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Pediatric Toxicology Emergencies
PEDIATRIC NURSING REVIEW QUESTIONS
PEDIATRIC TOXICOLOGY EMERGENCIES Authors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA, Dyer, IN, Vernon Hills, IL Section Editors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA
he review questions that are featured in each of the issues of the JEN are based upon the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. These questions appear online only.
T
REFERENCES 1. Olgun H, Yildirim Z, Karacan M, Ceviz N. Clinical, electrocardiographic, and laboratory findings in children with amitriptyline intoxication. Pediatr Emerg Care. 2009;25(3):170-3. 2. DeBoer S. Certified Pediatric Emergency Nurse Review: Putting It All Together. 2nd ed. Dyer, IN: Peds-R-Us Medical Education; 2011. 3. Glatstein M, Garcia-Bournissen F, Scolnik D, Rosenbloom E, Koren G. Sudden-onset tachypnea and confusion in a previously healthy teenager. Ther Drug Monit. 2010;32(6):700-3. 4. Ogilvie J, Rieder M, Lim R. Acetaminophen overdose in children. CMAJ. 2012;184(13):1492-6. 5. Blackford M, Felter T, Gothard M, Reed M. Assessment of the clinical use of intravenous and oral N-acetylcysteine in the treatment of acute acetaminophen poisoning in children: a retrospective review. Clin Ther. 2011;33(9):1322-30.
QUESTIONS 1. You are caring for a 16-year-old, 65-kg boy with a confirmed
intentional Elavil (amitriptyline) overdose that occurred approximately 5 hours ago. The patient is displaying a consistently prolonged QRS and occasional runs of widecomplex tachycardia, which seem to be occurring more frequently. The patient has 2 large-bore intravenous (IV) lines, and 0.9NS (normal saline) is infusing. When the patient goes into sustained ventricular tachycardia, you should anticipate which order next? A. Activated charcoal B. Immediate 12-lead electrocardiogram C. Sodium bicarbonate D. Lidocaine, 20 mg IV push 2. Despite the initial treatment chosen in question 1, the runs of
wide-complex tachycardia continue and the patient with a tricyclic antidepressant (TCA) overdose is now borderline hypotensive. Your next anticipated medication is A. Amiodarone B. Magnesium C. Bretylium D. Procainamide 3. You are the nurse of a 12-year-old with unknown drug
ingestion. The patient complains of ringing in his ears. On the basis of this presentation, the ED staff should evaluate the patient for what specific kind of overdose? A. Anticonvulsants B. Aspirin (acetylsalicylic acid) C. Antibiotics D. Acetaminophen 4. Which of the following correctly lists typical symptoms of Scott DeBoer is Flight Nurse, University of Chicago Hospitals, Chicago, IL, and Founder, Peds-R-Us Medical Education, Dyer, IN. Michael Seaver is Senior Healthcare Consultant, Vernon Hills, IL. Review questions and answers on topics about which nurses should be knowledgeable. J Emerg Nurs 2014;40:e121-e122. 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.12.002
November 2014
VOLUME 40 • ISSUE 6
Tylenol (acetaminophen, Panadol) overdose within the first 6 hours? A. Nausea, vomiting, diarrhea, headache B. Nothing, nonspecific, asymptomatic C. Altered mental status; prolonged PR, QRS, and QT intervals D. Abnormal liver function tests, bradycardia, hypotension
5. A non-pregnant, 16-year-old teen with type 1 diabetes took an
unknown quantity of Tylenol (acetaminophen, Panadol) 6 hours ago, stating “I don’t know . . . I just emptied the bottle .
