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1995 annual report of the American Association of Poison Control Centers toxic exposure surveillance system
Toxicology A special contributionfrom the AmericanAssociation of Poison ControlCenters.
1995 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System TOBY L. LITOVITZ, MD, LINDA FELBERG, MA, SUZANNE WHITE, MD, WENDY KLEIN-SCHWARTZ, PHARMD,MPH Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; they are used to support regulatory actions; and they form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1). H2
The cumulative AAPCC database now contains 18 million human poison exposure cases. This report includes 2,023,089 human exposure cases reported by 67 participating poison centers during 1995, an increase of 5% compared to 1994 poisoning reports.
Centers participating in this report include Children's Hospital of Alabama Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Samaritan Regional Poison Center, Phoenix, AZ; University of California Davis Medical Center Regional Poison Control Center, Sacramento, CA; San Diego Regional Poison Center, San Diego, CA; Santa Clara Valley Medical Center Regional Poison Center, San Jose, CA; San Francisco Bay Area Regional Poison Control Center, San Francisco, CA; Central California Regional Poison Control Center, Fresno, CA; Rocky Mountain Poison and Drug Center, Denver, CO; Connecticut Poison Control Center, Farmington, CT; National Capital Poison Center, Washington, DC; Florida Poison Information Center and Toxicology Resource Center, Tampa, FL; Florida Poison Information Center, Jacksonville, FL; Florida Poison Information Center, Miami, FL; Georgia Poison Control Center, Atlanta, GA; Idaho Poison Center, Boise, ID; Indiana Poison Center, Indianapolis, IN; St. Luke's Poison Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KS; Kentucky Regional Poison Center of Kosair Children's Hospital, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Maryland Poison Center, Baltimore, MD; Massachusetts Poison Control System, Boston, MA; Children's Hospital of Michigan Poison Control Center, Detroit, MI; Blodgett Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Minnesota Regional Poison Center, St. Paul, MN; Cardinal Glennon Children's Hospital Regional Poison Center, St. Louis, MO; The Poison Center, Omaha, NE; New Hampshire Poison Information Center, Lebanon, NH; New Jersey Poison Information and Education System, Newark, NJ; New Mexico Poison and Drug Information Center, Albuquerque, NM; New York City Poison Control Center, New York, NY; Hudson
Valley Regional Poison Center, North Tarrytown, NY; Long Island Regional Poison Control Center, Mineola, NY; Finger Lakes Regional Poison Center, Rochester, NY; Central New York Poison Control Center, Syracuse, NY; Western New York Regional Poison Control Center, Buffalo; Carolinas Poison Center, Charlotte, NC; North Dakota Poison Information Center, Fargo, ND; Akron Regional Poison Center, Akron, OH; Cincinnati Drug and Poison Information Center, Cincinnati, OH; Central Ohio Poison Center, Columbus, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Mahoning Valley Poison Center, Youngstown, OH; Oregon Poison Center, Portland, OR; Pittsburgh Poison Center, Pittsburgh, PA; The Poison Control Center, Philadelphia, PA; Central Pennsylvania Poison Center, Hershey, PA; Rhode Island Poison Center, Providence, RI; McKennan Poison Control Center, Sioux Falls, SD; Middle Tennessee Regional Poison and Clinical Toxicology Center, Nashville, TN; Southern Poison Center, Memphis, TN; Central Texas Poison Center, Temple, TX; North Texas Poison Center, Dallas, TX; Southeast Texas Poison Center, Galveston, TX; Texas Poison Center Network at Amarillo, Amarillo, TX; West Texas Regional Poison Center, El Paso, TX; South Texas Poison Center, San Antonio, TX; Utah Poison Control Center, Salt Lake City, UT; Virginia Poison Center, Richmond, VA; Blue Ridge Poison Center, Charlottesville, VA; Washington Poison Center, Seattle, WA; West Virginia Poison Center, Charleston, WV; University of Wisconsin Hospital Regional Poison Center, Madison, Wl; Poison Center of Eastern Wisconsin, Milwaukee, WI. ©1985-1996 by the American Association of Poison Control Centers. Published by permission. All rights reserved. Reprints are available at a cost of $10 each. Address requests to AAPCC, 3201 New Mexico Ave, Ste 310, Washington, DC 20016.
CHARACTERIZATIONOF PARTICIPATINGCENTERS Of the 67 reporting centers, 62 submitted data for the entire year. Forty-three of the 67 participating centers were certified as regional poison centers by the AAPCC in 1995. Annual center call volumes (human exposure cases only) ranged from 3,131 to 92,931 (mean, 31,376) for centers participating for the entire year. Penetrance, calculated by
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TABLE1. Growth of the AAPCC Toxic Exposure
TABLE2. Site of Caller and Site of Exposure, Human Poison
Surveillance System
Exposure Cases
Year 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Total
No. of Participating Centers
Population Served (Millions)
Human Exposures Reported
Exposures/ Thousand Population
16 47 56 57 63 64 70 72 73 68 64 65 67
43.1 99.8 113.6 132.1 137.5 155.7 182.4 191.7 200.7 196.7 181.3 215.9 218.5
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 18,214,463
5.8 7.3 7.9 8.3 8.5 8.8 8.7 8.9 9.2 9.5 9.7 8.9 9.3
state or portion of the state served, ranged from 1.1 to 18.2 per 1,000 with a mean of 9.3 reported exposures per 1,000 population. Penetrance is defined as the number of human poison exposure cases reported per 1,000 individuals in the population served. A total population of 218.5 million was served by the participating centers, including 38 entire states, portions of 6 states, and the District of Columbia (Figure 1). Noting the 262.8 million 1995 United States population, the data presented represent an estimated 83% of the human poison exposures that precipitated poison center contacts in the US during 1995. Extrapolating from the 2,023,089 human poison exposures reported in this database, 2.4 million human poison exposures are estimated to have been reported to all US poison centers in 1995. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the US cannot be made from these data alone, as considerable variations in
Residence Own Other Workplace Health care facility School Restau rant/food service Public area Other Unknown
Site of Caller (%)
Site of Exposure (%)
77.3 2.4 1.9 13.0 0.6 0.1 0.6 3.8 0.4
86.8 3.6 3.0 0.4 1.3 0.7 1.4 1.1 1.8
poison center penetrance were noted. Indeed, assuming all centers reached the penetrance level of 18.2 poisonings per 1,000 population reported for one state, 4.8 million poisonings would have been reported to poison centers in 1995. The data do not directly identify a trend in the overall incidence of poisonings in the US because of changing center participation from year to year and changes in center use. An analysis of data from 55 centers that participated for the entirety of both 1994 and 1995 shows a 5.9% increase in reported poison exposures from 1994 to 1995 within the regions served by these 55 centers. REVIEW OF THE DATA
Of the 2,023,089 human exposures reported in 1995, 90.4% occurred at a residence (Table 2). In 4.7% of cases (95,204 cases) multiple patients were implicated in the poison exposure episode (eg, siblings "shared" a household product, multiple patients inhaled vapors at a hazardous materials spill). Two unlikely sites of poisonings, health care facilities and schools, accounted for 7,919 (0.4%) and 26,186 (1.3%) poison exposures, respectively. Poison center peak call volumes were noted from 4 to 10 PM, although call
FIGURE 1. Sixty-seven poison centers participated in the Toxic Exposure Surveillance System in 1995. The shaded areas denote regions served by reporting centers.
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TABLE 3. Age and Gender Distribution of Human Poison Exposure Cases Male
Unknown
Female
Age (yr)
No.
%
<1 1 2 3 4 5 Unknown child < 5 6-12 13-19 Unknown child Total children (<20) 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total adults Unknown age
65,338 168,585 184,284 86,760 41,636 24,141 1,332 76,399 63,731 1,628 713,834 74,906 68,747 40,017 17,724 10,552 7,415 3,408 545 41,851 265,165 4,339
51.9 52.5 53,6 54.8 55.6 55,6 45.2 55.9 42.1 41.7 52.4 44.0 42.3 40.7 38.5 36.4 34.1 29.8 26.5 39.4 41.0 33.1
Total
983,338
48.6
%
No.
%
No.
59,960 151,848 158,512 71,190 33,001 19,138 1,045 59,397 87,129 1,430 642,650 95,014 93,655 58,237 28,291 18,436 14,316 8,009 1,510 62,032 379,500 5,892
47.6 47.3 46.1 44.9 44.1 44.0 35.4 43.4 57.5 36.7 47.2 55.9 57.6 59.2 61.4 63.6 65.8 70.1 73.5 58.5 58.6 44.9
589 848 818 458 267 176 571 915 588 843 6,073 194 139 68 39 21 29 13 0 2,237 2,740 2,896
0.5 0.3 0.2 0.3 0.4 0.4 19.4 0.7 0.4 21.6 0.4 0.1 0.1 0,1 0.1 0.1 0.1 0.1 0.0 2.1 0.4 22.1
125,887 321,281 343,614 158,408 74,904 43,455 2,948 136,711 151,448 3,901 1,362,557 170,114 162,541 98,322 46,054 29,009 21,760 11,430 2,055 106,120 647,405 13,127
1,028,042
50.8
11,709
0.6
2,023,089
No.
frequency remained consistently high between 8 A~ and midnight, with 91% of calls logged during this 16-hour period. The age and gender distribution of human poison exposure victims is outlined in Table 3. Children younger than 3 years of age were involved in 39% of cases, and 53% occurred in children younger than 6 years. A male predominance is found among poison exposure victims younger than 13 years of age, but the gender distribution is reversed in TABLE 4. Distribution of Age and Gender for 724 Fatalities
Age (yr) Male Female Unknown Total <1 3 1 5 2 2 3 2 4 0 5 0 6-12 6 13-19 21 20-29 69 30-39 106 40-49 79 50-59 34 60-69 24 70-79 21 80-89 12 90-99 3 Unknown adult 5 Total 392
%
Cumula- Cumulative rive Total %
5 2 1 0 0 0 0 19 40 84 63 34 28 20 23 4
0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
8 7 3 2 0 0 6 40 109 191 142 68 52 41 35 7
1.1 1.0 0.4 0.3 0.0 0.0 0.8 5.5 15.1 26.4 19.6 9.4 7.2 5.7 4.8 1.0
8 15 18 20 20 20 26 66 175 366 508 576 628 669 704 711
1.1 2.1 2.5 2.8 2.8 2.8 3.6 9.1 24.2 50.6 70.2 79.6 86.7 92.4 97.2 98.2
8 331
0 1
13 1.8 724 100.0
724 724
100.0 100.0
Cumulative Total
Total %
No.
%
6.2 15.9 17.0 7.8 3.7 2.1 0.1 6.8 7.5 0.2 67.4 8.4 8.0 4.9 2.3 1.4 1.1 0.6 0.1 5.2 32.0 0.6
125 887 447 168 790 782 949 190 1,024 094 1,067 549 1,070 497 1,207 208 1,358,656 1,362,557 1,362,557 1,532,671 1,695,212 1,793,534 1,839,588 1,868,597 1,890,357 1,901 387 1,903,842 2,009,962 2,009,962 2,023,089
6.2 22.1 39.1 46.9 50.6 52.8 52.9 59.7 67.2 67.4 67.4 75.8 83.8 88.7 90.9 92.4 93.4 94.0 94.1 99.4 99.4 100.0
100.0
2,023,089
100.0
teenagers and adults. Although the gender distribution was nearly equal for unintentional exposures, 60.9% of intentional exposures occurred in females, as did 65.1% of adverse reactions. Of all poison exposures captured, 6,484 occurred in pregnant women. Of those with known pregnancy duration, 30% occurred in the first trimester, 39% in the second trimester, and 31% in the third trimester. Table 4 presents the age and gender distribution for the 724 reported fatalities. Although responsible for the majority of poisoning reports, children younger than 6 years of age comprised just 2.8% (20) of the fatalities. Sixty-one percent of poisoning fatalities occurred in 20- to 49-year-old individuals. A single substance was implicated in 92.8% of reports, and 1.8% of patients were exposed to more than two possibly poisonous drugs or products (Table 5). The overwhelming majority of human exposures were acute (94.0%) compared to only 54.8% of poison-related fatal exposures. TABLE 5, Number of Substances Involved in Human Poison Exposure Cases No. of Substances 1 2 3 4 5 6 7 8 __>9 Total
No. of Cases
% of Cases
1,878,238 109,145 20,215 7,713 3,081 1,315 638 311 2,433 2,023,089
92.8 5.4 1.0 0.4 0.2 0.1 0.0 0.0 0.1 100.0
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TABLE 6. Reason for Human Poison Exposure Cases Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Occupational Food poisoning Unknown Total Intentional Suicidal Misuse Abuse Unknown Total Other Malicious Contaminant/tampering Total Adverse Reaction Drug Other Food Total Unknown Total
No.
%
1,339,318 110,038 77,368 58,559 54,378 45,989 45,505 3,260 1,734,415
66.2 5.4 3.8 2.9 2.7 2.3 2.3 0.2 85.7
160,478 30,060 26,416 12,545 229,499
7.9 1.5 1.3 0.6 11.3
5,913 5,218 11,131
0.3 0.3 0.6
28,296 9,908 4,491 42,695 5,349 2,023,089
1.4 0.5 0.2 2.1 0.3 100.0
Chronic exposures comprised 2.3% of all poison exposure reports, and acute-on-chronic exposures comprised 3.1%. (Chronic exposures were defined as continuous or repeated exposures occurring in a period exceeding 8 hours.) Reason for exposure was coded according to the following definitions: Unintentional general: All unintentional exposures not specifically defined below. Most unintentional exposures in children are captured here. Environmental: Any passive, nonoccupational exposure that results from contamination of air, water, or soil. Environmental exposures are usually caused by man-made contaminants. Occupational: An exposure that occurs as a direct result of the person being on the job or in the workplace. Therapeutic error: An unintentional deviation from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person, or administration of the wrong substance. Only exposures to medications or products substituted for medications are included. Drug interactions resulting from unintentional administration of drugs or foods that are known to interact are also included.
Unintentional misuse: Unintentional improper or incorrect use of a nonpharmaceutical substance. Unintentional misuse differs from intentional misuse in that the exposure was unplanned or not foreseen by the patient. Bite~sting: All animal bites and stings, with or without envenomation, are included. Food poisoning: Suspected or confirmed food poisoning; ingestion of food contaminated with microorganisms is included. Unintentional unknown: An exposure determined to be unintentional but the exact reason is unknown. Suspected suicidal: An exposure resulting from the inappropriate use of a substance for reasons that are suspected to be self destructive or manipulative. Intentional misuse: An exposure resulting from the intentional improper or incorrect use of a substance for reasons other than the pursuit of a psychotropic effect. Intentional abuse: An exposure resulting from the intentional improper or incorrect use of a substance by a victim who was likely attempting to achieve a euphoric or psychotropic effect. All recreational uses of substances for any effect are included. Intentional unknown: An exposure that is determined to be intentional but the specific motive is unknown. Contaminant~tampering: The patient is an unintentional victim of a substance that has been adulterated (either maliciously or unintentionally) by the introduction of an undesirable substance. Malicious: This category is used to capture patients who are victims of another person's intent to harm them. Adverse reaction: An adverse event occurring with normal, prescribed, labeled, or recommended use of a product, as opposed to overdose, misuse, or abuse. Included are cases with an unwanted effect caused by an allergic, hypersensitive, or idiosyncratic response to active ingredients, inactive ingredients, or excipients. Concomitant use of a contraindicated medication or food is excluded and coded instead as a therapeutic error. The vast majority (85.7%) of poison exposures were unintentional; suicidal intent was present in 7.9% of cases (Table 6). Therapeutic errors comprised 5.4% of exposures (110,038 cases), with unintentional nonpharmaceutical product misuse comprising another 2.9% of exposures (58,559 cases). Unintentional poisonings outnumbered intentional poisonings in all age groups (Table 7). In contrast, of the 724 human poisoning fatalities reported, 82% of adult deaths (older than 19 years of age) were intentional (Table 8). Ingestions accounted for 73.6% of exposure routes (Table 9), followed in frequency by dermal, inhalation, and ocular exposures, bites and stings, and parenteral and aspiration exposures. For the 724 fatalities, ingestion and inhalation were the predominant exposure routes. Clinical effects (signs, symptoms, or laboratory abnormali-
TABI.157. Distribution of Reason for Exposure by Age <6 Years
6-12 Years
13-19 Years
>19 Years
Unknown
Total
Reason
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Col %
Unintentional Intentional Other Adverse Reaction Unknown Total
1,064,532 685 927 3,847 506 1,070,497
61.4 0.3 8.3 9.0 9.5 52.9
124,777 7,419 1,585 2,427 503 136,711
7.2 3.2 14.2 5.7 9.4 6.8
77,042 68,211 2,032 3,396 767 151,448
4.4 29.7 18.3 8.0 14.3 7.5
456,139 149,178 6,369 32,500 3,219 647,405
26.3 65.0 57.2 76.1 60.2 32.0
11,925 4,006 218 525 354 17,028
0.7 1.7 2.0 1.2 6.6 0.8
1,734,415 229,499 11,131 42,695 5,349 2,023,089
85.7 11.3 0.6 2.1 0.3 100.0
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TABLE 8. Distribution of Reason for Exposure and Age for 724 Fatalities
Reason Unintentional General Environmental Occupational Therapeutic error Misuse Bite/sting Food poisoning Unknown Total intentional Suicide Misuse Abuse Unknown Total Other Adverse Reaction Unknown Total
TABLE 10. Management Site of Human Poison Exposure Cases
<6 6-12 13-19 >19 Years Years Years Years Unknown Total 10 3 0 1 1 0 0 0 15
0 1 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
2 23 3 33 3 3 0 1 68
0 0 0 0 0 0 0 0 0
12 27 3 34 4 3 0 1 84
0 1 1 0 2 0 1 2 20
2 0 2 0 4 0 1 0 6
19 2 13 3 37 0 1 2 40
384 25 95 34 538 0 11 41 658
0 0 0 0 0 0 0 0 0
405 28 111 37 581 0 14 45 724
ties) were coded in 31.9% of cases (18.3% had one effect, 8.0% had two effects, 3.5% had three effects, 1.4% had four effects, 0.4% had five effects, and 0.3% had more than five effects). Of 1,412,605 clinical effects coded, 77.9% were deemed related, 7.0% were considered not related, and 15.1% were coded as "unknown if related." The majority of cases reported to poison centers were managed in a non-health care facility (72.5%), usually at the site of exposure, the patient's own home (Table 10). Treatment in a health care facility was rendered in 23.6% of cases and recommended in another 2.3% of patients who refused the referral. Of cases managed in a health care facility, 58.6% were treated and released without admission, 12.6% were admitted for critical care, and 7.2% were admitted for noncritical care. When treatment was provided TABLE 9. Distribution of Route of Exposure for Human Poison Exposure Cases and 724 Fatalities All Exposure Cases
Fatal Exposure Cases
Route
No.
%
No.
%
Ingestion Dermal Inhalation Ocular Bites and stings Parenteral Aspiration Other Unknown Total
1,564,859 173,725 151,407 133,061 80,810 6,861 2,432 5,840 7,956 2,126,951
73.6 8.2 7.1 6.3 3.8 0.3 0.1 0.3 0.4 100.0
590 5 95 0 3 43 7 4 34 781
75.5 0.6 12.2 0.0 0.4 5.5 9.0 0.5 4.4 100.0
NOTE: Multiple routes of exposure were observed in many poison exposure victims. Percentage is based on the total number of exposure routes (2,126,951 for all patients, 781 for fatal cases) rather than the total number of human exposures (2,023,089) or fatalities (724).
Site
No.
%
Managed on-site, non-health care facility Managed in health care facility Treated and released Admitted to critical care Admitted to noncritical care Admitted to psychiatry Lost to follow-up; left AMA Unspecified level of care Subtotal Other Refused referral Unknown Total
1,467,630
72.5
279,667 60,375 34,322 26,212 75,546 1,325 477,447 16,751 47,070 14,191 2,023,089
13.8 3.0 1.7 1.3 3.7 0.1 23.6 0.8 2.3 0.7 100.0
ABBREVIATION:AMA, against medical advice.
in a health care facility, 43.8% of the patients were referred by a poison center and 56.2% were already in or en route to the health care facility when the poison center was contacted. Health care facilities included acute care hospitals (86.9%), freestanding emergency centers (2.0%), and physicians' offices or clinics (10.9%). Table 11 displays the medical outcome of the human poison exposure cases distributed by age, showing more severe outcomes in the older age groups. Table 12 compares medical outcome and reason for exposure, and demonstrates the greater frequency of serious outcome in intentional exposures. Table 13 demonstrates the increasing duration of the clinical effects observed with more severe outcomes. Note the medical outcome categories, as follows: No effect: The patient developed no signs or symptoms as a result of the exposure. Minor effect: The patient developed some signs or symptoms as a result of the exposure but they were minimally bothersome and generally resolved rapidly with no residual disability or disfigurement. A minor effect is often limited to the skin or mucous membranes (eg, selflimited gastrointestinal symptoms, drowsiness, skin irritation, first degree dermal burn, sinus tachycardia without hypotension, and transient cough). Moderate effect: The patient exhibited signs or symptoms as a result of the exposure that were more pronounced, more prolonged, or more of a systemic nature than minor symptoms. Usually some form of treatment is indicated. Symptoms were not life-threatening, and the patient has no residual disability or disfigurement (eg, corneal abrasion, acid-base disturbance, high fever, disorientation, hypotension that is rapidly responsive to treatment, and isolated brief seizures that respond readily to treatment). Major effect: The patient exhibited signs or symptoms as a result of the exposure that were life-threatening or resulted in significant residual disability or disfigurement (eg, repeated seizures or status epilepticus, respiratory compromise requiring intubation, ventricular tachycardia with hypotension, cardiac or respiratory arrest, esophageal stricture, and disseminated intravascular coagulation). Death: The patient died as a result of the exposure or as a direct complication of the exposure. Only those deaths that were probably or undoubtedly related to the exposure are coded here. Not followed, judged as nontoxic exposure: No follow-up calls were made to determine the patient's
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TABLE 11. Medical Outcome of Human Poison Exposure Cases by Patient Age <6 Years Outcome
No.
No effect 367,361 Minor effect 133,216 Moderate effect 10,582 Major effect 584 Death 20 No follow-up, nontoxic 275,045 No follow-up, minimaltoxicity 247,283 No follow-up, potentially toxic 17,562 Unrelated effect 18,890 Total 1,070,543
6-12 Years
13-19 Years
> 19 Years
Col %
No.
Col %
No.
Col %
No.
34.3 12.4 1.0 0.1 0.0 25.7 23.1 1.6 1.8 52.9
27,105 33,636 3,928 199 6 25,519 37,478 4,278 4,562 136,711
19.8 24.6 2.9 0.2 0.0 18.7 27.4 3.1 3.3 6.8
29,361 45,355 13,501 1,103 40 11,846 30,912 14,529 4,801 151,448
19.4 29.9 8.9 0.7 0.0 7.8 20.4 9.6 3.2 7.5
76,014 193,199 59,499 6,769 658 50,243 164,127 58,560 38,336 647,405
Col %
Unknown No.
1 1 . 7 1,778 29.8 2,771 9.2 576 1.0 56 0.1 0 7.8 2,165 25.4 4,196 9.0 4,764 5.9 676 32.0 16,982
Total
Col %
No.
%
10.5 16.3 3.4 0.3 0.0 12.8 24.7 28.1 4.0 0.8
501,619 408,177 88,086 8,711 724 364,818 483,996 99,693 67,265 2,023,089
24.8 20.2 4.4 0.4 0.0 18.0 23.9 4.9 3.3 100.0
TABLE 12. Distribution of Medical Outcome by Reason for Exposure for Human Poison Exposure Cases Unintentional Outcome
No.
No effect 453,034 Minor effect 325,949 Moderate effect 50,315 Major effect 2,233 Death 84 No follow-up, nontoxic 358,008 No follow-up, minimal toxicity 440,131 No follow-up, potentially toxic 51,415 Unrelated effect 53,245 Total 1,734,414
Col %
Intentional No.
Col %
26.1 46,434 18.8 66,024 2.9 32,516 0.1 6,008 0.0 581 20.6 4,550 25.4 25,000 3.0 43,356 3.1 5,031 85.7 229,500
TABLE 13. Duration of Clinical Effects by Medical Outcome
--<2 hours >2 hours, -<8 hours >8 hours, -<24 hours >24 hours, -<3 days >3 days, -<1 week >1 week, -<1 month >1 month Anticipated permanent Unknown
Minor Effect Moderate Effect Major Effect (Co1%) (Co1%) (Co1%) 40.6 23.8 18.0 6.1 2.2 0.6 0.2 0.0 8.6
6.8 20.7 31.3 17.3 7.0 2.5 0.7 0.2 13.6
No.
20.2 1,258 28.8 3,300 14.2 515 2.6 27 0.3 0 2.0 1,150 10.9 3,150 18.9 931 2.2 800 1 1 . 3 11,131
outcome because the substance implicated was nontoxic, the amount implicated was insignificant, or the route of exposure was unlikely to result in a clinical effect. Not followed, minimal clinical effects possible: No follow-up calls were made to determine the patient's outcome because the exposure was likely to result in only minimal toxicity of a trivial nature. (The patient was expected to experience no more than a minor effect.) Unable to follow, judged as a potentially toxic exposure: The patient was lost to follow-up, refused follow-up, or was not followed up, but the exposure was significant and may have resulted in a moderate, major, or fatal outcome. Unrelated effect: The exposure was probably not responsible for the effect. Confirmed nonexposure: This outcome option was used during coding to designate cases in which reliable and objective evidence
Duration of Effect
Other
2.9 8.1 27.3 29.4 13.7 5.7 1.5 3.1 8.4
Adverse Reaction
Col %
No.
Col %
11.3 29.6 4.6 0.2 0.0 10.3 28.3 8.4 7.2 0.6
476 12,034 4,076 276 14 863 14,680 2,860 7,416 42,695
1.1 28.2 9.5 0.6 0.0 2.0 34.4 6.7 17.4 2.1
Unknown No.
Total
Col %
No.
417 7.8 501,619 870 16.3 408,177 664 12.4 88,086 167 3.1 8,711 45 0.8 724 247 4.6 364,818 1,035 19.3 483,996 1,131 21.1 99,693 773 14.5 67,265 5,349 0.3 2,023,089
Col % 24.8 20.2 4.4 0.4 0.0 18.0 23.9 4.9 3.3 100.0
showed that an exposure initially believed to have occurred actually never occurred (eg, all missing pills are later located). All cases coded as confirmed nonexposure are excluded from this report. In 1995 there were 6,482 such cases reported nationally. Tables 14 and 15 outline the use of decontamination procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this database. These must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 2.3% of cases. In children younger than 6 years of age, ipecac syrup was most often administered outside a health care facility. This pattern was reversed in teenagers and adults. Ipecac was administered more often in children (3.6% of poison exposures occurring in children younger than 6 years of age compared with 0.7% of poison exposures occurring in patients older than 19 years). Table 16 demonstrates a continued decline in the use of ipecac-induced emesis in the treatment of poisoning. TABLE 14. Decontamination and Therapeutic Intervention Therapy
No. of Patients
%
Decontamination only No therapy provided Observation only Decontamination and other therapy Other therapy only (no decontamination) Unknown if therapy provided/patient refused
1,144,201 254,035 227,015 133,920 87,346 176,572
56.6 12.6 11.2 6.6 4.3 8.7
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
493
TABLE17A. Substances Most Frequently Involved in Human Exposures
TABLE 15. Therapy Provided in Human Exposure Cases Therapy
No.
Decontamination Dilution/irrigation Activated charcoal, single dose Cathartic Gastric lavage Ipecac syrup Activated charcoal, multidose Other emetic Whole bowel irrigation Measures to Enhance Elimination Alkalinization (with or without diuresis) Hemodialysis Hemoperfusion Other extracorporeal procedure Specific Antidote Administration N-acetylcysteine (oral) Naloxone Flumazenil Antivenin Atropine Ethanol Hyperbaric oxygen N-acetylcysteine (IV) Deferoxamine Phytonadione Pyridoxine Pralidoxime (2-PAM) Physostigmine Fab fragments Dimercaprol (BAL) Folate EDTA Succimer Methylene blue Sodium thiosulfate Sodium nitrite Penicillamine Hydroxocobalamin Other intervention Transplantation ECMO
970,152 140,359 106,761 72,862 47,359 15,521 5,976 1,690 7,261 772 59 53 9,601 7,373 2,567 833 770 623 562 432 422 356 281 228 219 194 136 127 122 107 81 70 57 45 15 16 12
TABLE16. Decontamination Trends
Year
Human Exposures Reported
% of Exposures Involving Children <6 Years
Ipecac Administered (% of Exposures)
Activated Charcoal Administered (% of Exposures)
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089
64.0 64.1 63.4 63.0 62.3 61.8 61.1 60.8 59.9 58.8 56.0 54.1 52.9
13.4 12.9 15.0 13.3 10.1 8.4 7.0 6.1 5.2 4.3 3.7 2.7 2.3
4.0 4.0 4.6 5.2 5.2 6.5 6.4 6.7 7.0 7.3 7.3 6.8 7.7
Substance
No.
%*
Cleaning substances Analgesics Cosmetics and personal care products Cough and cold preparations Plants Bites/envenomations Pesticides (includes rodenticides) Foreign bodies Topicals Food products, food poisoning Antimicrobials Hydrocarbons Sedatives/hypnotics/antipsychotics Antidepressants Alcohols Chemicals Vitamins
208,843 196,805 171,426 105,947 104,187 87,628 84,346 75,021 72,124 67,084 66,274 65,143 63,271 56,285 52,119 51,508 45,952
10.3 9.7 8.5 5.2 5.1 4.3 4.2 3.7 3.6 3.3 3.3 3.2 3.1 2.8 2.6 2.5 2.3
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of human exposures rather than the total number of substances.
Table 17A presents the most common substance categories listed by frequency of exposure. Tables 17B and 17C present similar data for children and adults, respectively, and show the considerable differences between pediatric and adult poison exposures. Table 18 lists the substance categories with the largest number of reported deaths; analgesics and antidepressants led this list. A remarkable chronological constancy of selected demographic data elements is shown in Table 19. A breakdown of plant exposures is provided for those most commonly implicated (Table 20). TABLE 17B. Substances Most Frequently Involved in Pediatric Exposures (Children Under 6 Years) Substance
No.
%*
Cosmetics and personal care products Cleaning substances Analgesics Plants Cough and cold preparations Foreign bodies Topicals Pesticides (includes rodenticides) Antimicrobials Vitamins Gastrointestinal preparations Hydrocarbons Arts/crafts/office supplies Antihistamines Hormones and hormone antagonists
127,419 118,332 81,643 74,829 70,862 53,972 53,875 44,150 39,718 36,553 34,922 26,723 26,421 18,330 18,291
11.9 11.1 7.6 7.0 6.6 5.0 5.0 4.1 3.7 3.4 3.3 2.5 2.5 1.7 1.7
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in children under six years, rather than the total number of substances.
494
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE170. Substances Most Frequently Involved in Adult Exposures (>19 years)
TABLE19. 13-Year Comparisons of Fatality Data
Substance
No.
%*
Analgesics Cleaning substances Bites/envenomations Sedatives/hypnotics/antipsychotics Antidepressants Food products, food poisoning Alcohols Fumes/gases/vapors Cosmetics and personal care products Chemicals Hydrocarbons Pesticides (includes rodenticides) Cardiovascular Cough and cold preparations Antihistamines
61,834 57,582 43,431 43,333 34,387 31,875 25,199 23,886 23,248 23,137 22,695 22,579 15,716 15,141 14,877
9.6 8.9 6.7 6.7 5.3 4.9 3.9 3.7 3.6 3.6 3.5 3.5 2.4 2.3 2.3
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in adults (over 19 years), rather than the total number of substances.
A summary of the 724 fatal exposures is presented in Table 21. Each of these cases was abstracted and verified by the reporting center, with only those exposures deemed "probably" or "undoubtedly" responsible for the fatality included in this compendium. The highest blood level of implicated substances is provided where available to the reporting poison center. Prehospital cardiac and/or respiratory arrests occurred in 40% of all fatalities, and these are indicated in Table 21. Tables 22A and 22B provide comprehensive demographic data on patient age, reason for exposure, medical outcome, and use of a health care facility for all 2,023,089 exposures, presented by category. Table 22A focuses on nonpharmaceuticals; Table 22B presents drugs. Of the 2,167,552 substances logged in Tables 22A and 22B, 57.9% were nonpharmaceuticals and 42.1% were pharmaceuticals. The reason for the exposure was intentional for 28.0% of pharmaceutical substances implicated compared with only 4.0% of TABLE18. Categories with Largest Numbers of Deaths
Category
No.
% of All Exposures in Category
Analgesics Antidepressants Cardiovascular drugs Stimulants and street drugs Sedative/hypnotics/antipsychotics Alcohols Gases and fumes Chemicals Asthma therapies Insecticides/pesticides (includes rodenticides) Automotive products Cleaning substances Hydrocarbons
235 168 115 108 97 82 48 23 20 18 17 17 14
0.119 0.298 0.347 0.319 0.153 0.157 0.113 0.045 0.103 0.021 0.125 0.008 0.021
Total Fatalities
Suicides
Pediatric Deaths (<6 years)
Year
No.
%
No.
%of Deaths
No.
% ~ Deaths
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
95 293 328 406 397 545 590 612 764 705 626 766 724
0.038 0.040 0.036 0.037 0.034 0.040 0.037 0.036 0.042 0.038 0.036 0.040 0.036
60 165 178 223 226 297 323 350 408 395 338 410 405
63.2 56.3 54.3 54.9 56.9 54.5 54.7 57.2 53.4 56.0 54.0 53.5 55.9
10 21 20 15 22 28 24 25 44 29 27 26 20
10.5 7.2 6.1 3.7 5.5 5.1 4.1 4.1 5.8 4.1 4.3 3.4 2.8
nonpharmaceutical substances. Correspondingly, treatment in a health care facility was provided in a higher percentage of exposures to pharmaceutical substances (37.2%) compared with nonpharmaceutical substances (18.0%). Pharmaceutical exposures also had more severe outcomes. Of substances implicated in fatal cases, 77.0% were pharmaceuticals, compared with only 42.1% in nonfatal cases. Similarly, 75.9% of substances implicated in major outcomes were pharmaceuticals. In closing, we gratefully acknowledge the extensive contributions of each participating poison center and the assistance of the many physicians and nurses who provided comprehensive data to the poison centers for inclusion in this database. TABLE20. Frequency of Plant Exposures by Plant Type Botanical Name
Common Name
Frequency
Capsicum annuum Philodendron spp. Euphorbia pulcherrima Ilex spp. Dieffenbachia spp. Spathiphyllum spp. Phytolacca americana Crassula spp. Toxicodendron radicans Epipremnum aureum Caladium spp. Rhododendron spp. Saintpaulia ionantha Eucalyptus Globulus Brassaia actinophylla Pyracantha spp. Hedera helix Chrysanthemum spp. Schlumbergera Bridgesfi Taraxacum officinale
Pepper Philodendron Poinsettia Holly Dumbcane Peace lily Pokeweed, inkberry Jade plant Poison ivy Pothos, devil's ivy Caladium Rhododendron, azalea African violet Eucalyptus Umbrella tree Pyracantha English ivy Chrysanthemum Christmas cactus Dandelion
4,984 4,378 2,952 2,871 2,648 2,632 2,207 1,715 1,478 1,258 1,058 1,033 991 984 982 946 884 811 803 795
NOTE: This table provides the frequency of involvement of plants in exposures reported to poison centers with no correlation with severity of toxicity. Several of the plants on the list pose little, if any, ingestion hazard.
