EMERGENCY CARE CONSULT
From the 62nd Annual Brennemann Memorial Lectures, presented September 22-25, 2005, by the Los Angeles
Pediatric Society
Angela C. Anderson, MD, Associate Professor of Emergency Medicine and Pediatrics, Brown University Medical
School and Attending Physician and Toxicologist, Hasbro Children’s Hospital, Providence
| FOREIGN BODIES: STRANGE INVADERS
|
| Foreign body in esophagus: after 24 hr, increased risk for perforation and aortoesophageal fistula (signs may include intermittent
hematemesis); once foreign body in stomach, ingestion often no longer worrisome
|
 | In esophagus: case—initial chief complaint that child swallowed coin; on x-ray, disc battery in esophagus (key finding
double ring); mechanisms of injury—pressure necrosis; electric current; toxic leakage (potassium hydroxide and sodium
hydroxide cause liquefaction necrosis); timing—time to burn ≈6 hr; time to perforation 4 hr; battery >15 mm in
child <6 yr of age—increased risk of becoming lodged in esophagus or another part of gastrointestinal (GI) tract; battery
in esophagus medical emergency (remove immediately); distal to esophagus—remove if significant symptoms
(eg, abdominal pain with tenderness, melena, or hematochezia)
|
| In stomach: almost all batteries in stomach pass through GI tract within 1 wk; if larger than dime and child <6 yr of age,
follow with x-rays every 2 to 3 days; syrup of ipecac—successful expulsion in <3%; case (reflux back into esophagus
required endoscopic removal)
|
| Past pylorus: follow with x-rays every 1 to 2 wk
|
| Lead ingestion (case): chief complaint vomiting; patient rehydrated, felt better, and sent home (twice); on day 3, seizures
(difficult to control; patient intubated); on chest x-ray, lead fishing sinker in stomach); patient died; blood lead level increased
from 12 to 48 µg/dL in 4 hr; if lead in stomach, remove
|
| Managing foreign bodies past pylorus: whole-bowel irrigation—polyethylene glycol-electrolyte solution
(GoLYTELY); 500 mL/hr in children (1-2 L/hr in teenager); some patients vomit (consider antiemetic, eg, metoclopramide
[Reglan])
|
| Hair tourniquet removal: digital—normally, speaker performs digital block; clitoral or penile—speaker has used depilatory
product (Nair) to remove hair; if hair visible, technique painless and works well
|
| Tick tricks: if tick’s abdomen sticking out—use suture material or thread to make loop and “lasso” tick; slide along skin
and tick will pop out; if completely embedded, procedure not effective; another approach—dab at skin with alcohol
swab (ticks averse and will disengage)
|
| Rings and things: case—young boy put finger in hole in bed frame; boy presented with portion of bed frame still around
finger; management—need to get swelling reduced; wrap, eg, Iodoform gauze down to base of finger; unwrap; push
edema to other side; repeat as needed; ring cutter not helpful
|
| Tar: case—child fell on new asphalt; tar sterile, but skin not (bacteria proliferate under occlusive barrier); removal—cool
skin if still hot; put baby oil (liquid paraffin) on gauze and apply for 1.0 to 1.5 hr; (butter or sunflower oil, ≈30 min); polymyxin
B sulfate, neomycin, and bacitracin (Neosporin)—ingredient Tween 80 has hydrophilic and lipophilic properties;
tar emulsified (wipe off)
|
| Case: 15-yr-old girl presents with intractable cough; lungs clear; heart normal (no problems on exertion); hair in left ear canal;
unusual side effects may include intractable cough or hiccups; report of ant in ear causing hiccups (resolved with removal
of ant); hiccup reflex arc similar to cough reflex arc
|
| Differential diagnosis: branches of vagus nerve in ear, meninges, larynx, and thoracic and abdominal areas (meningitis can
cause intractable cough); intracranial masses; alcohol removes inhibition of reflex arc; goiter, mediastinal masses [eg,
lymphoma]); pneumonia (cough or hiccups due to irritation of diaphragm)
|
| Management: auricular irrigation—consider 60-mL syringe; before starting procedure, pneumatic otoscopy to confirm
that tympanic membrane intact; contraindications—perforated tympanic membrane; battery removal; hygroscopic objects
(eg, vegetables or beans) swell when wet (however, speaker has had success); cyanoacrylate glue—in study,
used to remove foreign body from external auditory canal of cadavers; removal quicker using right-angle hook; to remove
cyanoacrylate glue from ear—warm 3% hydrogen peroxide; insecticidal activity of common reagents (slowest
to quickest)—water alone (≈3 min); lidocaine with epinephrine; 1% lidocaine alone; isopropyl alcohol
|
| Foreign body in nose: have patient blow nose or sneeze (do not overlook obvious methods)
|
