2002 annual report of the American association of poison control centers toxic exposure surveillance system

Management of beta-adrenergic blocker and calcium channel antagonist toxicity

State-of-the-art therapy for beta-adrenergic receptor blocker and calcium channel antagonist toxicity is reviewed in the light of new insights into drug-induced shock. A brief discussion of pathophysiology, including cardiac, hemodynamic, and metabolic effects of cardiac drug toxicity, provides a foundation for understanding the basis of therapy. The major focus of this review is a critical evaluation of antidotal use of calcium, glucagon, catecholamines, insulin-euglycemia, and other novel therapies based on investigational studies and cumulative clinical experience.

Superwarfarin poisoning: a report of two cases and review of the literature

Superwarfarins are anticoagulant rodenticides similar to warfarin, but which have various substituted phenyl groups replacing the terminal methyl group, resulting in a fat-soluble, long-acting anticoagulant that is nearly 100 times more potent than the parent compound. Since their development, many accidental and intentional cases of consumption have been reported. We describe two cases of consumption, one related to unknown etiology, and the other related to utilization of the superwarfarin to potentiate a drug of abuse. The clinical manifestations including bleeding symptoms and abnormal coagulation assays are discussed. The differential diagnosis is quite broad, and includes all causes of vitamin K deficiency, factor deficiency or inhibitor, disseminated intravascular coagulation (DIC), and liver disease. Differentiating superwarfarin ingestion from the other causes can be quite difficult, but extremely important, as management requires prolonged administration of vitamin K. Other treatment options are discussed as well including, fresh frozen plasma (FFP), and recombinant factor VIIa. Finally, the significance of "lacing" drugs of abuse with superwarfarin to potentiate their effect is discussed, as well as the complications that could develop from such a habit.

Pediatric Toxicology

Pediatric patients present unique concerns in the field of medical toxicology. First, there are medicines that are potentially dangerous to small children, even when they are exposed to very small amounts. Clinicians should be wary of these drugs even when young patients present with accidental ingestions of apparently insignificant amounts. Next, over-the-counter laxatives and syrup of ipecac, although not commonly considered abused substances, may be misused in both the setting of Munchausen's syndrome by proxy and in adolescents who have eating disorders. Their use should be considered in any gastrointestinal illness of uncertain origin. Finally, as the use of syrup of ipecac at home now has been discouraged by many, some have explored using activated charcoal at home as a new method of prehospital gastrointestinal decontamination. The literature examining activated charcoal and its use in this capacity is discussed.

Pattern of proton pump inhibitor calls to Texas poison centers, 1998-2004

There is little information on the management of potentially adverse exposures to proton pump inhibitors. This study examined the distribution of 2943 proton pump inhibitor exposures reported to Texas poison control centers during 1998-2004. In particular comparisons were made between exposures among pediatric (age < or =5 yr) and adult (age > or =20 yr) patients. Of the total exposures, 1813 (62%) were to the proton pump inhibitor alone. Of exposures to proton pump inhibitors alone, 66% were age < or =5 yr, 7% 6-19 yr, and 27% > or =20 yr. Pediatric and adult patients differed with respect to patient gender, exposure reason, exposure site, management site, final medical outcome, report of specific adverse clinical exposures, and listed treatments. Proton pump inhibitor exposures differed with patient age. In the majority of instances, potentially adverse proton pump inhibitor exposures reported to poison control centers may be successfully managed at home with favorable outcome.

Triage method for out-of-hospital poisoned patients

The aim of this study was to develop and evaluate a triage method to prevent unnecessary emergency department visits of out-of-hospital poisoned patients. From October 2003 to September 2004, the calls that lay persons gave to the Seoul Emergency Medical Information Center to seek advice on the out-of-hospital poisoned patients were enrolled. We designed a triage protocol that consisted of five factors and applied it to the patients. According to the medical outcomes, we classified the patients into two groups, the toxicity-positive and the toxicity-negative. We arranged the factors on the basis of the priority that was determined in order of the odds ratio of each factor for the toxicity-positive and made a flow chart as a triage method. Then we calculated a sensitivity, specificity, positive predictive value and negative predictive value of the method. We regarded the specificity as the ability of the method and the sensitivity as the safety. A total of 220 patients were enrolled in this study. The method showed a sensitivity, specificity, positive predictive value, and negative predictive value of 99.2%, 53.4%, 76.2%, and 97.9%, respectively. Our triage method prevented 53.4% of the unnecessary emergency department visits of out-of-hospital acutely poisoned patients, safely.

Oxycodone abuse in Texas, 1998-2004

Oxycodone is frequently abused, and this abuse appears to be increasing. The purpose of this study was to describe the patterns of oxycodone abuse identified by Texas poison control centers. All oxycodone calls received by Texas poison control centers during 1998-2004 were identified. Annual trends and geographic distributions were determined for drug identification (ID) calls and abuse calls. The distribution of abuse calls was then compared to the distribution of all other types of human exposure calls for a variety of factors. Both drug ID and abuse calls involving oxycodone increased over the 7-yr period. The numbers of abuse calls were higher than expected in the central part of Texas, while drug ID calls were higher than expected in eastern and central Texas. A higher proportion of oxycodone abuse than other types of oxycodone exposures involved males, adolescents, exposures at other residences and public areas, referral by the poison control center to a health care facility, and some sort of clinical effect. Oxycodone abuse calls in Texas are increasing. The proportion of calls varies by geographic region. Oxycodone abuse calls differ from other types of exposures with respect to both demographic factors and clinical management and outcome.

A case of serotonin syndrome and mutism associated with methadone

A patient was seen on the palliative care service at our institution who developed serotonin syndrome and mutism associated with methadone use. Serotonin syndrome is often described as a clinical triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities, but not all of these findings are consistently present in all patients with the disorder. The incidence of the serotonin syndrome is thought to mirror the increasing number of proserotonergic agents being used in clinical practice. In 2002, the Toxic Exposure Surveillance System, which receives case descriptions from office-based practices, inpatient settings, and emergency departments, reported 26,733 incidences of exposure to selective serotonin-reuptake inhibitors (SSRIs) that caused significant toxic effects in 7349 persons and resulted in 93 deaths. Serotonin syndrome is not an idiopathic drug reaction; it is a predictable consequence of excess serotonergic agonism of central nervous system (CNS) receptors and peripheral serotonergic receptors. The myriad of symptoms with which serotonin syndrome may present is compounded by the fact that more than 85% of physicians are unaware of serotonin syndrome as a clinical diagnosis. Other SSRIs such as fluoxetine and fluvoxamine have been shown to increase methadone plasma concentrations in dependent patients. Although the exact mechanism is unknown, there are several pathways via which a significant interaction could occur. This would include the effects methadone has on N-methyl-D-aspartate (NMDA) in addition to the impact of methadone on the cytochrome P450 enzyme system. The mainstay of treatment of serotonin syndrome is withdrawal of the offending agent and supportive care. These actions resulted in resolution of our patient's symptoms. Serotonin syndrome is becoming more common, and with the utilization of polypharmacy on many palliative care services should be considered as unifying differential diagnosis in the appropriate setting.

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data

PURPOSE

The severity of hazards posed by medications implicated in poisoning in older adults was characterized.