LITOVITZ ET AL •
TABLE 21. Case
1995 A A P C C A N N U A L R E P O R T
495
Summary of Fatal Exposures Reported to TESS in 1995 Age
Substances
Chronicity
Route
Reason
Blood Levels
NONPHARMACEUTICALS
Adhesives/glue lip 30 yr Alcohols 2 3~P 4P 5ip 6ip 7~ 8ip 9p 10 11
20 yr 23 yr 25 yr 36 yr 37 yr 41 yr 49 yr 64 yr 66yr 32 yr
12
75 yr
13
35 yr
14
20 yr
15~p
49 yr
16P
46 yr
17p
34 yr
18P
2 mo
19ip
43 yr
20P
47 yr
21 ip
36 yr
22 ip
53 yr
23 24 25 ~ 26 27
40 yr 47 yr 48 yr 63 yr 51 yr
Cement (tetrahydrofuran/methyl ethyl ketone)
A/C
Inhalation
Int abuse
Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol acetaminophen Ethanol acetaminophen Ethanol acetaminophen/decongestant Ethanol antidepressant trazodone Ethanol carbamazepine amitriptyline Ethanol fluoxetine
A U A A A/C U A/C C A/C C
Ingestion Unknown Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unknown Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse
A/C
Ingestion
Int abuse
C
Ingestion
Int abuse
A
Ingestion
lnt suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A
Ingestion
Unknown
A/C
Ingestion
Int abuse
140 mg/dL§ 0.02 pg/mL§ 240 mg/dL
A/C
Ingestion
Int abuse
16 mg/dL§
U
Ingestion
Unknown
U
Ingestion
Int suicide
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int abuse Unknown Int abuse Int abuse
carbamazepine Ethanol heroin Ethanol methamphetamine Ethanol morphine Ethanol propoxyphene Ethanol propoxyphene benzodiazepines Ethanol propoxyphene sertraline Methanol Methanol Methanol Methanol Methanol deodorant spray (ethanol)
290 182 456 342 330
mg/dL mg/dL mg/dL mg/dL mg/dL§
270 mg/dL 195 mg/dL
0.2 pg/mL
310 mg/dL 0.51 pg/mL§ norfluoxetine 0.32 #g/mL§ 6 I~g/mL§ 300 mg/dL
467 333 83 23 339
mg/dL mg/dL mg/dL mg/dL mg/dL
See also cases 37, 39, 46, 54, 65, 129, 130, 131, 132, 133, 155, 164, 170, 206, 207, 208, 218, 226, 228, 232, 240, 243, 244, 245, 274, 284, 285, 308, 309, 310, 317, 318, 328, 367, 368, 377, 378, 380, 381, 382, 417, 429, 430, 435, 445, 446, 447, 452, 465, 471, 475, 506, 527, 534, 545, 554, 584, 604, 608, 609, 617, 618, 619, 632, 650, 672, 673, 674, 686, 699, 701, 702, 703, 704, 705, 706, 715 (ethanol); 435 (isopropanol) ; 679 (methanol). Automotive products 28 31 yr Antifreeze (ethylene glycol) 29 45 yr Antifreeze (ethylene glycol) 30 45 yr Antifreeze (ethylene glycol) 31a 46 yr Antifreeze (ethylene glycol) 32 a 57yr Antifreeze (ethylene glycol) 33 62 yr Antifreeze (ethylene glycol) 34 74 yr Antifreeze (ethylene glycol) 35 86 yr Antifreeze (ethylene glycol) 36 36 yr Antifreeze (ethylene glycol) acetaminophen barbiturates
A A U U A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int unknown Int suicide Unknown Int suicide Unknown Int suicide Int suicide Int suicide
41 mg/dL 233 mg/dL
177 mg/dL 1,920 mg/dL 54 mg/dL
107 pg/mL
(Continued on following page)
12-14 h
496
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
37
27 yr
Substances
Antifreeze (ethylene glycol) ethanol 38 27 yr Antifreeze (ethylene glycol) sulfuric acid 39 43 yr Antifreeze (ethylene glycol) windshield washing fluid (methanol) mouthwash (ethanol) 40 33yr Brakefluid 41p 30 yr Windshield washing fluid (methanol) 42 36 yr Windshield washing fluid (methanol) 43P 48 yr Windshield washing fluid (methanol) nail polish remover (acetone) See also case 39 (windshield washing fluid). Bites and envenomations 44 a 66 yr Bee stings 45 a 88 yr Bee stings 46 ap 35 yr Crotalus horridus atricaudatus (canebrake rattlesnake) ethanol Chemicals 47 48 ap 49 50 51 52 i 53
35 yr 53yr 30 yr 32 yr 43 yr 46 yr 35 yr
Cyanide Cyanide Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol acetaminophen 54 52 yr Ethylene glycol ethanol 55P 64 yr Ethylene glycol nortriptyline chlorpromazine 56 35 yr Ethylene glycol rodenticide (unknown type) 57 31 yr Hydrochloric acid 58 45 yr Hydrochloric acid 59 17 yr Potassium hydroxide 60 a 24 yr Sodium azide 61~p 43 yr Sodium azide 62 a 43 yr Sodium azide carbon monoxide 63 35 yr Sulfuric acid See also case 38 (sulfuric acid).
Cleaning substances 64 52 yr Cleaning agent (acid) aspirin 65 49 yr Cleaning solution (methanol) ethanol 66 71 yr Deodorizing cleaner (cationic) 67 84 yr Detergent (cationic) 68 42 yr Drain opener rodenticide 69 37 yr Drain opener (hydrochloric acid) 70 20 yr Drain opener (sodium hydroxide) 71 73 yr Drain opener (sodium hydroxide crystals) 72 31 yr Drain opener (sulfuric acid) 73 a 40 yr Hydrofluoric acid rust remover (6-8%) 74 51 yr Lye (sodium hydroxide) 75ip 33 yr Sodium hydroxide/hypochlorite spray cleaner 76 56 yr Tire cleaner (acid) 77 30 yr Toilet bowl cleaner (acid) 78 45 yr Toilet bowl cleaner (HCI) 79 50 yr Toilet bowl cleaner (HCI)
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int suicide
194 mg/dL§
A
Ingestion
Int suicide
57 mg/dL
A
Ingestion
Int suicide
U A A A
Ingestion Ingestion Ingestion Ingestion
Unknown Int suicide Int suicide Int suicide
A A A
Bite/sting Bite/sting Bite/Ing
Bite/sting Bite/sting Bite/sting
697 mg/dL 610 mg/dL
7h
250 mg/dL§ A A U A A U A
Ingestion Ingestion Unknown Ingestion Ingestion Unknown Ingestion
Int suicide Int suicide Unknown Int unknown Int suicide Unknown Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A A A A A A
ingestion Ingestion Ingestion Ingestion Ingestion Derm/Inh
Int suicide Int suicide Int suicide Int suicide Int suicide Occ
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A A A
Ingestion Asp/Ing Ingestion
Unint gen Unint gen Int suicide
A A A A A A U
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Inhalation
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Env
A A A A
ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int misuse
17.4 pg/mL 8,000 mg/dL 59 mg/dL 177 mg/dL 223 mg/dL 765 pg/mL 202 417 1,850 1,663
mg/dL mg/dL§ ng/mL§ ng/mL§
5.58 mg/mL§
14%
(Continued on following page)
>35 mg/dL 20 mg/dL
2.3h
LITOVITZ ET A L •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
497
S u m m a r y of Fatal Exposures Reported to T E S S in 1995 (Cont'd)
Case
Age
80 81
72 yr 20 yr
82
65 yr
Substances
Chronicity
Toilet bowl cleaner (HCI, phosphoric acid) Toilet bowl cleaner (5-10% HCI) toilet bowl cleaner (15-20% HCI) Toilet bowl deodorizer (alkyl dimethyl benzyl ammonium chloride)
Cosmetics and personal care products 83o 42 yr Hair spray (ethanol, >50%)
Route
Reason
A A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
Blood Levels
414 mg/dL
See also cases 27 (deodorant spray, ethanol); 39 (mouthwash); 43 (nail polish remover, acetone). Deodorizers 84 85 i0
12 yr 15 yr
Air freshener Air freshener (propane, butane)
A A
Inhalation Inhalation
Int abuse Int abuse
86p 87ip
16 yr 24 yr
Air freshener Air freshener
A A
Inhalation Inhalation
Int abuse Int abuse
A
Ingestion
Int suicide
A A A A A A A A A A A A A A A C A A A A A A A A A A A A U C A A A A A U A A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Ing/Inh
Env Env Env Env Int suicide Env Unint mis Env Env Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Env Env Int suicide Env Env Int suicide Int suicide Int suicide Int suicide Env Int suicide Unknown Env Env Env Int suicide Env Int suicide Int suicide Env Env Env Env Int suicide
A
Inh/Unk
Int suicide
propane 6.4 ppm§ butane 9.0 ppm§
See also case 142 (air freshener). Essential oils 88 a 75 yr
Liniments (essential oils & herbals)
Foreign body
See cases 276, 369, 579 (activated charcoal); 685 (plastic bag). Fumes, gases and vapors 89P 5 mo Carbon monoxide/smoke 900 11 mo Carbon monoxide 91o 18 mo Carbon monoxide 92 ip 6yr Carbon monoxide 93P 23 yr Carbon monoxide 94p 24 yr Carbon monoxide/smoke g5 ip 25 yr Carbon monoxide 960 26 yr Carbon monoxide/smoke 97 ip 28 yr Carbon monoxide 980 33 yr Carbon monoxide 99 ip 33 yr Carbon monoxide 100P 34 yr Carbon monoxide 101 34 yr Carbon monoxide 102p 35 yr Carbon monoxide 103 ip 36 yr C&rbon monoxide 104 38 yr Carbon monoxide 105 j0 39 yr Carbon monoxide 1060 40 yr Carbon monoxide 107P 43 yr Carbon monoxide 108 j 44 yr Carbon monoxide/smoke 109 ~p 45 yr Carbon monoxide 110jp 47yr Carbon monoxide 111 aJ0 47 yr Carbon monoxide 112alp 47 yr Carbon monoxide 113j0 48 yr Carbon monoxide 114ip 49 yr Carbon monoxide/smoke 115 57 yr Carbon monoxide 116 60 yr Carbon monoxide 1170 65 yr Carbon monoxide 118p 70 yr Carbon monoxide 119i0 70 yr Carbon monoxide 120 aip 75 yr Carbon monoxide 121 77 yr Carbon monoxide 122 ip 83 yr Carbon monoxide 123 83 yr Carbon monoxide/smoke 124ip 85 yr Carbon monoxide 125P 89 yr Carbon monoxide/smoke 126P 91 yr Carbon monoxide 127 22 yr Carbon monoxide acetaminophen 128p 27 yr Carbon monoxide cocaine
(Continued on following page)
82% 55% 45%
54% 48% 45%
5O%
46% 20%
45%§ 30% 54% 48% 23%9 45% 28% 26% >4O% 50% 52% 70 #g/mL 23%§ 0.10 #g/mL§ cocaine metabolite 1.17 pg/mL§
2.5 h
498
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
129~p
46 yr
Substances
Carbon monoxide ethanol 130P 50 yr Carbon monoxide ethanol 131~n 57 yr Carbon monoxide ethanol 132 ip 59 yr Carbon monoxide ethanol 133P 65 yr Carbon monoxide ethanol See also cases 62, 225 (carbon monoxide).
Chronicity
Route
Reason
A
Ing/Inh
Env
A
Ing/Inh
Env
A
Ing/Inh
Env
A
Ing/Inh
Int suicide
A
Ing/Inh
Env
Arsenic
A
Ingestion
Int suicide
Diquat carbidopa/levodopa
A
Ingestion
Intsuicide
A A A A/C A A A
Inhalation Inhalation Inhalation Inhalation Asp/Ing Inhalation Inhalation
Int abuse Int abuse Int abuse Int abuse Unint gen Int abuse Int abuse
U A/C A A/C A A NC A/C
Inhalation Inhalation Inhalation InhaLation Asp/Ing Inhalation inhalation Inhalation
Int abuse Int abuse Unknown Int abuse Unint gen Env Int abuse Int abuse
C
Inhalation
Unint mis
A A C A
Ingestion Ingestion Dermal Ingestion
Int suicide Int suicide Adv rxn Int suicide
C A A A A
Derm/Inh Dermal Inhalation Ingestion Ingestion
Occ Unknown Env Int unknown Int suicide
A A A A
Ingestion Ingestion Ingestion Parenteral
Int unknown Unint mis Int suicide Int suicide
Paints and stripping agents 165P 32 yr Paint fumes
A
Inhalation
Occ
Plants 166 a
C
Derm/Ing
Int misuse
A A
Ingestion Ingestion
Unknown Unint mis
Heavy metals 134 27yr Herbicides 135a
September 1996
34yr
Hydrocarbons 136~p 13 yr 137P 15 yr 138P 17 yr 139P 18 yr 140 a 18 mo 141ip 14yr 142P 16 yr
Butane Butane Butane Butane Charcoal lighter fluid Chlorofluorocarbon Chlorofluorocarbon air freshener 143P 27 yr Difluorochloromethane 144ap t 2 yr Difluoroethane 145 ~p >19yr Difluoroethane propellant 146P 20yr Gasoline 147a 13mo Lighter fluid 148p 66 yr Natural gas 149 37 yr Toluene 150 ip 36yr Toluene cocaine See also case 396 (natural gas).
Industrial Cleaners 151 a 74 yr
Sodium hydroxide cleaner
Insecticides/pesticides (excluding rodenticides) 152 83 yr Carbaryl 153P 40syr Chlorpyrifos 154 34 yr DEET (repellants) 1551p 64 yr Diazinon ethanol 156 a 31 yr Disodium methyl arsonate 157 35 yr Fenthion 158P 64 yr Insecticide, unknown type 159 75yr Malathion 160a 73 yr Malathion carbaryl 161 85 yr Organophosphate 162P 71 yr Pesticide, unknown type 163 82 yr Pesticides, unknown type 164 43 yr Propetamphos ethanol See also case 160 (carbaryl).
11 mo Cayenne pepper garlic oil 167a 39 yr Herbal tea 168a 3 mo Pennyroyaltea See also case 166 (garlic oil).
(Continued on following page)
Blood Levels 77%§ 220 mg/dL§ 13% 31%§ 180 mg/dL§
33,5% 238 mg/dL
4.9 pg/mL
8.5 14g/mL§
19 pg/mL
23.7 h
LITOVlTZ ET AL •
TABLE 21. Case
499
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Rodenticides 169a 74 yr 170 80 yr
171a
1995 A A P C C A N N U A L REPORT
83 yr
Substances
Brodifacoum Rodenticide (arsenic trioxide,1.5%) ethanol fluoxetine Strychnine
Chronicity
C A
Route
Reason
Blood Levels
Ingestion Ingestion
Int unknown Int suicide
9.5 ng/mL§ 80 mg/dL 0.35 IJg/mL§
A
Ingestion
Int suicide
A
Ingestion
Int suicide
C C A A A A A A A A U U A C C A A U A/C A C A A A U C A C C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Ther error Int misuse Int suicide Int suicide Int suicide Int suicide Int unknown Int suicide Int suicide Int suicide Int suicide Unknown Int suicide Int suicide Int unknown Int suicide Int misuse Unknown Ther error Int suicide Ther error Int suicide Int unknown Int suicide Int suicide Ther error Int unknown Ther error Ther error Int suicide
C
Ingestion
Int misuse
U
Ingestion
Int suicide
U
Ingestion
Int unknown
C
Ingestion
Ther error
A/C
Ingestion
Int misuse
36 !Jg/mL 103 mg/dL 153 pg/mL
C
Ingestion
Int misuse
13 pg/mL
U
Ingestion
Int suicide
U
Ing/Paren
Int unknown
C
Ing/Paren
Int misuse
A
Ingestion
Int suicide
154 #g/mL 829 pg/dL 150 lJg/mL
A
Ingestion
Int suicide
280 IJg/mL
See also cases 273 ( brodifacoum); 56, 68 (rodenticide). Swimming pool/aquarium products 172 26 yr Swimming pool acid (HCI) aspirin/carisoprodol PHARMACEUTICALS Analgesics 173 a 9 me 174 13 yr 175 20 yr 176 24 yr 177 24 yr 178 24 yr 179 25 yr 180 26 yr 181 26 yr 182 a 26 yr 183 30 yr 184 30 yr 185 30 yr 186 31 yr 187 34yr 188 36yr 189 37 yr 190 38yr 191 38 yr 192 39yr 193 ~ 41 yr 194 46 yr 195 50 yr 196 51 yr 197 51 yr 198 59 yr 199 60 yr 200 71 yr 201 71 yr 202 15 yr 203
35 yr
204
43 yr
205
28 yr
206
26 yr
207
36 yr
208
37 yr
209
55 yr
210
54 yr
211
45 yr
212
35 yr
213
37 yr
Acetaminc )hen Acetamin¢ )hen Acetaminc )hen Acetaminc )hen Acetamino )hen Acetaminc )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino }hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino 3hen Acetamino 3hen Acetamino )hen Acetamino 3hen acetaminophen/diphenhydramine Acetaminophen aspirin Acetaminophen carbamazepine Acetaminc 3hen cocaine Acetamino 3hen ethanol Acetamino 3hen ethanol Acetaminc 3hen ethanol Acetamfnc 3hen fluoxetine Acetaminc 3hen heroin Acetaminc 3hen iron dextran Acetaminophen lisinopril Acetamlnophen oral hypoglycemic venlafaxine
(Continued on following page)
60 IJg/mL 63 pg/mL 218 IJg/mL 33 IJg/mL 81 IJg/mL 57 #g/mL 444 Hg/mL 70 #g/mL 650 IJg/mL 137 IJg/mL 96 pg/mL 35 IJg/mL 38 #g/mL 35 IJg/mL 76 #g/mL 267 #g/mL 462 pg/mL 45 tJg/mL 512 pg/mL 43 #g/mL 72 pg/mL 68 pg/mL 128 IJg/mL 63 pg/mL 17 #g/mL
103 4 740 59
27 h >48 h 35 h 22 h 8h 4h
36 h >24 h 14h
>24 h
#g/mL mg/dL IJg/mL IJg/mL
12h
48 h
500
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
214
24yr
215p 216p 217 218
23 yr 34 yr 70 yr 38yr
219p
46 yr
220p
57 yr
221 222 223 224
25 yr 27yr 35 yr 35yr
225
44 yr
226
81 yr
227 228p
37 yr 35yr
229
44 yr
Substances Acetaminophen theophylline aspirin Acetaminophen/aspirin/caffeine Acetaminophen/butalbital/caffeine Acetaminophen/codeine Acetaminophen/codeine amitriptyline ethanol Acetaminophen/codeine carisoprodol Acetaminophen/codeine carisoprodol Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine alprazolam opiate Acetaminophen/diphenhydramine carbon monoxide Acetaminophen/diphenhydramine ethanol Acetaminophen/hydrocodone Acetaminophen/hydrocodone acetaminophen/propoxyphene ethanol Acetaminophen/hydrocodone
Chronicity
Route
Reason
A
Ingestion Int suicide
U A U U
Ingestion Ingestion Ingestion Ingestion
U
Ingestion Int suicide
32 IJg/mUI
A
Ingestion Int suicide
4 pg/mLI
A U A A
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
333 iJg/mLII 362 pg/mU 94 pg/mLtl 86 pg/mLIL
A
Ing/Inh
Int suicide
A/C
Ingestion
Int unknown
7 pg/mUI 3% 46 pg/mLtl
C A
Ingestion Int misuse Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
C A
Ingestion Unknown Ingestion Int suicide
37 pg/mLI
C
Ingestion Int misuse
U U A A/C C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Adv rxn Int suicide
252 pg/mUl 38 mg/dL 150 gg/mLtl
A/C
Ingestion
Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
177 pg/mUL 265 mg/dL propoxyphene 0.24 pg/mL norpropoxyphene 0.37 pg/mL 290 mg/dL 190 #g/mUt
A
Ingestion Int suicide
130 pg/mLLi
A/C
Ingestion
567 pg/mLt]
Int suicide Int suicide Int suicide Int unknown
diazepam 230
46yr
231 232P
40 yr 38yr
233
43yr
234 235 236 237 238
39 yr 43 yr 44yr 88 yr 60 yr
239
39 yr
240P
36 yr
241
57 yr
242P
48 yr
243P
47 yr
244P
64 yr
245P
34 yr
246
42 yr
247
48 yr
Acetaminophen/hydrocodone temazepam Iorazepam Acetaminophen/oxycodone Acetaminophen/oxycodone propoxyphene ethanol Acetaminophen/oxycodone salicyIate Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene acetaminophen/codeine Acetaminophen/propoxyphene acetaminophen/codeine paroxetine Acetaminophen/propoxyphene acetaminophen/diphenhydramine ethanol Acetaminophen/propoxyphene alprazolam Acetaminophen/propoxyphene aspirin/butalbital nefazodone Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene hydroxyzine ethanol Acetaminophen/propoxyphene Iorazepam Acetaminophen/propoxyphene oxybutynin
Blood Levels 23 IJg/mL 3 pg/mL 4 mg/dL
72 h 72 h 72 h
103 pg/mLtt
>6 h
48 pg/mUI 248 pg/mUI
(Continued on following page)
-24 h 2d
130 mg/dL 36 pg/mLII hydrocodone 0.17 pg/mL§ 0.18 pg/mL nordiazepam 0.08 pg/mL 685 pg/mUI hydrocodone 0.35 pg/mL 0.34 pg/mL
44 pg/mLil 7 pg/mLH
272 pg/mUt 78 mg/dL
Int misuse
15 h
48 h
LITOVITZ ET AL •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
501
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
248
35 yr
249 a 250 251 252 253 254 255 256 a 257 258 259 260 261 262 263 264 265 266 267 268 269 270
2 yr 18 yr 19 yr 22 yr 25 yr 33 yr 35 yr 37 yr 37 yr 43 yr 50 yr 50 yr 55 yr 55 yr 56 yr 60 yr 69 yr 87 yr 88 yr 93 yr 95 yr 46 yr
271
15 yr
272
42 yr
273
22 yr
274
32 yr
275
33 yr
276
70 yr
277
33 yr
278
53 yr
279
71 yr
280
23 yr
281
35 yr
282
40 yr
283P
35 yr
284
68 yr
285
79 yr
286
37 yr
287
52 yr
Substances Acetaminophen/propoxyphene
temazepam Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspmn Aspmn Aspinn Aspirin Aspmn Aspmn Aspmn Aspirin Aspirin Aspirin Asptrin AspJnn Aspmn Aspmn Aspinn Aspmn acebutolol Aspirin acetaminophen Aspirin acetaminophen Aspirin acetaminophen brodifacoum Aspirin acetaminophen/diphenhydramine ethanol Aspirin acetaminophen/oxycodone Aspirin activated charcoal Aspirin amitriptyline Aspinn amitriptyline Aspirin amitriptyline/pe rphenazine amitriptyline Aspirin benztropine Iorazepam Aspirin bupropion haloperidol Aspirin carbamazepine Aspirin clonidine alprazolam Aspirin ethanol Aspirin ethanol Aspirin interferon Aspirin Iorazepam
Chrenicity
Route
Reason
U
Ingestion
Unknown
A A A A A A A A A A A/C C A C A A C A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Int suicide Unknown Int suicide Int suicide fnt suicide Int suicide Int suicide Int suicide Int suicide Ther error Int unknown Int suicide Ther error Int suicide Int suicide Unknown Int suicide Int suicide Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
U
Ingestion
Ther error
A
Ingestion
Int suicide
A
Ingestion
A
Blood Levels 320 #g/mL"§ propoxyphene 6.99 IJg/mL§ norproxyphene 4.03 IJg/mL§ 1.22 pg/mL§ 109 mg/dL 105 mg/dL 73 mg/dL 120 mg/dL 126 mg/dL 104 mg/dL 104 mg/dL 120 mg/dL 95 mg/dL 92 mg/dL 116 mg/dL 82 mg/dL 36 mg/dL 40 mg/dL 97 mg/dL 76 mg/dL 47 mg/dL 65 mg/dL 103 mg/dL 88 mg/dL 71 mg/dL 87 mg/dL§
6h
9h 5h 28 h 8h
2-3 d 9h
-22 h
130 mg/dL 103 IJg/mL 99 mg/dL 36 pg/mL 118 mg/dL 108 IJg/mL
7h 7h
Int suicide
73 mg/dL
1Oh
Ingestion
Int suicide
A
Asp/Ing
Int suicide
94 mg/dL 9 tJg/mL" 50 mg/dL
A
Ingestion
Int suicide
101 mg/dL
U
Ingestion
Int suicide
A
Ingestion
Int suicide
70 mg/dL 121 ng/mL 113 mg/dL
U
Ingestion
Unknown
210 ng/mL 69 mg/dL
A
Ingestion
Int suicide
86 mg/dL
A
Ingestion
Int suicide
91 mg/dL
U
Ingestion
Int suicide
116 mg/dL
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ing/Paren
A
Ingestion
42 h
10h
Int suicide
121 mg/dL 160 mg/dL 87 mg/dL
Int suicide
130 mg/dL
16h
(Continued on following page)
502
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
288
27 yr
289
43 yr
290
74yr
291 292p
15 yr >19 yr
293P
22 yr
Substances Aspirin phentermine phendimetrazine Aspirin temazepam Aspirin verapamil (Long-acting) Aspirin-containing sinus medication Aspirin/propoxyphene/caffeine flunitrazepam Codeine
Chronicity
Route
Reason
A
Ingestion
Int suicide
47 mg/dL§ 0.08 IJg/mL
A
Ingestion
Int suicide
119 mg/dL
A
Ingestion
Int suicide
73 mg/dL
A A
Ingestion Ingestion
Int suicide Int suicide
88 mg/dL 47 mg/dL¶
A
Ingestion
Int suicide
1.6 Ug/mL§ morphine 0.162 ug/mL§ 1,890 ng/mL§ norfluoxetine 2,270 ng/mL§
U
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U U
Ingestion Ingestion
Int unknown Int suicide
A A A A A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Unint gen Unint gen Int suicide Unknown Int suicide
fluoxetine 294 ip
295 a 296 297 a 298P 299P 300P 301 aip 302 ap 303 ~p 304p 305 Lp 306P
80 yr
Codeine oxycodone amitriptyline 38 yr Celchicine 48 yr Colchicine aspirin/carisoprodol 14 yr Colchicine trazodone 32 yr Hydrocodone alprazolam 49 yr Meperidine 32 yr Meperidine cocaine 19 me Methadone 2 yr Methadone 3 yr Methadone 20 yr Methadone 30 yr Methadone 39 yr Methadone amitriptyline
307p
30 yr
308P
21 yr
309n
23 yr
310P
28 yr
311 ap
47 yr
312P 313 314 ip
30 yr 75 yr 40 yr
315
69 yr
316 ip
33 yr
317 ~p
39 yr
318 ip
37 yr
319
61 yr
320 ~p
26 yr
Methadone amitriptyline chlordiazepoxide Methadone ethanol Methadone ethanol Methadone ethanol Methadone heroin Morphine (long-acting) Morphine (long-acting) Morphine acetaminophen/oxycodone diazepam Morphine alprazolam Morphine cocaine benzodiazepines Morphine ethanol benzodiazepines Morphine ethanol codeine Morphine hydromorphone metoprolol Morphine methamphetamine
Blood Levels
25 mg/dL¶
A/C
Ingestion
Int unknown
A
Ingestion
Int abuse
A
Ingestion
Int unknown
U
Ingestion
Unknown
A/C
Ingestion
Int abuse
U C U
Ingestion Ingestion Ing/Unk
Int abuse Ther error Int unknown
U
Ingestion
Int suicide
A/C
Ing/Inh/Par Int abuse
A
Ing/Paren
A/C
Ing/Inh/Par Int abuse
A
Ingestion
Int suicide
A/C
Parenteral
Int abuse
Int abuse
(Continued on following page)
186 ng/mL 33 ng/mL
0.5 pg/mL§
430 ng/mL nortriptyline 3,250 ng/mL 1.55 pg/mL§ 60 ng/mL§ nortriptyiine 120 ng/mL§ 0.2 pg/mL§ 5,010 pg/mL 59 mg/dL
0.29 pg/mL§ 200 mg/dL§
0.065 iJg/mL 27 mg/dL
0.056 pg/mL§ 0.30 pg/mL§
8h 6h
LITOVITZ ET AL •
TABLE 21.
Age
321~P
44yr
322 ~p
37 yr
323p 324p 325
34 yr 41 yr 22 yr
326P
41 yr
327P
46 yr
329P 330 a 331 332 ip 333 ~ 334P 335p
336 ip 337 ~p
338 ip
339
340
341 342 343
503
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
328
1995 A A P C C A N N U A L R E P O R T
Substances Morphine paroxetine thioridazine Morphine sertraline Opiates Opiates Opiates amphetamines Opiates chlordiazepoxide Opiates doxepin
benzodiazepines Opiates ethanol 46 yr Pentazocine/naloxone 40 yr Phenylbutazone 18 yr Propoxyphene 43 yr Propoxyphene 13-19 yr Propoxyphene 28 yr Propoxyphene acetaminophen 26 yr Propoxyphene acetaminophen fiuoxetine 31 yr Propoxyphene amitriptyline 38 yr Propoxyphene butalbital chlorpromazine 39 yr Propoxyphene cocaine benzodiazepines 82 yr Propoxyphene codeine benzodiazepine 41 yr Propoxyphene fentanyl carisoprodol 58 yr Salicylate 51 yr Salicylate >19 yr Salicylate 55 yr
Chronicity
Route
Reason
A/C
Ingestion
Int suicide
A/C
Ing/Unk
Int unknown
C A A
Unknown Ingestion Unknown
Int abuse Int misuse Int abuse
U
Unknown
Int unknown
U
Ingestion
Unknown
U
Unknown
Unknown
A U A/C A/C A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int unknown
Blood Levels
1,037 884 215 nordoxepin 84
ng/mL§ ng/mL ng/mL ng/mL
200 mg/dL
7.69 pg/mL >2,000 ng/mL 366 pg/mL 244 pg/mL
U
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
C A U
Ingestion Ingestion Ingestion
Int misuse Int suicide Unknown
71 mg/dL 166 mg/dL
See also cases 11, 12, 36, 53, 127, 271, 272, 273, 334, 335, 367, 390, 432, 476, 495, 542, 577, 611, 618, 643 (acetaminophen); 238, 239, 393, 578, 603 (acetaminophen/codeine); 13 (acetaminophen/decongestant); 202, 240, 274, 641 (aeetaminephen/diphenhydramine); 528, 543, 611 (aeetaminophen/hydreeodone); 275, 314 (acetaminophen/oxyeodone) ; 228, 368, 44& 647 (acetaminophen/propoxyphene) ; 64, 203, 214, 370, 430, 684 (aspirin); 242 (aspirin/butalbital); 172, 296 (aspirin/earisoprodol); 318, 339, 375, 404, 532, 698, 708 (codeine); 542 (eodeine/iodinated glycerol); 583 (diclofenac); 383 (etodoloc); 340 (fentanyl); 387, 449 (hydrocodone); 319 (hydromorphone); 431, 449, 458, 495, 496, 528, 585, 605 (ibuprofen); 452 (methadone); 19, 680 (morphine); 628 (naproxen); 224, 347, 474, 476, 648, 681, 682, 683 (opiate); 294, 389, 432, 468 (oxycodone); 589 (piroxicam); 20, 21, 22, 232, 590, 600, 707, 708 (propoxyphene); 233 (salicylate). Anesthetics 344 ap 345P 346 a 347
29yr 16 yr 28 yr 48 yr
Bupivacaine Halothane Isoflurane Udocaine opiates
A A/C U A
Parenteral Inhalation Inhalation Ingestion
Adv rxn Int abuse Int abuse Int suicide
A
Ingestion
Int suicide
benzodiazepines See also case 718 (ethyl ether). Anticholinergic drugs 348 35 yr Amantadine
See also cases 426 (amantadine); 280, 588, 628 (benztropine); 247 (oxybutynin); 621 (trihexyphenidyl). Anticoagulants 349 71 yr
Warfarin trimethoprim/sulfamethoxazole
C
Ingestion
Ther error
See also case 499 (warfarin). (Continued on following page)
145 IJg/mL§ 50 pg/mL
504
TABLE 21. Case
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Substances
Chronicity
Route
Reason
Anticonvulsants 350 30s yr Carbamazepine A/C Ingestion Int suicide 351 32 yr Valproic acid U Ingestion Int suicide See also cases 15, 16, 204, 282, 443, 477 (carbamazepine); 498 (phenytoin); 402 (valproate); 642 (valproic acid). Antidepressants 352~P 19 yr 353P 354 355 356 357P 358 359P 360p 361P 362P 363 364p
21 yr 22 yr 22 yr 24 yr 24 yr 27 yr 32 yr 32 yr 35 yr 36 yr 38 yr 41 yr
365 ip 366P 367P
57 yr >19 yr 58 yr
368P
35 yr
369
34 yr
370
41 yr
371P
36 yr
Blood Levels 40 IJg/mL 170.8 IJg/mL
Amitriptyline
A
Ingestion
Int misuse
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A A/C A/C A/C A U A A U A A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int unknown Int suicide Int suicide
Amitriptyline Amitriptyline Amitriptyline acetaminophen ethanol Amitriptyline acetaminophen/propoxyphene ethanol Amitriptyline
A/C A A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Asp/Ing
Int suicide
3,283 ng/mL nortriptyline 351 ng/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
1,250 ng/mL#§ 88 mg/dL 4,680 ng/mL nortriptyline 1,320 ng/mL 14,880 ng/mL 6,000 ng/mL
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
activated charcoal Amitriptyline aspirin Amitriptyline
372P
35 yr
373
47 yr
374P
29 yr
375P
>19 yr
376P
42 yr
377 ip
42 yr
378
38 yr
clomipramine diphenhydramine Amitriptyline clonazepam Amitriptyline clonazepam baclofen Amitriptyline cocaine Amitriptyline codeine benzodiazepines Amitriptyline cyclobenzaprine diazepam Amitriptyline cyclobenzaprine ethanol Amitriptyline
379p
45 yr
diazepam ethanol Amitriptyline
380p
27 yr
381P
34 yr
382p
55 yr
383
48 yr
diphenhydramine Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline etodolac
6,000 ng/mL nortriptyline 1,140 ng/mL
653 ng/mL
514 ng/mL 218 ng/mL nortriptyline 410 ng/mL
137 ng/mL 154 IJg/mL 586 mg/dL
4,100 ng/mL#
U
Ingestion
Int suicide
A
Ingestion
Int suicide
7,068 ng/mL§ nortriptyline 1,574 ng/mL§ 710 ng/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
2,350 ng/mL nortriptyline 3,830 ng/mL 0.20 pg/mL 1,460 ng/mL§ 124 mg/dL§
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
(Continued on following page)
5,200 ng/mL§ 70 mg/dL§
LITOVITZ ET AL •
TABLE 21,
505
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
384
57yr
385
69 yr
386 ip
47yr
387
38 yr
388 ap
1995 A A P C C A N N U A L R E P O R T
9 yr
Substances Amitriptyline fluoxetine Amitriptyline fosinopril alprazolam Amitriptyline heroin Amitriptyline hydrocodone alprazolam Amitriptyline
Chronicity
Route
Reason
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
64 IJg/mL >5,000 ng/mL
A/C
Ingestion
Int suicide
279 ng/mL
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A
Ing/Inh
Int suicide
A
Ingestion
Int suicide
imipramine
389P
25 yr
390
64yr
391
57 yr
392
48 yr
393
41 yr
394p
26 yr
395P
32 yr
396
34 yr
397P
49 yr
methylphenidate Amitriptyline oxycodone Amitriptyline phenelzine acetaminophen Amitriptyline prochlorperazine Amitriptyline risperidone terfenadine Amitriptyline paroxetine acetaminophen/codeJne Amitriptyline phenobarbital Amitriptyline thioridazine Amitriptyline thiothixene natural gas Amitriptyline
Blood Levels
verapamil 398 399 ap
75 yr 27 yr
Amitriptyline/perphenazine Bupropion
A A
Ingestion Ingestion
Int suicide Int suicide
400 p 401
61 yr 35 yr
A A
Ingestion Ingestion
Int suicide Int suicide
402P
25 yr
A/C
Ingestion
Int suicide
403 404P
51 yr 50 yr
A A/C
Ingestion Ingestion
Int suicide Int suicide
405 a 406 a 407P 408 409 410 ip 411 412P 413P 414 415P
1 yr 3 yr 14 yr 15 yr 18 yr 18 yr 19yr 21 yr 21 yr 34 yr 44 yr
A U A A A/C A A U A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Unknown Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
416
44 yr
Bupropion Bupropion sertraIine Bupropion valproate Iorazepam CIomipramine Clomipramine Ioxapine codeine Desipramine Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme alprazolam Desipramine barbiturate, unknown type trazodone
A/C
Ingestion
Int suicide
(Continued on followingpage)
1,100 ng/mL nortriptyline 1,200 ng/mL
1,430 nortriptyline 600 696 desipramine 636
860 nortriptylilne 150 0.48 norverapamil 0.51
ng/mL ng/mL ng/mL ng/mL
ng/mL§ ng/mL§ tJg/mL§ IJg/mL§
446 ng/mL hydroxybupropion 3,217 ng/mL 10.5 pg/mL desmethylsertraline 1.5 tJg/mL
2,600 ng/mL
1,472 ng/mL 1,800 ng/mL 8,200 ng/mL§ 3,500 ng/mL
506
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Case
Age
417~P
47 yr
418p
29yr
419
22 yr
420
25 yr
421
42 yr
422P 423P 424P 425
40 yr 40 yr 43 yr 84 yr
426
33 yr
427P
46 yr
428
78 yr
429P
34 yr
430P
50 yr
Substances Desipramine benzodiazepines ethanol Desipramine fluoxetine Desipramine haloperidol Desipramine lithium chlorpromazine Desipramine Iorazepam Doxepin Doxepin Doxepin Doxepin alprazolam paroxetine Doxepin amantadine Doxepin buspirone indapamide Doxepin chlorzoxazone diphenhydramine Doxepin ethanol Doxepin
Chronicity
Route
Reason
A/C
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
A
Ingestion Int suicide
A NC A A/C
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion Int suicide
NC
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Unknown
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Int suicide
Int suicide
431 i
30 yr
432P
42 yr
433P
30 yr
434ip
46 yr
435ip
50 yr
436P
12 yr
437
24 yr
Imipramine
A
Ingestion Int suicide
438 439P
29 yr 34 yr
Imipramine Imipramine
A A
Ingestion Int suicide Ingestion Int suicide
440
40 yr
Imipramine
A
Ingestion Int abuse
441
35 yr
Imiprarnine
A/C
Ingestion
Int suicide
442
43 yr
A/C
Ingestion
Int suicide
443P
39 yr
A
Ingestion Int suicide
444p
32 yr
U
Ingestion Int suicide
445P
29 yr
U
Ingestion Int suicide
446P
30 yr
A
Ingestion Int suicide
carbamazepine Imipramine cocaine Imipramine ethanol Imipramine ethanol
2,500 ng/mL
Int suicide
ethanol aspirin Doxepin ibuprofen Doxepin oxycodone acetaminophen Doxepin perphenazine Doxepin trazodone cannabinoids Fluoxetine isopropanol ethanol Imipramine
alprazolam Imipramine alprazolarn verapamil Imipramine
Blood Levels
(Continued on followingpage)
>3,000 ng/mL
2,900 ng/mL nordoxepin 1,200 ng/mL 32 pg/mL
1,300 ng/mL nordoxepin 90 ng/mL 220 mg/dL 6 mg/dL
3,600 ng/mL§ 0,3 pg/mL§
8,718 ng/mL desipramine 2,098 ng/mL 6,700 ng/mL desipramine 1,500 ng/mL 16,800 ng/mL§ desipramine 2,100 ng/mL§ 1,500 ng/mL desipramine 8,500 ng/mL 1,012 ng/mL§ desipramine 228 ng/mL
4,230 ng/mL§ desipramine 8,230 ng/mL§ 21.2 IJg/mL 8,168 ng/mL
1,934 ng/mL# 278 mg/dL
LITOVITZ ET AL •
TABLE 21.
