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LEARNING OBJECTIVES

LEARNING OBJECTIVES

  1. Explain the unique aspects of toxicology theory and practice in children compared to adults.

  2. List requirements for proper specimen selection for toxicology and therapeutic drug monitoring.

  3. Discuss various techniques involved in drug screening and confirmation.

  4. Explain advantages and disadvantages of immunoassays and chromatographic techniques.

  5. List both laboratory and clinical aspects of commonly identified toxins and drugs in pediatric patients.

  6. Discuss principles of therapeutic drug monitoring and basics of pharmacokinetics.

INTRODUCTION

Poisonings are recognized as a public health concern as exposures affect individuals across their lifespan. Developmental and behavioral changes throughout childhood result in different exposures, with unintentional exposures occurring in toddlers and young children due to their curious natures versus intentional exposures in adolescents due to drug abuse and suicidal intents. Causes range from overdoses to illicit drugs, environmental exposures, suicides and suicide attempts, homicides, unintended medication misuse, and unintended ingestion of household products. In fact, poisoning is a leading mechanism of injury and mortality. According to the Centers for Disease Control and Prevention, the drug poisoning death rate in 2008 was 4 times the rate that it was in 1999 and the leading cause of injury deaths in 2008. In addition, unintentional poisoning is the tenth leading cause of nonfatal injuries seen in Emergency Departments (ED). However, it is the second leading cause of injuries seen in EDs in 1-4 year olds.1,2

Current and past efforts have focused on preventing unintentional ingestions in young children. The emergence and increased utilization of poison control centers (PCCs), as well as the development of child-resistant closures on pill bottles resulted in a rapid decline of morbidity and mortality in young children attributed to poisoning over the past decades. Since that time, pediatric toxicology has evolved to include additional issues including law enforcement and environmental/public health.

In 2012, 57 PCCs submitted data to the American Association of Poison Control Centers (AAPCC). PCCs cared for 2,275,141 human exposures with 1,402,937 (61%) occurring in children 19 years of age and under.3 This is a gross underestimation as poison control centers rely on volunteer reporting. By far, the majority of calls and exposures occurred in residences. Approximately 20% of calls to PCCs were from health care professionals, as patients may present to health care facilities due to lack of knowledge of the PCC or the severity of the exposure. Ingestions account for the majority (83%) of exposures while dermal and inhalation exposures occur at a lesser frequency (7% and 6%, respectively).

Management largely occurs at the site of exposure (69%) with the primary site occurring at the patient's residence. Approximately 27% of patients were seen in a healthcare facility; however, this number is largely due to those patients who present to emergency departments prior to calling PCCs. Thus, many of these patients may not have required emergency care. Of those patients seen in the ED, ...

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