RESUMEN
To determine the risk of increased blood lead levels in children with aural, nasal, or gastrointestinal foreign bodies, the authors prospectively obtained venous blood lead and erythrocyte protoporphyrin levels from 40 study patients and two control groups without foreign bodies (65 patients presenting to a medical clinic and 40 patients presenting to an emergency department). A questionnaire was used to assess environmental and behavioral risk factors for lead poisoning in the three groups. Mean blood lead level was higher in children with foreign bodies (P less than .001), and they were more likely to have a venous blood lead value of more than 1.2 mumol/L (25 micrograms/dL, P less than .01) than patients in either control group. Seventy-eight percent of study patients had no prior lead screening by parent's report vs 64% of emergency department control subjects and 55% of medical clinic control subjects. Control patients in the emergency department had the same incidence of elevated blood lead values as patients enrolled from the medical clinic (6%). No differences in environmental risk factors were found among the three groups. Study patients more often had a history of pica or ingestion of a poison than control patients from the medical clinic. Inner-city children with foreign bodies have increased lead exposure and may have an increased risk for lead poisoning. In areas of high prevalence of lead poisoning, children with foreign bodies should be screened for lead poisoning in the emergency department. General lead screening in the emergency department may be justified for high-risk, inner-city populations.
Asunto(s)
Cuerpos Extraños , Plomo/sangre , Preescolar , Sistema Digestivo , Oído , Eritrocitos/química , Femenino , Cuerpos Extraños/complicaciones , Vivienda , Humanos , Intoxicación por Plomo/sangre , Masculino , Nariz , Pica/complicaciones , Prevalencia , Estudios Prospectivos , Protoporfirinas/sangre , Factores de RiesgoRESUMEN
Previous studies of childhood chest pain have been retrospective or considered only limited age groups or referred patients. In this study, all children who were admitted to the emergency department with chest pain were evaluated prospectively. Patients with ill-defined chest pain had ECGs and echocardiograms performed. A total of 407 children were evaluated. The most common causes of the pain were idiopathic (21%) and musculoskeletal (15%). Cardiac problems were found in 4%. Chest pain was acute (of less than 48 hours' duration) in 43% and chronic (of greater than 6 months' duration) in 7%. Pain caused 30% of children to stay out of school and 31% to awaken from sleep. Chest wall tenderness was the most common abnormality. ECGs were obtained in 47%; results of 31/191 were abnormal but only 4/191 ECG abnormalities were related to the diagnosis. Echocardiograms were obtained in 34%; results of 17/139 were abnormal (12/139 showed mitral valve prolapse). Young children are more likely to have cardiorespiratory problems; children older than 12 years of age are more likely to have psychogenic pain. The description and location of the pain and the patient's sex are not related to the diagnosis. Nonorganic disease is related to a family history of heart disease or chest pain or having chronic pain. Organic disease is related to pain of acute onset, abnormal physical examination results, pain that awakens the child from sleep, and the presence of fever. Laboratory tests are rarely helpful in evaluating children with chest pain. Chest pain in children is usually benign. Psychogenic pain and idiopathic pain are less common than previously believed.
Asunto(s)
Dolor en el Pecho/etiología , Enfermedad Aguda , Adolescente , Factores de Edad , Enfermedades Óseas/complicaciones , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/psicología , Niño , Preescolar , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Masculino , Enfermedades Musculares/complicaciones , Estudios ProspectivosRESUMEN
Acute accidental iron poisoning is a common serious and potentially fatal intoxication in the young child. Approximately 1 per cent of such poisoning have a fatal outcome, and outcome is closely related to the early onset of coma or shock. Long-term prognosis is excellent for all survivors of the acute episode, although there are occasional obstructive complications occurring four to six weeks later.
