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The change in legal status of cannabis (the botanical species Cannabis sativa, commonly known as marijuana) in the United States has had significant impact on pediatric drug exposures. In states with decriminalization of recreational and medicinal use of cannabis, emergency department visits and poison control center calls for unintentional pediatric cannabis intoxication are on the rise in the last few decades. Exploratory or unintentional ingestions of cannabis-containing products (as opposed to those derived from synthetic cannabinoids, which may mimic the structure and/or function of cannabis, but are not the focus of this article) can lead to significant pediatric toxicity, including encephalopathy, coma, and respiratory depression. With the increasing magnitude of the public health implications of widespread cannabis use, clinicians who care for pediatric patients routinely must be adept in the recognition, evaluation, management, and counseling of unintentional cannabis exposure.

OBJECTIVES: Drug misuse is a disturbing, common practice among youth. One in 4 American adolescents reports consuming prescription medications without a clinical indication. We sought to explore current trends of drug misuse in adolescents. METHODS: Using the 37 participating sites of the ToxIC (Toxicology Investigators Consortium) Case Registry, a cross-country surveillance tool, we conducted an observational cohort study of all adolescents (aged 13-18 years) who presented to emergency departments with drug misuse and required a bedside medical toxicology consultation between January 2010 and June 2013. RESULTS: Of 3043 poisonings, 202 (7%) involved drug misuse (139 [69%] were males). Illicit drugs (primarily synthetic cannabinoids and "bath salts") were encountered in 101 (50%), followed by prescription medications (56 [28%]) and over-the-counter (OTC) drugs (51 [25%]). Dextromethorphan was the most commonly misused legal medication (24 [12%]). Polypharmacy exposure was documented in 74 (37%). One hundred sixty-three adolescents (81%) were symptomatic; of these, 81% had central nervous system impairments: psychosis (38%), agitation (30%), coma (26%), myoclonus (11%), and seizures (10%); and 66 (41%) displayed a specific toxidrome, most commonly sedative-hypnotic. Benzodiazepines were the most frequently administered medications (46%). Antidotes were administered to 28% of adolescents, primarily naloxone, physostigmine, N-acetyl-cysteine, and flumazenil. No deaths were recorded. CONCLUSIONS: Adolescents presenting with drug misuse may be exposed to a wide range and combinations of therapeutics or illicit substances and frequently display central nervous system abnormalities, compromising the ability to obtain a reliable history. Frontline clinicians should maintain a high index of suspicion, as routine toxicology screenings fail to detect most contemporary misused legal and designer drugs. Language: en

Magnets are inherently attractive to young children, but present a risk when ingested. If consumed alone, small, smooth magnetic foreign bodies are likely to pass without significant event; however, ingestion of multiple magnets may have catastrophic consequences, including bowel perforation, obstruction, peritonitis, and death. Increasing reports of morbidity and mortality in recent years from the US National Electronic Injury Surveillance System has led to numerous safety statements from the American Academy of Pediatrics and the Centers for Disease Control and Prevention, as well as several product recalls from the Consumer Product Safety Commission. This article presents the background and mechanism of injury of magnet ingestion, as well as recommended management and potential complications. We also review current legislation and opportunities for further patient advocacy regarding this polarizing problem.

E-cigarettes, also known as electronic nicotine delivery systems and electronic cigarettes, are advertised as a healthier alternative product to tobacco cigarettes despite limited data on the consequences of e-cigarette use. Currently, there are no US Food and Drug Administration or other federal regulations of e-cigarettes, and calls to poison control centers regarding liquid nicotine toxicity, especially in children, are on the rise. This article presents the background and mechanism of action of e-cigarettes as well as up-to-date details of the toxicity of liquid nicotine. We also present management strategies in the setting of liquid nicotine toxicity.

Novel classes of synthetic drugs, including synthetic cathinones ("bath salts") and synthetic cannabinoids ("spice" or "K2"), have recently emerged as popular drugs of abuse. Salvia divinorum, a naturally occurring herb, has gained popularity in the last decade as a hallucinogenic as well. The legal status of these substances has been undergoing rapid changes and has been confusing to lawmakers and medical practitioners alike. We present an up-to-date information about the legality of these substances. We also discuss the historical background, chemical composition, patterns of abuse, clinical presentations, laboratory analysis, and management strategies for these drugs, with an emphasis on synthetic cathinones.