METHODS

Toxic Exposure Surveillance System (TESS) cases from 1993 through 2002 involving a single substance in patients age 60 years or older and coded as an adverse drug reaction (ADR) or therapeutic error were analyzed. Hazard factors were determined for each exposure reason by calculating the sum of the major effects and deaths for each substance category and subcategory and dividing this by the total number of exposures for the respective category or subcategory.

RESULTS

Hazard factors were calculated for 12,737 ADRs and 51,846 therapeutic errors. The overall rates of major effects and deaths were 7.5% and 1.6% in the ADR and therapeutic error groups, respectively. In the ADR group, five TESS categories had a hazard factor of > or =2.0: anesthetics, anticoagulants, antineoplastics, cardiovascular drugs, and radiopharmaceuticals. In the therapeutic error group, five drug categories also had a hazard factor of > or =2.0: anesthetics, anticoagulants, antineoplastics, asthma therapies, and serums/toxoids/vaccines. Six pharmaceutical categories were associated with hazard factors of > or =2.0 in both the ADR and therapeutic error groups.

CONCLUSION

An analysis of ADRs and therapeutic errors involving older adults and reported to poison control centers from 1993 through 2002 revealed overall rates of major effects and death of 7.5% and 1.6% in the ADR and therapeutic error groups, respectively. Antineoplastics, aminophylline or theophylline, cardiac glycosides, heparin, morphine, and warfarin were implicated in more than 50 cases and associated with hazard factors of > or =2.0 for both exposure groups.

Organophosphate exposures in the United States: a longitudinal analysis of incidents reported to poison centers

The implementation of the Food Quality Protection Act of 1996 resulted in a decision by the U.S. Environmental Protection Agency to phase out and eliminate the use of organophosphate insecticides in residential environments. The phase-out and cancellation process began in the year 2000 and was complete in 2005. The purpose of this investigation was to utilize national Poison Control Center data to assess whether the risk mitigation decision had an impact on the number of incident cases involving organophosphates in the United States. Organophosphate exposure incident data were extracted from Annual Reports of the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS) for the years 1995 to 2004. The number of organophosphate exposure incidents peaked at 20,135 in 1997, and declined in each subsequent year. A statistically significant decrease was observed in the average annual number of organophosphate exposure incidents when comparing data from the time periods before (1995-1999) and after (2000-2004) the commencement of the phase-out process. The decrease in organophosphate incident cases was observed for all age categories, as well as for the circumstances surrounding the exposure (unintentional and intentional exposure incidents). TESS data showed a significant decrease in incident cases involving organophosphates in association with the phase-out from residential uses. The results of this investigation are consistent with other studies that have reported that regulatory restriction of access to pesticide formulations may have a significant impact on the number of human exposure incidents.

Trends in antidepressant overdoses

BACKGROUND

Debate continues about antidepressants and suicide. However, there are few recent nation-wide data about antidepressant overdoses. The purpose of this study was to describe United States trends from 1983 through 2003 in antidepressant overdoses as well as trends in health care utilization and mortality.

METHODS

Data were obtained from the American Association of Poison Control Centers' (AAPPC) Toxic Exposure Surveillance System (TESS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) of emergency departments, and the National Hospital Discharge Survey(NHDS).

RESULTS

Antidepressant overdose reports rose dramatically in the United States (from 0.61 per 10,000 population in 1983 to 3.26 per 10,000 population in 2003) chiefly due to the rise in selective serotonin reuptake inhibitor (SSRI) ingestion. However, fatalities per antidepressant overdose report declined from 73 per 10,000 reported ingestions to 32 per 10,000 ingestions. Tricyclic antidepressant (TCA) overdoses had higher rates of hospitalization (78.7 vs. 64.7% hospitalized) and much higher fatality rates than did SSRI overdose reports (0.73 vs. 0.14% mortality). If the 55,977 SSRI overdoses in 2003 had represented TCA overdoses, then (other things being equal) approximately 410 fatalities would have been expected but only 106 people died. Emergency department visits associated with antidepressant overdose increased along with all emergency department visits. Hospitalization associated with antidepressant overdose increased in the early 1980s but then reached a plateau while overall hospitalizations declined.

CONCLUSIONS

The dramatic rise in United States antidepressant overdoses has not been reflected in antidepressant overdose fatalities nor in hospitalizations. If the marked increase in antidepressant overdoses in the United States had involved TCAs rather than SSRIs, then there would have been roughly 300 excess deaths annually.

Environmental hazards: evidence for effects on child health

The human fetus, child, and adult may experience adverse health outcomes from parental or childhood exposures to environmental toxicants. The fetus and infant are especially vulnerable to toxicants that disrupt developmental processes during relatively narrow time windows. This review summarizes knowledge of associations between child health and development outcomes and environmental exposures, including lead, methylmercury, polychlorinated biphenyls (PCBs), dioxins and related polyhalogenated aromatic hydrocarbons (PHAHs), certain pesticides, environmental tobacco smoke (ETS), aeroallergens, ambient air toxicants (especially particulate matter [PM] and ozone), chlorination disinfection by-products (DBPs), sunlight, power-frequency magnetic fields, radiofrequency (RF) radiation, residential proximity to hazardous waste disposal sites, and solvents. The adverse health effects linked to such exposures include fetal death, birth defects, being small for gestational age (SGA), preterm birth, clinically overt cognitive, neurologic, and behavioral abnormalities, subtle neuropsychologic deficits, childhood cancer, asthma, other respiratory diseases, and acute poisoning. Some environmental toxicants, notably lead, ionizing radiation, ETS, and certain ambient air toxicants, produce adverse health effects at relatively low exposure levels during fetal or child developmental time windows. For the many associations supported by limited or inadequate epidemiologic evidence, major sources of uncertainty include the limited number of studies conducted on specific exposure-outcome relationships and methodologic limitations. The latter include (1) crude exposure indices, (2) limited range of exposure levels, (3) small sample sizes, and (4) limited knowledge and control of potential confounders. Important knowledge gaps include the role of preconceptual paternal exposures, a topic much less studied than maternal or childhood exposures. Large longitudinal studies beginning before or during early pregnancy are urgently needed to accurately measure and assess the relative importance of parental and childhood exposures and evaluate relatively subtle health outcomes such as neuropsychologic and other functional deficits. Large case-control studies are also needed to assess the role of environmental exposures and their interactions with genetic factors in relatively uncommon outcomes such as specific types of birth defects and childhood cancers. There is also an urgent need to accelerate development and use of biomarkers of exposure and genetic susceptibility in epidemiologic studies. This review supports the priority assigned by international agencies to relationships between child health and air quality (indoor and outdoor), lead, pesticides, water contaminants, and ETS. To adequately address such priorities, governments and agencies must strengthen environmental health research capacities and adopt policies to reduce parental and childhood exposures to proven and emerging environmental threats.

