Pediatric poisonings comprise the majority of the toxic exposures reported to U.S. poison centers. Pediatric exposures to specific substances have the potential to cause significant morbidity and mortality, sometimes with even what might be considered small amounts to those not familiar with the risks of exposure. These toxins include such substances as specific prescription medications, over-the-counter medications, essential oils, and common household items. With such a vast array of potential toxic exposures that can affect children, it is imperative that health care practitioners who work with children understand the general management of the poisoned pediatric patient.

OBJECTIVE:To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge.METHODS:We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded.RESULTS:Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up.CONCLUSIONS:Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

Calculation of maintenance fluids for infants and children has long been a rite of passage for both medical students and trainee physicians, in a process based on the landmark work of Holliday and Segar. 1 Holliday MA Segar WE The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957; 19: 823-832 PubMed Google Scholar Carefully calculating the electrolyte needs and fluid requirements of paediatric patients on the basis of their daily requirements, bodyweight, and losses is a long-held tenet of our specialty. Common practice is still to give hypotonic fluid to meet hydration goals. In The Lancet, Sarah McNab and her colleagues 2 McNab S Duke T South M et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. Lancet. 2014; (published online Dec 1.)http://dx.doi.org/10.1016/S0140-6736(14)61459-8 PubMed Google Scholar gather data that argues for a switch to isotonic fluid. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trialUse of isotonic intravenous fluid with a sodium concentration of 140 mmol/L had a lower risk of hyponatraemia without an increase in adverse effects than did fluid containing 77 mmol/L of sodium. An isotonic fluid should be used as intravenous fluid for maintenance hydration in children. Full-Text PDF

Chapter 78 Fever and Rash in a Child David L. Eldridge MD, David L. Eldridge MDSearch for more papers by this author David L. Eldridge MD, David L. Eldridge MDSearch for more papers by this author Book Editor(s):Christopher P. Holstege MD, FACEP, FAAEM, FACMT, Christopher P. Holstege MD, FACEP, FAAEM, FACMT Director, Division of Medical Toxicology, Medical Director, Blue Ridge Poison Center, Associate Professor, Departments of Emergency Medicine and Pediatrics, University of Virginia, Charlottesville, VirginiaSearch for more papers by this authorAlexander B. Baer MD, Alexander B. Baer MD Associate Medical Director, Blue Ridge Poison Center, Clinical Assistant Professor, Department of Emergency Medicine, University of Virginia, Charlottesville, VirginiaSearch for more papers by this authorJesse M. Pines MD, MBA, FAAEM, Jesse M. Pines MD, MBA, FAAEM Lecturer, Department of Emergency Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PennsylvaniaSearch for more papers by this authorWilliam J. Brady MD, FACEP, FAAEM, William J. Brady MD, FACEP, FAAEM Vice Chair, Department of Emergency Medicine, Professor, Department of Emergency Medicine and Internal Medicine, University of Virginia, Charlottesville, VirginiaSearch for more papers by this author First published: 01 January 2006 https://doi.org/10.1002/9780470755921.ch78 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Visual Diagnosis in Emergency and Critical Care Medicine RelatedInformation

Case 4 A Neonate with Fever and Rash David L. Eldridge MD, David L. Eldridge MDSearch for more papers by this author David L. Eldridge MD, David L. Eldridge MDSearch for more papers by this author Book Editor(s):Christopher P. Holstege MD, Christopher P. Holstege MD Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA, USASearch for more papers by this authorAlexander B. Baer MD, Alexander B. Baer MD Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA, USASearch for more papers by this authorJesse M. Pines MD, Jesse M. Pines MD Center for Health Care Quality, Department of Emergency Medicine and Health Policy, George Washington University, Washington, DC, USASearch for more papers by this authorWilliam J. Brady MD, William J. Brady MD Department of Emergency Medicine, University of Virginia, Charlottesville, VA, USASearch for more papers by this author First published: 03 August 2011 https://doi.org/10.1002/9781444397994.ch4 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Visual Diagnosis in Emergency and Critical Care Medicine, Second Edition RelatedInformation

Intravenous (IV) catheter placement in the pediatric patient population can be challenging. Many health care providers automatically choose IV fluid administration to treat dehydration, often not considering other routes. This article reviews the available literature on difficulties in obtaining IV access in the pediatric population and discusses alternative methods for fluid replacement, their respective advantages and disadvantages, and place in therapy.

