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Three Part Question

In [pediatric and adult ED patients] presenting after [exposure to caffeine-containing energy drinks], what are the [clinical features associated with acute intoxication]?

Clinical Scenario

A 19-year-old male is brought via EMS to the emergency department for seizure like activity, agitation, and anxiety after reported ingestion of multiple Monster Energy Drinks. Following a negative urine drugs of abuse screen you question whether his symptoms could be caused from toxicity from energy drink use?

Search Strategy

Medline 1946-04/14 using OVID interface, Cochrane Library (2014), PubMed clinical queries
[(exp energy drinks) AND (poisoning.mp OR toxicity.mp OR complications.mp OR adverse effects.mp)]. Limit to English language

Search Outcome

150 papers were identified; of which three were relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
DEIDRYA A. E. JACKSON, et al. 2013 USA	173 Adolescent (13-17 y.o.) and Adult (18-25 y.o.) patients who had reported energy drink or caffeine use within 30 days prior to presentation to two urban emergency departments over a six week period.	Cross-sectional pilot study	Energy drink users had a greater number and frequency of self-reported adverse effects compared to caffeinated-only beverage users.	Behavioral and physiologic side effects include running short of money, getting into trouble at home, school, or work, mind racing and restlessness or jitteriness.	Information was self-reported and was not necessarily indicative of the patients chief complaint or reason for presentation to the emergency department. No dose response analysis with regards to the actual quantity of caffeine consumed was performed. Due to the small sample size the power was inadequate to detect potential further behavioral and physiologic discrepancies between energy drink users and caffeinated-beverage only users.
Sara M. Seifert; et al. 2013 USA	1662 cases of energy drink exposures reported to the US National Poison Data System (NPDS) between October 1, 2010 and September 30, 2011.	Retrospective review from NPDS of adult and pediatric patients exposed to energy drinks	Age and severity of toxicity to energy drink exposure	Greater than 50% of exposures to energy drinks reported to NPDS were of children <6 years of age. The incidence of moderate to major adverse effects of energy drink-related toxicity was 15.2% and 39.3% for non-alcoholic and alcoholic energy drinks, respectively.	This paper deals with clinical exposure to energy drink use and the incidence of moderate to major adverse effects is not related to dose related response. This article presents pre-hospital information. While the number of non-ICU and ICU admissions was reported there is no mention of whether those exposed were referred to an emergency department or if the emergency department initiated contact with Poison Control.
Sean Patrick Nordt, et al. 2012 USA	1298 emergency department patients in San Diego, California from January to December 2009	Cross-sectional study	Demographic and socioeconomic factors and well as side effects related to energy drink consumption	Energy drink consumption crosses wide range of demographic and socioeconomic boundaries. Adverse effects are reported in up to one third of energy drink users. Most reactions are not severe but some serious reactions include seizures.	Survey method used relied on the reliability and ability to recall information of research participants. There was no method for verifying participant responses. No relationship between dose of energy drink and reported adverse effects was noted.

Comment(s)

Energy drink use is a ubiquitous concern among pediatric and adult patients in the United States. Some of the popular energy drinks in the United States obtain as much as 10mg of caffeine per ounce of fluid. Guarana, taurine, ginseng, and other sugars are among the other products contained in these drinks that can contribute to their side-effect profile. Although little evidence is available to suggest these drinks are a primary reason for presentation to the emergency department serious behavioral and physiologic adverse effects have been shown to result from its use. Reported toxicologic concerns include "jitteriness", agitation, seizures, and cardiac dysrhythmias.

Clinical Bottom Line

The lack of therapeutic benefit and potential for serious adverse effect from energy drink use supports the American Academy of Pediatrics conclusion that the use and sale of said substances should be closely monitored. Emergency department clinicians should be aware of the growing use of energy drinks and potential serious outcomes that may result from their consumption.

References

1. DEIDRYA A. E. JACKSON, et al. Behavioral and physiologic adverse effects in adolescent and young adult emergency department patients reporting use of energy drinks and caffeine Clinical Toxicology 2013 Aug; 51(7):557-65
2. Sara M. Seifert, et al. An analysis of energy-drink toxicity in the National Poison Data System Clinical Toxicology August 2013; 51(7):566-574
3. Sean Patrick Nordt, et al. Energy Drink Use and Adverse Effects Among Emergency Department Patients Journal of Community Health 2012; 37:976–981