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1986 Annual report of the American Association of Poison Control Centers National Data Collection System
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Toxicology A special contribution from the American Association of Poison Control Centers.
I
I--@A. t
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Liii
1986 Annual Report of the American Association of Poison Control Centers National Data Collection System TOBY L. LITOVITZ,
The American Association of Poison Control Centers (AAPCC) National Data Collection System has grown since its inception in 1983. During that pilot year, 251,012 human poison exposures were reported from 16 poison centers.’ In 1984 and 1985,730,224 and 900,513 human exposures were reported, respectively.2,3 This report includes 1,098,894 human exposure cases reported by 57 participating poison centers during 1986. From the Data Collection Poison Control Centers.
Committee,
American
Association
of
The authors acknowledge the generous contribution of Micromedex, Inc., to the programming and processing of this annual report. Centers participating in this year’s report include Alabama Poison Center, Tuscaloosa, AL; Arizona Poison Control System, Tucson, AZ; St. Luke’s Poison Center, Phoenix, AZ; Fresno Community Hospital Regional Poison Control Center, Fresno, CA; Orange County Poison Center, Orange, CA; San Diego Regional Poison Center, San Diego, CA; San Francisco Bay Area Regional Poison Center, San Francisco, CA; Rocky Mountain Poison Center, Denver, CO; National Capital Poison Center, Washington, DC; Tampa Bay Regional Poison Center, Tampa FL; Idaho Poison Control Center, Boise, ID; Indiana Poison Center, Indianapolis, IN; St. Luke’s Poison Center, Sioux City, IA; Mid-America Poison Center, Kansas City, KS; Kentucky Regional Poison Center of KosairGhildren’s Hospital, Louisville, KY; Louisiana Regional Poison Control Center, Shreveport, LA; Maryland Poison Center, Baltimore, MD; Children’s Hospital of Michigan Poison Control Center, Detroit MI; Blodgett Regional Poison Center, Grand Rapids, MI; Great Lakes Poison Control Center, Kalamazoo, MI; Midwest Poison Center, Kalamazoo, MI; Saginaw Regional Poison Center, Saginaw, MI; Hennepin Poison Center, Minneapolis, MN; Minnesota Poison Control System, St. Paul, MN; St. Louis Regional Poison Center, St. Louis, MO; Mid-Plains Poison Control Center, Omaha, NE; New Jersey Poison Information and Education System, Newark, NJ; Hudson Valley Poison Center, Nyack, NY; Triad Poison Center,
MD, THOMAS G. MARTIN, MD, BARBARA SCHMITZ, RN
CHARACTERIZATIONOF PARTICIPATING CENTERS All 57 reporting centers submitted data for the entire year. Twenty-six of the 57 centers were certified as regional poison control centers by the AAPCC. Annual center call volumes (human exposure cases only) ranged from 1,273 to 72,351 (mean, 19,525). Center penetrance (defined as the number of human poison exposure cases reported to a center divided by the Greensboro, NC; North Dakota Poison Center, Fargo, ND: Akron Regional Poison Center, Akron, OH; Stark County Poison Control Center, Canton, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Central Ohio Poison Control Center, Columbus, OH; Oregon Poison Center, Portland, OR; LeHigh Valley Poison Center, Allentown, PA; Keystone Regional Poison Center, Altoona, PA; Northwest Poison Center, Erie, PA; Capital Area Poison Center, Hershey, PA; Delaware Valley Regional Poison Control Center, Philadelphia, PA; Pittsburgh Poison Center, Pittsburgh, PA; Rhode Island Poison Center, Providence, RI; Southern Poison Center, Inc., Memphis, TN; North Central Texas Poison Center, Dallas, TX; Intermountain Regional Poison Control Center, Salt Lake City, UT; Blue Ridge Poison Center, Charlottesville, VA; Tidewater Poison Center, Norfolk, VA; Central Virginia Poison Center, Richmond, VA; Seattle Poison Center, Seattle, WA; Spokane Poison Center, Spokane, WA: Mary Bridge Poison Center, Tacoma, WA; Central Washington Poison Center, Yakima, WA: West Virginia Poison Center, Charleston, WV: Eau Claire Poison Center, Eau Claire, WI; Lacrosse Area Poison Center, Lacrosse, WI; University of Wisconsin Hospital Regional Poison Control Center, Madison, WI; Milwaukee Children’s Hospital Poison Center, Milwaukee, WI. 0 1985, 1986, 1987, by the American Association of Poison Control Centers. Published by permission. All rights reserved. Address reprint requests to Dr. Litovitz: National Capital Poison Center, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007. 0735-6757187
$0.00 + .25 405
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
w Volume
5, Number
5 n September
1987
FIGURE 1. Fifty-seven centers participated in the Data Collection System in 1986. The cross-hatched served by reporting centers. (Map adapted from Hammond’s Outline Map of the United States.) TABLE 1. Exposure
Site of Caller and Site of Exposure, Cases
Human
Site of Caller
Residence Health care facility Workplace School Other Unknown TOTAL
Age and Sex Distribution
TABLE 2.
(“h)
82.1 14.1 1.5 0.6 1.3 0.5
91.6 0.5 2.5 0.8 2.1 2.4
100.0
100.0
of Human
population served by that center) ranged from 3. I to 19.9/l ,000, with a mean of 9.1 reported exposures per thousand population. A total population of 132.1 million was served by the participating centers including portions of 33 states and the District of Columbia (Fig. 1). Noting the 241.1 million estimated United States population, the data presented represent an estimated 55% of the human poison exposures reported to poison control centers in the United States during 1986. Thus, the 1,098,894 human poison exposures reported in this data base can be extrapolated to predict a nationwide
Site of Exposure
(“A)
Poison
Exposure
Cases’
Female
Male
46,538 (4.2) 111,421 (10.1) 115,748 (’10.5) 55,890 (5.1) 24,629 (2.2) 13,031 (1.2) 32,699 (3.0) 19,330 (1.8) 122,646 (’11.2) 7,582 (0.7)
46,194 (4.2) 19,389 (1.8) 10,236 (0.9) 24,044 (2.2) 27,498 (2.5) 157,593 (14.3) 8,678 (0.8)
549,514 (50.0)
530,768 (48.3)
6-12 13-17 >17 Unknownt TOTAL
41,834 97,475 97,827
* Numbers in parentheses are percentages. t In the unknown category, although the exact age was not reported, 406
Unknown
Age (yr)
2 3 4 5
areas denote regions
(3.8) (8.9) (8.9)
Total
1,246 (0.1) 2,112 (0.2)
2,275 1,183 514 315 792 507 4,112 5,556
(2.1) (0.1) (0.0) (0.0) (0.1) (0.0) (0.4) (0.5)
18,612 (1.7)
915 cases were infants
89,618 211,008 215,850 103,267 44,532 23,582 57,535 47,335 284,351 21,816
(8.2) (19.2) (19.6) (9.4) (4.1) (2.1) (5.2) (4.3) (25.9) (2.0)
1,098,894 (100.0)
and 3,810 were children
aged 2 to 5 years.
LITOVITZ ET AL n 1966 AAPCC ANNUAL REPORT
TABLE 3.
Distribution
of Age and Sex of 406 Fatalities
Age (yr)
Male
adult
TOTAL l
Data in parentheses
TABLE 4. Exposure
Number Cases
Female
3 3 2 1 1 0 2 22 55 46 19 26 11 13 4 0 10 0
1 2 1 0 0 0 0 19 35 25 25 23 27 14 5 3 6 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
218
186
2
1 2 3 4 5 6 7 8 9 310 Unknown TOTAL
Total’ 5 5 3
(1.2) (1.2) (0.7)
1
(0.2)
: 2 41 90 71 44 49 38 27 9 3 16 1
1:::; (0.5) (10.1) (22.2) (17.5) (10.8) (12.1) (9.4) (6.7) (2.2) (0.7) (3.9) (0.2)
406 (100.0)
are percentages.
of Substances
Involved
in Human
Poison
TABLE 5.
Reason for Human
Poison
Exposure No.
Cases Number of Substances
Unknown
NO.
1,027,452 53,759 9,949 2,726 1,011 433 179 92 65 231 2,997 1,098,894
%
93.5 4.9 0.9 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.3 100.0
incidence of 2 million human poison exposures. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the United States 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 19.9 poisonings/1,000 population reported for one state, then 4.8 million poisonings would have been reported to poison control centers in 1986. Because of the growth and development of this relatively new data collection project, with increasing center participation from year to year, the data do not directly identify a trend in the overall incidence of poisonings in the United States. However, an analysis of data from 47 centers that par-
Accidental General Misuse’ Occupational Environmental Unknown TOTAL
Cases %
930,320 24,345 19,115 5,237 1,192 980,209
84.7 2.2 1.7 0.5 0.1 89.2
Intentional Suicidal Abuse+ Misuse* Unknown TOTAL
61,788 12,841 11,312 10,190 96,131
5.6 1.2 1.0 0.9 8.7
Adverse Reaction Drug Food Other TOTAL
7,751 6,079 1,424 15,254
0.7 0.6 0.1 1.4
7,300
0.7
1,098,894
100.0
Unknown TOTAL
* Improper use of a substance where therapeutic or beneficial results were intended, e.g., an overdose occurring because both parents gave the same medication to a child and neither was aware (at the time) of the other’s action, or a case where misreading the label of a product results in an unintended exposure. t Improper use of a substance where the patient was seeking a psychotropic effect. * Intentional incorrect use of a substance where a psychotropic effect was not sought, e.g., intentional excessive dosing to obtain a more rapid or superior pharmacologic effect for presumed “therapeutic purposes.” 401
AMERICAN
TABLE 6.
JOURNAL
Distribution
Reason
of Reason for Exposure
687,801
Intentional Adverse reaction Unknown
1 ,105 1,774 1,902
TOTAL
692,582
Data in parentheses
TABLE 7.
MEDICINE
~6 Years
Accidental
l
OF EMERGENCY
Distribution
5 n September
5, Number
by Age, Human
Exposure
(99.3)
53,334
(92.7)
(0.2) (0.3) (0.3)
2,712 1,037 452
(4.7) (1.8) (0.8)
21,943 (46.4) 693 (1.5) 737 (1.6)
(63.0)
57,535
(5.2)
47,335
23,962
1987
Cases Only’
13- 17 Years
6- 12 Years
>17 Years
(50.6)
202,180
Unknown
(71 .l)
12,932
66,857 (23.5) 11,380 (4.0) 3,935 (1.4)
(4.3)
284,352
(25.9)
Total
(75.7)
980,209
(89.2)
3,514 (20.1) 370 (2.2) 274 (1.6)
96,131 15,254 7,300
(8.7) (1.4) (0.7)
1,098,894
(100.0)
17,090
(1.6)
are percentages.
of Reason for Exposure ~6 Years
Accidental General Environmental Misuse Occupational Unknown TOTAL
W Volume
and Age for 406 Human Fatalities 6-l
2 Years
13- 17 Years
>17 Years
Unknown
Total
9 1 3 0 0 13
1 1 0 0 0 2
0 2 2 0 0 4
10 8 13 5 4 40
0 0 0 0 0 0
20 12 18 5 4 59
Intentional Suicide Misuse Abuse Unknown TOTAL
0 0 1 0 1
0 0 0 0 0
16 1 3 1 21
207 12 40 31 290
0 0 1 0 1
223 13 45 32 313
Adverse
0
0
0
4
0
4
1
0
0
29
0
30
15
2
25
363
1
406
Reaction
Unknown TOTAL
TABLE 6. Exposure
Distribution of Route of Exposure Cases and 406 Fatalities*
for Human
Poison
TABLE 10.
Management
Site of Human
Poison
Exposure
Cases
No. (“/I)
Ingestion Dermal Ophthalmic Inhalation Bites and stings Parenteral Othefiunknown Multiple routes posure victims. total number of for fatal cases) sures (1,098,894) l
All Cases
Fatalities
897,518 (78.5) 75,127 (6.6) 63,558 (5.6) 60,520 (5.3) 35,395 (3.1) 3,524 (0.3) 7,496 (0.7)
326 (77.1) 4 (0.9) 0 (0.0) 46 (10.9) 1 (0.2) 31 (7.3) 15 (3.5)
of exposure were observed in many poison exPercentages (in parentheses) are based on the exposure routes (1,143,138 for all patients, 423 rather than the total number of human expoor fatalities (406).
Non-healthcare facility Healthcare facility Already there at time of call to poison center Referred by poison center Other/unknown TOTAL
820,629
(74.7)
127,807 125,694 24,764
(11.6) (11.4) (2.3)
1,098,894
(100.0)
for the entirety of 1985 and 1986 indicates an 8.4% increase in reported poison exposures from 1985 to 1986 within the regions served by these 47 centers. ticipated
REVIEW OF THE DATA TABLE 9. Symptom Poison Center
Assessment
at Time of Initial Call to
No. (%) Asymptomatic Symptomatic, Symptomatic, Symptomatic, Unknown TOTAL 408
related to exposure unrelated to exposure unknown if related
725,129 285,811 17,273 48,230 22,451
(66.0) (26.0) (1.6) (4.4) (2.0)
1,098,894
(100.0)
The 1,098,894 human poison exposures reported to AAPCC in 1986 represent the largest poison exposure data base ever compiled in the United States and an 18.1% increase in total reports from 1985. An analysis of the data indicates that 9 1.6% of exposures occurred in the home (Table 1). Two unlikely sites of poisonings, health care facilities and schools, accounted for 5,716 (0.5%) and 9,147 (0.8%) poison exposures, respectively. Poison center peak call volumes were
LITOVITZ
noted from 5 to 9 PM, although call frequency remained consistently high between 9 AM and 10 PM, with 82.6% of calls logged during this 13-hour period. The age and sex distribution of human poison exposure victims is outlined in Table 2. Forty-seven percent of cases involved children under 3 years of age, and 62.6% occurred in children under 6 years of age. A male predominance is found among poison exposure victims less than 12 years old, but the gender distribution is reversed in teenagers and adults. Table 3 gives the age and sex distribution for 406 fatalities. Despite variations from decade to decade among adults, overall, males account for a greater number of fatalities in children, teenagers, and adults. A single substance was implicated in 93.5% of reports, and only 1.3% of patients were exposed to more than two possibly poisonous drugs or products (Table 4). Most cases of human exposure were acute (98.7%), as were most poison-related fatalities (91.1%). (Chronic exposures were arbitrarily defined as repeated exposures to the same toxic substance or a single exposure lasting longer than eight hours.) Most poison exposures (89.2%) were accidental; suicidal intent was present in 5.6% of cases (Table 5). Nearly one quarter (23.2%) of cases with suicidal intent occurred in patients who were 13 to 17 years old. Whereas accidental poisonings outnumbered both intentional poisonings and adverse reactions in all age groups (Table 6), the ratio was lower in teenage and adult cases. In contrast, of the 406 human poisoning fatalities reported, this ratio was reversed among the adult deaths, with 7.25 times as many deaths resulting from intentional as compared with accidental exposures (Table 7). Ingestions accounted for 78.5% of poison exposures (Table 8), followed in frequency by dermal contact, ophthalmic exposure, inhalation, bites and stings, and parenteral exposure. For the 406 fatalities, ingestion and inhalation were the predominant exposure routes. Table 9 displays the symptom assessment at the time of the initial call to the participating poison center. In addition to the 26.0% of patients with initial symptoms clearly related to the exposure, symptoms developed during the subsequent course in 8,413 initially asymptomatic patients. Thus, symptoms definitely related to the exposure eventually developed in at least 26.8% of patients. Most of the patients reported to poison centers were managed in a non-health care facility (74.7%), usually at the site of exposure, the patient’s own home (Table 10). Treatment in a health care facility was rendered or recommended in 23.0% of cases, and of these, 53.0% involved treatment and release, 17.3% involved admission for medical care, and 2.3% involved admission for psychiatric treatment; 8.5% refused referral, and 19.0% were lost to follow-up.
ET AL W 1988 AAPCC ANNUAL
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REPORl
AMERICAN
JOURNAL
TABLE 12.
Distribution
OF EMERGENCY
of Medical
MEDICINE
Outcome
H Volume
by Reason for Exposure
Accidental No effect Minor effect Moderate effect Major effect Death Unknown, nontoxic Unknown, potentially Unrelated effect Unknown
toxic
TOTAL l
Data in parentheses
5, Number
Intentional
474,546 (43.2) 208,248 (19.0) 18,288 (1.7) 1,621 (0.1) 59 (0.0) 206,647 (18.8) 45,921 (4.2) 21,257 (1.9) 3,622 (0.3)
17,082 33,261 10,112 2,299 313 5,754 25,709 1,241 360
(1.6) (3.0) (0.9) (0.2) (0.0) (0.5) (2.3) (0.1) (0.0)
980,209
96,131
(8.7)
(89.2)
Provided
in Human
Poison
Exposure
Cases No.
Initial decontamination Dilution Irrigation/washing Ipecac syrup Activated charcoal Cathartic Gastric lavage Other emetic
423,744 201,583 145,949 56,619 47,013 17,639 2,537
Measures to enhance elimination Urinary alkalinization (with or without diuresis) Forced diuresis Hemodialysis Hemoperfusion (charcoal) Urinary acidification (with or without diuresis) Peritoneal dialysis Exchange transfusion Hemoperfusion (resin)
2,347 300 297 99 75 62 33 23
Specific antidote administration N-acetylcysteine (PO) Naloxone Atropine Deferoxamine Ethanol Physostigmine Antivenin/antitoxin Hydroxocobalamin N-acetylcysteine (IV) Pralidoxime (a-Pam) Dimercaprol @AL) Penicillamine Fab fragments Pyridoxine Methylene blue Cyanide antidote kit EDTA
3,009 3,209 529 506 453 375 349 202 153 151 147 130 105 103 90 84 84
410
for Human Adverse
Poison
1987
Exposure
Reaction
Victims* Unknown
(0.1) (0.7) (0.1) (0.0) (0.0) (0.2) (0.2) (0.1) (0.0)
1,472 1,751 493 106 30 1,369 1,663 356 60
(0.1) (0.2) (0.0) (0.0) (0.0) (0.1) (0.2) (0.0) (0.0)
15,254 (1.4)
7,300
(0.7)
1,607 7,726 1,044 75 4 1,820 1,667 1,268 43
Total 494,707 250,986 29,937 4,101 406 215,590 74,960 24,122 4,085 1,098,894
(45.0) (22.8) (2.7) (0.4) (0.0) (19.6) (6.8) (2.2) (0.4) (100.0)
are percentages
Table 11 shows the medical outcome of the human poison exposure victims distributed by age, emphasizing the more severe outcome observed in the older age groups. Table 12 compares medical outcome and reason for exposure, emphasizing the greater frequency of serious outcome in intentional exposures. Table 13 outlines the use of initial decontamination TABLE13. Therapy
5 l September
procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this data base. These figures must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 13.3% of cases. In children, ipecac syrup was most often administered outside a health care facility (Table 14). A summary of the 406 fatal exposures is presented in Table 15. Each of these cases was abstracted and/or verified by the reporting center, with only those fatalities deemed “probably” or “undoubtedly” related to the exposure included in this compendium. Confirmation of the cause of death by a postmortem report was obtained in 38.9% of cases. The highest blood level of implicated substances is provided where available to the reporting poison center. Cases with prehospital cardiorespiratory arrests are indicated. Abstracts are provided in the appendix for interesting or unusual cases. Tables 16 and 17 provide comprehensive demographic data on patient age, reason for exposure, medical outcome. and use of a health care facility for all 1,098,894 exposures, presented by category. Table 16 focuses on nonpharmaceuticals; Table 17 presents drugs. Table 18 presents the most common categories listed by frequency of exposure. Table 19 lists the substance categories with the largest number of reported deaths. A review of the fatality data demonstrates that 29.6% of the patients experienced cardiorespiratory arrest prior to arrival in the emergency department. Of the 49 patients who intentionally inhaled or injected toxins, 34 (69.4%) sustained a prehospital cardiac arrest. The 10 patients who ingested cyanide also experienced a higher incidence of prehospital cardiac arrest (70%); of the remaining three cases, two were agonal on presentation. In 19 ethylene glycol or methanol fatalities, diagnosis was substantially delayed in seven (36.8%), and two never received ethanolblocking therapy. (Text continues
on purge 435.)
LITOVITZ
TABLE 14.
Ipecac Administration
Non-health Care Facility
Health Care Facility
3,841 (2.6) 18,929 (13.0) 25,921 (17.8) 13,653 (9.4) 4,907 (3.4) 1,996 (1.4) 3,006 (2.1) 967 (0.7) 5,208 (3.6) 2,521 (1.7)
1,653 (1.1) 7,541 (5.2) 11,941 (8.2) 5,949 (4.1) 2,100 (1.4) 815 (0.6) 1,617 (1.1) 8,199 (5.6) 22,404 (15.4) 2,412 (1.7)
80,949
64,631
6-12 13-17 >17 Unknown TOTAL l
Data in parentheses
TABLE 15.
Summary
Adhesives 1* Alcohols 2’
51 60 17 19 24
7*
29
8*t 9
4 28 56 36 14 3 7 9 31 10
(44.3)
Total
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
5,507 26,526 37,951 19,662 7,026 2,818 4,636 9,182 27,667 4,974
(3.8) (18.2) (26.0) (13.5) (4.8) (1.9) (3.2) (6.3) (19.0) (3.4)
198 (0.1)
145,949
(100.0)
of Fatal Exposures
29
3t 4’ 5 6
(55.5)
Unknown
are percentages.
Age (yr)
Case
REPORT
by Site and Age’
Age (yr)
1 2 3 4 5
ET AL n 1986 AAPCC ANNUAL
48 55
See also cases 13, 78.95, 390 (ethanol].
Route of Exposure
Substances
Glue: methylene trichloroethane,
chloride, diethyl
Blood
Levels**
Inhalation
Act
occup
Ingestion
Int unknown
511 mg/dl
Parenteral Ingestion Ingestion Ingestion Ing and inh
Act misuse Act misuse Int unknown Int suicide Int suicide
40 170 46 109
Ingestion Ingestion
Int unknown Int unknown
ether
Ethanol benzodiazepines lsopropanol Methanol Methanol Methanol Methanol, methylene toluene Methanol Methanol
Reason
mg/dl, 36 hr mg/dl mg/dl mg/dl
chloride
124, 127, 150, 172, 193,
198,
Arts and crafts, and office supplies Typewriter correction fluids (TCF) 10 15 Trichloroethane Trichloroethane/ethylene 11* 16 Trichloroethane 12** 18 TCF (unknown ingredients) 32 13* paint ethanol Automotive/aircraft/boat products Ethylene glycol antifreeze 14 26 Ethylene glycol antifreeze 15 28 Ethylene glycol antifreeze 16 37 Ethylene glycol antifreeze 17 44 Methanol gasoline antifreeze 18 24 Methanol 19 27 Methanol windshield wash 20 28 Methanol windshield wash 21 55 Methanol gasoline antifreeze 22’ 55 Bites and envenomations Brown recluse spider bite 23t 69 Chemicals Cyanide 24 25 Cyanide 25*t 26 Cyanide 26* 27 Cyanide 27t 28 Cyanide 28’ 37 Cyanide (capsule tampering) 29 40
200, 236, 237, 238, 249, 290, 294, 304, 324,327,
Inhalation Inhalation Inhalation Inhalation
Int Int Int Int
585 mg/dl
333, 347, 357, 387, 388, 389,
abuse abuse abuse abuse
Ingestion
140 mg/dl
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int unknown Int suicide Int suicide Int unknown Unknown Int suicide Int unknown Int suicide
Bite/sting
Act
gen
Ingestion Ingestion Ingestion Ingestion Inhalation Ingestion
Int Int Int Int Int Int
suicide suicide suicide suicide suicide misuse
525 mg/dl 584 mgldl 200 233 135 203
mg/dl mg/dl mg/dl, mg/dl
>24 hr
2.5 mg/L
411
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 5, Number 5 n September
1987
TABLE15. Continued
Case
Age (yr)
30 31*
41 47
32* 33 34t 35t 364 37 38 39t 40t 41 42 43*t 44
48 52 29 32 62 78 31 22 33 19 >17 58 68
Cyanide Cyanide Cyanide Cyanide (capsule tampering) Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol Hydrochloric acid Hydrofluoric acid Hydrofluoric acid Methylene chloride Methemoglobin producer Strychnine (nux vomica) Sodium hydroxide (lye)
See also case 7 (methylene Cleaning 45 46 47 48t
substances 45 73 74 67
49 50 51 52 53 54
67 84 85 3 39 40 43 55t 56 56 59 57t 58 >17 Cosmetics/personal
Fumes, gases, and vapors 59* >17 60* 6 mo
79*t 80 81’ Fungicides 82t 412
Reason
Inhalation Ingestion Ingestion Ingestion ingestion Ingestion Ingestion Ingestion Ingestion Dermal Ingestion Ing, inh, derm Unknown Ingestion Ingestion
Int suicide Int suicide Act unknown Int misuse Int suicide Unknown Int unknown Unknown Int suicide Act occup Int suicide Unknown Int unknown Act misuse Unknown
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
suicide suicide suicide suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Act Act Act Int Int Act Int Int Int Act
unknown gen gen abuse suicide gen suicide suicide suicide gen
14 17 18 20 21 24 25 25 26 28 28 36 37 53 54 85 >17 20 29 >17 >17 (nonmedicinal) 30
Blood
Levels**
154 mg/dl,
18 hr
720 ~glml!j 88.0%
chloride).
Alkaline drain opener Alkaline drain opener Ammonia (household) Brass cleaner (chromic acid, sodium bisulfateibifluoride) Cationic cleaner Cationic cleaner Cationic cleaner-industrial Spot remover (naphtha) mo Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) care products
See cases 104 (aftershave,
61* 62 63’ 64’ 65* 66* 67*t 68’ 69 70 71* 72’ 73 74* 75* 76’ 77* 78*
Route of Exposure
Substances
ethanol),
123 (acetone,
nail polish
Anhydrous ammonia Carbon monoxide/burns/smoke inhalation Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke inh Carbon monoxide/smoke inh Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke inh ethanol Hydrogen sulfide Hydrogen sulfide Methane Calcium polysulfidei hydroxypolyoxyethylene
I.emover).
Inhalation
Act occup Act environ
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Int suicide Act environ Act environ Int suicide Int suicide Int suicide Act environ Act environ Act environ Act environ Int suicide Int suicide Act environ Int suicide Act environ Int suicide Act environ Act gen
Inhalation Inhalation Inhalation
Act occup Act environ Unknown
Ingestion
Int suicide
31.5% 35.9%
82.2% 58.0% 44.0%, 1 hr
52.40/c, 2-3 44.4% 54.8% 16.3%
hr
LITOVITZ
ET AL n 1986 AAPCC ANNUAL
REPORT
TABLE15. Continued
Age Case
(yr)
Heavy metals 83tS
35
Substances
Route of Exposure
Reason
Copper
Ingestion
Int misuse
40 30 52 64
2,4-D Paraquat Paraquat Paraquat
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
suicide suicide suicide suicide
92t 93*t 94 95*
79 15 23 15 12 13 mo 27 15
suicide misuse suicide unknown gen gen abuse abuse
53
Ingestion Inhalation Inhalation Inhalation Ingestion Ingestion Inhalation Inhalation Ingestion Ingestion
Int Act Int Int Act Act Int Int
96
Carbon tetrachloride Freon Freon lsobutane Lamp oil Mineral spirits Toluene Trichloroethane ethanol Turpentine
Arsenic pesticide Aldicarb Diazinon Diazinon, malathion Lindane Methyl bromide Organophosphate Phosphothioate aftershave (ethanol) Propoxur/pyrethrins/piperonyl butoxide combo Sodium fluoride roach powder
Ingestion Unknown Ingestion Ingestion Ingestion Inhalation lnhal + derm Ingestion Paren + ing
Unknown Act gen Int suicide Int suicide Unknown Act environ Act environ Int misuse Int suicide
Ing + dermal
Act
Combo with methanol/ Acetone/ Isopropanol/ Methylene chloride
Ingestion
Int suicide
Ambrosia artemisiifolia cow parsnip Marah oreganus seeds (tea)
Ingestion
Int unknown
Ingestion
Int abuse
Argon
Inhalation
Act
Brodifacoum Strychnine rodenticide Strychnine rodenticide
Ingestion Ingestion Ingestion
Int abuse Int suicide Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int unknown Int misuse Int suicide Int suicide Int suicide Unknown Int suicide
Blood
Levels**
See also case 150 (lead). Herbicides 84 85t 86 87t Hydrocarbons 88t 89* 90* 91*
See also cases 194 (lighter Insecticides 97 98t 99 100 101t 102t 103 104 105
and pesticides 70 2 41 57 41 16 6 59 24
13 mo 106t Paints and stripping agents 107t 62
fluid/naphtha);
Unknown
7 (toluene).
1.3 kg/ml
gen 104 mgfdl, 2 hr 114 mgldl, 2 hr 101 mgldl, 2 hr
See also case 13 (paint). Plants 108’ 109t Radioisotopes 110* Rodenticides ltlt* 112*t 113’
26 >17 32 35 18 >17
See also case 402 (unknown Analgesics 114 115t 116 lt7tS 118 119t 120 121t 122
20 20 24 25 25 29 63 65 >17
occup
rodenticide).
Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen aspirin
(adult) (adult) (adult) (adult) (adult) (adult) (adult) (adult)
45 67 175 22 172 175 65 739 >590 IO-20
pg/ml, 24 hr pg/ml, >40 hr +g/ml, 4 hr pg/ml pg/ml, 5 hr kg/ml, 13 hr kg/ml pg/ml, 7 hr bg/ml, 20 hr mgldl, 20 hr 413
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 5, Number 5 H September
1987
TABLE15. Continued
Age Case
(yr)
Substances
123t
42
124$
60
125
41
126 127
46 23
128t
65
Acetaminophen (adult) acetone (nail polish remover) Acetaminophen (adult) ethanol Acetaminophen sleep-aid (diphenhydramine) temazepam Acetaminophenicodeine Acetaminophenlhydrocodone ethanol Acetaminophen/oxycodone
129*
19
130$ 131* 132$
26 39 42
133 134
59 66
135 136 137 138 139 140 141 142 143 144 145*
14 24 32 44 48 51 54 70 71 72 63
146$
37
147*
37
148
20
149
22
150
54
151
66
152
64
153t
23
154 155 156
30 25 57
157t 158’ 159t 160*
57 62 78 >17
161 162’ 414
>17 34
Route of Exposure
Reason
Blood
Levels”
Ingestion
Int suicide
Ingestion
Int unknown
45 kgimll
Ingestion
Int unknown
300 pgiml,
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Acetaminophen/propoxyphene
Ingestion
Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophenipropoxyphene acetaminophen (adult) Acetaminophenipropoxyphene Acetaminophenipropoxyphene
Ingestion Unknown Ingestion
Int abuse Propoxyphene Norpropoxyphene Int suicide Unknown Int misuse
Acetaminophen/codeine Aspirin (adult) Aspirin (adult) Aspirin Aspirin Aspirin (adult) Aspirin Aspirin Aspirin (adult) Aspirin Aspirin (adult) Aspirin acetaminophen (adult) Aspirin acetaminophen/oxycodone Aspirin cimetidine Aspirin diphenhydramine Aspirin (adult) diphenhydramine Aspirin (adult) ethanol Aspirin (adult) lead (buckshot) Aspirin (adult) loxapine Aspirin methylene blue Rush (isobutyl nitrate) Aspirin/butalbital/codeine Aspirin/carisiprodol Codeine diazepam acetaminophen Colchicine Colchicine Colchicine Fentanyl diazepam lndomethacin Methadone
3 rJ,g/rnl
12 hr
70 kg/ml, 60 pglml, 1,000 6-12 42 2.8 13.5 216
kg/ml, hrcl ~glml$(i bg/ml§ pg/ml§ ~g/ml~
56 kg/mlc 491 *g/ml” 9 pg/mlF 315 ngiml
Ingestion Ingestion
Int suicide Int suicide Norpropoxyphene
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
Ingestion
Int misuse
Ingestion
Int misuse
Ingestion
Int suicide
100 mg/dl
Ingestion
Int unknown
100 mg/dl
Ingestion
Int suicide
Ingestion
Int suicide
130 mgidl, 170 mg/dl, 59 mg/dl
Ingestion
Int suicide
90 mgldl
Ing + paren
Int unknown
Ingestion Ingestion Ingestion
Int unknown Int suicide Unknown
Ingestion Ingestion Ingestion Parenteral
Int suicide Adv rxn Act misuse Int suicide
Ingestion Ingestion
Int unknown Int abuse
Codeine
>12 hr’l =z4 hrT
0.2 90 125 111 125 144 131 85 79 62 21 92 65 ~8 90
pg/ml mgidl, 14 hr mgidl mgidl, 3 hr mgldl mg/dl mg/dl mg/dl, 11 hr mg/dl mgidl mgldl wg/ml mgldl FgimlB mg/dl
12-15 12-15
115 mgldl
0.63 p.g/ml§ 0.78 pg/mlg# 11 *g/ml§
0.22 p,giml§
hr hr
LITOVITZ
ET AL H 1966 AAPCC ANNUAL
REPORT
TABLE15. Continued
Case 163’
Age (yr) 40
Substances Methadone
Route of Exposure Ingestion
Reason
Blood
Int suicide metab:
164*
39
165*
>17
166 167* 166* 169* 170
Unk 51 15 29 26
171t
37
Methadone triazolam Morphine sympathomimetic Opiate Pentazocine Propoxyphene Propoxyphene Propoxyphene cocaine dextromethorphan Propoxyphene
Ingestion
Int suicide
Parenteral
Int abuse
Parenteral Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
Ingestion
Int abuse Norpropoxyphene
abuse suicide suicide suicide abuse
diazepam 172’ 173
>17 33
Propoxyphene ethanol Sufentanil
Ingestion
Nordiazepam Int suicide
Parenteral
Int suicide
Levels”
14 kg/ml 6 pg/ml
12.5 pg/ml 4,500 ng/ml
1,021 2,766 1.67 62.9
ng/ml ng/ml pg/ml kg/ml
See also cases 190 (acefaminophen); 342, 343, 383 (acefaminophenlcodeine); 192, 233 (acetaminophenlpropoxyphene); 190, 327 (aspirin); 301 (aspirinldihydrocodone); 203, 290 (aspirinloxycodone); 313 (aspirinlpropoxyphene); 340, 397 (codeine); 197 (colchicine); 315, 350 (diflunisal); 245, 302 (ibuprofen); 227 (indomethacin); 315 (meperidine); 196 (morphine); 193, 356 (opiate); 382 (propoxyphene); 330 (salsalate). Anticholinergics 174t
Ingestion
Int unknown
Carbamazepine Carbamazepine Carbamazepine Carbamazepine amitriptyline Phenytoin
Ingestion Ingestion Ingestion Ingestion
Act gen Int suicide Act unknown Int suicide
Ingestion
Act
17 29 32 46
Amitriptyline Amitriptyline Amitriptyline Amitriptyline
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
164 165 166. 167$ 166*
47 46 46 59 59
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
169* 190
66 67
Amitriptyline Amitriptyline acetaminophen (adult) aspirin (adult) Amitriptyline alprazolam Amitriptyline alprazolam acetaminophen/propoxyphene Amitriptyline ethanol opiate Amitriptyline lighter fluid/naphtha flurazepam Amitriptyline glutethimide
Ingestion Ingestion
Int Int
31
Benztropine
amphetamine
See also cases 196, 250 (benztropine). Anticonvulsants 175 176t 177t 176 179t Antidepressants 160 161 162 163
2 19 34 36 3
191’
40
192’
42
193
34
194
16
195
65
gen suicide suicide suicide suicide Nortriptyline suicide suicide unknown suicide suicide Nortriptyline suicide suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
19 kg/ml5 120 kg/ml, 4 hr 55 kg/ml
50 pg/ml,
~4 hr
203 nglml 1,311 ng/ml 625 ng/ml
1,562 3,369 533 1,200
ng/ml# nglml ng/ml ng/ml§#
103 pg/ml, 60 mgidl,
12 hr 12 hr
160 mg/dl,
3-5
hr
415
AMERICAN
TABLE 15.