Intravenous (IV) catheter placement in the pediatric patient population can be challenging. Many health care providers automatically choose IV fluid administration to treat dehydration, often not considering other routes. This article reviews the available literature on difficulties in obtaining IV access in the pediatric population and discusses alternative methods for fluid replacement, their respective advantages and disadvantages, and place in therapy.

We report the results of an international Clostridium difficile typing study to cross reference strain designations for seven typing methodologies and facilitate inter-laboratory communication. Four genotypic and three phenotypic methods were used to type 100 isolates and compare the results to 39 PCR ribotypes identified among the collection.

Paraquat is an herbicide that is highly toxic to humans. Pediatric ingestion has become uncommon in the United States because of preventative efforts. We report here an unintentional, fatal paraquat ingestion by an 8-year-old child. Storage in an inappropriate container, confusion between herbicide trade names, nonspecific symptoms, and a delay in follow-up produced challenges in the diagnosis. In the absence of a clear history of ingestion, paraquat poisoning should be suspected in children who develop skin and mucous membrane burns, gastrointestinal symptoms, acute kidney injury, and respiratory failure.

The use of gastrointestinal decontamination (GID) has long been held as a primary tenet in the initial management of a poisoned pediatric patient. Although this approach seems logical, there is a lack of clinical evidence to indicate that GID use changes ultimate clinical outcome. Recent recommendations and guidelines have advised against routine use of any method of GID. With this in mind, the contraindications and safety precautions with each of these techniques deserve emphasized consideration. Recent research has endeavored to find more specific indications for GID in which clear clinical outcomes may be measured. With the removal of ipecac, the hunt for a safe and effective form of GID that can be used at home has also received research interest.

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.

In the early part of chemical terrorism or hazardous materials events, protective actions and patient care require empirical decisions because reliable and accurate information may not be readily available. It has become increasingly important to identify reliable information resources that are the most likely to be accessed for information during these events. We sought to identify information resources that volunteer Emergency Medical Services (EMS) providers would use during a suspected chemical exposure. Survey questionnaires were completed by 116 of 151 (76.8%) suburban and rural EMS providers. In the past 12 months, most participants used medical journals and textbooks (59.5%), internet sites (57.8%), and poison centers (55.2%) as information resources. For two hypothetical scenarios involving chemical exposures, poison centers were most frequently chosen as likely contacts for information regarding the identity of the agent (case 1: 52.6%, case 2: 48.3%), treatment (74.1%, 64.7%, respectively), and antidote (59.5%, 49.1%, respectively). Fire department hazardous materials team tied with poison centers as the highest for chemical agent in the second scenario (48.3%) and was ranked highest both for decontamination (75.0%, 64.7%, respectively) and personal protection (56.9%, 45.7%, respectively). Poison centers were selected as the best resource for timely information (70.7%), availability (69.0%), and ease of contact (72.4%), and second highest for knowledge of chemical agents (44.0%), after CHEMTREC (56.9%). Finally, poison centers and CHEMTREC received the highest overall ratings (28.4% and 26.7%, respectively). Poison centers are viewed as an important information resource by EMS providers and may be the most commonly sought resource for various information needs during a suspected chemical exposure.

Evaluating a suspected poisoning or drug overdose provides a special challenge to clinicians. Prompt diagnosis in these cases allows the choice of an appropriate antidote or, more commonly, the provision of appropriate supportive care. On the basis of fictional portrayals in the popular media, many have the misconception that just ‘sending a sample to the lab’ will provide the answers to these clinical quandaries.