| Parent’s “kiss”: consider oxymetazoline (Neo-Synephrine) to dry mucus membrane; have child open mouth; occlude opposite
nostril; have parent put mouth over child’s mouth as in cardiopulmonary resuscitation (CPR) and blow; in speaker’s experience,
foreign body ejected in 30% of cases and technique well-tolerated; consider Neo-Synephrine and/or topical anesthetic;
use papoose board and work quickly; speaker prefers Trendelenburg positioning (head down, lungs up); have
parent cover child’s mouth to prevent swallowing object after ejection
|
| Katz extractor: insert into nose, inflate small balloon at tip, and pull back out; pearl—insert further than thought needed
(object often larger than expected)
|
| Magnets: used to remove objects containing iron, nickel, or cobalt (not gold or silver) from ear, nose, or wound
|
| Forceps (case): patient choking on plastic bottle top; speaker used Magill forceps
|
| Eyelids glued together with cyanoacrylate: best treatment mineral oil compresses; leave on overnight (may require 2
nights); works for removing liquid skin adhesive (Dermabond) as well
|
Salicylate Overdose
| First hospital: 13-yr-old boy presented with shortness of breath, chest pain, and dizziness; history of anxiety and outbursts of
anger, attention-deficit/hyperactivity disorder (ADHD), and Tourette’s syndrome; taking amphetamine and dextroamphetamine
(Adderall); anxious and tachypneic; otherwise, physical examination unremarkable; patient given lorazepam
(Ativan) and felt better; initial diagnosis anxiety and hyperventilation; later same day, symptoms worse
|
| Second hospital: same complaints, diagnosis, and treatment; patient feeling better and discharged; next morning, still not
feeling well and returns to hospital; vital signs (slight tachycardia and tachypnea); alert and oriented but difficult; on
electrocardiography (ECG), sinus tachycardia; toxicology screen (amphetamines [Adderall]); patient treated with Ativan
and haloperidol (Haldol) and referred for evaluation
|
| Third hospital: patient acidotic (bicarbonate 14 mmol/L; pH 7.5); diagnosis—salicylate overdose (blood level 58.2 mg/
dL; overdose >30 mg/dL); second hospital screened for drugs of abuse (not full toxicology screen); patient never told
staff about salicylate use
|
| Background: ≈60% of cases misdiagnosed; usually neurologic signs present; 150 mg/kg toxic
|
| Sources: bismuth subsalicylate (Pepto-Bismol ES)—in toddler, 3 oz toxic (9 oz lethal); bottle 12 oz; Bengay (pain-relieving
rub)—1 oz contains 7 g salicylate (equivalent to 21 aspirin); methyl salicylate (oil of wintergreen)—1 tsp
equivalent to 21 aspirin
|
| Pathophysiology: salicylate overdose makes medulla sensitive to low levels of carbon dioxide; hyperventilation leads to
respiratory alkalosis; increases metabolism and lactic acid production by uncoupling oxidative phosphorylation; excess
O2 in system; increased heat production; hypoglycemia; breakdown of fatty acids and glycogen increases glucose level;
ketones in urine; finally, metabolic acidosis (anion gap acidosis)
|
| Differential diagnoses: “MUDPILES”—methanol; uremia; diabetic ketoacidosis (DKA); paraldehyde; iron; lactic acidosis;
ethylene glycol; and salicylates
|
| Long-term aspirin abuse: decreased platelet aggregation and synthesis of vitamin K-dependent clotting factors; capillary
leakage; pulmonary edema; clinical presentation—increased tachypnea (possible rales); cerebral edema (patient agitated);
with increased metabolism, increased body temperature; heart and respiratory rates elevated; possible Kussmaul
respirations (mimics DKA); rales due to pulmonary edema; can affect hair cells in inner ear, causing tinnitus; vomiting;
agitation and mental status change or seizures; diaphoresis; hyperventilation; early on, appearance may be normal
|
| Presentations: case 1—vomiting; Kussmaul respirations; urine positive for glucose; clinically suggests DKA, but glucose
150 mg/dL; case 2—fever, vomiting, increased respiratory rate, and rales (normally, suggests pneumonia); chest x-ray
reveals pulmonary edema, rather than infiltrate; case 3—patient agitated, hyperventilating, and anxious; not improving;
case 4—fever, vomiting, and mental status change (differential diagnosis meningitis); if not improving, suspect aspirin
overdose; more clues—unusual respiratory symptoms or fever; alkalosis or acidosis
|
Acetaminophen Overdose
| Case: 2-yr-old boy ingested contents of bottle of adult-strength acetaminophen (Tylenol) 2 hr ago
|
| Obtain stat accetaminophen level? nomogram does not start until 4 hr postingestion; at 4 hr, if level >150 µg/mL, acetylcysteine
(N-acetylcysteine; Mucomyst) indicated; must wait to determine level of absorption (2-hr level not helpful)