507
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
447
30 yr
448P
1995 A A P C C A N N U A L R E P O R T
>19 yr
449
30 yr
450
49 yr
451
46 yr
452P
31 yr
453
67 yr
454 455 456
41 yr 46 yr 37 yr
457
70 yr
458
19 yr
459 460 461P 462~P 463
>19 yr 17 yr 27 yr 31 yr 39 yr
464P
60 yr
465
43 yr
466
61 yr
467 468~P
39 yr 50 yr
469~p
37 yr
470
36 yr
471 ip
50 yr
472 473 474
54 yr 68 yr 31 yr
475p
59 yr
Substances Imipramine ethanol Imipramine fluoxetine acetaminophen/propoxyphene Imipramine hydrocodone ibuprofen Imipramine lithium Imipramine meclizine phenylpropanolamine/guaifenesin Imipramine methadone ethanol Imipramine thioridazine clonazepam Lithium Lithium Lithium fluphenazine Iorazepam Lithium theophylline thioridazine Lithium tricyclic antidepressants ibuprofen Loxapine Nortriptyline Nortriptyline Nortriptyline Nortriptyline atenolol venlafaxine Nortriptyline flurazepam Nortriptyline imipramine ethanol Nortriptyline trazodone Phenelzine Sertraline carisoprodol oxycodone Sertraline lithium propranolol Sertraline paroxetine Trazodone benzodiazepines ethanol Tricyclic antidepressant Tricyclicantidepressant Tricyclic antidepressant amphetamines opiates Tricyclic antidepressant
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int unknown
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
C C A
Ingestion Ingestion Ingestion
Ther error Ther error Int suicide
3.1 mEq/L 2.3 mEq/L
C
Ingestion
Int misuse
3.0 mEq/L 56 pg/mL
A/C
Ingestion
Int suicide
A A/C A A/C A/C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U U
Ingestion Ingestion
Unknown Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Ther error
A/C A/C A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Unknown
A
Ingestion
Int suicide
29,445 ng/mL
2,650 ng/mL desipramine 586 ng/mL 4.46 mEq/L
3,450 ng/mL§
2,423 ng/mL#
benzodiazepines 476P
28 yr
ethanol Tricyclicantidepressant opiate acetaminophen
246 pg/mL
(Continued on following page)
508
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
477a
30 yr
Substances
Chronicity
Route
Reason
Blood Levels
Venlafaxine A/C Ingestion Unknown 89 tJg/mL§ carbamazepine 19.2 IJg/mL§ See also cases 15, 218, 277, 278, 279, 294, 306, 307, 336, 669 (amitriptyline); 279 (amitriptyline/perphenazine); 14, 607 (antidepressant); 281 (bupropion); 371, 503, 642 (clomipramine); 621, 649 (desipramine); 327, 600 (doxepin); 16, 170, 209, 293, 335, 384, 418, 448, 595, 620 (fluoxetine); 388, 465, 534, 641 (imipramine); 420, 450, 469, 547, 629 (lithium); 404 (Ioxapine); 242 (nefazodone); 55, 504, 555 (nortriptyline); 239, 321,393,425, 470, 547 (paroxetine); 390 (phenelzine); 22, 322, 401,496, 612 (sertraline); 14, 297, 416, 434, 466 (trazodone); 458 (tricyclic antidepressant); 213, 463 (venlafaxine).
Antihistamines 478 48 yr Diphenhydramine A ingestion 479P 22 yr Diphenhydramine (OTC) sleep aid A Ingestion 480p 30 yr Diphenhydramine (OTC) sleep aid A Ingestion See also cases 371, 379, 428, 589 (diphenhydramine); 245, 609, 633 (hydroxyzine); 451
Int suicide Int suicide Int suicide (meclizine), 392 (terfenadine).
Antimicrobials 481 39 yr
Rifampin C Ingestion Adv rxn ethambutol clofazimine See also cases 481 (clofazimine); 481 (ethambutol); 583 (penicillin); 349 (trimethoprim/sulfamethoxazole).
Antineoplastics 482 81 yr
Doxerubicin
Asthma therapies 483 68 yr 484 48 yr 485 52 yr 486P 55 yr 487 65 yr 488 68yr 489 74 yr 490 74yr 491 76 yr 492 89 yr 493 >19yr 494 64yr
Aminophylline Theophylline Theophylline (long-acting) Theephylline Theophylline Theophylline Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline Theophylline (long-acting) alprazolam prednisone 495 18 yr Theophylline (long-acting) ibuprofen acetaminophen 496 20yr Theophylline ibuprofen sertraline 497 71 yr Theophylline isradipine 498 75 yr Theophylline phenytoin 499 71 yr Theophylline warfarin See also cases 214, 457, 577 (theophylline).
Cardiovascular drugs 500 28 yr Acebutolol enalapril 501 50 yr Amlodipine alprazolam verapamil 502 62 yr Amlodipine verapamil (long-acting) guanfacine 503 34yr Atenolol clonidine clomipramine 504 63 yr Atenolol trifluoperazine nortriptyline 505a 23 yr Cardiac glycoside extract from Bufo species (toad) sold as topical aphrodisiac
A
Parenteral Ther error
C C A/C A/C C C U C C C C A/C
Parenteral Ther error Ingestion Unknown Ingestion Int suicide Ingestion Int misuse Ingestion Int suicide Ing/Other Thererror Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Int suicide
47 t4g/mL >100 pg/mL 180 pg/mL 69 pg/mL 36 pg/mL 46 pg/mL 46 pg/mL 75 pg/mL 40 pg/mL 57 pg/mL 49 pg/mL 119 pg/mL
A
Ingestion Int suicide
167 IJg/mL
A
Ingestion Int suicide
19 pg/mL 105 pg/mL
NC
Ingestion
Int suicide
72 pg/mL
A/C
Unknown Unknown
C
Ingestion Ther error
37 IJg/mL 51.4 pg/mL 64 IJg/mL
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Int misuse
Int suicide
(Continued on following page)
4,750 ng/mL§ digoxin 0.9 ng/mL
LITOVITZ ET AL •
TABLE 21.
509
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
506
40 yr
507 508 509 510P 511 ~ 512 513 514
1995 A A P C C A N N U A L R E P O R T
> 19 yr 63 yr 74 yr 83 yr 89 yr 89 yr 94 yr 81 yr
515
92 yr
516
30 yr
517 518 519P 520 521P 522 523 524
34 yr 38 yr 60 yr 68 yr 80 yr 86 yr 90 yr 29 yr
525
69 yr
526
42 yr
527
49 yr
528
65 yr
Substances Cardiac glycoside extract from Bufospecies (toad) sold as topical aphrodisiac cocaine ethanol Cionidine Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Ioperamide Digoxin oxybutynin Digoxin verapamil Iorazepam Diltiazem (long-acting) Diltiazem Diltiazem (long-acting) Diltiazem (long-acting) Diltiazem Diltiazem (long-acting) Diltiazem (long-acting) Diltiazem captopril Diltiazem (long-acting) digoxin Diltiazem enalapril atenolol Diltiazem ethanol Diltiazem (long-acting) ibuprofen
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int misuse
digoxin 3.08 ng/mL
A A/C C A/C A/C A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int misuse Ther error Int suicide Ther error Int suicide Ther error Int unknown
>10 ng/mL >4.0 ng/mL 3.8 ng/mL§ 8 ng/mL 3.3 ng/mL
A/C
Ingestion
Int suicide
49.1 ng/mL
A/C
Ingestion
Int suicide
7.8 ng/mL
A A U A/C C A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Adv rxn Int suicide Int suicide Ther error Ther error Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
5.0 ng/mL 3-4 h
>2,000 mg/dL§ 6.8 ng/mL
16.3 pg/mL§ 80 pg/mL[I
8h
acetaminophen/hydrocodone 529 530 a 531
17 yr 20 yr 53 yr
532P
40 yr
533P 534
25 yr 26 yr
535 a 536P
72 yr 31 yr
537P 538 539 540 a 541p 542
23 yr 47 yr 57 yr 57 yr >19yr 22 yr
543P
544
58 yr
38 yr
Disopyramide Flecainide Isradipine enalapril cisapdde Metoprolol nifedepine codeine Mexiletine Mexiletine imipramine ethanol Milrinone Nadolol verapamil benzodiazepines Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine Nifedipine (long-acting) acetaminophen codeine/iodinated glycerol Nifedipine acetaminophen/hydrocodone alprazolam Nifedipine diltiazem (long-acting) enalapril
A/C A U
Ingestion Ingestion Unknown
Int suicide Int suicide Unknown
A/C
Ingestion
Int suicide
A U
Ingestion Ingestion
Int suicide Int unknown
A A/C
Parenteral Ingestion
Ther error Int misuse
U U A/C A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unknown Int suicide Int suicide Int misuse Unknown Int suicide
1.62 pg/mL
204 mg/dL
>200 ng/mL
123 pg/mL A/C
Ingestion
Int suicide 43,8 iJg/mLII
A
Ingestion
Int suicide
(Continued on following page)
10 h
510
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Case
Age
545
38 yr
546
36 yr
547
>19 yr
548
40 yr
549p
46 yr
550
35 yr
551 552 553
70 yr 37yr 79 yr
554~p
39 yr
555
26 yr
556 a
49 yr
557 558a
67 yr 50 yr
559 i 560 561P 562 563P 564P 565 566 567 568 569 570 571 572P 573 574P 575P 576 577
578
Substances
Chronicity
Route
Reason
Nifedipine (long-acting) ethanol Nifedipine (long-acting) glyburide methocarbamol Nifedipine (long-acting) lithium paroxetine Nifedipine (long-acting) verapamil (long-acting) Nifedipine (long-acting) verapamil (long-acting) Procainamide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
NC
Ingestion
Int suicide
Procainamide Propranolol (long-acting) Propranolol (long-acting) calcium channel blocker, unknown type Propranolol ethanol Propranolol nortriptyline Propranolol verapamil (long-acting)
Quinidine Quinidine captopril 79 yr Unknown cardiovascular drug 15 yr Verapamil 16 yr Verapamil 26 yr Verapamil (long-acting) 28 yr Verapamil (long-acting) 37yr Verapamil (long-acting) 38yr Verapamil (long-acting) 41 yr Verapamil (long-acting) 44yr Verapamil (long-acting) 46yr Verapamil (long-acting) 48 yr Verapamil (long-acting) 50yr Verapamil (long-acting) 50 yr Verapamil (long-acting) 54yr Verapamil (long-acting) 64yr Verapamil (long-acting) 64 yr Verapamil 70syr Verapamil (long-acting) 87 yr Verapamil 69 yr Verapamil (long-acting) acetaminophen theophylline 60yr Verapamil (long-acting)
5.6 mEq/L A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Unknown
A A C
Parenteral Ingestion Ingestion
Adv rxn Int suicide Adv rxn
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
C
Ingestion
Unknown
A A/C
Ingestion Ingestion
Int suicide Int suicide
A/C A A A A/C A A/C A A A U A/C A A A/C A/C A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int unknown Int suicide Ther error Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Ther error Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A/C
Asp/Ing
Int suicide
A
Ingestion
Int unknown
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
acetaminophen/codeine
579
54 yr
580P
30 yr
581 p
19 yr
582
55 yr
583
15 yr
benazepril Verapamil activated charcoal Verapamil amphetamines/methamphetamine Verapamil atenolol Verapamil cyclobenzaprine alprazolam Verapamil (long-acting) diclofenac penicillin
Blood Levels
(Continued on following page)
74 pg/mL N-acetylprocainamide 80 pg/mL
600 pg/mL 668 pg/mL norverapamil 301 pg/mL 12 pg/mL
2.6 pg/mL§
1,681 pg/mL
18.4 pg/mL
404 pg/mL 26 pg/mL 2.55 pg/mL§ norverapamil 0.30 lJg/mL§ 19 lag/mUI codeine 0.38 IJg/mL§ 15,800 ng/mL§ 509 tJg/mL norverapami1236 pg/mL
LITOVITZ ET AL •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
511
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
584
61 yr
Substances
Chronicity
Route
Reason
Blood Levels
Verapamil (long-acting) A/C Ingestion Intsuicide ethanol 585n 52 yr Verapamil A Ingestion Int suicide ibuprofen 586 52 yr Verapamil (long-acting) A Ingestion Int suicide molindone clonazepam 587 61 yr Verapamil (long-acting) A Ingestion Int suicide temazepam clorazepate 588 53 yr Verapamil A/C Ingestion Int suicide thiothixene benztropine See also cases 270 (acebutolol); 463, 526, 581 (atenolol); 578 (benazepril); 553 (calcium channel blocker, unknown type); 524, 558 (captopril); 283, 503, 638 (clonidine); 525, 625 (digoxin); 544 (diltiazem); 500, 526, 531, 544 (enalapril); 385 (fosinopril); 502 (guanfacine); 497 (isradipine); 212 (lisinopril), 319 (metoprolol); 532 (nifedipine); 469 (propranolol); 290, 397, 442, 501, 502, 516, 536, 548, 549, 556 (verapamil). Cough and cold preparations 589 28 yr Clemastine/phenylpropanolamine diphenhydramine piroxicam 590ip 33 yr Dextromethorphan phenylpropanolamine propoxyphene 591alp 592P 593 a
A
Ingestion
Int misuse
A
Ingestion
Int unknown
9 pg/mL 1.11 pg/mL 0.83 pg/mL norpropoxyphene 1.6 IJg/mL
17 yr 22 yr 43 yr
Ephedrine A Ingestion Int unknown Ephedrine A Ingestion Int misuse Phenylpropanolamine/ A Ingestion Int suicide brompheniramine See also cases 542 (codeine/iodinated glycerol); 451 (phenylpropanolamine/guaifenesin).
Diuretics See cases 629 (hydrochlorothiazide/triamterene); 427 (indapamide). Electrolytes and minerals 594 a 22 mo Ferrous sulfate 595 52 yr Potassium fluoxetine See also case 211 (iron dextran). Gastrointestinal preparations 596 2 yr Bismuth subsalicylate 597 a 63 yr Sodium biphosphate/phosphate enema See also cases 531 (cisapride) ; 514 (Ioperamide).
A A
Ingestion Ingestion
Unint gen Int suicide
C A
Ingestion Other
Adv rxn Ther error
2,583 IJg/dL 9.4 mEq/L
Hormones and hormone antagonists 598 44 yr Insulin A/C Parenteral Int suicide 599 30 yr Insulin A Ing/Paren Int suicide chlordiazepoxide carisoprodol 600 66 yr Insulin A Ing/Paren Int suicide doxepin propoxyphene 601 67 yr Phenformin C Ingestion Adv rxn See also cases 546 (glyburide); 637 (levothyroxine); 213 (oral hypoglycemic); 494 (prednisone). Miscellaneous drugs 602 85 yr AIIopurinol C Ingestion Adv rxn See also cases 135 (carbidopa/levodopa); 675 (gamma hydroxy butyrate); 286 (interferon). Muscle relaxants 603 41 yr
Carisoprodol A/C Ingestion Int suicide acetaminophen/codeine 604ip 33 yr Carisoprodol A Ingestion Int suicide ethanol 605 35 yr Cyclobenzaprine U Ingestion Int suicide ibuprofen See also cases 373 (baclofen); 219, 220, 340, 468, 599 (carisoprodol); 428 (chlorzoxazone); 376, 377, 582 (cyclobenzaprine); 546 (methocarbamol).
Sedatives/hypnotics/antipsychotics 606 73 yr Alprazolam 607 35 yr AIprazolam antidepressant, unknown type
A A
Ingestion Ingestion
Int suicide Int suicide
(Continued on following page)
6.5 h
512
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, N u m b e r 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
608 ~
30yr
609P
610P 611P
612P 613 p 614P 615 616 a 617 618P
619 a 620
621
622 623 624 625
626 a 627P 628iP
629
630 631 632P 633P
634 635
636ip 637P 638 a 639 640 641
Substances
Alprazolam ethanol 42 yr Alprazolam hydroxyzine ethanol 17 yr Benzodiazepines 49 yr Benzodiazepines acetaminophen/hydrocodone acetaminophen 82 yr Benzodiazepines sertraline 41 yr Chloral hydrate 80yr Chloral hydrate 85 yr Chlorpromazine 31 yr Clozapine 37 yr Diazepam ethanol 45 yr Diazepam ethanol acetaminophen 30 yr Ethchlorvynol ethanol 32 yr Fluphenazine chlorpromazine fluoxetine 36 yr Fluphenazine trihexyphenidyl desipramine 50s yr Flurazepam 84 yr Flurazepam 37 yr Flurazepam alprazolam 80 yr Flurazepam Iorazepam digoxin 16 yr Haloperidol 51 yr Haloperidol 24 yr Haloperidol benztropine naproxen 70 yr Haloperidol hydrochlorothiazide/triamterene lithium 42 yr Haloperidol perphenazine 91 yr Lorazepam > 19 yr Lorazepam ethanol 46 yr Lorazepam hydroxyzine chlordiazepoxide 32 yr Phenobarbital 41 yr Phenobarbital amphetamines benzodiazepines 36 yr Phenobarbital benzodiazepines 21 yr Phenobarbital levothyroxine 66 yr Risperidone clonidine 66 yr Secobarbital 80 yr Temazepam 47 yr Thioridazine acetaminophen/diphenhydramine imipramine
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int abuse
0.031 pg/mL§ 60 mg/dL§
NC
Ingestion
Int suicide
A A
Unknown Ingestion
Int unknown Int suicide
A/C
Ingestion
Int suicide
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Ther error Int suicide Int suicide
A/C
Ingestion
Int suicide
1,19 pg/mL§ 366 mg/dL
U
Ing/Paren
Int unknown
8.6 pg/mL§ 150 mg/dL
U
Ingestion
Int suicide
A/C
Ingestion
int suicide
A U A
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
C A U
Parenteral Ingestion Ingestion
Adv rxn Int suicide Int suicide
A/C
Ingestion
Int suicide
C
Parenteral
Adv rxn
A A
Ingestion Ingestion
Adv rxn Int suicide
A
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
U
Ingestion
Int unknown
A/C
Ingestion
Int suicide
AJC
Ingestion
Int suicide
A/C A A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
183 pg/mL
6-10 h
desalkylflurazepam 380 ng/mL N-desalkylflurazepam 189 ng/mL 5 ng/mL
2.7 ng/mL
0.3 mEq/L
(Continued on followingpage)
212 pg/mL
276.5 pg/mL
132 pg/mL 7 pg/mL 4,200 ng/mL 148 pg/mUI 230 ng/mL desipramine 1,300 ng/mL
18h 4h
TABLE 21.
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
642 ~p
31 yr
643
50 yr
644 ap
12 yr
Substances Thioridazine valproic acid clomipramine Trifluoperazine Iorazepam acetaminophen Trimethobenzamide
Chronicity
Route
Reason
C
Ingestion
Int misuse
A
Ingestion
Int suicide
C
Other
Adv rxn
Blood Levels
168 pg/mL 26.8 pg/mL
See also cases 224, 241, 283, 298, 315, 385, 387, 415, 425, 441, 442, 494, 501, 543, 582, 624, 669, 682 (alprazolam); 21, 316, 317, 327, 338, 339, 347, 375, 417, 471, 475, 536, 635, 636, 670, 683, 686, 695, 715 (benzodiazepines); 36, 416, 648 (barbiturates); 427 (buspirone); 337 (butalbital); 307, 326, 599, 633 (chlordiazepoxide); 55, 337, 420, 620 (chlorpromazine); 372, 373, 453, 586 (clonazepam); 229, 314, 376, 378, 671, 700 (diazepam); 292 (flunitrazepam); 456 (fluphenazine); 464 (flurazepam); 281, 419 (haloperidol); 230, 246, 280, 267, 402, 421, 456, 516, 625, 643 (Iorazepam); 433, 630 (perphenazine); 394 (phenobarbital); 391 (prochlorperazine); 392 (risperidone); 230, 248, 289, 587 (temazepam); 321, 395, 453, 457 (thioridazine); 396, 588 (thiothixene); 504 (trifluoperazine). Stimulants and street drugs 645n 43 yr Amphetamine 646 48 yr Amphetamine 647 51 yr Amphetamine acetaminophen/propoxyphene 6480 41 yr Amphetamine barbiturates opiates 649 60 yr Amphetamine desipramine 650 30 yr Amphetamines, hallucinogenic ethanol cannabinoids 651 35 yr Amphetamines marijuana 652an 11 mo Cocaine (crack) 653 18 yr Cocaine
A/C U A/C
Ingestion Unknown Ingestion
Int abuse Int unknown Int misuse
A/C
Unknown
Int abuse
U
Ingestion
Unint unk
U
Unknown
Int unknown
64 IJg/mUI
110 pg/m L 210 ng/mL§ 18 mg/dL A
Inhalation
Int abuse
A A
Ingestion Ingestion
Unint gen Int abuse
654P 655p 656 657p
25 yr 25 yr 27 yr 29 yr
Cocaine Cocaine Cocaine Cocaine
A A/C A A
Ing/Inh Ingestion Ingestion Ingestion
Int misuse Int misuse Int misuse Unknown
658~P 659 660 661p 662p 663 664 665P 666 667p 668p 669n
29 yr 30 yr 31 yr 31 yr 35 yr 35 yr 37 yr 38 yr 42 yr 42 yr 55 yr 34 yr
A AJC A A/C A A/C U A/C A U U A
Unknown Inhalation Unknown Inhalation Unknown Parenteral Unknown Inhalation Inhalation Unknown Inhalation Ing/Inh
Int abuse Int abuse Int abuse Int abuse Unknown Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int unknown
670
47 yr
A
Ing/Inh
Int abuse
671
29 yr
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine (crack) Cocaine Cocaine Cocaine Cocaine amitriptyline alprazolam Cocaine benzodiazepines amphetamines Cocaine
U
Ingestion
Int abuse
672Jp
30 yr
C
Ing/Inh
Int abuse
673p
35 yr
A
Unknown
Int abuse
674
24 yr
C
Ing/Inh
Int abuse
675
23 yr
A
Ing/Unk
Int abuse
676P
46 yr
A/C
Ing/Paren
Int abuse
diazepam Cocaine ethanol Cocaine ethanol Cocaine ethanol methamphetamine Cocaine gamma hydroxy butyrate Cocaine heroin methamphetamine
1,000 ng/mL
(Continued on following page)
25.66 0.31 benzoylecgonine 6.9 ecgonine methyl ester 2.87
IJg/mL§ pg/mL§ pg/mL§ #g/mL§
0.52 #g/mL benzoylecgonine 3.43 IJg/mL 0.3 pg/mL benzoylecgonine 8.8 IJg/mL§ 2.0 ~Jg/mL
0.06 IJg/mL§ benzoylecgonine 2.28 IJg/mL§ ecgonine methyl ester 0.75 pg/mL§ 0.9 pg/mL§
0.03 pg/mL§ benzoylecgonine 1.4 pg/mL§
514
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
677
41 yr
678P
26 yr
679
23yr
680~p
26 yr
6810
36yr
682
33yr
683P
51 yr
684
43yr
685ip
52 yr
6860
30 yr
687P 688P 689P 690 691P 692io 693P 694P 695iP
21 yr 34 yr 36 yr 42 yr 45 yr 46 yr 47yr 48 yr 43yr
696ip
32 yr
697i0
38yr
698P
39 yr
6990
47 yr
700P
28 yr
701 p
20yr
702P
30yr
703ip
34 yr
704P
37 yr
705P
46 yr
706ip
19 yr
707P
26 yr
708iP
26 yr
Substances Cocaine marijuana Cocaine methamphetamine heroin Cocaine (crack) methanol Cocaine morphine Cocaine opiates Cocaine opiates alprazolam Cocaine opiates benzodiazepines Cocaine phenylpropanolamine aspirin Cocaine (crack) plastic bag Fenfluramine ethanol benzodiazepmes Heroin, brown Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin benzodiazepines Heroin cocaine Heroin cocaine Heroin cocaine codeine Heroin cocaine ethanol Heroin diazepam Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol cannabinoids Heroin propoxyphene cocaine Heroin propoxyphene codeine
Chronicity
Route
Reason
A
Inhalation
Int abuse
A
Parenteral
Int abuse
U
Ing/Inh
Int abuse
A/C
Parenteral
Int abuse
A
Unknown
Int unknown
A/C
Ing/Unk
Int abuse
A
Ingestion
Int unknown
A/C
Ingestion
Int suicide
U
Asp/ing
Int abuse
U
Ingestion
Int suicide
Blood Levels
0.02 IJg/mL cocaine metabolite 0.19 ug/mL 0.02 IJg/mL
0.06 ug/mL benzoylecgonine 1.4 pg/mL 0.06 Ug/mL
79 mg/dL
109 mg/dL§ U A/C A/C A/C A A/C A A/C A/C
Inhalation Parenteral Parenteral Parenteral Parenteral Parenteral Parenteral Parenteral Ing/Paren
Int abuse Int suicide Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse
A/C
Inh/Paren
Int abuse
A/C
Inh/Paren
Int abuse
A/C
Unknown
Int abuse
A/C
Parenteral
Int abuse
NC
Ing/Paren
Int abuse
U
Ing/Paren
Int abuse
A/C
Ing/Paren
Int abuse
A/C
Ing/Paren
Int abuse
U
Ing/Paren
Int abuse
C
Parenteral
Int abuse
A/C
Ing/Inh/Par Int abuse
A
Parenteral
A
Ing/Inh/Unk Int abuse
morphine 0.028 pg/mL morphine 111 ug/mL
130 mg/dL
167 mg/dL
240 mg/dL
Int abuse
(Continued on following page)
LITOVITZ ET AL •
TABLE 21. Case 709 a 710 711a 712 713 714p
1995 A A P C C A N N U A L R E P O R T
515
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Substances
Chronicity
Route
Reason
1d 27 yr 30 yr 36 yr 37 yr >19yr
Methamphetamine Methamphetamine Methamphetamine Methamphetamine Methamphetamine Methamphetamine
C A U A/C A/C U
Other Ingestion Ing/Inh Unknown Parenteral Unknown
Int abuse Int abuse Int abuse Int abuse Int abuse Unknown
715
40 yr
U
Ing/Unk
Int abuse
716
37 yr
Methamphetamine benzodiazepines ethanol Methamphetamine
U
Unknown
Int abuse
717p
31 yr
cannabinoids Methamphetamine
A
Unknown
Int abuse
Blood Levels
1.1 pg/mL amphetamine 0.16 pg/mL
474 mg/dL >5,000 ng/mL amphetamine 3,590 ng/mL 0.80 pg/mL amphetamine 0.11 IJg/mL benzoyfecgonine 0.28 pg/mL§
cocaine Methamphetamine A Inh/Unk Int abuse ethyl ether 719P 19 yr Methylenedioxymethamphetamine A Ingestion Int abuse 0.54 pg/mL§ 720P 23 yr Methylenedioxymethamphetamine A Ingestion Int abuse 721 18 yr Phencyclidine U Unknown Int abuse 722p 38 yr Phencyclidine A Ingestion Int abuse 0.62 pg/mL§ See also cases 325, 474, 635, 670 (amphetamine); 580 (amphetamines/methamphetamine); 434, 650, 706, 716 (cannabinoids); 128, 150, 205, 300, 316, 338, 374, 444, 506, 696, 697, 698, 699, 707, 717(cocaine); 17, 210, 311, 386, 676, 678 (heroin); 651, 677(marijuana); 16, 320, 674, 676, 678 (methamphetamine); 388 (methylphenidate); 288 (phendimetrazine); 288 (phentermine); 590, 684 (phenylpropanolamine). 718ap
25 yr
Topical preparations 723 44 yr Methyl saficylate (oil of wintergreen) iodine (2%) See also case 723 (iodine). Vitamins 724 a
1 yr
Prenatal vitamins with iron
A
Ingestion
Int suicide
124 mg/dL
1-2 h
A
Ingestion
Unint gen
6,000 pg/dL
12-14 h
NOTE: The term "long-acting" is used throughout for all sustained release, delayed release, or long-acting formulation. ABBREVIATIONS: C, chronic exposure; A, acute exposure; A/C, acute on chronic; U, unknown; Adv rxn, adverse reaction; Env, environmental; Int, intentional; Occ, occupational; Ther error, therapeutic error; Unint gen, unintentional general. pPrehospital (cardiac and/or respiratory) arrest. ~Reported to poison center indirectly (by coroner, medical examiner, or from other sou rce) after the fatality occurred. aAbstract provided in Appendix. § Level obtained postmortem. ilAcetaminophen level. I] Salicylate level. # Level includes metabolite and parent compound.
516
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A.