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PEDIATRIC NURSING REVIEW QUESTIONS/DeBoer and Seaver
. . 3 handfuls, maybe 20 capsules….” Which of the following is an effective intervention for this patient? A. Syrup of Ipecac B. Gastric lavage C. N-acetylcysteine (NAC) D. Activated charcoal ANSWERS 1. Correct answer: C Sodium bicarbonate is the appropriate choice in this overdose case because we know an important factor, the specific medication, from the history. Sodium bicarbonate is preferred over lidocaine (a very tempting choice) in TCA overdose because it helps in 2 ways: The bicarbonate ion can act to reverse the metabolic acidosis that usually goes hand in hand with TCA overdose, and the high sodium load counteracts the conduction delay occurring through cardiac sodium channels. Bicarbonate should be administered as an initial bolus of 1 to 2 mEq/kg, followed by an infusion titrated to a QRS width of 100 milliseconds. The pH goal is 7.45 to 7.55. It is too late for activated charcoal, which is recommended in the first 1 to 2 hours after ingestion. An immediate 12-lead electrocardiogram, though nice to have, is not needed at this moment because there are potentially lethal arrhythmias obvious on 3 to 5 leads. There is also a great risk of seizure in these patients, especially within the first 6 to 8 hours, so one must be ready with benzodiazepines such as Ativan (lorazepam). Dilantin (phenytoin) is not recommended because it acts on sodium channels, which are the issue with TCA overdoses. The following additional pediatric ED and toxicology attending physician insights should be noted: Correction of acidosis should be guided by arterial blood gases, electrolytes, and clinical judgment. Attention should be directed to volume status and correction of poor perfusion in mild cases. Sodium bicarbonate may be used to correct the acidosis in severe cases with an initial push of 1 to 2 mEq/kg intravenously (not to exceed adult doses). Infusion of sodium bicarbonate in an appropriate fluid for the patient’s size and age may be guided by the base deficit in blood gases. Usually, this requires 1 to 2 ampules of sodium bicarbonate per liter of IV fluids administered at a rate appropriate for the patient’s weight. Additional added sodium bicarbonate or slow boluses may be required. A hypertonic solution with respect to sodium content should not be made. Sodium content should generally not exceed that of normal saline solution. Finally, one should remember in all cases like this to consult the Poison Control Center. Olgun et al, 1 170–173; DeBoer, 2 435–436. 2. Correct answer: B Magnesium is next because all of the rest of the medication choices are contraindicated in TCA overdose. Amiodarone and bretylium both prolong the QT interval, whereas procainamide (avoid the “ides”) will
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worsen the pre-existing conduction delay by further blocking sodium channels. Olgun et al, 1 170–173; DeBoer, 2 435–436. 3. Correct answer: B Ringing in the ears, or tinnitus, is one of the textbook side effects of a large aspirin overdose. Acute aspirin overdose may lead to nausea, vomiting (sometimes with blood), and stomach pain. Another classic sign of aspirin overdose is hyperventilation, as the body attempts to compensate for the developing respiratory alkalosis (caused by the ingested acetylsalicylic acid) by blowing off CO2. Other signs and symptoms of aspirin overdose include temporary deafness, dizziness, drowsiness, hyperactivity, seizures, and even coma. One mnemonic used to remember how to treat overdoses or ingestions is SIREN: S, stabilize the child’s condition; I, identify the poison; R, reverse its effect and reduce absorption; E, eliminate the toxin; N, need for consultation with poison control, ongoing physical care, and psychiatric consultation (was the incident a suicide attempt?). DeBoer, 2 442; Glatstein et al, 3 700–703. 4. Correct answer: B Early acetaminophen overdose may be hard to identify because patients often exhibit “nothing, nonspecific, and/or asymptomatic” symptomatology. This is why obtaining an accurate patient history, providing empiric treatment, performing initial/repeat laboratory tests, and contacting Poison Control are so important in a suspected acetaminophen overdose. Patients may be asymptomatic for 24 hours or more, but the liver damage has begun before that point. DeBoer, 2 437–438; Ogilvie et al, 4 1492–1496. 5. Correct answer: C N-acetylcysteine, or NAC (Mucomyst, oral form; Acetadote, IV form), is the appropriate intervention in this scenario. Aside from the “guestimated” amount ingested, all of the other variables given are irrelevant distracters. One should follow local protocols and Poison Control guidance for N-acetylcysteine dosing guidelines. If possible, the serum acetaminophen concentration will be determined and used, along with the estimated time and amount of ingestion, to guide treatment. It should be noted that the toxicity nomogram starts at 4 hours. Serum acetaminophen levels obtained less than 4 hours after ingestion are of little use except to determine whether any of the medication was ingested. Aside from smelling like rotten eggs, Mucomyst has few adverse side effects and may be given with little risk until the laboratory results are known. With few exceptions (ie, Poison Control recommendation), syrup of ipecac and gastric lavage are no longer recommended, and even activated charcoal is falling out of favor unless the ingestion occurred within 1 hour of presentation to the emergency department. DeBoer, 2 437–438; Ogilvie et al, 4 1492–1496; Blackford et al, 5 1322–1330.
