Pediatric Poisonings: Do They Really Need That PICU Bed?*
Poisonings remain a significant public health concern and a major cause of injury-related death in pediatrics. Data from the American Academy of Poison Control Centers show that calls to poison centers continue to increase every year since at least 2000 (1). They report over 2.8 million calls in 2015 or a call every 14.5 seconds across the United States. Most of these can be managed at home (67%), but the referrals to hospitals have gone up—particularly in the adolescent age group. Many referred to hospitals also go home from the emergency department (ED), but recent data suggest that up to 39% referred in for ingestions are admitted to the hospital (2, 3). Who gets admitted and where remains highly variable based on an estimation of the real and potential risks of ingestion based on the pharmacology of poisons, the amount of drug taken, toxicology recommendations, capabilities of the ward or observational units, and presence or absence of any toxidrome. If the decision to admit to the PICU is made for any of these reasons, our PICUs obviously take them when at all possible.
Despite the fact that poisonings or ingestions have been reported to account for between 3% and 8% of all PICU admissions (4, 5), there are surprisingly little data to drive practice or provide guidance for a busy PICU trying to manage beds effectively and efficiently. What we do know from the literature is that despite the significant number of admissions, most are in the PICU for a day at most and thus are a much smaller percentage of bed usage compared with other diagnoses. We also know that a very wide variety of ingested poisons lead to PICU admission, that usually more than half are in children less than 5 years old with unintentional ingestions, and that intentional ingestions are more common in adolescents, who tend to present sicker and are more likely to be polypharmaceutical intoxications (1–5). Death and morbidity also are very low in this population, but it is unclear how much that relates to appropriate supportive care or to very few patients actually reaching a lethal dose concentration of drug in their body.
The important question remains as to what admission criteria to the PICU can be used to be safe and reliable for children with acute intoxications.