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals
Age (yr) Substance Implicated In the Exposure Adhesives/glues Cyanoacrylates Epoxy Toluene/xylene Nontoxic Unknown *Category totals Alcohols Ethanol (beverage) Ethanol (other) Higher alcohols Isopropanol Methanol Rubbing alcohol Ethanol, with methyl salicylate Ethanol, without methyl salicylate Isopropanol, with methyl salicylate Isopropanol, without methyl salicylate Unknown rubbing alcohol Other alcohol Unknown alcohol *Category totals Arts/crafts/office supplies Artist paints, non-watercolor Chalk Clay Crayon Glazes Office supplies: miscellaneous Pencil Pens/ink Typewriter correction fluid Water color Other Unknown *Category totals Auto/aircraftJboat products Ethylene glycol Glycols: other Glycol and methanol Hydrocarbons Methanol Nontoxic Other Unknown *Category totals Batteries Automotive batteries Disc batteries Alkaline (MnO=) Lithium Mercuric oxide Nickel cadmium Silver oxide Zinc-air Other Unknown Dry cell batteries Other batteries Unknown batteries
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
12,235 804 2,040 1,522 4,553 21,154
12,403 822 2,134 1,577 4,742 21,678
3,831 322 1,447 1,120 2,606 9,326
2,472 66 324 330 640 3,832
4,568 331 257 109 1,163 6,428
28,981 2,367 147 9,781 842
1,581 1,469 54 6,649 206
4,303 226 24 849 114
20,417 562 46 1,944 442
31
22
2
6
29
319
249
21
40
356
276
21
52
8,540 191 35 529 52,119
6,283 127 17 76 17,009
717 24 3 88 6,392
1,325 35 11 319 25,199
1,091 1,903 1,727 2,767 253
761 1,677 1,450 2,410 97
156 165 163 223 41
129 41 89 101 101
1,059 1,888 1,703 2,743 246
314 3,054 12,982 2,394 3,309 5,662 365 35,821
105 1,528 9,543 1,551 2,659 4,374 266 26,421
39 1,174 2,744 610 375 677 69 6,436
126 257 474 177 230 486 27 2,238
4,362 1,544 90 3,546 1,290 53 2,587 159 13,631
722 471 36 1,680 395 35 1,084 45 4,368
630 131 12 432 191 11 393 30 1,830
1,785
179
94 68 13 5 35 96 8 1,532 4,007 92 30
71 32 4 1 23 49 5 1,060 2,119 34 9
Int
Outcome None
Minor
Moderate Major Death
113 6 82 40 131 372
37 2 8 12 23 82
14 7 3 1 28 53
2,795 302 308 73 841 4,319
1,579 190 621 275 1,230 3,895
3,067 229 489 102 1,041 4,928
680 70 47 11 175 983
11 0 2 0 7 20
0 0 0 0 1 1
4,198 23,902 2,165 160 143 3 8,807 902 753 78
170 8 0 37 6
501 28 0 11 0
20,245 381 54 2,043 435
3,469 788 42 3,671 238
9,395 402 37 1,948 246
4,370 53 12 294 52
706 2 0 41 17
20 0 0 1 6
2
0
0
7
10
8
1
0
0
308
10
0
0
47
134
47
3
1
0
335
19
0
0
82
174
60
9
3
0
7,862 612 170 17 32 1 228 290 25,030 25,996
43 3 0 2 269
3 0 2 6 551
1,340 27 9 325 24,995
3,247 53 12 75 11,913
1,512 17 9 105 13,786
152 5 0 74 5,025
10 0 1 12 793
0 0 0 0 82
26 10 16 19 6
2 1 0 0 1
4 2 7 4 0
90 37 67 80 43
307 346 284 450 80
135 51 93 70 34
16 3 3 5 4
3 1 0 0 1
0 0 0 0 0
304 2,963 12,663 2,244 3,264 5,562 354 34,993
8 30 271 130 37 82 6 641
0 56 24 12 2 12 2 112
1 2 15 2 6 5 2 50
56 153 375 228 84 280 28 1,521
54 318 2,796 811 706 1,065 72 7,289
77 361 468 302 145 340 23 2,099
8 14 34 13 10 27 4 141
1 0 1 1 1 0 0 9
0 0 0 0 0 0 0 0
2,450 752 32 1,223 563 6 861 73 5,960
4,038 1,474 86 3,430 1,187 52 2,515 147 12,929
285 56 4 96 91 0 44 11 586
18 10 0 12 9 1 12 1 63
8 0 0 5 1 0 14 0 28
1,523 523 32 941 575 6 876 67 4,543
1,031 381 26 929 448 12 513 20 3,360
1,067 583 32 1,345 375 9 1,036 69 4,516
298 73 2 155 58 2 202 15 805
80 13 0 10 14 0 3 1 121
11 1 0 0 5 0 0 0 17
220
1,034
1,766
11
4
1
579
802
194
6
0
11 13 2 1 5 6 2 333 1,017 30 13
4 14 6 2 5 38 1 106 631 22 5
89 63 13 5 32 94 8 1,497 3,831 91 29
2
3
0
0
1 0 0 0 0 0 0 3 0 0
11 11 0 1 3 4 0 69 1,093 23 14
0
0 0 0 1 0 0 0 36 0 0
63 37 7 2 22 75 4 1,093 615 20 11
3
4 0 0 2 2 0 29 134 1 1
2 0 0 1 0 0 15 172 5 1
1 0 0 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0 0
(Continued on followingpage)
156 61 17 6 1 21 69 2 881 1,051 22 5
LITOVITZ ET A L •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
517
Demographic Profile of Exposure Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure *Category totals Bites and envenomations Coelenterate Fish Other/unknown marine animal Insects Ant/fire ant Bee/wasp/hornet Caterpillar Centipede/millipede Mosquito Scorpion Tick Other insect Mammals Bat Cat Dog Fox Human Raccoon Rodents/lagomorphs Skunk Other mammal Reptile other/unknown Snakes Copperhead Coral Cottonmouth Crotalid: unknown Rattlesnake Exotic snakes Poisonous Nonpoisonous Unknown if poisonous Nonpoisonous snake Unknown snake Spiders Black widow Brown recluse Other spider Tarantula Unknown insect or spider Other/unknown animal bite *Category totals Building and construction products Caulking compounds and putties Cement, concrete Insulation Asbestos Fiberglass Urea/formaldehyde Other Unknown Soldering flux Other construction product Unknown construction product *Category totals Chemicals Acetone
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
7,765
3,586
1,653
1,868
7,518
186
44
5
2,528
2,292
2,031
393
9
0
52 1,233
13 25
11 204
22 853
52 1,228
0 1
0 2
0 2
11 408
1 26
14 550
3 173
0 5
0 0
217
70
35
97
213
2
0
2
64
21
49
18
0
0
3,121 17,874 2,554 105 287 11,005 3,211 10,876
1,255 3,795 714 41 101 915 882 2,362
460 4,060 686 20 55 2,161 788 2,030
1,173 8,408 1,020 33 104 6,793 1,264 5,495
3,099 17,853 2,535 105 286 11,00t 3,202 10,676
6 11 8 0 0 3 2 22
13 2 4 0 1 0 0 136
2 8 6 0 0 1 3 29
358 1,771 217 9 46 761 644 1,976
78 206 81 8 1 122 195 394
1,232 7,706 979 38 101 5,917 698 3,384
184 947 86 3 19 733 55 669
6 22 1 0 2 21 2 3
0 2 0 0 0 0 0 0
180 744 1,407 27 62 103 1,703 233 964 1,342
18 131 261 7 18 9 453 27 168 509
39 176 530 5 19 19 652 63 335 445
93 357 514 14 16 67 455 102 356 296
176 740 1,407 27 53 101 1,685 231 957 1,313
1 1 0 0 0 1 1 0 1 9
0 0 0 0 9 0 13 1 1 9
1 2 0 0 0 0 2 1 2 8
110 359 851 19 27 61 383 26 365 188
21 12 17 1 2 5 63 19 55 153
38 160 233 2 14 25 512 78 218 431
3 23 39 0 7 4 28 11 21 37
0 1 2 0 0 0 0 0 3 0
0 0 0 0 0 0 0 0 0 1
467 45 81 5 817
29 4 2 1 55
103 9 18 1 158
302 31 52 3 533
467 44 81 5 811
0 0 0 0 4
0 0 0 0 1
0 1 0 0 1
406 38 68 3 708
9 6 3 1 26
185 19 30 0 201
167 5 24 2 355
10 1 2 0 74
0 0 0 0 1
104 237 1 2,044 1,957
11 26 0 243 213
14 80 0 937 651
63 110 1 715 971
101 237 1 2,040 1,956
1 0 0 0 1
0 0 0 1 0
1 0 0 1 0
84 69 1 444 1,130
5 4 O 79 118
21 77 0 867 946
28 12 0 43 225
8 0 0 1 22
0 0 0 0 0
2,080 2,003 6,687 107 12,672 1,021 87,628
184 180 944 17 2,076 101 15,860
336 301 1,343 41 2,320 463 19,568
1,400 1,239 3,854 38 6,172 415 43,431
2,076 1,997 6,668 106 12,648 1,019 87,197
3 2 8 0 5 1 94
1 1 2 0 13 0 210
0 1 8 1 4 1 88
689 1,051 1,118 16 2,681 142 17,302
130 43 135 2 189 14 2,245
950 570 2,400 56 5,280 328 34,309
321 493 372 2 1,025 66 6,203
14 25 4 0 13 0 242
0 0 0 0 0 0 4
3,428 1,455
2,563 361
222 116
461 779
3,379 1,430
28 14
4 3
15 7
252 618
1,057 200
321 400
45 303
2 16
0 0
200 1,503 119 246 60 463 1,875
28 586 44 103 32 190 1,014
36 252 20 34 5 70 184
95 515 38 80 19 159 534
195 1,448 116 240 56 454 1,851
1 15 1 2 0 3 13
0 19 0 0 2 3 4
1 12 2 4 2 2 6
65 214 29 38 16 154 347
31 200 16 59 9 100 361
25 380 24 41 3 148 375
5 48 8 6 3 40 80
0 0 0 0 0 3 0
0 0 0 0 0 0 0
64 9,413
12 4,933
7 946
35 2,715
62 9,231
0 77
0 35
2 53
22 1,755
5 2,038
23 1,740
7 545
0 21
0 0
1,197
439
139
508
1,124
47
8
7
369
248
384
67
3
0
(Continued on followingpage)
518
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A.
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Acids Hydrochloric Hydrofluoric Other Unknown Alkali Ammonia Borates/boric acid Chlorates Cyanide Dioxin Formaldehyde/formalin Glycol: ethylene Glycol: other Ketones Methylene chloride Nitrates and nitrites Phenol/creosote Strychnine Toluene diisocyanate Other chemicals Unknown chemicals *Category totals Cleaning substances (household) Ammonia cleaners (all purpose) Automatic dishwasher detergents Granules Liquids Rinse agents Other/unknown Bleaches Borate Hypechlorite Nonhypochlorite Other/unknown Carpet/upholstery cleaners Cleansers Anionic/nonionic Other/unknown Disinfectants Hypochlorite Phenol Pine oil Other/unknown Drain cleaners Acid Alkali Other/unknown Fabric softeners/antistatic agents Aerosol/spray Dry/powder Liquid Solid/sheet Other/unknown Glass cleaners Ammonia Anienic/nonionic Isopropanol Other/unknown Hand dishwashing Anionic/nonionic Other/unknown
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
2,968 1,435 4,895 484 4,958 5,653 3,622 76 287 16 1,572 660 1,210 986 697 970 1,349 29 430 15,565 2,449 51,506
176 105 656 57 1,181 1,627 2,074 29 15 1 246 122 475 261 101 255 204 7 66 4,881 1,159 14,137
576 84 716 84 806 704 358 10 15 0 309 70 231 85 65 355 172 8 36 2,117 376 7,316
1,750 954 2,680 267 2,241 2,713 999 30 200 13 772 361 390 512 415 281 756 9 241 6,388 657 23,137
2,883 1,410 4,771 456 4,831 5,416 3,417 73 251 14 1,493 546 1,162 974 684 889 1,313 13 422 14,272 2,341 48,755
56 14 74 14 60 182 152 3 20 1 48 99 29 5 6 51 18 9 4 441 19 1,352
15 5 22 13 38 31 30 0 11 0 15 3 5 2 3 21 2 3 1 476 59 763
8 2 20 0 18 18 13 0 1 0 7 1 11 5 2 5 16 2 2 264 24 426
1,174 1,095 2,184 209 2,339 1,918 559 44 181 14 674 319 450 496 360 253 546 16 172 4,960 402 18,734
267 135 475 34 622 640 950 12 49 2 215 128 297 147 77 250 126 7 56 2,971 426 8,134
1,288 573 1,980 189 1,700 2,209 361 13 91 5 517 137 353 385 292 239 480 2 120 3,928 354 15,600
439 367 728 93 908 622 45 5 18 2 114 63 71 113 84 43 178 1 42 986 52 5,041
20 25 35 3 41 21 1 1 9 0 7 44 6 4 3 2 7 0 2 63 2 299
3 0 5 0 0 0 0 0 2 0 0 9 0 0 0 0 0 0 0 4 0 23
3,643
1,687
360
1,375
3,505
112
18
5
679
789
1,092
200
2
0
4,930 2,182 1,171 803
4,114 1,744 1,094 621
279 108 33 53
429 266 37 91
4,890 2,159 1,170 791
25 15 1 4
10 0 0 6
1 8 0 2
244 137 22 55
2,121 873 342 322
942 372 155 143
54 34 3 11
0 1 1 0
0 0 0 0
806 47,495 822 314 4,207
379 19,837 446 156 3,191
56 5,052 65 25 276
306 18,967 251 112 558
773 45,615 794 290 4,135
14 1,430 19 15 24
3 309 4 6 7
15 94 4 2 39
99 8,937 133 55 388
184 7,938 194 63 1,223
254 16,911 270 106 806
30 2,396 16 17 71
1 51 1 0 2
0 0 0 0 0
7,755 1,085
5,904 675
551 96
1,036 273
7,507 1,031
163 43
39 5
35 3
728 186
2,403 326
1,447 268
149 41
1 0
0 0
5,657 4,793 10,802 1,847
2,730 3,282 7,500 862
667 489 853 256
1,894 801 2,107 560
5,525 4,546 10,337 1,716
75 188 375 87
25 39 54 27
31 13 16 14
1,139 687 1,959 499
1,319 1,197 3,801 442
1,959 1,317 2,522 635
425 106 256 87
8 5 19 1
0 0 0 0
938 3,447 397
96 653 105
80 368 60
594 1,969 192
911 3,199 370
20 220 22
4 22 1
2 0 3
341 1,240 84
90 483 71
373 1,252 139
187 497 21
7 26 1
1 2 1
61 6 1,158 366 26
37 5 939 313 20
4 1 64 25 0
18 0 120 21 5
60 6 1,109 348 25
0 0 16 2 1
1 0 2 1 0
0 0 31 14 0
8 0 89 8 4
13 2 398 108 6
18 2 149 32 3
1 0 11 0 2
0 0 0 0 0
0 0 0 0 0
2,702 30 4,400 4,479
2,083 12 3,446 3,499
229 5 403 408
291 10 452 405
2,612 26 4,262 4,329
70 2 107 100
15 0 24 31
4 1 3 13
219 6 351 340
820 7 1,375 1,328
541 9 1,015 1,045
21 2 43 44
2 0 1 3
0 0 0 0
7,877 1,373
4,963 764
776 150
1,682 361
7,521 1,272
104 29
88 29
156 42
480 107
1,587 181
2,322 335
108 20
4 0
0 0
(Continued on following page)
LITOVITZ ET AL •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
519
Demographic Profile of E x p o s u r e Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Laundry additives Bluing/brightening agent Detergent booster Enzyme/microbiological additive Water softener Other/unknown Laundry detergents Granules Liquids Soaps Other/unknown Laundry prewash/stain removers Dry solvent-based Liquid solvent-based Spray solvent-based Other/unknown solventbased Dry surfactant-based Liquid surfactant- based Spray surfactant- based Other/unknown surfactant-based Other/unknown Miscellaneous cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Phenol Other/unknown Oven cleaner Acid Alkali Detergent type Other/unknown Rust remover Alkali Anionic/nonionic Hydrofluoric acid Acid other Other/unknown Spot removers/dry cleaning agent Anionic/nonionic Glycol Carbon tetrachloride PerChloroethylene Other halogenated hydrocarbon Isopropanol Other nonhalogenated hydrocarbon Other/unknown Starch/fabric finishes~sizing Toilet bowl cleaner Acid Alkali Other/unknown Wall~floor~tilecleaner Acid Alkali
No, of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
62 34
41 21
13 3
7 5
60 31
1 2
0 1
0 0
4 6
19 6
3 11
0 0
0 0
0 0
47 141 89
27 31 50
4 10 6
12 91 22
45 131 78
1 0 0
0 3 2
0 7 9
7 23 29
16 40 15
8 28 29
1 5 10
0 0 0
0 0 0
8,271 3,481 172 136
6,939 2,468 117 89
470 263 12 13
700 615 34 30
8,046 3,256 169 132
95 82 2 2
10 6 0 0
115 130 0 2
983 442 13 28
2,378 714 35 43
2,312 974 36 38
195 64 3 5
4 1 0 t
0 0 0 0
88 376 536
79 292 399
4 20 27
5 49 76
88 373 528
0 2 2
0 0 0
0 1 6
6 44 100
20 115 122
10 82 174
1 14 30
0 1 0
0 0 0
72 657 2,315 383
42 553 1,912 304
5 25 113 25
18 43 199 42
71 646 2,277 376
1 4 23 3
0 0 4 3
0 7 11 1
11 32 287 47
25 179 610 76
13 103 590 161
1 5 99 9
0 0 2 0
0 0 0 0
20 40
15 23
0 2
1 10
20 39
0 0
0 0
0 1
3 13
3 8
4 14
1 2
0 0
0 0
701 6,585 8,675 3,798 454 1,915 1,464 50 16 2,918
272 3,258 5,822 2,056 280 1,234 983 30 2 1,613
52 645 702 457 34 184 224 4 7 325
284 2,074 1,661 970 108 395 198 15 7 737
684 6,366 8,414 3,617 433 1,865 1,419 49 15 2,766
10 142 155 126 14 27 26 0 1 76
3 52 37 23 2 11 15 1 0 38
3 23 62 24 5 8 4 0 0 33
205 2,115 1,173 835 72 278 201 17 3 580
174 1,602 2,192 969 128 599 476 13 5 758
243 2,177 2,203 1,039 121 465 398 19 8 804
49 585 201 161 16 47 28 1 0 112
1 19 5 6 0 1 0 0 0 3
1 2 0 1 0 0 0 0 0 0
13 3,419 26 280
2 815 12 65
4 430 3 36
3 1,660 11 146
11 3,313 25 273
2 55 0 2
0 32 1 2
0 12 0 2
5 1,477 3 108
1 312 9 22
4 1,277 3 93
2 595 1 29
0 19 0 1
0 0 0 0
31 1 1,563 209 312
11 0 113 64 55
3 1 109 13 30
11 0 1,217 112 197
30 1 1,531 199 302
1 0 29 6 2
0 0 3 2 1
0 0 0 1 6
t0 1 969 74 61
9 0 155 42 55
10 1 807 79 115
3 0 389 21 37
0 0 17 0 1
0 0 1 0 0
495 108 0 73
389 77 0 36
35 6 0 5
54 16 0 26
492 104 0 69
2 3 0 4
0 0 0 0
1 1 0 0
61 12 0 25
146 37 0 16
123 33 0 14
12 2 0 6
0 0 0 0
0 0 0 0
136 33
41 23
11 2
62 7
132 31
2 1
0 0
2 1
24 4
18 12
43 8
5 0
0 0
0 0
153 51 1,180
96 25 956
10 5 118
35 19 83
149 49 1,126
4 1 47
0 0 2
0 0 3
30 15 55
57 15 284
42 14 172
5 2 9
0 0 1
0 0 0
3,445 545 2,696
1,257 335 2,036
322 28 123
1,444 153 381
3,288 537 2,645
128 7 32
15 1 6
9 0 12
990 76 227
758 191 804
1,315 122 333
342 29 51
19 0 1
5 0 0
3,054 8,506
1,242 4,970
257 758
1,228 2,373
2,986 8,283
43 136
8 38
15 38
755 1,811
674 2,212
1,263 3,188
249 524
3 13
0 1
(Continued on following page)
520
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22A.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Other/unknown *Category totals Industrial cleaners Acids Alkali Anionic/nonionic Cationic Other/unknown *Category totals Cosmetics/personal care products Bath oil, bubble bath Creams, lotions, make-up Dental care products False teeth cleaning Toothpaste with fluoride Toothpaste without fluoride Other Deodorants Depilatories Douches Eye products Hair care products Coloring agents Rinses, conditioners, relaxers Shampoos Sprays Other Lipsticks/balms, with camphor Lipsticks/balms, without camphor Mouthwash Ethanol Nonethanol Fluoride Unknown Nail products Polish Polish removers: acetone Polish removers: other Polish removers: unknown Other miscellaneous Perfume, cologne, aftershave Peroxide Powders: talc Powders: without talc Soaps Suntan/sunscreen products *Category totals Deodorizers Air fresheners Diaper pail deodorizers Toilet bowl deodorizers Other Unknown *Category totals
No. of Exposures
<6
6-19
819 526 70 2,094 1,442 172 8 2 2 1,643 1,138 143 63 43 5 1 0 1 424 193 34 200,449 116,073 18,177 1,823 2,909 1,137 761 1,764 8,394
427 541 642 150 499 2,259
8,955 16,195
Treated in Health Care Other Adv Rxn Facility
Reason >19 162 390 0 302 13 0 148 53,844
Unint
Int
788 21 2,051 25 7 0 1,598 29 62 1 1 0 405 13 193,316 4,676
Outcome None
Minor
Moderate Major Death
6 6 0 8 0 0 4 1,116
4 11 1 7 0 0 1 1,130
126 222 1 257 9 1 125 34,315
198 645 0 473 23 0 96 48,610
202 582 2 429 14 0 124 58,913
25 56 0 55 1 1 31 8,980
1 0 0 1 0 0 1 259
0 0 0 0 0 0 0 15
227 453 134 149 224 1,187
910 1,426 278 325 799 3,738
1,777 2,780 1,104 714 1,686 8,061
37 93 20 36 48 234
8 18 6 5 23 60
1 13 7 4 4 29
778 1,664 262 321 728 3,753
274 375 263 104 278 1,294
765 1,170 352 326 690 3,303
234 523 48 81 211 1,097
5 19 0 5 1 30
0 1 0 1 0 2
8,172 12,089
444 1,031
239 2,504
8,799 14,825
32 183
5 49
114 1,118
247 746
2,535 3,424
1,169 1,385
37 110
0 2
0 0
1,242 4,499
235 3,417
73 326
842 547
1,207 4,026
19 39
7 24
4 393
95 246
380 1,272
144 825
8 24
0 0
0 0
252 1,350 11,235 646 272 1,425
177 835 8,920 206 171 1,076
25 165 971 125 24 73
44 289 1,016 246 69 213
231 1,291 10,163 493 243 1,368
7 24 158 24 7 10
1 0 26 13 0 1
13 33 885 116 20 45
12 121 445 133 41 103
55 357 2,574 111 69 323
45 289 1,592 208 40 165
3 9 65 63 4 20
0 0 1 1 0 2
0 0 1 0 0 0
1,632
700
143
622
1,473
12
2
143
405
349
542
110
1
0
3,840 8,515 3,843 3,144
2,831 6,657 2,500 2,048
336 733 599 306
474 937 579 613
3,646 8,153 3,366 2,893
52 237 387 89
10 12 27 12
129 103 59 147
974 587 512 588
1,047 2,088 989 894
964 1,775 1,020 660
251 t01 85 136
1 7 5 7
0 0 1 0
630
561
34
27
621
3
1
5
23
149
65
2
0
0
2,374
2,183
110
66
2,345
8
1
18
50
447
94
4
0
0
9,682 431 1,263 249
3,598 244 938 47
1,975 91 265 136
3,435 80 53 51
8,719 386 1,248 212
828 36 4 12
62 0 2 22
52 6 9 2
996 71 38 29
2,665 194 457 25
1,159 57 77 127
153 2 1 9
19 0 0 0
0 0 0 0
8,354 3,335 2,111
7,402 2,625 1,645
505 294 205
353 351 219
8,266 3,244 2,065
59 69 31
14 13 2
14 8 11
545 377 158
2,442 1,284 794
1,682 677 435
50 33 33
1 0 1
0 1 0
6,748 4,295
5,110 2,560
725 655
738 848
6,533 4,216
170 41
33 3
8 34
748 1,163
2,211 978
1,315 1,286
53 288
2 7
0 0
29,038 2 6 , 0 9 1 1,586 14,362 7,632 1,502 3,839 3,338 242 1,225 1,119 67 12,033 8,843 1,016 4,412 3,449 498 171,426 127,419 15,280
1,157 4,274 209 33 1,743 377 23,248
28,556 349 13,911 317 3,782 36 1,206 8 11,130 176 4,211 23 162,828 3,450
79 40 4 2 65 5 537
45 79 17 9 648 168 4,455
1,704 1,014 376 36 665 282 13,530
4,797 2,659 1,154 262 2,129 1,543 30,341
142 176 51 13 105 57 2,198
1 6 2 0 0 3 69
0 0 0 0 0 0 3
50 0 0 12 1 63
77 1 3 84 1 166
1,000 24 87 512 26 1,649
3,733 23 95 800 40 4,691
138 1 7 66 1 213
7 0 0 1 0 8
5 0 1 0 0 6
15,031 632 998 3,725 142 20,528
12,413 593 884 2,606 96 16,592
1,338 23 53 326 17 1,757
802 13 52 517 24 1,408
14,687 631 986 3,572 137 20,013
210 0 9 51 2 272
(Continued on followingpage)
10,614 3,286 1,044 226 2,927 756 46,986 4,044 292 400 1,029 46 5,811
LITOVITZ ET A L •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
521
D e m o g r a p h i c Profile of Exposure C a s e s by Generic C a t e g o r y of Substances and Products: Nonpharmaceuticals ( C o n r d )
Age (yr) Substance Implicated In the Exposure Dyes Fabric Food dye (eg, Easter egg) Leather Other Unknown *Category totals Essential oils Fertilizers Household plant food Outdoor fertilizers Plant hormones Other Unknown *Category totals Fire extinguishers Food products/food porsoning Foreign bodies/toys/ miscellaneous Ashes Bubble blowing solutions Charcoal Christmas ornaments Coins Desiccants Feces/urine Glass Incense, punk Soil Thermometer Toys Other Unknown *Category totals
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
790 1,076 141 604 72 2,683 3,451
634 897 113 388 50 2,082 2,354
75 122 11 146 5 359 452
65 40 13 52 14 184 509
777 1,038 137 585 68 2,605 3,236
6 23 3 7 0 39 129
1 3 0 3 3 10 26
5 10 1 9 1 26 58
68 26 16 52 9 171 476
275 258 40 201 25 799 808
36 58 11 54 7 166 1,287
5 2 1 5 2 15 73
0 0 0 0 1 1 2
0 0 0 0 0 0 2
4,964 2,840 118 324 1,756 10,002 2,954 67,084
3,248 1,878 48 189 1,097 6,460 273 17,677
659 293 13 41 242 1,248 829 10,857
877 459 41 76 319 1,772 1,347 31,875
4,911 2,805 117 318 1,715 9,866 2,744 62,063
33 13 1 1 19 67 61 540
11 4 0 3 7 25 130 959
7 14 0 2 13 36 7 3,387
145 159 23 30 175 532 846 6,571
1,296 765 32 76 447 2,616 439 7,121
206 232 19 24 244 725 1,149 12,929
6 22 6 5 31 70 153 2,893
2 0 0 1 0 3 4 79
0 0 0 0 0 0 0 0
626 3,833 842 1,317 3,731 20,537 3,329 2,212 259 2,098 12,919 5,553 17,529 236 75,021
554 3,542 606 1,115 3,004 18,230 2,667 729 224 1,778 6,908 3,888 10,581 146 53,972
32 202 71 111 620 1,487 204 289 19 129 3,522 1,489 4,350 44 12,569
30 69 142 68 82 567 363 940 11 159 1,772 125 1,996 29 6,353
618 3,814 813 1,304 3,690 20,376 3,263 1,913 255 2,080 12,827 5,479 16,543 209 73,184
4 8 20 9 34 120 10 19 3 11 63 58 298 3 660
1 6 3 0 3 34 53 267 0 3 18 8 572 21 989
3 4 6 3 1 1 0 10 1 3 6 7 100 2 147
35 104 59 83 1,311 497 113 308 9 68 708 313 1,672 36 5,316
124 727 205 322 1,188 3,375 663 352 70 422 2,501 1,177 3,576 52 14,754
75 1,028 84 81 417 148 190 300 18 118 248 819 2,361 32 5,919
10 17 18 11 37 7 13 20 2 6 13 19 183 4 360
0 0 5 0 1 2 0 1 0 0 0 1 4 1 15
0 0 3 0 0 0 0 0 0 0 0 0 1 0 4
409 19,253 3,089
39 2,655 110
109 3,147 192
196 10,500 2,305
389 18,797 2,977
17 394 107
1 5 0
1 18 2
90 7,719 829
40 1,904 112
125 6,673 1,472
29 1,856 383
0 187 2
0 47 0
1,163 5,400 1,407 4,081 5
29 424 140 640 2
171 1,057 150 700 1
797 3,133 714 2,081 2
1,148 5,270 1,400 4,017 5
12 81 3 47 0
2 13 4 9 0
1 32 0 3 0
333 1,925 482 1,202 1
47 261 164 509 0
547 2,645 423 1,393 0
196 936 134 223 1
4 20 12 6 0
0 0 0 1 0
2,852 2,748 1,898 42,305
241 257 162 4,699
694 387 264 6,872
1,464 1,652 1,042 23,886
2,602 2,621 1,867 41,093
236 48 10 955
4 53 11 102
1 17 4 79
992 1,166 489 15,228
285 296 150 3,768
961 975 809 16,023
283 302 114 4,457
20 15 0 267
0 0 0 48
290 16 425 271 566 1,568
93 10 77 142 148 470
25 3 40 40 42 150
124 3 192 62 198 579
283 15 399 257 541 1,495
5 1 7 8 4 25
0 0 1 1 0 2
1 0 17 5 19 42
77 8 138 38 129 390
62 3 66 57 91 279
69 4 114 35 131 353
14 3 22 4 23 66
0 0 2 0 0 2
0 0 0 0 0 0
743
362
82
231
723
6
5
7
99
146
68
24
2
0
569 19 61 925 15 3 3,039
52 4 9 171 11 1 1,459
33 3 6 311 3 0 500
392 10 34 339 0 1 827
405 15 53 846 15 3 2,902
28 2 3 31 0 0 44
77 0 1 24 0 0 31
3 2 0 18 0 0 9
347 9 35 273 3 0 1,250
87 4 9 152 2 0 619
76 3 12 268 1 0 206
31 2 1 69 0 0 81
7 0 2 2 0 0 7
2 0 0 0 0 0 0
Fumes~gases~vapors Carbon dioxide Carbon monoxide Chloramine Chlorine: acid mixed with hypochlorite Chlorine: other Hydrogen sulfide Methane and natural gas Polymer fume fever Propane/simple asphyxiants Other Unknown *Category totals Fungicides Carbamate fungicide Mercurial fungicide Nonmercurial fungicide Phthalimide fungicide Other/unknown *Category totals Heavy metals Aluminum Arsenic (excluding pesticides) Barium Cadmium Copper Fireplace flame colors Gold Lead
(Continued on following page)
522
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A,
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Manganese Mercury Metal fume fever Selenium Thallium Other Unknown *Category totals Herbicides Carbamate herbicide 2,4-D or 2,4,5-T Diquat Paraquat Paraquat/diquat Triazine herbicide Urea herbicide Other Unknown *Category totals Hydrocarbons Benzene Carbon tetrachloride Diesel fuel Freon and other propellants Gasoline Halogenated hydrocarbon: other Kerosene Lighter fluid/naphtha Lubricating oil/motor oil Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other Unknown *Category totals Insecticides/pesticides (excluding rodenticides) Arsenic pesticides Borates/boric acid Carbamate only Carbamate with other pesticide Chlorinated hydrocarbon only Chlorinated hydrocarbon with other pesticide Metaldehyde Nicotine Organophosphate only With carbamate With chlorinated hydrocarbon With other pesticide With carbamate & chlorinated hydrocarbon Piperonyl butoxide only Piperonyl butoxide/pyrethrin Pyrethrins only Repellants (insect) Rotenone Veterinary insecticide
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
43 2,157 1,078 93 106 796 29 9,676
4 762 24 31 33 270 6 3,199
14 459 62 8 8 123 5 1,617
19 702 851 46 22 308 18 3,800
37 1,970 1,071 76 94 709 22 8,941
4 119 2 11 3 40 0 293
0 23 0 1 1 4 6 173
1 27 5 5 7 37 1 122
22 443 330 27 14 290 7 3,149
5 599 17 21 7 155 9 1,832
10 121 351 23 8 137 4 1,286
7 39 195 6 2 47 1 505
1 3 2 0 0 1 1 28
0 0 0 0 0 0 0 2
65 2,712 319 231 2 517 62 5,127 306 9,341
9 762 81 6 0 99 7 1,373 89 2,426
4 300 28 28 1 51 5 481 38 936
27 949 171 112 1 224 39 2,418 143 4,084
64 2,603 307 220 1 490 60 4,844 290 8,879
0 17 6 6 1 5 1 40 3 79
0 6 0 2 0 1 0 23 8 40
1 79 4 3 0 19 1 204 5 316
26 576 133 127 2 172 25 1,229 85 2,375
11 433 75 22 1 59 6 1,104 54 1,765
20 564 90 44 0 118 15 1,271 74 2,196
1 99 27 32 1 27 3 174 13 377
1 6 1 2 0 0 1 9 0 20
0 0 1 0 0 0 0 0 0 1
105 46 1,034 7,195 21,284
19 3 214 643 7,004
9 6 139 919 4,338
56 26 525 4,190 8,187
95 46 1,000 6,933 20,039
4 0 23 226 1,133
6 0 6 19 80
0 0 3 10 10
61 16 229 1,526 3,435
9 9 161 1,249 4,449
32 13 423 1,971 9,427
10 4 45 382 728
1 0 0 11 34
0 0 0 5 1
1,097 3,072 4,256 4,159 258 5,661 1,894 1,182 6,456 7,444 65,143
195 1,901 2,431 2,841 222 2,768 318 483 3,092 4,569 26,723
151 335 518 378 19 805 207 195 804 709 9,532
577 646 1,029 712 13 1,675 1,114 420 1,889 1,636 22,695
1,034 2,987 4,024 4,072 255 5,405 1,704 1,021 6,174 7,210 61,999
40 54 184 48 2 201 169 143 210 150 2,587
9 19 33 33 1 31 9 10 38 46 340
12 3 10 2 0 19 6 3 26 28 132
469 963 1,293 593 28 1,258 943 334 1,698 1,916 14,762
123 472 806 1,074 1,250 1,351 1,583 766 131 36 1,497 1,803 251 741 274 360 1,784 1,703 2,219 2,133 15,795 22,305
113 202 241 85 4 255 240 41 395 401 3,146
8 11 17 0 0 14 18 3 21 27 165
0 0 2 0 0 0 2 0 4 0 14
442 3,534 5,750
307 2,856 2,602
71 191 535
50 398 1,853
424 3,458 5,510
16 60 151
2 10 20
0 5 61
80 355 1,101
183 1,101 1,287
25 190 962
8 16 222
0 1 14
0 0 2
1,319
408
138
567
1,242
43
11
21
265
222
372
50
2
0
3,002
1,237
523
1,009
2,709
122
4
150
1,063
965
681
109
25
0
162 325 7 16,586 1,088
52 228 4 5,678 364
20 33 0 1,335 105
56 44 3 6,326 425
159 321 6 15,895 1,028
0 1 1 350 38
0 1 0 50 7
3 1 0 261 12
25 48 3 3,903 192
34 114 3 3,189 205
32 20 1 3,340 249
7 6 1 702 38
0 1 0 67 2
0 0 0 7 0
260 1,940
59 551
23 193
107 794
248 1,840
4 55
4 7
4 36
61 390
44 366
56 488
16 92
2 5
0 0
44 109
17 40
4 10
20 48
43 103
1 3
0 1
0 2
17 34
12 22
9 28
1 8
1 0
0 0
7,396 6,576 6,745 134 4,396
2,285 2,108 4,332 49 2,639
941 787 1,168 13 514
2,586 2,806 792 57 1,005
6,813 6,123 6,243 131 4,245
196 156 66 1 77
37 29 37 0 9
336 250 388 2 60
1,523 1,628 895 22 576
1,157 1,107 1,569 32 1,365
1,730 1,705 1,691 32 975
398 338 158 6 100
10 11 11 0 2
0 0 1 0 0
(Continued on following page)
LITOVITZ ET A L •
1995 A A P C C A N N U A L R E P O R T
523
TABLE 22A. Demographic Profile of Exposure Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Other Unknown *Category totals Lacrimators Capsicum/peppers Lacrimators: CN Lacrimators: CR Lacrimators: CS Lacdmators: DM Other Unknown *Category totals Matches/fireworks/explosives Eplosives Fireworks Matches Other Unknown *Category totals Moth repellants Naphthalene Paradichlorobenzene Other Unknown *Category totals Mushrooms Copdne Cyclopeptide Gastrointestinal irritants Hallucinogenic Ibotenic acid Miscellaneous, nontoxic Monomethylhydrazine Muscarine Orellanine Other potentially toxic Unknown *Category totals Paints and stripping agents Paint: antialgae Paint: anticorrosion Paint: oil-base Paint: water-base Stains Stripping agents Methylene chloride Other Unknown Varnishes, lacquers Wood preservatives Other paint/varnish/lacquer Unknown paint/varnish/ lacquer *Category totals Photographic products
No. of Exposures
<6
6-19
Treated in HeaFth Care Other Adv Rxn Facility
Reason >19
3,984 3,360 67,159
2,461 983 29,250
263 429 7,296
913 1,508 21,367
1,313 7,743 0 528 1 109 3,346 13,040
394 2,212 0 204 0 23 877 3,710
459 2,829 0 192 1 27 1,142 4,650
334 1,868 0 78 0 41 1,014 3,335
275 581 1,561 54 4 2,475
125 474 1,398 28 3 2,028
91 78 99 10 0 278
2,008 119 51 2,868 5,046
1,576 85 40 2,218 3,919
10 41 304 515 37 190 79 11 0 32 7,904 9,123
Unint 3,876 3,121 63,538
Int
Outcome None
Minor
Moderate Major Death
40 90 1,473
10 74 313
50 60 1,702
521 911 13,613
1,042 571 14,590
464 753 13,793
86 141 2,503
6 9 169
0 3 13
1,123 6,639 0 471 0 101 2,877 11,211
39 137 0 5 0 5 66 252
120 855 0 50 1 3 361 1,390
22 17 0 1 0 0 9 49
177 1,149 0 100 0 33 518 1,977
33 329 0 29 0 5 118 514
805 4,565 0 363 0 60 1,952 7,745
39 246 0 10 0 11 171 477
0 3 0 1 0 1 3 8
0 0 0 0 0 0 0 0
38 17 50 11 1 117
240 562 1,540 48 4 2,394
16 8 17 5 0 46
18 6 2 0 0 26
0 2 0 0 0 2
66 40 57 21 0 184
67 195 496 17 2 777
68 88 37 9 0 202
11 12 7 6 1 37
0 1 0 2 0 3
0 0 0 0 0 0
141 7 4 198 350
222 21 5 331 579
1,971 117 51 2,813 4,952
26 2 0 25 53
7 0 0 20 27
2 0 0 6 8
445 11 3 557 1,016
1,028 48 24 1,223 2,323
163 15 5 198 381
18 0 1 34 53
3 0 0 1 4
0 0 0 0 0
8 11 130 65 2 78 4 6 0 19 5,875 6,198
1 5 60 244 18 30 7 1 0 3 1,140 1,509
1 22 90 165 17 72 56 3 0 9 745 1,180
10 28 269 122 16 169 67 9 0 31 7,277 7,998
0 7 26 383 21 3 2 1 0 1 536 980
0 0 1 5 0 0 0 0 0 0 13 19
0 5 7 4 0 18 10 1 0 0 72 117
1 31 103 322 29 36 35 10 0 17 2,024 2,608
8 10 71 56 4 61 10 6 0 20 4,974 5,220
0 9 61 97 4 37 32 2 0 3 758 1,003
1 9 38 155 15 5 11 3 0 4 235 476
0 4 1 6 1 0 1 0 0 0 9 22
0 0 0 0 0 0 0 0 0 0 0 0
6 76 4,409 4,102 1,100
0 24 1,244 2,982 451
0 13 942 267 117
5 34 1,747 578 449
6 75 4,085 4,042 1,070
0 1 270 26 9
0 0 17 8 6
0 0 30 26 12
2 21 1,084 310 206
1 9 721 939 249
1 26 1,483 380 283
1 7 303 46 46
0 0 10 1 1
0 0 0 0 0
1,422 665 431 986 641 1,234
260 139 127 312 169 538
146 48 57 133 66 158
784 363 188 430 305 404
1,382 650 417 961 624 1,191
33 9 8 15 9 24
0 1 2 6 0 2
5 4 4 3 7 15
507 257 143 235 159 267
119 76 72 155 81 233
699 264 131 295 192 308
152 76 53 60 34 77
6 1 4 4 1 2
0 0 0 0 0 0
10,354 25,426
6,049 12,295
1,155 3,102
2,342 7,629
10,081 24,584
184 588
28 70
41 147
1,547 4,738
2,042 4,697
1,560 5,622
270 1,125
10 40
1 1
460 2 331 15 808
58 1 191 1 251
153 0 32 4 189
183 1 94 8 286
450 2 325 14 791
5 0 2 1 8
1 0 2 0 3
4 0 2 0 6
145 1 52 9 207
54 0 71 1 126
193 1 51 7 252
41 0 6 1 48
0 0 0 0 0
0 0 0 0 0
2,592 1,052
1,970 241
378 584
186 168
2,518 470
29 560
8 14
35 6
138 586
779 162
103 242
17 318
2 24
0 0
Developers~fixing~stop baths Photographic coating fluids Other Unknown *Category totals Plants Amygdalin/cyanogenic glycosides Anticholinergic
(Continued on following page)
524
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22A.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Cardiac glycosides Colchicine Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine Nontoxic plant Oxalate Solanine Stimulants Toxalbumins Other Unknown *Category totals Polishes and waxes Radioisotopes Rodenticides ANTU Anticoagulant: standard Anticoagulant: long-acting Barium carbonate Cyanide Monofluoroacetate Strychnine Vacor Other Unknown *Category totals Sporting equipment Fishing bait Fishing products, other Golf balls Golf products, other Gun bluing Hunting products, other Other Unknown *Category totals Swimming pool/aquarium Tobacco products Other/unknown nondrug substances Total number of nonpharmaceutical substances % of nonpharmaceutical substances % of all substances
No. of Exposures 2,437 19 54 20,373 18,521 278 270 19,485 14,586 1,691 604 203 3,211 18,811 104,187 7,911 181
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
1,713 421 228 15 3 1 30 4 13 9,914 3,603 5,133 14,678 1,852 1,577 137 83 46 72 84 89 16,311 1,836 1,014 12,494 1,363 567 1,357 150 155 311 106 160 105 33 50 2,270 427 387 13,211 2,644 2,210 74,829 13,571 11,984 5,942 633 870 25 24 103
2,325 94 19 0 43 9 19,185 214 17,923 370 181 80 254 6 19,160 122 14,443 113 1,654 19 464 69 187 14 3,016 85 18,145 278 99,987 2,062 7,708 137 165 2
2 0 0 244 25 1 1 13 1 1 2 0 7 77 396 19 1
15 0 2 685 191 13 8 179 22 16 65 1 93 285 1,616 43 10
362 6 17 1,700 1,169 84 107 485 530 233 192 115 331 1,616 7,671 958 64
1,054 10 18 2,830 6,297 69 57 3,250 5,404 856 234 73 1,039 5,764 27,896 2,989 18
176 1 6 5,839 1,745 28 100 835 2,364 137 98 51 360 1,887 13,972 1,441 17
28 1 1 573 180 26 30 79 85 16 37 13 45 237 1,686 156 10
2 0 0 5 3 1 0 2 6 1 6 0 11 10 73 8 1
0 0 0 1 0 0 0 0 0 0 0 0 1 0 2 0 0
0 1,287 13,423 0 19 1 158 5 978 1,316 17,187
0 1,139 12,028 0 0 1 29 2 732 969 14,900
0 36 536 0 0 0 17 0 65 69 723
0 94 673 0 17 0 85 3 134 206 1,212
0 1,234 12,962 0 16 1 69 5 910 1,152 16,349
0 44 392 0 1 0 52 0 57 115 661
0 6 46 0 2 0 26 0 8 39 127
0 1 6 0 0 0 3 0 3 2 15
0 428 5,051 0 16 1 94 3 272 595 6,460
0 542 5,869 0 7 1 33 2 313 468 7,235
0 27 226 0 5 0 14 0 51 57 380
0 5 80 0 5 0 21 1 12 19 143
0 3 8 0 0 0 3 0 4 2 20
0 0 1 0 0 0 1 0 2 1 5
111 39 68 0 54 419 195 0 886 7,100 9,733
78 25 9 0 21 262 111 0 506 3,490 7,917
26 8 39 0 4 81 56 0 214 1,188 600
4 2 15 0 26 60 10 0 117 1,806 1,038
108 37 62 0 52 387 180 0 826 6,949 8,963
1 2 6 0 1 19 8 0 37 49 231
1 0 0 0 0 8 1 0 10 8 330
1 0 0 0 0 2 6 0 9 91 196
5 11 19 0 33 117 38 0 223 1,172 2,037
20 11 7 0 13 185 64 0 300 1,617 3,450
8 8 26 0 19 41 19 0 121 2,201 2,542
0 2 1 0 12 8 2 0 25 421 200
0 0 0 0 0 0 0 0 0 9 8
0 0 0 0 0 0 0 0 0 0 0
15,846
5,638
2,487
5,957
13,219
585
1,118
390
4,607
2,876
3,281
755
77
0
649,216 166,611 347,878 1,176,764 50,535 10,007
15,787
226,295
51,854
2,908
245
1.3% 0.7%
18.0% 10.4%
1,255,696
57.9%
51.7% 30.0%
13.3% 7.7%
27.7% 16.0%
93.7% 54.3%
4.0% 2.3%
0.8% 0.5%
268,471 293,550 21.4% 12.4%
NOTE: Patients with unknown age, reason, or medical outcome were omitted from the respective tabulations. ABBREVIATIONS:Adv rxn, adverse reaction: Int, intentional: Unint, unintentional.
