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1999 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System
Toxicology A special contribution from the American Association of Poison Control Centers.
1999 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System TOBY L. LITOVITZ, MD, WENDY KLEIN-SCHWARTZ, PHARMD, MPH, SUZANNE WHITE, MD, DANIEL J. COBAUGH, PHARMD, JESSICA YOUNISS, MBA, ALISON DRAB, BS, AND BLAINE E. BENSON, PHARMD Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products.
From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1).1-16 The cumulative AAPCC database now contains 27.0 million human poison exposure cases. This report includes 2,201,156 human exposure cases reported by 64 participating poison centers during 1999, a decrease of 1.8% compared with 1998 poisoning reports.
The American Association of Poison Control Centers gratefully acknowledges the generous financial support of McNeil Consumer Healthcare, without which the compilation and production of this report would not have been possible. Centers participating in this report include Children’s Hospital of Alabama Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Samaritan Regional Poison Center, Phoenix, AZ; Arkansas Poison and Drug Information Center, Little Rock, AR; 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 Control Center, Chicago, IL; Indiana Poison Center, Indianapolis, IN; Iowa Poison Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KS; Kentucky Regional Poison Center, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Maryland Poison Center, Baltimore, MD; Regional Center for Poison Control and Prevention Services for Massachusetts and Rhode Island, Boston, MA; Children’s Hospital of Michigan Regional Poison Control Center, Detroit, MI; Spectrum Health Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Cardinal Glennon Children’s Hospital Regional Poison Center, St. Louis, MO; The Poison Center, Omaha, NE; New Hampshire Poison Information Center, Lebanon, NH; 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; Hudson Valley Regional Poison Center, Sleepy Hollow, NY; Long Island Regional Poison Control Center, Mineola, NY; Finger Lakes Regional Poison and Drug Information Center, Rochester, NY; Central New York Poison Control Center, Syracuse, NY; Western New York Regional Poison Control Center, Buffalo, NY; Carolinas Poison Center, Charlotte, NC; North Dakota Poison Information Center, Fargo, ND; 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; Central Pennsylvania Poison Center, Hershey, PA; Lifespan Poison Center, Providence, RI; Middle Tennessee Poison Center, Nashville, TN; Southern Poison Center, Memphis, 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; University of Wisconsin Hospital Clinics Poison Control Center, Madison, WI; Children’s Hospital of Wisconsin Poison Center, Milwaukee, WI. r1985-2000 by the American Association of Poison Control Centers. Published by permission. All rights reserved. Reprints are available at a cost of $10 each. Address requests to AAPCC, 3201 New Mexico Ave, Suite 310, Washington, DC 20016. doi:10.1053/ajem.2000.9261 517
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TABLE 1. Growth of the AAPCC Toxic Exposure Surveillance System
Year 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Total
No. of Participating Centers
Population Served (Millions)
Human Exposures Reported
Exposures/ Thousand Population
16 47 56 57 63 64 70 72 73 68 64 65 67 67 66 65 64
43.1 99.8 113.6 132.1 137.5 155.7 182.4 191.7 200.7 196.7 181.3 215.9 218.5 232.3 250.1 257.5 260.9
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 2,155,952 2,192,088 2,241,082 2,201,156 27,004,741
5.8 7.3 7.9 8.3 8.5 8.8 8.7 8.9 9.2 9.5 9.7 8.9 9.3 9.3 8.8 8.7 8.4
CHARACTERIZATION OF PARTICIPATING CENTERS Of the 64 reporting centers, 60 submitted data for the entire year. Fifty-one of the 64 participating centers were certified as regional poison centers by the AAPCC in 1999. Annual center call volumes (human exposure cases only) ranged from 3,539 to 92,890 (mean 35,259) for centers participating for the entire year. Penetrance, calculated only for states that were completely served by centers participating in TESS, ranged from 4.9 to 18.5 per 1,000 population with a mean of 8.4 reported exposures per 1,000 population. Penetrance is defined as the number of human poison exposure cases reported per 1,000 individuals in the population served. A total population of 260.9 million was served by the participating centers, including 43 entire states, portions of 2
TABLE 2. Site of Caller and Site of Exposure, Human Poison Exposure Cases
Residence Own Other Health care facility Workplace School Public area Restaurant/food service Other Unknown
Site of Caller (%)
Site of Exposure (%)
77.2 2.3 13.3 1.7 0.7 0.5 0.1 4.1 0.2
88.8 3.2 0.3 2.7 1.4 1.2 0.5 1.0 1.0
states, and the District of Columbia (Figure 1). Noting the 272.7 million 1999 United States population, the data presented represent an estimated 95.7% of the human poison exposures that precipitated poison center contacts in the US during 1999. Extrapolating from the 2,201,156 human poison exposures reported in this database, 2.3 million human poison exposures are estimated to have been reported to all US poison centers in 1999. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the US cannot be made from these data alone, as considerable variations in poison center penetrance were noted. Indeed, assuming all centers reached the penetrance level of 18.5 poisonings/ 1,000 population reported for one state, 5.0 million poisonings would have been reported to poison centers in 1999. The data do not directly identify a trend in the overall incidence of poisonings in the US because of changing center participation from year to year and changes in center use. An analysis of data from 59 centers that participated for the entirety of both 1998 and 1999 shows no significant change (a decrease of only 0.005%) in the number of reported poison exposures from 1998 to 1999 within the regions served by these 59 centers.
FIGURE 1. Sixty-four poison centers participated in the Toxic Exposure Surveillance System in 1999. The shaded areas denote regions served by reporting centers.
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TABLE 3. Age and Gender Distribution of Human Poison Exposure Cases Male
Female
Unknown
Total
Cumulative Total
Age (yr)
No.
Row %
No.
Row %
No.
Row %
No.
Col %
No.
Col %
⬍1 1 2 3 4 5 Unknown child ⬍ 5 6-12 13-19 Unknown child Total children (⬍20) 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total adults Unknown age Total
74,287 194,783 191,664 89,370 42,446 24,834 1,706 87,177 70,453 944 777,664 79,707 77,801 54,853 28,050 14,933 10,591 5,051 828 27,072 298,886 3,114 1,079,664
52.4 53.1 53.3 55.0 55.9 56.3 45.6 56.4 44.6 39.0 52.9 44.7 42.7 42.0 39.0 37.7 35.0 31.6 26.9 38.4 41.4 34.2 49.1
67,019 171,756 167,401 72,889 33,273 19,147 1,447 66,677 87,114 923 687,646 98,332 104,085 75,679 43,848 24,716 19,619 10,903 2,248 41,334 420,764 3,996 1,112,406
47.3 46.8 46.5 44.8 43.8 43.4 38.7 43.1 55.1 38.2 46.8 55.2 57.2 57.9 61.0 62.3 64.9 68.3 73.0 58.6 58.3 43.9 50.5
429 579 621 263 176 123 586 752 426 551 4,506 210 131 101 37 13 15 12 3 2,071 2,593 1,987 9,086
0.3 0.2 0.2 0.2 0.2 0.3 15.7 0.5 0.3 22.8 0.3 0.1 0.1 0.1 0.1 0.0 0.0 0.1 0.1 2.9 0.4 21.8 0.4
141,735 367,118 359,686 162,522 75,895 44,104 3,739 154,606 157,993 2,418 1,469,816 178,249 182,017 130,633 71,935 39,662 30,225 15,966 3,079 70,477 722,243 9,097 2,201,156
6.4 16.7 16.3 7.4 3.4 2.0 0.2 7.0 7.2 0.1 66.8 8.1 8.3 5.9 3.3 1.8 1.4 0.7 0.1 3.2 32.8 0.4 100.0
141,735 508,853 868,539 1,031,061 1,106,956 1,151,060 1,154,799 1,309,405 1,467,398 1,469,816 1,469,816 1,648,065 1,830,082 1,960,715 2,032,650 2,072,312 2,102,537 2,118,503 2,121,582 2,192,059 2,192,059 2,201,156 2,201,156
6.4 23.1 39.5 46.8 50.3 52.3 52.5 59.5 66.7 66.8 66.8 74.9 83.1 89.1 92.3 94.1 95.5 96.2 96.4 99.6 99.6 100.0 100.0
REVIEW OF THE DATA Of the 2,201,156 human exposures reported in 1999, 92.0% occurred at a residence (Table 2). Exposures occurred in the workplace in 2.7% of cases, in schools (1.4%), health care facilities (0.3%), and restaurants or food services (0.5%). Poison center peak call volumes were noted from 4 to 10 PM, although call frequency remained consistently high between 8 AM and midnight, with 91% of calls logged during this 16-hour period. Although the average number of poison TABLE 4. Distribution of Age and Gender for 873 Fatalities
Age (yr) ⬍1 1 2 3 4 5 6-12 13-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total
Cumu- Cumuative ative Total %
Male Female Unknown Total
%
1 6 3 3 2 1 4 28 72 94 123 50 39 18 14 3
2 2 2 0 1 1 4 25 52 92 96 34 34 30 14 6
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
3 8 5 3 3 2 8 53 124 186 219 85 73 48 28 9
0.3 0.9 0.6 0.3 0.3 0.2 0.9 6.1 14.2 21.3 25.1 9.7 8.4 5.5 3.2 1.0
3 11 16 19 22 24 32 85 209 395 614 699 772 820 848 857
0.3 1.3 1.8 2.2 2.5 2.7 3.7 9.7 23.9 45.2 70.3 80.1 88.4 93.9 97.1 98.2
14 475
2 397
0 1
16 873
1.8 100.0
873 873
100.0 100.0
center consultations handled per day by all participating U.S. poison centers was 6,031, higher volumes were observed in the warmer months (up to 6,464/day in July) compared to 5,331 consultations per day in December. On average, ignoring time of day and seasonal fluctuations, U.S. poison centers handled one poison exposure every 14 seconds. The age and gender distribution of human poison exposure victims is outlined in Table 3. Children younger than 3 years of age were involved in 39.5% of cases, and 52.5% occurred in children younger than 6 years. A male predominance is found among poison exposure victims younger than 13 years of age, but the gender distribution is reversed in teenagers and adults. Of all poison exposures captured, 8,980 occurred in pregnant women. Of those with known pregnancy duration, 32% occurred in the first trimester, 38% in the second trimester, and 30% in the third trimester. In 4.4% of cases (95,690 cases) multiple patients were impliTABLE 5. Number of Substances Involved in Human Poison Exposure Cases No. of Substances
No. of Cases
% of Cases
1 2 3 4 5 6 7 8 ⱖ9 Total
2,033,490 135,340 17,597 7,281 3,082 1,492 644 343 1,887 2,201,156
92.4 6.1 0.8 0.3 0.1 0.1 0.0 0.0 0.1 100.0
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TABLE 6. Reason for Human Poison Exposure Cases Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Food poisoning Occupational Unknown Total Intentional Suicidal Misuse Abuse Unknown Total Other Malicious Contaminant/tampering Total Adverse Reaction Drug Other Food Total Unknown Total
No.
%
1,460,073 154,422 78,697 72,083 51,751 46,054 42,088 2,897 1,908,065
66.3 7.0 3.6 3.3 2.4 2.1 1.9 0.1 86.7
154,355 35,261 31,157 9,147 229,920
7.0 1.6 1.4 0.4 10.4
7,046 5,010 12,056
0.3 0.2 0.5
32,742 8,139 4,328 45,209 5,906 2,201,156
1.5 0.4 0.2 2.1 0.3 100.0
cated in the poison exposure episode (eg, siblings ‘‘shared’’ a household product, multiple patients inhaled vapors at a hazardous materials spill). Fatalities differed from the total exposure data set in several ways. Table 4 presents the age and gender distribution for the 873 reported fatalities. Although responsible for the majority of poisoning reports, children younger than 6 years of age comprised just 2.7% (24) of the fatalities. Sixty-one percent of poisoning fatalities occurred in 20- to 49-year-old individuals. A single substance was implicated in 92.4% of reports, and 1.5% of patients were exposed to more than two possibly poisonous drugs or products (Table 5). In contrast, 45% of fatal cases involved two or more drugs or products. The overwhelming majority of human exposures were acute (93.2%) compared to only 51.9% of poison-related fatal exposures. Chronic exposures comprised 2.1% of all poison exposure reports, and acute-on-chronic exposures comprised 4.0%. (Chronic exposures were defined as continuous
or repeated exposures occurring in a period exceeding 8 hours.) Reason for exposure was coded according to the following definitions: Unintentional general: All unintentional exposures not specifically defined below. Most unintentional exposures in children are captured here. Environmental: Any passive, nonoccupational exposure that results from contamination of air, water, or soil. Environmental exposures are usually caused by man-made contaminants. Occupational: An exposure that occurs as a direct result of the person being on the job or in the workplace. Therapeutic error: An unintentional deviation from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person, or administration of the wrong substance. Only exposures to medications or products substituted for medications are included. Drug interactions resulting from unintentional administration of drugs or foods which are known to interact are also included. Unintentional misuse: Unintentional improper or incorrect use of a nonpharmaceutical substance. Unintentional misuse differs from intentional misuse in that the exposure was unplanned or not foreseen by the patient. Bite/sting: All animal bites and stings, with or without envenomation, are included. Food poisoning: Suspected or confirmed food poisoning; ingestion of food contaminated with microorganisms is included. Unintentional unknown: An exposure determined to be unintentional but the exact reason is unknown. Suspected suicidal: An exposure resulting from the inappropriate use of a substance for reasons that are suspected to be self-destructive or manipulative. Intentional misuse: An exposure resulting from the intentional improper or incorrect use of a substance for reasons other than the pursuit of a psychotropic effect. Intentional abuse: An exposure resulting from the intentional improper or incorrect use of a substance where the victim was likely attempting to achieve a euphoric or psychotropic effect. All recreational use of substances for any effect is included. Intentional unknown: An exposure that is determined to be intentional but the specific motive is unknown. Contaminant/tampering: The patient is an unintentional victim of a substance that has been adulterated (either maliciously or unintentionally) by the introduction of an undesirable substance. Malicious: This category is used to capture patients who are victims of another person’s intent to harm them. Adverse reaction: An adverse event occurring with normal, prescribed, labeled or recommended use of the product, as opposed to overdose, misuse or abuse. Included are cases with an unwanted effect caused by an allergic, hypersensitive, or idiosyncratic re-
TABLE 7. Distribution of Reason for Exposure by Age ⬍6 Years
6-12 Years
13-19 Years
⬎19 Years
Unknown*
Total
Reason
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Col %
Unintentional Intentional Other Adverse Reaction Unknown Total
1,148,693 688 1,059 3,888 471 1,154,799
60.2 0.3 8.8 8.6 8.0 52.5
142,085 7,661 1,743 2,626 491 154,606
7.4 3.3 14.5 5.8 8.3 7.0
86,757 64,574 2,114 3,663 885 157,993
4.5 28.1 17.5 8.1 15.0 7.2
522,985 153,867 6,983 34,638 3,770 722,243
27.4 66.9 57.9 76.6 63.8 32.8
7,545 3,130 157 394 289 11,515
0.4 1.4 1.3 0.9 4.9 0.5
1,908,065 229,920 12,056 45,209 5,906 2,201,156
86.7 10.4 0.5 2.1 0.3 100.0
*Unknown child plus unknown age (excludes unknown adult)
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TABLE 8. Distribution of Reason for Exposure and Age for 873 Fatalities
Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Food poisoning Occupational Unknown Total Intentional Suicide Misuse Abuse Unknown Total Other Adverse Reaction Unknown Total
⬍6 Years
6-12 Years
13-19 Years
⬎19 Years
Total
9 3 0 0 8 0 0 0 20
0 0 1 0 2 0 0 0 3
0 0 0 0 2 0 0 0 2
1 50 6 11 11 0 11 0 90
10 53 7 11 23 0 11 0 115
0 1 0 0 1 3 0 0 24
0 1 1 0 2 0 3 0 8
23 1 19 2 45 1 1 4 53
449 57 117 38 661 1 7 29 788
472 60 137 40 709 5 11 33 873
sponse to the active ingredients, inactive ingredients, or excipients. Concomitant use of a contraindicated medication or food is excluded, and coded instead as a therapeutic error. The vast majority (86.7%) of poison exposures were unintentional; suicidal intent was present in 7.0% of cases (Table 6). Therapeutic errors comprised 7.0% of exposures (154,422 cases), with unintentional nonpharmaceutical product misuse comprising another 3.3% of exposures (72,083 cases). Unintentional poisonings outnumbered intentional poisonings in all age groups (Table 7). In contrast, of the 873 human poisoning fatalities reported, 85% of adolescent deaths and 84% of adult deaths (older than 19 years of age) were intentional (Table 8). Ingestions accounted for 75.0% of exposure routes (Table 9), followed in frequency by dermal, inhalation, and ocular exposures. For the 873 fatalities, ingestion, inhalation, and parenteral were the predominant exposure routes. TABLE 9. Distribution of Route of Exposure for Human Poison Exposure Cases and 873 Fatalities All Exposure Cases
Fatal Exposure Cases
Route
No.
%
No.
%
Ingestion Dermal Inhalation Ocular Bites and stings Parenteral Aspiration Other Unknown Total
1,731,553 185,509 146,717 134,669 85,102 8,740 2,935 5,916 7,843 2,308,984
75.0 8.0 6.4 5.8 3.7 0.4 0.1 0.3 0.3 100.0
712 12 93 1 7 42 10 3 58 938
75.9 1.3 9.9 0.1 0.7 4.5 1.1 0.3 6.2 100.0
NOTE: Multiple routes of exposure were observed in many poison exposure victims. Percentage is based on the total number of exposure routes (2,308,984 for all patients, 938 for fatal cases) rather than the total number of human exposures (2,201,156) or fatalities (873).
TABLE 10. Management Site of Human Poison Exposure Cases Site
No.
%
Managed on-site, non-health care facility Managed in health care facility Treated and released Admitted to critical care Admitted to noncritical care Admitted to psychiatry Lost to follow-up; left AMA Subtotal Other Refused referral Unknown Total
1,654,942
75.2
270,279 61,723 33,358 32,235 76,017 473,612 20,341 42,827 9,434 2,201,156
12.3 2.8 1.5 1.5 3.4 21.5 0.9 1.9 0.4 100.0
ABBREVIATION: AMA, against medical advice.
Clinical effects (signs, symptoms, or laboratory abnormalities) were coded in 30.5% of cases (17.4% had one effect, 7.8% had two effects, 3.3% had three effects, 1.3% had four effects, 0.4% had five effects, and 0.3% had more than five effects). Of 1,455,796 clinical effects coded, 79.3% were deemed related, 8.1% were considered not related, and 12.6% were coded as ‘‘unknown if related.’’ The majority of cases reported to poison centers were managed in a nonhealth care facility (78%), usually at the site of exposure, the patient’s own home (Table 10). Treatment in a health care facility was rendered in 21.5% of cases and recommended in another 1.9% of patients who refused the referral. The percentage of patients treated in a health care facility varied considerably with age. Only 10.6% of children under 6 years and only 13.7% of children between 6 and 12 years were managed in a health care facility compared to 44.5% of teenagers (13 to 19 years of age) and 35.4% of adults (older than 19 years of age). Of cases managed in a health care facility, 57.1% were treated and released without admission, 13.0% were admitted for critical care, and 7.0% were admitted for noncritical care. Where treatment was provided in a health care facility, 36.6% of the patients were referred in by the poison center and 63.4% were already in or en route to the health care facility when the poison center was contacted. Health care facilities included acute care hospitals (86.1%), physician offices or clinics (11.3%), and freestanding emergency centers (2.6%). Table 11 displays the medical outcome of the human poison exposure cases distributed by age, showing more severe outcomes in the older age groups. Table 12 compares medical outcome and reason for exposure, and shows a greater frequency of serious outcomes in intentional exposures. Table 13 shows an increasing duration of the clinical effects observed with more severe outcomes. Medical outcome categories were as follows: No effect: The patient developed no signs or symptoms as a result of the exposure. Minor effect: The patient developed some signs or symptoms as a result of the exposure, but they were minimally bothersome and generally resolved rapidly with no residual disability or disfigurement. A minor effect is often limited to the skin or mucous membranes (eg, self-limited gastrointestinal symptoms, drowsiness, skin irritation, first degree
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TABLE 11. Medical Outcome of Human Poison Exposure Cases by Patient Age ⬍6 Years Outcome
No.
No effect 352,271 Minor effect 116,766 Moderate effect 9,241 Major effect 728 Death 24 No follow-up, nontoxic 276,608 No follow-up, minimal toxicity 364,720 No follow-up, potentially toxic 13,972 Unrelated effect 20,469 Total 1,154,799
6-12 Years
13-19 Years
⬎19 Years
Col %
No.
Col %
No.
Col %
No.
Col %
No.
Col %
30.5 10.1 0.8 0.1 0.0 24.0 31.6 1.2 1.8 52.5
28,500 29,578 3,906 261 8 28,172 56,096 3,207 4,878 154,606
18.4 19.1 2.5 0.2 0.0 18.2 36.3 2.1 3.2 7.0
27,684 40,638 13,967 1,705 53 12,077 43,257 13,178 5,434 157,993
17.5 25.7 8.8 1.1 0.0 7.6 27.4 8.3 3.4 7.2
85,118 171,098 64,467 10,742 788 58,591 238,782 51,639 41,018 722,243
11.8 23.7 8.9 1.5 0.1 8.1 33.1 7.2 5.7 32.8
1,249 1,630 427 64 0 1,014 3,253 3,465 413 11,515
10.8 14.2 3.7 0.6 0.0 8.8 28.3 30.1 3.6 0.5
Unknown
Total No.
%
494,822 22.5 359,710 16.3 92,008 4.2 13,500 0.6 873 0.0 376,462 17.1 706,108 32.1 85,461 3.9 72,212 3.3 2,201,156 100.0
TABLE 12. Distribution of Medical Outcome by Reason for Exposure for Human Poison Exposure Cases Unintentional Outcome
No.
No effect 447,577 Minor effect 283,633 Moderate effect 50,865 Major effect 3,272 Death 115 No follow-up, nontoxic 369,664 No follow-up, minimal toxicity 653,192 No follow-up, potentially toxic 42,281 Unrelated effect 57,466 Total 1,908,065
Intentional
Total
Col %
No.
Col %
No.
Col %
No.
Col %
No.
Col %
23.5 14.9 2.7 0.2 0.0 19.4 34.2 2.2 3.0 86.7
44,880 62,768 34,713 9,245 709 4,331 29,767 38,335 5,172 229,920
19.5 27.3 15.1 4.0 0.3 1.9 12.9 16.7 2.2 10.4
1,254 2,967 718 92 5 1,064 3,941 1,030 985 12,056
10.4 24.6 6.0 0.8 0.0 8.8 32.7 8.5 8.2 0.5
650 9,553 4,902 485 11 1,183 18,070 2,568 7,787 45,209
1.4 21.1 10.8 1.1 0.0 2.6 40.0 5.7 17.2 2.1
461 789 810 406 33 220 1,138 1,247 802 5,906
7.8 13.4 13.7 6.9 0.6 3.7 19.3 21.1 13.6 0.3
494,822 359,710 92,008 13,500 873 376,462 706,108 85,461 72,212 2,201,156
22.5 16.3 4.2 0.6 0.0 17.1 32.1 3.9 3.3 100.0
Minor Effect Moderate Effect Major Effect (Col %) (Col %) (Col %) 43.5 24.4 17.7 6.0 2.1 0.5 0.2 0.0 5.5
Unknown
No.
TABLE 13. Duration of Clinical Effects by Medical Outcome
ⱕ2 hours ⬎2 hours, ⱕ8 hours ⬎8 hours, ⱕ24 hours ⬎24 hours, ⱕ3 days ⬎3 days, ⱕ1 week ⬎1 week, ⱕ1 month ⬎1 month Anticipated permanent Unknown
Adverse Reaction
Col %
dermal burn, sinus tachycardia without hypotension, and transient cough). Moderate effect: The patient exhibited signs or symptoms as a result of the exposure that were more pronounced, more prolonged, or more systemic in nature than minor symptoms. Usually some form of treatment is indicated. Symptoms were not life-threatening and the patient had no residual disability or disfigurement (eg, corneal abrasion, acid-base disturbance, high fever, disorientation, hypotension that is rapidly responsive to treatment, and isolated brief seizures that respond readily to treatment). Major effect: The patient exhibited signs or symptoms as a result of the exposure that were life-threatening or resulted in significant residual disability or disfigurement (eg, repeated seizures or status epilepticus, respiratory compromise requiring intubation, ventricular tachycardia with hypotension, cardiac or respiratory arrest, esophageal stricture, and
Duration of Effect
Other
8.0 22.1 30.8 17.1 7.9 2.7 0.7 0.2 10.6
3.2 10.7 29.1 28.5 13.1 4.6 1.4 2.5 6.9
disseminated intravascular coagulation). Death: The patient died as a result of the exposure or as a direct complication of the exposure. Only those deaths that were probably or undoubtedly related to the exposure are coded here. Not followed, judged as nontoxic exposure: No follow-up calls were made to determine the patient’s outcome because the substance implicated was nontoxic, the amount implicated was insignificant, or the route of exposure was unlikely to result in a clinical effect. Not followed, minimal clinical effects possible: No follow-up calls were made to determine the patient’s outcome because the exposure was likely to result in only minimal toxicity of a trivial nature. (The patient was expected to experience no more than a minor effect.) Unable to follow, judged as a potentially toxic exposure: The patient was lost to follow-up, refused followup, or was not followed but the exposure was significant and may have resulted in a moderate, major, or fatal outcome. Unrelated effect: The exposure was probably not responsible for the effect. Confirmed nonexposure: This outcome option was coded to designate cases where there was reliable TABLE 14. Decontamination and Therapeutic Intervention Therapy
No. of Patients
%
Decontamination only Observation only No therapy provided Decontamination and other therapy Other therapy only (no decontamination) Unknown if therapy provided/patient refused
1,269,005 295,301 259,634 140,888 103,196 133,132
57.7 13.4 11.8 6.4 4.7 6.0
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TABLE 15. Therapy Provided in Human Exposure Cases Therapy
TABLE 17A. Substances Most Frequently Involved in Human Exposures No.
Decontamination Dilution/irrigation Activated charcoal, single dose Cathartic Gastric lavage Ipecac syrup Activated charcoal, multidose Other emetic Whole bowel irrigation Measures to Enhance Elimination Hemodialysis Hemoperfusion Other extracorporeal procedure Specific Antidote Administration N-acetylcysteine (oral) Naloxone Flumazenil Antivenin Atropine N-acetylcysteine (IV) Ethanol Phytonadione Fab fragments Hyperbaric oxygen Pyridoxine Folate Physostigmine Pralidoxime (2-PAM) Deferoxamine Succimer Methylene blue EDTA Dimercaprol (BAL) Sodium thiosulfate Amyl nitrite Sodium nitrite Penicillamine Hydroxocobalamin Other intervention Alkalinization Transplantation ECMO
1,129,656 136,151 69,039 37,084 21,942 9,702 6,667 2,064 1,049 33 25 10,893 8,195 1,952 910 815 785 602 370 334 293 253 235 180 178 149 139 105 88 79 59 44 44 33 5 6,247 23 13
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 2,155,952 2,192,088 2,241,082 2,201,156
% of Exposures Ipecac Activated Involving Administered Charcoal Children (% of Administered ⬍6 Years Exposures) (% of Exposures) 64.0 64.1 63.4 63.0 62.3 61.8 61.1 60.8 59.9 58.8 56.0 54.1 52.9 52.8 52.5 52.7 52.5
No.
%*
Cleaning substances Analgesics Cosmetics and personal care products Plants Foreign bodies Cough and cold preparations Bites/envenomations Topicals Insecticides/pesticides (includes rodenticides) Food products, food poisoning Sedatives/hypnotics/antipsychotics Antidepressants Hydrocarbons Antimicrobials Chemicals Alcohols
217,476 214,066 205,242 113,864 105,837 99,873 92,137 84,922 78,853 74,980 71,809 70,060 62,772 59,933 59,312 54,282
9.9 9.7 9.3 5.2 4.8 4.5 4.2 3.9 3.6 3.4 3.3 3.2 2.9 2.7 2.7 2.5
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of human exposures rather than the total number of substances.
and objective evidence that an exposure initially believed to have occurred actually never occurred (eg, all missing pills are later located). All cases coded as confirmed nonexposure are excluded from this report. In 1999 there were 6,954 such cases reported nationally. Tables 14 and 15 outline the use of decontamination procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this database. These must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 1.0% of cases. In children under 6 years of age, ipecac syrup was most often administered outside a health care facility. This pattern was reversed TABLE 17B. Substances Most Frequently Involved in Pediatric Exposures (Children Under 6 Years)
TABLE 16. Decontamination Trends
Human Exposures Year Reported
Substance
13.4 12.9 15.0 13.3 10.1 8.4 7.0 6.1 5.2 4.3 3.7 2.7 2.3 1.8 1.5 1.2 1.0
4.0 4.0 4.6 5.2 5.2 6.5 6.4 6.7 7.0 7.3 7.3 6.8 7.7 7.3 7.1 6.8 6.6
Substance
No.
%*
Cosmetics and personal care products Cleaning substances Analgesics Plants Foreign bodies Topicals Cough and cold preparations Insecticides/pesticides (includes rodenticides) Vitamins Gastrointestinal preparations Antimicrobials Arts/crafts/office supplies Antihistamines Hydrocarbons Hormones and hormone antagonists
153,057 123,575 87,471 79,287 76,268 65,561 63,951 43,107 38,651 36,133 34,940 29,225 24,981 24,468 23,661
13.3 10.7 7.6 6.9 6.6 5.7 5.5 3.7 3.3 3.1 3.0 2.5 2.2 2.1 2.0
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in children under six years, rather than the total number of substances.
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TABLE 17C. Substances Most Frequently Involved in Adult Exposures (⬎19 years)
TABLE 19. 17-Year Comparisons of Fatality Data
Substance
No.
%*
Analgesics Cleaning substances Bites/envenomations Sedatives/hypnotics/antipsychotics Antidepressants Food products, food poisoning Cosmetics and personal care products Chemicals Alcohols Hydrocarbons Fumes/gases/vapors Insecticides/pesticides (includes rodenticides) Cardiovascular drugs Plants Cough and cold preparations Antihistamines
74,602 64,691 52,349 50,311 42,983 36,924 30,029 29,441 28,020 25,676 25,056 24,510 22,947 16,764 15,868 15,294
10.3 9.0 7.2 7.0 6.0 5.1 4.2 4.1 3.9 3.6 3.5 3.4 3.2 2.3 2.2 2.1
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in adults (over 19 years), rather than the total number of substances.
in teenagers and adults, likely reflecting the greater proportion of these patients treated in emergency departments. Ipecac was used most frequently in children under 6 years of age (83.4% of all ipecac use). Table 16 shows a continuing decline in the use of ipecac-induced emesis in the treatment of poisoning. Table 17A presents the most common substance categories listed by frequency of exposure. Tables 17B and 17C present similar data for children and adults, respectively, and show the considerable differences between pediatric and adult poison exposures. Table 18 lists the substance categories with the largest number of reported deaths; analgesics and antidepressants lead this list. Table 19 shows little TABLE 18. Categories with Largest Numbers of Deaths
Category
No.
% of All Exposures in Category
Analgesics Antidepressants Cardiovascular drugs Stimulants and street drugs Sedative/hypnotics/antipsychotics Alcohols Gases and fumes Chemicals Antihistamines Muscle relaxants Automotive products Insecticides/pesticides (includes rodenticides) Anticonvulsants Hormones/hormone antagonists Cleaning substances
340 153 127 121 110 97 45 43 28 18 15 15 14 13 13
0.159 0.218 0.290 0.346 0.153 0.179 0.109 0.072 0.054 0.137 0.103 0.019 0.060 0.033 0.006
NOTE: Tables 18, 22A and 22B are based on a total of up to two substances coded per exposure, while Table 21 has up to three substances coded.
Total Fatalities
Suicides
Pediatric Deaths (⬍6 years)
Year
No.
% of Cases
No.
% of Deaths
No.
% of Deaths
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
95 293 328 406 397 545 590 612 764 705 626 766 724 726 786 775 873
0.038 0.040 0.036 0.037 0.034 0.040 0.037 0.036 0.042 0.038 0.036 0.040 0.036 0.034 0.036 0.035 0.040
60 165 178 223 226 297 323 350 408 395 338 410 405 358 418 421 472
63.2 56.3 54.3 54.9 56.9 54.5 54.7 57.2 53.4 56.0 54.0 53.5 55.9 49.3 53.2 54.3 54.1
10 21 20 15 22 28 24 25 44 29 27 26 20 29 25 16 24
10.5 7.2 6.1 3.7 5.5 5.1 4.1 4.1 5.8 4.1 4.3 3.4 2.8 4.0 3.2 2.1 2.7
variation over the past 17 years in the percentage of cases reported to TESS that are fatal poisonings and in the percentage of reported fatalities due to suicide. In contrast, the percentage of reported fatalities involving children younger than 6 years has declined. A breakdown of plant exposures is provided for those most commonly implicated (Table 20). A summary of the 873 fatal exposures is presented in Table 21. Each of these cases was abstracted and verified by the reporting center, with only those exposures deemed ‘‘probably’’ or ‘‘undoubtedly’’ responsible for the fatality included in this compendium. The highest blood concentration of implicated substances is provided when available to the reporting poison center. Prehospital cardiac and/or respiratory arrests occurred in 34% of all fatalities, and these are indicated in Table 21. All fatality abstracts from participating centers were reviewed in detail. Selected representative, interesting or unusual cases are presented in the Appendix. After extensive review, 873 fatalities reported in 1999 were deemed related to the exposure. Although the overall number of deaths increased by over 10% compared to 1998, much of this increase is attributed to an increase in the number of indirect reports obtained from medical examiners. Analgesics, antidepressant, cardiovascular drugs and stimulant and street drugs were the primary substances involved in 64% of the fatalities. The majority of analgesic fatalities (71%) were caused by acetaminophen, aspirin, and other salicylates. Although nontricyclic antidepressants accounted for 80% of antidepressant exposures, tricyclic antidepressants were the primary substances implicated in 75% of antidepressant fatalities. Of the 92 deaths in which cardiovascular drugs were the primary substances, calcium channel blockers accounted for 55%. Cocaine and heroin were responsible for 55% and 29%, respectively, of the 91 deaths for which stimulants and street drugs were the primary substances. Remarkably, 75% of fatalities involving digoxin were therapeutic errors.
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TABLE 20. Frequency of Plant Exposures by Plant Type Botanical Name
Common Name
Frequency
Capsicum annuum Philodendron spp. Spathiphyllum spp. Euphorbia pulcherrima Ilex spp. Phytolacca americana Ficus spp. Dieffenbachia spp. Toxicodendron radicans Crassula spp. Epipremnum aureum Malus spp.
Pepper Philodendron Peace lily Poinsettia Holly Pokeweed, inkberry Rubber tree, weeping fig Dumbcane Poison ivy Jade plant Pothos, devil’s ivy Apple, crabapple (plant parts) Eucalyptus English ivy Rhododendron, azalea Dandelion Chrysanthemum African violet Christmas cactus Pyracantha
4,721 3,790 3,429 3,236 3,197 2,839 1,975 1,870 1,617 1,458 1,227 1,120
Eucalyptus spp. Hedera helix Rhododendron spp. Taraxacum officinale Chrysanthemum spp. Saintpaulia ionantha Schlumbergera Bridgesii Pyracantha spp.
fourth infant died from methadone intentionally added to formula by the infant’s mother for sedation. Two of the three therapeutic errors occurred in hospitals. Fourteen (58%) deaths in children younger than 6 years of age were caused by nonpharmaceuticals; this contrasts sharply with the observation that pharmaceuticals were involved in 78% of all deaths in this report. One-third of deaths in children under 6 years of age were environmental, with all but one of these deaths caused by carbon monoxide. Three deaths in children 2 years of age and under resulted from aspiration of an oil or hydrocarbon. In adolescents (13 to 19 years of age), 85% of deaths were intentional and for 66% of these deaths, pharmaceuticals were the primary substance responsible. Many adolescent fatalities were caused by substances which are relatively inexpensive and easily accessible to adolescents such as nonprescription analgesics and volatile inhalants. Analgesics, primarily products containing acetaminophen and aspirin, were involved in 30% of deaths. Volatile inhalant abuse is a persistent problem in adolescents. Of 53 fatalities in adolescents, 23% resulted from intentional inhalation abuse of air fresheners and hydrocarbons. An additional death in a 14-year-old resulted from chronic inhalation of a xylene/methanol containing solvent for an unknown reason. Stimulants and street drugs were involved in 10 (19%) adolescent deaths. Tables 22A and 22B provide comprehensive demographic data on patient age, reason for exposure, medical outcome, and use of a health care facility for all 2,201,156 exposures, presented by category. Table 22A focuses on nonpharmaceuticals; Table 22B presents drugs. Of the 2,368,496 substances logged in Tables 22A and 22B, 56.9% were nonpharmaceuticals and 43.1% were pharmaceuticals. The reason for the exposure was intentional for 25.0% of pharmaceutical substances implicated compared with only 3.9% of nonpharmaceutical substances. Correspondingly, treatment in a health care facility was provided in a higher percentage of exposures to pharmaceutical substances (34.4%) compared with nonpharmaceutical substances (16.2%). Pharmaceutical exposures also had more severe outcomes. Of substances implicated in fatal cases, 78.0% were pharmaceuticals, compared with only 43.1% in nonfatal cases. Similarly, 79.0% of substances implicated in major outcomes were pharmaceuticals. In closing, we gratefully acknowledge the extensive contributions of each participating poison center and the assistance of the many health care providers who provided comprehensive data to the poison centers for inclusion in this database.
1,009 1,000 942 919 883 877 859 781
NOTE: This table provides the frequency of involvement of plants in exposures reported to poison centers with no correlation with severity of toxicity. Several of the plants on the list pose little, if any, ingestion hazard.
Among nonpharmaceuticals, the largest single category responsible for fatalities was fumes and gases, which included 32 carbon monoxide exposures. Interestingly, there were eight deaths from mushrooms and plants in adults. All of the mushroom deaths resulted from mistaking a poisonous mushroom for an edible nonpoisonous one. All three of the plant exposures were intentional. There were 10 deaths associated with gamma hydroxybutyrate (GHB) or a GHB analog in 1999 compared with only one to two deaths each year between 1995 and 1998. For eight of the deaths, GHB or a GHB analog was the primary substance. Nine of the deaths occurred in adults and were intentional. One additional death in an 18-year-old involved ethanol as the primary substance and was malicious. As federal and state restrictions on GHB and its analogs become more stringent, it will be interesting to look for trends in GHB related exposures and fatalities. In children under 6 years of age, 83% of the 24 deaths were unintentional. Three of the remaining deaths were the result of malicious intent by a parent or caretaker and the TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999
Case
Age
Substances
Chronicity
Route
Reason
Parenteral Parenteral Ingestion
Adv rxn Adv rxn Int suicide
NONPHARMACEUTICALS Adhesives/glue 42 yr 1a 78 yr 2a 41 yr 3a
Methylmethacrylate Methylmethacrylate Tetrahydrofuran/methyl ethyl ketone cement methyl ethyl ketone cleaner See also case 185 (glue).
A A A
(Continued on following page)
Blood Concentrations
Interval After Exposure
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TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case Alcohols 4ipm 5ipm 6ipm 7ipm 8ipm 9 10ipm 11 12 13 14
Age
21 yr 42 yr 45 yr 45 yr 46 yr 51 yr 57 yr 60 yr 62 yr 62 yr 43 yr
15p
32 yr
16
43 yr
17p
42 yr
Substances
Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol acetaminophen Ethanol acetaminophen/hydrocodone diazepam Ethanol benzodiazepine marijuana Ethanol carisoprodol
Chronicity
Route
Reason
A U U U A/C C U A/C C U C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int abuse Int abuse Int abuse Int abuse Unknown Int abuse Int abuse Int suicide Int abuse Unknown Int abuse
A
Ingestion
Int abuse
A/C
Ingestion
Int abuse
A
Ingestion
Int suicide
propoxyphene 18
Blood Concentrations
Interval After Exposure
207 mg/dL 400 mg/dL
220 mg/dL 16 µg/mL¥ hydrocodone 150 ng/mL 240 ng/mL 533 mg/dL
100 mg/dL§ 15.8 µg/mL§ meprobamate 21 µg/mL§ 0.17 µg/mL§ norpropoxyphene 0.86 µg/mL§
44 yr
Ethanol A/C Ing/Inh Int abuse cocaine 36 yr Ethanol A Ingestion Int abuse 337 mg/dL 19p diazepam propoxyphene 20 51 yr Ethanol A/C Ingestion Int suicide 360 mg/dL doxepin acetaminophen/codeine 18 yr Ethanol A Ingestion Malicious 367 mg/dL 21ap gamma hydroxybutyrate 17 µg/mL ⬎19 yr Ethanol A/C Ingestion Int suicide 380 mg/dL§ 22ip paroxetine 970 ng/mL§ chlordiazepoxide 47 yr Ethanol A/C Ingestion Int abuse 600 mg/dL 23p trifluoperazine trazodone 24 69 yr Isopropanol A Ingestion Int abuse 184 mg/dL 25 47 yr Methanol A Ingestion Unknown 70 mg/dL 26 50 yr Methanol A Ingestion Int suicide 252 mg/dL 27 62 yr Methanol A Ingestion Int suicide 90 mg/dL 28 68 yr Methanol U Ingestion Int unk 126 mg/dL 29 41 yr Methanol A Ingestion Int unk cocaine 30 46 yr Methanol A Ingestion Int suicide cocaine opiate See also cases 46, 53, 71, 74, 82, 140, 141, 162, 173, 244 thru 252, 261, 271 thru 273, 293, 297, 300 thru 302, 306, 327, 328, 361, 362, 385, 386, 390, 401, 409, 420, 422-429, 438, 447, 448, 453, 482, 490, 493-498, 502, 507, 517, 518, 541, 549, 554, 573, 578, 584, 585, 612, 617, 649, 659, 665, 670, 683, 718, 721, 749, 750, 757, 774, 779, 818 thru 820, 826, 854 thru 856, 862, 863, 867 (ethanol). Automotive products 31 23 yr 32 26 yr 30 yr 33p 34 30 yr 35 42 yr 50 yr 36p 37 51 yr 38 54 yr 39 56 yr 40 37 yr
Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) amitriptyline
A A A A A A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Unknown Ingestion
(Continued on following page)
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int unk Int suicide Int suicide Int suicide
13 mg/dL 86 mg/dL§
160 mg/dL
948 mg/dL
9.5 h
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TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 41 42p 43p 44
Age 25 yr 34 yr 44 yr 85 yr
Substances
Gas line antifreeze (methanol) Gas line antifreeze (methanol) Gas line antifreeze (methanol) Transmission fluid (hydrocarbon) alprazolam 40 yr Windshield washer fluid (methanol) 45ap 36 yr Windshield washer fluid (methanol) 46p ethanol transmission fluid (hydrocarbon) 47 15 yr Unknown automotive product See also case 46 (transmission fluid, hydrocarbon). Bites and envenomations 48 41 yr Hymenoptera 83 yr Hymenoptera 49p 50 56 yr Hymenoptera pyrethrins 6 yr Loxosceles reclusa 51ai 42 yr Loxosceles reclusa 52a 43 yr Rattlesnake 53a ethanol 45 yr Unknown snake 54p
Chronicity
Route
Reason
A A A A
Ingestion Ingestion Ingestion Asp/Ing
Int suicide Int suicide Int suicide Int suicide
A A
Ingestion Ingestion
Int abuse Int suicide
A
Derm/Inh
Env
A A A
Bite/sting Bite/sting Bite/sting
A A A
Bite/sting Bite/sting Bite/ sting/Inh Bite/sting Bite/sting Bite/sting
Bite/sting Bite/sting Bite/sting
A
Bite/sting
Bite/sting
Blood Concentrations
431 mg/dL
Interval After Exposure
16 h
Chemicals 55ap 56p 57a 58
25 yr 32 yr 97 yr ⬎19 yr
Cyanide, potassium A Ingestion Int suicide Cyanide, potassium A Ingestion Int suicide Cyanide A Inhalation Int suicide Cyanide A Inhalation Env carbon monoxide/smoke 59 29 yr Dichromated titanium/amorphous boron/ A Derm/Inh Occ potassium perchlorate/barium chromate 15 yr Ethylene glycol U Ingestion Unknown 60a 61 25 yr Ethylene glycol A Ingestion Int suicide 62 27 yr Ethylene glycol A Ingestion Int suicide 63 32 yr Ethylene glycol A Ingestion Int suicide 64 35 yr Ethylene glycol A Ingestion Int unk 65 39 yr Ethylene glycol U Ingestion Int unk 66 42 yr Ethylene glycol A Ingestion Int suicide 67 44 yr Ethylene glycol A Ingestion Int suicide 68 44 yr Ethylene glycol A Ingestion Int suicide 69 44 yr Ethylene glycol A Ingestion Int suicide 70 28 yr Ethylene glycol A Ingestion Int suicide diphenhydramine 71 25 yr Ethylene glycol A Ingestion Int suicide ethanol 17 yr Ethylene glycol A Ingestion Int suicide 72a flurazepam 27 yr Formaldehyde A Ingestion Int suicide 73a 74 39 yr Hydrochloric acid A Ingestion Int suicide ethanol 75 68 yr Hydrochloric acid A Ing/Ocular Int suicide gasoline 76 70 yr Hydrochloric acid A Ingestion Int suicide malathion calcium acid methanearsonate 77 30’s yr Hydrofluoric acid A Derm/Inh Occ 78 30’s yr Hydrofluoric acid A Derm/Inh Occ 79 48 yr Hydrofluoric acid (70%) A Dermal Occ ⬎19 yr Hydrofluoric acid A Derm/Inh Occ 80p 81 63 yr Lye A Ingestion Int suicide 82 61 yr Propylene glycol A Ingestion Int unk ethanol 69 yr Sodium nitrite A/C Ingestion Int misuse 83a 84 72 yr Sulfuric acid (20%) A Ingestion Int suicide See also cases 771 (ammonia); 136 thru 138 (cyanide); 351 (hydrofluoric acid); 145 (phosphoric acid).
(Continued on following page)
150 µg/mL§ 120 µg/mL§ ⬎10 µg/mL 553 µg/mL
77 mg/dL 65 µg/mL§ 71 mg/dL 40 mg/dL 376 mg/dL 78 mg/dL 58 mg/dL
29 mg/dL ⬎5,000 µg/mL§ 197 mg/dL
4 mg/dL§ methemoglobin 38%
18 h
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TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Cleaning substances 12 mo Degreaser (hydrochloric acid 3%/ A Ingestion Unint gen 85a ammonium bifluoride 14%) 86 65 yr Disinfectant (diethylene glycol monobutyl A Ingestion Int abuse ether/alkyl dimethyl benzyl ammonium chlorides) 87 61 yr Drain opener (hydrochloric acid, 15-18%) A Ingestion Int suicide 88 43 yr Drain opener (sodium hydroxide, 50-60%) A Ingestion Int suicide 89 54 yr Drain opener (sodium hydroxide) A Ingestion Malicious 65 yr Drain opener (sodium hydroxide) A Ingestion Int suicide 90ip 66 yr Drain opener (sulfuric acid, 93-100%) A Ingestion Int suicide 91a 48 yr Hydrofluoric acid cleaner A Ingestion Int suicide 92a 93 51 yr Hydrofluoric acid cleaner A Ingestion Unknown 94 51 yr Pine oil/isopropanol cleaner A Asp/Ing Int suicide 82 yr Pine oil/isopropanol cleaner A Asp/Ing Int suicide 95a 96 51 yr Pine oil/isopropanol cleaner A Ingestion Int suicide cocaine benzodiazepine 30’s yr Tape head cleaner (ethylene chloride) A Inhalation Int abuse 97p air freshener 18 mo Tire cleaner (hydrofluoric acid or ammonium A Ingestion Unint gen 98a bifluoride) 99 45 yr Toilet bowl cleaner (hydrochloric acid, 15%) A Ingestion Int suicide See also cases 3 (cleaner, methyl ethyl ketone); 872 (cleaner, trichlorocyanuric acid); 771 (fabric spray, zinc chloride); 188 (toilet bowl cleaner, hydrochloric acid). Cosmetics and personal care products 12 mo Hair oil (safflower oil/mineral oil) 100a 16 yr Hair spray (hydrofluorocarbon/isobutane/ethanol) 101a amphetamine/dextroamphetamine 102 64 yr Mouthwash (ethanol 26.9%/methyl salicylate/eucalyptol) See also case 586 (mouthwash, ethanol). Deodorizers 103 104p 105p 106p
12 yr 14 yr 16 yr 16 yr
Air freshener Air freshener (isobutane/propane propellant) Air freshener (aerosol) Air freshener (butane/isobutane/propane propellant) 19 yr Air freshener (aerosol) 107p See also case 97 (air freshener). Essential Oils 2 yr 108a 87 yr 109a
Citronella oil Potpourri oil
A A
Asp/Ing Ing/Inh
Unint gen Int abuse
A/C
Ingestion
Int misuse
A A A A
Inhalation Inhalation Inhalation Inhalation
Int abuse Int abuse Int abuse Int abuse
A
Inhalation
Int abuse
A A
Asp/Ing Asp/Ing
Unint gen Unint misuse
A A A A A A A A A A A A A A A A A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Occ Env Env Env Env Env Env Env Env Env Env Int suicide Int suicide Int suicide Env Int suicide Int suicide Int suicide
amphetamine 0.12 µg/mL§
Foreign Bodies See also cases 458, 460 (activated charcoal). Fumes, gases and vapors 50 yr Carbon dioxide (dry ice) 110ap 18 mo Carbon monoxide/smoke 111p 2 yr Carbon monoxide 112a 113 2 yr Carbon monoxide/smoke 3 yr Carbon monoxide 114p 115 4 yr Carbon monoxide/smoke 5 yr Carbon monoxide/smoke 116p 5 yr Carbon monoxide/smoke 117p 11 yr Carbon monoxide 118p 12 yr Carbon monoxide 119p 20 yr Carbon monoxide 120i 27 yr Carbon monoxide 121p 30 yr Carbon monoxide 122p 30’s yr Carbon monoxide 123ip 36 yr Carbon monoxide 124p 37 yr Carbon monoxide 125p 39 yr Carbon monoxide 126p 39 yr Carbon monoxide 127p
(Continued on following page)
39% 37% 45% 40% 36% 55% 57% 52%§ 42% 72%§
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TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 128p 129p 130p 131p 132p 133p 134 135p 136
Age
Substances
42 yr 44 yr 48 yr 67 yr 73 yr 76 yr 80 yr ⬎19 yr 18 yr
Chronicity
Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke Carbon monoxide/smoke Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke cyanide 40’s yr Carbon monoxide/smoke 137p cyanide 56 yr Carbon monoxide/smoke 138p cyanide 22 yr Carbon monoxide 139p diphenhydramine 24 yr Carbon monoxide 140ip ethanol 53 yr Carbon monoxide 141ip ethanol 142 50 yr Carbon monoxide hydroxyzine 70 yr Chlorine gas (sulfuric acid and hypochlorite drain 143p opener mixed) 32 yr Hydrogen sulfide 144p 40 yr Hydrogen sulfide 145p phosphoric acid 18 yr Nitrous oxide propellant (whipped cream) 146p 20 yr Nitrous oxide propellant (whipped cream) 147p 16 yr Propane 148p 31 yr Propane 149p 150 30 yr Unknown sewer gas See also cases 58, 357, 358, 440 (carbon monoxide).
Route
Reason
Blood Concentrations
A A A A A A U A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Env Int suicide Env Env Env Int suicide Env Env Env
14% 55% 27%
A
Inhalation
Env
35%
A
Inhalation
Env
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Inhalation
Unint misuse
A A
Inhalation Inhalation
Occ Occ
A A A/C A A
Inhalation Inhalation Inhalation Inhalation Inhalation
Int abuse Int unk Int abuse Int abuse Occ
Heavy metals 72 yr Lead 151a 152 42 yr Mercury See also case 76 (calcium acid methanearsonate).
C U
Ingestion Inhalation
Unint misuse Unknown
Herbicides 38 yr Acrolein 153ap 60 yr Dinitrobutylphenol 154a 47 yr Glyphosate 155a 44 yr Monosodium methylarsonate 156a 157 58 yr Monosodium methylarsonate (35%) 16 yr Paraquat 158a See also case 830 (herbicide, unknown type).
A A A A A A
Derm/Inh Ingestion Ingestion Ingestion Ingestion Ingestion
Occ Unint misuse Int unk Int suicide Int suicide Int suicide
A/C A A A
Inhalation Inhalation Inhalation Ing/Inh
Int abuse Int abuse Int abuse Int abuse
A A A A C
Inhalation Inhalation Inhalation Asp/Ing Inhalation
Malicious Int abuse Occ Unint gen Unknown
Hydrocarbons 159p 160ap 161p 162p
14 yr 15 yr 17 yr 18 yr
Butane Butane Butane Butane ethanol marijuana 4 yr Chlorodifluoromethane 163ap 39 yr Difluoroethane 164p 35 yr Fluorocarbon 165p 2 yr Lighter fluid 166a 167 14 yr Solvent (xylene/methanol) See also case 75 (gasoline).
