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The Medical Toxicology Subboard approved modifications to the Core Content of Medical Toxicology in March 2021. The document outlines the areas of knowledge considered essential for the practice of medical toxicology. The Core Content provides the organizational framework for the development of the Medical Toxicology Certification and Cognitive Expertise Examinations and serves as a template for the development of curricula for medical toxicology fellowship training programs.

The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol.

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.

Ambient air pollution is produced by sources including vehicular traffic, coal-fired power plants, hydraulic fracturing, agricultural production, and forest fires. It consists of primary pollutants generated by combustion and secondary pollutants formed in the atmosphere from precursor gases. Air pollution causes and exacerbates climate change, and climate change worsens health effects of air pollution. Infants and children are uniquely sensitive to air pollution, because their organs are developing and they have higher air per body weight intake. Health effects linked to air pollution include not only exacerbations of respiratory diseases but also reduced lung function development and increased asthma incidence. Additional outcomes of concern include preterm birth, low birth weight, neurodevelopmental disorders, IQ loss, pediatric cancers, and increased risks for adult chronic diseases. These effects are mediated by oxidative stress, chronic inflammation, endocrine disruption, and genetic and epigenetic mechanisms across the life span. Natural experiments demonstrate that with initiatives such as increased use of public transportation, both air quality and community health improve. Similarly, the Clean Air Act has improved air quality, although exposure inequities persist. Other effective strategies for reducing air pollution include ending reliance on coal, oil, and gas; regulating industrial emissions; reducing exposure with attention to proximity of residences, schools, and child care facilities to traffic; and a greater awareness of the Air Quality Index. This policy reviews both short- and long-term health consequences of ambient air pollution, especially in relation to developmental exposures. It examines individual, community, and legislative strategies to mitigate air pollution.

Background Small rare earth magnets pose a known health risk to children and many cases of ingestion and aspiration with associated complications have been described. More unusual, but also seen in children, are retained foreign bodies in the oropharynx that require extraction. Case Report We present the case of a 3-year-old boy with persistent left-sided sore throat 1 h after ingestion of several 3-mm spherical rare earth magnets. No foreign bodies were visible in the oropharynx on examination; however, a chest radiograph revealed two adjacent magnets within the lower pharyngeal space, as well as four magnets linearly clumped within the small intestine. The patient was taken to the operating room, where visual inspection under general anesthesia revealed two magnets adhered to the pharyngoepiglottic folds (one on the laryngeal surface and one on the glottic surface). They were removed in full without issue, preventing aspiration. Why Should an Emergency Physician Be Aware of This? Given the recent increase in incidence of rare earth magnet ingestion, emergency providers ought to be aware of the risks and complications associated with magnetic foreign body ingestion in children and the workup and considerations involved in their removal. Providers should also advocate for improved safety controls of these products, which have been found to be effective in the past.

Children are potential victims of chemical or biological terrorism. In recent years, children have been victims of terrorist acts such as the chemical attacks (2017-2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has broadened to an all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks (eg, natural events such as earthquakes or pandemic influenza or man-made catastrophes such as a hazardous-materials spill). In response to new principles and programs that have evolved over the last decade, this technical report supports the accompanying update of the American Academy of Pediatrics 2006 policy statement "Chemical-Biological Terrorism and its Impact on Children." The roles of the pediatrician and public health agencies continue to evolve, and only their coordinated readiness and response efforts will ensure that the medical and mental health needs of children will be met successfully. In this document, we will address chemical and biological incidents. Radiation disasters are addressed separately.

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

Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT).Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK.The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073).This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

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.

BackgroundIt is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes.MethodsWe conducted a cross-sectional analysis on a sample of emergency medical services providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients’ expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased).ResultsThere were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (PP=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (PPP=0.01; OR: 5.55; IQR: 1.47, 20.0).ConclusionOur simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM. (Disaster Med Public Health Preparedness. 2016;10:253–260)

This study aimed to investigate the effects of alcohol-based hand hygiene solution (ABHS) use by care providers on point-of-care alcohol breath analyzer interpretation under different clinically relevant conditions. Among each test condition (foam vehicle with immediate testing, gel vehicle with immediate testing, allowing hands to dry after the use of ABHS, and donning gloves after the use of ABHS), alcohol was detected in breath at 1 minute after use of ABHS. Because the use of ABHS by individuals administering breath alcohol detection may result in false-positive detection of alcohol, staff using these devices should consider traditional hand hygiene with soap and water.