23.4% 13.5%
4.1% 2.4%
0.2% 0.0% 0.1% 0.0%
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals
Age (yr) Substance Implicated In the Exposure Analgesics Acetaminophen only Adult formulations Pediatric formulations Unknown formulations Acetaminophen in combination with: Aspirin (with other ingredients) Aspirin (no other ingredients) Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Aspirin alone Adult formulations Pediatric formulations Unknown formulations Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotics Other drugs (adult formulations) Other drugs (pediatric formulations) Narcotics Codeine Meperidine Methadone Morphine Oxycodone Pentazoeine Propoxyphene Other/unknown Nonaspirin salicylates Other nensteroidal antiinflammatory drugs Colchicine Ibuprofen, OTC Ibuprofen, Rx Ibuprofen, unknown if OTC or Rx Indomethaein Other Unknown Phenacetin Phenazopyridine Salicylamide Other analgesic Unknown analgesic *Category totals Anesthetics Inhalation anesthetics Nitrous oxide Other/unknown Ketamine and analogs Local and topical anesthetic Other anesthetic Unknown anesthetic
Treated in Health Care Other AdvRxn Facility
Reason
No. of Exposures
<6
6-19
>19
Unint
27,566 36,106 9,197
6,760 32,858 2,618
10,429 2,788 3,152
9,329 390 2,993
11,998 15,200 35,555 402 3,897 5,128
2,621
1,024
779
713
1,455
26 7,108 2,853 5,180 7,878
12 1,346 384 734 956
6 1,425 355 669 1,222
5 3,817 1,826 3,380 5,021
12,401
2,259
2,956
219
36
33
4,965 628 9,955
1,653 521 2,067
1,622 83 3,826
714 328 64 46
119 51 14 10
104 39 7 5
2,374
509
9
Int
18 8 10
292 127 103
1,062
3
93
1,195
14 2,686 1,038 1,622 2,721
12 3,870 1,538 3,268 4,449
0 2 0 3 2
0 518 256 244 654
6,378
4,300
7,661
1
127
81
122
2,336 586 3,298
448 204 36 25
488
7
1,458 603 534 795 127 292 686 3,181 1,152
631 72 54 94 12 26 73 512 575
171 17,553 11,688
45 9,051 7,138
10,120 822 15,891 4 4 715 112 464 175 196,805
Outcome None
Minor
4,268 774 1,499
1,464 58 688
308 4 189
35 0 20
853
532
103
4
2
15 4,201 1,619 3,505 4,458
8 1,732 588 1,240 1,605
5 1,698 737 1,456 2,220
2 519 240 529 625
0 85 55 104 97
0 7 5 16 6
383
7,833
3,209
3,249
1,072
144
11
0
15
135
61
66
19
5
1
2,469 32 6,423
5 0 8
132 8 159
2,723 129 6,798
1,531 279 2,698
878 30 2,212
471 10 1,296
34 1 129
11 0 37
226 122 27 18
449 181 33 24
1 0 0 0
36 23 4 4
469 187 34 18
156 67 20 11
228 91 16 11
79 17 4 3
15 11 0 0
0 0 1 0
1,237
894
1,371
1
93
1,436
575
619
255
33
3
2
0
7
2
0
0
6
4
2
0
0
0
317 92 35 84 15 35 78 387 173
410 372 397 514 82 197 466 1,979 347
961 238 169 340 37 90 186 1,303 790
391 292 303 370 71 154 458 1,331 307
1 0 2 3 0 1 1 1 0
97 70 46 68 15 45 33 502 49
497 359 395 468 76 159 481 1,734 441
413 112 24 139 20 43 148 542 379
264 166 116 147 31 98 193 884 203
64 73 113 93 12 31 70 394 69
10 12 30 38 1 4 34 110 7
4 2 12 13 3 1 17 16 0
24 4,509 1,711
83 3,442 2,527
101 11,233 8,626
44 5,957 2,824
25 317 215
107 6,098 3,263
47 6,306 4,077
37 1,995 1,123
14 375 242
1 21 22
3 2 2
4,956 4,858 395 336 8 , 2 5 1 6,677 1 2 2 1 613 70 93 16 173 206 46 114 111,485 78,478
92
27I 89 919 1 1 30 3 83 13 6,036
4,806 386 7,157 3 3 231 34 240 109 88,585
3,555 249 5,327 2 1 320 66 88 33 59,407
1,567 171 2,642 1 1 93 8 102 37 30,670
372 51 676 0 1 16 2 42 13 10,177
3,525 3,119 226 129 4,933 3,673 1 1 2 0 534 68 87 11 87 58 27 71 81,643 44,580
1,481 21 3,515
2,925 409 6,273 2 2 101 12 282 66 61,834
1 6 , 6 1 1 9,096 4,433 10,931 5,733 2,852
Moderate Major Death
37 2 4 0 47 3 0 0 0 0 1 0 0 0 16 0 0 0 1,613 235
204 180 66
13 32 1
78 26 15
79 89 41
80 149 14
104 18 50
1 4 1
19 9 0
104 72 5t
26 22 5
43 74 19
21 13 10
5 6 7
0 3 0
5,797 16 3
4,14t 7 2
544 1 0
863 8 1
5,387 12 2
155 3 0
19 0 0
228 1 1
1,139 6 0
2,461 3 0
813 3 1
88 1 0
16 1 0
2 0 0
(Continued on folio wing page)
526
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Substance Implicated In the Exposure *Category totals Anticholinergic drugs Anticoagulants Heparin Warfarin (excluding rodenticides) Other Unknown *Category totals Anticonvulsants Carbamazepine Phenytoin Succinimides Valproic acid Other Unknown *Category totals Antidepressants Cyclic antidepressants Amitrintyline Amoxapine Desipramine Doxepin Imipramine Maprotiline Nortriptyline Protriptyline Other cyclic antidepressant Unknown cyclic antidepressant Cyclic antidepressant formulated with a benzodiazepine Cyclic antidepressant formulated with a phenothiazine Lithium MAO inhibitors Trazodone Other antidepressant Unknown antidepressant *Category totals Antihistamines H 2 receptor antagonists Diphenhydramine, unknown if OTC or Rx Diphenhydramine, Rx Diphenhydramine, OTC Other *Category totals Antimicrobials Antibiotics: systemic Antibiotics: topical Antibiotics: unknown Antifungals: systemic Antifungals: topical Antifungals: unknown Anthelmintics: diethylcarbamazine Anthelmintics: piperazine Anthelmintics: other Anthelmintics: unknown Antiparasitics: antimalarial
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason
Age (yr) >19
Unint
Int
Outcome None
Minor
Moderate Major Death
5,644 2,020
330 1,987
25 12
258 236
1,372 2,729
2,517 1,235
953 965
133 670
35 100
5 6
32
51
4
0
2
24
15
8
8
3
0
475 60 1 568
890 109 11 1,061
185 8 2 199
1 0 0 1
37 7 0 46
525 49 11 609
425 50 9 499
62 13 0 83
81 3 0 92
21 1 0 25
2 0 0 2
1,333 416 41 945 73 1 2,809
2,918 2,584 35 2,195 326 3 8,061
3,809 2,266 108 1,912 405 8 8,508
2,461 1,613 20 1,981 113 1 6,189
3 7 0 1 1 0 12
265 289 4 223 42 0 823
4,356 2,849 39 2,580 247 5 10,076
1,681 1,126 46 1,256 164 2 4,275
1,756 999 23 971 129 3 3,881
1,032 619 3 437 41 0 2,132
283 92 1 88 7 0 471
6 1 0 3 0 0 10
987 15 174 175 764 11 227 3
942 13 227 272 1,161 4 401 3
5,313 76 590 2,188 1,396 48 1,411 24
2,069 40 390 564 1,512 23 675 10
5,466 69 611 2,216 1,816 38 1,428 26
5 0 0 4 1 0 2 0
156 3 49 61 144 3 91 0
6,358 89 774 2,402 2,480 50 1,666 26
1,291 22 235 405 999 13 443 11
1,903 25 222 801 782 14 554 9
1,849 23 190 677 555 16 387 1
822 8 69 290 216 7 128 3
54 0 17 15 21 0 9 0
993
65
153
678
256
687
1
40
754
212
290
174
41
5
155
8
24
105
18
127
3
3
141
16
28
41
29
5
147
24
17
97
49
93
0
3
107
27
39
30
9
0
87 53 376 1,093 50 17 433 847 3,156 5,574 4 4 6,559 10,805
326 3,457 307 4,758 13,576 37 34,387
155 322 1,570 3,205 166 162 1,404 4,964 6,894 15,955 8 42 15,803 37,227
0 8 0 1 13 0 38
14 429 87 304 1,386 1 2,774
394 4,122 293 5,094 17,086 38 41,874
102 1,187 82 1,436 7,309 8 13,798
126 1,455 79 2,369 6,124 16 14,836
101 925 99 804 2,393 3 8,268
42 168 28 116 365 1 2,342
2 9 2 4 23 2 168
1,172
2
378
1,631
1,673
574
185
17
0
3,260 2,997 119 119 10,513 5,433 9,475 5,026 26,730 14,747
14 0 4 6 26
209 10 307 622 1,526
3,424 129 6,654 6,743 18,581
1,576 56 4,829 5,054 13,188
1,587 57 3,819 2,915 8,952
783 28 1,209 1,057 3,262
83 2 108 107 317
3 0 1 4 8
6,215 62 542 116 63 0
25 1 1 0 8 0
4,597 120 286 87 142 2
8,703 247 616 189 321 0
11,173 1,490 345 260 1,960 5
4,684 353 337 92 650 2
853 36 67 20 35 0
70 1 8 2 2 0
1 0 0 0 0 0
1 21 9 4 50
0 0 0 0 0
0 1 46 1 29
15 61 175 4 139
244 239 206 14 108
15 27 131 1 41
1 8 30 1 23
0 1 0 0 3
0 0 0 0 0
6,266 4,297
4,196 1,228
664 536
57
18
1
1,118 126 13 1,314
541 58 10 627
61 1 1 64
6,602 4,258 132 41149 563 9 15,713
2,044 978 52 741 121 5 3,941
7,784 113 1,061 2,874 3,491 64 2,213 36
496 5,313 420 6,716 24,358 51 56,285
678
1,081 2,296
4,933
2,010
1,991
6,523 250 16,292 15,193 43,191
2,187 74 8,281 5,778 18,330
1 , 3 8 1 2,636 45 114 2 , 5 4 1 4,908 3,464 5,228 8,109 14,877
43,904 6,357 1,711 940 7,953 18
25,226 4,789 501 514 6,257 11
7,264 476 493 125 418 1
640 635 711 37 271
442 480 364 22 92
29 66 73 2 37
3,363
9,523 32,964 859 6,168 583 878 250 737 1,001 7,739 5 16 148 77 198 10 118
639 612 653 32 191
(Continued on following page)
LITOVITZ ET AL •
TABLE 22B.
1995 A A P C C A N N U A L REPORT
527
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Substance Implicated In the Exposure
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason
Age(y0
Outcome
>19
Unint
558 62 198 26 17 0 386 18 18 14 2 14,071 393
620 175 220 43 17 2 590 52 53 64 2 52,467 710
256 16 256 11 7 0 274 3 9 8 3 7,926 72
0 0 0 0 1 0 0 0 0 0 0 36 0
230 29 38 12 7 0 66 2 4 6 0 5,705 55
348 38 397 29 15 0 385 3 22 20 2 11,729 284
270 69 121 15 10 0 298 9 23 36 0 16,895 283
180 31 76 12 2 0 116 8 4 14 2 6,778 111
46 3 71 2 1 0 44 1 1 1 0 1,244 23
3 1 93 0 1 0 3 1 0 0 0 189 5
0 0 0 1 1 0 0 0 0 0 0 3 2
808
681
103
19
Int
None
Minor
Moderate Major Death
Antiparasitics:
metronidazole Antiparasitics: other Antituberculars: isoniazid Antituberculars: rifampin Antituberculars: other Antituberculars: unknown Antivirals: systemic Antivirals: topical Antivirals: unknown Other antimicrobial Unknown antimicrobial *Category totals Antineoplastics Asthma therapies Aminophylrine/theophylline Terbutaline and other beta-2 agonists Other beta agonists Other Unknown *Category totals Cardiovascular drugs Alpha blockers Antiarrhythmics Antihypertensives Beta blockers Calcium antagonists Cardiac glycosides Hydralazine Long-acting nitrates Nitroglycerin Nitroprusside Other vasodilator Unknown types of vasodilators Vasopressor Other cardiovascular drug Unknown cardiovascular drug *Category totals Cough and cold preparations Diagnostic agents Diuretics Furosemide Thiazide Other Unknown *Category totals Electrolytes and minerals Calcium Fluoride Iron Magnesium Potassium Sodium Zinc Other Unknown *Category totals
1,116 221 521 67 32 2 932 57 66 78 5 66,274 840
294 118 106 25 10 0 346 31 33 57 0 39,718 295
171 30 193 13 2 2 133 4 12 7 1 9,552 61
3,683
785
851
1,913
2,110
1,313
1
225
2,388
927
12,168 1,982 1,601 12 19,446
9,401 553 1,097 4 11,840
1,619 760 249 5 3,484
967 585 225 2 3,692
11,081 858 1,263 7 15,319
699 1,039 299 4 3,354
14 5 4 1 25
351 69 30 0 675
4,380 1,121 420 8 8,317
4,564 487 551 2 6,531
2,374 532 191 1 3,906
956 296 102 2 2,037
15 9 2 0 129
0 1 0 0 20
392 1,069 9,648 6,524 8,396 2,557 204 773 2,174 17 364
146 220 4,068 1,920 2,258 1,003 70 341 1,443 0 187
28 50 1,765 744 630 121 20 37 141 1 23
194 721 3,417 3,466 5,028 1,347 108 363 518 14 139
285 916 7,406 4,490 6,178 2,099 159 691 1,885 4 321
80 104 1,923 1,789 1,973 313 39 67 246 0 36
0 0 5 5 6 0 0 0 1 0 0
27 44 273 209 207 129 6 15 33 13 6
213 418 4,941 3,660 4,747 1,343 85 275 671 17 122
174 441 3,860 2,729 3,468 1,045 85 362 1,146 2 170
48 112 1,607 701 948 196 31 83 216 4 39
38 58 1,023 690 846 297 12 34 51 3 16
3 21 130 133 227 83 1 4 6 1 3
0 8 12 13 69 11 0 0 0 0 0
13 24 884
5 8 258
1 1 210
5 12 363
7 22 772
5 1 77
0 0 2
1 1 32
11 14 296
6
3
2 230
9 186
1 3 66
0 1 5
0 1 0
55 33,094 105,947 383
23 11,950 70,862 92
5 3,777 17,887 26
21 15,716 15,141 179
38 25,273 90,987 322
13 6,666 11,457 13
0 19 44 1
4 1,000 3,270 46
27 16,840 23,058 152
23 13,743 34,865 74
1 4,184 19,126 91
3 3,141 3,147 26
0 618 134 0
1 115 7 0
1,437 1,281 1,330 266 4,314
780 585 656 133 2,154
111 151 130 30 422
493 483 480 95 1,551
1,236 1,013 1,074 205 3,528
165 216 204 47 632
0 2 0 2 4
30 47 50 11 138
496 412 422 98 1,428
533 514 550 103 1,700
199 104 137 34 474
67 54 63 8 192
1 4 7 2 14
0 1 0 0 1
2,134 3,611 4,528 323 1,006 2,485 1,072 121 26 15,306
1,730 3,186 3,026 109 543 1,713 557 79
156 292 674 52 112 417 122 5
22
2
10,965
1,832
198 112 710 122 312 263 309 32 2 2,060
2,037 3,539 3,562 281 826 2,326 993 112 25 13,701
56 38 875 26 139 103 41 1 0 1,279
0 3 5 1 1 29 1 1 0 41
39 29 73 14 38 18 34 7 1 253
161 234 2,215 114 301 357 222 24 1 3,629
464 1,321 1,920 85 367 736 232 27 1 5,173
123 468 775 53 85 453 189 10 2 2,158
21 14 195 29 39 42 58 4 0 402
0 0 25 3 3 1 2 0 0 34
0 0 2 0 1 0 0 0 0 3
64 2,673 432 17
50 1,504 307 6
6 268 29 3
6 741 68 5
1 76 7 0
0 7 0 0
2 106 6 0
29 580 18 3
38 1,133 103 5
9 419 64 5
1 50 3 0
0 1 0 0
0 0 0 0
Eye~ear~nose~throat preparations Nasal preparations Tetrahydrazoline Other decongestant Other Unknown
61 2,480 419 17
(Continued on following page)
528
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Ophthalmic preparations Contact lens products Glaucoma therapies Tetrahydrazoline Other ophthalmic sympathomimetics Other Unknown Otic preparations Combination products Other Unknown Steroids-topical for eye/nose/throat Throat preparations Lozenges without local anesthetics Lozenges with local anesthetics Other Unknown *Category totals Gastrointestinal preparations Antacids: salicylate-containing Antacids: other Antidiarrheals: diphenoxylate Antidiarrheals: nonnarcotic Antidiarrheals: paregoric Antidiarrheals: other narcotic Antispasmodics: anticholinergic Antispasmodics: other Laxatives Other Unknown *Category totals Hormones and hormone antagonists Androgens Corticosteroids Estrogens Insulin Oral contraceptives Oral hypoglycemics Progestins Thyroid preparations Other hormones Other hormone antagonists Unknown hormones or antagonists *Category totals Miscellaneous drugs AIIopurinol L-dopa and related drugs Disulfiram Ergot alkaloids Homeopathic preparations Methylsergide Neuromuscular blocking agent Other *Category totals
No. of Exposures
<6
6-19
Treated in Health Care Other AdvRxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
3,782 152 1,882
2,176 52 1,337
314 10 181
995 72 293
3,721 130 1,717
26 4 58
10 0 83
14 17 15
519 30 818
708 39 1,033
725 40 217
156 8 27
5 0 3
0 0 0
290 598 18
168 318 5
31 63 3
72 177 6
250 536 14
9 19 0
0 2 1
30 41 1
91 58 5
117 91 3
44 98 3
10 13 0
0 2 0
0 0 0
987 1,886 44
719 1,052 20
103 220 7
132 505 14
978 1,863 44
3 6 0
0 0 0
6 17 0
108 181 7
366 420 9
220 589 15
14 29 1
0 0 0
0 0 0
1,004
530
164
246
907
37
0
59
86
187
177
16
0
0
705
536
75
74
665
18
2
20
40
172
63
5
1
0 0
293 427 5 15,259
189 252 4 9,225
67 113 1 1,658
30 46 0 3,482
273 381 4 14,460
10 39 0 313
0 0 0 105
9 7 1 351
15 94 0 2,682
78 156 1 4,659
22 73 0 2,783
3 7 0 343
0 2 0 14
0 0 0
2,562 18,931
2,155 17,228
207 720
166 813
2,406 18,559
67 199
1 26
88 140
223 507
892 4,363
131 496
12 38
1 2
1 0
1,390 644 122
720 508 94
184 48 6
432 73 17
1,023 598 102
231 19 11
4 2 0
124 24 7
676 52 46
565 137 50
239 32 23
66 8 4
5 2 0
1 0 0
4
2
2
0
4
0
0
0
1
3
0
0
0
0
1,539 9 13,614 4,278 912 44,005
591 4 9,843 3,287 490 34,922
307 2 1,426 315 58 3,275
570 3 1,991 574 296 4,935
878 7 12,292 3,786 688 40,343
568 1 857 320 137 2,410
0 0 168 10 0 211
82 1 276 153 83 978
819 1 1,933 773 221 5,252
514 2 2,917 1,233 316 10,992
342 1 2,774 325 61 4,424
146 1 275 110 8 668
19 0 7 9 4 49
1 0 1 0 0 4
198 6,396 2,805 1,118 7,795 2,815 1,254 5,338 322 232
41 3,833 2,050 75 6,596 1,381 706 3,385 120 95
50 741 188 78 753 230 178 525 50 26
88 1,511 483 856 339 1,084 318 1,224 124 95
88 5,539 2,560 780 7,271 2,214 1,058 4,853 226 188
87 398 168 309 431 518 110 410 57 35
0 2 1 5 12 2 1 2 0 1
21 443 72 17 67 65 84 67 35 8
84 783 314 485 567 2,067 187 1,069 125 67
23 1,446 803 388 1,657 1,264 320 1,658 96 85
20 424 116 105 272 291 60 236 71 14
13 84 22 180 19 527 17 85 25 8
2 7 1 21 1 51 1 5 2 0
0 0 0 3 0 3 0 1 0 0
22 28,295
9 18,291
3 2,822
5 6,127
14 24,791
2 2,525
0 26
2 881
8 5,756
3 7,743
0 1,609
2 982
0 91
0 7
349 421 526 631 2,968 5
214 163 24 267 1,980 3
30 11 19 92 256 1
95 221 388 240 602 1
294 365 149 387 2,372 3
44 36 297 174 262 2
0 0 4 1 4 0
11 17 70 66 316 0
90 140 302 365 633 2
144 151 52 218 1,006 1
20 64 133 159 340 1
5 21 96 52 73 0
3 3 4 1 7 0
1 1 0 0 1 0
7 9,400 14,307
1 4,345 6,997
0 1,069 1,478
4 3,391 4,942
6 7,081 10,657
0 1,672 2,487
0 24 33
1 585 1,066
3 2,796 4,331
2 2,757 4,331
2 1,653 2,372
0 534 781
0 73 91
0 0 3
(Continued on following page)
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Muscle relaxants Cyclobenzaprine Methocarbamol Other Unknown *Category totals Narcotic antagonist Radiopharmaceuticals Sedative/hypnotics/ antipsychotics Barbiturates: long-acting Barbiturates: short-acting Barbiturates: unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone Phenothiazines Sleep aids (OTC) Other Unknown *Category totals Serum, toxoids, vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids: phenylpropanolamine Diet aids: phenylpropanolamine and caffeine Diet aids: other, OTC Diet aids: other, Rx Diet aids: unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine Phenylpropanolamine look-alike drugs Other stimulants Other hallucinogens Unknown hallucinogens Other street drugs Unknown stimulant/street drugs *Category totals Topical preparations Acne preparations Boric acid/borates Calamine Camphor Camphor/methyl salicylate Diaper products Hexachlorophene antiseptic Hydrogen peroxide Iodine or iodide antiseptics Mercury antiseptics Methyl salicylate Podophyllin Silver nitrate Topical steroids
No. of Exposures
<6
6-19
>19
Unint
3,641 1,112 5,444 38 10,235 103 14
657 134 565 1 1,357 6 0
588 209 624 12 1,433 5 1
2,142 664 3,826 23 6,655 77 11
3,475 1,481 2O 37,044 480 161 19 274 6o 11,577 2,498 5,874 308 63,271 1,455
798 146 1 4,522 121 13 2 26 4 1,441 159 461 19 7,713 370
379 183 4 3,272 37 9 4 21 18 1,679 428 685 50 6,769 155
2,057 1,020 13 25,935 292 127 13 211 29 7,566 1,698 4,180 192 43,333 696
12,981 92 7,655 3,875
3,634 12 1,174 135
5,177 18 4,335 496
3,514 46 1,782 2,847
7,345 35 2,600 325
1,703
515
701
429
332 261 280 187 1,156 1,708 1,734 189 426
81 125 127 51 9 32 90 57 19
139 70 29 65 69 1,142 888 49 154
97 1,032 3 13 24
12 207 0 0 1
53 408 2 5 13
81 33,829
Treated in Health Care Other Adv Rxn Facility
Reason
None
Minor
2,289 709 3,738 31 6,767 51 0
0 1 4 0 5 1 0
81 33 201 1 316 30 3
2,617 740 3,862 25 7,244 71 5
847 254 960 4 2,065 10 3
1,766 1,562 418 987 1 19 8,879 27,103 159 277 29 124 2 17 72 193 6 50 3,775 6,976 385 2,072 1,515 3,997 39 250 17,046 43,627 1,013 17
5 2 0 48 4 1 0 0 2 17 8 7 1 95 1
87 58 0 760 36 4 0 6 0 701 22 301 14 1,989 416
2,116 1,051 20 27,566 364 135 15 215 46 8,719 1,940 4,216 223 46,626 468
823 271 2 6,602 68 12 0 50 3 2,627 491 1,119 36 12,104 120
5,122 53 4,704 3,440
81 1 24 39
349 1 292 16
6,925 44 3,627 3,422
758
878
0
57
99 61 114 58 964 409 598 70 220
147 159 179 73 88 153 254 139 49
171 66 71 91 1,030 1,467 1,409 42 353
0 1 0 0 18 74 21 3 8
28 353 1 8 9
23 288 0 1 6
69 716 3 8 17
7 64 12,629 19,774
3 38 33 6,284 13,851 11,643
1,255 358 1,460 5 3,078 20 10
Int
Outcome
527 89 724 2 1,342 15 1
99 18 167 0 284 0 0
4 0 6 0 10 0 0
847 452 8 12,844 175 53 4 57 17 3,016 731 1,979 94 20,277 368
466 179 4 4,265 82 40 3 50 7 2,192 356 687 33 8,364 82
160 54 2 837 30 16 3 18 3 355 43 117 1 1,639 3
5 4 1 55 2 1 0 0 0 25 1 3 0 97 0
3,568 15 1,070 468
2,676 25 2,538 837
1,781 4 1,021 1,014
189 1 18 250
27 0 0 49
1,001
536
350
258
6
0
12 33 27 23 9 8 28 5 0
213 91 163 108 1,001 1,240 1,184 62 375
70 82 104 39 70 104 132 10 22
74 38 51 50 197 377 432 61 99
43 14 31 22 294 566 322 37 144
2 0 4 0 157 19 41 0 38
0 0 1 0 26 0 3 0 2
1 3 0 4 1
4 16 0 0 0
68 676 1 9 15
18 228 0 0 2
28 278 1 1 5
23 195 0 7 4
0 9 0 0 2
0 0 0 0 0
7 286
5
6,543
17 5,797
0
20,291
27 8,145
2
882
738
108
2
66
1,078 331 1,831 11 3,251 27 4
Moderate Major Death
1,732 381 4,838 8,914 1,273 19,164
847 256 3,853 7,101 995 17,747
453 24 242 575 68 701
327 90 638 1,029 187 576
1,545 365 4,781 8,684 1,216 19,109
23 10 34 152 17 35
3 0 1 15 2 4
158 3 22 58 38 16
206 39 268 1,314 167 256
367 103 1,161 3,850 518 4,179
416 50 332 1,374 235 673
76 4 14 76 11 17
0 0 1 5 1 1
0 0 0 0 0 0
124 7,195 1,588 480 9,820 64 161 6,625
65 3,648 608 384 7,101 24 19 4,850
13 764 246 37 873 6 58 425
36 2,339 592 51 1,510 27 62 1,064
109 7,011 1,355 457 9,667 55 147 6,499
9 139 171 17 54 3 4 39
0 9 8 1 16 0 0 2
4 26 46 4 82 6 9 80
31 469 392 58 953 24 37 189
37 1,484 427 195 3,005 15 18 1,193
23 1,552 371 32 2,232 12 61 447
1 78 52 6 80 9 8 28
0 3 5 0 4 0 0 1
0 0 1 0 1 0 0 0
(Continued on following page)
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Topical steroid with antibiotics Wart preparations Other liniment Other topical antiseptic *Category totals Veterinary drugs Vitamins Multiple vitamins tablets: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with flouride Multiple vitamin tablets: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Other vitamins Vitamin A Niacin (B3) Pyridoxine (B6) Other B complex vitamins Vitamin C Vitamin D Vitamin E Other Unknown *Category totals Unknown drugs Total number of pharmaceutical substances % of pharmaceutical substances % of all substances
No. of Exposures
<6
6-19
1,583 1,654 1,975 4,553 72,124 3,614
1,225 1,084 1,070 2,998 53,875 2,057
2,223 4,934 99 122
1,498 3,414 82 119
260 605 10 2
8,138 15,419 618 1,478
7,138 13,810 592 1,402
57 91 3 2
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
None
Minor
Moderate Major Death
1,534 1,583 1,814 4,387 70,318 3,568
17 35 16 94 869 32
3 6 1 13 84 1
27 27 142 58 806 10
85 191 178 516 5,373 312
384 462 420 1,536 19,354 1,114
163 343 629 702 9,647 559
9 49 29 55 602 47
1 0 0 4 26 5
0 0 0 0 2 0
393 775 5 0
1,835 4,089 89 121
212 649 9 1
3 4 0 0
169 177 1 0
306 1,209 25 6
636 1,963 44 46
220 457 12 7
24 51 0 0
1 4 0 0
0 1 0 0
936 1,486 21 66
38 93 3 6
6,002 15,144 613 1,473
101 218 2 5
1 1 0 0
29 45 0 0
254 2,223 50 56
2,675 6,646 164 494
270 1,199 42 50
3 74 2 0
0 2 0 0
0 0 0 0
33 46 2 2
8 11 0 0
14 33 0 0
47 71 3 2
2 13 0 0
0 1 0 0
8 6 0 0
9 20 1 0
12 29 0 1
13 5 0 1
0 1 0 0
0 0 0 0
0 0 0 0
260 472 98 460
244 460 97 429
11 7 1 26
4 5 0 5
256 458 98 459
1 4 0 0
0 3 0 0
3 7 0 1
19 44 5 19
62 155 40 178
19 27 6 20
0 2 0 0
0 0 0 0
0 0 0 0
45 1,688 9 4
34 1,219 8 3
2 245 0 0
8 188 1 1
38 1,461 8 3
3 175 0 0
0 3 0 0
3 41 1 1
3 447 1 1
11 699 2 1
2 163 0 1
1 20 0 0
0 2 0 0
0 0 0 0
47 74 6 14
41 64 5 13
6 8 1 1
0 1 0 0
44 73 5 14
2 1 1 0
0 0 0 0
0 0 0 0
2 14 1 0
12 44 1 8
4 5 1 0
0 0 0 0
0 0 0 0
0 0 0 0
947 2,260 321
690 446 220
76 275 31
150 1,325 55
856 1,030 264
44 136 41
0 2 1
40 1,089 14
117 247 55
261 103 97
58 1,081 21
13 80 8
1 2 5
0 0 0
1,318 2,193 141 1,207 609 595 45,952 9,918
871 1,710 86 976 414 385 36,553 3,624
86 257 6 84 54 87 4,669 1,910
294 183 40 112 121 99 3,952 3,462
1,082 2,017 120 1,115 509 493 41,892 5,394
105 123 13 60 39 58 2,018 3,590
0 3 0 1 2 3 28 221
124 45 8 28 57 38 1,935 474
147 103 26 80 116 125 5,731 5,600
293 609 32 347 158 162 15,985 2,625
137 119 11 39 87 62 4,139 1,597
22 6 3 3 10 12 335 809
1 0 1 0 1 0 20 171
0 0 0 0 0 0 1 1
618,777255,036
1,473
32,978
339,005
261,831 156,370
55,114
9,157
818
0.2% 0.1%
3.6% 1.5%
37.2% 15.6%
6.0% 2.5%
1.0% 0.1% 0.4% 0.0%
911,856
42.1%
124 187 228 277 161 599 503 864 5,501 10,455 280 1,038
Int
Outcome
445,674 146,415 276,735 48.9% 20.6%
16.3% 6.8%
30.3% 12.8%
67.9% 28.5%
28.0% 11.8%
28.7% 12.1%
NOTE: Patients with unknown age, reason, or medical outcome were omitted from the respective tabulations. ABBREVIATIONS:Adv Rxn, adverse reaction; Int, intentional; Unint, unintentional.
