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PubMedDate not supplied

Quality improvement process in the adherence to gastric decontamination guidelines for poison exposures as recommended by a poison control center.

PURPOSE: Adherence to new guidelines for the use of ipecac syrup, gastric lavage, cathartics, and activated charcoal by a poison control center was studied with a quality improvement framework. METHODS: The rates of gastric decontamination were monitored through an electronic case record system. In February 2002, a revised guideline that narrowed the use of gastric decontamination was implemented with a performance improvement process. The rates of recommendation and utilization during 12 months following implementation of the new guidelines were compared with those during 12 previous months. RESULTS: Recommendations for the use of ipecac syrup declined from 1.50% to 0.02% (OR; 95% CI = 0.02; 0.01, 0.03), single-dose-activated charcoal declined from 5.39% to 1.38% (0.25; 0.22, 0.28), gastric lavage declined from 4.19% to 0.22% (0.05; 0.04, 0.06), and a cathartic declined from 1.48% to 0.13% (0.08; 0.06, 0.12). Declines in utilization were also significant (P < .001) for all forms of gastric decontamination. The proportions of patients managed at the scene of the poisoning were unchanged (1.04; 0.99, 1.09) before (67.64%) and after (68.50%) the new guidelines as were those for referral to a health care facility (20.57% and 21.42%, respectively, 1.05; 1.00, 1.11). CONCLUSION: Recommendations on gastric decontamination can be effectively modified with no detriment to patient outcome.

Decontamination↗
PubMed2000

A preschool program for safety and injury prevention delivered by home visitors.

OBJECTIVE: To evaluate the feasibility, acceptability, and effectiveness of an injury prevention program delivered by school based home visitors to the families of low income children attending preschool enrichment programs in Washington State. STUDY SAMPLE: The families of children attending preschool Head Start programs in two regions were eligible. A total of 213 families (77.8% of those eligible) from intervention sites, and 149 families (71.9% of those eligible) from concurrent comparison sites, agreed to participate and completed the trial. INTERVENTION: Trained school personnel conducted home safety inspections as part of a planned home visit. Intervention families were offered educational materials as well as smoke detectors, batteries, ipecac, and age appropriate car safety restraints based on results of the home inspection. EVALUATION METHODS: At a repeat home visit three months later, the proportion of families with a positive change in injury prevention knowledge or behavior among those in the intervention group was compared with the proportion in the comparison group. Smoke detector presence and function were observed. RESULTS: Among families without a working smoke detector at baseline, the intervention was associated with an increased probability of having a working detector at follow up (relative risk (RR) 3.3, 95% confidence interval (CI) 1.3 to 8.6). Intervention families were also more likely to report the presence of ipecac in the home (RR 4.7, 95% CI 3.0 to 7.3) at follow up and to have obtained an age appropriate booster seat (RR 4.1, 95% CI 1.9 to 8.8). The program was acceptable to client families and to the home visitors who conducted the intervention. CONCLUSIONS: Among the families of low income children enrolled in preschool enrichment programs, home safety inspections and the distribution of safety supplies by school based home visitors appears to improve knowledge and behavior related to poisoning, smoke detector installation, and car safety seat use over three months of follow up.

Accidents, Home↗
PubMed1998

Preschool children at risk for repeat injuries.

Home-related injuries are a major problem in young children. This study investigated maternal and child characteristics related to repeat injuries in preschool children. A secondary data analysis was conducted on a national probability sample of African American and White mothers who participated in the longitudinal study of the National Maternal and Infant Health Survey. Repeat injuries in the African group were associated with poor maternal health status, maternal use of alcohol, and Ipecac in the home. Significant factors for the White group were male child, unmarried mother, difficulty managing the child, maternal depression, poor maternal health status, and Ipecac in the home. Findings support the need to identify high-risk children and to provide interventions specially aimed at amelioration of those factors related to repeat injuries.

Accidents, Home↗
PubMed1998

Exposure to and compliance with pediatric injury prevention counseling--United States, 1994.