JOURNAL
OF EMERGENCY
MEDICINE
W Volume
5 n September
Substances
(yr)
Route of Exposure
Int suicide
Ingestion
Int suicide
198*
51
199
46
200
61
201
28
202
18
203
74
204
50
205t
59
206t 207 208 209-f 210
18 36 37 60 40
211 212 213 214 215 216 217* 218 219 220 221 222 223 224
14 17 17 18 25 26 31 37 38 40 43 60 66 47
225’
31
226
20
227*
22
228”
16
229 230
24 34
231
36
Doxepin
Ingestion
232 233
73 50
Doxepin Doxepin acetaminophen/propoxyphene lorazepam
Ingestion Ingestion
33
197
30
Reason
Ingestion
Amitriptyline haloperidol benztropine Amitriptyline lithium colchicine Amitriptyline morphine ethanol Amitriptyline nortriptyline Amitriptyline perphenazine ethanol Amitriptyline propranolol Amitriptyline theophylline (long-acting) Amitriptyline/perphenazine aspirin/oxycodone Amitriptylineiperphenazine diazepam Amitriptylineiperphenazine triazolam Amoxapine Amoxapine Amoxapine Amoxapine Amoxapine perphenazine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine alprazolam Desipramine amphetamine Desipramine imipramine Desipramine indomethacin Desipramine thiothixene pindolol Doxepin Doxepin
196’
416
1987
Continued
Age Case
5, Number
Blood
Levels**
4.0 mEq/L Ingestion
Unknown
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Unknown Int suicide Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
Ingestion
Int unknown
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide Nordoxepin Int suicide Nordoxepin Int suicide Int suicide
28,000 ng/ml 19,000 ngiml
390 ng/ml#
suicide suicide suicide suicide suicide 4,200 ng/ml$ 1,334 ngiml. : .4 hr 2,518 ng/ml
1,145 ng/ml
1,936 ngiml 1,960 ngiml
3,885 ng/ml
9,900 600 3,413 243
ng/ml§ ng/ml§ ng/ml ng/ml
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
TABLE15. Continued
Case
Age (yr)
234
43
235
35
236*
27
237*
30
238
38
239’
30
240* 241 242* 243’ 244$ 245
31 34 36 45 80 14
246
25
247
20
248*
50
249
33
250
19
251
53
252T 253* 254 255 256 257
64 70 38 49 58 52
258
64
259 260-f 2617 262
22 24 39 54
263T 264
44 30
265T
67
266
66
Substances Doxepin desipramine Doxepin diphenhydramine Doxepin ethanol Doxepin ethanol Doxepin metoprolol ethanol Doxepin phenobarbital lmipramine lmipramine lmipramine lmipramine lmipramine lmipramine alprazolam ibuprofen lmipramine chloral hydrate loxapine lmipramine clorazepate lmipramine diazepam lmipramine ethanol lmipramine perphenazine benztropine lmipramine thioridazine mesoridazine Lithium Lithium Loxapine Loxapine Loxapine Maprotiline amitriptyline/perphenazine Nortriptyline desipramine doxepin Phenelzine Phenelzine Phenelzine Phenelzine alprazolam Tranylcypromine Tranylcypromine /-thyroxine flurazepam Trazodone digoxin Unk cyclic antidepressant
See also cases 778, 376 (amitriptyline); (maprotiline);
293 (nortriptyline);
314 (amitriptylinelperphenazine); 370 (trazodone).
Route of Exposure
Reason
Blood Levels**
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide Nordoxepin
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Act misuse Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide Desipramine
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Unknown Int suicide Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion
Unknown
8,500 ng/ml§ 4.1 kg/m& 1,300 ng/ml 1,400 ng/ml$ 500 ng/ml$ 300 mg/dl§
233 mg/dl 75.3 kg/ml
348 (desipramine);
suicide suicide suicide suicide
325 (lithium);
4,210 ng/ml§
1,078 ng/ml
5,210 ng/ml§ 4,040 ng/ml§
8.5 mEq/L 2.7 mEq/L
140 ng/ml§
5,800 ng/ml 2.0 ng/ml
152 (loxapine);
338
417
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
W Volume
5, Number
5 n September
1987
TABLE 15. Continued Route of Exposure
Age Case
(yr)
Antihistamines 267t
15
Substances
See also cases 147 (cimetidine); Antimicrobials 268
1 mo
12 mo 269*t Antineoplastics 24 270 Asthma therapies 6 mo 271 t* 2 272$ 15 273t 17 274t 28 275 44 276 62 277 65 278$ 70 279* 70 280$ 71 281$ 72 282$ 76 283$ 77 284$ 81 285+ 83 2864 73 287 288t$
72
2894
51
Ingestion
Diphenhydramine
Reason
Int suicide
-
Blood
Levels”
9.7 wg/ml§
148, 149, 235, 355, 394 (diphenhydramine).
Chloramphenicol error) Chloroquine Methotrexate
(lOO-fold
(3 grams)
Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline (long-acting) digoxin Theophylline ethchlorvynol Theophylline (long-acting) phenylpropanolamine
dosing
Parenteral
Act
misuse
Ingestion
Act
gen
Parenteral
Act
misuse
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Parenteral Ingestion Ingestion Ingestion Ingestion Ingestion
Act misuse Act misuse Int suicide Int suicide Int suicide Int suicide Int suicide Act misuse Unknown Act gen Int unknown Act misuse Unknown Act gen Act misuse Act misuse Int suicide
Ingestion
Int misuse
Ingestion
Act
Ingestion
Int suicide
Ingestion Ingestion
Unknown Int suicide
Ingestion
Int suicide
gen
40 41 190 117 108 160 50 60 53 40 120 65 72 36 64 40 82 5.6 40
r*g/ml kg/ml pg/ml pg/ml pg/ml, pg/ml, pg/ml, pgiml pg/ml pg/ml kg/ml kg/ml kg/ml kg/ml pg/ml *g/ml pg/ml ng/ml pg/ml
4 hr l-3 hr 2 hr
57 pgiml 4.7 pg/ml§
See a/so cases 202, 306 (theophylline). Cardiovascular 290’
drugs 55
291t 292
65 15
293’
27
294t
63
295 296t 297* 298 299t 300* 301
4 54 70 71 79 91 34
302
70
303t
78
304t
48
418
Acebutolol aspirin/oxycodone ethanol Amiodarone Atenolol diltiazem Captopril nortriptyline flurazepam Captopril ethanol Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin aspirinidihydrocodone Digoxin ibuprofen Digoxin methyldopa Digoxin metoprolol ethanol
14 kg/ml
1,400 ngiml 90 ngiml Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Act Int Act Act Int Int Int
Ingestion
Int suicide
9.8 ng/ml
Ingestion
Unknown
3.9 nglml
Ingestion
Int suicide
238 mg/dl§ gen suicide misuse unknown suicide unknown suicide
30.8 5 3.4 24.9 3.4 6
ng/ml, ngiml ng/ml ng/ml ng/ml ng/ml,
10 ngiml
2 hr
10 hr
LITOVITZ
ET AL H 1986 AAPCC ANNUAL
REPORT
TABLE15. Continued Route of Exposure
Age Case
Substances
(yr)
305
58
306$
65
307’
90
308 309
16 40
310
25
311’ 312t
29 21
313
68
314
32
Digoxin propranolol diazepam Digoxin theophylline (long-acting) Digoxin triazolam Diltiazem Disopyramide trifluoperazine Disopyramide metoprolol trazodone Encainide Flecainide propranolol Methyldopa aspirinipropoxyphene Metoprolol amitriptyline/perphenazine
Reason
Ingestion
Int suicide
Ingestion
Int misuse
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion Ingestion
Int suicide Int suicide Nortriptyline
315
42
316
64
317
22
318
52
319* 320 321 322* 323 324
85 86 16 55 70 48
325
40
326
51
amphetamine Metoprolol diflunisal meperidine Metoprolol amitriptyline prazosin Nifedipine propranolol clonidine Procainamide nifedipine Procainamide Procainamide (lo-fold Propafenone Propranolol Quinidine Verapamil atenolol ethanol Verapamil lithium Verapamil
See also cases 265, 287 (digoxin);
error)
238 (metoprolol);
Cold and cough preparations Triprolidine/pseudoephedrine 327 19 aspirin ethanol
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Parenteral Ingestion Ingestion Ingestion Ingestion
Act Act Int Int Int Int
Ingestion
Int suicide
Ingestion
Int suicide
misuse misuse suicide suicide suicide unknown
Blood
Levels”
12 ng/ml 35 pg/ml
5,500 nglml
10.9 cLg/rnl§ 1.1 hg/ml§
24.3 kg/m& 510 ng/ml§ 210 ng/ml§
0.3 pg/ml§ 110 ng/ml§#
59 pg/ml
210 mg/dl
228 (pindolol);
1.3 mEq/L 1.1 mg/dl§
201 (propranolol). Ingestion
Unknown 85 mgidl,
8 hr
See also case 170 (dextromethorphan). Electrolytes and 328T Gastrointestinal 329 330t 331t Hormones
minerals Ferrous sulfate 18 mo preparations Dicyclomine 67 Loperamide 40 salsalate Sodium bicarbonate 16 and hormone antagonists
Ingestion
Act
Ingestion Ingestion
Unknown Int suicide
Ingestion
Int misuse
gen
23,000 pg/dl
90 mgidl
See also cases 264, 362 (l-thyroxine). Miscellaneous
drugs
See also case 153 (methylene
blue). 419
TABLE15. Continued
Age Case
(yr)
Substances
Sedative/hypnotic and antipsychotic agents. Alprazolam 332* 69 333 >17 Butabarbital ethanol Chloral hydrate 334 50 335 Chloral hydrate 55 336 53 Chlorpromazine Chlorpromazine 337 63 338* 35 Clonazepam chloral hydrate maprotiline 339’ >17 Ethchlorvynol diazepam Ethchlorvynol 340 33 glutethimide codeine 341’ Ethinamate 54 342’ Glutethimide 18 acetaminophen/codeine Glutethimide 343* 32 acetaminophen/codeine Haloperidol 344t 31 Mesoridazine 345 75 Pentobarbital 346* 87 Pentobarbital 347 18 ethanol Perphenazine 348 35 desipramine chlorpromazine Phenobarbital 349 39 Promethazine 350 37 diflunisal Temazepam 351* 39 Thioridazine 352 59 >17 Thioridazine 353t* Thioridazine 354* 92 haloperidol Thiothixene 355 22 diphenhydramine Triazolam 356 58 Unknown barbiturate 357* 20 ethanol 24 Sleep-aid/diphenhydramine 358 opiate 359” Sleep-aid/diphenhydramine 31
Route of Exposure
Reason
Blood
Levels*’
Ingestion Ingestion
Int suicide Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
suicide suicide suicide suicide suicide
151 ng/ml
Ingestion
Int suicide
45 kg/ml
Ingestion
Int unknown
Ingestion Ingestion
Int suicide Int abuse
Ingestion
Int abuse
Parenteral Ingestion Ingestion Ingestion
Adv rxn Int suicide Int suicide Int suicide
Ingestion
Int suicide
lnaestion Ingestion
Int suicide Int suicide
Ingestion lnaestion Ingestion Ingestion
Int suicide Int suicide Adv rxn Adv rxn
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
30 kg/ml
9 cLg/ml§ 12 5.2 12 0.1
*g/m&q pgiml kgimla pgiml
30.8 kg/ml 27 kg/ml
91 kg/ml, 12-15 0.1 kg/m&$ 260 ~g/ml$ 11 pglL
See also cases 191, 192, 224, 245, 262 (alprazolam); 246 (chloral hydrate); 247 (clorazepate); 156, 160, 171, 204, 248, 305, 382, 386 (diazepam); 288 (ethchlorvynol); 194, 264, 293 (flurazepam); 195, 383 (glutethimide); 196 (haloperidol); 233 (lorazepam); 403 (meprobamate); 251 (mesoridazine); 200, 210, 250 (perphenazine); 239 (phenobarbital); 125 (temazepam); 251 (thioridazine); 228 (thiothixene); 164, 205, 307 (triazolam); 309 (trifluoperazine); 125 (sleep-aidldiphenhydramine); 2 (unspecified benzodiazepine). Stimulants 360* 361 t 362 363t 364 365 366’ 367’ 368 369 370’ 371* 372 373* 374 375’ 420
and street drugs 38 1 15 19 20 20 23 23 25 26 27 28 29 29 30 31
Amphetamines Caffeine (diet aid) Caffeine /-thyroxine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine
Ingestion Ingestion Ingestion
Int unknown Act gen Int suicide
Ingestion Inhalation Parenteral Ingestion Unknown Inhalation Parenteral Inhalation Unknown Ingestion Parenteral Unknown Parenteral
Int misuse Int abuse Int abuse Unknown Int abuse Int abuse Int unknown Int abuse Int abuse Int suicide Int Abuse Int abuse Int abuse
161 mg/dl,
24 pgiml§
0.015 *g/ml§#
>40 hr
TABLE15. Continued
Case
Age (yr)
376’ 377’ 378* 379’ 380’ 381*
35 36 49 50 58 28
382*
33
383
36
384
54
385’ 386T
27 25
387*
29
388
26
389’
27
390’
31
391*
46
392 393’ 394
26 47 29
395 396 397’ 398 399
26 38 27 30 21
400
29
401
33
402
25
403*
29
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine amphetamine Cocaine propoxyphene diazepam Cocaine glutethimide acetaminophenlcodeine Cocaine heroin Heroin Heroin cocaine diazepam Heroin cocaine ethanol Heroin ethanol cocaine Heroin ethanol marijuana Heroin ethanol Heroin methamphetamine codeine Methamphetamine Methamphetamine Methamphetamine diphenhydramine Methylphenidate Methylphenidate Phencyclidine Phencyclidine Phencyclidine cocaine Phencyclidine cocaine Phencyclidine cocaine Phencyclidine rodenticide (unknown Phenmetrazine meprobamate
See also cases 174, 225, 314 (amphetamines); (unspecified sympathomimetic). Topicals 404 405T 406
Route of Exposure
Substances
Unknown Inhalation Parenteral Inhalation Parenteral Parenteral
Unknown Int abuse Int abuse Int abuse Int abuse Int abuse
Ing + paren
Int abuse
Ing + paren
Norpropoxyphene Nordiazepam Int unknown
Blood
Levels**
16 kg/m& 6.2 kg/m@
2.4 9.8 20.8 0.3
pg/ml§# fJ,g/rnlO fJ,g/ml$ pg/ml$
13.4 mgidl 85 PglmlT Parenteral
Int abuse
Parenteral Ing + inhal + parenteral
Int abuse Int abuse
Paren
+ ing
Int abuse
Paren
+ ing
Int abuse
Paren + ing
Int abuse
Paren
Int abuse
160 ng/mI§# 71 mg/dl
+ ing
Parenteral
Int abuse
Unknown Unknown Ingestion
Int unknown Int unknown Int abuse
Parenteral Ingestion Unknown Ingestion Ingestion
Int unknown Unknown Int abuse Int suicide Int abuse
Ingestion
Int unknown
Ingestion
Int abuse
Ingestion
Unk reason
Parenteral
Int abuse
160 ng/ml§# 100 mg/dl§ 98 ng/ml§#
870 ng/ml§#
4.7 pg/ml§#
0.4 pg/ml$
type)
170 (cocaine);
153 (isobutyi
nitrite,
Rush); 289 (phenylpropanolamine);
4 mo 52
Merthiolate (?aspiration) Povidone iodine antiseptic
Ingestion Other
Unknown Act misuse
20
Camphorated
Ingestion
Unknown
oil
* Prehospital cardiac arrest T Abstract of case provided at conclusion of manuscript. $ Chronic exposure; all others are acute 0 Level obtained postmortem ll Acetaminophen level # Level includes metabolite and parent compound * Where multiple blood levels were available, the highest l
Reason
level obtained
is reported.
Time after exposure
165
5 pg/ml§
is unknown
unless indicated. 421
Demographic
Bites and envenomations Fish and coelenterate Insects Bee/wasp/hornet Scorpion Other Mammals Reptile-other/unknown Snakes-exotic Snakes indigenous to U.S. Rattlesnake Copperhead Coral Cottonmouth Nonpoisonous snake Unknown crotalid Unknown type of snake
1,794 1,215 1,221 257 4,487
Batteries Penlightlflashlightidry cells Automotive Button batteries Other/unknown TOTAL 64 2,960 273 1,169 875 60 21 19 6 5 2 84 1 101
1,076
11,597 2,966 3,302 2,598 195 199 303 44 19 37 611 6 1,002
1,283 211 893 155 2,542
556 608 345 449 1,958
1,239 4,546 187 351 13,786
1,561 5,798 249 909 31,345
1,822 998 706 999 4,525
4,088 3,005 370
17,608 4,245 975
15,060
6,642
11,747
18,809
16
Number of Exposures
47 11 5 8 323 2 351
2,602 510 635 848 79 39
238
328 138 166 47 679
148 78 57 105 388
2,367
82 309 18 102 2,801
1,910 278 102
1,490
6-17
Age (years)
225 24 9 26 196 3 526
5,861 2,136 1,433 1,006 51 136
750
171 837 149 51 1,208
1,080 295 293 425 2,093
1,204
226 880 40 445 14,099
11,116 912 480
3,338
>17
301 43 18 37 601 6 995
11,380 2,958 3,247 2,568 195 194
1,058
1,770 1,203 1,202 253 4,428
1,739 992 655 979 4,365
18,542
1,489 5,415 231 601 19,475
6,921 3,920 898
1 0 0 0 1 0 0
2 1 0 8 0 0
3
21 9 17 1 48
72 5 47 16 140
192
48 362 18 278 11,154
10,104 285 61
118
Int
Reason
and Products;
11,581
ACC
Profile of Exposure Cases by Generic Category of Substances
Arts/crafts/office supplies Auto/aircraft/boat products Glycols Hydrocarbons Methanol Other/unknown TOTAL
Adhesives/glues Alcohols Ethanolt lsopropanolt Methanol Rubbing alcohol Ethanol lsopropanol Unknown type Other/unknown TOTAL
TABLE 16.
11
0 0 0 0 4 0 4
3 40 12 0 1
174
13
0 1 0 1 2
1 0 1 1 3
8
3 0 0 12 203
177 7 4
Rxn
Adv
273 41 15 34 129 5 496
2,099 419 757 1,175 39 163
369
194 415 801 50 1,460
672 184 375 316 1,547
875
228 1,102 64 438 14,364
11,106 926 500
2,120
Treated in HCF
Nonpharmaceuticals’
29 2 2 3 153 2 223
759 164 410 474 40 16
51
85 19 11 18 335 1 482
7,953 2,230 1,862 1,237 83 94
662
597 842 110 91 1,440
564 353 166 447 1,530
742 460 377 329 1,908
819 225 798 114 1,956
1,334
249 1,041 51 271 8,813
5,933 959 309
3,577
Minor
10,341
974 3,092 133 299 11,029
3,829 2,267 435
4,757
NOW
92 14 1 8 4 3 50
529 189 153 159 2 44
159
28 99 14 4 145
57 18 25 41 141
62
11 99 4 63 2,002
1,709 89 27
238
Moderate
Outcome
1
37 0 0 1 0 0
24 16 5 2 0 8
2
4 4 0 9
1
21 2 9 5 37
6
2 15 1 8 339
288 14 11
9
Major
0 0 0 0 0 0 0
0 0 0 0 0 0
0
0 0 0 0 0
4 0 5 0 9
4
0 1 0 0 26
19 0 6
1
Death
i?l w
Cleaning substances Ammonia cleaners Bleaches (household) Hypochlorite-containing Other/unknown Cleansers Anionic/nonionic Other/unknown
Building/construction supplies Chemicals Acetone (excluding nail polish removers) Acids Hydrofluoric acid Other/unknown acid Alkali Ammonia Berates/boric acid (excluding topicals and insecticides) Chlorates (excluding matches and fireworks) Cyanide (excluding rodenticides) Dioxin Formaldehyde/formalin Glycols (excluding automotive products) Ketones Methylene chloride (excluding paint strippers) Nitrates and nitrites (excluding medications and abused substances) Phenol/creosote (excluding disinfectants) Strychnine (excluding rodenticides) Toluene diisocyanate Other TOTAL
Spiders Black widow Brown recluse Other/unknown TOTAL
599
164 12 23 2 154
1,538 35 32 2 284 1,198 426
2,335 86
512 18 1.150
2,228 1,078
10 23 4,709 12,933
66 392 9,889 33.945
1,290 59 235 53
9,405 741 5,107 940
4,458
18,000 1,128
6,026 1,199
330
2,070
5,919 1,181
17,495 1,110
6,962 316 832 193
4,310
29 382 9,604 32,856
1,691
686
1,365
1,968
46 328 4,043 16,973
1,034
182
446
1,716 7 20 885 3,146
276
164
265
721
836
2,150 1,063
837 561
153
424 18 1,089
84
2,226
833 4,863 3,130 1,720
1,499
4,269
1,532 534 10,625 36,292
437 13 665
1,404
158 61
732 3,519 1,601 1,002
25 547 288 178
58 756 1,233 548
843 4,982 3,193 1,782
33
411
123
992
1,550
1.530
1,085 403 6,303 20,173
286
199 62 1,787 7,746
2,404
219 60 2,447 8.166
4,316
1,537 538 10,729 36.759
89 14
391 11
123
31 4 187 772
15
33
25
53 10
47 0 43
4 1
23 4
6
1 3 39 107
7
2
4
6 2
23 0 7
1
0
457 152
3,873 205
1,068
50 226 2,875 12,032
596
239
559
592 458
300 8 483
23
475
645 2,372 1,236 594
0 4 3 1
3
301
965
487 381 2,439 9,321
1
12
0 3 79 333
93
5 91 47 48
40
12
2 0 3 21
3,188 824
5,969 485
1,382
15 41 3,340 10.032
351
276
295
928 296
124 2 282
15
1,280
85 901 832 386
583
1,705
293 33 671 3,325
1,137 246
7,346 331
1,844
15 210 2,929 12,885
839
225
745
615 471
480
132
33
265
391 2,611 1,292 965
446
1,154
750 194 6,492 22.508
49 15
480 18
177
5 50 350 1,937
145
20
93
54 60
25 3 53
3
19
208 456 285 84
24
219
209 135 713 2.464
0 0 22
0 26 170
1
2
1
12
0 0
0 0
1
1
12
0 3
2
4
4
4 0
10 0 0
11 2 5 19 1
0
0
4 1
2 1 1 0
0
4 18 24 34 6
0
0 1 0 1
8
12 12 7 127
B 2
z
$ l-
E
%
%
Y
?
1
Disinfectants (household) Hypochlorite-containing Phenol Pine oil Otherlunknown Drain Cleaners Acid Alkali Other/unknown Electric dishwasher detergent Alkali Other/unknown Fabric softeners Cationic Other/unknown Glass cleaners (household) Hand dishwashing detergents Industrial cleaners Acids Alkali Other/unknown Laundry detergents Anioniclnonionic Alkali Other/unknown Miscellaneous Acid Alkali Anionic/nonionic Cationic MethanoVglycols lsopropanol Ethanol Other/unknown Oven cleaners Alkali Other/unknown Rust removers Hydrofluoric acid
TABLE16. Continued
288 377 17
3,418 958 945 64 3,894 5,077 17 140 247 4,786 2,398 723 145 2,619 4,273 1,465 1,262 876 70 1,281 887 47 86
3,801 1,095 1,022 74 4,720 6,598 193 683 807 5,808 2,714 890 423 5,873 5,905 2,418 1,621 1,141 83 1,892 2,488 161 555
29
219 13
40 449 295 190 100 63 5 123
211 70 35
48 70
22 0
72 31
13 24 4
28 78 8
180 255 40
348 121 221 43
6-17
1,390 1,086 4,123 367
<6
Age (years)
3,356 1,705 5,102 598
Exposures
0t
Number
420
1,290 98
226 2,652 1,267 717 246 194 7 444
763 234 126
153 450 470
1,092
504
52 10
263 103
137 144 23
1,574 472 706 178
>17
540
2,456 154
414 5,678 5,775 2,343 1,591 1,076 80 1,847
5,725 2,685 873
190 674 788
6,527
4,631
1,011 73
3,783 1,094
178 243 37
3,295 1,592 4,926 574
ACC
13
24 6
9 172 96 59 25 60 3 37
42 19 8
3 8 17
39
78
3 0
8 0
0 11 2
49 100 147 20
Int
Reason
-
0 0 1
6
1
3 0
2 0
0 0 0
6 0 5 1
0 6 7 7 1 1 0 2
20 4 5
Rxn
Adv
406
945 69
171 2,151 744 566 179 202 14 424
493 394 97
137 363 366
290
320
45 5
250 73
86 113 16
798 364 1,152 147
Treated in HCF
86
474 27
835
125 1,798 2,565 1,047 776 577 41
2,708 1,332 418
136 218
27
2,783
2,543
617 47
2,434 602
21 54 10
869 754 2,792 261
NOlE
287
1,359 72
179 2,414 1,518 749 496 220 21 470
1,736 815 263
114 365 365
1,945
960
117 10
647 192
102 121 16
1,526 492 1,194 194
Minor
93
216 17
42 397 63 66 16 15 3 44
55 80 11
29 82 55
39
22
1 1
21 5
22 28 2
144 28 56 16
Moderate
Outcome
4
11 1
1 46 2 6 1 4 0 1
3 1 0
4 8 2
1
2
0 0
2 0
1 2 0
8 1 6 1
Major
0
0 0
1 0 0 2 0 0 0 0
0 0 0
0 0 1
0
0
0 0
0 0
0 2 0
0 0 0 0
Death
133 13 865 211 827 193 88 578 28,803
19 17 126 55 109 54 27 97 6,101
259 292 1,110 1,309 1,015 751 559 1,386 68,070
2,133 1,595
2,005 1,012 678 2,090 104,546
21,033 875 2,245
732 311 93 616 83 6,574
184 17 194 395 159 199 898 661
509 59 63 271 60 3,576
149 8 92 249 126 278 452 243
19,962 520 2,110 5,636 1,007 69,525
3,051 1,311 2,244 6,606 2,318 1,158 4,460 132
21,268 903 2,274
6,576
1,160 80,214
3,402 1,339 2,552 7,293
2,618 1,655 5,883 1,081
Deodorizers (not for personal use) Air Fresheners Diaper paildeodorizers Other TOTAL
Dyes Essentialoils Fertilizers Fire extinguishers
2,590 1,567 5,827 1,047
3,368 1,337 2,532 7,237
1,138 78,745
6,435
1,048
172
45
1,055
3,019 6,980 1,768 5,497 288 148 748 11,659 1,868 2,897 5,242 5,857
822
2,873 6,170 1,050 4,934 170 111 674 9,609 1,770 2,075 4,896 5,136
3,039 7,094 1,826 5,581 312 152 756 11,917 1,876 3,121 5,289 6,015
76 652 614 388 104 28 47 1,478 44 471 165 500
1,965 992 669 2,041 102,154
2,058 1,581
401 324
1,089 166
76 224 135 228 29 10 24 710 54 549 196 334
416 326
686 103
77 12
324 44
1,110 169
Cosmetics/personal care products Bath oil/bubblebath Creams, lotions,make-up Dental care products Deodorants Depilatories Douches Eye products Hair care products Lipsticksand lipbalms Mouthwash Nail polish Nail polish removers Nail products, miscellaneous Perfumelcolognel aftershave Peroxide Powders Soaps(bar, hand, complexion) Suntan/sunscreen products TOTAL
Other acid Other/unknown Spot remover/dry cleaning agents Starch Toiletbowl cleaners Acid Other/unknown Wall/floor/tile cleaners Alkali Anioniclnonionic Glycols Other/unknown TOTAL 6 1 1 4 135
28 16 5 40 1,880
15 11 7 0
7 71 34 29
9 28
5 0 1 6
12 245
67
16 13 3
2
18
5 952
55
165 11 15
191 32 141
7 21 16 6 6 1 3 57 3 8 3 1
607 181
4 0
64 9
4 65 29 57 16 2 3 159
98 7
1 1
12
13,037 338 1,159
1,167 119 181
137 310 320 341
212 46 329 587
80 5,785
1,532 572 3,353 294
2,041 935 1,545 4,521
537 43,366
3,102
504
164
432
1,649 4,056 897 2,910 98 85 417 5,557 1,031 1,701 2,734 3,554
564 503 361 950 43,491
823 937
184 194
295 55
98 321 173 261 82 28 31 1,121 52 388 316 771
569 125 62 386 19,581
365 46
0 0
16 3
126 752 482 531
433 59 333 825
310 13,900
1,414
2,741 286 560
269
446 582 399 791 129 18 60 2,929 117 540 1,195 1,117
941 239 151 662 33,726
840 241
140 30
559 70
0 0 2 1
27
3 2 5
2 13 28 13 21 24
0
0 26
13
10 453
2
0 0
13 14 36
6
2
0 0 0 0 0 0 0 6 0 3 2 5
4 0 0 1 182
24 0
1 0
3 2
65
20
3 12 13 28 14 1 0 140 2 35 17 30
85 15 5 47 2,746
113 14
12 1
76 10
0
0 0 0
0 0 0
0
0 2
0
0 0
1
0
0 0 0 0 0 0 0 0 0 0 0 1
0 0 0 0 14
6 0
1 0
0 0
2
B
I?
$ D
%
s 8
h
7 P
J
2
r
iz
Herbicides 2,4-D or 2,4,5-T Diquat/paraquat
TOTAL
Fungicides (non-medicinal) Heavy metals Arsenic Copper Lead Mercury Metal fume fever Selenium Thallium Other/unknown
TOTAL
Fumes/gases/vapors Carbon monoxide Chloramine Chlorine gas (mixing household products) Chlorine gas (other) Hydrogen sulfide Methane Polymer fume fever Propane/simple asphyxiants Other/unknown
TOTAL
Food products/food poisoning Foreign bodies/toys/ miscellaneous Bubble blowing solutions Christmas ornaments Coins Dessicants Feces/urine Glass Soil Thermometer Toys Other/unknown foreign body
TABLE16. Continued
541 28
109 142 647 368 66 16 6 390 1,744
399 583 1,181 1,121 836 45 13 1,000 5,178 1,450 224
522
58 298 1,557
547 2,469 13,849 1,203
34 429 40 144 3
673 3,174 439 941 20
8,478 32,431
11,868 41,521 514 37
1,746 1,027 2,168 9,341 1,030 430 1,327 4,392 2,492
1,849 1,089 2,585 10,290 1,161 881 1,462 7,433 2,903
4,287 1,299
9,207
<6
38,891
Number of Exposures
145 19
27 148 162 225 24 3 0 89 678
142
130 217 1,702
34 589 25 102 4
552 49
1,233 4,693
76 38 332 619 44 65 24 1,933 329
4,934
6-17
Age (years)
742 168
248 255 350 440 724 21 6 489 2,533
510
340 1,827 10,110
579 2,096 346 649 13
3,093 1,167
2,024 3,978
19 21 72 250 82 366 102 976 64
23,333
>17
1,428 208
360 564 1,153 1,081 828 34 11 975 5,006
1,188
478 2,423 13,399
660 3,151 434 894 20
4,068 1,271
11,711 41,183
1,841 1,089 2,572 10,232 1,140 869 1,459 7,385 2,885
32,500
ACC
14 11
25 15 21 26 3 6 2 12 110
10
64 29 347
41 0
1
12 15
157 28
69 159
0 0 10 25 14 5 0 29 7
170
Int
Reason
2 2
2 3 1 6 1 4 0 4 21
2
0 8 12
0 2 0 0 0
2 0
22 37
0 0 0 0 2 7 0 2 4
5,767
Rxn
Adv
410 118
208 207 391 284 254 13 7 357 1,721
259
219 1,041 6,158
256 1,231 172 436 5
2,404 394
1,970 4,085
43 54 749 434 65 142 104 384 140
4,366
Treated in HCF
426 71
87 234 120 155 471 10 2 263 1,342
112 176 506 573 70 17 5 337 1,796 490 54
337
477
267 1,127 7,601
470 1,899 212 464 8
44 383 67 163 7 109 462 1,765
2,337 817
1,602 3,317
5,575 21,233 462 88
3 1 9 2 2 16 19 4 6
505 76 289 154 73 129 125 197 167
839 594 1,204 5,614 589 388 766 3,948 1,736
55 6
21 22 31 13 106 2 1 47 243
33
43 173 1,237
80 311 37 57 3
429 104
311 373
1,011
Moderate
12,554
Minor
9,836
NOfW
Outcome
5 1
7 0 4 6 2 0 1 6 26
1
1 12 91
3 14 2 5 0
53 1
25 27
0 0 1 0 0 0 1 0 0
17
Major
1 3
0 1 1 0 0 0 0 0 2
1
0 1 23
0 0 2 1 0
19 0
0 0
0 0 0 0 0 0 0 0 0
0
Death
$
1,811 443
Moth repellents Napthalene Paradichlorobenzene 1,598 383
2,030 519 2,549
2,103 635 2,738
1,356 723 1,850 3,759 19,629
2,809 1,737 2,439 6,286 36,541 868
304 155 357 445 2,908
283 68
612 146
2,403
42 14
190
527
68 13
32 71 103
733
46
189
1,086
2,420
5 92 209 357 10 683
134 43
34 37 71
721
1,073 815 211 1,873 13,087
275 63
267
1,069
30 328 1,205 1,228 30 4,620
2,379 448 347 290 74 1,035 1,236 413 3,310 16,114
222 133 118 116 28 272 256 144 763 5,013
113 1,972 2,932 2,059 211 3,027
328 2,160 1,597 1,958 1,090 2,639 945 840 7,390 24,012
3,097 2,771 2,081 2,386 1,200 3,998 2,510 1,421 11,676 46,005
61 672 5,849
1,271 2,181
8 210 2,745
227 391
149 2,410 4,423 3,743 257 8,583
29 509 4,527
629 1,198
100 1,494 13,271
2,209 3,883
Lacrimators Matches/fireworks/ explosives Matches Other/unknown TOTAL
Insecticides/pesticides (excluding rodenticides) Arsenic-pesticides only Berates/boric acid Carbamates Chlorinated hydrocarbon Metaldehyde Organophosphate alone Organophosphate and carbamate Organophosphate and chlorinated hydrocarbon Organophosphate and other pesticide Piperonyl butoxide alone Piperonyl butoxide and pyrethrins Pyrethrins alone Insect repellants Other/unknown TOTAL
Hydrocarbons Benzene Diesel fuel Gasoline Halogenated hydrocarbons Kerosene Lighter fluid/naphtha Lubricating/motor oils Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other/unknown TOTAL
TOTAL
Other/unknown
1,791 441
2,086 626 2,712
2,353
2,725 1,681 2,401 6,128 35,489
596 144
497
2,300
140 2,336 4,331 3,606 251 8,373
2,979 2,733 1,999 2,369 1,181 2,910 2,344 1,325 11,387 44,590
92 1,453 12,818
2,171 3,807
3 1
8 6 14
27
0 0
0 1 1
6
36 22 7 14 168
1 1
12 1 38 42 13 121 701
0
10
91
25
1 1 8 33 0 34
3 1 0 0 0 1 2 2 12 22
0 0 1
16 20
8 60 63 86 6 135
90 25 78 14 17 68 147 83 220 1,184
5 40 397
16 41
100 130 65 19 25 90 118 27 323 1,222
1,271 935 589 374 159 1,301 1,104 499 3,335 16,574
866 1,211 1,052 1,572 810 1,881 751 540 5,615 19,177
335 33
1,281 282
1,270 352 1,622
265
492
74 69 143
969 559 1,119 3,366 16,356
651 434 230 1,381 8,633
162 44
17 0
2 9 11
84
1,690
65 83 148
109 62 21 120 926
891 581 807 1,177 8,877
3 0
20 2 178 45
237 45 165 35
1
9
142 218 125
4
6 4 0 15 128
13
59
647
971 518
2 3 12 7 0 62
6 8 8 0 9 8 17 2 27 99
1 0 13
4 9
18 239 761 829 14 2,548
4 18 105 86 2 309
9 32 284
95 156
36 623 6,348
705 1,202
32 481 4,366
667 1,211
98 1,393 2,387 1,751 161 3,082 57 465 896 976 50 2,650
980 995 580 297 233 947 900 408 2,798 11,000
46 400 2,416
705 1,233
0 0
0 0 0
0
0 0 0 2 10
0 0
0
0
1 0 2 1 0 4
4 0 1 0 0 1 1 1 2 10
0 0 0
0 4
i?l
cc
424 1,188 6,882 4,437
1,719 7,385 8,854
6,972 39 682 7,693
7,723 103 879 8,705 672
1,458 15
164 22,438 14,233 1,874 263 201 8,670 72,514
236 24,491 15,327 2,167 316 289 10,217 84,409 1,795 126
237 1,627 15 2,373 349 6,782 13,075 213
457 2,097 18 2,924 372 10,082 15,121 295
-
1,425
167 205
151
178 9 38 225
73 16
36 926 478 143 25 37 892 5,171
113 252 1 328 14 990 894 42
482 965 57
6,885 8,588 602
8,330 13,610 842
6-17
87 166
<6
Age (years)
1,480 3,461
1,672 3,926
Number of Exposures
2,734
354 268
84
481 49 136 666
252 90
33 896 520 130 25 48 555 5,921
102 200 2 193 8 2,148 1,024 37
879 3,827 171
92 269
>17
8,496
1,701 7,269
852
7,490 78 825 8,393
1,761 123
221 24,293 15,232 2,143 313 273 10,015 83,204
326 2,051 18 2,883 369 9,882 14,920 265
7,868 13,353 835
1,660 3,892
ACC
9 13
165
89
12
18
199 18 48 265
28 2
7 70 56 9 2 11 94 602
122 35 0 14 1 44 109 28
365 181 4
Int
Reason
51 21 0
1 1
79
2 11
0
3 0 0 3
2 0
7 50 4 12 0 0 48 290
1 4 0 16 0 106 41 1
Rxn
Adv
1,938
237 1,223
185
1,911 54 338 2,303
187 47
62 850 567 272 66 123 886 5,363
192 352 1 202 26 911 999 54
1,744 2,142 112
266 634
Treated in HCF
3,466
809 4,073
357
4,934 44 532 5,510
1,007 23
109 12,766 9,653 1,537 203 162 6,187 47,725
209 1,356 12 1,731 283 4,134 9,205 178
5,910 6,008 441
1,143 2,706
NOW
2,316
446 1,585
114
222 13 63 298
397 58
50 1,006 2,155 195 35 68 971 9,142
108 163 1 137 17 2,679 1,530 27
948 3,130 125
112 318
Minor
199
23 71
23
29 3 10 42
16 5
3 60 78 24 5 21 91 786
52 24 0 12 0 301 111 4
215 289 13
1 18
Moderate
Outcome
l
Abbreviations: act, accidental; adv rxn, adverse reaction; int, intentional. Medical outcome data were also collected in categories labeled “unknown, nontoxic,” “unknown, potentially toxic,” and “unrelated effect.” Thus, the numbers not represent the total poison exposure experience. Patients with totally unknown age, reason or medical outcome were omitted from the respective tabulations. t Excluding rubbing alcohol.