17.1% 7.2%
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
REFERENCES 1. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1984;2:420-443 2. Litovitz TL, Veltri JC: 1984 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1985;3:423-450 3. Litovitz TL, Normann SA, Veltri JC: 1985 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1986;4:427-458 4. Litovitz TL, Martin TG, Schmitz B: 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1987;5:405-445 5. Litovitz TL, Schmitz BF, Matyunas N, et al: 1987Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1988;6:479-515 6. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989;7:495-545 7. Litovitz TL, Schmitz BF, Bailey KM: 1989 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1990;8:394-442 8. Litovitz TL, Bailey KM, Schmitz BF, et al: 1990Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1991;9:461-509 9. Litovitz TL, Holm KC, Bailey KM, et al: 1991 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1992; 10:452-505 10. Litovitz TL, Holm KC, Clancy C, et al: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993; 11:494-555 11. Litovitz TL, Clark LR, Soloway RA: 1993 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-584 12. Litovitz TL, Felberg L, Soloway RA, et al: 1994 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1995; 13:551-597
APPENDIX Drug and chemical levels provided in these abstracts were obtained on blood, serum, or plasma unless otherwise indicated. Case 31. A 46-year-old man presented 3 days after an exposure to antifreeze with nausea, vomiting, and abdominal cramping of 2 days' duration. He stated that some of the chemical had been ingested when he was "splashed" with radiator fluid while working. There were no witnesses to corroborate the exposure history. Clinical findings included a diminished urine output and intractable vomiting. Initial laboratory results were as follows: arterial pH, 7.39; creatinine, 10.8 mg/dL; blood urea nitrogen (BUN), 78 mg/dL; and white blood cell count, 20,500/pL. The urinalysis showed amorphous crystals, sloughed renal cells, 3+ leukocyte esterase, 4 + proteinuria, moderate blood, mad >50 white blood cells. The patient became dialysis-dependent and was discharged from the hospital. Three weeks later, he presented with seizure activity, decorticate posturing, and deficits of cranial nerves V, VII, and IX. Computed tomography (CT) of the head showed white matter changes, and the cerebrospinal fluid (CSF) was remarkable for elevated protein. The patient died 26 days after the exposure. Case 32. A 57-year-old man with a history of Parkinson's disease, chronic obstructive pulmonary disease (COPD), sleep apnea, right heart failure, chronically elevated creatine phosphokinase, and previous myocardial infarction was found stumbling and disoriented by his wife. There was no initial history of overdose. Four hours later in the emergency department (ED), his mental status further deteriorated and he was intubated. CT of the head was negative. Laboratory study results showed the following: ethylene
531
glycol, 177 mg/dL; lactate, 4.8 retool/L; osmolal gap, 35 rnosm/L; anion gap, 40 mEq/L; sodium, 147 mEq/L; potassium, 3.8 mEq/L; chloride, 100 mEq/L; bicarbonate, 7 mEq/L; BUN, 15 mg/dL; creatinine, 2.4 mg/dL; calcium, 7.6 mg/dL; white blood cell count, 35,900/gL; ionized calcium, 0.6 mmol/L; arterial pH, 7.01; Pco2, 29.3 mm Hg; and Po2, 224 mm Hg. The urinalysis showed more than 50 red blood cells/high-powered field (HPF), 26 white blood cells/HPF, and hippuric acid crystals. The electrocardiogram showed ST elevations in leads V~ to V3 with ST depressions in the anterolateral leads. Subsequent treatment included intravenous ethanol, 4-methylpyrazole, large doses of sodium bicarbonate, and hemodialysis. The patient suffered a myocardial infarction and developed refractory hypotension, unresponsive to dopamine, norepinephrine, and epinephrine. He died 36 hours postingestion. Case 44. A 66-year-old man with a history of prostate cancer with liver and bone metastases was attacked by a swarm of bees while reading the newspaper in his backyard. On initial evaluation, 25 stingers were noted on his head with additional stings noted about the shoulders, chest, back, and upper and lower extremities. One bee was found inside his mouth. Initial vital signs included: blood pressure, 160/100 mm Hg; pulse, 100 beats/min; and respirations, 18 breaths/min. En route to the hospital, the patient became light-headed and vomited. He was hypertensive on arrival to the hospital, and except for multiple stings, the physical examination was unremarkable. In all, 120 stingers were removed from his body. Over the next 24 hours, he developed disseminated intravascular coagulation (DIC), rhabdomyolysis, renal dysfunction, elevated liver function tests, and pulmonary edema. He died from renal failure 5 days after admission. Case 45. An 88-year-old woman with a history of chronic abdominal pain treated with oral meperidine opened the door to a shed in her backyard and was suddenly enveloped in a swarm of bees. She collapsed at the scene after sustaining several hundred bee stings. The patient's initial vital signs were as follows: pulse, 100 beats/min; blood pressure, unobtainable; respirations, 28 breaths/min. Initial therapy included intravenous fluids, diphenhydramine, methylprednisolone, and military antishock trousers (MAST). At the hospital, blood pressure increased to 194/90 mm Hg and the patient complained of increasing abdominal pain. Laboratory studies were remarkable for a platelet count that decreased from an initial 232,000/~L to 32,000/pL and a decreasing hematocrit over the next 48 hours. Transfusions of platelets and packed red blood cells were required. Myoglobinuria developed, and she was treated with intravenous fluids, sodium bicarbonate, and furosemide. After the patient developed rebound and guarding, a laparotomy was performed. Findings included diffuse necrosis of the entire small and large intestine and complete necrosis of the colon. Supportive care was withdrawn and the patient died on the 4th hospital day. Case 46. A 35-year-old man sustained a bite to the region of the right radial artery while playing with a Crotalus horridus atricaudatus (canebrake rattlesnake). The patient was asystolic when emergency medical services (EMS) arrived 30 minutes later. The bite area was swollen and discolored. Resuscitative efforts were not successful. At autopsy, no tissue necrosis was noted. The postmortem blood ethanol level was 250 mg/dL. No other drugs were detected. Case 48. A 53-year-old woman ingested an unknown amount of cyanide in the hospital shortly after seeing her psychiatrist. She was found in respiratory arrest, with a junctional rhythm, hypotension (systolic blood pressure 80 to 90 mm Hg by palpation), and acidosis. The cyanide antidote kit was administered without significant improvement. Seizure activity developed. Dopamine and second doses of cyanide antidote medications were administered, with improvement in the blood pressure and restoration of the cardiac rhythm. The patient remained unresponsive and was declared brain dead 21 hours postingestion. The heart, liver, and
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
both kidneys were harvested for organ transplantation. Pertinent laboratory studies were: initial arterial pH, 7.12; Pco2, 20 mm Hg; Po2 300 mm Hg; repeat arterial pH, 7.48; Pco2, 25 mm Hg; Po2, 364 mm Hg; creatine phosphokinase, 1,500 IU/L; MB fraction, 5%; lithium, 0.55 mEq/L; toxicology screen, negative. Serial plasma cyanide levels were: 15 minutes postingestion, 6.75 ~g/mL; 2.3 hours postingesfion, 17.4 pg/mL; 14 hours postingestion, 0.99
~,g/mL. Case 60. A 24-year-old graduate student, found by paramedics in the hallway of his research building, admitted to the ingestion of rat poison (later identified as sodium azide). At the scene, he was lethargic and hypotensive. On arrival to the ED, vital signs were: blood pressure, 107/46 mm Hg; pulse, 133 beats/min; respirations, 32 hreaths/min; temperature, 36.2°C. He was diaphoretic with clenched teeth and upward, rightward ocular deviation. He withdrew to pain with only the right hand. Initial treatment included gastric lavage, activated charcoal, and sodium thiosulfate 5 grams intravenously. Within 1 hour, hypotension (blood pressure 60/40 mm Hg) and a junctional escape rhythm developed. Minutes later, the patient was asystolic and did not respond to atropine, epinephrine, sodium bicarbonate, dopamine, or external pacing. Initial laboratory results were as follows: arterial pH, 7.49; Pco2, 17 mm Hg; sodium, 143 mEq/L; potassium, 3.1 mEq/L; chloride, 102 mEq/L; bicarbonate, 22 mEq/L; anion gap 19 mEq/L. Autopsy findings included acute parahippocampal focal neuronal necrosis, mild cerebral edema, diffuse congestion of the lungs, liver, spleen, and kidneys, acute tubular necrosis, and early myocardial necrosis. Postmortem blood sodium azide level was 5.58 mg/mL. Case 62. A 43-year-old man was the victim of a sodium azide explosion at the work site. He suffered burns over 60% of his body and multiple fractures. At the scene, he was noted to have pulmonary edema and hypotension, and was treated with intubation, neuromuscular paralysis, and epinephrine. Multiple boluses of caicium and magnesium were administered. In the ED, twitching was noted, although the patient was still partially paralyzed. The initial carboxyhemoglobin level was 14%. Hemodynamic instability worsened with blood pressure and pulse rate fluctuations from 30 to 100 mm Hg systolic and 110 to 140 beats/rain, respectively. Pulmonary edema, renal failure, and severe metabolic acidosis persisted, despite treatment with epinephrine and sodium bicarbonate infusions. The patient died approximately 24 hours after the explosion. Case 73. A 40-year-old woman with a history of renal, thyroid, and psychiatric disease ingested three ounces of rust stain remover (6% to 8% hydrofluoric acid) in a suicide attempt. She presented to the ED 90 minutes after ingestion, after six episodes of spontaneous emesis. She denied throat irritation, abdominal pain, or shortness of breath. Physical findings were remarkable for the absence of oral burns, drooling, respiratory distress, or chest or abdominal abnormalities. Vital signs were as follows: pulse rate, 124 beats/rain; blood pressure, 102/63 mm Hg; and respirations, 20 breaths/min. The electrocardiogram showed sinus tachycardia with a QTc interval of 0.35 seconds, and nonspecific T wave flattening in the lateral leads. The patient later developed ventricular fibrillation only minutes after appropriately conversing with a nurse. Defibrillation, calcium gluconate, magnesium sulfate, and cardiac pacing were not effective. The serum calcium at the time of cardiac arrest was 7.2 mg/dL. Case 88. A 75-year-old man with a history of diabetes and emphysema intentionally ingested Pomswnon Oil (a liniment containing cinnamon oil, peppermint oil, tea tree oil, licorice, dragon's blood, and skullcap) along with another reportedly identical herbal liniment preparation. Within 1 hour, he developed vomiting and was taken to the ED. On arrival, his systolic blood pressure was 86 mm Hg and his pulse rate was 140 beats/rain. The patient then seized and suffered a cardiac arrest. Resuscitative efforts were unsuccessful and he died within I hour.
Cases 111 and 120. A 75-year-old woman was found dead in bed at home. The postmortem carboxyhemoglobin level was 45%. (Her 47-year-old daughter was also found dead inside a vehicle in the attached garage. A hose was found connected to the exhaust pipe and the driver's window of the car. The daughter had a history of depression and had left a suicide note). Case 135. A 34-year-old man with a history of narcotic and ethanol abuse and Parkinson's disease was brought to the El) with altered mental status. Two hours earlier, he had reportedly ingested 8 ounces of a liquid from an unmarked bottle, thought initially to contain the herbicide glyphosate, along with his antiparkinsonian medications, carbidopa/levodopa. Initial vital signs were: pulse, 120 beats/rain; blood pressure, 156/116 mm Hg; and respirations, 18 breaths/rain. He was noted to have mydriasis and hyperreflexia. Initial treatment included gastric lavage and activated charcoal. Within 8 hours, hyperpyrexia, seizures, and hypotension developed. Respiratory failure, hemodynamic instability, and renal failure developed. The patient died 37 hours after ingestion. Of note, the family later brought a bottle which contained the black liquid that had been ingested. It was identified as diquat. Serum and gastric diquat levels were 4.9 pg/mL and 1.1 lag/mL respectively, 23.7 hours postingestion. The paraquat assay was negative. Case 140. An 18-month-old boy was left unattended outside. His parents had borrowed charcoal lighter fluid from the neighbors to start a fire, and left the unused portion outdoors in a bowl. Following ingestion of the lighter fluid, the child developed vomiting and seizure activity. Initial treatment included lorazepam and intnbation, with high pressure ventilation. The initial chest X-ray showed a possible infiltrate in the left lower lobe. Clinical and radiographic deterioration occurred. On hospital day 2, extracorporeal membrane oxygenation (ECMO) therapy was initiated. The chest X-ray showed bilateral "white out." Life support was removed on hospital day 4. Autopsy findings included diffuse alveolar damage, pneumonia, and diffuse ischemic neuronal injury. Case 144. A 12-year-old boy was found face down in the bathtub, in cardiopulmonary arrest by his father. He had not been seen for a prolonged period of time. Along with the patient, a rubber hose and spray can containing an unknown substance were found in the water. The presenting cardiac rhythm was asystole which did not respond to prolonged resuscitative efforts. Autopsy findings included nasal injury consistent with inhalant abuse and blood and lung samples positive for difluoroethane. The patient's older brother later admitted to teaching him how to "huff" a few weeks earlier. Case 147. A 13-month-old girl ingested an unknown quantity of lighter fluid. Initial symptoms included coughing and difficulty breathing. In the ED, the child developed seizures and cyanosis. Despite intubation, she died within 3 hours of arrival. Case 151. A 74-year-old man inhaled a spray cleaner (sodium hydroxide >0.5%) for most of an entire day while cleaning his boat in an enclosed garage. That evening, he developed dyspnea, which became progressively worse over the next 5 days. On presentation to the hospital, intubation, intravenous steroids, and high concentrations of oxygen (FIo2, 0.70) were required to support respirations. Later, multiple attempts at weaning were unsuccessful and he died on hospital day 15. An open lung biopsy showed acute lung injury consistent with toxic pneumonitis. Case 156. A 31-year-old farmer who had been spraying disod i m methyl arsonate for 2 weeks presented with diarrhea, weakness, and inability to walk. The patient was admitted for dehydration and developed progressive renal failure, coagulopathy, fluid overload, and hypotension. Despite treatment with 3 to 4 doses of dimercaprol (5 mg/kg), the patient died approximately 5 days later. Case 160. A 73-year-old man was found unconscious in his back yard. An empty container of earharyl was found nearby. Further search of the area suggested that the patient may have also ingested
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
malathion. He was intubated at the scene. In the ED, vital signs were: pulse, 80 to 100 beats/rain; respirations, 40 breaths/min, and temperature, 33.3°C. Copious diarrhea and respiratory secretions, miosis, and fasciculations of the eyelids and chest wall were noted. Atropine was administered to decrease secretions. Pralidoxime bolus and infusion therapy were initiated. Fluids and dopamine were given for hypotension and a Swan-Ganz catheter was placed. His mental status remained depressed, although he would occasionally respond to verbal or painful stimuli. The patient developed renal failure and hypotension that was refractory to fluids and increasing doses of vasopressors. By day 4 he was flaccid with fixed pupils and metabolic acidosis. He expired on the 6th hospital day. An initial plasma cholinesterase level was 0.3 KU/L (reference range 4.5 to 10.3 KU/L). Case 166. An 11-month-old girl presented with cold symptoms and a productive cough of unknown duration culminating in a seizure episode just prior to arrival to the ED. Home therapy included steam and topical and oral administration of cayenne pepper and ground garlic in oil. The child was limp and unresponsive with the following vital signs: pulse, 220 beats/min; respirations 52 breaths/min; temperature, 40.8°C. The skin, face, and oropharynx were covered with cayenne pepper. Treatment included intubation, antibiotics, vasopressors, lorazepam, and phenobarbital. Thirty-six hours later, hypertension, bradycardia, and fixed, dilated pupils were noted. CT of the head showed cerebral edema. The child was declared brain dead on hospital day 3. Pertinent laboratory results included: sodium, 142 mEq/L; potassium, 7.7 mEq/L; chloride, 109 mEq/L; BUN, 32 mg/dL; bicarbonate, 15 mEq/L; creatinine, 1.5 mg/dL; glucose, 44 mg/dL; white blood cell count, 28,800/gL; platelets, 419,000/gL; hemoglobin, 12.7 gm/dL; with no CSF red or white blood cells. The chest X-ray showed fight upper lobe atelectasis and bilateral perihilar infiltrates. Autopsy findings included localized edema of the trachea. Case 167. A 39-year-old man drank an herbal tea made from an unknown root from the Dominican Republic and developed vomiting, increased salivation, and incontinence. Physical findings included pinpoint pupils, fasciculations, a blood pressure of 200/100 mm Hg and a pulse rate of 98 beats/rain. Treatment included intubation, naloxone (8 mg without response), and atropine (10 mg). Despite the above therapy, the patient developed hypotension and suffered a cardiac arrest. Depressed plasma cholinesterase levels were subsequently reported. Case 168. A 12-week-old Hispanic boy had a history of rhinorrhea and mild cough for 3 days. No bowel or bladder changes were noted and adequate oral intake was maintained. One evening before admission, he was treated with acetaminophen, an antihistamine/decongestant (brompheniramine/phenylpropanolamine), and 4 ounces of tea made from 3 to 4 leaves from a plant growing in the aunt's yard. The following morning the child was found to be floppy, in respiratory distress, with "eyes rolled back." On arrival to the ED, the child had a respiratory rate of 80 breaths/rain. The arterial pH was 7.22 and the blood glucose was 29 mg/dL. Treatment included intubation, 15% dextrose, normal saline, and albumin. Subsequent laboratory studies included: pH, 7.02; Pco2, 65 mm Hg; PTT, >150 seconds; international normalized ratio (INR), 4.7; fibrin split products, >80 ~tg/mL; d-dimers, >200; fibrin monomer, positive; hematocrit, 21.5%; total bilirnbin, 1.1 mg/dL; aspartate transaminase (AST), 3,225 IU/L; alkaline phosphatase, 351 IU/L; potassium, 7.7 mEq/L; BUN, 23 mg/dL; creatinine, 2.1 mg/dL. Drug screens were negative for acetaminophen and salicylates. Hypocalcemia was also noted. Additional testing revealed cerebral edema on CT scan, left ventricular hypokinesis on echocardiogram, pulmonary edema, and oliguria. Subsequent treatment included blood transfusions, sodium polystyrene sulfonate, glucose, insulin, furosemide, ampicillin, cefotaxime, clindamycin, ganciclovir, ranitidine, vitamin K, and N-
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acetylcysteine. Fulminant hepatic failure developed, and liver transplantation was considered. Metabolic acidosis and renal and hepatic dysfunction progressed with the following laboratory results: BUN, 25 mg/dL; creatinine, 1.8 mg/dL; ammonia, 173; INR, 5.2; total bilirubin, 4.4 mg/dL; AST, >4500 IU/L; and alkaline phosphatase, 309 IU/L. The child died before liver transplantation. Antemortem blood was qualitatively positive for pulegone (pennyroyal) at approximately 2.5 days postingestion (limit of detection, 20 pg/mL). Case 169. A 74-year-old woman was found unresponsive and was suspected to have suffered a stroke. On physical examination, there were multiple ecchymotic skin lesions and a teal color staining of her teeth. In her pockets were several teal colored pellets later identified as brodifaenum. In addition to hypoglycemia and elevated liver function tests, initial laboratory results included a PT of 21 seconds and platelet count of 8,000/i.tL. Treatment included activated charcoal, vitamin K, platelet and fresh frozen plasma transfusions. She died 28 hours later. Postmortem blood revealed a brodifacoum level of 9.5 ng/mL. Case 171. An 83-year-old man with a history of lymphoma admitted to the ingestion of rat poison 30 to 45 minutes earlier. After an apparent seizure, he was found by paramedics to be diaphoretic and not responding verbally, with a blood pressure of 160/70 mm Hg and a pulse rate of 116 beats/rain. On arrival to the ED, he was lethargic, answered questions, and exhibited intermittent periods of screaming, neck extension, and "shaking." While being interviewed by a physician, the patient had a seizure followed by bradycardia and then pulselessness. Treatment included CPR, epinephrine, atropine, and sodium bicarbonate. The patient died after 10 minutes. Laboratory results included: arterial pH, 7.03; Pco2, 32 mm Hg; sodium, 134 mEq/L; potassium, 5.2 mEq/L; chloride, 104 mEq/L; bicarbonate, 9 mEq/L; BUN, 20 mg/dL; creatinine, 1.0 mg/dL; glucose, 248 mg/dL; and anion gap 30 mEq/L. The patient's wife revealed that he had threatened to take strychnine which was stored in an old container in their garage. Autopsy findings included acute pulmonary edema, visceral congestion, lymphoma with generalized lymphadenopathy and splenomegaly, generalized atherosclerosis, emphysema, and benign prostatic hypertrophy. A postmortem blood strychnine level was 0.35 ~tg/mL. Case 173. A previously healthy, premature 9-month-old, 9-kg girl presented with hyperpyrexia and respiratory distress. The child had evidence of septic shock and hepatic and renal failure. Upper respiratory symptoms had been present for about 3 days before arrival. The child's mother was treating her with aeetaminophen infant drops. After running out, she switched to chewable acetarninophen, and finally crushed adult strength acetaminophen tablets mixed into the child's formula. The total amount of acetaminophen administered was unknown. Treatment included vasopressors, intubation, plasmapheresis, and hemodialysis. The patient died the same day. Laboratory studies included: acetaminophen, 60 ~tg/mL; AST, 13,000 IU/L; alanine transaminase (ALT), 8,000 IU/L; PT, >90 seconds; ammonia, 384 gmol/L; CSF studies were normal. Autopsy findings were indicative of acetaminophen toxicity. Case 182. A 26-year-old woman with a history of schizophrenia and ethanol abuse ingested an unknown amount of aeetaminophen 1 hour before arrival to the ED. The patient had a prior history of acetaminophen overdose 1 month earlier with resultant hepatotoxicity. On this admission, serial acetaminophen levels were: at 1 hour postingestion, 133 lag/mL; 4 hours postingestion, 70 ~ag/mL; and 8 hours postingestion, 26 ~tg/mL. Liver function tests were not performed and the patient was transferred to a psychiatric unit. Three days later, fuhninant hepatic failure developed. There was no acetaminophen detectable in the serum at that time. In addition to acidemia, the patient had multiple laboratory abnormalities: PT, >100 seconds; creatinine, 2.0 mg/dL; AST, 12,000 IU/L. The oral N-acetylcysteine formulation was administered intravenously ev-
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ery 4 hours, along with intensive supportive care. Renal failure worsened over the next day with the creatinine level increasing to 4.5 mg/dL. The patient was not considered a candidate for liver transplantation and died 11 days postingestion. Case 249. A 2-year-old girl presented with tachypnea, nausea, and vomiting following the ingestion of an unknown number of 325-mg aspirin tablets. The initial vital signs were: temperature, 38.0°C; and respirations, 48 breaths/min. When seizures developed, the patient was transported to another facility. Subsequent therapy included intubation, activated charcoal with cathartic, and urinary alkalinization. The 6-hour salicylate level was 109 mg/dL. Other laboratory results included: initial arterial pH, 7.36; Pco2, 17 mm Hg; Po2, 120 mm Hg; PT, 14 seconds; and PTT, 39 seconds. Refractory seizures were treated with phenobarbital, lorazepam, and hemodialysis. The child remained comatose, with reactive pupils, an adequate urine output (urine pH, 7.0), and a repeat salicylate level of <5.0 mg/dL on the second hospital day. A C T scan of the head at that time showed cerebral edema. The patient suffered an intracranial hemorrhage, and was pronounced brain dead on hospital day 5. Case 256. A 37-year-old woman made a slurry using brandy plus 150 to 250 unknown strength aspirin tablets. She then drank one half of the mixture. Two hours later, she developed vomiting and called 911. Charcoal with cathartic were administered en route to the ED by prehospital personnel. Five and one half hours postingestion she was awake and alert with the following vital signs: pulse rate, 93 beats/rain; blood pressure, 199/85 mm Hg; respirations, 24 breaths/rain; temperature, 36.6°C. The initial salicylate level was 62 mg/dL. Other laboratory results were: sodium, 145 mEq/L; potassium, 3.4 mEq/L; chloride, 109 mEq/L; bicarbonate, 22 mEq/L; arterial pH, 7.43; Pco2, 27 mm Hg; and Po2, 121 mm Hg. A repeat salicylate level drawn 6 hours later was 41 mg/dL. Initial treatment included sodium bicarbonate boluses, potassium chloride, and two additional doses of activated charcoal with sorbitol. Fifteen hours after ingestion the patient had stable vital signs and was transferred to the psychiatric division. At 22 hours after ingestion, she complained of stomach upset and had multiple episodes of emesis which precluded the administration of oral medications. At 28 hours postingestion she was found lying on the floor, disoriented, diaphoretic, with the following vital signs: respirations, 24 breaths/min; pulse rate, 80 beats/rain; blood pressure, 158/78 mm Hg; and temperature, 36°C. Shortly thereafter, she had a grand mal seizure and developed ventricular fibrillation. Resuscitative efforts were not successful. A salicylate level drawn during CPR was 120 mg/dL, with a postmortem level of 85.8 mg/dL. Case 295. A 38-year-old man ingested 25, 0.5 mg eolehieine tablets, five hours prior to presentation. A British Textbook of Suicide was found in the patient's home. He was noted to complain of severe abdominal pain, hematemesis, and hematochezia. The patient's vital signs were: blood pressure, 158/80 mm Hg; pulse rate, 118 beats/min; temperature, 38.3°C; respirations, 20 breaths/ rain. Orthostatic pulse and blood pressure changes were noted. The electrocardiogram showed a normal sinus rhythm without ectopy or abnormal intervals. The initial blood gas analysis on room air showed: arterial pH, 7.38; Pco2, 33 mm Hg; and Po2, 83 mm Hg. Volume resuscitation was successful using six units of whole blood and 3 liters of lactated ringers. Multiple dose activated charcoal therapy was initiated. Twenty-three hours after ingestion the patient was talking to the nurse when he developed ventricular tachycardia followed by ventricular fibrillation. Defibrillation, lidocaine, epinephrine, magnesium, atropine, and sodium bicarbonate therapy were unsuccessful. Case 297. A 14-year-old girl ingested eolehieine and trazodone within 3 days of arrival to the ED. Initial symptoms included multiple episodes of vomiting and diarrhea. She was treated with activated charcoal and sorbitol, prophylactic antibiotics and fresh
frozen plasma. Laboratory results included: white blood cell count, 40,000/pL; AST, 320 IU/L; ALT, 280 IU/L; LDH, 7,300 IU/L; PT, 16 seconds; PTT, 30 seconds, BUN, 8 mg/dL; creatinine, 0.9 mg/dL; acetarninophen, <10 lag/mE The urine toxicology screen was negative. One day later, respiratory distress, refractory hypotension, and bradycardia developed. An agonal ventricular rhythm developed, which was unresponsive to prolonged advanced cardiac life support (ACLS) measures. Case 301. A 19-month-old boy was found comatose by his mother. Severn bottles of methadone elixir were found in the home. Both the mother and her boyfriend were in methadone treatment programs. The amount of methadone ingested was never determined. On arrival to the ED, the child was in cardiac arrest. Treatment included ACLS measures and naloxone. Resuscitative efforts were not successful. Autopsy findings included a postmortem blood methadone concentration of 0.5 gg/mL, and death was attributed to methadone intoxication. Case 302. A 2-year-old boy was given an uncertain amount of his uncle's methadone by his 4-year-old sibling. Seven hours later, his mother noted bizarre movements with "eyes rolling back into his head." She placed him in bed. One hour later, she checked on him, noting that he had persistently abnormal extremity and ocular movements. Four to five hours later he was apneic. On arrival to the ED, the child was pronounced dead. Case 311. A 47-year-old man on methadone maintenance intentionallyingested additional methadone to get high. On arrival to the hospital, he was comatose with hypoventilation. Treatment included naloxone boluses and infusion and admission to a critical care setting. The patient left the unit against medical advice and was found dead in the hospital chapel 4 hours later. A white powder, presumed to be heroin, was found in his pockets. Case 330. A 40-year-old woman ingested an unknown amount of phenylbutazone. On arrival to the ED, she was seizing, unresponsive, hypotensive and had severe acidosis (arterial pH, 6.3). After intubation, diazepam and phenobarbital were administered to control the seizures. Additional therapy included gastric lavage, multiple dose activated charcoal, cathartic, and bicarbonate. A repeat arterial pH was 7.3. The patient became more awake, but was agitated, tachycardic, and required neuromuscular paralysis. Subsequent laboratory studies included: glucose, 325 mg/dL; AST, 346 IU/L; ALT, 240 IU/L; lactic dehydrogenase (LDH), 381 IU/L; calcium, 7.6 mg/dL; and arterial pH, 7.47. The patient died 24 hours later. Autopsy findings included mild cerebral edema and unidentified white, grainy material in the small bowel. Case 344. A 29-year-old woman received a 40-mL injection of bupivaeaine 0.5% into the knee joint at her physician's office. Within 2 minutes, she seized and suffered a respiratory arrest. Prehospital CPR was initiated. On EMS arrival, the patient was noted to be bradycardic, but rapidly deteriorated to ventricular fibrillation. During transport, seizures continued. In the ED, seizures were controlled with lorazepam and phenytoin, and the acidosis was corrected with bicarbonate. After resuscitation, the patient's pupils were fixed and dilated, and she remained comatose. The bilirubin was noted to be elevated at 1.9 mg/dL on hospital day 4. Two days later, she died. Case 346. A 28-year-old male hospital housekeeper was found unconscious with an empty bottle of isoflurane and cotton balls strapped to his face. Pulseless electrical activity was noted and treatment included sodium bicarbonate, atropine, and epinephrine. Despite pacemaker placement, progressive tachyarrhythmias and, finally, asystole developed. Autopsy findings were negative. A postmortem isoflurane blood level was 145 gg/mL. Case 388. A 9-year-old boy was noted to have an unsteady gait prior to developing a seizure and cardiorespiratory arrest. Paramedics arrived approximately 10 minutes later and noted empty bottles of imipramine, amitriptyline, and methylphenidate nearby, On arrival to the ED, the patient was hypotensive with a wide complex
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
bradycardia. Treatment included intravenous fluids and sodium bicarbonate (arterial pH maintained at 7.45 to 7.48) and multiple dose activated charcoal. The cardiac conduction delay improved with a subsequent QRS duration of 0.10 seconds. Continuous squinting activity was observed. Electroencephalogram (EEG) tracings were consistent with seizure activity, CT of the head was negative, and the patient was treated with phenytoin. His clinical condition gradually deteriorated, and the patient died on hospital day 3. The antemortem blood analysis showed: amitriptyline, 1,430 ng/mL; nortriptyline, 600 ng/mL; imipramine, 696 ng/mL; and desipramine, 636 ng/mL. Case 399. A 27-year-old man called a crisis hotline stating that he had taken some medications and had only 2 hours to live. A first responder found him to be lethargic and attempted to walk him around at the scene to increase his alertness. He subsequently seized. A second seizure occurred en route to the hospital and was followed by a cardiac arrest. He was treated with CPR, intravenous fluids, and sodium bicarbonate. In the ED, a pulseless idioventricular rhythm and apnea were noted. Subsequent therapy with epinephrine, atropine, and intubation resulted in the return of spontaneous circulation, and the following vital signs were noted: pulse rate, 118 beats/min; blood pressure, 82/25 rnm Hg; respirations, 15 breaths/min. Dopamine and norepinephrine were required to support the blood pressure. Initial laboratory results included; arterial pH, 6.75; Pco2, 33 mm Hg; Po2, 244 mm Hg; and bicarbonate, 16.9 mEq/L. Life support was withdrawn 5 days later when an EEG showed no evidence of brain activity. Blood bupropion and hydroxybupropion levels taken 21 hours after admission were 446 ng/mL and 3,217 ng/mL respectively. Case 405. A 1-year-old girl ingested an unknown quantity of desipramine and was taken by ambulance to the ED. The child had a widened QRS of more than 0.12 seconds, and was treated with gastric lavage, activated charcoal, and intravenous sodium bicarbonate. Deterioration occurred, with a respiratory arrest, bradycardia, and acidosis (arterial pH, 7.06). Despite additional therapy including epinephrine, atropine, cardioversion, dopamine, and CPR, the patient died within 3 hours of arrival. Case 406. A 3-year-old boy with a history of attention deficit disorder was brought by ambulance to the ED following a 1-minute shaking spell at home. Earlier, he had received his usual bedtime dose of desiprarnine, 100 rag. Both the patient and his 6-year-old sibling were chronically treated with desipramine. It was determined that at most, two to three tablets from either prescription were missing. In the ED, a second tonic clonic seizure was followed by asystole. The patient was resuscitated with CPR, intubation, epinephrine, sodium bicarbonate, calcium, and atropine. A wide-complex tachycardia and persistent seizure activity led to the administration of additional sodium bicarbonate, benzodiazepines, and phenobarbital. After transfer to a tertiary care center, refractory seizures were treated with phenytoin and pentobarbital coma. The patient remained hemodynamically stable for 26 hours and then required fluid boluses and d0Pamine for hypotension. EEGs performed at 28 and 36 hours were flat line without evidence of brainstem activity. Life support was discontinued at approximately 47 hours. Laboratory results included: glucose, 308 mg/dL; serum desipramine on arrival, 1,472 ng/mL; and repeat antemortem desipranline, 215 ng/mL. The urine drug screen was positive for barbiturates, caffeine, imipramine, desipramine, and phenytoin. Autopsy findings included cerebral edema and bilateral diffuse bronchopneumonia. Case 477. A 30-year-old woman ingested an unknown quantity of venlafaxine and carbamazepine. She presented with the following vital signs: pulse rate, 160 beats/min; respirations, 28 breaths/min; and blood pressure, 148/82 mm Hg. To control the tachycardia, overdrive pacing was attempted. The patient's pulse rate steadily decreased to asystole. Prolonged resuscitative efforts were not successful. The initial urine drug screen was positive for
