LISTSERV mailing list manager LISTSERV 16.5

Help for PED-EM-L Archives


PED-EM-L Archives

PED-EM-L Archives


PED-EM-L@LISTSERV.BROWN.EDU


View:

Message:

[

First

|

Previous

|

Next

|

Last

]

By Topic:

[

First

|

Previous

|

Next

|

Last

]

By Author:

[

First

|

Previous

|

Next

|

Last

]

Font:

Monospaced Font

LISTSERV Archives

LISTSERV Archives

PED-EM-L Home

PED-EM-L Home

PED-EM-L  February 2015

PED-EM-L February 2015

Subject:

Re: Possible Acetaminophen ingestion - level timing

From:

"Goetz, Kathleen" <[log in to unmask]>

Reply-To:

Goetz, Kathleen

Date:

Thu, 19 Feb 2015 08:35:50 +0000

Content-Type:

multipart/related

Parts/Attachments:

Parts/Attachments

text/plain (251 lines) , image002.jpg (251 lines) , image003.gif (251 lines)

Thank you all for your thoughtful input. Great discussion that brought up the many different scenarios we have to take into consideration.
So good to have your expertise specific to the conundrum of pediatric "possible" ingestions Dr. Tenebein that present to our ERs on a regular basis.
I'm glad that I asked :)
Kathey

Kathleen Goetz, MD
Medical Director, Swedish Pediatric Emergency Services
Swedish FH ED
747 Broadway
Seattle, WA 98122-4307
Ofc: 206-386-3313 FH ED: 206-386-2573 Fax: 206-386-2577 Cell: 253-370-7571
[Description: untitled]

CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential, proprietary, and/or privileged information protected by law. If you are not the intended recipient, you may not use, copy or distribute this email message or attachments. If you believe you have received this email message in error, please contact the sender by reply email and destroy all copies of the original message.


From: Milton Tenenbein [mailto:[log in to unmask]]
Sent: Wednesday, February 18, 2015 2:43 PM
To: Goetz, Kathleen; [log in to unmask]
Cc: Jeff Linzer; Sophie Gosselin
Subject: RE: Possible Acetaminophen ingestion - level timing


Dear All,



I have chosen the original post to base my response.

I have read all of the posts including yesterday's post by Dr. Nemeth of Dr. Gosselin's opinion.

While I do not take issue with Dr. Gosselin's points - they are not relevant to the original post.

Her opinion is relevant to the adult poly-substance overdose patient in whom there is the potential for delayed gastric emptying as a consequence of the co-ingested drugs.

I suspect that Dr. Gosselin did not see the original post.



Here is the essence of Dr. Goetz'S query:



2.5yo healthy child found with open tylenol bottle, 1 pill on floor, ingestion uncertain. Event 1.5 hours prior to ER evaluation, patient very active, no distress, no emesis or evident abdominal pain, neuro intact, VS normal.

Questions:

1 - Any value in a 2 hour acetaminophen level?

2 - If 2 hour acetaminophen level = 0 is that a reliable predictor of no ingestion and safe to discharge?

Poison Control says no, must get 4 hour level.



My answer:

1. Yes there is value for a 2 hour blood concentration determination.

2. If acetaminophen is not detected then send the child home.

In fact I cite this very scenario in one of my CME talks with the point being that a 2 hour serum acetaminophen concentration is very helpful if it is zero.



In this situation we are using the blood test for a different reason.

The typical indication is to assess the risk for hepatotoxicity,

For that, as we all know, the blood draw needs to be at a minimum of 4 hours after drug ingestion.



Here we are using the test to assess whether an ingestion has occurred rather than for prediction of toxicity.

So, if none is detected at 2 hours - there has been no ingestion.

Over the counter analgesics are designed by industry to have rapid dissolution times - for acetaminophen - it is less than 20 minutes.

If this were not the case- then there would not be "rapid relief of the headache" and consumers would not purchase the product.