Sporting equipment Swimming pool/aquarium products Tobacco products Unknown nondrug substances
Polishes and waxes Radio-isotopes Rodenticides Anticoagulants Strychnine Other/unknown TOTAL
Mushrooms Paints and stripping agents Photographic products Plants Anticholinergic Cardiac glycosides Colchicine Cyanogenic glycosides Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine (no tobacco products) Nontoxic plant Oxalate Solanine Stimulants Toxalbumins Other/unknown TOTAL
Other/unknown TOTAL
TABLE16. Continued
0 _
0 0
0
1 2 1 4
0 1
0 0 0 0 0 0 1 2
0 0 0 0 0 1 0 0
0 2 0
0 0
Death
listed here do
24
1 10
7
3 5
1
1
1 0
0 4 2 9 0 0 9 48
4 4 0 4 0 6 5 1
22 20 0
0 2
Map
Q
Anesthetics Anticholinergic Anticoagulants
TOTAL
Analgesics Acetaminophen only Adult formulation Pediatric formulation Unknown type Acetaminophen combination with: Aspirin Codeine Oxycodone Propoxyphene Other narcotic/analog Other drug Aspirin only Adult formulation Pediatric formulation Unknown type Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotic/analog Other drug Narcotics Codeine Meperidine Methadone Morphine Pentazocine Propoxyphene Other/unknown Nonaspirin salicylates Nonsteroidal antiinflammatory Ibuprofen Other/unknown Other/unknown
TABLE 17. Demographic
1,983 2,115 1,785
186 144 13 84 835 310 51 22 28 31 125 121 292
5,899 1,757 483 55,629
6,317 2,298 5,659
1,049 697 94 400 3,173 866 417 165 130 317 785 522 520
11,205 4,867 730 102,759 2,466 1,314 271
284 1,070 189 409 118 706
1,277 5,147 1,225 2,246 885 2,523
3,289 3,667 440
4,268 30,615 1,706
<6
13,894 31,973 3,378
Number of Exposures
239 511 30
1,628 763 64 15,527
102 48 16 8 32 98 52 57
149 64 10 46 860
1,815 144 1,564
373 821 160 281 114 511
3,984 1,112 651
6-17
Age (years)
539 1,767 126
3,512 2,239 161 29,969
428 306 125 91 236 537 332 168
692 468 68 259 1,415
2,356 31 2,162
591 3,118 842 1,513 613 1,250
5,316 173 967
s17
3,086 1,976 338
7,221 2,712 562 68,304
459 145 55 67 95 270 237 371
397 293 32 156 1,410
3,027 2,228 2,699
525 2,085 476 781 334 1,134
132 1,501 86
3,665 1,788 143 31,345
333 229 94 48 180 477 238 123
587 360 53 203 1,599
3,096 54 2,788
674 2,709 646 1,353 455 1,284
6,796 211 1,159
Int
Reason
Pharmaceuticals
6,749 31,644 2,140
ACC
Profile of Exposure Cases by Generic Category of Substance,
59 30 11 11 38 22 37 17
41 31 3 32 109
78 8 82
51 250 77 64 65 59
138 50 32
47 128 13
186 276 19 1,876
RXll
Adv
587 2,226 188
4,432 2,339 280 42,619
452 307 115 91 201 577 336 197
722 441 70 256 1,896
3,681 399 3,354
742 3,352 786 1,646 575 1,555
8,391 3,892 1,534
Treated in HCF
1,864 1,311 178
5,641 1,954 372 49,807
251 66 24 30 39 171 102 243
216 163 24 100 1,065
2,349 1,576 2,040
464 1,322 266 558 179 923
6,257 21,955 1,457
NOW
572 1,060 53
1,800 1,086 137 17,001
257 136 32 23 129 234 151 105
361 215 32 121 1,058
1,479 165 1,390
361 1,705 373 737 274 735
2,308 1,098 499
Minor
37 301 15
233 186 33 3,336
42 33 19 11 35 72 49 26
78 41 7 25 173
355 19 388
51 266 77 170 53 130
570 48 146
Moderate
Outcome
13 60 5
30 22 6 586
19 4 9 6 8 19 24 3
17 11 4 3 22
48 2 46
4 43 16 41 9 22
100 13 35
Major
0 1 0
1 7 0 82
1 0 3 2 1 6 4 1
1 2 1 1 1
9 0 12
0 4 2 7 1 0
13 0 2
Death
e 0
Antimicrobials Antibiotics Antifungals Antihelmintics Diethylcarbamazine Otheriunknown Antiparasitics Antimalarials Metronidazole Other/unknown Antituberculars lsoniazid Other/unknown
TOTAL
Antihistamines H, blockers Diphenhydramine Other/unknown
TOTAL
Antidepressants Cyclic antidepressants Amitriptyline Amoxapine Desipramine Doxepin lmipramine Maprotiline Nortriptyline Protriptyline Formulated with a: Benzodiazepine Phenothiazine Other/unknown Lithium MAO inhibitor Trazodone Other/unknown
TOTAL
Anticonvulsants Carbamazepine Phenytoin Valproic acid Other/unknown
TABLE17. Continued
16,277 2,297 1,645 557 42 150 440 38 17
24,260 2,921 2,631 704 114 540 673 189 42
515 3,512 1,538 5,565
61 175 77 157 64 136 7 1,999
433 870 688 1,509 528 1,129 46 14,428
1,285 7,175 3,263 11,723
456 47 141 155 430 46 39 8
540 728 203 45 1,516
<6
3,400 359 717 1,918 1,954 356 458 63
1,516 2,595 402 103 4,616
Exposures
Number of
45 8
18 63 63
97 61
2,946 134
181 1,016 657 1,854
39 96 51 138 14 107 5 1,464
342 20 80 163 319 28 57 5
274 331 61 21 687
6-17
Age (years)
98 17
49 309 160
862 79
4,728 450
568 2,518 1,009 4,095
324 574 538 1,147 432 857 30 10,570
2,503 287 475 1,555 1,162 280 358 48
681 1,467 130 36 2,314
>17
74 23
78 303 544
2,586 688
19,157 2,816
783 4,509 2,227 7,519
113 287 220 551 180 374 12 4,653
1,048 97 245 514 780 106 112 14
940 1,460 315 78 2,793
ACC
98 6
22 148 67
23 9
3,376 66
434 2,412 916 3,762
294 547 417 830 255 680 30 8,940
2,203 244 430 1,315 1,087 237 326 45
506 1,011 76 24 1,617
Int
Reason
12 13
12 83 54
1 6
1,556 30
52 146 81 279
6 13 28 81 84 51 2 460
50 11 24 39 52 6 11 2
53 72 8 0 133
Fixn
Adv
158 20
62 193 126
124 81
4,946 175
627 3,421 1,364 5,412
371 745 555 1,215 409 867 35 11,922
2,896 310 596 1,654 1,537 299 384 49
1,782 175 48 2,965
960
in HCF
Treated
54 17
37 174 354
1,592 416
11,786 1,516
611 2,800 1,500 4,911
36 11
32 147 101
127 72
3,177 383
230 2,029 787 3,046
144 285 203 485 154 436 8 4,471
72 188 105 353 120 253 8 2,790
938 115 222 607 614 105 133 22
461 754 82 26 1,323
Minor
545 51 168 254 500 69 88 16
481 801 207 42 1,531
NOW3
36 5
6 21 8
3 3
302 14
42 363 112 517
70 138 120 177 101 96 6 2,331
693 75 90 353 276 57 76 3
190 297 19 6 512
Moderate
Outcome
26 2
3 1 1
1 0
22 4
9 43 18 70
32 66 40 61 16 15 3 967
349 29 41 161 97 26 31 0
51 41 3 1 96
Major
1 6 0 7
0 5 5 4 6 1 0 100
25 5 21 11 13 1 3 0
4 1 0 0 5
Death
c
Eye/ear/nose/throat preparations Gastrointestinal preparations
Diagnostic agents Diuretics Electrolytes/minerals Calcium salts Fluoride (excluding vitamins) Iron (excluding vitamins) Magnesium salts Potassium salts Sodium salts Zinc Other/unknown TOTAL
Cold and cough preparations Acetaminophen + decongestant/ antihistamine Aspirin + acetaminophen + decongestanv antihistamine Aspirin + decongestant/ antihistamine ExpectoranWantitussives Other formulations for cough/colds TOTAL
Cardiovascular drugs Antiarrhythmics Anti-hypertensives Beta-blockers Calcium antagonists Cardiac glycosides Vasodilators Other/unknown TOTAL
Antineoplastics Asthma therapies Aminophyllinel theophylline Beta-2 agonists Other/unknown TOTAL
Antivirals Other/unknown TOTAL
146
34,926 42,753 119 2,112 3,195 3,189 1,911 62 360 906 390 40 10,053
44,448 221 3,698 3,587 3,511 2,574 133 617 1,200 739 72 12,433 8,118
5,761
18 408
791 3,257
1,340 4,117
55,703
42
91
447
226 246 10 72 151 41 6 898
4,253 5,629
236 381
15
3,737
744
52 163 383 78 94 203 5 978
5,707
224 1,271 1,555 579 720 2,124 41 6,514
1,157 359 41 1,557
1,622 1,449 99 3,170
4,497 2,191 193 6,881
748 2,249 3,535 1,272 1,357 3,129 84 12,374
8
37 11 3,483
89
137 57 21,857
220
282 94 32,450
1,789
81 383 55 172 135 288 26 1,365
225
74 1,141
4,960 6,914
299 461
30
1,164
456 782 1,552 596 529 779 34 4,728
1,624 361 50 2,035
113
102 21 8,875
7,904
3,469 2,171 119 517 1,169 694 63 11,695
3,493
201 2,766
40,005 49,458
1,021 3,830
52
4,550
583 1,713 2,456 1,008 1,074 2,669 65 9,568
2,989 1,809 166 4,964
196
215 79 26,563
112
22 367 9 82 27 20 3 582
52
10 801
3,587 5,143
284 227
37
1,008
127 453 962 226 240 396 14 2,418
71
8 18 3 15 1 19 4 89
21
9 79
623 832
25 66
2
116
35 60 72 29 21 41 3 261
153 83 7 243
9
1,278 287 20 1,585
1,786
13
18
45 13 3,873
1,203
325 1,270 39 194 190 178 15 2,361
150
76 1,529
10,782 13,793
442 740
54
1,775
351 1,445 1,922 606 816 1,048 36 6,224
2,693 813 40 3,546
118
84 27 5,996
4,412
283 28 6,522
1,911 1,246 48 351
1,996
103 1,823
23,174 28,808
652 2,160
37
2,785
344 953 1,824 655 668 1,907 43 6,394
1,569 1,067 103 2,739
109
120 48 16,114
1,557
654 601 32 76 234 202 11 1,964
154
40 747
10,588 12,966
271 781
30
1,296
131 576 601 226 198 403 13 2,148
1,282 600 28 1,910
49
45 16 4,147
86
19 113 3 13 17 41 2 213
5
14 113
684 900
34 69
3
110
31 225 182 53 98 76 1 666
495 66 5 566
4
7 6 411
10
1 16 3 0 2 1 0 25
2
2 22
56 76
2 7
0
11
15 61 44 25 60 13 2 220
87
0
0 1 0 0 0 0 0 1
0
0 0
0 1
1 0
0
0
15 0 0 50
10 4 14 7
21 0 0 21
1
0
84 2 1
0 0 2
1 0 61
3
2,876 280 7,349 691 2,231 2,022 15,449
Hormones and hormone antagonists Corticosteroids Insulin Oral contraceptives Oral hypoglycemics Thyroid preparations Other/unknown TOTAL
Muscle relaxants Sedative/hypnotics/ antipsychotics Barbiturates Long acting Short/intermediateacting Unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone OTC sleep aids Phenothiazines Other/unknown TOTAL
Miscellaneous drugs Allopurinol L-Dopa and related drugs Disulfiram Ergot alkaloids Homeopathic/herbal preparations Other TOTAL
1,448 7,308 696 15,812
2,438 9,029 1,061 19,522
505
834 210 3 3,264 76 21 8 48 12 191 1,649 29 6,345
3,098
1,690 16 19,835 304 307 209 460 203 3,571 6,961 272 36,926
523 2,695 3,739
682 3,828 5,884 2,543
142 70 43 364
206 130 535 487
2,080 32 6,679 375 1,717 1,353 12,236
6,360
<6
6,994
Number of Exposures
Antacids AntidiarrheaW antispasmodics Laxatives Other/unknown TOTAL
TABLE 17. Continued
191 1 1,593 21 15 5 46 29 538 733 46 3,648
430
355
28 306 413
10 4 20 98
191 11 415 57 149 185 1,008
934
1,610
1,222 10 14,390 190 267 191 351 144 2,700 4,415 191 25,821
496 5 6,163 123 52 31 147 28 691 2,979 67 12,390
1,608
606 3,522 4,971
123 793 1,636
1,750
173 112 189 364
2,633 177 7,086 534 2,018 1,707 14,155
1,766 8,554 866 18,059
6,873
ACC
47 55 448 22
566 227 204 249 342 459 2,047
1,045 255 2,286
310 599 98 1,269
>17
336
-
262
6-17
Age (years)
62
1,103 11 12,901 164 245 167 289 168 2,764 3,556 192 22,930
1,370
1,499
41 224 688
26 16 281 98
155 80 222 138 193 246 1,034
593 385 138 1,178
int
Reason
37
29 0 266 12 1 3 8 3 15 293 6 682
46
53
31 69 179
5 1 51 22
78 18 25 14 8 55 198
50 60 51 198
Fan
Adv
1,350 15 14,812 243 289 192 354 180 2,996 5,072 219 27,745
2,023
1,846
152 710 1,569
64 53 380 210
315 158 537 432 643 488 2,573
1,310 1,210 282 3,131
329
Treated in HCF
322 0 3,580 41 24 17 86 14 714 1,907 33 7,602
864
590
385 1,615 2,519
126 70 98 225
564 0 7,246 120 94 67 151 53 1,333 2,345 63 12,955
919
832
90 1,052 1,482
22 20 177 121
211 50 303 121 203 287 1,175
615 2,250 142 3,357
1,095 3,852 525 9,392
1,482 106 4,082 376 1,327 1,014 8,387
350
3,920
Minor
8 1,806 36 66 50 70 32 316 783 34 3,794
231
362
60 0 412 19 34 24 21 5 32 140 10 855
98
46
2 4 20
15 100 198 245
3 2 4 5
2 8 53 20
8 6 3 14 6 6 43
24 7 1 35
126 146 23 313
17 19 6 48 47 33 170
3
Major
18
Moderate
Outcome
3 1 20 4 3 5 1 0 3 18 0 61
3
0
0 1 1
0 0 0 0
0 0 0 0 2 0 2
2 0 0 3
1
Death
Veterinary drug (no human equivalent) Vitamins Multiple vitamins (adult preparations) No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride
Topicals Acne preparations Boric acid antiseptics Calamine Camphor Camphor and methyl salicylate Diaper care products Hexachlorophene antiseptics Hydrogen peroxide Iodine antiseptics Mercurial antiseptics Methyl salicylate Podophyllin Steroids Wart preparations Other/unknown TOTAL
(PPA) PPA and caffeine Other/unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine PPA-containing “lookali kes” Other/unknown TOTAL
Serums, toxoids 8 vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids Phenylpropanolamine
92
260 265 5 0
2,271 2,465 67 22
2,830 3,021 79 23
23 781 161 42 249 9 113 142 126 2,221
803
179 5,495 612 1,229 4,281 19 3,382 1,039 1,519 34,047
265 8,824 1,417 1,426 5,072 50 3,898 1,369 1,957 42,736
80 79
79 38 118 181
26 99 3,541
1,296
945 8,706
1,241 8,936
54 73 4,208
149 443 16,109 370 391 2,359 3,521
902 281 202 9 27 145 65 27
1,876 616 367 427 615 805 200 526
550 559 2,912 4,260
713 37 1,322 121
1,254 29 1,080 60
3,778 185 3,769 2,353
433 160 60 15 182 213 46 114
24
50
214
281 279 7 1
367
58 2,380 619 139 495 22 381 177 284 6,026
203 111
98 122 412 525
68 255 7,783
514 162 98 376 359 400 85 352
1,688 103 1,284 2,039
132
2,632 2,709 74 22
1,270
254 8,609 1,223 1,370 5,020 45 3,862 1,324 1,897 41,803
1,202 8,902
524 538 2,865 4,168
66 132 6,885
1,179 375 239 55 134 260 117 142
1,981 81 1,824 300
148
106 343 10,412
2 2 249
131 273 5 1
55 24 0 0
4
1 8 19 2 11 2 7 8 12 110
7 173 163 50 31 3 15 30 39 673 19
10 3
273 793 20 4
204
48 564 405 159 599 24 88 191 290 4,556
297 120
50 71 248 1,402
959 320 186 390 462 501 102 465
37 13 7 4 7 11 0 5
13 4 2 8
2,506 107 1,929 2,036
87
57 0 87 17
65
28 7
8 12 32 75
78 302 8,690
632 222 116 362 465 520 80 356
1,676 99 1,783 1,999
1
1,460 1,897 46 15
678
130 4,294 669 879 2,866 16 2,196 639 1,089 23,471
604 5,208
260 328 1,614 2,679
38 59 3,709
832 227 138 32 32 108 32 47
1,043 31 962 128
42
262 352 13 3
241
55 1,756 276 81 971 12 229 384 319 6,183
350 532
136 76 253 743
49 128 5,405
463 175 93 98 231 335 93 183
1,152 65 1,515 825
71
21 30 1 0
13
1 59 30 4 32 6 8 18 20 271
16 10
11 4 5 47
13 44 1,568
97 38 22 88 91 67 24 125
357 18 212 372
21
1 2 4 1 6 1 0 3 3 33
0 0
1 1 0 10
2 9 307
13 2 0 63 11 6 0 35
42 2 18 104
1
0 0 0 0
0
0 0 1 1 0 0 0 0 0 3
0 0
0 0 0 1
0 1 57
1 0 0 8 0 0 0 6
11 0 2 28
0
Continued
drug 7,163
preparations) 7,237 11,256 420 1,793 620 637 122 803 1,862 229 638 1,661 33,231
Number of Exposures
2,737
6,498 10,220 402 1,748 493 131 93 609 1,527 181 528 1,326 28,581
<6
1,133
696 989 17 39 42 30 9 52 202 11 44 138 2,779
6-17
Age (years)
3,091
31 44 0 3 77 447 19 131 112 32 63 179 1,706
>17
5,027
7,150 11,130 417 1,782 571 361 102 729 1,756 208 602 1,530 31,775
ACC
1,586
58 98 1 5 29 36 15 37 79 14 23 112 917
Int
Reason
208
7 5 0 0 15 237 4 28 20 7 10 15 427
Rxn
Adv
3,790
265 1,961 66 70 69 83 16 83 105 42 45 362 4,257
Treated in HCF
2,270
4,295 6,874 280 1,317 341 60 62 401 956 135 340 977 19,458
NOM2
1,837
524 1,630 48 93 58 434 13 129 200 13 40 208 4,018
Minor
365
9 70 1 1 3 15 3 5 10 2 2 12 185
Moderate
Outcome
ABBREVIATIONS: act, accidental; adv rxn, adverse reaction; int, intentional. * Medical outcome data were also collected in categories labeled “unknown, nontoxic, ” “unknown, effect.” Thus, the numbers potentially toxic, ” and “unrelated not represent the total poison exposure experience. Patients with totally unknown age, reason or medical outcome were omitted from the respective tabulations.
Unknown
Multiple vitamins (pediatric No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Vitamin A Niacin Pyridoxine Other B complex vitamins Vitamin C Vitamin D Vitamin E Other/unknown TOTAL
TABLE 17.
0
0 0 0 0 0 0 0 0 0 0 0 0 0
Death
listed here do
68
4 15 0 0 0 0 0 0 2 1 1 0 25
Major
LITOVITZ
Hydrochloric-acid-containing toilet bowl cleaners were implicated in six fatalities in 1986, appearing for the first time in this data base. In the group of 13 patients with ingestions of caustic agents, six (46.2%) presented with acute repiratory insufficiency from severe chemical pneumonitis. Significant metabolic acidosis occurred early in five of the 21 deaths involving acetaminophen alone or in combination as a primary agent. Three of these cases were associated with severe hypoglycemia. Case 117 may represent an example of fatal chronic acetaminophen toxicity. In case 119, the delay in treatment resulting from failure to tolerate the oral form of N-acetylcysteine may have contributed to the poor outcome. In the group of cases primarily involving cyclic antidepressants, 28 reports noted the QRS complex, and 20 (71.4%) observed it to be widened. Case 205 is sketchy but suggests a delayed catastrophic deterioration in a cyclic antidepressant overdose. Two cases were reported that demonstrated severe deterioration following the use of physostigmine in cyclic antidepressant poisoning. All five of the amoxapine cases were associated with early seizures, and at least three were refractory to conventional therapy. The reason for the exposure was listed as accidental in 59 (14.5%) and intentional in 313 (77.1%) of the fatal cases. This trend was reversed where theophylline was the primary agent with nine (52.9%) of the 17 cases with known reason classified as accidental and at least two more as intentional but not suicidal (64.7% nonsuicidal). All of the nonsuicidal theophylTABLE 18. Substances Poison Exposures*
Most Frequently
Cleaning substances Analgesics Plants Cosmetics Cough and cold preparations Hydrocarbons Pesticides (includes rodenticides) Topicals Foreign bodies Food poisoning Sedativeihypnoticslantipsychotics Bites/envenomations Chemicals Vitamins Antimicrobials Alcohols
Involved
TABLE 19.
Categories
ET AL W 1986 AAPCC ANNUAL
with Largest
Antidepressants Analgesics Sedative/hypnotics Stimulants and street drugs Cardiovascular drugs AlcohoWglycols Gases and fumes Chemicals Asthma therapies Cleaning substances Insecticides/pesticides/rodenticides Hydrocarbons
Numbers
REPORT
of Deaths
No.
Percentage of All Exposures in Category
100 82 61 57 50 35 23 22 21 14 14 10
0.7 0.1 0.2 0.4 0.4 0.1 0.2 0.1 0.3 0.0 0.0 0.0
line fatalities occurred in the very young or the elderly. The average peak theophylline level was 118 pg/ml in the acute cases and 56 pg/ml in the chronic cases. Hemoperfusion or dialysis was employed in four (21.1%) of the 19 fatal theophylline cases. Five of the 10 digoxin fatalities with levels recorded had peak digoxin levels less than 6 &ml. Case 300 may represent a case of digoxin-specific fab fragment failure in a very elderly patient. The failure to treat early with digoxin-specific fab fragments (secondary to limited availability) or the administration of grossly inadequate amounts occurred in eight of the 13 digoxin fatalities (61.5%) in which digoxin was the primary agent.
REFERENCES
in Human
No.
%t
104,546 102,759 64,409 60,214 55,703 46,005 45,246 42,736 41,521 38,691 36,926 36,759 33,945 33,231 32,450 31,345
9.2 9.0 7.4 7.1 4.9 4.1 4.0 3.8 3.7 3.4 3.3 3.2 3.0 2.9 2.9 2.6
* Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather, often represent only ready availability of the substance. t Percentages are based on total number of known substances (1,135,701) rather than the total number of human exposures cases.
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
Appendix: Abstracts of Fatal Poisoning Cases Case 3. A 60-year-old man was admitted to the hospital with gastrointestinal bleeding. While undergoing a radiologic procedure, he was inadvertently injected with 4 ml of 70% isopropanol via the mesenteric artery. The patient died three weeks later from acute peritonitis and sepsis secondary to bowel infarction from the isopropanol injection. Autopsy revealed extensive necrosis of the small and large intestines. The peritoneal cavity was occupied by a conglomerate, necrotic mass of intestine. Case 8. A 48-year-old man presented after ingesting 435
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
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methanol. Initially, he was comatose and in full arrest. The initial methanol level was 585 mg/dl (falling to 290 mgldl at eight hours and 188 mg/dl at 14 hours after presentation). Potassium was 9.1 mEq/L; glucose, 466 mg/dl; PO,, 100 mm Hg; PCO,, 43 mm Hg; and pH 6.98. Ethanol infusion and dialysis were initiated within three hours of presentation. Hypotension persisted (40 mm Hg, systolic) despite dopamine. Dialysis was continued for four hours, discontinued for two hours. then performed for another four-hour period. The patient died 19 hours after presentation. At autopsy the ethanol level was 260 mg/dl, and methanol level was 150 mg/dl. Case 23. A 69-year-old woman was hospitalized with a necrotizing gluteal abscess from a spider bite of one week earlier. A brown recluse spider had been found at her home and was the presumed culprit. She was treated with a variety of antibiotics in addition to incision, drainage, and local care. Two weeks following admission, the patient developed refractory lactic acidosis associated with enterococcal sepsis. Cardiac arrest ensued. Case 25. A 26-year-old schizophrenic man told a fellow resident that he was about to take his medications (thiothixene, diphenhydramine, benztropine, methocarbamol, and ibuprofen) and that he should pray for him. Fifteen minutes later, the man collapsed in respiratory arrest. The paramedics found him with apnea and bradycardia and initiated cardiopulmonary resuscitation (CPR). In the emergency department (ED), he was treated unsuccessfully with an external and then internal cardiac pacer, fluids, and isoproterenol. He died 45 minutes after presentation. Later, a suicide note was found with a one-third-empty bottle of potassium cyanide. Cyanide was demonstrated in body tissues on postmortem examination. Case 27. A 28-year-old man presented after an intentional ingestion of cyanide. On arrival he was unconscious with respiratory depression and seizures. The cyanide antidote kit was administered with an immediate response. He was awake and breathing spontaneously when admitted. At live hours after ingestion, he became hypotensive (91/52 mm Hg), with tachycardia (138/min) and tachypnea (48/min). He became comatose and developed respiratory and renal failure; the patient died 15 hours after ingestion. Case 34. A 29-year-old man presented approximately 18 hours after intentionally ingesting ethylene gIyco1. Initial toxicologic analysis revealed ethylene glycol(154 mg/dl).The poison center was contacted 12 hours after presentation. At the time of the call, the patient was severely acidotic (pH, 7.03), was experiencing intermittent seizures, was comatose, and had been dialyzed for an unknown period of time. An ethanol infusion was initiated after prompting from the poison center. He continued to deteriorate and be436
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came markedly hypotensive, necessitating a dopamine infusion. The patient died approximately 4.5 days after the ingestion. Postmortem examination confirmed the cause of death as ethylene glycol intoxication. Case 35. A 32-year-old man presented in a coma: empty bottles of aspirin/butalbital and diazepam were brought to the ED as well. On admission, his serum was negative for aspirin and barbiturates; the ethanol level was 9 mg/dl; sodium, 163 mEq/L; potassium, 4.7 mEq/L; glucose, 321 mg/dl; and blood urea nitrogen, 16 mg/dl. Multiple urinalyses were negative for crystals but became trace-positive for blood. Arterial blood-gas sampling revealed a pH of 6.9 and then 7.05 after 500 mEq of sodium bicarbonate. The poison center was first contacted to determine if diazepam was dialyzable. A serum osmolality determination was recommended and was 371 mOsm/kg H,O. An ethanol infusion was initiated. The patient seized and required dopamine for blood pressure maintenance. Because he was too unstable to transfer for hemodialysis, peritoneal dialysis was initiated. An electroencephalogram (EEG) showed no electrical activity. The patient died 24 hours later. Postmortem examination revealed acute tubular necrosis with intratubular calcium oxalate crystals (probably secondary to ethylene glycol) and fatty changes of liver with centrilobular hydropic degeneration. Case 39. A 22-year-old man was exposed to hydrofluoric acid used to clean trucks. He sustained 27% surface area burns to his arms and back. He experienced increasing pain despite three doses of meperidine. Thirty minutes after presentation, the patient became dusky, with circumoral cyanosis and difficulty protecting his airway. Naloxone was administered, and he was intubated. Blood pressure was 90 mm Hg (palpable); pulse, 120/min; and respirations, 24/min. The cardiac monitor showed a widened QRS. All blood specimens drawn were hemolyzed. He arrested 90 minutes after presentation and could not be resuscitated. Postmortem examination revealed massive hemorrhaging in the mediastinum and distal colon. The right lung was edematous. The laboratory reported an unofficial ionized calcium level of I .7 mg/dl because the blood pH could only be raised to 7.15. Case 40. A 33-year-old man intentionally ingested a product containing hydrofluoric acid one hour prior to presentation. The paramedics found him unresponsive, with a pulse of 1IOimin; respirations, 18imin; and blood pressure, 140 mm Hg (palpable). He was given intravenous calcium chloride and sodium bicarbonate, which improved his level of consciousness. At two hours after ingestion, he arrested. Postmortem examination revealed marked pulmonary congestion and hemorrhage, mucosal sloughing in the trachea, esophageal inflammation, gastric mucosal necrosis. and
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
pancreatic autolysis. The blood ethanol level was 80 mg/dl, and fluoride level was 720 pg/ml (normal, ~37
p,g/ml). Case 43. A B-year-old woman accidentally ingested 120 ml of a diluted Christmas tree life extender containing aluminum sulfate, potassium chloride, benzalkonium chloride, and iron. She was asymptomatic, and dilution was the only treatment recommended by the poison center. The patient was determined to empty her stomach and sought ipecac from her family physician. She was given the last remaining ounce of a 4-0~ bottle labeled “for vomiting.” Thirty minutes after the administration of this medicine, she called the physician to report stiffness and tingling throughout her body. The paramedics found her in cardiac arrest. During intubation, her neck and jaw were noted to be stiff. The patient did not respond to the usual resuscitative measures. Postmortem examination revealed severe acute erosions and inflammation of the esophagus and gastrum. Analysis of the gastric contents and blood revealed large amounts of strychnine. Analysis of the tree life extender proved negative for strychnine. It was later learned that nux vomica had been stored in the family physician’s office 30 years earlier by a previous physician tenant. Case 48. A 67-year-old man presented one hour after intentionally ingesting 60 ml of a brass cleaner containing chromic acid, sodium bisulfate, sodium bifluoride, and ammonium chloride. Initially, he complained of chills, abdominal cramps, and watery black stools. Hypertension and dyspnea were noted on examination. Charcoal was administered. At 90 minutes after ingestion, a chest radiograph was normal. At 26 hours after ingestion, the patient developed increased dyspnea and hypotension. A central venous pressure of 6 mm Hg was observed. Vital signs remained stable, although the watery stool continued. Acute renal failure occurred, but he remained conscious and otherwise stable. He died at 115 hours after ingestion despite dialysis (initiated 90 hours after ingestion). Case 55. A 43-year-old woman presented two hours after intentionally ingesting 32 oz of toilet bowl cleaner containing 15% hydrochloric acid. On presentation she had severe oral burns and was frothing a blue-green solution. Her blood pH was 6.7, and sodium bicarbonate was administered. She arrested and could not be resuscitated. Postmortem examination revealed oral burns, gastric perforation, and chemical pneumonia. Case 57. A .59-year-old man was discharged from a health care facility with the diagnosis of “coin lesion” in the right lung and depression. That evening he ingested 32 ounces of a toilet bowl cleaner containing 23% hydrochloric acid and vomited spontaneously. After gastric lavage, he complained of “feeling sick,” with erythematous, swollen lips. He became acidotic
and hypotensive, requiring ventilation and pressor agents. A toxicology screen was negative. On the fourth day after ingestion, he underwent total gastrectomy, pancreatectomy, splenectomy, esophagectomy, cholecystectomy and jejunostomy. Postoperatively, he experienced acute renal failure requiring dialysis, adult respiratory distress syndrome (ARDS), and sepsis. He died on the sixteenth day after ingestion. During surgery, biopsy was done of the “coin lesion” in the right lung; it was found to be benign. Case 67. A 25year-old man experienced arrest after an estimated 5-minute exposure to carbon monoxide from a kitchen fire. His initial carboxyhemoglobin level was 44%. At the hyperbaric facility, he was unresponsive and ventilator dependent, with a pulse of 116/min and a blood pressure of 160/102 mm Hg. The carboxyhemoglobin level fell to 22% after 60 minutes of 100% oxygen and was 2% just prior to hyperbaric oxygen. The carboxyhemoglobin level was 0% after hyperbaric oxygen. Nonetheless, he remained unresponsive. On the second day after exposure, an EEG showed no electrical activity. The EEG was unchanged 24 hours later, and respiratory support was removed. Case 79. A 29-year-old man was trapped while cleaning a meat-processing fat vat thought to be filled with’ hydrogen sulfide. The patient was unconscious and was given 100% oxygen and basic life support by EMTs but could not be resuscitated. Postmortem examination showed acute tracheal bronchitis with severe pulmonary edema and hemorrhage of the lungs. Case 82. A 30-year-old woman presented after ingesting 480 ml of a product containing 26% calcium polysulfide and 10% alpha-@-( 1,1,3,3_tetramethylbutyl) phenyl-omega-hydroxypoly (oxyethylene). She vomited spontaneously and 30 minutes later lost consciousness and seized. She was administered diazepam, sodium bicarbonate, and amyl nitrite. She was subsequently placed in a hyperbaric oxygen chamber, where she manifested a right bundle branch block and arrested. Resuscitation was unsuccessful, and she died 7.5 hours after presentation. Autopsy revealed no significant anatomic findings. Case 83. A 35-year-old woman had been taking copper supplements for eight years on the advice of a chiropractor. She developed progressive hepatic and renal failure. She presented with coma, ascites, anuria, reticulosis, phosphaturia, choreoathetoid movements, Coombs-negative hemolytic anemia, and hypophosphatemia (1.1 mg/dl). Kayser-Fleischer rings were noted in the eyes. She was given 150 mg of dimercaprol and hemodialyzed once. There was a modest improvement in blood pressure, but later she arrested and died. Case 85. A 30-year-old man intentionally ingested paraquat 10 hours prior to presentation. He underwent 431
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intubation and lavage, and received charcoal hemoperfusion. He was given multiple doses of charcoal, and diatomaceous earth retention enemas were administered. He became hypoxic and hypotensive-requiring vasopressors-and then experienced upper gastrointestinal bleeding, metabolic acidosis, and anuria. The patient died on the second hospital day. Case 87. A 64-year-old man presented after intentionally ingesting 180 ml of paraquat. He initially complained of diarrhea and experienced bradycardia and diaphoresis. Atropine was given, followed by charcoal hemoperfusion and administration of diatomaceous earth. He subsequently developed renal failure, fixed and dilated pupils, and hypotension, requiring vasopressors. He had evidence of esophageal burns and pulmonary fibrosis and died 24 hours after exposure. Case 88. A 79-year-old woman presented 9.5 hours after intentionally ingesting 40 ml of carbon tetrachloride. She complained of vomiting and diarrhea although alert with normal vital signs. The leukocyte count was 28,300/mm3; serum glutamic oxaloacetic transaminase (SGOT), 149 U/L; and total bilirubin, 2.1 mg/dl. She was loaded with 9,800 mg N-acetylcysteine, followed by 4,900 mg every four hours, orally. On the second hospital day, her condition rapidly deteriorated. She developed metabolic acidosis, weakness, lethargy, and decreased renal function. The serum SGOT was 1,404 U/L; blood urea nitrogen, 38 mg/dl; creatinine, 2.1 mg/dl; and bilirubin, 2.5 mg/dl. She developed pulmonary congestion and hypotension. At 44 hours after ingestion, she developed asystole and died. Case 92. A 12-year-old boy, with cerebral palsy and mental retardation, accidentally ingested 300 to 360 ml of lamp oil. Initially, he experienced vomiting and coughing, and was cyanotic. The chest radiograph showed a total white-out of the right lower lobe. Secretions were oily and pinkish. The patient required intubation and ventilation. By the third day after exposure, the secretions had become copious and bloody. By the sixth day after exposure, the patient had three chest tubes for pneumothoraces. Dopamine was required for hypotension. By the ninth day after exposure, the patient had a total of five chest tubes, required positive end expiratory pressure (PEEP) at 16 cm H,O and a ventilatory rate of 48/min. On the tenth day after exposure, he developed diffuse subcutaneous crepitus with decreased cardiac and urinary output, and eventually arrested. Case 93. A 13-month-old boy ingested paint thinner (100% mineral spirits). Paramedics observed asystole on arrival but achieved sinus rhythm after intubation. A frothy substance was suctioned from the endotracheal tube. The blood pressure was 84/O mm Hg. Naloxone, dextrose, and sodium bicarbonate were administered. Arterial blood gases revealed a pH of 6.9; 438
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PCO,, 53 mm Hg; and PO, 71 mm Hg with positive end-expiratory pressure (PEEP). Diazepam and phenobarbital were administered for seizure activity and dopamine for hypotension. A chest tube was inserted five hours after ingestion. Later, the blood pressure was 95/16 mm Hg; pulse, 164/min; respirations, 56/ min; pH, 7.51; PCO,, 13 mm Hg; and PO,, 471 mm Hg. The drug screen was negative. Urine output ceased and did not respond to albumin or furosemide. Sixteen hours after ingestion CPR was initiated for hypotension and dysrhythmias, resulting in normal sinus rhythm. The patient experienced three more episodes of bradycardia and hypotension, which responded to drug therapy until he died 22.5 hours after ingestion. Arterial blood gases just prior to death were pH, 7.17; PC02. 48 mm Hg; and PO, 75 mm Hg. Postmortem examination revealed chemical pneumonitis. Case 98. A 2-year-old boy presented several hours after exposure to aldicarb. Increased secretions, respiratory depression, miosis, hypothermia, and evidence of aspiration were noted. Initial red blood cell cholinesterase levels were depressed. He arrested 14 hours after exposure and was successfully resuscitated. Large doses of atropine resulted in a heart rate of 1601 min without resolution of rales. An atropine infusion was maintained for three days. Dopamine and insulin were also required. Blood glucose ranged from 150 to 400 mg/dl. On the third day after exposure, exchange transfusions were performed. Seizures developed on the sixth day and were controlled with diazepam. EEGs indicated no brain activity. Life support systems were discontinued on the thirteenth day. Massive amounts of aldicarb and its metabolites were found in the urine. Case 101. A 41-year-old (96-kg) man was being admitted to a mental health facility when he drank 60 ml of shampoo containing lindane. He vomited spontaneously then was given ipecac syrup. Thirty minutes later, he seized. On arrival at the hospital, he was lethargic and diaphoretic, with a blood pressure of 180/80 mm Hg; pulse, 116/min; and respirations, 16/ min. Five minutes later, he arrested and was resuscitated. He underwent lavage and was given lidocaine, phenytoin, charcoal, cholestyramine, and sorbitol. Chest radiograph initially revealed a right lower lobe infiltrate that progressed to diffuse bilateral infiltrates. Clindamycin, tobramycin, and hydrocortisone were added. He remained flaccid and developed pitting edema of the upper extremities. On the fifth day, his creatine phosphokinase peaked at 2,795 U/L, and he was extubated. Arterial blood gas testing revealed a pH of 7.47; PCO,, 32 mm Hg; and PO,, 82 mm Hg on 40% oxygen with respirations of 44/min. On the seventh day, he arrested and could not be resuscitated. Lindane levels were 1.3 pgiml on admission and 0. I pg/ml on the sixth day. The levels at autopsy were
LITOVITZ