Asunto(s)
Urgencias Médicas , Hierro/envenenamiento , Enfermedades Cardiovasculares/inducido químicamente , Catárticos/uso terapéutico , Enfermedades del Sistema Nervioso Central/inducido químicamente , Enfermedad Hepática Inducida por Sustancias y Drogas , Niño , Preescolar , Deferoxamina/uso terapéutico , Dieta , Compuestos Ferrosos/administración & dosificación , Lavado Gástrico , Enfermedades Gastrointestinales/inducido químicamente , Humanos , Absorción Intestinal , Ipeca/uso terapéutico , Hierro/administración & dosificación , Hierro/sangre , Enfermedades Metabólicas/inducido químicamente , PronósticoRESUMEN
The effect of elevated blood lead levels on the blood pressure of children has not been clearly described. In order to define this association better, we conducted a cross-sectional study, evaluating the association between lead and high blood pressure. Using a Dinamap monitor to measure blood pressures, blood pressures and blood lead levels were measured in 149 children (ages 1-10 years) receiving medical care at the General Medical and Lead Poisoning Clinics at Children's Hospital of Philadelphia. Blood lead levels ranged from 7 to 70 mg/dL with a mean of 27 mg/dL. The mean systolic blood pressure was 108 mmHg and the mean diastolic reading was 63 mmHg. Higher systolic blood pressure was significantly correlated with increased weight, age, and height. Diastolic pressure was significantly associated with weight and height. There was a small, negative correlation between blood lead levels and systolic blood pressure, and a positive but insignificant correlation between lead levels and diastolic blood pressure. Our study population had both higher mean lead levels and a higher prevalence of hypertension than is true of the U.S. population as a whole. We concluded that elevated blood lead levels are not associated with elevated blood pressure in children.
Asunto(s)
Presión Sanguínea/efectos de los fármacos , Intoxicación por Plomo/fisiopatología , Niño , Preescolar , Estudios Transversales , Femenino , Humanos , Hipertensión/inducido químicamente , Lactante , Intoxicación por Plomo/sangre , Intoxicación por Plomo/complicaciones , MasculinoRESUMEN
Our approach to the management of fear and pain in the pediatric emergency department is presented. Tricks to attempt the gaining of rapport with frightened children in pain are noted, with emphasis on a developmental approach. The use of analgesic medications, local anesthetics, ketamine, and nitrous oxide as appropriate to emergency situations is outlined. Lastly, the guidelines of the American Academy of Pediatrics for outpatient sedation are reviewed.
Asunto(s)
Servicio de Urgencia en Hospital , Manejo del Dolor , Analgésicos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/uso terapéutico , Actitud del Personal de Salud , Niño , Humanos , Relaciones Padres-Hijo , Examen Físico/métodos , Terapia por Relajación , Restricción FísicaRESUMEN
The incidence of serious pediatric morbidity and mortality has fortunately declined over the past two decades due to better prevention efforts, the development of regionalized poison information programs, and advances in the emergency management and critical care of poisoned patients. Still, children continue to explore and often ingest many substances they discover in their world. Some of these children will become patients who present to the emergency department, requiring a coordinated approach to the seriously or even critically ill poisoned child by physicians who can access specialized resources to manage a vast spectrum of potential toxins. This article summarized one such approach, emphasizing initial attention to life support priorities, followed by a detailed evaluation process using readily available clinical and laboratory data. Management strategies including decontamination, urgent antidotal therapy, initiation of excretion enhancement, and optimal supportive care were reviewed. Several specific intoxications were illustrated briefly in an attempt to facilitate pattern recognition of characteristic pediatric exposures.
Asunto(s)
Intoxicación/terapia , Acetaminofén/envenenamiento , Intoxicación Alcohólica/diagnóstico , Intoxicación Alcohólica/terapia , Astemizol/envenenamiento , Niño , Preescolar , Clonidina/envenenamiento , Cocaína/envenenamiento , Cuidados Críticos , Dextrometorfano/envenenamiento , Sobredosis de Droga , Femenino , Humanos , Hidrocarburos/envenenamiento , Lactante , Insecticidas/envenenamiento , Hierro/envenenamiento , Masculino , Compuestos OrganofosforadosRESUMEN
Acute accidental iron poisoning is a common serious and potentially fatal intoxication in the young child. Approximately 1 per cent of such poisonings have a fatal outcome, and outcome is closely related to the early onset of coma or shock. Long-term prognosis is excellent for all survivors of the acute episode, although there are occasional obstructive complications occurring four to six weeks later.
