Regional Poison Control Center Research Articles

Toxic ingestions in pregnancy: abortifacient use in a case series of pregnant overdose patients.

To profile young, pregnant patients with an overdose reported to an urban poison center; and to characterize the ingestions and short-term outcomes of these overdose patients. A prospective, observational study of female overdose patients was performed from November 1, 1994, through March 31, 1995. Consecutive cases were identified from all calls to the regional poison center (annual call volume = 70,000) regarding intentional overdose in women between the ages of 12 and 30 years. Pregnancy tests were recommended by the poison center during the study period in female patients aged 12-30 years who presented to a health care facility (usually an urban ED) with an intentional overdose. Pregnant patients were then followed during their hospitalizations, and the results of toxicology studies and maternal and short-term fetal outcomes were recorded. Pregnancy tests were obtained for 371 (32%) of 1,142 eligible patients. Of patients with pregnancy tests, 43 (11.6%) were pregnant. Although most cases were comparable to general adult intentional ingestions, 5 of the 43 pregnant patients ingested known abortifacients. Most pregnant patients (35/43, 81%) had toxicity at or below American Association of Poison Control Centers (AAPCC) criteria for minimal toxicity, and all patients recovered completely. Pregnancy was a common finding in this sample of young, female, intentional overdose patients reported to our regional poison control center. Frequent use of abortifacients for toxic ingestions has not been previously reported. A pregnancy test should be obtained for all female patients of childbearing age with an intentional ingestion to address the potential association of the ingestion with an unanticipated or undesired pregnancy.

Cost-effectiveness of Regional Poison Control Centers

Poison exposures are a significant public health concern. Despite the impact that regional poison control centers have on reducing morbidity and mortality associated with poison exposures, they are facing a serious financial crisis today resulting in an increased emphasis on their economic justification. Using decision-analysis techniques, the cost-effectiveness of the treatment of poison exposures with the services of a regional poison control center compared with treatment without access to any poison control center was evaluated. The relative cost-effectiveness was modeled based on 2 outcomes (morbidity and mortality) for each of 4 typical poison exposures. Additionally, analyses were conducted to test the sensitivity of the cost-effectiveness ratios to outcome probability, average inpatient and emergency department costs, and proportion of poison exposures treated on site by the regional poison control center. A societal perspective was adopted. The regional poison control center was substantially more cost-effective than the treatment of poison exposures without the services of a regional poison control center for both outcomes (morbidity and mortality) in each of the poison exposures considered. The results of the sensitivity analyses demonstrated that the outcomes of the decision analyses do not change regardless of the type of poison exposure, outcome considered, clinical outcome probabilities, average inpatient and emergency department costs, and proportion of poison-exposure cases treated on site by a regional poison control center. The regional poison control center is consistently more cost-effective in the treatment of poison exposures with an average cost-effectiveness ratio (cost per successful outcome) approximately half of that achieved without the services of a regional poison control center. Finally, significant cost savings to society are realized for each additional successful outcome obtained with a regional poison control center.

Cost-effectiveness of regional poison control centers

Cost-effectiveness of regional poison control centers

Poisonous Plants:Understanding the Need for Accurate Identification and Timely Information

Only a few of the thousands of existing plants are considered to be poisonous or potentially harmful in any manner. No universal guidelines are available to determine whether a plant or specific exposure will result in harm. This article reviews commonly encountered poisonous plants and suggests resources for information if exposure occurs. Poisonous plants are commonplace in homes or offices and should be properly identified in anticipation of a child or animal ingesting one of these plants. Although plants or mushrooms encountered in nature may resemble common foods, one should ask an expert to positively identify them before eating them. The telephone number of a regional poison control center or another emergency contact should be posted in an accessible area in case of an accidental poisoning. This is the fourth and final article in a continuing education update series. Following this series, particpants should be able to recognize the hazards and know what to do when encountering a poisonous plant or mushroom, understand how plants can clean the environment, and identify the role plants play in ancient and modern-day pharmaceuticals.

Sertraline overdose.