blood, 0.02 pg/ml; fat, 1.45 mg/kg; heart, 0.26 mg/kg; and liver, 0.16 mg/kg. Case 102. A 16-year-old boy, intent on burglary, entered a house following methyl bromide fumigation for termites. He was inside for approximately 45 minutes. One hour after leaving the house, be began to vomit and complained of being dizzy. On presentation, his heart rate was 160/min, and pH was 7.0. He experienced respiratory failure from marked pulmonary edema. Benzodiazepines and phenytoin were used to treat seizures. At 16 hours after inhalation he arrested. He was resuscitated but died on the second day after inhalation. Case 107. A 62-year-old woman presented two hours after intentionally ingesting a furniture-refinishing agent containing 20% methanol, 36% acetone, 20% toluene, and 24% isopropanol. She was unresponsive and apneic with a blood pressure of 60 mm Hg, a pulse of 104/min, and no urine output. Levels on admission were methanol, 104 mgldl; acetone, 114 mg/dl; isopropanol, 101 mg/dl; and ethanol, 108 mg/dl. Blood pressures remained at 50 mm Hg in spite of dopamine and norepinephine administration. Charcoal was administered and an ethanol infusion initiated, but the family refused dialysis. She remained unresponsive and hypotensive until her death 48 hours after ingestion. Case 109. A 40-year-old man presented after ingesting a “wild” or “mock” cucumber (Echinocystis) several hours earlier. He developed progressive leg and abdominal cramping. Profound shock and tachycardia were treated with antishock trousers and fluids. Dilated pupils and a hematocrit level of 81%~ were noted. The poison center determined that a mock cucumber was nontoxic, and information on a wild cucumber was not available. The patient developed disseminated intravascular coagulation and refractory shock despite aggressive supportive therapy. Repeated doses of physostigmine and naloxone were ineffective, and he died several hours later. The medical examiner found seeds in the stomach, identified as Marah oregunus (common name, coast manroot). Apparently, the patient had prepared a tea for its hallucinogenic properties. This plant resembles a lemon cucumber. Some of the Marah plants contain flavinoids. This particular plant contained cucurbitacin, which is cytotoxic. Case 111. A 35-year-old man complained of epistaxis, hematuria, gingival bleeding, and bilateral back pain. Examination revealed a blood pressure of 124/70 mm Hg; pulse, 72/min; temperature, 36.8”C; diffuse ecchymosis on left side of body; and an inappropriate affect. Laboratory results revealed a prothrombin time of 60 seconds (control, 12.4 seconds), a bleeding time greater than 15 minutes, and a platelet count of 147,000/mm3. An ingestion was denied, although he
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of bleeding that required later reported “dreams” massive doses of vitamin K, and he was vague on questions regarding ingestion of brodifacoum. Treatment consisted of six units of fresh frozen plasma and massive subcutaneous doses of phytonadione over 24 hours, with gradual return of the prothrombin time toward normal. Oral phytonadione was instituted with a prothrombin time of 15.6 seconds (control, 12.4 seconds) on discharge five days later. He returned to clinic for follow-up, but refused laboratory work. Seventeen days after discharge, he was found in status epilepticus. Computed tomographic (CT) scanning revealed a massive intradural bleed with multiple small hemorrhages. He was pronounced brain dead in the ED with a prothrombin time of 60 seconds (control, 12.6 seconds) and partial thromboplastin time of 86.6 seconds (control, 26.8 seconds). Case 112. An 18-year-old man presented one hour after ingesting a rodenticide. He was comatose, with tonic-clonic activity of both upper and lower extremities. He arrested and was resuscitated in the field. In the ED, he was cyanotic, with a pulse of 122/min; blood pressure, 86 mm Hg; temperature, 38.l”C; and no respirations. Laboratory results included a pH of 6.51; PO,, 269 mm Hg; PCO,, 63 mm Hg; creatine phosphokinase, 430 U/L; glucose, 683 mg/dl; and serum lactate, 39.5 mmol/L. The urine toxicology screen was positive for strychnine only. Treatment included sodium bicarbonate, diazepam, fluids, dopamine, and ventilation. Gastric lavage was performed, and charcoal and magnesium citrate were administered. Tonic muscle activity was controlled with pancuronium bromide after no response to phenobarbital. At 12 hours, hyperthermia developed and was treated with cooling blankets and ice packs. Rhabdomyolysis resulted in renal failure. ARDS, requiring PEEP, was complicated by a pneumothorax. Brainstem herniation secondary to acidosis and anoxia were diagnosed. The patient was pronounced dead on day 5 from refractory hypotension and bradycardia. Case 115. A 20-year-old man presented with vomiting, abdominal pain, and tachycardia 40 hours after an intentional overdose of acetaminophen. He had notified his girlfriend of his intent, but denied the ingestion to police who went to his house to check on him. Oral N-acetylcysteine was initiated. Admission laboratory findings included an SGOT of 2,645 U/L; alkaline phosphatase, 84 IU/L; bilirubin, 4.5 mg/dl; and acetaminophen, 67 pg/ml. On the fourth day after ingestion, the patient became lethargic. Repeat laboratory testing revealed an SGOT of 26,700 U/L; uric acid, 52 mg/dl; and bilirubin, 6.5 mg/dl. He died on the fifth day after ingestion. Case 117. A 25-year-old man, who had been taking acetaminophen throughout the day prior to hospitalization, presented with right-sided head pain. His wife 439
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stated he had been taking two to three acetaminophen every hour. His acetaminophen level, four hours after the last dose, was 22 p,g/ml. The admission laboratory findings included an SGOT of 9,410 U/L; serum glutamic pyruvic transaminase (SGPT), 2,290 U/L; and prothrombin time, 18.3 seconds (control, 11.8 seconds). N-acetylcysteine was given, and he did well until he suddenly deteriorated and died. Case 119. A 29-year-old woman presented 12.5 hours after intentionally ingesting 24.5 g of acetaminophen. The patient vomited spontaneously. The acetaminophen level was 175 p,g/ml 13 hours after ingestion, and N-acetylcysteine administration was begun. The serum salicylate level was 2.7 mg/dl. She continued to vomit and required metoclopramide, promethazine, and nasogastric tube insertion to retain the N-acetylcysteine. She developed progressive hepatic and renal insufficiency requiring lactulose, a proteinsparing diet, and dialysis. Approximately 30 hours after ingestion, the SGOT was greater than 5,000 U/L; SGPT, greater than 5,000 U/L; and lactate dehydrogenase, greater than 6,000 U/L. On the third hospital day, prothrombin time was 77 seconds (control. I I seconds), and arterial ammonia was 280 mmol/L, rising to 597 mmol/L on the fourth day. She died from multiple organ failure on the fifth hospital day. Case 121. A 65-year-old woman presented with a history of lethargy for two days prior to an intentional ingestion of acetaminophen. She was unresponsive on examination. The seven-hour acetaminophen level was 739 kg/ml, and the 16-hour level was 503 kg/ml. Toxicology screening was positive only for acetaminophen and benzodiazepines. The patient was started on oral N-acetylcysteine by 12 hours after ingestion. Admission laboratory findings included an SGOT of 715 U/L; bilirubin, 1.5 mg/dl: prothrombin time, 13 seconds; glucose, 29 mg/dl (240 mg/dl after 2 g dextrose); pH, 7.08 (after 100 mEq of bicarbonate): PCO,, 30 mm Hg; and PO,, 106 mm Hg. On the second day after ingestion, intubation and pressor therapy (dopamine and levarterenol) were required. The patient developed progressive cardiac and renal failure and died later that day. Case 123. A 42-year-old woman presented with lethargy three days after intentionally ingesting acetaminophen, nail polish remover (87% acetone), and a liquid cough and cold preparation. Vital signs were a temperature of 36°C; pulse, 130/min; respirations, 451 min; and blood pressure, 120/70 mm Hg. Hepatic and renal failure developed with coagulation defects, hypoglycemia, and encephalopathy. Hypotension did not respond to 4 L of saline but did respond to dopamine. Naloxone, 50% dextrose, sodium bicarbonate, and calcium chloride were administered. The initial acetaminophen level was 3.3 Kg/ml; alkaline phosphatase, 241 III/L; creatinine, 6.1 mg/dl; blood urea ni440
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trogen, 20 mg/dl; albumin, 3.5 g/d& salicylate level, 34 mg/dl; lactic acid, 15.4 mEq/L; CO,, 12 mEq/L; and glucose, 42 mg/dl. A full course of oral N-acetylcysteine was given. Hemodialysis and filtration were done to treat renal failure. Ten days after ingestion, a CT scan documented severe cerebral edema. The patient progressively deteriorated and died 21 days after ingestion. Laboratory
Tests SGOT
SGPT
Bilirubin
Day
(U/L)
(U/L)
(mg/dl)
Prothrombin Time (seconds)
3 6 8 11 12 20 21
20,920 1,278 296 118 88 -
2,950 654 330 123 81 -
7 9 10 18 16 31 36
43 21 23 15 -
Case 128. A 65-year-old woman presented six to 12 hours after intentionally ingesting up to 80 500-mg acetamiuophen 15-mg oxycodone capsules. Initially, she was comatose, with apnea, hypotension, and fixed and dilated pupils. Gastric lavage was performed and charcoal given. Naloxone (1.6 mg) was given with no level was response. The admission acetaminophen 1,000 Kg/ml. N-acetylcysteine was administered, and levarterenol was required to maintain the blood pressure. On the first day after ingestion, the patient remained on the ventilator and pressor infusion and developed signs of impending liver failure. She died later that day. Case 153. A 23-year-old man presented two hours after intentionally inhaling isobutyl nitrite and ingesting salicylates. On arrival he was hallucinating and vomiting. Salicylate concentration was 115 mg/dl. Three hours after presentation, cyanosis appeared, which was unresponsive to oxygen and methylene blue. It was learned that the patient received 70 ml of methylene blue (1%) instead of the recommended 7 ml. He arrested eight hours after ingestion and died. The methemoglobin level was 30% prior to the arrest. Case 157. A 57-year-old man presented two days after intentionally ingesting 15 mg of colchicine. He complained of vomiting, diarrhea, and anorexia and was hypotensive and febrile. Laboratory findings included leukocytosis and elevated renal function parameters. Multiple doses of charcoal were attempted, but vomiting continued during the next 24 hours. The hypotension was refractory to fluids and necessitated dopamine. Renal function deteriorated, and aspiration pneumonia developed, requiring antimicrobial therapy. On the fourth day after ingestion, bleeding
LITOVITZ
occurred from multiple sites and renal failure required peritoneal dialysis. He experienced leukopenia and ARDS and died on the fifth day after ingestion. Case 159. A 78-year-old man presented with diarrhea, weakness, and inability to walk. He had received a prescription for colchicine 10 days prior to admission, and only 14 of 60 tablets remained. His heart rate was 98/min; blood pressure, 104/70 mm Hg; respiration, IWmin; and temperature, 35.8”C. Mucous membranes were dry, and his skin “tented” secondary to dehydration. There was no sensation in the lower extremities, and no deep tendon reflexes, only sensation around the trunk. Laboratory studies revealed renal insufficiency (creatinine, 5.6 mg/dl; blood urea nitrogen, 54 mg/dl), leukopenia (leukocyte count, 1 ,600/mm3), and thrombocytopenia (platelets, 110,000/mm3). He became hypotensive but was otherwise stable for 48 hours. Then he became progressively unresponsive, went into third-degree heart block and arrested. Postmortem examination revealed bilateral lower lobe congestion, mild splenomegaly, and mild hepatic fibrosis. Case 171. A 37-year-old man was admitted to the psychiatric ward of a hospital. Two days later he was found in cardiopulmonary arrest. He responded to intubation, lidocaine, and naloxone. Blood pressure was 90 mm Hg, and body temperature was 35.8”C. Toxicologic screen revealed diazepam, 1.67 p,g/ml; nordiazepam, 6.29 kg/ml; propoxyphene, 1,021 &ml; norpropoxyphene, 2,786 ng/ml. Seizures were refractory to phenytoin, phenobarbital, and paraldehyde but responded to general anesthesia. Aspiration pneumonia occurred, and the patient progressively deteriorated over the next two weeks. Case 174. A 31-year-old man presented with an altered mental status, hyperthermia (42.7”C), tachycardia, and hyperkalemia (7.4 mEq/L). The delirium was treated with haloperidol and benztropine. It was later learned that he ingested benztropine several hours earlier. Toxicologic screen was positive for benzodiazepine, nicotine, amphetamines, and phenobarbital. Multiple doses of physostigmine were given without result. Dantrolene sodium was used for the hyperthermia. He developed refractory ventricular arrhythmias and died. Case 176. A IPyear-old man presented four hours after intentionally ingesting carbamazepine, temazepam, aspirin, and levothyroxine. He was unconscious, with a blood pressure of 120/80 mm Hg; a pulse of 130/min, and shallow respirations. Intubation, ventilation, and lavage were done, and charcoal and a cathartic were administered. A grand ma1 seizure was treated with diazepam, and dopamine was required for persistent hypotension. The admission carbamazepine level was 120 Kg/ml, which decreased to 63.6 pg/ml after three hours of charcoal hemoperfusion. Seven
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hours later, the level rebounded up to 108 &ml then fell to 75 p,g/ml after three additional hours of hemoperfusion. Subsequently, he arrested and was initially resuscitated but died after a second cardiac arrest 35 hours after ingestion. Blood toxicology results were also positive for salicylates 21 mg/dl and temazepam 178 ng/ml. The thyroxine concentration was 21.9 pg/dl. Postmortem examination revealed pulmonary edema. Case 177. A 34-year-old mentally handicapped man presented in a coma and seizures. Vital signs included a blood pressure of 50 mm Hg and a pulse of 75/min. He underwent intubation, ventilation, and lavage. Dopamine, levarterenol, and charcoal were administered. The initial carbamazepine level was 54.8 p&ml. Seizure activity persisted despite diazepam, phenytoin, and phenobarbital administration. Ventricular tachycardia was treated with lidocaine. At seven hours after the first poison center call, hyperthermia (41.9” C) occurred and was treated with acetaminophen, cooling mats, and ice packs. By 16 hours, the seizure activity had ceased, and the temperature was 38.1” C rectally; pulse, 120/min; and blood pressure, 112/60 mm Hg. By 28 hours, the carbamazepine level had dropped to 12.7 kg/ml. At 52 hours, he was obtunded and anuric. He died at 72 hours. (All times are referenced to the first poison center contact.) Case 179. A 3-year-old boy presented one hour after ingesting six or more phenytoin capsules. He was ataxic, and emesis was induced with ipecac syrup. Five hours after ingestion, the child was agitated, with tachycardia (130/min) and tachypnea (40/min). Nine hours after ingestion, he experienced a respiratory arrest and was resuscitated. Coma was noted 12 hours after ingestion. A toxicology screen also revealed benzyl alcohol. Multiple doses of charcoal were administered. Pertinent laboratory findings included sodium, 125 mEq/L; potassium, 2.9 mEq/L; arterial pH, 7.3; and PCO,, 30 mm Hg. At 24 hours postingestion, diabetes insipidus developed, requiring vasopressin. On the third day after ingestion, an EEG showed “minimal” activity; he died later that day.
Time After Ingestion lh 12 h 18 h 24-48 h
Case scious zolam, lavage,
205. after and and
Plasma Phenytoin Levels (kg/ml) 50 47 43 40
A 59-year-old man was admitted unconingesting amitriptyline/perphenazine, triadiazepam. He underwent intubation and was given charcoal and a cathartic. His 441
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vital signs were “unremarkable,” with a pulse of 80/ min. He was extubated nine hours after admission. Multiple doses of charcoal were given. He was awake and walking 24 hours after admission. Unexpectedly, he seized, then arrested. The coroner concluded that the death was from cardiac dysrhythmias. Case 206. An 1%year-old woman intentionally ingested amoxapine. At first she was alert and responsive. She was given ipecac and experienced seizures prior to emesis. The seizures continued despite diazepam, phenytoin, phenobarbital, and sodium bicarbonate administration. She underwent intubation, ventilation, and lavage, and was given charcoal, a cathartic, and physostigmine. The vital signs and cardiac rhythm were normal, and the seizure activity stopped. Later she was described as “bleeding from every orifice” and was unresponsive to any stimuli. The patient died on the third day after ingestion. Case 209. A 60-year-old woman presented two hours after ingesting amoxapine. A sinus tachycardia was noted, and subsequently she seized. The seizures responded to diazepam, and she was loaded with phenytoin. She underwent intubation and lavage, and was given charcoal, a cathartic, and sodium bicarbonate. Arterial blood gases obtained two hours after ingestion disclosed a pH of 6.97. Five hours after ingestion, seizures recurred and were unresponsive to diazepam, phenytoin, and phenobarbital. Physostigmine was administered, resulting in bradycardia and hypotension. Levarterenol was administered without response, and the patient arrested and died. Case 252. A 64-year-old woman presented the morning after intentionally ingesting lithium carbonate. She complained of nausea and vomiting but was alert, oriented, and without tremors. The electrocardiogram (EKG) was normal, and the lithium level was 8.5 mEq/L. Charcoal and a cathartic were administered. Urine output was low. The lithium level on the second day after ingestion was 6 mEq/L. The patient continued to be alert and oriented. Mannitol and intravenous fluids were given, and urine output increased to 100 ml/h. Vital signs and the EKG were normal. On the third day after ingestion, she became more lethargic, with a lithium level of 7.1 mEq/L. The urine output was 20 ml/h, and the blood urea nitrogen and creatinine were 47 mg/dl and 4.2 mgidl, respectively. The patient was hemodialyzed. On the fourth day after ingestion, she arrested and was resuscitated. The lithium level at that time was 5.6 mEq/L. Hypotension (60 mm Hg) occurred and was refractory to levarterenol. Electromechanical dissociation led to her death on the fifth day after ingestion. The toxicologic screen was positive only for lithium. Case 260. A 24-year-old man presented 14 hours after intentionally ingesting 1.5 g of phenelzine. While initially awake and alert, by 24 hours after ingestion 442
5 W September
1987
he was comatose and tremulous with tachycardia (170/min). His blood pressure was normal, but he experienced frequent seizures. The supraventricular tachycardia was treated with propranolol but converted to refractory ventricular tachycardia. He died on the second day after ingestion. Case 261. A 39-year-old man presented 10 hours after intentionally ingesting phenelzine (3.8 to 8.8 mg/kg). He was diaphoretic and tremulous. Blood pressure was 104/50 mm Hg; pulse, 64imin; respirations, 16/min; and temperature, 35.9” C. The toxicology screen revealed trifluoperazine and phenelzine. Lavage was performed, and he was given serial doses of charcoal, a cathartic, and fluids. Increasing confusion and rigidity required diazepam and restraints. By 36 hours after ingestion. his pulse was 17Olmin, blood pressure fell to 70 mm Hg, and body temperature was 42” C. The hypotension was refractory to usual therapy including dopamine and norepinephrine. Hyperthermia responded to acetaminophen, cold packs, a cooling blanket, and dantrolene. Refractory pulmonary edema, disseminated intravascular coagulation, and hypercarbia occurred. The pressure fell to 40 mm Hg and was unresponsive to calcium and glucagon. At 43 hours after ingestion, fatal electromechanical dissociation ensued. Postmortem examination revealed marked pulmonary edema and a blood phenelzine level of 140 ng/ml. Case 263. A 44-year-old man was found unresponsive after intentionally ingesting tranylcypromine (up to 900 mg). He was tremulous with mydriasis. Vital signs included respirations 18/min; blood pressure, 102/72 mm Hg; temperature. 40.4” C: and pulse. 1301 min. The EKG demonstrated atria1 fibrillation with a QRS duration of 0.11 seconds. He underwent intubation and lavage, and was given charcoal and a cathartic. Arterial blood gases revealed a pH of 7.27, PCO,, 57; and PO*, 100 mm Hg. Three hours after admission of the patient, a grand ma1 seizure was treated with diazepam and phenytoin. Body temperature increased to 42.5” C. After the seizure, he became hypotensive but responded to fluids and dopamine. He was acidemic and anuric. Intermittent wide complex arrhythmias developed, which rapidly deteriorated to ventricular fibrillation. He died from refractory electromechanical dissociation four hours after presentation. Case 265. A 67-year-old diabetic woman (history of congestive heart failure) intentionally ingested trazodone. The patient was on digoxin therapeutically and had a digoxin level of 2.0 ng/ml on admission. Bradycardia (5O/min) with a good pulse was noted. The QTc interval was 0.54 seconds, and QRS was 0.1 seconds. The serum trazodone level was 5,800 &ml. Later that day, the patient experienced ventricular tachycardia, then fibrillation. She was intubated then shocked into
LITOVITZ
asystole. Isoproterenol resulted in a sinus rhythm with pulses. “Torsades de Pointes” developed, which responded to overdrive pacing. Rigidity and decorticate posturing were observed. On the fourth day after ingestion, she was extubated, and the pacer was removed. She was very lethargic and answered some questions appropriately. The QT interval gradually returned to normal (0.43 seconds). On the seventh day after ingestion, she arrested three times. Thereafter, she was unresponsive and died on the nineteenth day after ingestion. Case 267. A 15year-old girl presented two to four hours after intentionally ingesting 6,250 mg of diphenhydramine. She was seizing, and had a temperature of 41.8” C, a pulse of 160/min, and marked acidosis. The seizures was unresponsive to diazepam, phenytoin, and physostigmine, so the patient was paralyzed with pancuronium. She underwent lavage and was given charcoal. The pulse decreased to 120/min after physostigmine. The patient developed refractory asystole and was pronounced dead five to seven hours after ingestion. The postmortem blood diphenhydramine level was 9.7 pglml and liver was 52.6 p.g/g_ Case 269. A 12-month-old girl ingested 1 g of chloroquine. Unaware of the toxicity, the parents allowed the child to go to sleep. They found her unresponsive 30 minutes later. The child presented in a full cardiopulmonary arrest. She was resuscitated but manifested refractory hypotension. Ventilatory support was terminated on the third day after ingestion. Case 271. A 6-month-old boy was hospitalized for pulmonary insufficiency from bronchopulmonary dysplasia and right ventricular hypertrophy. The admitting theophylline level was 2 ).&ml, and the dosage was increased. Within two days, the level increased to 24 pg/ml, and the dosage was decreased. However, 24 hours later the level was 40 t&ml, and he manifested tachycardia and shock. Theophylline was discontinued, and charcoal and a cathartic were administered. Seven hours later the level decreased to 33 kg/ml, but the pulse was 190/min. Three hours later refractory asystole occurred, and the patient died. Case 273. A 15year-old girl presented after intentionally ingesting 30 g of sustained-action theophylline. The initial blood level was 88 pg/ml. She was obtunded, with tachycardia (120 to 130lmin) and hypotension (100 mm Hg). Charcoal hemoperfusion was performed but the theophylline level was 190 pg/ml afterward. Ventricular fibrillation occurred but was refractory to treatment. She was placed on cardiac bypass from which she could not be weaned. Case 274. A 17-year-old girl presented several hours after intentionally ingesting 2.9 g of sustainedrelease theophylhne. Her pulse was 190/min and blood pressure was 110/80 mm Hg; and she seized. Her initial theophylline concentration was 93 l&ml, and a
ET AL n 1986 AAPCC ANNUAL
REPORT
second level was 117 t&ml. Fourteen hours after ingestion she was given pancuronium and thiopental for the seizures and dopamine and levarterenol for hypotension. Body temperature reached 40.1” C despite external cooling. Hemodialysis was not performed at this time because of extreme hypotension. On the second day after ingestion, her theophylline level was 80 pg/ml. She developed refractory ventricular fibrillation and was pronounced dead 38 hours after ingestion. The urine toxicology screen revealed no other drugs. Case 288. A 72-year-old woman had been chronically abusing ethchlorvinyl and theophylline. She presented with ataxia, vomiting, and multifocal atria1 tachycardia (140/min). The theophylline level was 40 kg/ml with a potassium level of 1.9 mEq/L. The theophylline level decreased to 29 pg/ml, and the potassium level increased to 2.9 mEq/L. She developed respiratory failure from aspiration pneumonia and sepsis. The potassium eventually increased to 4.2 mEq/L before she died. Case 291. A 65-year-old woman presented with suspected amiodarone toxicity. The EKG revealed a sinus arrest with a ventricular escape rate of 40/min. Atropine, isoproterenol, and glucagon were ineffective. The pulse remained at 40/min, with a palpable blood pressure of 80. Three hours after admission it was decided that no further life-sustaining measures were to be initiated. The serum amiodarone level was 14 t&ml (toxic is 2.5 to 6.7 pg/ml). The patient died 24 hours after admission. Case 294. A 63-year-old woman presented after intentionally ingesting 1 g of captopril and some ethanol. She was comatose with miotic pupils, a blood pressure of 72 mm Hg, and a pulse of 10Wmin. Arterial blood gases revealed a pH of 7.17; P02, 45 mm Hg; and PCO,, 45 mm Hg. She underwent intubation and lavage, and was given fluids, naloxone, dopamine, and charcoal. The hypotension did not respond, and she died within six hours of presentation. Blood ethanol at postmortem examination was 238 mg/dl. Case 296. A 54-year-old man presented two hours after intentionally ingesting digoxin. The pulse was 36/ min; temperature, 36. I” C; respirations 24/min; and blood pressure, 96/60 mm Hg. The digoxin level was 30.8 ng/ml, and potassium was 6.1 mEq/L. Lavage was performed and phenytoin infused. Eight hours after ingestion, he became confused and suddenly developed a complex ventricular dysrhythmia. He died nine hours after ingestion without receiving digoxinspecific Fab fragments. Case 299. A 79-year-old male physician was admitted to rule out a myocardial infarction. A routine serum digoxin level, available seven hours after admission, was 24.9 rig/ml. While the digoxin-specific antibody was en route, he arrested but was revived. 443
AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 5, Number 5 n September 1987
He was stabilized on dopamine, epinephrine, and a pacemaker. A digoxin level drawn 17 hours after admission was 16.4 ng/ml. The digoxin-specific Fab fragments were administered 19 hours after admission with little improvement. He experienced arrest again 39 hours after admission and died. An autopsy did not identify any other likely cause of death. Case 303. A 78-year-old woman became toxic on prescribed digoxin and methyldopa. She complained of nausea and vomiting, with confusion and decreased bowel sounds noted. An idioventricular rhythm (40/ min) was observed, and the blood pressure was 90 mm Hg. The digoxin level was 3.9 ng/ml, and potassium was 3.9 mEq/L. Atropine increased the pulse to 801 min with occasional premature ventricular beats. The blood pressure increased to 110 mm Hg with a dopamine infusion. She appeared stable for several hours until she developed sudden refractory ventricular fibrillation. The patient did not have a repeat digoxin level assay done and never received digoxin-specific fab fragments. Case 304. A 48-year-old man intentionally ingested digoxin, metoprolol, and ethanol. On arrival he was awake and moaning with a pulse of 30/min. The digoxin level was 10 ng/ml, and digoxin-specific antibodies were requested. While awaiting their arrival, a pacemaker was inserted but did not capture. The patient died seven hours after presentation, before digoxin-specific antibodies could be procured. Case 312. A 21-year-old woman presented one hour after intentionally ingesting up to 2 g of propranolol and 12 g of flecainide. These drugs were prescribed for her chronic ventricular tachycardia. Her blood pressure was 70/40 mm Hg; pulse, 70/min; respirations 201 min. She developed first-degree heart block 80 minutes after ingestion. She was treated with a theophylline infusion, a transcutaneous pacer, atropine, and dopamine. Two hours after ingestion, she was comatose, the QRS widened, and third-degree heart block was diagnosed. Three hours after ingestion, asystole occurred, which was unresponsive to standard pharmacologic intervention, glucagon, pacing, and open-heart massage. She was pronounced dead 6.5 hours after ingestion. The serum flecainide level at the time of death was 3.2 kg/ml, and postmortem levels were blood, 10.9 kg/ml, and liver, 256 p,g/g. The postmortem blood propranolol level was 1.1 p,g/ml. Case 328. An 18-month-old child presented four hours after ingesting ferrous sulfate. The child was unconscious, and the serum iron level six hours after ingestion was 23,000 pg/ml. Intravenous deferoxamine was initiated at 15 mg/kg/h. At 12 to 16 hours after ingestion, hypotension occurred, which responded to fluids. At 24 hours after ingestion, an acute surgical abdomen was diagnosed. An exploratory laparotomy revealed 40 cm of necrotic bowel at the distal ileum, 444
with perforation and peritonitis. Broad spectrum antibiotics were administered. The serum iron at 24 to 30 hours after ingestion was 200 pg/dl. By 48 to 72 hours after ingestion, elevated liver function tests, bilirubin, and prothrombin time were noted. By 72 hours after ingestion, the child’s sensorium cleared. All liver functions returned to normal with supportive care. Respiratory insufficiency beginning seven days after exposure led to the patient’s death on the fourteenth day after ingestion. Case 330. A 40-year-old woman presented after ingestion up to 40 mg of loperamide and an unknown amount of salsalate. Lavage recovered many green tablet particles. She had tachycardia, with a blood pressure of 100/60 mm Hg and respirations of 36/min. Naloxone and sodium bicarbonate were administered. The salicylate level was 77 mg/dl initially and 90 mg/dl 2.5 hours later. At 21 hours after presentation, refractory asystole developed, and the patient died. Case 331. A lbyear-old bulimic girl presented one hour after intentionally ingesting 8 to 16 ounces of baking soda (sodium bicarbonate) in an attempt to induce vomiting. Lavage was attempted without success because of inability to intubate the stomach. Severe gastrointestinal distension compressed and damaged vital organs. She died 16 hours after ingestion of complications from an infarcted small intestine. Case 344. A 3 1-year-old psychotic man received IO mg of haloperidol intramuscularly every four hours for 24 hours to control his behavior. He was noted to be lethargic all day. He was found in his room, in fourpoint restraints, in full cardiorespiratory arrest. Resuscitation was unsuccessful. Serum haloperidol level at postmortem examination was 0.1 pg/ml, and no other cause of death was found. Case 353. An adult woman was found unconscious and hyperthermic (41.7”(Z). She had been an inpatient at a state mental institution, where thioridazine administration, 150 mg four times daily, was begun three days earlier. She developed ventricular tachycardia with numerous arrests. Despite vigorous resuscitative efforts, her temperature remained between 39.3” and 41.7”C, and extensive multisystem failure occurred. She died two days after admission. The cause of death, as listed by the coroner, was neuroleptic malignant syndrome secondary to thioridazine. Case 361. A l-year-old boy presented 15 minutes after ingesting some of his mother’s diet pills. He initially convulsed seizure and was treated with diazepam. He was tremulous with a pulse of 200/min; blood pressure, 120/70 mm Hg; and temperature, 38.3” C. Gastric emptying was induced with ipecac syrup; no pill fragments were seen, however. Rigidity, hyperreflexia, and tachycardia (190/min) were noted. During aeromedical transfer 30 hours after ingestion, the child developed status epilepticus and hypoten-
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
sion (52 mm Hg). He arrested and was resuscitated, underwent lavage, and was given dopamine and albumin. The toxicologic screen showed a caffeine level of 110 mg/dl at 40 hours after ingestion. He developed diabetes insipidus requiring vasopressin. Phenobarbital, glucose, and insulin were administered. The caffeine level after three fourths of an exchange transfusion was 161 mg/dl. A CT scan showed diffuse cerebral edema. He became hypertensive (1901115 mm Hg) and responded to hydralazine and hyperventilation. At 72 hours after ingestion, an EEG indicated brain death. Life support was discontinued. Case 363. A 19-year-old man ingested five bags of cocaine and presented with tachydysrhythmias and shallow respirations. He was intubated and ventilated, and underwent lavage; charcoal and a cathartic were administered. His tachycardia responded to propran0101. Six hours after presentation, he was extubated. Twelve hours after presentation, he arrested and could not be resuscitated, Cocaine toxicity was confirmed by the medical examiner. Case 386. A 25-year-old woman presented after injecting heroin, snorting cocaine, and ingesting diaz-
epam. She arrested and was resuscitated with naloxone and dopamine. Her blood pressure was 40 mm Hg, and her temperature was 28.9” C. The hypothermia was due to her boyfriend packing her in ice. She underwent intubation, ventilation, and lavage. Aspiration pneumonia was suspected, but by four hours after admission, she had fulminant pulmonary edema. The PO, on 100% oxygen was 50 mm Hg. Naloxone, dopamine, and dobutamine infusions were required. She arrested several times during the night. By the second day after ingestion, no brain stem functions were present. She died from hypoxic encephalopathy and ARDS. Case 405. A 52-year-old man was exposed to 250 ml of povidone iodine, which was accidently dropped into his chest cavity during a thoracotomy. His condition deteriorated one hour after the incident. Metabolic acidosis and hypotension required dopamine and large volumes of fluid. Urine output remained low. Aggressive physical therapy and lavage of the povidone iodine from the tracheobronchial tree were employed. He continued to deteriorate, remained acidotic, and died.
Toxicology A special contribution from the American Association of Poison Control Centers.
I
I--@A. t
-
Liii
1986 Annual Report of the American Association of Poison Control Centers National Data Collection System TOBY L. LITOVITZ,
The American Association of Poison Control Centers (AAPCC) National Data Collection System has grown since its inception in 1983. During that pilot year, 251,012 human poison exposures were reported from 16 poison centers.’ In 1984 and 1985,730,224 and 900,513 human exposures were reported, respectively.2,3 This report includes 1,098,894 human exposure cases reported by 57 participating poison centers during 1986. From the Data Collection Poison Control Centers.