|
| Induce vomiting at home? if ingestion >1 hr ago, ipecac or lavage not effective; anticholinergic (eg, diphenhydramine
[Benadryl]) may slow gastric motility; most liquids absorbed within 20 or 30 min (ability to extract from child almost
nil); ipecac or lavage?—if object fits through nose, too small; lavage in 2 yr old (speaker uses 30F orogastric tube);
only 30% of stomach contents removed with lavage or ipecac; speaker prefers lavage (results immediate); ipecac takes
5 to 30 min; with either intervention, 70% remains available for absorption; activated charcoal—best efficacy when
administered within 1 hr of ingestion
|
| Immediate treatment with N-acetylcysteine? works as well at 7 or 8 hr postingestion as 1 hr; wait for blood level (avoids
conflict; if not obtainable within reasonable time, use Mucomyst)
|
| Best approach: acetaminophen level within 4 hr postingestion; (if level toxic, Mucomyst within 8 hr); if <1 hr, consider activated
charcoal
|
Hydrocarbon Inhalation
| Aliphatic hydrocarbon aspiration: causes pneumonitis (potentially fatal); sources—lamp oil; citronella; hair oil; gasoline;
kerosene; lighter fluid
|
| Lighter fluid: key question whether patient coughs, chokes, or sputters; case—patient 22 mo of age; at 3 days, pneumopericardium;
at 5 days, pulmonary interstitial emphysema (worse on day 9); day 10, pneumoperitoneum
|
| Take-home points: keep eg, citronella out of reach of young children; observe at least 4 to 6 hr postingestion; admit if—
respiratory symptoms; abnormal pulse oximetry or chest x-ray; x-ray at end of 4- to 6-hr window gives best chance of
detection; discharge based on symptoms—not chest x-ray (takes 2 wk to normalize); if child not sick within 24-hr
observation period, send home
|
| Hydrocarbon propellant (eg, air freshener) abuse: problem in older children; potentially lethal; legal and inexpensive to
purchase; rapid high with short duration
|
| Neurologic: potentiates inhibitory neurotransmitter γ-amino butyric acid (GABA); causes white matter degeneration
|
| Cardiovascular: bradycardia (potentially lethal); sensitizes myocardium to catecholamines; case—child bradycardic and
disoriented; model glue on fingernails; patient given atropine (no improvement); given epinephrine (progression to
ventricular fibrillation); patient shocked out of it, well for a while, then bradycardic; given atropine (no improvement);
given epinephrine (progression to ventricular tachycardia; shock administered); myocardial sensitization to catecholamines
key (epinephrine contraindicated; use pace medication); Sudden Sniffing Death Syndrome—patient sniffing glue
or air freshener; gets caught by parents (catecholamines spike); cardiac arrest
|
| Sources: fuels—butane; propane; motor oil; gasoline; shop class and teacher’s desk—model glue; correction fluid;
toiletries—deodorant; hairspray; any aerosol propellant can be abused; kitchen—cooking spray; nitrous oxide (from eg,
aerosol can of whipped cream)
|
| Clinical presentation: often, appearance normal (intoxication dissipates quickly); patients may appear inebriated or euphoric,
have hallucinations and/or delusions; wheezing (aerosol irritates airways; catecholamine [eg, albuterol] contraindicated);
consider ipratropium (Atrovent; muscarinic blocker as opposed to sympathomimetic); bradycardia; huffer’s acne (rash
around mouth); mucous membrane irritation—nasal irritation; chronic cough; hemoptysis; red eyes
|
Alcohol Abuse
| Case: parents had party at home previous night; next morning, 2-yr-old girl wakes up before parents; patient tired and less
active (“not herself”); seizures in office; glucose level 10 mg/dL; soon afterward, twin brother also seizing
|
| Signs and symptoms: hypoactivity; hypothermia; hypopupils; hypoglycemia—ingestion of alcohol (ethanol) causes impairment
of gluconeogenesis and glycogenolysis; gluconeogenesis—converting pyruvate to glucose; requires nicotinamide
adenine dinucleotide (NAD), but NAD used up metabolizing alcohol; glycogenolysis—utilizes glycogen stores in
liver (much smaller in child than adult); ethanol content—beer (6%); wine (12%-14%); mouthwash (28%); vanilla extract
(35%); whiskey (45%); some perfumes (90%)
|
| Pyrethrins (case): 3-yr-old child ate insect; parent sprayed insecticide (RAID) down child’s throat; fortunately, low
toxicity—most common problem allergy (50% cross-reactivity with ragweed)
|
Educational Objectives
| The goal of this program is to educate the listener about selected medical emergencies in children. After hearing and assimilating
this program, the clinician will be better able to:
|
| 1. Diagnose and localize foreign body ingestion.