(Continued on following page)
48% 43%
51% 2,900 µg/mL 40%§ 0.53 µg/mL§ 85%§ 10 mg/dL§ 81%§ 60 mg/dL§ 27%
302 µg/dL 29.5 µg/dL
7.7 µg/mL
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
530
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Insecticides/pesticides (excluding rodenticides) 16 mo Aluminum phosphate 168p 62 yr Chlordane 169a 170 60 yr Chlorpyrifos 171 33 yr Malathion 172 55 yr Malathion 173 ⬎19 yr Malathion ethanol 27 yr Nitric acid/lead arsenate 174a 175 21 yr Prolan 176 11 yr Unknown insecticide 177 45 yr Unknown insecticide See also cases 76 (malathion); 50 (pyrethrins); 828 (unknown pesticide). Mushrooms 178 61 yr Amanita species 63 yr Amanita species 179a 62 yr Lepiota josserandii 180a 181 70 yr Mushroom (probably Amanita species) 182 88 yr Mushroom (probably Amanita species) See also case 823 (mushroom, hallucinogenic). Plants 183a 184ap 185a
20 yr 21 yr 48 yr
Jimson weed (Datura stramonium) Jimson weed (Datura stramonium) Melia azedarach glue
Rodenticides 186 33 yr 187 38 yr
Anticoagulant rodenticide (long acting) Anticoagulant rodenticide bromethalin 188 60 yr Zinc phosphide toilet bowel cleaner (hydrochloric acid, 15-20%) See also case 187 (bromethalin). PHARMACEUTICALS Analgesics 189 12 yr 17 yr 190a 191 20 yr 192 20’s yr 193 22 yr 194 22 yr 195 23 yr 24 yr 196a 197 25 yr 198 25 yr 199 26 yr 200 26 yr 201 27 yr 202 30 yr 203 31 yr 204 31 yr 205 31 yr 206 32 yr 207 33 yr 208 33 yr 209 34 yr
Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen
Route
Reason
C A A A A A
Ing/Inh Ingestion Ingestion Ingestion Ingestion Ingestion
Env Int suicide Int suicide Unint misuse Unknown Int suicide
A A C A
Ingestion Ingestion Inhalation Ingestion
Int unk Unint misuse Int misuse Unint gen
A A A U A
Ingestion Ingestion Ingestion Ingestion Ingestion
Unint misuse Unint misuse Unint misuse Unint misuse Unint misuse
A A C
Ing/Inh Ing/Inh Ing/Inh
Int abuse Int abuse Int misuse
C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
C A U A A A A/C A A A C A A/C A C A A C A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Adv rxn Int suicide Int suicide Int misuse Int misuse Int suicide Int misuse Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int suicide Int suicide Ther error Int suicide Int suicide Int suicide
(Continued on following page)
Blood Concentrations
Interval After Exposure
51 µg/mL
69 µg/mL 54 µg/mL 465 µg/mL 27 µg/mL 19 µg/mL 126 µg/mL 155 µg/mL 173 µg/mL
36 h
28 h
42 µg/mL
352 µg/mL
16.5 h
97 µg/mL
72 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
531
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 210 211 212 213 214a 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236
Age 38 yr 40 yr 40 yr 40’s yr 41 yr 41 yr 41 yr 43 yr 44 yr 49 yr 50 yr 51 yr 54 yr 56 yr 64 yr 65 yr 66 yr 68 yr 70 yr 70 yr 74 yr 74 yr 75 yr 88 yr 97 yr 97 yr 40 yr
237
48 yr
238
79 yr
239
57 yr
240
54 yr
241
50 yr
242
31 yr
243
39 yr
244
16 yr
245
32 yr
246
40 yr
247
42 yr
248
44 yr
249
51 yr
250
67 yr
251
77 yr
252
55 yr
253
42 yr
254
23 yr
Substances Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen acetaminophen/diphenhydramine Acetaminophen acetaminophen/hydrocodone Acetaminophen acetaminophen/oxycodone Acetaminophen aspirin Acetaminophen aspirin ibuprofen Acetaminophen benzodiazepine Acetaminophen carisoprodol Acetaminophen diphenhydramine Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol aspirin Acetaminophen fluphenazine trihexyphenidyl Acetaminophen heroin
Chronicity
Route
Reason
Blood Concentrations
C A C C A C C A A A C A U C A U C U C U A U C C C A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int misuse Int suicide Int misuse Ther error Int suicide Ther error Int misuse Int suicide Int suicide Int suicide Int misuse Int abuse Unknown Int misuse Unknown Int suicide Int unk Ther error Ther error Unknown Int unk Int suicide Ther error Ther error Ther error Ther error Int suicide
57 µg/mL 14 µg/mL 154 µg/mL 19 µg/mL 180 µg/mL 40 µg/mL 157 µg/mL
160 µg/mL 28 µg/mL 619 µg/mL 79 µg/mL 36 µg/mL 105 µg/mL 100 µg/mL 90 µg/mL 205 µg/mL
A
Ingestion
Int suicide
479 µg/mL
A/C
Ingestion
Int misuse
191 µg/mL
C
Ingestion
Int misuse
C
Ingestion
Int misuse
66 µg/mL 43 mg/dL 75 µg/mL 27 mg/dL
A/C
Ingestion
Int suicide
675 µg/mL
U
Ingestion
Int suicide
76 µg/mL
A
Ingestion
Int suicide
29 µg/mL
A
Ingestion
Int misuse
89 µg/mL
U
Ingestion
Int suicide
C
Ingestion
Int misuse
100 mg/dL 63 µg/mL
A/C
Ingestion
Int suicide
27 µg/mL
C
Ingestion
Int misuse
100 µg/mL
C
Ingestion
Int misuse
147 µg/mL
C
Ingestion
Int misuse
61 µg/mL
A
Ingestion
Int suicide
⬎400 µg/mL
C
Ingestion
Int misuse
146 µg/mL
A/C
Ingestion
Int suicide
A
Ing/Inh/Par Int abuse
72 h
48 h
34 µg/mL 54 µg/mL 631 µg/mL 48 µg/mL 200 µg/mL 26 µg/mL 145 µg/mL 29 µg/mL
32 mg/dL
(Continued on following page)
Interval After Exposure
153 µg/mL
12-20 h
14 h
19 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
532
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
255
71 yr
256
35 yr
257
17 yr
258
54 yr
259
72 yr
260
27 yr
Acetaminophen hydrochlorothiazide/lisinopril Acetaminophen ketoprofen Acetaminophen multiple vitamins with iron Acetaminophen oxycodone Acetaminophen quetiapine trazodone Acetaminophen/aspirin
261
36 yr
naproxen Acetaminophen/aspirin/caffeine
262 263
18 yr 30 yr
264 265 266 267 268 269
37 yr 21 yr 29 yr 39 yr 46 yr 35 yr
270p
90 yr
ethanol Acetaminophen/butalbital/caffeine/codeine Acetaminophen/caffeine acetaminophen/oxycodone acetaminophen/propoxyphene Acetaminophen/codeine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine acetaminophen/oxycodone carisoprodol Acetaminophen/diphenhydramine
271p
33 yr
acetaminophen/propoxyphene Acetaminophen/diphenhydramine
Route
Reason
A
Ingestion
Int suicide
1283 µg/mL
A
Ingestion
Int suicide
280 µg/mL
15 h
A
Ingestion
Int suicide
36 h 36 h
A/C
Ingestion
Int suicide
30 µg/mL iron 219 µg/dL 61 µg/mL
A
Ingestion
Int suicide
1441 µg/mL
A
Ingestion
Int suicide
359 µg/mL¥ 59 mg/dL¶
A
Ingestion
Int suicide
172 µg/mL¥ 50 mg/dL¶ 228 mg/dL
A C
Ingestion Ingestion
Int suicide Int misuse
13 µg/mL¥
A/C A A A A C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse
100 µg/mL¥ 269 µg/mL¥ 12 µg/mL¥
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
161 µg/mL¥
8h
U
Ingestion
Int misuse
59 µg/mL¥
19 h
A A C A U A A/C C U C C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int abuse Int unk Int suicide Int suicide Int misuse Int misuse Unknown Int suicide Int misuse Int suicide
132 µg/mL¥ 53 µg/mL¥ 15 µg/mL¥ 14 µg/mL¥ 134 µg/mL¥ 77 µg/mL¥ 33 µg/mL¥§
U U
Ingestion Ingestion
Int suicide Int unk
84 µg/mL¥
A/C
Ingestion
Int suicide
168 µg/mL¥
A
Ingestion
Unknown
A/C
Ingestion
Int suicide
ethanol 272
41 yr
273p
42 yr
274
46 yr
275
23 yr
276 277 278 279 280i 281 282p 283 284 285p 286 287
28 yr 36 yr 36 yr 36 yr 38 yr 46 yr 47 yr 47 yr 47 yr 48 yr 62 yr 63 yr
288 289
⬎19 yr 36 yr
290
40 yr
291
39 yr
292
42 yr
Acetaminophen/diphenhydramine ethanol Acetaminophen/diphenhydramine ethanol Acetaminophen/diphenhydramine zolpidem Acetaminophen/diphenhydramine unknown drug Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone
Acetaminophen/hydrocodone Acetaminophen/hydrocodone acetaminophen/oxycodone Acetaminophen/hydrocodone acetaminophen/oxycodone Acetaminophen/hydrocodone alprazolam Acetaminophen/hydrocodone alprazolam carisoprodol
Blood Concentrations
Interval After Exposure
(Continued on following page)
1.5 h 1.5 h
22 h
638 µg/mL¥ diphenhydramine 10.4 µg/mL§ 290 µg/mL¥§ diphenhydramine 19 µg/mL§ 210 mg/dL§ 109 µg/mL¥
30 µg/mL¥ 22 µg/mL¥ 65 µg/mL¥ hydrocodone 0.62 µg/mL
59 µg/mL¥
3-4 d
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
533
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
293p
37 yr
294p
41 yr
295
24 yr
296p
32 yr
297
44 yr
298
40 yr
299p
39 yr
300p
46 yr
301
55 yr
302
20 yr
303
46 yr
304
47 yr
305p
18 yr
306
35 yr
Substances Acetaminophen/hydrocodone benzodiazepine ethanol Acetaminophen/hydrocodone butorphanol carisoprodol Acetaminophen/hydrocodone carisoprodol Acetaminophen/hydrocodone carisoprodol diazepam Acetaminophen/hydrocodone chlordiazepoxide ethanol Acetaminophen/hydrocodone clonazepam Acetaminophen/hydrocodone diazepam cocaine Acetaminophen/hydrocodone ethanol Acetaminophen/hydrocodone ethanol Acetaminophen/hydrocodone ethanol cocaine Acetaminophen/hydrocodone hydromorphone alprazolam Acetaminophen/hydrocodone lorazepam acetaminophen/isometheptene/ dichloralphenazone Acetaminophen/hydrocodone methadone Acetaminophen/hydrocodone
307
22 yr
308
49 yr
309 310 311 312
43 yr 47 yr ⬎19 yr 42 yr
313
39 yr
314ip
42 yr
315
66 yr
316p
27 yr
317p
33 yr
318p
23 yr
methadone ethanol Acetaminophen/hydrocodone morphine (long-acting) Acetaminophen/hydrocodone oxycodone (long-acting) amitriptyline Acetaminophen/oxycodone Acetaminophen/oxycodone Acetaminophen/oxycodone Acetaminophen/oxycodone acetaminophen/codeine Acetaminophen/oxycodone acetaminophen/propoxyphene acetaminophen Acetaminophen/oxycodone alprazolam Acetaminophen/oxycodone amitriptyline Acetaminophen/oxycodone aspirin/carisoprodol alprazolam Acetaminophen/oxycodone zolpidem Acetaminophen/propoxyphene
319
36 yr
Acetaminophen/propoxyphene
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
A
Ingestion
Int unk
A/C
Ingestion
Int abuse
C
Ingestion
Int misuse
C
Ingestion
Int misuse
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int misuse
C
Ingestion
Int misuse
44 µg/mL¥
U
Ingestion
Int suicide
263 µg/mL¥
A
Ingestion
Int suicide
A
Ingestion
Int suicide
176 µg/mL¥
24 h
A
Ingestion
Int suicide
193 µg/mL¥
3h
U
Ingestion
Int unk
A/C
Ingestion
Int suicide
C
Ingestion
Int misuse
331 µg/mL¥ hydrocodone 870 ng/mL§ 0.29 µg/mL§ 229 mg/dL 88 µg/mL¥
A/C
Ingestion
Int suicide
193 µg/mL¥
U A A U
Ingestion Ingestion Ingestion Ingestion
Int misuse Int suicide Int suicide Int suicide
20 µg/mL¥
239 µg/mL¥
A
Ingestion
Int unk
161 µg/mL¥
A
Ingestion
Int unk
A/C
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
(Continued on following page)
85 µg/mL¥
92 µg/mL¥ hydrocodone 102 ng/mL 3400 ng/mL 53 mg/dL 15 µg/mL¥
34 µg/mL¥
143 µg/mL¥ propoxyphene 1.4 µg/mL norpropoxyphene 0.83 µg/mL 115 µg/mL¥
3h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
534
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 320 321p 322p 323
Age 77 yr 86 yr ⬎19 yr 87 yr
324
36 yr
325
53 yr
326p
24 yr
327p
36 yr
328p
20 yr
329
67 yr
330 331 332 333 334 335 336 337 338 339 340i 341 342 343 344 345 346 347 348 349
16 yr 16 yr 18 yr 40 yr 41 yr 41 yr 42 yr 43 yr 48 yr 54 yr 56 yr 61 yr 64 yr 70 yr 71 yr 72 yr 80 yr 89 yr 92 yr 20 yr
350
17 yr
351
35 yr
352
47 yr
353p
71 yr
354
50 yr
355i
70 yr
356p
23 yr
357
50 yr
358
67 yr
359
38 yr
360
64 yr
Substances Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene acetaminophen Acetaminophen/propoxyphene acetaminophen/hydrocodone Acetaminophen/propoxyphene alprazolam zolpidem Acetaminophen/propoxyphene cocaine tramadol Acetaminophen/propoxyphene cyclobenzaprine ethanol Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene lorazepam Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin acetaminophen Aspirin acetaminophen amphetamines Aspirin acetaminophen hydrofluoric acid Aspirin acetaminophen opiate Aspirin amitriptyline Aspirin amlodipine Aspirin aspirin/acetaminophen/caffeine Aspirin benztropine fluoxetine Aspirin carbon monoxide Aspirin carbon monoxide/smoke Aspirin chlorpromazine Aspirin diazepam trifluoperazine
Chronicity
Route
Reason
Blood Concentrations
A A A/C C
Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int misuse Int misuse
150 µg/mL¥ 99 µg/mL¥ 124 µg/mL¥
A
Ingestion
Int suicide
34 µg/mL¥
A
Ingestion
Int suicide
585 µg/mL¥
A/C
Ing/Unk
Int suicidal
60 µg/mL¥
A/C
Ingestion
Int suicide
74 µg/mL¥
A
Ingestion
Int suicide
300 mg/dL 85 µg/mL¥ 98 mg/dL
A/C
Ingestion
Int suicide
A A A A U C A A A A A A A/C A/C C A A/C A C U
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int misuse Ther error Int suicide Int suicide Int suicide Ther error Int suicide
A
Ingestion
Int suicide
A
Ing/Inh
Int suicide
80 mg/dL 142 µg/mL
A
Ingestion
Int suicide
52 mg/dL 251 µg/mL
C
Ingestion
Int misuse
44 mg/dL
A/C
Ingestion
Int suicide
115 mg/dL
C
Ingestion
Int suicide
73 mg/dL
A
Ingestion
Int suicide
50 mg/dL
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
134 mg/dL 12% 123 mg/dL
A
Ingestion
Int suicide
88 mg/dL
A
Ingestion
Int suicide
68 mg/dL
(Continued on following page)
110 mg/dL 134 mg/dL 110 mg/dL 121 mg/dL 104 mg/dL 57 mg/dL 150 mg/dL 80 mg/dL 109 mg/dL 113 mg/dL 102 mg/dL 88 mg/dL 45 mg/dL 99 mg/dL 81 mg/dL 34 mg/dL 78 mg/dL 101 mg/dL 43 mg/dL 55 mg/dL 148 µg/mL 124 mg/dL 157 µg/mL
Interval After Exposure
48 h
10 h
18.5 h
8h
17 h 9h 31 h 17 h
6h 4.5 h
⬎10 h ⬎10 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
535
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
361
51 yr
362
58 yr
363
58 yr
364a
15 yr
365
86 yr
366
43 yr
367
16 yr
368
49 yr
369
50 yr
370p 371 372
⬎19 yr 56 yr 45 yr
373 374 375a 376 377 378 379p 380p
44 yr 45 yr 45 yr 46 yr 68 yr 86 yr 45 yr 76 yr
381p
68 yr
382p
46 yr
383
42 yr
384
37 yr
385p
51 yr
386p
387 388
389p
390 391 392aip 393p 394p
Substances Aspirin ethanol Aspirin ethanol Aspirin metformin Aspirin loratadine hydrochlorothiazide/triamterene Aspirin opioid Aspirin propoxyphene fluoxetine Aspirin pseudoephedrine/brompheniramine diphenhydramine Aspirin/butalbital diphenhydramine fluoxetine Aspirin/butalbital/caffeine/codeine alprazolam Aspirin/caffeine/dihydrocodeine Aspirin/oxycodone Aspirin/oxycodone trazodone hydroxyzine Colchicine Colchicine Colchicine Colchicine Colchicine Colchicine Fentanyl Fentanyl alprazolam promethazine Fentanyl irbesartan Fentanyl paroxetine acetaminophen/hydrocodone Fentanyl sufentanil morphine Hydrocodone benzodiazepine Hydrocodone
ethanol celecoxib 42 yr Hydrocodone ethanol olanzapine 39 yr Hydromorphone 42 yr Hydromorphone acetaminophen/hydrocodone carisoprodol 45 yr Hydromorphone methamphetamine imipramine 46 yr Ibuprofen ethanol ⬎19 yr Meperidine 5 mo Methadone 19 yr Methadone 35 yr Methadone
Chronicity
Route
Reason
Blood Concentrations
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
95 mg/dL 230 mg/dL 73 mg/dL 124 mg/dL 108 mg/dL
A
Ingestion
Int suicide
82 mg/dL
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
112 mg/dL codeine 0.662 µg/mL§ 104 mg/dL 0.72 µg/mL§ norpropoxyphene 2.5 µg/mL§ 1.65 µg/mL§ 101 mg/dL
A
Ingestion
Int suicide
29 mg/dL¶
A/C
Ingestion
Int suicide
U C A
Ingestion Ingestion Ingestion
Int suicide Ther error Int suicide
U A A A A/C C U C
Unknown Ingestion Ingestion Ingestion Ingestion Parenteral Dermal Derm/Ing
Unknown Int suicide Int suicide Int suicide Int suicide Ther error Int abuse Adv rxn
C
Derm/Ing
Int misuse
A/C
Derm/Ing
Int suicide
A
Parenteral
Int suicide
A
Ingestion
Int suicide
A
Ingestion
U
Ingestion
Unknown
A/C A
Parenteral Ingestion
Ther error Int suicide
A
Ing/Paren
Int suicide
C
Ingestion
Adv rxn
A A U A/C
Parenteral Ingestion Ingestion Ingestion
Ther error Int misuse Int abuse Int suicide
(Continued on following page)
40 mg/dL¶ 75 mg/dL¶
Interval After Exposure
5h
9h
8-12 h
9.6 ng/mL
4.3 ng/mL 21 ng/mL
220 ng/mL 780 ng/mL Int suicide hydrocodeine 300 ng/mL§ dihydrocodeine 34 ng/mL§ 185 mg/dL 480 ng/mL§ 130 mg/dL§
27.6 µg/mL§
0.3 µg/mL§
20 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
536
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
395ipm 396ipm 397p 398p
47 yr 56 yr 58 yr 37 yr
A U A A/C
Unknown Unknown Ingestion Ingestion
Int abuse Int abuse Int suicide Int abuse
399
37 yr
A
Ingestion
Int abuse
400p
60 yr
A/C
Ingestion
Int suicide
401p
36 yr
A/C
Ingestion
Int suicide
402p
30 yr
Methadone Methadone Methadone Methadone acetaminophen/hydrocodone Methadone alprazolam Methadone doxepin zolpidem Methadone ethanol Methadone promethazine diazepam
U
Ingestion
Int abuse
403p 404 405p 406p
37 yr 70 yr 85 yr 47 yr
A/C A/C A U
Ingestion Ingestion Ingestion Unknown
Int misuse Int suicide Int suicide Int unk
40 ng/mL§
407p
20 yr
A
Ing/Inh
Int abuse
65 ng/mL§
408
78 yr
Morphine (long acting) Morphine Morphine Morphine amphetamines marijuana Morphine codeine cocaine Morphine diphenhydramine diazepam
A
Ing/Paren
Int suicide
409p
35 yr
A
Ing/Unk
Int abuse
410p
38 yr
U
Ingestion
Int abuse
411ip
62 yr
A/C
Ingestion
Ther error
412p 413 414ipm 415ipm 416ipm 417
27 yr 37 yr 38 yr 41 yr 48 yr 23 yr
U U A U U U
Unknown Ingestion Unknown Unknown Unknown Unknown
Unknown Int suicide Int abuse Int abuse Int abuse Int unk
418p
42 yr
U
Ingestion
Int unk
419p
65 yr
A/C
Ingestion
Int suicide
420
22 yr
A
Ingestion
Int abuse
421
18 yr
Morphine ethanol Morphine meperidine clomipramine Morphine zolpidem propoxyphene Opiate Opiate Opiate Opiate Opiate Opiate benzodiazepine Opiate benzodiazepine Opiate benzodiazepine amphetamine Opiate benzodiazepine ethanol Opiate
A
Ingestion
U
Unknown
Int abuse
U
Unknown
Int abuse
U
Ingestion
Int abuse
U
Unknown
Int abuse
U
Unknown
Int abuse
diazepam
422ipm
21 yr
423ipm
24 yr
424ipm
24 yr
425ipm
31 yr
426ipm
36 yr
chlordiazepoxide Opiate ethanol Opiate ethanol Opiate ethanol Opiate ethanol Opiate ethanol
(Continued on following page)
Reason
Blood Concentrations
1.07 µg/mL§ 11 ng/mL§
0.33 µg/mL§ 370 mg/dL 0.35 µg/mL§ 0.07 µg/mL§ 80 ng/mL§ nordiazepam 360 ng/mL§
830 ng/mL 930 ng/mL 1450 ng/mL nordiazepam 410 ng/mL 57 ng/mL§ 30 mg/dL 160 ng/mL§ normeperidine 0.24 µg/mL§ 730 ng/mL§ 45 ng/mL§ norpropoxyphene 0.12 µg/mL§
30 mg/dL Unknown morphine 190 ng/mL§ mono-acetyl-morphine 100 ng/mL§ 110 ng/mL§ nordiazepam 20 ng/mL§
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
537
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
427ipm
38 yr
428ipm
43 yr
429ipm
45 yr
430
36 yr
431p 432ip 433p 434p 435p
22 yr 38 yr 46 yr 47 yr 19 yr
436p
39 yr
437p
40 yr
438im
42 yr
439
63 yr
440p
52 yr
441p 442ip
28 yr 43 yr
443 444p
74 yr 37 yr
Substances
Chronicity
Route
Reason
Opiate ethanol Opiate ethanol Opiate ethanol Opiate gabapentin unknown drug Oxycodone Oxycodone (long-acting) Oxycodone Oxycodone Oxycodone acetaminophen methocarbamol Oxycodone acetaminophen/oxycodone Oxycodone benzodiazepine Oxycodone ethanol Oxycodone (long-acting) nadolol Oxycodone temazepam carbon monoxide Propoxyphene Propoxyphene
U
Unknown
Int abuse
U
Unknown
Int abuse
U
Unknown
Int abuse
A/C
Ingestion
Int suicide
U A U A/C A/C
Unknown Parenteral Ingestion Unknown Ingestion
Int unk Int abuse Int suicide Int suicide Int suicide
A
Parenteral
Int abuse
A/C
Ingestion
Int suicide
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ing/Inh
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int unk
Propoxyphene Propoxyphene amitriptyline
A/C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Unknown
Int abuse
A
Ingestion
Int suicide
U U A/C
Ingestion Ingestion Ingestion
Int unk Unknown Int suicide
diazepam 445p
15 yr
446p
39 yr
447p
29 yr
448ipm
45 yr
449
29 yr
450 451 452
60 yr 63 yr 34 yr
Propoxyphene cyclobenzaprine Propoxyphene diphenhydramine alprazolam Propoxyphene diphenhydramine ethanol Propoxyphene hydrocodone ethanol Propoxyphene lorazepam acetaminophen/oxycodone Salicylate Salicylate Salicylate sertraline paroxetine
(Continued on following page)
Blood Concentrations
8.17 µg/mL§ norpropoxyphene 9.89 µg/mL§ 5 µg/mL§ 800 ng/mL§ nortriptyline 400 ng/mL§ 140 ng/mL§ nordiazepam 370 ng/mL§ 1 µg/mL norpropoxyphene 1 µg/mL
2.62 µg/mL§ norpropoxyphene 1.55 µg/mL§
86 mg/dL 108 mg/dL 68 mg/dL§ 1.9 µg/mL§ desmethylsertraline 0.6 µg/mL§ 2.1 µg/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
538
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
453ip
33 yr
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Tramadol U Ing/Paren Int unk 2600 ng/mL ethanol 380 mg/dL propranolol 0.59 µg/mL See also cases 14, 313, 323, 349 thru 352, 435, 457, 568, 644, 664, 687, 729 (acetaminophen); 20, 312, 535, 571 (acetaminophen/codeine); 236 (acetaminophen/ diphenhydramine); 702 (acetaminophen/diphenhydramine/pseudoephedrine/dextromethorphan); 15, 237, 324, 382, 388, 398, 559, 616, 739, 740 (acetaminophen/ hydrocodone); 304, 570, 693 (acetaminophen/isometheptene/dichloralphenazone); 238, 263, 269, 289, 290, 436, 449, 566 (acetaminophen/oxycodone); 263, 270, 313, 481, 482, 535, 570 (acetaminophen/propoxyphene); 239, 240, 252, 458, 513, 555, 710 (aspirin); 355 (aspirin/acetaminophen/caffeine); 316 (aspirin/carisoprodol); 294 (butorphanol); 385, 486 (celecoxib); 407, 774, 824 (codeine); 448, 731 (hydrocodone); 303 (hydromorphone); 240, 650, 653, 689, 735 (ibuprofen); 256 (ketoprofen); 410 (meperidine); 305, 306, 492, 500, 501, 737, 857 (methadone); 307, 383, 545 (morphine); 260 (naproxen); 30, 352, 365, 714, 723, 743, 825, 826 (opiate/opioid); 258, 308 (oxycodone); 17, 19, 366, 411, 506, 668, 746, 831 (propoxyphene); 383 (sufentanil); 326, 509 (tramadol) Anesthetics 37 yr Enflurane A 454ap Anticholinergic drugs 66 yr Amantadine C 455p atenolol amlodipine See also cases 356, 483, 756 (benztropine); 567 (oxybutynin), 253 (trihexyphenidyl).
Inhalation
Int unk
Ingestion
Ther error
Anticoagulants 2 day Heparin 456a 457 77 yr Warfarin acetaminophen
Parenteral Ingestion
Ther error Int suicide
A A/C
45 µg/mL
Anticonvulsants 458 40’s yr
Gabapentin A/C Asp/Ing Int suicide aspirin activated charcoal 10 yr Lamotrigine C Ingestion Adv rxn 459a 460 70 yr Phenytoin A/C Asp/Ing Ther error activated charcoal 461 23 yr Valproic acid U Ingestion Int suicide 462 27 yr Valproic acid A/C Ingestion Int suicide 30 yr Valproic acid A/C Ingestion Int suicide 463a 464 39 yr Valproic acid A Ingestion Int suicide 465 36 yr Valproic acid A/C Ingestion Int suicide olanzapine 466 36 yr Valproic acid U Ingestion Int suicide olanzapine See also cases 430, 523, 569, 575 (gabapentin); 765 (primidone); 675 (topiramate); 541, 654, 766, 772 (valproic acid). Antidepressants 14 yr 467p 468 16 yr 19 yr 469p 20 yr 470p
Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A A/C A/C A/C
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
471 472p 473p 474p 475 476p 477 478p
34 yr 37 yr 39 yr 40 yr 40 yr 40 yr 42 yr 49 yr
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A/C A A U U A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
479 480ipm 481
51 yr 55 yr 24 yr
A/C A/C A
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
482p
46 yr
A
Ingestion
Int suicide
483p
76 yr
Amitriptyline Amitriptyline Amitriptyline acetaminophen/propoxyphene Amitriptyline acetaminophen/propoxyphene ethanol Amitriptyline benztropine sertraline
A/C
Ingestion
Int suicide
56 mg/dL
70 µg/mL 432 µg/mL 3,000 µg/mL 1,280 µg/mL 400 µg/mL 1,425 µg/mL 1,200 µg/mL
4,700 ng/mL§ 900 ng/mL nortriptyline 350 ng/mL 670 ng/mL§
332 ng/mL§ nortriptyline 260 ng/mL§
propoxyphene 1.5 µg/mL§
(Continued on following page)
5h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
539
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
484
32 yr
485
⬎19 yr
486ip
32 yr
487
57 yr
488
57 yr
489
60 yr
490
39 yr
491
35 yr
492
35 yr
493
31 yr
494p
39 yr
495
40 yr
496ipm
43 yr
497
53 yr
498p
61 yr
499p
46 yr
500p
34 yr
501p
39 yr
502
21 yr
503
34 yr
504
35 yr
505
53 yr
506i
27 yr
507p
40 yr
508
50 yr
Substances Amitriptyline bupropion haloperidol Amitriptyline carisoprodol Amitriptyline celecoxib Amitriptyline citalopram quinapril Amitriptyline clonazepam Amitriptyline clonazepam Amitriptyline clonazepam ethanol Amitriptyline cocaine Amitriptyline diphenhydramine methadone Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline fluoxetine Amitriptyline methadone benzodiazepine Amitriptyline methadone clonazepam Amitriptyline methamphetamine ethanol Amitriptyline metoclopramide paroxetine Amitriptyline mibefradil diltiazem Amitriptyline nortriptyline methamphetamine Amitriptyline propoxyphene benzodiazepine Amitriptyline propranolol ethanol Amitriptyline
Chronicity
Route
Reason
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ing/Inh
Int unk
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int unk
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Ther error
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Blood Concentrations
4,500 ng/mL§ nortriptyline 900 ng/mL§ 2,000 ng/mL
210 mg/dL
1,510 ng/mL 0.37 µg/mL§ 0.35 µg/mL§ 300 mg/dL
sertraline clonazepam
(Continued on following page)
4600 ng/mL§ nortriptyline 3200 ng/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
540
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
509p
45 yr
Substances Amitriptyline
Chronicity
Route Ingestion
A/C
Ingestion
A/C
Ingestion
840 ng/mL§ nortriptyline 250 ng/mL§ o-desmethyl tramadol 700 ng/mL§ n-desmethyl tramadol 84 ng/mL§ 36.1 µg/mL§ meprobamate 22.6 µg/mL§ Int suicide 5200 ng/mL§ nortriptyline 2400 ng/mL§ 0.1 µg/mL§ 0.1 µg/mL§ Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
U A A U
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
carisoprodol 43 yr
511
35 yr
512
68 yr
513
66 yr
Amitriptyline trazodone diphenhydramine Amitriptyline verapamil olanzapine Amitriptyline zolpidem Amitriptyline/chlordiazepoxide aspirin paroxetine Bupropion Bupropion Bupropion (long acting) Bupropion (long-acting) ethanol Bupropion ethanol sibutramine Bupropion fluvoxamine olanzapine Bupropion imipramine desipramine Bupropion (long acting) olanzapine Bupropion olanzapine fluoxetine Bupropion olanzapine gabapentin Bupropion paroxetine Desipramine Desipramine fluoxetine sertraline
Blood Concentrations
A
tramadol
510ip
Reason Int suicide
amitriptyline 530 ng/mL§ nortriptyline 460 ng/mL§ 69 mg/dL
514ipm 515p 516 517
24 yr 41 yr 45 yr 42 yr
518
29 yr
519
35 yr
520
41 yr
521
40 yr
522
36 yr
523p
57 yr
524
16 yr
525 526
40 yr 54 yr
527 528 529ipm 530ipm 531 532 533
21 yr 30 yr 32 yr 32 yr 37 yr 39 yr 39 yr
Doxepin Doxepin Doxepin Doxepin Doxepin Doxepin Doxepin
A U A/C U A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
534p 535
64 yr 52 yr
A/C A/C
Ingestion Ingestion
536
68 yr
A/C
Ingestion
Int suicide
537p
32 yr
A
Ingestion
Int suicide
538p
56 yr
Doxepin Doxepin acetaminophen/propoxyphene acetaminophen/codeine Doxepin chlordiazepoxide Doxepin diazepam Doxepin procainamide
21,900 ng/mL§ 2,400 ng/mL§ 720 ng/mL§ desmethylsertraline 1,030 ng/mL§ Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide ⬎1,500 ng/mL Int suicide 14,000 ng/mL§ nordoxepin 6,960 ng/mL§ Int suicide Int suicide
A
Ingestion
Int suicide
206 mg/dL
(Continued on following page)
2,800 ng/mL 946 ng/mL
700 ng/mL
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
541
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
539
48 yr
540
45 yr
541
36 yr
Substances
Chronicity
Route
Reason
545
48 yr
546p
44 yr
547
42 yr
548 549
40 yr 35 yr
550
24 yr
Doxepin risperidone trazodone Doxepin trazodone prednisone Doxepin valproic acid ethanol Doxepin venlafaxine risperidone Fluoxetine Fluoxetine benzodiazepine Fluoxetine diphenhydramine morphine Fluoxetine trazodone heroin Fluoxetine zolpidem diltiazem Fluvoxamine Fluvoxamine ethanol Imipramine
551 552
36 yr 37 yr
Imipramine Imipramine
A A/C
Ingestion Ingestion
Int suicide Int suicide
553 554ipm
50 yr 43 yr
A U
Ingestion Ingestion
Int suicide Int suicide
555
65 yr
A
Ingestion
Int suicide
556 557 558 559
58 yr 61 yr 79 yr 33 yr
C A/C A/C A/C
Ingestion Ingestion Ingestion Ingestion
Ther error Int suicide Int suicide Int suicide
560
74 yr
A/C
Ingestion
Ther error
561
42 yr
A/C
Ingestion
Int suicide
1.7 mEq/L 848 ng/mL 4.3 mEq/L
562 563 564ipm 565p 566
36 yr 55 yr 60 yr 60 yr 49 yr
A/C A/C A/C A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide
1,720 ng/mL§ 6,950 ng/mL§ 6,950 ng/mL§ 6,950 ng/mL§ 122 µg/mL
567
49 yr
A/C
Ingestion
Int suicide
819 ng/mL
568p
29 yr
A
Ingestion
Int suicide
569
28 yr
A/C
Ingestion
Int suicide
570
30 yr
Imipramine Imipramine ethanol Imipramine thioridazine aspirin Lithium Lithium Lithium Lithium acetaminophen/hydrocodone olanzapine Lithium amitriptyline Lithium olanzapine Nortriptyline Nortriptyline Nortriptyline Nortriptyline Nortriptyline acetaminophen/oxycodone Nortriptyline clonazepam oxybutynin Nortriptyline paroxetine acetaminophen Paroxetine gabapentin Sertraline acetaminophen/propoxyphene acetaminophen/isometheptene/ dichloralphenazone
U
Ingestion
Int suicide
542
543 544p
74 yr
50 yr ⬎19 yr
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Blood Concentrations
200 µg/mL 164 mg/dL A
Ingestion
Int suicide
U A/C
Ingestion Ingestion
Unknown Int suicide
240 ng/mL§
A
Ingestion
Int suicide
norfluoxetine 3,760 ng/mL§ 0.38 µg/mL§ 350 ng/mL§
U
Ing/Paren
Int suicide
A/C
Ingestion
Int suicide
A/C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
3,000 ng/mL§ desipramine 5,000 ng/mL§ 2,200 ng/mL§ desipramine 310 ng/mL§ 700 ng/mL
66 mg/dL 4.2 mEq/L 7.0 mEq/L 2.8 mEq/L 27 µg/mL¥
129 µg/mL
(Continued on following page)
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
542
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
571
36 yr
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Trazodone A Ingestion Int suicide cocaine acetaminophen/codeine 40 yr Tricyclic antidepressant A Ingestion Int suicide ⬎500 ng/mL 572p 573 42 yr Tricyclic antidepressant A Ingestion Int suicide benzodiazepine ethanol 41 yr Tricyclic antidepressant A Ingestion Int suicide 574p cocaine 40 yr Tricyclic antidepressant A Ingestion Int suicide 575p gabapentin paroxetine 576 49 yr Tricyclic antidepressant A Ingestion Int unk 1781 ng/mL heroin cocaine 577 42 yr Venlafaxine A Ingestion Int suicide 94 µg/mL§ See also cases 40, 308, 315, 353, 444, 560, 645, 674, 675, 681, 764, 767 (amitriptyline); 760 (amoxapine); 484 (bupropion); 487 (citalopram); 410 (clomipramine); 520 (desipramine); 20, 400 (doxepin); 356, 366, 368, 499, 522, 526, 763 (fluoxetine); 519 (fluvoxamine); 389, 520, 608 (imipramine); 505, 609 (nortriptyline); 22, 382, 452, 503, 513, 524, 568, 575, 694, 740, 768 (paroxetine); 452, 483, 508, 526, 614, 758 (sertraline); 23, 259, 372, 510, 539, 540, 546, 760, 763, 769 (trazodone); 827 (tricyclic antidepressant); 542, 697, 769 (venlafaxine). Antihistamines 35 yr 578p
Cetirizine A/C Ingestion Int suicide ethanol 109 mg/dL 579 28 yr Diphenhydramine A Ingestion Int suicide 580 29 yr Diphenhydramine A Ingestion Int suicide 7.8 µg/mL 54 yr Diphenhydramine U Ingestion Unknown 11 µg/mL§ 581p 582 55 yr Diphenhydramine A Ingestion Int suicide dimenhydrinate 40 yr Diphenhydramine A Ingestion Int suicide 9.1 µg/mL§ 583p doxylamine 6.7 µg/mL§ 584 20 yr Diphenhydramine A Ingestion Int misuse ethanol 585 57 yr Diphenhydramine A Ingestion Int suicide ethanol 586 28 yr Diphenhydramine A Ingestion Int suicide 12 µg/mL§ mouthwash (ethanol) 200 mg/dL 587 46 yr Diphenhydramine A/C Ingestion Int suicide phencyclidine marijuana 43 yr Doxylamine A Ingestion Int suicide 588p 54 yr Doxylamine A Ingestion Int suicide 589p See also cases 70, 139, 243, 367, 368, 408, 446, 447, 492, 510, 545, 676, 730, 746 (diphenhydramine); 582 (dimenhydrinate); 583 (doxylamine); 142, 372, 775 (hydroxyzine); 364 (loratadine). Antimicrobials 590 89 yr 35 yr 591p 592 15 yr 39 yr 593a
Fluconazole Hydroxychloroquine Isoniazid Isoniazid cocaine 16 yr Zidovudine/lamivudine 594a See also case 633 (clarithromycin). Antineoplastics 51 yr 595a 596 82 yr
Methotrexate Methotrexate
Asthma therapies 3 yr Theophylline (long-acting) 597a 598 40 yr Theophylline (long-acting) 599 52 yr Theophylline 600 58 yr Theophylline 601 63 yr Theophylline 602 68 yr Theophylline (long-acting) 603 80 yr Theophylline 604 83 yr Theophylline 605 90 yr Theophylline See also case 668 (theophylline).
A U A/C A/C
Ingestion Ingestion Ingestion Ingestion
Adv rxn Int suicide Int unk Int suicide
C
Ingestion
Adv rxn
C C
Ingestion Ingestion
Ther error Ther error
0.29 µmol/L 0.3 µmol/L
A U C A/C C A/C C C C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Int suicide Int misuse Ther error Ther error Int misuse Ther error Ther error Unknown
114 µg/mL 101 µg/mL 40 µg/mL 41 µg/mL 34 µg/mL 36 µg/mL 55 µg/mL 42 µg/mL 28 µg/mL
(Continued on following page)
27 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
543
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Cardiovascular drugs 606 71 yr Amiodarone 607 51 yr Amlodipine benazepril metformin 46 yr Amlodipine 608p imipramine 43 yr Amlodipine 609p nortriptyline alprazolam 610 50 yr Atenolol amlodipine zolpidem 611 62 yr Atenolol diltiazem 612 55 yr Atenolol nifedipine ethanol 613 82 yr Beta blocker calcium channel blocker 614 33 yr Captopril sertraline alprazolam 23 mo Clonidine 615a 616 28 yr Clonidine acetaminophen/hydrocodone methyldopa 617 55 yr Clonidine ethanol lisinopril 618 60’s yr Digoxin 61 yr Digoxin 619p 620 69 yr Digoxin 621 69 yr Digoxin 622 72 yr Digoxin 623 76 yr Digoxin 624 77 yr Digoxin 625 78 yr Digoxin 626 79 yr Digoxin 627 82 yr Digoxin 88 yr Digoxin 628p 629 88 yr Digoxin 630 92 yr Digoxin 631 92 yr Digoxin 632 76 yr Digoxin amiodarone 89 yr Digoxin 633p clarithromycin 634 79 yr Digoxin propafenone 635 60 yr Digoxin temazepam verapamil 636 51 yr Digoxin verapamil metoprolol 637 29 yr Diltiazem (long-acting) 43 yr Diltiazem 638a 639 44 yr Diltiazem (long-acting) 640 45 yr Diltiazem (long-acting) 641 47 yr Diltiazem (long-acting) 642 49 yr Diltiazem (long-acting) 643 89 yr Diltiazem (long-acting) 644 49 yr Diltiazem acetaminophen 645 49 yr Diltiazem amitriptyline
Chronicity
Route
Reason
Blood Concentrations
A/C A/C
Ingestion Ingestion
Int suicide Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int unk
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Ther error
A
Ingestion
Int misuse
A A
Ingestion Ingestion
Unint gen Int suicide
A/C
Ingestion
Int suicide
C A/C C C C C C C C A/C C C C C C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Ther error Unknown Ther error Ther error Ther error Ther error Unknown Ther error Ther error Int suicide Ther error Ther error Ther error Ther error Ther error
4.6 ng/mL 5.4 ng/mL 3 ng/mL 2.1 ng/mL 3.5 ng/mL
C
Ingestion
Ther error
5.5 ng/mL
A/C
Ingestion
Ther error
A/C
Ingestion
Int suicide
11 ng/mL
A/C
Ingestion
Int suicide
9.8 ng/mL
A/C A A A/C U A A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
238 mg/dL
46 ng/mL§
6.7 ng/mL 5.4 ng/mL 10 ng/mL 2.7 ng/mL 2.4 ng/mL 3.6 ng/mL 4 ng/mL 8.2 ng/mL 4.8 ng/mL
46 µg/mL§
163 µg/mL
(Continued on following page)
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
544
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
646p
43 yr
647
31 yr
648
41 yr
649
40 yr
650
29 yr
651
66 yr
652
76 yr
653
47 yr
654
26 yr
655
21 yr
656p 657p
45 yr 39 yr
658
29 yr
659ipm
21 yr
660 661
30 yr 49 yr
662ai 663 664
20 mo 43 yr 53 yr
665
40 yr
666
42 yr
667p
45 yr
668
52 yr
669a 670ap
80 yr 69 yr
671a 672 673 674
48 yr 49 yr 50 yr 45 yr
675
40 yr
676p
19 yr
677
46 yr
Substances Diltiazem (long-acting) atenolol Diltiazem atenolol clozapine Diltiazem digoxin Diltiazem (long acting) ethanol Diltiazem (long-acting) ibuprofen Diltiazem metformin glimepiride Diltiazem metoprolol Diltiazem phenobarbital ibuprofen Diltiazem propafenone valproic acid Diltiazem verapamil metoprolol Disopyramide Felodipine buspirone alprazolam Flecainide cocaine (crack) Flecainide ethanol Metoprolol Metoprolol clonidine Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) acetaminophen diazepam Nifedipine (long-acting) ethanol Nifedipine (long-acting) metoprolol (long-acting) cocaine Nifedipine (long acting) propranolol diazepam Nifedipine theophylline propoxyphene Nitroglycerin Procainamide ethanol Propafenone Propranolol Propranolol Propranolol amitriptyline thioridazine Propranolol amitriptyline topiramate Propranolol diphenhydramine Verapamil (long-acting)
Chronicity
Route
Reason
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
C
Ingestion
Ther error
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A/C
Ing/Inh
Int suicide
U
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A A/C A
Ingestion Ingestion Ingestion
Unint gen Int suicide Int suicide
Blood Concentrations
2.9 ng/mL
9.5 µg/mL§
0.8 µg/mL§ 9.49 µg/mL§ 51 µg/mL§
560 µg/mL§
263 µg/mL A
Ingestion
Int suicide
A/C
Ing/Unk
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
benzoylecgonine 380 ng/mL§
33 µg/mL A A/C
Dermal Ingestion
Ther error Int suicide
A/C A A/C A
Ingestion Ingestion Ingestion Ingestion
Ther error Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
(Continued on following page)
52 µg/mL 221 mg/dL 4.88 µg/mL
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
545
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 678 679 680 681
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
52 yr 60 yr 60 yr 45 yr
Verapamil (long-acting) A Ingestion Int suicide Verapamil (long-acting) A/C Ingestion Int suicide Verapamil (long-acting) A/C Ingestion Int suicide Verapamil A Ingestion Int suicide amitriptyline clonazepam 682 30 yr Verapamil (long-acting) A Ingestion Int suicide atenolol 683 24 yr Verapamil A/C Ingestion Int suicide atenolol ethanol 308 mg/dL 684 17 yr Verapamil A Ingestion Int suicide atenolol potassium chloride 685 48 yr Verapamil (long-acting) A/C Ingestion Int suicide carisoprodol 686 72 yr Verapamil A/C Ingestion Int suicide clonazepam risperidone A Ing/Unk Int suicide 687 46 yr Verapamil (long-acting) cocaine acetaminophen 688 39 yr Verapamil (long-acting) A Ingestion Int suicide enalapril 689 31 yr Verapamil A Ingestion Int suicide ibuprofen 690 20 yr Verapamil A Ingestion Int suicide lorazepam clonazepam 691 65 yr Verapamil A/C Ingestion Int suicide metoprolol 692 69 yr Verapamil (long-acting) A/C Ingestion Int suicide metoprolol risperidone A Ingestion Int suicide 693 29 yr Verapamil nadolol acetaminophen/isometheptene/ dichloralphenazone 694 40 yr Verapamil A/C Ingestion Int suicide propranolol paroxetine 67 yr Verapamil A/C Ingestion Ther error 695p quetiapine 696 45 yr Verapamil A Ingestion Int suicide simvastatin 62 yr Verapamil A Ingestion Int suicide 697p hydrochlorothiazide/triamterene venlafaxine See also cases 632 (amiodarone); 354, 455, 610 (amlodipine); 455, 646, 647, 682 thru 684 (atenolol); 607 (benazepril); 613 (calcium channel blocker); 661 (clonidine); 648 (digoxin); 504, 547, 611, 758 (diltiazem); 688 (enalapril); 255 (hydrochlorothiazide/lisinopril); 364, 697 (hydrochlorothiazide/triamterene); 381 (irbesartan); 617 (lisinopril); 616 (methyldopa); 636, 652, 655, 666, 691, 692 (metoprolol); 504 (mibefradil); 439, 693 (nadolol); 612 (nifedipine); 538 (procainamide); 634, 654 (propafenone); 453, 507, 667, 694, (propranolol); 487 (quinapril); 696 (simvastatin); 511, 635, 636, 655 (verapamil). Corticosteroids See also case 540 (prednisone). Cough and cold preparations 21 yr Benzonatate 698p 3 yr Codeine/guaifenesin 699p 2 yr Hydrocodone/guaifenesin 700aip 42 yr Phenylpropanolamine/guaifenesin 701p 23 yr Phenylpropanolamine (long-acting) 702a acetaminophen/diphenhydramine/ pseudoephedrine/dextromethorphan See also case 367 (pseudoephedrine/brompheniramine). Electrolytes and minerals 14 mo Iron 703a See also case 684 (potassium chloride).
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Malicious Ther error Int misuse Int suicide
A
Ingestion
Unint gen
(Continued on following page)
hydrocodone 80 ng/mL§ 0.95 µg/mL 14.8 µg/mL¥ pseudoephedrine 0.33 µg/mL
18,750 µg/dL
3h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
546
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Gastrointestinal preparations 73 yr Magnesium citrate 704a 6 yr Trimethobenzamide 705a See also case 503 (metoclopramide).
Reason
Blood Concentrations
Asp/Ing Other
Ther error Adv rxn
magnesium 6.6 mEq/L
Ingestion Parenteral Parenteral Parenteral Ing/Paren
Ther error Int suicide Int suicide Ther error Int suicide
Ingestion Ingestion Ingestion Ingestion
Unknown Ther error Int suicide Int unk
Ingestion
Int suicide
A/C A C
Ingestion Parenteral Ingestion
Int abuse Ther error Int abuse
U A A
Ingestion Ingestion Ingestion
Int unk Int abuse Int abuse
U
Ing/Inh
Int abuse
C
Ingestion
Int abuse
U
Ingestion
Int suicide
A A A
Ingestion Ingestion Ingestion
Int suicide Adv rxn Int suicide
A A
Hormones and hormone antagonists 706 47 yr Glipizide A 707 32 yr Insulin A 45 yr Insulin U 708ipm 709 78 yr Insulin A 710 19 yr Insulin A/C aspirin 711 36 yr Metformin C 712 80 yr Metformin C 713 80 yr Metformin A/C 714 52 yr Metformin A/C opiate benzodiazepine 38 yr Metformin A/C 715a sulfonylurea See also cases 651 (glimepiride); 363, 607, 651 (metformin); 715 (sulfonylurea). Miscellaneous drugs 29 yr 1,4-butanediol 716ap 4 yr Disodium edetate 717a 52 yr Gamma butyrolactone 718a ethanol 24 yr Gamma hydroxybutyrate 719p 42 yr Gamma hydroxybutyrate 720p 21 yr Gamma hydroxybutyrate 721p ethanol 33 yr Gamma hydroxybutyrate 722p nitrite (volatile) 723 26 yr Gamma hydroxybutyrate opioid benzodiazepine 36 yr Gamma hydroxybutyrate 724ipm unknown drug 38 yr Nicotine (transdermal patch) 725aip 726 62 yr Sildenafil 727 13 yr Throat spray (phenol, 1.4%) unknown liquid See also cases 21, 822 (gamma hydroxybutyrate); 518 (sibutramine).
Route
91 mg/dL
375 µg/mL§ 240 µg/mL§ 50 mg/dL§ 503 µg/mL§
106 µg/mL§
Muscle relaxants 44 yr 728p 52 yr 729p
Baclofen A/C Ingestion Int suicide Baclofen A/C Ingestion Int suicide methocarbamol acetaminophen 38 yr Carisoprodol A Ingestion Int suicide meprobamate 15.7 µg/mL 730p diphenhydramine 731 44 yr Carisoprodol A Ingestion Int suicide hydrocodone 21 yr Cyclobenzaprine A Ingestion Int suicide 732p 733 34 yr Cyclobenzaprine U Ingestion Int suicide 38 yr Cyclobenzaprine A Ingestion Int suicide 734p alprazolam 735 43 yr Cyclobenzaprine U Ingestion Int suicide lorazepam ibuprofen See also cases 17, 242, 269, 292, 294 thru 296, 388, 485, 509, 685, 817 (carisoprodol); 327, 445 (cyclobenzaprine); 435, 729 (methocarbamol). Narcotic Antagonists 30 yr Naltrexone 736ap 737 37 yr Naltrexone methadone cocaine
A A/C
Other Ingestion
Adv rxn Int abuse 1.5 µg/mL§ 0.1 µg/mL§
(Continued on following page)
Interval After Exposure
4h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
547
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Sedatives/hypnotics/antipsychotics 32 yr Alprazolam 738p 739 40 yr Alprazolam acetaminophen/hydrocodone 740p
46 yr
741ipm 742ipm 743p
45 yr 75 yr 39 yr
744p 745a 746
39 yr 73 yr 42 yr
747p 748 749
37 yr 40 yr 52 yr
750
46 yr
751 752ipm 753ipm
39 yr 52 yr 52 yr
754
73 yr
755 756
26 yr 41 yr
757
51 yr
758
34 yr
759p 760
51 yr 54 yr
761 762p 763
84 yr 32 yr 23 yr
764
66 yr
765p
32 yr
766p
40 yr
767p
40 yr
768p
17 yr
769
45 yr
770 771
25 yr 30 yr
Alprazolam paroxetine acetaminophen/hydrocodone Barbiturate Barbiturate Benzodiazepine opiate cocaine Chloral hydrate Chloral hydrate Chlordiazepoxide propoxyphene diphenhydramine Clonazepam Clonazepam Clonazepam ethanol Clozapine ethanol Diazepam Diazepam Diazepam alprazolam Diazepam zolpidem Glutethimide/codeine Haloperidol benztropine Lorazepam ethanol Loxapine diltiazem sertraline Mesoridazine Molindone trazodone amoxapine Nitrazepam Olanzapine Olanzapine trazodone fluoxetine Phenobarbital amitriptyline Phenobarbital primidone Phenobarbital valproic acid haloperidol Promethazine amitriptyline oxazepam Quetiapine paroxetine Quetiapine trazodone venlafaxine Risperidone Risperidone ammonia fabric spray (zinc chloride ⬍1%)
Chronicity
Route
Reason
Blood Concentrations
A/C A
Ingestion Ingestion
Int abuse Int suicide
A
Ingestion
Unknown
U U U
Unknown Unknown Ing/Unk
Int suicide Int suicide Unknown
Interval After Exposure
260 ng/mL§ 95 µg/mL¥ hydrocodone 650 ng/mL§
morphine 250 ng/mL§ monoacetyl morphine 540 ng/mL§ A A/C U
Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide
A A/C A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
A U A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int abuse Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U U
Ingestion Ingestion
Unknown Int suicide
U U U
Ingestion Ingestion Ingestion
Int suicide Int suicide Int unk
A/C
Ingestion
Int suicide
31 µg/mL
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
76 µg/mL§ 66 µg/mL§ 51 µg/mL 127 µg/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
11,250 ng/mL§ 2.828 µg/mL§ norpropoxyphene 5.55 µg/mL§ 0.7 µg/mL§
248 mg/dL
(Continued on following page)
36 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
548
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 772
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
42 yr
Interval After Exposure
Risperidone A/C Ingestion Int suicide clonazepam valproic acid 374 µg/mL 773 50 yr Secobarbital A Ingestion Int suicide 774 95 yr Temazepam A/C Ingestion Int unk codeine ethanol 775 49 yr Temazepam A/C Ingestion Int unk hydroxyzine 46 yr Triazolam A Ingestion Int suicide 776p See also cases 44, 291, 292, 303, 314, 316, 325, 369, 380, 399, 446, 609, 614, 657, 734, 753, 830, 867 (alprazolam); 16, 96, 241, 293, 384, 417 thru 420, 437, 500, 506, 544, 573, 714, 723, 779, 816, 846, 857 (benzodiazepine); 657 (buspirone); 22, 297, 421, 536 (chlordiazepoxide); 359 (chlorpromazine); 298, 488 thru 490, 501, 508, 567, 681, 686, 690, 772, 831 (clonazepam); 647 (clozapine); 15, 19, 296, 299, 360, 402, 408, 421, 444, 537, 664, 667 (diazepam); 821 (flunitrazepam); 253 (fluphenazine); 72 (flurazepam); 484, 766 (haloperidol); 304, 329, 449, 690, 735 (lorazepam); 386, 465, 466, 511, 519, 521 thru 523, 559, 561 (olanzapine); 767 (oxazepam); 653 (phenobarbital); 380, 402 (promethazine); 259, 695 (quetiapine); 539, 542, 686, 692 (risperidone); 440, 635 (temazepam); 555, 674 (thioridazine); 23, 360 (trifluoperazine); 274, 317, 325, 400, 411, 512, 547, 610, 754 (zolpidem). Stimulants and street drugs 25 yr Amphetamine 777p 778 37 yr Amphetamine 779 21 yr Amphetamine benzodiazepine ethanol 2 mo Cocaine 780aip 781 19 yr Cocaine 782 19 yr Cocaine 783 20 yr Cocaine 21 yr Cocaine 784p 21 yr Cocaine 785p 786 22 yr Cocaine 22 yr Cocaine (crack) 787p 788 24 yr Cocaine 24 yr Cocaine 789ipm 790 24 yr Cocaine
U C A
Unknown Unknown Ingestion
Int abuse Int abuse Int suicide
A C A A A A A A/C U U A
Inhalation Unknown Unknown Parenteral Ingestion Ingestion Unknown Ingestion Unknown Unknown Ingestion
Malicious Int abuse Int abuse Int abuse Int unk Int misuse Int abuse Int misuse Int abuse Int abuse Int misuse
103 mg/dL
791p 792 793 794 795
26 yr 28 yr 30 yr 30 yr 30 yr
Cocaine Cocaine Cocaine Cocaine Cocaine (crack)
A A A/C A A
Ingestion Inhalation Unknown Ingestion Ingestion
796 797 798p 799p 800p 801p 802ipm 803 804 805 806 807ipm 808 809p 810p 811ipm 812ipm 813ipm 814ipm 815ipm 816p
31 yr 33 yr 34 yr 34 yr 35 yr 35 yr 35 yr 36 yr 38 yr 39 yr 40 yr 40 yr 42 yr 42 yr 43 yr 45 yr 45 yr 45 yr 46 yr 47 yr 27 yr
A U A U A A U A A A/C C A C U A U A A U U A
Ingestion Parenteral Ingestion Parenteral Inhalation Inhalation Unknown Ingestion Ing/Paren Unknown Unknown Unknown Unknown Parenteral Other Unknown Unknown Unknown Unknown Unknown Ingestion
817p
27 yr
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine benzodiazepine marijuana Cocaine carisoprodol
5.9 µg/mL benzoylecgonine 14 µg/mL§ ecgonine methyl ester 5.1 µg/mL§ Int misuse Int abuse Unknown Int misuse Int misuse 0.55 µg/mL§ benzoylecgonine 11.7 µg/mL§ Int abuse Int abuse Int suicide Int abuse Int abuse Int suicide Int abuse Int misuse Int misuse ⬎1 µg/mL§ Int abuse Int abuse Int abuse Int abuse Int abuse Int misuse Int abuse Int abuse Int abuse Int suicide Int abuse Int abuse
A/C
Ing/Unk
Int abuse
(Continued on following page)
benzoylecgonine 1.3 µg/mL§
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
549
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
818p
20 yr
819p
24 yr
820
39 yr
821
18 yr
822p
30 yr
823
27 yr
824p
41 yr
825p
32 yr
826p
26 yr
827p
44 yr
828
36 yr
829p
27 yr
830
32 yr
831p
43 yr
832 833p 834a 835ipm 836p 837p 838p 839 840p 841p 842p 843p 844 845p 846
20 yr 20 yr 20 yr 24 yr 27 yr 28 yr 31 yr 32 yr 34 yr 36 yr 38 yr 44 yr 48 yr ⬎19 yr 44 yr
847p
17 yr
848p
27 yr
849p
30 yr
850
37 yr
851
37 yr
852p
40 yr
853p
40 yr
854p
⬎19 yr
Substances Cocaine ethanol Cocaine ethanol Cocaine ethanol Cocaine flunitrazepam Cocaine gamma hydroxybutyrate marijuana Cocaine hallucinogenic mushroom Cocaine heroin codeine Cocaine opiates Cocaine opiates ethanol Cocaine tricyclic antidepressants amphetamines Cocaine unknown pesticide Cocaine/heroin marijuana Diet drug (unknown type) alprazolam herbicide (unknown type) Dextroamphetamine propoxyphene clonazepam Heroin Heroin Heroin (body packer) Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin benzodiazepine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine ethanol
Chronicity
Route
Reason
U
Unknown
Int abuse
U
Ingestion
Int abuse
A/C
Unknown
Int abuse
A
Ingestion
Int abuse
A/C
Ing/Inh
Int abuse
A
Ing/Inh
Int abuse
A/C
Ing/Paren
Int abuse
A/C
Parenteral
Int abuse
U
Ung/Unk
Unknown
U
Ing/Unk
Int suicide
U
Unknown
Int unk
A
Inh/Paren
Int abuse
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C U U A/C U A A A/C A A A/C A/C A A/C
Ingestion Parenteral Ingestion Unknown Unknown Parenteral Parenteral Parenteral Parenteral Unknown Parenteral Inhalation Parenteral Parenteral Ing/Paren
Int misuse Int abuse Int misuse Int unk Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int suicide
A/C
Parenteral
Int abuse
A/C
Parenteral
Int abuse
A
Unknown
Int suicide
U
Unknown
Int unk
A
Parenteral
Int abuse
U
Parenteral
Int abuse
A/C
Parenteral
Int abuse
A
Ing/Inh
Int abuse
Blood Concentrations
benzoylecgonine 120 ng/mL§ cocaethylene 47 ng/mL§ 270 mg/dL
morphine 87 ng/mL§
morphine 80 ng/mL§ benzoylecgonine 0.03 µg/mL§
benzoylecgonine 0.45 µg/mL
(Continued on following page)
morphine 70 ng/mL§ 0.31 µg/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
550
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
Reason
Interval After Exposure
Blood Concentrations
⬎19 yr Heroin Ing/Inh Int abuse A cocaine ethanol 29 yr Heroin Ing/Paren Int abuse 856p A ethanol 59 mg/dL 46 yr Heroin Unknown Int suicide 857p A methadone benzodiazepine 858 19 yr Methamphetamine Ingestion Int abuse 5.99 µg/mL A 859 22 yr Methamphetamine Ingestion Int abuse A 860 35 yr Methamphetamine Ingestion Int abuse 1.7 µg/mL U 40 yr Methamphetamine Inhalation Int abuse 861p A 23 yr Methamphetamine Ingestion Int abuse 862p C ethanol 48 yr Methamphetamine Ingestion Int abuse 863p U ethanol 19 yr Methylenedioxymethamphetamine Ingestion Int abuse 864p A 19 yr Methylenedioxymethamphetamine Ingestion Int abuse 865p U 23 yr Methylenedioxymethamphetamine Ingestion Int abuse 866a A 22 yr Methylenedioxymethamphetamine Ingestion Int abuse 0.82 µg/mL 867a A ethanol alprazolam See also cases 350, 406, 419, 827 (amphetamine); 101 (amphetamine/dextroamphetamine); 18, 29, 30, 96, 299, 302, 326, 407, 491, 571, 574, 576, 593, 658, 666, 687, 737, 743, 847 thru 855 (cocaine); 254, 546, 576, 824 (heroin); 16, 162, 406, 587, 816, 822, 829 (marijuana); 389, 502, 505 (methamphetamine); 722 (nitrite, volatile); 587 (phencyclidine). 855p
Topical preparations 17 yr Cardiac glycoside (topical aphrodisiac) 868a Unknown substances 19 yr Unknown drug 869p 870 38 yr Unknown drug 39 yr Unknown drug 871ipm 872 ⬎19 yr Unknown drug trichlorocyanuric acid (0.1-1%) cleaner See also cases 275, 430, 724 (unknown drug); 727 (unknown liquid). Vitamins 34 yr Prenatal vitamins with iron 873p See also case 257 (vitamins with iron).
A
Ingestion
Int suicide
digoxin 4.2 ng/mL
A A U A
Ingestion Ingestion Ingestion Unknown
Unknown Int suicide Int suicide Int unknown
A
Ingestion
Int suicide
92 µg/dL
ABBREVIATIONS: C, chronic exposure; A, acute exposure; A/C, acute on chronic; U, unknown; Oc, ocular; Inh, inhalation; Ing, ingestion; Adv rxn, adverse reaction; Env, environmental; Int, intentional; Occ, occupational; Ther error, therapeutic error; Unint gen, unintentional general pPrehospital (cardiac and/or respiratory) arrest iReported to poison center indirectly (by coroner, medical examiner, or from other source) after the fatality occurred. §Concentration obtained postmortem ¥Acetaminophen concentration ¶Salicylate concentration #Concentration includes metabolite and parent compound aAbstract provided in Appendix mReported by medical examiner to poison center. No abstract or additional clinical or scenario data available. The term ‘‘long-acting’’ is used throughout for all sustained release, extended release, delayed release, or long-acting formulations.