Committee,
American
Association
of
The authors acknowledge the generous contribution of Micromedex, Inc., to the programming and processing of this annual report. Centers participating in this year’s report include Alabama Poison Center, Tuscaloosa, AL; Arizona Poison Control System, Tucson, AZ; St. Luke’s Poison Center, Phoenix, AZ; Fresno Community Hospital Regional Poison Control Center, Fresno, CA; Orange County Poison Center, Orange, CA; San Diego Regional Poison Center, San Diego, CA; San Francisco Bay Area Regional Poison Center, San Francisco, CA; Rocky Mountain Poison Center, Denver, CO; National Capital Poison Center, Washington, DC; Tampa Bay Regional Poison Center, Tampa FL; Idaho Poison Control Center, Boise, ID; Indiana Poison Center, Indianapolis, IN; St. Luke’s Poison Center, Sioux City, IA; Mid-America Poison Center, Kansas City, KS; Kentucky Regional Poison Center of KosairGhildren’s Hospital, Louisville, KY; Louisiana Regional Poison Control Center, Shreveport, LA; Maryland Poison Center, Baltimore, MD; Children’s Hospital of Michigan Poison Control Center, Detroit MI; Blodgett Regional Poison Center, Grand Rapids, MI; Great Lakes Poison Control Center, Kalamazoo, MI; Midwest Poison Center, Kalamazoo, MI; Saginaw Regional Poison Center, Saginaw, MI; Hennepin Poison Center, Minneapolis, MN; Minnesota Poison Control System, St. Paul, MN; St. Louis Regional Poison Center, St. Louis, MO; Mid-Plains Poison Control Center, Omaha, NE; New Jersey Poison Information and Education System, Newark, NJ; Hudson Valley Poison Center, Nyack, NY; Triad Poison Center,
MD, THOMAS G. MARTIN, MD, BARBARA SCHMITZ, RN
CHARACTERIZATIONOF PARTICIPATING CENTERS All 57 reporting centers submitted data for the entire year. Twenty-six of the 57 centers were certified as regional poison control centers by the AAPCC. Annual center call volumes (human exposure cases only) ranged from 1,273 to 72,351 (mean, 19,525). Center penetrance (defined as the number of human poison exposure cases reported to a center divided by the Greensboro, NC; North Dakota Poison Center, Fargo, ND: Akron Regional Poison Center, Akron, OH; Stark County Poison Control Center, Canton, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Central Ohio Poison Control Center, Columbus, OH; Oregon Poison Center, Portland, OR; LeHigh Valley Poison Center, Allentown, PA; Keystone Regional Poison Center, Altoona, PA; Northwest Poison Center, Erie, PA; Capital Area Poison Center, Hershey, PA; Delaware Valley Regional Poison Control Center, Philadelphia, PA; Pittsburgh Poison Center, Pittsburgh, PA; Rhode Island Poison Center, Providence, RI; Southern Poison Center, Inc., Memphis, TN; North Central Texas Poison Center, Dallas, TX; Intermountain Regional Poison Control Center, Salt Lake City, UT; Blue Ridge Poison Center, Charlottesville, VA; Tidewater Poison Center, Norfolk, VA; Central Virginia Poison Center, Richmond, VA; Seattle Poison Center, Seattle, WA; Spokane Poison Center, Spokane, WA: Mary Bridge Poison Center, Tacoma, WA; Central Washington Poison Center, Yakima, WA: West Virginia Poison Center, Charleston, WV: Eau Claire Poison Center, Eau Claire, WI; Lacrosse Area Poison Center, Lacrosse, WI; University of Wisconsin Hospital Regional Poison Control Center, Madison, WI; Milwaukee Children’s Hospital Poison Center, Milwaukee, WI. 0 1985, 1986, 1987, by the American Association of Poison Control Centers. Published by permission. All rights reserved. Address reprint requests to Dr. Litovitz: National Capital Poison Center, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007. 0735-6757187
$0.00 + .25 405
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
w Volume
5, Number
5 n September
1987
FIGURE 1. Fifty-seven centers participated in the Data Collection System in 1986. The cross-hatched served by reporting centers. (Map adapted from Hammond’s Outline Map of the United States.) TABLE 1. Exposure
Site of Caller and Site of Exposure, Cases
Human
Site of Caller
Residence Health care facility Workplace School Other Unknown TOTAL
Age and Sex Distribution
TABLE 2.
(“h)
82.1 14.1 1.5 0.6 1.3 0.5
91.6 0.5 2.5 0.8 2.1 2.4
100.0
100.0
of Human
population served by that center) ranged from 3. I to 19.9/l ,000, with a mean of 9.1 reported exposures per thousand population. A total population of 132.1 million was served by the participating centers including portions of 33 states and the District of Columbia (Fig. 1). Noting the 241.1 million estimated United States population, the data presented represent an estimated 55% of the human poison exposures reported to poison control centers in the United States during 1986. Thus, the 1,098,894 human poison exposures reported in this data base can be extrapolated to predict a nationwide
Site of Exposure
(“A)
Poison
Exposure
Cases’
Female
Male
46,538 (4.2) 111,421 (10.1) 115,748 (’10.5) 55,890 (5.1) 24,629 (2.2) 13,031 (1.2) 32,699 (3.0) 19,330 (1.8) 122,646 (’11.2) 7,582 (0.7)
46,194 (4.2) 19,389 (1.8) 10,236 (0.9) 24,044 (2.2) 27,498 (2.5) 157,593 (14.3) 8,678 (0.8)
549,514 (50.0)
530,768 (48.3)
6-12 13-17 >17 Unknownt TOTAL
41,834 97,475 97,827
* Numbers in parentheses are percentages. t In the unknown category, although the exact age was not reported, 406
Unknown
Age (yr)
2 3 4 5
areas denote regions
(3.8) (8.9) (8.9)
Total
1,246 (0.1) 2,112 (0.2)
2,275 1,183 514 315 792 507 4,112 5,556
(2.1) (0.1) (0.0) (0.0) (0.1) (0.0) (0.4) (0.5)
18,612 (1.7)
915 cases were infants
89,618 211,008 215,850 103,267 44,532 23,582 57,535 47,335 284,351 21,816
(8.2) (19.2) (19.6) (9.4) (4.1) (2.1) (5.2) (4.3) (25.9) (2.0)
1,098,894 (100.0)
and 3,810 were children
aged 2 to 5 years.
LITOVITZ ET AL n 1966 AAPCC ANNUAL REPORT
TABLE 3.
Distribution
of Age and Sex of 406 Fatalities
Age (yr)
Male
adult
TOTAL l
Data in parentheses
TABLE 4. Exposure
Number Cases
Female
3 3 2 1 1 0 2 22 55 46 19 26 11 13 4 0 10 0
1 2 1 0 0 0 0 19 35 25 25 23 27 14 5 3 6 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
218
186
2
1 2 3 4 5 6 7 8 9 310 Unknown TOTAL
Total’ 5 5 3
(1.2) (1.2) (0.7)
1
(0.2)
: 2 41 90 71 44 49 38 27 9 3 16 1
1:::; (0.5) (10.1) (22.2) (17.5) (10.8) (12.1) (9.4) (6.7) (2.2) (0.7) (3.9) (0.2)
406 (100.0)
are percentages.
of Substances
Involved
in Human
Poison
TABLE 5.
Reason for Human
Poison
Exposure No.
Cases Number of Substances
Unknown
NO.
1,027,452 53,759 9,949 2,726 1,011 433 179 92 65 231 2,997 1,098,894
%
93.5 4.9 0.9 0.2 0.1 0.0 0.0 0.0 0.0 0.0 0.3 100.0
incidence of 2 million human poison exposures. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the United States 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 19.9 poisonings/1,000 population reported for one state, then 4.8 million poisonings would have been reported to poison control centers in 1986. Because of the growth and development of this relatively new data collection project, with increasing center participation from year to year, the data do not directly identify a trend in the overall incidence of poisonings in the United States. However, an analysis of data from 47 centers that par-
Accidental General Misuse’ Occupational Environmental Unknown TOTAL
Cases %
930,320 24,345 19,115 5,237 1,192 980,209
84.7 2.2 1.7 0.5 0.1 89.2
Intentional Suicidal Abuse+ Misuse* Unknown TOTAL
61,788 12,841 11,312 10,190 96,131
5.6 1.2 1.0 0.9 8.7
Adverse Reaction Drug Food Other TOTAL
7,751 6,079 1,424 15,254
0.7 0.6 0.1 1.4
7,300
0.7
1,098,894
100.0
Unknown TOTAL
* Improper use of a substance where therapeutic or beneficial results were intended, e.g., an overdose occurring because both parents gave the same medication to a child and neither was aware (at the time) of the other’s action, or a case where misreading the label of a product results in an unintended exposure. t Improper use of a substance where the patient was seeking a psychotropic effect. * Intentional incorrect use of a substance where a psychotropic effect was not sought, e.g., intentional excessive dosing to obtain a more rapid or superior pharmacologic effect for presumed “therapeutic purposes.” 401
AMERICAN
TABLE 6.
JOURNAL
Distribution
Reason
of Reason for Exposure
687,801
Intentional Adverse reaction Unknown
1 ,105 1,774 1,902
TOTAL
692,582
Data in parentheses
TABLE 7.
MEDICINE
~6 Years
Accidental
l
OF EMERGENCY
Distribution
5 n September
5, Number
by Age, Human
Exposure
(99.3)
53,334
(92.7)
(0.2) (0.3) (0.3)
2,712 1,037 452
(4.7) (1.8) (0.8)
21,943 (46.4) 693 (1.5) 737 (1.6)
(63.0)
57,535
(5.2)
47,335
23,962
1987
Cases Only’
13- 17 Years
6- 12 Years
>17 Years
(50.6)
202,180
Unknown
(71 .l)
12,932
66,857 (23.5) 11,380 (4.0) 3,935 (1.4)
(4.3)
284,352
(25.9)
Total
(75.7)
980,209
(89.2)
3,514 (20.1) 370 (2.2) 274 (1.6)
96,131 15,254 7,300
(8.7) (1.4) (0.7)
1,098,894
(100.0)
17,090
(1.6)
are percentages.
of Reason for Exposure ~6 Years
Accidental General Environmental Misuse Occupational Unknown TOTAL
W Volume
and Age for 406 Human Fatalities 6-l
2 Years
13- 17 Years
>17 Years
Unknown
Total
9 1 3 0 0 13
1 1 0 0 0 2
0 2 2 0 0 4
10 8 13 5 4 40
0 0 0 0 0 0
20 12 18 5 4 59
Intentional Suicide Misuse Abuse Unknown TOTAL
0 0 1 0 1
0 0 0 0 0
16 1 3 1 21
207 12 40 31 290
0 0 1 0 1
223 13 45 32 313
Adverse
0
0
0
4
0
4
1
0
0
29
0
30
15
2
25
363
1
406
Reaction
Unknown TOTAL
TABLE 6. Exposure
Distribution of Route of Exposure Cases and 406 Fatalities*
for Human
Poison
TABLE 10.
Management
Site of Human
Poison
Exposure
Cases
No. (“/I)
Ingestion Dermal Ophthalmic Inhalation Bites and stings Parenteral Othefiunknown Multiple routes posure victims. total number of for fatal cases) sures (1,098,894) l
All Cases
Fatalities
897,518 (78.5) 75,127 (6.6) 63,558 (5.6) 60,520 (5.3) 35,395 (3.1) 3,524 (0.3) 7,496 (0.7)
326 (77.1) 4 (0.9) 0 (0.0) 46 (10.9) 1 (0.2) 31 (7.3) 15 (3.5)
of exposure were observed in many poison exPercentages (in parentheses) are based on the exposure routes (1,143,138 for all patients, 423 rather than the total number of human expoor fatalities (406).
Non-healthcare facility Healthcare facility Already there at time of call to poison center Referred by poison center Other/unknown TOTAL
820,629
(74.7)
127,807 125,694 24,764
(11.6) (11.4) (2.3)
1,098,894
(100.0)
for the entirety of 1985 and 1986 indicates an 8.4% increase in reported poison exposures from 1985 to 1986 within the regions served by these 47 centers. ticipated
REVIEW OF THE DATA TABLE 9. Symptom Poison Center
Assessment
at Time of Initial Call to
No. (%) Asymptomatic Symptomatic, Symptomatic, Symptomatic, Unknown TOTAL 408
related to exposure unrelated to exposure unknown if related
725,129 285,811 17,273 48,230 22,451
(66.0) (26.0) (1.6) (4.4) (2.0)
1,098,894
(100.0)
The 1,098,894 human poison exposures reported to AAPCC in 1986 represent the largest poison exposure data base ever compiled in the United States and an 18.1% increase in total reports from 1985. An analysis of the data indicates that 9 1.6% of exposures occurred in the home (Table 1). Two unlikely sites of poisonings, health care facilities and schools, accounted for 5,716 (0.5%) and 9,147 (0.8%) poison exposures, respectively. Poison center peak call volumes were
LITOVITZ
noted from 5 to 9 PM, although call frequency remained consistently high between 9 AM and 10 PM, with 82.6% of calls logged during this 13-hour period. The age and sex distribution of human poison exposure victims is outlined in Table 2. Forty-seven percent of cases involved children under 3 years of age, and 62.6% occurred in children under 6 years of age. A male predominance is found among poison exposure victims less than 12 years old, but the gender distribution is reversed in teenagers and adults. Table 3 gives the age and sex distribution for 406 fatalities. Despite variations from decade to decade among adults, overall, males account for a greater number of fatalities in children, teenagers, and adults. A single substance was implicated in 93.5% of reports, and only 1.3% of patients were exposed to more than two possibly poisonous drugs or products (Table 4). Most cases of human exposure were acute (98.7%), as were most poison-related fatalities (91.1%). (Chronic exposures were arbitrarily defined as repeated exposures to the same toxic substance or a single exposure lasting longer than eight hours.) Most poison exposures (89.2%) were accidental; suicidal intent was present in 5.6% of cases (Table 5). Nearly one quarter (23.2%) of cases with suicidal intent occurred in patients who were 13 to 17 years old. Whereas accidental poisonings outnumbered both intentional poisonings and adverse reactions in all age groups (Table 6), the ratio was lower in teenage and adult cases. In contrast, of the 406 human poisoning fatalities reported, this ratio was reversed among the adult deaths, with 7.25 times as many deaths resulting from intentional as compared with accidental exposures (Table 7). Ingestions accounted for 78.5% of poison exposures (Table 8), followed in frequency by dermal contact, ophthalmic exposure, inhalation, bites and stings, and parenteral exposure. For the 406 fatalities, ingestion and inhalation were the predominant exposure routes. Table 9 displays the symptom assessment at the time of the initial call to the participating poison center. In addition to the 26.0% of patients with initial symptoms clearly related to the exposure, symptoms developed during the subsequent course in 8,413 initially asymptomatic patients. Thus, symptoms definitely related to the exposure eventually developed in at least 26.8% of patients. Most of the patients reported to poison centers were managed in a non-health care facility (74.7%), usually at the site of exposure, the patient’s own home (Table 10). Treatment in a health care facility was rendered or recommended in 23.0% of cases, and of these, 53.0% involved treatment and release, 17.3% involved admission for medical care, and 2.3% involved admission for psychiatric treatment; 8.5% refused referral, and 19.0% were lost to follow-up.
ET AL W 1988 AAPCC ANNUAL
h-------l
Ntcor‘TrSorm
v)Q)WOO--3NO NC+,---,-,--v-
%%.‘4Nfi-J8”
v--w-0‘
z
ro
r-OWrrDWCO-r
VT-
F
_-
g
u-iw- ;
%
REPORl
AMERICAN
JOURNAL
TABLE 12.
Distribution
OF EMERGENCY
of Medical
MEDICINE
Outcome
H Volume
by Reason for Exposure
Accidental No effect Minor effect Moderate effect Major effect Death Unknown, nontoxic Unknown, potentially Unrelated effect Unknown
toxic
TOTAL l
Data in parentheses
5, Number
Intentional
474,546 (43.2) 208,248 (19.0) 18,288 (1.7) 1,621 (0.1) 59 (0.0) 206,647 (18.8) 45,921 (4.2) 21,257 (1.9) 3,622 (0.3)
17,082 33,261 10,112 2,299 313 5,754 25,709 1,241 360
(1.6) (3.0) (0.9) (0.2) (0.0) (0.5) (2.3) (0.1) (0.0)
980,209
96,131
(8.7)
(89.2)
Provided
in Human
Poison
Exposure
Cases No.
Initial decontamination Dilution Irrigation/washing Ipecac syrup Activated charcoal Cathartic Gastric lavage Other emetic
423,744 201,583 145,949 56,619 47,013 17,639 2,537
Measures to enhance elimination Urinary alkalinization (with or without diuresis) Forced diuresis Hemodialysis Hemoperfusion (charcoal) Urinary acidification (with or without diuresis) Peritoneal dialysis Exchange transfusion Hemoperfusion (resin)
2,347 300 297 99 75 62 33 23
Specific antidote administration N-acetylcysteine (PO) Naloxone Atropine Deferoxamine Ethanol Physostigmine Antivenin/antitoxin Hydroxocobalamin N-acetylcysteine (IV) Pralidoxime (a-Pam) Dimercaprol @AL) Penicillamine Fab fragments Pyridoxine Methylene blue Cyanide antidote kit EDTA
3,009 3,209 529 506 453 375 349 202 153 151 147 130 105 103 90 84 84
410
for Human Adverse
Poison
1987
Exposure
Reaction
Victims* Unknown
(0.1) (0.7) (0.1) (0.0) (0.0) (0.2) (0.2) (0.1) (0.0)
1,472 1,751 493 106 30 1,369 1,663 356 60
(0.1) (0.2) (0.0) (0.0) (0.0) (0.1) (0.2) (0.0) (0.0)
15,254 (1.4)
7,300
(0.7)
1,607 7,726 1,044 75 4 1,820 1,667 1,268 43
Total 494,707 250,986 29,937 4,101 406 215,590 74,960 24,122 4,085 1,098,894
(45.0) (22.8) (2.7) (0.4) (0.0) (19.6) (6.8) (2.2) (0.4) (100.0)
are percentages
Table 11 shows the medical outcome of the human poison exposure victims distributed by age, emphasizing the more severe outcome observed in the older age groups. Table 12 compares medical outcome and reason for exposure, emphasizing the greater frequency of serious outcome in intentional exposures. Table 13 outlines the use of initial decontamination TABLE13. Therapy
5 l September
procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this data base. These figures must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 13.3% of cases. In children, ipecac syrup was most often administered outside a health care facility (Table 14). A summary of the 406 fatal exposures is presented in Table 15. Each of these cases was abstracted and/or verified by the reporting center, with only those fatalities deemed “probably” or “undoubtedly” related to the exposure included in this compendium. Confirmation of the cause of death by a postmortem report was obtained in 38.9% of cases. The highest blood level of implicated substances is provided where available to the reporting poison center. Cases with prehospital cardiorespiratory arrests are indicated. Abstracts are provided in the appendix for interesting or unusual cases. Tables 16 and 17 provide comprehensive demographic data on patient age, reason for exposure, medical outcome. and use of a health care facility for all 1,098,894 exposures, presented by category. Table 16 focuses on nonpharmaceuticals; Table 17 presents drugs. Table 18 presents the most common categories listed by frequency of exposure. Table 19 lists the substance categories with the largest number of reported deaths. A review of the fatality data demonstrates that 29.6% of the patients experienced cardiorespiratory arrest prior to arrival in the emergency department. Of the 49 patients who intentionally inhaled or injected toxins, 34 (69.4%) sustained a prehospital cardiac arrest. The 10 patients who ingested cyanide also experienced a higher incidence of prehospital cardiac arrest (70%); of the remaining three cases, two were agonal on presentation. In 19 ethylene glycol or methanol fatalities, diagnosis was substantially delayed in seven (36.8%), and two never received ethanolblocking therapy. (Text continues
on purge 435.)
LITOVITZ
TABLE 14.
Ipecac Administration
Non-health Care Facility
Health Care Facility
3,841 (2.6) 18,929 (13.0) 25,921 (17.8) 13,653 (9.4) 4,907 (3.4) 1,996 (1.4) 3,006 (2.1) 967 (0.7) 5,208 (3.6) 2,521 (1.7)
1,653 (1.1) 7,541 (5.2) 11,941 (8.2) 5,949 (4.1) 2,100 (1.4) 815 (0.6) 1,617 (1.1) 8,199 (5.6) 22,404 (15.4) 2,412 (1.7)
80,949
64,631
6-12 13-17 >17 Unknown TOTAL l
Data in parentheses
TABLE 15.
Summary
Adhesives 1* Alcohols 2’
51 60 17 19 24
7*
29
8*t 9
4 28 56 36 14 3 7 9 31 10
(44.3)
Total
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
5,507 26,526 37,951 19,662 7,026 2,818 4,636 9,182 27,667 4,974
(3.8) (18.2) (26.0) (13.5) (4.8) (1.9) (3.2) (6.3) (19.0) (3.4)
198 (0.1)
145,949
(100.0)
of Fatal Exposures
29
3t 4’ 5 6
(55.5)
Unknown
are percentages.
Age (yr)
Case
REPORT
by Site and Age’
Age (yr)
1 2 3 4 5
ET AL n 1986 AAPCC ANNUAL
48 55
See also cases 13, 78.95, 390 (ethanol].
Route of Exposure
Substances
Glue: methylene trichloroethane,
chloride, diethyl
Blood
Levels**
Inhalation
Act
occup
Ingestion
Int unknown
511 mg/dl
Parenteral Ingestion Ingestion Ingestion Ing and inh
Act misuse Act misuse Int unknown Int suicide Int suicide
40 170 46 109
Ingestion Ingestion
Int unknown Int unknown
ether
Ethanol benzodiazepines lsopropanol Methanol Methanol Methanol Methanol, methylene toluene Methanol Methanol
Reason
mg/dl, 36 hr mg/dl mg/dl mg/dl
chloride
124, 127, 150, 172, 193,
198,
Arts and crafts, and office supplies Typewriter correction fluids (TCF) 10 15 Trichloroethane Trichloroethane/ethylene 11* 16 Trichloroethane 12** 18 TCF (unknown ingredients) 32 13* paint ethanol Automotive/aircraft/boat products Ethylene glycol antifreeze 14 26 Ethylene glycol antifreeze 15 28 Ethylene glycol antifreeze 16 37 Ethylene glycol antifreeze 17 44 Methanol gasoline antifreeze 18 24 Methanol 19 27 Methanol windshield wash 20 28 Methanol windshield wash 21 55 Methanol gasoline antifreeze 22’ 55 Bites and envenomations Brown recluse spider bite 23t 69 Chemicals Cyanide 24 25 Cyanide 25*t 26 Cyanide 26* 27 Cyanide 27t 28 Cyanide 28’ 37 Cyanide (capsule tampering) 29 40
200, 236, 237, 238, 249, 290, 294, 304, 324,327,
Inhalation Inhalation Inhalation Inhalation
Int Int Int Int
585 mg/dl
333, 347, 357, 387, 388, 389,
abuse abuse abuse abuse
Ingestion
140 mg/dl
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int unknown Int suicide Int suicide Int unknown Unknown Int suicide Int unknown Int suicide
Bite/sting
Act
gen
Ingestion Ingestion Ingestion Ingestion Inhalation Ingestion
Int Int Int Int Int Int
suicide suicide suicide suicide suicide misuse
525 mg/dl 584 mgldl 200 233 135 203
mg/dl mg/dl mg/dl, mg/dl
>24 hr
2.5 mg/L
411
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 5, Number 5 n September
1987
TABLE15. Continued
Case
Age (yr)
30 31*
41 47
32* 33 34t 35t 364 37 38 39t 40t 41 42 43*t 44
48 52 29 32 62 78 31 22 33 19 >17 58 68
Cyanide Cyanide Cyanide Cyanide (capsule tampering) Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol Hydrochloric acid Hydrofluoric acid Hydrofluoric acid Methylene chloride Methemoglobin producer Strychnine (nux vomica) Sodium hydroxide (lye)
See also case 7 (methylene Cleaning 45 46 47 48t
substances 45 73 74 67
49 50 51 52 53 54
67 84 85 3 39 40 43 55t 56 56 59 57t 58 >17 Cosmetics/personal
Fumes, gases, and vapors 59* >17 60* 6 mo
79*t 80 81’ Fungicides 82t 412
Reason
Inhalation Ingestion Ingestion Ingestion ingestion Ingestion Ingestion Ingestion Ingestion Dermal Ingestion Ing, inh, derm Unknown Ingestion Ingestion
Int suicide Int suicide Act unknown Int misuse Int suicide Unknown Int unknown Unknown Int suicide Act occup Int suicide Unknown Int unknown Act misuse Unknown
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
suicide suicide suicide suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Act Act Act Int Int Act Int Int Int Act
unknown gen gen abuse suicide gen suicide suicide suicide gen
14 17 18 20 21 24 25 25 26 28 28 36 37 53 54 85 >17 20 29 >17 >17 (nonmedicinal) 30
Blood
Levels**
154 mg/dl,
18 hr
720 ~glml!j 88.0%
chloride).
Alkaline drain opener Alkaline drain opener Ammonia (household) Brass cleaner (chromic acid, sodium bisulfateibifluoride) Cationic cleaner Cationic cleaner Cationic cleaner-industrial Spot remover (naphtha) mo Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) Toilet bowl cleaner (HCI) care products
See cases 104 (aftershave,
61* 62 63’ 64’ 65* 66* 67*t 68’ 69 70 71* 72’ 73 74* 75* 76’ 77* 78*
Route of Exposure
Substances
ethanol),
123 (acetone,
nail polish
Anhydrous ammonia Carbon monoxide/burns/smoke inhalation Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke inh Carbon monoxide/smoke inh Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide Carbon monoxide/smoke inh ethanol Hydrogen sulfide Hydrogen sulfide Methane Calcium polysulfidei hydroxypolyoxyethylene
I.emover).
Inhalation
Act occup Act environ
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation
Int suicide Act environ Act environ Int suicide Int suicide Int suicide Act environ Act environ Act environ Act environ Int suicide Int suicide Act environ Int suicide Act environ Int suicide Act environ Act gen
Inhalation Inhalation Inhalation
Act occup Act environ Unknown
Ingestion
Int suicide
31.5% 35.9%
82.2% 58.0% 44.0%, 1 hr
52.40/c, 2-3 44.4% 54.8% 16.3%
hr
LITOVITZ
ET AL n 1986 AAPCC ANNUAL
REPORT
TABLE15. Continued
Age Case
(yr)
Heavy metals 83tS
35
Substances
Route of Exposure
Reason
Copper
Ingestion
Int misuse
40 30 52 64
2,4-D Paraquat Paraquat Paraquat
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
suicide suicide suicide suicide
92t 93*t 94 95*
79 15 23 15 12 13 mo 27 15
suicide misuse suicide unknown gen gen abuse abuse
53
Ingestion Inhalation Inhalation Inhalation Ingestion Ingestion Inhalation Inhalation Ingestion Ingestion
Int Act Int Int Act Act Int Int
96
Carbon tetrachloride Freon Freon lsobutane Lamp oil Mineral spirits Toluene Trichloroethane ethanol Turpentine
Arsenic pesticide Aldicarb Diazinon Diazinon, malathion Lindane Methyl bromide Organophosphate Phosphothioate aftershave (ethanol) Propoxur/pyrethrins/piperonyl butoxide combo Sodium fluoride roach powder
Ingestion Unknown Ingestion Ingestion Ingestion Inhalation lnhal + derm Ingestion Paren + ing
Unknown Act gen Int suicide Int suicide Unknown Act environ Act environ Int misuse Int suicide
Ing + dermal
Act
Combo with methanol/ Acetone/ Isopropanol/ Methylene chloride
Ingestion
Int suicide
Ambrosia artemisiifolia cow parsnip Marah oreganus seeds (tea)
Ingestion
Int unknown
Ingestion
Int abuse
Argon
Inhalation
Act
Brodifacoum Strychnine rodenticide Strychnine rodenticide
Ingestion Ingestion Ingestion
Int abuse Int suicide Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int unknown Int misuse Int suicide Int suicide Int suicide Unknown Int suicide
Blood
Levels**
See also case 150 (lead). Herbicides 84 85t 86 87t Hydrocarbons 88t 89* 90* 91*
See also cases 194 (lighter Insecticides 97 98t 99 100 101t 102t 103 104 105
and pesticides 70 2 41 57 41 16 6 59 24
13 mo 106t Paints and stripping agents 107t 62
fluid/naphtha);
Unknown
7 (toluene).
1.3 kg/ml
gen 104 mgfdl, 2 hr 114 mgldl, 2 hr 101 mgldl, 2 hr
See also case 13 (paint). Plants 108’ 109t Radioisotopes 110* Rodenticides ltlt* 112*t 113’
26 >17 32 35 18 >17
See also case 402 (unknown Analgesics 114 115t 116 lt7tS 118 119t 120 121t 122
20 20 24 25 25 29 63 65 >17
occup
rodenticide).
Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen aspirin
(adult) (adult) (adult) (adult) (adult) (adult) (adult) (adult)
45 67 175 22 172 175 65 739 >590 IO-20
pg/ml, 24 hr pg/ml, >40 hr +g/ml, 4 hr pg/ml pg/ml, 5 hr kg/ml, 13 hr kg/ml pg/ml, 7 hr bg/ml, 20 hr mgldl, 20 hr 413
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 5, Number 5 H September
1987
TABLE15. Continued
Age Case
(yr)
Substances
123t
42
124$
60
125
41
126 127
46 23
128t
65
Acetaminophen (adult) acetone (nail polish remover) Acetaminophen (adult) ethanol Acetaminophen sleep-aid (diphenhydramine) temazepam Acetaminophenicodeine Acetaminophenlhydrocodone ethanol Acetaminophen/oxycodone
129*
19
130$ 131* 132$
26 39 42
133 134
59 66
135 136 137 138 139 140 141 142 143 144 145*
14 24 32 44 48 51 54 70 71 72 63
146$
37
147*
37
148
20
149
22
150
54
151
66
152
64
153t
23
154 155 156
30 25 57
157t 158’ 159t 160*
57 62 78 >17
161 162’ 414
>17 34
Route of Exposure
Reason
Blood
Levels”
Ingestion
Int suicide
Ingestion
Int unknown
45 kgimll
Ingestion
Int unknown
300 pgiml,
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Acetaminophen/propoxyphene
Ingestion
Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophenipropoxyphene acetaminophen (adult) Acetaminophenipropoxyphene Acetaminophenipropoxyphene
Ingestion Unknown Ingestion
Int abuse Propoxyphene Norpropoxyphene Int suicide Unknown Int misuse
Acetaminophen/codeine Aspirin (adult) Aspirin (adult) Aspirin Aspirin Aspirin (adult) Aspirin Aspirin Aspirin (adult) Aspirin Aspirin (adult) Aspirin acetaminophen (adult) Aspirin acetaminophen/oxycodone Aspirin cimetidine Aspirin diphenhydramine Aspirin (adult) diphenhydramine Aspirin (adult) ethanol Aspirin (adult) lead (buckshot) Aspirin (adult) loxapine Aspirin methylene blue Rush (isobutyl nitrate) Aspirin/butalbital/codeine Aspirin/carisiprodol Codeine diazepam acetaminophen Colchicine Colchicine Colchicine Fentanyl diazepam lndomethacin Methadone
3 rJ,g/rnl
12 hr
70 kg/ml, 60 pglml, 1,000 6-12 42 2.8 13.5 216
kg/ml, hrcl ~glml$(i bg/ml§ pg/ml§ ~g/ml~
56 kg/mlc 491 *g/ml” 9 pg/mlF 315 ngiml
Ingestion Ingestion
Int suicide Int suicide Norpropoxyphene
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
Ingestion
Int misuse
Ingestion
Int misuse
Ingestion
Int suicide
100 mg/dl
Ingestion
Int unknown
100 mg/dl
Ingestion
Int suicide
Ingestion
Int suicide
130 mgidl, 170 mg/dl, 59 mg/dl
Ingestion
Int suicide
90 mgldl
Ing + paren
Int unknown
Ingestion Ingestion Ingestion
Int unknown Int suicide Unknown
Ingestion Ingestion Ingestion Parenteral
Int suicide Adv rxn Act misuse Int suicide
Ingestion Ingestion
Int unknown Int abuse
Codeine
>12 hr’l =z4 hrT
0.2 90 125 111 125 144 131 85 79 62 21 92 65 ~8 90
pg/ml mgidl, 14 hr mgidl mgidl, 3 hr mgldl mg/dl mg/dl mg/dl, 11 hr mg/dl mgidl mgldl wg/ml mgldl FgimlB mg/dl
12-15 12-15
115 mgldl
0.63 p.g/ml§ 0.78 pg/mlg# 11 *g/ml§
0.22 p,giml§
hr hr
LITOVITZ
ET AL H 1966 AAPCC ANNUAL
REPORT
TABLE15. Continued
Case 163’
Age (yr) 40
Substances Methadone
Route of Exposure Ingestion
Reason
Blood
Int suicide metab:
164*
39
165*
>17
166 167* 166* 169* 170
Unk 51 15 29 26
171t
37
Methadone triazolam Morphine sympathomimetic Opiate Pentazocine Propoxyphene Propoxyphene Propoxyphene cocaine dextromethorphan Propoxyphene
Ingestion
Int suicide
Parenteral
Int abuse
Parenteral Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
Ingestion
Int abuse Norpropoxyphene
abuse suicide suicide suicide abuse
diazepam 172’ 173
>17 33
Propoxyphene ethanol Sufentanil
Ingestion
Nordiazepam Int suicide
Parenteral
Int suicide
Levels”
14 kg/ml 6 pg/ml
12.5 pg/ml 4,500 ng/ml
1,021 2,766 1.67 62.9
ng/ml ng/ml pg/ml kg/ml
See also cases 190 (acefaminophen); 342, 343, 383 (acefaminophenlcodeine); 192, 233 (acetaminophenlpropoxyphene); 190, 327 (aspirin); 301 (aspirinldihydrocodone); 203, 290 (aspirinloxycodone); 313 (aspirinlpropoxyphene); 340, 397 (codeine); 197 (colchicine); 315, 350 (diflunisal); 245, 302 (ibuprofen); 227 (indomethacin); 315 (meperidine); 196 (morphine); 193, 356 (opiate); 382 (propoxyphene); 330 (salsalate). Anticholinergics 174t
Ingestion
Int unknown
Carbamazepine Carbamazepine Carbamazepine Carbamazepine amitriptyline Phenytoin
Ingestion Ingestion Ingestion Ingestion
Act gen Int suicide Act unknown Int suicide
Ingestion
Act
17 29 32 46
Amitriptyline Amitriptyline Amitriptyline Amitriptyline
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
164 165 166. 167$ 166*
47 46 46 59 59
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
169* 190
66 67
Amitriptyline Amitriptyline acetaminophen (adult) aspirin (adult) Amitriptyline alprazolam Amitriptyline alprazolam acetaminophen/propoxyphene Amitriptyline ethanol opiate Amitriptyline lighter fluid/naphtha flurazepam Amitriptyline glutethimide
Ingestion Ingestion
Int Int
31
Benztropine
amphetamine
See also cases 196, 250 (benztropine). Anticonvulsants 175 176t 177t 176 179t Antidepressants 160 161 162 163
2 19 34 36 3
191’
40
192’
42
193
34
194
16
195
65
gen suicide suicide suicide suicide Nortriptyline suicide suicide unknown suicide suicide Nortriptyline suicide suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
19 kg/ml5 120 kg/ml, 4 hr 55 kg/ml
50 pg/ml,
~4 hr
203 nglml 1,311 ng/ml 625 ng/ml
1,562 3,369 533 1,200
ng/ml# nglml ng/ml ng/ml§#
103 pg/ml, 60 mgidl,
12 hr 12 hr
160 mg/dl,
3-5
hr
415
AMERICAN
TABLE 15.
