Milton Tenenbein

Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose.

The efficacy of ipecac-induced emesis, large-bore orogastric lavage, and activated charcoal as gastrointestinal decontamination procedures after acute drug overdose is unknown. Using an ampicillin overdose model, these three procedures were compared with one another and to a control ingestion in ten human volunteers. Serial serum ampicillin levels were used to compute the areas under the concentration vs time curves (AUC) for each study. The reductions of ampicillin absorption compared to control were as follows: orogastric lavage 32% (NS), ipecac-induced emesis 38% (P less than .01), and activated charcoal 57% (P less than .01). This model examines each intervention in a mutually exclusive fashion. It supports activated charcoal administration as the primary gastrointestinal decontamination procedure after acute drug overdose.

House fire injury prevention update. Part I. A review of risk factors for fatal and non-fatal house fire injury

Objective—To summarize house fire injury risk factor data, using relative risk estimation as a uniform method of comparison. Methods—Residential fire risk factor studies were identified as follows: MEDLINE (1983 to March 1997) was searched using the keywords fire*/burn*, with etiology/cause*, prevention, epidemiology, and smoke detector* or alarm*. ERIC (1966 to March 1997) and PSYCLIT (1974 to June 1997) were searched by the above keywords, as well as safety, skills, education, and training. Other sources included: references of retrieved publications, review articles, and injury prevention books; Injury Prevention journal hand search; government documents; and internet sources. When not provided by the authors, relative risk (RR), odds ratio, and standardized mortality ratios were calculated, to enhance comparison between studies. Results—Fifteen relevant articles were retrieved, including two case-control studies. Non-modifiable risk factors included young age (RR 1.8–7.5), old age (RR 2.6–3.6), male gender (RR 1.4–2.9), non-white race (RR 1.3–15.0), low income (RR 3.4), disability (RR 2.5–6.5), and late night/early morning occurrence (RR 4.1). Modifiable risk factors included place of residence (RR 2.1–4.2), type of residence (RR 1.7–10.5), smoking (RR 1.5 to 7.7), and alcohol use (RR 0.7–7.5). Mobile homes and homes with fewer safety features, such as a smoke detector or a telephone, presented a higher risk of fatal injury. Conclusions—Risk factor data should be used to assist in the development, targeting, and evaluation of preventive strategies. Development of a series of quantitative systematic reviews could synthesize existing data in areas such as house fire injury prevention.

Whole‐bowel irrigation versus activated charcoal in sorbitol for the ingestion of modified‐release pharmaceuticals

Overdose with modified‐release pharmaceuticals is an increasing phenomenon. This study examines whole‐bowel irrigation as a potential decontamination strategy after overdose with enteric‐coated acetylsalicylic acid and compares it with administration of activated charcoal in sorbitol, which is currently the recommended intervention. A three‐phase randomized crossover protocol was used in 10 adult volunteers. Each volunteer ingested nine 325 mg doses of enteric‐coated acetylsalicylic acid on three occasions, with at least 1 week between each administration period. Serum samples were analyzed for salicylic acid concentration by HPLC. Both interventions decreased peak salicylic acid concentration, time‐to‐zero salicylic acid concentration, and AUC when compared with control (p < 0.01). Whole‐bowel irrigation was superior to activated charcoal in sorbitol by all three criteria (p < 0.05). Adverse effects were qualitatively and quantitatively greater during activated charcoal in sorbitol, and the volunteers preferred whole‐bowel irrigation over charcoal in sorbitol. Our data suggest that whole‐bowel irrigation should be considered for overdose of other modified‐release pharmaceuticals.

