Selected Topics: ToxicologyThe Limited Utility of Screening Laboratory Tests and Electrocardiograms in the Management of Unintentional Asymptomatic Pediatric Ingestions
Introduction
Most ingestions by children are unintentional, involve a single substance, and do not produce significant clinical effects. The acute mortality rate in pediatric poisonings is <0.0004% 1, 2. In 2009, poison control centers reported approximately 2.5 million calls, with 1.5 million unintentional poisonings for children, including adolescents in the 12–19 years age range 1, 2. Ingestions in adolescents have characteristics similar to adult ingestions, with significant doses and multiple medications taken intentionally. The approach to the pediatric unintentional ingestion can vary; some physicians might approach it similar to how they would approach the adolescent or adult ingestion, and others without laboratory or ancillary tests.
Many laboratory tests are available to support providers caring for poisoned patients in the Emergency Department (ED) (3). Management of patients with ingestions in the ED can include performing any number of these laboratory and ancillary tests with disposition options ranging from discharge, observation alone, or admission (4). Electrocardiograms (ECGs) are often obtained in the evaluation of patients with ingestions due to the association between certain drugs and electrocardiographic abnormalities, although their use in the evaluation of all ingestions is unclear 5, 6. Previous studies have shown low utility of comprehensive toxicological screens and have emphasized using history and clinical examination to direct evaluation and treatment 4, 7.
The objective of this study was to assess the utility of screening laboratory and ECGs in the management of unintentional asymptomatic ingestions by children younger than 12 years of age in the ED.
Section snippets
Methods
This was a retrospective chart review of pediatric patients younger than 12 years of age presenting to a children's hospital ED for evaluation of ingestion from January 2005 through December 2008. Cases were identified by the following International Classification of Diseases-9th revision codes: 930–939 (effects of foreign body entering through orifices), 960–979 (poisoning by drugs, medicinal and biological substances), 980–989 (toxic effects of substances chiefly nonmedicinal as to course),
Results
Between January 2005 and December 2008, 595 patients younger than 12 years of age were evaluated in the ED for unintentional ingestions, including 47 button-battery ingestions. Median age was 2.6 years (interquartile range 1.6–3.0 years) and 334 (56%) were male. The types of ingestions are listed in Table 1. The other category included such miscellaneous ingestions as antibiotics, diuretics, arts and crafts, muscle relaxants, antidiabetics, plants, anesthetics, electrolytes, nicotine,
Discussion
The yield of laboratory screening and ECGs for unintentional asymptomatic ingestions by children remained low during the 4-year period. Screening tests were only helpful in patients who were symptomatic without an ingestion history. In patients younger than 12 years with unintentional ingestions who had normal vital signs and mental status for age, there were no positive screening tests. The screening tests that changed management were only observed in patients who presented with multiple
Conclusions
Screening laboratory tests such as blood gases, electrolytes, blood counts, and ECG were of limited utility and rarely changed management, despite being ordered in a significant number of patients. Screening tests are rarely indicated in unintentional overdoses in children who are asymptomatic.
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