JOURNAL
OF EMERGENCY
MEDICINE
W Volume
5 n September
Substances
(yr)
Route of Exposure
Int suicide
Ingestion
Int suicide
198*
51
199
46
200
61
201
28
202
18
203
74
204
50
205t
59
206t 207 208 209-f 210
18 36 37 60 40
211 212 213 214 215 216 217* 218 219 220 221 222 223 224
14 17 17 18 25 26 31 37 38 40 43 60 66 47
225’
31
226
20
227*
22
228”
16
229 230
24 34
231
36
Doxepin
Ingestion
232 233
73 50
Doxepin Doxepin acetaminophen/propoxyphene lorazepam
Ingestion Ingestion
33
197
30
Reason
Ingestion
Amitriptyline haloperidol benztropine Amitriptyline lithium colchicine Amitriptyline morphine ethanol Amitriptyline nortriptyline Amitriptyline perphenazine ethanol Amitriptyline propranolol Amitriptyline theophylline (long-acting) Amitriptyline/perphenazine aspirin/oxycodone Amitriptylineiperphenazine diazepam Amitriptylineiperphenazine triazolam Amoxapine Amoxapine Amoxapine Amoxapine Amoxapine perphenazine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine Desipramine alprazolam Desipramine amphetamine Desipramine imipramine Desipramine indomethacin Desipramine thiothixene pindolol Doxepin Doxepin
196’
416
1987
Continued
Age Case
5, Number
Blood
Levels**
4.0 mEq/L Ingestion
Unknown
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Unknown Int suicide Int misuse Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
Ingestion
Int unknown
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide Nordoxepin Int suicide Nordoxepin Int suicide Int suicide
28,000 ng/ml 19,000 ngiml
390 ng/ml#
suicide suicide suicide suicide suicide 4,200 ng/ml$ 1,334 ngiml. : .4 hr 2,518 ng/ml
1,145 ng/ml
1,936 ngiml 1,960 ngiml
3,885 ng/ml
9,900 600 3,413 243
ng/ml§ ng/ml§ ng/ml ng/ml
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
TABLE15. Continued
Case
Age (yr)
234
43
235
35
236*
27
237*
30
238
38
239’
30
240* 241 242* 243’ 244$ 245
31 34 36 45 80 14
246
25
247
20
248*
50
249
33
250
19
251
53
252T 253* 254 255 256 257
64 70 38 49 58 52
258
64
259 260-f 2617 262
22 24 39 54
263T 264
44 30
265T
67
266
66
Substances Doxepin desipramine Doxepin diphenhydramine Doxepin ethanol Doxepin ethanol Doxepin metoprolol ethanol Doxepin phenobarbital lmipramine lmipramine lmipramine lmipramine lmipramine lmipramine alprazolam ibuprofen lmipramine chloral hydrate loxapine lmipramine clorazepate lmipramine diazepam lmipramine ethanol lmipramine perphenazine benztropine lmipramine thioridazine mesoridazine Lithium Lithium Loxapine Loxapine Loxapine Maprotiline amitriptyline/perphenazine Nortriptyline desipramine doxepin Phenelzine Phenelzine Phenelzine Phenelzine alprazolam Tranylcypromine Tranylcypromine /-thyroxine flurazepam Trazodone digoxin Unk cyclic antidepressant
See also cases 778, 376 (amitriptyline); (maprotiline);
293 (nortriptyline);
314 (amitriptylinelperphenazine); 370 (trazodone).
Route of Exposure
Reason
Blood Levels**
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide Nordoxepin
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Act misuse Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide Desipramine
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Unknown Int suicide Int suicide
Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion
Int Int Int Int
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion
Unknown
8,500 ng/ml§ 4.1 kg/m& 1,300 ng/ml 1,400 ng/ml$ 500 ng/ml$ 300 mg/dl§
233 mg/dl 75.3 kg/ml
348 (desipramine);
suicide suicide suicide suicide
325 (lithium);
4,210 ng/ml§
1,078 ng/ml
5,210 ng/ml§ 4,040 ng/ml§
8.5 mEq/L 2.7 mEq/L
140 ng/ml§
5,800 ng/ml 2.0 ng/ml
152 (loxapine);
338
417
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
W Volume
5, Number
5 n September
1987
TABLE 15. Continued Route of Exposure
Age Case
(yr)
Antihistamines 267t
15
Substances
See also cases 147 (cimetidine); Antimicrobials 268
1 mo
12 mo 269*t Antineoplastics 24 270 Asthma therapies 6 mo 271 t* 2 272$ 15 273t 17 274t 28 275 44 276 62 277 65 278$ 70 279* 70 280$ 71 281$ 72 282$ 76 283$ 77 284$ 81 285+ 83 2864 73 287 288t$
72
2894
51
Ingestion
Diphenhydramine
Reason
Int suicide
-
Blood
Levels”
9.7 wg/ml§
148, 149, 235, 355, 394 (diphenhydramine).
Chloramphenicol error) Chloroquine Methotrexate
(lOO-fold
(3 grams)
Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline (long-acting) Theophylline (long-acting) Theophylline Theophylline (long-acting) digoxin Theophylline ethchlorvynol Theophylline (long-acting) phenylpropanolamine
dosing
Parenteral
Act
misuse
Ingestion
Act
gen
Parenteral
Act
misuse
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Parenteral Ingestion Ingestion Ingestion Ingestion Ingestion
Act misuse Act misuse Int suicide Int suicide Int suicide Int suicide Int suicide Act misuse Unknown Act gen Int unknown Act misuse Unknown Act gen Act misuse Act misuse Int suicide
Ingestion
Int misuse
Ingestion
Act
Ingestion
Int suicide
Ingestion Ingestion
Unknown Int suicide
Ingestion
Int suicide
gen
40 41 190 117 108 160 50 60 53 40 120 65 72 36 64 40 82 5.6 40
r*g/ml kg/ml pg/ml pg/ml pg/ml, pg/ml, pg/ml, pgiml pg/ml pg/ml kg/ml kg/ml kg/ml kg/ml pg/ml *g/ml pg/ml ng/ml pg/ml
4 hr l-3 hr 2 hr
57 pgiml 4.7 pg/ml§
See a/so cases 202, 306 (theophylline). Cardiovascular 290’
drugs 55
291t 292
65 15
293’
27
294t
63
295 296t 297* 298 299t 300* 301
4 54 70 71 79 91 34
302
70
303t
78
304t
48
418
Acebutolol aspirin/oxycodone ethanol Amiodarone Atenolol diltiazem Captopril nortriptyline flurazepam Captopril ethanol Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin aspirinidihydrocodone Digoxin ibuprofen Digoxin methyldopa Digoxin metoprolol ethanol
14 kg/ml
1,400 ngiml 90 ngiml Ingestion
Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Act Int Act Act Int Int Int
Ingestion
Int suicide
9.8 ng/ml
Ingestion
Unknown
3.9 nglml
Ingestion
Int suicide
238 mg/dl§ gen suicide misuse unknown suicide unknown suicide
30.8 5 3.4 24.9 3.4 6
ng/ml, ngiml ng/ml ng/ml ng/ml ng/ml,
10 ngiml
2 hr
10 hr
LITOVITZ
ET AL H 1986 AAPCC ANNUAL
REPORT
TABLE15. Continued Route of Exposure
Age Case
Substances
(yr)
305
58
306$
65
307’
90
308 309
16 40
310
25
311’ 312t
29 21
313
68
314
32
Digoxin propranolol diazepam Digoxin theophylline (long-acting) Digoxin triazolam Diltiazem Disopyramide trifluoperazine Disopyramide metoprolol trazodone Encainide Flecainide propranolol Methyldopa aspirinipropoxyphene Metoprolol amitriptyline/perphenazine
Reason
Ingestion
Int suicide
Ingestion
Int misuse
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion Ingestion
Int suicide Int suicide Nortriptyline
315
42
316
64
317
22
318
52
319* 320 321 322* 323 324
85 86 16 55 70 48
325
40
326
51
amphetamine Metoprolol diflunisal meperidine Metoprolol amitriptyline prazosin Nifedipine propranolol clonidine Procainamide nifedipine Procainamide Procainamide (lo-fold Propafenone Propranolol Quinidine Verapamil atenolol ethanol Verapamil lithium Verapamil
See also cases 265, 287 (digoxin);
error)
238 (metoprolol);
Cold and cough preparations Triprolidine/pseudoephedrine 327 19 aspirin ethanol
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
Ingestion Parenteral Ingestion Ingestion Ingestion Ingestion
Act Act Int Int Int Int
Ingestion
Int suicide
Ingestion
Int suicide
misuse misuse suicide suicide suicide unknown
Blood
Levels”
12 ng/ml 35 pg/ml
5,500 nglml
10.9 cLg/rnl§ 1.1 hg/ml§
24.3 kg/m& 510 ng/ml§ 210 ng/ml§
0.3 pg/ml§ 110 ng/ml§#
59 pg/ml
210 mg/dl
228 (pindolol);
1.3 mEq/L 1.1 mg/dl§
201 (propranolol). Ingestion
Unknown 85 mgidl,
8 hr
See also case 170 (dextromethorphan). Electrolytes and 328T Gastrointestinal 329 330t 331t Hormones
minerals Ferrous sulfate 18 mo preparations Dicyclomine 67 Loperamide 40 salsalate Sodium bicarbonate 16 and hormone antagonists
Ingestion
Act
Ingestion Ingestion
Unknown Int suicide
Ingestion
Int misuse
gen
23,000 pg/dl
90 mgidl
See also cases 264, 362 (l-thyroxine). Miscellaneous
drugs
See also case 153 (methylene
blue). 419
TABLE15. Continued
Age Case
(yr)
Substances
Sedative/hypnotic and antipsychotic agents. Alprazolam 332* 69 333 >17 Butabarbital ethanol Chloral hydrate 334 50 335 Chloral hydrate 55 336 53 Chlorpromazine Chlorpromazine 337 63 338* 35 Clonazepam chloral hydrate maprotiline 339’ >17 Ethchlorvynol diazepam Ethchlorvynol 340 33 glutethimide codeine 341’ Ethinamate 54 342’ Glutethimide 18 acetaminophen/codeine Glutethimide 343* 32 acetaminophen/codeine Haloperidol 344t 31 Mesoridazine 345 75 Pentobarbital 346* 87 Pentobarbital 347 18 ethanol Perphenazine 348 35 desipramine chlorpromazine Phenobarbital 349 39 Promethazine 350 37 diflunisal Temazepam 351* 39 Thioridazine 352 59 >17 Thioridazine 353t* Thioridazine 354* 92 haloperidol Thiothixene 355 22 diphenhydramine Triazolam 356 58 Unknown barbiturate 357* 20 ethanol 24 Sleep-aid/diphenhydramine 358 opiate 359” Sleep-aid/diphenhydramine 31
Route of Exposure
Reason
Blood
Levels*’
Ingestion Ingestion
Int suicide Int suicide
Ingestion Ingestion Ingestion Ingestion Ingestion
Int Int Int Int Int
suicide suicide suicide suicide suicide
151 ng/ml
Ingestion
Int suicide
45 kg/ml
Ingestion
Int unknown
Ingestion Ingestion
Int suicide Int abuse
Ingestion
Int abuse
Parenteral Ingestion Ingestion Ingestion
Adv rxn Int suicide Int suicide Int suicide
Ingestion
Int suicide
lnaestion Ingestion
Int suicide Int suicide
Ingestion lnaestion Ingestion Ingestion
Int suicide Int suicide Adv rxn Adv rxn
Ingestion
Int suicide
Ingestion Ingestion
Int suicide Int suicide
Ingestion
Int suicide
Ingestion
Int suicide
30 kg/ml
9 cLg/ml§ 12 5.2 12 0.1
*g/m&q pgiml kgimla pgiml
30.8 kg/ml 27 kg/ml
91 kg/ml, 12-15 0.1 kg/m&$ 260 ~g/ml$ 11 pglL
See also cases 191, 192, 224, 245, 262 (alprazolam); 246 (chloral hydrate); 247 (clorazepate); 156, 160, 171, 204, 248, 305, 382, 386 (diazepam); 288 (ethchlorvynol); 194, 264, 293 (flurazepam); 195, 383 (glutethimide); 196 (haloperidol); 233 (lorazepam); 403 (meprobamate); 251 (mesoridazine); 200, 210, 250 (perphenazine); 239 (phenobarbital); 125 (temazepam); 251 (thioridazine); 228 (thiothixene); 164, 205, 307 (triazolam); 309 (trifluoperazine); 125 (sleep-aidldiphenhydramine); 2 (unspecified benzodiazepine). Stimulants 360* 361 t 362 363t 364 365 366’ 367’ 368 369 370’ 371* 372 373* 374 375’ 420
and street drugs 38 1 15 19 20 20 23 23 25 26 27 28 29 29 30 31
Amphetamines Caffeine (diet aid) Caffeine /-thyroxine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine
Ingestion Ingestion Ingestion
Int unknown Act gen Int suicide
Ingestion Inhalation Parenteral Ingestion Unknown Inhalation Parenteral Inhalation Unknown Ingestion Parenteral Unknown Parenteral
Int misuse Int abuse Int abuse Unknown Int abuse Int abuse Int unknown Int abuse Int abuse Int suicide Int Abuse Int abuse Int abuse
161 mg/dl,
24 pgiml§
0.015 *g/ml§#
>40 hr
TABLE15. Continued
Case
Age (yr)
376’ 377’ 378* 379’ 380’ 381*
35 36 49 50 58 28
382*
33
383
36
384
54
385’ 386T
27 25
387*
29
388
26
389’
27
390’
31
391*
46
392 393’ 394
26 47 29
395 396 397’ 398 399
26 38 27 30 21
400
29
401
33
402
25
403*
29
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine amphetamine Cocaine propoxyphene diazepam Cocaine glutethimide acetaminophenlcodeine Cocaine heroin Heroin Heroin cocaine diazepam Heroin cocaine ethanol Heroin ethanol cocaine Heroin ethanol marijuana Heroin ethanol Heroin methamphetamine codeine Methamphetamine Methamphetamine Methamphetamine diphenhydramine Methylphenidate Methylphenidate Phencyclidine Phencyclidine Phencyclidine cocaine Phencyclidine cocaine Phencyclidine cocaine Phencyclidine rodenticide (unknown Phenmetrazine meprobamate
See also cases 174, 225, 314 (amphetamines); (unspecified sympathomimetic). Topicals 404 405T 406
Route of Exposure
Substances
Unknown Inhalation Parenteral Inhalation Parenteral Parenteral
Unknown Int abuse Int abuse Int abuse Int abuse Int abuse
Ing + paren
Int abuse
Ing + paren
Norpropoxyphene Nordiazepam Int unknown
Blood
Levels**
16 kg/m& 6.2 kg/m@
2.4 9.8 20.8 0.3
pg/ml§# fJ,g/rnlO fJ,g/ml$ pg/ml$
13.4 mgidl 85 PglmlT Parenteral
Int abuse
Parenteral Ing + inhal + parenteral
Int abuse Int abuse
Paren
+ ing
Int abuse
Paren
+ ing
Int abuse
Paren + ing
Int abuse
Paren
Int abuse
160 ng/mI§# 71 mg/dl
+ ing
Parenteral
Int abuse
Unknown Unknown Ingestion
Int unknown Int unknown Int abuse
Parenteral Ingestion Unknown Ingestion Ingestion
Int unknown Unknown Int abuse Int suicide Int abuse
Ingestion
Int unknown
Ingestion
Int abuse
Ingestion
Unk reason
Parenteral
Int abuse
160 ng/ml§# 100 mg/dl§ 98 ng/ml§#
870 ng/ml§#
4.7 pg/ml§#
0.4 pg/ml$
type)
170 (cocaine);
153 (isobutyi
nitrite,
Rush); 289 (phenylpropanolamine);
4 mo 52
Merthiolate (?aspiration) Povidone iodine antiseptic
Ingestion Other
Unknown Act misuse
20
Camphorated
Ingestion
Unknown
oil
* Prehospital cardiac arrest T Abstract of case provided at conclusion of manuscript. $ Chronic exposure; all others are acute 0 Level obtained postmortem ll Acetaminophen level # Level includes metabolite and parent compound * Where multiple blood levels were available, the highest l
Reason
level obtained
is reported.
Time after exposure
165
5 pg/ml§
is unknown
unless indicated. 421
Demographic
Bites and envenomations Fish and coelenterate Insects Bee/wasp/hornet Scorpion Other Mammals Reptile-other/unknown Snakes-exotic Snakes indigenous to U.S. Rattlesnake Copperhead Coral Cottonmouth Nonpoisonous snake Unknown crotalid Unknown type of snake
1,794 1,215 1,221 257 4,487
Batteries Penlightlflashlightidry cells Automotive Button batteries Other/unknown TOTAL 64 2,960 273 1,169 875 60 21 19 6 5 2 84 1 101
1,076
11,597 2,966 3,302 2,598 195 199 303 44 19 37 611 6 1,002
1,283 211 893 155 2,542
556 608 345 449 1,958
1,239 4,546 187 351 13,786
1,561 5,798 249 909 31,345
1,822 998 706 999 4,525
4,088 3,005 370
17,608 4,245 975
15,060
6,642
11,747
18,809
16
Number of Exposures
47 11 5 8 323 2 351
2,602 510 635 848 79 39
238
328 138 166 47 679
148 78 57 105 388
2,367
82 309 18 102 2,801
1,910 278 102
1,490
6-17
Age (years)
225 24 9 26 196 3 526
5,861 2,136 1,433 1,006 51 136
750
171 837 149 51 1,208
1,080 295 293 425 2,093
1,204
226 880 40 445 14,099
11,116 912 480
3,338
>17
301 43 18 37 601 6 995
11,380 2,958 3,247 2,568 195 194
1,058
1,770 1,203 1,202 253 4,428
1,739 992 655 979 4,365
18,542
1,489 5,415 231 601 19,475
6,921 3,920 898
1 0 0 0 1 0 0
2 1 0 8 0 0
3
21 9 17 1 48
72 5 47 16 140
192
48 362 18 278 11,154
10,104 285 61
118
Int
Reason
and Products;
11,581
ACC
Profile of Exposure Cases by Generic Category of Substances
Arts/crafts/office supplies Auto/aircraft/boat products Glycols Hydrocarbons Methanol Other/unknown TOTAL
Adhesives/glues Alcohols Ethanolt lsopropanolt Methanol Rubbing alcohol Ethanol lsopropanol Unknown type Other/unknown TOTAL
TABLE 16.
11
0 0 0 0 4 0 4
3 40 12 0 1
174
13
0 1 0 1 2
1 0 1 1 3
8
3 0 0 12 203
177 7 4
Rxn
Adv
273 41 15 34 129 5 496
2,099 419 757 1,175 39 163
369
194 415 801 50 1,460
672 184 375 316 1,547
875
228 1,102 64 438 14,364
11,106 926 500
2,120
Treated in HCF
Nonpharmaceuticals’
29 2 2 3 153 2 223
759 164 410 474 40 16
51
85 19 11 18 335 1 482
7,953 2,230 1,862 1,237 83 94
662
597 842 110 91 1,440
564 353 166 447 1,530
742 460 377 329 1,908
819 225 798 114 1,956
1,334
249 1,041 51 271 8,813
5,933 959 309
3,577
Minor
10,341
974 3,092 133 299 11,029
3,829 2,267 435
4,757
NOW
92 14 1 8 4 3 50
529 189 153 159 2 44
159
28 99 14 4 145
57 18 25 41 141
62
11 99 4 63 2,002
1,709 89 27
238
Moderate
Outcome
1
37 0 0 1 0 0
24 16 5 2 0 8
2
4 4 0 9
1
21 2 9 5 37
6
2 15 1 8 339
288 14 11
9
Major
0 0 0 0 0 0 0
0 0 0 0 0 0
0
0 0 0 0 0
4 0 5 0 9
4
0 1 0 0 26
19 0 6
1
Death
i?l w
Cleaning substances Ammonia cleaners Bleaches (household) Hypochlorite-containing Other/unknown Cleansers Anionic/nonionic Other/unknown
Building/construction supplies Chemicals Acetone (excluding nail polish removers) Acids Hydrofluoric acid Other/unknown acid Alkali Ammonia Berates/boric acid (excluding topicals and insecticides) Chlorates (excluding matches and fireworks) Cyanide (excluding rodenticides) Dioxin Formaldehyde/formalin Glycols (excluding automotive products) Ketones Methylene chloride (excluding paint strippers) Nitrates and nitrites (excluding medications and abused substances) Phenol/creosote (excluding disinfectants) Strychnine (excluding rodenticides) Toluene diisocyanate Other TOTAL
Spiders Black widow Brown recluse Other/unknown TOTAL
599
164 12 23 2 154
1,538 35 32 2 284 1,198 426
2,335 86
512 18 1.150
2,228 1,078
10 23 4,709 12,933
66 392 9,889 33.945
1,290 59 235 53
9,405 741 5,107 940
4,458
18,000 1,128
6,026 1,199
330
2,070
5,919 1,181
17,495 1,110
6,962 316 832 193
4,310
29 382 9,604 32,856
1,691
686
1,365
1,968
46 328 4,043 16,973
1,034
182
446
1,716 7 20 885 3,146
276
164
265
721
836
2,150 1,063
837 561
153
424 18 1,089
84
2,226
833 4,863 3,130 1,720
1,499
4,269
1,532 534 10,625 36,292
437 13 665
1,404
158 61
732 3,519 1,601 1,002
25 547 288 178
58 756 1,233 548
843 4,982 3,193 1,782
33
411
123
992
1,550
1.530
1,085 403 6,303 20,173
286
199 62 1,787 7,746
2,404
219 60 2,447 8.166
4,316
1,537 538 10,729 36.759
89 14
391 11
123
31 4 187 772
15
33
25
53 10
47 0 43
4 1
23 4
6
1 3 39 107
7
2
4
6 2
23 0 7
1
0
457 152
3,873 205
1,068
50 226 2,875 12,032
596
239
559
592 458
300 8 483
23
475
645 2,372 1,236 594
0 4 3 1
3
301
965
487 381 2,439 9,321
1
12
0 3 79 333
93
5 91 47 48
40
12
2 0 3 21
3,188 824
5,969 485
1,382
15 41 3,340 10.032
351
276
295
928 296
124 2 282
15
1,280
85 901 832 386
583
1,705
293 33 671 3,325
1,137 246
7,346 331
1,844
15 210 2,929 12,885
839
225
745
615 471
480
132
33
265
391 2,611 1,292 965
446
1,154
750 194 6,492 22.508
49 15
480 18
177
5 50 350 1,937
145
20
93
54 60
25 3 53
3
19
208 456 285 84
24
219
209 135 713 2.464
0 0 22
0 26 170
1
2
1
12
0 0
0 0
1
1
12
0 3
2
4
4
4 0
10 0 0
11 2 5 19 1
0
0
4 1
2 1 1 0
0
4 18 24 34 6
0
0 1 0 1
8
12 12 7 127
B 2
z
$ l-
E
%
%
Y
?
1
Disinfectants (household) Hypochlorite-containing Phenol Pine oil Otherlunknown Drain Cleaners Acid Alkali Other/unknown Electric dishwasher detergent Alkali Other/unknown Fabric softeners Cationic Other/unknown Glass cleaners (household) Hand dishwashing detergents Industrial cleaners Acids Alkali Other/unknown Laundry detergents Anioniclnonionic Alkali Other/unknown Miscellaneous Acid Alkali Anionic/nonionic Cationic MethanoVglycols lsopropanol Ethanol Other/unknown Oven cleaners Alkali Other/unknown Rust removers Hydrofluoric acid
TABLE16. Continued
288 377 17
3,418 958 945 64 3,894 5,077 17 140 247 4,786 2,398 723 145 2,619 4,273 1,465 1,262 876 70 1,281 887 47 86
3,801 1,095 1,022 74 4,720 6,598 193 683 807 5,808 2,714 890 423 5,873 5,905 2,418 1,621 1,141 83 1,892 2,488 161 555
29
219 13
40 449 295 190 100 63 5 123
211 70 35
48 70
22 0
72 31
13 24 4
28 78 8
180 255 40
348 121 221 43
6-17
1,390 1,086 4,123 367
<6
Age (years)
3,356 1,705 5,102 598
Exposures
0t
Number
420
1,290 98
226 2,652 1,267 717 246 194 7 444
763 234 126
153 450 470
1,092
504
52 10
263 103
137 144 23
1,574 472 706 178
>17
540
2,456 154
414 5,678 5,775 2,343 1,591 1,076 80 1,847
5,725 2,685 873
190 674 788
6,527
4,631
1,011 73
3,783 1,094
178 243 37
3,295 1,592 4,926 574
ACC
13
24 6
9 172 96 59 25 60 3 37
42 19 8
3 8 17
39
78
3 0
8 0
0 11 2
49 100 147 20
Int
Reason
-
0 0 1
6
1
3 0
2 0
0 0 0
6 0 5 1
0 6 7 7 1 1 0 2
20 4 5
Rxn
Adv
406
945 69
171 2,151 744 566 179 202 14 424
493 394 97
137 363 366
290
320
45 5
250 73
86 113 16
798 364 1,152 147
Treated in HCF
86
474 27
835
125 1,798 2,565 1,047 776 577 41
2,708 1,332 418
136 218
27
2,783
2,543
617 47
2,434 602
21 54 10
869 754 2,792 261
NOlE
287
1,359 72
179 2,414 1,518 749 496 220 21 470
1,736 815 263
114 365 365
1,945
960
117 10
647 192
102 121 16
1,526 492 1,194 194
Minor
93
216 17
42 397 63 66 16 15 3 44
55 80 11
29 82 55
39
22
1 1
21 5
22 28 2
144 28 56 16
Moderate
Outcome
4
11 1
1 46 2 6 1 4 0 1
3 1 0
4 8 2
1
2
0 0
2 0
1 2 0
8 1 6 1
Major
0
0 0
1 0 0 2 0 0 0 0
0 0 0
0 0 1
0
0
0 0
0 0
0 2 0
0 0 0 0
Death
133 13 865 211 827 193 88 578 28,803
19 17 126 55 109 54 27 97 6,101
259 292 1,110 1,309 1,015 751 559 1,386 68,070
2,133 1,595
2,005 1,012 678 2,090 104,546
21,033 875 2,245
732 311 93 616 83 6,574
184 17 194 395 159 199 898 661
509 59 63 271 60 3,576
149 8 92 249 126 278 452 243
19,962 520 2,110 5,636 1,007 69,525
3,051 1,311 2,244 6,606 2,318 1,158 4,460 132
21,268 903 2,274
6,576
1,160 80,214
3,402 1,339 2,552 7,293
2,618 1,655 5,883 1,081
Deodorizers (not for personal use) Air Fresheners Diaper paildeodorizers Other TOTAL
Dyes Essentialoils Fertilizers Fire extinguishers
2,590 1,567 5,827 1,047
3,368 1,337 2,532 7,237
1,138 78,745
6,435
1,048
172
45
1,055
3,019 6,980 1,768 5,497 288 148 748 11,659 1,868 2,897 5,242 5,857
822
2,873 6,170 1,050 4,934 170 111 674 9,609 1,770 2,075 4,896 5,136
3,039 7,094 1,826 5,581 312 152 756 11,917 1,876 3,121 5,289 6,015
76 652 614 388 104 28 47 1,478 44 471 165 500
1,965 992 669 2,041 102,154
2,058 1,581
401 324
1,089 166
76 224 135 228 29 10 24 710 54 549 196 334
416 326
686 103
77 12
324 44
1,110 169
Cosmetics/personal care products Bath oil/bubblebath Creams, lotions,make-up Dental care products Deodorants Depilatories Douches Eye products Hair care products Lipsticksand lipbalms Mouthwash Nail polish Nail polish removers Nail products, miscellaneous Perfumelcolognel aftershave Peroxide Powders Soaps(bar, hand, complexion) Suntan/sunscreen products TOTAL
Other acid Other/unknown Spot remover/dry cleaning agents Starch Toiletbowl cleaners Acid Other/unknown Wall/floor/tile cleaners Alkali Anioniclnonionic Glycols Other/unknown TOTAL 6 1 1 4 135
28 16 5 40 1,880
15 11 7 0
7 71 34 29
9 28
5 0 1 6
12 245
67
16 13 3
2
18
5 952
55
165 11 15
191 32 141
7 21 16 6 6 1 3 57 3 8 3 1
607 181
4 0
64 9
4 65 29 57 16 2 3 159
98 7
1 1
12
13,037 338 1,159
1,167 119 181
137 310 320 341
212 46 329 587
80 5,785
1,532 572 3,353 294
2,041 935 1,545 4,521
537 43,366
3,102
504
164
432
1,649 4,056 897 2,910 98 85 417 5,557 1,031 1,701 2,734 3,554
564 503 361 950 43,491
823 937
184 194
295 55
98 321 173 261 82 28 31 1,121 52 388 316 771
569 125 62 386 19,581
365 46
0 0
16 3
126 752 482 531
433 59 333 825
310 13,900
1,414
2,741 286 560
269
446 582 399 791 129 18 60 2,929 117 540 1,195 1,117
941 239 151 662 33,726
840 241
140 30
559 70
0 0 2 1
27
3 2 5
2 13 28 13 21 24
0
0 26
13
10 453
2
0 0
13 14 36
6
2
0 0 0 0 0 0 0 6 0 3 2 5
4 0 0 1 182
24 0
1 0
3 2
65
20
3 12 13 28 14 1 0 140 2 35 17 30
85 15 5 47 2,746
113 14
12 1
76 10
0
0 0 0
0 0 0
0
0 2
0
0 0
1
0
0 0 0 0 0 0 0 0 0 0 0 1
0 0 0 0 14
6 0
1 0
0 0
2
B
I?
$ D
%
s 8
h
7 P
J
2
r
iz
Herbicides 2,4-D or 2,4,5-T Diquat/paraquat
TOTAL
Fungicides (non-medicinal) Heavy metals Arsenic Copper Lead Mercury Metal fume fever Selenium Thallium Other/unknown
TOTAL
Fumes/gases/vapors Carbon monoxide Chloramine Chlorine gas (mixing household products) Chlorine gas (other) Hydrogen sulfide Methane Polymer fume fever Propane/simple asphyxiants Other/unknown
TOTAL
Food products/food poisoning Foreign bodies/toys/ miscellaneous Bubble blowing solutions Christmas ornaments Coins Dessicants Feces/urine Glass Soil Thermometer Toys Other/unknown foreign body
TABLE16. Continued
541 28
109 142 647 368 66 16 6 390 1,744
399 583 1,181 1,121 836 45 13 1,000 5,178 1,450 224
522
58 298 1,557
547 2,469 13,849 1,203
34 429 40 144 3
673 3,174 439 941 20
8,478 32,431
11,868 41,521 514 37
1,746 1,027 2,168 9,341 1,030 430 1,327 4,392 2,492
1,849 1,089 2,585 10,290 1,161 881 1,462 7,433 2,903
4,287 1,299
9,207
<6
38,891
Number of Exposures
145 19
27 148 162 225 24 3 0 89 678
142
130 217 1,702
34 589 25 102 4
552 49
1,233 4,693
76 38 332 619 44 65 24 1,933 329
4,934
6-17
Age (years)
742 168
248 255 350 440 724 21 6 489 2,533
510
340 1,827 10,110
579 2,096 346 649 13
3,093 1,167
2,024 3,978
19 21 72 250 82 366 102 976 64
23,333
>17
1,428 208
360 564 1,153 1,081 828 34 11 975 5,006
1,188
478 2,423 13,399
660 3,151 434 894 20
4,068 1,271
11,711 41,183
1,841 1,089 2,572 10,232 1,140 869 1,459 7,385 2,885
32,500
ACC
14 11
25 15 21 26 3 6 2 12 110
10
64 29 347
41 0
1
12 15
157 28
69 159
0 0 10 25 14 5 0 29 7
170
Int
Reason
2 2
2 3 1 6 1 4 0 4 21
2
0 8 12
0 2 0 0 0
2 0
22 37
0 0 0 0 2 7 0 2 4
5,767
Rxn
Adv
410 118
208 207 391 284 254 13 7 357 1,721
259
219 1,041 6,158
256 1,231 172 436 5
2,404 394
1,970 4,085
43 54 749 434 65 142 104 384 140
4,366
Treated in HCF
426 71
87 234 120 155 471 10 2 263 1,342
112 176 506 573 70 17 5 337 1,796 490 54
337
477
267 1,127 7,601
470 1,899 212 464 8
44 383 67 163 7 109 462 1,765
2,337 817
1,602 3,317
5,575 21,233 462 88
3 1 9 2 2 16 19 4 6
505 76 289 154 73 129 125 197 167
839 594 1,204 5,614 589 388 766 3,948 1,736
55 6
21 22 31 13 106 2 1 47 243
33
43 173 1,237
80 311 37 57 3
429 104
311 373
1,011
Moderate
12,554
Minor
9,836
NOfW
Outcome
5 1
7 0 4 6 2 0 1 6 26
1
1 12 91
3 14 2 5 0
53 1
25 27
0 0 1 0 0 0 1 0 0
17
Major
1 3
0 1 1 0 0 0 0 0 2
1
0 1 23
0 0 2 1 0
19 0
0 0
0 0 0 0 0 0 0 0 0
0
Death
$
1,811 443
Moth repellents Napthalene Paradichlorobenzene 1,598 383
2,030 519 2,549
2,103 635 2,738
1,356 723 1,850 3,759 19,629
2,809 1,737 2,439 6,286 36,541 868
304 155 357 445 2,908
283 68
612 146
2,403
42 14
190
527
68 13
32 71 103
733
46
189
1,086
2,420
5 92 209 357 10 683
134 43
34 37 71
721
1,073 815 211 1,873 13,087
275 63
267
1,069
30 328 1,205 1,228 30 4,620
2,379 448 347 290 74 1,035 1,236 413 3,310 16,114
222 133 118 116 28 272 256 144 763 5,013
113 1,972 2,932 2,059 211 3,027
328 2,160 1,597 1,958 1,090 2,639 945 840 7,390 24,012
3,097 2,771 2,081 2,386 1,200 3,998 2,510 1,421 11,676 46,005
61 672 5,849
1,271 2,181
8 210 2,745
227 391
149 2,410 4,423 3,743 257 8,583
29 509 4,527
629 1,198
100 1,494 13,271
2,209 3,883
Lacrimators Matches/fireworks/ explosives Matches Other/unknown TOTAL
Insecticides/pesticides (excluding rodenticides) Arsenic-pesticides only Berates/boric acid Carbamates Chlorinated hydrocarbon Metaldehyde Organophosphate alone Organophosphate and carbamate Organophosphate and chlorinated hydrocarbon Organophosphate and other pesticide Piperonyl butoxide alone Piperonyl butoxide and pyrethrins Pyrethrins alone Insect repellants Other/unknown TOTAL
Hydrocarbons Benzene Diesel fuel Gasoline Halogenated hydrocarbons Kerosene Lighter fluid/naphtha Lubricating/motor oils Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other/unknown TOTAL
TOTAL
Other/unknown
1,791 441
2,086 626 2,712
2,353
2,725 1,681 2,401 6,128 35,489
596 144
497
2,300
140 2,336 4,331 3,606 251 8,373
2,979 2,733 1,999 2,369 1,181 2,910 2,344 1,325 11,387 44,590
92 1,453 12,818
2,171 3,807
3 1
8 6 14
27
0 0
0 1 1
6
36 22 7 14 168
1 1
12 1 38 42 13 121 701
0
10
91
25
1 1 8 33 0 34
3 1 0 0 0 1 2 2 12 22
0 0 1
16 20
8 60 63 86 6 135
90 25 78 14 17 68 147 83 220 1,184
5 40 397
16 41
100 130 65 19 25 90 118 27 323 1,222
1,271 935 589 374 159 1,301 1,104 499 3,335 16,574
866 1,211 1,052 1,572 810 1,881 751 540 5,615 19,177
335 33
1,281 282
1,270 352 1,622
265
492
74 69 143
969 559 1,119 3,366 16,356
651 434 230 1,381 8,633
162 44
17 0
2 9 11
84
1,690
65 83 148
109 62 21 120 926
891 581 807 1,177 8,877
3 0
20 2 178 45
237 45 165 35
1
9
142 218 125
4
6 4 0 15 128
13
59
647
971 518
2 3 12 7 0 62
6 8 8 0 9 8 17 2 27 99
1 0 13
4 9
18 239 761 829 14 2,548
4 18 105 86 2 309
9 32 284
95 156
36 623 6,348
705 1,202
32 481 4,366
667 1,211
98 1,393 2,387 1,751 161 3,082 57 465 896 976 50 2,650
980 995 580 297 233 947 900 408 2,798 11,000
46 400 2,416
705 1,233
0 0
0 0 0
0
0 0 0 2 10
0 0
0
0
1 0 2 1 0 4
4 0 1 0 0 1 1 1 2 10
0 0 0
0 4
i?l
cc
424 1,188 6,882 4,437
1,719 7,385 8,854
6,972 39 682 7,693
7,723 103 879 8,705 672
1,458 15
164 22,438 14,233 1,874 263 201 8,670 72,514
236 24,491 15,327 2,167 316 289 10,217 84,409 1,795 126
237 1,627 15 2,373 349 6,782 13,075 213
457 2,097 18 2,924 372 10,082 15,121 295
-
1,425
167 205
151
178 9 38 225
73 16
36 926 478 143 25 37 892 5,171
113 252 1 328 14 990 894 42
482 965 57
6,885 8,588 602
8,330 13,610 842
6-17
87 166
<6
Age (years)
1,480 3,461
1,672 3,926
Number of Exposures
2,734
354 268
84
481 49 136 666
252 90
33 896 520 130 25 48 555 5,921
102 200 2 193 8 2,148 1,024 37
879 3,827 171
92 269
>17
8,496
1,701 7,269
852
7,490 78 825 8,393
1,761 123
221 24,293 15,232 2,143 313 273 10,015 83,204
326 2,051 18 2,883 369 9,882 14,920 265
7,868 13,353 835
1,660 3,892
ACC
9 13
165
89
12
18
199 18 48 265
28 2
7 70 56 9 2 11 94 602
122 35 0 14 1 44 109 28
365 181 4
Int
Reason
51 21 0
1 1
79
2 11
0
3 0 0 3
2 0
7 50 4 12 0 0 48 290
1 4 0 16 0 106 41 1
Rxn
Adv
1,938
237 1,223
185
1,911 54 338 2,303
187 47
62 850 567 272 66 123 886 5,363
192 352 1 202 26 911 999 54
1,744 2,142 112
266 634
Treated in HCF
3,466
809 4,073
357
4,934 44 532 5,510
1,007 23
109 12,766 9,653 1,537 203 162 6,187 47,725
209 1,356 12 1,731 283 4,134 9,205 178
5,910 6,008 441
1,143 2,706
NOW
2,316
446 1,585
114
222 13 63 298
397 58
50 1,006 2,155 195 35 68 971 9,142
108 163 1 137 17 2,679 1,530 27
948 3,130 125
112 318
Minor
199
23 71
23
29 3 10 42
16 5
3 60 78 24 5 21 91 786
52 24 0 12 0 301 111 4
215 289 13
1 18
Moderate
Outcome
l
Abbreviations: act, accidental; adv rxn, adverse reaction; int, intentional. Medical outcome data were also collected in categories labeled “unknown, nontoxic,” “unknown, potentially toxic,” and “unrelated effect.” Thus, the numbers not represent the total poison exposure experience. Patients with totally unknown age, reason or medical outcome were omitted from the respective tabulations. t Excluding rubbing alcohol.