Asunto(s)
Enfermedades Cardiovasculares/inducido químicamente , Enfermedades del Sistema Nervioso Central/inducido químicamente , Enfermedades Gastrointestinales/inducido químicamente , Hierro/envenenamiento , Enfermedad Aguda , Animales , Niño , Preescolar , Deferoxamina/uso terapéutico , Diagnóstico Diferencial , Urgencias Médicas , Compuestos Ferrosos/toxicidad , Lavado Gástrico , Enfermedades Gastrointestinales/terapia , Humanos , Lactante , Ipeca/uso terapéutico , Hierro/sangre , Pronóstico , Riesgo , Factores de Tiempo , TriajeRESUMEN
Acute lead encephalopathy has become a rare syndrome in the United States. Early recognition of the disease, with institution of specific chelation therapy, is critical in order to minimize mortality and morbidity. Lead intoxication, however, may mimic other more common diseases. We report an 8-year-old child with known sickle cell anemia who presented initially with findings suggestive of vaso-occlusive crisis but who deteriorated rapidly and was found to have severe lead poisoning. We present her hospital course and review the management of lead encephalopathy in detail.
Asunto(s)
Encefalopatías/inducido químicamente , Intoxicación por Plomo/complicaciones , Anemia de Células Falciformes/complicaciones , Anemia de Células Falciformes/terapia , Encefalopatías/complicaciones , Encefalopatías/tratamiento farmacológico , Quelantes/uso terapéutico , Niño , Diagnóstico Diferencial , Urgencias Médicas , Eritrocitos/análisis , Recambio Total de Sangre , Femenino , Estudios de Seguimiento , Humanos , Plomo/sangre , Intoxicación por Plomo/sangre , Intoxicación por Plomo/tratamiento farmacológico , Pica/sangre , Protoporfirinas/sangre , Convulsiones/tratamiento farmacológico , Convulsiones/etiología , Factores SocioeconómicosRESUMEN
This study was a 13-month prospective, descriptive case series of risperidone overdose reported by telephone to a regional poison control center (PCC) serving Philadelphia, PA. Patients were seen in local Philadelphia-area emergency departments. The variables examined were medical history, therapeutic use of risperidone, time postingestion, reported coingestants, clinical findings, decontamination and treatment, electrocardiograph results, laboratory data, standard toxicologic screen results, and length of time in hospital. Thirty-one patients (29 adult/adolescent, 2 pediatric) with reported risperidone overdose were identified. Risperidone was the sole ingestant in 15 cases (1 mg to 180 mg). The major observed effects in this group included lethargy (7), spasm/dystonia (3), hypotension (2), tachycardia (6), and dysrhythmia (1). Sixteen cases involved coingestants, including benzodiazepines, selective serotonin reuptake inhibitors, ethanol, tricyclic antidepressants, lithium, anticonvulsants, diphenhydramine, ibuprofen, and anticholinergic agents. Major effects in these patients included lethargy (10), coma (1), seizure (1), tachycardia (7), bradycardia (1), hypotension (4), and a syndrome of muscle spasms, diaphoresis, and fever. Treatment provided for patients in this study included antiarrhythmics (1), diphenhydramine (2), anticonvulsant (1), vasopressor agent (1), endotracheal intubation/assisted ventilation (5), and supportive care. One patient who coingested imipramine died of medical complications. In the remaining patients, symptoms resolved with 24 hours in the majority, with all patients asymptomatic at 72 hours postingestion. These data show that risperidone toxicity manifests primarily as mild central nervous system effects and reversible neuromuscular and cardiovascular effects.
Asunto(s)
Antipsicóticos/efectos adversos , Tratamiento de Urgencia , Risperidona/efectos adversos , Adolescente , Adulto , Niño , Preescolar , Sobredosis de Droga/terapia , Femenino , Humanos , Lactante , Masculino , Philadelphia , Centros de Control de Intoxicaciones , Estudios Prospectivos , Teléfono , Resultado del TratamientoRESUMEN
To better characterize methemoglobinemia in children, we reviewed the charts of 17 patients who were admitted to a children's hospital over the last 10 years. Two distinct groups were identified: (1) The endogenous group (n = 9) included patients with methemoglobinemia associated with an intercurrent illness. (2) The exogenous group (n = 8) included patients with methemoglobinemia secondary to drug exposure. Despite similar initial methemoglobin levels in the endogenous (mean, 29%) and exogenous (mean, 28%) groups, children in the endogenous group had more acidosis (serum bicarbonate levels of 5.9 vs 19.1 mmol/L and arterial pH of 7.01 vs 7.35). All the children in the exogenous group with methemoglobinemia secondary to an accidental ingestion stayed only 1 day in the hospital, while children in the endogenous group were admitted for an average of 19 days. Children with methemoglobinemia secondary to a drug exposure have a more benign illness with a shorter duration than children with methemoglobinemia associated with an intercurrent illness. It appears that the absolute level of methemoglobin is not as important as the underlying cause in determining both the course and severity of illness.