Evidence:

One commentator cited the famous "how do we know that parachutes work without having an RCT to prove it?"

I believe that this metaphor is apt.



Several commentators (in addition to Dr. Goetz) remarked that poison control insists on a four hour determination.

This is the advice from a nurse who is reading a protocol from a database (a proxy textbook).



Several commentators remarked that the four hour determination was the "peak level."

Actually it is not the peak level.

The reason for waiting this long is that this typically represents the post distribution phase after oral dosing.



Now (ugh) some pharmacokinetic principles:



After acute oral dosing there are three phases; absorption, distribution and excretion.

Below is a classic plot of concentration vs. time after acute oral dosing of conventional (non-modified release) pharmaceuticals.

In this instance the absorptive phase is 0 to approximately 4 hours - its conclusion is marked by the peak concentration of 8 ng/mL.



Distribution is the second phase.

This phase is during the vertically oriented downward slope of this curve beginning at or about 4 hours and concluding at or about 12 hours.

The corresponding concentrations are 8 and 3 ng/mL.



The key principle is that during distribution drug is leaving the blood stream and binding to cell receptors.

During distribution there is no proportional relationship between blood concentration and tissue concentration.

Thus during this phase it cannot be a predictor of toxicity.

Proportionality exists when distribution is complete which is the onset of the third phase - excretion.



This is depicted on the graph by the horizontally oriented downward slope.

In this instance - beginning at or about 12 hours.



The reason why we wait for 4 hours after acetaminophen ingestion is that we are waiting for distribution to be complete.

When this occurs there is a proportional relationship between blood and tissue acetaminophen concentrations making it a reliable risk assessment criterion.



Best wishes,



Milton Tenenbein






[http://omicsonline.org/ArchiveJBB/2009/October/03/images/JBB1.86Figure3.gif]









-----Original Message-----
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Goetz, Kathleen
Sent: Saturday, February 14, 2015 4:23 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Possible Acetaminophen ingestion - level timing



Hi all,

2.5yo healthy child found with open tylenol bottle, 1 pill on floor, ingestion uncertain. Event 1.5 hours prior to ER evaluation, patient very active, no distress, no emesis or evident abdominal pain, neuro intact, VS normal.

Questions:

1 - Any value in a 2 hour acetaminophen level?

2 - If 2 hour acetaminophen level = 0 is that a reliable predictor of no ingestion and safe to discharge?

Poison Control says no, must get 4 hour level.

Can't find any literature to support 2 hour level (quick lit search).

Input appreciated. Happy Valentines Day Kathey Goetz



Kathleen Goetz, MD

Medical Director, Swedish Pediatric Emergency Services Swedish FH ED

747 Broadway

Seattle, WA 98122-4307

Ofc: 206-386-3313 FH ED: 206-386-2573 Fax: 206-386-2577 Cell: 253-370-7571





CONFIDENTIALITY NOTICE: This email message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential, proprietary, and/or privileged information protected by law. If you are not the intended recipient, you may not use, copy or distribute this email message or attachments. If you believe you have received this email message in error, please contact the sender by reply email and destroy all copies of the original message.







________________________________________

From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Itai Shavit [[log in to unmask]]

Sent: Friday, February 13, 2015 12:54 AM

To: [log in to unmask]<mailto:[log in to unmask]>

Subject: PEM-Database Studies update - Feb 13, 2015



PEM-Database Studies update - Feb 13, 2015





http://www.pemdatabase.org/



For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:

                 http://listserv.brown.edu/ped-em-l.html

For more information, send mail to [log in to unmask]<mailto:[log in to unmask]> with the message: info PED-EM-L The URL for the PED-EM-L Web Page is:

                 http://listserv.brown.edu/ped-em-l.html

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html

Top of Message | Previous Page | Permalink

Advanced Options


Options

Log In

Log In

Get Password

Get Password


Search Archives

Search Archives


Subscribe or Unsubscribe

Subscribe or Unsubscribe


Archives

September 2019
August 2019
July 2019
June 2019
May 2019
April 2019
March 2019
February 2019
January 2019
December 2018
November 2018
October 2018
September 2018
August 2018
July 2018
June 2018
May 2018
April 2018
March 2018
February 2018
January 2018
December 2017
November 2017
October 2017
September 2017
August 2017
July 2017
June 2017
May 2017
April 2017
March 2017
February 2017
January 2017
December 2016
November 2016
October 2016
September 2016
August 2016
July 2016
June 2016
May 2016
April 2016
March 2016
February 2016
January 2016
December 2015
November 2015
October 2015
September 2015
August 2015
July 2015
June 2015
May 2015
April 2015
March 2015
February 2015
January 2015
December 2014
November 2014
October 2014
September 2014
August 2014
July 2014
June 2014
May 2014
April 2014
March 2014
February 2014
January 2014
December 2013
November 2013
October 2013
September 2013
August 2013
July 2013
June 2013
May 2013
April 2013
March 2013
February 2013
January 2013
December 2012
November 2012
October 2012
September 2012
August 2012
July 2012
June 2012
May 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September 2011
August 2011
July 2011
June 2011
May 2011
April 2011
March 2011
February 2011
January 2011
December 2010
November 2010
October 2010
September 2010
August 2010
July 2010
June 2010
May 2010
April 2010
March 2010
February 2010
January 2010
December 2009
November 2009
October 2009
September 2009
August 2009
July 2009
June 2009
May 2009
April 2009
March 2009
February 2009
January 2009
December 2008
November 2008
October 2008
September 2008
August 2008
July 2008
June 2008
May 2008
April 2008
March 2008
February 2008
January 2008
December 2007
November 2007
October 2007
September 2007
August 2007
July 2007
June 2007
May 2007
April 2007
March 2007
February 2007
January 2007
December 2006
November 2006
October 2006
September 2006
August 2006
July 2006
June 2006
May 2006
April 2006
March 2006
February 2006
January 2006
December 2005
November 2005
October 2005
September 2005
August 2005
July 2005
June 2005
May 2005
April 2005
March 2005
February 2005
January 2005
December 2004
November 2004
October 2004
September 2004
August 2004
July 2004
June 2004
May 2004
April 2004
March 2004
February 2004
January 2004
December 2003
November 2003
October 2003
September 2003
August 2003
July 2003
June 2003
May 2003
April 2003
March 2003
February 2003
January 2003
December 2002
November 2002
October 2002
September 2002
August 2002
July 2002
June 2002
May 2002
April 2002
March 2002
February 2002
January 2002
December 2001
November 2001
October 2001
September 2001
August 2001
July 2001
June 2001
May 2001
April 2001
March 2001
February 2001
January 2001
December 2000
November 2000
October 2000
September 2000
August 2000
July 2000
June 2000
May 2000
April 2000
March 2000
February 2000
January 2000
December 1999
November 1999
October 1999
September 1999
August 1999
July 1999
June 1999
May 1999
April 1999
March 1999
February 1999
January 1999
December 1998
November 1998
October 1998
September 1998
August 1998
July 1998
June 1998
May 1998
April 1998
March 1998
February 1998
January 1998
December 1997
November 1997
October 1997
September 1997
August 1997
July 1997
June 1997
May 1997
April 1997
March 1997
February 1997
January 1997
December 1996
November 1996
October 1996
September 1996
August 1996
July 1996
June 1996
May 1996
April 1996
March 1996
February 1996
January 1996
December 1995
November 1995
October 1995
September 1995
August 1995
July 1995
June 1995
May 1995
April 1995
March 1995
February 1995
January 1995
December 1994
November 1994
October 1994
September 1994

ATOM RSS1 RSS2



LISTSERV.BROWN.EDU

CataList Email List Search Powered by the LISTSERV Email List Manager