestions occur most commonly in children younger than 6 years of age. swollen lips). comprise 50% of ingested caustic agents. tile. Asymptomatic patients who present with a questionable history of corrosive ingestion may Copyright © 2010 by the American Academy of Pediatrics page 11 .5) are associated with a high risk of caustic burns. these agents are responsible for significant morbidity in young children and are associated with a high mortality rate in adolescents and adults. Standard laundry bleach probably is the single most commonly ingested household cleaning product. Postingestion evaluation and management depend on the nature of the ingestion and the presence or absence of symptoms. undergo rapid transit to the stomach. Caustic ingestions represent an unknown fraction of these exposures. the overall incidence of caustic ingestions in children appears to be declining. although gastric injury also may occur. Strong acids. Nevertheless. In some cases. alkaline products are likely to be ingested in greater amounts. including oven. Nevertheless. The esophagus is the site of greatest mucosal damage following alkali consumption. with most affected children being 1 to 4 years old. These agents have a low viscosity and.5. Among pediatric patients.000 known exposures to household cleaning agents are reported annually in the United States. In contrast. the esophagus is spared in 80% of cases.

Rebouissoux L.gov/pubmed/19543088 Kay M. although their efficacy has not been fully established. Fayon M. Pharmacologic management approaches to caustic injuries are either controversial (corticosteroids) or have failed to undergo controlled clinical trials (antibiotics). including bleeding and esophageal strictures.33:81-84.gie. Gastrointest Endosc.ncbi.org/article/PIIS0016510708027041/fulltext Lamireau T.Dr _F aq eh i 2011 PREP SA on CD-ROM be observed and allowed to consume liquids. Available at: http://www. Available at: http://journals.ncbi. Vergnes P.nih. Gastrointest Endosc. 2008.aspx Copyright © 2010 by the American Academy of Pediatrics page 12 . 2009.1 4. stricture formation is likely with grade 3 lesions. as long as no signs of perforation are noted. pose the greatest threat of early perforation and fistula formation and require long-term parenteral support for administration of fluids and nutrition. Suggested reading: Betalli P.2008. Antibiotics. a barium swallow study is not helpful early postingestion in symptomatic patients. Wyllie R. Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study. Wyllie R.2008.003.21:651-654. et al. Denis D.1016/j.69:1407.nlm. However.016. because it cannot be used to determine the nature or extent of esophageal injury.lww. Caustic ingestions in children. Curr Opin Pediatr. 2009. Accidental caustic ingestion in children: is endoscopy always mandatory? J Pediatr Gastroenterol Nutr. Giuliani S. Corticosteroids may be used in patients who have airway symptoms related to perilaryngeal edema.68:434-439.gov/pubmed/18448103 Kay M. Patients who have grades 0 and 1 injuries (grade 1 is seen in 80% of patients who have an endoscopically confirmed injury) may be sent home after the procedure if they are tolerating feedings. Abstract available at: http://www. Lancelin F. 2001. a barium swallow study should be performed to assess for esophageal stricture.nih.and long-term complications.nlm. and in the setting of suspected or documented perforation. such as the child described in the vignette.gie. They may be fed postendoscopy. Those who have grade 2 injuries require intravenous support until the extent of damage becomes evident. DOI: 10. should be reserved for patients who have grades 2 or 3 injuries. Endoscopy permits grading of the injury and guides further management. Grade 3 injuries.giejournal. Falchetti D. in cases where steroids are administered. Abstract available at: http://www. characterized by circumferential mucosal necrosis. when prescribed.1016/j. Symptoms may not adequately predict extent of injury in pediatric patients after a caustic ingestion [letter].com/jpgn/Fulltext/2001/07000/Accidental_Caustic_Ingestion_in_Children__Is.10. DOI: 10. Grade 2 lesions are associated with a greater than 10% likelihood of subsequent esophageal stricture. Caustic injury to the esophagus is graded on a scale of 0 to 3. Patients who have grades 2 to 3 lesions are at greater risk for both short.02. If symptoms of dysphagia develop.

esophageal strictures. Abstract available at: http://www.Dr _F aq eh i 2011 PREP SA on CD-ROM Turner A.nlm. Emerg Med J.nih. Respiratory and gastrointestinal complications of caustic ingestion in children.gov/pubmed/11689365 Copyright © 2010 by the American Academy of Pediatrics page 13 . 2005. and achalasia in children. Robinson P. Scheimann AO. Gastrointest Endosc Clin N Am.11:767-787. The role of upper gastrointestinal endoscopy in the diagnosis and treatment of caustic ingestion.22:359—361.ncbi. Wilsey MJ Jr. Gilger MA. 2001.