Asunto(s)
Metahemoglobinemia/etiología , Bicarbonatos/sangre , Análisis de los Gases de la Sangre , Causalidad , Preescolar , Femenino , Humanos , Concentración de Iones de Hidrógeno , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico , Tiempo de Internación , Recuento de Leucocitos , Masculino , Metahemoglobinemia/sangre , Metahemoglobinemia/inducido químicamente , PronósticoRESUMEN
An 18-month-old boy ingested approximately 18 g FeSO4, equivalent to 336 mg/kg elemental Fe. He rapidly developed severe gastroenteric symptoms, obtundation, and transient hypotension. The serum iron level two hours after ingestion was 6,798 micrograms/dL. He was treated with deferoxamine intravenously, enterally, and as a lavage solution. His hospital course was notable for lack of severe neurologic, hepatic, metabolic, or cardiovascular complications acutely with apparent complete recovery, although he returned six weeks after ingestion with intestinal obstruction due to a jejunal stricture.
Asunto(s)
Deferoxamina/uso terapéutico , Compuestos Ferrosos/envenenamiento , Obstrucción Intestinal/etiología , Hierro/envenenamiento , Humanos , Lactante , Hierro/sangre , MasculinoRESUMEN
We reviewed 47 consecutive inpatient records to determine the clinical course, role of supportive measures, and response to naloxone in children with clonidine poisoning. Severity of illness was assigned by means of the "pediatric risk of mortality" (PRISM) score. The children's ages ranged from 9 to 84 months. Central nervous system effects were noted in 44 patients; bradycardia occurred in 25, and apnea or depressed respiration was seen in 18. Thirty-four patients had symptoms within 1 hour of presentation, but no patient had further clinical deterioration more than 4 hours after presentation. Six patients required endotracheal intubation and mechanical ventilation. There was no difference in PRISM score or duration of symptoms between those patients who received naloxone and those who did not. More patients receiving naloxone required intubation, and only three patients had definite improvement after naloxone administration. We conclude that (1) young children who ingest clonidine have a wide spectrum of serious findings, (2) delayed progression of symptoms after clonidine poisoning is unlikely in a young child with normal renal function, and (3) naloxone is an inconsistent antidote for clonidine poisoning.
Asunto(s)
Clonidina/envenenamiento , Naloxona/uso terapéutico , Atropina/uso terapéutico , Bradicardia/tratamiento farmacológico , Carbón Orgánico/uso terapéutico , Niño , Preescolar , Clonidina/antagonistas & inhibidores , Femenino , Lavado Gástrico , Frecuencia Cardíaca , Humanos , Lactante , Ipeca/uso terapéutico , Masculino , Respiración ArtificialRESUMEN
The ability to detect the characteristic "chocolate" brown color of methemoglobin containing blood was tested in a double blind study. We prepared three concentrations of methemoglobin by adding sodium nitrite to 1-2 ml of venous, heparinized blood that was "arterialized" by mixing with room air in vacutainer tubes. House officers (HO) were asked, in a standardized protocol, to make observations ("chocolate", "abnormal" or "normal") about the methemoglobin blood alone (first in Vacutainer, and then on filter paper), and then in comparison with control blood, again in Vacutainer, then filter paper. Each HO assessed only one methemoglobin concentration. Three methemoglobin blood samples were studied with 12-14%, 26-35% and 68% methemoglobin concentrations respectively. We found that the ability to detect visually an abnormal appearance of methemoglobin was significantly improved when the test sample was compared to control blood. The descriptive term "darker than normal" was much more commonly used than "chocolate" to describe the methemoglobin blood.
