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Toxicity, Lead: Follow-up

Author: Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Aug 10, 2009

Follow-up

Further Inpatient Care

  • Careful attention to renal and hepatic function is important while administering chelation therapy.
    • Monitor fluid and electrolyte levels carefully because fluid shifts may occur during therapy.
    • Reports in the 1960s document cases of children who deteriorated after the onset of chelation therapy.
    • Several children have been reported to develop the syndrome of inappropriate secretion of antidiuretic hormone shortly after beginning chelation therapy.
  • All patients must have careful follow-up at weekly intervals to watch for unexpected re-exposure or re-equilibration of lead from bony stores after discontinuation of chelation.
  • Consideration for discharge must include the following:
    • Source of lead must be determined and possibility of re-exposure eliminated.
    • If outpatient chelation is indicated, the medication must be in the hand of the responsible individual related to administration of the medication.
    • The individual must demonstrate knowledge about and ability to dose the patient.
    • The lead level must have dropped an appreciable amount while on in-patient chelation.

Further Outpatient Care

  • All patients treated for lead poisoning require extensive outpatient follow-up. The intent of such follow-up is to avoid further exposure to lead and to maintain lead levels in the acceptable range. It is imperative that children not be exposed to more lead, if they are, their lead levels will rapidly rise again.

Inpatient & Outpatient Medications

  • Although separation of the patient from continued exposure to lead is of paramount importance, consider the use of chelation therapy to acutely lower blood lead levels.

Transfer

  • Transfer patients with symptomatic lead poisoning, particularly those with lead encephalopathy, to an institution adept at treating patients with critical increases in intracranial pressure. Children should be treated in specialized pediatric intensive care units.

Deterrence/Prevention

  • Many local health departments have programs for appropriate lead screening of children, in cooperation with local pediatricians. Stressing the need for screening in any patient at risk (because of housing, industrial, ethnic, recreational concerns) is important. Repairs of older homes must be done carefully to avoid lead exposure. Proper lead abatement in older homes prevents future exposure to lead and, thus, prevents further lead poisoning.

Complications

  • Lead poisoning, with or without encephalopathy, may result in neurological, renal, hepatic, or cardiac damage. All organ systems may be potentially damaged by lead. A possibility that symptoms may progress with chelation exists, and the treating physician must be prepared to manage them. Such complications may consist of syndrome of inappropriate excretion of antidiuretic hormone (SIADH), increased intracranial pressure (ICP), renal impairment from the chelated lead complex, and hypertension.

Prognosis

  • In the pediatric population, fatalities associated with lead encephalopathy were reported in the 1960s. Today, with aggressive management of ICP, these deaths are preventable and no such reports have been made in recent years. Occasional cases of acute lead encephalopathy still occur, and these often result in severe neurological damage. Asymptomatic lead poisoning has a far better prognosis. Long-term effects range from seizure disorders to hyperactivity, depressed school function, learning disability, and dyslexia.
  • Adults generally do not develop central effects but may develop distal motor neuropathies. Some reports document an increase in depressive disorders, aggressive behavior, and other maladaptive affective disorders in adult patients with lead poisoning.
  • Defects in sexual performance, frank impotence, infertility, and increased fetal wastage have been associated with lead poisoning in adults.

Patient Education

  • All patients must be educated in lead avoidance. The termination of exposure to lead is imperative.
  • A good substantial diet is important; lead absorption is increased when a diet rich in fats is consumed. Also, diets low in iron, calcium, and vitamin C increase the likelihood of lead absorption and resultant lead poisoning. Dietary fiber helps promote good peristalsis and decreases the opportunity for lead absorption; thus, at least 15 g of dietary fiber are suggested for children each day.
  • For excellent patient education resources, visit eMedicine's Poisoning Center. Also, see eMedicine's patient education article Poisoning.

Miscellaneous

Medicolegal Pitfalls

  • The greatest danger is failure to recognize the possibility of lead poisoning.
    • The symptoms and signs of lead toxicity are subtle and easily overlooked.
    • One suit developed after a child was seen in several hospital EDs, presenting with the symptoms of poor appetite, vomiting, and sore throat. A throat culture obtained at one ED revealed beta-hemolytic streptococcus, and the child received appropriate penicillin therapy only to return several days later actively convulsing with a lead level higher than 170 mcg/dL.
  • Failure to initiate removal of the patient from the area of the exposure (eg, lead-based paint)
  • Failure to diagnose and treat other members of the family/friends with similar lead exposure
  • Failure to suspect lead toxicity/encephalopathy in patients presenting with afebrile seizures
  • Spinal tap performed on the patients with lead encephalopathy and increased intracranial pressure can precipitate cerebral herniation and death.
 


More on Toxicity, Lead

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Treatment & Medication: Toxicity, Lead
Follow-up: Toxicity, Lead
Multimedia: Toxicity, Lead
References
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Further Reading

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Keywords

lead toxicity, lead poisoning, lead consumption, lead poisoning causes, lead poisoning treatment, adult lead poisoning, pediatric lead poisoning, effects of lead poisoning, lead contamination, lead paint, lead exposure, childhood lead exposure, childhood lead poisoning, lead-related occupations, lead-pigmented paint, iron deficiency

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Contributor Information and Disclosures

Author

Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Medical Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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