His pupils are 4 mm and briskly reactive to 2 mm. After administering activated charcoal. On physical examination. his heart rate is 140 beats/min. serum sodium assessment E. respiratory rate is 24 breaths/min. The remainder of his examination findings are normal. serum creatine phosphokinase assessment D. electrocardiography C. and oxygen saturation is 100%. abdominal radiography B. He has had one episode of emesis and is complaining of abdominal pain.Dr _F aq eh i 2011 PREP SA on CD-ROM Question: 208 A 2-year-old boy is brought to the emergency department after his father found him with the leaf from a foxglove plant in his mouth (Item Q208). blood pressure is 100/60 mm Hg. urine toxicology screening Copyright © 2010 by the American Academy of Pediatrics page 14 . the MOST appropriate next step is A.

Dr _F aq eh i 2011 PREP SA on CD-ROM Question: 208 (Courtesy of M Wright) Foxglove Copyright © 2010 by the American Academy of Pediatrics page 15 .

Because most serious plant ingestions have cardiac effects. This is especially true for the patient described in the vignette. Plant poisoning. Unintentional child poisonings treated in United States hospital emergency departments: national estimates of incident cases.25:375-433.000 plant exposures are reported to the American Association of Poison Control Centers annually. and urine toxicology screening are of no utility. 2008. Ibrahim D.2007.ncbi. In addition.nlm. Abstract available at: http://www. who has ingested foxglove. Rhabdomyolysis may be a late finding in foxglove ingestion.emc.02.2007-3551.1016/j.013. evaluation and treatment are directed at decontamination and assessment/support of vital functions. 2007. Emerg Med Clin North Am. Furbee RB. As with most poisonings. a source of potent cardiac glycosides. In general.Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 208 Preferred Response: B More than 100.122:1244-1251. or mistake the plant for a nontoxic look-alike. Available at: http://pediatrics.org/cgi/content/full/122/6/1244 Froberg B. use it for perceived medicinal purposes. but it should not delay the initial evaluation and decontamination. serum sodium determination.nih. electrocardiography should be considered in affected patients. the toxicities of plants affect one or more of three organ systems: cardiac.aappublications. or gastrointestinal (Item C208). most of which are not serious. only a few account for most of the fatalities and emergency department visits. and product involvement. Abdominal radiography. DOI: 10. Although there are many potentially toxic plants in the environment. DOI: 10.gov/pubmed/17482026 Copyright © 2010 by the American Academy of Pediatrics page 16 . Rodgers GB. A serum creatine phosphokinase determination may be considered if the patient develops muscle tenderness or myoglobinuria. neurologic. Suggested reading: Franklin RL. most of these occur in adults who intentionally ingest the plant. Plant identification is helpful in determining a treatment plan (and can be facilitated by the local Poison Control Center). Pediatrics.1542/peds. population-based poisoning rates.

Dr _F aq eh i 2011 PREP SA on CD-ROM Critique: 208 Copyright © 2010 by the American Academy of Pediatrics page 17 .

the next MOST appropriate step is to A. Of the following. On physical examination. PR interval of 130 msec. All other findings are within normal parameters. His pupils are 6 mm. administer amiodarone C. respiratory rate is 6 breaths/min. treated with imipramine. begin external pacing E. administer sodium bicarbonate D. Electrocardiography demonstrates sinus tachycardia. and given a 20-mL/kg bolus of normal saline. administer adenosine B. and QRS duration of 140 msec. placed on a cardiac monitor. he has enuresis.5 J/kg Copyright © 2010 by the American Academy of Pediatrics page 1 . Of note. his heart rate is 120 beats/min. and sluggishly reactive. They report that he has had no recent illnesses and was in his usual state of health when he went to bed last night. and blood pressure is 60/40 mm Hg. He is endotracheally intubated. he is responsive only to pain. perform synchronized cardioversion at 0. ventilated with 100% oxygen.Dr _F aq eh i 2010 PREP SA on CD-ROM Question: 32 The parents of a 12-year-old boy bring him to the emergency department after finding him unresponsive in bed when they tried to wake him for school. equal.