Are one or two dangerous? Methyl salicylate exposure in toddlers

Serious toxicity can result from exposure to small amounts of methyl salicylate. Methyl salicylate is widely available as a component in many over-the-counter brands of creams, ointments, lotions, liniments and medicated oils intended for topical application to relieve musculoskeletal aches and pains. Among the most potent forms of methyl salicylate is oil of wintergreen (98% methyl salicylate). Other products with varying concentrations of methyl salicylate are ubiquitous throughout many parts of the world, including a number of products marketed as Asian herbal remedies. The toxic potential of all of these formulations is often underestimated by health care providers and the general public. A comprehensive review of the existing medical literature on methyl salicylate poisoning was performed, and data compiled over the past two decades by the American Association of Poison Control Centers (AAPCC) was examined. Methyl salicylate continues to be a relatively common source of pediatric exposures. Persistent reports of life-threatening and fatal toxicity were found. In children less than 6 years of age, a teaspoon (5 mL) or less of oil of wintergreen has been implicated in several well-documented deaths. More needs to be done to educate both health care providers and the general public regarding the dangers of these widely available formulations.

2005 Annual Report of the American Association of Poison Control Centers' national poisoning and exposure database

BACKGROUND

The American Association of Poison Control Centers (AAPCC; <a href="http://www.aapcc.org" target="BLANK">http://www.aapcc.org</a>) maintains the national database of information logged by the country's 61 Poison Control Centers (PCCs). Case records in this database are from self-reported calls: they reflect only information provided when the public or healthcare professionals report an actual or potential exposure to a substance (e.g., an ingestion, inhalation, or topical exposure.), or request information/educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may go unreported to PCCs, and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s). U.S. Poison Centers make possible the compilation and reporting of this report through their staffs' meticulous documentation of each case using standardized definitions and compatible computer systems. The 61 participating poison centers in 2005 are: Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Banner Poison Control Center, Phoenix, AZ; Arkansas Poison and Drug Information Center, Little Rock, AK; California Poison Control System-Fresno/Madera Division, CA; California Poison Control System-Sacramento Division, CA; California Poison Control System-San Diego Division, CA; California Poison Control System-San Francisco Division, CA; Rocky Mountain Poison and Drug Center, Denver, CO; Connecticut Poison Control Center, Farmington, CT; National Capital Poison Center, Washington, DC; Florida Poison Information Center, Tampa, FL; Florida Poison Information Center, Jacksonville, FL; Florida Poison Information Center, Miami, FL; Georgia Poison Center, Atlanta, GA; Illinois Poison Center, Chicago, IL; Indiana Poison Center, Indianapolis, IN; Iowa Statewide Poison Control Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KA; Kentucky Regional Poison Center, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Northern New England Poison Center, Portland, ME; Maryland Poison Center, Baltimore, MD; Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA; Children's Hospital of Michigan Regional Poison Control Center, Detroit, MI; DeVos Children's Hospital Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Mississippi Regional Poison Control Center, Jackson, MS; Missouri Regional Poison Center, St Louis, MO; Nebraska Regional Poison Center, Omaha, NE; New Jersey Poison Information and Education System, Newark, NJ; New Mexico Poison and Drug Information Center, Albuquerque, NM; New York City Poison Control Center, New York, NY; Long Island Regional Poison and Drug Information Center, Mineola, NY; Ruth A. Lawrence Poison and Drug Information Center, Rochester, NY; Upstate (formerly Central) New York Poison Center, Syracuse, NY; Western New York Poison Center, Buffalo, NY; Carolinas Poison Center, Charlotte, NC; Cincinnati Drug and Poison Information Center, Cincinnati, OH; Central Ohio Poison Center, Columbus, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Oklahoma Poison Control Center, Oklahoma City, OK; Oregon Poison Center, Portland, OR; Pittsburgh Poison Center, Pittsburgh, PA; The Poison Control Center, Philadelphia, PA; Puerto Rico Poison Center, San Juan, PR; Palmetto Poison Center, Columbia, SC; Tennessee Poison Center, Nashville, TN; Central Texas Poison Center, Temple, TX; North Texas Poison Center, Dallas, TX; Southeast Texas Poison Center, Galveston, TX; Texas Panhandle Poison Center, Amarillo, TX; West Texas Regional Poison Center, El Paso, TX; South Texas Poison Center, San Antonio, TX; Utah Poison Control Center, Salt Lake City, UT; Virginia Poison Center, Richmond, VA; Blue Ridge Poison Center, Charlottesville, VA; Washington Poison Center, Seattle, WA; West Virginia Poison Center, Charleston, WV; Wisconsin Poison Center, Milwaukee, WI.

Drug identification calls from law enforcement received by Texas poison control centers, 2002-2004

Aside from calls involving human exposures to potentially toxic substances, poison control centers handle other types of calls such as drug identifications (drug IDs). A portion of drug ID requests originates from law enforcement. The objective of this study was to describe such drug ID requests from law enforcement received by Texas poison control centers during 2002-2004. These calls were examined with respect to year of call, location of caller, and type of drug. There were in total 26,752 drug ID calls (involving 27,800 individual drug ID requests) from law enforcement, representing 3% of total calls and 16% of all drug ID calls received. The number of drug ID calls received from law enforcement and the proportion of total calls and all drug ID calls these represented increased from 2002 to 2004. A disproportionate number of the drug ID requests originated from eastern-central Texas. The most frequently involved drugs were analgesics (particularly acetaminophen and hydrocodone), sedatives and related drugs (particularly alprazolam), and muscle relaxants (particularly carisoprodol).

Intoxication-related fatalities in northern Germany

BACKGROUND

Knowing what substances cause death in intoxicated patients is of medical, legal, and political relevance. Harmonized data documentation like TESS (Toxic Exposure Surveillance System) in the United States does not exist yet in Germany. However, the GIZ-Nord Poison Center in Göttingen issues an annual report that includes fatalities. The aim of this study was to obtain an overview of the substances resulting in fatal poisoning and to define risk factors.

METHODS

In a retrospective study, all fatalities due to poisoning from January 1996 until March 2003 were analyzed.

RESULTS

From 1996 to 2003, the GIZ-Nord Poison Center was consulted in 168,000 cases. There were 142 fatalities due to poisoning (0.08% of all consultations). In 79 cases, the lethal substance was a medical drug, mostly tricyclic antidepressants and cardiovascular drugs. Two immigrants of German origin from the former Soviet Union died after consuming Amanita mushrooms. Five elderly, disorientated patients died of respiratory failure due to aspiration of detergent products from soap or shampoo.

CONCLUSION

Three groups of patients with a high risk of dying from intoxication can be defined: (1) suicidal patients with access to tricyclic antidepressants or cardiovascular drugs, (2) immigrants from the former Soviet Union who mistake toxic German mushrooms for edible species, and (3) elderly, disorientated patients who ingest large amounts of soap or shampoo.

Carbon dioxide poisoning

Carbon dioxide is a physiologically important gas, produced by the body as a result of cellular metabolism. It is widely used in the food industry in the carbonation of beverages, in fire extinguishers as an 'inerting' agent and in the chemical industry. Its main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level. At low concentrations, gaseous carbon dioxide appears to have little toxicological effect. At higher concentrations it leads to an increased respiratory rate, tachycardia, cardiac arrhythmias and impaired consciousness. Concentrations >10% may cause convulsions, coma and death. Solid carbon dioxide may cause burns following direct contact. If it is warmed rapidly, large amounts of carbon dioxide are generated, which can be dangerous, particularly within confined areas. The management of carbon dioxide poisoning requires the immediate removal of the casualty from the toxic environment, the administration of oxygen and appropriate supportive care. In severe cases, assisted ventilation may be required. Dry ice burns are treated similarly to other cryogenic burns, requiring thawing of the tissue and suitable analgesia. Healing may be delayed and surgical intervention may be required in severe cases.