Asunto(s)
Metahemoglobinemia/sangre , Recolección de Muestras de Sangre/instrumentación , Color , Método Doble Ciego , Filtración/instrumentación , Humanos , Metahemoglobinemia/diagnóstico , PapelRESUMEN
We describe life-threatening methemoglobinemia in a child who ingested a nitroethane artificial-fingernail remover initially mistaken to be an acetone-based polish remover. Nitroethane-induced methemoglobinemia may be delayed and recurrent; patients ingesting this substance may warrant close observation for at least 24 hours. Care givers are cautioned to determine the precise substance involved in ingestions of potentially toxic fingernail products.
Asunto(s)
Cosméticos/envenenamiento , Etano/análogos & derivados , Metahemoglobinemia/inducido químicamente , Nitroparafinas/envenenamiento , Etano/envenenamiento , Femenino , Humanos , Lactante , Metahemoglobinemia/diagnóstico , Metahemoglobinemia/terapia , Índice de Severidad de la EnfermedadRESUMEN
The establishment of pediatric emergency medicine as a subspecialty of emergency medicine has engendered the need for closer examination and development of guidelines for fellowship training. Core content and curriculum documents pertaining to fellowship training in pediatric emergency medicine for pediatric graduates have been published previously. However, the educational needs of emergency medicine graduates for such training are significantly different from those of pediatric graduates in several important respects. We believe that emergency physicians should take an active role in the creation and refinement of educational guidelines for fellowship training in pediatric emergency medicine for emergency medicine graduates. For this reason, we present a proposed core content outline in the hope that it will serve to foster this process.
Asunto(s)
Curriculum , Educación de Postgrado en Medicina/organización & administración , Medicina de Emergencia/educación , Becas/organización & administración , Guías como Asunto , Pediatría/educación , Rol del Médico , Humanos , Desarrollo de Programa , Estados UnidosRESUMEN
A two-year retrospective review of accidental albuterol ingestions in children less than 12 years old was performed to assess overdose toxicity and to investigate a dose-effect relationship. One hundred twelve exposures were located. Seventeen cases were excluded owing to coingestants, leaving 95 cases for evaluation. Twenty-nine children (30%) remained at home without intervention or telephone followup because of an ingestion of less than 0.6 mg/kg. Twenty-eight patients (30%) were followed at home by telephone (12 of whom received ipecac). Dosages ranged from 1 to 27 mg, with dose/weight ratios of 0.1 to 1.9 mg/kg. Two children experienced transient mild symptoms (irritability, brief nausea, and vomiting). The remaining 26 children were asymptomatic. Thirty eight cases (40%) were treated in an emergency department. Ingestions ranged from 2 to 96 mg, with dose/weight ratios of 0.3 to 6.3 mg/kg. Ages ranged from one to 11 years. Transient restlessness or irritability was observed in 16 patients, tachycardia in 15, tremors in six, and a widened pulse pressure in one. No serious events occurred in this series, and no patient required treatment beyond gastrointestinal decontamination. For ingestions of 0.6 mg/kg or less, treatment at home with observation may be sufficient. For larger ingestions, eg, greater than 0.6 mg/kg, consideration should be given to direct medical evaluation and gastrointestinal decontamination.
Asunto(s)
Albuterol/envenenamiento , Accidentes Domésticos , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Sobredosis de Droga/complicaciones , Sobredosis de Droga/terapia , Humanos , Lactante , Estudios RetrospectivosRESUMEN
A semiquantitative nasopharyngeal culture was found to be sensitive and specific in predicting middle ear pathogens in children with acute bacterial otitis media. In nasopharyngeal specimens with growth of at least 1,000 colonies, the tympanocentesis isolate was present and was either the predominant isolate or accounted for 50% of growth in 16 of 16 children. Data suggest that virulence of nasopharyngeal organisms plays a role in the pathogenesis of acute otitis media. Qualitative differences were found in the nasopharyngeal flora of children with bacterial otitis media as compared with children with clinical otitis media and sterile tympanocentesis cultures, children with uncomplicated upper respiratory illness, and healthy children. Abundant growth of Haemophilus influenzae (greater than or equal to 50% total colony count) was associated with children with bacterial otitis media, and abundant Branhamella catarrhalis was associated with the others (P less than or equal to 0.01). Abundant growth of Streptococcus pneumoniae occurred frequently and regardless of clinical category. Antibiotic treatment of children with otitis media resulted in rapid quantitative and qualitative changes in nasopharyngeal flora.