|
| 2. Choose appropriate methods for removing foreign bodies.
|
| 3. Identify common household toxins.
|
| 4. Diagnose toxic ingestions.
|
| 5. Choose appropriate treatment for selected toxic ingestions.
|
Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP; several formulations and trade names)
Acetylcysteine (N -acetylcysteine) [Acetadote, Mucomyst, Mucosil-10, -20]
Albuterol (salbutamol sulphate in United Kingdom) (several formulations and trade names)
Amphetamine and dextroamphetamine [Adderall, Adderall XR]
Aspirin (acetylsalicylic acid; ASA; several formulations and trade names)
Atropine sulfate [AtroPen, Atropine Sulfate Ophthalmic, Atropine Care, Atropine-1, Atropisol, Isopto Atropine, Sal-
Tropine]
Bismuth subsalicylate (BSS) [Bismatrol, Bismatrol Extra Strength, Pepto-Bismol, Pepto-Bismol Maximum Strength, Pink
Bismuth]
Diphenhydramine HCl (several formulations and trade names)
Epinephrine [Adrenalin Chloride, Adrenalin Chloride Solution, Epifrin, EpiPen, EpiPen Jr., Glaucon, microNefrin,
Nephron, Primatene Mist, S2]
Haloperidol [Haldol, Haldol Decanoate 50, Haldol Decanoate 100]
Hydrogen peroxide (H2 O2 )
Ipratropium bromide [Atrovent]
Lorazepam [Ativan, Lorazepam Intensol]
Methyl 2-cyanoacrylate (MCA)
Methyl salicylate (wintergreen oil)
Metoclopramide [Clopra, Maxolon, Metoclopramide Intensol, Octamide, Octamide PFS, Reclamide, Reglan]
Oxymetazoline HCl (several formulations and trade names)
Polyethylene glycol-electrolyte solution (PEG-ES) [CoLyte, GoLYTELY, NuLytely, OCL]
Polymyxin B sulfate, neomycin, and bacitracin (several formulations and trade names)
Resources
National Button Battery Ingestion Hotline: 202-625-3333
Suggested Reading
Anato B et al: Foreign body ingestion causing gastric an.diaphragmatic perforation in a child. Pediatr Surg Int 21:326,
2005; Antonelli PJ et al: Insecticidal activity of common reagents for insect foreign bodies of the ear. Laryngoscope
111:15, 2001; Botma M et al: ‘A parent’s kiss: evaluating an unusual method for removing nasal foreign bodies in children.
J Laryngol Otol 114:598, 2000; Broderick M: Pediatric poisoning! RN 67:37, 2004; Cakir B et al: Localization and
removal of ferromagnetic foreign bodies by magnet. Ann Plast Surg 49:541, 2002; Clifton JC 2nd et al: Acute pediatric
lead poisoning: combined whole bowel irrigation, succimer therapy, and endoscopic removal of ingested lead pellets. Pediatr
Emerg Care 18:200, 2002; Douglas DD: Dissolving hair wrapped around an infant’s digit. J Pediatr 91:162, 1977;
Franzese CB, Schweinfurth JM: Delayed diagnosis of a pediatric airway foreign body: case report and review of the literature.
Ear Nose Throat J 81:655, 2002; Isbister G et al: Pediatric acetaminophen poisoning. Arch Pediatr Adolesc Med
155:417, 2001; Kurul S, Kandogan T: Pharyngeal foreign body in a child persisting for three years. Emerg Med J 19:361,
2002; Mohiuddin S et al: Esophageal foreign body aspiration presenting as asthma in the pediatric patient. South Med J
97:93, 2004; Persaud R: A novel approach to the removal of superglue from the ear. J Laryngol Otol 115:901, 2001;
Rovin JD, Rodgers BM: Pediatric foreign body aspiration. Pediatr Rev 21:86, 2000;
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, Dr. Anderson
reported nothing to disclose.
Dr. Anderson was recorded at the 62nd Annual Brennemann Memorial Lectures, presented September 22-25, 2005, in
San Diego by the Los Angeles Pediatric Society. The Audio-Digest Foundation thanks Dr. Anderson and the Los Angeles
Pediatric Society for their cooperation in the production of this program.
|