Sporting equipment Swimming pool/aquarium products Tobacco products Unknown nondrug substances
Polishes and waxes Radio-isotopes Rodenticides Anticoagulants Strychnine Other/unknown TOTAL
Mushrooms Paints and stripping agents Photographic products Plants Anticholinergic Cardiac glycosides Colchicine Cyanogenic glycosides Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine (no tobacco products) Nontoxic plant Oxalate Solanine Stimulants Toxalbumins Other/unknown TOTAL
Other/unknown TOTAL
TABLE16. Continued
0 _
0 0
0
1 2 1 4
0 1
0 0 0 0 0 0 1 2
0 0 0 0 0 1 0 0
0 2 0
0 0
Death
listed here do
24
1 10
7
3 5
1
1
1 0
0 4 2 9 0 0 9 48
4 4 0 4 0 6 5 1
22 20 0
0 2
Map
Q
Anesthetics Anticholinergic Anticoagulants
TOTAL
Analgesics Acetaminophen only Adult formulation Pediatric formulation Unknown type Acetaminophen combination with: Aspirin Codeine Oxycodone Propoxyphene Other narcotic/analog Other drug Aspirin only Adult formulation Pediatric formulation Unknown type Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotic/analog Other drug Narcotics Codeine Meperidine Methadone Morphine Pentazocine Propoxyphene Other/unknown Nonaspirin salicylates Nonsteroidal antiinflammatory Ibuprofen Other/unknown Other/unknown
TABLE 17. Demographic
1,983 2,115 1,785
186 144 13 84 835 310 51 22 28 31 125 121 292
5,899 1,757 483 55,629
6,317 2,298 5,659
1,049 697 94 400 3,173 866 417 165 130 317 785 522 520
11,205 4,867 730 102,759 2,466 1,314 271
284 1,070 189 409 118 706
1,277 5,147 1,225 2,246 885 2,523
3,289 3,667 440
4,268 30,615 1,706
<6
13,894 31,973 3,378
Number of Exposures
239 511 30
1,628 763 64 15,527
102 48 16 8 32 98 52 57
149 64 10 46 860
1,815 144 1,564
373 821 160 281 114 511
3,984 1,112 651
6-17
Age (years)
539 1,767 126
3,512 2,239 161 29,969
428 306 125 91 236 537 332 168
692 468 68 259 1,415
2,356 31 2,162
591 3,118 842 1,513 613 1,250
5,316 173 967
s17
3,086 1,976 338
7,221 2,712 562 68,304
459 145 55 67 95 270 237 371
397 293 32 156 1,410
3,027 2,228 2,699
525 2,085 476 781 334 1,134
132 1,501 86
3,665 1,788 143 31,345
333 229 94 48 180 477 238 123
587 360 53 203 1,599
3,096 54 2,788
674 2,709 646 1,353 455 1,284
6,796 211 1,159
Int
Reason
Pharmaceuticals
6,749 31,644 2,140
ACC
Profile of Exposure Cases by Generic Category of Substance,
59 30 11 11 38 22 37 17
41 31 3 32 109
78 8 82
51 250 77 64 65 59
138 50 32
47 128 13
186 276 19 1,876
RXll
Adv
587 2,226 188
4,432 2,339 280 42,619
452 307 115 91 201 577 336 197
722 441 70 256 1,896
3,681 399 3,354
742 3,352 786 1,646 575 1,555
8,391 3,892 1,534
Treated in HCF
1,864 1,311 178
5,641 1,954 372 49,807
251 66 24 30 39 171 102 243
216 163 24 100 1,065
2,349 1,576 2,040
464 1,322 266 558 179 923
6,257 21,955 1,457
NOW
572 1,060 53
1,800 1,086 137 17,001
257 136 32 23 129 234 151 105
361 215 32 121 1,058
1,479 165 1,390
361 1,705 373 737 274 735
2,308 1,098 499
Minor
37 301 15
233 186 33 3,336
42 33 19 11 35 72 49 26
78 41 7 25 173
355 19 388
51 266 77 170 53 130
570 48 146
Moderate
Outcome
13 60 5
30 22 6 586
19 4 9 6 8 19 24 3
17 11 4 3 22
48 2 46
4 43 16 41 9 22
100 13 35
Major
0 1 0
1 7 0 82
1 0 3 2 1 6 4 1
1 2 1 1 1
9 0 12
0 4 2 7 1 0
13 0 2
Death
e 0
Antimicrobials Antibiotics Antifungals Antihelmintics Diethylcarbamazine Otheriunknown Antiparasitics Antimalarials Metronidazole Other/unknown Antituberculars lsoniazid Other/unknown
TOTAL
Antihistamines H, blockers Diphenhydramine Other/unknown
TOTAL
Antidepressants Cyclic antidepressants Amitriptyline Amoxapine Desipramine Doxepin lmipramine Maprotiline Nortriptyline Protriptyline Formulated with a: Benzodiazepine Phenothiazine Other/unknown Lithium MAO inhibitor Trazodone Other/unknown
TOTAL
Anticonvulsants Carbamazepine Phenytoin Valproic acid Other/unknown
TABLE17. Continued
16,277 2,297 1,645 557 42 150 440 38 17
24,260 2,921 2,631 704 114 540 673 189 42
515 3,512 1,538 5,565
61 175 77 157 64 136 7 1,999
433 870 688 1,509 528 1,129 46 14,428
1,285 7,175 3,263 11,723
456 47 141 155 430 46 39 8
540 728 203 45 1,516
<6
3,400 359 717 1,918 1,954 356 458 63
1,516 2,595 402 103 4,616
Exposures
Number of
45 8
18 63 63
97 61
2,946 134
181 1,016 657 1,854
39 96 51 138 14 107 5 1,464
342 20 80 163 319 28 57 5
274 331 61 21 687
6-17
Age (years)
98 17
49 309 160
862 79
4,728 450
568 2,518 1,009 4,095
324 574 538 1,147 432 857 30 10,570
2,503 287 475 1,555 1,162 280 358 48
681 1,467 130 36 2,314
>17
74 23
78 303 544
2,586 688
19,157 2,816
783 4,509 2,227 7,519
113 287 220 551 180 374 12 4,653
1,048 97 245 514 780 106 112 14
940 1,460 315 78 2,793
ACC
98 6
22 148 67
23 9
3,376 66
434 2,412 916 3,762
294 547 417 830 255 680 30 8,940
2,203 244 430 1,315 1,087 237 326 45
506 1,011 76 24 1,617
Int
Reason
12 13
12 83 54
1 6
1,556 30
52 146 81 279
6 13 28 81 84 51 2 460
50 11 24 39 52 6 11 2
53 72 8 0 133
Fixn
Adv
158 20
62 193 126
124 81
4,946 175
627 3,421 1,364 5,412
371 745 555 1,215 409 867 35 11,922
2,896 310 596 1,654 1,537 299 384 49
1,782 175 48 2,965
960
in HCF
Treated
54 17
37 174 354
1,592 416
11,786 1,516
611 2,800 1,500 4,911
36 11
32 147 101
127 72
3,177 383
230 2,029 787 3,046
144 285 203 485 154 436 8 4,471
72 188 105 353 120 253 8 2,790
938 115 222 607 614 105 133 22
461 754 82 26 1,323
Minor
545 51 168 254 500 69 88 16
481 801 207 42 1,531
NOW3
36 5
6 21 8
3 3
302 14
42 363 112 517
70 138 120 177 101 96 6 2,331
693 75 90 353 276 57 76 3
190 297 19 6 512
Moderate
Outcome
26 2
3 1 1
1 0
22 4
9 43 18 70
32 66 40 61 16 15 3 967
349 29 41 161 97 26 31 0
51 41 3 1 96
Major
1 6 0 7
0 5 5 4 6 1 0 100
25 5 21 11 13 1 3 0
4 1 0 0 5
Death
c
Eye/ear/nose/throat preparations Gastrointestinal preparations
Diagnostic agents Diuretics Electrolytes/minerals Calcium salts Fluoride (excluding vitamins) Iron (excluding vitamins) Magnesium salts Potassium salts Sodium salts Zinc Other/unknown TOTAL
Cold and cough preparations Acetaminophen + decongestant/ antihistamine Aspirin + acetaminophen + decongestanv antihistamine Aspirin + decongestant/ antihistamine ExpectoranWantitussives Other formulations for cough/colds TOTAL
Cardiovascular drugs Antiarrhythmics Anti-hypertensives Beta-blockers Calcium antagonists Cardiac glycosides Vasodilators Other/unknown TOTAL
Antineoplastics Asthma therapies Aminophyllinel theophylline Beta-2 agonists Other/unknown TOTAL
Antivirals Other/unknown TOTAL
146
34,926 42,753 119 2,112 3,195 3,189 1,911 62 360 906 390 40 10,053
44,448 221 3,698 3,587 3,511 2,574 133 617 1,200 739 72 12,433 8,118
5,761
18 408
791 3,257
1,340 4,117
55,703
42
91
447
226 246 10 72 151 41 6 898
4,253 5,629
236 381
15
3,737
744
52 163 383 78 94 203 5 978
5,707
224 1,271 1,555 579 720 2,124 41 6,514
1,157 359 41 1,557
1,622 1,449 99 3,170
4,497 2,191 193 6,881
748 2,249 3,535 1,272 1,357 3,129 84 12,374
8
37 11 3,483
89
137 57 21,857
220
282 94 32,450
1,789
81 383 55 172 135 288 26 1,365
225
74 1,141
4,960 6,914
299 461
30
1,164
456 782 1,552 596 529 779 34 4,728
1,624 361 50 2,035
113
102 21 8,875
7,904
3,469 2,171 119 517 1,169 694 63 11,695
3,493
201 2,766
40,005 49,458
1,021 3,830
52
4,550
583 1,713 2,456 1,008 1,074 2,669 65 9,568
2,989 1,809 166 4,964
196
215 79 26,563
112
22 367 9 82 27 20 3 582
52
10 801
3,587 5,143
284 227
37
1,008
127 453 962 226 240 396 14 2,418
71
8 18 3 15 1 19 4 89
21
9 79
623 832
25 66
2
116
35 60 72 29 21 41 3 261
153 83 7 243
9
1,278 287 20 1,585
1,786
13
18
45 13 3,873
1,203
325 1,270 39 194 190 178 15 2,361
150
76 1,529
10,782 13,793
442 740
54
1,775
351 1,445 1,922 606 816 1,048 36 6,224
2,693 813 40 3,546
118
84 27 5,996
4,412
283 28 6,522
1,911 1,246 48 351
1,996
103 1,823
23,174 28,808
652 2,160
37
2,785
344 953 1,824 655 668 1,907 43 6,394
1,569 1,067 103 2,739
109
120 48 16,114
1,557
654 601 32 76 234 202 11 1,964
154
40 747
10,588 12,966
271 781
30
1,296
131 576 601 226 198 403 13 2,148
1,282 600 28 1,910
49
45 16 4,147
86
19 113 3 13 17 41 2 213
5
14 113
684 900
34 69
3
110
31 225 182 53 98 76 1 666
495 66 5 566
4
7 6 411
10
1 16 3 0 2 1 0 25
2
2 22
56 76
2 7
0
11
15 61 44 25 60 13 2 220
87
0
0 1 0 0 0 0 0 1
0
0 0
0 1
1 0
0
0
15 0 0 50
10 4 14 7
21 0 0 21
1
0
84 2 1
0 0 2
1 0 61
3
2,876 280 7,349 691 2,231 2,022 15,449
Hormones and hormone antagonists Corticosteroids Insulin Oral contraceptives Oral hypoglycemics Thyroid preparations Other/unknown TOTAL
Muscle relaxants Sedative/hypnotics/ antipsychotics Barbiturates Long acting Short/intermediateacting Unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone OTC sleep aids Phenothiazines Other/unknown TOTAL
Miscellaneous drugs Allopurinol L-Dopa and related drugs Disulfiram Ergot alkaloids Homeopathic/herbal preparations Other TOTAL
1,448 7,308 696 15,812
2,438 9,029 1,061 19,522
505
834 210 3 3,264 76 21 8 48 12 191 1,649 29 6,345
3,098
1,690 16 19,835 304 307 209 460 203 3,571 6,961 272 36,926
523 2,695 3,739
682 3,828 5,884 2,543
142 70 43 364
206 130 535 487
2,080 32 6,679 375 1,717 1,353 12,236
6,360
<6
6,994
Number of Exposures
Antacids AntidiarrheaW antispasmodics Laxatives Other/unknown TOTAL
TABLE 17. Continued
191 1 1,593 21 15 5 46 29 538 733 46 3,648
430
355
28 306 413
10 4 20 98
191 11 415 57 149 185 1,008
934
1,610
1,222 10 14,390 190 267 191 351 144 2,700 4,415 191 25,821
496 5 6,163 123 52 31 147 28 691 2,979 67 12,390
1,608
606 3,522 4,971
123 793 1,636
1,750
173 112 189 364
2,633 177 7,086 534 2,018 1,707 14,155
1,766 8,554 866 18,059
6,873
ACC
47 55 448 22
566 227 204 249 342 459 2,047
1,045 255 2,286
310 599 98 1,269
>17
336
-
262
6-17
Age (years)
62
1,103 11 12,901 164 245 167 289 168 2,764 3,556 192 22,930
1,370
1,499
41 224 688
26 16 281 98
155 80 222 138 193 246 1,034
593 385 138 1,178
int
Reason
37
29 0 266 12 1 3 8 3 15 293 6 682
46
53
31 69 179
5 1 51 22
78 18 25 14 8 55 198
50 60 51 198
Fan
Adv
1,350 15 14,812 243 289 192 354 180 2,996 5,072 219 27,745
2,023
1,846
152 710 1,569
64 53 380 210
315 158 537 432 643 488 2,573
1,310 1,210 282 3,131
329
Treated in HCF
322 0 3,580 41 24 17 86 14 714 1,907 33 7,602
864
590
385 1,615 2,519
126 70 98 225
564 0 7,246 120 94 67 151 53 1,333 2,345 63 12,955
919
832
90 1,052 1,482
22 20 177 121
211 50 303 121 203 287 1,175
615 2,250 142 3,357
1,095 3,852 525 9,392
1,482 106 4,082 376 1,327 1,014 8,387
350
3,920
Minor
8 1,806 36 66 50 70 32 316 783 34 3,794
231
362
60 0 412 19 34 24 21 5 32 140 10 855
98
46
2 4 20
15 100 198 245
3 2 4 5
2 8 53 20
8 6 3 14 6 6 43
24 7 1 35
126 146 23 313
17 19 6 48 47 33 170
3
Major
18
Moderate
Outcome
3 1 20 4 3 5 1 0 3 18 0 61
3
0
0 1 1
0 0 0 0
0 0 0 0 2 0 2
2 0 0 3
1
Death
Veterinary drug (no human equivalent) Vitamins Multiple vitamins (adult preparations) No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride
Topicals Acne preparations Boric acid antiseptics Calamine Camphor Camphor and methyl salicylate Diaper care products Hexachlorophene antiseptics Hydrogen peroxide Iodine antiseptics Mercurial antiseptics Methyl salicylate Podophyllin Steroids Wart preparations Other/unknown TOTAL
(PPA) PPA and caffeine Other/unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine PPA-containing “lookali kes” Other/unknown TOTAL
Serums, toxoids 8 vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids Phenylpropanolamine
92
260 265 5 0
2,271 2,465 67 22
2,830 3,021 79 23
23 781 161 42 249 9 113 142 126 2,221
803
179 5,495 612 1,229 4,281 19 3,382 1,039 1,519 34,047
265 8,824 1,417 1,426 5,072 50 3,898 1,369 1,957 42,736
80 79
79 38 118 181
26 99 3,541
1,296
945 8,706
1,241 8,936
54 73 4,208
149 443 16,109 370 391 2,359 3,521
902 281 202 9 27 145 65 27
1,876 616 367 427 615 805 200 526
550 559 2,912 4,260
713 37 1,322 121
1,254 29 1,080 60
3,778 185 3,769 2,353
433 160 60 15 182 213 46 114
24
50
214
281 279 7 1
367
58 2,380 619 139 495 22 381 177 284 6,026
203 111
98 122 412 525
68 255 7,783
514 162 98 376 359 400 85 352
1,688 103 1,284 2,039
132
2,632 2,709 74 22
1,270
254 8,609 1,223 1,370 5,020 45 3,862 1,324 1,897 41,803
1,202 8,902
524 538 2,865 4,168
66 132 6,885
1,179 375 239 55 134 260 117 142
1,981 81 1,824 300
148
106 343 10,412
2 2 249
131 273 5 1
55 24 0 0
4
1 8 19 2 11 2 7 8 12 110
7 173 163 50 31 3 15 30 39 673 19
10 3
273 793 20 4
204
48 564 405 159 599 24 88 191 290 4,556
297 120
50 71 248 1,402
959 320 186 390 462 501 102 465
37 13 7 4 7 11 0 5
13 4 2 8
2,506 107 1,929 2,036
87
57 0 87 17
65
28 7
8 12 32 75
78 302 8,690
632 222 116 362 465 520 80 356
1,676 99 1,783 1,999
1
1,460 1,897 46 15
678
130 4,294 669 879 2,866 16 2,196 639 1,089 23,471
604 5,208
260 328 1,614 2,679
38 59 3,709
832 227 138 32 32 108 32 47
1,043 31 962 128
42
262 352 13 3
241
55 1,756 276 81 971 12 229 384 319 6,183
350 532
136 76 253 743
49 128 5,405
463 175 93 98 231 335 93 183
1,152 65 1,515 825
71
21 30 1 0
13
1 59 30 4 32 6 8 18 20 271
16 10
11 4 5 47
13 44 1,568
97 38 22 88 91 67 24 125
357 18 212 372
21
1 2 4 1 6 1 0 3 3 33
0 0
1 1 0 10
2 9 307
13 2 0 63 11 6 0 35
42 2 18 104
1
0 0 0 0
0
0 0 1 1 0 0 0 0 0 3
0 0
0 0 0 1
0 1 57
1 0 0 8 0 0 0 6
11 0 2 28
0
Continued
drug 7,163
preparations) 7,237 11,256 420 1,793 620 637 122 803 1,862 229 638 1,661 33,231
Number of Exposures
2,737
6,498 10,220 402 1,748 493 131 93 609 1,527 181 528 1,326 28,581
<6
1,133
696 989 17 39 42 30 9 52 202 11 44 138 2,779
6-17
Age (years)
3,091
31 44 0 3 77 447 19 131 112 32 63 179 1,706
>17
5,027
7,150 11,130 417 1,782 571 361 102 729 1,756 208 602 1,530 31,775
ACC
1,586
58 98 1 5 29 36 15 37 79 14 23 112 917
Int
Reason
208
7 5 0 0 15 237 4 28 20 7 10 15 427
Rxn
Adv
3,790
265 1,961 66 70 69 83 16 83 105 42 45 362 4,257
Treated in HCF
2,270
4,295 6,874 280 1,317 341 60 62 401 956 135 340 977 19,458
NOM2
1,837
524 1,630 48 93 58 434 13 129 200 13 40 208 4,018
Minor
365
9 70 1 1 3 15 3 5 10 2 2 12 185
Moderate
Outcome
ABBREVIATIONS: act, accidental; adv rxn, adverse reaction; int, intentional. * Medical outcome data were also collected in categories labeled “unknown, nontoxic, ” “unknown, effect.” Thus, the numbers potentially toxic, ” and “unrelated not represent the total poison exposure experience. Patients with totally unknown age, reason or medical outcome were omitted from the respective tabulations.
Unknown
Multiple vitamins (pediatric No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Vitamin A Niacin Pyridoxine Other B complex vitamins Vitamin C Vitamin D Vitamin E Other/unknown TOTAL
TABLE 17.
0
0 0 0 0 0 0 0 0 0 0 0 0 0
Death
listed here do
68
4 15 0 0 0 0 0 0 2 1 1 0 25
Major
LITOVITZ
Hydrochloric-acid-containing toilet bowl cleaners were implicated in six fatalities in 1986, appearing for the first time in this data base. In the group of 13 patients with ingestions of caustic agents, six (46.2%) presented with acute repiratory insufficiency from severe chemical pneumonitis. Significant metabolic acidosis occurred early in five of the 21 deaths involving acetaminophen alone or in combination as a primary agent. Three of these cases were associated with severe hypoglycemia. Case 117 may represent an example of fatal chronic acetaminophen toxicity. In case 119, the delay in treatment resulting from failure to tolerate the oral form of N-acetylcysteine may have contributed to the poor outcome. In the group of cases primarily involving cyclic antidepressants, 28 reports noted the QRS complex, and 20 (71.4%) observed it to be widened. Case 205 is sketchy but suggests a delayed catastrophic deterioration in a cyclic antidepressant overdose. Two cases were reported that demonstrated severe deterioration following the use of physostigmine in cyclic antidepressant poisoning. All five of the amoxapine cases were associated with early seizures, and at least three were refractory to conventional therapy. The reason for the exposure was listed as accidental in 59 (14.5%) and intentional in 313 (77.1%) of the fatal cases. This trend was reversed where theophylline was the primary agent with nine (52.9%) of the 17 cases with known reason classified as accidental and at least two more as intentional but not suicidal (64.7% nonsuicidal). All of the nonsuicidal theophylTABLE 18. Substances Poison Exposures*
Most Frequently
Cleaning substances Analgesics Plants Cosmetics Cough and cold preparations Hydrocarbons Pesticides (includes rodenticides) Topicals Foreign bodies Food poisoning Sedativeihypnoticslantipsychotics Bites/envenomations Chemicals Vitamins Antimicrobials Alcohols
Involved
TABLE 19.
Categories
ET AL W 1986 AAPCC ANNUAL
with Largest
Antidepressants Analgesics Sedative/hypnotics Stimulants and street drugs Cardiovascular drugs AlcohoWglycols Gases and fumes Chemicals Asthma therapies Cleaning substances Insecticides/pesticides/rodenticides Hydrocarbons
Numbers
REPORT
of Deaths
No.
Percentage of All Exposures in Category
100 82 61 57 50 35 23 22 21 14 14 10
0.7 0.1 0.2 0.4 0.4 0.1 0.2 0.1 0.3 0.0 0.0 0.0
line fatalities occurred in the very young or the elderly. The average peak theophylline level was 118 pg/ml in the acute cases and 56 pg/ml in the chronic cases. Hemoperfusion or dialysis was employed in four (21.1%) of the 19 fatal theophylline cases. Five of the 10 digoxin fatalities with levels recorded had peak digoxin levels less than 6 &ml. Case 300 may represent a case of digoxin-specific fab fragment failure in a very elderly patient. The failure to treat early with digoxin-specific fab fragments (secondary to limited availability) or the administration of grossly inadequate amounts occurred in eight of the 13 digoxin fatalities (61.5%) in which digoxin was the primary agent.
REFERENCES
in Human
No.
%t
104,546 102,759 64,409 60,214 55,703 46,005 45,246 42,736 41,521 38,691 36,926 36,759 33,945 33,231 32,450 31,345
9.2 9.0 7.4 7.1 4.9 4.1 4.0 3.8 3.7 3.4 3.3 3.2 3.0 2.9 2.9 2.6
* Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather, often represent only ready availability of the substance. t Percentages are based on total number of known substances (1,135,701) rather than the total number of human exposures cases.
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
Appendix: Abstracts of Fatal Poisoning Cases Case 3. A 60-year-old man was admitted to the hospital with gastrointestinal bleeding. While undergoing a radiologic procedure, he was inadvertently injected with 4 ml of 70% isopropanol via the mesenteric artery. The patient died three weeks later from acute peritonitis and sepsis secondary to bowel infarction from the isopropanol injection. Autopsy revealed extensive necrosis of the small and large intestines. The peritoneal cavity was occupied by a conglomerate, necrotic mass of intestine. Case 8. A 48-year-old man presented after ingesting 435
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methanol. Initially, he was comatose and in full arrest. The initial methanol level was 585 mg/dl (falling to 290 mgldl at eight hours and 188 mg/dl at 14 hours after presentation). Potassium was 9.1 mEq/L; glucose, 466 mg/dl; PO,, 100 mm Hg; PCO,, 43 mm Hg; and pH 6.98. Ethanol infusion and dialysis were initiated within three hours of presentation. Hypotension persisted (40 mm Hg, systolic) despite dopamine. Dialysis was continued for four hours, discontinued for two hours. then performed for another four-hour period. The patient died 19 hours after presentation. At autopsy the ethanol level was 260 mg/dl, and methanol level was 150 mg/dl. Case 23. A 69-year-old woman was hospitalized with a necrotizing gluteal abscess from a spider bite of one week earlier. A brown recluse spider had been found at her home and was the presumed culprit. She was treated with a variety of antibiotics in addition to incision, drainage, and local care. Two weeks following admission, the patient developed refractory lactic acidosis associated with enterococcal sepsis. Cardiac arrest ensued. Case 25. A 26-year-old schizophrenic man told a fellow resident that he was about to take his medications (thiothixene, diphenhydramine, benztropine, methocarbamol, and ibuprofen) and that he should pray for him. Fifteen minutes later, the man collapsed in respiratory arrest. The paramedics found him with apnea and bradycardia and initiated cardiopulmonary resuscitation (CPR). In the emergency department (ED), he was treated unsuccessfully with an external and then internal cardiac pacer, fluids, and isoproterenol. He died 45 minutes after presentation. Later, a suicide note was found with a one-third-empty bottle of potassium cyanide. Cyanide was demonstrated in body tissues on postmortem examination. Case 27. A 28-year-old man presented after an intentional ingestion of cyanide. On arrival he was unconscious with respiratory depression and seizures. The cyanide antidote kit was administered with an immediate response. He was awake and breathing spontaneously when admitted. At live hours after ingestion, he became hypotensive (91/52 mm Hg), with tachycardia (138/min) and tachypnea (48/min). He became comatose and developed respiratory and renal failure; the patient died 15 hours after ingestion. Case 34. A 29-year-old man presented approximately 18 hours after intentionally ingesting ethylene gIyco1. Initial toxicologic analysis revealed ethylene glycol(154 mg/dl).The poison center was contacted 12 hours after presentation. At the time of the call, the patient was severely acidotic (pH, 7.03), was experiencing intermittent seizures, was comatose, and had been dialyzed for an unknown period of time. An ethanol infusion was initiated after prompting from the poison center. He continued to deteriorate and be436
5 W September
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came markedly hypotensive, necessitating a dopamine infusion. The patient died approximately 4.5 days after the ingestion. Postmortem examination confirmed the cause of death as ethylene glycol intoxication. Case 35. A 32-year-old man presented in a coma: empty bottles of aspirin/butalbital and diazepam were brought to the ED as well. On admission, his serum was negative for aspirin and barbiturates; the ethanol level was 9 mg/dl; sodium, 163 mEq/L; potassium, 4.7 mEq/L; glucose, 321 mg/dl; and blood urea nitrogen, 16 mg/dl. Multiple urinalyses were negative for crystals but became trace-positive for blood. Arterial blood-gas sampling revealed a pH of 6.9 and then 7.05 after 500 mEq of sodium bicarbonate. The poison center was first contacted to determine if diazepam was dialyzable. A serum osmolality determination was recommended and was 371 mOsm/kg H,O. An ethanol infusion was initiated. The patient seized and required dopamine for blood pressure maintenance. Because he was too unstable to transfer for hemodialysis, peritoneal dialysis was initiated. An electroencephalogram (EEG) showed no electrical activity. The patient died 24 hours later. Postmortem examination revealed acute tubular necrosis with intratubular calcium oxalate crystals (probably secondary to ethylene glycol) and fatty changes of liver with centrilobular hydropic degeneration. Case 39. A 22-year-old man was exposed to hydrofluoric acid used to clean trucks. He sustained 27% surface area burns to his arms and back. He experienced increasing pain despite three doses of meperidine. Thirty minutes after presentation, the patient became dusky, with circumoral cyanosis and difficulty protecting his airway. Naloxone was administered, and he was intubated. Blood pressure was 90 mm Hg (palpable); pulse, 120/min; and respirations, 24/min. The cardiac monitor showed a widened QRS. All blood specimens drawn were hemolyzed. He arrested 90 minutes after presentation and could not be resuscitated. Postmortem examination revealed massive hemorrhaging in the mediastinum and distal colon. The right lung was edematous. The laboratory reported an unofficial ionized calcium level of I .7 mg/dl because the blood pH could only be raised to 7.15. Case 40. A 33-year-old man intentionally ingested a product containing hydrofluoric acid one hour prior to presentation. The paramedics found him unresponsive, with a pulse of 1IOimin; respirations, 18imin; and blood pressure, 140 mm Hg (palpable). He was given intravenous calcium chloride and sodium bicarbonate, which improved his level of consciousness. At two hours after ingestion, he arrested. Postmortem examination revealed marked pulmonary congestion and hemorrhage, mucosal sloughing in the trachea, esophageal inflammation, gastric mucosal necrosis. and
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
pancreatic autolysis. The blood ethanol level was 80 mg/dl, and fluoride level was 720 pg/ml (normal, ~37
p,g/ml). Case 43. A B-year-old woman accidentally ingested 120 ml of a diluted Christmas tree life extender containing aluminum sulfate, potassium chloride, benzalkonium chloride, and iron. She was asymptomatic, and dilution was the only treatment recommended by the poison center. The patient was determined to empty her stomach and sought ipecac from her family physician. She was given the last remaining ounce of a 4-0~ bottle labeled “for vomiting.” Thirty minutes after the administration of this medicine, she called the physician to report stiffness and tingling throughout her body. The paramedics found her in cardiac arrest. During intubation, her neck and jaw were noted to be stiff. The patient did not respond to the usual resuscitative measures. Postmortem examination revealed severe acute erosions and inflammation of the esophagus and gastrum. Analysis of the gastric contents and blood revealed large amounts of strychnine. Analysis of the tree life extender proved negative for strychnine. It was later learned that nux vomica had been stored in the family physician’s office 30 years earlier by a previous physician tenant. Case 48. A 67-year-old man presented one hour after intentionally ingesting 60 ml of a brass cleaner containing chromic acid, sodium bisulfate, sodium bifluoride, and ammonium chloride. Initially, he complained of chills, abdominal cramps, and watery black stools. Hypertension and dyspnea were noted on examination. Charcoal was administered. At 90 minutes after ingestion, a chest radiograph was normal. At 26 hours after ingestion, the patient developed increased dyspnea and hypotension. A central venous pressure of 6 mm Hg was observed. Vital signs remained stable, although the watery stool continued. Acute renal failure occurred, but he remained conscious and otherwise stable. He died at 115 hours after ingestion despite dialysis (initiated 90 hours after ingestion). Case 55. A 43-year-old woman presented two hours after intentionally ingesting 32 oz of toilet bowl cleaner containing 15% hydrochloric acid. On presentation she had severe oral burns and was frothing a blue-green solution. Her blood pH was 6.7, and sodium bicarbonate was administered. She arrested and could not be resuscitated. Postmortem examination revealed oral burns, gastric perforation, and chemical pneumonia. Case 57. A .59-year-old man was discharged from a health care facility with the diagnosis of “coin lesion” in the right lung and depression. That evening he ingested 32 ounces of a toilet bowl cleaner containing 23% hydrochloric acid and vomited spontaneously. After gastric lavage, he complained of “feeling sick,” with erythematous, swollen lips. He became acidotic
and hypotensive, requiring ventilation and pressor agents. A toxicology screen was negative. On the fourth day after ingestion, he underwent total gastrectomy, pancreatectomy, splenectomy, esophagectomy, cholecystectomy and jejunostomy. Postoperatively, he experienced acute renal failure requiring dialysis, adult respiratory distress syndrome (ARDS), and sepsis. He died on the sixteenth day after ingestion. During surgery, biopsy was done of the “coin lesion” in the right lung; it was found to be benign. Case 67. A 25year-old man experienced arrest after an estimated 5-minute exposure to carbon monoxide from a kitchen fire. His initial carboxyhemoglobin level was 44%. At the hyperbaric facility, he was unresponsive and ventilator dependent, with a pulse of 116/min and a blood pressure of 160/102 mm Hg. The carboxyhemoglobin level fell to 22% after 60 minutes of 100% oxygen and was 2% just prior to hyperbaric oxygen. The carboxyhemoglobin level was 0% after hyperbaric oxygen. Nonetheless, he remained unresponsive. On the second day after exposure, an EEG showed no electrical activity. The EEG was unchanged 24 hours later, and respiratory support was removed. Case 79. A 29-year-old man was trapped while cleaning a meat-processing fat vat thought to be filled with’ hydrogen sulfide. The patient was unconscious and was given 100% oxygen and basic life support by EMTs but could not be resuscitated. Postmortem examination showed acute tracheal bronchitis with severe pulmonary edema and hemorrhage of the lungs. Case 82. A 30-year-old woman presented after ingesting 480 ml of a product containing 26% calcium polysulfide and 10% alpha-@-( 1,1,3,3_tetramethylbutyl) phenyl-omega-hydroxypoly (oxyethylene). She vomited spontaneously and 30 minutes later lost consciousness and seized. She was administered diazepam, sodium bicarbonate, and amyl nitrite. She was subsequently placed in a hyperbaric oxygen chamber, where she manifested a right bundle branch block and arrested. Resuscitation was unsuccessful, and she died 7.5 hours after presentation. Autopsy revealed no significant anatomic findings. Case 83. A 35-year-old woman had been taking copper supplements for eight years on the advice of a chiropractor. She developed progressive hepatic and renal failure. She presented with coma, ascites, anuria, reticulosis, phosphaturia, choreoathetoid movements, Coombs-negative hemolytic anemia, and hypophosphatemia (1.1 mg/dl). Kayser-Fleischer rings were noted in the eyes. She was given 150 mg of dimercaprol and hemodialyzed once. There was a modest improvement in blood pressure, but later she arrested and died. Case 85. A 30-year-old man intentionally ingested paraquat 10 hours prior to presentation. He underwent 431
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intubation and lavage, and received charcoal hemoperfusion. He was given multiple doses of charcoal, and diatomaceous earth retention enemas were administered. He became hypoxic and hypotensive-requiring vasopressors-and then experienced upper gastrointestinal bleeding, metabolic acidosis, and anuria. The patient died on the second hospital day. Case 87. A 64-year-old man presented after intentionally ingesting 180 ml of paraquat. He initially complained of diarrhea and experienced bradycardia and diaphoresis. Atropine was given, followed by charcoal hemoperfusion and administration of diatomaceous earth. He subsequently developed renal failure, fixed and dilated pupils, and hypotension, requiring vasopressors. He had evidence of esophageal burns and pulmonary fibrosis and died 24 hours after exposure. Case 88. A 79-year-old woman presented 9.5 hours after intentionally ingesting 40 ml of carbon tetrachloride. She complained of vomiting and diarrhea although alert with normal vital signs. The leukocyte count was 28,300/mm3; serum glutamic oxaloacetic transaminase (SGOT), 149 U/L; and total bilirubin, 2.1 mg/dl. She was loaded with 9,800 mg N-acetylcysteine, followed by 4,900 mg every four hours, orally. On the second hospital day, her condition rapidly deteriorated. She developed metabolic acidosis, weakness, lethargy, and decreased renal function. The serum SGOT was 1,404 U/L; blood urea nitrogen, 38 mg/dl; creatinine, 2.1 mg/dl; and bilirubin, 2.5 mg/dl. She developed pulmonary congestion and hypotension. At 44 hours after ingestion, she developed asystole and died. Case 92. A 12-year-old boy, with cerebral palsy and mental retardation, accidentally ingested 300 to 360 ml of lamp oil. Initially, he experienced vomiting and coughing, and was cyanotic. The chest radiograph showed a total white-out of the right lower lobe. Secretions were oily and pinkish. The patient required intubation and ventilation. By the third day after exposure, the secretions had become copious and bloody. By the sixth day after exposure, the patient had three chest tubes for pneumothoraces. Dopamine was required for hypotension. By the ninth day after exposure, the patient had a total of five chest tubes, required positive end expiratory pressure (PEEP) at 16 cm H,O and a ventilatory rate of 48/min. On the tenth day after exposure, he developed diffuse subcutaneous crepitus with decreased cardiac and urinary output, and eventually arrested. Case 93. A 13-month-old boy ingested paint thinner (100% mineral spirits). Paramedics observed asystole on arrival but achieved sinus rhythm after intubation. A frothy substance was suctioned from the endotracheal tube. The blood pressure was 84/O mm Hg. Naloxone, dextrose, and sodium bicarbonate were administered. Arterial blood gases revealed a pH of 6.9; 438
1987
PCO,, 53 mm Hg; and PO, 71 mm Hg with positive end-expiratory pressure (PEEP). Diazepam and phenobarbital were administered for seizure activity and dopamine for hypotension. A chest tube was inserted five hours after ingestion. Later, the blood pressure was 95/16 mm Hg; pulse, 164/min; respirations, 56/ min; pH, 7.51; PCO,, 13 mm Hg; and PO,, 471 mm Hg. The drug screen was negative. Urine output ceased and did not respond to albumin or furosemide. Sixteen hours after ingestion CPR was initiated for hypotension and dysrhythmias, resulting in normal sinus rhythm. The patient experienced three more episodes of bradycardia and hypotension, which responded to drug therapy until he died 22.5 hours after ingestion. Arterial blood gases just prior to death were pH, 7.17; PC02. 48 mm Hg; and PO, 75 mm Hg. Postmortem examination revealed chemical pneumonitis. Case 98. A 2-year-old boy presented several hours after exposure to aldicarb. Increased secretions, respiratory depression, miosis, hypothermia, and evidence of aspiration were noted. Initial red blood cell cholinesterase levels were depressed. He arrested 14 hours after exposure and was successfully resuscitated. Large doses of atropine resulted in a heart rate of 1601 min without resolution of rales. An atropine infusion was maintained for three days. Dopamine and insulin were also required. Blood glucose ranged from 150 to 400 mg/dl. On the third day after exposure, exchange transfusions were performed. Seizures developed on the sixth day and were controlled with diazepam. EEGs indicated no brain activity. Life support systems were discontinued on the thirteenth day. Massive amounts of aldicarb and its metabolites were found in the urine. Case 101. A 41-year-old (96-kg) man was being admitted to a mental health facility when he drank 60 ml of shampoo containing lindane. He vomited spontaneously then was given ipecac syrup. Thirty minutes later, he seized. On arrival at the hospital, he was lethargic and diaphoretic, with a blood pressure of 180/80 mm Hg; pulse, 116/min; and respirations, 16/ min. Five minutes later, he arrested and was resuscitated. He underwent lavage and was given lidocaine, phenytoin, charcoal, cholestyramine, and sorbitol. Chest radiograph initially revealed a right lower lobe infiltrate that progressed to diffuse bilateral infiltrates. Clindamycin, tobramycin, and hydrocortisone were added. He remained flaccid and developed pitting edema of the upper extremities. On the fifth day, his creatine phosphokinase peaked at 2,795 U/L, and he was extubated. Arterial blood gas testing revealed a pH of 7.47; PCO,, 32 mm Hg; and PO,, 82 mm Hg on 40% oxygen with respirations of 44/min. On the seventh day, he arrested and could not be resuscitated. Lindane levels were 1.3 pgiml on admission and 0. I pg/ml on the sixth day. The levels at autopsy were
