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Pediatric Carbamazepine Toxicity Workup

  • Author: Muhammad Waseem, MD, MS; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Apr 22, 2016
 

Laboratory Studies

The workup in a patient with suspected carbamazepine poisoning should include appropriate comprehensive serum and urine drug screening, plus analysis of the following:

  • Alcohol level, if alcohol toxicity is suspected, particularly in adolescents
  • Serum electrolyte levels, including glucose, calcium, magnesium, phosphate, serum bicarbonate, BUN, and serum creatinine levels
  • Liver function tests, because elevated liver enzyme levels, hepatitis, and hyperammonemia may be noted with chronic toxicity

Serum drug testing should be based on the history of ingestion and/or the patient’s toxidrome.

A serum and urine drug screen may not detect carbamazepine; therefore, the serum carbamazepine level should also be determined if the patient has access to carbamazepine. Structural similarity between carbamazepine and tricyclic antidepressants (TCAs) may cause false-positive results with immunoassay for TCAs. Patients who are taking carbamazepine should have therapeutic drug monitoring using serum carbamazepine levels.[21]

Because carbamazepine absorption varies, the serum concentration may not peak for as long as 24-72 hours. With controlled-release formulation, levels may continue to rise until 4 days postingestion. In fact, the initial carbamazepine level may be misleading. For this reason, serial measurements documenting a declining carbamazepine level and prolonged observation are recommended when managing these overdoses.[22]

Initial serum levels of more than 35 mg/L (127 µmol/L) suggest serious toxicity. However, lower initial serum levels do not necessarily indicate a benign course and the patient still needs to be closely monitored for signs and symptoms of significant toxicity.

The serum concentration may not always directly correlate with the clinical picture. The severity of toxicity is assessed on the basis of the clinical status and not only the serum carbamazepine concentration.

Toxicity may result from carbamazepine itself or its active epoxide metabolite. However, measuring epoxide levels along with the carbamazepine level provides no additional advantage.

The complete blood cell count (CBC) with a differential should be obtained.

Although in utero exposure to carbamazepine has not been associated with adverse neuropsychological function, it has been associated with reduced verbal abilities.Therefore, a urine pregnancy test should be obtained on adolescent girls and if they are pregnant they should be counseled as to the possible effects of carbamazepine on the development of the fetus.[23]

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Imaging Studies

With acute carbamazepine toxicity, ultrasonography may reveal chemical pancreatitis. These patients may have no accompanying pain or other signs and symptoms.

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Other Tests

Other tests to consider include the following:

  • Perform a 12-lead ECG in patients with suspected poisoning.
  • Continuous EEG recordings in a case with unconsciousness, absent brainstem reflexes, and stimulus-sensitive multifocal myoclonus revealed a burst-suppression pattern, with bursts containing only generalized spikes accompanying myoclonic activity. [24] After treatment, EEG became more continuous and rhythmic without epileptiform discharges and with declining serum carbamazepine levels.
  • Carbamazepine is incorporated and retained in hair, depending on the blood levels. Sectional hair analysis helps investigators determine if chronic poisoning is an issue. [25]
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Contributor Information and Disclosures
Author

Muhammad Waseem, MD, MS Associate Professor of Emergency Medicine in Clinical Pediatrics, Associate Professor of Clinical Healthcare Policy and Research, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Muhammad Waseem, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, Society of Critical Care Medicine, Society for Simulation in Healthcare, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Joel R Gernsheimer, MD, FACEP Visiting Associate Professor, Department of Emergency Medicine, Attending Physician and Director of Geriatric Emergency Medicine, State University of New York Downstate Medical Center

Joel R Gernsheimer, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Geriatrics Society

Disclosure: Nothing to disclose.

Nicholas D Caputo, MD House Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center/Weill Cornell Medical College

Nicholas D Caputo, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Received salary from Merck for employment.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

William T Zempsky, MD Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Girish G Deshpande, MD, to the original writing and development of this article.

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Chemical structure of carbamazepine.
 
 
 
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