BACKGROUND: Because injuries are the leading cause of death in children, injury prevention counseling is recommended as part of routine pediatric care. Increasing such counseling is a national health objective. Estimating the proportion of US children who receive such counseling and assessing their compliance with safety recommendations may help improve counseling efforts. METHODS: Respondents to a 1994 random digit-dial telephone survey of the US population were asked about receipt of age-appropriate injury prevention counseling at a medical visit and related safety practices for a randomly selected child 0 to 14 years of age in the household (N = 1596). RESULTS: Receiving any injury prevention counseling was reported for 39.3% of children 0 to 14 years old who had a medical visit in the past year and was more common among children who were younger, lived in urban areas, and lived in poverty. In general, receiving counseling was associated with safer behaviors. Counseling about ipecac was reported for 17.2% of children 0 to 6 years old; having ipecac in the home was more likely for those counseled (73.4% vs 32.0%). Counseling about posting the poison control number was reported for 24.9% of children 0 to 6 years old; posting this number was more common among those counseled (79.3% vs 52.6%). Counseling about bicycle helmets was reported for 18.6% of children 5 to 14 years old; a report of always wearing a helmet was more common among those counseled (43.9% vs 19.1%). Counseling about car seats and safety belts was reported for 25.4% of children 0 to 14 years old; a report of always using occupant restraints was more common among those counseled (89.0% vs 78.2%). CONCLUSIONS: Injury prevention counseling is associated with reported preventive safety practices among US children, but a relatively small proportion of households with young children report receiving such counseling. Health care providers should increase efforts to provide injury prevention counseling. counseling, wounds and injuries, child, accident prevention.

Accident Prevention↗
PubMedDate not supplied

Toxic effects of nonsteroidal anti-inflammatory drugs in overdose. An overview of recent evidence on clinical effects and dose-response relationships.

Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical classes: acetic acids, fenamic acids, oxicams and propionic acids. Most NSAID overdoses result in a benign outcome. Of 50,614 exposures reported to poison centres in the United States in a 2-year period, 131 (0.26%) had a major outcome, with 10 deaths. Despite the generally mild effects reported in large patient series, isolated case reports have documented serious toxicity, such as seizures, hypotension, apnoea, coma and renal failure. The majority of these consequences occur after ingestion of substantial quantities by adults attempting suicide. Rarely, with ibuprofen and piroxicam, children who ingest small amounts in accidental exposure develop serious toxicity. Typical signs and symptoms of NSAID overdose include nausea, vomiting, headache, drowsiness, blurred vision and dizziness. Seizures are rarely documented across all NSAID classes, with the exception of mefenamic acid (where seizures occur in over one-third of cases), or following massive ingestion of other agents. Drugs in the propionic acid group have produced metabolic acidosis, respiratory depression and coma in severe cases. Ibuprofen is the agent with the most published data on overdose, probably because it is available without a prescription in many countries. Symptoms are unlikely after ingestion of 100 mg/kg or less, and are usually not life-threatening unless more than 400 mg/kg is ingested. There is some relationship between plasma concentrations and the potential for development of symptoms, but plasma concentrations have no impact on treatment decisions. Treatment of NSAID overdose is entirely supportive. Recent trends in emergency department procedures regarding gastric decontamination are evolving towards the recommended administration of activated charcoal without gastric emptying in patients presenting more than 1 hour after ingestion, although gastric lavage, followed by administration of activated charcoal, may be advisable in patients who present earlier. Home administration of syrup of ipecac is still recommended if treatment is given shortly after ingestion, with a few exceptions: for example, ipecac is contraindicated after ingestion of mefenamic acid or ibuprofen in amounts greater than 400 mg/kg. Urine alkalinisation and diuresis have been recommended to enhance the elimination of NSAIDs, based on a pKa in the range of 3 to 5. However, because the drugs are universally highly protein bound, with little unchanged renal excretion, this technique is not likely to be beneficial. Haemodialysis is also unlikely to enhance elimination, but may be required if oliguric renal failure develops. Multiple dose activated charcoal may be useful in enhancing elimination of NSAIDs with long half-lives, such as piroxicam and sulindac.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1981

Emergency induction of emesis using liquid detergent products: a report of 15 cases.

Solutions of liquid detergent products were used to induce emesis in 15 patients who could not or would not obtain syrup of ipecac. Four patients refused to drink any of the solution and two others refused part, one of whom vomited. In the patients who drank all or part of the solution, 91% (10/11) vomited with a mean time to the onset of emesis of 6.5 min. None of these patients developed symptoms attributable to the ingested poison or the detergent solution. Liquid detergent solutions may be a useful alternative emetic for the poison center when a patient cannot be given syrup of ipecac.

Adult↗
PubMed1996

Relative toxicity of beta blockers in overdose.