Early Analgesia for Children With Acute Abdominal Pain

Objectives. The objectives of this study were to determine whether the administration of morphine to children with acute abdominal pain would impede the diagnosis of appendicitis and to determine the efficacy of morphine in relieving the pain. Methods. This was a double-blind, randomized, placebo-controlled trial involving 5- to 16-year-old children who presented to the emergency department of a children’s hospital with a chief complaint of acute abdominal pain that was thought by the pediatric emergency attending physician to require a surgical consultation. Subjects were randomized to receive intravenously administered morphine or normal saline solution. Clinical data and the emergency physician’s confidence in his or her clinical diagnosis (0–100%) were recorded systematically with a standardized form. This was repeated 15 minutes after administration of the study medication. The surgeon assessed the child within 1 hour and completed a similar data collection sheet. Pain was assessed, with a color analog scale, before and after study medication administration. Each subject was monitored for 2 weeks after enrollment. Results. One hundred eight children were enrolled; 52 received morphine and 56 received a placebo saline solution. There were no differences between groups in demographic variables or the degree of pain. There were no differences between groups in the diagnoses of appendicitis or perforated appendicitis or the number of children who were observed and then underwent laparotomy. The reduction in the mean pain score was significantly greater in the morphine group (2.2 vs 1.2 cm). The emergency physicians’ and surgeons’ confidence in their diagnoses was not affected by the administration of morphine. Conclusions. Our data show that morphine effectively reduces the intensity of pain among children with acute abdominal pain and morphine does not seem to impede the diagnosis of appendicitis.

Whole Bowel Irrigation as a Gastrointestinal Decontamination Procedure After Acute Poisoning

Assuming a stable or stabilised patient, preventing the absorption of ingested toxins becomes a primary objective in the treatment of acute overdose. Traditional interventions aimed at achieving this end include ipecac-induced emesis, large bore orogastric lavage and activated charcoal administration (Cupit & Temple 1984; Easom & Lovejoy 1979). Whether any of these procedures benefits the patient remains unknown. Induced emesis and gastric lavage have especially been questioned (Comstock et al. 1981; Corby et al. 1968; Fane et al. 1971; Neuvonen et al. 1983; Tenenbein 1985a; Vale et al. 1986) and the literature seems to favour activated charcoal administration without a gastric emptying procedure (Chin 1972; Curtis et al. 1984; Fane et al. 1971; Kulig et al. 1985; Tenenbein et al. 1987a). However, the most common practice is to use one of the gastric emptying procedures, followed by activated charcoal. Apart from the concerns about their effectiveness, situations arise where all 3 of these interventions can be expected to be of limited benefit to the poisoned patient. These include the ingestion of a very large amount of a toxic substance (e.g. many times the lethal dose) , late presentation after the overdose, ingestion of delayed release pharmaceuticals and ingestion of substances not adsorbed by activated charcoal (particularly iron). In these situations whole bowel irrigation with polyethylene glycol electrolyte lavage solution offers promise as a method of treatment. The purpose of this article is to review relevant data and experience regarding this technique.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Does Iron Deficiency Raise the Seizure Threshold

To determine the effect of iron status on the seizure threshold, measures of iron sufficiency were prospectively evaluated in 51 children presenting to a pediatric emergency department with a febrile illness with (26) or without (25) an associated febrile seizure. A higher proportion of children from the febrile seizure group had a family history of mental retardation (5/26 versus 0/25, P = .02) or of previous febrile seizures (10/26 versus 2/23, P = .01). The two groups were otherwise comparable for age, sex, race, family history of afebrile seizures, temperature at presentation, white blood cell count, differential, and vitamin and antibiotic use. Patients with febrile seizures were less frequently iron deficient as defined by a free erythrocyte protoporphyrin level above 0.80 ng/L (2/23 versus 10/25, P < .01), hemoglobin concentration less than 110 g/L (1/26 versus 6/25, P < .03), hematocrit less than 0.30 L/L (0/22 versus 4/25, P < .02), mean corpuscular hemoglobin less than 20 pg (0/25 versus 3/24, P < .04), mean corpuscular volume less than 65 fL (0/26 versus 4/24, P < .02), and platelet count higher than 550 x 109/L (0/26 versus 3/25, P < .04). This association was even stronger when adjusted for differences in family history. None of the patients in the febrile seizure group was being treated for iron deficiency at presentation, whereas three of 25 controls used an iron supplement (P < .04). Iron deficiency may protect against the development of febrile seizures. (J Child Neurol 1995;10:105-109).