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benzoylecgonine. Postmortem results were: serum venlafaxine, 89 lag/mL; liver venlafaxine, 132 tag/mL; total gastric venlafaxine, 800 mg; serum carbamazepine 19.2 ~tg/mL; serum benzoylecgonine, none detected. Autopsy findings were remarkable only for the presence of alveolar fluid. Case 505. A 23-year-old man ingested a topical aphrodisiac called "Love Stone" purchased in a "smoke shop." Thirty minutes later he developed vomiting and diarrhea that persisted until his arrival to the ED the next day. On physical exam, the patient's vital signs were: pulse rate, 76 beats/min; respirations, 28 breaths/min; temperature, 33.8°C; and blood pressure, 98/60 mm Hg. He was noted to be alert, in respiratory distress, with diaphoresis and midrange, reactive pupils. A chest X-ray showed evidence of pulmonary edema. During intubation, the patient's heart rate decreased to 20 beats/min. He was treated with atropine, and the heart rate increased to 150 beats/min. Three hours after ED presentation, ventricular fibrillation developed. Despite Fab fragment therapy, the patient died. Antemortem laboratory results included: digoxin, 0.9 ng/mL; sodium, 139 mEq/L; potassium, 4.3 mEq/L; chloride, 100 mEq/L; bicarbonate, 2l mEq/L; BUN, 14 mg/dL; creatinine, 1.0 mg/dL; glucose, 104 mg/dL; arterial pH, 7.44; Pco2, 23 mm Hg; Po2, 41 mm Hg (on room air). A right bundle branch block pattern was noted on the electrocardiogram. The product was identified as an extract from the Bufo species of toad, known to contain a number of cardiac glycosides. Case 530. A drowsy 20-year-old woman admitted to the ingestion of naproxen and ethanol in a suicide attempt. (Later, police also discovered an empty bottle of her father's flecainide in the home). Prehospital providers found the patient to be lethargic, cool and clammy, with sluggishly reactive pupils and some purposeful movements. The pulse rate was 20 to 40 beats/min and the systolic blood pressure was 70 mm Hg by palpation. Intubation was performed at the scene. Ventricular fibrillation converted to pulseless electrical activity with defibrillation and lidocaine therapy. Atropine and epinephrine were then administered. Widened QRS complexes did not respond to 150 mEq of intravenous sodium bicarbonate. Hypotension persisted despite glucagon, calcium chloride, transvenous pacing, dopamine, norepinephrine, and isoproterenol. Additional complications included adult respiratory distress syndrome (ARDS) and renal failure. The patient was placed on ECMO for 2 days and developed a refractory coagulopathy. Death occurred shortly after removal from ECMO. An antemortem flecainide level was 1.62 lag/mL. Case 535. A 72-year-old man with an extensive cardiac history, an indwelling pacemaker, and renal failure was administered 50 mg of milrinone intravenously as a loading dose, instead of 3 mg. He became hypotensive (blood pressure, 60 mm Hg), and developed cardiogenic shock and anuria. High doses of vasopressor agents, including dopamine, norepinephfine, and phenylephrine, were administered for blood pressure support. The patient failed to respond to the above therapy and succumbed to a cardiac arrest 18 hours after exposure. Case 540. A 57-year-old man with a history of hypertension, asthma, peripheral vascular disease, and alcohol abuse presented to the ED after ingesting 15 of his own long.acting nifedipine for chest pain. Initial findings included hypotension, third degree heart block, ST elevations on electrocardiogram, acidosis, and lethargy. He was treated with gastric lavage, charcoal, cathartic, norepinephfine, dopamine, and calcium chloride. Whole bowel irrigation was initiated but discontinued upon the development of an ileus. Subsequent therapy for persistent hypotension and bradycardia included glucagon, calcium chloride infusion, epinephrine, transvenous cardiac pacing, and theophylline. Nonetheless, the patient died. Laboratory studies included: arterial pH, 7.28; Po2, 76 mm Hg (Fio2, 0.8); Pco2, 30 mm Hg; sodium, 136 mEq/L; potassium 3.5 mEq/L; chloride, 97 mEq/L; bicarbonate, 8 mEq/L; BUN, 15 mg/dL; creatinine, 2.7 mg/dL; glucose, 216 mg/dL; calcium, 13.1
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mg/dL (after bolus); ionized calcium, 2.41 mmol/L; and creatine phosphokinase, 2,200 IU/L (100% MM fraction). The serum drug screen was negative for ethylene glycol, methanol, salicylates, and acetone. The urine drug screen was positive for opiates. Serum nifedipine levels were greater than 200 ng/mL by dilution. Case 556. A 49-year-old woman with a history of adult onset diabetes, hypertension, and hemorrhagic stroke presented with acute dyspnea. The family denied a history of suicide attempt or symptoms of depression. Her only medication was sustained release verapamil. Initial physical examination revealed confusion, agitation, bradycardia at 20 beats/min, poor skin perfusion, and a systolic blood pressure of 60 mm Hg by palpation. The electrocardiogram revealed a junctional bradycardia with QRS duration of •108 seconds and normal T wave appearance. Resuscitative efforts included rapid sequence intubation, atropine, isoproterenol, dobutamine, calcium chloride, norepinephrine, sodium bicarbonate, crystalloid infusion, insulin infusion and transvenous pacemaker placement. Despite 3 hours of aggressive resuscitation, the patient developed progressive bradycardia and hypotension, and died. Pertinent laboratory findings were: hemoglobin, 13.9 gm/dL; white blood cell count, 9,000/pL; glucose, 562 mg/dL; creatinine, 1.3 mg/dL; sodium, 137 mEq/L; potassium, 6.7 mEq/L; bicarbonate, 21 mEq/L; anion gap, 10 mEq/L. Autopsy findings revealed biventricular hypertrophy, diffuse coronary stenosis without acute coronary thrombus, and hepatic cirrhosis. Toxicologic blood analysis revealed the following: propranoiol, 600 ~tg/mL; verapamil, 668 tag/mL; norverapamil, 301 ~tg/mL; and the presence of diphenhydramine. Case 558. A 50-year-old man with a history of cardiac disease and hypertension ingested a mixture of 50 tablets of eaptopril and quinidlne. Prehospital intubation was performed and vital signs included a pulse of 52 beats/rain and a systolic blood pressure of 50 mm Hg. In the ED, treatment included gastric lavage, charcoal, cathartic, norepinephrine, isoproterenol, dopamine, atropine, and sodium bicarbonate. The electrocardiogram showed a QRS duration of 0.21 seconds (right bundle branch block pattern) and first degree AV block• The patient developed seizures, pulmonary edema, and dysrhythmias. His neurological status improved slightly prior to the onset of refractory hypotension and bradycardia on the third hospital day. Laboratory results included: quinidine, 12 ~tg/mL; initial digoxin, 1.8 ng/mL; sodium, 134 mEq/L; and potassium, 3.4 mEq/L. Case 591. A 17-year-old man reportedly ingested approximately 40 ephedrine tablets and then fell asleep. Later that evening, and early the next morning, friends heard him snoring. He was found unresponsive at noon the following day. On arrival to the ED, ventricular fibrillation was noted and was treated with defibrillation, fluids, and pacemaker placement. His body temperature was greater than 37.8°C. Resuscitative efforts were not successful. The initial laboratory results included: arterial pH, 6.53; Pco2, 29 mm Hg; Poe, 151 mm Hg; bicarbonate, 3.3 mEq/L, potassium, 11.03 mEq/L. The urine drug screen was positive for ephedrine, and negative for other drugs of abuse. A quantitative urine ephedrine level was 140/ag/mL. Autopsy findings included an intracerebral hemorrhage, cerebral edema, severe hemorrhagic gastritis, and bilateral pulmonary edema. Case 593. A 43-year-old woman with a history of hypertension intentionally ingested an unknown number of antihistamine/ decongestant tablets (75 mg phenylpropanolamine with 12 mg brompheniramine per tablet). On presentation, she was alert and oriented and complained of dizziness. Physical findings included diaphoresis, small to midrange pupils, normal bowel sounds, and good urine output• Vital signs were: pulse rate, 60 beats/rain; respirations, 20 breaths/rain; blood pressure, 165/125 mm Hg; temperature, 36.2°C. Over the course of several hours, the patient's blood pressure and pulse rate decreased to 150/90 mm Hg and 50 beats/rain, respectively. She became increasingly lethargic. A
subsequent CT scan revealed a large intracerebral bleed. Progressive coma, hypotension, and multiple organ failure resulted in death 3 days after ingestion. Case 594. A 22-month-old boy ingested 96 325-mg ferrous sulfate tablets (549 mg/kg elemental iron) 15 minutes before to arrival to the ED. Initial therapy included endoscopy, gastric lavage, and deferoxamine. Early laboratory results included: hemoglobin, 10.8 gm/dL; white blood cell count, 8,100//aL; serum iron, 50 lag/dL. After transfer to a second facility, the patient was somnolent and mildly combative with the following vital signs: pulse rate, 190 beats/rain; respirations, 30 breaths/rain; and blood pressure, 131/106 mm Hg. Repeat laboratory analysis included: serum iron (6½ hours postingestion), 2,583 /ag/dL; glucose, 393 mg/dL; white blood cell count, 26,800/pL; bicarbonate 13 mEq/L; PT, 27.1 seconds; PTT, 92 seconds; arterial pH, 7.24; Pco2, 22 mm Hg; and Po2, 99 mm Hg. Subsequent treatment included intubation, albumin, crystalloids, activated charcoal with cathartic, exchange transfusions, vasopressors, and a continuous deferoxamine infusion. A v i n r o s e urinary color change was noted. Repeat endoscopy showed corrosive changes in the cervical esophagus with retained charcoal and pill fragments in the gastric fundus. On hospital day 2, deterioration occurred with the development of ARDS, worsened coagulopathy, and acidosis. Multiple organ failure and hemodynamic instability ensued and the patient died that day. Blood cultures were positive for pneumococcus and pseudomonas. Case 597. A 63-year-old man with a history of colon cancer was being prepared for repair of stenosis of his colostomy. Ten enemas (each containing sodium biphosphate, 19 grams, and sodium phosphate, 7 grams per 118 mL) were administered into the ostomy. Three to four hours later he suffered a cardiac arrest. The patient was initially resuscitated with intubation and cardiac pacing. Vital signs were: blood pressure, 90/30 mm Hg; pulse rate, 96 beats/min; and temperature, 34.9°C. Laboratory results 1 hour after cardiac arrest were as follows: ionized calcium, 0.3 mg/dL; phosphorus, 10.8 mg/dL. Repeat laboratory results 3 hours later showed: sodium, 157 mEq/L; potassium, 8.2 mEq/L; chloride, 93 mEq/L; bicarbonate, 8 mEq/L; arterial pH, 7.17. Despite peritoneal dialysis, the patient died 12 hours after enema administration. Case 616. A 31-year-old man presented to the ED 3.5 hours after ingesting 14 tablets of 100 mg elozapine. He was awake, alert and in no distress with the following vital signs: blood pressure, 132/90 mm Hg; pulse rate, 100 beats/min. The initial electrocardiogram showed a QRS duration of 0.08 seconds. Five to six hours postingestion, the patient became uncooperative, pulled off the cardiac monitor lead wires and ran around the ED. Shortly thereafter, his level of consciousness became depressed and intnbation was performed. The QRS duration had increased to 0.24 seconds at that time. No seizure activity was noted. Treatment, including sodium bicarbonate, physostigmine (2 mg), epinephrine, atropine, and dopamine, was unsuccessful, and the patient died. Case 619. A 30-year-old man with a history of cocaine, marijuana, heroin, and ethanol abuse injected ethehlorvynol intravenously prior to arriving to the ED with complaints of shortness of breath. Initial physical findings included cyanosis, tachypnea, tachycardia, and hypotension. Treatment included intubation, 100% oxygen, positive end expiratory pressure of 15 cm H20, fluid restriction, vasopressor therapy, and invasive hemodynamic monitoring. The central venous pressure was 5 to 7 cm H20 and the systemic vascular resistance was low. Hemodialysis was attempted, but was aborted after 30 minutes because of hemodynamic instability. The patient died within 12 hours of arrival. Laboratory studies included: arterial pH, 7.21; Pco2, 58 mm Hg; Poe, 42 mm Hg; ethanol, 150 mg/dL; methanol, salicylate, ethylene glycol, and acetaminophen levels were below detection limits. Autopsy findings included acute pulmonary edema, early pneumonia, passive congestion of the liver, kidneys, spleen, and viscera,
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
and bilateral hydrothoraces. A postmortem ethchlorvynol level was 8.6 pg/mL. Case 626. A 16-year-old boy with a history of viral meningitis/ encephalitis complicated by seizures and agitation was being treated in a pediatric intensive care unit. In addition to anticonvulsants, haloperidol was given in escalating doses for 2 weeks. After receiving haloperidol 8 mg three times daily for 24 hours, dystonia was noted. Benztropine 2 mg was given. Thereafter, hyperkinesis, hyperthermia (temperature, 41.7°C), and cardiac arrest occurred. The patient was resuscitated, but developed DIC and generalized bleeding, and died within 12 hours. Pertinent laboratory results at the time of the cardiac arrest included creatine phosphokinase, 2,000 IU/L and potassium, 8.0 mEq/L. Case 638. A 66-year-old man with a history of angina, hypertension, psychosis, and previous suicide attempts intentionally ingested an 8-day supply of risperidone, 240 mg of nifedipine, 400 mg of sertraline, 1.6 mg of elonidine, and 10 to 15 mg of clonazepam. In the ED, the patient was arousable with slightly labored respirations. Treatment included cardiac monitoring, gastric lavage, activated charcoal, sorbitol, naloxone, and flumazenil. The patient seized, became apneic and was intubated. Recurrent seizures required diazepam and phenobarbital therapy. Later that day, his temperature rose to 41.7°C. He was treated with antipyretics and dantrolene. He deteriorated and developed persistent seizures and ultimately ventricular fibrillation. Resuscitation attempts were unsuccessful. Case 644. A 12-year-old autistic boy presented with a 40-hour duration of vomiting and poor oral intake. There was no history of diarrhea or fever. The diagnosis of gastroenteritis was made, and the patient was treated with trimethobenzamide suppositories. Over the next 24 hours, vomiting decreased, but the child was anuric and continued to complain of abdominal pain. Later, he was found flaccid, cyanotic, pulseless, and apneic by his brother. Prehospital CPR, intubation, epinephrine, and bicarbonate therapy was administered. ACLS measures continued in the ED with the return of spontaneous circulation. The patient suffered anoxic encephalopathy and subsequently died. Autopsy findings included hepatic microvesicular fatty change and axonal changes. Both urine and blood (26.8 pg/mL) trimethobenzamide levels were elevated. The cause of death was anoxic encephalopathy secondary to cardiopulmonary arrest. Case 652. Paramedics were called to transport an 11-month-old girl to the ED after the alleged ingestion of an unknown rat poison. En route, the child developed seizures and ventricular tachycardia. In the ED, she was treated with intubation, gastric lavage, and naioxone. The electrocardiogram showed a wide-complex tachycardia and a prolonged QTc. Deterioration of the cardiac rhythm occurred, and the patient was treated with atropine, epinephrine, and defibrillation. Despite initial stabilization, the child died because of refractory ventricular fibrillation. Laboratory results included: arterial pH, 6.51; Po2, 105 mm Hg; Pco2, 94 mm Hg; glucose, "normal." The urine drug screen was positive for cocaine metabolites. On autopsy, crack cocaine particles were noted in the duodenum. Postmortem toxicologic analysis revealed the following cocaine levels: heart, 17.74 ~g/mL; blood, 25.66 ~g/mL; liver, 11.56 mg/kg; brain, 29.55 mg/kg. The parents later admitted that they had Seen the child's 2-year-old sibling feeding her crack cocaine.
537
Case 709. A 1-day-old girl born to a mother with a history of methamphetamine abuse developed tonic-clonic seizures. The mother admitted to methamphetamine use 3 days before delivery. The patient had agitation, fluctuating temperature, poor urine output, and intermittent apnea. Seizure control necessitated intubation and phenobarbital therapy. The patient remained sedated and died on the 6th hospital day. Autopsy findings included bilateral cerebral artery infarction with brain stem hemorrhage and herniation. Case 711. A 30-year-old man presented to the ED a few hours after snorting and ingesting crank (methamphetamine). He complained of sweating, chills, weakness, shakiness, and chest pain radiating to the neck. Flushing, tachycardia, hypotension, oliguria, and hyperkalemia were noted. Treatment included dopamine, norepinephrine, and hemodialysis. Swan-Ganz catheter insertion revealed a very low cardiac index and systemic vascular resistance. Shortly thereafter, the patient deteriorated further. Ventricular fibrillation progressed to asystole, and then to refractory pulseless electrical activity despite intubation and aggressive resuscitation. Death occurred within 1 hour. Autopsy findings included cystic medial necrosis of the ascending aorta with dissection and rupture into the pericardial sac (50 mL fluid); two vessel coronary atherosclerosis; pulmonary congestion and edema; renal congestion; and acute erosive hemorrhagic gastritis. The toxicology screen was positive for amphetamines. Case 718. A 25-year-old woman was found unconscious and in respiratory arrest in a hotel room. A young male was found dead in the same room, which smelled strongly of ethyl ether. Equipment and chemicals used to produce methamphetamine were found in the bathroom, and paraphernalia for smoking methamphetamine along with large amounts of the drug were seen on a table. The patient was transported to the ED after intubation. Resuscitative efforts were not successful, and she was pronounced dead approximately l hour after arrival. The cause of death was determined to be from methamphetamine poisoning with ethyl ether as a possible contributing factor. Case 724. A 1-year-old boy was unresponsive and cyanotic, with shallow respirations on presentation to the ED 12 to 14 hours after the ingestion of an unknown number of prenatal vitamins with iron. The initial vital signs were blood pressure, 40/29 mm Hg; and respirations, 28 breaths/min. The patient was treated with fluids and fresh frozen plasma through internal jugular and left ankle cutdown sites. A continuous infusion of deferoxamine was started (19 mg/kg/h). Two hours after arrival, the child was semicomatose and had evidence of disseminated intravascular coagulopathy. Further treatment included epinephrine, dopamine, dobutamine, and blood transfusions. Despite resuscitative efforts and transfer to a tertiary care facility, the patient died 11 hours after arrival. (Of note, the patient's sibling was evaluated for a possible iron ingestion one night earlier. It was not known at that time that the younger child had also ingested the prenatal vitamins). Laboratory results included: serial serum iron levels, 5,900 pg/dL, 6,000 pg/dL, 5,927 pg/dL; serial total iron binding capacity, 9,195 pg/dL, 2,196 pg/dL; PT, 27.3 seconds; PTT, 150 seconds; sodium, 145 mEq/L; potassium, 2.5 mEq/1; chloride, 109 mEq/L; bicarbonate, 17 mEq/L; BUN, 20 mg/dL; creatinine, 0.7 mg/dL; ALT 100 IU/L; AST 291 IU/L; LDH, 3,512 IU/L. Abdominal X-ray showed one tablet visible in the gastric region.
1995 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System TOBY L. LITOVITZ, MD, LINDA FELBERG, MA, SUZANNE WHITE, MD, WENDY KLEIN-SCHWARTZ, PHARMD,MPH Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; they are used to support regulatory actions; and they form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1). H2
The cumulative AAPCC database now contains 18 million human poison exposure cases. This report includes 2,023,089 human exposure cases reported by 67 participating poison centers during 1995, an increase of 5% compared to 1994 poisoning reports.
Centers participating in this report include Children's Hospital of Alabama Regional Poison Control Center, Birmingham, AL; Alabama Poison Center, Tuscaloosa, AL; Arizona Poison and Drug Information Center, Tucson, AZ; Samaritan Regional Poison Center, Phoenix, AZ; University of California Davis Medical Center Regional Poison Control Center, Sacramento, CA; San Diego Regional Poison Center, San Diego, CA; Santa Clara Valley Medical Center Regional Poison Center, San Jose, CA; San Francisco Bay Area Regional Poison Control Center, San Francisco, CA; Central California Regional Poison Control Center, Fresno, CA; Rocky Mountain Poison and Drug Center, Denver, CO; Connecticut Poison Control Center, Farmington, CT; National Capital Poison Center, Washington, DC; Florida Poison Information Center and Toxicology Resource Center, Tampa, FL; Florida Poison Information Center, Jacksonville, FL; Florida Poison Information Center, Miami, FL; Georgia Poison Control Center, Atlanta, GA; Idaho Poison Center, Boise, ID; Indiana Poison Center, Indianapolis, IN; St. Luke's Poison Center, Sioux City, IA; Mid-America Poison Control Center, Kansas City, KS; Kentucky Regional Poison Center of Kosair Children's Hospital, Louisville, KY; Louisiana Drug and Poison Information Center, Monroe, LA; Maryland Poison Center, Baltimore, MD; Massachusetts Poison Control System, Boston, MA; Children's Hospital of Michigan Poison Control Center, Detroit, MI; Blodgett Regional Poison Center, Grand Rapids, MI; Hennepin Regional Poison Center, Minneapolis, MN; Minnesota Regional Poison Center, St. Paul, MN; Cardinal Glennon Children's Hospital Regional Poison Center, St. Louis, MO; The Poison Center, Omaha, NE; New Hampshire Poison Information Center, Lebanon, NH; New Jersey Poison Information and Education System, Newark, NJ; New Mexico Poison and Drug Information Center, Albuquerque, NM; New York City Poison Control Center, New York, NY; Hudson
Valley Regional Poison Center, North Tarrytown, NY; Long Island Regional Poison Control Center, Mineola, NY; Finger Lakes Regional Poison Center, Rochester, NY; Central New York Poison Control Center, Syracuse, NY; Western New York Regional Poison Control Center, Buffalo; Carolinas Poison Center, Charlotte, NC; North Dakota Poison Information Center, Fargo, ND; Akron Regional Poison Center, Akron, OH; Cincinnati Drug and Poison Information Center, Cincinnati, OH; Central Ohio Poison Center, Columbus, OH; Greater Cleveland Poison Control Center, Cleveland, OH; Mahoning Valley Poison Center, Youngstown, OH; Oregon Poison Center, Portland, OR; Pittsburgh Poison Center, Pittsburgh, PA; The Poison Control Center, Philadelphia, PA; Central Pennsylvania Poison Center, Hershey, PA; Rhode Island Poison Center, Providence, RI; McKennan Poison Control Center, Sioux Falls, SD; Middle Tennessee Regional Poison and Clinical Toxicology Center, Nashville, TN; Southern Poison Center, Memphis, TN; Central Texas Poison Center, Temple, TX; North Texas Poison Center, Dallas, TX; Southeast Texas Poison Center, Galveston, TX; Texas Poison Center Network at Amarillo, Amarillo, TX; West Texas Regional Poison Center, El Paso, TX; South Texas Poison Center, San Antonio, TX; Utah Poison Control Center, Salt Lake City, UT; Virginia Poison Center, Richmond, VA; Blue Ridge Poison Center, Charlottesville, VA; Washington Poison Center, Seattle, WA; West Virginia Poison Center, Charleston, WV; University of Wisconsin Hospital Regional Poison Center, Madison, Wl; Poison Center of Eastern Wisconsin, Milwaukee, WI. ©1985-1996 by the American Association of Poison Control Centers. Published by permission. All rights reserved. Reprints are available at a cost of $10 each. Address requests to AAPCC, 3201 New Mexico Ave, Ste 310, Washington, DC 20016.
CHARACTERIZATIONOF PARTICIPATINGCENTERS Of the 67 reporting centers, 62 submitted data for the entire year. Forty-three of the 67 participating centers were certified as regional poison centers by the AAPCC in 1995. Annual center call volumes (human exposure cases only) ranged from 3,131 to 92,931 (mean, 31,376) for centers participating for the entire year. Penetrance, calculated by
487
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE1. Growth of the AAPCC Toxic Exposure
TABLE2. Site of Caller and Site of Exposure, Human Poison
Surveillance System
Exposure Cases
Year 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Total
No. of Participating Centers
Population Served (Millions)
Human Exposures Reported
Exposures/ Thousand Population
16 47 56 57 63 64 70 72 73 68 64 65 67
43.1 99.8 113.6 132.1 137.5 155.7 182.4 191.7 200.7 196.7 181.3 215.9 218.5
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089 18,214,463
5.8 7.3 7.9 8.3 8.5 8.8 8.7 8.9 9.2 9.5 9.7 8.9 9.3
state or portion of the state served, ranged from 1.1 to 18.2 per 1,000 with a mean of 9.3 reported exposures per 1,000 population. Penetrance is defined as the number of human poison exposure cases reported per 1,000 individuals in the population served. A total population of 218.5 million was served by the participating centers, including 38 entire states, portions of 6 states, and the District of Columbia (Figure 1). Noting the 262.8 million 1995 United States population, the data presented represent an estimated 83% of the human poison exposures that precipitated poison center contacts in the US during 1995. Extrapolating from the 2,023,089 human poison exposures reported in this database, 2.4 million human poison exposures are estimated to have been reported to all US poison centers in 1995. However, extrapolations from the number of reported poisonings to the number of actual poisonings occurring annually in the US cannot be made from these data alone, as considerable variations in
Residence Own Other Workplace Health care facility School Restau rant/food service Public area Other Unknown
Site of Caller (%)
Site of Exposure (%)
77.3 2.4 1.9 13.0 0.6 0.1 0.6 3.8 0.4
86.8 3.6 3.0 0.4 1.3 0.7 1.4 1.1 1.8
poison center penetrance were noted. Indeed, assuming all centers reached the penetrance level of 18.2 poisonings per 1,000 population reported for one state, 4.8 million poisonings would have been reported to poison centers in 1995. The data do not directly identify a trend in the overall incidence of poisonings in the US because of changing center participation from year to year and changes in center use. An analysis of data from 55 centers that participated for the entirety of both 1994 and 1995 shows a 5.9% increase in reported poison exposures from 1994 to 1995 within the regions served by these 55 centers. REVIEW OF THE DATA
Of the 2,023,089 human exposures reported in 1995, 90.4% occurred at a residence (Table 2). In 4.7% of cases (95,204 cases) multiple patients were implicated in the poison exposure episode (eg, siblings "shared" a household product, multiple patients inhaled vapors at a hazardous materials spill). Two unlikely sites of poisonings, health care facilities and schools, accounted for 7,919 (0.4%) and 26,186 (1.3%) poison exposures, respectively. Poison center peak call volumes were noted from 4 to 10 PM, although call
FIGURE 1. Sixty-seven poison centers participated in the Toxic Exposure Surveillance System in 1995. The shaded areas denote regions served by reporting centers.
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
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TABLE 3. Age and Gender Distribution of Human Poison Exposure Cases Male
Unknown
Female
Age (yr)
No.
%
<1 1 2 3 4 5 Unknown child < 5 6-12 13-19 Unknown child Total children (<20) 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Unknown adult Total adults Unknown age
65,338 168,585 184,284 86,760 41,636 24,141 1,332 76,399 63,731 1,628 713,834 74,906 68,747 40,017 17,724 10,552 7,415 3,408 545 41,851 265,165 4,339
51.9 52.5 53,6 54.8 55.6 55,6 45.2 55.9 42.1 41.7 52.4 44.0 42.3 40.7 38.5 36.4 34.1 29.8 26.5 39.4 41.0 33.1
Total
983,338
48.6
%
No.
%
No.
59,960 151,848 158,512 71,190 33,001 19,138 1,045 59,397 87,129 1,430 642,650 95,014 93,655 58,237 28,291 18,436 14,316 8,009 1,510 62,032 379,500 5,892
47.6 47.3 46.1 44.9 44.1 44.0 35.4 43.4 57.5 36.7 47.2 55.9 57.6 59.2 61.4 63.6 65.8 70.1 73.5 58.5 58.6 44.9
589 848 818 458 267 176 571 915 588 843 6,073 194 139 68 39 21 29 13 0 2,237 2,740 2,896
0.5 0.3 0.2 0.3 0.4 0.4 19.4 0.7 0.4 21.6 0.4 0.1 0.1 0,1 0.1 0.1 0.1 0.1 0.0 2.1 0.4 22.1
125,887 321,281 343,614 158,408 74,904 43,455 2,948 136,711 151,448 3,901 1,362,557 170,114 162,541 98,322 46,054 29,009 21,760 11,430 2,055 106,120 647,405 13,127
1,028,042
50.8
11,709
0.6
2,023,089
No.
frequency remained consistently high between 8 A~ and midnight, with 91% of calls logged during this 16-hour period. The age and gender distribution of human poison exposure victims is outlined in Table 3. Children younger than 3 years of age were involved in 39% of cases, and 53% occurred in children younger than 6 years. A male predominance is found among poison exposure victims younger than 13 years of age, but the gender distribution is reversed in TABLE 4. Distribution of Age and Gender for 724 Fatalities
Age (yr) Male Female Unknown Total <1 3 1 5 2 2 3 2 4 0 5 0 6-12 6 13-19 21 20-29 69 30-39 106 40-49 79 50-59 34 60-69 24 70-79 21 80-89 12 90-99 3 Unknown adult 5 Total 392
%
Cumula- Cumulative rive Total %
5 2 1 0 0 0 0 19 40 84 63 34 28 20 23 4
0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
8 7 3 2 0 0 6 40 109 191 142 68 52 41 35 7
1.1 1.0 0.4 0.3 0.0 0.0 0.8 5.5 15.1 26.4 19.6 9.4 7.2 5.7 4.8 1.0
8 15 18 20 20 20 26 66 175 366 508 576 628 669 704 711
1.1 2.1 2.5 2.8 2.8 2.8 3.6 9.1 24.2 50.6 70.2 79.6 86.7 92.4 97.2 98.2
8 331
0 1
13 1.8 724 100.0
724 724
100.0 100.0
Cumulative Total
Total %
No.
%
6.2 15.9 17.0 7.8 3.7 2.1 0.1 6.8 7.5 0.2 67.4 8.4 8.0 4.9 2.3 1.4 1.1 0.6 0.1 5.2 32.0 0.6
125 887 447 168 790 782 949 190 1,024 094 1,067 549 1,070 497 1,207 208 1,358,656 1,362,557 1,362,557 1,532,671 1,695,212 1,793,534 1,839,588 1,868,597 1,890,357 1,901 387 1,903,842 2,009,962 2,009,962 2,023,089
6.2 22.1 39.1 46.9 50.6 52.8 52.9 59.7 67.2 67.4 67.4 75.8 83.8 88.7 90.9 92.4 93.4 94.0 94.1 99.4 99.4 100.0
100.0
2,023,089
100.0
teenagers and adults. Although the gender distribution was nearly equal for unintentional exposures, 60.9% of intentional exposures occurred in females, as did 65.1% of adverse reactions. Of all poison exposures captured, 6,484 occurred in pregnant women. Of those with known pregnancy duration, 30% occurred in the first trimester, 39% in the second trimester, and 31% in the third trimester. Table 4 presents the age and gender distribution for the 724 reported fatalities. Although responsible for the majority of poisoning reports, children younger than 6 years of age comprised just 2.8% (20) of the fatalities. Sixty-one percent of poisoning fatalities occurred in 20- to 49-year-old individuals. A single substance was implicated in 92.8% of reports, and 1.8% of patients were exposed to more than two possibly poisonous drugs or products (Table 5). The overwhelming majority of human exposures were acute (94.0%) compared to only 54.8% of poison-related fatal exposures. TABLE 5, Number of Substances Involved in Human Poison Exposure Cases No. of Substances 1 2 3 4 5 6 7 8 __>9 Total
No. of Cases
% of Cases
1,878,238 109,145 20,215 7,713 3,081 1,315 638 311 2,433 2,023,089
92.8 5.4 1.0 0.4 0.2 0.1 0.0 0.0 0.1 100.0
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TABLE 6. Reason for Human Poison Exposure Cases Reason Unintentional General Therapeutic error Bite/sting Misuse Environmental Occupational Food poisoning Unknown Total Intentional Suicidal Misuse Abuse Unknown Total Other Malicious Contaminant/tampering Total Adverse Reaction Drug Other Food Total Unknown Total
No.
%
1,339,318 110,038 77,368 58,559 54,378 45,989 45,505 3,260 1,734,415
66.2 5.4 3.8 2.9 2.7 2.3 2.3 0.2 85.7
160,478 30,060 26,416 12,545 229,499
7.9 1.5 1.3 0.6 11.3
5,913 5,218 11,131
0.3 0.3 0.6
28,296 9,908 4,491 42,695 5,349 2,023,089
1.4 0.5 0.2 2.1 0.3 100.0
Chronic exposures comprised 2.3% of all poison exposure reports, and acute-on-chronic exposures comprised 3.1%. (Chronic exposures were defined as continuous or repeated exposures occurring in a period exceeding 8 hours.) Reason for exposure was coded according to the following definitions: Unintentional general: All unintentional exposures not specifically defined below. Most unintentional exposures in children are captured here. Environmental: Any passive, nonoccupational exposure that results from contamination of air, water, or soil. Environmental exposures are usually caused by man-made contaminants. Occupational: An exposure that occurs as a direct result of the person being on the job or in the workplace. Therapeutic error: An unintentional deviation from a proper therapeutic regimen that results in the wrong dose, incorrect route of administration, administration to the wrong person, or administration of the wrong substance. Only exposures to medications or products substituted for medications are included. Drug interactions resulting from unintentional administration of drugs or foods that are known to interact are also included.
Unintentional misuse: Unintentional improper or incorrect use of a nonpharmaceutical substance. Unintentional misuse differs from intentional misuse in that the exposure was unplanned or not foreseen by the patient. Bite~sting: All animal bites and stings, with or without envenomation, are included. Food poisoning: Suspected or confirmed food poisoning; ingestion of food contaminated with microorganisms is included. Unintentional unknown: An exposure determined to be unintentional but the exact reason is unknown. Suspected suicidal: An exposure resulting from the inappropriate use of a substance for reasons that are suspected to be self destructive or manipulative. Intentional misuse: An exposure resulting from the intentional improper or incorrect use of a substance for reasons other than the pursuit of a psychotropic effect. Intentional abuse: An exposure resulting from the intentional improper or incorrect use of a substance by a victim who was likely attempting to achieve a euphoric or psychotropic effect. All recreational uses of substances for any effect are included. Intentional unknown: An exposure that is determined to be intentional but the specific motive is unknown. Contaminant~tampering: The patient is an unintentional victim of a substance that has been adulterated (either maliciously or unintentionally) by the introduction of an undesirable substance. Malicious: This category is used to capture patients who are victims of another person's intent to harm them. Adverse reaction: An adverse event occurring with normal, prescribed, labeled, or recommended use of a product, as opposed to overdose, misuse, or abuse. Included are cases with an unwanted effect caused by an allergic, hypersensitive, or idiosyncratic response to active ingredients, inactive ingredients, or excipients. Concomitant use of a contraindicated medication or food is excluded and coded instead as a therapeutic error. The vast majority (85.7%) of poison exposures were unintentional; suicidal intent was present in 7.9% of cases (Table 6). Therapeutic errors comprised 5.4% of exposures (110,038 cases), with unintentional nonpharmaceutical product misuse comprising another 2.9% of exposures (58,559 cases). Unintentional poisonings outnumbered intentional poisonings in all age groups (Table 7). In contrast, of the 724 human poisoning fatalities reported, 82% of adult deaths (older than 19 years of age) were intentional (Table 8). Ingestions accounted for 73.6% of exposure routes (Table 9), followed in frequency by dermal, inhalation, and ocular exposures, bites and stings, and parenteral and aspiration exposures. For the 724 fatalities, ingestion and inhalation were the predominant exposure routes. Clinical effects (signs, symptoms, or laboratory abnormali-
TABI.157. Distribution of Reason for Exposure by Age <6 Years
6-12 Years
13-19 Years
>19 Years
Unknown
Total
Reason
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Row %
No.
Col %
Unintentional Intentional Other Adverse Reaction Unknown Total
1,064,532 685 927 3,847 506 1,070,497
61.4 0.3 8.3 9.0 9.5 52.9
124,777 7,419 1,585 2,427 503 136,711
7.2 3.2 14.2 5.7 9.4 6.8
77,042 68,211 2,032 3,396 767 151,448
4.4 29.7 18.3 8.0 14.3 7.5
456,139 149,178 6,369 32,500 3,219 647,405
26.3 65.0 57.2 76.1 60.2 32.0
11,925 4,006 218 525 354 17,028
0.7 1.7 2.0 1.2 6.6 0.8
1,734,415 229,499 11,131 42,695 5,349 2,023,089
85.7 11.3 0.6 2.1 0.3 100.0
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491
TABLE 8. Distribution of Reason for Exposure and Age for 724 Fatalities
Reason Unintentional General Environmental Occupational Therapeutic error Misuse Bite/sting Food poisoning Unknown Total intentional Suicide Misuse Abuse Unknown Total Other Adverse Reaction Unknown Total
TABLE 10. Management Site of Human Poison Exposure Cases
<6 6-12 13-19 >19 Years Years Years Years Unknown Total 10 3 0 1 1 0 0 0 15
0 1 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
2 23 3 33 3 3 0 1 68
0 0 0 0 0 0 0 0 0
12 27 3 34 4 3 0 1 84
0 1 1 0 2 0 1 2 20
2 0 2 0 4 0 1 0 6
19 2 13 3 37 0 1 2 40
384 25 95 34 538 0 11 41 658
0 0 0 0 0 0 0 0 0
405 28 111 37 581 0 14 45 724
ties) were coded in 31.9% of cases (18.3% had one effect, 8.0% had two effects, 3.5% had three effects, 1.4% had four effects, 0.4% had five effects, and 0.3% had more than five effects). Of 1,412,605 clinical effects coded, 77.9% were deemed related, 7.0% were considered not related, and 15.1% were coded as "unknown if related." The majority of cases reported to poison centers were managed in a non-health care facility (72.5%), usually at the site of exposure, the patient's own home (Table 10). Treatment in a health care facility was rendered in 23.6% of cases and recommended in another 2.3% of patients who refused the referral. Of cases managed in a health care facility, 58.6% were treated and released without admission, 12.6% were admitted for critical care, and 7.2% were admitted for noncritical care. When treatment was provided TABLE 9. Distribution of Route of Exposure for Human Poison Exposure Cases and 724 Fatalities All Exposure Cases
Fatal Exposure Cases
Route
No.