OBJECTIVE: To compare the toxicity of beta blockers in overdose and to identify clinical features predictive of serious toxicity. DESIGN: Comparison of clinical data collected prospectively on a relational database of subjects presenting to hospital with self-poisoning, coroner's data and prescription data. SETTING: Newcastle and Lake Macquarie, Australia, 1987-1995. MAIN OUTCOME MEASURES: Death, seizure, cardiovascular collapse, hypoglycemia, coma and respiratory depression. SUBJECTS: Fifty-eight self-poisonings with beta blockers and two deaths investigated by the coroner with evidence of propranolol poisoning. RESULTS: All patients who developed toxicity did so within six hours of ingestion. The use of ipecac was temporally associated with cardiorespiratory arrest in one patient. Propranolol was the only beta blocker associated with seizure; of those who ingested more than 2 g of propranolol, two thirds had a seizure. There was a significant association between a QRS duration of > 100 ms and risk of seizures. Propranolol was over represented in beta blocker poisoning when prescription data were also examined. Propranolol was the only beta blocker associated with death. Propranolol was taken by a younger age group. CONCLUSIONS: Propranolol should be avoided in patients at risk of self-poisoning. Propranolol poisonings should be observed closely for the first six hours post ingestion. Syrup of ipecac should not be used to decontaminate the gastrointestinal tract after beta blocker overdose.

Adolescent↗
PubMed1992

Ingestion of cylindrical and button batteries: an analysis of 2382 cases.

During a 7-year period, 2382 cases of battery ingestion were reported to a national registry. Button cells were ingested by 2320 of these patients; 62 patients ingested cylindrical cells. These cases are analyzed to reassess current therapeutic recommendations, hypotheses about battery-induced injury, and strategies for prevention and intervention. Hearing aids were the most common intended use of ingested cells (952 cases, 44.6%); and in 312 (32.8%) of these cases, the battery actually was removed by a child from the child's own aid. Overall, 9.9% of patients were symptomatic. Two children experienced severe esophageal injury following the ingestion of large diameter cells and required repeated dilatation. In this series and in prior reports, most batteries which lodged in the esophagus and caused esophageal injury were large diameter (20 to 23 mm). However, neither battery diameter nor symptom occurrence could be used to detect all patients with esophageal battery position. Outcome was not affected by battery discharge state, but was influenced by chemical system. Lithium cells, with their larger diameters and greater voltage, were associated disproportionately with adverse effects. Mercuric oxide cells were substantially more likely to fragment, compared with other chemical systems. No clinical evidence of mercury toxicity occurred in this series, although one patient demonstrated minimal elevation of blood mercury levels. In this series and 10 prior reports, all patients with elevated blood mercury levels had ingested batteries which fragmented and showed evidence of radio-opaque droplets in the gut. Special monitoring may be advisable for individuals who have ingested 15.6-mm-diameter mercuric oxide cells. Ipecac was administered in 37 cases of button cell ingestion, causing battery expulsion in only one patient. Retrograde battery movement from the stomach to the esophagus necessitating emergent endoscopic retrieval occurred as a complication of ipecac administration in another patient. The use of endoscopic and surgical intervention declined more than fivefold during the study period. Endoscopic retrieval success was a function of battery location, with batteries in the esophagus more readily retrieved than those in more distal gastrointestinal locations (90.0% vs 46.7%, respectively). A current management protocol is presented advocating a noninvasive approach for most cases of button cell ingestion where an esophageal position is excluded. Manufacturers are urged to provide more securely fastened, child-resistant battery compartments on hearing aids as well as other battery-powered products in household use.

Age Factors↗
PubMed1989

Accidental terfenadine ingestion in children.

Terfenadine is a newly marketed non-sedating antihistamine. It binds strongly with peripheral H-1 receptors and only weakly with muscarinic, alpha and beta-adrenergic receptors. There is limited information about ingestion by children 1-5 years old and no reports in the literature of accidental ingestion. We performed a 1-year retrospective study at the DVRPCC and NJPIES. Twenty-eight cases of accidental ingestions of terfenadine by children aged 1-5 yrs were identified; 27 cases were treated at home and 1 treated in a hospital. Two cases (120 mg and 300 mg) received ipecac at home and were followed by telephone with 1.4 and 24 hr callbacks. No symptoms were reported. In 1 case (180 mg) ipecac was advised but the mother refused to give it. No symptoms were reported on followup. One case (2 yr, 900mg) was referred to a hospital and arrived asymptomatic 2 hr postingestion. The child received activated charcoal and sorbitol, remained asymptomatic and was discharged 6 hr postingestion. The remaining 24 cases (60 mg-120 mg) were treated at home with observation alone. Twenty-one of these cases reported no symptoms on followup. Three cases were lost to followup. Evidence suggests that accidental ingestions of small doses of terfenadine (60 mg-120 mg) in children will not produce toxicity. Larger studies may be needed to verify these findings.