When children and adolescents present to the emergency department with agitation or mental status changes, intoxication from synthetic drug use should be in the differential diagnosis. Identifying the responsible compound(s) may be difficult, so asking the patient broad questions and utilizing appropriate diagnostic studies, when indicated, will aid in making the diagnosis and help identify more-serious complications. This issue discusses the challenges presented by the changing chemical formulations of synthetic cannabinoids, cathinones, and phenethylamines; outlines common presentations of intoxication from these substances; and summarizes best practices for evaluating and managing patients who present with intoxication after consumption of these synthetic drugs of abuse.

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.

IntroductionDisasters are high-stakes, low-frequency events. Telemedicine may offer a useful adjunct for paramedics performing disaster triage. The objective of this study was to determine the feasibility of telemedicine in disaster triage, and to determine whether telemedicine has an effect on the accuracy of triage or the time needed to perform triage.MethodsThis is a feasibility study in which an intervention team of two paramedics used the mobile device Google Glass (Google Inc; Mountain View, California USA) to communicate with an off-site physician disaster expert. The paramedic team triaged simulated disaster victims at the triennial drill of a commercial airport. The simulated victims had preassigned expected triage levels. The physician had an audio-video interface with the paramedic team and was able to observe the victims remotely. A control team of two paramedics performed disaster triage in the usual fashion. Both teams used the SMART Triage System (TSG Associates LLP; Halifax, England), which assigns patients into Red, Yellow, Green, and Black triage categories. The paramedics were video recorded, and their time required to triage was logged. It was determined whether the intervention team and the control team varied regarding accuracy of triage. Finally, the amount of time the intervention team needed to triage patients when telemedicine was used was compared to when that team did not use telemedicine.ResultsThe two teams triaged the same 20 patients. There was no significant difference between the two groups in overall triage accuracy (85.7% for the intervention group vs 75.9% for the control group;P= .39). Two patients were triaged with telemedicine. For the intervention group, there was a significant difference in time to triage patients with telemedicine versus those without telemedicine (35.5 seconds; 95% CI, 72.5-143.5 vs 18.5 seconds; 95% CI, 13.4-23.6;P= .041).ConclusionThere was no increase in triage accuracy when paramedics evaluating disaster victims used telemedicine, and telemedicine required more time than conventional triage. There are a number of obstacles to available technology that, if overcome, might improve the utility of telemedicine in disaster response.CiceroMX,WalshB,SoladY,WhitfillT,PaesanoG,KimK,BaumCR,ConeDC.Do you see what I see? Insights from using Google Glass for disaster telemedicine triage.Prehosp Disaster Med.2015;30(1):1-5.

Background This study evaluates the extent of village doctors’ knowledge of lead poisoning in children in rural China and assesses the characteristics associated with possessing accurate knowledge. Methods A cross-sectional, questionnaire-based survey of 297 village doctors in Fenghuang County, Hunan Province, China was conducted. All village doctors were interviewed face-to-face using a “What do you know” test questionnaire focusing on prevention strategies and lead sources in rural children. Results A total of 287 (96.6%) village doctors completed the survey in full. Most village doctors had an appropriate degree of general knowledge of lead poisoning; however, they had relatively poor knowledge of lead sources and prevention measures. Village doctors with an undergraduate level education scored an average of 2.7 points higher than those who had a junior college level education (p = 0.033). Village doctors with an annual income ≤ 10,000 RMB yuan scored 1.03 points lower than those whose income was >10,001 RMB yuan. Ethnic Han village doctors scored 1.12 points higher, on average, than ethnic Tujia village doctors (p = 0.027). Conclusions This study identified important gaps in knowledge concerning lead poisoning in children among a rural population of village doctors. There is a clear need for multifaceted interventions that target village doctors to improve their knowledge regarding lead poisoning in children. The “What do you know” questionnaire is a new tool to evaluate lead poisoning knowledge and education projects.

