Howard C. Mofenson

Management of the choking child.

There is controversy regarding the best maneuver to expel a completely obstructing foreign body from the upper airway of a patient. Further study and research are needed. However, we recommend that no change in the present recommendations be made until these studies are accomplished. We have attempted to outline the major aspects of the controversy and give the rationale for the present recommendations.

Injuries at Play

The problem of toy-related injuries is a complicated one. The authors detail specific hazards related to toys, playgrounds, skateboards, and baby walkers. Guidelines are provided for toy suitability for children of all ages.

Poisoning By Antidysrhythmic Drugs

This article discusses the management of antidysrhythmic drug overdoses in children and adolescents.

Toxicity from Lomotil: Accidental Ingestion by a 22-Month-Old Child

A case study is presented of Lomotil toxicity in a 22-month-old following ingestion of eight to ten tablets (20-25 mg of diphenoxylate and 0.20-0.25 mg of atropine). Early symptoms are those of atropinism, followed later by dangerous central nervous system depression from the second component. Hospitalization, watchful supervision, and intelligent use of opiate antagonists are the essentials of good management.

A Nationwide Survey of the Management of Unintentional—Low Dose Tricyclic Antidepressant Ingestions Involving Asymptomatic Children: Implications for the Development Of an Evidence-Based Clinical Guideline

Background: The triage of unintentional tricyclic and cyclic antidepressant ingestions involving children <6 years seems based on single cases or small studies. Walsh, in describing 2 cases involving 15–20 mg/kg ingestions, recommended hospitalizing all children ingesting tricyclic and cyclic antidepressants. Objective: To evaluate the patterns of triage for pediatric tricyclic and cyclic antidepressants practiced by regional poison control centers nationwide, and to determine the amount ingested (mg/kg) that resulted in referral to the emergency department, including the recommended duration of observation time for asymptomatic children. Second, to analyze the cost implications, as well as the need for a practice guideline based on severity stratification. Methods: We sent a survey to 44 major regional poison control centers. We reviewed Health Care Financing Administrations tricyclic and cyclic antidepressants management related costs. Results: Thirty centers responded (68%). Eighty-seven percent of all centers send children, regardless of dose ingested, to the emergency department. Four out of the 30 recommended observation based on dose in mg/kg ingested (range >1.5–5). Recommended observation times in the emergency department varied between 6–24 hours. Twenty-seven (90%) Poison Control Centers recommended 6 hours (although one recommended doing so only after administering activated charcoal). One recommended 6–12 hours of observation and 2 Poison Control Centers recommended 24-hour observation. Only 1 center recommended obtaining tricyclic and cyclic antidepressant plasma levels. Discussion: In our review of the literature, the lowest toxic dose reported was 6.7 mg/kg. This is consistent with our Poison Control Center data over the past 5 years where no child was toxic at doses <5 mg/kg. While only 13% of the centers surveyed utilize a stratification strategy to triage pediatric tricyclic and cyclic antidepressant ingestions, the current referral patterns support evaluation based on pharmacokinetics, not worst case incidents. Conclusion: This survey demonstrates that most children with tricyclic and cyclic antidepressant ingestions will be sent to the emergency department, regardless of the amount ingested. A prospective study is needed to determine the probable dose of tricyclic and cyclic antidepressant ingestions that requires observation at a health care facility.