Globally, natural and created events have underscored the vulnerability of children in disasters. There is an unmet need for a standardized pediatric disaster medicine (PDM) curriculum.To create and implement a PDM course, measure course efficacy, and assess residents' attitudes toward and experience in disaster medicine.An educational intervention was conducted for pediatric and emergency medicine residents at a tertiary care teaching hospital. Participants completed a precourse survey of PDM attitudes and experience. Paired t tests were used to compare pretest, immediate posttest, and delayed posttest scores. Test performance was assessed by resident type and postgraduate year. A postcourse survey gauged reaction to the course and interest in further PDM training.Among the participants, 11 residents (9.4%) have treated disaster victims, and 5 (4.3%) had formal disaster medicine education. Most (83%) felt PDM is an important part of their training. Seventy-five eligible residents (64.6%) completed the intervention. Pairwise comparison of scores showed a mean improvement in scores of 24.5% immediately after taking the course (95% confidence interval, 22.9%-30.1%; P0.001). Two months later, residents scored a mean of 69.0% for the delayed posttest, with a retained improvement in scores (18.3%; 95% confidence interval, 14.3%-22.3%; P0.001). Residents preferred future PDM exercises to additional didactic training (72.0% vs. 32.7%; P0.001%).Residents who complete this curriculum increase their knowledge of PDM with moderate retention of information. Most residents lack PDM training, believe it is important, and request disaster-training exercises.

The emergency airway management of children and adolescents with critical illnesses may necessitate rapid sequence intubation with a sedating and a neuromuscular blocking agent. Etomidate and rocuronium have become increasingly popular for the sedation and paralysis, respectively, of pediatric patients in rapid sequence intubation, and there are many advantages to the use of both agents. Both etomidate and rocuronium have a rapid onset of action, and both agents are relatively free of hemodynamic adverse effects. Etomidate does, however, suppress adrenal function, and consequently, its use in patients with septic shock is controversial. Rocuronium can produce optimal intubating conditions without the serious complications that can accompany succinylcholine. The available evidence supports the safety of etomidate and rocuronium in rapid sequence intubation but also suggests that more prospective studies are needed in pediatric patients.

Natural and man-made disasters are unpredictable but certainly will include children as victims. Increasingly, knowledge of pediatric disaster preparedness is required of emergency and primary care practitioners. A complete pediatric disaster plan comprises the following elements: appropriate personnel and equipment, disaster- and venue-specific training, and family preparedness. Disaster preparedness exercises are crucial for training plan implementation and response evaluation. Exercise content depends on local hazard vulnerabilities and learner training needs. Postexercise evaluations follow a stepwise process that culminates in improved disaster plans. This article will review disaster planning and the design, implementation, and evaluation of pediatric disaster exercises. Language: en

Methadone exposures in children have increased as the drug has gained more prevalence in the treatment of adult narcotic dependency. Previous literature concerning pediatric methadone ingestion has focused primarily on unintentional ingestions. We describe a 2-month-old male infant presenting with respiratory failure from suspected intentional methadone administration. The infant was born to a mother with narcotic dependency and at birth was treated for neonatal abstinence syndrome. After discharge for neonatal abstinence syndrome treatment, the infant continued to be fussy and persistently irritable. We believe the infant was intentionally given methadone at home by his mother for these symptoms. It is important for pediatric providers to be vigilant of households with methadone present. Family-centered education on prevention of methadone ingestion (eg, safe storage) and anticipatory guidance on the signs, symptoms, and treatment of toxicity are key.

The element mercury exists as inorganic, elemental, or organic species. Routes of exposure and toxicity in humans vary according to the species of mercury involved. Treatment of mercury poisoning generally requires the use of sulfhydryl bond-containing chelation agents, including the parenterally administered dimercaprol and its oral congeners. These oral chelators, meso-2,3-dimercaptosuccinic acid and sodium 2,3-dimercapto-1-propanesulfonate, have numerous advantages over dimercaprol, including less toxicity. Although dimercaprol is contraindicated in organic mercury exposures, meso-2,3-dimercaptosuccinic acid and sodium 2,3-dimercapto-1-propanesulfonate may be used to chelate all species of mercury. Recent evidence suggests that their efficacy in organic mercury poisoning is uncertain.