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Adhesives/glues Cyanoacrylates Epoxy Toluene/xylene Non-toxic Unknown *Category totals
11,115 874 1,420 1,503 4,812 19,724
3,485 309 805 1,004 2,589 8,192
2,425 58 274 376 658 3,791
4,322 444 262 106 1,379 6,513
10,894 850 1,346 1,441 4,632 19,163
145 15 61 48 107 376
45 2 8 10 32 97
20 7 5 4 36 72
Alcohols Ethanol (beverage) Ethanol (other)
29,960 2,600
1,465 1,508
4,866 251
21,624 751
5,449 2,391
23,330 164
326 12
597 26
Int
(Continued on following page)
None
Minor
Moderate Major Death
2,624 249 258 64 854 4,049
1,373 184 322 245 1,036 3,160
2,354 188 351 84 870 3,847
593 73 44 10 171 891
7 1 1 0 9 18
0 0 0 0 3 3
20,055 357
3,209 750
8,780 361
4,660 55
1,149 5
89 0
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
551
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr)
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
Higher alcohols Isopropanol Methanol Rubbing alcohol Ethanol, with methyl salicylate Ethanol, without methyl salicylate Isopropanol, with methyl salicylate Isopropanol, without methyl salicylate Unknown rubbing alcohol Other Unknown *Category totals
211 11,422 976
90 7,247 227
33 1,067 136
74 2,751 542
197 10,227 839
9 1,068 110
2 73 12
3 17 1
62 2,058 470
72 3,490 252
41 2,193 246
14 330 73
2 82 35
0 1 6
38
31
3
4
36
1
1
0
4
9
9
0
0
0
369
257
28
81
350
18
0
0
50
109
64
7
1
0
309
234
21
51
286
21
1
1
59
117
66
8
2
0
7,674 15 57 651 54,282
5,220 10 23 99 16,411
584 1 3 100 7,093
1,724 1 26 391 28,020
6,917 14 51 264 27,021
682 1 3 368 25,775
54 0 0 4 485
8 0 3 6 662
1,222 3 16 335 24,691
2,490 7 17 72 10,594
1,278 1 7 129 13,175
156 0 1 89 5,393
28 1 1 25 1,331
0 0 0 1 97
1,741 1,737 2,057 2,259 194
1,149 1,563 1,718 2,012 79
266 132 183 168 54
289 37 140 70 50
1,694 1,708 2,035 2,242 188
32 20 13 12 5
5 4 0 1 1
8 4 8 4 0
148 32 77 42 36
351 307 311 307 53
180 51 95 36 26
28 3 6 3 6
2 0 0 0 0
0 0 0 0 0
448 3,354 15,753 2,551 2,753 9,207 376 42,430
187 1,624 9,570 1,764 2,198 7,083 278 29,225
48 1,384 5,439 544 326 1,344 72 9,960
185 267 602 203 199 672 22 2,736
442 3,235 15,279 2,408 2,689 9,037 371 41,328
4 62 403 112 48 123 3 837
2 44 38 21 8 8 2 134
0 3 25 2 7 34 0 95
66 148 378 183 68 302 8 1,488
109 368 2,794 819 528 1,574 60 7,581
73 282 551 268 110 430 15 2,117
10 15 36 16 4 47 0 174
0 0 1 0 0 1 0 4
0 0 0 0 0 0 0 0
Automotive/aircraft/boat products Ethylene glycol 5,427 Glycols: other 1,695 Glycol and methanol 99 Hydrocarbons 3,485 Methanol 1,396 Non-toxic 41 Other 2,240 Unknown 146 *Category totals 14,529
788 447 24 1,554 352 27 986 36 4,214
852 173 19 388 217 4 302 23 1,978
3,246 945 51 1,350 714 10 807 76 7,199
4,978 1,639 93 3,329 1,269 40 2,177 132 13,657
391 43 4 130 102 1 30 9 710
40 5 1 17 17 0 20 3 103
4 5 1 3 0 0 13 1 27
1,669 570 25 941 565 4 698 63 4,535
1,171 368 27 973 409 11 434 23 3,416
1,086 601 25 987 403 7 731 48 3,888
312 110 4 170 55 1 147 11 810
101 8 2 11 17 0 6 3 148
9 0 0 1 4 0 0 1 15
1,609
124
214
1,080
1,590
10
6
1
516
133
591
199
2
0
42 84 9 10 28 63 2 1,701 4,898 68 13 8,527
30 30 3 5 14 21 0 1,031 2,407 24 1 3,690
7 18 0 1 3 6 1 451 1,166 17 6 1,890
4 29 4 3 11 35 1 190 1,091 23 4 2,475
41 81 9 9 28 63 2 1,652 4,677 66 13 8,231
0 1 0 0 0 0 0 37 178 2 0 228
0 0 0 0 0 0 0 6 14 0 0 26
0 0 0 1 0 0 0 1 20 0 0 23
27 44 5 3 23 41 0 1,121 692 13 0 2,485
23 28 5 4 11 48 0 907 1,199 14 4 2,376
4 6 0 1 1 1 0 75 1,051 19 3 1,752
1 4 0 0 2 0 0 15 188 5 0 414
0 0 0 1 0 0 0 2 4 0 0 9
0 0 0 0 0 0 0 0 0 0 0 0
1,008 1,389 467
114 20 240
474 230 59
387 1,064 154
1,003 1,381 458
1 3 7
0 0 0
4 5 2
121 436 87
9 22 83
240 481 61
51 164 23
0 0 1
0 0 0
2,895 14,924
1,095 2,855
422 3,160
1,281 8,141
2,878 14,909
1 10
12 1
2 2
265 1,316
62 178
865 5,271
170 731
6 21
0 3
Arts/crafts/office supplies Artist paints, non-watercolor Chalk Clay Crayon Glazes Office supplies: miscellaneous Pencil Pens/ink Typewriter correction fluid Water color Other Unknown *Category totals
Batteries Automotive batteries Disc batteries Alkaline (MnO2) Lithium Mercuric oxide Nickel cadmium Silver oxide Zinc-air Other Unknown Dry cell batteries Other Unknown *Category totals Bites and envenomations Aquatic Coelenterate Fish Other/unknown Insects Ant/fire ant Bee/wasp/hornet
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
552
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr)
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
Caterpillar Centipede/millipede Mosquito Scorpion Tick Other Mammals Bat Cat Dog Fox Human Raccoon Rodents/lagomorphs Skunk Other Reptile: other/unknown Snakes Copperhead Coral Cottonmouth Crotalid: unknown Rattlesnake Exotic snakes Poisonous Non-poisonous Unknown if poisonous Nonpoisonous snake bite Unknown snake Spiders Black widow Brown recluse Other spider Tarantula Unknown insect or spider Other/unknown bite/ envenomation *Category totals
2,569 176 730 13,642 3,337 17,472
603 54 184 1,055 848 3,610
676 36 158 2,737 720 3,033
1,212 74 306 9,553 1,557 9,737
2,554 176 728 13,627 3,332 17,282
8 0 0 13 3 19
3 0 0 1 0 111
4 0 1 0 1 43
187 19 92 814 551 2,578
58 12 6 133 141 534
783 55 111 5,140 513 4,113
61 9 29 505 54 1,143
0 0 1 20 4 19
0 0 0 0 0 0
355 900 1,912 16 52 141 1,727 273 1,507 1,065
49 149 377 0 11 10 434 30 264 346
66 203 822 5 14 32 626 67 496 368
205 469 639 11 21 83 563 133 634 301
354 898 1,909 15 47 140 1,705 272 1,500 1,043
1 0 1 0 2 0 4 0 4 10
0 0 1 0 2 0 13 0 1 2
0 2 1 1 0 1 3 0 2 8
197 413 1,187 7 19 89 378 34 629 219
57 17 29 3 0 14 99 39 95 59
47 146 275 1 9 23 336 63 288 293
5 18 78 0 4 1 22 3 38 32
0 1 2 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
579 46 111 2 993
30 0 0 0 51
130 12 29 0 177
391 32 78 2 717
578 46 111 2 980
1 0 0 0 7
0 0 0 0 1
0 0 0 0 3
519 42 98 0 859
9 3 3 0 43
190 25 39 0 215
251 7 38 0 407
24 3 3 0 115
0 0 0 0 1
80 190 1 1,982 1,783
3 14 0 183 126
21 77 0 895 575
50 87 1 822 1,005
80 190 1 1,970 1,776
0 0 0 1 3
0 0 0 0 2
0 0 0 10 1
66 60 1 491 1,115
6 2 0 80 64
26 60 0 786 803
23 6 0 49 266
6 0 1 1 45
0 0 0 0 1
2,471 2,402 10,057 209 4,647
202 201 1,390 18 671
387 354 1,901 68 866
1,795 1,669 6,099 107 2,952
2,466 2,400 10,030 202 4,644
2 1 10 1 3
3 0 5 0 0
0 1 3 5 0
855 1,034 1,738 46 561
163 32 189 5 132
860 448 2,756 75 1,078
363 582 667 15 138
20 35 9 2 4
0 2 0 0 0
27 92,137
4 15,241
3 19,899
17 52,349
27 91,714
0 116
0 158
0 105
9 17,132
0 2,381
7 26,482
1 5,954
1 344
0 7
2,379 430
217 165
719 1,079
3,347 1,813
22 13
4 1
22 10
264 666
789 236
247 440
58 331
1 10
0 0
20 523 37 164 18 150 1,263 11 4,995
31 288 8 44 6 61 162 2 984
141 638 23 132 20 206 573 46 3,577
237 1,540 75 356 45 449 2,066 61 9,989
0 7 0 2 2 5 11 0 62
0 8 0 2 0 1 2 0 18
0 14 1 0 0 0 14 1 62
54 189 10 51 13 151 320 25 1,743
25 162 12 64 4 85 420 8 1,805
13 362 9 45 12 117 286 14 1,545
10 54 1 16 1 43 75 3 592
0 1 0 0 0 1 3 0 16
0 0 0 0 0 0 0 0 0
1,309
444
161
590
1,220
60
15
11
393
222
313
87
5
0
3,243 1,516 5,371 490 5,903 5,603 3,007 67 328 22
196 67 561 47 1,291 1,302 1,590 15 9 1
576 125 873 68 1,061 776 307 15 23 1
2,174 1,159 3,407 312 3,027 3,060 971 34 252 19
3,160 1,484 5,220 470 5,720 5,333 2,790 65 280 19
58 18 96 12 101 189 156 1 22 0
17 6 29 4 50 49 35 1 21 3
4 5 22 3 20 21 23 0 1 0
1,229 1,159 2,276 212 2,646 1,804 477 19 206 9
263 131 560 46 728 567 791 8 59 4
1,160 561 1,907 146 1,869 1,848 273 5 70 3
462 399 782 93 918 652 65 6 41 2
20 24 33 3 81 35 5 0 8 0
3 7 3 0 1 1 0 0 6 0
Building and construction products Caulking compounds and putties 3,395 Cement, concrete 1,837 Insulation Asbestos 237 Fiberglass 1,570 Urea/formaldehyde 76 Other 361 Unknown 47 Soldering flux 456 Other 2,096 Unknown 62 *Category totals 10,137 Chemicals Acetone Acids Hydrochloric Hydrofluoric Other Unknown Alkali Ammonia Borates/boric acid Chlorates Cyanide Dioxin
(Continued on following page)
Moderate Major Death
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
553
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Formaldehyde/formalin Glycol: ethylene Glycol: other Ketones Methylene chloride Nitrates and nitrites Phenol/creosote Strychnine Toluene diisocyanate Other Unknown *Category totals Cleaning substances (household) Ammonia cleaners (all purpose) Automatic dishwasher detergents Granules Liquids Rinse agents Other/unknown Bleaches Borate Hypochlorite Nonhypochlorite Other/unknown Carpet/upholstery cleaners Cleansers Anionic/nonionic Other/unknown Disinfectants Hypochlorite Phenol Pine oil Other/unknown Drain cleaners Acid Alkali Other/unknown Fabric softeners/antistatic agents Aerosol/spray Dry/powder Liquid Solid/sheet Other/unknown Glass cleaners Ammonia Anionic/nonionic Isopropanol Other/unknown Hand dishwashing Anionic/nonionic Other/unknown Laundry additives Bluing/brightening agent Detergent booster Enzyme/microbiological additive Water softener Other/unknown
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
1,555 854 1,729 954 769 1,176 1,526 50 829 20,038 2,973 59,312
173 134 661 243 115 307 282 27 121 6,509 1,454 15,549
344 121 331 86 108 441 189 5 105 3,133 464 9,313
889 546 610 542 467 353 895 15 520 8,705 894 29,441
1,437 637 1,614 913 734 1,058 1,483 38 814 18,412 2,817 55,718
86 178 71 23 31 79 17 2 6 660 46 1,912
15 12 18 9 3 24 4 9 1 374 61 760
11 3 19 8 1 12 15 1 5 481 39 705
576 441 516 428 335 292 537 19 215 5,586 415 19,790
230 193 340 170 108 229 197 21 107 3,779 455 9,208
408 157 477 290 265 224 432 2 186 4,006 309 14,911
139 95 81 114 94 84 158 3 58 1,207 86 5,626
7 75 13 13 1 3 7 1 2 94 5 435
1 16 1 1 0 1 0 0 0 2 0 43
3,064
1,341
282
1,291
2,914
106
27
11
527
608
754
181
6
0
5,947 3,307 1,069 1,071
5,143 2,761 993 865
241 145 21 55
505 358 46 128
5,901 3,292 1,064 1,064
19 7 5 4
25 4 0 2
0 3 0 1
250 224 56 84
2,572 1,179 300 376
984 684 148 196
59 51 9 19
2 1 0 3
0 0 0 0
418 50,696 783 155 5,012
197 19,784 364 72 3,768
41 5,751 78 12 305
163 22,379 289 57 838
402 48,256 748 152 4,896
12 1,742 25 3 41
2 476 4 0 18
2 154 6 0 56
61 8,946 111 31 431
84 7,641 134 33 1,287
85 14,958 216 47 921
21 2,478 30 14 90
1 60 0 0 3
0 0 0 0 0
3,646 1,038
2,583 598
288 118
690 283
3,536 995
81 27
13 8
13 7
441 197
1,015 235
617 233
97 35
2 3
0 0
9,080 3,713 8,414 2,647
5,574 2,490 5,558 1,485
865 381 774 339
2,348 721 1,853 708
8,856 3,558 7,848 2,504
145 111 449 88
41 30 69 28
33 11 29 23
1,538 479 1,611 523
2,308 805 2,507 626
2,284 936 1,795 676
442 83 201 107
21 8 21 2
1 0 3 0
1,143 4,204 552
97 652 90
97 399 46
826 2,730 351
1,100 3,951 527
33 217 20
8 20 3
2 10 2
431 1,330 127
106 569 82
365 1,279 152
233 579 55
9 46 2
2 3 0
60 4 1,142 328 39
35 4 950 280 29
5 0 58 20 1
18 0 120 27 9
53 4 1,108 321 39
4 0 24 4 0
2 0 5 0 0
1 0 5 3 0
4 0 104 13 6
14 1 376 87 11
10 1 149 15 7
0 0 10 3 2
0 0 1 0 0
0 0 0 0 0
1,776 166 6,957 3,288
1,386 94 5,525 2,527
140 12 639 343
219 53 700 369
1,712 164 6,690 3,133
47 2 194 119
11 0 55 28
3 0 8 4
142 38 567 293
521 38 1,898 890
304 42 1,324 645
31 13 70 36
1 0 4 3
0 0 0 0
7,931 1,028
5,306 577
670 101
1,771 321
7,645 952
93 22
96 25
94 27
477 56
1,272 129
1,741 199
80 8
2 0
0 0
63 182
38 116
12 16
12 43
60 179
3 2
0 0
0 1
5 23
22 41
9 51
1 4
0 0
0 0
109 99 2,073
75 18 1,662
5 10 148
22 59 230
108 87 2,001
0 0 17
0 9 16
0 3 36
15 11 148
36 41 573
20 20 324
5 2 29
0 0 2
0 0 0
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
554
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Laundry detergents Granules Liquids Soaps Other/unknown Laundry prewash/stain removers Dry solvent-based Liquid solvent-based Spray solvent-based Other/unknown solventbased Dry surfactant-based Liquid surfactant-based Spray surfactant-based Other/unknown surfactant-based Other/unknown Miscellaneous cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Phenol Other/unknown Oven cleaner Acid Alkali Detergent type Other/unknown Rust remover Alkali Anionic/nonionic Hydrofluoric acid Other acid Other/unknown Spot removers/dry cleaning agents Anionic/nonionic Glycol Carbon tetrachloride Perchloroethylene Other halogenated hydrocarbon Isopropanol Other nonhalogenated hydrocarbon Other/unknown Starch/fabric finishes/sizing Toilet bowl cleaner Acid Alkali Other/unknown Wall/floor/tile cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Other/unknown *Category totals
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
7,296 3,651 142 164
6,150 2,606 97 90
380 283 7 21
663 685 36 47
7,133 3,505 140 149
79 79 0 12
25 7 1 1
55 57 1 2
713 461 13 18
1,879 705 31 36
1,819 1,027 27 33
108 75 1 6
4 5 0 0
0 0 0 0
3 370 339
3 305 284
0 21 14
0 36 35
3 366 336
0 2 3
0 1 0
0 1 0
0 34 44
2 119 82
0 63 80
0 9 12
0 0 0
0 0 0
29 291 2,169 285
20 254 1,843 251
2 14 102 8
7 19 192 21
28 288 2,143 282
0 1 20 2
1 0 2 1
0 2 4 0
5 14 222 32
6 90 571 64
4 41 421 72
1 1 41 7
0 0 0 0
0 0 0 0
70 28
62 19
2 3
6 4
70 26
0 1
0 0
0 1
2 4
18 8
4 4
3 1
0 0
0 0
779 7,825 7,506 2,985 1,068 3,883 1,966 45 296 3,143
281 4,088 4,935 1,382 799 2,918 1,178 28 169 1,764
68 757 663 386 108 293 396 5 29 328
378 2,611 1,689 1,024 134 578 334 12 85 899
754 7,583 7,188 2,812 1,033 3,771 1,883 44 272 3,029
16 162 173 127 20 53 52 1 17 74
2 39 72 31 9 34 21 0 2 19
4 33 67 12 3 23 4 0 3 17
200 2,358 957 825 83 453 296 15 49 655
157 1,689 1,649 653 252 1,096 518 14 55 724
239 2,341 1,527 841 284 889 501 9 90 710
55 679 189 177 14 71 43 1 7 145
0 35 5 11 0 1 6 0 0 3
0 1 0 0 0 0 0 0 0 1
25 3,250 21 264
11 750 7 64
2 413 1 28
10 1,806 9 143
25 3,167 21 257
0 42 0 3
0 21 0 2
0 16 0 2
3 1,330 4 93
5 306 7 29
7 1,066 5 71
0 510 1 31
0 14 0 1
0 0 0 0
25 1 729 757 299
8 0 80 226 48
3 0 48 60 23
12 1 552 420 197
24 1 709 718 283
1 0 17 27 3
0 0 2 4 0
0 0 1 6 13
7 0 400 176 50
8 0 113 170 31
8 1 347 209 81
2 0 127 53 43
0 0 2 1 1
0 0 0 0 0
521 93 0 36
417 53 0 23
29 12 0 1
65 25 0 12
511 91 0 36
4 0 0 0
1 1 0 0
5 1 0 0
49 16 0 8
126 23 0 10
98 16 0 11
11 1 0 1
1 0 0 0
0 0 0 0
136 12
50 6
15 2
64 2
131 11
3 1
1 0
1 0
31 4
23 4
33 1
13 0
0 0
0 0
116 99 1,146
72 60 942
14 7 89
26 27 99
114 97 1,112
2 1 28
0 1 4
0 0 0
18 19 50
35 28 244
34 23 94
6 7 4
0 0 0
0 0 0
3,851 1,203 1,754
1,336 959 1,308
414 64 91
1,825 158 301
3,664 1,192 1,708
163 8 40
17 1 5
5 2 1
1,067 114 183
711 415 499
1,317 157 210
447 30 45
18 1 3
2 0 0
1,697 296 5,697 703 640 87 923 104 4 0 1,449 147 1,026 109 283 42 120,702 19,112
1,360 1,978 268 265 2 367 257 166 60,449
3,463 8,342 986 1,295 6 1,937 1,370 492 200,421
74 168 29 24 0 52 36 17 5,303
23 45 3 4 0 9 6 8 1,451
20 32 5 8 0 9 18 4 986
872 1,536 211 200 0 234 200 118 33,746
722 2,244 214 332 2 520 385 136 46,177
1,305 2,558 183 367 1 374 351 121 52,266
299 369 27 52 0 45 59 19 8,926
7 13 3 1 0 1 2 1 343
0 0 0 0 0 0 0 0 13
3,580 8,591 1,024 1,332 6 2,007 1,430 522 208,367
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
555
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Industrial cleaners Acids Alkali Anionic/nonionic Cationic Other/unknown *Category totals Cosmetics/personal care products Bath oil, bubble bath Creams, lotions, make-up Dental care products Denture cleaning Toothpaste with fluoride Toothpaste without fluoride Other Deodorants Depilatories Douches Eye products Hair care products Coloring agents Rinses, conditioners, relaxers Shampoos Sprays Other Lipsticks/balms, with camphor Lipsticks/balms, without camphor Mouthwash Ethanol Fluoride Non-ethanol Unknown Nail products Polish Polish removers: acetone Polish removers: other Polish removers: unknown Other Perfume, cologne, aftershave Peroxide Powders: talc Powders: without talc Soaps Suntan/sunscreen products *Category totals Deodorizers Air fresheners Diaper pail deodorizers Toilet bowl deodorizers Other Unknown *Category totals Dyes Fabric Food dye (eg, Easter egg) Leather Other
No. of Exposures
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
⬍6
6–19
⬎19
1,639 3,320 1,031 1,300 1,819 9,109
631 814 533 353 542 2,873
169 546 130 241 253 1,339
726 1,717 317 604 878 4,242
1,590 3,154 979 1,213 1,700 8,636
31 91 35 67 60 284
8 58 7 15 39 127
9 12 8 4 15 48
8,260 19,519
7,680 15,770
358 1,330
195 2,202
8,180 18,845
31 240
11 58
1,441 21,678
245 19,320
70 1,029
1,063 1,228
1,390 21,041
36 216
761 1,531 10,330 1,096 139 1,772
609 921 8,540 380 101 1,208
45 218 723 180 6 129
99 362 980 454 25 363
735 1,471 9,685 852 128 1,741
1,871
828
196
724
3,894 8,136 2,891 3,324
2,945 6,373 1,826 2,195
322 687 505 343
868
793
2,527
None
Minor
565 1,623 242 505 690 3,625
317 426 211 202 272 1,428
505 1,225 279 459 587 3,055
172 487 47 116 168 990
8 31 5 2 6 52
0 0 0 0 0 0
36 365
192 769
2,015 4,104
939 1,441
28 115
0 5
0 0
6 44
5 372
87 403
386 6,557
123 1,322
10 32
2 1
0 0
15 19 145 52 4 8
2 3 18 9 2 2
9 36 477 181 4 20
28 112 338 261 8 174
174 340 1,999 170 42 276
49 244 997 295 9 252
2 12 46 110 1 49
0 0 1 3 1 1
0 0 0 0 0 0
1,691
15
4
161
400
365
526
96
0
0
549 978 478 679
3,751 7,808 2,505 3,084
72 212 361 89
4 12 10 13
64 93 11 136
1,009 517 491 601
939 1,632 694 783
909 1,476 711 622
233 87 68 172
6 4 12 2
0 0 1 1
47
26
861
1
2
4
11
177
44
1
0
0
2,368
99
56
2,504
8
0
14
37
424
69
3
0
0
12,934 1,959 327 340
3,769 1,367 127 69
2,440 448 87 142
6,051 127 106 111
11,821 1,940 275 310
1,018 18 48 17
45 0 0 12
38 1 4 1
1,070 42 53 36
2,871 556 97 41
1,079 60 37 128
178 2 7 11
33 0 1 0
2 0 0 0
10,422 3,434 2,406
9,208 2,685 1,896
744 335 216
408 396 267
10,285 3,344 2,349
111 71 46
11 16 8
12 3 3
550 314 211
2,610 1,144 754
1,644 611 457
56 19 15
3 0 3
0 0 0
9,528 4,363
7,079 2,396
1,052 821
1,233 986
9,251 4,254
212 36
53 12
6 56
991 1,301
2,827 928
1,771 1,184
67 329
2 4
0 0
20,051 1,902 7,182 1,646 3,942 255 1,328 46 12,777 1,418 7,079 735 153,057 18,574
1,234 5,778 193 31 2,211 436 30,029
22,700 14,875 4,368 1,406 16,020 8,128 197,598
478 312 38 4 255 23 4,211
107 54 7 2 96 12 635
46 92 15 0 257 167 2,689
1,336 1,042 309 35 805 381 13,914
7,029 2,931 1,063 272 3,968 1,456 49,624
4,441 2,645 1,102 301 2,447 2,161 30,096
112 180 55 7 152 73 2,328
3 6 0 1 4 0 98
0 0 0 0 0 0 4
23,342 15,347 4,429 1,412 16,631 8,330 205,242
Unint
Int
Moderate Major Death
12,874 301 863 3,440 95 17,573
10,734 287 777 2,378 61 14,237
1,127 7 43 309 11 1,497
881 7 39 659 22 1,608
12,577 298 855 3,353 88 17,171
219 3 4 51 4 281
43 0 1 20 0 64
26 0 3 16 3 48
916 13 99 490 11 1,529
3,123 118 325 921 25 4,512
2,752 15 65 681 20 3,533
131 0 6 77 1 215
4 1 0 5 0 10
6 0 0 0 0 6
849 1,088 92 675
685 889 78 353
62 143 3 199
89 42 8 106
833 1,046 91 643
4 25 1 13
1 2 0 0
10 13 0 19
59 19 5 70
268 260 17 172
39 56 3 57
2 0 1 11
0 0 0 1
0 0 0 0
(Continued on following page)
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
556
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
Unknown *Category totals
74 2,778
51 2,056
4 411
14 259
64 2,677
0 43
2 5
8 50
8 161
14 731
3 158
2 16
0 1
0 0
Essential oils
4,099
2,772
435
779
3,893
102
19
84
548
958
1,166
78
9
1
4,412 3,921 162 493 2,162 11,150
2,788 2,612 77 273 1,462 7,212
565 449 11 71 255 1,351
923 761 66 134 386 2,270
4,364 3,864 155 479 2,125 10,987
22 19 2 8 11 62
17 16 2 2 6 43
4 19 3 4 18 48
133 198 35 26 185 577
1,080 1,006 40 129 513 2,768
157 207 21 30 165 580
7 34 9 4 27 81
1 1 0 0 0 2
0 0 0 0 0 0
3,477
307
1,087
1,742
3,200
70
194
2
857
506
1,067
225
6
0
74,980
21,351
12,224
36,924
70,556
548
866
2,908
6,092
7,652
10,668
2,247
79
0
558 4,619 943 1,112 4,017 33,090 5,764 2,038 279 2,483 19,239 7,830 23,685 180 105,837
460 4,283 694 901 3,338 29,815 4,740 765 242 2,147 9,093 5,351 14,346 93 76,268
28 234 84 87 584 2,030 355 269 11 129 5,071 2,170 6,077 38 17,167
53 89 147 106 83 1,039 569 858 23 181 3,971 254 2,733 38 10,144
548 4,596 898 1,104 3,963 32,876 5,619 1,923 275 2,462 19,087 7,716 22,668 144 103,879
7 9 30 5 44 152 38 23 4 9 106 74 413 11 925
2 8 6 1 5 42 102 82 0 5 35 25 388 14 715
1 5 8 1 0 11 2 4 0 5 7 12 193 5 254
45 121 67 68 1,284 849 163 253 21 63 1,098 364 2,158 33 6,587
91 770 210 251 1,100 5,189 939 314 74 474 3,702 1,379 4,182 55 18,730
45 1,209 74 69 336 200 152 193 26 97 268 1,111 2,696 23 6,499
7 19 11 4 45 8 19 18 1 7 10 30 200 4 383
1 0 13 1 4 3 1 0 0 0 3 3 12 0 41
0 0 1 0 0 0 0 0 0 0 0 0 0 0 1
496 17,006 3,542
43 2,180 107
167 2,852 292
242 10,137 2,817
462 16,614 3,405
20 330 125
10 15 5
4 7 5
109 5,843 851
65 1,954 139
94 4,662 1,292
45 1,444 582
4 164 6
1 35 0
Fertilizers Household plant food Outdoor fertilizers Plant hormones Other Unknown *Category totals Fire extinguishers Food products/food poisoning Foreign bodies/toys/ miscellaneous Ashes Bubble blowing solutions Charcoal Christmas ornaments Coins Desiccants Feces/urine Glass Incense, punk Soil Thermometer Toys Other Unknown *Category totals Fumes/gases/vapors Carbon dioxide Carbon monoxide Chloramine Chlorine: acid mixed with hypochlorite Chlorine: other Methane and natural gas Hydrogen sulfide Propane/simple asphyxiants Other Unknown *Category totals
509 6,610 4,841 1,580
13 529 852 167
77 1,272 780 185
363 4,157 2,497 978
498 6,449 4,790 1,570
10 99 40 2
1 24 3 3
0 30 3 2
188 2,020 1,129 442
17 317 881 157
191 2,641 1,124 430
114 1,275 228 140
1 23 20 19
1 1 0 2
2,777 2,433 1,393 41,187
276 283 109 4,559
580 347 195 6,747
1,651 1,413 801 25,056
2,565 2,328 1,354 40,035
196 45 10 877
5 36 16 118
1 20 5 77
860 814 366 12,622
334 277 133 4,274
812 562 362 12,170
279 220 119 4,446
9 12 3 261
2 3 0 45
Fungicides Carbamate fungicide Mercurial fungicide Non-mercurial fungicide Phthalimide fungicide Other/unknown *Category totals
257 11 301 198 287 1,054
69 8 55 101 106 339
22 0 32 36 33 123
94 2 185 51 120 452
215 11 292 194 282 994
40 0 5 1 2 48
1 0 1 2 1 5
1 0 3 0 2 6
75 3 103 26 42 249
86 3 51 55 58 253
39 1 81 15 59 195
15 1 16 6 5 43
0 0 2 0 1 3
0 0 0 0 0 0
978
445
114
353
941
8
18
5
125
131
103
23
3
0
1,003 26 85 1,169 14 5
135 1 8 215 10 3
66 1 6 378 2 0
686 17 56 481 2 1
705 19 76 1,105 14 5
47 0 0 40 0 0
155 0 1 11 0 0
6 7 0 11 0 0
540 10 45 333 2 1
145 3 6 188 3 0
72 1 9 328 4 2
76 2 9 81 0 0
14 0 1 2 0 0
2 0 0 0 0 0
Heavy metals Aluminum Arsenic (excluding pesticides) Barium Cadmium Copper Fireplace flame colors Gold
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
557
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Lead Manganese Mercury Metal fume fever Selenium Thallium Other Unknown *Category totals Herbicides Carbamate herbicide 2,4-D or 2,4,5-T Diquat Paraquat Paraquat/diquat Triazine herbicide Urea herbicide Other Unknown *Category totals Hydrocarbons Benzene Carbon tetrachloride Diesel fuel Fluorochlorocarbons/ propellants Gasoline Halogenated hydrocarbon: other Kerosene Lighter fluid/naphtha Lubricating oils/motor oil Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other Unknown *Category totals
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
3,317 57 3,861 1,045 151 40 890 19 12,660
1,535 11 957 19 67 10 271 5 3,692
539 5 1,137 61 6 4 157 2 2,478
1,059 34 1,372 886 75 25 393 12 5,452
3,172 54 3,497 1,039 132 28 811 15 11,613
60 1 254 4 6 2 24 0 446
39 1 35 0 1 5 16 3 285
8 1 36 2 11 2 36 0 125
1,253 23 789 289 32 18 302 9 3,771
663 9 1,123 25 41 7 142 3 2,489
138 6 111 302 19 3 135 0 1,233
89 4 52 153 5 0 48 2 544
13 0 6 4 0 2 1 0 46
1 0 1 0 0 0 0 0 4
76 2,293 374 114 1 396 80 5,594 263 9,191
11 703 85 7 0 74 24 1,624 71 2,599
17 246 32 7 0 44 9 484 21 860
44 1,145 235 93 1 220 42 2,984 134 4,898
76 2,229 362 102 1 381 76 5,276 250 8,753
0 15 3 6 0 6 0 47 0 77
0 5 1 2 0 2 2 33 4 49
0 42 8 2 0 6 2 228 8 296
50 511 94 71 0 127 18 1,256 75 2,202
33 453 104 16 0 65 10 1,422 33 2,136
20 469 87 22 1 65 18 1,233 39 1,954
2 97 16 5 0 23 3 143 13 302
0 4 2 4 0 1 0 9 0 20
0 0 0 1 0 0 0 3 0 4
120 44 921
12 4 171
5 4 101
88 29 583
116 40 898
0 2 18
4 1 4
0 0 0
57 20 228
19 8 118
21 10 280
18 3 43
2 0 2
0 0 0
7,134 20,720
598 6,320
974 3,872
4,702 9,253
6,838 19,495
248 1,112
34 75
10 10
1,417 3,089
1,220 3,580
1,622 8,290
449 645
14 24
3 1
794 2,677 4,011 3,984 188 4,755 2,366 954 6,600 7,504 62,772
179 1,450 2,075 2,643 164 2,082 474 313 3,228 4,755 24,468
92 346 487 373 7 665 313 152 726 596 8,713
421 765 1,297 833 14 1,788 1,396 428 2,236 1,843 25,676
754 2,533 3,755 3,882 184 4,497 2,181 825 6,329 7,288 59,615
23 92 163 63 1 175 161 113 188 128 2,487
7 42 69 34 1 52 13 9 38 55 438
9 5 13 2 2 20 5 6 35 24 141
340 835 1,223 601 25 1,093 1,055 273 1,657 2,097 14,010
115 610 1,015 1,429 97 1,114 316 190 1,688 2,076 13,595
262 777 1,168 668 17 1,305 776 241 1,400 1,920 18,757
95 175 225 84 0 208 240 46 375 504 3,110
7 9 16 1 0 14 33 2 28 39 191
0 0 1 0 0 0 0 0 4 0 9
22 158 336
60 322 1,321
322 2,912 3,094
11 45 84
1 4 23
0 6 26
41 250 657
142 796 717
17 118 474
5 10 140
0 2 9
0 0 0
101
503
915
25
11
12
166
149
191
31
1
0
429
968
2,317
100
4
104
818
745
489
87
11
2
8 16 1
81 69 3
138 241 7
2 6 0
0 0 0
0 0 0
20 45 1
16 97 2
29 20 1
7 1 0
0 0 0
0 0 0
929 61
6,003 254
10,725 508
258 10
40 8
140 4
2,943 70
2,350 125
1,972 78
567 16
72 0
5 0
13 152
100 779
167 1,348
7 28
1 7
1 13
46 279
27 291
31 359
9 71
2 9
0 0
7 28
28 71
50 180
0 5
0 1
1 4
11 35
9 31
14 49
2 9
0 0
0 0
1,158 1,094
3,120 3,996
6,742 7,890
202 216
46 47
296 310
1,498 1,863
1,313 1,414
1,535 2,009
434 471
13 23
0 1
Insecticides/pesticides (excluding rodenticides) Arsenic pesticides 335 249 Borates/boric acid 2,971 2,445 Carbamate only 3,231 1,377 Carbamate with other pesticide 963 309 Chlorinated hydrocarbon only 2,528 988 Chlorinated hydrocarbon with other pesticide 140 38 Metaldehyde 248 156 Nicotine 7 3 Organophosphate Alone 11,193 3,420 With carbamate 530 199 With chlorinated hydrocarbon 176 50 With other pesticide 1,398 378 With carbamate and chlorinated hydrocarbon 51 9 Piperonyl butoxide only 191 79 Piperonyl butoxide/ pyrethrin 7,293 2,608 Pyrethrins only 8,475 2,814
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
558
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
6,498 103 4,378 4,374 3,564 58,647
4,446 41 2,119 2,917 964 25,609
1,092 13 614 276 415 6,923
804 44 1,450 999 1,863 22,838
6,156 98 4,218 4,266 3,284 55,578
50 1 80 39 94 1,263
47 0 12 11 90 353
241 3 68 55 73 1,357
637 18 490 482 922 11,292
1,412 29 1,027 1,094 505 12,291
1,532 24 734 419 552 10,647
106 1 92 68 168 2,295
6 0 9 6 13 176
0 0 0 0 3 11
Lacrimators Capsicum/peppers Lacrimators: CN Lacrimators: CS Other Unknown *Category totals
156 2,432 137 99 324 3,148
63 580 57 12 52 764
67 741 44 18 125 995
20 874 32 69 94 1,089
138 2,013 119 95 189 2,554
3 71 0 1 42 117
12 305 18 1 90 426
2 12 0 2 0 16
30 436 22 21 104 613
2 90 10 6 6 114
92 1,208 86 36 199 1,621
4 110 3 6 10 133
0 0 1 0 0 1
0 0 0 0 0 0
Matches/fireworks/explosives Explosives Fireworks Matches Other Unknown *Category totals
279 482 1,478 55 4 2,298
144 392 1,334 28 1 1,899
72 63 60 12 0 207
48 20 62 14 3 147
250 469 1,458 54 4 2,235
17 4 16 1 0 38
11 9 1 0 0 21
0 0 2 0 0 2
65 42 56 16 1 180
80 164 390 21 1 656
48 63 22 9 1 143
12 9 4 4 0 29
0 0 0 1 0 1
0 0 0 0 0 0
Moth repellants Naphthalene Paradichlorobenzene Other Unknown *Category totals
1,767 38 83 2,703 4,591
1,341 21 61 1,839 3,262
100 6 4 221 331
269 10 15 518 812
1,744 35 82 2,621 4,482
19 2 0 41 62
2 0 1 28 31
2 1 0 10 13
404 3 11 491 909
741 7 22 936 1,706
120 3 8 241 372
22 0 1 40 63
4 0 0 1 5
0 0 0 0 0
Mushrooms Coprine Cyclopeptide Gastrointestinal irritants Hallucinogenic Ibotenic acid Miscellaneous, nontoxic Monomethylhydrazine Muscarine Orellanine Other potentially toxic Unknown *Category totals
20 41 181 782 37 181 36 9 3 7 7,699 8,996
5 13 74 42 8 85 3 0 1 7 5,738 5,976
4 7 40 452 12 25 2 3 0 0 1,009 1,554
10 20 61 250 16 64 27 6 2 0 846 1,302
15 38 150 134 26 161 29 4 1 7 7,080 7,645
4 1 20 633 11 1 2 5 1 0 534 1,212
1 0 0 10 0 0 0 0 0 0 10 21
0 2 11 1 0 19 5 0 1 0 63 102
12 25 75 542 27 39 15 7 2 0 2,186 2,930
7 11 68 56 8 51 3 0 1 4 4,449 4,658
4 8 55 152 7 31 12 2 0 0 721 992
1 4 28 258 14 10 6 1 1 0 253 576
0 2 0 20 2 0 0 0 1 0 31 56
0 4 1 1 0 0 0 0 0 0 0 6
9 93 4,166 4,337 1,036
0 22 1,232 3,126 416
0 12 819 265 95
8 50 1,867 755 440
9 91 3,908 4,288 1,012
0 1 206 18 6
0 0 19 9 6
0 1 27 20 10
2 30 937 298 200
1 9 658 864 168
2 24 1,161 313 243
1 10 244 142 39
0 0 14 0 2
0 0 0 0 0
Repellants (insect) Rotenone Veterinary insecticide Other Unknown *Category totals
Moderate Major Death
Paints and stripping agents Paints Anti-algae Anticorrosion Oil-base Water-base Stains Stripping agents Methylene chloride Other Unknown Varnishes, lacquers Wood preservatives Other paint/varnish/lacquer Unknown paint/varnish/ lacquer *Category totals
1,183 758 315 965 588 1,348
181 155 94 294 141 653
123 66 36 101 66 121
766 457 163 491 333 494
1,143 732 302 937 576 1,322
29 13 3 19 5 17
1 3 3 6 2 3
9 8 6 3 5 6
442 262 102 205 151 262
85 69 52 117 104 203
511 250 98 228 123 240
107 93 21 52 27 64
5 0 1 4 0 5
0 1 0 0 0 0
10,703 25,501
6,654 12,968
1,025 2,729
2,578 8,402
10,426 24,746
177 494
36 88
57 152
1,261 4,152
1,853 4,183
1,104 4,297
223 1,023
15 46
0 1
Photographic products Developers/fixing/stop baths Photographic coating fluids Other Unknown *Category totals
577 5 416 25 1,023
83 3 204 4 294
226 0 60 5 291
218 2 132 10 362
562 5 410 25 1,002
1 0 4 0 5
8 0 2 0 10
6 0 0 0 6
191 0 75 3 269
77 1 76 5 159
220 1 91 9 321
27 0 15 0 42
0 0 0 0 0
0 0 0 0 0
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
559
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
No. of Exposures
Plants Amygdalin/cyanogenic glycosides Anticholinergic Cardiac glycosides Colchicine Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine Non-toxic plant Oxalate Solanine Stimulants Toxalbumins Other Unknown *Category totals
3,519 988 2,498 24 71 25,774 19,488 366 254 19,132 13,025 1,856 397 245 3,734 22,493 113,864
Polishes and waxes Radioisotopes Rodenticides ANTU Anticoagulant: standard Anticoagulant: long-acting Barium carbonate Cyanide Monofluoroacetate Strychnine Vacor Other Unknown *Category totals Sporting equipment Fishing bait Fishing products, other Golf balls Gun bluing Hunting products, other Other Unknown *Category totals
⬍6
6–19
2,518 593 285 475 1,784 365 17 7 29 11 11,007 5,144 15,695 1,750 158 72 105 49 15,873 1,827 11,464 934 1,466 144 225 62 115 40 2,711 432 15,835 3,072 79,287 14,977
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
353 210 318 0 27 8,136 1,801 121 82 1,209 533 203 92 77 501 3,101 16,764
3,400 504 2,389 24 54 23,521 18,949 242 236 18,653 12,876 1,805 342 224 3,534 21,624 108,377
53 452 84 0 10 405 292 76 9 166 98 20 37 10 70 416 2,198
2 6 3 0 0 714 32 3 3 11 5 3 1 7 9 56 855
64 20 19 0 7 1,079 200 43 4 292 38 25 16 4 113 371 2,295
145 537 348 0 17 2,196 1,041 128 81 529 405 183 111 110 328 1,458 7,617
919 171 981 6 21 3,051 5,816 101 50 3,292 4,493 693 144 86 1,049 6,060 26,933
101 120 134 0 9 7,360 1,336 50 71 741 1,634 115 42 49 388 1,603 13,753
19 325 28 0 4 742 144 50 21 91 67 12 19 13 54 248 1,837
3 34 3 0 0 25 8 4 2 4 3 0 1 1 6 12 106
0 2 0 0 0 0 0 0 0 0 0 0 1 0 1 0 4
7,152
5,529
515
948
6,969
140
23
16
815
2,618
1,122
126
5
0
235
22
33
152
220
4
0
7
64
26
8
6
0
0
1 1,916 15,862 0 2 12 171 4 839 1,399 20,206
0 1,660 14,232 0 2 0 24 2 565 1,013 17,498
1 69 536 0 0 2 28 2 52 82 772
0 161 963 0 0 10 97 0 193 248 1,672
0 1,838 15,303 0 2 10 83 2 781 1,229 19,248
1 64 461 0 0 1 50 0 44 109 730
0 12 67 0 0 1 31 2 10 45 168
0 0 10 0 0 0 1 0 1 5 17
0 579 5,301 0 1 7 96 2 224 632 6,842
1 671 6,311 0 0 1 27 1 268 493 7,773
0 27 173 0 0 5 9 0 63 40 317
0 10 60 0 0 2 14 2 15 14 117
0 3 30 0 0 0 8 0 6 8 55
0 0 2 0 0 0 0 0 2 0 4
61 27 59 36 406 259 7 855
50 20 2 13 223 170 5 483
8 7 43 2 85 47 1 193
1 0 14 20 81 38 1 155
58 27 52 34 371 248 7 797
1 0 7 1 14 6 0 29
1 0 0 0 16 4 0 21
1 0 0 0 1 1 0 3
1 2 11 11 126 49 1 201
12 4 10 8 149 89 2 274
9 3 24 11 31 23 1 102
1 0 4 3 8 6 0 22
0 0 0 0 1 0 0 1
0 0 0 0 0 0 0 0
Swimming pool/aquarium
7,354
3,365
1,279
2,437
7,171
89
14
75
1,185
1,405
2,100
489
11
0
Tobacco products Other/unknown nondrug substances
7,884
6,947
332
549
7,618
156
43
62
1,446
2,912
1,876
105
4
0
15,590
5,921
2,435
5,932
13,310
530 1,024
387
3,558
2,541
2,354
682
90
1
1,347,898 703,833 180,592 405,851 1,268,801 52,847 9,893
14,023
218,476 264,603 251,139
51,333
4,024
279
Total number of nonpharmaceutical substances % of nonpharmaceutical substances % of all substances
56.9%
52.2% 29.7%
13.4% 7.6%
30.1% 17.1%
94.1% 53.6%
3.9% 2.2%
0.7% 0.4%
1.0% 0.6%
16.2% 9.2%
19.6% 11.2%
18.6% 10.6%
3.8% 2.2%
0.3% 0.0% 0.2% 0.0%
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
560
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals
Age (yr) Substances Implicated In the Exposure Analgesics Acetaminophen only Adult formulations Pediatric formulations Unknown formulations Acetaminophen in combination with: Aspirin (with other ingredients) Aspirin (no other ingredients) Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Aspirin alone Adult formulations Pediatric formulations Unknown formulations Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Narcotics Codeine Meperidine Methadone Morphine Oxycodone Pentazocine Propoxyphene Other/unknown Nonaspirin salicylates Other nonsteroidal antiinflammatory drugs Colchicine Ibuprofen Indomethacin Other Unknown Phenacetin Phenazopyridine Salicylamide Other Unknown *Category totals Anesthetics Inhalation anesthetics Nitrous oxide Other Unknown Ketamine and analogs Local and topical anesthetics
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
25,978 26,151 8,963
6,412 23,324 2,572
9,084 2,508 2,852
9,657 273 3,222
13,257 12,346 25,694 343 4,342 4,433
5,423
2,016
1,476
1,756
3,096
12 5,741 3,553 5,120 11,626
5 1,090 434 594 1,212
3 1,150 446 629 1,721
4 3,214 2,385 3,611 7,987
15,213
2,222
3,760
322
224
4,022 482 9,350
Int
None
Minor
Moderate Major Death
15 10 6
272 92 98
14,610 3,075 5,237
8,258 7,141 2,413
3,531 398 1,390
1,451 63 662
457 22 261
38 0 47
2,061
1
246
2,432
1,649
968
248
22
4
7 2,505 1,460 1,824 4,465
4 2,755 1,745 3,024 6,175
0 4 3 0 7
1 444 317 223 874
4 3,084 1,836 3,295 6,409
3 1,364 678 1,162 2,211
2 1,349 850 1,338 2,741
1 439 265 519 979
0 98 81 193 320
0 3 15 18 40
8,528
5,383
9,323
10
406
9,701
3,523
3,842
1,604
312
12
60
34
289
25
0
8
44
74
54
8
2
0
1,545 385 1,938
1,184 73 3,355
1,206 21 3,699
2,280 444 3,512
1,632 34 5,560
9 0 6
90 4 205
1,902 90 6,231
1,202 194 2,490
619 25 1,949
317 7 1276
38 0 213
7 0 38
353 234 41 33
49 29 7 10
37 30 5 7
244 161 27 13
126 98 21 23
209 120 17 9
0 0 0 0
16 15 3 1
228 123 22 17
67 43 8 9
94 45 11 7
36 27 3 1
18 5 2 1
1 2 0 1
1,785
377
371
949
823
852
1
96
956
403
382
180
30
2
3
1
1
1
3
0
0
0
1
1
0
0
0
0
1,258 600 1,047 1,218 1,632 204 560 3,267 1,065
497 59 79 146 187 15 53 468 536
273 74 108 125 111 17 47 431 143
437 415 792 843 1,201 156 416 2,141 359
873 253 342 562 792 77 193 1,377 792
290 259 580 529 652 87 325 1,404 231
2 0 4 8 2 0 0 4 0
89 82 84 100 163 38 35 435 41
369 316 705 706 804 95 361 1,690 377
311 96 87 189 268 25 99 503 342
210 134 190 245 324 57 113 702 146
50 72 204 169 181 14 83 419 63
16 25 117 61 71 7 33 159 5
3 2 17 10 12 0 12 44 0
146 54,643 682 18,181 8 2 913 75 4,058 102 214,066
45 33,886 203 5,300 3 1 693 67 771 16 87,471
22 10,376 82 3,716 0 0 77 1 466 37 44,858
78 9,356 357 8,322 4 1 133 7 2,553 39 74,602
94 32 41,986 11,678 392 209 10,809 5,910 6 1 2 0 819 47 70 3 2,069 1,419 30 63 131,190 74,386
0 21 0 10 0 0 0 0 1 1 125
19 854 77 1,381 1 0 47 2 545 6 7,410
82 13,013 284 6,710 2 0 221 23 1,792 61 86,908
43 17,073 180 5,174 1 0 396 35 751 22 58,488
17 4,149 120 2,532 1 0 96 3 1,102 18 29,754
17 854 30 738 0 0 14 0 377 5 11,376
6 105 4 115 0 0 1 0 89 0 2,889
6 3 0 3 0 0 0 0 0 0 340
232 199 2 294
16 18 0 12
105 25 0 113
96 138 0 156
108 160 0 52
85 23 0 227
2 3 0 5
35 12 2 4
114 87 2 247
23 15 0 24
46 57 0 67
32 28 1 88
12 3 0 24
2 1 0 0
6,966
4,731
652
1,390
6,421
164
35
335
1,184
2,531
821
144
31
0
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
561
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
⬎19
Unint
None
Minor
Other Unknown *Category totals
41 6 7,740
8 2 4,787
7 3 905
22 1 1,803
24 3 6,768
6 1 506
0 1 46
10 1 399
27 3 1,664
5 0 2,598
9 3 1,003
6 1 300
2 0 72
0 0 3
Anticholinergic drugs
4,689
1,576
630
2,308
2,868
1,462
11
299
2,384
1,227
869
600
132
4
95
19
11
52
83
5
0
7
50
22
8
9
5
1
1,699 439 6 2,239
666 129 3 817
84 23 0 118
883 269 2 1,206
1,336 371 4 1,794
263 35 2 305
6 0 0 6
82 33 0 122
725 140 5 920
511 153 2 688
69 26 0 103
105 10 1 125
84 5 0 94
1 0 0 2
6,132 4,045 98 8,743 4,378 14 23,410
1,741 786 48 1,027 544 8 4,154
1,305 345 29 2,202 727 1 4,609
2,864 2,720 20 5,100 2,847 4 13,555
3,812 2,310 91 3,672 2,115 10 12,010
1,958 1,319 6 4,691 1,928 4 9,906
5 3 0 1 4 0 13
277 337 1 297 311 0 1,223
3,768 2,575 22 5,762 2,472 9 14,608
1,338 910 41 2,391 1,075 3 5,758
1,614 955 9 2,095 968 1 5,642
927 559 1 1,012 472 1 2,972
285 115 0 336 140 0 876
0 1 0 8 5 0 14
7,787 48 334 1,854 1,704 37 1,332 21
969 4 44 134 437 6 163 9
980 8 57 156 551 6 206 4
5,456 35 219 1,463 668 24 894 7
2,410 16 133 490 966 16 536 15
5,048 30 180 1,288 659 20 728 5
6 1 0 5 1 0 0 0
192 1 19 50 68 1 57 1
6,157 35 240 1,494 1,036 26 935 15
1,241 4 79 274 518 5 291 8
1,794 10 61 434 346 5 298 6
1,727 7 66 423 227 8 203 2
1,021 10 23 243 95 7 108 0
62 0 2 18 8 0 9 0
751
74
87
545
376
325
3
43
434
169
198
110
48
1
15
0
0
12
2
12
0
1
11
0
1
4
4
1
70
10
6
50
25
41
0
2
44
12
14
11
7
1
198 4,361 372 28,563 10,501 12,088 24 70,060
30 277 46 4,743 767 1,806 0 9,519
18 734 8 7,030 1,590 2,364 5 13,810
146 3,145 288 15,278 7,480 7,258 15 42,983
80 1,567 215 10,568 2,916 4,757 4 25,092
106 2,264 102 16,335 7,077 6,634 20 40,874
0 8 0 23 8 4 0 59
7 428 52 1,485 442 634 0 3,483
148 3,381 227 18,023 7,552 8,203 17 47,978
33 941 69 8,561 2,307 3,275 1 17,788
32 1,020 52 6,296 3,292 2,719 7 16,585
47 898 87 2,518 1,284 1,709 1 9,332
20 253 21 473 218 551 2 3,104
0 6 0 22 9 14 0 153
17,632 332
9,245 105
2,902 71
5,070 143
12,492 194
4,724 127
9 0
357 10
6,264 167
4,716 87
3,327 61
1,401 41
175 9
6 0
5,936 5,721 22,497 52,118
2,092 3,429 10,110 24,981
1,240 655 5,590 10,458
2,400 1,484 6,197 15,294
3,353 4,854 16,805 37,698
2,347 654 4,825 12,677
4 1 19 33
195 196 770 1,528
2,741 1,152 7,457 17,781
1,309 1,834 6,984 14,930
1,239 426 3,193 8,246
702 88 1,198 3,430
105 9 156 454
14 0 8 28
36,763 7,314 879
20,232 5,460 286
5,848 497 207
9,529 1,168 341
28,951 7,109 488
3,584 67 226
22 1 0
4,107 133 161
6,073 203 282
8,166 1,480 153
3,259 341 190
781 19 22
54 3 2
2 0 0
1,180 8,137
625 6,132
147 430
361 1,379
952 7,889
96 52
0 9
129 181
261 283
305 1,718
114 596
26 37
1 1
1 0
Anticoagulants Heparin Warfarin (excluding rodenticides) Other Unknown *Category totals Anticonvulsants Carbamazepine Phenytoin Succinimides Valproic acid Other Unknown *Category totals Antidepressants Cyclic antidepressants Amitriptyline Amoxapine Desipramine Doxepin Imipramine Maprotiline Nortriptyline Protriptyline Other cyclic antidepressants Unknown cyclic antidepressants Cyclic antidepressant formulated with a benzodiazepine Cyclic antidepressant formulated with a phenothiazine Lithium MAO inhibitors SSRIs Trazodone Other Unknown *Category totals Antihistamines Diphenhydramine, (OTC) Diphenhydramine, (Rx) Diphenhydramine, unknown if OTC or Rx H2 receptor antagonists Other *Category totals Antimicrobials Antibiotics Systemic Topical Unknown Antifungals Systemic Topical
6–19
Int
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
562
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown Anthelmintics Diethylcarbamazine Piperazine Other Unknown Antiparasitics Antimalarial Metronidazole Other Antituberculars Isoniazid Rifampin Other Unknown Antivirals Systemic Topical Unknown Other Unknown *Category totals Antineoplastics Asthma therapies Aminophylline/theophylline Terbutaline and other beta-2 agonists Other beta agonists Other Unknown *Category totals
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
13
7
0
6
12
0
0
1
2
5
3
0
0
0
250 508 731 23
130 391 400 15
15 42 84 2
96 69 199 5
241 488 691 21
6 10 12 1
0 2 5 0
2 6 22 1
13 50 163 4
65 178 189 5
10 24 118 1
2 2 22 1
0 1 3 0
0 0 0 0
437 1,253 108
129 307 62
69 192 15
213 669 28
332 768 102
67 238 2
1 0 0
36 245 4
195 327 20
151 247 28
40 183 10
34 43 0
7 1 0
1 0 0
412 49 14 3
86 16 3 2
160 10 1 0
152 21 10 1
187 34 11 2
189 8 1 1
0 0 0 0
31 7 2 0
301 24 5 1
102 13 4 1
53 11 1 1
42 2 1 0
86 0 0 0
2 0 0 0
1,575 48 53 174 9 59,933
480 29 17 129 2 34,940
200 7 9 18 2 7,955
807 10 25 24 4 15,117
1,030 47 34 147 6 49,542
346 0 6 14 2 4,928
0 0 0 0 0 40
191 1 13 13 1 5,287
558 3 13 35 3 8,819
394 14 12 65 0 13,295
159 4 2 14 2 5,136
69 0 2 2 0 1,107
23 0 0 0 0 182
1 0 0 0 0 7
1,257
392
83
678
1,075
63
4
113
427
381
129
48
14
2
1,641
357
190
1,048
1,110
395
2
110
962
401
286
313
65
10
9,536 2,412 3,306 10 16,905
7,297 560 2,254 2 10,470
1,255 577 562 4 2,588
900 1,149 441 4 3,542
8,746 1,105 3,010 5 13,976
449 1,050 216 4 2,114
13 3 3 0 21
317 236 71 0 734
2,282 1,270 500 5 5,019
3,103 468 1,228 1 5,201
1,488 576 188 1 2,539
534 376 47 2 1,272
15 37 5 0 122
0 0 0 0 10
Cardiovascular drugs ACE inhibitors Alpha blockers Antiarrhythmics Antihypertensives Beta blockers Calcium antagonists Cardiac glycosides Hydralazine Long-acting nitrates Nitroglycerin Nitroprusside Other vasodilator Unknown types of vasodilators Vasopressor Other Unknown *Category totals
7,160 1,455 1,046 6,683 9,502 8,844 2,810 152 582 2,194 36 301
2,836 540 199 2,308 2,556 2,304 812 42 232 1,313 3 136
488 90 51 2,066 972 554 128 14 15 139 2 24
3,600 775 754 2,173 5,622 5,665 1,799 95 314 681 25 131
5,984 1,194 916 5,142 7,124 6,831 2,247 117 517 1,900 15 276
951 186 73 1,302 2,078 1,723 285 31 54 246 0 19
4 2 0 11 10 5 1 0 0 9 0 0
209 68 53 183 259 252 234 4 8 34 21 4
2,410 681 383 3,659 4,684 4,667 1,404 73 185 641 32 91
3,083 602 391 2,001 3,817 3,622 964 61 256 1,024 4 133
452 151 75 1,248 827 801 191 22 40 152 8 27
381 121 72 1,038 890 883 408 16 33 65 5 10
50 18 23 171 195 243 153 3 3 10 4 0
4 0 9 5 26 61 20 0 0 1 0 0
2 7 3,060 22 43,856
0 2 1,294 6 14,583
0 2 344 1 4,890
1 3 1,296 13 22,947
1 6 2,689 11 34,970
0 0 216 10 7,174
0 0 3 0 45
1 0 144 1 1,475
0 5 706 12 19,633
0 2 941 3 16,904
0 2 262 0 4,258
0 0 95 1 4,018
0 0 13 0 886
0 0 1 0 127
Cold and cough preparations
99,873
63,951
18,650
15,868
86,784
9,889
49
2,974
18,717
27,445
14,501
2,900
199
5
454
85
37
270
387
9
3
52
178
72
99
27
2
0
Diuretics Furosemide Thiazide Other Unknown *Category totals
1,687 1,869 1,404 302 5,262
829 814 636 141 2,420
145 183 132 27 487
658 809 588 123 2,178
1,495 1,556 1,168 247 4,466
152 240 165 34 591
1 2 2 1 6
33 67 64 19 183
488 580 419 107 1,594
541 655 528 109 1,833
212 159 134 32 537
73 76 53 17 219
7 9 9 3 28
0 1 0 0 1
Electrolytes and minerals Calcium Fluoride Iron
4,045 3,911 3,654
3,407 3,398 2,265
284 341 530
306 150 781
3,912 3,850 3,005
72 24 534
3 2 9
55 33 96
189 213 1,257
949 1,238 1,282
120 357 447
20 13 110
2 0 9
0 0 1
Diagnostic agents
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
563
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Magnesium Potassium Sodium Zinc Other Unknown *Category totals Eye/ear/nose/throat preparations Nasal preparations Tetrahydrozoline Other decongestant Other Unknown Ophthalmic preparations Contact lens products Glaucoma therapies Tetrahydrozoline Other ophthalmic sympathomimetics Other Unknown Otic preparations Combination products Other Unknown Steroids-topical for eye/nose/throat Throat preparations Lozenges without local anesthetics Lozenges with local anesthetics Other Unknown *Category totals Gastrointestinal preparations Antacids Salicylate-containing Other Antidiarrheals Diphenoxylate/atropine Non-narcotic Paregoric Other narcotic Antispasmodics Anticholinergic Other Laxatives Other Unknown *Category totals Hormones and hormone antagonists Androgens Corticosteroids Estrogens Insulin Oral contraceptives Oral hypoglycemics Progestins Thyroid preparations Other hormones Other hormone antagonists
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
447 1,163 2,426 2,574 857 6 19,083
161 556 1,600 1,778 557 1 13,723
68 112 442 192 92 1 2,062
194 453 328 543 190 4 2,949
377 1,015 2,306 2,430 681 3 17,579
35 112 87 49 96 2 1,011
4 2 18 0 1 0 39
30 29 13 87 77 1 421
122 308 295 205 178 3 2,770
85 425 615 495 245 4 5,338
71 87 370 237 85 1 1,775
25 43 39 41 21 0 312
5 6 4 0 3 0 29
1 0 0 0 0 0 2
75 2,317 568 12
53 1,033 388 4
3 403 42 2
17 790 120 4
67 2,023 544 10
3 166 7 1
0 8 0 0
5 115 17 1
27 431 22 2
33 756 134 3
10 336 78 2
1 82 7 0
0 6 0 0
0 0 0 0
3,209 125 1,666
1,872 48 1,128
287 3 177
889 67 321
3,155 113 1,455
24 1 76
13 0 98
17 11 33
311 26 571
527 37 793
535 18 161
97 6 36
1 0 3
0 0 0
471 1,119 34
232 531 8
65 136 7
150 406 13
402 1,036 23
10 27 4
1 7 2
58 48 3
119 149 7
159 176 6
73 148 6
17 35 0
1 3 0
0 0 0
1,172 2,188 25
844 1,100 9
117 214 2
186 764 14
1,165 2,164 24
2 11 1
0 0 0
4 8 0
114 216 3
354 380 3
291 648 7
12 56 0
0 3 0
0 0 0
723
390
103
197
679
18
1
24
56
111
119
8
0
0
738
581
81
71
705
13
0
20
27
169
37
4
0
0
259 310 6 15,017
167 157 5 8,550
48 93 0 1,783
43 51 1 4,104
236 254 6 14,061
15 47 0 426
0 0 0 130
8 7 0 379
20 70 1 2,172
61 102 1 3,805
14 39 0 2,522
4 4 0 369
0 0 0 17
0 0 0 0
2,325 18,014
1,799 16,397
256 703
238 807
2,157 17,694
80 160
1 26
84 128
196 447
688 3,637
102 396
18 38
1 6
0 0
1,064 690 44 182
517 514 29 128
147 59 6 15
369 105 6 34
815 636 36 161
183 20 5 8
1 1 0 0
63 31 3 12
465 78 12 36
397 188 13 95
154 30 10 13
59 10 0 2
12 0 2 0
0 0 0 0
928 9 13,509 7,933 1,885 46,583
294 4 9,512 5,941 998 36,133
194 1 1,269 484 146 3,280
402 3 2,444 1,355 674 6,437
524 8 12,257 7,140 1,571 42,999
341 0 747 443 209 2,196
1 0 127 6 0 163
56 0 354 326 103 1,160
485 2 1,615 1,394 402 5,132
282 6 2,591 2,211 694 10,802
184 0 2,014 506 113 3,522
93 1 195 207 33 656
19 0 6 22 6 74
0 0 0 1 0 1
502 9,483 3,463 1,428 8,730 5,351 1,147 6,930 1,986 321
185 5,538 2,539 116 7,294 2,137 607 4,156 976 110
61 1,172 183 100 784 402 169 625 360 40
220 2,447 668 1,105 558 2,636 337 1,987 564 152
321 8,491 3,279 1,048 8,165 4,296 1,004 6,435 1,504 258
116 368 108 330 435 862 61 394 379 41
2 8 3 7 6 1 2 3 8 1
58 603 72 34 120 162 78 89 93 21
166 818 332 558 627 3,349 164 1,179 534 87
106 1,937 889 416 1,910 2,355 277 1,872 562 94
57 572 94 104 277 422 54 231 257 21
29 100 29 248 9 812 8 83 43 10
7 7 3 43 2 129 3 11 8 2
0 0 0 4 0 9 0 0 0 0
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
564
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown hormone or antagonists *Category totals Miscellaneous drugs Allopurinol L-dopa and related drugs Dietary supplements/ homeopathic Disulfiram Ergot alkaloids Methysergide Neuromuscular blocking agents Nicotine pharmaceuticals Other *Category totals Muscle relaxants Carisoprodol (formulated alone) Cyclobenzaprine Methocarbamol Other Unknown *Category totals Narcotic antagonists Radiopharmaceuticals Sedative/hypnotics/ antipsychotics Barbiturates Long-acting Short-acting Unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone Phenothiazines Sleep aids (OTC) Other Unknown *Category totals Serums, toxoids, vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids Phenylpropanolamine Phenylpropanolamine and caffeine Other, OTC Other, Rx Unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine Phenylpropanolamine lookalike drugs Other stimulants Other hallucinogens
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
10 39,351
3 23,661
0 3,896
6 10,680
6 34,807
1 3,095
0 41
2 1,332
278 668
163 200
13 17
102 437
240 566
18 62
0 0
13,722 410 479 3
6,313 13 230 2
1,894 15 52 0
5,097 333 181 1
8,482 115 328 2
3,396 223 94 1
21 750 11,788 28,119
0 221 5,093 12,235
3 80 1,247 3,321
16 409 4,903 11,479
10 481 9,823 20,047
5,267 4,441 1,199 2,139 49 13,095
285 834 168 443 7 1,737
505 686 185 310 13 1,699
4,193 2,671 768 1,250 27 8,909
219
11
20
16
2
3,478 961 4 40,299 305 59 8 139 38 6,952 1,533 17,793 240 71,809
None
Minor
5 7,819
1 10,419
1 2,090
1 1,372
1 216
0 13
18 35
67 225
106 196
19 95
8 50
0 5
0 0
271 3 0 0
1,410 64 53 0
5,413 223 289 2
3,008 47 168 1
1,796 82 77 0
1,641 67 45 0
744 14 5 0
10 0 0 0
5 77 1,000 4,876
0 2 41 317
5 189 887 2,661
17 127 2,826 9,189
3 150 3,058 6,737
3 153 1,730 3,955
6 55 522 2,394
0 0 65 833
0 1 4 15
1,295 1,776 479 962 15 4,527
3,776 2,519 653 1,036 33 8,017
2 2 1 1 0 6
131 108 51 119 1 410
4,002 2,948 692 1,317 33 8,992
661 1,015 269 494 10 2,449
1,807 1,193 296 458 13 3,767
858 647 84 299 3 1,891
280 183 33 135 0 631
9 6 1 2 0 18
173
72
104
1
39
140
31
45
34
13
2
0
13
8
3
0
5
9
0
4
0
1
0
727 81 0 4,663 74 4 3 9 0 1,041 100 1,502 14 8,218
322 108 0 4,016 33 1 1 10 7 976 228 3,167 32 8,901
2,273 703 4 28,946 184 53 4 112 27 4,549 1,115 12,176 165 50,311
1,994 315 0 11,301 123 12 4 43 6 3,033 327 5,578 65 22,801
1,346 598 3 27,544 143 44 4 91 31 3,330 1,167 11,178 152 45,631
2 2 0 291 0 0 0 0 0 13 1 14 12 335
90 36 1 792 34 2 0 2 0 497 25 848 9 2,336
1,833 670 4 29,087 223 49 5 103 29 4,696 1,151 12,755 179 50,784
703 156 0 6,965 25 5 4 17 1 1,529 278 3,415 29 13,127
751 274 1 13,299 102 11 1 34 8 1,583 428 5,368 53 21,913
425 132 0 4,942 58 19 0 27 8 1,342 247 2,745 40 9,985
213 50 1 1,354 27 11 0 14 1 258 40 673 6 2,648
7 1 0 65 2 0 1 0 0 8 2 23 1 110
2,003
361
307
1,107
1,432
32
1
530
618
160
381
90
5
0
16,684 105 6,264 4,286
4,593 12 1,039 91
6,995 8 3,162 584
4,614 74 1,846 3,352
9,945 44 2,477 465
6,006 58 3,423 3,691
167 2 16 40
438 0 312 21
8,743 50 2,927 3,730
4,274 13 847 643
3,028 27 1,909 833
2,324 10 807 1,080
389 2 26 374
18 1 0 70
1,125
400
341
349
623
437
0
58
599
355
169
141
11
1
180 235 178 152 1,669 1,252 1,930 173 465
67 116 55 46 12 20 125 43 21
60 46 46 38 175 830 878 45 140
49 65 68 57 1,387 335 819 79 271
93 147 80 78 117 156 367 125 90
78 50 81 42 1,503 1,002 1,457 40 343
0 0 1 1 12 72 44 2 14
8 38 13 28 24 11 36 5 4
108 81 124 75 1,484 902 1,304 58 400
59 75 55 40 146 48 164 8 34
32 29 39 24 267 219 449 58 82
25 25 28 15 521 446 420 22 167
1 0 1 0 230 42 65 2 44
0 0 0 0 30 0 0 0 1
19 198 1
3 44 0
4 59 0
9 91 1
6 77 1
13 115 0
0 0 0
0 5 0
11 133 1
3 46 0
3 49 0
4 43 0
1 3 0
0 0 0
(Continued on following page)
Moderate Major Death
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
565
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown hallucinogens Other street drugs Unknown stimulant/street drugs *Category totals Topical preparations Acne preparations Boric acid/borates Calamine Camphor Camphor/methyl salicylate Diaper products Hexachlorophene antiseptic Hydrogen peroxide Iodine or iodide antiseptics Mercury antiseptics Methyl salicylate Podophyllin Silver nitrate Topical steroids Topical steroid with antibiotics Wart preparation Other liniment Other topical antiseptic *Category totals Veterinary drugs Vitamins Multiple vitamin tablets: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin tablets: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
10 25
1 0
4 7
3 18
1 4
3 20
5 1
0 0
7 18
0 3
0 8
2 6
0 1
0 0
59 35,010
2 6,690
24 13,446
27 13,514
10 14,906
36 18,398
10 387
0 1,001
45 20,800
7 6,820
7 7,232
14 6,100
3 1,195
0 121
2,207 214 3,516 8,486 1,126 33,901
1,217 100 2,579 6,501 938 32,078
500 19 211 580 66 915
435 85 669 1,273 111 800
2,022 199 3,467 8,282 1,101 33,810
61 11 30 144 5 24
4 1 3 18 2 9
119 3 14 38 17 52
153 29 175 979 110 315
520 44 810 2,995 413 6,729
349 26 215 1,315 193 846
35 4 9 78 8 22
2 0 0 7 0 1
0 0 0 0 0 0
157 7,772 1,628 267 9,250 54 221 6,825
108 3,421 540 211 6,898 16 17 4,896
16 819 295 14 809 10 96 437
31 3,291 702 34 1,386 24 90 1,317
152 7,583 1,406 254 9,063 47 191 6,675
2 104 148 6 70 4 14 42
0 34 8 0 15 0 2 11
3 50 61 6 100 3 12 95
20 432 396 30 804 20 39 165
29 1,461 400 87 2,501 9 25 1,207
16 1,377 300 14 2,037 10 57 376
5 57 65 2 59 2 9 33
0 1 3 1 8 2 0 0
0 0 0 0 0 0 0 0
1,276 1,524 2,585 3,913 84,922
946 971 1,447 2,677 65,561
108 221 209 376 5,701
196 296 829 762 12,331
1,240 1,470 2,365 3,723 83,050
6 25 18 90 804
1 3 4 7 122
28 26 197 85 909
46 146 187 442 4,488
279 421 478 1,121 19,529
117 263 640 493 8,644
8 28 35 55 514
0 2 2 9 38
0 0 0 0 0
3,316
1,729
243
1,170
3,249
47
7
11
259
872
426
46
5
0
2,578 5,856 60 24
1,782 3,994 57 24
281 614 2 0
481 1,130 1 0
2,256 5,225 59 24
169 506 0 0
3 2 0 0
143 118 1 0
283 942 6 2
563 1,862 10 6
177 302 7 4
26 41 0 0
4 5 0 0
0 2 0 0
7,262 15,760 672 1,404
6,340 14,057 645 1,321
869 1,594 22 68
46 93 4 12
7,154 15,536 668 1,388
94 200 4 7
1 4 0 6
10 17 0 2
224 1,440 34 36
1,860 5,289 162 397
170 705 17 20
9 34 2 0
0 2 0 0
0 0 0 0
79 119 4 2
43 66 2 1
9 11 1 0
23 36 1 1
62 96 3 2
8 10 0 0
0 0 0 0
9 13 1 0
17 23 0 0
13 30 0 0
6 10 0 0
2 1 0 0
0 0 0 0
0 0 0 0
214 508 92 405
201 482 91 394
9 20 1 7
4 5 0 4
210 502 92 403
1 3 0 0
0 0 0 0
3 3 0 2
10 30 3 10
56 145 23 104
5 30 2 10
2 1 0 1
0 0 0 0
0 0 0 0
18 2,068 4 25
10 1,471 3 24
3 265 1 1
5 293 0 0
11 1,857 3 25
4 166 1 0
0 2 0 0
3 36 0 0
2 322 2 0
5 602 2 4
1 112 0 0
0 21 0 0
0 2 0 0
0 0 0 0
(Continued on following page)
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
566
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Multiple vitamins, unspecified pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride Other vitamins Vitamin A Niacin (B3) Pyridoxine (B6) Other B complex vitamins Vitamin C Vitamin D Vitamin E Other Unknown *Category totals Unknown drug Total number of pharmaceutical substances % of pharmaceutical substances % of all substances
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
41 85 10
37 73 9
3 11 1
1 1 0
41 84 10
0 1 0
0 0 0
0 0 0
0 11 0
10 33 0
0 5 0
0 0 0
0 0 0
0 0 0
1,555 2,088 445
1,288 454 268
75 345 68
176 1,166 96
1,491 1,065 352
30 217 65
2 3 0
32 800 28
95 278 95
358 136 128
43 780 30
7 58 11
2 2 4
0 0 0
1,535 2,470 228 1,869 610 651 48,741
1,068 1,908 133 1,524 433 448 38,651
112 281 18 100 55 91 4,938
309 242 66 214 111 94 4,615
1,346 2,285 208 1,776 525 562 45,321
105 128 8 58 24 53 1,862
2 3 0 1 1 2 32
76 52 12 34 60 32 1,487
189 126 29 99 88 89 4,485
344 540 60 423 134 195 13,494
71 119 9 58 53 33 2,779
12 13 5 7 10 6 269
2 1 1 1 0 0 26
0 0 0 0 0 0 2
11,452
3,416
2,409
4,845
6,056
3,629
723
639
6,516
2,332
1,593
1,206
388
7
1,020,598 480,824 162,084 344,988 719,535 255,015 2,765
38,602
62,964 15,173
987
43.1%
47.1% 20.3%
15.9% 6.8%
33.8% 14.6%
70.5% 30.4%
REFERENCES 1. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1984;2:420-443 2. Litovitz TL, Veltri JC: 1984 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1985;3:423-450 3. Litovitz TL, Normann SA, Veltri JC: 1985 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1986;4:427-458 4. Litovitz TL, Martin TG, Schmitz B: 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1987;5:405-445 5. Litovitz TL, Schmitz BF, Matyunas N, et al: 1987 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1988;6:479-515 6. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989;7:495-545 7. Litovitz TL, Schmitz BF, Bailey KM: 1989 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1990;8:394-442 8. Litovitz TL, Bailey KM, Schmitz BF, et al: 1990 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1991;9:461-509 9. Litovitz TL, Holm KC, Bailey KM, et al: 1991 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1992;10:452-505 10. Litovitz TL, Holm KC, Clancy C, et al: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993;11:494-555 11. Litovitz TL, Clark LR, Soloway RA: 1993 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-584 12. Litovitz TL, Felberg L, Soloway RA, et al: 1994 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1995;13:551-597
25.0% 10.8%
0.3% 0.1%
3.8% 1.6%
350,803 262,523 150,049 34.4% 14.8%
25.7% 11.1%
14.7% 6.3%
6.2% 2.7%
1.5% 0.1% 0.6% 0.0%
13. Litovitz TL, Felberg L, White S, et al: 1995 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1996;14:487-537 14. Litovitz TL, Smilkstein M, Felberg L, et al: 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1997;15:447-500 15. Litovitz TL, Klein-Schwartz W, Dyer KS, et al: 1997 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1998;16:443-497 16. Litovitz TL, Klein-Schwartz W, Caravati EM, et al: 1998 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999;17:435-487
APPENDIX Drug and chemical concentrations provided in these abstracts were obtained on blood, serum, or plasma unless otherwise indicated. Cases 1 & 2. A 78-year-old woman with a history of coronary artery disease and hypertension was undergoing a multilevel vertebroplasty using methylmethacrylate injected percutaneously into the vertebra. She developed sudden dysrhythmias, pulmonary hypertension, and poor oxygenation during the series of injections and died in the OR. No postmortem was performed. The same day, a 42-year-old woman with a history of Crohn’s disease and no known cardiac disease underwent a similar procedure, again using methylmethacrylate injected percutaneously into the vertebra. She also developed sudden dysrhythmias and poor oxygenation with pulmonary hypertension during the series of injections and died. The postmortem examination showed large amounts of methylmethacrylate in the lungs suggesting pulmonary embolization.
