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The treatment of poisonings—aggressive or conservative?
April, 1970 T h e .Journal o[ P E D I A T R I C S
651
The treatment of poisonings-aggressive or conservative? C R I T I (3 A L
evaluation
of
procedures u s e d
in the treatment of accidental poisoning in young children is difficult. Although most children fortunately recover from such accidents, uncertainties concerning the amoffnt of poison ingested and the amount absorbed usually make it impossible to determine whether recovery occurred because of, or in spite of, the treatment used. Studies designed to assess the value of specific antidotes and procedures are therefore usually carried out in laboratory animals under conditions in which the dose of poison and other variables can be better controlled. Judiciously interpreted, the results of such studies may be applicable to the clinical situation. The paper by Movassaghi and associates 1 (in the October issue of JOURNAL OF PEDIATRICS) compares the effectiveness of exchange transfusion, infusion of deferoxamine, and a combination of the two in removing iron from dogs which were given a lethal dose of ferrous sulfate. Under the conditions of these experiments, much more iron was removed by exchange transfusion, mainly because oliguria in the poisoned animals limited the excretion of iron complexed with deferoxamine. Two of the animals treated by exchange transfusion alone recovered, and, although the treatment groups were small, the survival time was longer in the animals treated by exchange transfusion. The authors, quite properly, do not attempt to extrapolate their data to the clinical situation, although a few children with severe iron intoxication have been successfully treated by exchange transfusion. Before any such extrapolations are made, one needs to know: (a) whether the experimental con-
ditions chosen simulate those of clinical poisonings, (b) what mortality rate can be expected in iron intoxication treated by supportive measures alone or by infusion of deferoxamine. It is hoped that the authors will extend their studies in order to determine whether the apparent effectiveness of exchange transfusion in reducing the mortality rate from ingestion of iron is confirmed for other quantities of ingested iron, for different times after ingestion, and for other species. It is now apparent that the over-all mortality rate from iron poisoning in children is substantially lower than was formerly believed. In a recent series of 66 consecutive cases admitted to the Los Angeles CountyUniversity of Southern California Medical Center there were no deaths, and in the series of 172 cases collected by Westlin 2 from several medical centers there were but 3 deaths (1.7 per cent). Most of the patients in "these series received deferoxamine, along with supportive therapy. In the face of these encouraging results, the added value of exchange transfusion, a procedure carrying a significant intrinsic morbidity, will be most difficult to define. It is clear that better means are needed for recognizing early the child who has ingested a lethal or probably lethal dose of iron: Not only do such children require the most intensive treatment, but the opportunity is greatest to determine whether a particular form of treatment, such as exchange transfusion, is effective. The average child with iron intoxication may be expected to recover with supportive therapy, perhaps supplemented by deferoxamine, and the use of complex or heroic measures may be danVo[. 76, No. 4, pp. 651-652
652
Editor's column
The Journal of Pediatrics April 1970
gerous. These considerations are valid in m a n y types of poisoning accidents where the pressure to "do something" m a y t e m p t the physician to experiment with clinically u n t r i e d a n d potentially dangerous approaches to treatment.
John A. ]ames, M.D. Los Angeles, Call[:
REFERENCES
1. Movassaghi, N., Purugganan, G. G., and Leikin, S.: Comparison of exchange transfusion and deferoxamine in the treatment of acute iron poisoning, J. PEDIAT. 75: 604, 1969. 2. Westlin, W. F.: Desferoxamine in the treatment of acute iron poisoning. Clinical experiences with 172 children, Clin. Pediat. 5: 531, 1966.
651
The treatment of poisonings-aggressive or conservative? C R I T I (3 A L
evaluation
of
procedures u s e d
in the treatment of accidental poisoning in young children is difficult. Although most children fortunately recover from such accidents, uncertainties concerning the amoffnt of poison ingested and the amount absorbed usually make it impossible to determine whether recovery occurred because of, or in spite of, the treatment used. Studies designed to assess the value of specific antidotes and procedures are therefore usually carried out in laboratory animals under conditions in which the dose of poison and other variables can be better controlled. Judiciously interpreted, the results of such studies may be applicable to the clinical situation. The paper by Movassaghi and associates 1 (in the October issue of JOURNAL OF PEDIATRICS) compares the effectiveness of exchange transfusion, infusion of deferoxamine, and a combination of the two in removing iron from dogs which were given a lethal dose of ferrous sulfate. Under the conditions of these experiments, much more iron was removed by exchange transfusion, mainly because oliguria in the poisoned animals limited the excretion of iron complexed with deferoxamine. Two of the animals treated by exchange transfusion alone recovered, and, although the treatment groups were small, the survival time was longer in the animals treated by exchange transfusion. The authors, quite properly, do not attempt to extrapolate their data to the clinical situation, although a few children with severe iron intoxication have been successfully treated by exchange transfusion. Before any such extrapolations are made, one needs to know: (a) whether the experimental con-
ditions chosen simulate those of clinical poisonings, (b) what mortality rate can be expected in iron intoxication treated by supportive measures alone or by infusion of deferoxamine. It is hoped that the authors will extend their studies in order to determine whether the apparent effectiveness of exchange transfusion in reducing the mortality rate from ingestion of iron is confirmed for other quantities of ingested iron, for different times after ingestion, and for other species. It is now apparent that the over-all mortality rate from iron poisoning in children is substantially lower than was formerly believed. In a recent series of 66 consecutive cases admitted to the Los Angeles CountyUniversity of Southern California Medical Center there were no deaths, and in the series of 172 cases collected by Westlin 2 from several medical centers there were but 3 deaths (1.7 per cent). Most of the patients in "these series received deferoxamine, along with supportive therapy. In the face of these encouraging results, the added value of exchange transfusion, a procedure carrying a significant intrinsic morbidity, will be most difficult to define. It is clear that better means are needed for recognizing early the child who has ingested a lethal or probably lethal dose of iron: Not only do such children require the most intensive treatment, but the opportunity is greatest to determine whether a particular form of treatment, such as exchange transfusion, is effective. The average child with iron intoxication may be expected to recover with supportive therapy, perhaps supplemented by deferoxamine, and the use of complex or heroic measures may be danVo[. 76, No. 4, pp. 651-652
652
Editor's column
The Journal of Pediatrics April 1970
gerous. These considerations are valid in m a n y types of poisoning accidents where the pressure to "do something" m a y t e m p t the physician to experiment with clinically u n t r i e d a n d potentially dangerous approaches to treatment.
John A. ]ames, M.D. Los Angeles, Call[:
REFERENCES
1. Movassaghi, N., Purugganan, G. G., and Leikin, S.: Comparison of exchange transfusion and deferoxamine in the treatment of acute iron poisoning, J. PEDIAT. 75: 604, 1969. 2. Westlin, W. F.: Desferoxamine in the treatment of acute iron poisoning. Clinical experiences with 172 children, Clin. Pediat. 5: 531, 1966.