Home safety measures and the risk of unintentional injury among young children: a multicentre case–control study

Background: Young children may sustain injuries when exposed to certain hazards in the home. To better understand the relation between several childproofing strategies and the risk of injuries to children in the home, we undertook a multicentre case–control study in which we compared hazards in the homes of children with and without injuries. Methods: We conducted this case-control study using records from 5 pediatric hospital emergency departments for the 2-year period 1995–1996. The 351 case subjects were children aged 7 years and less who presented with injuries from falls, burns or scalds, ingestions or choking. The matched control subjects were children who presented during the same period with acute non-injury-related conditions. A home visitor, blinded to case-control status, assessed 19 injury hazards at the childrens homes. Results: Hazards found in the homes included baby walkers (21% of homes with infants), no functioning smoke alarm (17% of homes) and no fire extinguisher (51% of homes). Cases did not differ from controls in the mean proportion of home hazards. After controlling for siblings, maternal education and employment, we found that cases differed from controls for 5 hazards: the presence of a baby walker (odds ratio [OR] 9.0, 95% confidence interval [CI] 1.1–71.0), the presence of choking hazards within a childs reach (OR 2.0, 95% CI 1.0–3.7), no child-resistant lids in bathroom (OR 1.6, 95% CI 1.0–2.5), no smoke alarm (OR 3.2, 95% CI 1.4–7.7) and no functioning smoke alarm (OR 1.7, 95% CI 1.0–2.8). Interpretation: Homes of children with injuries differed from those of children without injuries in the proportions of specific hazards for falls, choking, poisoning and burns, with a striking difference noted for the presence of a baby walker. In addition to counselling parents about specific hazards, clinicians should consider that the presence of some hazards may indicate an increased risk for home injuries beyond those directly related to the hazard found. Families with any home hazard may be candidates for interventions to childproof against other types of home hazards.

Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial

Objective: To assess the long term effect of a home safety visit on the rate of home injury. Design: Telephone survey conducted 36 months after participation in a randomized controlled trial of a home safety intervention. A structured interview assessed participant knowledge, beliefs, or practices around injury prevention and the number of injuries requiring medical attention. Setting: Five pediatric teaching hospitals in four Canadian urban centres. Participants: Children less than 8 years of age presenting to an emergency department with a targeted home injury (fall, scald, burn, poisoning or ingestion, choking, or head injury while riding a bicycle), a non-targeted injury, or a medical illness. Results: We contacted 774 (66%) of the 1172 original participants. A higher proportion of participants in the intervention group (63%) reported that home visits changed their knowledge, beliefs, or practices around the prevention of home injuries compared with those in the non-intervention group (43%; p<0.001). Over the 36 month follow up period the rate of injury visits to the doctor was significantly less for the intervention group (rate ratio = 0.74; 95% CI 0.63 to 0.87), consistent with the original (12 month) study results (rate ratio = 0.69; 95% CI 0.54 to 0.88). However, the effectiveness of the intervention appears to be diminishing with time (rate ratio for the 12–36 month study interval = 0.80; 95% CI 0.64 to 1.00). Conclusions: A home safety visit was able to demonstrate sustained, but modest, effectiveness of an intervention aimed at improving home safety and reducing injury. This study reinforces the need of home safety programs to focus on passive intervention and a simple well defined message.

How long after drug ingestion is activated charcoal still effective

Objective: The recent American Academy of Clinical Toxicology/European Association of Poisons Centres and Clinical Toxicologists position statement on activated charcoal stated “there are insufficient data to support or exclude its use after 1 hour of ingestion.” The purpose of this study was to determine the effectiveness of activated charcoal administered 1, 2, and 3 hours after drug ingestion. Methods: This was a human volunteer, randomized crossover study. Ten volunteers ingested 4 g of acetaminophen on four occasions at least 1 week apart. One ingestion served as a control and the other three as experimental ingestions with charcoal being administered at 1, 2, and 3 hours after acetaminophen dosing. Eight blood specimens were obtained over the initial 8 hours for serum acetaminophen concentrations that were used for calculation of routine pharmacokinetic parameters. Repeated measures of ANOVA and Tukeys HSD test were used for statistical analysis. Results: Pharmacokinetic parameters for acetaminophen in our volunteers were consistent with literature values. The mean area under the curve (AUC ± SD) for the control and the 1-, 2-, and 3-hour groups were 221 ± 54, 154 ± 71, 206 ± 67 and 204 ± 58 mg/L/h, respectively. The 1-hour group was the only one differing from control (p < 0.01). The decrease of bioavailability at 1 hour was 30.3%, which is similar to previous studies. Conclusion: Our data do not support the administration of activated charcoal as a gastrointestinal decontamination strategy beyond 1 hour after drug overdose.