VOLUME 40 • ISSUE 6
November 2014
PEDIATRIC TOXICOLOGY EMERGENCIES Authors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA, Dyer, IN, Vernon Hills, IL Section Editors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA
he review questions that are featured in each of the issues of the JEN are based upon the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. These questions appear online only.
T
REFERENCES 1. Olgun H, Yildirim Z, Karacan M, Ceviz N. Clinical, electrocardiographic, and laboratory findings in children with amitriptyline intoxication. Pediatr Emerg Care. 2009;25(3):170-3. 2. DeBoer S. Certified Pediatric Emergency Nurse Review: Putting It All Together. 2nd ed. Dyer, IN: Peds-R-Us Medical Education; 2011. 3. Glatstein M, Garcia-Bournissen F, Scolnik D, Rosenbloom E, Koren G. Sudden-onset tachypnea and confusion in a previously healthy teenager. Ther Drug Monit. 2010;32(6):700-3. 4. Ogilvie J, Rieder M, Lim R. Acetaminophen overdose in children. CMAJ. 2012;184(13):1492-6. 5. Blackford M, Felter T, Gothard M, Reed M. Assessment of the clinical use of intravenous and oral N-acetylcysteine in the treatment of acute acetaminophen poisoning in children: a retrospective review. Clin Ther. 2011;33(9):1322-30.
QUESTIONS 1. You are caring for a 16-year-old, 65-kg boy with a confirmed
intentional Elavil (amitriptyline) overdose that occurred approximately 5 hours ago. The patient is displaying a consistently prolonged QRS and occasional runs of widecomplex tachycardia, which seem to be occurring more frequently. The patient has 2 large-bore intravenous (IV) lines, and 0.9NS (normal saline) is infusing. When the patient goes into sustained ventricular tachycardia, you should anticipate which order next? A. Activated charcoal B. Immediate 12-lead electrocardiogram C. Sodium bicarbonate D. Lidocaine, 20 mg IV push 2. Despite the initial treatment chosen in question 1, the runs of
wide-complex tachycardia continue and the patient with a tricyclic antidepressant (TCA) overdose is now borderline hypotensive. Your next anticipated medication is A. Amiodarone B. Magnesium C. Bretylium D. Procainamide 3. You are the nurse of a 12-year-old with unknown drug
ingestion. The patient complains of ringing in his ears. On the basis of this presentation, the ED staff should evaluate the patient for what specific kind of overdose? A. Anticonvulsants B. Aspirin (acetylsalicylic acid) C. Antibiotics D. Acetaminophen 4. Which of the following correctly lists typical symptoms of Scott DeBoer is Flight Nurse, University of Chicago Hospitals, Chicago, IL, and Founder, Peds-R-Us Medical Education, Dyer, IN. Michael Seaver is Senior Healthcare Consultant, Vernon Hills, IL. Review questions and answers on topics about which nurses should be knowledgeable. J Emerg Nurs 2014;40:e121-e122. 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.12.002
November 2014
VOLUME 40 • ISSUE 6
Tylenol (acetaminophen, Panadol) overdose within the first 6 hours? A. Nausea, vomiting, diarrhea, headache B. Nothing, nonspecific, asymptomatic C. Altered mental status; prolonged PR, QRS, and QT intervals D. Abnormal liver function tests, bradycardia, hypotension
5. A non-pregnant, 16-year-old teen with type 1 diabetes took an
unknown quantity of Tylenol (acetaminophen, Panadol) 6 hours ago, stating “I don’t know . . . I just emptied the bottle .