To determine the clinical presenting signs and symptoms in presumed overdoses of sertraline, a recently approved antidepressant. A prospective study involving five western regional poison control centers was performed to evaluate the clinical manifestations of presumed sertraline ingestions (overdoses). Information about calls pertaining to sertraline ingestions was recorded on a standard data collection form. Data including subject age, sex, amount ingested, coingestants, time interval to evaluation, vital signs, presenting signs and symptoms, ECG abnormalities, treatment given, disposition, and length of stay in the ED were collected over a nine-month period. Of 42 ingestions reported, two were adverse reactions to normal doses and 40 were overdoses. Stated amounts of sertraline ingested ranged from 50 to 8,000 mg (mean 1,579 mg). Mean patient age was 35.3 years (range 1 to 69 years). Mean interval to presentation was 3.0 hours. Seventeen of the 40 patients ingested sertraline alone. Of this subgroup, ten had no sign or symptom. The most common abnormalties reported in isolated sertraline overdose were tremor, lethargy, and nausea. Less common findings included agitation, confusion, and vomiting. There was no significant morbidity in this subgroup of presumed isolated sertraline ingestion. Of the 23 patients who ingested other medications along with sertraline, four were asymptomatic. Benzodiazepines and alcohol were the most frequently coingested substances. Lethargy, nausea, dry mouth, and mydriasis were the most common features reported in this group. Treatment included lavage, activated charcoal, and observation. Twelve patients were admitted for 24-hour observation, none had an adverse outcome. Of the patients released from the ED, the mean length of stay was 3.9 hours. Sertraline is commonly taken in overdose with other medications or alcohol. The signs and symptoms that develop in association with an overdose of sertraline appear to be minor and of short duration.

Acute iron poisoning.

The acute ingestion of medicinal iron preparations may result in serious poisoning, particularly in young children. The principle products involved are adult iron preparations, with or without vitamins. Although a single value for the toxic dose has not been established, significant gastrointestinal manifestations occur following the ingestion of 20 mg of elemental iron per kilogram of body weight while systemic toxicity may occur following the ingestion of at least 60 mg of elemental iron per kilogram of body weight. Treatment consists of stabilizing vital functions, removing unabsorbed iron from the gastrointestinal tract, and administering intravenous deferoxamine when there are serious clinical symptoms or when a serum iron level > 500 micrograms/dL is measured within 8 hours of the ingestion. Optimal management, with the involvement of a medical toxicologist or a regional poison control center, often results in a favorable outcome.

Five year retrospective evaluation of sulfonylurea ingestion in children.

Oral hypoglycemic medications are frequently used for Type II diabetes and accidental ingestions by children may occur. There are no comprehensive pediatric studies documenting poison center experiences. To evaluate the toxicity of oral sulfonylurea ingestion in children and the efficacy of treatments instituted in these cases. Retrospective review of all ingestions of oral sulfonylureas reported to a single regional poison control center 1987-1991. Ninety-three cases were identified, one to 16 years old (mean of 3.5 years). Eighty cases (86%) were less than six years of age. Of the six medications used, three, chlorpropamide, glipizide and glyburide made up 88 (95%) cases. Twenty-five patients (27%) became hypoglycemic (glucose < 60 mg/dL). The mean minimum blood glucose in these patients was 46.5 mg/dL (minimum 20 mg/dL). Time of onset of hypoglycemia ranged from 0.5 to 16 h (mean 4.3 h; median 2 h). Only four patients had the onset of chemical hypoglycemia more than four hours postexposure. Persistent hypoglycemia occurred in nine children (10%) despite intravenous glucose therapy. There were no seizures. Mean time to decontamination of patients with and without hypoglycemia was 1.4 and 1.2 h respectively. Intravenous glucose of the following concentrations was administered: 5% (40), 10% (15), 20% (1), and 50% (3). Accidental ingestion of a single tablet of chlorpropamide (250 mg), glipizide (5 mg). and glyburide (2.5 mg) each produced hypoglycemia in children ages one to four years. Accidental ingestion of 5-10 mg glyburide produced a blood glucose of 57 mg/dL in an 11-year-old child. All patients recovered fully. There were no neurological sequelae noted. Children ingesting oral hypoglycemics should be admitted to a health care facility for 24 h observation. In this series a single tablet produced hypoglycemia.