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Case 3. A 41-year-old man was found unconscious next to his car with empty cans of a PVC pipe cleaner, PVC cement, and beer. The products were found to contain tetrahydrofuran and methyl ethyl ketone. In the ED, his vitals were within normal limits, pupils were fixed and dilated, and he remained unresponsive. Attempts to pass an Ewald tube into the esophagus were not successful. The patient suffered a cardiac arrest and expired the next day. Autopsy findings included: an eroded esophagus coated with an irregular plaque-like material; a similar coating of material in the stomach, along with 1 liter of tan fluid with an acetone-like odor that tested positive for methyl ethyl ketone and tetrahydrofuran; and methyl ethyl ketone and tetrahydrofuran detected in the blood. Case 21. An 18-year-old woman was found unresponsive and in cardiac arrest at a party, after apparently having been raped. She was resuscitated and intubated, but remained comatose and required maximal vasopressor therapy. She subsequently developed cerebral edema. Despite treatment with mannitol, brain flow studies showed no flow and patient was pronounced brain dead 10 days after admission. Autopsy showed hypoxic encephalopathy, a laceration of the urethral meatus, multiple contusions, and ischemia of the toes and right heel. Her blood ethanol concentration was 367 mg/dL and gamma hydroxybutyrate (GHB) concentration was 17 µg/mL. Case 45. A 40-year-old alcoholic with a history of recent paint thinner ingestion was released from a detox center and ingested one gallon of windshield washer fluid. Approximately 16 hours later, he was found comatose with labored respirations. Asystole developed en route to the ED. After 10 to 15 minutes of resuscitation, he had tachycardia and was vasopressor-dependent. The arterial pH was 6.98. Treatment included hemodialysis in the ED, intravenous ethanol, serum alkalinization, leucovorin, pyridoxine and thiamine. The patient’s hemodynamic status deteriorated, and he never regained consciousness. The initial antemortem methanolconcentration was 431 mg/dL. Postmortem showed cerebral edema. Case 51. A 6-year-old girl presented with fever, vomiting, hematuria, and a history of recent spider bites. The child’s condition rapidly deteriorated and she suffered a cardiac arrest. Antemortem cultures were negative. Autopsy findings included: interstitial hemorrhages in the chest, abdomen, retroperitoneum, and mesentery; petechiae and fluid in the pleural, pericardial and peritoneal cavities; hematuria; and intraepidermal bullae with inflammatory infiltrate consisting of eosinophils, lymphocytes and neutrophils, consistent with a hypersensitivity reaction. There was no evidence of foreign debris within the epidermis or dermis. The presumed spider was Loxosceles reclusa. Case 52. A 42-year-old woman presented 3 days after a possible brown recluse spider (Loxosceles reclusa) bite with abscess formation and tissue necrosis of the abdominal wall, hypoxia, hypertension, peripheral cyanosis, and a white blood cell count of 40,000/µL. The patient expired shortly thereafter. Case 53. A 43-year-old man who was drinking with friends was bitten on the hand by a rattlesnake presumed to be dead. After further ethanol consumption, he presented 1 hour later with complaints of hand pain and mild abdominal
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cramping. Vital signs were: heart rate, 134 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 81/46 mm Hg. Tongue swelling, fang marks, and minimal edema of the hand were noted. Hypotension necessitated vasopressor therapy and increased tongue edema was treated with diphenhydramine and steroids. Unsuccessful attempts at intubation were complicated by hypoxia, and cricothyrotomy was performed. Further treatment included sodium bicarbonate for metabolic acidosis, 10 units of polyvalent antivenin, and fresh frozen plasma. The course was complicated by acute renal failure secondary to hemolysis requiring hemodialysis, rhabdomyolysis, and prolonged ventilatory support. On the 13th hospital day, cardiac arrest secondary to pulmonary embolism occurred, following which the patient was declared brain dead. Case 55. A 25-year-old man with a history of psychiatric illness ingested potassium cyanide obtained from his workplace (a university laboratory). He was found by students in full cardiopulmonary arrest. Resuscitative efforts, including intubation, 100% oxygen, advanced cardiac life support, sodium nitrite, and sodium thiosulfate resulted in return of spontaneous circulation. His course was complicated by neurologic unresponsiveness, fixed dilated pupils, acidosis, vasopressor dependence, and multiple cardiopulmonary arrests. Postmortem blood toxicology revealed a cyanide concentration of 150 µg/mL. Case 57. A 97-year-old man with a history of lymphoma inhaled the vapors of a cyanide mixture and was found on the floor unresponsive. Following intubation, occasional spontaneous respirations were noted. Laboratory studies included: arterial pH, 7.11; pCO2, 20 mm Hg; pO2, 485 mm Hg; serum bicarbonate, 6.2 mEq/L, lactate, 16.4 mmol/L; and anion gap, 28 mEq/L. He was treated with sodium nitrite, sodium thiosulfate, and dopamine. The posttreatment methemoglobin concentration of 5.9% increased to 16% after second doses of sodium nitrite and sodium thiosulfate were administered. Resuscitative efforts were discontinued when it was discovered that the patient had a living will. He died approximately 12 hours postexposure. Antemortem blood cyanide concentration was greater than 10 µg/mL. Case 60. A 15-year-old girl with a history of flu-like symptoms for approximately 1 week, developed abdominal pain and vomiting on the day of presentation. She presented with coma and an increased anion gap metabolic acidosis. Laboratory results revealed: bicarbonate, less than 5 mEq/L; BUN, 14 mg/dL; creatinine, 3.2 mg/dL; glucose, 216 mg/dL; anion gap, 39 mEq/L; osmolar gap, 18 mOsm/L; salicylate, 4.6 mg/dL; and normal liver transaminases. Treatment included sodium bicarbonate and fomepizole. An abdominal radiograph showing radiopaque foreign bodies prompted treatment with dimercaprol, which was discontinued after the blood lead concentration returned at 19 µg/dL and it was determined that she had received bismuth subsalicylate. The hospital course was complicated by seizures treated with anticonvulsants; oliguric renal failure; and increased intracranial pressure treated with intrathecal drainage. She died from apparent brain herniation on the fourth hospital day. The autopsy showed cerebral edema with brainstem herniation, renal tubular casts, dilatation and intratubular birefringent oxalate crystals, with no oxalate crystals in the heart or liver. Antemortem blood ethylene
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glycol and glycolic acid concentrations were 77 mg/dL and 76.5 mg/dL, respectively. A postmortem glycolic acid concentration was 86 mg/dL. Case 72. A 17-year-old boy with a history of depression presented with slurred speech, a decreased level of consciousness, and profound acidosis after a suspected overdose of flurazepam and another substance (presumed to be a toxic alcohol). Treatment included flumazenil, an ethanol infusion, fomepizole, and intubation. His parents later reported that the patient had exhibited upper and lower extremity paresis before arrival, which prompted magnetic resonance imaging of the brain and cervical spine. Bilateral basal ganglia and brainstem infarcts were seen. An ethylene glycol concentration was 29 mg/dL 18 hours postingestion. The following day, repeat imaging studies showed absent cerebral blood flow, diffuse cortical ischemia, and bilateral uncal herniation. Case 73. A 27-year-old man drank an unknown amount of formaldehyde in a suicide attempt. In the ED, his unconscious state deteriorated to cardiac arrest. Resuscitative efforts including CPR, cardioversion, sodium bicarbonate, and folate were unsuccessful. After 4 ampules of sodium bicarbonate his arterial pH was 6.8. The postmortem findings included a blood formaldehyde concentration greater than 5,000 µg/mL; extensive fixation of the esophagus, stomach and proximal small intestine; and partial fixation of the tongue, liver, spleen, transverse colon, left adrenal gland and left kidney. Case 83. A 69-year-old chemist presented with sudden onset of crushing chest pain and shortness of breath. For 4 to 6 weeks, he had been self-medicating symptoms of chronic, intermittent chest pain with 30 to 60 mg of sodium nitrite. He took 300 mg of sodium nitrite for severe pain on the day of presentation. Physical examination revealed cyanosis, a blood pressure of 77/50 mm Hg and a heart rate of 102 beats/min. Oxygen saturation by pulse oximetry was 68% and arterial blood gas results were: pH, 7.42; pCO2, 26 mm Hg; pO2, 316 mm Hg on 100% oxygen; and methemoglobin, 38%. ECG findings were consistent with an acute anterior wall myocardial infarction. Treatment with intravenous fluids and 120 mg of methylene blue resulted in decreased cyanosis, hemodynamic improvement, and increased oxygen saturation to 94% by pulse oximetry. Cardiac catheterization revealed a 95% occlusion of the left main coronary artery. Cardiogenic shock necessitated balloon pump assistance and vasopressor therapy. He died within 2 hours of arrival. Case 85. A 12-month-old boy ingested an unknown quantity of a degreaser and descaler containing 3% hydrochloric acid and 14% ammonium bifluoride, with a pH of 1. Two episodes of emesis occurred initially. In the hospital, the heart rate was 175 beats/min and the pulse oximetry reading was 94 to 96%. The initial serum calcium measurement was 2.5 mmol/L. The patient was treated with intravenous fluids and calcium. Ventricular fibrillation and seizures developed and were refractory to resuscitative efforts. Case 91. A 66-year-old man with a history of hypothyroidism, congestive heart failure, and depression presented to the hospital with a sore throat about 1 hour after the intentional ingestion of a drain opener containing 93-100% sulfuric acid. Several episodes of spontaneous emesis occurred
before arrival. Vital signs were: blood pressure, 146/89 mm Hg; pulse, 110 beats/min; and respiratory rate, 20 breaths/ min. He had no stridor, hoarseness, oropharyngeal burns, or chest radiographic findings. Endoscopy performed approximately 3 hours after arrival revealed second and third degree burns of the distal esophagus and stomach. The patient suffered an asystolic cardiac arrest and died 6 to 7 hours after the ingestion. Postmortem showed findings included minimal laryngeal edema, ulceration and necrosis of the distal two-thirds of the esophagus, and necrosis of the stomach extending to the pylorus. Case 92. A 48-year-old woman with a psychiatric history was found in the bathroom obtunded and foaming at the mouth, with blood-streaked emesis. An empty 1 L bottle of bathroom descaler containing an unknown concentration of hydrofluoric acid was next to her. In the ED, she was agitated, uncooperative, and had edema of the pharynx. Treatment included gastric lavage and administration of 60 mL of magnesium hydroxide. Evidence of upper gastrointestinal bleeding persisted. Twelve hours postingestion, the ECG showed peaked T-waves and a normal QT interval, despite a potassium of 6.2 mEq/L and calcium of 2.8 mg/dL. Although ventricular dysrhythmias developing shortly thereafter responded to intravenous calcium, refractory hypocalcemia (2.9 mg/dL), ventricular fibrillation, and asystole occurred 17 hours postingestion. Case 95. A suicidal 82-year-old woman vomited after drinking an estimated 150 to 300 mL of a pine oil/ isopropanol cleaner. Intubation was required within 3 hours of the ingestion for rapidly progressive aspiration pneumonitis. She developed adult respiratory distress syndrome and died on the 10th hospital day. Case 98. An 18-month-old boy ingested an unknown amount of a tire cleaner (hydrofluoric acid or ammonium bifluoride) from an unmarked container and developed hematemesis and respiratory distress. The child required intubation for progressive lethargy and respiratory failure. Initial vital signs were: temperature, 37.9°C (rectal); heart rate, 168 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 70/31 mm Hg. The pulse oximetry reading was 82%. Treatment included steroids and bronchodilators. An initial potassium was 5.2 mEq/L, with arterial pH (90 minutes postingestion), 7.08; pCO2, 28.9 mm Hg; and pO2, 393 mm Hg. At that time, ventricular fibrillation occurred and was refractory to multiple defibrillation attempts and epinephrine. Autopsy findings included: absence of burns in the mouth and esophagus; full-thickness burns (without perforation) to the depth of the muscularis mucosal layer from the stomach to the ileum; evidence of pulmonary aspiration; and massive hemolysis. Case 100. A 12-month-old boy ingested a large amount of hair oil containing safflower (50% to 80%), mineral (30% to 50%), castor (⬍2%), avocado (⬍2%), sesame (⬍2%, and jojoba oils (⬍2%) 40 minutes prior to arrival at an urgent care center. He exhibited persistent cough and hypoxemia with a pulse oximetry reading of 89% on room air. His respiratory status deteriorated over the next 24 hours, necessitating intubation, high frequency/oscillatory ventilatory support and positive end-expiratory pressure. He developed bilateral pneumothoraces and was ultimately placed on ECMO 6 days postexposure. Although ECMO was contin-
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ued for 24 days, multisystem organ failure developed, and the patient died after unsuccessful weaning. Case 101. A 16-year-old boy was using a stimulant medication containing amphetamine and dextroamphetamine while studying for an examination. The medication had recently been discarded in a neighbor’s trash. During a study break, the patient also huffed hair spray, containing hydrofluorocarbons, isobutane, and ethanol. He collapsed, was found to be in ventricular fibrillation, and was not able to be resuscitated. A subsequent toxicology screen was positive for amphetamines. Postmortem heart blood amphetamine concentration was 0.12 µg/mL. Blood, urine and vitreous humor were positive for isobutane and dimethyl ether. Case 108. A 2-year-old boy ingested citronella oil stored in a perfume container. He developed aspiration pneumonitis, hypoxemia, and refractory hypotension. Treatment included mechanical ventilation, vasopressors, and antibiotics. Bilateral pneumothoraces developed, and the child died 66 hours after the exposure. Case 109. An 87-year-old woman with dementia, colon cancer, and alcoholism developed acute respiratory distress and unresponsiveness after ingesting 1 cup of potpourri oil, mistaken for juice. Radiographic evidence of aspiration pneumonitis was present. The patient was not intubated, per her family’s wishes, and developed progressive hypoxia and acidemia. She died on the third hospital day. Case 110. A 50-year-old medical researcher was found dead in a refrigerated room that contained 15 new blocks of dry ice which had been placed there 3 hours earlier. The decedent had been crouching to store samples in a container several inches above the ground. There were no signs of struggle and there was no history of psychiatric disorder, recent personal crises, or medical illness. The external ventilation system in the cold room was not functioning, although internal air movement occurred via a cooling fan. Postmortem examination and toxicologic studies were not revealing. To confirm the cause of death, the conditions at the time of the event were reproduced. Air was sampled serially at several heights. At a height of 9 inches, the drop in FiO2 (13.6%) and rise in CO2 (27.6%) were maximal by 3 hours. The temperature of the room fell to ⫺15°C. The cause of death was thus determined to be from simple asphyxia secondary to carbon dioxide release from dry ice. Case 112. A 2-year-old boy was found near his dead 3-year-old sister after riding in the rear of a car with a leaking exhaust system for several hours. In the ED, the child displayed lethargy and vomiting. His initial carboxyhemoglobin was measured as 37%. Despite treatment with 100% oxygen and a decrease in the carboxyhemoglobin to 2.2% 90 minutes later, the child remained lethargic. Neurologic deterioration occurred, with the development of fixed, dilated pupils, lack of response to painful stimuli, and body temperature dysregulation. Postmortem findings included necrosis of the basal ganglia, consistent with carbon monoxide poisoning. Case 151. A 72-year-old man was found to have an elevated serum lead concentration of 302 µg/dL. The exposure was thought to be caused by ingestion of leadcontaminated moonshine. The patient was encephalopathic and hemodynamically unstable. Treatment included intuba-
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tion and chelation therapy with dimercaprol (BAL) and calcium disodium EDTA. Prolonged intensive care and continued chelation were continued for 11 weeks. Lead concentrations slowly dropped over the first few weeks to 33 µg/dL. Complications included staphylococcal infection, hypertension, and renal failure requiring hemodialysis. He died with multisystem organ failure. Case 153. A 38-year-old man suffered a large inhalational and dermal exposure to an acrolein herbicide after a worksite spill. He developed immediate shortness of breath, was transported to the ED, and was discharged after a period of observation. According to the patient’s wife, he developed increasing dyspnea that evening and was unable to sleep. He was found dead in a chair approximately 18 hours postexposure. Postmortem findings were consistent with pulmonary edema. Case 154. A 60-year-old man ingested fluid found in the garage that he mistook for white wine. On presentation, he was confused, diaphoretic, and vomiting. Lung fields were clear and pupils were pinpoint. Atropine resulted in no pupillary change, but caused an increase in heart rate and blood pressure to 180 beats/min and 210/100 mm Hg. Arterial blood gas results were: pH, 7.42; pCO2, 31 mm Hg; and pO2, 71 mm Hg. Pralidoxime was administered. The patient suffered a cardiac arrest and died. Postmortem dinitrobutylphenol concentrations were 20.2 µg/mL (toxic ⬎10 µg/mL) in the blood; 0.32 µg/mL (bile); 0.86 mg/kg (brain); 0.15 mg/kg (liver); and 2.8 mg/kg (gastric contents). Antemortem blood concentrations were 7.7 µg/mL. Case 155. A 47-year-old alcoholic ingested 540 mL of an herbicide containing glyphosate. He presented with lethargy, hypotension, bradycardia, metabolic acidosis, and an ethanol concentration of 140 mg/dL. Charcoal administration was followed by vomiting. Nine hours postingestion the patient developed flash pulmonary edema. Treatment included furosemide, intubation, and vasopressors. Abnormal renal function tests and minimal urine output were noted. The patient died 12 hours after the ingestion. Case 156. A 44-year-old man showed miosis, tachycardia, hypersalivation, and loss of urinary and stool continence 4 hours after the intentional ingestion of an unknown amount of monosodium methanearsonate herbicide. Lack of dimercaprol necessitated transfer to a tertiary facility. Cardiovascular collapse and death occurred en route. On autopsy, toxic levels of arsenic were found in blood and urine and the medical examiner ruled the death as suicide by acute arsenic intoxication. Case 158. A 16-year-old girl in her fourth month of pregnancy ingested an unknown quantity of paraquat in a suicide attempt. At presentation 24 hours later, her creatinine was 4 mg/dL. Six days later, renal function tests were: BUN, 91 mg/dL; and creatinine, 6.8 mg/dL. Hepatic transaminases, bilirubin and LDH were also elevated. On the seventh day after the ingestion, she developed shortness of breath and oxygen desaturation (94%) on room air. Over the next few days, oxygenation further deteriorated despite improvement in renal function. On the 11th day, the patient developed severe dyspnea, cyanosis, and chest radiographic findings suggestive of adult respiratory distress syndrome, then died. Case 160. A 15-year-old boy collapsed after taking four
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‘‘hits’’ from a tank of butane gas while inhaling with an adolescent friend. Paramedics found the youth in cardiopulmonary arrest. Prolonged resuscitative efforts were unsuccessful. Case 163. A 4-year-old boy was taking a bath when his father pumped liquid chlorodifluoromethane into the bath water with a hose. The child became drowsy and was found lying face-down in the water a short time later. He was transported to a hospital where he later died. The medical examiner ruled that he died from liquid chlorodifluoromethane intoxication and that the manner was homicide. Case 166. A 2-year-old boy had a seizure outdoors near a charcoal lighter fluid container. He arrived to the ED with lethargy and drooling. In less than an hour, the patient had developed recurrent seizures, treated with diazepam, midazolam, and succinylcholine. Frothy oral secretions and chest radiographic evidence of pulmonary edema were noted within 90 minutes of arrival. During transfer, the patient developed pulseless electrical activity, which responded to atropine and epinephrine. Cerebral edema developed and he was declared brain dead 21 hours after the exposure. Case 169. A 62-year-old man ingested a large amount of a product containing 72% chlordane. He was found lying on the ground shaking. After transport to the hospital, he was reportedly awake, alert, and oriented. At 90 minutes postingestion, the patient vomited and seized. Treatment included decontamination, intubation, benzodiazepines and activated charcoal. The hospital course was complicated by metabolic acidosis, recurrent seizures, hypotension, and decreased urine output. Neurologic, pulmonary, and hemodynamic deterioration occurred on the third hospital day and the patient died. Case 174. A 27-year-old man who reportedly drank a mixture of ‘‘opium’’ and ethanol presented with dyspnea, epiglottic swelling, hypoxia, tachycardia, and red urine. The ECG showed QRS prolongation, peaked T waves, elevated ST segments, and absent P waves. The ingested fluid was actually determined to be an old insecticide containing nitric acid and lead arsenate. The patient was intubated and placed on a ventilator. A gray, swollen epiglottis was noted. Laboratory results were: urine drug screen, positive for marijuana; blood ethanol, 63 mg/dL; acetaminophen, negative; and methemoglobin, 9%. Complications included perforation of the stomach and renal failure. Despite tracheostomy placement, supportive care, and hemodialysis, sepsis developed and the patient died on the sixth hospital day. Case 179. A 63-year-old man picked wild mushrooms from his yard and ate them in a salad. The mushrooms were later identified as either Amanita verna or Amanita virosa. He developed headache, nausea, vomiting, abdominal pain, and diarrhea 7 hours postingestion. These symptoms persisted through the following day when he presented to the ED with fever, tachycardia, and the following laboratory abnormalities: AST, 1749 U/L; ALT, 1710 U/L; total bilirubin, 4.3 mg/dL; BUN, 48 mg/dL; creatinine, 6.5 mg/dL; anion gap, 31 mEq/L; PT, 25.5 seconds; and PTT, 48.4 seconds. Treatment included hydration, phytonadione, fresh frozen plasma, and antiemetics. At 60 hours postingestion, the gastrointestinal symptoms had resolved, but both renal dysfunction and coagulation abnormalities persisted. Ultimately, his hepatic and renal dysfunction worsened and
encephalopathy, rhabdomyolysis, and hyperkalemia developed. He died approximately 91 hours postingestion. Case 180. A 62-year-old woman presented 48 hours after eating a stir-fry meal containing self-harvested mushrooms. Similar mushrooms were later identified as Lepiota josserandii. Initial symptoms were fatigue, nausea, and abdominal cramps that began 16 hours post ingestion, followed by multiple episodes of diarrhea. After initial treatment with meperidine, hydroxyzine, and intravenous fluids, the patient was discharged home. Because of an elevated AST of 2,262 U/L, she was called back to the hospital. Repeat laboratory results on return were: AST, 12,904 U/L; PT, 40.8 sec; and INR, 10.2. Although transaminases gradually declined, the PT continued to rise to more than 100 seconds and the lactate increased. Despite treatment with intravenous penicillin G, cimetidine and milk thistle, encephalopathy developed within 48 hours of presentation. Amanitin was not detected. The next day, emergent orthotopic liver transplantation was performed. The patient had a complicated posttransplant course, including abnormal liver function tests and the development of fungal sepsis. Despite aggressive medical and surgical management, she died 23 days after the mushroom meal. The histology of the native liver showed massive necrosis. Other autopsy findings included CNS necrosis related to fungal infection and hypoxia. Cases 183 & 184. A 20-year-old man presented comatose with a rectal temperature of 42.8°C after ingesting six to seven seed pods and smoking the leaves of jimson weed (Datura stramonium) with friends. His initial heart rate was 178 beats/min and blood pressure, 58/36 mm Hg. He was treated with fluids, intubation, ice water lavage and cooling blankets. Laboratory results were: urine drug screen, negative; pH, 7.29; pCO2, 22.7 mm Hg; pO2, 74 mm Hg, HCO3, 9.4 mEq/L; oxygen saturation, 91.9%; BUN, 30 mg/dL, creatinine, 4.0 mg/dL; and potassium, 2.3 mEq/L. The patient died 6 hours after admission. His 21-year-old male friend, who also ingested six to seven pods containing jimson weed seeds and smoked some leaves, died at the scene. Case 185. A 48-year-old man with a history of hypertension, peptic ulcer disease, gastroplasty, hyperchloremic metabolic acidosis attributed to gastric outlet obstruction, and depression was found unresponsive with labored respirations. He had been in a small enclosed room working with ‘‘glue’’ and ‘‘fireworks’’ and also had been consuming the fruit of the china berry tree (Melia azedarach) for 1 week before admission. Positive plant identification was performed. In the ED, the patient was described as awake but dyspneic, and the following laboratory results were noted: serum pH, 6.96; pCO2, 8.8 mm Hg; pO2 (Fi02 1.0), 72 mm Hg; serum bicarbonate, 2 mEq/L; BUN, 23 mg/dL; creatinine, 3.0 mg/dL; and anion gap, 29 mEq/L. Mental status deterioration, multisystem organ failure, and acute myocardial infarction developed. He expired after a prolonged hospitalization. Autopsy revealed necrotizing vasculitis of the brain stem and cranial nerve roots, subacute hemorrhagic infarcts in the cerebrum and cerebellum, centrilobular necrosis in the liver, and hemorrhagic infarcts of the lungs. The cause of death was determined to be a result of acute CNS and liver pathology followed by multiorgan failure
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temporally related to glue inhalation and china berry ingestion. Case 190. A 17-year-old girl with a history of intravenous drug abuse and migraine headaches managed with nonprescription analgesics presented with an altered mental status. Initial laboratory studies included: drugs of abuse screen, negative; serum acetaminophen, less than 10 µg/mL; salicylates, negative; AST, 5441 IU/L; ALT, 9559 IU/L; total bilirubin, 4.9 mg/dL; PT, 25 seconds; INR, 4.33, BUN, 24 mg/dL; creatinine 1.3 mg/dL, ammonia 183 µmol/L. Progressive neurologic deterioration and worsening hepatic dysfunction occurred, and she was pronounced brain dead within 24 hours. Later, her 8-year-old sister admitted that she had seen the patient take a whole bottle of acetaminophen 4 days earlier, but had been sworn to secrecy. Case 196. A 24-year-old pregnant woman presented after rupture of membranes. She had normal labor progression until immediately before delivery when acute, severe fetal heart rate decelerations were noted. Forceps delivery yielded a stillborn full-term infant with no external anomalies. Soon after delivery, the mother developed a decreased level of consciousness, metabolic acidosis, and anuria. Within 48 hours, disseminated intravascular coagulopathy, multisystem organ failure, and death occurred. Admission serum acetaminophen concentration was 465 µg/mL, with a postdelivery concentration of 398 µg/mL. Days after her death, the patient’s family reported that she may have taken as many as 100 acetaminophen tablets for back and labor pain. The infant’s death was attributed to massive maternal acetaminophen overdose. Case 214. A 41-year-old man ingested an unknown amount of acetaminophen 48 hours before presentation. He was awake and alert, had unremarkable vital signs, and complained of right upper quadrant abdominal pain. Laboratory results were: acetaminophen concentration, 180 µg/mL; total bilirubin, 10.6 mg/dL; AST, 8,272 U/L; ALT, 7400 U/L; PT, 46.4 seconds; and PTT, 40.5 seconds. Initial treatment included oral N-acetylcysteine. Bioartificial liver support was started 21⁄2 days after presentation and was continued for 5 days. The patient died of hepatic failure on the eighth hospital day. Case 364. A 15-year-old girl was admitted 7 hours after an intentional ingestion of 200 aspirin tablets along with clarithromycin, ibuprofen, loratadine, and hydrochlorothiazide/triamterene. Postingestion salicylate concentrations were: 6 mg/dL at 1 hour, 46 mg/dL at 3 hours, and 81.5 mg/dL at 5 hours. Initial arterial pH was 7.4 and pCO2 was 37 mm Hg. The patient seized 5 hours postingestion and was then delirious, shouting, and complaining of nausea. Laboratory results at that time were: pH, 7.35; pCO2, 27 mm Hg; serum bicarbonate, 15 mEq/L; salicylate, 78.8 mg/dL; and acetaminophen, less than 1 µg/mL. Treatment included intravenous fluids and sodium bicarbonate. Recurrent ventricular tachycardia occurred and was treated with additional sodium bicarbonate and lidocaine. Hypotension, fever and purpura developed. Despite hemodialysis, she died approximately 22 hours after the ingestion. Case 375. A 45-year-old man who had ingested 70 colchicine (0.6 mg) tablets 3 to 4 days earlier, presented with diminished oral intake, nausea, vomiting, diarrhea, abdominal pain and evidence of dehydration. Abnormal
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laboratory results were: WBC, 1,000/µL; platelets 20,000/ µL; sodium, 125 mEq/L; creatinine, 1.4 mg/dL: AST, 436 U/L, and creatine kinase, 5,684 U/L. On the third hospital day, he had evidence of mental status alteration, hypoxia, hypotension, worsened renal failure and persistent diarrhea. His white blood cell count was 2,000/µL. Further treatment included granulocyte colony stimulating factor, platelet transfusions, albumin, intravenous fluids and sodium bicarbonate. He became hemodynamically unstable and died on the third hospital day. Case 392. A 5-month-old girl presented in respiratory arrest. Police reports suggested that the infant’s mother had intentionally added the methadone to the child’s formula in an attempt to sedate the child. The medical examiner determined that the infant formula contained a methadone concentration of 21 µg/mL. The postmortem methadone concentration was 0.3 µg/mL (heart blood) and 1.4 mg/kg (liver). Case 454. A 37-year-old anesthesiologist with a history of depression and inhalational anesthetic abuse was found apneic and asystolic in his hospital on-call room with a plastic bag over his face. Inside the bag was a gauze pad, which at the time of discovery was dry. An empty bottle of enflurane was also present. Forensic reconstruction suggested that the patient saturated the gauze pad with enflurane and placed it in the bag for rebreathing. When the patient lost consciousness, the bag covered his mouth and nose resulting in asphyxiation. Several months earlier, this same physician had been successfully resuscitated after a similar event, had been rehabilitated, and returned to unsupervised work. Case 456. An 1,800 gram, 2-day-old infant born at 33 weeks gestation age, was unintentionally given 9,000 units of heparin intravenously through an umbilical catheter. Approximately 12 hours later, the patient’s status deteriorated, and a grade 3 to 4 intracranial bleed was diagnosed. The therapeutic error was discovered the following morning when the patient’s prothrombin time was 17 seconds and the PTT unmeasurable. At 26 hours postexposure the extent of the intracranial bleed was noted to be severe, and life support systems were removed. Case 459. A 10-year-old boy with a history of autism and seizure disorder was being treated with lamotrigine, clonazepam, and fluoxetine. Three weeks after the lamotrigine dose was increased, he developed status epilepticus, hyperthermia, and runs of ventricular tachycardia. The patient was comatose with increased tone in the upper and lower extremities. Initial treatment included intubation, cooling, benzodiazepines, phenobarbital, phenytoin, urinary alkalinization, and broad-spectrum antibiotics. Ultimately, the patient received numerous other therapies, including vasopressors, dobutamine, nitroprusside, continuous arteriovenous hemofiltration, and sodium thiosulfate for suspected cyanide toxicity secondary to prolonged nitroprusside therapy. Laboratory studies revealed elevated hepatic transaminases and the following abnormalities: lactate, 8.6 mmol/L; creatine kinase, 990 U/L; platelets, 6,000/µL; PT, 50 seconds; PTT, greater than 100 seconds; and d-dimer, greater than 60 µg/dL. The patient died on the fourth hospital day. Autopsy findings confirmed rhabdomyolysis, hepatic necrosis and disseminated intravascular coagulation resulting from lamotrigine.
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Case 463. A 30-year-old woman was found unresponsive. No response to naloxone was noted, and intubation was required. Initial vital signs were: heart rate, 60 beats/min; blood pressure, 95/50 mm Hg; and respiratory rate, 14 breaths/min. The valproic acid concentration was 1,280 µg/mL and the urine drug screen was positive for amphetamines. The patient remained unresponsive despite a decreasing valproic acid concentration (875 µg/mL), and required vasopressor support for hypotension. Pertinent laboratory findings on the fourth hospital day were: valproic acid, 410 µg/mL; ammonia 197 µg/dL; AST, 136 U/L; ALT, 32 U/L; platelets, 84,000/µL; and glucose, 27 mg/dL. An EEG showed diffuse cerebral dysfunction. A prolonged hospital course was complicated by persistent coma, aspiration pneumonia, ventilator-dependence, bowel obstruction, renal failure, thrombocytopenia, endocrine dysfunction, hypoglycemia, and gastrointestinal bleeding. Case 593. A 39-year-old man with a history of depression ingested his own isoniazid and was found in status epilepticus. Diazepam, lorazepam, and phenobarbital were administered without control of the seizures. Neuromuscular paralysis and transfer to a tertiary facility known to stock pyridoxine were performed. There, the patient continued to have seizures despite receiving a lorazepam infusion at 1 mg/hr. Five grams of pyridoxine were administered and the lorazepam infusion was increased to 2 mg/hr, without effect. Phenytoin loading was performed, and seizures abated after 8 hours. A CT scan of the brain revealed a large left cerebellar hemorrhage. A ventriculostomy was placed to control hydrocephalus. Hepatic and renal dysfunction, rhabdomyolysis, and disseminated intravascular coagulation developed. The urine drug screen was positive for cocaine metabolites. Because the patient’s prognosis for neurologic recovery was poor, supportive care was withdrawn and he died on the fourth hospital day. Case 594. A 16-year-old girl treated with zidovudine and lamivudine presented with nausea and vomiting. She had tachypnea and a profound, high anion gap metabolic acidosis. Salicylate and toxic alcohol determinations were negative. Mental status deterioration, hypoxemia, and progressive lactic acidosis (lactate, 10.9 mEq/L) resulted. Treatment included intubation, sodium bicarbonate, carnitine, thiamine, and vitamin C for presumed zidovudine-induced lactic acidosis. Despite this, the patient’s status did not improve and she died after a cardiac arrest on the sixth hospital day. Case 595. A 51-year-old man with multiple medical problems was being treated for severe pustular psoriasis with methotrexate 12.5 mg weekly. He was unintentionally given methotrexate daily for approximately 2 weeks. He presented with sore throat, fever, cough, vomiting, and the following vital signs: heart rate, 164 beats/min; blood pressure, 90/60 mm Hg; and temperature, 39°C. Laboratory results were: WBC, 200/µL; hematocrit, 23%; platelets, 11,000/µL; BUN, 90 mg/dL; and creatinine, 3.5 mg/dL. Treatment included intubation for severe oral mucositis, intravenous fluids, vasopressors, granulocyte colony stimulating factor, broad-spectrum antibiotics, leucovorin, and continuous venovenous hemodiafiltration. The serum methotrexate concentration on day 2 was 0.29 µmol/L (toxic ⬎ 0.1). The patient remained hypotensive, developed a myocardial
infarction, and expired 4 days after admission. The autopsy revealed multifocal hemorrhages in the lungs and epicardium, centrilobular hepatic necrosis, pulmonary aspiration, cardiomyopathy, lymphocytic ablation, and cellular atypia. Case 597. A 3-year-old boy developed status epilepticus after multiple bouts of coffee ground emesis. Seizures were recalcitrant to therapy with lorazepam, phenobarbital, phenytoin, and midazolam. The following morning it was discovered that the child had access to sustained-release theophylline. A blood theophylline concentration was 114 µg/mL. Other treatment included mechanical ventilation, multiple dose activated charcoal, and hemodialysis. Postdialysis, the theophylline concentration was 23 µg/mL. The patient was pronounced dead 60 hours after presentation. The postmortem examination revealed cerebral herniation and necrosis. Case 615. A 23-month-old girl ingested an unknown number of 0.3 mg clonidine tablets. In the ED, the child was stuporous with a heart rate of 57 beats/min. Atropine was administered and resulted in an increased heart rate to 200 beats/min, followed by slowing to 125 beats/min. Both improvement in the level of consciousness and agitation were noted after naloxone administration. During intubation, bradycardia progressed to pulseless electrical activity, and frothy sputum was noted. Resuscitative efforts were not successful. The autopsy revealed moderate congestion and edema of the lungs. The postmortem blood clonidine concentration was 46 ng/mL. Case 638. A 43-year-old male physician became hypotensive and unresponsive after paramedics administered nitroglycerin sublingually for complaints of chest pain. Empty vials of sildenafil and diltiazem were discovered later after scene investigation. In the ED, the patient suffered a respiratory arrest, was resuscitated, but appeared to exhibit signs of brain death. A cardiac arrest occurred on the sixth hospital day. Antemortem toxicology results revealed lethal concentrations of diltiazem and the presence of diphenhydramine. Sildenafil was not detected. Case 662. A 20-month-old boy was noted to be ‘‘fussy and crying’’ after ingesting his grandmother’s sustained release nifedipine (possibly in addition to other unknown cardiac medications). He began ‘‘shaking’’ while being bathed. In the ED, intact nifedipine tablets were found in the infant’s throat during intubation, and he died shortly after arrival to the ED. Nifedipine concentrations were 560 µg/mL (blood) and 3,990 µg/mL (gastric contents). Case 669. A week after an abdominal aortic aneurysm repair, an 80-year-old man, received an application of a large amount of nitroglycerin ointment, in lieu of antifungal ointment, to the abdomen wall area. One hour later, the patient experienced an episode of hypotension that responded to fluids and removal of the nitroglycerin ointment. Hypotension recurred 7 hours later and responded to treatment with fluids and vasopressors. The skin was further decontaminated with soap and water. Over the next 12 hours, the patient experienced a bowel infarction and died. Case 670. A 69-year-old man ingested an unknown number of procainamide 250 mg capsules along with ethanol. In the ED, he had a systolic blood pressure of 50 mm Hg, a heart rate of 60 beats/min, and displayed an
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
idioventricular rhythm. The serum procainamide concentration was 52 µg/mL and blood ethanol was 221 mg/dL. Treatment included temporary pacemaker insertion, intravenous sodium bicarbonate, and dopamine. One hour after admission, he was awake and alert with a systolic blood pressure of 120 mm Hg. Four hours after admission he developed recurrent episodes of ventricular tachycardia and hypotension, and could not be resuscitated. Case 671. A 48-year-old legally blind woman with a history of asthma, atrial fibrillation, valvular replacement, and Wolff-Parkinson-White Syndrome, unintentionally ingested five 300 mg propafenone tablets after mistaking them for prednisone while reading her medication labels in Braille. She received prehospital oral activated charcoal. En route to the ED, she developed bradycardia and seized. Treatment included external pacing, intubation, dopamine, sodium bicarbonate, atropine, and glucagon. Asystolic cardiac arrest resulted in prolonged resuscitative efforts. Severe diffuse anoxic brain injury was noted on CT and life support was withdrawn. A prehospital blood propafenone concentration was 4.88 µg/mL. Case 700. A 2-year-old boy was found dead in his bed. He had been ill with a viral infection for an unknown period of time, and received three doses of a cough syrup containing hydrocodone bitartrate and guaifenesin. The autopsy revealed cerebral and pulmonary edema and a serum postmortem hydrocodone concentration of 80 ng/mL (therapeutic, ⬍20 ng/mL). The cause of death was respiratory arrest, acute pneumonia, and medication effect. Case 702. A 23-year-old woman with a history of bulimia ingested 20 diet capsules containing sustained-release phenylpropanolamine and 12 cold capsules containing acetaminophen, diphenhydramine, pseudoephedrine and dextromethorphan, then self-induced vomiting at home. On presentation to the ED 30 minutes later, her blood pressure was 156/91 mm Hg, heart rate was 60 beats/min and she was awake. She was treated with activated charcoal and whole bowel irrigation. An episode of transient hypertension (blood pressure, 165/120 mm Hg) with type I second degree AV block was followed by tachycardia with normalization of the blood pressure. The patient required intubation for pulmonary edema, despite the absence of ECG changes or enzymatic evidence of myocardial ischemia. Subsequent complications included severe tachycardia, ventricular dysrhythmias, and cardiac arrest. Autopsy findings included pulmonary edema, numerous small foci of fibrosis in the myocardium, and a focal hemorrhage in the left basal ganglia. Antemortem blood toxicology results were: acetaminophen, 14.8 µg/mL; fluoxetine, 0.51 µg/mL; pseudoephedrine, 0.33 µg/mL; and phenylpropanolamine, 0.95 µg/mL. Case 703. A 14-month-old boy presented 20 minutes after ingesting an unknown number of iron tablets with evidence of gastrointestinal bleeding and disseminated intravascular coagulation. Treatment included intubation, exploratory laparotomy to remove iron tablets, blood product transfusions, and an intravenous deferoxamine infusion. Laboratory results were: initial serum iron, 15,000 µg/dL; 3-hour serum iron, 18,750 µg/dL; 6-hour serum iron, 4,000 µg/dL; hemoglobin, 5.4 gm/dL; and WBC, 26,000/µL. The patient died 16 hours after arrival.
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Case 704. A 73-year-old woman with multiple chronic medical illnesses was hospitalized to rule out bowel obstruction. After receiving two bottles of oral magnesium citrate, the patient suffered ventricular fibrillation and cardiac arrest. Resuscitative efforts included intubation, dopamine, calcium, and furosemide. Laboratory findings after the arrest included: BUN, 20 mg/dL; creatinine, 1.2 mg/dL; magnesium, 6.6 mEq/L; and a normal ECG. An abdominal CT scan ruled out bowel perforation, however, the chest radiograph showed white-out of the right lung, suggesting aspiration of the magnesium citrate. Complications included renal failure, cyanosis, and unresponsiveness with fixed dilated pupils. The patient died on the third hospital day. Case 705. A 6-year-old boy was found staring and unresponsive, with arms flexed and legs extended, 1 hour after the administration of a trimethobenzamide suppository for vomiting and headache. He was choking at the time and may have aspirated vomitus. In the ED, he was unresponsive, in acute respiratory distress, with hypoxia, tachycardia, and muscle rigidity. Chest radiograph showed multilobar infiltrates. Treatment included high flow oxygen, intubation, and diphenhydramine, without improvement in rigidity. There was no improvement in mental status. Hemodynamic deterioration occurred and he died the following day. Ante- and postmortem cultures, including cerebrospinal fluid, were negative. Death was attributed to either a dystonic reaction or seizure resulting in aspiration of gastric contents. Case 715. A 38-year-old depressed, diabetic woman took an unknown number of pills. She initially refused to reveal what medications had been ingested. Six hours after a medical evaluation, she was discharged to a mental health facility. Two hours later, she became somnolent with slurred speech and was returned to the ED. It was then determined that she may have overdosed on metformin, an unidentified sulfonylurea, cephalexin, acetaminophen/hydrocodone, clonazepam, and ibuprofen. Laboratory results at that time were: glucose, 10 mg/dL; lactic acid, 20 mEq/L; arterial pH, 6.9; serum bicarbonate, 6 mEq/L. Treatment included 50% dextrose, sodium bicarbonate infusion, and hemodialysis against a bicarbonate bath. The patient became comatose. Postdialysis laboratory results were: pH, 6.97; lactic acid, 27 mEq/L; creatinine 1.9 mg/dL; and glucose, 300 mg/dL. Additional treatment included infusions of dextrose and bicarbonate, insulin, thiamine, and high-dose vasopressors. Despite this, lactic acidosis was refractory, and additional attempts at hemodialysis were not tolerated secondary to hypotension. Case 716. A 29-year-old body-builder with a history of drug and alcohol abuse experienced sudden loss of consciousness and cardiopulmonary arrest after taking 1,4-butanediol at a party with friends. He had apparently ‘‘passed out’’ 2 weeks before this event after an ingestion of the same product. He had fixed, dilated pupils on arrival to the ED, and within 2 hours began to have uncontrollable seizures and upward ocular deviation. Refractory seizures continued for 9 hours and were treated with lorazepam, phenytoin, and midazolam. His subsequent course was complicated by CT evidence of generalized edema, increased intracranial pressure, and diabetes insipidus.
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Case 717. A 4-year-old boy with a history of AML treated with intrathecal methotrexate and possibly other chemotherapeutic agents, was given 300 to 650 mg of disodium edetate through a central venous line. He developed cardiorespiratory arrest. The ionized calcium level was 0.55 mmol/L. Case 718. A 52-year-old man with a history of chronic ethanol abuse was brought to the ED presumably in a postictal state. He had been taking 4 mouthfuls of gamma butyrolactone every 4 hours for 8 months, according to his wife. Four days earlier, after his wife discarded his gamma butyrolactone supply, he began consuming large amounts of water and another dietary supplement obtained through the internet that also contained gamma butyrolactone. Admission laboratories were remarkable for a sodium of 107 mEq/L. He was treated with phenytoin. Within 24 hours, the patient developed coma with fixed, dilated pupils, and was noted to have cerebral edema. Despite intensive therapy, life support was withdrawn after a brain scan revealed no cerebral blood flow. Case 725. A 38-year-old man with a history of depression was found dead in his bedroom. Five discarded enema bottles were present; two of these contained small amounts of residual dark fluid. Autopsy findings showed two partiallyfolded transdermal nicotine patches lodged in the esophagus and three patches in the stomach. The postmortem peripheral blood nicotine concentration was 106 µg/mL. Case 736. A 30-year-old man maintained on methadone for heroin abuse underwent a rapid opioid detoxification procedure. Anesthesia was induced with propofol, midazolam, and ketamine. Naltrexone pellets were implanted subcutaneously on his abdomen, and parenteral opiate antagonists were administered. The patient was then discharged to a hotel room. A visiting nurse administered somatostatin, acetaminophen, diphenhydramine, and trazodone the next day. He was found unresponsive on the third day and transported to an emergency department. He was in respiratory distress and required intubation. Vital signs were: blood pressure, 170/100 mm Hg; heart rate, 140 beats/min; and temperature, 40°C. Subsequent complications included variceal bleeding, probable aspiration pneumonia, prerenal azotemia, multiple seizures, and cardiac arrest. Case 745. A 73-year-old woman with a history of diabetes presented unresponsive after possibly ingesting up to 90 mL of chloral hydrate syrup. Her blood pressure on arrival was 125/58 mm Hg. Within 30 minutes, she developed frequent premature ventricular contractions which were treated with lidocaine. Bradycardia followed and was treated with atropine. After a ‘‘do not resuscitate’’ status was established, she experienced asystole and died. Case 780. A 2-month-old boy was found dead at home by paramedics summoned by his mother. The autopsy revealed a urinary cocaine metabolite concentration of 2,506 ng/mL, and mild to moderate pulmonary congestion, without evidence of foul play or SIDS. Death was caused by cocaine toxicity possibly resulting from inhalation of free-base cocaine smoke. The death was ruled a homicide. Case 834. A 20-year-old woman who recently arrived
from Colombia was found unconscious, lying in emesis, in her hotel room. After naloxone was given in the ED, she became more responsive. She was febrile and had a blood pressure of 135/72 mm Hg and a heart rate of 120 to 130 beats/min. An abdominal radiograph showed numerous foreign bodies and a chest radiograph showed aspiration pneumonia. The urine drug screen was positive for opiates, marijuana, methadone, and cocaine. Whole bowel irrigation resulted in the passage of 99 intact bags containing pure heroin over the course of several days. Intermittent naloxone and intubation were required to maintain ventilation. Multiple complications developed, including adult respiratory distress syndrome, hypotension, subcutaneous emphysema, agitation, tachycardia, and ultimately asystole on the 17th hospital day. Case 866. A 23-year-old man, with a history of intentional abuse of an unknown amount of ‘‘Ecstasy’’ (methylenedioxymethamphetamine) 2 days previously, was found in a hotel room incoherent, yet able to follow commands, with right-sided paralysis and aphasia. Vital signs were within normal limits, except that he was febrile. Drug screens were positive for barbiturates and amphetamines. Urine, blood, and CSF cultures were negative. A CT scan approximately 36 hours after admission showed a large left nonhemorrhagic infarct. Subsequent neurologic deterioration resulted in decerebrate posturing, with dilated, sluggishly reactive pupils. A repeat CT scan the next day revealed a thrombus in the left main carotid artery and a small gyral hemorrhage. The patient died 4 days later from cerebral edema and herniation. Case 867. A 22-year-old man presented unresponsive after abusing methylenedioxymethamphetamine (MDMA, Ecstasy), ethanol and alprazolam with a friend. Vital signs were: temperature, 41.7°C; heart rate, 192 beats/min; and blood pressure, 93/65 mm Hg. Complications included hypoglycemia, rhabdomyolysis, and disseminated intravascular coagulation. Treatment included intubation, dextrose, sodium bicarbonate, fresh frozen plasma, phytonadione and vasopressors. He remained unresponsive and hemodynamically unstable, and was declared brain dead 36 hours after admission. Antemortem methylenedioxyamphetamine and methylenedioxymethamphetamine serum concentrations were 0.02 µg/mL and 0.82 µg/mL, respectively. Case 868. A 17-year-old girl intentionally ingested an unknown substance in a suicide attempt. She presented to the hospital with chest pain, dizziness, vertigo, and drowsiness. She was afebrile with a blood pressure of 103/50 mm Hg, heart rate of 60 beats/min and respiratory rate of 40 breaths/min. The ECG showed third-degree AV block. Treatment included fluids, atropine, and antibiotics. Laboratory results were: potassium, 8.9 mEq/L; digoxin, 4.2 ng/mL; and WBC, 20,900/µL. She developed a ventricular dysrhythmia that did not respond to ACLS protocols. Using a different assay, the medical examiner reported the digoxin concentration as 2.0 ng/mL. This finding suggested the presence of a nondigoxin cardiac glycoside (topical aphrodisiac).
1999 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System TOBY L. LITOVITZ, MD, WENDY KLEIN-SCHWARTZ, PHARMD, MPH, SUZANNE WHITE, MD, DANIEL J. COBAUGH, PHARMD, JESSICA YOUNISS, MBA, ALISON DRAB, BS, AND BLAINE E. BENSON, PHARMD Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products.
From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1).1-16 The cumulative AAPCC database now contains 27.0 million human poison exposure cases. This report includes 2,201,156 human exposure cases reported by 64 participating poison centers during 1999, a decrease of 1.8% compared with 1998 poisoning reports.