Accidents, Home↗
PubMed1989

Emetine identified in urine by HPLC, with fluorescence and ultraviolet/diode array detection, in a patient with cardiomyopathy.

A 15-year-old girl with a four-month history of cardiac failure from undetermined cause was admitted to the hospital with weakness, fatigue, and weight loss. During her hospitalization she was found to have abused diet aids, laxatives, and cathartics. Although an electrocardiogram revealed nonspecific T-wave abnormalities and laboratory studies showed supranormal enzyme test results for creatine kinase and lactate dehydrogenase, no definite explanation of the cardiomyopathy was forthcoming. Ipecac abuse leading to cardiomyopathy was suspected early in the hospitalization. HPLC analysis of a urine sample showed emetine, a principle component of ipecac, the presence of which was later confirmed by more-specific HPLC analysis with photodiode array detection.

Adolescent↗
PubMed1985

Levothyroxine ingestions in children: an analysis of 78 cases.

A series of 78 cases of accidental levothyroxine ingestion in children (less than 12 years old) with treatment limited to ipecac-induced emesis and a single oral dose of activated charcoal is presented. No patient received any form of dialysis or hemoperfusion, propylthiouracil, cholestyramine, steroids, or serial doses of oral activated charcoal. Propranolol was used in one case despite the absence of clinical manifestations of toxicity. Only four children developed symptoms, limited to modest fever (38.3 degrees C), supraventricular tachycardia (120-176 beats/min), lethargy, irritability, vomiting, diarrhea, and abdominal pain. Peak T4RIA values in three patients were 32.8, 30.0, and 26.4 micrograms/dl, respectively, and two of these patients remained asymptomatic. Initial therapy for acute levothyroxine ingestions in children can be safely limited to routine gastrointestinal decontamination. Hospitalization or prophylactic treatment with propranolol, propylthiouracil, corticosteroids, cholestyramine, or extracorporeal detoxification are unnecessary in the early asymptomatic phase.

Charcoal↗
PubMed1990

Prospective evaluation of gastric emptying in the self-poisoned patient.

The authors prospectively studied the effect of gastric emptying (GE) and activated charcoal (AC) upon clinical outcome in acutely self-poisoned patients. Presumed overdose patients (n = 808) were treated using an alternate day protocol based on a 10-question cognitive function examination and presenting vital sign parameters. Asymptomatic patients (n = 451) did not receive GE. AC was administered to asymptomatic patients only on even days. GE in the remaining symptomatic patients (n = 357) was performed only on even days. On emptying days, alert patients had ipecac-induced emesis while obtunded patients received gastric lavage. AC therapy followed gastric emptying. On nonemptying days, symptomatic patients were treated only with AC. No clinical deterioration occurred in the asymptomatic patients treated without GE. AC use did not alter outcome measures in asymptomatic patients. GE procedures in symptomatic patients did not significantly alter the length of stay in the emergency department, mean length of time intubated, or mean length of stay in the intensive care unit. Gastric lavage was associated with a higher prevalence of medical intensive care unit admissions (P = .0001) and aspiration pneumonia (P = .0001). The data support the management of selected acute overdose patients without GE and fail to show a benefit from AC in asymptomatic overdose patients.

Adolescent↗
PubMed1985

Inefficacy of gastric emptying procedures.

Gastric lavage or ipecac-induced emesis are routinely recommended in the management of the acutely poisoned patient. Efficacy of either procedure has not been shown. Three cases are described clearly demonstrating inefficacy of emesis and wide bore orogastric lavage. The role of these procedures requires careful controlled evaluation. Until the publication of supportive data, their efficacy is unproven.

Adolescent↗
PubMed1985

Atrioventricular block following overdose of decongestant cold medication.

A 24-year-old man developed high-degree atrioventricular (A-V) block with a pulse rate of 40 beats per minute and hypertension following an overdose of a combination decongestant cold medication that contained phenylpropanolamine, phenylephrine, chlorpheniramine, and phenyltoloxamine. The patient was treated with ipecac, activated charcoal, and cathartics in the emergency department (ED). After his admission to the coronary care unit, the A-V block gradually resolved to sinus rhythm with periods of second-degree block, Mobitz types I and II. No treatment was required. The patient had a normal sinus rhythm and normal blood pressure prior to discharge.