Outcomes of Ocular Exposures Reported to a Regional Poison Control Center

Although toxic chemical ocular exposures are common, there has been little epidemiologic study of this problem. We carried out a systematic follow-up study of symptomatic ocular exposures reported to a regional poison control center (PCC). We interviewed 279 (76%) of 368 patients reported to the PCC that met study criteria. Exposures were heterogeneous, including personal care and medicinal products, 42 (15%); hydrocarbon solvents 30 (11%); hypochlorite bleach, 20 (7%); strong acids and bases 19 (7%); and all other causes 168 (60%). The median duration that eye irrigation was performed as a first aid measure was 15 min; 203 (73%) initiated irrigation within 2 min or less. Only 30 (11%) reported that symptoms persisted longer than 2 days; 85 (31%) were treated by a physician for the exposure. Taking into account other factors such as type of exposure and extent of involvement, reported increased length of irrigation time was associated with worse outcome whether measured by number of symptoms (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.2-2.2, per 10 min irrigation); symptoms persistent for more than 2 days (OR 1.8, 95% CI 1.3-2.6); or receipt of physician care (OR 2.3,95% CI 1.7-3.2). These data show that ocular chemical exposures reported in PCC case surveillance are heterogeneous and largely self-limited. Nonetheless, specific exposure- and treatment-related factors may predict worse outcome and may warrant further investigation. Epidemiologic assessment of this common cause of ocular morbidity is important to guide prevention activities.

ECG Lead aVR Versus QRS Interval in Predicting Seizures and Arrhythmias in Acute Tricyclic Antidepressant Toxicity

Study objective: To compare the value of ECG measurements from lead aVR with the QRS-interval duration in predicting seizures and ventricular arrhythmias due to acute tricyclic antidepressant (TCA) toxicity. Design: Prospective cohort series of referral calls from hospitals to a regional poison control center. Participants: Seventy-nine patients (mean age, 30±15 years) who presented within 24 hours of ingestion. Seizures occurred in 16 patients (20%) and ventricular arrhythmias in 5 (6%). Interventions: The amplitude of the terminal R wave in lead aVR (R aVR), the R-wave/S-wave ratio in lead aVR (R/S aVR), and the maximal limb-lead QRS interval were measured on the initial ECG. Results: R aVRwas greater in those patients who had seizures or arrhythmias than in those who did not (4.4 versus 1.8 mm, P<.001), as was R/S aVR(1.4 versus .5, P<.001). The sensitivity of an R aVRof 3 mm or more was 81% and that of an R/S aVRof .7 or more was 75%, compared with 82% for QRS intervals greater than 100 milliseconds. The positive predictive value (PPV) of an R aVRof 3 mm or more was 43% and that of the R/S aVRof .7 or more 46%, compared with a PPV for QRS interval of 100 milliseconds or more of 35%. Multiple logistic-regression analysis demonstrated that an R aVRof 3 mm or more was the only ECG variable that significantly predicted seizures and arrhythmias (OR, 6.9 [95% CI, 1.2 to 40], P =.03). Conclusion: R aVRand R/S aVRwere greater in patients in whom seizures or arrhythmias developed after an acute TCA overdose. R aVRof 3 mm or more was the only ECG variable that significantly predicted these adverse outcomes. [Liebelt EL, Francis PD, Woolf AD: ECG lead aVR versus QRS interval in predicting seizures and arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med August 1995;26:195-201.]

The production model as a basis for conducting economic evaluations of regional poison control centers.

To identify the significant inputs, activities, and outputs of a regional poison control center, a production model is described and its potential application to the conduct of economic evaluations delineated. The model can help the researcher identify the significant inputs (costs) incurred through the provision of poison control center services. These inputs directly influence the activities that the poison center is capable of undertaking. Activities undertaken by a poison center are intermediate steps between the inputs and outputs, and serve to convert the various inputs into associated outputs. They form the basis for determining the outputs produced by the poison center services. The outputs derived from poison center services provide the conceptual framework for assessing the effectiveness of a poison center in an economic analysis. Also described are potential applications of the production model in conducting poison center cost-effectiveness and cost-benefit analyses.

