Selected Topics: Toxicology
The Limited Utility of Screening Laboratory Tests and Electrocardiograms in the Management of Unintentional Asymptomatic Pediatric Ingestions

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Abstract

Background

Suspected ingestions are a common chief complaint to the emergency department although the majority of ingestions by children are insignificant.

Objective

Assess the utility of screening laboratory tests and Electrocardiograms (ECGs) in unintentional asymptomatic pediatric poisonings.

Methods

Retrospective chart review at a tertiary care children's hospital and a regional poison center of patients less than 12 years of age using ICD-9 codes from January 2005 through December 2008. Laboratory or ECG results requiring intervention and/or direct treatment, a non-RPC subspecialty consultation, and/or prolonged Emergency Department stay was considered changed management.

Results

Five hundred ninety five suspected ingestions met our criteria. The median age was 2.6 years (IQR 1.6, 3.0 years) and 56% were male. One laboratory test or ECG was obtained in 233 patients (39%). Of 24 screening ECGs, 32 complete blood counts and 34 blood gases, none were clinically significant. Fifty-two patients received screening metabolic panels, 3 were abnormal and 2 changed management (anion gap metabolic acidosis with unsuspected salicylate ingestions). None of the 127 (21%) screening acetaminophen levels changed management. Two of sixty-five (13%) screening salicylate levels changed management. Three screening urine toxicology tests on patients with altered mental status were positive without ingestion history. No patient under the age of 12 years with normal vital signs and normal mental status had positive screening tests.

Conclusions

Screening laboratory tests and ECGs 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.

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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Cited by (6)

  • The Use of Electrocardiography in the Emergency Department

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    Citation Excerpt :

    In all pediatric patients with accidental or nonaccidental overdoses, it is prudent to contact the poison control center for specific recommendations based on the substance(s) ingested and the age and size of the patient. For most asymptomatic patients with accidental overdoses, obtaining an ECG is not recommended, as it has been found to be low yield.29 One notable exception to this recommendation is any patient who has accidentally or nonaccidentally overdosed on a tricyclic antidepressant (TCA).

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