The American Association of Poison Control Centers gratefully acknowledges the generous financial support of McNeil Consumer Healthcare, without which the compilation and production of this report would not have been possible. Centers participating in this report include Children’s Hospital of Alabama Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Samaritan Regional Poison Center, Phoenix, AZ; Arkansas Poison and Drug Information Center, Little Rock, AR; 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 Control Center, Chicago, IL; Indiana Poison Center, Indianapolis, IN; Iowa Poison Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KS; Kentucky Regional Poison Center, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Maryland Poison Center, Baltimore, MD; Regional Center for Poison Control and Prevention Services for Massachusetts and Rhode Island, Boston, MA; Children’s Hospital of Michigan Regional Poison Control Center, Detroit, MI; Spectrum Health Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Cardinal Glennon Children’s Hospital Regional Poison Center, St. Louis, MO; The Poison Center, Omaha, NE; New Hampshire Poison Information Center, Lebanon, NH; 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; Hudson Valley Regional Poison Center, Sleepy Hollow, NY; Long Island Regional Poison Control Center, Mineola, NY; Finger Lakes Regional Poison and Drug Information Center, Rochester, NY; Central New York Poison Control Center, Syracuse, NY; Western New York Regional Poison Control Center, Buffalo, NY; Carolinas Poison Center, Charlotte, NC; North Dakota Poison Information Center, Fargo, ND; 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; Central Pennsylvania Poison Center, Hershey, PA; Lifespan Poison Center, Providence, RI; Middle Tennessee Poison Center, Nashville, TN; Southern Poison Center, Memphis, 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; University of Wisconsin Hospital Clinics Poison Control Center, Madison, WI; Children’s Hospital of Wisconsin Poison Center, Milwaukee, WI. r1985-2000 by the American Association of Poison Control Centers. Published by permission. All rights reserved. Reprints are available at a cost of $10 each. Address requests to AAPCC, 3201 New Mexico Ave, Suite 310, Washington, DC 20016. doi:10.1053/ajem.2000.9261 517
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TABLE 1. Growth of the AAPCC Toxic Exposure Surveillance System
Year 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Total
No. of Participating Centers
Population Served (Millions)
Human Exposures Reported
Exposures/ Thousand Population
16 47 56 57 63 64 70 72 73 68 64 65 67 67 66 65 64
43.1 99.8 113.6 132.1 137.5 155.7 182.4 191.7 200.7 196.7 181.3 215.9 218.5 232.3 250.1 257.5 260.9
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 2,155,952 2,192,088 2,241,082 2,201,156 27,004,741
5.8 7.3 7.9 8.3 8.5 8.8 8.7 8.9 9.2 9.5 9.7 8.9 9.3 9.3 8.8 8.7 8.4
CHARACTERIZATION OF PARTICIPATING CENTERS Of the 64 reporting centers, 60 submitted data for the entire year. Fifty-one of the 64 participating centers were certified as regional poison centers by the AAPCC in 1999. Annual center call volumes (human exposure cases only) ranged from 3,539 to 92,890 (mean 35,259) for centers participating for the entire year. Penetrance, calculated only for states that were completely served by centers participating in TESS, ranged from 4.9 to 18.5 per 1,000 population with a mean of 8.4 reported exposures per 1,000 population. Penetrance is defined as the number of human poison exposure cases reported per 1,000 individuals in the population served. A total population of 260.9 million was served by the participating centers, including 43 entire states, portions of 2
TABLE 2. Site of Caller and Site of Exposure, Human Poison Exposure Cases
Residence Own Other Health care facility Workplace School Public area Restaurant/food service Other Unknown
Site of Caller (%)
Site of Exposure (%)
77.2 2.3 13.3 1.7 0.7 0.5 0.1 4.1 0.2
88.8 3.2 0.3 2.7 1.4 1.2 0.5 1.0 1.0
states, and the District of Columbia (Figure 1). Noting the 272.7 million 1999 United States population, the data presented represent an estimated 95.7% of the human poison exposures that precipitated poison center contacts in the US during 1999. Extrapolating from the 2,201,156 human poison exposures reported in this database, 2.3 million human poison exposures are estimated to have been reported to all US poison centers in 1999. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the US cannot be made from these data alone, as considerable variations in poison center penetrance were noted. Indeed, assuming all centers reached the penetrance level of 18.5 poisonings/ 1,000 population reported for one state, 5.0 million poisonings would have been reported to poison centers in 1999. The data do not directly identify a trend in the overall incidence of poisonings in the US because of changing center participation from year to year and changes in center use. An analysis of data from 59 centers that participated for the entirety of both 1998 and 1999 shows no significant change (a decrease of only 0.005%) in the number of reported poison exposures from 1998 to 1999 within the regions served by these 59 centers.
FIGURE 1. Sixty-four poison centers participated in the Toxic Exposure Surveillance System in 1999. The shaded areas denote regions served by reporting centers.
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TABLE 3. Age and Gender Distribution of Human Poison Exposure Cases Male
Female
Unknown
Total
Cumulative Total
Age (yr)
No.
Row %
No.
Row %
No.
Row %
No.
Col %
No.
Col %
⬍1 1 2 3 4 5 Unknown child ⬍ 5 6-12 13-19 Unknown child Total children (⬍20) 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total adults Unknown age Total
74,287 194,783 191,664 89,370 42,446 24,834 1,706 87,177 70,453 944 777,664 79,707 77,801 54,853 28,050 14,933 10,591 5,051 828 27,072 298,886 3,114 1,079,664
52.4 53.1 53.3 55.0 55.9 56.3 45.6 56.4 44.6 39.0 52.9 44.7 42.7 42.0 39.0 37.7 35.0 31.6 26.9 38.4 41.4 34.2 49.1
67,019 171,756 167,401 72,889 33,273 19,147 1,447 66,677 87,114 923 687,646 98,332 104,085 75,679 43,848 24,716 19,619 10,903 2,248 41,334 420,764 3,996 1,112,406
47.3 46.8 46.5 44.8 43.8 43.4 38.7 43.1 55.1 38.2 46.8 55.2 57.2 57.9 61.0 62.3 64.9 68.3 73.0 58.6 58.3 43.9 50.5
429 579 621 263 176 123 586 752 426 551 4,506 210 131 101 37 13 15 12 3 2,071 2,593 1,987 9,086
0.3 0.2 0.2 0.2 0.2 0.3 15.7 0.5 0.3 22.8 0.3 0.1 0.1 0.1 0.1 0.0 0.0 0.1 0.1 2.9 0.4 21.8 0.4
141,735 367,118 359,686 162,522 75,895 44,104 3,739 154,606 157,993 2,418 1,469,816 178,249 182,017 130,633 71,935 39,662 30,225 15,966 3,079 70,477 722,243 9,097 2,201,156
6.4 16.7 16.3 7.4 3.4 2.0 0.2 7.0 7.2 0.1 66.8 8.1 8.3 5.9 3.3 1.8 1.4 0.7 0.1 3.2 32.8 0.4 100.0
141,735 508,853 868,539 1,031,061 1,106,956 1,151,060 1,154,799 1,309,405 1,467,398 1,469,816 1,469,816 1,648,065 1,830,082 1,960,715 2,032,650 2,072,312 2,102,537 2,118,503 2,121,582 2,192,059 2,192,059 2,201,156 2,201,156
6.4 23.1 39.5 46.8 50.3 52.3 52.5 59.5 66.7 66.8 66.8 74.9 83.1 89.1 92.3 94.1 95.5 96.2 96.4 99.6 99.6 100.0 100.0
REVIEW OF THE DATA Of the 2,201,156 human exposures reported in 1999, 92.0% occurred at a residence (Table 2). Exposures occurred in the workplace in 2.7% of cases, in schools (1.4%), health care facilities (0.3%), and restaurants or food services (0.5%). Poison center peak call volumes were noted from 4 to 10 PM, although call frequency remained consistently high between 8 AM and midnight, with 91% of calls logged during this 16-hour period. Although the average number of poison TABLE 4. Distribution of Age and Gender for 873 Fatalities
Age (yr) ⬍1 1 2 3 4 5 6-12 13-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total
Cumu- Cumuative ative Total %
Male Female Unknown Total
%
1 6 3 3 2 1 4 28 72 94 123 50 39 18 14 3
2 2 2 0 1 1 4 25 52 92 96 34 34 30 14 6
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
3 8 5 3 3 2 8 53 124 186 219 85 73 48 28 9
0.3 0.9 0.6 0.3 0.3 0.2 0.9 6.1 14.2 21.3 25.1 9.7 8.4 5.5 3.2 1.0
3 11 16 19 22 24 32 85 209 395 614 699 772 820 848 857
0.3 1.3 1.8 2.2 2.5 2.7 3.7 9.7 23.9 45.2 70.3 80.1 88.4 93.9 97.1 98.2
14 475
2 397
0 1
16 873
1.8 100.0
873 873
100.0 100.0
center consultations handled per day by all participating U.S. poison centers was 6,031, higher volumes were observed in the warmer months (up to 6,464/day in July) compared to 5,331 consultations per day in December. On average, ignoring time of day and seasonal fluctuations, U.S. poison centers handled one poison exposure every 14 seconds. The age and gender distribution of human poison exposure victims is outlined in Table 3. Children younger than 3 years of age were involved in 39.5% of cases, and 52.5% occurred in children younger than 6 years. A male predominance is found among poison exposure victims younger than 13 years of age, but the gender distribution is reversed in teenagers and adults. Of all poison exposures captured, 8,980 occurred in pregnant women. Of those with known pregnancy duration, 32% occurred in the first trimester, 38% in the second trimester, and 30% in the third trimester. In 4.4% of cases (95,690 cases) multiple patients were impliTABLE 5. Number of Substances Involved in Human Poison Exposure Cases No. of Substances
No. of Cases
% of Cases
1 2 3 4 5 6 7 8 ⱖ9 Total
2,033,490 135,340 17,597 7,281 3,082 1,492 644 343 1,887 2,201,156
92.4 6.1 0.8 0.3 0.1 0.1 0.0 0.0 0.1 100.0
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TABLE 6. Reason for Human Poison Exposure Cases Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Food poisoning Occupational Unknown Total Intentional Suicidal Misuse Abuse Unknown Total Other Malicious Contaminant/tampering Total Adverse Reaction Drug Other Food Total Unknown Total
No.
%
1,460,073 154,422 78,697 72,083 51,751 46,054 42,088 2,897 1,908,065
66.3 7.0 3.6 3.3 2.4 2.1 1.9 0.1 86.7
154,355 35,261 31,157 9,147 229,920
7.0 1.6 1.4 0.4 10.4
7,046 5,010 12,056
0.3 0.2 0.5
32,742 8,139 4,328 45,209 5,906 2,201,156
1.5 0.4 0.2 2.1 0.3 100.0
cated in the poison exposure episode (eg, siblings ‘‘shared’’ a household product, multiple patients inhaled vapors at a hazardous materials spill). Fatalities differed from the total exposure data set in several ways. Table 4 presents the age and gender distribution for the 873 reported fatalities. Although responsible for the majority of poisoning reports, children younger than 6 years of age comprised just 2.7% (24) of the fatalities. Sixty-one percent of poisoning fatalities occurred in 20- to 49-year-old individuals. A single substance was implicated in 92.4% of reports, and 1.5% of patients were exposed to more than two possibly poisonous drugs or products (Table 5). In contrast, 45% of fatal cases involved two or more drugs or products. The overwhelming majority of human exposures were acute (93.2%) compared to only 51.9% of poison-related fatal exposures. Chronic exposures comprised 2.1% of all poison exposure reports, and acute-on-chronic exposures comprised 4.0%. (Chronic exposures were defined as continuous
or repeated exposures occurring in a period exceeding 8 hours.) Reason for exposure was coded according to the following definitions: Unintentional general: All unintentional exposures not specifically defined below. Most unintentional exposures in children are captured here. Environmental: Any passive, nonoccupational exposure that results from contamination of air, water, or soil. Environmental exposures are usually caused by man-made contaminants. Occupational: An exposure that occurs as a direct result of the person being on the job or in the workplace. Therapeutic error: An unintentional deviation from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person, or administration of the wrong substance. Only exposures to medications or products substituted for medications are included. Drug interactions resulting from unintentional administration of drugs or foods which are known to interact are also included. Unintentional misuse: Unintentional improper or incorrect use of a nonpharmaceutical substance. Unintentional misuse differs from intentional misuse in that the exposure was unplanned or not foreseen by the patient. Bite/sting: All animal bites and stings, with or without envenomation, are included. Food poisoning: Suspected or confirmed food poisoning; ingestion of food contaminated with microorganisms is included. Unintentional unknown: An exposure determined to be unintentional but the exact reason is unknown. Suspected suicidal: An exposure resulting from the inappropriate use of a substance for reasons that are suspected to be self-destructive or manipulative. Intentional misuse: An exposure resulting from the intentional improper or incorrect use of a substance for reasons other than the pursuit of a psychotropic effect. Intentional abuse: An exposure resulting from the intentional improper or incorrect use of a substance where the victim was likely attempting to achieve a euphoric or psychotropic effect. All recreational use of substances for any effect is included. Intentional unknown: An exposure that is determined to be intentional but the specific motive is unknown. Contaminant/tampering: The patient is an unintentional victim of a substance that has been adulterated (either maliciously or unintentionally) by the introduction of an undesirable substance. Malicious: This category is used to capture patients who are victims of another person’s intent to harm them. Adverse reaction: An adverse event occurring with normal, prescribed, labeled or recommended use of the product, as opposed to overdose, misuse or abuse. Included are cases with an unwanted effect caused by an allergic, hypersensitive, or idiosyncratic re-
TABLE 7. Distribution of Reason for Exposure by Age ⬍6 Years
6-12 Years
13-19 Years
⬎19 Years
Unknown*
Total
Reason
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Col %
Unintentional Intentional Other Adverse Reaction Unknown Total
1,148,693 688 1,059 3,888 471 1,154,799
60.2 0.3 8.8 8.6 8.0 52.5
142,085 7,661 1,743 2,626 491 154,606
7.4 3.3 14.5 5.8 8.3 7.0
86,757 64,574 2,114 3,663 885 157,993
4.5 28.1 17.5 8.1 15.0 7.2
522,985 153,867 6,983 34,638 3,770 722,243
27.4 66.9 57.9 76.6 63.8 32.8
7,545 3,130 157 394 289 11,515
0.4 1.4 1.3 0.9 4.9 0.5
1,908,065 229,920 12,056 45,209 5,906 2,201,156
86.7 10.4 0.5 2.1 0.3 100.0
*Unknown child plus unknown age (excludes unknown adult)
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TABLE 8. Distribution of Reason for Exposure and Age for 873 Fatalities
Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Food poisoning Occupational Unknown Total Intentional Suicide Misuse Abuse Unknown Total Other Adverse Reaction Unknown Total
⬍6 Years
6-12 Years
13-19 Years
⬎19 Years
Total
9 3 0 0 8 0 0 0 20
0 0 1 0 2 0 0 0 3
0 0 0 0 2 0 0 0 2
1 50 6 11 11 0 11 0 90
10 53 7 11 23 0 11 0 115
0 1 0 0 1 3 0 0 24
0 1 1 0 2 0 3 0 8
23 1 19 2 45 1 1 4 53
449 57 117 38 661 1 7 29 788
472 60 137 40 709 5 11 33 873
sponse to the active ingredients, inactive ingredients, or excipients. Concomitant use of a contraindicated medication or food is excluded, and coded instead as a therapeutic error. The vast majority (86.7%) of poison exposures were unintentional; suicidal intent was present in 7.0% of cases (Table 6). Therapeutic errors comprised 7.0% of exposures (154,422 cases), with unintentional nonpharmaceutical product misuse comprising another 3.3% of exposures (72,083 cases). Unintentional poisonings outnumbered intentional poisonings in all age groups (Table 7). In contrast, of the 873 human poisoning fatalities reported, 85% of adolescent deaths and 84% of adult deaths (older than 19 years of age) were intentional (Table 8). Ingestions accounted for 75.0% of exposure routes (Table 9), followed in frequency by dermal, inhalation, and ocular exposures. For the 873 fatalities, ingestion, inhalation, and parenteral were the predominant exposure routes. TABLE 9. Distribution of Route of Exposure for Human Poison Exposure Cases and 873 Fatalities All Exposure Cases
Fatal Exposure Cases
Route
No.
%
No.
%
Ingestion Dermal Inhalation Ocular Bites and stings Parenteral Aspiration Other Unknown Total
1,731,553 185,509 146,717 134,669 85,102 8,740 2,935 5,916 7,843 2,308,984
75.0 8.0 6.4 5.8 3.7 0.4 0.1 0.3 0.3 100.0
712 12 93 1 7 42 10 3 58 938
75.9 1.3 9.9 0.1 0.7 4.5 1.1 0.3 6.2 100.0
NOTE: Multiple routes of exposure were observed in many poison exposure victims. Percentage is based on the total number of exposure routes (2,308,984 for all patients, 938 for fatal cases) rather than the total number of human exposures (2,201,156) or fatalities (873).
TABLE 10. Management Site of Human Poison Exposure Cases Site
No.
%
Managed on-site, non-health care facility Managed in health care facility Treated and released Admitted to critical care Admitted to noncritical care Admitted to psychiatry Lost to follow-up; left AMA Subtotal Other Refused referral Unknown Total
1,654,942
75.2
270,279 61,723 33,358 32,235 76,017 473,612 20,341 42,827 9,434 2,201,156
12.3 2.8 1.5 1.5 3.4 21.5 0.9 1.9 0.4 100.0
ABBREVIATION: AMA, against medical advice.
Clinical effects (signs, symptoms, or laboratory abnormalities) were coded in 30.5% of cases (17.4% had one effect, 7.8% had two effects, 3.3% had three effects, 1.3% had four effects, 0.4% had five effects, and 0.3% had more than five effects). Of 1,455,796 clinical effects coded, 79.3% were deemed related, 8.1% were considered not related, and 12.6% were coded as ‘‘unknown if related.’’ The majority of cases reported to poison centers were managed in a nonhealth care facility (78%), usually at the site of exposure, the patient’s own home (Table 10). Treatment in a health care facility was rendered in 21.5% of cases and recommended in another 1.9% of patients who refused the referral. The percentage of patients treated in a health care facility varied considerably with age. Only 10.6% of children under 6 years and only 13.7% of children between 6 and 12 years were managed in a health care facility compared to 44.5% of teenagers (13 to 19 years of age) and 35.4% of adults (older than 19 years of age). Of cases managed in a health care facility, 57.1% were treated and released without admission, 13.0% were admitted for critical care, and 7.0% were admitted for noncritical care. Where treatment was provided in a health care facility, 36.6% of the patients were referred in by the poison center and 63.4% were already in or en route to the health care facility when the poison center was contacted. Health care facilities included acute care hospitals (86.1%), physician offices or clinics (11.3%), and freestanding emergency centers (2.6%). Table 11 displays the medical outcome of the human poison exposure cases distributed by age, showing more severe outcomes in the older age groups. Table 12 compares medical outcome and reason for exposure, and shows a greater frequency of serious outcomes in intentional exposures. Table 13 shows an increasing duration of the clinical effects observed with more severe outcomes. Medical outcome categories were as follows: No effect: The patient developed no signs or symptoms as a result of the exposure. Minor effect: The patient developed some signs or symptoms as a result of the exposure, but they were minimally bothersome and generally resolved rapidly with no residual disability or disfigurement. A minor effect is often limited to the skin or mucous membranes (eg, self-limited gastrointestinal symptoms, drowsiness, skin irritation, first degree
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TABLE 11. Medical Outcome of Human Poison Exposure Cases by Patient Age ⬍6 Years Outcome
No.
No effect 352,271 Minor effect 116,766 Moderate effect 9,241 Major effect 728 Death 24 No follow-up, nontoxic 276,608 No follow-up, minimal toxicity 364,720 No follow-up, potentially toxic 13,972 Unrelated effect 20,469 Total 1,154,799
6-12 Years
13-19 Years
⬎19 Years
Col %
No.
Col %
No.
Col %
No.
Col %
No.
Col %
30.5 10.1 0.8 0.1 0.0 24.0 31.6 1.2 1.8 52.5
28,500 29,578 3,906 261 8 28,172 56,096 3,207 4,878 154,606
18.4 19.1 2.5 0.2 0.0 18.2 36.3 2.1 3.2 7.0
27,684 40,638 13,967 1,705 53 12,077 43,257 13,178 5,434 157,993
17.5 25.7 8.8 1.1 0.0 7.6 27.4 8.3 3.4 7.2
85,118 171,098 64,467 10,742 788 58,591 238,782 51,639 41,018 722,243
11.8 23.7 8.9 1.5 0.1 8.1 33.1 7.2 5.7 32.8
1,249 1,630 427 64 0 1,014 3,253 3,465 413 11,515
10.8 14.2 3.7 0.6 0.0 8.8 28.3 30.1 3.6 0.5
Unknown
Total No.
%
494,822 22.5 359,710 16.3 92,008 4.2 13,500 0.6 873 0.0 376,462 17.1 706,108 32.1 85,461 3.9 72,212 3.3 2,201,156 100.0
TABLE 12. Distribution of Medical Outcome by Reason for Exposure for Human Poison Exposure Cases Unintentional Outcome
No.
No effect 447,577 Minor effect 283,633 Moderate effect 50,865 Major effect 3,272 Death 115 No follow-up, nontoxic 369,664 No follow-up, minimal toxicity 653,192 No follow-up, potentially toxic 42,281 Unrelated effect 57,466 Total 1,908,065
Intentional
Total
Col %
No.
Col %
No.
Col %
No.
Col %
No.
Col %
23.5 14.9 2.7 0.2 0.0 19.4 34.2 2.2 3.0 86.7
44,880 62,768 34,713 9,245 709 4,331 29,767 38,335 5,172 229,920
19.5 27.3 15.1 4.0 0.3 1.9 12.9 16.7 2.2 10.4
1,254 2,967 718 92 5 1,064 3,941 1,030 985 12,056
10.4 24.6 6.0 0.8 0.0 8.8 32.7 8.5 8.2 0.5
650 9,553 4,902 485 11 1,183 18,070 2,568 7,787 45,209
1.4 21.1 10.8 1.1 0.0 2.6 40.0 5.7 17.2 2.1
461 789 810 406 33 220 1,138 1,247 802 5,906
7.8 13.4 13.7 6.9 0.6 3.7 19.3 21.1 13.6 0.3
494,822 359,710 92,008 13,500 873 376,462 706,108 85,461 72,212 2,201,156
22.5 16.3 4.2 0.6 0.0 17.1 32.1 3.9 3.3 100.0
Minor Effect Moderate Effect Major Effect (Col %) (Col %) (Col %) 43.5 24.4 17.7 6.0 2.1 0.5 0.2 0.0 5.5
Unknown
No.
TABLE 13. Duration of Clinical Effects by Medical Outcome
ⱕ2 hours ⬎2 hours, ⱕ8 hours ⬎8 hours, ⱕ24 hours ⬎24 hours, ⱕ3 days ⬎3 days, ⱕ1 week ⬎1 week, ⱕ1 month ⬎1 month Anticipated permanent Unknown
Adverse Reaction
Col %
dermal burn, sinus tachycardia without hypotension, and transient cough). Moderate effect: The patient exhibited signs or symptoms as a result of the exposure that were more pronounced, more prolonged, or more systemic in nature than minor symptoms. Usually some form of treatment is indicated. Symptoms were not life-threatening and the patient had no residual disability or disfigurement (eg, corneal abrasion, acid-base disturbance, high fever, disorientation, hypotension that is rapidly responsive to treatment, and isolated brief seizures that respond readily to treatment). Major effect: The patient exhibited signs or symptoms as a result of the exposure that were life-threatening or resulted in significant residual disability or disfigurement (eg, repeated seizures or status epilepticus, respiratory compromise requiring intubation, ventricular tachycardia with hypotension, cardiac or respiratory arrest, esophageal stricture, and
Duration of Effect
Other
8.0 22.1 30.8 17.1 7.9 2.7 0.7 0.2 10.6
3.2 10.7 29.1 28.5 13.1 4.6 1.4 2.5 6.9
disseminated intravascular coagulation). Death: The patient died as a result of the exposure or as a direct complication of the exposure. Only those deaths that were probably or undoubtedly related to the exposure are coded here. Not followed, judged as nontoxic exposure: No follow-up calls were made to determine the patient’s outcome because the substance implicated was nontoxic, the amount implicated was insignificant, or the route of exposure was unlikely to result in a clinical effect. Not followed, minimal clinical effects possible: No follow-up calls were made to determine the patient’s outcome because the exposure was likely to result in only minimal toxicity of a trivial nature. (The patient was expected to experience no more than a minor effect.) Unable to follow, judged as a potentially toxic exposure: The patient was lost to follow-up, refused followup, or was not followed but the exposure was significant and may have resulted in a moderate, major, or fatal outcome. Unrelated effect: The exposure was probably not responsible for the effect. Confirmed nonexposure: This outcome option was coded to designate cases where there was reliable TABLE 14. Decontamination and Therapeutic Intervention Therapy
No. of Patients
%
Decontamination only Observation only No therapy provided Decontamination and other therapy Other therapy only (no decontamination) Unknown if therapy provided/patient refused
1,269,005 295,301 259,634 140,888 103,196 133,132
57.7 13.4 11.8 6.4 4.7 6.0
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TABLE 15. Therapy Provided in Human Exposure Cases Therapy
TABLE 17A. Substances Most Frequently Involved in Human Exposures No.
Decontamination Dilution/irrigation Activated charcoal, single dose Cathartic Gastric lavage Ipecac syrup Activated charcoal, multidose Other emetic Whole bowel irrigation Measures to Enhance Elimination Hemodialysis Hemoperfusion Other extracorporeal procedure Specific Antidote Administration N-acetylcysteine (oral) Naloxone Flumazenil Antivenin Atropine N-acetylcysteine (IV) Ethanol Phytonadione Fab fragments Hyperbaric oxygen Pyridoxine Folate Physostigmine Pralidoxime (2-PAM) Deferoxamine Succimer Methylene blue EDTA Dimercaprol (BAL) Sodium thiosulfate Amyl nitrite Sodium nitrite Penicillamine Hydroxocobalamin Other intervention Alkalinization Transplantation ECMO
1,129,656 136,151 69,039 37,084 21,942 9,702 6,667 2,064 1,049 33 25 10,893 8,195 1,952 910 815 785 602 370 334 293 253 235 180 178 149 139 105 88 79 59 44 44 33 5 6,247 23 13
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 2,155,952 2,192,088 2,241,082 2,201,156
% of Exposures Ipecac Activated Involving Administered Charcoal Children (% of Administered ⬍6 Years Exposures) (% of Exposures) 64.0 64.1 63.4 63.0 62.3 61.8 61.1 60.8 59.9 58.8 56.0 54.1 52.9 52.8 52.5 52.7 52.5
No.
%*
Cleaning substances Analgesics Cosmetics and personal care products Plants Foreign bodies Cough and cold preparations Bites/envenomations Topicals Insecticides/pesticides (includes rodenticides) Food products, food poisoning Sedatives/hypnotics/antipsychotics Antidepressants Hydrocarbons Antimicrobials Chemicals Alcohols
217,476 214,066 205,242 113,864 105,837 99,873 92,137 84,922 78,853 74,980 71,809 70,060 62,772 59,933 59,312 54,282
9.9 9.7 9.3 5.2 4.8 4.5 4.2 3.9 3.6 3.4 3.3 3.2 2.9 2.7 2.7 2.5
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of human exposures rather than the total number of substances.
and objective evidence that an exposure initially believed to have occurred actually never occurred (eg, all missing pills are later located). All cases coded as confirmed nonexposure are excluded from this report. In 1999 there were 6,954 such cases reported nationally. Tables 14 and 15 outline the use of decontamination procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this database. These must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 1.0% of cases. In children under 6 years of age, ipecac syrup was most often administered outside a health care facility. This pattern was reversed TABLE 17B. Substances Most Frequently Involved in Pediatric Exposures (Children Under 6 Years)
TABLE 16. Decontamination Trends
Human Exposures Year Reported
Substance
13.4 12.9 15.0 13.3 10.1 8.4 7.0 6.1 5.2 4.3 3.7 2.7 2.3 1.8 1.5 1.2 1.0
4.0 4.0 4.6 5.2 5.2 6.5 6.4 6.7 7.0 7.3 7.3 6.8 7.7 7.3 7.1 6.8 6.6
Substance
No.
%*
Cosmetics and personal care products Cleaning substances Analgesics Plants Foreign bodies Topicals Cough and cold preparations Insecticides/pesticides (includes rodenticides) Vitamins Gastrointestinal preparations Antimicrobials Arts/crafts/office supplies Antihistamines Hydrocarbons Hormones and hormone antagonists
153,057 123,575 87,471 79,287 76,268 65,561 63,951 43,107 38,651 36,133 34,940 29,225 24,981 24,468 23,661
13.3 10.7 7.6 6.9 6.6 5.7 5.5 3.7 3.3 3.1 3.0 2.5 2.2 2.1 2.0
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in children under six years, rather than the total number of substances.
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TABLE 17C. Substances Most Frequently Involved in Adult Exposures (⬎19 years)
TABLE 19. 17-Year Comparisons of Fatality Data
Substance
No.
%*
Analgesics Cleaning substances Bites/envenomations Sedatives/hypnotics/antipsychotics Antidepressants Food products, food poisoning Cosmetics and personal care products Chemicals Alcohols Hydrocarbons Fumes/gases/vapors Insecticides/pesticides (includes rodenticides) Cardiovascular drugs Plants Cough and cold preparations Antihistamines
74,602 64,691 52,349 50,311 42,983 36,924 30,029 29,441 28,020 25,676 25,056 24,510 22,947 16,764 15,868 15,294
10.3 9.0 7.2 7.0 6.0 5.1 4.2 4.1 3.9 3.6 3.5 3.4 3.2 2.3 2.2 2.1
NOTE: Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in adults (over 19 years), rather than the total number of substances.
in teenagers and adults, likely reflecting the greater proportion of these patients treated in emergency departments. Ipecac was used most frequently in children under 6 years of age (83.4% of all ipecac use). Table 16 shows a continuing decline in the use of ipecac-induced emesis in the treatment of poisoning. Table 17A presents the most common substance categories listed by frequency of exposure. Tables 17B and 17C present similar data for children and adults, respectively, and show the considerable differences between pediatric and adult poison exposures. Table 18 lists the substance categories with the largest number of reported deaths; analgesics and antidepressants lead this list. Table 19 shows little TABLE 18. Categories with Largest Numbers of Deaths
Category
No.
% of All Exposures in Category
Analgesics Antidepressants Cardiovascular drugs Stimulants and street drugs Sedative/hypnotics/antipsychotics Alcohols Gases and fumes Chemicals Antihistamines Muscle relaxants Automotive products Insecticides/pesticides (includes rodenticides) Anticonvulsants Hormones/hormone antagonists Cleaning substances
340 153 127 121 110 97 45 43 28 18 15 15 14 13 13
0.159 0.218 0.290 0.346 0.153 0.179 0.109 0.072 0.054 0.137 0.103 0.019 0.060 0.033 0.006
NOTE: Tables 18, 22A and 22B are based on a total of up to two substances coded per exposure, while Table 21 has up to three substances coded.
Total Fatalities
Suicides
Pediatric Deaths (⬍6 years)
Year
No.
% of Cases
No.
% of Deaths
No.
% of Deaths
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
95 293 328 406 397 545 590 612 764 705 626 766 724 726 786 775 873
0.038 0.040 0.036 0.037 0.034 0.040 0.037 0.036 0.042 0.038 0.036 0.040 0.036 0.034 0.036 0.035 0.040
60 165 178 223 226 297 323 350 408 395 338 410 405 358 418 421 472
63.2 56.3 54.3 54.9 56.9 54.5 54.7 57.2 53.4 56.0 54.0 53.5 55.9 49.3 53.2 54.3 54.1
10 21 20 15 22 28 24 25 44 29 27 26 20 29 25 16 24
10.5 7.2 6.1 3.7 5.5 5.1 4.1 4.1 5.8 4.1 4.3 3.4 2.8 4.0 3.2 2.1 2.7
variation over the past 17 years in the percentage of cases reported to TESS that are fatal poisonings and in the percentage of reported fatalities due to suicide. In contrast, the percentage of reported fatalities involving children younger than 6 years has declined. A breakdown of plant exposures is provided for those most commonly implicated (Table 20). A summary of the 873 fatal exposures is presented in Table 21. Each of these cases was abstracted and verified by the reporting center, with only those exposures deemed ‘‘probably’’ or ‘‘undoubtedly’’ responsible for the fatality included in this compendium. The highest blood concentration of implicated substances is provided when available to the reporting poison center. Prehospital cardiac and/or respiratory arrests occurred in 34% of all fatalities, and these are indicated in Table 21. All fatality abstracts from participating centers were reviewed in detail. Selected representative, interesting or unusual cases are presented in the Appendix. After extensive review, 873 fatalities reported in 1999 were deemed related to the exposure. Although the overall number of deaths increased by over 10% compared to 1998, much of this increase is attributed to an increase in the number of indirect reports obtained from medical examiners. Analgesics, antidepressant, cardiovascular drugs and stimulant and street drugs were the primary substances involved in 64% of the fatalities. The majority of analgesic fatalities (71%) were caused by acetaminophen, aspirin, and other salicylates. Although nontricyclic antidepressants accounted for 80% of antidepressant exposures, tricyclic antidepressants were the primary substances implicated in 75% of antidepressant fatalities. Of the 92 deaths in which cardiovascular drugs were the primary substances, calcium channel blockers accounted for 55%. Cocaine and heroin were responsible for 55% and 29%, respectively, of the 91 deaths for which stimulants and street drugs were the primary substances. Remarkably, 75% of fatalities involving digoxin were therapeutic errors.
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TABLE 20. Frequency of Plant Exposures by Plant Type Botanical Name
Common Name
Frequency
Capsicum annuum Philodendron spp. Spathiphyllum spp. Euphorbia pulcherrima Ilex spp. Phytolacca americana Ficus spp. Dieffenbachia spp. Toxicodendron radicans Crassula spp. Epipremnum aureum Malus spp.
Pepper Philodendron Peace lily Poinsettia Holly Pokeweed, inkberry Rubber tree, weeping fig Dumbcane Poison ivy Jade plant Pothos, devil’s ivy Apple, crabapple (plant parts) Eucalyptus English ivy Rhododendron, azalea Dandelion Chrysanthemum African violet Christmas cactus Pyracantha
4,721 3,790 3,429 3,236 3,197 2,839 1,975 1,870 1,617 1,458 1,227 1,120
Eucalyptus spp. Hedera helix Rhododendron spp. Taraxacum officinale Chrysanthemum spp. Saintpaulia ionantha Schlumbergera Bridgesii Pyracantha spp.
fourth infant died from methadone intentionally added to formula by the infant’s mother for sedation. Two of the three therapeutic errors occurred in hospitals. Fourteen (58%) deaths in children younger than 6 years of age were caused by nonpharmaceuticals; this contrasts sharply with the observation that pharmaceuticals were involved in 78% of all deaths in this report. One-third of deaths in children under 6 years of age were environmental, with all but one of these deaths caused by carbon monoxide. Three deaths in children 2 years of age and under resulted from aspiration of an oil or hydrocarbon. In adolescents (13 to 19 years of age), 85% of deaths were intentional and for 66% of these deaths, pharmaceuticals were the primary substance responsible. Many adolescent fatalities were caused by substances which are relatively inexpensive and easily accessible to adolescents such as nonprescription analgesics and volatile inhalants. Analgesics, primarily products containing acetaminophen and aspirin, were involved in 30% of deaths. Volatile inhalant abuse is a persistent problem in adolescents. Of 53 fatalities in adolescents, 23% resulted from intentional inhalation abuse of air fresheners and hydrocarbons. An additional death in a 14-year-old resulted from chronic inhalation of a xylene/methanol containing solvent for an unknown reason. Stimulants and street drugs were involved in 10 (19%) adolescent deaths. Tables 22A and 22B provide comprehensive demographic data on patient age, reason for exposure, medical outcome, and use of a health care facility for all 2,201,156 exposures, presented by category. Table 22A focuses on nonpharmaceuticals; Table 22B presents drugs. Of the 2,368,496 substances logged in Tables 22A and 22B, 56.9% were nonpharmaceuticals and 43.1% were pharmaceuticals. The reason for the exposure was intentional for 25.0% of pharmaceutical substances implicated compared with only 3.9% of nonpharmaceutical substances. Correspondingly, treatment in a health care facility was provided in a higher percentage of exposures to pharmaceutical substances (34.4%) compared with nonpharmaceutical substances (16.2%). Pharmaceutical exposures also had more severe outcomes. Of substances implicated in fatal cases, 78.0% were pharmaceuticals, compared with only 43.1% in nonfatal cases. Similarly, 79.0% of substances implicated in major outcomes were pharmaceuticals. In closing, we gratefully acknowledge the extensive contributions of each participating poison center and the assistance of the many health care providers who provided comprehensive data to the poison centers for inclusion in this database.
1,009 1,000 942 919 883 877 859 781
NOTE: This table provides the frequency of involvement of plants in exposures reported to poison centers with no correlation with severity of toxicity. Several of the plants on the list pose little, if any, ingestion hazard.
Among nonpharmaceuticals, the largest single category responsible for fatalities was fumes and gases, which included 32 carbon monoxide exposures. Interestingly, there were eight deaths from mushrooms and plants in adults. All of the mushroom deaths resulted from mistaking a poisonous mushroom for an edible nonpoisonous one. All three of the plant exposures were intentional. There were 10 deaths associated with gamma hydroxybutyrate (GHB) or a GHB analog in 1999 compared with only one to two deaths each year between 1995 and 1998. For eight of the deaths, GHB or a GHB analog was the primary substance. Nine of the deaths occurred in adults and were intentional. One additional death in an 18-year-old involved ethanol as the primary substance and was malicious. As federal and state restrictions on GHB and its analogs become more stringent, it will be interesting to look for trends in GHB related exposures and fatalities. In children under 6 years of age, 83% of the 24 deaths were unintentional. Three of the remaining deaths were the result of malicious intent by a parent or caretaker and the TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999
Case
Age
Substances
Chronicity
Route
Reason
Parenteral Parenteral Ingestion
Adv rxn Adv rxn Int suicide
NONPHARMACEUTICALS Adhesives/glue 42 yr 1a 78 yr 2a 41 yr 3a
Methylmethacrylate Methylmethacrylate Tetrahydrofuran/methyl ethyl ketone cement methyl ethyl ketone cleaner See also case 185 (glue).
A A A
(Continued on following page)
Blood Concentrations
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
526
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case Alcohols 4ipm 5ipm 6ipm 7ipm 8ipm 9 10ipm 11 12 13 14
Age
21 yr 42 yr 45 yr 45 yr 46 yr 51 yr 57 yr 60 yr 62 yr 62 yr 43 yr
15p
32 yr
16
43 yr
17p
42 yr
Substances
Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol acetaminophen Ethanol acetaminophen/hydrocodone diazepam Ethanol benzodiazepine marijuana Ethanol carisoprodol
Chronicity
Route
Reason
A U U U A/C C U A/C C U C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int abuse Int abuse Int abuse Int abuse Unknown Int abuse Int abuse Int suicide Int abuse Unknown Int abuse
A
Ingestion
Int abuse
A/C
Ingestion
Int abuse
A
Ingestion
Int suicide
propoxyphene 18
Blood Concentrations
Interval After Exposure
207 mg/dL 400 mg/dL
220 mg/dL 16 µg/mL¥ hydrocodone 150 ng/mL 240 ng/mL 533 mg/dL
100 mg/dL§ 15.8 µg/mL§ meprobamate 21 µg/mL§ 0.17 µg/mL§ norpropoxyphene 0.86 µg/mL§
44 yr
Ethanol A/C Ing/Inh Int abuse cocaine 36 yr Ethanol A Ingestion Int abuse 337 mg/dL 19p diazepam propoxyphene 20 51 yr Ethanol A/C Ingestion Int suicide 360 mg/dL doxepin acetaminophen/codeine 18 yr Ethanol A Ingestion Malicious 367 mg/dL 21ap gamma hydroxybutyrate 17 µg/mL ⬎19 yr Ethanol A/C Ingestion Int suicide 380 mg/dL§ 22ip paroxetine 970 ng/mL§ chlordiazepoxide 47 yr Ethanol A/C Ingestion Int abuse 600 mg/dL 23p trifluoperazine trazodone 24 69 yr Isopropanol A Ingestion Int abuse 184 mg/dL 25 47 yr Methanol A Ingestion Unknown 70 mg/dL 26 50 yr Methanol A Ingestion Int suicide 252 mg/dL 27 62 yr Methanol A Ingestion Int suicide 90 mg/dL 28 68 yr Methanol U Ingestion Int unk 126 mg/dL 29 41 yr Methanol A Ingestion Int unk cocaine 30 46 yr Methanol A Ingestion Int suicide cocaine opiate See also cases 46, 53, 71, 74, 82, 140, 141, 162, 173, 244 thru 252, 261, 271 thru 273, 293, 297, 300 thru 302, 306, 327, 328, 361, 362, 385, 386, 390, 401, 409, 420, 422-429, 438, 447, 448, 453, 482, 490, 493-498, 502, 507, 517, 518, 541, 549, 554, 573, 578, 584, 585, 612, 617, 649, 659, 665, 670, 683, 718, 721, 749, 750, 757, 774, 779, 818 thru 820, 826, 854 thru 856, 862, 863, 867 (ethanol). Automotive products 31 23 yr 32 26 yr 30 yr 33p 34 30 yr 35 42 yr 50 yr 36p 37 51 yr 38 54 yr 39 56 yr 40 37 yr
Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) Antifreeze (ethylene glycol) amitriptyline
A A A A A A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Unknown Ingestion
(Continued on following page)
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int unk Int suicide Int suicide Int suicide
13 mg/dL 86 mg/dL§
160 mg/dL
948 mg/dL
9.5 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
527
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 41 42p 43p 44
Age 25 yr 34 yr 44 yr 85 yr
Substances
Gas line antifreeze (methanol) Gas line antifreeze (methanol) Gas line antifreeze (methanol) Transmission fluid (hydrocarbon) alprazolam 40 yr Windshield washer fluid (methanol) 45ap 36 yr Windshield washer fluid (methanol) 46p ethanol transmission fluid (hydrocarbon) 47 15 yr Unknown automotive product See also case 46 (transmission fluid, hydrocarbon). Bites and envenomations 48 41 yr Hymenoptera 83 yr Hymenoptera 49p 50 56 yr Hymenoptera pyrethrins 6 yr Loxosceles reclusa 51ai 42 yr Loxosceles reclusa 52a 43 yr Rattlesnake 53a ethanol 45 yr Unknown snake 54p
Chronicity
Route
Reason
A A A A
Ingestion Ingestion Ingestion Asp/Ing
Int suicide Int suicide Int suicide Int suicide
A A
Ingestion Ingestion
Int abuse Int suicide
A
Derm/Inh
Env
A A A
Bite/sting Bite/sting Bite/sting
A A A
Bite/sting Bite/sting Bite/ sting/Inh Bite/sting Bite/sting Bite/sting
Bite/sting Bite/sting Bite/sting
A
Bite/sting
Bite/sting
Blood Concentrations
431 mg/dL
Interval After Exposure
16 h
Chemicals 55ap 56p 57a 58
25 yr 32 yr 97 yr ⬎19 yr
Cyanide, potassium A Ingestion Int suicide Cyanide, potassium A Ingestion Int suicide Cyanide A Inhalation Int suicide Cyanide A Inhalation Env carbon monoxide/smoke 59 29 yr Dichromated titanium/amorphous boron/ A Derm/Inh Occ potassium perchlorate/barium chromate 15 yr Ethylene glycol U Ingestion Unknown 60a 61 25 yr Ethylene glycol A Ingestion Int suicide 62 27 yr Ethylene glycol A Ingestion Int suicide 63 32 yr Ethylene glycol A Ingestion Int suicide 64 35 yr Ethylene glycol A Ingestion Int unk 65 39 yr Ethylene glycol U Ingestion Int unk 66 42 yr Ethylene glycol A Ingestion Int suicide 67 44 yr Ethylene glycol A Ingestion Int suicide 68 44 yr Ethylene glycol A Ingestion Int suicide 69 44 yr Ethylene glycol A Ingestion Int suicide 70 28 yr Ethylene glycol A Ingestion Int suicide diphenhydramine 71 25 yr Ethylene glycol A Ingestion Int suicide ethanol 17 yr Ethylene glycol A Ingestion Int suicide 72a flurazepam 27 yr Formaldehyde A Ingestion Int suicide 73a 74 39 yr Hydrochloric acid A Ingestion Int suicide ethanol 75 68 yr Hydrochloric acid A Ing/Ocular Int suicide gasoline 76 70 yr Hydrochloric acid A Ingestion Int suicide malathion calcium acid methanearsonate 77 30’s yr Hydrofluoric acid A Derm/Inh Occ 78 30’s yr Hydrofluoric acid A Derm/Inh Occ 79 48 yr Hydrofluoric acid (70%) A Dermal Occ ⬎19 yr Hydrofluoric acid A Derm/Inh Occ 80p 81 63 yr Lye A Ingestion Int suicide 82 61 yr Propylene glycol A Ingestion Int unk ethanol 69 yr Sodium nitrite A/C Ingestion Int misuse 83a 84 72 yr Sulfuric acid (20%) A Ingestion Int suicide See also cases 771 (ammonia); 136 thru 138 (cyanide); 351 (hydrofluoric acid); 145 (phosphoric acid).
(Continued on following page)
150 µg/mL§ 120 µg/mL§ ⬎10 µg/mL 553 µg/mL
77 mg/dL 65 µg/mL§ 71 mg/dL 40 mg/dL 376 mg/dL 78 mg/dL 58 mg/dL
29 mg/dL ⬎5,000 µg/mL§ 197 mg/dL
4 mg/dL§ methemoglobin 38%
18 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
528
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Cleaning substances 12 mo Degreaser (hydrochloric acid 3%/ A Ingestion Unint gen 85a ammonium bifluoride 14%) 86 65 yr Disinfectant (diethylene glycol monobutyl A Ingestion Int abuse ether/alkyl dimethyl benzyl ammonium chlorides) 87 61 yr Drain opener (hydrochloric acid, 15-18%) A Ingestion Int suicide 88 43 yr Drain opener (sodium hydroxide, 50-60%) A Ingestion Int suicide 89 54 yr Drain opener (sodium hydroxide) A Ingestion Malicious 65 yr Drain opener (sodium hydroxide) A Ingestion Int suicide 90ip 66 yr Drain opener (sulfuric acid, 93-100%) A Ingestion Int suicide 91a 48 yr Hydrofluoric acid cleaner A Ingestion Int suicide 92a 93 51 yr Hydrofluoric acid cleaner A Ingestion Unknown 94 51 yr Pine oil/isopropanol cleaner A Asp/Ing Int suicide 82 yr Pine oil/isopropanol cleaner A Asp/Ing Int suicide 95a 96 51 yr Pine oil/isopropanol cleaner A Ingestion Int suicide cocaine benzodiazepine 30’s yr Tape head cleaner (ethylene chloride) A Inhalation Int abuse 97p air freshener 18 mo Tire cleaner (hydrofluoric acid or ammonium A Ingestion Unint gen 98a bifluoride) 99 45 yr Toilet bowl cleaner (hydrochloric acid, 15%) A Ingestion Int suicide See also cases 3 (cleaner, methyl ethyl ketone); 872 (cleaner, trichlorocyanuric acid); 771 (fabric spray, zinc chloride); 188 (toilet bowl cleaner, hydrochloric acid). Cosmetics and personal care products 12 mo Hair oil (safflower oil/mineral oil) 100a 16 yr Hair spray (hydrofluorocarbon/isobutane/ethanol) 101a amphetamine/dextroamphetamine 102 64 yr Mouthwash (ethanol 26.9%/methyl salicylate/eucalyptol) See also case 586 (mouthwash, ethanol). Deodorizers 103 104p 105p 106p
12 yr 14 yr 16 yr 16 yr
Air freshener Air freshener (isobutane/propane propellant) Air freshener (aerosol) Air freshener (butane/isobutane/propane propellant) 19 yr Air freshener (aerosol) 107p See also case 97 (air freshener). Essential Oils 2 yr 108a 87 yr 109a
Citronella oil Potpourri oil
A A
Asp/Ing Ing/Inh
Unint gen Int abuse
A/C
Ingestion
Int misuse
A A A A
Inhalation Inhalation Inhalation Inhalation
Int abuse Int abuse Int abuse Int abuse
A
Inhalation
Int abuse
A A
Asp/Ing Asp/Ing
Unint gen Unint misuse
A A A A A A A A A A A A A A A A A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Occ Env Env Env Env Env Env Env Env Env Env Int suicide Int suicide Int suicide Env Int suicide Int suicide Int suicide
amphetamine 0.12 µg/mL§
Foreign Bodies See also cases 458, 460 (activated charcoal). Fumes, gases and vapors 50 yr Carbon dioxide (dry ice) 110ap 18 mo Carbon monoxide/smoke 111p 2 yr Carbon monoxide 112a 113 2 yr Carbon monoxide/smoke 3 yr Carbon monoxide 114p 115 4 yr Carbon monoxide/smoke 5 yr Carbon monoxide/smoke 116p 5 yr Carbon monoxide/smoke 117p 11 yr Carbon monoxide 118p 12 yr Carbon monoxide 119p 20 yr Carbon monoxide 120i 27 yr Carbon monoxide 121p 30 yr Carbon monoxide 122p 30’s yr Carbon monoxide 123ip 36 yr Carbon monoxide 124p 37 yr Carbon monoxide 125p 39 yr Carbon monoxide 126p 39 yr Carbon monoxide 127p
(Continued on following page)
39% 37% 45% 40% 36% 55% 57% 52%§ 42% 72%§
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
529
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 128p 129p 130p 131p 132p 133p 134 135p 136
Age
Substances
42 yr 44 yr 48 yr 67 yr 73 yr 76 yr 80 yr ⬎19 yr 18 yr
Chronicity
Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke Carbon monoxide/smoke Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke cyanide 40’s yr Carbon monoxide/smoke 137p cyanide 56 yr Carbon monoxide/smoke 138p cyanide 22 yr Carbon monoxide 139p diphenhydramine 24 yr Carbon monoxide 140ip ethanol 53 yr Carbon monoxide 141ip ethanol 142 50 yr Carbon monoxide hydroxyzine 70 yr Chlorine gas (sulfuric acid and hypochlorite drain 143p opener mixed) 32 yr Hydrogen sulfide 144p 40 yr Hydrogen sulfide 145p phosphoric acid 18 yr Nitrous oxide propellant (whipped cream) 146p 20 yr Nitrous oxide propellant (whipped cream) 147p 16 yr Propane 148p 31 yr Propane 149p 150 30 yr Unknown sewer gas See also cases 58, 357, 358, 440 (carbon monoxide).
Route
Reason
Blood Concentrations
A A A A A A U A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Env Int suicide Env Env Env Int suicide Env Env Env
14% 55% 27%
A
Inhalation
Env
35%
A
Inhalation
Env
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
A
Inhalation
Unint misuse
A A
Inhalation Inhalation
Occ Occ
A A A/C A A
Inhalation Inhalation Inhalation Inhalation Inhalation
Int abuse Int unk Int abuse Int abuse Occ
Heavy metals 72 yr Lead 151a 152 42 yr Mercury See also case 76 (calcium acid methanearsonate).
C U
Ingestion Inhalation
Unint misuse Unknown
Herbicides 38 yr Acrolein 153ap 60 yr Dinitrobutylphenol 154a 47 yr Glyphosate 155a 44 yr Monosodium methylarsonate 156a 157 58 yr Monosodium methylarsonate (35%) 16 yr Paraquat 158a See also case 830 (herbicide, unknown type).
A A A A A A
Derm/Inh Ingestion Ingestion Ingestion Ingestion Ingestion
Occ Unint misuse Int unk Int suicide Int suicide Int suicide
A/C A A A
Inhalation Inhalation Inhalation Ing/Inh
Int abuse Int abuse Int abuse Int abuse
A A A A C
Inhalation Inhalation Inhalation Asp/Ing Inhalation
Malicious Int abuse Occ Unint gen Unknown
Hydrocarbons 159p 160ap 161p 162p
14 yr 15 yr 17 yr 18 yr
Butane Butane Butane Butane ethanol marijuana 4 yr Chlorodifluoromethane 163ap 39 yr Difluoroethane 164p 35 yr Fluorocarbon 165p 2 yr Lighter fluid 166a 167 14 yr Solvent (xylene/methanol) See also case 75 (gasoline).