Intrathecal baclofen therapy, given via an implanted pump in the abdominal wall either as a continuous infusion or bolus dosing, has been used for more than 25 years to treat the spasticity and dystonia associated with various brain and spinal cord conditions. Pediatric clinicians occasionally encounter baclofen pumps, and in the pediatric setting, significant morbidity can arise from their use. This article presents the background, mechanism of action, uses, and complications of intrathecal baclofen therapy and discusses various management strategies should complications occur.

Many women of reproductive age in the United States are marginally iodine deficient, perhaps because the salt in processed foods is not iodized. Iodine deficiency, per se, can interfere with normal brain development in their offspring; in addition, it increases vulnerability to the effects of certain environmental pollutants, such as nitrate, thiocyanate, and perchlorate. Although pregnant and lactating women should take a supplement containing adequate iodide, only about 15% do so. Such supplements, however, may not contain enough iodide and may not be labeled accurately. The American Thyroid Association recommends that pregnant and lactating women take a supplement with adequate iodide. The American Academy of Pediatrics recommends that pregnant and lactating women also avoid exposure to excess nitrate, which would usually occur from contaminated well water, and thiocyanate, which is in cigarette smoke. Perchlorate is currently a candidate for regulation as a water pollutant. The Environmental Protection Agency should proceed with appropriate regulation, and the Food and Drug Administration should address the mislabeling of the iodine content of prenatal/lactation supplements.

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.

Mercury has long been an object of fascination and fear. There have been increasing reports in the media on various mercury exposures, raising concern and confusion in both the public and medical field about its toxicity and need for specific treatment. There has also been increasing concern from national environmental and public health agencies over low-level mercury exposure, especially in children. In its most familiar, elemental form, mercury presents an inhalational hazard. Less familiar are the other species: inorganic mercury, a potential threat to the gastrointestinal and renal systems; and various organic forms that include the neurotoxic methylmercury, associated historically with seafood contamination in Minamata Bay, Japan. The consequences to exposed children depend on the specific form of mercury and the circumstances of the exposure. The practitioner must be able to distinguish among these forms and their routes of exposure, to assess for toxicity, and to formulate a plan for mitigation and treatment.

Blood lead concentrations have decreased dramatically in US children over the past 4 decades, but too many children still live in housing with deteriorated lead-based paint and are at risk for lead exposure with resulting lead-associated cognitive impairment and behavioral problems. Evidence continues to accrue that commonly encountered blood lead concentrations, even those below 5 µg/dL (50 ppb), impair cognition; there is no identified threshold or safe level of lead in blood. From 2007 to 2010, approximately 2.6% of preschool children in the United States had a blood lead concentration ≥5 µg/dL (≥50 ppb), which represents about 535 000 US children 1 to 5 years of age. Evidence-based guidance is available for managing increased lead exposure in children, and reducing sources of lead in the environment, including lead in housing, soil, water, and consumer products, has been shown to be cost-beneficial. Primary prevention should be the focus of policy on childhood lead toxicity.

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

Drowning is a leading cause of injury-related death in children. In 2006, fatal drowning claimed the lives of approximately 1100 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

To date, there appear to be no studies investigating the practice settings of all Medical Toxicology (MT) diplomates. The MT Assessment of Practice Performance Taskforce queried all MT diplomates about their current practice settings relative to the number of patients seen, the most common diagnoses, and the percent of time spent in their roles as medical toxicologists (MTs) and in their primary specialty. One hundred twenty-seven surveys were completed (44% response rate). Seventy-nine percent of respondents were affiliated with poison centers. Eighty-eight percent of participants were clinically active and reported seeing or consulting on behalf of at least ten patients over a 2-year period. Acetaminophen toxicity was the most common diagnosis encountered by respondents. Other common diagnoses included antidepressant toxicity, antipsychotic toxicity, mental status alteration, metal/environmental toxicity, envenomation, and pesticide toxicity. While respondents were likely to spend more time in direct patient care in their primary specialty, compared to consulting on behalf of patients, they were more likely to consult on behalf of patients in their role as MTs. Respondents spent more time in research, education, and population health in their role as an MT than in their primary specialty. Administrative activities were more commonly reported in association with the respondents' primary specialty than in their role as MTs. Most MTs encounter certain diagnoses with significant frequency and see a substantial number of patients within these categories. The majority spends more time on direct patient care in their primary specialty but is actively engaged in MT education, research, population health, and administration. A longitudinal assessment of MT practice patterns could inform MT curricular development and practice performance evaluation.