Quality Improvement Process in the Adherence to Gastric Decontamination Guidelines for Poison Exposures as Recommended by a Poison Control Center

PURPOSE

Adherence to new guidelines for the use of ipecac syrup, gastric lavage, cathartics, and activated charcoal by a poison control center was studied with a quality improvement framework.

METHODS

The rates of gastric decontamination were monitored through an electronic case record system. In February 2002, a revised guideline that narrowed the use of gastric decontamination was implemented with a performance improvement process. The rates of recommendation and utilization during 12 months following implementation of the new guidelines were compared with those during 12 previous months.

RESULTS

Recommendations for the use of ipecac syrup declined from 1.50% to 0.02% (OR; 95% CI = 0.02; 0.01, 0.03), single-dose-activated charcoal declined from 5.39% to 1.38% (0.25; 0.22, 0.28), gastric lavage declined from 4.19% to 0.22% (0.05; 0.04, 0.06), and a cathartic declined from 1.48% to 0.13% (0.08; 0.06, 0.12). Declines in utilization were also significant (P < .001) for all forms of gastric decontamination. The proportions of patients managed at the scene of the poisoning were unchanged (1.04; 0.99, 1.09) before (67.64%) and after (68.50%) the new guidelines as were those for referral to a health care facility (20.57% and 21.42%, respectively, 1.05; 1.00, 1.11).

CONCLUSION

Recommendations on gastric decontamination can be effectively modified with no detriment to patient outcome.

The Availability and Use of Charcoal Hemoperfusion in the Treatment of Poisoned Patients

BACKGROUND

Charcoal hemoperfusion (CHP) has been one of the preferred methods to enhance the elimination of certain toxins in selected poisoned patients. However, the availability of CHP may be limited because of the expense of cartridges, their narrow indications, and their limited shelf life. Improvements in hemodialysis (HD) technology may contribute to making CHP obsolete. We investigated the availability of CHP in in-hospital HD units at hospitals receiving ambulances dispatched through New York City's emergency response system, hereafter referred to as 911-receiving hospitals, and their recent history of CHP use in poisoned patients.

METHODS

The medical directors or managers of all in-hospital HD units in the 911-receiving hospitals of New York City were contacted by E-mail and/or telephone. Participants were administered a standard survey that included questions regarding the availability of CHP cartridges and the date and indication for last CHP use. Participants at institutions that did not stock CHP cartridges were questioned about their opinions on the utility of CHP.

RESULTS

Forty-two in-hospital HD units were surveyed, of which 34 (81%) completed the survey. Ten units (29%) had CHP cartridges available for immediate use. Each of these 10 units stocked between 1 and 4 adult-size CHP cartridges, and 1 unit stocked 2 pediatric-size CHP cartridges. Nine units had in-date CHP cartridges, and 1 unit had only expired CHP cartridges. Only 3 units performed CHP in the past 5 years (2 units, theophylline poisonings; 1 unit, aluminum overload). In the 24 units without CHP cartridges, 21 directors believed that most common toxins could be removed effectively through HD and thus CHP rarely was indicated. Only 1 director cited expense as a factor in not stocking CHP cartridges. Two directors reported no specific reason for not stocking the cartridges.

CONCLUSION

CHP cartridges are available in only approximately one third of 911-receiving hospitals in New York City. CHP is infrequently performed to enhance toxin elimination in poisoned patients.

Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention

Effective management of cyanide poisoning from chemical terrorism, inhalation of fire smoke, and other causes constitutes a critical challenge for the prehospital care provider. The ability to meet the challenge of managing cyanide poisoning in the prehospital setting may be enhanced by the availability of the cyanide antidote hydroxocobalamin, currently under development for potential introduction in the United States. This paper discusses the causes, recognition, and management of acute cyanide poisoning in the prehospital setting with emphasis on the emerging profile of hydroxocobalamin, an antidote that may have a risk:benefit ratio suitable for empiric, out-of-hospital treatment of the range of causes of cyanide poisoning. If introduced in the U.S., hydroxocobalamin may enhance the role of the U.S. prehospital responder in providing emergency care in a cyanide incident.

Are one or two dangerous? Phenothiazine exposure in toddlers

Traditionally, pediatric phenothiazine exposures are considered dangerous even at low doses. The actual risk of exposure to 1-2 tablets is unclear. In an attempt to determine this risk, the authors performed a literature search, review of the American Association of Poison Control Center data, and evaluation of related resources (e.g., textbooks, bibliographies of relevant papers). This review reveals only sparse data from case reports regarding morbidity and mortality in the pediatric population despite years of clinical experience. Serious toxicity from exposure to low doses is rare and nearly always the result of chlorpromazine ingestion. Although the risk to the toddler ingesting 1-2 tablets seems to be extremely low, several factors should be considered when determining the need for triage to a health care facility.

Psychopharmacology in pediatric critical care

Psychopharmacologic treatment in pediatric critical care requires a careful child or adolescent psychiatric evaluation, including a thorough review of the history of present illness or injury, any current or pre-existing psychiatric disorder, past history, and laboratory studies. Although there is limited evidence to guide psychopharmacologic practice in this setting, psychopharmacologic treatment is increasing in critical care, with known indications for treatment, benefits, and risks; initial dosing guidelines; and best practices. Treatment is guided by the knowledge bases in pediatric physiology, psycho-pharmacology, and treatment of critically ill adults. Pharmacologic considerations include pharmacokinetic and pharmcodynamic aspects of specific drugs and drug classes, in particular elimination half-life, developmental considerations, drug interactions, and adverse effects. Evaluation and management of pain is a key initial step, as pain may mimic psychiatric symptoms and its effective treatment can ameliorate them. Patient comfort and safety are primary objectives for children who are acutely ill and who will survive and for those who will not. Judicious use of psychopharmacolgic agents in pediatric critical care using the limited but growing evidence base and a clinical best practices collaborative approach can reduce anxiety,sadness, disorientation, and agitation; improve analgesia; and save lives of children who are suicidal or delirious. In addition to pain, other disorders or indications for psychopharmacologic treatment are affective disorders;PTSD; post-suicide attempt patients; disruptive behavior disorders (especially ADHD); and adjustment, developmental, and substance use disorders. Treating children who are critically ill with psychotropic drugs is an integral component of comprehensive pediatric critical care in relieving pain and delirium; reducing inattention or agitation or aggressive behavior;relieving acute stress, anxiety, or depression; and improving sleep and nutrition. In palliative care, psychopharmacology is integrated with psychologicapproaches to enhance children's comfort at the end of life. Defining how best to prevent the adverse consequences of suffering and stress in pediatric critical care is a goal for protocols and for new psychopharmacologic research [23,153].