Adult↗
PubMed1985

Advances in clinical toxicology.

New data are reviewed in two areas in the management of the acute overdose: gastrointestinal decontamination and systemic antidotes. The mechanism and effectiveness of Ipecac syrup, gastric aspiration and lavage, activated charcoal, gastrointestinal dialysis, and saline cathartics are discussed. Special problems posed by disc batteries and packet ingestion of cocaine (in transporting contraband) are highlighted. The pharmacology and uses of pyridoxine and naloxone as antidotes are detailed.

Antidotes↗
PubMed1986

Gastrointestinal decontamination for acute poisoning.

Gastric decontamination remains an important element in the therapy of pediatric poisoning; however, several issues remain unresolved. Additional studies, particularly in the clinical setting, are necessary to establish optimal therapeutic recommendations. Based on the data presented in this review, the following general recommendations can be made for gastric decontamination in children: If it is necessary to remove an ingested toxin, ipecac syrup is the preferred method if contraindications to its use are not present. The dose should be 30 ml in children older than 1 year of age and 10 ml in children 6 to 12 months of age. Pending further studies, the use of emetics in children younger than 6 months of age cannot be generally recommended, particularly in the home setting. Gastric lavage should be considered to be of very limited use in pediatric patients. Lavage using small nasogastric tubes, except under special circumstances, is nonproductive and cannot be advocated. If it must be used, a large-bore orogastric hose should be used. Administration of activated charcoal prior to lavage should be considered. In situations in which prompt induction of emesis is not possible or contraindications to emesis exist, activated charcoal followed by, or mixed with, a cathartic (preferably sorbitol) should be used as an alternative to removal of gastric contents. Patients with significant symptoms from ingestion requiring hospitalization should receive repeat doses of charcoal and cathartic until symptoms resolve. Activated charcoal should be given in conjunction with other appropriate therapies. Although the data to substantiate this recommendation are limited, particularly in pediatric patients, it is a benign therapy that holds promise of increasing drug elimination.

Absorption↗
PubMed1992

Fatal rodenticide poisoning with brodifacoum.

The increased prevalence of rodents resistant to warfarin led to the development of the hydroxycoumarin anticoagulant brodifacoum. A 25-year-old man attempted suicide by consuming four boxes of d-CON Mouse-Prufe II; each box contains 42 g of bait that is 0.005% brodifacoum. He presented to a hospital nine days later with syncope, hematochezia, gross hematuria, epistaxis, anemia, and a severe coagulopathy. Radiographic studies were consistent with pleural, pericardial, and mediastinal hemorrhages. Vitamin K and fresh frozen plasma were given, and he was later discharged on oral phytonadione (vitamin K1). The patient's coagulopathy recurred, necessitating multiple plasma transfusions and prolonged treatment with oral phytonadione. Fifteen weeks after hospital discharge, he presented again with a history of additional brodifacoum ingestion. Neurologic status was initially normal, but in the emergency department he suddenly became comatose soon after emesis was induced with syrup of ipecac. Computed tomography of the brain revealed a subarachnoid hemorrhage that led to brain death less than 24 hours later. This case demonstrates the severe and prolonged coagulopathy that can result from ingestion of brodifacoum, a compound that has a toxic potency about 200-fold that of warfarin and a half-life as much as 60 times longer.

4-Hydroxycoumarins↗
PubMed1990

Whole-bowel irrigation as treatment for zinc sulfate overdose.

A 16-year-old boy ingested approximately 50 zinc sulfate tablets (ZnSO4; 500-mg tablets). After spontaneous emesis, ipecac-induced emesis, and orogastric lavage, an abdominal radiograph performed four hours after ingestion still demonstrated approximately 50 ZnSO4 tablets within the stomach and three pills within the colon. Whole-bowel irrigation was begun with a polyethylene glycol lavage solution (PEG; Golytely) that was administered through a nasogastric tube; within one hour, the patient began producing a rectal effluent that contained pills. The patient remained asymptomatic throughout whole-bowel irrigation. Stool guaiac tests were negative. The serum chloride, however, increased from 105 to 127 mEq/L. Follow-up kidney, ureter, and bladder studies demonstrated the clearance of the zinc tablets from the gastrointestinal tract during the next 24 hours.

Administration, Rectal↗