To date, there appear to be no studies that assess Medical Toxicologists’ (MTs) practice improvement (PI) activities in their Medical Toxicology practice settings. The MT Assessment of Practice Performance (APP) Taskforce queried all MT diplomates about (1) activities currently available in their practice settings that potentially would meet the requirements of APP, (2) potential APP activities that best fit with current MT practice, and (3) the relationship between MT practice patterns and APP requirements. One hundred twenty-seven surveys were completed. Participation in MT practice improvement activities is not universal, with approximately a third of the survey participants reporting that they are not involved in any practice improvement activity. Few respondents reported that they collected performance improvement-related data. Most who did so participated in CME, case, or chart reviews. Peer reviews, self-improvement plans based on chart reviews, and population research were considered the most valid measures of MT practice improvement. Communication skills were considered important topics for patient surveys. Suggested outcomes for peer assessment included accuracy of information provided, understanding medical staff concerns, timeliness of feedback, and helpfulness. Most respondents rated all of the APP options as being somewhat very intrusive. Access to those with sufficient knowledge of the diplomate’s practice improvement program to verify APP could pose a challenge to a successful completion of APP requirements. Optimal settings for the APP program administration are hospitals and poison centers. While barriers to MT APP activities exist, studying current MT diplomates’ opinions and practices could inform the future development and administration of such programs.

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

Despite advances in carbon monoxide detection in the residential setting, this product of incomplete combustion continues to present a significant hazard to children. The clinician must have a high index of suspicion if a patient presents even with vague symptoms and signs that are consistent with carbon monoxide poisoning, which may produce both immediate and delayed effects. Treatment should focus on immediate administration of 100% oxygen, with consideration for hyperbaric oxygen.

Environmental hazards may give rise to a variety of emergencies. Members of the lay public may believe that these emergencies are simply accidents, destined to occur, and therefore may not appreciate the critical role that prevention may play. Medical professionals should be cognizant of environmental hazards, and be able to discuss prevention strategies with parents and others who care for children.

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.

Although ocular injury from alkaline household cleaning products is well described, there is less known about the significance and extent of injury with ocular exposure to detergent pods. We report a 12-month-old with diffuse corneal abrasion caused by ocular contact with a laundry detergent pod. In addition to the known risks with aspiration with detergent pods, the potential for severe ocular injury is important for parents and clinicians to recognize. Children with ocular exposure to detergent pods should seek immediate medical care.

There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy.We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios.After two rounds of the modified Delphi, consensus for expected triage level was85% for 28 of 30 victims, with the remaining two achieving85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation.The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

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.

The use of a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia in the emergency department setting shows promise as an agent that may minimize adverse effects of ketamine or propofol as single agents. This article provides a summary of current literature regarding ketofol. It also reviews the comparative pharmacokinetics, adverse effects, and dosing of ketamine, propofol, and ketofol as agents for procedural sedation and analgesia.