Conservative management of patients with moderately elevated serum iron levels.

For the four year period 1990-1993, we retrospectively reviewed all cases of iron ingestion reported to a regional poison control center that had serum iron levels in the 300-500 micrograms/dL range and did not receive deferoxamine. A total of 32 patients did not undergo deferoxamine therapy or challenge testing. The mean age was 6.7 years (range five months to 21 years). The mean serum iron level was 372.8 micrograms/dL (range 301-487 micrograms/dL). Ten patients (31.3%) were asymptomatic. Symptoms included vomiting in 18 (56.3%), diarrhea in six (18.8%), lethargy in one (3.1%), and transient hypotension in one patient (3.1%). No patients presented with grossly bloody emesis or stool. Fifteen patients (46.9%) were hospitalized for at least one day. Seventeen (53.1%) were treated and released from the emergency department. All 32 patients recovered without sequelae. A conservative approach without deferoxamine therapy or challenge should be considered when serum iron levels are in the 300-500 micrograms/dL range in asymptomatic patients, as well as in those with self-limited, non-bloody emesis or diarrhea without other symptoms.

Unintentional albuterol ingestion in children.

This study was designed to determine the threshold dose for toxicity, the potential for serious medical complications, and the medical care required after unintentional albuterol ingestion in children. This study was prospective and descriptive. Data were obtained on pediatric albuterol ingestions evaluated emergently as reported to three regional poison control centers. Data elements included dose ingested, physical findings, medical treatment, and outcome. During 18 months, 78 patients who ingested albuterol and who received urgent medical evaluation were identified. Mean age was 2.8 years. The amount ingested ranged from 0.2 to 8.8 mg/kg. The most commonly reported signs of toxicity were tachycardia (57%, 44/78), widened pulse pressure (50%, 27/54), hyperglycemia (50%, 12/24), agitation (45%, 35/78), low serum carbon dioxide (42%, 10/24), vomiting (26%, 20/78), and hypokalemia (26%, 9/35). We found a threshold dose o 1 mg/kg for three or more signs of toxicity (P < 0.01). No patient required any specific treatment for toxicity. Seventy-two percent of patients were discharged from medical care within six hours of ingestion. Albuterol overdose in children causes a variety of cardiovascular, neuromuscular, and metabolic effects that are usually benign. The threshold dose for the development of three or more signs of toxicity is 1 mg/kg or three to 10 times the recommended daily dose. Toxicity is short-lived and does not require specific therapy or hospital admission in most cases.

Bupropion overdose: A 3-year multi-center retrospective analysis

Bupropion (Wellbutrin; Burroughs Welcome Co, Research Triangle Park, NC) is a unique monocyclic antidepressant about which there is limited overdose information. A retrospective analysis of all bupropion ingestions reported to five regional poison control centers from 1989 through 1991 was conducted. There were 58 cases of bupropion ingestion and nine cases of combined bupropion and benzodiazepine ingestion. Sinus tachycardia was the only toxic cardiovascular effect noted, except for one case of hypotension in the bupropion and benzodiazepine group. Neurological toxicity was commonly encountered and included lethargy, tremors, and seizures. Both benzodiazepines and phenytoin were efficacious in controlling seizures. Five cases of pure bupropion overdose had electrolytes reported. Serum potassium ranged from 2.6 to 4.2 mEq/L (mean, 3.3 mEq/L). In overdose, bupropion seems to lack major cardiovascular toxicity; however, it does manifest significant neurological toxicity.

Hydrogen peroxide exposure--325 exposures reported to a regional poison control center.

