Rosen & Barkin's 5-Minute Emergency Medicine Consult (25 page)

FOLLOW-UP

• Observation and intervention for traumatic injury
  
• Concerns about disposition or lack of availability of child welfare receiving site, if required
  
• Goal must always be to ensure safety of child and siblings.
  

• Adequate ED evaluation and medical follow-up
  
• Safe setting for child must determine disposition
  
• An abused child has a significant chance of further abuse so disposition must be determined in collaboration with social services and family evaluation
  
• Child (and siblings) may require placement in foster care.
  

• All patients require referral to the appropriate child welfare agency.
  
• Other family members may require evaluation before disposition is determined.
  

• A history inconsistent with the physical findings should lead to a suspicion of NAT.
  
• When child abuse is suspected, it must be reported.
  

• American Academy of Pediatrics, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse.
  Pediatrics
  . 2007;119:1232.
  
• Guenther E, Knight S, Olson LM, et al. Prediction of child abuse risk from emergency department use.
  J Pediatr
  . 2009;154:272–277.
  
• Hudson M, Kaplan R. Clinical response to child abuse.
  Pediatr Clin North Am
  . 2006;53:27–39.
  
• Kleinman PK, ed.
  Diagnostic Imaging of Child Abuse
  . 2nd ed. St. Louis, MO: Mosby; 1998.
  
• Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal pain in children with suspected physical abuse.
  Pediatrics.
  2009;129:1595.
  
• Lindberg DM, Shapiro RA, Laskey AL, et al: Prevalence of abusive injuries in siblings and household contacts of physically abused children.
  Pediatrics.
  2012;130:193.
  
• Togioka BM, Arnold MA, Bathurst MA, et al. Retinal hemorrhages and shaken baby syndrome: An evidence-based review.
  J Emerg Med
  . 2009;37:98–106.
  
• Vandeven AM, Newton AW. Update on child physical abuse, sexual abuse and prevention.
  Curr Open Pediatr.
  2006;18:201
  

See Also (Topic, Algorithm, Electronic Media Element)

Trauma, Multiple

CODES

• 995.50 Child abuse, unspecified
  
• 995.53 Child sexual abuse
  
• 995.54 Child physical abuse
  

BASICS

• Acetaminophen (APAP) is available alone, in combination with oral opiate, and in >200 OTC cold remedies:
  
  • One of the most common drugs implicated in intentional and unintentional poisonings
    
  • The number 1 reason for hepatic transplantation in the US
    
• N
  -acetyl-p-benzoquinoneimine (NAPQI) produced when APAP metabolized by cytochrome P-450:
  
  • NAPQI normally detoxified by glutathione
    
  • In overdose, glutathione is quickly depleted and NAPQI causes hepatic damage.
    
  • N
    -acetylcysteine (NAC) replenishes the liver’s glutathione stores.
    
• Increased risk of toxicity:
  
  • Patients with poor nutrition have decreased glutathione stores.
    
• Pharmacokinetics:
  
  • APAP half-life:
    
    • 2.5–4 hr in a nonoverdose setting
      
    • >4 hr in overdose
      
• Toxic dose >150 mg/kg acutely
  
• Probable toxic level is 140
  μ
  g/mL at 4 hr postingestion (see Fig. 1 nomogram for acute intoxication).
  
• Therapeutic plasma concentration is 5–20 μg/mL.
  

Rumack–Matthew nomogram. (Adapted from Rumack BH, Matthew H. Acetaminophen poisoning and toxicity.
Pediatrics
. 1975;55:871–876.)

DIAGNOSIS

Acute overdose:

• Phase 1: 0.5–24 hr postingestion:
  
  • Nausea, vomiting, malaise
    
  • Occurs with large overdoses
    
  • May not be present with smaller toxic doses
    
• Phase 2: 24–72 hr postingestion:
  
  • Decreased GI symptoms
    
  • Hepatic damage is occurring.
    
  • Right upper quadrant pain and tenderness
    
  • Elevation of liver enzymes, PT/INR, bilirubin
    
  • Oliguria
    
  • Prolonged (>4 hr) APAP half-life implies hepatic toxicity.
    
• Phase 3: 72–96 hr postingestion:
  
  • Critical time period in the prognosis
    
  • Peak liver function abnormalities
    
  • Hepatic encephalopathy develops.
    
  • If the PT/INR continues to rise and/or renal insufficiency develops beyond the 3rd day postingestion, there is high likelihood that the patient will require hepatic transplantation.
    
• Phase 4: 96 hr to 10 days postingestion:
  
  • Resolution of hepatic injury or progression to complete hepatic failure
    

• Ingestion history of all APAP-containing products
  
• Time of ingestion
  
• APAP level:
  
  • Obtain 4 hr postingestion level or immediately on presentation if >4 hr postingestion.
    
  • Use Rumack–Matthew nomogram as therapeutic guide for single acute overdose (see Fig. 1).
    
  • In chronic or very late ingestions (>24 hr), obtain level, but do not use nomogram for therapeutic guidance.
    
• Call poison center ([800] 222-1222) or toxicologist.
  

• APAP level
  
• Electrolytes, BUN, creatinine, and glucose
  
• Liver enzymes:
  
  • Elevated AST is the first abnormality detected.
    
  • AST/ALT levels may rise >10,000 in stage III of toxicity.
    
  • Bilirubin
    
• PT/INR
  
• Pregnancy test
  
• Toxicology screen
  

• Suspect APAP as coingestant with other drugs in overdose.
  
• Causes of acute onset hepatotoxicity:
  
  • Infectious hepatitis
    
  • Reye syndrome
    
  • Amanita
    sp. mushrooms toxicity
    
  • Herbal and dietary supplements
    
  • Other drug ingestions
    

TREATMENT