Homicidal Ethylene Glycol Intoxication

We report a case of a 75-year-old hypertensive, diabetic man who presented to the emergency room with symptoms and signs of nausea, acute intoxication, significant alteration in mental status with rapid neurologic deterioration, and blunt impact injuries sustained during a recent altercation with a 36-year-old female companion-caretaker. He denied a history of ethanol abuse or other recent toxic ingestion and had not been diagnosed with or treated for depression. Hospital laboratory tests revealed a metabolic acidosis and a negative urine toxicology screen. He was diagnosed with toxic encephalopathy with metabolic acidosis secondary to metformin. Despite treatments including hemodialysis, he expired after approximately 28 hours of hospitalization. A postmortem anatomic examination revealed recent blunt-impact injuries and cardiac and renal pathology. A subsequent histologic examination revealed the presence of calcium oxalate crystals in the kidneys and brain, in addition to cardiac and renal pathology. Comprehensive forensic toxicologic testing was performed on antemortem and postmortem samples and revealed lethal levels of ethylene glycol. The cause of death was as a result of acute intoxication by ethylene glycol with another condition of multiple blunt impacts to the head, trunk, and extremities. The manner of death was ruled as homicide. A trial by jury, involving the female companion-caretaker, resulted in her conviction, and she was sentenced to 23 years to life in prison. In this report, we present an unusual case of homicidal ethylene glycol intoxication in which legal proceedings have occurred.

Crotalidae polyvalent immune Fab (ovine) antivenom is effective in the neutralization of South American viperidae venoms in a murine model

STUDY OBJECTIVE

Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) is used in the treatment of symptomatic crotaline envenomations in North America. Unlike Antivenin (Crotalidae) Polyvalent, which is approved for treatment of crotaline envenomation in North and South America, FabAV is manufactured using only venoms from crotaline snakes native to the United States. This study was designed to evaluate the efficacy of FabAV in the neutralization of venom from 2 South American crotaline snakes: Crotalus durissus terrificus (tropical rattlesnake) and Bothrops atrox (fer-de-lance).

METHODS

A randomized, blinded, placebo-controlled murine model of intraperitoneal venom injection was used. Venom potency was determined in preliminary median lethal dose (LD 50) dosing studies. Study animals were then divided into 7 groups: (1) C durissus terrificus venom (Sigma-Aldrich Co.)+FabAV, (2) C durissus terrificus venom (Sigma-Aldrich Co.)+0.9% normal saline solution, (3) C durissus terrificus venom (Biotoxins Inc.)+FabAV, (4) C durissus terrificus venom (Biotoxins Inc.)+normal saline solution, (5) B atrox venom+FabAV, (6) B atrox venom+normal saline solution, and (7) FabAV+normal saline solution. Twice the estimated LD 50 was the chosen venom dose, and the amount of FabAV injected was 10 times the amount needed for venom neutralization. Statistical analysis included Fisher's exact test and log-rank testing to compare survival rates and times.

RESULTS

The venom LD 50 was found in preliminary studies to be 0.9 mg/kg and 1.35 mg/kg for the C durissus terrificus venom obtained from Sigma-Aldrich Co. and Biotoxins Inc., respectively. The LD 50 for B atrox venom was 5.0 mg/kg. All animals receiving venom only and saline solution died. Animals receiving FabAV together with either venom survived to the end of the 24-hour observation period ( P <.001). Comparison of survival times between groups demonstrated a significant difference in time to death between venom-only control groups and the FabAV+venom groups (P <.001). All animals in the FabAV+normal saline solution group survived to the conclusion of the study.

CONCLUSION

FabAV, when premixed with venom, decreases lethality in a murine model of intraperitoneal venom injection of the South American pit vipers, C durissus terrificus and B atrox .

Extracorporeal management of valproic acid toxicity: a case report and review of the literature

The incidence of intentional or accidental valproic acid (VPA) overdose is increasing. Severe VPA toxicity may lead to coma and death. Traditionally the treatment of patients with VPA toxicity has been limited to supportive measures. VPA is highly protein bound and therefore it is considered not to be removable by extracorporeal means. However, studies of VPA toxicokinetics indicate that at blood levels that exceed therapeutic concentrations, VPA protein binding sites become saturated, leading to increased concentration of the free unbound drug. The free unbound drug has a small molecular weight and therefore it is theoretically amenable to removal by extracorporeal means. We present a patient with VPA toxicity who was successfully treated with "in-series" hemodialysis and hemoperfusion followed by continuous venovenous hemodiafiltration (CVVHDF) and review the literature on the management of VPA toxicity using extracorporeal therapies.

Nonketotic hyperglycemic coma in toddlers after unintentional methadone ingestion

Methadone overdoses are increasing in parallel with the increased frequency of opiate substitution therapy in adults. Although unintentional methadone intoxication in children is rare, it is becoming more frequently recognized. We report 3 cases of unintentional methadone overdose in toddlers who initially displayed central nervous system depression associated with severe nonketotic hyperglycemia and discuss the possible pathophysiologic mechanisms of an underrecognized symptom of opiate intoxication in young children.

Case report: esophageal foreign body mistaken for impacted button battery

Foreign body ingestion is a common complaint in the pediatric emergency department. Here, we report an interesting case of a coin ingestion in which the radiographic findings were alarming and inconsistent with the history provided by our patient. A brief review of the diagnosis and management of gastrointestinal foreign bodies is presented, with particular focus on ingested coins and button batteries.

Epidemiology of nonfatal deliberate self-harm in the United States as described in three medical databases

The absence of validated U.S. rates of nonfatal suicidal behavior places risk management and injury prevention programs at danger of being poorly informed and inadequately conceptualized. In this study we compare estimated rates of intentional self-harm from two ongoing surveys (National Electronic Injury Surveillance System-All Injury Program-NEISS-AIP; National Hospital Ambulatory Medical Care Survey-NHAMCS) to data from the Toxic Exposure Surveillance System. Results suggest that, for every 2002-2003 suicide, there were 12 (NEISSAIP) or 15 (NHAMCS) self-harm-related emergency department visits, and for every intentional self-poisoning death there were 33 intentional overdoses reported to poison control centers, of which two ultimately went untreated.

Deadly ingestions

More than 50% of the toxic-exposure calls to US poison centers involve children. Although most of these exposures are nontoxic, there are several products and medications that are widely available to the pediatric population that can lead to severe toxicity or even death. With some of these medications, death or severe symptoms can occur with the ingestion of only a small amount. It is important that the clinician be familiar with presenting signs and symptoms of potentially toxic ingestions and is able to initiate a therapeutic and life-saving intervention. This article reviews some of the deadlier ingestions that children may be exposed to.

Fatality from Diphenhydramine Monointoxication

As an antihistamine, diphenhydramine (DPH) is well known for its use in allergy treatment. Since its introduction in 1946, it has been marketed under various trade names, the most popular being Benadryl. Three years after its introduction, the first fatality due to DPH toxicity was reported in 1949. To better understand the incidence of fatalities due to DPH monointoxication, we reviewed deaths that were reported from 2 data sources: (1) the English-language literature using PubMed, from 1946 through 2003; and (2) the Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System (ARAAPCCTESS), from 1983 through 2002. The results were then tabulated using age, gender, clinicopathologic findings, and toxicology results. Combined results from both data sets show the following mean (and range) for age and DPH levels: Adult, 35.6 years (18-84) and 19.53 mg/L (0.087-48.5); pediatric, 8.6 years (1.25-17) and 7.4 mg/L (1.3-13.7); infant, 31 weeks (6 weeks-11 months) and 1.53 mg/L (1.1-2.2), respectively. Most deaths were certified as accident or suicide; however, 6 infant homicides were reported. The most common symptoms for all cases were cardiac dysrhythmias, seizure activity, and/or sympathetic pupil responses. The most common autopsy finding was pulmonary congestion.