Isolated case reports have documented that hydrogen peroxide exposure can be associated with serious toxicity by various routes of exposure. The purpose of this study was to better delineate the epidemiology, medical outcome, and potential health hazards of hydrogen peroxide exposures to the general public. We performed a retrospective review of all exposures reported to a regional poison center over a 36 month period and found that of 95,052 exposures reported, 325 (.34%) were due to hydrogen peroxide. The pediatric population (< 18 years) accounted for 71% of hydrogen peroxide exposures and ingestion was the most common route of exposure (83%). Nausea and vomiting were the most common symptoms secondary to ingestion. Ocular and dermal exposures to dilute solutions resulted in transient symptoms without permanent sequelae. While most exposures by all routes resulted in a benign outcome (no effect or minor effect), there was a trend toward more severe outcomes in those who ingested a concentration greater than 10% (p = 0.011).

The emergency medical response to the Cantara hazardous materials incident.

On 14 July 1991, at 2150 h, a train derailment occurred near the Cantara rail curve about six miles above Dunsmuir in Northern California. The derailment spilled approximately 19,000 gallons of metam-sodium into the Sacramento River. When mixed with water, metam-sodium degrades to methylisothiocyanate (MITC) and other gases. The contaminated river water passed the town of Dunsmuir and other occupied areas exposing residents to MITC gas. From 15 July to 20 July (five days), a total of 360 people underwent triage. The majority of patients displayed minor exposure symptoms that did not require hospital care. Mercy Mt. Shasta Hospital, a small rural hospital close to Dunsmuir, received the majority of patients. As of 29 July, 15 days after the incident, Mercy Mt. Shasta Hospital had seen 244 exposed patients in its emergency department, and had admitted five. Three had symptoms that could have been spill-related. Three Regional Poison Control Centers provided medical toxicology advice. Medical management of the emergency medical services (EMS) response to the event was piecemeal and weak. There did not appear to be a medical operations component at local Emergency Operations Centers (EOC). Most health care personnel interviewed complained about inadequate information about the substance and the situation. Local fire service mutual-aid agreements to obtain additional fire service and ambulance personnel worked well. It is important to emphasize that everyone who believed they had been exposed to the chemical underwent triage and received appropriate acute medical care.

Seizures associated with poisoning and drug overdose

A retrospective review of cases consulted by the San Francisco Bay Area Regional Poison Control Center during a 2-year period was performed to determine the causes and consequences of seizures associated with poisoning and drug intoxication. Of 233 charts coded as involving seizures, 191 occurred in humans and were available for analysis. The leading causes of seizures reported to the Poison Control Center were cyclic antidepressants (55 cases, 29%); cocaine and other stimulants (55 cases, 29%); diphenhydramine and other antihistamines (14 cases, 7%); theophylline (10 cases, 5%); and isoniazid (10 cases, 5%). Stimulants and diphenhydramine were more likely than other drugs to produce brief, self-limited seizures. In contrast, poisoning by cyclic antidepressants, cardiodepressant antiarrhythmic agents, or theophylline was more likely to be associated with death. Seizures in elderly patients were more likely to result in complications and death. The frequency of seizure-related cases by substance type was also compared with the results of an earlier survey performed in 1981, and found a striking increase in the proportion of seizures caused by cocaine and (23% in 1988 to 1989 compared with 4% in 1981). Poison Control Center data can provide valuable information about the causes and consequences of drug-related medical complications, as well as highlight changing trends in drug-related injury.

Six Year Retrospective Review of Fatalities Reported to a Regional Poison Control Center

s Third International Congress of Therapeutic Drug Monitoring and Clinical Toxicology: PDF Only

Effect of acute versus chronic intoxication on clinical features of theophylline poisoning in children