IntroductionPediatric disaster medicine (PDM) triage is a vital skill set for pediatricians, and is a required component of residency training by the Accreditation Council for Graduate Medical Education (ACGME). Simulation training is an effective tool for preparing providers for high-stakes, low-frequency events. Debriefing is a learner-centered approach that affords reflection on one's performance, and increases the efficacy of simulation training. The purpose of this study was to measure the efficacy of a multiple-victim simulation in facilitating learners’ acquisition of pediatric disaster medicine (PDM) skills, including the JumpSTART triage algorithm. It was hypothesized that multiple patient simulations and a structured debriefing would improve triage performance.MethodsA 10-victim school-shooting scenario was created. Victims were portrayed by adult volunteers, and by high- and low-fidelity simulation manikins that responded physiologically to airway maneuvers. Learners were pediatrics residents. Expected triage levels were not revealed. After a didactic session, learners completed the first simulation. Learners assigned triage levels to all victims, and recorded responses on a standardized form. A group structured debriefing followed the first simulation. The debriefing allowed learners to review the victims and discuss triage rationale. A new 10-victim trauma disaster scenario was presented one week later, and a third scenario was presented five months later. During the second and third scenarios, learners again assigned triage levels to multiple victims. Wilcoxon sign rank tests were used to compare pre- and post-test scores and performance on pre- and post-debriefing simulations.ResultsA total of 53 learners completed the educational intervention. Initial mean triage performance was 6.9/10 patients accurately triaged (range = 5-10, SD = 1.3); one week after the structured debriefing, the mean triage performance improved to 8.0/10 patients (range = 5-10, SD = 1.37, P < .0001); five months later, there was maintenance of triage improvement, with a mean triage score of 7.8/10 patients (SD = 1.33, P < .0001).Over-triage of an uninjured child with special health care needs (CSHCN) (67.8% of learners prior to debriefing, 49.0% one week post-debriefing, 26.2% five months post-debriefing) and under-triage of head-injured, unresponsive patients (41.2% of learners pre-debriefing, 37.5% post-debriefing, 11.0% five months post-debriefing) were the most common errors.ConclusionsStructured debriefings are a key component of PDM simulation education, and resulted in improved triage accuracy; the improvement was maintained five months after the educational intervention. Future curricula should emphasize assessment of CSHCN and head-injured patients.Cicero MX, Auerbach MA, Zigmont J, Riera A, Ching K, Baum CR. Simulation training with structured debriefing improves residents’ pediatric disaster triage performance. Prehosp Disaster Med. 2012;27(3):1-6.

Objective To design an instrument for scoring residents learning pediatric disaster triage (PDT), and to test the validity and reliability of the instrument. Methods We designed a checklist-based scoring instrument including PDT knowledge and skills and performance, as well as a global assessment. Learners' performance in a 10-patient school bus crash simulation was video recorded and scored with the instrument. Learners triaged the patients with a color-coded algorithm (JumpSTART, Simple Triage and Rapid Treatment). Three evaluators observed the recordings and scored triage performance for each learner. Internal and construct validity of the instrument were established via comparison of resident performance by postgraduate year (PGY) and correlating instrument items with overall score. Validity was assessed with analysis of variance and the D statistic. We calculated evaluators' intraclass correlation coefficient (ICC) for each patient, skill, triage decision, and global assessment. Results There were 37 learners and 111 observations. There was no difference in total scores by PGY ( P = .77), establishing internal validity. Regarding construct validity, most instrument items had a D statistic of >0.5. The overall ICC among scores was 0.83 (95% confidence interval [CI] 0.74–0.89). Individual patient score reliability was high and was greatest among patients with head injury (ICC 0.86; 95% CI 0.79–0.91). Reliability was low for an ambulatory patient (ICC 0.29; 95% CI 0.07–0.48). Triage skills evaluation showed excellent reliability, including airway management (ICC 0.91; 95% CI 0.86–0.94) and triage speed (ICC 0.81; 95% CI 0.72–0.88). The global assessment had moderate reliability for skills (ICC 0.63; 95% CI 0.47–0.75) and knowledge (ICC 0.64; 95% CI 0.49–0.76). Conclusions We report the validity and reliability testing of a PDT-scoring instrument. Validity was confirmed with no performance differential by PGY. Reliability of the scoring instrument for most patient-level triage, knowledge, and specific skills was high.

Children with behavioral or psychiatric complaints are often evaluated in pediatric emergency room settings, and may present as agitated or violent at any point during the evaluation process. Emergency department-based practitioners should be aware of risk factors associated with agitation and should be able to assess the agitated patient in a timely fashion. Management may require the use of pharmacological agents that can mitigate agitation safely and effectively, thus ensuring good outcomes for patients and emergency department staff.

An 18-month-old male presented to the emergency department (ED) for evaluation of lethargy and apnea. Four hours before presentation, the patient was found with an empty bottle of ibuprofen, an ingestion of as much as 7.2 grams (600 mg/kg). The ED course was remarkable for a 30-second tonic-clonic seizure. Laboratory analysis was notable for metabolic acidosis. Four-hour and 7.5-hour serum ibuprofen levels were 640 and 39 microg/mL, respectively. Following treatment, the patient improved and was extubated the next morning. While metabolic acidosis has been frequently described at doses exceeding 400 mg/kg, seizures occurring early in the course of ibuprofen toxicity have been rarely noted.