Scopolamine treatment for severe extra-pyramidal signs following organophosphate (chlorpyrifos) ingestion

BACKGROUND

The use of competitive inhibitors of acetylcholine other than atropine, for patients with organophosphate poisoning is controversial. Because scopolamine ability to cross the blood-brain barrier is better than that of atropine, it has been suggested that it should be used in patients with organophosphate poisoning who have central nervous system manifestations.

CASE DESCRIPTION

A 17-year-old girl was admitted to the pediatric ward after ingesting chlorpyrifos as a suicidal attempt. She reported vomiting three times. She had no other symptoms for 12 hours and then over the course of 36 hours gradually developed extrapyramidal signs and became comatose. She was treated with intravenous scopolamine. Within 3 minutes the patient started to respond to verbal commands and answered simple questions rigidity subsided, and she was able to sit in bed. She was discharged after 4 days with no neurological sequelae.

CONCLUSIONS

We suggest, that in patients with organophosphate poisoning who have mainly central nervous system toxicity scopolamine administration might be considered.

Evaluation of toxicity of topiramate exposures reported to poison centers

Published literature on the toxicity of a topiramate overdose is limited to case reports. This retrospective study of poison center data was performed to examine the severity of topiramate overdoses. Data on single substance exposures to topiramate reported to the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System (TESS) in 2000 and 2001 were retrospectively analysed. A total of 567 cases met the inclusion criteria, of which 39% occurred in adults over 19 years of age and 30.2% in children < or = 4 years old. The majority of patients (62.1%) experienced no toxicity. The most common clinical effects reported were drowsiness/lethargy (15.5%), dizziness/vertigo (4.9%), agitation (4.9%), confusion (3.9%), nausea (2.6%) and vomiting (2.5%). Symptomatic patients were older than asymptomatic patients and adults were more likely to be managed in a healthcare facility (P <0.0001). Patients who received gastrointestinal decontamination experienced less serious outcomes than those without decontamination (P <0.02). It is concluded that clinicians should expect relatively mild mental status changes in adults or children with toxicity from topiramate overdose. Serious toxic effects, such as CNS depression with respiratory depression or persistent non-anion gap metabolic acidosis, are infrequent.

Deoxyribonuclease 1 aggravates acetaminophen-induced liver necrosis in male CD-1 mice

An overdose of acetaminophen (APAP) (N-acetyl-p-aminophenol) leads to hepatocellular necrosis induced by its metabolite N-acetyl-p-benzoquinone-imine, which is generated during the metabolic phase of liver intoxication. It has been reported that DNA damage occurs during the toxic phase; however, the nucleases responsible for this effect are unknown. In this study, we analyzed the participation of the hepatic endonuclease deoxyribonuclease 1 (DNASE1) during APAP-induced hepatotoxicity by employing a Dnase1 knockout (KO) mouse model. Male CD-1 Dnase1 wild-type (WT) (Dnase1+/+) and KO (Dnase1-/-) mice were treated with 2 different doses of APAP. Hepatic histopathology was performed, and biochemical parameters for APAP metabolism and necrosis were investigated, including depletion of glutathione/glutathione-disulfide (GSH+GSSG), beta-nicotinamide adenine dinucleotide (NADH+NAD+), and adenosine triphosphate (ATP); release of aminotransferases and Dnase1; and occurrence of DNA fragmentation. As expected, an APAP overdose in WT mice led to massive hepatocellular necrosis characterized by the release of aminotransferases and depletion of hepatocellular GSH+GSSG, NADH+NAD+, and ATP. These metabolic events were accompanied by extensive DNA degradation. In contrast, Dnase1 KO mice were considerably less affected. In conclusion, whereas the innermost pericentral hepatocytes of both mouse strains underwent necrosis to the same extent independent of DNA damage, the progression of necrosis to more outwardly located cells was dependent on DNA damage and only occurred in WT mice. Dnase1 aggravates APAP-induced liver necrosis.

Patterns of exposures at school among children age 6-19 years reported to Texas poison centers, 1998-2002

Although children and adolescents spend a large amount of time in school, there is little information on the factors involved in school exposures that are reported to poison centers. This study used data involving exposures among children age 6-19 yr reported to 6 Texas poison centers during 1998-2002. The distribution of school and nonschool exposures was determined for various demographic and other factors, and comparisons were made between the two types of exposures. The lowest proportion of reported school exposures occurred in June-August and the next lowest proportion occurred in December-January; nonschool exposures were more constant throughout the year. Males accounted for 58% of school exposures and 49% of nonschool exposures. The exposure was unintentional in 74% of school and 67% of nonschool exposures. Ingestion was the most frequently reported exposure route for school (64%) and nonschool (76%) exposures. Among those cases with known medical outcome, the most frequently reported medical outcome involved minor effects for both school exposures (58%) and nonschool exposures (46%). Nonpharmaceuticals were involved in 75% of school exposures and 48% of nonschool exposures. The most frequently reported substances involved in school exposures were arts, crafts, and office supplies (18%), while the most frequently reported substances involved in nonschool exposures were analgesics (17%). This information may allow school administrators and health care providers to implement prevention strategies.

Amitriptyline poisoning in a 2-year old

We describe a case of a 2-year-old boy who ingested 35 mg.kg(-1) of amitriptyline. He developed central nervous system toxicity, as demonstrated by coma and seizures and cardiac toxicity (cardiac arrest) within 1 h of ingestion. The cardiac toxicity was refractory to standard therapy. His cardiac rhythm alternated between ventricular tachycardia and pulseless ventricular tachycardia/ventricular fibrillation for a period of 17 h. Following prolonged cardiopulmonary resuscitation and aggressive supportive management, the patient recovered both cardiovascularly and neurologically. An echocardiogram and MRI brain were subsequently performed and were normal. The patient was discharged 2 weeks later with normal cognitive, behavioral and motor function. We discuss the benefit of prolonged and effective cardiopulmonary resuscitation in the management of this potentially fatal poisoning.

Capillary electrophoresis screening of poisonous anions extracted from biological samples

A method was developed for screening human biological samples for poisonous anions using capillary electrophoresis (CE) employing indirect UV detection. The run buffer consisted of 2.25 mM pyromellitic acid, 1.6 mM triethanolamine, 0.75 mM hexamethonium hydroxide and 6.5mM NaOH at pH 7.7. Biological samples were pretreated using solid phase extraction. The method was applied to the analysis of human blood, plasma, urine, and intestinal contents. Twenty-nine different anions were detectable at aqueous concentrations of 1 part per million (ppm) with a typical analysis time less than 20 min. Intraday migration time R.S.D. and peak area R.S.D. for blood samples were less than 1.1% and 6.3%, respectively. Interday migration time R.S.D. for plasma samples ranged from 7.5% to 10.4%. The new method produced efficient separations of various target anions extracted from complex biological matrices.