Hallucinogens. Nichols DE. Pharmacol Ther. 2004;101:131–181National Institute on Drug Abuse Web Site. Available at http://www.drugabuse.govThe Psychopharmacology of Hallucinogens. Abraham HD, Aldridge AM, Gogia P. Neuropsychopharmacol. 1996;14:285–298Toxic Psychoses as Pharmacological Models of Schizophrenia. Potvin S, Stip E, Roy J. Curr Psychiatr Rev. 2005;1:23–32The hallucinogens comprise a group of drugs that alters perception, cognition, and mood. Despite their name, hallucinogens only sometimes cause true hallucinations, defined as perceiving experiences that do not occur. These substances exert their mind-altering effects primarily through agonism at serotonin receptors (specifically 5-HT2a) in the central nervous system. There is some controversy over which drugs of abuse fit neatly into the category of hallucinogens. Although phencyclidine (PCP) may cause hallucinations, it is classified as a dissociative drug. Other drugs of abuse such as cocaine, anticholinergics, marijuana, and methylenedioxymethamphetamine (MDMA or “ecstasy”) can alter perception or produce hallucinations, but these drugs are not classified as hallucinogens because of different mechanisms of action and numerous other important physiologic and toxicologic effects.The best-known hallucinogen is the semisynthetic compound lysergic acid diethylamide (LSD). Naturally occurring hallucinogens include psilocybin, obtained from Psilocybe cubensis or “magic mushrooms,” and mescaline, derived from the peyote cactus. Lesser known but similar compounds include N,N-dimethyltryptamine (DMT), derived from many botanical sources, and lysergic acid amide (LSA), derived from morning glory seeds. Although most of these compounds are ingested, DMT is smoked or inhaled nasally.Historically, hallucinogens have been used for religious ceremonies, recreational abuse, and even research purposes to induce alterations of perception. The Monitoring the Future Survey of the National Institute on Drug Abuse provides an annual assessment of the extent of drug use among 8th-, 10th-, and 12th-grade students nationwide. The use by adolescents of hallucinogens as a class, and specifically of LSD, began to decline in the 1990s. Use of these drugs has remained stable at historically low levels of lifetime use: 3.5% of 8th graders and 9.7% of 12th graders stated use on data collected from 2002 through 2004.Physiologic effects of hallucinogen use include paresthesias, dizziness, weakness, drowsiness, nausea, and blurred vision. The desired effect is altered perception by the user. Typical perceptual symptoms include distortion of shapes and colors and hallucinations that usually are visual. A classic, although uncommon, hallucinogen-induced perceptual change is synesthesia, in which one sense is perceived as another. For example, a user who has synesthesia may feel that he or she is “hearing” colors or “seeing” smells. Hallucinogen users may experience distorted cognition and have difficulty expressing thoughts or an imprecise sense of time. Users may describe a transcendent or dreamlike state. Mood often is affected greatly and varies from euphoria to a “bad trip,” in which the user experiences profound anxiety or fear.Unlike many other drugs of abuse, no current evidence suggests direct end-organ toxicity or overdose fatalities from hallucinogens. The acute danger of hallucinogens, instead, comes from their effect on judgment while the individual is in an altered state. Although reports are relatively rare, the unsupervised, altered patient may have a deadly accident, as in an attempt to fly. Irreversible ocular damage has been reported from staring at the sun. There is no evidence that these substances are physiologically addictive or produce a withdrawal syndrome.A long-term adverse outcome of hallucinogen use is the occurrence of “flashbacks,” now more appropriately referred to as hallucinogen persisting perception disorder. This condition consists of episodes of re-experiencing one or more of the perceptual symptoms previously induced by hallucinogen use after the drug has worn off and in the absence of another disorder, such as psychiatric illness. Although case reports of this phenomenon exist, it is believed to be rare.Symptoms of hallucinogen intoxication may be difficult to distinguish from those of psychiatric illness, particularly schizophrenia. Lack of a family history of psychiatric disorders, absence of symptoms when the drug has cleared, and variable severity of symptoms that can be related to an ingestion suggest hallucinogen toxicity. Although hallucinogens may cause visual perceptual disturbances and visual hallucinations, they do not cause the disorganized thinking, true delusions, and auditory hallucinations that are typical of schizophrenia.The treatment of a patient who is suspected of being under the influence of a hallucinogen is primarily supportive. Acutely intoxicated patients should be placed in a calm, quiet, protected environment and provided contact with familiar people and objects. Those experiencing a “bad trip” may benefit from benzodiazepines.Comment: The word hallucinogen, derived from Latin, means to wander in mind or talk idly. Research on hallucinogens has been challenging because these preparations exert varying effects, depending on the perception of the user and the setting where the use has taken place. The therapeutic benefits of these drugs have been debated. Additional research is needed to explore the neurocognitive effects of hallucinogens in an attempt to understand consciousness better, reduce anxiety in terminally ill patients facing death, and perhaps understand the mechanisms of certain mental illnesses, such as psychoses and schizophrenia.

Acetaminophen (acetyl-para-amino-phenol or APAP), an antipyretic and analgesic, is a common component in hundreds of over-the counter and prescription medications. The wide usage of this drug results in many potentially toxic exposures. It is therefore critical for the clinician to be comfortable with the diagnosis and treatment of APAP toxicity. Prompt recognition of APAP overdose and institution of appropriate therapy are essential to preventing morbidity and mortality.