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PV Card: Pediatric Ingestion Dose Thresholds for ED Referral

Clinical Toxicology has published guidelines for out-of-hospital management of 16 distinct overdoses and their dose thresholds, above which, pediatric patients should be referred to the Emergency Department for evaluation. Clinical Toxicology is the official journal of the American Academy of Clinical Toxicology (AACT, @AACTinfo), the American Association of Poison Control Centers (AAPCC, @AAPCC), and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT). There are two caveats to be aware of regarding these guidelines.

  1. They were developed between 2005 and 2007. New medications have been approved since that time and there may be more recent data available.
  2. As with any poisoning, dose is only one factor when determining disposition. Consideration should also be given to intent, underlying medical conditions, co-ingestion of other medications, presence of symptoms, and drug formulation.

This PV Card summarizes the pediatric ingestion dose thresholds for referral to an ED.

PV Card: Pediatric Dose Thresholds


Adapted from [1–16]
Go to ALiEM (PV) Cards for more resources.

Thanks to Zlatan Coralic, PharmD (@ZEDPharm) for his excellently detailed expert peer review and suggestions for revisions for this important card.

References

  1. Wax P, Erdman A, Chyka P, et al. beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(3):131-146. [PubMed]
  2. Caravati E, Erdman A, Christianson G, et al. Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(5):327-345. [PubMed]
  3. Manoguerra A, Erdman A, Booze L, et al. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(6):553-570. [PubMed]
  4. Olson K, Erdman A, Woolf A, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(7):797-822. [PubMed]
  5. Dart R, Erdman A, Olson K, et al. Acetaminophen poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(1):1-18. [PubMed]
  6. Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(3):205-223. [PubMed]
  7. Manoguerra A, Erdman A, Wax P, et al. Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(4):357-370. [PubMed]
  8. Caravati E, Erdman A, Scharman E, et al. Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(1):1-22. [PubMed]
  9. Chyka P, Erdman A, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. [PubMed]
  10. Woolf A, Erdman A, Nelson L, et al. Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(3):203-233. [PubMed]
  11. Nelson L, Erdman A, Booze L, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(4):315-332. [PubMed]
  12. Chyka P, Erdman A, Manoguerra A, et al. Dextromethorphan poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(6):662-677. [PubMed]
  13. Scharman E, Erdman A, Cobaugh D, et al. Methylphenidate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(7):737-752. [PubMed]
  14. Cobaugh D, Erdman A, Booze L, et al. Atypical antipsychotic medication poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(8):918-942. [PubMed]
  15. Caravati E, Erdman A, Christianson G, et al. Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(1):1-21. [PubMed]
  16. Manoguerra A, Erdman A, Woolf A, et al. Valproic acid poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2008;46(7):661-676. [PubMed]
By |2021-10-06T10:12:48-07:00Jul 9, 2014|ALiEM Cards, Expert Peer Reviewed (Clinical), Tox & Medications|
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PV Card: Local anesthetic toxicity calculations

Local Anesthetic LidocaineLocal anesthetics (LAs) are widely employed to achieve tissue infiltration, peripheral and regional anesthesia, and neuraxial blockades. Despite their well-established toxic dose limits, these agents continue to pose a substantial risk of morbidity and mortality due to local anesthetic toxicity and overdose.

For example, LAs and epinephrine account for a large proportion of medication errors resulting in adverse patient outcomes due to drug dosing miscalculations or errors converting between units. Dosage calculations vary by patient weight as well as by pharmacokinetics and pharmacodynamics of individual LA formulations. Further, non-standard units, additives (epinephrine), and varying concentrations among LAs complicate correct dosage derivations.

Toxicity nomogram

In an effort to curb calculation errors and avert LA toxicity, Williams and Walker derived a helpful nomogram1 to calculate the maximum, weight-based volume of commonly used LAs (lidocaine, prilocaine, bupivacaine, and ropivacaine). This nomogram was validated against a calculator in the original article. Please note that while this nomogram may aid in dosage verification, there is no substitute for a second, independent derivation of the total maximum dose using a different method, as an additional safeguard to prevent dosage error.

Local anesthetic toxicity presentation

LA toxicity presents clinically as a constellation of symptoms including, but not limited to, tinnitus, circumoral tingling, metallic taste, and dizziness. Severe manifestations include altered mentation, arrhythmias, and cardiovascular collapse. Management is predicated upon stopping the offending agent, providing supportive measures, and administering weight-based intravenous 20% lipid emulsion. The authors, Williams and Walker, derived a separate nomogram to guide treatment by calculating the appropriate weight-based lipid therapy, specifying the initial bolus amount, infusion rate, and total maximum dose of lipid emulsion.

Both the toxicity and lipid emulsion nomograms are displayed in this Paucis Verbis card.

Go to ALiEM (PV) Cards for more resources.

Ideal Body Weight (IBW) Calculation

The Devine formulation is the most commonly accepted calculation (most applicable for people at least 60 inches, or 5 feet, tall):

  • IBW for men (kg) = 50 + 2.3 * (Height (in)-60)
  • IBW for women (kg) = 45.5 + 2.3 * (Height (in)-60)

See the MDCalc calculator for IBW.

Reference

  1. Williams D, Walker J. A nomogram for calculating the maximum dose of local anaesthetic. Anaesthesia. 2014;69(8):847-853. [PubMed]
By |2021-10-06T19:43:15-07:00Jun 13, 2014|ALiEM Cards, Expert Peer Reviewed (Clinical), Pre Publication Critique (Clinical), Tox & Medications|
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Geriatric Emergency Departments: Coming to a Hospital Near You?

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By |2016-11-11T19:20:40-08:00Apr 29, 2014|Expert Peer Reviewed (Clinical), Geriatrics|
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By |2018-10-28T21:23:04-07:00Apr 17, 2014|Expert Peer Reviewed (Clinical), Tricks of the Trade, Ultrasound|
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PEITHO Trial: Fibrinolysis for Intermediate-Risk Pulmonary Embolism

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By |2019-09-10T13:34:00-07:00Apr 11, 2014|Cardiovascular, Expert Peer Reviewed (Clinical), Pulmonary|
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By |2016-11-11T19:20:03-08:00Apr 10, 2014|Expert Peer Reviewed (Clinical), Genitourinary, Radiology|
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High Sensitivity Troponin T and Acute Myocardial Infarction: One and Done?

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By |2019-09-10T13:34:11-07:00Apr 3, 2014|Cardiovascular, Expert Peer Reviewed (Clinical)|
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