Phenytoin poisoning

Phenytoin toxicity may result from intentional overdose, dosage adjustments, drug interactions, or alterations in physiology. Intoxication manifests predominantly as nausea, central nervous system dysfunction (particularly confusion, nystagmus, and ataxia), with depressed conscious state, coma, and seizures occurring in more severe cases. Cardiac complications such as arrhythmias and hypotension are rare in cases of phenytoin ingestion, but they may be seen in parenteral administration of phenytoin or fosphenytoin. Deaths are unlikely after phenytoin intoxication alone. A greatly increased half-life in overdose due to zero-order pharmacokinetics can result in a prolonged duration of symptoms and thus prolonged hospitalization with its attendant complications. The mainstay of therapy for a patient with phenytoin intoxication is supportive care. Treatment includes attention to vital functions, management of nausea and vomiting, and prevention of injuries due to confusion and ataxia. There is no antidote, and there is no evidence that any method of gastrointestinal decontamination or enhanced elimination improves outcome. Activated charcoal should be considered if the patient presents early; however, the role of multiple-dose activated charcoal is controversial. Experimental studies have proven increased clearance rates, but this effect has not been translated into clinical benefit. There is no evidence that any invasive method of enhanced elimination (such as plasmapheresis, hemodialysis, or hemoperfusion) provides any benefit. This article provides an overview of phenytoin pharmacokinetics and the clinical manifestations of toxicity, followed by a detailed review of the various treatment modalities.

Agrochemical Poisoning

A general increase in the use of chemicals in agriculture has brought about a concomitant increase in the incidence of agrochemical poisoning. Organophosphates are the most common agrochemical poisons followed closely by herbicides. Many agricultural poisons, such as parathion and paraquat are now mixed with a coloring agent such as indigocarmine to prevent their use criminally. In addition, paraquat is fortified with a “stenching” agent. Organo-chlorines have an entirely different mechanism of action. Whereas organophosphates have an anticholinesterase activity, organochlorines act on nerve cells interfering with the transmission of impulses through them. A kerosene-like smell also emanates from death due to organochlorines. The diagnosis lies in the chemical identification of organochlorines in the stomach contents or viscera. Organochlorines also resist putrefaction and can be detected long after death. Paraquat has been involved in suicidal, accidental, and homicidal poisonings. It is mildly corrosive and ulceration around lips and mouth is common in this poisoning. However, the hallmark of paraquat poisoning, especially when the victim has survived a few days, are the profound changes in lungs. Other agrochemicals such as algicides, aphicides, herbicide safeneres, fertilizers, and so on, are less commonly encountered. Governments in most countries have passed legislations to prevent accidental poisonings with these agents. The US government passed the Federal Insecticide, Fungicide and Rodenticide Act (FIFRA) in 1962 and the Indian government passed The Insecticides Act in 1968. Among other things, these acts require manufacturers to use signal words on the labels of insecticides, so the public is warned of their toxicity and accompanying danger.

Serial Bispectral index scores in patients undergoing observation for sedative overdose in the emergency department

STUDY OBJECTIVE

Many patients who overdose on sedatives experience a declining mental status and eventually require endotracheal intubation. The goal of this study was to determine if serial bedside Bispectral index (BIS) scores monitoring can be used to detect the eventual need for intubation in overdosed patients who are undergoing observation in the ED.

METHODS

This was a prospective, observational study of a convenience sample of patients who presented to the Hennepin County Medical Center ED between June and November 2002. Patients being treated and observed for a suspected sedative ingestion were eligible. Upon presentation, a Bispectral electroencephalographic probe was applied to the patient's forehead, and a BIS score was recorded at 0 and 20 minutes. The Altered Mental Status scale was used to describe the patient's clinical status. Data were collected by trained research assistants. Data are described with descriptive statistics. The mean changes in BIS score between patients who did and did not require intubation are compared with t tests, and the outcome of patients with stable vs declining BIS scores were compared with chi(2) tests.

RESULTS

Seventy-six patients were enrolled. The mean initial BIS score was 83.9 (95% CI, 79.7-88.1; range, 9-99). The mean change in BIS scores during the 20-minute observation period for the patients who required intubation was -13.5 (95% CI, -30.2 to 3.2) and was +6.7 (95% CI, 3.3-10.1) for those who were not intubated. Sixteen patients had an initial BIS score below 70. Of these patients, 6 were intubated. All intubations occurred during the 20 minutes, and this group had a mean initial BIS of 47.2 (95% CI, 35.6-58.8). The 10 patients with an initial BIS below 70 who were not intubated had a mean increase in BIS score of 23.3 (95% CI, 11.7-33.9) during the 20 minutes. Of the 60 patients whose first BIS score was above 70, 5 were eventually intubated during their ED treatment. The mean change in BIS was -36.4 (95% CI, -18.7 to -54.1) for the intubated patients vs +7.9 (95% CI, 4.4-11.3) for nonintubated patients during the first 20 minutes.

CONCLUSION

The overdosed patients who required intubation during their ED treatment experienced a mean decrease in BIS during the first 20 minutes, compared with those who did not. Bispectral index scores monitoring may prove useful for earlier ED treatment and decision making regarding sedative overdose patients.

Designing sensor systems capable of differentiating children from adults

INTRODUCTION

Injury prevention systems intended to prevent children from entering hazardous locations (or at least alert caregivers if that occurs) often respond to every instance of a person's presence, regardless of whether the intruder is a child. This performance results in a high nuisance alarm rate that sometimes causes adults to disable or circumvent the safety system. If a child safety system can accurately identify intruders as adults or children, nuisance alarm rates can be decreased.

METHOD

This analysis selects three human factors (height, foot length, and cognition) amenable to adult/child differentiation and describes likely sensor strategies, advantages, and disadvantages.

RESULTS

Preliminary testing of prototypes systems shows that simple sensor systems are capable of acquiring adequate data for adult/child differentiation. The discussion addresses requirements for discriminator systems and the effects of various sensor combinations on overall performance.

Excess fatality from desipramine in children and adolescents

OBJECTIVE

To compare the case fatality rate (CFR) from desipramine ingestion in children and adolescents with that of other tricyclic antidepressants.

METHOD

All mentions of desipramine, amitriptyline, imipramine, nortriptyline, and doxepin in children and adolescents recorded in the American Association of Poison Control Centers Toxic Exposure Surveillance System from 1983 to 2002 were analyzed. The CFR for each drug was defined as the ratio of the number of deaths/number of mentioned exposures.

RESULTS

There were 24 fatalities in children younger than 6 years old (desipramine, n=10; amitriptyline, n=7; doxepin, n=3; imipramine, n=3; nortriptyline, n=1) and 144 fatalities in older children and adolescents (desipramine, n=56; amitriptyline, n=30; doxepin, n=16; imipramine, n=31; nortriptyline, n=11). The CFR from desipramine was significantly higher compared with the other tricyclic antidepressants in children younger than 6 years old (chi=36, p<.001) and in older children and adolescents (chi=155, p<.001). The CFR from desipramine exceeded that of amitriptyline, doxepin, imipramine, and nortriptyline by 7- to 8-, 4-, 6- to 12-, and 7- to 10-fold, respectively.

CONCLUSIONS

The excess CFR from desipramine in children and adolescents and the reports of sudden death in children treated with therapeutic doses call for caution in prescribing desipramine to children and adolescents.

Trends in gamma-hydroxybutyrate (GHB) and related drug intoxication: 1999 to 2003

STUDY OBJECTIVE

To analyze changes in gamma-hydroxybutyrate (GHB) case reporting, we review GHB or congener drug cases reported to the California Poison Control System, comparing these to other data sets.