To determine whether the method of intoxication influences the metabolic disturbances and pattern of life-threatening events that occur after theophylline intoxication in children. Five-year prospective observational study of consecutive pediatric patients referred to a regional poison control center with a theophylline concentration (theo) greater than or equal to 30 micrograms/ml. At the time of referral, intoxication was categorized as acute (single toxic exposure), chronic (long-term toxic exposure), or acute-on-therapeutic (single toxic exposure superimposed on maintenance therapy). One-hundred twenty-five patients were monitored. Mean age was 12 years (range, 3 days to 20 y). Seventy-four patients (59%) had acute intoxication, 31 (25%) had chronic intoxication, and 20 (16%) had acute-on-therapeutic intoxication. Mean peak serum (theo) was 55 micrograms/ml. Life-threatening events occurred in 12 patients (10%). Patients with acute intoxication had a significantly lower serum potassium level (3.04 vs 3.80 mmol/L; p less than 0.001) and higher serum glucose level (10.8 vs 7.0 mmol/L (194 vs 127 mg/dl); p less than 0.001) than did children with chronic intoxication. Although life-threatening events (seizures or arrhythmias) occurred at a similar rate across categories, the (theo) at which these events occurred was significantly higher in patients with acute intoxication than in those with chronic intoxication (100 vs 42 micrograms/ml; p = 0.02). Among children with chronic intoxication, those who had life-threatening events had (theo) similar to those who remained well (42 vs 47 micrograms/ml) but were significantly younger (1.6 vs 8.0 years; p less than 0.001). These data indicate that method of intoxication has significant effects on the metabolic and clinical consequences of theophylline poisoning. Life-threatening events occur in those with acute theophylline intoxication at significantly higher (theo) than in those with chronic intoxication. After chronic intoxication, peak (theo) does not identify patients at risk for life-threatening events; young age appears to be the primary risk factor. These findings potentially complicate the management of theophylline poisoning, given the difficulty of extracorporeal drug removal in young infants.

Louis Gdalman, pioneer in hospital pharmacy poison information services

The role played by hospital pharmacist Louis Gdalman in the development of poisoning information services in the Chicago area is described. In the 1930s, decades before the creation of the Chicago Poisoning Control Program, Louis Gdalman had already established a poison information service at St. Luke's Hospital in Chicago. Pharmacists provided poison information to the physicians and nurses working in the emergency room. By the early 1950s, Gdalman had established an extensive library of information on the management of acute and chronic poisoning and had developed a standard form for the collection of data from poison information calls. He personally provided a 24-hour poison information service and often took calls at home. In 1953, the American Academy of Pediatrics initiated the Chicago Area Poisoning Control Program and established treatment and referral centers at 11 hospitals, including St. Luke's Hospital. Louis Gdalman was the only pharmacist involved in this city-wide program. By 1962, the Master Poison Control Center was established at St. Luke's Hospital, which had merged with Presbyterian Hospital in 1956. Today, this center, known as the Chicago and Northeastern Illinois Regional Poison Control Center, is located at the Rush-Presbyterian-St. Luke's Medical Center in Chicago. Louis Gdalman, a hospital pharmacist, pioneered the area of poison information and established what was perhaps the first hospital-based comprehensive poison control center.

Acute fluoxetine overdose: A report of 234 cases

Limited toxicity information is available in the medical literature on the antidepressant fluoxetine (Prozac, Dista Products Co, Indianapolis, IN). The goal of this prospective multicenter study was to develop a toxicity profile of initial signs and symptoms observed in an acute fluoxetine overdose. A prospective study was made of patients reported to one of four American Association of Poison Control Centers' regional poison control centers after ingesting an acute overdose of fluoxetine. A standard data collection form was used on all patients ingesting fluoxetine. Information obtained included age, current medications, dose, coingested drugs, presenting symptoms, vital signs, electrocardiogram abnormalities, outcome, and fluoxetine levels. The authors collected 272 cases; 234 cases met the criteria of the study. Fluoxetine was ingested alone in 87 cases and with ethanol or other drugs in the remaining 147 cases. Of the 87 cases where fluoxetine was ingested alone, 67 patients were adults and 20 were children. Symptoms that were seen in the adult group included: tachycardia ( 15 67 ), drowsiness ( 14 67 ), tremor (five/67), vomiting (four/67), or nausea (four/67). Thirty patients did not develop symptoms. Twelve of the adult overdose patients had total fluoxetine levels ranging from 232 to 1390 ng/mL. The authors conclude that symptoms that develop after an acute overdose of fluoxetine appear minor and of short duration. Aggressive supportive care is the only intervention necessary.