(Continued on following page)
48% 43%
51% 2,900 µg/mL 40%§ 0.53 µg/mL§ 85%§ 10 mg/dL§ 81%§ 60 mg/dL§ 27%
302 µg/dL 29.5 µg/dL
7.7 µg/mL
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
530
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Insecticides/pesticides (excluding rodenticides) 16 mo Aluminum phosphate 168p 62 yr Chlordane 169a 170 60 yr Chlorpyrifos 171 33 yr Malathion 172 55 yr Malathion 173 ⬎19 yr Malathion ethanol 27 yr Nitric acid/lead arsenate 174a 175 21 yr Prolan 176 11 yr Unknown insecticide 177 45 yr Unknown insecticide See also cases 76 (malathion); 50 (pyrethrins); 828 (unknown pesticide). Mushrooms 178 61 yr Amanita species 63 yr Amanita species 179a 62 yr Lepiota josserandii 180a 181 70 yr Mushroom (probably Amanita species) 182 88 yr Mushroom (probably Amanita species) See also case 823 (mushroom, hallucinogenic). Plants 183a 184ap 185a
20 yr 21 yr 48 yr
Jimson weed (Datura stramonium) Jimson weed (Datura stramonium) Melia azedarach glue
Rodenticides 186 33 yr 187 38 yr
Anticoagulant rodenticide (long acting) Anticoagulant rodenticide bromethalin 188 60 yr Zinc phosphide toilet bowel cleaner (hydrochloric acid, 15-20%) See also case 187 (bromethalin). PHARMACEUTICALS Analgesics 189 12 yr 17 yr 190a 191 20 yr 192 20’s yr 193 22 yr 194 22 yr 195 23 yr 24 yr 196a 197 25 yr 198 25 yr 199 26 yr 200 26 yr 201 27 yr 202 30 yr 203 31 yr 204 31 yr 205 31 yr 206 32 yr 207 33 yr 208 33 yr 209 34 yr
Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen
Route
Reason
C A A A A A
Ing/Inh Ingestion Ingestion Ingestion Ingestion Ingestion
Env Int suicide Int suicide Unint misuse Unknown Int suicide
A A C A
Ingestion Ingestion Inhalation Ingestion
Int unk Unint misuse Int misuse Unint gen
A A A U A
Ingestion Ingestion Ingestion Ingestion Ingestion
Unint misuse Unint misuse Unint misuse Unint misuse Unint misuse
A A C
Ing/Inh Ing/Inh Ing/Inh
Int abuse Int abuse Int misuse
C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
C A U A A A A/C A A A C A A/C A C A A C A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Adv rxn Int suicide Int suicide Int misuse Int misuse Int suicide Int misuse Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int suicide Int suicide Ther error Int suicide Int suicide Int suicide
(Continued on following page)
Blood Concentrations
Interval After Exposure
51 µg/mL
69 µg/mL 54 µg/mL 465 µg/mL 27 µg/mL 19 µg/mL 126 µg/mL 155 µg/mL 173 µg/mL
36 h
28 h
42 µg/mL
352 µg/mL
16.5 h
97 µg/mL
72 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
531
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 210 211 212 213 214a 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236
Age 38 yr 40 yr 40 yr 40’s yr 41 yr 41 yr 41 yr 43 yr 44 yr 49 yr 50 yr 51 yr 54 yr 56 yr 64 yr 65 yr 66 yr 68 yr 70 yr 70 yr 74 yr 74 yr 75 yr 88 yr 97 yr 97 yr 40 yr
237
48 yr
238
79 yr
239
57 yr
240
54 yr
241
50 yr
242
31 yr
243
39 yr
244
16 yr
245
32 yr
246
40 yr
247
42 yr
248
44 yr
249
51 yr
250
67 yr
251
77 yr
252
55 yr
253
42 yr
254
23 yr
Substances Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen acetaminophen/diphenhydramine Acetaminophen acetaminophen/hydrocodone Acetaminophen acetaminophen/oxycodone Acetaminophen aspirin Acetaminophen aspirin ibuprofen Acetaminophen benzodiazepine Acetaminophen carisoprodol Acetaminophen diphenhydramine Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol Acetaminophen ethanol aspirin Acetaminophen fluphenazine trihexyphenidyl Acetaminophen heroin
Chronicity
Route
Reason
Blood Concentrations
C A C C A C C A A A C A U C A U C U C U A U C C C A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int misuse Int suicide Int misuse Ther error Int suicide Ther error Int misuse Int suicide Int suicide Int suicide Int misuse Int abuse Unknown Int misuse Unknown Int suicide Int unk Ther error Ther error Unknown Int unk Int suicide Ther error Ther error Ther error Ther error Int suicide
57 µg/mL 14 µg/mL 154 µg/mL 19 µg/mL 180 µg/mL 40 µg/mL 157 µg/mL
160 µg/mL 28 µg/mL 619 µg/mL 79 µg/mL 36 µg/mL 105 µg/mL 100 µg/mL 90 µg/mL 205 µg/mL
A
Ingestion
Int suicide
479 µg/mL
A/C
Ingestion
Int misuse
191 µg/mL
C
Ingestion
Int misuse
C
Ingestion
Int misuse
66 µg/mL 43 mg/dL 75 µg/mL 27 mg/dL
A/C
Ingestion
Int suicide
675 µg/mL
U
Ingestion
Int suicide
76 µg/mL
A
Ingestion
Int suicide
29 µg/mL
A
Ingestion
Int misuse
89 µg/mL
U
Ingestion
Int suicide
C
Ingestion
Int misuse
100 mg/dL 63 µg/mL
A/C
Ingestion
Int suicide
27 µg/mL
C
Ingestion
Int misuse
100 µg/mL
C
Ingestion
Int misuse
147 µg/mL
C
Ingestion
Int misuse
61 µg/mL
A
Ingestion
Int suicide
⬎400 µg/mL
C
Ingestion
Int misuse
146 µg/mL
A/C
Ingestion
Int suicide
A
Ing/Inh/Par Int abuse
72 h
48 h
34 µg/mL 54 µg/mL 631 µg/mL 48 µg/mL 200 µg/mL 26 µg/mL 145 µg/mL 29 µg/mL
32 mg/dL
(Continued on following page)
Interval After Exposure
153 µg/mL
12-20 h
14 h
19 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
532
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
255
71 yr
256
35 yr
257
17 yr
258
54 yr
259
72 yr
260
27 yr
Acetaminophen hydrochlorothiazide/lisinopril Acetaminophen ketoprofen Acetaminophen multiple vitamins with iron Acetaminophen oxycodone Acetaminophen quetiapine trazodone Acetaminophen/aspirin
261
36 yr
naproxen Acetaminophen/aspirin/caffeine
262 263
18 yr 30 yr
264 265 266 267 268 269
37 yr 21 yr 29 yr 39 yr 46 yr 35 yr
270p
90 yr
ethanol Acetaminophen/butalbital/caffeine/codeine Acetaminophen/caffeine acetaminophen/oxycodone acetaminophen/propoxyphene Acetaminophen/codeine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine acetaminophen/oxycodone carisoprodol Acetaminophen/diphenhydramine
271p
33 yr
acetaminophen/propoxyphene Acetaminophen/diphenhydramine
Route
Reason
A
Ingestion
Int suicide
1283 µg/mL
A
Ingestion
Int suicide
280 µg/mL
15 h
A
Ingestion
Int suicide
36 h 36 h
A/C
Ingestion
Int suicide
30 µg/mL iron 219 µg/dL 61 µg/mL
A
Ingestion
Int suicide
1441 µg/mL
A
Ingestion
Int suicide
359 µg/mL¥ 59 mg/dL¶
A
Ingestion
Int suicide
172 µg/mL¥ 50 mg/dL¶ 228 mg/dL
A C
Ingestion Ingestion
Int suicide Int misuse
13 µg/mL¥
A/C A A A A C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse
100 µg/mL¥ 269 µg/mL¥ 12 µg/mL¥
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
161 µg/mL¥
8h
U
Ingestion
Int misuse
59 µg/mL¥
19 h
A A C A U A A/C C U C C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int abuse Int unk Int suicide Int suicide Int misuse Int misuse Unknown Int suicide Int misuse Int suicide
132 µg/mL¥ 53 µg/mL¥ 15 µg/mL¥ 14 µg/mL¥ 134 µg/mL¥ 77 µg/mL¥ 33 µg/mL¥§
U U
Ingestion Ingestion
Int suicide Int unk
84 µg/mL¥
A/C
Ingestion
Int suicide
168 µg/mL¥
A
Ingestion
Unknown
A/C
Ingestion
Int suicide
ethanol 272
41 yr
273p
42 yr
274
46 yr
275
23 yr
276 277 278 279 280i 281 282p 283 284 285p 286 287
28 yr 36 yr 36 yr 36 yr 38 yr 46 yr 47 yr 47 yr 47 yr 48 yr 62 yr 63 yr
288 289
⬎19 yr 36 yr
290
40 yr
291
39 yr
292
42 yr
Acetaminophen/diphenhydramine ethanol Acetaminophen/diphenhydramine ethanol Acetaminophen/diphenhydramine zolpidem Acetaminophen/diphenhydramine unknown drug Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone Acetaminophen/hydrocodone
Acetaminophen/hydrocodone Acetaminophen/hydrocodone acetaminophen/oxycodone Acetaminophen/hydrocodone acetaminophen/oxycodone Acetaminophen/hydrocodone alprazolam Acetaminophen/hydrocodone alprazolam carisoprodol
Blood Concentrations
Interval After Exposure
(Continued on following page)
1.5 h 1.5 h
22 h
638 µg/mL¥ diphenhydramine 10.4 µg/mL§ 290 µg/mL¥§ diphenhydramine 19 µg/mL§ 210 mg/dL§ 109 µg/mL¥
30 µg/mL¥ 22 µg/mL¥ 65 µg/mL¥ hydrocodone 0.62 µg/mL
59 µg/mL¥
3-4 d
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
533
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
293p
37 yr
294p
41 yr
295
24 yr
296p
32 yr
297
44 yr
298
40 yr
299p
39 yr
300p
46 yr
301
55 yr
302
20 yr
303
46 yr
304
47 yr
305p
18 yr
306
35 yr
Substances Acetaminophen/hydrocodone benzodiazepine ethanol Acetaminophen/hydrocodone butorphanol carisoprodol Acetaminophen/hydrocodone carisoprodol Acetaminophen/hydrocodone carisoprodol diazepam Acetaminophen/hydrocodone chlordiazepoxide ethanol Acetaminophen/hydrocodone clonazepam Acetaminophen/hydrocodone diazepam cocaine Acetaminophen/hydrocodone ethanol Acetaminophen/hydrocodone ethanol Acetaminophen/hydrocodone ethanol cocaine Acetaminophen/hydrocodone hydromorphone alprazolam Acetaminophen/hydrocodone lorazepam acetaminophen/isometheptene/ dichloralphenazone Acetaminophen/hydrocodone methadone Acetaminophen/hydrocodone
307
22 yr
308
49 yr
309 310 311 312
43 yr 47 yr ⬎19 yr 42 yr
313
39 yr
314ip
42 yr
315
66 yr
316p
27 yr
317p
33 yr
318p
23 yr
methadone ethanol Acetaminophen/hydrocodone morphine (long-acting) Acetaminophen/hydrocodone oxycodone (long-acting) amitriptyline Acetaminophen/oxycodone Acetaminophen/oxycodone Acetaminophen/oxycodone Acetaminophen/oxycodone acetaminophen/codeine Acetaminophen/oxycodone acetaminophen/propoxyphene acetaminophen Acetaminophen/oxycodone alprazolam Acetaminophen/oxycodone amitriptyline Acetaminophen/oxycodone aspirin/carisoprodol alprazolam Acetaminophen/oxycodone zolpidem Acetaminophen/propoxyphene
319
36 yr
Acetaminophen/propoxyphene
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
A
Ingestion
Int unk
A/C
Ingestion
Int abuse
C
Ingestion
Int misuse
C
Ingestion
Int misuse
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int misuse
C
Ingestion
Int misuse
44 µg/mL¥
U
Ingestion
Int suicide
263 µg/mL¥
A
Ingestion
Int suicide
A
Ingestion
Int suicide
176 µg/mL¥
24 h
A
Ingestion
Int suicide
193 µg/mL¥
3h
U
Ingestion
Int unk
A/C
Ingestion
Int suicide
C
Ingestion
Int misuse
331 µg/mL¥ hydrocodone 870 ng/mL§ 0.29 µg/mL§ 229 mg/dL 88 µg/mL¥
A/C
Ingestion
Int suicide
193 µg/mL¥
U A A U
Ingestion Ingestion Ingestion Ingestion
Int misuse Int suicide Int suicide Int suicide
20 µg/mL¥
239 µg/mL¥
A
Ingestion
Int unk
161 µg/mL¥
A
Ingestion
Int unk
A/C
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
(Continued on following page)
85 µg/mL¥
92 µg/mL¥ hydrocodone 102 ng/mL 3400 ng/mL 53 mg/dL 15 µg/mL¥
34 µg/mL¥
143 µg/mL¥ propoxyphene 1.4 µg/mL norpropoxyphene 0.83 µg/mL 115 µg/mL¥
3h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
534
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 320 321p 322p 323
Age 77 yr 86 yr ⬎19 yr 87 yr
324
36 yr
325
53 yr
326p
24 yr
327p
36 yr
328p
20 yr
329
67 yr
330 331 332 333 334 335 336 337 338 339 340i 341 342 343 344 345 346 347 348 349
16 yr 16 yr 18 yr 40 yr 41 yr 41 yr 42 yr 43 yr 48 yr 54 yr 56 yr 61 yr 64 yr 70 yr 71 yr 72 yr 80 yr 89 yr 92 yr 20 yr
350
17 yr
351
35 yr
352
47 yr
353p
71 yr
354
50 yr
355i
70 yr
356p
23 yr
357
50 yr
358
67 yr
359
38 yr
360
64 yr
Substances Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene acetaminophen Acetaminophen/propoxyphene acetaminophen/hydrocodone Acetaminophen/propoxyphene alprazolam zolpidem Acetaminophen/propoxyphene cocaine tramadol Acetaminophen/propoxyphene cyclobenzaprine ethanol Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene lorazepam Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin acetaminophen Aspirin acetaminophen amphetamines Aspirin acetaminophen hydrofluoric acid Aspirin acetaminophen opiate Aspirin amitriptyline Aspirin amlodipine Aspirin aspirin/acetaminophen/caffeine Aspirin benztropine fluoxetine Aspirin carbon monoxide Aspirin carbon monoxide/smoke Aspirin chlorpromazine Aspirin diazepam trifluoperazine
Chronicity
Route
Reason
Blood Concentrations
A A A/C C
Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int misuse Int misuse
150 µg/mL¥ 99 µg/mL¥ 124 µg/mL¥
A
Ingestion
Int suicide
34 µg/mL¥
A
Ingestion
Int suicide
585 µg/mL¥
A/C
Ing/Unk
Int suicidal
60 µg/mL¥
A/C
Ingestion
Int suicide
74 µg/mL¥
A
Ingestion
Int suicide
300 mg/dL 85 µg/mL¥ 98 mg/dL
A/C
Ingestion
Int suicide
A A A A U C A A A A A A A/C A/C C A A/C A C U
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int misuse Int misuse Ther error Int suicide Int suicide Int suicide Ther error Int suicide
A
Ingestion
Int suicide
A
Ing/Inh
Int suicide
80 mg/dL 142 µg/mL
A
Ingestion
Int suicide
52 mg/dL 251 µg/mL
C
Ingestion
Int misuse
44 mg/dL
A/C
Ingestion
Int suicide
115 mg/dL
C
Ingestion
Int suicide
73 mg/dL
A
Ingestion
Int suicide
50 mg/dL
A
Ing/Inh
Int suicide
A
Ing/Inh
Int suicide
134 mg/dL 12% 123 mg/dL
A
Ingestion
Int suicide
88 mg/dL
A
Ingestion
Int suicide
68 mg/dL
(Continued on following page)
110 mg/dL 134 mg/dL 110 mg/dL 121 mg/dL 104 mg/dL 57 mg/dL 150 mg/dL 80 mg/dL 109 mg/dL 113 mg/dL 102 mg/dL 88 mg/dL 45 mg/dL 99 mg/dL 81 mg/dL 34 mg/dL 78 mg/dL 101 mg/dL 43 mg/dL 55 mg/dL 148 µg/mL 124 mg/dL 157 µg/mL
Interval After Exposure
48 h
10 h
18.5 h
8h
17 h 9h 31 h 17 h
6h 4.5 h
⬎10 h ⬎10 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
535
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
361
51 yr
362
58 yr
363
58 yr
364a
15 yr
365
86 yr
366
43 yr
367
16 yr
368
49 yr
369
50 yr
370p 371 372
⬎19 yr 56 yr 45 yr
373 374 375a 376 377 378 379p 380p
44 yr 45 yr 45 yr 46 yr 68 yr 86 yr 45 yr 76 yr
381p
68 yr
382p
46 yr
383
42 yr
384
37 yr
385p
51 yr
386p
387 388
389p
390 391 392aip 393p 394p
Substances Aspirin ethanol Aspirin ethanol Aspirin metformin Aspirin loratadine hydrochlorothiazide/triamterene Aspirin opioid Aspirin propoxyphene fluoxetine Aspirin pseudoephedrine/brompheniramine diphenhydramine Aspirin/butalbital diphenhydramine fluoxetine Aspirin/butalbital/caffeine/codeine alprazolam Aspirin/caffeine/dihydrocodeine Aspirin/oxycodone Aspirin/oxycodone trazodone hydroxyzine Colchicine Colchicine Colchicine Colchicine Colchicine Colchicine Fentanyl Fentanyl alprazolam promethazine Fentanyl irbesartan Fentanyl paroxetine acetaminophen/hydrocodone Fentanyl sufentanil morphine Hydrocodone benzodiazepine Hydrocodone
ethanol celecoxib 42 yr Hydrocodone ethanol olanzapine 39 yr Hydromorphone 42 yr Hydromorphone acetaminophen/hydrocodone carisoprodol 45 yr Hydromorphone methamphetamine imipramine 46 yr Ibuprofen ethanol ⬎19 yr Meperidine 5 mo Methadone 19 yr Methadone 35 yr Methadone
Chronicity
Route
Reason
Blood Concentrations
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
95 mg/dL 230 mg/dL 73 mg/dL 124 mg/dL 108 mg/dL
A
Ingestion
Int suicide
82 mg/dL
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
112 mg/dL codeine 0.662 µg/mL§ 104 mg/dL 0.72 µg/mL§ norpropoxyphene 2.5 µg/mL§ 1.65 µg/mL§ 101 mg/dL
A
Ingestion
Int suicide
29 mg/dL¶
A/C
Ingestion
Int suicide
U C A
Ingestion Ingestion Ingestion
Int suicide Ther error Int suicide
U A A A A/C C U C
Unknown Ingestion Ingestion Ingestion Ingestion Parenteral Dermal Derm/Ing
Unknown Int suicide Int suicide Int suicide Int suicide Ther error Int abuse Adv rxn
C
Derm/Ing
Int misuse
A/C
Derm/Ing
Int suicide
A
Parenteral
Int suicide
A
Ingestion
Int suicide
A
Ingestion
U
Ingestion
Unknown
A/C A
Parenteral Ingestion
Ther error Int suicide
A
Ing/Paren
Int suicide
C
Ingestion
Adv rxn
A A U A/C
Parenteral Ingestion Ingestion Ingestion
Ther error Int misuse Int abuse Int suicide
(Continued on following page)
40 mg/dL¶ 75 mg/dL¶
Interval After Exposure
5h
9h
8-12 h
9.6 ng/mL
4.3 ng/mL 21 ng/mL
220 ng/mL 780 ng/mL Int suicide hydrocodeine 300 ng/mL§ dihydrocodeine 34 ng/mL§ 185 mg/dL 480 ng/mL§ 130 mg/dL§
27.6 µg/mL§
0.3 µg/mL§
20 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
536
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
395ipm 396ipm 397p 398p
47 yr 56 yr 58 yr 37 yr
A U A A/C
Unknown Unknown Ingestion Ingestion
Int abuse Int abuse Int suicide Int abuse
399
37 yr
A
Ingestion
Int abuse
400p
60 yr
A/C
Ingestion
Int suicide
401p
36 yr
A/C
Ingestion
Int suicide
402p
30 yr
Methadone Methadone Methadone Methadone acetaminophen/hydrocodone Methadone alprazolam Methadone doxepin zolpidem Methadone ethanol Methadone promethazine diazepam
U
Ingestion
Int abuse
403p 404 405p 406p
37 yr 70 yr 85 yr 47 yr
A/C A/C A U
Ingestion Ingestion Ingestion Unknown
Int misuse Int suicide Int suicide Int unk
40 ng/mL§
407p
20 yr
A
Ing/Inh
Int abuse
65 ng/mL§
408
78 yr
Morphine (long acting) Morphine Morphine Morphine amphetamines marijuana Morphine codeine cocaine Morphine diphenhydramine diazepam
A
Ing/Paren
Int suicide
409p
35 yr
A
Ing/Unk
Int abuse
410p
38 yr
U
Ingestion
Int abuse
411ip
62 yr
A/C
Ingestion
Ther error
412p 413 414ipm 415ipm 416ipm 417
27 yr 37 yr 38 yr 41 yr 48 yr 23 yr
U U A U U U
Unknown Ingestion Unknown Unknown Unknown Unknown
Unknown Int suicide Int abuse Int abuse Int abuse Int unk
418p
42 yr
U
Ingestion
Int unk
419p
65 yr
A/C
Ingestion
Int suicide
420
22 yr
A
Ingestion
Int abuse
421
18 yr
Morphine ethanol Morphine meperidine clomipramine Morphine zolpidem propoxyphene Opiate Opiate Opiate Opiate Opiate Opiate benzodiazepine Opiate benzodiazepine Opiate benzodiazepine amphetamine Opiate benzodiazepine ethanol Opiate
A
Ingestion
U
Unknown
Int abuse
U
Unknown
Int abuse
U
Ingestion
Int abuse
U
Unknown
Int abuse
U
Unknown
Int abuse
diazepam
422ipm
21 yr
423ipm
24 yr
424ipm
24 yr
425ipm
31 yr
426ipm
36 yr
chlordiazepoxide Opiate ethanol Opiate ethanol Opiate ethanol Opiate ethanol Opiate ethanol
(Continued on following page)
Reason
Blood Concentrations
1.07 µg/mL§ 11 ng/mL§
0.33 µg/mL§ 370 mg/dL 0.35 µg/mL§ 0.07 µg/mL§ 80 ng/mL§ nordiazepam 360 ng/mL§
830 ng/mL 930 ng/mL 1450 ng/mL nordiazepam 410 ng/mL 57 ng/mL§ 30 mg/dL 160 ng/mL§ normeperidine 0.24 µg/mL§ 730 ng/mL§ 45 ng/mL§ norpropoxyphene 0.12 µg/mL§
30 mg/dL Unknown morphine 190 ng/mL§ mono-acetyl-morphine 100 ng/mL§ 110 ng/mL§ nordiazepam 20 ng/mL§
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
537
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
427ipm
38 yr
428ipm
43 yr
429ipm
45 yr
430
36 yr
431p 432ip 433p 434p 435p
22 yr 38 yr 46 yr 47 yr 19 yr
436p
39 yr
437p
40 yr
438im
42 yr
439
63 yr
440p
52 yr
441p 442ip
28 yr 43 yr
443 444p
74 yr 37 yr
Substances
Chronicity
Route
Reason
Opiate ethanol Opiate ethanol Opiate ethanol Opiate gabapentin unknown drug Oxycodone Oxycodone (long-acting) Oxycodone Oxycodone Oxycodone acetaminophen methocarbamol Oxycodone acetaminophen/oxycodone Oxycodone benzodiazepine Oxycodone ethanol Oxycodone (long-acting) nadolol Oxycodone temazepam carbon monoxide Propoxyphene Propoxyphene
U
Unknown
Int abuse
U
Unknown
Int abuse
U
Unknown
Int abuse
A/C
Ingestion
Int suicide
U A U A/C A/C
Unknown Parenteral Ingestion Unknown Ingestion
Int unk Int abuse Int suicide Int suicide Int suicide
A
Parenteral
Int abuse
A/C
Ingestion
Int suicide
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ing/Inh
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int unk
Propoxyphene Propoxyphene amitriptyline
A/C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Unknown
Int abuse
A
Ingestion
Int suicide
U U A/C
Ingestion Ingestion Ingestion
Int unk Unknown Int suicide
diazepam 445p
15 yr
446p
39 yr
447p
29 yr
448ipm
45 yr
449
29 yr
450 451 452
60 yr 63 yr 34 yr
Propoxyphene cyclobenzaprine Propoxyphene diphenhydramine alprazolam Propoxyphene diphenhydramine ethanol Propoxyphene hydrocodone ethanol Propoxyphene lorazepam acetaminophen/oxycodone Salicylate Salicylate Salicylate sertraline paroxetine
(Continued on following page)
Blood Concentrations
8.17 µg/mL§ norpropoxyphene 9.89 µg/mL§ 5 µg/mL§ 800 ng/mL§ nortriptyline 400 ng/mL§ 140 ng/mL§ nordiazepam 370 ng/mL§ 1 µg/mL norpropoxyphene 1 µg/mL
2.62 µg/mL§ norpropoxyphene 1.55 µg/mL§
86 mg/dL 108 mg/dL 68 mg/dL§ 1.9 µg/mL§ desmethylsertraline 0.6 µg/mL§ 2.1 µg/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
538
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
453ip
33 yr
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Tramadol U Ing/Paren Int unk 2600 ng/mL ethanol 380 mg/dL propranolol 0.59 µg/mL See also cases 14, 313, 323, 349 thru 352, 435, 457, 568, 644, 664, 687, 729 (acetaminophen); 20, 312, 535, 571 (acetaminophen/codeine); 236 (acetaminophen/ diphenhydramine); 702 (acetaminophen/diphenhydramine/pseudoephedrine/dextromethorphan); 15, 237, 324, 382, 388, 398, 559, 616, 739, 740 (acetaminophen/ hydrocodone); 304, 570, 693 (acetaminophen/isometheptene/dichloralphenazone); 238, 263, 269, 289, 290, 436, 449, 566 (acetaminophen/oxycodone); 263, 270, 313, 481, 482, 535, 570 (acetaminophen/propoxyphene); 239, 240, 252, 458, 513, 555, 710 (aspirin); 355 (aspirin/acetaminophen/caffeine); 316 (aspirin/carisoprodol); 294 (butorphanol); 385, 486 (celecoxib); 407, 774, 824 (codeine); 448, 731 (hydrocodone); 303 (hydromorphone); 240, 650, 653, 689, 735 (ibuprofen); 256 (ketoprofen); 410 (meperidine); 305, 306, 492, 500, 501, 737, 857 (methadone); 307, 383, 545 (morphine); 260 (naproxen); 30, 352, 365, 714, 723, 743, 825, 826 (opiate/opioid); 258, 308 (oxycodone); 17, 19, 366, 411, 506, 668, 746, 831 (propoxyphene); 383 (sufentanil); 326, 509 (tramadol) Anesthetics 37 yr Enflurane A 454ap Anticholinergic drugs 66 yr Amantadine C 455p atenolol amlodipine See also cases 356, 483, 756 (benztropine); 567 (oxybutynin), 253 (trihexyphenidyl).
Inhalation
Int unk
Ingestion
Ther error
Anticoagulants 2 day Heparin 456a 457 77 yr Warfarin acetaminophen
Parenteral Ingestion
Ther error Int suicide
A A/C
45 µg/mL
Anticonvulsants 458 40’s yr
Gabapentin A/C Asp/Ing Int suicide aspirin activated charcoal 10 yr Lamotrigine C Ingestion Adv rxn 459a 460 70 yr Phenytoin A/C Asp/Ing Ther error activated charcoal 461 23 yr Valproic acid U Ingestion Int suicide 462 27 yr Valproic acid A/C Ingestion Int suicide 30 yr Valproic acid A/C Ingestion Int suicide 463a 464 39 yr Valproic acid A Ingestion Int suicide 465 36 yr Valproic acid A/C Ingestion Int suicide olanzapine 466 36 yr Valproic acid U Ingestion Int suicide olanzapine See also cases 430, 523, 569, 575 (gabapentin); 765 (primidone); 675 (topiramate); 541, 654, 766, 772 (valproic acid). Antidepressants 14 yr 467p 468 16 yr 19 yr 469p 20 yr 470p
Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A A/C A/C A/C
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
471 472p 473p 474p 475 476p 477 478p
34 yr 37 yr 39 yr 40 yr 40 yr 40 yr 42 yr 49 yr
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A/C A A U U A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
479 480ipm 481
51 yr 55 yr 24 yr
A/C A/C A
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
482p
46 yr
A
Ingestion
Int suicide
483p
76 yr
Amitriptyline Amitriptyline Amitriptyline acetaminophen/propoxyphene Amitriptyline acetaminophen/propoxyphene ethanol Amitriptyline benztropine sertraline
A/C
Ingestion
Int suicide
56 mg/dL
70 µg/mL 432 µg/mL 3,000 µg/mL 1,280 µg/mL 400 µg/mL 1,425 µg/mL 1,200 µg/mL
4,700 ng/mL§ 900 ng/mL nortriptyline 350 ng/mL 670 ng/mL§
332 ng/mL§ nortriptyline 260 ng/mL§
propoxyphene 1.5 µg/mL§
(Continued on following page)
5h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
539
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
484
32 yr
485
⬎19 yr
486ip
32 yr
487
57 yr
488
57 yr
489
60 yr
490
39 yr
491
35 yr
492
35 yr
493
31 yr
494p
39 yr
495
40 yr
496ipm
43 yr
497
53 yr
498p
61 yr
499p
46 yr
500p
34 yr
501p
39 yr
502
21 yr
503
34 yr
504
35 yr
505
53 yr
506i
27 yr
507p
40 yr
508
50 yr
Substances Amitriptyline bupropion haloperidol Amitriptyline carisoprodol Amitriptyline celecoxib Amitriptyline citalopram quinapril Amitriptyline clonazepam Amitriptyline clonazepam Amitriptyline clonazepam ethanol Amitriptyline cocaine Amitriptyline diphenhydramine methadone Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline fluoxetine Amitriptyline methadone benzodiazepine Amitriptyline methadone clonazepam Amitriptyline methamphetamine ethanol Amitriptyline metoclopramide paroxetine Amitriptyline mibefradil diltiazem Amitriptyline nortriptyline methamphetamine Amitriptyline propoxyphene benzodiazepine Amitriptyline propranolol ethanol Amitriptyline
Chronicity
Route
Reason
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ing/Inh
Int unk
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int unk
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Ther error
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Blood Concentrations
4,500 ng/mL§ nortriptyline 900 ng/mL§ 2,000 ng/mL
210 mg/dL
1,510 ng/mL 0.37 µg/mL§ 0.35 µg/mL§ 300 mg/dL
sertraline clonazepam
(Continued on following page)
4600 ng/mL§ nortriptyline 3200 ng/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
540
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
509p
45 yr
Substances Amitriptyline
Chronicity
Route Ingestion
A/C
Ingestion
A/C
Ingestion
840 ng/mL§ nortriptyline 250 ng/mL§ o-desmethyl tramadol 700 ng/mL§ n-desmethyl tramadol 84 ng/mL§ 36.1 µg/mL§ meprobamate 22.6 µg/mL§ Int suicide 5200 ng/mL§ nortriptyline 2400 ng/mL§ 0.1 µg/mL§ 0.1 µg/mL§ Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
U A A U
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
carisoprodol 43 yr
511
35 yr
512
68 yr
513
66 yr
Amitriptyline trazodone diphenhydramine Amitriptyline verapamil olanzapine Amitriptyline zolpidem Amitriptyline/chlordiazepoxide aspirin paroxetine Bupropion Bupropion Bupropion (long acting) Bupropion (long-acting) ethanol Bupropion ethanol sibutramine Bupropion fluvoxamine olanzapine Bupropion imipramine desipramine Bupropion (long acting) olanzapine Bupropion olanzapine fluoxetine Bupropion olanzapine gabapentin Bupropion paroxetine Desipramine Desipramine fluoxetine sertraline
Blood Concentrations
A
tramadol
510ip
Reason Int suicide
amitriptyline 530 ng/mL§ nortriptyline 460 ng/mL§ 69 mg/dL
514ipm 515p 516 517
24 yr 41 yr 45 yr 42 yr
518
29 yr
519
35 yr
520
41 yr
521
40 yr
522
36 yr
523p
57 yr
524
16 yr
525 526
40 yr 54 yr
527 528 529ipm 530ipm 531 532 533
21 yr 30 yr 32 yr 32 yr 37 yr 39 yr 39 yr
Doxepin Doxepin Doxepin Doxepin Doxepin Doxepin Doxepin
A U A/C U A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
534p 535
64 yr 52 yr
A/C A/C
Ingestion Ingestion
536
68 yr
A/C
Ingestion
Int suicide
537p
32 yr
A
Ingestion
Int suicide
538p
56 yr
Doxepin Doxepin acetaminophen/propoxyphene acetaminophen/codeine Doxepin chlordiazepoxide Doxepin diazepam Doxepin procainamide
21,900 ng/mL§ 2,400 ng/mL§ 720 ng/mL§ desmethylsertraline 1,030 ng/mL§ Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide ⬎1,500 ng/mL Int suicide 14,000 ng/mL§ nordoxepin 6,960 ng/mL§ Int suicide Int suicide
A
Ingestion
Int suicide
206 mg/dL
(Continued on following page)
2,800 ng/mL 946 ng/mL
700 ng/mL
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
541
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
539
48 yr
540
45 yr
541
36 yr
Substances
Chronicity
Route
Reason
545
48 yr
546p
44 yr
547
42 yr
548 549
40 yr 35 yr
550
24 yr
Doxepin risperidone trazodone Doxepin trazodone prednisone Doxepin valproic acid ethanol Doxepin venlafaxine risperidone Fluoxetine Fluoxetine benzodiazepine Fluoxetine diphenhydramine morphine Fluoxetine trazodone heroin Fluoxetine zolpidem diltiazem Fluvoxamine Fluvoxamine ethanol Imipramine
551 552
36 yr 37 yr
Imipramine Imipramine
A A/C
Ingestion Ingestion
Int suicide Int suicide
553 554ipm
50 yr 43 yr
A U
Ingestion Ingestion
Int suicide Int suicide
555
65 yr
A
Ingestion
Int suicide
556 557 558 559
58 yr 61 yr 79 yr 33 yr
C A/C A/C A/C
Ingestion Ingestion Ingestion Ingestion
Ther error Int suicide Int suicide Int suicide
560
74 yr
A/C
Ingestion
Ther error
561
42 yr
A/C
Ingestion
Int suicide
1.7 mEq/L 848 ng/mL 4.3 mEq/L
562 563 564ipm 565p 566
36 yr 55 yr 60 yr 60 yr 49 yr
A/C A/C A/C A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide
1,720 ng/mL§ 6,950 ng/mL§ 6,950 ng/mL§ 6,950 ng/mL§ 122 µg/mL
567
49 yr
A/C
Ingestion
Int suicide
819 ng/mL
568p
29 yr
A
Ingestion
Int suicide
569
28 yr
A/C
Ingestion
Int suicide
570
30 yr
Imipramine Imipramine ethanol Imipramine thioridazine aspirin Lithium Lithium Lithium Lithium acetaminophen/hydrocodone olanzapine Lithium amitriptyline Lithium olanzapine Nortriptyline Nortriptyline Nortriptyline Nortriptyline Nortriptyline acetaminophen/oxycodone Nortriptyline clonazepam oxybutynin Nortriptyline paroxetine acetaminophen Paroxetine gabapentin Sertraline acetaminophen/propoxyphene acetaminophen/isometheptene/ dichloralphenazone
U
Ingestion
Int suicide
542
543 544p
74 yr
50 yr ⬎19 yr
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Blood Concentrations
200 µg/mL 164 mg/dL A
Ingestion
Int suicide
U A/C
Ingestion Ingestion
Unknown Int suicide
240 ng/mL§
A
Ingestion
Int suicide
norfluoxetine 3,760 ng/mL§ 0.38 µg/mL§ 350 ng/mL§
U
Ing/Paren
Int suicide
A/C
Ingestion
Int suicide
A/C A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
3,000 ng/mL§ desipramine 5,000 ng/mL§ 2,200 ng/mL§ desipramine 310 ng/mL§ 700 ng/mL
66 mg/dL 4.2 mEq/L 7.0 mEq/L 2.8 mEq/L 27 µg/mL¥
129 µg/mL
(Continued on following page)
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
542
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
571
36 yr
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
Trazodone A Ingestion Int suicide cocaine acetaminophen/codeine 40 yr Tricyclic antidepressant A Ingestion Int suicide ⬎500 ng/mL 572p 573 42 yr Tricyclic antidepressant A Ingestion Int suicide benzodiazepine ethanol 41 yr Tricyclic antidepressant A Ingestion Int suicide 574p cocaine 40 yr Tricyclic antidepressant A Ingestion Int suicide 575p gabapentin paroxetine 576 49 yr Tricyclic antidepressant A Ingestion Int unk 1781 ng/mL heroin cocaine 577 42 yr Venlafaxine A Ingestion Int suicide 94 µg/mL§ See also cases 40, 308, 315, 353, 444, 560, 645, 674, 675, 681, 764, 767 (amitriptyline); 760 (amoxapine); 484 (bupropion); 487 (citalopram); 410 (clomipramine); 520 (desipramine); 20, 400 (doxepin); 356, 366, 368, 499, 522, 526, 763 (fluoxetine); 519 (fluvoxamine); 389, 520, 608 (imipramine); 505, 609 (nortriptyline); 22, 382, 452, 503, 513, 524, 568, 575, 694, 740, 768 (paroxetine); 452, 483, 508, 526, 614, 758 (sertraline); 23, 259, 372, 510, 539, 540, 546, 760, 763, 769 (trazodone); 827 (tricyclic antidepressant); 542, 697, 769 (venlafaxine). Antihistamines 35 yr 578p
Cetirizine A/C Ingestion Int suicide ethanol 109 mg/dL 579 28 yr Diphenhydramine A Ingestion Int suicide 580 29 yr Diphenhydramine A Ingestion Int suicide 7.8 µg/mL 54 yr Diphenhydramine U Ingestion Unknown 11 µg/mL§ 581p 582 55 yr Diphenhydramine A Ingestion Int suicide dimenhydrinate 40 yr Diphenhydramine A Ingestion Int suicide 9.1 µg/mL§ 583p doxylamine 6.7 µg/mL§ 584 20 yr Diphenhydramine A Ingestion Int misuse ethanol 585 57 yr Diphenhydramine A Ingestion Int suicide ethanol 586 28 yr Diphenhydramine A Ingestion Int suicide 12 µg/mL§ mouthwash (ethanol) 200 mg/dL 587 46 yr Diphenhydramine A/C Ingestion Int suicide phencyclidine marijuana 43 yr Doxylamine A Ingestion Int suicide 588p 54 yr Doxylamine A Ingestion Int suicide 589p See also cases 70, 139, 243, 367, 368, 408, 446, 447, 492, 510, 545, 676, 730, 746 (diphenhydramine); 582 (dimenhydrinate); 583 (doxylamine); 142, 372, 775 (hydroxyzine); 364 (loratadine). Antimicrobials 590 89 yr 35 yr 591p 592 15 yr 39 yr 593a
Fluconazole Hydroxychloroquine Isoniazid Isoniazid cocaine 16 yr Zidovudine/lamivudine 594a See also case 633 (clarithromycin). Antineoplastics 51 yr 595a 596 82 yr
Methotrexate Methotrexate
Asthma therapies 3 yr Theophylline (long-acting) 597a 598 40 yr Theophylline (long-acting) 599 52 yr Theophylline 600 58 yr Theophylline 601 63 yr Theophylline 602 68 yr Theophylline (long-acting) 603 80 yr Theophylline 604 83 yr Theophylline 605 90 yr Theophylline See also case 668 (theophylline).
A U A/C A/C
Ingestion Ingestion Ingestion Ingestion
Adv rxn Int suicide Int unk Int suicide
C
Ingestion
Adv rxn
C C
Ingestion Ingestion
Ther error Ther error
0.29 µmol/L 0.3 µmol/L
A U C A/C C A/C C C C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Int suicide Int misuse Ther error Ther error Int misuse Ther error Ther error Unknown
114 µg/mL 101 µg/mL 40 µg/mL 41 µg/mL 34 µg/mL 36 µg/mL 55 µg/mL 42 µg/mL 28 µg/mL
(Continued on following page)
27 h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
543
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Cardiovascular drugs 606 71 yr Amiodarone 607 51 yr Amlodipine benazepril metformin 46 yr Amlodipine 608p imipramine 43 yr Amlodipine 609p nortriptyline alprazolam 610 50 yr Atenolol amlodipine zolpidem 611 62 yr Atenolol diltiazem 612 55 yr Atenolol nifedipine ethanol 613 82 yr Beta blocker calcium channel blocker 614 33 yr Captopril sertraline alprazolam 23 mo Clonidine 615a 616 28 yr Clonidine acetaminophen/hydrocodone methyldopa 617 55 yr Clonidine ethanol lisinopril 618 60’s yr Digoxin 61 yr Digoxin 619p 620 69 yr Digoxin 621 69 yr Digoxin 622 72 yr Digoxin 623 76 yr Digoxin 624 77 yr Digoxin 625 78 yr Digoxin 626 79 yr Digoxin 627 82 yr Digoxin 88 yr Digoxin 628p 629 88 yr Digoxin 630 92 yr Digoxin 631 92 yr Digoxin 632 76 yr Digoxin amiodarone 89 yr Digoxin 633p clarithromycin 634 79 yr Digoxin propafenone 635 60 yr Digoxin temazepam verapamil 636 51 yr Digoxin verapamil metoprolol 637 29 yr Diltiazem (long-acting) 43 yr Diltiazem 638a 639 44 yr Diltiazem (long-acting) 640 45 yr Diltiazem (long-acting) 641 47 yr Diltiazem (long-acting) 642 49 yr Diltiazem (long-acting) 643 89 yr Diltiazem (long-acting) 644 49 yr Diltiazem acetaminophen 645 49 yr Diltiazem amitriptyline
Chronicity
Route
Reason
Blood Concentrations
A/C A/C
Ingestion Ingestion
Int suicide Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int unk
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Ther error
A
Ingestion
Int misuse
A A
Ingestion Ingestion
Unint gen Int suicide
A/C
Ingestion
Int suicide
C A/C C C C C C C C A/C C C C C C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Ther error Unknown Ther error Ther error Ther error Ther error Unknown Ther error Ther error Int suicide Ther error Ther error Ther error Ther error Ther error
4.6 ng/mL 5.4 ng/mL 3 ng/mL 2.1 ng/mL 3.5 ng/mL
C
Ingestion
Ther error
5.5 ng/mL
A/C
Ingestion
Ther error
A/C
Ingestion
Int suicide
11 ng/mL
A/C
Ingestion
Int suicide
9.8 ng/mL
A/C A A A/C U A A A/C
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
238 mg/dL
46 ng/mL§
6.7 ng/mL 5.4 ng/mL 10 ng/mL 2.7 ng/mL 2.4 ng/mL 3.6 ng/mL 4 ng/mL 8.2 ng/mL 4.8 ng/mL
46 µg/mL§
163 µg/mL
(Continued on following page)
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
544
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
646p
43 yr
647
31 yr
648
41 yr
649
40 yr
650
29 yr
651
66 yr
652
76 yr
653
47 yr
654
26 yr
655
21 yr
656p 657p
45 yr 39 yr
658
29 yr
659ipm
21 yr
660 661
30 yr 49 yr
662ai 663 664
20 mo 43 yr 53 yr
665
40 yr
666
42 yr
667p
45 yr
668
52 yr
669a 670ap
80 yr 69 yr
671a 672 673 674
48 yr 49 yr 50 yr 45 yr
675
40 yr
676p
19 yr
677
46 yr
Substances Diltiazem (long-acting) atenolol Diltiazem atenolol clozapine Diltiazem digoxin Diltiazem (long acting) ethanol Diltiazem (long-acting) ibuprofen Diltiazem metformin glimepiride Diltiazem metoprolol Diltiazem phenobarbital ibuprofen Diltiazem propafenone valproic acid Diltiazem verapamil metoprolol Disopyramide Felodipine buspirone alprazolam Flecainide cocaine (crack) Flecainide ethanol Metoprolol Metoprolol clonidine Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) acetaminophen diazepam Nifedipine (long-acting) ethanol Nifedipine (long-acting) metoprolol (long-acting) cocaine Nifedipine (long acting) propranolol diazepam Nifedipine theophylline propoxyphene Nitroglycerin Procainamide ethanol Propafenone Propranolol Propranolol Propranolol amitriptyline thioridazine Propranolol amitriptyline topiramate Propranolol diphenhydramine Verapamil (long-acting)
Chronicity
Route
Reason
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
C
Ingestion
Ther error
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A/C
Ing/Inh
Int suicide
U
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A A/C A
Ingestion Ingestion Ingestion
Unint gen Int suicide Int suicide
Blood Concentrations
2.9 ng/mL
9.5 µg/mL§
0.8 µg/mL§ 9.49 µg/mL§ 51 µg/mL§
560 µg/mL§
263 µg/mL A
Ingestion
Int suicide
A/C
Ing/Unk
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
benzoylecgonine 380 ng/mL§
33 µg/mL A A/C
Dermal Ingestion
Ther error Int suicide
A/C A A/C A
Ingestion Ingestion Ingestion Ingestion
Ther error Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
(Continued on following page)
52 µg/mL 221 mg/dL 4.88 µg/mL
Interval After Exposure
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
545
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 678 679 680 681
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
Interval After Exposure
52 yr 60 yr 60 yr 45 yr
Verapamil (long-acting) A Ingestion Int suicide Verapamil (long-acting) A/C Ingestion Int suicide Verapamil (long-acting) A/C Ingestion Int suicide Verapamil A Ingestion Int suicide amitriptyline clonazepam 682 30 yr Verapamil (long-acting) A Ingestion Int suicide atenolol 683 24 yr Verapamil A/C Ingestion Int suicide atenolol ethanol 308 mg/dL 684 17 yr Verapamil A Ingestion Int suicide atenolol potassium chloride 685 48 yr Verapamil (long-acting) A/C Ingestion Int suicide carisoprodol 686 72 yr Verapamil A/C Ingestion Int suicide clonazepam risperidone A Ing/Unk Int suicide 687 46 yr Verapamil (long-acting) cocaine acetaminophen 688 39 yr Verapamil (long-acting) A Ingestion Int suicide enalapril 689 31 yr Verapamil A Ingestion Int suicide ibuprofen 690 20 yr Verapamil A Ingestion Int suicide lorazepam clonazepam 691 65 yr Verapamil A/C Ingestion Int suicide metoprolol 692 69 yr Verapamil (long-acting) A/C Ingestion Int suicide metoprolol risperidone A Ingestion Int suicide 693 29 yr Verapamil nadolol acetaminophen/isometheptene/ dichloralphenazone 694 40 yr Verapamil A/C Ingestion Int suicide propranolol paroxetine 67 yr Verapamil A/C Ingestion Ther error 695p quetiapine 696 45 yr Verapamil A Ingestion Int suicide simvastatin 62 yr Verapamil A Ingestion Int suicide 697p hydrochlorothiazide/triamterene venlafaxine See also cases 632 (amiodarone); 354, 455, 610 (amlodipine); 455, 646, 647, 682 thru 684 (atenolol); 607 (benazepril); 613 (calcium channel blocker); 661 (clonidine); 648 (digoxin); 504, 547, 611, 758 (diltiazem); 688 (enalapril); 255 (hydrochlorothiazide/lisinopril); 364, 697 (hydrochlorothiazide/triamterene); 381 (irbesartan); 617 (lisinopril); 616 (methyldopa); 636, 652, 655, 666, 691, 692 (metoprolol); 504 (mibefradil); 439, 693 (nadolol); 612 (nifedipine); 538 (procainamide); 634, 654 (propafenone); 453, 507, 667, 694, (propranolol); 487 (quinapril); 696 (simvastatin); 511, 635, 636, 655 (verapamil). Corticosteroids See also case 540 (prednisone). Cough and cold preparations 21 yr Benzonatate 698p 3 yr Codeine/guaifenesin 699p 2 yr Hydrocodone/guaifenesin 700aip 42 yr Phenylpropanolamine/guaifenesin 701p 23 yr Phenylpropanolamine (long-acting) 702a acetaminophen/diphenhydramine/ pseudoephedrine/dextromethorphan See also case 367 (pseudoephedrine/brompheniramine). Electrolytes and minerals 14 mo Iron 703a See also case 684 (potassium chloride).
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Malicious Ther error Int misuse Int suicide
A
Ingestion
Unint gen
(Continued on following page)
hydrocodone 80 ng/mL§ 0.95 µg/mL 14.8 µg/mL¥ pseudoephedrine 0.33 µg/mL
18,750 µg/dL
3h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
546
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Gastrointestinal preparations 73 yr Magnesium citrate 704a 6 yr Trimethobenzamide 705a See also case 503 (metoclopramide).
Reason
Blood Concentrations
Asp/Ing Other
Ther error Adv rxn
magnesium 6.6 mEq/L
Ingestion Parenteral Parenteral Parenteral Ing/Paren
Ther error Int suicide Int suicide Ther error Int suicide
Ingestion Ingestion Ingestion Ingestion
Unknown Ther error Int suicide Int unk
Ingestion
Int suicide
A/C A C
Ingestion Parenteral Ingestion
Int abuse Ther error Int abuse
U A A
Ingestion Ingestion Ingestion
Int unk Int abuse Int abuse
U
Ing/Inh
Int abuse
C
Ingestion
Int abuse
U
Ingestion
Int suicide
A A A
Ingestion Ingestion Ingestion
Int suicide Adv rxn Int suicide
A A
Hormones and hormone antagonists 706 47 yr Glipizide A 707 32 yr Insulin A 45 yr Insulin U 708ipm 709 78 yr Insulin A 710 19 yr Insulin A/C aspirin 711 36 yr Metformin C 712 80 yr Metformin C 713 80 yr Metformin A/C 714 52 yr Metformin A/C opiate benzodiazepine 38 yr Metformin A/C 715a sulfonylurea See also cases 651 (glimepiride); 363, 607, 651 (metformin); 715 (sulfonylurea). Miscellaneous drugs 29 yr 1,4-butanediol 716ap 4 yr Disodium edetate 717a 52 yr Gamma butyrolactone 718a ethanol 24 yr Gamma hydroxybutyrate 719p 42 yr Gamma hydroxybutyrate 720p 21 yr Gamma hydroxybutyrate 721p ethanol 33 yr Gamma hydroxybutyrate 722p nitrite (volatile) 723 26 yr Gamma hydroxybutyrate opioid benzodiazepine 36 yr Gamma hydroxybutyrate 724ipm unknown drug 38 yr Nicotine (transdermal patch) 725aip 726 62 yr Sildenafil 727 13 yr Throat spray (phenol, 1.4%) unknown liquid See also cases 21, 822 (gamma hydroxybutyrate); 518 (sibutramine).
Route
91 mg/dL
375 µg/mL§ 240 µg/mL§ 50 mg/dL§ 503 µg/mL§
106 µg/mL§
Muscle relaxants 44 yr 728p 52 yr 729p
Baclofen A/C Ingestion Int suicide Baclofen A/C Ingestion Int suicide methocarbamol acetaminophen 38 yr Carisoprodol A Ingestion Int suicide meprobamate 15.7 µg/mL 730p diphenhydramine 731 44 yr Carisoprodol A Ingestion Int suicide hydrocodone 21 yr Cyclobenzaprine A Ingestion Int suicide 732p 733 34 yr Cyclobenzaprine U Ingestion Int suicide 38 yr Cyclobenzaprine A Ingestion Int suicide 734p alprazolam 735 43 yr Cyclobenzaprine U Ingestion Int suicide lorazepam ibuprofen See also cases 17, 242, 269, 292, 294 thru 296, 388, 485, 509, 685, 817 (carisoprodol); 327, 445 (cyclobenzaprine); 435, 729 (methocarbamol). Narcotic Antagonists 30 yr Naltrexone 736ap 737 37 yr Naltrexone methadone cocaine
A A/C
Other Ingestion
Adv rxn Int abuse 1.5 µg/mL§ 0.1 µg/mL§
(Continued on following page)
Interval After Exposure
4h
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
547
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Sedatives/hypnotics/antipsychotics 32 yr Alprazolam 738p 739 40 yr Alprazolam acetaminophen/hydrocodone 740p
46 yr
741ipm 742ipm 743p
45 yr 75 yr 39 yr
744p 745a 746
39 yr 73 yr 42 yr
747p 748 749
37 yr 40 yr 52 yr
750
46 yr
751 752ipm 753ipm
39 yr 52 yr 52 yr
754
73 yr
755 756
26 yr 41 yr
757
51 yr
758
34 yr
759p 760
51 yr 54 yr
761 762p 763
84 yr 32 yr 23 yr
764
66 yr
765p
32 yr
766p
40 yr
767p
40 yr
768p
17 yr
769
45 yr
770 771
25 yr 30 yr
Alprazolam paroxetine acetaminophen/hydrocodone Barbiturate Barbiturate Benzodiazepine opiate cocaine Chloral hydrate Chloral hydrate Chlordiazepoxide propoxyphene diphenhydramine Clonazepam Clonazepam Clonazepam ethanol Clozapine ethanol Diazepam Diazepam Diazepam alprazolam Diazepam zolpidem Glutethimide/codeine Haloperidol benztropine Lorazepam ethanol Loxapine diltiazem sertraline Mesoridazine Molindone trazodone amoxapine Nitrazepam Olanzapine Olanzapine trazodone fluoxetine Phenobarbital amitriptyline Phenobarbital primidone Phenobarbital valproic acid haloperidol Promethazine amitriptyline oxazepam Quetiapine paroxetine Quetiapine trazodone venlafaxine Risperidone Risperidone ammonia fabric spray (zinc chloride ⬍1%)
Chronicity
Route
Reason
Blood Concentrations
A/C A
Ingestion Ingestion
Int abuse Int suicide
A
Ingestion
Unknown
U U U
Unknown Unknown Ing/Unk
Int suicide Int suicide Unknown
Interval After Exposure
260 ng/mL§ 95 µg/mL¥ hydrocodone 650 ng/mL§
morphine 250 ng/mL§ monoacetyl morphine 540 ng/mL§ A A/C U
Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide
A A/C A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
A U A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int abuse Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U U
Ingestion Ingestion
Unknown Int suicide
U U U
Ingestion Ingestion Ingestion
Int suicide Int suicide Int unk
A/C
Ingestion
Int suicide
31 µg/mL
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
76 µg/mL§ 66 µg/mL§ 51 µg/mL 127 µg/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
11,250 ng/mL§ 2.828 µg/mL§ norpropoxyphene 5.55 µg/mL§ 0.7 µg/mL§
248 mg/dL
(Continued on following page)
36 h
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
548
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case 772
Age
Substances
Chronicity
Route
Reason
Blood Concentrations
42 yr
Interval After Exposure
Risperidone A/C Ingestion Int suicide clonazepam valproic acid 374 µg/mL 773 50 yr Secobarbital A Ingestion Int suicide 774 95 yr Temazepam A/C Ingestion Int unk codeine ethanol 775 49 yr Temazepam A/C Ingestion Int unk hydroxyzine 46 yr Triazolam A Ingestion Int suicide 776p See also cases 44, 291, 292, 303, 314, 316, 325, 369, 380, 399, 446, 609, 614, 657, 734, 753, 830, 867 (alprazolam); 16, 96, 241, 293, 384, 417 thru 420, 437, 500, 506, 544, 573, 714, 723, 779, 816, 846, 857 (benzodiazepine); 657 (buspirone); 22, 297, 421, 536 (chlordiazepoxide); 359 (chlorpromazine); 298, 488 thru 490, 501, 508, 567, 681, 686, 690, 772, 831 (clonazepam); 647 (clozapine); 15, 19, 296, 299, 360, 402, 408, 421, 444, 537, 664, 667 (diazepam); 821 (flunitrazepam); 253 (fluphenazine); 72 (flurazepam); 484, 766 (haloperidol); 304, 329, 449, 690, 735 (lorazepam); 386, 465, 466, 511, 519, 521 thru 523, 559, 561 (olanzapine); 767 (oxazepam); 653 (phenobarbital); 380, 402 (promethazine); 259, 695 (quetiapine); 539, 542, 686, 692 (risperidone); 440, 635 (temazepam); 555, 674 (thioridazine); 23, 360 (trifluoperazine); 274, 317, 325, 400, 411, 512, 547, 610, 754 (zolpidem). Stimulants and street drugs 25 yr Amphetamine 777p 778 37 yr Amphetamine 779 21 yr Amphetamine benzodiazepine ethanol 2 mo Cocaine 780aip 781 19 yr Cocaine 782 19 yr Cocaine 783 20 yr Cocaine 21 yr Cocaine 784p 21 yr Cocaine 785p 786 22 yr Cocaine 22 yr Cocaine (crack) 787p 788 24 yr Cocaine 24 yr Cocaine 789ipm 790 24 yr Cocaine
U C A
Unknown Unknown Ingestion
Int abuse Int abuse Int suicide
A C A A A A A A/C U U A
Inhalation Unknown Unknown Parenteral Ingestion Ingestion Unknown Ingestion Unknown Unknown Ingestion
Malicious Int abuse Int abuse Int abuse Int unk Int misuse Int abuse Int misuse Int abuse Int abuse Int misuse
103 mg/dL
791p 792 793 794 795
26 yr 28 yr 30 yr 30 yr 30 yr
Cocaine Cocaine Cocaine Cocaine Cocaine (crack)
A A A/C A A
Ingestion Inhalation Unknown Ingestion Ingestion
796 797 798p 799p 800p 801p 802ipm 803 804 805 806 807ipm 808 809p 810p 811ipm 812ipm 813ipm 814ipm 815ipm 816p
31 yr 33 yr 34 yr 34 yr 35 yr 35 yr 35 yr 36 yr 38 yr 39 yr 40 yr 40 yr 42 yr 42 yr 43 yr 45 yr 45 yr 45 yr 46 yr 47 yr 27 yr
A U A U A A U A A A/C C A C U A U A A U U A
Ingestion Parenteral Ingestion Parenteral Inhalation Inhalation Unknown Ingestion Ing/Paren Unknown Unknown Unknown Unknown Parenteral Other Unknown Unknown Unknown Unknown Unknown Ingestion
817p
27 yr
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine benzodiazepine marijuana Cocaine carisoprodol
5.9 µg/mL benzoylecgonine 14 µg/mL§ ecgonine methyl ester 5.1 µg/mL§ Int misuse Int abuse Unknown Int misuse Int misuse 0.55 µg/mL§ benzoylecgonine 11.7 µg/mL§ Int abuse Int abuse Int suicide Int abuse Int abuse Int suicide Int abuse Int misuse Int misuse ⬎1 µg/mL§ Int abuse Int abuse Int abuse Int abuse Int abuse Int misuse Int abuse Int abuse Int abuse Int suicide Int abuse Int abuse
A/C
Ing/Unk
Int abuse
(Continued on following page)
benzoylecgonine 1.3 µg/mL§
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
549
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
818p
20 yr
819p
24 yr
820
39 yr
821
18 yr
822p
30 yr
823
27 yr
824p
41 yr
825p
32 yr
826p
26 yr
827p
44 yr
828
36 yr
829p
27 yr
830
32 yr
831p
43 yr
832 833p 834a 835ipm 836p 837p 838p 839 840p 841p 842p 843p 844 845p 846
20 yr 20 yr 20 yr 24 yr 27 yr 28 yr 31 yr 32 yr 34 yr 36 yr 38 yr 44 yr 48 yr ⬎19 yr 44 yr
847p
17 yr
848p
27 yr
849p
30 yr
850
37 yr
851
37 yr
852p
40 yr
853p
40 yr
854p
⬎19 yr
Substances Cocaine ethanol Cocaine ethanol Cocaine ethanol Cocaine flunitrazepam Cocaine gamma hydroxybutyrate marijuana Cocaine hallucinogenic mushroom Cocaine heroin codeine Cocaine opiates Cocaine opiates ethanol Cocaine tricyclic antidepressants amphetamines Cocaine unknown pesticide Cocaine/heroin marijuana Diet drug (unknown type) alprazolam herbicide (unknown type) Dextroamphetamine propoxyphene clonazepam Heroin Heroin Heroin (body packer) Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin benzodiazepine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine Heroin cocaine ethanol
Chronicity
Route
Reason
U
Unknown
Int abuse
U
Ingestion
Int abuse
A/C
Unknown
Int abuse
A
Ingestion
Int abuse
A/C
Ing/Inh
Int abuse
A
Ing/Inh
Int abuse
A/C
Ing/Paren
Int abuse
A/C
Parenteral
Int abuse
U
Ung/Unk
Unknown
U
Ing/Unk
Int suicide
U
Unknown
Int unk
A
Inh/Paren
Int abuse
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A A/C U U A/C U A A A/C A A A/C A/C A A/C
Ingestion Parenteral Ingestion Unknown Unknown Parenteral Parenteral Parenteral Parenteral Unknown Parenteral Inhalation Parenteral Parenteral Ing/Paren
Int misuse Int abuse Int misuse Int unk Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int suicide
A/C
Parenteral
Int abuse
A/C
Parenteral
Int abuse
A
Unknown
Int suicide
U
Unknown
Int unk
A
Parenteral
Int abuse
U
Parenteral
Int abuse
A/C
Parenteral
Int abuse
A
Ing/Inh
Int abuse
Blood Concentrations
benzoylecgonine 120 ng/mL§ cocaethylene 47 ng/mL§ 270 mg/dL
morphine 87 ng/mL§
morphine 80 ng/mL§ benzoylecgonine 0.03 µg/mL§
benzoylecgonine 0.45 µg/mL
(Continued on following page)
morphine 70 ng/mL§ 0.31 µg/mL§
Interval After Exposure
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
550
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1999 (Cont’d)
Case
Age
Substances
Chronicity
Route
Reason
Interval After Exposure
Blood Concentrations
⬎19 yr Heroin Ing/Inh Int abuse A cocaine ethanol 29 yr Heroin Ing/Paren Int abuse 856p A ethanol 59 mg/dL 46 yr Heroin Unknown Int suicide 857p A methadone benzodiazepine 858 19 yr Methamphetamine Ingestion Int abuse 5.99 µg/mL A 859 22 yr Methamphetamine Ingestion Int abuse A 860 35 yr Methamphetamine Ingestion Int abuse 1.7 µg/mL U 40 yr Methamphetamine Inhalation Int abuse 861p A 23 yr Methamphetamine Ingestion Int abuse 862p C ethanol 48 yr Methamphetamine Ingestion Int abuse 863p U ethanol 19 yr Methylenedioxymethamphetamine Ingestion Int abuse 864p A 19 yr Methylenedioxymethamphetamine Ingestion Int abuse 865p U 23 yr Methylenedioxymethamphetamine Ingestion Int abuse 866a A 22 yr Methylenedioxymethamphetamine Ingestion Int abuse 0.82 µg/mL 867a A ethanol alprazolam See also cases 350, 406, 419, 827 (amphetamine); 101 (amphetamine/dextroamphetamine); 18, 29, 30, 96, 299, 302, 326, 407, 491, 571, 574, 576, 593, 658, 666, 687, 737, 743, 847 thru 855 (cocaine); 254, 546, 576, 824 (heroin); 16, 162, 406, 587, 816, 822, 829 (marijuana); 389, 502, 505 (methamphetamine); 722 (nitrite, volatile); 587 (phencyclidine). 855p
Topical preparations 17 yr Cardiac glycoside (topical aphrodisiac) 868a Unknown substances 19 yr Unknown drug 869p 870 38 yr Unknown drug 39 yr Unknown drug 871ipm 872 ⬎19 yr Unknown drug trichlorocyanuric acid (0.1-1%) cleaner See also cases 275, 430, 724 (unknown drug); 727 (unknown liquid). Vitamins 34 yr Prenatal vitamins with iron 873p See also case 257 (vitamins with iron).
A
Ingestion
Int suicide
digoxin 4.2 ng/mL
A A U A
Ingestion Ingestion Ingestion Unknown
Unknown Int suicide Int suicide Int unknown
A
Ingestion
Int suicide
92 µg/dL
ABBREVIATIONS: C, chronic exposure; A, acute exposure; A/C, acute on chronic; U, unknown; Oc, ocular; Inh, inhalation; Ing, ingestion; Adv rxn, adverse reaction; Env, environmental; Int, intentional; Occ, occupational; Ther error, therapeutic error; Unint gen, unintentional general pPrehospital (cardiac and/or respiratory) arrest iReported to poison center indirectly (by coroner, medical examiner, or from other source) after the fatality occurred. §Concentration obtained postmortem ¥Acetaminophen concentration ¶Salicylate concentration #Concentration includes metabolite and parent compound aAbstract provided in Appendix mReported by medical examiner to poison center. No abstract or additional clinical or scenario data available. The term ‘‘long-acting’’ is used throughout for all sustained release, extended release, delayed release, or long-acting formulations.