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PEDIATRIC NURSING REVIEW QUESTIONS/DeBoer and Seaver
. . 3 handfuls, maybe 20 capsules….” Which of the following is an effective intervention for this patient? A. Syrup of Ipecac B. Gastric lavage C. N-acetylcysteine (NAC) D. Activated charcoal ANSWERS 1. Correct answer: C Sodium bicarbonate is the appropriate choice in this overdose case because we know an important factor, the specific medication, from the history. Sodium bicarbonate is preferred over lidocaine (a very tempting choice) in TCA overdose because it helps in 2 ways: The bicarbonate ion can act to reverse the metabolic acidosis that usually goes hand in hand with TCA overdose, and the high sodium load counteracts the conduction delay occurring through cardiac sodium channels. Bicarbonate should be administered as an initial bolus of 1 to 2 mEq/kg, followed by an infusion titrated to a QRS width of 100 milliseconds. The pH goal is 7.45 to 7.55. It is too late for activated charcoal, which is recommended in the first 1 to 2 hours after ingestion. An immediate 12-lead electrocardiogram, though nice to have, is not needed at this moment because there are potentially lethal arrhythmias obvious on 3 to 5 leads. There is also a great risk of seizure in these patients, especially within the first 6 to 8 hours, so one must be ready with benzodiazepines such as Ativan (lorazepam). Dilantin (phenytoin) is not recommended because it acts on sodium channels, which are the issue with TCA overdoses. The following additional pediatric ED and toxicology attending physician insights should be noted: Correction of acidosis should be guided by arterial blood gases, electrolytes, and clinical judgment. Attention should be directed to volume status and correction of poor perfusion in mild cases. Sodium bicarbonate may be used to correct the acidosis in severe cases with an initial push of 1 to 2 mEq/kg intravenously (not to exceed adult doses). Infusion of sodium bicarbonate in an appropriate fluid for the patient’s size and age may be guided by the base deficit in blood gases. Usually, this requires 1 to 2 ampules of sodium bicarbonate per liter of IV fluids administered at a rate appropriate for the patient’s weight. Additional added sodium bicarbonate or slow boluses may be required. A hypertonic solution with respect to sodium content should not be made. Sodium content should generally not exceed that of normal saline solution. Finally, one should remember in all cases like this to consult the Poison Control Center. Olgun et al, 1 170–173; DeBoer, 2 435–436. 2. Correct answer: B Magnesium is next because all of the rest of the medication choices are contraindicated in TCA overdose. Amiodarone and bretylium both prolong the QT interval, whereas procainamide (avoid the “ides”) will
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worsen the pre-existing conduction delay by further blocking sodium channels. Olgun et al, 1 170–173; DeBoer, 2 435–436. 3. Correct answer: B Ringing in the ears, or tinnitus, is one of the textbook side effects of a large aspirin overdose. Acute aspirin overdose may lead to nausea, vomiting (sometimes with blood), and stomach pain. Another classic sign of aspirin overdose is hyperventilation, as the body attempts to compensate for the developing respiratory alkalosis (caused by the ingested acetylsalicylic acid) by blowing off CO2. Other signs and symptoms of aspirin overdose include temporary deafness, dizziness, drowsiness, hyperactivity, seizures, and even coma. One mnemonic used to remember how to treat overdoses or ingestions is SIREN: S, stabilize the child’s condition; I, identify the poison; R, reverse its effect and reduce absorption; E, eliminate the toxin; N, need for consultation with poison control, ongoing physical care, and psychiatric consultation (was the incident a suicide attempt?). DeBoer, 2 442; Glatstein et al, 3 700–703. 4. Correct answer: B Early acetaminophen overdose may be hard to identify because patients often exhibit “nothing, nonspecific, and/or asymptomatic” symptomatology. This is why obtaining an accurate patient history, providing empiric treatment, performing initial/repeat laboratory tests, and contacting Poison Control are so important in a suspected acetaminophen overdose. Patients may be asymptomatic for 24 hours or more, but the liver damage has begun before that point. DeBoer, 2 437–438; Ogilvie et al, 4 1492–1496. 5. Correct answer: C N-acetylcysteine, or NAC (Mucomyst, oral form; Acetadote, IV form), is the appropriate intervention in this scenario. Aside from the “guestimated” amount ingested, all of the other variables given are irrelevant distracters. One should follow local protocols and Poison Control guidance for N-acetylcysteine dosing guidelines. If possible, the serum acetaminophen concentration will be determined and used, along with the estimated time and amount of ingestion, to guide treatment. It should be noted that the toxicity nomogram starts at 4 hours. Serum acetaminophen levels obtained less than 4 hours after ingestion are of little use except to determine whether any of the medication was ingested. Aside from smelling like rotten eggs, Mucomyst has few adverse side effects and may be given with little risk until the laboratory results are known. With few exceptions (ie, Poison Control recommendation), syrup of ipecac and gastric lavage are no longer recommended, and even activated charcoal is falling out of favor unless the ingestion occurred within 1 hour of presentation to the emergency department. DeBoer, 2 437–438; Ogilvie et al, 4 1492–1496; Blackford et al, 5 1322–1330.
VOLUME 40 • ISSUE 6
November 2014