LITOVITZ
blood, 0.02 pg/ml; fat, 1.45 mg/kg; heart, 0.26 mg/kg; and liver, 0.16 mg/kg. Case 102. A 16-year-old boy, intent on burglary, entered a house following methyl bromide fumigation for termites. He was inside for approximately 45 minutes. One hour after leaving the house, be began to vomit and complained of being dizzy. On presentation, his heart rate was 160/min, and pH was 7.0. He experienced respiratory failure from marked pulmonary edema. Benzodiazepines and phenytoin were used to treat seizures. At 16 hours after inhalation he arrested. He was resuscitated but died on the second day after inhalation. Case 107. A 62-year-old woman presented two hours after intentionally ingesting a furniture-refinishing agent containing 20% methanol, 36% acetone, 20% toluene, and 24% isopropanol. She was unresponsive and apneic with a blood pressure of 60 mm Hg, a pulse of 104/min, and no urine output. Levels on admission were methanol, 104 mgldl; acetone, 114 mg/dl; isopropanol, 101 mg/dl; and ethanol, 108 mg/dl. Blood pressures remained at 50 mm Hg in spite of dopamine and norepinephine administration. Charcoal was administered and an ethanol infusion initiated, but the family refused dialysis. She remained unresponsive and hypotensive until her death 48 hours after ingestion. Case 109. A 40-year-old man presented after ingesting a “wild” or “mock” cucumber (Echinocystis) several hours earlier. He developed progressive leg and abdominal cramping. Profound shock and tachycardia were treated with antishock trousers and fluids. Dilated pupils and a hematocrit level of 81%~ were noted. The poison center determined that a mock cucumber was nontoxic, and information on a wild cucumber was not available. The patient developed disseminated intravascular coagulation and refractory shock despite aggressive supportive therapy. Repeated doses of physostigmine and naloxone were ineffective, and he died several hours later. The medical examiner found seeds in the stomach, identified as Marah oregunus (common name, coast manroot). Apparently, the patient had prepared a tea for its hallucinogenic properties. This plant resembles a lemon cucumber. Some of the Marah plants contain flavinoids. This particular plant contained cucurbitacin, which is cytotoxic. Case 111. A 35-year-old man complained of epistaxis, hematuria, gingival bleeding, and bilateral back pain. Examination revealed a blood pressure of 124/70 mm Hg; pulse, 72/min; temperature, 36.8”C; diffuse ecchymosis on left side of body; and an inappropriate affect. Laboratory results revealed a prothrombin time of 60 seconds (control, 12.4 seconds), a bleeding time greater than 15 minutes, and a platelet count of 147,000/mm3. An ingestion was denied, although he
ET AL W 1986 AAPCC ANNUAL
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of bleeding that required later reported “dreams” massive doses of vitamin K, and he was vague on questions regarding ingestion of brodifacoum. Treatment consisted of six units of fresh frozen plasma and massive subcutaneous doses of phytonadione over 24 hours, with gradual return of the prothrombin time toward normal. Oral phytonadione was instituted with a prothrombin time of 15.6 seconds (control, 12.4 seconds) on discharge five days later. He returned to clinic for follow-up, but refused laboratory work. Seventeen days after discharge, he was found in status epilepticus. Computed tomographic (CT) scanning revealed a massive intradural bleed with multiple small hemorrhages. He was pronounced brain dead in the ED with a prothrombin time of 60 seconds (control, 12.6 seconds) and partial thromboplastin time of 86.6 seconds (control, 26.8 seconds). Case 112. An 18-year-old man presented one hour after ingesting a rodenticide. He was comatose, with tonic-clonic activity of both upper and lower extremities. He arrested and was resuscitated in the field. In the ED, he was cyanotic, with a pulse of 122/min; blood pressure, 86 mm Hg; temperature, 38.l”C; and no respirations. Laboratory results included a pH of 6.51; PO,, 269 mm Hg; PCO,, 63 mm Hg; creatine phosphokinase, 430 U/L; glucose, 683 mg/dl; and serum lactate, 39.5 mmol/L. The urine toxicology screen was positive for strychnine only. Treatment included sodium bicarbonate, diazepam, fluids, dopamine, and ventilation. Gastric lavage was performed, and charcoal and magnesium citrate were administered. Tonic muscle activity was controlled with pancuronium bromide after no response to phenobarbital. At 12 hours, hyperthermia developed and was treated with cooling blankets and ice packs. Rhabdomyolysis resulted in renal failure. ARDS, requiring PEEP, was complicated by a pneumothorax. Brainstem herniation secondary to acidosis and anoxia were diagnosed. The patient was pronounced dead on day 5 from refractory hypotension and bradycardia. Case 115. A 20-year-old man presented with vomiting, abdominal pain, and tachycardia 40 hours after an intentional overdose of acetaminophen. He had notified his girlfriend of his intent, but denied the ingestion to police who went to his house to check on him. Oral N-acetylcysteine was initiated. Admission laboratory findings included an SGOT of 2,645 U/L; alkaline phosphatase, 84 IU/L; bilirubin, 4.5 mg/dl; and acetaminophen, 67 pg/ml. On the fourth day after ingestion, the patient became lethargic. Repeat laboratory testing revealed an SGOT of 26,700 U/L; uric acid, 52 mg/dl; and bilirubin, 6.5 mg/dl. He died on the fifth day after ingestion. Case 117. A 25-year-old man, who had been taking acetaminophen throughout the day prior to hospitalization, presented with right-sided head pain. His wife 439
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stated he had been taking two to three acetaminophen every hour. His acetaminophen level, four hours after the last dose, was 22 p,g/ml. The admission laboratory findings included an SGOT of 9,410 U/L; serum glutamic pyruvic transaminase (SGPT), 2,290 U/L; and prothrombin time, 18.3 seconds (control, 11.8 seconds). N-acetylcysteine was given, and he did well until he suddenly deteriorated and died. Case 119. A 29-year-old woman presented 12.5 hours after intentionally ingesting 24.5 g of acetaminophen. The patient vomited spontaneously. The acetaminophen level was 175 p,g/ml 13 hours after ingestion, and N-acetylcysteine administration was begun. The serum salicylate level was 2.7 mg/dl. She continued to vomit and required metoclopramide, promethazine, and nasogastric tube insertion to retain the N-acetylcysteine. She developed progressive hepatic and renal insufficiency requiring lactulose, a proteinsparing diet, and dialysis. Approximately 30 hours after ingestion, the SGOT was greater than 5,000 U/L; SGPT, greater than 5,000 U/L; and lactate dehydrogenase, greater than 6,000 U/L. On the third hospital day, prothrombin time was 77 seconds (control. I I seconds), and arterial ammonia was 280 mmol/L, rising to 597 mmol/L on the fourth day. She died from multiple organ failure on the fifth hospital day. Case 121. A 65-year-old woman presented with a history of lethargy for two days prior to an intentional ingestion of acetaminophen. She was unresponsive on examination. The seven-hour acetaminophen level was 739 kg/ml, and the 16-hour level was 503 kg/ml. Toxicology screening was positive only for acetaminophen and benzodiazepines. The patient was started on oral N-acetylcysteine by 12 hours after ingestion. Admission laboratory findings included an SGOT of 715 U/L; bilirubin, 1.5 mg/dl: prothrombin time, 13 seconds; glucose, 29 mg/dl (240 mg/dl after 2 g dextrose); pH, 7.08 (after 100 mEq of bicarbonate): PCO,, 30 mm Hg; and PO,, 106 mm Hg. On the second day after ingestion, intubation and pressor therapy (dopamine and levarterenol) were required. The patient developed progressive cardiac and renal failure and died later that day. Case 123. A 42-year-old woman presented with lethargy three days after intentionally ingesting acetaminophen, nail polish remover (87% acetone), and a liquid cough and cold preparation. Vital signs were a temperature of 36°C; pulse, 130/min; respirations, 451 min; and blood pressure, 120/70 mm Hg. Hepatic and renal failure developed with coagulation defects, hypoglycemia, and encephalopathy. Hypotension did not respond to 4 L of saline but did respond to dopamine. Naloxone, 50% dextrose, sodium bicarbonate, and calcium chloride were administered. The initial acetaminophen level was 3.3 Kg/ml; alkaline phosphatase, 241 III/L; creatinine, 6.1 mg/dl; blood urea ni440
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trogen, 20 mg/dl; albumin, 3.5 g/d& salicylate level, 34 mg/dl; lactic acid, 15.4 mEq/L; CO,, 12 mEq/L; and glucose, 42 mg/dl. A full course of oral N-acetylcysteine was given. Hemodialysis and filtration were done to treat renal failure. Ten days after ingestion, a CT scan documented severe cerebral edema. The patient progressively deteriorated and died 21 days after ingestion. Laboratory
Tests SGOT
SGPT
Bilirubin
Day
(U/L)
(U/L)
(mg/dl)
Prothrombin Time (seconds)
3 6 8 11 12 20 21
20,920 1,278 296 118 88 -
2,950 654 330 123 81 -
7 9 10 18 16 31 36
43 21 23 15 -
Case 128. A 65-year-old woman presented six to 12 hours after intentionally ingesting up to 80 500-mg acetamiuophen 15-mg oxycodone capsules. Initially, she was comatose, with apnea, hypotension, and fixed and dilated pupils. Gastric lavage was performed and charcoal given. Naloxone (1.6 mg) was given with no level was response. The admission acetaminophen 1,000 Kg/ml. N-acetylcysteine was administered, and levarterenol was required to maintain the blood pressure. On the first day after ingestion, the patient remained on the ventilator and pressor infusion and developed signs of impending liver failure. She died later that day. Case 153. A 23-year-old man presented two hours after intentionally inhaling isobutyl nitrite and ingesting salicylates. On arrival he was hallucinating and vomiting. Salicylate concentration was 115 mg/dl. Three hours after presentation, cyanosis appeared, which was unresponsive to oxygen and methylene blue. It was learned that the patient received 70 ml of methylene blue (1%) instead of the recommended 7 ml. He arrested eight hours after ingestion and died. The methemoglobin level was 30% prior to the arrest. Case 157. A 57-year-old man presented two days after intentionally ingesting 15 mg of colchicine. He complained of vomiting, diarrhea, and anorexia and was hypotensive and febrile. Laboratory findings included leukocytosis and elevated renal function parameters. Multiple doses of charcoal were attempted, but vomiting continued during the next 24 hours. The hypotension was refractory to fluids and necessitated dopamine. Renal function deteriorated, and aspiration pneumonia developed, requiring antimicrobial therapy. On the fourth day after ingestion, bleeding
LITOVITZ
occurred from multiple sites and renal failure required peritoneal dialysis. He experienced leukopenia and ARDS and died on the fifth day after ingestion. Case 159. A 78-year-old man presented with diarrhea, weakness, and inability to walk. He had received a prescription for colchicine 10 days prior to admission, and only 14 of 60 tablets remained. His heart rate was 98/min; blood pressure, 104/70 mm Hg; respiration, IWmin; and temperature, 35.8”C. Mucous membranes were dry, and his skin “tented” secondary to dehydration. There was no sensation in the lower extremities, and no deep tendon reflexes, only sensation around the trunk. Laboratory studies revealed renal insufficiency (creatinine, 5.6 mg/dl; blood urea nitrogen, 54 mg/dl), leukopenia (leukocyte count, 1 ,600/mm3), and thrombocytopenia (platelets, 110,000/mm3). He became hypotensive but was otherwise stable for 48 hours. Then he became progressively unresponsive, went into third-degree heart block and arrested. Postmortem examination revealed bilateral lower lobe congestion, mild splenomegaly, and mild hepatic fibrosis. Case 171. A 37-year-old man was admitted to the psychiatric ward of a hospital. Two days later he was found in cardiopulmonary arrest. He responded to intubation, lidocaine, and naloxone. Blood pressure was 90 mm Hg, and body temperature was 35.8”C. Toxicologic screen revealed diazepam, 1.67 p,g/ml; nordiazepam, 6.29 kg/ml; propoxyphene, 1,021 &ml; norpropoxyphene, 2,786 ng/ml. Seizures were refractory to phenytoin, phenobarbital, and paraldehyde but responded to general anesthesia. Aspiration pneumonia occurred, and the patient progressively deteriorated over the next two weeks. Case 174. A 31-year-old man presented with an altered mental status, hyperthermia (42.7”C), tachycardia, and hyperkalemia (7.4 mEq/L). The delirium was treated with haloperidol and benztropine. It was later learned that he ingested benztropine several hours earlier. Toxicologic screen was positive for benzodiazepine, nicotine, amphetamines, and phenobarbital. Multiple doses of physostigmine were given without result. Dantrolene sodium was used for the hyperthermia. He developed refractory ventricular arrhythmias and died. Case 176. A IPyear-old man presented four hours after intentionally ingesting carbamazepine, temazepam, aspirin, and levothyroxine. He was unconscious, with a blood pressure of 120/80 mm Hg; a pulse of 130/min, and shallow respirations. Intubation, ventilation, and lavage were done, and charcoal and a cathartic were administered. A grand ma1 seizure was treated with diazepam, and dopamine was required for persistent hypotension. The admission carbamazepine level was 120 Kg/ml, which decreased to 63.6 pg/ml after three hours of charcoal hemoperfusion. Seven
ET AL m 1986 AAPCC ANNUAL
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hours later, the level rebounded up to 108 &ml then fell to 75 p,g/ml after three additional hours of hemoperfusion. Subsequently, he arrested and was initially resuscitated but died after a second cardiac arrest 35 hours after ingestion. Blood toxicology results were also positive for salicylates 21 mg/dl and temazepam 178 ng/ml. The thyroxine concentration was 21.9 pg/dl. Postmortem examination revealed pulmonary edema. Case 177. A 34-year-old mentally handicapped man presented in a coma and seizures. Vital signs included a blood pressure of 50 mm Hg and a pulse of 75/min. He underwent intubation, ventilation, and lavage. Dopamine, levarterenol, and charcoal were administered. The initial carbamazepine level was 54.8 p&ml. Seizure activity persisted despite diazepam, phenytoin, and phenobarbital administration. Ventricular tachycardia was treated with lidocaine. At seven hours after the first poison center call, hyperthermia (41.9” C) occurred and was treated with acetaminophen, cooling mats, and ice packs. By 16 hours, the seizure activity had ceased, and the temperature was 38.1” C rectally; pulse, 120/min; and blood pressure, 112/60 mm Hg. By 28 hours, the carbamazepine level had dropped to 12.7 kg/ml. At 52 hours, he was obtunded and anuric. He died at 72 hours. (All times are referenced to the first poison center contact.) Case 179. A 3-year-old boy presented one hour after ingesting six or more phenytoin capsules. He was ataxic, and emesis was induced with ipecac syrup. Five hours after ingestion, the child was agitated, with tachycardia (130/min) and tachypnea (40/min). Nine hours after ingestion, he experienced a respiratory arrest and was resuscitated. Coma was noted 12 hours after ingestion. A toxicology screen also revealed benzyl alcohol. Multiple doses of charcoal were administered. Pertinent laboratory findings included sodium, 125 mEq/L; potassium, 2.9 mEq/L; arterial pH, 7.3; and PCO,, 30 mm Hg. At 24 hours postingestion, diabetes insipidus developed, requiring vasopressin. On the third day after ingestion, an EEG showed “minimal” activity; he died later that day.
Time After Ingestion lh 12 h 18 h 24-48 h
Case scious zolam, lavage,
205. after and and
Plasma Phenytoin Levels (kg/ml) 50 47 43 40
A 59-year-old man was admitted unconingesting amitriptyline/perphenazine, triadiazepam. He underwent intubation and was given charcoal and a cathartic. His 441
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vital signs were “unremarkable,” with a pulse of 80/ min. He was extubated nine hours after admission. Multiple doses of charcoal were given. He was awake and walking 24 hours after admission. Unexpectedly, he seized, then arrested. The coroner concluded that the death was from cardiac dysrhythmias. Case 206. An 1%year-old woman intentionally ingested amoxapine. At first she was alert and responsive. She was given ipecac and experienced seizures prior to emesis. The seizures continued despite diazepam, phenytoin, phenobarbital, and sodium bicarbonate administration. She underwent intubation, ventilation, and lavage, and was given charcoal, a cathartic, and physostigmine. The vital signs and cardiac rhythm were normal, and the seizure activity stopped. Later she was described as “bleeding from every orifice” and was unresponsive to any stimuli. The patient died on the third day after ingestion. Case 209. A 60-year-old woman presented two hours after ingesting amoxapine. A sinus tachycardia was noted, and subsequently she seized. The seizures responded to diazepam, and she was loaded with phenytoin. She underwent intubation and lavage, and was given charcoal, a cathartic, and sodium bicarbonate. Arterial blood gases obtained two hours after ingestion disclosed a pH of 6.97. Five hours after ingestion, seizures recurred and were unresponsive to diazepam, phenytoin, and phenobarbital. Physostigmine was administered, resulting in bradycardia and hypotension. Levarterenol was administered without response, and the patient arrested and died. Case 252. A 64-year-old woman presented the morning after intentionally ingesting lithium carbonate. She complained of nausea and vomiting but was alert, oriented, and without tremors. The electrocardiogram (EKG) was normal, and the lithium level was 8.5 mEq/L. Charcoal and a cathartic were administered. Urine output was low. The lithium level on the second day after ingestion was 6 mEq/L. The patient continued to be alert and oriented. Mannitol and intravenous fluids were given, and urine output increased to 100 ml/h. Vital signs and the EKG were normal. On the third day after ingestion, she became more lethargic, with a lithium level of 7.1 mEq/L. The urine output was 20 ml/h, and the blood urea nitrogen and creatinine were 47 mg/dl and 4.2 mgidl, respectively. The patient was hemodialyzed. On the fourth day after ingestion, she arrested and was resuscitated. The lithium level at that time was 5.6 mEq/L. Hypotension (60 mm Hg) occurred and was refractory to levarterenol. Electromechanical dissociation led to her death on the fifth day after ingestion. The toxicologic screen was positive only for lithium. Case 260. A 24-year-old man presented 14 hours after intentionally ingesting 1.5 g of phenelzine. While initially awake and alert, by 24 hours after ingestion 442
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he was comatose and tremulous with tachycardia (170/min). His blood pressure was normal, but he experienced frequent seizures. The supraventricular tachycardia was treated with propranolol but converted to refractory ventricular tachycardia. He died on the second day after ingestion. Case 261. A 39-year-old man presented 10 hours after intentionally ingesting phenelzine (3.8 to 8.8 mg/kg). He was diaphoretic and tremulous. Blood pressure was 104/50 mm Hg; pulse, 64imin; respirations, 16/min; and temperature, 35.9” C. The toxicology screen revealed trifluoperazine and phenelzine. Lavage was performed, and he was given serial doses of charcoal, a cathartic, and fluids. Increasing confusion and rigidity required diazepam and restraints. By 36 hours after ingestion. his pulse was 17Olmin, blood pressure fell to 70 mm Hg, and body temperature was 42” C. The hypotension was refractory to usual therapy including dopamine and norepinephrine. Hyperthermia responded to acetaminophen, cold packs, a cooling blanket, and dantrolene. Refractory pulmonary edema, disseminated intravascular coagulation, and hypercarbia occurred. The pressure fell to 40 mm Hg and was unresponsive to calcium and glucagon. At 43 hours after ingestion, fatal electromechanical dissociation ensued. Postmortem examination revealed marked pulmonary edema and a blood phenelzine level of 140 ng/ml. Case 263. A 44-year-old man was found unresponsive after intentionally ingesting tranylcypromine (up to 900 mg). He was tremulous with mydriasis. Vital signs included respirations 18/min; blood pressure, 102/72 mm Hg; temperature. 40.4” C: and pulse. 1301 min. The EKG demonstrated atria1 fibrillation with a QRS duration of 0.11 seconds. He underwent intubation and lavage, and was given charcoal and a cathartic. Arterial blood gases revealed a pH of 7.27, PCO,, 57; and PO*, 100 mm Hg. Three hours after admission of the patient, a grand ma1 seizure was treated with diazepam and phenytoin. Body temperature increased to 42.5” C. After the seizure, he became hypotensive but responded to fluids and dopamine. He was acidemic and anuric. Intermittent wide complex arrhythmias developed, which rapidly deteriorated to ventricular fibrillation. He died from refractory electromechanical dissociation four hours after presentation. Case 265. A 67-year-old diabetic woman (history of congestive heart failure) intentionally ingested trazodone. The patient was on digoxin therapeutically and had a digoxin level of 2.0 ng/ml on admission. Bradycardia (5O/min) with a good pulse was noted. The QTc interval was 0.54 seconds, and QRS was 0.1 seconds. The serum trazodone level was 5,800 &ml. Later that day, the patient experienced ventricular tachycardia, then fibrillation. She was intubated then shocked into
LITOVITZ
asystole. Isoproterenol resulted in a sinus rhythm with pulses. “Torsades de Pointes” developed, which responded to overdrive pacing. Rigidity and decorticate posturing were observed. On the fourth day after ingestion, she was extubated, and the pacer was removed. She was very lethargic and answered some questions appropriately. The QT interval gradually returned to normal (0.43 seconds). On the seventh day after ingestion, she arrested three times. Thereafter, she was unresponsive and died on the nineteenth day after ingestion. Case 267. A 15year-old girl presented two to four hours after intentionally ingesting 6,250 mg of diphenhydramine. She was seizing, and had a temperature of 41.8” C, a pulse of 160/min, and marked acidosis. The seizures was unresponsive to diazepam, phenytoin, and physostigmine, so the patient was paralyzed with pancuronium. She underwent lavage and was given charcoal. The pulse decreased to 120/min after physostigmine. The patient developed refractory asystole and was pronounced dead five to seven hours after ingestion. The postmortem blood diphenhydramine level was 9.7 pglml and liver was 52.6 p.g/g_ Case 269. A 12-month-old girl ingested 1 g of chloroquine. Unaware of the toxicity, the parents allowed the child to go to sleep. They found her unresponsive 30 minutes later. The child presented in a full cardiopulmonary arrest. She was resuscitated but manifested refractory hypotension. Ventilatory support was terminated on the third day after ingestion. Case 271. A 6-month-old boy was hospitalized for pulmonary insufficiency from bronchopulmonary dysplasia and right ventricular hypertrophy. The admitting theophylline level was 2 ).&ml, and the dosage was increased. Within two days, the level increased to 24 pg/ml, and the dosage was decreased. However, 24 hours later the level was 40 t&ml, and he manifested tachycardia and shock. Theophylline was discontinued, and charcoal and a cathartic were administered. Seven hours later the level decreased to 33 kg/ml, but the pulse was 190/min. Three hours later refractory asystole occurred, and the patient died. Case 273. A 15year-old girl presented after intentionally ingesting 30 g of sustained-action theophylline. The initial blood level was 88 pg/ml. She was obtunded, with tachycardia (120 to 130lmin) and hypotension (100 mm Hg). Charcoal hemoperfusion was performed but the theophylline level was 190 pg/ml afterward. Ventricular fibrillation occurred but was refractory to treatment. She was placed on cardiac bypass from which she could not be weaned. Case 274. A 17-year-old girl presented several hours after intentionally ingesting 2.9 g of sustainedrelease theophylhne. Her pulse was 190/min and blood pressure was 110/80 mm Hg; and she seized. Her initial theophylline concentration was 93 l&ml, and a
ET AL n 1986 AAPCC ANNUAL
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second level was 117 t&ml. Fourteen hours after ingestion she was given pancuronium and thiopental for the seizures and dopamine and levarterenol for hypotension. Body temperature reached 40.1” C despite external cooling. Hemodialysis was not performed at this time because of extreme hypotension. On the second day after ingestion, her theophylline level was 80 pg/ml. She developed refractory ventricular fibrillation and was pronounced dead 38 hours after ingestion. The urine toxicology screen revealed no other drugs. Case 288. A 72-year-old woman had been chronically abusing ethchlorvinyl and theophylline. She presented with ataxia, vomiting, and multifocal atria1 tachycardia (140/min). The theophylline level was 40 kg/ml with a potassium level of 1.9 mEq/L. The theophylline level decreased to 29 pg/ml, and the potassium level increased to 2.9 mEq/L. She developed respiratory failure from aspiration pneumonia and sepsis. The potassium eventually increased to 4.2 mEq/L before she died. Case 291. A 65-year-old woman presented with suspected amiodarone toxicity. The EKG revealed a sinus arrest with a ventricular escape rate of 40/min. Atropine, isoproterenol, and glucagon were ineffective. The pulse remained at 40/min, with a palpable blood pressure of 80. Three hours after admission it was decided that no further life-sustaining measures were to be initiated. The serum amiodarone level was 14 t&ml (toxic is 2.5 to 6.7 pg/ml). The patient died 24 hours after admission. Case 294. A 63-year-old woman presented after intentionally ingesting 1 g of captopril and some ethanol. She was comatose with miotic pupils, a blood pressure of 72 mm Hg, and a pulse of 10Wmin. Arterial blood gases revealed a pH of 7.17; P02, 45 mm Hg; and PCO,, 45 mm Hg. She underwent intubation and lavage, and was given fluids, naloxone, dopamine, and charcoal. The hypotension did not respond, and she died within six hours of presentation. Blood ethanol at postmortem examination was 238 mg/dl. Case 296. A 54-year-old man presented two hours after intentionally ingesting digoxin. The pulse was 36/ min; temperature, 36. I” C; respirations 24/min; and blood pressure, 96/60 mm Hg. The digoxin level was 30.8 ng/ml, and potassium was 6.1 mEq/L. Lavage was performed and phenytoin infused. Eight hours after ingestion, he became confused and suddenly developed a complex ventricular dysrhythmia. He died nine hours after ingestion without receiving digoxinspecific Fab fragments. Case 299. A 79-year-old male physician was admitted to rule out a myocardial infarction. A routine serum digoxin level, available seven hours after admission, was 24.9 rig/ml. While the digoxin-specific antibody was en route, he arrested but was revived. 443
AMERICAN JOURNAL OF EMERGENCY MEDICINE W Volume 5, Number 5 n September 1987
He was stabilized on dopamine, epinephrine, and a pacemaker. A digoxin level drawn 17 hours after admission was 16.4 ng/ml. The digoxin-specific Fab fragments were administered 19 hours after admission with little improvement. He experienced arrest again 39 hours after admission and died. An autopsy did not identify any other likely cause of death. Case 303. A 78-year-old woman became toxic on prescribed digoxin and methyldopa. She complained of nausea and vomiting, with confusion and decreased bowel sounds noted. An idioventricular rhythm (40/ min) was observed, and the blood pressure was 90 mm Hg. The digoxin level was 3.9 ng/ml, and potassium was 3.9 mEq/L. Atropine increased the pulse to 801 min with occasional premature ventricular beats. The blood pressure increased to 110 mm Hg with a dopamine infusion. She appeared stable for several hours until she developed sudden refractory ventricular fibrillation. The patient did not have a repeat digoxin level assay done and never received digoxin-specific fab fragments. Case 304. A 48-year-old man intentionally ingested digoxin, metoprolol, and ethanol. On arrival he was awake and moaning with a pulse of 30/min. The digoxin level was 10 ng/ml, and digoxin-specific antibodies were requested. While awaiting their arrival, a pacemaker was inserted but did not capture. The patient died seven hours after presentation, before digoxin-specific antibodies could be procured. Case 312. A 21-year-old woman presented one hour after intentionally ingesting up to 2 g of propranolol and 12 g of flecainide. These drugs were prescribed for her chronic ventricular tachycardia. Her blood pressure was 70/40 mm Hg; pulse, 70/min; respirations 201 min. She developed first-degree heart block 80 minutes after ingestion. She was treated with a theophylline infusion, a transcutaneous pacer, atropine, and dopamine. Two hours after ingestion, she was comatose, the QRS widened, and third-degree heart block was diagnosed. Three hours after ingestion, asystole occurred, which was unresponsive to standard pharmacologic intervention, glucagon, pacing, and open-heart massage. She was pronounced dead 6.5 hours after ingestion. The serum flecainide level at the time of death was 3.2 kg/ml, and postmortem levels were blood, 10.9 kg/ml, and liver, 256 p,g/g. The postmortem blood propranolol level was 1.1 p,g/ml. Case 328. An 18-month-old child presented four hours after ingesting ferrous sulfate. The child was unconscious, and the serum iron level six hours after ingestion was 23,000 pg/ml. Intravenous deferoxamine was initiated at 15 mg/kg/h. At 12 to 16 hours after ingestion, hypotension occurred, which responded to fluids. At 24 hours after ingestion, an acute surgical abdomen was diagnosed. An exploratory laparotomy revealed 40 cm of necrotic bowel at the distal ileum, 444
with perforation and peritonitis. Broad spectrum antibiotics were administered. The serum iron at 24 to 30 hours after ingestion was 200 pg/dl. By 48 to 72 hours after ingestion, elevated liver function tests, bilirubin, and prothrombin time were noted. By 72 hours after ingestion, the child’s sensorium cleared. All liver functions returned to normal with supportive care. Respiratory insufficiency beginning seven days after exposure led to the patient’s death on the fourteenth day after ingestion. Case 330. A 40-year-old woman presented after ingestion up to 40 mg of loperamide and an unknown amount of salsalate. Lavage recovered many green tablet particles. She had tachycardia, with a blood pressure of 100/60 mm Hg and respirations of 36/min. Naloxone and sodium bicarbonate were administered. The salicylate level was 77 mg/dl initially and 90 mg/dl 2.5 hours later. At 21 hours after presentation, refractory asystole developed, and the patient died. Case 331. A lbyear-old bulimic girl presented one hour after intentionally ingesting 8 to 16 ounces of baking soda (sodium bicarbonate) in an attempt to induce vomiting. Lavage was attempted without success because of inability to intubate the stomach. Severe gastrointestinal distension compressed and damaged vital organs. She died 16 hours after ingestion of complications from an infarcted small intestine. Case 344. A 3 1-year-old psychotic man received IO mg of haloperidol intramuscularly every four hours for 24 hours to control his behavior. He was noted to be lethargic all day. He was found in his room, in fourpoint restraints, in full cardiorespiratory arrest. Resuscitation was unsuccessful. Serum haloperidol level at postmortem examination was 0.1 pg/ml, and no other cause of death was found. Case 353. An adult woman was found unconscious and hyperthermic (41.7”(Z). She had been an inpatient at a state mental institution, where thioridazine administration, 150 mg four times daily, was begun three days earlier. She developed ventricular tachycardia with numerous arrests. Despite vigorous resuscitative efforts, her temperature remained between 39.3” and 41.7”C, and extensive multisystem failure occurred. She died two days after admission. The cause of death, as listed by the coroner, was neuroleptic malignant syndrome secondary to thioridazine. Case 361. A l-year-old boy presented 15 minutes after ingesting some of his mother’s diet pills. He initially convulsed seizure and was treated with diazepam. He was tremulous with a pulse of 200/min; blood pressure, 120/70 mm Hg; and temperature, 38.3” C. Gastric emptying was induced with ipecac syrup; no pill fragments were seen, however. Rigidity, hyperreflexia, and tachycardia (190/min) were noted. During aeromedical transfer 30 hours after ingestion, the child developed status epilepticus and hypoten-
LITOVITZ ET AL n 1986 AAPCC ANNUAL REPORT
sion (52 mm Hg). He arrested and was resuscitated, underwent lavage, and was given dopamine and albumin. The toxicologic screen showed a caffeine level of 110 mg/dl at 40 hours after ingestion. He developed diabetes insipidus requiring vasopressin. Phenobarbital, glucose, and insulin were administered. The caffeine level after three fourths of an exchange transfusion was 161 mg/dl. A CT scan showed diffuse cerebral edema. He became hypertensive (1901115 mm Hg) and responded to hydralazine and hyperventilation. At 72 hours after ingestion, an EEG indicated brain death. Life support was discontinued. Case 363. A 19-year-old man ingested five bags of cocaine and presented with tachydysrhythmias and shallow respirations. He was intubated and ventilated, and underwent lavage; charcoal and a cathartic were administered. His tachycardia responded to propran0101. Six hours after presentation, he was extubated. Twelve hours after presentation, he arrested and could not be resuscitated, Cocaine toxicity was confirmed by the medical examiner. Case 386. A 25-year-old woman presented after injecting heroin, snorting cocaine, and ingesting diaz-
epam. She arrested and was resuscitated with naloxone and dopamine. Her blood pressure was 40 mm Hg, and her temperature was 28.9” C. The hypothermia was due to her boyfriend packing her in ice. She underwent intubation, ventilation, and lavage. Aspiration pneumonia was suspected, but by four hours after admission, she had fulminant pulmonary edema. The PO, on 100% oxygen was 50 mm Hg. Naloxone, dopamine, and dobutamine infusions were required. She arrested several times during the night. By the second day after ingestion, no brain stem functions were present. She died from hypoxic encephalopathy and ARDS. Case 405. A 52-year-old man was exposed to 250 ml of povidone iodine, which was accidently dropped into his chest cavity during a thoracotomy. His condition deteriorated one hour after the incident. Metabolic acidosis and hypotension required dopamine and large volumes of fluid. Urine output remained low. Aggressive physical therapy and lavage of the povidone iodine from the tracheobronchial tree were employed. He continued to deteriorate, remained acidotic, and died.