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Adhesives/glues Cyanoacrylates Epoxy Toluene/xylene Non-toxic Unknown *Category totals
11,115 874 1,420 1,503 4,812 19,724
3,485 309 805 1,004 2,589 8,192
2,425 58 274 376 658 3,791
4,322 444 262 106 1,379 6,513
10,894 850 1,346 1,441 4,632 19,163
145 15 61 48 107 376
45 2 8 10 32 97
20 7 5 4 36 72
Alcohols Ethanol (beverage) Ethanol (other)
29,960 2,600
1,465 1,508
4,866 251
21,624 751
5,449 2,391
23,330 164
326 12
597 26
Int
(Continued on following page)
None
Minor
Moderate Major Death
2,624 249 258 64 854 4,049
1,373 184 322 245 1,036 3,160
2,354 188 351 84 870 3,847
593 73 44 10 171 891
7 1 1 0 9 18
0 0 0 0 3 3
20,055 357
3,209 750
8,780 361
4,660 55
1,149 5
89 0
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
551
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr)
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
Higher alcohols Isopropanol Methanol Rubbing alcohol Ethanol, with methyl salicylate Ethanol, without methyl salicylate Isopropanol, with methyl salicylate Isopropanol, without methyl salicylate Unknown rubbing alcohol Other Unknown *Category totals
211 11,422 976
90 7,247 227
33 1,067 136
74 2,751 542
197 10,227 839
9 1,068 110
2 73 12
3 17 1
62 2,058 470
72 3,490 252
41 2,193 246
14 330 73
2 82 35
0 1 6
38
31
3
4
36
1
1
0
4
9
9
0
0
0
369
257
28
81
350
18
0
0
50
109
64
7
1
0
309
234
21
51
286
21
1
1
59
117
66
8
2
0
7,674 15 57 651 54,282
5,220 10 23 99 16,411
584 1 3 100 7,093
1,724 1 26 391 28,020
6,917 14 51 264 27,021
682 1 3 368 25,775
54 0 0 4 485
8 0 3 6 662
1,222 3 16 335 24,691
2,490 7 17 72 10,594
1,278 1 7 129 13,175
156 0 1 89 5,393
28 1 1 25 1,331
0 0 0 1 97
1,741 1,737 2,057 2,259 194
1,149 1,563 1,718 2,012 79
266 132 183 168 54
289 37 140 70 50
1,694 1,708 2,035 2,242 188
32 20 13 12 5
5 4 0 1 1
8 4 8 4 0
148 32 77 42 36
351 307 311 307 53
180 51 95 36 26
28 3 6 3 6
2 0 0 0 0
0 0 0 0 0
448 3,354 15,753 2,551 2,753 9,207 376 42,430
187 1,624 9,570 1,764 2,198 7,083 278 29,225
48 1,384 5,439 544 326 1,344 72 9,960
185 267 602 203 199 672 22 2,736
442 3,235 15,279 2,408 2,689 9,037 371 41,328
4 62 403 112 48 123 3 837
2 44 38 21 8 8 2 134
0 3 25 2 7 34 0 95
66 148 378 183 68 302 8 1,488
109 368 2,794 819 528 1,574 60 7,581
73 282 551 268 110 430 15 2,117
10 15 36 16 4 47 0 174
0 0 1 0 0 1 0 4
0 0 0 0 0 0 0 0
Automotive/aircraft/boat products Ethylene glycol 5,427 Glycols: other 1,695 Glycol and methanol 99 Hydrocarbons 3,485 Methanol 1,396 Non-toxic 41 Other 2,240 Unknown 146 *Category totals 14,529
788 447 24 1,554 352 27 986 36 4,214
852 173 19 388 217 4 302 23 1,978
3,246 945 51 1,350 714 10 807 76 7,199
4,978 1,639 93 3,329 1,269 40 2,177 132 13,657
391 43 4 130 102 1 30 9 710
40 5 1 17 17 0 20 3 103
4 5 1 3 0 0 13 1 27
1,669 570 25 941 565 4 698 63 4,535
1,171 368 27 973 409 11 434 23 3,416
1,086 601 25 987 403 7 731 48 3,888
312 110 4 170 55 1 147 11 810
101 8 2 11 17 0 6 3 148
9 0 0 1 4 0 0 1 15
1,609
124
214
1,080
1,590
10
6
1
516
133
591
199
2
0
42 84 9 10 28 63 2 1,701 4,898 68 13 8,527
30 30 3 5 14 21 0 1,031 2,407 24 1 3,690
7 18 0 1 3 6 1 451 1,166 17 6 1,890
4 29 4 3 11 35 1 190 1,091 23 4 2,475
41 81 9 9 28 63 2 1,652 4,677 66 13 8,231
0 1 0 0 0 0 0 37 178 2 0 228
0 0 0 0 0 0 0 6 14 0 0 26
0 0 0 1 0 0 0 1 20 0 0 23
27 44 5 3 23 41 0 1,121 692 13 0 2,485
23 28 5 4 11 48 0 907 1,199 14 4 2,376
4 6 0 1 1 1 0 75 1,051 19 3 1,752
1 4 0 0 2 0 0 15 188 5 0 414
0 0 0 1 0 0 0 2 4 0 0 9
0 0 0 0 0 0 0 0 0 0 0 0
1,008 1,389 467
114 20 240
474 230 59
387 1,064 154
1,003 1,381 458
1 3 7
0 0 0
4 5 2
121 436 87
9 22 83
240 481 61
51 164 23
0 0 1
0 0 0
2,895 14,924
1,095 2,855
422 3,160
1,281 8,141
2,878 14,909
1 10
12 1
2 2
265 1,316
62 178
865 5,271
170 731
6 21
0 3
Arts/crafts/office supplies Artist paints, non-watercolor Chalk Clay Crayon Glazes Office supplies: miscellaneous Pencil Pens/ink Typewriter correction fluid Water color Other Unknown *Category totals
Batteries Automotive batteries Disc batteries Alkaline (MnO2) Lithium Mercuric oxide Nickel cadmium Silver oxide Zinc-air Other Unknown Dry cell batteries Other Unknown *Category totals Bites and envenomations Aquatic Coelenterate Fish Other/unknown Insects Ant/fire ant Bee/wasp/hornet
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
552
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr)
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
Caterpillar Centipede/millipede Mosquito Scorpion Tick Other Mammals Bat Cat Dog Fox Human Raccoon Rodents/lagomorphs Skunk Other Reptile: other/unknown Snakes Copperhead Coral Cottonmouth Crotalid: unknown Rattlesnake Exotic snakes Poisonous Non-poisonous Unknown if poisonous Nonpoisonous snake bite Unknown snake Spiders Black widow Brown recluse Other spider Tarantula Unknown insect or spider Other/unknown bite/ envenomation *Category totals
2,569 176 730 13,642 3,337 17,472
603 54 184 1,055 848 3,610
676 36 158 2,737 720 3,033
1,212 74 306 9,553 1,557 9,737
2,554 176 728 13,627 3,332 17,282
8 0 0 13 3 19
3 0 0 1 0 111
4 0 1 0 1 43
187 19 92 814 551 2,578
58 12 6 133 141 534
783 55 111 5,140 513 4,113
61 9 29 505 54 1,143
0 0 1 20 4 19
0 0 0 0 0 0
355 900 1,912 16 52 141 1,727 273 1,507 1,065
49 149 377 0 11 10 434 30 264 346
66 203 822 5 14 32 626 67 496 368
205 469 639 11 21 83 563 133 634 301
354 898 1,909 15 47 140 1,705 272 1,500 1,043
1 0 1 0 2 0 4 0 4 10
0 0 1 0 2 0 13 0 1 2
0 2 1 1 0 1 3 0 2 8
197 413 1,187 7 19 89 378 34 629 219
57 17 29 3 0 14 99 39 95 59
47 146 275 1 9 23 336 63 288 293
5 18 78 0 4 1 22 3 38 32
0 1 2 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
579 46 111 2 993
30 0 0 0 51
130 12 29 0 177
391 32 78 2 717
578 46 111 2 980
1 0 0 0 7
0 0 0 0 1
0 0 0 0 3
519 42 98 0 859
9 3 3 0 43
190 25 39 0 215
251 7 38 0 407
24 3 3 0 115
0 0 0 0 1
80 190 1 1,982 1,783
3 14 0 183 126
21 77 0 895 575
50 87 1 822 1,005
80 190 1 1,970 1,776
0 0 0 1 3
0 0 0 0 2
0 0 0 10 1
66 60 1 491 1,115
6 2 0 80 64
26 60 0 786 803
23 6 0 49 266
6 0 1 1 45
0 0 0 0 1
2,471 2,402 10,057 209 4,647
202 201 1,390 18 671
387 354 1,901 68 866
1,795 1,669 6,099 107 2,952
2,466 2,400 10,030 202 4,644
2 1 10 1 3
3 0 5 0 0
0 1 3 5 0
855 1,034 1,738 46 561
163 32 189 5 132
860 448 2,756 75 1,078
363 582 667 15 138
20 35 9 2 4
0 2 0 0 0
27 92,137
4 15,241
3 19,899
17 52,349
27 91,714
0 116
0 158
0 105
9 17,132
0 2,381
7 26,482
1 5,954
1 344
0 7
2,379 430
217 165
719 1,079
3,347 1,813
22 13
4 1
22 10
264 666
789 236
247 440
58 331
1 10
0 0
20 523 37 164 18 150 1,263 11 4,995
31 288 8 44 6 61 162 2 984
141 638 23 132 20 206 573 46 3,577
237 1,540 75 356 45 449 2,066 61 9,989
0 7 0 2 2 5 11 0 62
0 8 0 2 0 1 2 0 18
0 14 1 0 0 0 14 1 62
54 189 10 51 13 151 320 25 1,743
25 162 12 64 4 85 420 8 1,805
13 362 9 45 12 117 286 14 1,545
10 54 1 16 1 43 75 3 592
0 1 0 0 0 1 3 0 16
0 0 0 0 0 0 0 0 0
1,309
444
161
590
1,220
60
15
11
393
222
313
87
5
0
3,243 1,516 5,371 490 5,903 5,603 3,007 67 328 22
196 67 561 47 1,291 1,302 1,590 15 9 1
576 125 873 68 1,061 776 307 15 23 1
2,174 1,159 3,407 312 3,027 3,060 971 34 252 19
3,160 1,484 5,220 470 5,720 5,333 2,790 65 280 19
58 18 96 12 101 189 156 1 22 0
17 6 29 4 50 49 35 1 21 3
4 5 22 3 20 21 23 0 1 0
1,229 1,159 2,276 212 2,646 1,804 477 19 206 9
263 131 560 46 728 567 791 8 59 4
1,160 561 1,907 146 1,869 1,848 273 5 70 3
462 399 782 93 918 652 65 6 41 2
20 24 33 3 81 35 5 0 8 0
3 7 3 0 1 1 0 0 6 0
Building and construction products Caulking compounds and putties 3,395 Cement, concrete 1,837 Insulation Asbestos 237 Fiberglass 1,570 Urea/formaldehyde 76 Other 361 Unknown 47 Soldering flux 456 Other 2,096 Unknown 62 *Category totals 10,137 Chemicals Acetone Acids Hydrochloric Hydrofluoric Other Unknown Alkali Ammonia Borates/boric acid Chlorates Cyanide Dioxin
(Continued on following page)
Moderate Major Death
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
553
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Formaldehyde/formalin Glycol: ethylene Glycol: other Ketones Methylene chloride Nitrates and nitrites Phenol/creosote Strychnine Toluene diisocyanate Other Unknown *Category totals Cleaning substances (household) Ammonia cleaners (all purpose) Automatic dishwasher detergents Granules Liquids Rinse agents Other/unknown Bleaches Borate Hypochlorite Nonhypochlorite Other/unknown Carpet/upholstery cleaners Cleansers Anionic/nonionic Other/unknown Disinfectants Hypochlorite Phenol Pine oil Other/unknown Drain cleaners Acid Alkali Other/unknown Fabric softeners/antistatic agents Aerosol/spray Dry/powder Liquid Solid/sheet Other/unknown Glass cleaners Ammonia Anionic/nonionic Isopropanol Other/unknown Hand dishwashing Anionic/nonionic Other/unknown Laundry additives Bluing/brightening agent Detergent booster Enzyme/microbiological additive Water softener Other/unknown
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
1,555 854 1,729 954 769 1,176 1,526 50 829 20,038 2,973 59,312
173 134 661 243 115 307 282 27 121 6,509 1,454 15,549
344 121 331 86 108 441 189 5 105 3,133 464 9,313
889 546 610 542 467 353 895 15 520 8,705 894 29,441
1,437 637 1,614 913 734 1,058 1,483 38 814 18,412 2,817 55,718
86 178 71 23 31 79 17 2 6 660 46 1,912
15 12 18 9 3 24 4 9 1 374 61 760
11 3 19 8 1 12 15 1 5 481 39 705
576 441 516 428 335 292 537 19 215 5,586 415 19,790
230 193 340 170 108 229 197 21 107 3,779 455 9,208
408 157 477 290 265 224 432 2 186 4,006 309 14,911
139 95 81 114 94 84 158 3 58 1,207 86 5,626
7 75 13 13 1 3 7 1 2 94 5 435
1 16 1 1 0 1 0 0 0 2 0 43
3,064
1,341
282
1,291
2,914
106
27
11
527
608
754
181
6
0
5,947 3,307 1,069 1,071
5,143 2,761 993 865
241 145 21 55
505 358 46 128
5,901 3,292 1,064 1,064
19 7 5 4
25 4 0 2
0 3 0 1
250 224 56 84
2,572 1,179 300 376
984 684 148 196
59 51 9 19
2 1 0 3
0 0 0 0
418 50,696 783 155 5,012
197 19,784 364 72 3,768
41 5,751 78 12 305
163 22,379 289 57 838
402 48,256 748 152 4,896
12 1,742 25 3 41
2 476 4 0 18
2 154 6 0 56
61 8,946 111 31 431
84 7,641 134 33 1,287
85 14,958 216 47 921
21 2,478 30 14 90
1 60 0 0 3
0 0 0 0 0
3,646 1,038
2,583 598
288 118
690 283
3,536 995
81 27
13 8
13 7
441 197
1,015 235
617 233
97 35
2 3
0 0
9,080 3,713 8,414 2,647
5,574 2,490 5,558 1,485
865 381 774 339
2,348 721 1,853 708
8,856 3,558 7,848 2,504
145 111 449 88
41 30 69 28
33 11 29 23
1,538 479 1,611 523
2,308 805 2,507 626
2,284 936 1,795 676
442 83 201 107
21 8 21 2
1 0 3 0
1,143 4,204 552
97 652 90
97 399 46
826 2,730 351
1,100 3,951 527
33 217 20
8 20 3
2 10 2
431 1,330 127
106 569 82
365 1,279 152
233 579 55
9 46 2
2 3 0
60 4 1,142 328 39
35 4 950 280 29
5 0 58 20 1
18 0 120 27 9
53 4 1,108 321 39
4 0 24 4 0
2 0 5 0 0
1 0 5 3 0
4 0 104 13 6
14 1 376 87 11
10 1 149 15 7
0 0 10 3 2
0 0 1 0 0
0 0 0 0 0
1,776 166 6,957 3,288
1,386 94 5,525 2,527
140 12 639 343
219 53 700 369
1,712 164 6,690 3,133
47 2 194 119
11 0 55 28
3 0 8 4
142 38 567 293
521 38 1,898 890
304 42 1,324 645
31 13 70 36
1 0 4 3
0 0 0 0
7,931 1,028
5,306 577
670 101
1,771 321
7,645 952
93 22
96 25
94 27
477 56
1,272 129
1,741 199
80 8
2 0
0 0
63 182
38 116
12 16
12 43
60 179
3 2
0 0
0 1
5 23
22 41
9 51
1 4
0 0
0 0
109 99 2,073
75 18 1,662
5 10 148
22 59 230
108 87 2,001
0 0 17
0 9 16
0 3 36
15 11 148
36 41 573
20 20 324
5 2 29
0 0 2
0 0 0
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
554
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Laundry detergents Granules Liquids Soaps Other/unknown Laundry prewash/stain removers Dry solvent-based Liquid solvent-based Spray solvent-based Other/unknown solventbased Dry surfactant-based Liquid surfactant-based Spray surfactant-based Other/unknown surfactant-based Other/unknown Miscellaneous cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Phenol Other/unknown Oven cleaner Acid Alkali Detergent type Other/unknown Rust remover Alkali Anionic/nonionic Hydrofluoric acid Other acid Other/unknown Spot removers/dry cleaning agents Anionic/nonionic Glycol Carbon tetrachloride Perchloroethylene Other halogenated hydrocarbon Isopropanol Other nonhalogenated hydrocarbon Other/unknown Starch/fabric finishes/sizing Toilet bowl cleaner Acid Alkali Other/unknown Wall/floor/tile cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Other/unknown *Category totals
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
7,296 3,651 142 164
6,150 2,606 97 90
380 283 7 21
663 685 36 47
7,133 3,505 140 149
79 79 0 12
25 7 1 1
55 57 1 2
713 461 13 18
1,879 705 31 36
1,819 1,027 27 33
108 75 1 6
4 5 0 0
0 0 0 0
3 370 339
3 305 284
0 21 14
0 36 35
3 366 336
0 2 3
0 1 0
0 1 0
0 34 44
2 119 82
0 63 80
0 9 12
0 0 0
0 0 0
29 291 2,169 285
20 254 1,843 251
2 14 102 8
7 19 192 21
28 288 2,143 282
0 1 20 2
1 0 2 1
0 2 4 0
5 14 222 32
6 90 571 64
4 41 421 72
1 1 41 7
0 0 0 0
0 0 0 0
70 28
62 19
2 3
6 4
70 26
0 1
0 0
0 1
2 4
18 8
4 4
3 1
0 0
0 0
779 7,825 7,506 2,985 1,068 3,883 1,966 45 296 3,143
281 4,088 4,935 1,382 799 2,918 1,178 28 169 1,764
68 757 663 386 108 293 396 5 29 328
378 2,611 1,689 1,024 134 578 334 12 85 899
754 7,583 7,188 2,812 1,033 3,771 1,883 44 272 3,029
16 162 173 127 20 53 52 1 17 74
2 39 72 31 9 34 21 0 2 19
4 33 67 12 3 23 4 0 3 17
200 2,358 957 825 83 453 296 15 49 655
157 1,689 1,649 653 252 1,096 518 14 55 724
239 2,341 1,527 841 284 889 501 9 90 710
55 679 189 177 14 71 43 1 7 145
0 35 5 11 0 1 6 0 0 3
0 1 0 0 0 0 0 0 0 1
25 3,250 21 264
11 750 7 64
2 413 1 28
10 1,806 9 143
25 3,167 21 257
0 42 0 3
0 21 0 2
0 16 0 2
3 1,330 4 93
5 306 7 29
7 1,066 5 71
0 510 1 31
0 14 0 1
0 0 0 0
25 1 729 757 299
8 0 80 226 48
3 0 48 60 23
12 1 552 420 197
24 1 709 718 283
1 0 17 27 3
0 0 2 4 0
0 0 1 6 13
7 0 400 176 50
8 0 113 170 31
8 1 347 209 81
2 0 127 53 43
0 0 2 1 1
0 0 0 0 0
521 93 0 36
417 53 0 23
29 12 0 1
65 25 0 12
511 91 0 36
4 0 0 0
1 1 0 0
5 1 0 0
49 16 0 8
126 23 0 10
98 16 0 11
11 1 0 1
1 0 0 0
0 0 0 0
136 12
50 6
15 2
64 2
131 11
3 1
1 0
1 0
31 4
23 4
33 1
13 0
0 0
0 0
116 99 1,146
72 60 942
14 7 89
26 27 99
114 97 1,112
2 1 28
0 1 4
0 0 0
18 19 50
35 28 244
34 23 94
6 7 4
0 0 0
0 0 0
3,851 1,203 1,754
1,336 959 1,308
414 64 91
1,825 158 301
3,664 1,192 1,708
163 8 40
17 1 5
5 2 1
1,067 114 183
711 415 499
1,317 157 210
447 30 45
18 1 3
2 0 0
1,697 296 5,697 703 640 87 923 104 4 0 1,449 147 1,026 109 283 42 120,702 19,112
1,360 1,978 268 265 2 367 257 166 60,449
3,463 8,342 986 1,295 6 1,937 1,370 492 200,421
74 168 29 24 0 52 36 17 5,303
23 45 3 4 0 9 6 8 1,451
20 32 5 8 0 9 18 4 986
872 1,536 211 200 0 234 200 118 33,746
722 2,244 214 332 2 520 385 136 46,177
1,305 2,558 183 367 1 374 351 121 52,266
299 369 27 52 0 45 59 19 8,926
7 13 3 1 0 1 2 1 343
0 0 0 0 0 0 0 0 13
3,580 8,591 1,024 1,332 6 2,007 1,430 522 208,367
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
555
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Industrial cleaners Acids Alkali Anionic/nonionic Cationic Other/unknown *Category totals Cosmetics/personal care products Bath oil, bubble bath Creams, lotions, make-up Dental care products Denture cleaning Toothpaste with fluoride Toothpaste without fluoride Other Deodorants Depilatories Douches Eye products Hair care products Coloring agents Rinses, conditioners, relaxers Shampoos Sprays Other Lipsticks/balms, with camphor Lipsticks/balms, without camphor Mouthwash Ethanol Fluoride Non-ethanol Unknown Nail products Polish Polish removers: acetone Polish removers: other Polish removers: unknown Other Perfume, cologne, aftershave Peroxide Powders: talc Powders: without talc Soaps Suntan/sunscreen products *Category totals Deodorizers Air fresheners Diaper pail deodorizers Toilet bowl deodorizers Other Unknown *Category totals Dyes Fabric Food dye (eg, Easter egg) Leather Other
No. of Exposures
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
⬍6
6–19
⬎19
1,639 3,320 1,031 1,300 1,819 9,109
631 814 533 353 542 2,873
169 546 130 241 253 1,339
726 1,717 317 604 878 4,242
1,590 3,154 979 1,213 1,700 8,636
31 91 35 67 60 284
8 58 7 15 39 127
9 12 8 4 15 48
8,260 19,519
7,680 15,770
358 1,330
195 2,202
8,180 18,845
31 240
11 58
1,441 21,678
245 19,320
70 1,029
1,063 1,228
1,390 21,041
36 216
761 1,531 10,330 1,096 139 1,772
609 921 8,540 380 101 1,208
45 218 723 180 6 129
99 362 980 454 25 363
735 1,471 9,685 852 128 1,741
1,871
828
196
724
3,894 8,136 2,891 3,324
2,945 6,373 1,826 2,195
322 687 505 343
868
793
2,527
None
Minor
565 1,623 242 505 690 3,625
317 426 211 202 272 1,428
505 1,225 279 459 587 3,055
172 487 47 116 168 990
8 31 5 2 6 52
0 0 0 0 0 0
36 365
192 769
2,015 4,104
939 1,441
28 115
0 5
0 0
6 44
5 372
87 403
386 6,557
123 1,322
10 32
2 1
0 0
15 19 145 52 4 8
2 3 18 9 2 2
9 36 477 181 4 20
28 112 338 261 8 174
174 340 1,999 170 42 276
49 244 997 295 9 252
2 12 46 110 1 49
0 0 1 3 1 1
0 0 0 0 0 0
1,691
15
4
161
400
365
526
96
0
0
549 978 478 679
3,751 7,808 2,505 3,084
72 212 361 89
4 12 10 13
64 93 11 136
1,009 517 491 601
939 1,632 694 783
909 1,476 711 622
233 87 68 172
6 4 12 2
0 0 1 1
47
26
861
1
2
4
11
177
44
1
0
0
2,368
99
56
2,504
8
0
14
37
424
69
3
0
0
12,934 1,959 327 340
3,769 1,367 127 69
2,440 448 87 142
6,051 127 106 111
11,821 1,940 275 310
1,018 18 48 17
45 0 0 12
38 1 4 1
1,070 42 53 36
2,871 556 97 41
1,079 60 37 128
178 2 7 11
33 0 1 0
2 0 0 0
10,422 3,434 2,406
9,208 2,685 1,896
744 335 216
408 396 267
10,285 3,344 2,349
111 71 46
11 16 8
12 3 3
550 314 211
2,610 1,144 754
1,644 611 457
56 19 15
3 0 3
0 0 0
9,528 4,363
7,079 2,396
1,052 821
1,233 986
9,251 4,254
212 36
53 12
6 56
991 1,301
2,827 928
1,771 1,184
67 329
2 4
0 0
20,051 1,902 7,182 1,646 3,942 255 1,328 46 12,777 1,418 7,079 735 153,057 18,574
1,234 5,778 193 31 2,211 436 30,029
22,700 14,875 4,368 1,406 16,020 8,128 197,598
478 312 38 4 255 23 4,211
107 54 7 2 96 12 635
46 92 15 0 257 167 2,689
1,336 1,042 309 35 805 381 13,914
7,029 2,931 1,063 272 3,968 1,456 49,624
4,441 2,645 1,102 301 2,447 2,161 30,096
112 180 55 7 152 73 2,328
3 6 0 1 4 0 98
0 0 0 0 0 0 4
23,342 15,347 4,429 1,412 16,631 8,330 205,242
Unint
Int
Moderate Major Death
12,874 301 863 3,440 95 17,573
10,734 287 777 2,378 61 14,237
1,127 7 43 309 11 1,497
881 7 39 659 22 1,608
12,577 298 855 3,353 88 17,171
219 3 4 51 4 281
43 0 1 20 0 64
26 0 3 16 3 48
916 13 99 490 11 1,529
3,123 118 325 921 25 4,512
2,752 15 65 681 20 3,533
131 0 6 77 1 215
4 1 0 5 0 10
6 0 0 0 0 6
849 1,088 92 675
685 889 78 353
62 143 3 199
89 42 8 106
833 1,046 91 643
4 25 1 13
1 2 0 0
10 13 0 19
59 19 5 70
268 260 17 172
39 56 3 57
2 0 1 11
0 0 0 1
0 0 0 0
(Continued on following page)
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
556
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
Unknown *Category totals
74 2,778
51 2,056
4 411
14 259
64 2,677
0 43
2 5
8 50
8 161
14 731
3 158
2 16
0 1
0 0
Essential oils
4,099
2,772
435
779
3,893
102
19
84
548
958
1,166
78
9
1
4,412 3,921 162 493 2,162 11,150
2,788 2,612 77 273 1,462 7,212
565 449 11 71 255 1,351
923 761 66 134 386 2,270
4,364 3,864 155 479 2,125 10,987
22 19 2 8 11 62
17 16 2 2 6 43
4 19 3 4 18 48
133 198 35 26 185 577
1,080 1,006 40 129 513 2,768
157 207 21 30 165 580
7 34 9 4 27 81
1 1 0 0 0 2
0 0 0 0 0 0
3,477
307
1,087
1,742
3,200
70
194
2
857
506
1,067
225
6
0
74,980
21,351
12,224
36,924
70,556
548
866
2,908
6,092
7,652
10,668
2,247
79
0
558 4,619 943 1,112 4,017 33,090 5,764 2,038 279 2,483 19,239 7,830 23,685 180 105,837
460 4,283 694 901 3,338 29,815 4,740 765 242 2,147 9,093 5,351 14,346 93 76,268
28 234 84 87 584 2,030 355 269 11 129 5,071 2,170 6,077 38 17,167
53 89 147 106 83 1,039 569 858 23 181 3,971 254 2,733 38 10,144
548 4,596 898 1,104 3,963 32,876 5,619 1,923 275 2,462 19,087 7,716 22,668 144 103,879
7 9 30 5 44 152 38 23 4 9 106 74 413 11 925
2 8 6 1 5 42 102 82 0 5 35 25 388 14 715
1 5 8 1 0 11 2 4 0 5 7 12 193 5 254
45 121 67 68 1,284 849 163 253 21 63 1,098 364 2,158 33 6,587
91 770 210 251 1,100 5,189 939 314 74 474 3,702 1,379 4,182 55 18,730
45 1,209 74 69 336 200 152 193 26 97 268 1,111 2,696 23 6,499
7 19 11 4 45 8 19 18 1 7 10 30 200 4 383
1 0 13 1 4 3 1 0 0 0 3 3 12 0 41
0 0 1 0 0 0 0 0 0 0 0 0 0 0 1
496 17,006 3,542
43 2,180 107
167 2,852 292
242 10,137 2,817
462 16,614 3,405
20 330 125
10 15 5
4 7 5
109 5,843 851
65 1,954 139
94 4,662 1,292
45 1,444 582
4 164 6
1 35 0
Fertilizers Household plant food Outdoor fertilizers Plant hormones Other Unknown *Category totals Fire extinguishers Food products/food poisoning Foreign bodies/toys/ miscellaneous Ashes Bubble blowing solutions Charcoal Christmas ornaments Coins Desiccants Feces/urine Glass Incense, punk Soil Thermometer Toys Other Unknown *Category totals Fumes/gases/vapors Carbon dioxide Carbon monoxide Chloramine Chlorine: acid mixed with hypochlorite Chlorine: other Methane and natural gas Hydrogen sulfide Propane/simple asphyxiants Other Unknown *Category totals
509 6,610 4,841 1,580
13 529 852 167
77 1,272 780 185
363 4,157 2,497 978
498 6,449 4,790 1,570
10 99 40 2
1 24 3 3
0 30 3 2
188 2,020 1,129 442
17 317 881 157
191 2,641 1,124 430
114 1,275 228 140
1 23 20 19
1 1 0 2
2,777 2,433 1,393 41,187
276 283 109 4,559
580 347 195 6,747
1,651 1,413 801 25,056
2,565 2,328 1,354 40,035
196 45 10 877
5 36 16 118
1 20 5 77
860 814 366 12,622
334 277 133 4,274
812 562 362 12,170
279 220 119 4,446
9 12 3 261
2 3 0 45
Fungicides Carbamate fungicide Mercurial fungicide Non-mercurial fungicide Phthalimide fungicide Other/unknown *Category totals
257 11 301 198 287 1,054
69 8 55 101 106 339
22 0 32 36 33 123
94 2 185 51 120 452
215 11 292 194 282 994
40 0 5 1 2 48
1 0 1 2 1 5
1 0 3 0 2 6
75 3 103 26 42 249
86 3 51 55 58 253
39 1 81 15 59 195
15 1 16 6 5 43
0 0 2 0 1 3
0 0 0 0 0 0
978
445
114
353
941
8
18
5
125
131
103
23
3
0
1,003 26 85 1,169 14 5
135 1 8 215 10 3
66 1 6 378 2 0
686 17 56 481 2 1
705 19 76 1,105 14 5
47 0 0 40 0 0
155 0 1 11 0 0
6 7 0 11 0 0
540 10 45 333 2 1
145 3 6 188 3 0
72 1 9 328 4 2
76 2 9 81 0 0
14 0 1 2 0 0
2 0 0 0 0 0
Heavy metals Aluminum Arsenic (excluding pesticides) Barium Cadmium Copper Fireplace flame colors Gold
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
557
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Lead Manganese Mercury Metal fume fever Selenium Thallium Other Unknown *Category totals Herbicides Carbamate herbicide 2,4-D or 2,4,5-T Diquat Paraquat Paraquat/diquat Triazine herbicide Urea herbicide Other Unknown *Category totals Hydrocarbons Benzene Carbon tetrachloride Diesel fuel Fluorochlorocarbons/ propellants Gasoline Halogenated hydrocarbon: other Kerosene Lighter fluid/naphtha Lubricating oils/motor oil Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other Unknown *Category totals
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
3,317 57 3,861 1,045 151 40 890 19 12,660
1,535 11 957 19 67 10 271 5 3,692
539 5 1,137 61 6 4 157 2 2,478
1,059 34 1,372 886 75 25 393 12 5,452
3,172 54 3,497 1,039 132 28 811 15 11,613
60 1 254 4 6 2 24 0 446
39 1 35 0 1 5 16 3 285
8 1 36 2 11 2 36 0 125
1,253 23 789 289 32 18 302 9 3,771
663 9 1,123 25 41 7 142 3 2,489
138 6 111 302 19 3 135 0 1,233
89 4 52 153 5 0 48 2 544
13 0 6 4 0 2 1 0 46
1 0 1 0 0 0 0 0 4
76 2,293 374 114 1 396 80 5,594 263 9,191
11 703 85 7 0 74 24 1,624 71 2,599
17 246 32 7 0 44 9 484 21 860
44 1,145 235 93 1 220 42 2,984 134 4,898
76 2,229 362 102 1 381 76 5,276 250 8,753
0 15 3 6 0 6 0 47 0 77
0 5 1 2 0 2 2 33 4 49
0 42 8 2 0 6 2 228 8 296
50 511 94 71 0 127 18 1,256 75 2,202
33 453 104 16 0 65 10 1,422 33 2,136
20 469 87 22 1 65 18 1,233 39 1,954
2 97 16 5 0 23 3 143 13 302
0 4 2 4 0 1 0 9 0 20
0 0 0 1 0 0 0 3 0 4
120 44 921
12 4 171
5 4 101
88 29 583
116 40 898
0 2 18
4 1 4
0 0 0
57 20 228
19 8 118
21 10 280
18 3 43
2 0 2
0 0 0
7,134 20,720
598 6,320
974 3,872
4,702 9,253
6,838 19,495
248 1,112
34 75
10 10
1,417 3,089
1,220 3,580
1,622 8,290
449 645
14 24
3 1
794 2,677 4,011 3,984 188 4,755 2,366 954 6,600 7,504 62,772
179 1,450 2,075 2,643 164 2,082 474 313 3,228 4,755 24,468
92 346 487 373 7 665 313 152 726 596 8,713
421 765 1,297 833 14 1,788 1,396 428 2,236 1,843 25,676
754 2,533 3,755 3,882 184 4,497 2,181 825 6,329 7,288 59,615
23 92 163 63 1 175 161 113 188 128 2,487
7 42 69 34 1 52 13 9 38 55 438
9 5 13 2 2 20 5 6 35 24 141
340 835 1,223 601 25 1,093 1,055 273 1,657 2,097 14,010
115 610 1,015 1,429 97 1,114 316 190 1,688 2,076 13,595
262 777 1,168 668 17 1,305 776 241 1,400 1,920 18,757
95 175 225 84 0 208 240 46 375 504 3,110
7 9 16 1 0 14 33 2 28 39 191
0 0 1 0 0 0 0 0 4 0 9
22 158 336
60 322 1,321
322 2,912 3,094
11 45 84
1 4 23
0 6 26
41 250 657
142 796 717
17 118 474
5 10 140
0 2 9
0 0 0
101
503
915
25
11
12
166
149
191
31
1
0
429
968
2,317
100
4
104
818
745
489
87
11
2
8 16 1
81 69 3
138 241 7
2 6 0
0 0 0
0 0 0
20 45 1
16 97 2
29 20 1
7 1 0
0 0 0
0 0 0
929 61
6,003 254
10,725 508
258 10
40 8
140 4
2,943 70
2,350 125
1,972 78
567 16
72 0
5 0
13 152
100 779
167 1,348
7 28
1 7
1 13
46 279
27 291
31 359
9 71
2 9
0 0
7 28
28 71
50 180
0 5
0 1
1 4
11 35
9 31
14 49
2 9
0 0
0 0
1,158 1,094
3,120 3,996
6,742 7,890
202 216
46 47
296 310
1,498 1,863
1,313 1,414
1,535 2,009
434 471
13 23
0 1
Insecticides/pesticides (excluding rodenticides) Arsenic pesticides 335 249 Borates/boric acid 2,971 2,445 Carbamate only 3,231 1,377 Carbamate with other pesticide 963 309 Chlorinated hydrocarbon only 2,528 988 Chlorinated hydrocarbon with other pesticide 140 38 Metaldehyde 248 156 Nicotine 7 3 Organophosphate Alone 11,193 3,420 With carbamate 530 199 With chlorinated hydrocarbon 176 50 With other pesticide 1,398 378 With carbamate and chlorinated hydrocarbon 51 9 Piperonyl butoxide only 191 79 Piperonyl butoxide/ pyrethrin 7,293 2,608 Pyrethrins only 8,475 2,814
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
558
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
6,498 103 4,378 4,374 3,564 58,647
4,446 41 2,119 2,917 964 25,609
1,092 13 614 276 415 6,923
804 44 1,450 999 1,863 22,838
6,156 98 4,218 4,266 3,284 55,578
50 1 80 39 94 1,263
47 0 12 11 90 353
241 3 68 55 73 1,357
637 18 490 482 922 11,292
1,412 29 1,027 1,094 505 12,291
1,532 24 734 419 552 10,647
106 1 92 68 168 2,295
6 0 9 6 13 176
0 0 0 0 3 11
Lacrimators Capsicum/peppers Lacrimators: CN Lacrimators: CS Other Unknown *Category totals
156 2,432 137 99 324 3,148
63 580 57 12 52 764
67 741 44 18 125 995
20 874 32 69 94 1,089
138 2,013 119 95 189 2,554
3 71 0 1 42 117
12 305 18 1 90 426
2 12 0 2 0 16
30 436 22 21 104 613
2 90 10 6 6 114
92 1,208 86 36 199 1,621
4 110 3 6 10 133
0 0 1 0 0 1
0 0 0 0 0 0
Matches/fireworks/explosives Explosives Fireworks Matches Other Unknown *Category totals
279 482 1,478 55 4 2,298
144 392 1,334 28 1 1,899
72 63 60 12 0 207
48 20 62 14 3 147
250 469 1,458 54 4 2,235
17 4 16 1 0 38
11 9 1 0 0 21
0 0 2 0 0 2
65 42 56 16 1 180
80 164 390 21 1 656
48 63 22 9 1 143
12 9 4 4 0 29
0 0 0 1 0 1
0 0 0 0 0 0
Moth repellants Naphthalene Paradichlorobenzene Other Unknown *Category totals
1,767 38 83 2,703 4,591
1,341 21 61 1,839 3,262
100 6 4 221 331
269 10 15 518 812
1,744 35 82 2,621 4,482
19 2 0 41 62
2 0 1 28 31
2 1 0 10 13
404 3 11 491 909
741 7 22 936 1,706
120 3 8 241 372
22 0 1 40 63
4 0 0 1 5
0 0 0 0 0
Mushrooms Coprine Cyclopeptide Gastrointestinal irritants Hallucinogenic Ibotenic acid Miscellaneous, nontoxic Monomethylhydrazine Muscarine Orellanine Other potentially toxic Unknown *Category totals
20 41 181 782 37 181 36 9 3 7 7,699 8,996
5 13 74 42 8 85 3 0 1 7 5,738 5,976
4 7 40 452 12 25 2 3 0 0 1,009 1,554
10 20 61 250 16 64 27 6 2 0 846 1,302
15 38 150 134 26 161 29 4 1 7 7,080 7,645
4 1 20 633 11 1 2 5 1 0 534 1,212
1 0 0 10 0 0 0 0 0 0 10 21
0 2 11 1 0 19 5 0 1 0 63 102
12 25 75 542 27 39 15 7 2 0 2,186 2,930
7 11 68 56 8 51 3 0 1 4 4,449 4,658
4 8 55 152 7 31 12 2 0 0 721 992
1 4 28 258 14 10 6 1 1 0 253 576
0 2 0 20 2 0 0 0 1 0 31 56
0 4 1 1 0 0 0 0 0 0 0 6
9 93 4,166 4,337 1,036
0 22 1,232 3,126 416
0 12 819 265 95
8 50 1,867 755 440
9 91 3,908 4,288 1,012
0 1 206 18 6
0 0 19 9 6
0 1 27 20 10
2 30 937 298 200
1 9 658 864 168
2 24 1,161 313 243
1 10 244 142 39
0 0 14 0 2
0 0 0 0 0
Repellants (insect) Rotenone Veterinary insecticide Other Unknown *Category totals
Moderate Major Death
Paints and stripping agents Paints Anti-algae Anticorrosion Oil-base Water-base Stains Stripping agents Methylene chloride Other Unknown Varnishes, lacquers Wood preservatives Other paint/varnish/lacquer Unknown paint/varnish/ lacquer *Category totals
1,183 758 315 965 588 1,348
181 155 94 294 141 653
123 66 36 101 66 121
766 457 163 491 333 494
1,143 732 302 937 576 1,322
29 13 3 19 5 17
1 3 3 6 2 3
9 8 6 3 5 6
442 262 102 205 151 262
85 69 52 117 104 203
511 250 98 228 123 240
107 93 21 52 27 64
5 0 1 4 0 5
0 1 0 0 0 0
10,703 25,501
6,654 12,968
1,025 2,729
2,578 8,402
10,426 24,746
177 494
36 88
57 152
1,261 4,152
1,853 4,183
1,104 4,297
223 1,023
15 46
0 1
Photographic products Developers/fixing/stop baths Photographic coating fluids Other Unknown *Category totals
577 5 416 25 1,023
83 3 204 4 294
226 0 60 5 291
218 2 132 10 362
562 5 410 25 1,002
1 0 4 0 5
8 0 2 0 10
6 0 0 0 6
191 0 75 3 269
77 1 76 5 159
220 1 91 9 321
27 0 15 0 42
0 0 0 0 0
0 0 0 0 0
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
559
TABLE 22A. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
No. of Exposures
Plants Amygdalin/cyanogenic glycosides Anticholinergic Cardiac glycosides Colchicine Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine Non-toxic plant Oxalate Solanine Stimulants Toxalbumins Other Unknown *Category totals
3,519 988 2,498 24 71 25,774 19,488 366 254 19,132 13,025 1,856 397 245 3,734 22,493 113,864
Polishes and waxes Radioisotopes Rodenticides ANTU Anticoagulant: standard Anticoagulant: long-acting Barium carbonate Cyanide Monofluoroacetate Strychnine Vacor Other Unknown *Category totals Sporting equipment Fishing bait Fishing products, other Golf balls Gun bluing Hunting products, other Other Unknown *Category totals
⬍6
6–19
2,518 593 285 475 1,784 365 17 7 29 11 11,007 5,144 15,695 1,750 158 72 105 49 15,873 1,827 11,464 934 1,466 144 225 62 115 40 2,711 432 15,835 3,072 79,287 14,977
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
353 210 318 0 27 8,136 1,801 121 82 1,209 533 203 92 77 501 3,101 16,764
3,400 504 2,389 24 54 23,521 18,949 242 236 18,653 12,876 1,805 342 224 3,534 21,624 108,377
53 452 84 0 10 405 292 76 9 166 98 20 37 10 70 416 2,198
2 6 3 0 0 714 32 3 3 11 5 3 1 7 9 56 855
64 20 19 0 7 1,079 200 43 4 292 38 25 16 4 113 371 2,295
145 537 348 0 17 2,196 1,041 128 81 529 405 183 111 110 328 1,458 7,617
919 171 981 6 21 3,051 5,816 101 50 3,292 4,493 693 144 86 1,049 6,060 26,933
101 120 134 0 9 7,360 1,336 50 71 741 1,634 115 42 49 388 1,603 13,753
19 325 28 0 4 742 144 50 21 91 67 12 19 13 54 248 1,837
3 34 3 0 0 25 8 4 2 4 3 0 1 1 6 12 106
0 2 0 0 0 0 0 0 0 0 0 0 1 0 1 0 4
7,152
5,529
515
948
6,969
140
23
16
815
2,618
1,122
126
5
0
235
22
33
152
220
4
0
7
64
26
8
6
0
0
1 1,916 15,862 0 2 12 171 4 839 1,399 20,206
0 1,660 14,232 0 2 0 24 2 565 1,013 17,498
1 69 536 0 0 2 28 2 52 82 772
0 161 963 0 0 10 97 0 193 248 1,672
0 1,838 15,303 0 2 10 83 2 781 1,229 19,248
1 64 461 0 0 1 50 0 44 109 730
0 12 67 0 0 1 31 2 10 45 168
0 0 10 0 0 0 1 0 1 5 17
0 579 5,301 0 1 7 96 2 224 632 6,842
1 671 6,311 0 0 1 27 1 268 493 7,773
0 27 173 0 0 5 9 0 63 40 317
0 10 60 0 0 2 14 2 15 14 117
0 3 30 0 0 0 8 0 6 8 55
0 0 2 0 0 0 0 0 2 0 4
61 27 59 36 406 259 7 855
50 20 2 13 223 170 5 483
8 7 43 2 85 47 1 193
1 0 14 20 81 38 1 155
58 27 52 34 371 248 7 797
1 0 7 1 14 6 0 29
1 0 0 0 16 4 0 21
1 0 0 0 1 1 0 3
1 2 11 11 126 49 1 201
12 4 10 8 149 89 2 274
9 3 24 11 31 23 1 102
1 0 4 3 8 6 0 22
0 0 0 0 1 0 0 1
0 0 0 0 0 0 0 0
Swimming pool/aquarium
7,354
3,365
1,279
2,437
7,171
89
14
75
1,185
1,405
2,100
489
11
0
Tobacco products Other/unknown nondrug substances
7,884
6,947
332
549
7,618
156
43
62
1,446
2,912
1,876
105
4
0
15,590
5,921
2,435
5,932
13,310
530 1,024
387
3,558
2,541
2,354
682
90
1
1,347,898 703,833 180,592 405,851 1,268,801 52,847 9,893
14,023
218,476 264,603 251,139
51,333
4,024
279
Total number of nonpharmaceutical substances % of nonpharmaceutical substances % of all substances
56.9%
52.2% 29.7%
13.4% 7.6%
30.1% 17.1%
94.1% 53.6%
3.9% 2.2%
0.7% 0.4%
1.0% 0.6%
16.2% 9.2%
19.6% 11.2%
18.6% 10.6%
3.8% 2.2%
0.3% 0.0% 0.2% 0.0%
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
560
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals
Age (yr) Substances Implicated In the Exposure Analgesics Acetaminophen only Adult formulations Pediatric formulations Unknown formulations Acetaminophen in combination with: Aspirin (with other ingredients) Aspirin (no other ingredients) Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Aspirin alone Adult formulations Pediatric formulations Unknown formulations Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Narcotics Codeine Meperidine Methadone Morphine Oxycodone Pentazocine Propoxyphene Other/unknown Nonaspirin salicylates Other nonsteroidal antiinflammatory drugs Colchicine Ibuprofen Indomethacin Other Unknown Phenacetin Phenazopyridine Salicylamide Other Unknown *Category totals Anesthetics Inhalation anesthetics Nitrous oxide Other Unknown Ketamine and analogs Local and topical anesthetics
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
25,978 26,151 8,963
6,412 23,324 2,572
9,084 2,508 2,852
9,657 273 3,222
13,257 12,346 25,694 343 4,342 4,433
5,423
2,016
1,476
1,756
3,096
12 5,741 3,553 5,120 11,626
5 1,090 434 594 1,212
3 1,150 446 629 1,721
4 3,214 2,385 3,611 7,987
15,213
2,222
3,760
322
224
4,022 482 9,350
Int
None
Minor
Moderate Major Death
15 10 6
272 92 98
14,610 3,075 5,237
8,258 7,141 2,413
3,531 398 1,390
1,451 63 662
457 22 261
38 0 47
2,061
1
246
2,432
1,649
968
248
22
4
7 2,505 1,460 1,824 4,465
4 2,755 1,745 3,024 6,175
0 4 3 0 7
1 444 317 223 874
4 3,084 1,836 3,295 6,409
3 1,364 678 1,162 2,211
2 1,349 850 1,338 2,741
1 439 265 519 979
0 98 81 193 320
0 3 15 18 40
8,528
5,383
9,323
10
406
9,701
3,523
3,842
1,604
312
12
60
34
289
25
0
8
44
74
54
8
2
0
1,545 385 1,938
1,184 73 3,355
1,206 21 3,699
2,280 444 3,512
1,632 34 5,560
9 0 6
90 4 205
1,902 90 6,231
1,202 194 2,490
619 25 1,949
317 7 1276
38 0 213
7 0 38
353 234 41 33
49 29 7 10
37 30 5 7
244 161 27 13
126 98 21 23
209 120 17 9
0 0 0 0
16 15 3 1
228 123 22 17
67 43 8 9
94 45 11 7
36 27 3 1
18 5 2 1
1 2 0 1
1,785
377
371
949
823
852
1
96
956
403
382
180
30
2
3
1
1
1
3
0
0
0
1
1
0
0
0
0
1,258 600 1,047 1,218 1,632 204 560 3,267 1,065
497 59 79 146 187 15 53 468 536
273 74 108 125 111 17 47 431 143
437 415 792 843 1,201 156 416 2,141 359
873 253 342 562 792 77 193 1,377 792
290 259 580 529 652 87 325 1,404 231
2 0 4 8 2 0 0 4 0
89 82 84 100 163 38 35 435 41
369 316 705 706 804 95 361 1,690 377
311 96 87 189 268 25 99 503 342
210 134 190 245 324 57 113 702 146
50 72 204 169 181 14 83 419 63
16 25 117 61 71 7 33 159 5
3 2 17 10 12 0 12 44 0
146 54,643 682 18,181 8 2 913 75 4,058 102 214,066
45 33,886 203 5,300 3 1 693 67 771 16 87,471
22 10,376 82 3,716 0 0 77 1 466 37 44,858
78 9,356 357 8,322 4 1 133 7 2,553 39 74,602
94 32 41,986 11,678 392 209 10,809 5,910 6 1 2 0 819 47 70 3 2,069 1,419 30 63 131,190 74,386
0 21 0 10 0 0 0 0 1 1 125
19 854 77 1,381 1 0 47 2 545 6 7,410
82 13,013 284 6,710 2 0 221 23 1,792 61 86,908
43 17,073 180 5,174 1 0 396 35 751 22 58,488
17 4,149 120 2,532 1 0 96 3 1,102 18 29,754
17 854 30 738 0 0 14 0 377 5 11,376
6 105 4 115 0 0 1 0 89 0 2,889
6 3 0 3 0 0 0 0 0 0 340
232 199 2 294
16 18 0 12
105 25 0 113
96 138 0 156
108 160 0 52
85 23 0 227
2 3 0 5
35 12 2 4
114 87 2 247
23 15 0 24
46 57 0 67
32 28 1 88
12 3 0 24
2 1 0 0
6,966
4,731
652
1,390
6,421
164
35
335
1,184
2,531
821
144
31
0
(Continued on following page)
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
561
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
⬎19
Unint
None
Minor
Other Unknown *Category totals
41 6 7,740
8 2 4,787
7 3 905
22 1 1,803
24 3 6,768
6 1 506
0 1 46
10 1 399
27 3 1,664
5 0 2,598
9 3 1,003
6 1 300
2 0 72
0 0 3
Anticholinergic drugs
4,689
1,576
630
2,308
2,868
1,462
11
299
2,384
1,227
869
600
132
4
95
19
11
52
83
5
0
7
50
22
8
9
5
1
1,699 439 6 2,239
666 129 3 817
84 23 0 118
883 269 2 1,206
1,336 371 4 1,794
263 35 2 305
6 0 0 6
82 33 0 122
725 140 5 920
511 153 2 688
69 26 0 103
105 10 1 125
84 5 0 94
1 0 0 2
6,132 4,045 98 8,743 4,378 14 23,410
1,741 786 48 1,027 544 8 4,154
1,305 345 29 2,202 727 1 4,609
2,864 2,720 20 5,100 2,847 4 13,555
3,812 2,310 91 3,672 2,115 10 12,010
1,958 1,319 6 4,691 1,928 4 9,906
5 3 0 1 4 0 13
277 337 1 297 311 0 1,223
3,768 2,575 22 5,762 2,472 9 14,608
1,338 910 41 2,391 1,075 3 5,758
1,614 955 9 2,095 968 1 5,642
927 559 1 1,012 472 1 2,972
285 115 0 336 140 0 876
0 1 0 8 5 0 14
7,787 48 334 1,854 1,704 37 1,332 21
969 4 44 134 437 6 163 9
980 8 57 156 551 6 206 4
5,456 35 219 1,463 668 24 894 7
2,410 16 133 490 966 16 536 15
5,048 30 180 1,288 659 20 728 5
6 1 0 5 1 0 0 0
192 1 19 50 68 1 57 1
6,157 35 240 1,494 1,036 26 935 15
1,241 4 79 274 518 5 291 8
1,794 10 61 434 346 5 298 6
1,727 7 66 423 227 8 203 2
1,021 10 23 243 95 7 108 0
62 0 2 18 8 0 9 0
751
74
87
545
376
325
3
43
434
169
198
110
48
1
15
0
0
12
2
12
0
1
11
0
1
4
4
1
70
10
6
50
25
41
0
2
44
12
14
11
7
1
198 4,361 372 28,563 10,501 12,088 24 70,060
30 277 46 4,743 767 1,806 0 9,519
18 734 8 7,030 1,590 2,364 5 13,810
146 3,145 288 15,278 7,480 7,258 15 42,983
80 1,567 215 10,568 2,916 4,757 4 25,092
106 2,264 102 16,335 7,077 6,634 20 40,874
0 8 0 23 8 4 0 59
7 428 52 1,485 442 634 0 3,483
148 3,381 227 18,023 7,552 8,203 17 47,978
33 941 69 8,561 2,307 3,275 1 17,788
32 1,020 52 6,296 3,292 2,719 7 16,585
47 898 87 2,518 1,284 1,709 1 9,332
20 253 21 473 218 551 2 3,104
0 6 0 22 9 14 0 153
17,632 332
9,245 105
2,902 71
5,070 143
12,492 194
4,724 127
9 0
357 10
6,264 167
4,716 87
3,327 61
1,401 41
175 9
6 0
5,936 5,721 22,497 52,118
2,092 3,429 10,110 24,981
1,240 655 5,590 10,458
2,400 1,484 6,197 15,294
3,353 4,854 16,805 37,698
2,347 654 4,825 12,677
4 1 19 33
195 196 770 1,528
2,741 1,152 7,457 17,781
1,309 1,834 6,984 14,930
1,239 426 3,193 8,246
702 88 1,198 3,430
105 9 156 454
14 0 8 28
36,763 7,314 879
20,232 5,460 286
5,848 497 207
9,529 1,168 341
28,951 7,109 488
3,584 67 226
22 1 0
4,107 133 161
6,073 203 282
8,166 1,480 153
3,259 341 190
781 19 22
54 3 2
2 0 0
1,180 8,137
625 6,132
147 430
361 1,379
952 7,889
96 52
0 9
129 181
261 283
305 1,718
114 596
26 37
1 1
1 0
Anticoagulants Heparin Warfarin (excluding rodenticides) Other Unknown *Category totals Anticonvulsants Carbamazepine Phenytoin Succinimides Valproic acid Other Unknown *Category totals Antidepressants Cyclic antidepressants Amitriptyline Amoxapine Desipramine Doxepin Imipramine Maprotiline Nortriptyline Protriptyline Other cyclic antidepressants Unknown cyclic antidepressants Cyclic antidepressant formulated with a benzodiazepine Cyclic antidepressant formulated with a phenothiazine Lithium MAO inhibitors SSRIs Trazodone Other Unknown *Category totals Antihistamines Diphenhydramine, (OTC) Diphenhydramine, (Rx) Diphenhydramine, unknown if OTC or Rx H2 receptor antagonists Other *Category totals Antimicrobials Antibiotics Systemic Topical Unknown Antifungals Systemic Topical
6–19
Int
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
562
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown Anthelmintics Diethylcarbamazine Piperazine Other Unknown Antiparasitics Antimalarial Metronidazole Other Antituberculars Isoniazid Rifampin Other Unknown Antivirals Systemic Topical Unknown Other Unknown *Category totals Antineoplastics Asthma therapies Aminophylline/theophylline Terbutaline and other beta-2 agonists Other beta agonists Other Unknown *Category totals
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
13
7
0
6
12
0
0
1
2
5
3
0
0
0
250 508 731 23
130 391 400 15
15 42 84 2
96 69 199 5
241 488 691 21
6 10 12 1
0 2 5 0
2 6 22 1
13 50 163 4
65 178 189 5
10 24 118 1
2 2 22 1
0 1 3 0
0 0 0 0
437 1,253 108
129 307 62
69 192 15
213 669 28
332 768 102
67 238 2
1 0 0
36 245 4
195 327 20
151 247 28
40 183 10
34 43 0
7 1 0
1 0 0
412 49 14 3
86 16 3 2
160 10 1 0
152 21 10 1
187 34 11 2
189 8 1 1
0 0 0 0
31 7 2 0
301 24 5 1
102 13 4 1
53 11 1 1
42 2 1 0
86 0 0 0
2 0 0 0
1,575 48 53 174 9 59,933
480 29 17 129 2 34,940
200 7 9 18 2 7,955
807 10 25 24 4 15,117
1,030 47 34 147 6 49,542
346 0 6 14 2 4,928
0 0 0 0 0 40
191 1 13 13 1 5,287
558 3 13 35 3 8,819
394 14 12 65 0 13,295
159 4 2 14 2 5,136
69 0 2 2 0 1,107
23 0 0 0 0 182
1 0 0 0 0 7
1,257
392
83
678
1,075
63
4
113
427
381
129
48
14
2
1,641
357
190
1,048
1,110
395
2
110
962
401
286
313
65
10
9,536 2,412 3,306 10 16,905
7,297 560 2,254 2 10,470
1,255 577 562 4 2,588
900 1,149 441 4 3,542
8,746 1,105 3,010 5 13,976
449 1,050 216 4 2,114
13 3 3 0 21
317 236 71 0 734
2,282 1,270 500 5 5,019
3,103 468 1,228 1 5,201
1,488 576 188 1 2,539
534 376 47 2 1,272
15 37 5 0 122
0 0 0 0 10
Cardiovascular drugs ACE inhibitors Alpha blockers Antiarrhythmics Antihypertensives Beta blockers Calcium antagonists Cardiac glycosides Hydralazine Long-acting nitrates Nitroglycerin Nitroprusside Other vasodilator Unknown types of vasodilators Vasopressor Other Unknown *Category totals
7,160 1,455 1,046 6,683 9,502 8,844 2,810 152 582 2,194 36 301
2,836 540 199 2,308 2,556 2,304 812 42 232 1,313 3 136
488 90 51 2,066 972 554 128 14 15 139 2 24
3,600 775 754 2,173 5,622 5,665 1,799 95 314 681 25 131
5,984 1,194 916 5,142 7,124 6,831 2,247 117 517 1,900 15 276
951 186 73 1,302 2,078 1,723 285 31 54 246 0 19
4 2 0 11 10 5 1 0 0 9 0 0
209 68 53 183 259 252 234 4 8 34 21 4
2,410 681 383 3,659 4,684 4,667 1,404 73 185 641 32 91
3,083 602 391 2,001 3,817 3,622 964 61 256 1,024 4 133
452 151 75 1,248 827 801 191 22 40 152 8 27
381 121 72 1,038 890 883 408 16 33 65 5 10
50 18 23 171 195 243 153 3 3 10 4 0
4 0 9 5 26 61 20 0 0 1 0 0
2 7 3,060 22 43,856
0 2 1,294 6 14,583
0 2 344 1 4,890
1 3 1,296 13 22,947
1 6 2,689 11 34,970
0 0 216 10 7,174
0 0 3 0 45
1 0 144 1 1,475
0 5 706 12 19,633
0 2 941 3 16,904
0 2 262 0 4,258
0 0 95 1 4,018
0 0 13 0 886
0 0 1 0 127
Cold and cough preparations
99,873
63,951
18,650
15,868
86,784
9,889
49
2,974
18,717
27,445
14,501
2,900
199
5
454
85
37
270
387
9
3
52
178
72
99
27
2
0
Diuretics Furosemide Thiazide Other Unknown *Category totals
1,687 1,869 1,404 302 5,262
829 814 636 141 2,420
145 183 132 27 487
658 809 588 123 2,178
1,495 1,556 1,168 247 4,466
152 240 165 34 591
1 2 2 1 6
33 67 64 19 183
488 580 419 107 1,594
541 655 528 109 1,833
212 159 134 32 537
73 76 53 17 219
7 9 9 3 28
0 1 0 0 1
Electrolytes and minerals Calcium Fluoride Iron
4,045 3,911 3,654
3,407 3,398 2,265
284 341 530
306 150 781
3,912 3,850 3,005
72 24 534
3 2 9
55 33 96
189 213 1,257
949 1,238 1,282
120 357 447
20 13 110
2 0 9
0 0 1
Diagnostic agents
(Continued on following page)
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TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Magnesium Potassium Sodium Zinc Other Unknown *Category totals Eye/ear/nose/throat preparations Nasal preparations Tetrahydrozoline Other decongestant Other Unknown Ophthalmic preparations Contact lens products Glaucoma therapies Tetrahydrozoline Other ophthalmic sympathomimetics Other Unknown Otic preparations Combination products Other Unknown Steroids-topical for eye/nose/throat Throat preparations Lozenges without local anesthetics Lozenges with local anesthetics Other Unknown *Category totals Gastrointestinal preparations Antacids Salicylate-containing Other Antidiarrheals Diphenoxylate/atropine Non-narcotic Paregoric Other narcotic Antispasmodics Anticholinergic Other Laxatives Other Unknown *Category totals Hormones and hormone antagonists Androgens Corticosteroids Estrogens Insulin Oral contraceptives Oral hypoglycemics Progestins Thyroid preparations Other hormones Other hormone antagonists
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
None
Minor
447 1,163 2,426 2,574 857 6 19,083
161 556 1,600 1,778 557 1 13,723
68 112 442 192 92 1 2,062
194 453 328 543 190 4 2,949
377 1,015 2,306 2,430 681 3 17,579
35 112 87 49 96 2 1,011
4 2 18 0 1 0 39
30 29 13 87 77 1 421
122 308 295 205 178 3 2,770
85 425 615 495 245 4 5,338
71 87 370 237 85 1 1,775
25 43 39 41 21 0 312
5 6 4 0 3 0 29
1 0 0 0 0 0 2
75 2,317 568 12
53 1,033 388 4
3 403 42 2
17 790 120 4
67 2,023 544 10
3 166 7 1
0 8 0 0
5 115 17 1
27 431 22 2
33 756 134 3
10 336 78 2
1 82 7 0
0 6 0 0
0 0 0 0
3,209 125 1,666
1,872 48 1,128
287 3 177
889 67 321
3,155 113 1,455
24 1 76
13 0 98
17 11 33
311 26 571
527 37 793
535 18 161
97 6 36
1 0 3
0 0 0
471 1,119 34
232 531 8
65 136 7
150 406 13
402 1,036 23
10 27 4
1 7 2
58 48 3
119 149 7
159 176 6
73 148 6
17 35 0
1 3 0
0 0 0
1,172 2,188 25
844 1,100 9
117 214 2
186 764 14
1,165 2,164 24
2 11 1
0 0 0
4 8 0
114 216 3
354 380 3
291 648 7
12 56 0
0 3 0
0 0 0
723
390
103
197
679
18
1
24
56
111
119
8
0
0
738
581
81
71
705
13
0
20
27
169
37
4
0
0
259 310 6 15,017
167 157 5 8,550
48 93 0 1,783
43 51 1 4,104
236 254 6 14,061
15 47 0 426
0 0 0 130
8 7 0 379
20 70 1 2,172
61 102 1 3,805
14 39 0 2,522
4 4 0 369
0 0 0 17
0 0 0 0
2,325 18,014
1,799 16,397
256 703
238 807
2,157 17,694
80 160
1 26
84 128
196 447
688 3,637
102 396
18 38
1 6
0 0
1,064 690 44 182
517 514 29 128
147 59 6 15
369 105 6 34
815 636 36 161
183 20 5 8
1 1 0 0
63 31 3 12
465 78 12 36
397 188 13 95
154 30 10 13
59 10 0 2
12 0 2 0
0 0 0 0
928 9 13,509 7,933 1,885 46,583
294 4 9,512 5,941 998 36,133
194 1 1,269 484 146 3,280
402 3 2,444 1,355 674 6,437
524 8 12,257 7,140 1,571 42,999
341 0 747 443 209 2,196
1 0 127 6 0 163
56 0 354 326 103 1,160
485 2 1,615 1,394 402 5,132
282 6 2,591 2,211 694 10,802
184 0 2,014 506 113 3,522
93 1 195 207 33 656
19 0 6 22 6 74
0 0 0 1 0 1
502 9,483 3,463 1,428 8,730 5,351 1,147 6,930 1,986 321
185 5,538 2,539 116 7,294 2,137 607 4,156 976 110
61 1,172 183 100 784 402 169 625 360 40
220 2,447 668 1,105 558 2,636 337 1,987 564 152
321 8,491 3,279 1,048 8,165 4,296 1,004 6,435 1,504 258
116 368 108 330 435 862 61 394 379 41
2 8 3 7 6 1 2 3 8 1
58 603 72 34 120 162 78 89 93 21
166 818 332 558 627 3,349 164 1,179 534 87
106 1,937 889 416 1,910 2,355 277 1,872 562 94
57 572 94 104 277 422 54 231 257 21
29 100 29 248 9 812 8 83 43 10
7 7 3 43 2 129 3 11 8 2
0 0 0 4 0 9 0 0 0 0
(Continued on following page)
Moderate Major Death
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
564
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown hormone or antagonists *Category totals Miscellaneous drugs Allopurinol L-dopa and related drugs Dietary supplements/ homeopathic Disulfiram Ergot alkaloids Methysergide Neuromuscular blocking agents Nicotine pharmaceuticals Other *Category totals Muscle relaxants Carisoprodol (formulated alone) Cyclobenzaprine Methocarbamol Other Unknown *Category totals Narcotic antagonists Radiopharmaceuticals Sedative/hypnotics/ antipsychotics Barbiturates Long-acting Short-acting Unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone Phenothiazines Sleep aids (OTC) Other Unknown *Category totals Serums, toxoids, vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids Phenylpropanolamine Phenylpropanolamine and caffeine Other, OTC Other, Rx Unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine Phenylpropanolamine lookalike drugs Other stimulants Other hallucinogens
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason
No. of Exposures
⬍6
6–19
⬎19
Unint
Int
10 39,351
3 23,661
0 3,896
6 10,680
6 34,807
1 3,095
0 41
2 1,332
278 668
163 200
13 17
102 437
240 566
18 62
0 0
13,722 410 479 3
6,313 13 230 2
1,894 15 52 0
5,097 333 181 1
8,482 115 328 2
3,396 223 94 1
21 750 11,788 28,119
0 221 5,093 12,235
3 80 1,247 3,321
16 409 4,903 11,479
10 481 9,823 20,047
5,267 4,441 1,199 2,139 49 13,095
285 834 168 443 7 1,737
505 686 185 310 13 1,699
4,193 2,671 768 1,250 27 8,909
219
11
20
16
2
3,478 961 4 40,299 305 59 8 139 38 6,952 1,533 17,793 240 71,809
None
Minor
5 7,819
1 10,419
1 2,090
1 1,372
1 216
0 13
18 35
67 225
106 196
19 95
8 50
0 5
0 0
271 3 0 0
1,410 64 53 0
5,413 223 289 2
3,008 47 168 1
1,796 82 77 0
1,641 67 45 0
744 14 5 0
10 0 0 0
5 77 1,000 4,876
0 2 41 317
5 189 887 2,661
17 127 2,826 9,189
3 150 3,058 6,737
3 153 1,730 3,955
6 55 522 2,394
0 0 65 833
0 1 4 15
1,295 1,776 479 962 15 4,527
3,776 2,519 653 1,036 33 8,017
2 2 1 1 0 6
131 108 51 119 1 410
4,002 2,948 692 1,317 33 8,992
661 1,015 269 494 10 2,449
1,807 1,193 296 458 13 3,767
858 647 84 299 3 1,891
280 183 33 135 0 631
9 6 1 2 0 18
173
72
104
1
39
140
31
45
34
13
2
0
13
8
3
0
5
9
0
4
0
1
0
727 81 0 4,663 74 4 3 9 0 1,041 100 1,502 14 8,218
322 108 0 4,016 33 1 1 10 7 976 228 3,167 32 8,901
2,273 703 4 28,946 184 53 4 112 27 4,549 1,115 12,176 165 50,311
1,994 315 0 11,301 123 12 4 43 6 3,033 327 5,578 65 22,801
1,346 598 3 27,544 143 44 4 91 31 3,330 1,167 11,178 152 45,631
2 2 0 291 0 0 0 0 0 13 1 14 12 335
90 36 1 792 34 2 0 2 0 497 25 848 9 2,336
1,833 670 4 29,087 223 49 5 103 29 4,696 1,151 12,755 179 50,784
703 156 0 6,965 25 5 4 17 1 1,529 278 3,415 29 13,127
751 274 1 13,299 102 11 1 34 8 1,583 428 5,368 53 21,913
425 132 0 4,942 58 19 0 27 8 1,342 247 2,745 40 9,985
213 50 1 1,354 27 11 0 14 1 258 40 673 6 2,648
7 1 0 65 2 0 1 0 0 8 2 23 1 110
2,003
361
307
1,107
1,432
32
1
530
618
160
381
90
5
0
16,684 105 6,264 4,286
4,593 12 1,039 91
6,995 8 3,162 584
4,614 74 1,846 3,352
9,945 44 2,477 465
6,006 58 3,423 3,691
167 2 16 40
438 0 312 21
8,743 50 2,927 3,730
4,274 13 847 643
3,028 27 1,909 833
2,324 10 807 1,080
389 2 26 374
18 1 0 70
1,125
400
341
349
623
437
0
58
599
355
169
141
11
1
180 235 178 152 1,669 1,252 1,930 173 465
67 116 55 46 12 20 125 43 21
60 46 46 38 175 830 878 45 140
49 65 68 57 1,387 335 819 79 271
93 147 80 78 117 156 367 125 90
78 50 81 42 1,503 1,002 1,457 40 343
0 0 1 1 12 72 44 2 14
8 38 13 28 24 11 36 5 4
108 81 124 75 1,484 902 1,304 58 400
59 75 55 40 146 48 164 8 34
32 29 39 24 267 219 449 58 82
25 25 28 15 521 446 420 22 167
1 0 1 0 230 42 65 2 44
0 0 0 0 30 0 0 0 1
19 198 1
3 44 0
4 59 0
9 91 1
6 77 1
13 115 0
0 0 0
0 5 0
11 133 1
3 46 0
3 49 0
4 43 0
1 3 0
0 0 0
(Continued on following page)
Moderate Major Death
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
565
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Unknown hallucinogens Other street drugs Unknown stimulant/street drugs *Category totals Topical preparations Acne preparations Boric acid/borates Calamine Camphor Camphor/methyl salicylate Diaper products Hexachlorophene antiseptic Hydrogen peroxide Iodine or iodide antiseptics Mercury antiseptics Methyl salicylate Podophyllin Silver nitrate Topical steroids Topical steroid with antibiotics Wart preparation Other liniment Other topical antiseptic *Category totals Veterinary drugs Vitamins Multiple vitamin tablets: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin tablets: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
10 25
1 0
4 7
3 18
1 4
3 20
5 1
0 0
7 18
0 3
0 8
2 6
0 1
0 0
59 35,010
2 6,690
24 13,446
27 13,514
10 14,906
36 18,398
10 387
0 1,001
45 20,800
7 6,820
7 7,232
14 6,100
3 1,195
0 121
2,207 214 3,516 8,486 1,126 33,901
1,217 100 2,579 6,501 938 32,078
500 19 211 580 66 915
435 85 669 1,273 111 800
2,022 199 3,467 8,282 1,101 33,810
61 11 30 144 5 24
4 1 3 18 2 9
119 3 14 38 17 52
153 29 175 979 110 315
520 44 810 2,995 413 6,729
349 26 215 1,315 193 846
35 4 9 78 8 22
2 0 0 7 0 1
0 0 0 0 0 0
157 7,772 1,628 267 9,250 54 221 6,825
108 3,421 540 211 6,898 16 17 4,896
16 819 295 14 809 10 96 437
31 3,291 702 34 1,386 24 90 1,317
152 7,583 1,406 254 9,063 47 191 6,675
2 104 148 6 70 4 14 42
0 34 8 0 15 0 2 11
3 50 61 6 100 3 12 95
20 432 396 30 804 20 39 165
29 1,461 400 87 2,501 9 25 1,207
16 1,377 300 14 2,037 10 57 376
5 57 65 2 59 2 9 33
0 1 3 1 8 2 0 0
0 0 0 0 0 0 0 0
1,276 1,524 2,585 3,913 84,922
946 971 1,447 2,677 65,561
108 221 209 376 5,701
196 296 829 762 12,331
1,240 1,470 2,365 3,723 83,050
6 25 18 90 804
1 3 4 7 122
28 26 197 85 909
46 146 187 442 4,488
279 421 478 1,121 19,529
117 263 640 493 8,644
8 28 35 55 514
0 2 2 9 38
0 0 0 0 0
3,316
1,729
243
1,170
3,249
47
7
11
259
872
426
46
5
0
2,578 5,856 60 24
1,782 3,994 57 24
281 614 2 0
481 1,130 1 0
2,256 5,225 59 24
169 506 0 0
3 2 0 0
143 118 1 0
283 942 6 2
563 1,862 10 6
177 302 7 4
26 41 0 0
4 5 0 0
0 2 0 0
7,262 15,760 672 1,404
6,340 14,057 645 1,321
869 1,594 22 68
46 93 4 12
7,154 15,536 668 1,388
94 200 4 7
1 4 0 6
10 17 0 2
224 1,440 34 36
1,860 5,289 162 397
170 705 17 20
9 34 2 0
0 2 0 0
0 0 0 0
79 119 4 2
43 66 2 1
9 11 1 0
23 36 1 1
62 96 3 2
8 10 0 0
0 0 0 0
9 13 1 0
17 23 0 0
13 30 0 0
6 10 0 0
2 1 0 0
0 0 0 0
0 0 0 0
214 508 92 405
201 482 91 394
9 20 1 7
4 5 0 4
210 502 92 403
1 3 0 0
0 0 0 0
3 3 0 2
10 30 3 10
56 145 23 104
5 30 2 10
2 1 0 1
0 0 0 0
0 0 0 0
18 2,068 4 25
10 1,471 3 24
3 265 1 1
5 293 0 0
11 1,857 3 25
4 166 1 0
0 2 0 0
3 36 0 0
2 322 2 0
5 602 2 4
1 112 0 0
0 21 0 0
0 2 0 0
0 0 0 0
(Continued on following page)
AMERICAN JOURNAL OF EMERGENCY MEDICINE 䊏 Volume 18, Number 5 䊏 September 2000
566
TABLE 22B. Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont’d)
Age (yr) Substances Implicated In the Exposure Multiple vitamins, unspecified pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride Other vitamins Vitamin A Niacin (B3) Pyridoxine (B6) Other B complex vitamins Vitamin C Vitamin D Vitamin E Other Unknown *Category totals Unknown drug Total number of pharmaceutical substances % of pharmaceutical substances % of all substances
No. of Exposures
⬍6
6–19
Treated in Health Care Other Adv Rxn Facility
Outcome
Reason ⬎19
Unint
Int
None
Minor
Moderate Major Death
41 85 10
37 73 9
3 11 1
1 1 0
41 84 10
0 1 0
0 0 0
0 0 0
0 11 0
10 33 0
0 5 0
0 0 0
0 0 0
0 0 0
1,555 2,088 445
1,288 454 268
75 345 68
176 1,166 96
1,491 1,065 352
30 217 65
2 3 0
32 800 28
95 278 95
358 136 128
43 780 30
7 58 11
2 2 4
0 0 0
1,535 2,470 228 1,869 610 651 48,741
1,068 1,908 133 1,524 433 448 38,651
112 281 18 100 55 91 4,938
309 242 66 214 111 94 4,615
1,346 2,285 208 1,776 525 562 45,321
105 128 8 58 24 53 1,862
2 3 0 1 1 2 32
76 52 12 34 60 32 1,487
189 126 29 99 88 89 4,485
344 540 60 423 134 195 13,494
71 119 9 58 53 33 2,779
12 13 5 7 10 6 269
2 1 1 1 0 0 26
0 0 0 0 0 0 2
11,452
3,416
2,409
4,845
6,056
3,629
723
639
6,516
2,332
1,593
1,206
388
7
1,020,598 480,824 162,084 344,988 719,535 255,015 2,765
38,602
62,964 15,173
987
43.1%
47.1% 20.3%
15.9% 6.8%
33.8% 14.6%
70.5% 30.4%
REFERENCES 1. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1984;2:420-443 2. Litovitz TL, Veltri JC: 1984 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1985;3:423-450 3. Litovitz TL, Normann SA, Veltri JC: 1985 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1986;4:427-458 4. Litovitz TL, Martin TG, Schmitz B: 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1987;5:405-445 5. Litovitz TL, Schmitz BF, Matyunas N, et al: 1987 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1988;6:479-515 6. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989;7:495-545 7. Litovitz TL, Schmitz BF, Bailey KM: 1989 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1990;8:394-442 8. Litovitz TL, Bailey KM, Schmitz BF, et al: 1990 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1991;9:461-509 9. Litovitz TL, Holm KC, Bailey KM, et al: 1991 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1992;10:452-505 10. Litovitz TL, Holm KC, Clancy C, et al: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993;11:494-555 11. Litovitz TL, Clark LR, Soloway RA: 1993 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-584 12. Litovitz TL, Felberg L, Soloway RA, et al: 1994 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1995;13:551-597
25.0% 10.8%
0.3% 0.1%
3.8% 1.6%
350,803 262,523 150,049 34.4% 14.8%
25.7% 11.1%
14.7% 6.3%
6.2% 2.7%
1.5% 0.1% 0.6% 0.0%
13. Litovitz TL, Felberg L, White S, et al: 1995 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1996;14:487-537 14. Litovitz TL, Smilkstein M, Felberg L, et al: 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1997;15:447-500 15. Litovitz TL, Klein-Schwartz W, Dyer KS, et al: 1997 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1998;16:443-497 16. Litovitz TL, Klein-Schwartz W, Caravati EM, et al: 1998 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999;17:435-487
APPENDIX Drug and chemical concentrations provided in these abstracts were obtained on blood, serum, or plasma unless otherwise indicated. Cases 1 & 2. A 78-year-old woman with a history of coronary artery disease and hypertension was undergoing a multilevel vertebroplasty using methylmethacrylate injected percutaneously into the vertebra. She developed sudden dysrhythmias, pulmonary hypertension, and poor oxygenation during the series of injections and died in the OR. No postmortem was performed. The same day, a 42-year-old woman with a history of Crohn’s disease and no known cardiac disease underwent a similar procedure, again using methylmethacrylate injected percutaneously into the vertebra. She also developed sudden dysrhythmias and poor oxygenation with pulmonary hypertension during the series of injections and died. The postmortem examination showed large amounts of methylmethacrylate in the lungs suggesting pulmonary embolization.