The most serious toxicities from TCA overdose affect the heart and central nervous system (CNS). as is fluid resuscitation with boluses of normal saline. Tricyclic antidepressants cause these clinical features by inhibiting a variety of neurotransmitter receptors. These effects.com/online/content/topic. flushed skin. tachycardia. The exact mechanism for this effect is unknown.313:474-479. especially in intentional ingestions to evaluate for possible coingestants. Tricyclic antidepressant poisoning. Available at: http://www. Sodium bicarbonate should be administered until the QRS duration is less than 100 msec. are responsible for the hypotension and conduction delays that are seen commonly. Alpha-adrenergic pressors (eg.ncbi. and agitation. and perfusion. conduction velocity is decreased. hypotension.nih.utdol.nlm. In addition. Decontamination should be performed with activated charcoal. Value of QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. 1985.3. repolarization duration and absolute refractory periods are prolonged. dysrhythmias.do?topicKey=ad_tox/10025&selectedTitle=1~150&sou Copyright © 2010 by the American Academy of Pediatrics page 2 . Abstract available at: http://www. Initial management of a TCA overdose begins with ensuring a patent airway and restoring adequate oxygenation. Intubation and mechanical ventilation often are necessary. respiratory depression. References: Boehnert MT. The QRS widening is related to fast sodium channel blockade caused by direct TCA effects and exacerbated by acidemia.gov/pubmed/4022081 Hutchinson MD. Although acetaminophen and aspirin concentrations should be measured. Adenosine and synchronized cardioversion are treatments for supraventricular tachycardia. N Engl J Med. Amiodarone is a drug of choice for ventricular arrhythmias. 2008. ventilation. coupled with alpha-1-adrenergic antagonism. Lovejoy FH Jr. measurement of TCA concentrations is not clinically useful. alpha-1-adrenergic. symptomatic bradycardia. gamma aminobutyric acid (GABA). Traub SJ. and dilated pupils described for the patient in the vignette are consistent with an acute tricyclic antidepressant (TCA) overdose. and histamine receptors as well as cardiac fast sodium channels. Because of the TCA effect on fast sodium channels. including muscarinic acetylcholine. norepinephrine) may be required to treat refractory hypotension. In a study from 1985. Among the additional signs that might be observed are seizures. Seizures are treated with benzodiazepines. and other anticholinergic features such as dry mouth. hyperthermia.Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 32 Preferred Response: C The coma. External pacing is appropriate treatment for refractory. The single most useful diagnostic and prognostic test in the setting of a TCA overdose is electrocardiography. These effects can be overcome by the administration of sodium bicarbonate boluses. urinary retention. CNS excitation and seizures or depression may be related to effects on GABA or histamine receptors. toxicologists found that a QRS duration of greater than 100 msec predicted seizures in 34% and dysrhythmias in 14% of patients who had TCA overdoses. UpToDate Online 16.

45:203-233.com/emerg/topic37. et al. 2008.emedicine. Clin Toxicol (Phila). Nelson LS. 2007. Toxicity. Brief summary available at: http://guidelines. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management.aspx?doc_id=9906&nbr=005302&string=tricyclic+AND+ antidepressant+AND+overdose Copyright © 2010 by the American Academy of Pediatrics page 3 .htm Woolf AD. Emergency medicine. In: eMedicine Specialties. Toxicology. Available at: http://www.gov/summary/summary.Dr _F aq eh i 2010 PREP SA on CD-ROM rce=search_result11 Jacob J. antidepressant. Erdman AR.

observe the child at home for symptoms E. The child is acting normally. Her daughter weighs 25 lb. The mother reports that the label says there is 30 mg of elemental iron per tablet and five tablets are missing from the bottle she picked up at the pharmacy this morning. bring the child to office in the morning for assessment of serum iron concentration B. give the child syrup of ipecac D. the MOST appropriate advice to give the mother is to A. give the child activated charcoal C. Of the following.Dr _F aq eh i 2010 PREP SA on CD-ROM Question: 48 The mother of one of your patients calls frantically because she just found her 2-year-old daughter with an open bottle of prenatal vitamins and several of the tablets in her mouth. take the child to the nearest emergency department Copyright © 2010 by the American Academy of Pediatrics page 4 .