METHODS

We identified cases from the California Poison Control System computerized database using standardized codes and key terms for GHB and congener drugs ("gamma butyrolactone," "1,4-butanediol," "gamma valerolactone"). We noted California Poison Control System date, caller and exposure site, patient age and sex, reported coingestions, and outcomes. We compared California Poison Control System data to case incidence from American Association of Poison Control Centers and Drug Abuse Warning Network data and drug use prevalence from National Institute for Drug Abuse survey data.

RESULTS

A total of 1,331 patients were included over the 5-year period (1999-2003). California Poison Control System-reported GHB exposures decreased by 76% from baseline (n=426) to the final study year (n=101). The absolute decrease was present across all case types, although there was a significant proportional decrease in routine drug abuse cases and an increase in malicious events, including GHB-facilitated sexual assault (P=.002). American Association of Poison Control Centers data showed a similar decrease from 2001 to 2003. Drug Abuse Warning Network incidence flattened from 2001 to 2002 and decreased sharply in 2003. National Institute for Drug Abuse survey time trends were inconsistent across age groups.

CONCLUSION

Based on the precipitous decrease in California Poison Control System case incidence for GHB during 5 years, the parallel trend in American Association of Poison Control Centers data, and a more recent decrease in Drug Abuse Warning Network cases, a true decrease in case incidence is likely. This could be due to decreased abuse rates or because fewer abusers seek emergency medical care. Case reporting may account for part of the decrease in the incidence of poison center contacts involving GHB.

Diagnosis and management of the poisoned child

Pediatric toxic ingestions are treated commonly by pediatricians and emergency physicians. Significant injury after these ingestions is infrequent, but identifying the dangerous ingestion is sometimes a difficult task. By performing a detailed history, focused physical examination, and directed laboratory evaluation, an estimation of risk can be developed. This article introduced the term "toxic triage" to describe this process. The toxic triage estimation allows the clinician to make thoughtful decontamination and treatment decisions. Familiarity with the literature supporting or refuting each decontamination method allows educated decisions to be made. Supportive care is an integral part of treatment for all poisonings, from asymptomatic to life-threatening. Most antidotes are used rarely in clinical practice, but familiarity with common antidotes benefits those patients with specific hazardous ingestions. Prevention efforts have the potential to decrease the incidence of pediatric poisonings. The universal poison control center number provided should be distributed and posted in homes, clinics, and emergency departments.

Overdoses and ingestions of second-generation antipsychotics in children and adolescents

OBJECTIVE

We reviewed the available published data on intentional or unintentional secondgeneration antipsychotic overdoses in children and adolescents. The prescribing of secondgeneration antipsychotics has continued to increase over the past decade for children, adolescents, and adults. The authors reviewed the existing literature to determine the circumstances, presenting problems, treatment, and outcomes of youths who were exposed to nontherapeutic doses of these medications.

METHODS

A systematic English-language Medline search of all reports (1989-2005) and a review of the bibliographies of all articles obtained was done to identify papers reporting an overdose or ingestion of a second-generation antipsychotic. Data were reviewed on clozapine, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole. The annual reports of the American Association of Poison Control Centers National Data Collection System were reviewed from 1990 to 2003, the most recent report currently available. All fatalities in children and youths under 18 years of age were included.

RESULTS

The literature review identified 40 reports that included 63 patients, ranging in age from 1 day to 17 years of age. The clinical presentations included drowsiness, lethargy, agitation, irritability, combativeness, and tachycardia. There were 11 fatalities in the cases reviewed, 1 from clozapine overdose, 3 from risperidone overdose, 2 from olanzapine overdose, and 5 from quetiapine overdose. All other cases reported no significant sequelae and resolved without any reported clinical consequences. Duration of overdose symptoms ranged from 24 hours to 7 days. One case of clozapine intoxication showed resolution of symptoms in 6 hours and, in another case of olanzapine overdose, symptoms resolved in 13 days. The most frequently employed treatments included intubation, gastric lavage, activated charcoal, intravenous fluids, artificial respiration, and restraints or sedatives.

CONCLUSIONS

There is a need for future case reports to include serum medication level, weight of patient, coingestants, the health of the patient at baseline, relevant laboratory and toxicology studies and a standardized scale to rate the level of consciousness, such as the Glasgow Coma Scale. The existing pharmacovigilance data reports indicate these medications are relatively safe when taken in overdose, particularly when coingestants are not involved.

Dietary supplement-related adverse events reported to the California Poison Control System

PURPOSE

Dietary supplement (DS)-related adverse events (AEs) reported to the California Poison Control System (CPCS) were studied.

METHODS

The CPCS database was used to search for all telephone calls from consumers concerning DS-related AEs received during the six-month period between April and September 2002. The calls were characterized according to the substance involved, the caller's age (adult or pediatric), and the type of ingestion (accidental or intentional). Each exposure in which symptoms were reported was categorized as involving an AE. Each AE was assessed for severity and causality.

RESULTS

Data on a total of 1183 telephone calls were retrieved, of which 828 calls (70%) met the study's inclusion criteria. DS exposure occurred in 389 adults (47%) and 438 children (53%). DS ingestion was accidental in 360 patients (43%) and intentional in 467 patients (56%). Exposure resulted in an AE in 480 patients (58%). AEs were reported in 353 patients (74%) who ingested products containing ephedra; other exposures frequently involved zinc, kava, creatine, and valerian. AEs were classified as moderate in 198 patients (41%) who ingested a DS and as severe in 40 patients (8%). One patient had a fatal reaction. Among the 480 AEs in DS-exposed consumers, the DS was classified as the definite cause of 1 AE (<1%) and a probable cause of 237 (49.4%). The most frequently reported AE symptoms were increased heart rate (45%), agitation (30%), vomiting (30%), and nausea (15%).

CONCLUSION

A majority of DS-related AEs reported by consumers to CPCS involved ephedra-containing products.

Trends in the incidence of carbon monoxide poisoning in the United States

PURPOSE

Recent data demonstrate that the mortality rate from carbon monoxide poisoning has declined over the past 2 decades. It is not known whether this decrease in mortality is reflective of the total burden of carbon monoxide poisoning. This study sought to examine trends in other potential indicators of the incidence of carbon monoxide poisoning in the United States.

BASIC PROCEDURES

Published data from US poison control centers (PCCs) were used to calculate annual rates of calls regarding carbon monoxide exposures. Data on numbers of carbon monoxide-poisoned patients treated with hyperbaric oxygen (HBO) were used to calculate annual treatment rates. Trends in rates of carbon monoxide-related mortality, calls to PCCs, and HBO treatment were then compared.

MAIN FINDINGS

Contrary to the decline in carbon monoxide-related mortality from 1968 to 1998, rates of calls to PCCs significantly increased over the same period. Neither rates of PCC calls nor HBO treatment changed significantly from 1992 to 2002. The latter 2 measures were strongly correlated.

PRINCIPAL CONCLUSIONS

Although deaths from carbon monoxide poisoning have clearly decreased in the United States, other indicators of the incidence of the condition suggest that the total burden (fatal and nonfatal) may not have significantly changed. Efforts to prevent carbon monoxide poisoning should not be relaxed.