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
Case 3. A 41-year-old man was found unconscious next to his car with empty cans of a PVC pipe cleaner, PVC cement, and beer. The products were found to contain tetrahydrofuran and methyl ethyl ketone. In the ED, his vitals were within normal limits, pupils were fixed and dilated, and he remained unresponsive. Attempts to pass an Ewald tube into the esophagus were not successful. The patient suffered a cardiac arrest and expired the next day. Autopsy findings included: an eroded esophagus coated with an irregular plaque-like material; a similar coating of material in the stomach, along with 1 liter of tan fluid with an acetone-like odor that tested positive for methyl ethyl ketone and tetrahydrofuran; and methyl ethyl ketone and tetrahydrofuran detected in the blood. Case 21. An 18-year-old woman was found unresponsive and in cardiac arrest at a party, after apparently having been raped. She was resuscitated and intubated, but remained comatose and required maximal vasopressor therapy. She subsequently developed cerebral edema. Despite treatment with mannitol, brain flow studies showed no flow and patient was pronounced brain dead 10 days after admission. Autopsy showed hypoxic encephalopathy, a laceration of the urethral meatus, multiple contusions, and ischemia of the toes and right heel. Her blood ethanol concentration was 367 mg/dL and gamma hydroxybutyrate (GHB) concentration was 17 µg/mL. Case 45. A 40-year-old alcoholic with a history of recent paint thinner ingestion was released from a detox center and ingested one gallon of windshield washer fluid. Approximately 16 hours later, he was found comatose with labored respirations. Asystole developed en route to the ED. After 10 to 15 minutes of resuscitation, he had tachycardia and was vasopressor-dependent. The arterial pH was 6.98. Treatment included hemodialysis in the ED, intravenous ethanol, serum alkalinization, leucovorin, pyridoxine and thiamine. The patient’s hemodynamic status deteriorated, and he never regained consciousness. The initial antemortem methanolconcentration was 431 mg/dL. Postmortem showed cerebral edema. Case 51. A 6-year-old girl presented with fever, vomiting, hematuria, and a history of recent spider bites. The child’s condition rapidly deteriorated and she suffered a cardiac arrest. Antemortem cultures were negative. Autopsy findings included: interstitial hemorrhages in the chest, abdomen, retroperitoneum, and mesentery; petechiae and fluid in the pleural, pericardial and peritoneal cavities; hematuria; and intraepidermal bullae with inflammatory infiltrate consisting of eosinophils, lymphocytes and neutrophils, consistent with a hypersensitivity reaction. There was no evidence of foreign debris within the epidermis or dermis. The presumed spider was Loxosceles reclusa. Case 52. A 42-year-old woman presented 3 days after a possible brown recluse spider (Loxosceles reclusa) bite with abscess formation and tissue necrosis of the abdominal wall, hypoxia, hypertension, peripheral cyanosis, and a white blood cell count of 40,000/µL. The patient expired shortly thereafter. Case 53. A 43-year-old man who was drinking with friends was bitten on the hand by a rattlesnake presumed to be dead. After further ethanol consumption, he presented 1 hour later with complaints of hand pain and mild abdominal
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cramping. Vital signs were: heart rate, 134 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 81/46 mm Hg. Tongue swelling, fang marks, and minimal edema of the hand were noted. Hypotension necessitated vasopressor therapy and increased tongue edema was treated with diphenhydramine and steroids. Unsuccessful attempts at intubation were complicated by hypoxia, and cricothyrotomy was performed. Further treatment included sodium bicarbonate for metabolic acidosis, 10 units of polyvalent antivenin, and fresh frozen plasma. The course was complicated by acute renal failure secondary to hemolysis requiring hemodialysis, rhabdomyolysis, and prolonged ventilatory support. On the 13th hospital day, cardiac arrest secondary to pulmonary embolism occurred, following which the patient was declared brain dead. Case 55. A 25-year-old man with a history of psychiatric illness ingested potassium cyanide obtained from his workplace (a university laboratory). He was found by students in full cardiopulmonary arrest. Resuscitative efforts, including intubation, 100% oxygen, advanced cardiac life support, sodium nitrite, and sodium thiosulfate resulted in return of spontaneous circulation. His course was complicated by neurologic unresponsiveness, fixed dilated pupils, acidosis, vasopressor dependence, and multiple cardiopulmonary arrests. Postmortem blood toxicology revealed a cyanide concentration of 150 µg/mL. Case 57. A 97-year-old man with a history of lymphoma inhaled the vapors of a cyanide mixture and was found on the floor unresponsive. Following intubation, occasional spontaneous respirations were noted. Laboratory studies included: arterial pH, 7.11; pCO2, 20 mm Hg; pO2, 485 mm Hg; serum bicarbonate, 6.2 mEq/L, lactate, 16.4 mmol/L; and anion gap, 28 mEq/L. He was treated with sodium nitrite, sodium thiosulfate, and dopamine. The posttreatment methemoglobin concentration of 5.9% increased to 16% after second doses of sodium nitrite and sodium thiosulfate were administered. Resuscitative efforts were discontinued when it was discovered that the patient had a living will. He died approximately 12 hours postexposure. Antemortem blood cyanide concentration was greater than 10 µg/mL. Case 60. A 15-year-old girl with a history of flu-like symptoms for approximately 1 week, developed abdominal pain and vomiting on the day of presentation. She presented with coma and an increased anion gap metabolic acidosis. Laboratory results revealed: bicarbonate, less than 5 mEq/L; BUN, 14 mg/dL; creatinine, 3.2 mg/dL; glucose, 216 mg/dL; anion gap, 39 mEq/L; osmolar gap, 18 mOsm/L; salicylate, 4.6 mg/dL; and normal liver transaminases. Treatment included sodium bicarbonate and fomepizole. An abdominal radiograph showing radiopaque foreign bodies prompted treatment with dimercaprol, which was discontinued after the blood lead concentration returned at 19 µg/dL and it was determined that she had received bismuth subsalicylate. The hospital course was complicated by seizures treated with anticonvulsants; oliguric renal failure; and increased intracranial pressure treated with intrathecal drainage. She died from apparent brain herniation on the fourth hospital day. The autopsy showed cerebral edema with brainstem herniation, renal tubular casts, dilatation and intratubular birefringent oxalate crystals, with no oxalate crystals in the heart or liver. Antemortem blood ethylene
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glycol and glycolic acid concentrations were 77 mg/dL and 76.5 mg/dL, respectively. A postmortem glycolic acid concentration was 86 mg/dL. Case 72. A 17-year-old boy with a history of depression presented with slurred speech, a decreased level of consciousness, and profound acidosis after a suspected overdose of flurazepam and another substance (presumed to be a toxic alcohol). Treatment included flumazenil, an ethanol infusion, fomepizole, and intubation. His parents later reported that the patient had exhibited upper and lower extremity paresis before arrival, which prompted magnetic resonance imaging of the brain and cervical spine. Bilateral basal ganglia and brainstem infarcts were seen. An ethylene glycol concentration was 29 mg/dL 18 hours postingestion. The following day, repeat imaging studies showed absent cerebral blood flow, diffuse cortical ischemia, and bilateral uncal herniation. Case 73. A 27-year-old man drank an unknown amount of formaldehyde in a suicide attempt. In the ED, his unconscious state deteriorated to cardiac arrest. Resuscitative efforts including CPR, cardioversion, sodium bicarbonate, and folate were unsuccessful. After 4 ampules of sodium bicarbonate his arterial pH was 6.8. The postmortem findings included a blood formaldehyde concentration greater than 5,000 µg/mL; extensive fixation of the esophagus, stomach and proximal small intestine; and partial fixation of the tongue, liver, spleen, transverse colon, left adrenal gland and left kidney. Case 83. A 69-year-old chemist presented with sudden onset of crushing chest pain and shortness of breath. For 4 to 6 weeks, he had been self-medicating symptoms of chronic, intermittent chest pain with 30 to 60 mg of sodium nitrite. He took 300 mg of sodium nitrite for severe pain on the day of presentation. Physical examination revealed cyanosis, a blood pressure of 77/50 mm Hg and a heart rate of 102 beats/min. Oxygen saturation by pulse oximetry was 68% and arterial blood gas results were: pH, 7.42; pCO2, 26 mm Hg; pO2, 316 mm Hg on 100% oxygen; and methemoglobin, 38%. ECG findings were consistent with an acute anterior wall myocardial infarction. Treatment with intravenous fluids and 120 mg of methylene blue resulted in decreased cyanosis, hemodynamic improvement, and increased oxygen saturation to 94% by pulse oximetry. Cardiac catheterization revealed a 95% occlusion of the left main coronary artery. Cardiogenic shock necessitated balloon pump assistance and vasopressor therapy. He died within 2 hours of arrival. Case 85. A 12-month-old boy ingested an unknown quantity of a degreaser and descaler containing 3% hydrochloric acid and 14% ammonium bifluoride, with a pH of 1. Two episodes of emesis occurred initially. In the hospital, the heart rate was 175 beats/min and the pulse oximetry reading was 94 to 96%. The initial serum calcium measurement was 2.5 mmol/L. The patient was treated with intravenous fluids and calcium. Ventricular fibrillation and seizures developed and were refractory to resuscitative efforts. Case 91. A 66-year-old man with a history of hypothyroidism, congestive heart failure, and depression presented to the hospital with a sore throat about 1 hour after the intentional ingestion of a drain opener containing 93-100% sulfuric acid. Several episodes of spontaneous emesis occurred
before arrival. Vital signs were: blood pressure, 146/89 mm Hg; pulse, 110 beats/min; and respiratory rate, 20 breaths/ min. He had no stridor, hoarseness, oropharyngeal burns, or chest radiographic findings. Endoscopy performed approximately 3 hours after arrival revealed second and third degree burns of the distal esophagus and stomach. The patient suffered an asystolic cardiac arrest and died 6 to 7 hours after the ingestion. Postmortem showed findings included minimal laryngeal edema, ulceration and necrosis of the distal two-thirds of the esophagus, and necrosis of the stomach extending to the pylorus. Case 92. A 48-year-old woman with a psychiatric history was found in the bathroom obtunded and foaming at the mouth, with blood-streaked emesis. An empty 1 L bottle of bathroom descaler containing an unknown concentration of hydrofluoric acid was next to her. In the ED, she was agitated, uncooperative, and had edema of the pharynx. Treatment included gastric lavage and administration of 60 mL of magnesium hydroxide. Evidence of upper gastrointestinal bleeding persisted. Twelve hours postingestion, the ECG showed peaked T-waves and a normal QT interval, despite a potassium of 6.2 mEq/L and calcium of 2.8 mg/dL. Although ventricular dysrhythmias developing shortly thereafter responded to intravenous calcium, refractory hypocalcemia (2.9 mg/dL), ventricular fibrillation, and asystole occurred 17 hours postingestion. Case 95. A suicidal 82-year-old woman vomited after drinking an estimated 150 to 300 mL of a pine oil/ isopropanol cleaner. Intubation was required within 3 hours of the ingestion for rapidly progressive aspiration pneumonitis. She developed adult respiratory distress syndrome and died on the 10th hospital day. Case 98. An 18-month-old boy ingested an unknown amount of a tire cleaner (hydrofluoric acid or ammonium bifluoride) from an unmarked container and developed hematemesis and respiratory distress. The child required intubation for progressive lethargy and respiratory failure. Initial vital signs were: temperature, 37.9°C (rectal); heart rate, 168 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 70/31 mm Hg. The pulse oximetry reading was 82%. Treatment included steroids and bronchodilators. An initial potassium was 5.2 mEq/L, with arterial pH (90 minutes postingestion), 7.08; pCO2, 28.9 mm Hg; and pO2, 393 mm Hg. At that time, ventricular fibrillation occurred and was refractory to multiple defibrillation attempts and epinephrine. Autopsy findings included: absence of burns in the mouth and esophagus; full-thickness burns (without perforation) to the depth of the muscularis mucosal layer from the stomach to the ileum; evidence of pulmonary aspiration; and massive hemolysis. Case 100. A 12-month-old boy ingested a large amount of hair oil containing safflower (50% to 80%), mineral (30% to 50%), castor (⬍2%), avocado (⬍2%), sesame (⬍2%, and jojoba oils (⬍2%) 40 minutes prior to arrival at an urgent care center. He exhibited persistent cough and hypoxemia with a pulse oximetry reading of 89% on room air. His respiratory status deteriorated over the next 24 hours, necessitating intubation, high frequency/oscillatory ventilatory support and positive end-expiratory pressure. He developed bilateral pneumothoraces and was ultimately placed on ECMO 6 days postexposure. Although ECMO was contin-
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ued for 24 days, multisystem organ failure developed, and the patient died after unsuccessful weaning. Case 101. A 16-year-old boy was using a stimulant medication containing amphetamine and dextroamphetamine while studying for an examination. The medication had recently been discarded in a neighbor’s trash. During a study break, the patient also huffed hair spray, containing hydrofluorocarbons, isobutane, and ethanol. He collapsed, was found to be in ventricular fibrillation, and was not able to be resuscitated. A subsequent toxicology screen was positive for amphetamines. Postmortem heart blood amphetamine concentration was 0.12 µg/mL. Blood, urine and vitreous humor were positive for isobutane and dimethyl ether. Case 108. A 2-year-old boy ingested citronella oil stored in a perfume container. He developed aspiration pneumonitis, hypoxemia, and refractory hypotension. Treatment included mechanical ventilation, vasopressors, and antibiotics. Bilateral pneumothoraces developed, and the child died 66 hours after the exposure. Case 109. An 87-year-old woman with dementia, colon cancer, and alcoholism developed acute respiratory distress and unresponsiveness after ingesting 1 cup of potpourri oil, mistaken for juice. Radiographic evidence of aspiration pneumonitis was present. The patient was not intubated, per her family’s wishes, and developed progressive hypoxia and acidemia. She died on the third hospital day. Case 110. A 50-year-old medical researcher was found dead in a refrigerated room that contained 15 new blocks of dry ice which had been placed there 3 hours earlier. The decedent had been crouching to store samples in a container several inches above the ground. There were no signs of struggle and there was no history of psychiatric disorder, recent personal crises, or medical illness. The external ventilation system in the cold room was not functioning, although internal air movement occurred via a cooling fan. Postmortem examination and toxicologic studies were not revealing. To confirm the cause of death, the conditions at the time of the event were reproduced. Air was sampled serially at several heights. At a height of 9 inches, the drop in FiO2 (13.6%) and rise in CO2 (27.6%) were maximal by 3 hours. The temperature of the room fell to ⫺15°C. The cause of death was thus determined to be from simple asphyxia secondary to carbon dioxide release from dry ice. Case 112. A 2-year-old boy was found near his dead 3-year-old sister after riding in the rear of a car with a leaking exhaust system for several hours. In the ED, the child displayed lethargy and vomiting. His initial carboxyhemoglobin was measured as 37%. Despite treatment with 100% oxygen and a decrease in the carboxyhemoglobin to 2.2% 90 minutes later, the child remained lethargic. Neurologic deterioration occurred, with the development of fixed, dilated pupils, lack of response to painful stimuli, and body temperature dysregulation. Postmortem findings included necrosis of the basal ganglia, consistent with carbon monoxide poisoning. Case 151. A 72-year-old man was found to have an elevated serum lead concentration of 302 µg/dL. The exposure was thought to be caused by ingestion of leadcontaminated moonshine. The patient was encephalopathic and hemodynamically unstable. Treatment included intuba-
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tion and chelation therapy with dimercaprol (BAL) and calcium disodium EDTA. Prolonged intensive care and continued chelation were continued for 11 weeks. Lead concentrations slowly dropped over the first few weeks to 33 µg/dL. Complications included staphylococcal infection, hypertension, and renal failure requiring hemodialysis. He died with multisystem organ failure. Case 153. A 38-year-old man suffered a large inhalational and dermal exposure to an acrolein herbicide after a worksite spill. He developed immediate shortness of breath, was transported to the ED, and was discharged after a period of observation. According to the patient’s wife, he developed increasing dyspnea that evening and was unable to sleep. He was found dead in a chair approximately 18 hours postexposure. Postmortem findings were consistent with pulmonary edema. Case 154. A 60-year-old man ingested fluid found in the garage that he mistook for white wine. On presentation, he was confused, diaphoretic, and vomiting. Lung fields were clear and pupils were pinpoint. Atropine resulted in no pupillary change, but caused an increase in heart rate and blood pressure to 180 beats/min and 210/100 mm Hg. Arterial blood gas results were: pH, 7.42; pCO2, 31 mm Hg; and pO2, 71 mm Hg. Pralidoxime was administered. The patient suffered a cardiac arrest and died. Postmortem dinitrobutylphenol concentrations were 20.2 µg/mL (toxic ⬎10 µg/mL) in the blood; 0.32 µg/mL (bile); 0.86 mg/kg (brain); 0.15 mg/kg (liver); and 2.8 mg/kg (gastric contents). Antemortem blood concentrations were 7.7 µg/mL. Case 155. A 47-year-old alcoholic ingested 540 mL of an herbicide containing glyphosate. He presented with lethargy, hypotension, bradycardia, metabolic acidosis, and an ethanol concentration of 140 mg/dL. Charcoal administration was followed by vomiting. Nine hours postingestion the patient developed flash pulmonary edema. Treatment included furosemide, intubation, and vasopressors. Abnormal renal function tests and minimal urine output were noted. The patient died 12 hours after the ingestion. Case 156. A 44-year-old man showed miosis, tachycardia, hypersalivation, and loss of urinary and stool continence 4 hours after the intentional ingestion of an unknown amount of monosodium methanearsonate herbicide. Lack of dimercaprol necessitated transfer to a tertiary facility. Cardiovascular collapse and death occurred en route. On autopsy, toxic levels of arsenic were found in blood and urine and the medical examiner ruled the death as suicide by acute arsenic intoxication. Case 158. A 16-year-old girl in her fourth month of pregnancy ingested an unknown quantity of paraquat in a suicide attempt. At presentation 24 hours later, her creatinine was 4 mg/dL. Six days later, renal function tests were: BUN, 91 mg/dL; and creatinine, 6.8 mg/dL. Hepatic transaminases, bilirubin and LDH were also elevated. On the seventh day after the ingestion, she developed shortness of breath and oxygen desaturation (94%) on room air. Over the next few days, oxygenation further deteriorated despite improvement in renal function. On the 11th day, the patient developed severe dyspnea, cyanosis, and chest radiographic findings suggestive of adult respiratory distress syndrome, then died. Case 160. A 15-year-old boy collapsed after taking four
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‘‘hits’’ from a tank of butane gas while inhaling with an adolescent friend. Paramedics found the youth in cardiopulmonary arrest. Prolonged resuscitative efforts were unsuccessful. Case 163. A 4-year-old boy was taking a bath when his father pumped liquid chlorodifluoromethane into the bath water with a hose. The child became drowsy and was found lying face-down in the water a short time later. He was transported to a hospital where he later died. The medical examiner ruled that he died from liquid chlorodifluoromethane intoxication and that the manner was homicide. Case 166. A 2-year-old boy had a seizure outdoors near a charcoal lighter fluid container. He arrived to the ED with lethargy and drooling. In less than an hour, the patient had developed recurrent seizures, treated with diazepam, midazolam, and succinylcholine. Frothy oral secretions and chest radiographic evidence of pulmonary edema were noted within 90 minutes of arrival. During transfer, the patient developed pulseless electrical activity, which responded to atropine and epinephrine. Cerebral edema developed and he was declared brain dead 21 hours after the exposure. Case 169. A 62-year-old man ingested a large amount of a product containing 72% chlordane. He was found lying on the ground shaking. After transport to the hospital, he was reportedly awake, alert, and oriented. At 90 minutes postingestion, the patient vomited and seized. Treatment included decontamination, intubation, benzodiazepines and activated charcoal. The hospital course was complicated by metabolic acidosis, recurrent seizures, hypotension, and decreased urine output. Neurologic, pulmonary, and hemodynamic deterioration occurred on the third hospital day and the patient died. Case 174. A 27-year-old man who reportedly drank a mixture of ‘‘opium’’ and ethanol presented with dyspnea, epiglottic swelling, hypoxia, tachycardia, and red urine. The ECG showed QRS prolongation, peaked T waves, elevated ST segments, and absent P waves. The ingested fluid was actually determined to be an old insecticide containing nitric acid and lead arsenate. The patient was intubated and placed on a ventilator. A gray, swollen epiglottis was noted. Laboratory results were: urine drug screen, positive for marijuana; blood ethanol, 63 mg/dL; acetaminophen, negative; and methemoglobin, 9%. Complications included perforation of the stomach and renal failure. Despite tracheostomy placement, supportive care, and hemodialysis, sepsis developed and the patient died on the sixth hospital day. Case 179. A 63-year-old man picked wild mushrooms from his yard and ate them in a salad. The mushrooms were later identified as either Amanita verna or Amanita virosa. He developed headache, nausea, vomiting, abdominal pain, and diarrhea 7 hours postingestion. These symptoms persisted through the following day when he presented to the ED with fever, tachycardia, and the following laboratory abnormalities: AST, 1749 U/L; ALT, 1710 U/L; total bilirubin, 4.3 mg/dL; BUN, 48 mg/dL; creatinine, 6.5 mg/dL; anion gap, 31 mEq/L; PT, 25.5 seconds; and PTT, 48.4 seconds. Treatment included hydration, phytonadione, fresh frozen plasma, and antiemetics. At 60 hours postingestion, the gastrointestinal symptoms had resolved, but both renal dysfunction and coagulation abnormalities persisted. Ultimately, his hepatic and renal dysfunction worsened and
encephalopathy, rhabdomyolysis, and hyperkalemia developed. He died approximately 91 hours postingestion. Case 180. A 62-year-old woman presented 48 hours after eating a stir-fry meal containing self-harvested mushrooms. Similar mushrooms were later identified as Lepiota josserandii. Initial symptoms were fatigue, nausea, and abdominal cramps that began 16 hours post ingestion, followed by multiple episodes of diarrhea. After initial treatment with meperidine, hydroxyzine, and intravenous fluids, the patient was discharged home. Because of an elevated AST of 2,262 U/L, she was called back to the hospital. Repeat laboratory results on return were: AST, 12,904 U/L; PT, 40.8 sec; and INR, 10.2. Although transaminases gradually declined, the PT continued to rise to more than 100 seconds and the lactate increased. Despite treatment with intravenous penicillin G, cimetidine and milk thistle, encephalopathy developed within 48 hours of presentation. Amanitin was not detected. The next day, emergent orthotopic liver transplantation was performed. The patient had a complicated posttransplant course, including abnormal liver function tests and the development of fungal sepsis. Despite aggressive medical and surgical management, she died 23 days after the mushroom meal. The histology of the native liver showed massive necrosis. Other autopsy findings included CNS necrosis related to fungal infection and hypoxia. Cases 183 & 184. A 20-year-old man presented comatose with a rectal temperature of 42.8°C after ingesting six to seven seed pods and smoking the leaves of jimson weed (Datura stramonium) with friends. His initial heart rate was 178 beats/min and blood pressure, 58/36 mm Hg. He was treated with fluids, intubation, ice water lavage and cooling blankets. Laboratory results were: urine drug screen, negative; pH, 7.29; pCO2, 22.7 mm Hg; pO2, 74 mm Hg, HCO3, 9.4 mEq/L; oxygen saturation, 91.9%; BUN, 30 mg/dL, creatinine, 4.0 mg/dL; and potassium, 2.3 mEq/L. The patient died 6 hours after admission. His 21-year-old male friend, who also ingested six to seven pods containing jimson weed seeds and smoked some leaves, died at the scene. Case 185. A 48-year-old man with a history of hypertension, peptic ulcer disease, gastroplasty, hyperchloremic metabolic acidosis attributed to gastric outlet obstruction, and depression was found unresponsive with labored respirations. He had been in a small enclosed room working with ‘‘glue’’ and ‘‘fireworks’’ and also had been consuming the fruit of the china berry tree (Melia azedarach) for 1 week before admission. Positive plant identification was performed. In the ED, the patient was described as awake but dyspneic, and the following laboratory results were noted: serum pH, 6.96; pCO2, 8.8 mm Hg; pO2 (Fi02 1.0), 72 mm Hg; serum bicarbonate, 2 mEq/L; BUN, 23 mg/dL; creatinine, 3.0 mg/dL; and anion gap, 29 mEq/L. Mental status deterioration, multisystem organ failure, and acute myocardial infarction developed. He expired after a prolonged hospitalization. Autopsy revealed necrotizing vasculitis of the brain stem and cranial nerve roots, subacute hemorrhagic infarcts in the cerebrum and cerebellum, centrilobular necrosis in the liver, and hemorrhagic infarcts of the lungs. The cause of death was determined to be a result of acute CNS and liver pathology followed by multiorgan failure
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temporally related to glue inhalation and china berry ingestion. Case 190. A 17-year-old girl with a history of intravenous drug abuse and migraine headaches managed with nonprescription analgesics presented with an altered mental status. Initial laboratory studies included: drugs of abuse screen, negative; serum acetaminophen, less than 10 µg/mL; salicylates, negative; AST, 5441 IU/L; ALT, 9559 IU/L; total bilirubin, 4.9 mg/dL; PT, 25 seconds; INR, 4.33, BUN, 24 mg/dL; creatinine 1.3 mg/dL, ammonia 183 µmol/L. Progressive neurologic deterioration and worsening hepatic dysfunction occurred, and she was pronounced brain dead within 24 hours. Later, her 8-year-old sister admitted that she had seen the patient take a whole bottle of acetaminophen 4 days earlier, but had been sworn to secrecy. Case 196. A 24-year-old pregnant woman presented after rupture of membranes. She had normal labor progression until immediately before delivery when acute, severe fetal heart rate decelerations were noted. Forceps delivery yielded a stillborn full-term infant with no external anomalies. Soon after delivery, the mother developed a decreased level of consciousness, metabolic acidosis, and anuria. Within 48 hours, disseminated intravascular coagulopathy, multisystem organ failure, and death occurred. Admission serum acetaminophen concentration was 465 µg/mL, with a postdelivery concentration of 398 µg/mL. Days after her death, the patient’s family reported that she may have taken as many as 100 acetaminophen tablets for back and labor pain. The infant’s death was attributed to massive maternal acetaminophen overdose. Case 214. A 41-year-old man ingested an unknown amount of acetaminophen 48 hours before presentation. He was awake and alert, had unremarkable vital signs, and complained of right upper quadrant abdominal pain. Laboratory results were: acetaminophen concentration, 180 µg/mL; total bilirubin, 10.6 mg/dL; AST, 8,272 U/L; ALT, 7400 U/L; PT, 46.4 seconds; and PTT, 40.5 seconds. Initial treatment included oral N-acetylcysteine. Bioartificial liver support was started 21⁄2 days after presentation and was continued for 5 days. The patient died of hepatic failure on the eighth hospital day. Case 364. A 15-year-old girl was admitted 7 hours after an intentional ingestion of 200 aspirin tablets along with clarithromycin, ibuprofen, loratadine, and hydrochlorothiazide/triamterene. Postingestion salicylate concentrations were: 6 mg/dL at 1 hour, 46 mg/dL at 3 hours, and 81.5 mg/dL at 5 hours. Initial arterial pH was 7.4 and pCO2 was 37 mm Hg. The patient seized 5 hours postingestion and was then delirious, shouting, and complaining of nausea. Laboratory results at that time were: pH, 7.35; pCO2, 27 mm Hg; serum bicarbonate, 15 mEq/L; salicylate, 78.8 mg/dL; and acetaminophen, less than 1 µg/mL. Treatment included intravenous fluids and sodium bicarbonate. Recurrent ventricular tachycardia occurred and was treated with additional sodium bicarbonate and lidocaine. Hypotension, fever and purpura developed. Despite hemodialysis, she died approximately 22 hours after the ingestion. Case 375. A 45-year-old man who had ingested 70 colchicine (0.6 mg) tablets 3 to 4 days earlier, presented with diminished oral intake, nausea, vomiting, diarrhea, abdominal pain and evidence of dehydration. Abnormal
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laboratory results were: WBC, 1,000/µL; platelets 20,000/ µL; sodium, 125 mEq/L; creatinine, 1.4 mg/dL: AST, 436 U/L, and creatine kinase, 5,684 U/L. On the third hospital day, he had evidence of mental status alteration, hypoxia, hypotension, worsened renal failure and persistent diarrhea. His white blood cell count was 2,000/µL. Further treatment included granulocyte colony stimulating factor, platelet transfusions, albumin, intravenous fluids and sodium bicarbonate. He became hemodynamically unstable and died on the third hospital day. Case 392. A 5-month-old girl presented in respiratory arrest. Police reports suggested that the infant’s mother had intentionally added the methadone to the child’s formula in an attempt to sedate the child. The medical examiner determined that the infant formula contained a methadone concentration of 21 µg/mL. The postmortem methadone concentration was 0.3 µg/mL (heart blood) and 1.4 mg/kg (liver). Case 454. A 37-year-old anesthesiologist with a history of depression and inhalational anesthetic abuse was found apneic and asystolic in his hospital on-call room with a plastic bag over his face. Inside the bag was a gauze pad, which at the time of discovery was dry. An empty bottle of enflurane was also present. Forensic reconstruction suggested that the patient saturated the gauze pad with enflurane and placed it in the bag for rebreathing. When the patient lost consciousness, the bag covered his mouth and nose resulting in asphyxiation. Several months earlier, this same physician had been successfully resuscitated after a similar event, had been rehabilitated, and returned to unsupervised work. Case 456. An 1,800 gram, 2-day-old infant born at 33 weeks gestation age, was unintentionally given 9,000 units of heparin intravenously through an umbilical catheter. Approximately 12 hours later, the patient’s status deteriorated, and a grade 3 to 4 intracranial bleed was diagnosed. The therapeutic error was discovered the following morning when the patient’s prothrombin time was 17 seconds and the PTT unmeasurable. At 26 hours postexposure the extent of the intracranial bleed was noted to be severe, and life support systems were removed. Case 459. A 10-year-old boy with a history of autism and seizure disorder was being treated with lamotrigine, clonazepam, and fluoxetine. Three weeks after the lamotrigine dose was increased, he developed status epilepticus, hyperthermia, and runs of ventricular tachycardia. The patient was comatose with increased tone in the upper and lower extremities. Initial treatment included intubation, cooling, benzodiazepines, phenobarbital, phenytoin, urinary alkalinization, and broad-spectrum antibiotics. Ultimately, the patient received numerous other therapies, including vasopressors, dobutamine, nitroprusside, continuous arteriovenous hemofiltration, and sodium thiosulfate for suspected cyanide toxicity secondary to prolonged nitroprusside therapy. Laboratory studies revealed elevated hepatic transaminases and the following abnormalities: lactate, 8.6 mmol/L; creatine kinase, 990 U/L; platelets, 6,000/µL; PT, 50 seconds; PTT, greater than 100 seconds; and d-dimer, greater than 60 µg/dL. The patient died on the fourth hospital day. Autopsy findings confirmed rhabdomyolysis, hepatic necrosis and disseminated intravascular coagulation resulting from lamotrigine.
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Case 463. A 30-year-old woman was found unresponsive. No response to naloxone was noted, and intubation was required. Initial vital signs were: heart rate, 60 beats/min; blood pressure, 95/50 mm Hg; and respiratory rate, 14 breaths/min. The valproic acid concentration was 1,280 µg/mL and the urine drug screen was positive for amphetamines. The patient remained unresponsive despite a decreasing valproic acid concentration (875 µg/mL), and required vasopressor support for hypotension. Pertinent laboratory findings on the fourth hospital day were: valproic acid, 410 µg/mL; ammonia 197 µg/dL; AST, 136 U/L; ALT, 32 U/L; platelets, 84,000/µL; and glucose, 27 mg/dL. An EEG showed diffuse cerebral dysfunction. A prolonged hospital course was complicated by persistent coma, aspiration pneumonia, ventilator-dependence, bowel obstruction, renal failure, thrombocytopenia, endocrine dysfunction, hypoglycemia, and gastrointestinal bleeding. Case 593. A 39-year-old man with a history of depression ingested his own isoniazid and was found in status epilepticus. Diazepam, lorazepam, and phenobarbital were administered without control of the seizures. Neuromuscular paralysis and transfer to a tertiary facility known to stock pyridoxine were performed. There, the patient continued to have seizures despite receiving a lorazepam infusion at 1 mg/hr. Five grams of pyridoxine were administered and the lorazepam infusion was increased to 2 mg/hr, without effect. Phenytoin loading was performed, and seizures abated after 8 hours. A CT scan of the brain revealed a large left cerebellar hemorrhage. A ventriculostomy was placed to control hydrocephalus. Hepatic and renal dysfunction, rhabdomyolysis, and disseminated intravascular coagulation developed. The urine drug screen was positive for cocaine metabolites. Because the patient’s prognosis for neurologic recovery was poor, supportive care was withdrawn and he died on the fourth hospital day. Case 594. A 16-year-old girl treated with zidovudine and lamivudine presented with nausea and vomiting. She had tachypnea and a profound, high anion gap metabolic acidosis. Salicylate and toxic alcohol determinations were negative. Mental status deterioration, hypoxemia, and progressive lactic acidosis (lactate, 10.9 mEq/L) resulted. Treatment included intubation, sodium bicarbonate, carnitine, thiamine, and vitamin C for presumed zidovudine-induced lactic acidosis. Despite this, the patient’s status did not improve and she died after a cardiac arrest on the sixth hospital day. Case 595. A 51-year-old man with multiple medical problems was being treated for severe pustular psoriasis with methotrexate 12.5 mg weekly. He was unintentionally given methotrexate daily for approximately 2 weeks. He presented with sore throat, fever, cough, vomiting, and the following vital signs: heart rate, 164 beats/min; blood pressure, 90/60 mm Hg; and temperature, 39°C. Laboratory results were: WBC, 200/µL; hematocrit, 23%; platelets, 11,000/µL; BUN, 90 mg/dL; and creatinine, 3.5 mg/dL. Treatment included intubation for severe oral mucositis, intravenous fluids, vasopressors, granulocyte colony stimulating factor, broad-spectrum antibiotics, leucovorin, and continuous venovenous hemodiafiltration. The serum methotrexate concentration on day 2 was 0.29 µmol/L (toxic ⬎ 0.1). The patient remained hypotensive, developed a myocardial
infarction, and expired 4 days after admission. The autopsy revealed multifocal hemorrhages in the lungs and epicardium, centrilobular hepatic necrosis, pulmonary aspiration, cardiomyopathy, lymphocytic ablation, and cellular atypia. Case 597. A 3-year-old boy developed status epilepticus after multiple bouts of coffee ground emesis. Seizures were recalcitrant to therapy with lorazepam, phenobarbital, phenytoin, and midazolam. The following morning it was discovered that the child had access to sustained-release theophylline. A blood theophylline concentration was 114 µg/mL. Other treatment included mechanical ventilation, multiple dose activated charcoal, and hemodialysis. Postdialysis, the theophylline concentration was 23 µg/mL. The patient was pronounced dead 60 hours after presentation. The postmortem examination revealed cerebral herniation and necrosis. Case 615. A 23-month-old girl ingested an unknown number of 0.3 mg clonidine tablets. In the ED, the child was stuporous with a heart rate of 57 beats/min. Atropine was administered and resulted in an increased heart rate to 200 beats/min, followed by slowing to 125 beats/min. Both improvement in the level of consciousness and agitation were noted after naloxone administration. During intubation, bradycardia progressed to pulseless electrical activity, and frothy sputum was noted. Resuscitative efforts were not successful. The autopsy revealed moderate congestion and edema of the lungs. The postmortem blood clonidine concentration was 46 ng/mL. Case 638. A 43-year-old male physician became hypotensive and unresponsive after paramedics administered nitroglycerin sublingually for complaints of chest pain. Empty vials of sildenafil and diltiazem were discovered later after scene investigation. In the ED, the patient suffered a respiratory arrest, was resuscitated, but appeared to exhibit signs of brain death. A cardiac arrest occurred on the sixth hospital day. Antemortem toxicology results revealed lethal concentrations of diltiazem and the presence of diphenhydramine. Sildenafil was not detected. Case 662. A 20-month-old boy was noted to be ‘‘fussy and crying’’ after ingesting his grandmother’s sustained release nifedipine (possibly in addition to other unknown cardiac medications). He began ‘‘shaking’’ while being bathed. In the ED, intact nifedipine tablets were found in the infant’s throat during intubation, and he died shortly after arrival to the ED. Nifedipine concentrations were 560 µg/mL (blood) and 3,990 µg/mL (gastric contents). Case 669. A week after an abdominal aortic aneurysm repair, an 80-year-old man, received an application of a large amount of nitroglycerin ointment, in lieu of antifungal ointment, to the abdomen wall area. One hour later, the patient experienced an episode of hypotension that responded to fluids and removal of the nitroglycerin ointment. Hypotension recurred 7 hours later and responded to treatment with fluids and vasopressors. The skin was further decontaminated with soap and water. Over the next 12 hours, the patient experienced a bowel infarction and died. Case 670. A 69-year-old man ingested an unknown number of procainamide 250 mg capsules along with ethanol. In the ED, he had a systolic blood pressure of 50 mm Hg, a heart rate of 60 beats/min, and displayed an
LITOVITZ ET AL 䊏 1999 AAPCC ANNUAL REPORT
idioventricular rhythm. The serum procainamide concentration was 52 µg/mL and blood ethanol was 221 mg/dL. Treatment included temporary pacemaker insertion, intravenous sodium bicarbonate, and dopamine. One hour after admission, he was awake and alert with a systolic blood pressure of 120 mm Hg. Four hours after admission he developed recurrent episodes of ventricular tachycardia and hypotension, and could not be resuscitated. Case 671. A 48-year-old legally blind woman with a history of asthma, atrial fibrillation, valvular replacement, and Wolff-Parkinson-White Syndrome, unintentionally ingested five 300 mg propafenone tablets after mistaking them for prednisone while reading her medication labels in Braille. She received prehospital oral activated charcoal. En route to the ED, she developed bradycardia and seized. Treatment included external pacing, intubation, dopamine, sodium bicarbonate, atropine, and glucagon. Asystolic cardiac arrest resulted in prolonged resuscitative efforts. Severe diffuse anoxic brain injury was noted on CT and life support was withdrawn. A prehospital blood propafenone concentration was 4.88 µg/mL. Case 700. A 2-year-old boy was found dead in his bed. He had been ill with a viral infection for an unknown period of time, and received three doses of a cough syrup containing hydrocodone bitartrate and guaifenesin. The autopsy revealed cerebral and pulmonary edema and a serum postmortem hydrocodone concentration of 80 ng/mL (therapeutic, ⬍20 ng/mL). The cause of death was respiratory arrest, acute pneumonia, and medication effect. Case 702. A 23-year-old woman with a history of bulimia ingested 20 diet capsules containing sustained-release phenylpropanolamine and 12 cold capsules containing acetaminophen, diphenhydramine, pseudoephedrine and dextromethorphan, then self-induced vomiting at home. On presentation to the ED 30 minutes later, her blood pressure was 156/91 mm Hg, heart rate was 60 beats/min and she was awake. She was treated with activated charcoal and whole bowel irrigation. An episode of transient hypertension (blood pressure, 165/120 mm Hg) with type I second degree AV block was followed by tachycardia with normalization of the blood pressure. The patient required intubation for pulmonary edema, despite the absence of ECG changes or enzymatic evidence of myocardial ischemia. Subsequent complications included severe tachycardia, ventricular dysrhythmias, and cardiac arrest. Autopsy findings included pulmonary edema, numerous small foci of fibrosis in the myocardium, and a focal hemorrhage in the left basal ganglia. Antemortem blood toxicology results were: acetaminophen, 14.8 µg/mL; fluoxetine, 0.51 µg/mL; pseudoephedrine, 0.33 µg/mL; and phenylpropanolamine, 0.95 µg/mL. Case 703. A 14-month-old boy presented 20 minutes after ingesting an unknown number of iron tablets with evidence of gastrointestinal bleeding and disseminated intravascular coagulation. Treatment included intubation, exploratory laparotomy to remove iron tablets, blood product transfusions, and an intravenous deferoxamine infusion. Laboratory results were: initial serum iron, 15,000 µg/dL; 3-hour serum iron, 18,750 µg/dL; 6-hour serum iron, 4,000 µg/dL; hemoglobin, 5.4 gm/dL; and WBC, 26,000/µL. The patient died 16 hours after arrival.
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Case 704. A 73-year-old woman with multiple chronic medical illnesses was hospitalized to rule out bowel obstruction. After receiving two bottles of oral magnesium citrate, the patient suffered ventricular fibrillation and cardiac arrest. Resuscitative efforts included intubation, dopamine, calcium, and furosemide. Laboratory findings after the arrest included: BUN, 20 mg/dL; creatinine, 1.2 mg/dL; magnesium, 6.6 mEq/L; and a normal ECG. An abdominal CT scan ruled out bowel perforation, however, the chest radiograph showed white-out of the right lung, suggesting aspiration of the magnesium citrate. Complications included renal failure, cyanosis, and unresponsiveness with fixed dilated pupils. The patient died on the third hospital day. Case 705. A 6-year-old boy was found staring and unresponsive, with arms flexed and legs extended, 1 hour after the administration of a trimethobenzamide suppository for vomiting and headache. He was choking at the time and may have aspirated vomitus. In the ED, he was unresponsive, in acute respiratory distress, with hypoxia, tachycardia, and muscle rigidity. Chest radiograph showed multilobar infiltrates. Treatment included high flow oxygen, intubation, and diphenhydramine, without improvement in rigidity. There was no improvement in mental status. Hemodynamic deterioration occurred and he died the following day. Ante- and postmortem cultures, including cerebrospinal fluid, were negative. Death was attributed to either a dystonic reaction or seizure resulting in aspiration of gastric contents. Case 715. A 38-year-old depressed, diabetic woman took an unknown number of pills. She initially refused to reveal what medications had been ingested. Six hours after a medical evaluation, she was discharged to a mental health facility. Two hours later, she became somnolent with slurred speech and was returned to the ED. It was then determined that she may have overdosed on metformin, an unidentified sulfonylurea, cephalexin, acetaminophen/hydrocodone, clonazepam, and ibuprofen. Laboratory results at that time were: glucose, 10 mg/dL; lactic acid, 20 mEq/L; arterial pH, 6.9; serum bicarbonate, 6 mEq/L. Treatment included 50% dextrose, sodium bicarbonate infusion, and hemodialysis against a bicarbonate bath. The patient became comatose. Postdialysis laboratory results were: pH, 6.97; lactic acid, 27 mEq/L; creatinine 1.9 mg/dL; and glucose, 300 mg/dL. Additional treatment included infusions of dextrose and bicarbonate, insulin, thiamine, and high-dose vasopressors. Despite this, lactic acidosis was refractory, and additional attempts at hemodialysis were not tolerated secondary to hypotension. Case 716. A 29-year-old body-builder with a history of drug and alcohol abuse experienced sudden loss of consciousness and cardiopulmonary arrest after taking 1,4-butanediol at a party with friends. He had apparently ‘‘passed out’’ 2 weeks before this event after an ingestion of the same product. He had fixed, dilated pupils on arrival to the ED, and within 2 hours began to have uncontrollable seizures and upward ocular deviation. Refractory seizures continued for 9 hours and were treated with lorazepam, phenytoin, and midazolam. His subsequent course was complicated by CT evidence of generalized edema, increased intracranial pressure, and diabetes insipidus.
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Case 717. A 4-year-old boy with a history of AML treated with intrathecal methotrexate and possibly other chemotherapeutic agents, was given 300 to 650 mg of disodium edetate through a central venous line. He developed cardiorespiratory arrest. The ionized calcium level was 0.55 mmol/L. Case 718. A 52-year-old man with a history of chronic ethanol abuse was brought to the ED presumably in a postictal state. He had been taking 4 mouthfuls of gamma butyrolactone every 4 hours for 8 months, according to his wife. Four days earlier, after his wife discarded his gamma butyrolactone supply, he began consuming large amounts of water and another dietary supplement obtained through the internet that also contained gamma butyrolactone. Admission laboratories were remarkable for a sodium of 107 mEq/L. He was treated with phenytoin. Within 24 hours, the patient developed coma with fixed, dilated pupils, and was noted to have cerebral edema. Despite intensive therapy, life support was withdrawn after a brain scan revealed no cerebral blood flow. Case 725. A 38-year-old man with a history of depression was found dead in his bedroom. Five discarded enema bottles were present; two of these contained small amounts of residual dark fluid. Autopsy findings showed two partiallyfolded transdermal nicotine patches lodged in the esophagus and three patches in the stomach. The postmortem peripheral blood nicotine concentration was 106 µg/mL. Case 736. A 30-year-old man maintained on methadone for heroin abuse underwent a rapid opioid detoxification procedure. Anesthesia was induced with propofol, midazolam, and ketamine. Naltrexone pellets were implanted subcutaneously on his abdomen, and parenteral opiate antagonists were administered. The patient was then discharged to a hotel room. A visiting nurse administered somatostatin, acetaminophen, diphenhydramine, and trazodone the next day. He was found unresponsive on the third day and transported to an emergency department. He was in respiratory distress and required intubation. Vital signs were: blood pressure, 170/100 mm Hg; heart rate, 140 beats/min; and temperature, 40°C. Subsequent complications included variceal bleeding, probable aspiration pneumonia, prerenal azotemia, multiple seizures, and cardiac arrest. Case 745. A 73-year-old woman with a history of diabetes presented unresponsive after possibly ingesting up to 90 mL of chloral hydrate syrup. Her blood pressure on arrival was 125/58 mm Hg. Within 30 minutes, she developed frequent premature ventricular contractions which were treated with lidocaine. Bradycardia followed and was treated with atropine. After a ‘‘do not resuscitate’’ status was established, she experienced asystole and died. Case 780. A 2-month-old boy was found dead at home by paramedics summoned by his mother. The autopsy revealed a urinary cocaine metabolite concentration of 2,506 ng/mL, and mild to moderate pulmonary congestion, without evidence of foul play or SIDS. Death was caused by cocaine toxicity possibly resulting from inhalation of free-base cocaine smoke. The death was ruled a homicide. Case 834. A 20-year-old woman who recently arrived
from Colombia was found unconscious, lying in emesis, in her hotel room. After naloxone was given in the ED, she became more responsive. She was febrile and had a blood pressure of 135/72 mm Hg and a heart rate of 120 to 130 beats/min. An abdominal radiograph showed numerous foreign bodies and a chest radiograph showed aspiration pneumonia. The urine drug screen was positive for opiates, marijuana, methadone, and cocaine. Whole bowel irrigation resulted in the passage of 99 intact bags containing pure heroin over the course of several days. Intermittent naloxone and intubation were required to maintain ventilation. Multiple complications developed, including adult respiratory distress syndrome, hypotension, subcutaneous emphysema, agitation, tachycardia, and ultimately asystole on the 17th hospital day. Case 866. A 23-year-old man, with a history of intentional abuse of an unknown amount of ‘‘Ecstasy’’ (methylenedioxymethamphetamine) 2 days previously, was found in a hotel room incoherent, yet able to follow commands, with right-sided paralysis and aphasia. Vital signs were within normal limits, except that he was febrile. Drug screens were positive for barbiturates and amphetamines. Urine, blood, and CSF cultures were negative. A CT scan approximately 36 hours after admission showed a large left nonhemorrhagic infarct. Subsequent neurologic deterioration resulted in decerebrate posturing, with dilated, sluggishly reactive pupils. A repeat CT scan the next day revealed a thrombus in the left main carotid artery and a small gyral hemorrhage. The patient died 4 days later from cerebral edema and herniation. Case 867. A 22-year-old man presented unresponsive after abusing methylenedioxymethamphetamine (MDMA, Ecstasy), ethanol and alprazolam with a friend. Vital signs were: temperature, 41.7°C; heart rate, 192 beats/min; and blood pressure, 93/65 mm Hg. Complications included hypoglycemia, rhabdomyolysis, and disseminated intravascular coagulation. Treatment included intubation, dextrose, sodium bicarbonate, fresh frozen plasma, phytonadione and vasopressors. He remained unresponsive and hemodynamically unstable, and was declared brain dead 36 hours after admission. Antemortem methylenedioxyamphetamine and methylenedioxymethamphetamine serum concentrations were 0.02 µg/mL and 0.82 µg/mL, respectively. Case 868. A 17-year-old girl intentionally ingested an unknown substance in a suicide attempt. She presented to the hospital with chest pain, dizziness, vertigo, and drowsiness. She was afebrile with a blood pressure of 103/50 mm Hg, heart rate of 60 beats/min and respiratory rate of 40 breaths/min. The ECG showed third-degree AV block. Treatment included fluids, atropine, and antibiotics. Laboratory results were: potassium, 8.9 mEq/L; digoxin, 4.2 ng/mL; and WBC, 20,900/µL. She developed a ventricular dysrhythmia that did not respond to ACLS protocols. Using a different assay, the medical examiner reported the digoxin concentration as 2.0 ng/mL. This finding suggested the presence of a nondigoxin cardiac glycoside (topical aphrodisiac).