and coagulation tests. serum electrolyte and aminotransferase determinations.utdol. Any child who is symptomatic within 6 hours after ingesting iron. In a symptomatic patient. and the patient can be observed at home. Patients who have severe symptoms. For the patient who has a significant ingestion.0x103/mcL (15.5 mcmol/L). Phase 1 (gastrointestinal phase) occurs between 30 minutes to 6 hours after ingestion and includes vomiting. abdominal radiography should be used to look for the presence of retained tablets in the gastrointestinal tract. diarrhea. Laboratory indicators of a potentially significant ingestion include serum iron concentration greater than 350 mcg/dL (62. Phase 4 (bowel obstruction phase) occurs 2 to 8 weeks after the acute ingestion and results from gastrointestinal tract scarring following iron-induced corrosive damage. regardless of the estimated dose.2 mg/kg of elemental iron (<40 mg/kg). The clinical phases of significant iron toxicity are attributable directly to these two mechanisms. If she develops symptoms. hepatic failure phase) may be seen as early as 6 to 12 hours after ingestion and is the result of mitochondrial dysfunction and cell death. if possible. If she remains asymptomatic for more than 6 hours. Neither activated charcoal. abdominal pain.7 mcmol/L). In the asymptomatic child. Most of these ingestions are unintentional and do not result in significant toxicity. how much elemental iron was ingested and if the patient is symptomatic. UpToDate Online 16. Phase 2 (latent phase) occurs 6 to 12 hours after ingestion but can last as long as 24 hours. nor syrup of ipecac is indicated for decontamination. ingestions of less than 40 mg/kg of elemental iron are not significant. or a significant number of pills visible on abdominal radiography should be treated with deferoxamine to chelate free circulating iron. Patients often are asymptomatic during this time while free iron is taken up into the reticuloendothelial organs. and serum glucose values greater than 150 mg/dL (8. metabolic acidosis. 2008. Management of iron ingestion begins with determining. she is unlikely to develop toxicity and can be observed at home. However. The mother in the vignette can be reassured that because her child ingested 13. Acute iron poisoning.do?topicKey=ped_tox/4912&selectedTitle=1~150&sou Copyright © 2010 by the American Academy of Pediatrics page 5 . or if the dose is unknown. she should be taken to an emergency department for evaluation and treatment. white blood cell count greater than 15. no further evaluation or treatment is necessary.3 mmol/L). and hematemesis or melena. a complete blood count. References: Liebelt EL.com/online/content/topic. gastrointestinal decontamination using whole-bowel irrigation is indicated. laboratory evaluation should include measurement of a serum iron concentration within 4 hours of ingestion. Such signs and symptoms are caused by the agent’s corrosive effects on the gastrointestinal mucosa. anion gap acidosis.3.0x109/L). Iron is both a corrosive and a cellular toxin. If present.Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 48 Preferred Response: D Iron overdoses continue to be common among children younger than 6 years of age. Kronfol R. should be brought to medical attention. which adsorbs iron poorly. serum iron concentrations of greater than 500 mcg/dL (89. iron ingestion can cause fatalities. Phase 3 (shock. Available at: http://www. especially in the setting of an intentional ingestion or exposure to an adult preparation.

com/emerg/topic285. Toxicity. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Booze LL. Toxicology. Emergency Medicine.ncbi. 2005.nih.43:553-570. Available at: http://www. iron. et al. 2007.Dr _F aq eh i 2010 PREP SA on CD-ROM rce=search_result11 Manoguerra AS.nlm. Clin Toxicol (Phila).emedicine.htm Copyright © 2010 by the American Academy of Pediatrics page 6 .gov/pubmed/16255338 Spanierman C. eMedicine Specialties. Erdman AR. Abstract available at: http://www.

10 mg/dL (3. turpentine Copyright © 2010 by the American Academy of Pediatrics page 7 .9 mmol/L) •Chloride.Dr _F aq eh i 2010 PREP SA on CD-ROM Question: 64 A father brings his 2-year-old son to the emergency department in status epilepticus. organophosphate insecticide E. 335 mOsm/kg (335 mmol/kg) Of the following.5 mmol/L) •Serum osmolality. the boy is given a dose of lorazepam to stop the seizure and is endotracheally intubated because of respiratory depression. vomited. and seemed like he was "drunk. 5. 100 mEq/L (100 mmol/L) •Bicarbonate.7 mmol/L) •Blood urea nitrogen.6 mmol/L) •Calcium. He reports that the boy spent several hours in the garage with him while he was repairing the car. the father states that over the course of the afternoon the child seemed sleepier than usual. 120 mg/dL (6. motor oil D. then became lethargic." On the way to the hospital he began having seizures. 4. gasoline C. His initial laboratory results are: •Sodium. ethylene glycol B. the MOST likely cause of this child’s clinical condition is ingestion of A.5 mEq/L (5. In the emergency department. 6 mEq/L (6 mmol/L) •Glucose. On questioning.9 mEq/L (4. 138 mEq/L (138 mmol/L) •Potassium.

Approach to the child with metabolic acidosis. Fomepizole inhibits alcohol dehydrogenase. Initial treatment involves stabilization of vital functions. Motor oil also is a hydrocarbon. Organophosphate insecticides inhibit acetylcholinesterase and cause a cholinergic crisis manifested by bradycardia.utdol.htm Sharman M. there is little role for gastrointestinal decontamination. 2008. References: Keyes DC. Toxicology. 2008. Because alcohols are absorbed so quickly from the gastric mucosa. and administration of the antidote fomepizole (or ethanol.com/emerg/topic177.3.Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 64 Preferred Response: A The progressive lethargy. seizures.emedicine. Hemodialysis is indicated for severe poisonings. which is excreted in the urine as crystals (Item C64C). This is a particular diagnostic possibility because the boy may have had access in the garage to such potential toxic alcohols as ethylene glycol (antifreeze) and methanol (windshield wiper fluid). Often. hematuria.com/online/content/topic. ethylene glycol. but because of its high viscosity and low volatility.3. cerebral herniation. anion gap metabolic acidosis of 30 mEq/L (Item C64A).utdol.do?topicKey=ad_tox/8204&selectedTitle=2~105&sour ce=search_result Copyright © 2010 by the American Academy of Pediatrics page 8 . it poses little risk for aspiration or toxicity. Gasoline and turpentine are volatile hydrocarbons that cause pulmonary injury after aspiration. hypersalivation. Indirect laboratory evidence of alcohol toxicity includes an anion gap acidosis and an osmolar gap greater than 10 mmol/L.com/online/content/topic. which metabolizes the nontoxic parent alcohols into their toxic byproducts. ataxia. eMedicine Specialties. Rapid diagnosis is critical for a patient who has symptomatic ethylene glycol poisoning because delay in treatment can lead to renal damage. bronchorrhea. 2007. and muscle weakness. Methanol and ethylene glycol poisoning. Winchester JF. if fomepizole is unavailable). UpToDate Online 16. Emergency Medicine. administration of sodium bicarbonate to correct acidosis. The hypocalcemia suggests ethylene glycol exposure because the metabolism of ethylene glycol uses the patient’s calcium stores to create calcium oxalate. Many household products are toxic and frequently accessible to young children. multiple organ system failure. Toxicity. Sarnaik AP. initial treatment is based on clinical suspicion before alcohol values are available. UpToDate Online 16. Available at http://www.do?topicKey=pedineph/16228&selectedTitle=2~150&s ource=search_result Sivilotti MLA. diarrhea. and death. Other findings in ethylene glycol poisoning may include flank pain. Available at: http://www. and osmolar gap of 53 mmol/L (Item C64B) described for the boy in the vignette are highly suggestive of alcohol poisoning. Available at: http://www. and acute renal failure.

Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 64 Copyright © 2010 by the American Academy of Pediatrics page 9 .

Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 64 Copyright © 2010 by the American Academy of Pediatrics page 10 .

2003. Reprinted with permission from Schumann GB.Dr _F aq eh i 2010 PREP SA on CD-ROM Critique: 64 Calcium oxalate crystals (arrows). Copyright © 2010 by the American Academy of Pediatrics page 11 . Ill: American Society for Clinical Pathology. Chicago. Friedman SK. Wet Urinalysis.