%
No.
%
Ingestion Dermal Inhalation Ocular Bites and stings Parenteral Aspiration Other Unknown Total
1,564,859 173,725 151,407 133,061 80,810 6,861 2,432 5,840 7,956 2,126,951
73.6 8.2 7.1 6.3 3.8 0.3 0.1 0.3 0.4 100.0
590 5 95 0 3 43 7 4 34 781
75.5 0.6 12.2 0.0 0.4 5.5 9.0 0.5 4.4 100.0
NOTE: Multiple routes of exposure were observed in many poison exposure victims. Percentage is based on the total number of exposure routes (2,126,951 for all patients, 781 for fatal cases) rather than the total number of human exposures (2,023,089) or fatalities (724).
Site
No.
%
Managed on-site, non-health care facility Managed in health care facility Treated and released Admitted to critical care Admitted to noncritical care Admitted to psychiatry Lost to follow-up; left AMA Unspecified level of care Subtotal Other Refused referral Unknown Total
1,467,630
72.5
279,667 60,375 34,322 26,212 75,546 1,325 477,447 16,751 47,070 14,191 2,023,089
13.8 3.0 1.7 1.3 3.7 0.1 23.6 0.8 2.3 0.7 100.0
ABBREVIATION:AMA, against medical advice.
in a health care facility, 43.8% of the patients were referred by a poison center and 56.2% were already in or en route to the health care facility when the poison center was contacted. Health care facilities included acute care hospitals (86.9%), freestanding emergency centers (2.0%), and physicians' offices or clinics (10.9%). Table 11 displays the medical outcome of the human poison exposure cases distributed by age, showing more severe outcomes in the older age groups. Table 12 compares medical outcome and reason for exposure, and demonstrates the greater frequency of serious outcome in intentional exposures. Table 13 demonstrates the increasing duration of the clinical effects observed with more severe outcomes. Note the medical outcome categories, as follows: No effect: The patient developed no signs or symptoms as a result of the exposure. Minor effect: The patient developed some signs or symptoms as a result of the exposure but they were minimally bothersome and generally resolved rapidly with no residual disability or disfigurement. A minor effect is often limited to the skin or mucous membranes (eg, selflimited gastrointestinal symptoms, drowsiness, skin irritation, first degree dermal burn, sinus tachycardia without hypotension, and transient cough). Moderate effect: The patient exhibited signs or symptoms as a result of the exposure that were more pronounced, more prolonged, or more of a systemic nature than minor symptoms. Usually some form of treatment is indicated. Symptoms were not life-threatening, and the patient has no residual disability or disfigurement (eg, corneal abrasion, acid-base disturbance, high fever, disorientation, hypotension that is rapidly responsive to treatment, and isolated brief seizures that respond readily to treatment). Major effect: The patient exhibited signs or symptoms as a result of the exposure that were life-threatening or resulted in significant residual disability or disfigurement (eg, repeated seizures or status epilepticus, respiratory compromise requiring intubation, ventricular tachycardia with hypotension, cardiac or respiratory arrest, esophageal stricture, and disseminated intravascular coagulation). Death: The patient died as a result of the exposure or as a direct complication of the exposure. Only those deaths that were probably or undoubtedly related to the exposure are coded here. Not followed, judged as nontoxic exposure: No follow-up calls were made to determine the patient's
492
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE 11. Medical Outcome of Human Poison Exposure Cases by Patient Age <6 Years Outcome
No.
No effect 367,361 Minor effect 133,216 Moderate effect 10,582 Major effect 584 Death 20 No follow-up, nontoxic 275,045 No follow-up, minimaltoxicity 247,283 No follow-up, potentially toxic 17,562 Unrelated effect 18,890 Total 1,070,543
6-12 Years
13-19 Years
> 19 Years
Col %
No.
Col %
No.
Col %
No.
34.3 12.4 1.0 0.1 0.0 25.7 23.1 1.6 1.8 52.9
27,105 33,636 3,928 199 6 25,519 37,478 4,278 4,562 136,711
19.8 24.6 2.9 0.2 0.0 18.7 27.4 3.1 3.3 6.8
29,361 45,355 13,501 1,103 40 11,846 30,912 14,529 4,801 151,448
19.4 29.9 8.9 0.7 0.0 7.8 20.4 9.6 3.2 7.5
76,014 193,199 59,499 6,769 658 50,243 164,127 58,560 38,336 647,405
Col %
Unknown No.
1 1 . 7 1,778 29.8 2,771 9.2 576 1.0 56 0.1 0 7.8 2,165 25.4 4,196 9.0 4,764 5.9 676 32.0 16,982
Total
Col %
No.
%
10.5 16.3 3.4 0.3 0.0 12.8 24.7 28.1 4.0 0.8
501,619 408,177 88,086 8,711 724 364,818 483,996 99,693 67,265 2,023,089
24.8 20.2 4.4 0.4 0.0 18.0 23.9 4.9 3.3 100.0
TABLE 12. Distribution of Medical Outcome by Reason for Exposure for Human Poison Exposure Cases Unintentional Outcome
No.
No effect 453,034 Minor effect 325,949 Moderate effect 50,315 Major effect 2,233 Death 84 No follow-up, nontoxic 358,008 No follow-up, minimal toxicity 440,131 No follow-up, potentially toxic 51,415 Unrelated effect 53,245 Total 1,734,414
Col %
Intentional No.
Col %
26.1 46,434 18.8 66,024 2.9 32,516 0.1 6,008 0.0 581 20.6 4,550 25.4 25,000 3.0 43,356 3.1 5,031 85.7 229,500
TABLE 13. Duration of Clinical Effects by Medical Outcome
--<2 hours >2 hours, -<8 hours >8 hours, -<24 hours >24 hours, -<3 days >3 days, -<1 week >1 week, -<1 month >1 month Anticipated permanent Unknown
Minor Effect Moderate Effect Major Effect (Co1%) (Co1%) (Co1%) 40.6 23.8 18.0 6.1 2.2 0.6 0.2 0.0 8.6
6.8 20.7 31.3 17.3 7.0 2.5 0.7 0.2 13.6
No.
20.2 1,258 28.8 3,300 14.2 515 2.6 27 0.3 0 2.0 1,150 10.9 3,150 18.9 931 2.2 800 1 1 . 3 11,131
outcome because the substance implicated was nontoxic, the amount implicated was insignificant, or the route of exposure was unlikely to result in a clinical effect. Not followed, minimal clinical effects possible: No follow-up calls were made to determine the patient's outcome because the exposure was likely to result in only minimal toxicity of a trivial nature. (The patient was expected to experience no more than a minor effect.) Unable to follow, judged as a potentially toxic exposure: The patient was lost to follow-up, refused follow-up, or was not followed up, but the exposure was significant and may have resulted in a moderate, major, or fatal outcome. Unrelated effect: The exposure was probably not responsible for the effect. Confirmed nonexposure: This outcome option was used during coding to designate cases in which reliable and objective evidence
Duration of Effect
Other
2.9 8.1 27.3 29.4 13.7 5.7 1.5 3.1 8.4
Adverse Reaction
Col %
No.
Col %
11.3 29.6 4.6 0.2 0.0 10.3 28.3 8.4 7.2 0.6
476 12,034 4,076 276 14 863 14,680 2,860 7,416 42,695
1.1 28.2 9.5 0.6 0.0 2.0 34.4 6.7 17.4 2.1
Unknown No.
Total
Col %
No.
417 7.8 501,619 870 16.3 408,177 664 12.4 88,086 167 3.1 8,711 45 0.8 724 247 4.6 364,818 1,035 19.3 483,996 1,131 21.1 99,693 773 14.5 67,265 5,349 0.3 2,023,089
Col % 24.8 20.2 4.4 0.4 0.0 18.0 23.9 4.9 3.3 100.0
showed that an exposure initially believed to have occurred actually never occurred (eg, all missing pills are later located). All cases coded as confirmed nonexposure are excluded from this report. In 1995 there were 6,482 such cases reported nationally. Tables 14 and 15 outline the use of decontamination procedures, specific antidotes, and measures to enhance elimination in the treatment of patients reported in this database. These must be interpreted as minimum frequencies because of the limitations of telephone data gathering. Ipecac syrup was administered in 2.3% of cases. In children younger than 6 years of age, ipecac syrup was most often administered outside a health care facility. This pattern was reversed in teenagers and adults. Ipecac was administered more often in children (3.6% of poison exposures occurring in children younger than 6 years of age compared with 0.7% of poison exposures occurring in patients older than 19 years). Table 16 demonstrates a continued decline in the use of ipecac-induced emesis in the treatment of poisoning. TABLE 14. Decontamination and Therapeutic Intervention Therapy
No. of Patients
%
Decontamination only No therapy provided Observation only Decontamination and other therapy Other therapy only (no decontamination) Unknown if therapy provided/patient refused
1,144,201 254,035 227,015 133,920 87,346 176,572
56.6 12.6 11.2 6.6 4.3 8.7
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
493
TABLE17A. Substances Most Frequently Involved in Human Exposures
TABLE 15. Therapy Provided in Human Exposure Cases Therapy
No.
Decontamination Dilution/irrigation Activated charcoal, single dose Cathartic Gastric lavage Ipecac syrup Activated charcoal, multidose Other emetic Whole bowel irrigation Measures to Enhance Elimination Alkalinization (with or without diuresis) Hemodialysis Hemoperfusion Other extracorporeal procedure Specific Antidote Administration N-acetylcysteine (oral) Naloxone Flumazenil Antivenin Atropine Ethanol Hyperbaric oxygen N-acetylcysteine (IV) Deferoxamine Phytonadione Pyridoxine Pralidoxime (2-PAM) Physostigmine Fab fragments Dimercaprol (BAL) Folate EDTA Succimer Methylene blue Sodium thiosulfate Sodium nitrite Penicillamine Hydroxocobalamin Other intervention Transplantation ECMO
970,152 140,359 106,761 72,862 47,359 15,521 5,976 1,690 7,261 772 59 53 9,601 7,373 2,567 833 770 623 562 432 422 356 281 228 219 194 136 127 122 107 81 70 57 45 15 16 12
TABLE16. Decontamination Trends
Year
Human Exposures Reported
% of Exposures Involving Children <6 Years
Ipecac Administered (% of Exposures)
Activated Charcoal Administered (% of Exposures)
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
251,012 730,224 900,513 1,098,894 1,166,940 1,368,748 1,581,540 1,713,462 1,837,939 1,864,188 1,751,476 1,926,438 2,023,089
64.0 64.1 63.4 63.0 62.3 61.8 61.1 60.8 59.9 58.8 56.0 54.1 52.9
13.4 12.9 15.0 13.3 10.1 8.4 7.0 6.1 5.2 4.3 3.7 2.7 2.3
4.0 4.0 4.6 5.2 5.2 6.5 6.4 6.7 7.0 7.3 7.3 6.8 7.7
Substance
No.
%*
Cleaning substances Analgesics Cosmetics and personal care products Cough and cold preparations Plants Bites/envenomations Pesticides (includes rodenticides) Foreign bodies Topicals Food products, food poisoning Antimicrobials Hydrocarbons Sedatives/hypnotics/antipsychotics Antidepressants Alcohols Chemicals Vitamins
208,843 196,805 171,426 105,947 104,187 87,628 84,346 75,021 72,124 67,084 66,274 65,143 63,271 56,285 52,119 51,508 45,952
10.3 9.7 8.5 5.2 5.1 4.3 4.2 3.7 3.6 3.3 3.3 3.2 3.1 2.8 2.6 2.5 2.3
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of human exposures rather than the total number of substances.
Table 17A presents the most common substance categories listed by frequency of exposure. Tables 17B and 17C present similar data for children and adults, respectively, and show the considerable differences between pediatric and adult poison exposures. Table 18 lists the substance categories with the largest number of reported deaths; analgesics and antidepressants led this list. A remarkable chronological constancy of selected demographic data elements is shown in Table 19. A breakdown of plant exposures is provided for those most commonly implicated (Table 20). TABLE 17B. Substances Most Frequently Involved in Pediatric Exposures (Children Under 6 Years) Substance
No.
%*
Cosmetics and personal care products Cleaning substances Analgesics Plants Cough and cold preparations Foreign bodies Topicals Pesticides (includes rodenticides) Antimicrobials Vitamins Gastrointestinal preparations Hydrocarbons Arts/crafts/office supplies Antihistamines Hormones and hormone antagonists
127,419 118,332 81,643 74,829 70,862 53,972 53,875 44,150 39,718 36,553 34,922 26,723 26,421 18,330 18,291
11.9 11.1 7.6 7.0 6.6 5.0 5.0 4.1 3.7 3.4 3.3 2.5 2.5 1.7 1.7
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in children under six years, rather than the total number of substances.
494
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE170. Substances Most Frequently Involved in Adult Exposures (>19 years)
TABLE19. 13-Year Comparisons of Fatality Data
Substance
No.
%*
Analgesics Cleaning substances Bites/envenomations Sedatives/hypnotics/antipsychotics Antidepressants Food products, food poisoning Alcohols Fumes/gases/vapors Cosmetics and personal care products Chemicals Hydrocarbons Pesticides (includes rodenticides) Cardiovascular Cough and cold preparations Antihistamines
61,834 57,582 43,431 43,333 34,387 31,875 25,199 23,886 23,248 23,137 22,695 22,579 15,716 15,141 14,877
9.6 8.9 6.7 6.7 5.3 4.9 3.9 3.7 3.6 3.6 3.5 3.5 2.4 2.3 2.3
NOTE:Despite a high frequency of involvement, these substances are not necessarily the most toxic, but rather may only be the most readily accessible. *Percentages are based on the total number of exposures in adults (over 19 years), rather than the total number of substances.
A summary of the 724 fatal exposures is presented in Table 21. Each of these cases was abstracted and verified by the reporting center, with only those exposures deemed "probably" or "undoubtedly" responsible for the fatality included in this compendium. The highest blood level of implicated substances is provided where available to the reporting poison center. Prehospital cardiac and/or respiratory arrests occurred in 40% of all fatalities, and these are indicated in Table 21. Tables 22A and 22B provide comprehensive demographic data on patient age, reason for exposure, medical outcome, and use of a health care facility for all 2,023,089 exposures, presented by category. Table 22A focuses on nonpharmaceuticals; Table 22B presents drugs. Of the 2,167,552 substances logged in Tables 22A and 22B, 57.9% were nonpharmaceuticals and 42.1% were pharmaceuticals. The reason for the exposure was intentional for 28.0% of pharmaceutical substances implicated compared with only 4.0% of TABLE18. Categories with Largest Numbers of Deaths
Category
No.
% of All Exposures in Category
Analgesics Antidepressants Cardiovascular drugs Stimulants and street drugs Sedative/hypnotics/antipsychotics Alcohols Gases and fumes Chemicals Asthma therapies Insecticides/pesticides (includes rodenticides) Automotive products Cleaning substances Hydrocarbons
235 168 115 108 97 82 48 23 20 18 17 17 14
0.119 0.298 0.347 0.319 0.153 0.157 0.113 0.045 0.103 0.021 0.125 0.008 0.021
Total Fatalities
Suicides
Pediatric Deaths (<6 years)
Year
No.
%
No.
%of Deaths
No.
% ~ Deaths
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
95 293 328 406 397 545 590 612 764 705 626 766 724
0.038 0.040 0.036 0.037 0.034 0.040 0.037 0.036 0.042 0.038 0.036 0.040 0.036
60 165 178 223 226 297 323 350 408 395 338 410 405
63.2 56.3 54.3 54.9 56.9 54.5 54.7 57.2 53.4 56.0 54.0 53.5 55.9
10 21 20 15 22 28 24 25 44 29 27 26 20
10.5 7.2 6.1 3.7 5.5 5.1 4.1 4.1 5.8 4.1 4.3 3.4 2.8
nonpharmaceutical substances. Correspondingly, treatment in a health care facility was provided in a higher percentage of exposures to pharmaceutical substances (37.2%) compared with nonpharmaceutical substances (18.0%). Pharmaceutical exposures also had more severe outcomes. Of substances implicated in fatal cases, 77.0% were pharmaceuticals, compared with only 42.1% in nonfatal cases. Similarly, 75.9% of substances implicated in major outcomes were pharmaceuticals. In closing, we gratefully acknowledge the extensive contributions of each participating poison center and the assistance of the many physicians and nurses who provided comprehensive data to the poison centers for inclusion in this database. TABLE20. Frequency of Plant Exposures by Plant Type Botanical Name
Common Name
Frequency
Capsicum annuum Philodendron spp. Euphorbia pulcherrima Ilex spp. Dieffenbachia spp. Spathiphyllum spp. Phytolacca americana Crassula spp. Toxicodendron radicans Epipremnum aureum Caladium spp. Rhododendron spp. Saintpaulia ionantha Eucalyptus Globulus Brassaia actinophylla Pyracantha spp. Hedera helix Chrysanthemum spp. Schlumbergera Bridgesfi Taraxacum officinale
Pepper Philodendron Poinsettia Holly Dumbcane Peace lily Pokeweed, inkberry Jade plant Poison ivy Pothos, devil's ivy Caladium Rhododendron, azalea African violet Eucalyptus Umbrella tree Pyracantha English ivy Chrysanthemum Christmas cactus Dandelion
4,984 4,378 2,952 2,871 2,648 2,632 2,207 1,715 1,478 1,258 1,058 1,033 991 984 982 946 884 811 803 795
NOTE: This table provides the frequency of involvement of plants in exposures reported to poison centers with no correlation with severity of toxicity. Several of the plants on the list pose little, if any, ingestion hazard.
LITOVITZ ET AL •
TABLE 21. Case
1995 A A P C C A N N U A L R E P O R T
495
Summary of Fatal Exposures Reported to TESS in 1995 Age
Substances
Chronicity
Route
Reason
Blood Levels
NONPHARMACEUTICALS
Adhesives/glue lip 30 yr Alcohols 2 3~P 4P 5ip 6ip 7~ 8ip 9p 10 11
20 yr 23 yr 25 yr 36 yr 37 yr 41 yr 49 yr 64 yr 66yr 32 yr
12
75 yr
13
35 yr
14
20 yr
15~p
49 yr
16P
46 yr
17p
34 yr
18P
2 mo
19ip
43 yr
20P
47 yr
21 ip
36 yr
22 ip
53 yr
23 24 25 ~ 26 27
40 yr 47 yr 48 yr 63 yr 51 yr
Cement (tetrahydrofuran/methyl ethyl ketone)
A/C
Inhalation
Int abuse
Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol Ethanol acetaminophen Ethanol acetaminophen Ethanol acetaminophen/decongestant Ethanol antidepressant trazodone Ethanol carbamazepine amitriptyline Ethanol fluoxetine
A U A A A/C U A/C C A/C C
Ingestion Unknown Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unknown Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse
A/C
Ingestion
Int abuse
C
Ingestion
Int abuse
A
Ingestion
lnt suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A
Ingestion
Unknown
A/C
Ingestion
Int abuse
140 mg/dL§ 0.02 pg/mL§ 240 mg/dL
A/C
Ingestion
Int abuse
16 mg/dL§
U
Ingestion
Unknown
U
Ingestion
Int suicide
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int abuse Unknown Int abuse Int abuse
carbamazepine Ethanol heroin Ethanol methamphetamine Ethanol morphine Ethanol propoxyphene Ethanol propoxyphene benzodiazepines Ethanol propoxyphene sertraline Methanol Methanol Methanol Methanol Methanol deodorant spray (ethanol)
290 182 456 342 330
mg/dL mg/dL mg/dL mg/dL mg/dL§
270 mg/dL 195 mg/dL
0.2 pg/mL
310 mg/dL 0.51 pg/mL§ norfluoxetine 0.32 #g/mL§ 6 I~g/mL§ 300 mg/dL
467 333 83 23 339
mg/dL mg/dL mg/dL mg/dL mg/dL
See also cases 37, 39, 46, 54, 65, 129, 130, 131, 132, 133, 155, 164, 170, 206, 207, 208, 218, 226, 228, 232, 240, 243, 244, 245, 274, 284, 285, 308, 309, 310, 317, 318, 328, 367, 368, 377, 378, 380, 381, 382, 417, 429, 430, 435, 445, 446, 447, 452, 465, 471, 475, 506, 527, 534, 545, 554, 584, 604, 608, 609, 617, 618, 619, 632, 650, 672, 673, 674, 686, 699, 701, 702, 703, 704, 705, 706, 715 (ethanol); 435 (isopropanol) ; 679 (methanol). Automotive products 28 31 yr Antifreeze (ethylene glycol) 29 45 yr Antifreeze (ethylene glycol) 30 45 yr Antifreeze (ethylene glycol) 31a 46 yr Antifreeze (ethylene glycol) 32 a 57yr Antifreeze (ethylene glycol) 33 62 yr Antifreeze (ethylene glycol) 34 74 yr Antifreeze (ethylene glycol) 35 86 yr Antifreeze (ethylene glycol) 36 36 yr Antifreeze (ethylene glycol) acetaminophen barbiturates
A A U U A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int unknown Int suicide Unknown Int suicide Unknown Int suicide Int suicide Int suicide
41 mg/dL 233 mg/dL
177 mg/dL 1,920 mg/dL 54 mg/dL
107 pg/mL
(Continued on following page)
12-14 h
496
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
37
27 yr
Substances
Antifreeze (ethylene glycol) ethanol 38 27 yr Antifreeze (ethylene glycol) sulfuric acid 39 43 yr Antifreeze (ethylene glycol) windshield washing fluid (methanol) mouthwash (ethanol) 40 33yr Brakefluid 41p 30 yr Windshield washing fluid (methanol) 42 36 yr Windshield washing fluid (methanol) 43P 48 yr Windshield washing fluid (methanol) nail polish remover (acetone) See also case 39 (windshield washing fluid). Bites and envenomations 44 a 66 yr Bee stings 45 a 88 yr Bee stings 46 ap 35 yr Crotalus horridus atricaudatus (canebrake rattlesnake) ethanol Chemicals 47 48 ap 49 50 51 52 i 53
35 yr 53yr 30 yr 32 yr 43 yr 46 yr 35 yr
Cyanide Cyanide Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol Ethylene glycol acetaminophen 54 52 yr Ethylene glycol ethanol 55P 64 yr Ethylene glycol nortriptyline chlorpromazine 56 35 yr Ethylene glycol rodenticide (unknown type) 57 31 yr Hydrochloric acid 58 45 yr Hydrochloric acid 59 17 yr Potassium hydroxide 60 a 24 yr Sodium azide 61~p 43 yr Sodium azide 62 a 43 yr Sodium azide carbon monoxide 63 35 yr Sulfuric acid See also case 38 (sulfuric acid).
Cleaning substances 64 52 yr Cleaning agent (acid) aspirin 65 49 yr Cleaning solution (methanol) ethanol 66 71 yr Deodorizing cleaner (cationic) 67 84 yr Detergent (cationic) 68 42 yr Drain opener rodenticide 69 37 yr Drain opener (hydrochloric acid) 70 20 yr Drain opener (sodium hydroxide) 71 73 yr Drain opener (sodium hydroxide crystals) 72 31 yr Drain opener (sulfuric acid) 73 a 40 yr Hydrofluoric acid rust remover (6-8%) 74 51 yr Lye (sodium hydroxide) 75ip 33 yr Sodium hydroxide/hypochlorite spray cleaner 76 56 yr Tire cleaner (acid) 77 30 yr Toilet bowl cleaner (acid) 78 45 yr Toilet bowl cleaner (HCI) 79 50 yr Toilet bowl cleaner (HCI)
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int suicide
194 mg/dL§
A
Ingestion
Int suicide
57 mg/dL
A
Ingestion
Int suicide
U A A A
Ingestion Ingestion Ingestion Ingestion
Unknown Int suicide Int suicide Int suicide
A A A
Bite/sting Bite/sting Bite/Ing
Bite/sting Bite/sting Bite/sting
697 mg/dL 610 mg/dL
7h
250 mg/dL§ A A U A A U A
Ingestion Ingestion Unknown Ingestion Ingestion Unknown Ingestion
Int suicide Int suicide Unknown Int unknown Int suicide Unknown Int suicide
A/C
Ingestion
Int abuse
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A A A A A A
ingestion Ingestion Ingestion Ingestion Ingestion Derm/Inh
Int suicide Int suicide Int suicide Int suicide Int suicide Occ
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
A A A
Ingestion Asp/Ing Ingestion
Unint gen Unint gen Int suicide
A A A A A A U
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Inhalation
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Env
A A A A
ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int misuse
17.4 pg/mL 8,000 mg/dL 59 mg/dL 177 mg/dL 223 mg/dL 765 pg/mL 202 417 1,850 1,663
mg/dL mg/dL§ ng/mL§ ng/mL§
5.58 mg/mL§
14%
(Continued on following page)
>35 mg/dL 20 mg/dL
2.3h
LITOVITZ ET A L •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
497
S u m m a r y of Fatal Exposures Reported to T E S S in 1995 (Cont'd)
Case
Age
80 81
72 yr 20 yr
82
65 yr
Substances
Chronicity
Toilet bowl cleaner (HCI, phosphoric acid) Toilet bowl cleaner (5-10% HCI) toilet bowl cleaner (15-20% HCI) Toilet bowl deodorizer (alkyl dimethyl benzyl ammonium chloride)
Cosmetics and personal care products 83o 42 yr Hair spray (ethanol, >50%)
Route
Reason
A A
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int abuse
Blood Levels
414 mg/dL
See also cases 27 (deodorant spray, ethanol); 39 (mouthwash); 43 (nail polish remover, acetone). Deodorizers 84 85 i0
12 yr 15 yr
Air freshener Air freshener (propane, butane)
A A
Inhalation Inhalation
Int abuse Int abuse
86p 87ip
16 yr 24 yr
Air freshener Air freshener
A A
Inhalation Inhalation
Int abuse Int abuse
A
Ingestion
Int suicide
A A A A A A A A A A A A A A A C A A A A A A A A A A A A U C A A A A A U A A A
Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Inhalation Ing/Inh
Env Env Env Env Int suicide Env Unint mis Env Env Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Env Env Int suicide Env Env Int suicide Int suicide Int suicide Int suicide Env Int suicide Unknown Env Env Env Int suicide Env Int suicide Int suicide Env Env Env Env Int suicide
A
Inh/Unk
Int suicide
propane 6.4 ppm§ butane 9.0 ppm§
See also case 142 (air freshener). Essential oils 88 a 75 yr
Liniments (essential oils & herbals)
Foreign body
See cases 276, 369, 579 (activated charcoal); 685 (plastic bag). Fumes, gases and vapors 89P 5 mo Carbon monoxide/smoke 900 11 mo Carbon monoxide 91o 18 mo Carbon monoxide 92 ip 6yr Carbon monoxide 93P 23 yr Carbon monoxide 94p 24 yr Carbon monoxide/smoke g5 ip 25 yr Carbon monoxide 960 26 yr Carbon monoxide/smoke 97 ip 28 yr Carbon monoxide 980 33 yr Carbon monoxide 99 ip 33 yr Carbon monoxide 100P 34 yr Carbon monoxide 101 34 yr Carbon monoxide 102p 35 yr Carbon monoxide 103 ip 36 yr C&rbon monoxide 104 38 yr Carbon monoxide 105 j0 39 yr Carbon monoxide 1060 40 yr Carbon monoxide 107P 43 yr Carbon monoxide 108 j 44 yr Carbon monoxide/smoke 109 ~p 45 yr Carbon monoxide 110jp 47yr Carbon monoxide 111 aJ0 47 yr Carbon monoxide 112alp 47 yr Carbon monoxide 113j0 48 yr Carbon monoxide 114ip 49 yr Carbon monoxide/smoke 115 57 yr Carbon monoxide 116 60 yr Carbon monoxide 1170 65 yr Carbon monoxide 118p 70 yr Carbon monoxide 119i0 70 yr Carbon monoxide 120 aip 75 yr Carbon monoxide 121 77 yr Carbon monoxide 122 ip 83 yr Carbon monoxide 123 83 yr Carbon monoxide/smoke 124ip 85 yr Carbon monoxide 125P 89 yr Carbon monoxide/smoke 126P 91 yr Carbon monoxide 127 22 yr Carbon monoxide acetaminophen 128p 27 yr Carbon monoxide cocaine
(Continued on following page)
82% 55% 45%
54% 48% 45%
5O%
46% 20%
45%§ 30% 54% 48% 23%9 45% 28% 26% >4O% 50% 52% 70 #g/mL 23%§ 0.10 #g/mL§ cocaine metabolite 1.17 pg/mL§
2.5 h
498
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
129~p
46 yr
Substances
Carbon monoxide ethanol 130P 50 yr Carbon monoxide ethanol 131~n 57 yr Carbon monoxide ethanol 132 ip 59 yr Carbon monoxide ethanol 133P 65 yr Carbon monoxide ethanol See also cases 62, 225 (carbon monoxide).
Chronicity
Route
Reason
A
Ing/Inh
Env
A
Ing/Inh
Env
A
Ing/Inh
Env
A
Ing/Inh
Int suicide
A
Ing/Inh
Env
Arsenic
A
Ingestion
Int suicide
Diquat carbidopa/levodopa
A
Ingestion
Intsuicide
A A A A/C A A A
Inhalation Inhalation Inhalation Inhalation Asp/Ing Inhalation Inhalation
Int abuse Int abuse Int abuse Int abuse Unint gen Int abuse Int abuse
U A/C A A/C A A NC A/C
Inhalation Inhalation Inhalation InhaLation Asp/Ing Inhalation inhalation Inhalation
Int abuse Int abuse Unknown Int abuse Unint gen Env Int abuse Int abuse
C
Inhalation
Unint mis
A A C A
Ingestion Ingestion Dermal Ingestion
Int suicide Int suicide Adv rxn Int suicide
C A A A A
Derm/Inh Dermal Inhalation Ingestion Ingestion
Occ Unknown Env Int unknown Int suicide
A A A A
Ingestion Ingestion Ingestion Parenteral
Int unknown Unint mis Int suicide Int suicide
Paints and stripping agents 165P 32 yr Paint fumes
A
Inhalation
Occ
Plants 166 a
C
Derm/Ing
Int misuse
A A
Ingestion Ingestion
Unknown Unint mis
Heavy metals 134 27yr Herbicides 135a
September 1996
34yr
Hydrocarbons 136~p 13 yr 137P 15 yr 138P 17 yr 139P 18 yr 140 a 18 mo 141ip 14yr 142P 16 yr
Butane Butane Butane Butane Charcoal lighter fluid Chlorofluorocarbon Chlorofluorocarbon air freshener 143P 27 yr Difluorochloromethane 144ap t 2 yr Difluoroethane 145 ~p >19yr Difluoroethane propellant 146P 20yr Gasoline 147a 13mo Lighter fluid 148p 66 yr Natural gas 149 37 yr Toluene 150 ip 36yr Toluene cocaine See also case 396 (natural gas).
Industrial Cleaners 151 a 74 yr
Sodium hydroxide cleaner
Insecticides/pesticides (excluding rodenticides) 152 83 yr Carbaryl 153P 40syr Chlorpyrifos 154 34 yr DEET (repellants) 1551p 64 yr Diazinon ethanol 156 a 31 yr Disodium methyl arsonate 157 35 yr Fenthion 158P 64 yr Insecticide, unknown type 159 75yr Malathion 160a 73 yr Malathion carbaryl 161 85 yr Organophosphate 162P 71 yr Pesticide, unknown type 163 82 yr Pesticides, unknown type 164 43 yr Propetamphos ethanol See also case 160 (carbaryl).
11 mo Cayenne pepper garlic oil 167a 39 yr Herbal tea 168a 3 mo Pennyroyaltea See also case 166 (garlic oil).
(Continued on following page)
Blood Levels 77%§ 220 mg/dL§ 13% 31%§ 180 mg/dL§
33,5% 238 mg/dL
4.9 pg/mL
8.5 14g/mL§
19 pg/mL
23.7 h
LITOVlTZ ET AL •
TABLE 21. Case
499
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Rodenticides 169a 74 yr 170 80 yr
171a
1995 A A P C C A N N U A L REPORT
83 yr
Substances
Brodifacoum Rodenticide (arsenic trioxide,1.5%) ethanol fluoxetine Strychnine
Chronicity
C A
Route
Reason
Blood Levels
Ingestion Ingestion
Int unknown Int suicide
9.5 ng/mL§ 80 mg/dL 0.35 IJg/mL§
A
Ingestion
Int suicide
A
Ingestion
Int suicide
C C A A A A A A A A U U A C C A A U A/C A C A A A U C A C C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Ther error Int misuse Int suicide Int suicide Int suicide Int suicide Int unknown Int suicide Int suicide Int suicide Int suicide Unknown Int suicide Int suicide Int unknown Int suicide Int misuse Unknown Ther error Int suicide Ther error Int suicide Int unknown Int suicide Int suicide Ther error Int unknown Ther error Ther error Int suicide
C
Ingestion
Int misuse
U
Ingestion
Int suicide
U
Ingestion
Int unknown
C
Ingestion
Ther error
A/C
Ingestion
Int misuse
36 !Jg/mL 103 mg/dL 153 pg/mL
C
Ingestion
Int misuse
13 pg/mL
U
Ingestion
Int suicide
U
Ing/Paren
Int unknown
C
Ing/Paren
Int misuse
A
Ingestion
Int suicide
154 #g/mL 829 pg/dL 150 lJg/mL
A
Ingestion
Int suicide
280 IJg/mL
See also cases 273 ( brodifacoum); 56, 68 (rodenticide). Swimming pool/aquarium products 172 26 yr Swimming pool acid (HCI) aspirin/carisoprodol PHARMACEUTICALS Analgesics 173 a 9 me 174 13 yr 175 20 yr 176 24 yr 177 24 yr 178 24 yr 179 25 yr 180 26 yr 181 26 yr 182 a 26 yr 183 30 yr 184 30 yr 185 30 yr 186 31 yr 187 34yr 188 36yr 189 37 yr 190 38yr 191 38 yr 192 39yr 193 ~ 41 yr 194 46 yr 195 50 yr 196 51 yr 197 51 yr 198 59 yr 199 60 yr 200 71 yr 201 71 yr 202 15 yr 203
35 yr
204
43 yr
205
28 yr
206
26 yr
207
36 yr
208
37 yr
209
55 yr
210
54 yr
211
45 yr
212
35 yr
213
37 yr
Acetaminc )hen Acetamin¢ )hen Acetaminc )hen Acetaminc )hen Acetamino )hen Acetaminc )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino }hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino )hen Acetamino 3hen Acetamino 3hen Acetamino )hen Acetamino 3hen acetaminophen/diphenhydramine Acetaminophen aspirin Acetaminophen carbamazepine Acetaminc 3hen cocaine Acetamino 3hen ethanol Acetamino 3hen ethanol Acetaminc 3hen ethanol Acetamfnc 3hen fluoxetine Acetaminc 3hen heroin Acetaminc 3hen iron dextran Acetaminophen lisinopril Acetamlnophen oral hypoglycemic venlafaxine
(Continued on following page)
60 IJg/mL 63 pg/mL 218 IJg/mL 33 IJg/mL 81 IJg/mL 57 #g/mL 444 Hg/mL 70 #g/mL 650 IJg/mL 137 IJg/mL 96 pg/mL 35 IJg/mL 38 #g/mL 35 IJg/mL 76 #g/mL 267 #g/mL 462 pg/mL 45 tJg/mL 512 pg/mL 43 #g/mL 72 pg/mL 68 pg/mL 128 IJg/mL 63 pg/mL 17 #g/mL
103 4 740 59
27 h >48 h 35 h 22 h 8h 4h
36 h >24 h 14h
>24 h
#g/mL mg/dL IJg/mL IJg/mL
12h
48 h
500
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
214
24yr
215p 216p 217 218
23 yr 34 yr 70 yr 38yr
219p
46 yr
220p
57 yr
221 222 223 224
25 yr 27yr 35 yr 35yr
225
44 yr
226
81 yr
227 228p
37 yr 35yr
229
44 yr
Substances Acetaminophen theophylline aspirin Acetaminophen/aspirin/caffeine Acetaminophen/butalbital/caffeine Acetaminophen/codeine Acetaminophen/codeine amitriptyline ethanol Acetaminophen/codeine carisoprodol Acetaminophen/codeine carisoprodol Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine Acetaminophen/diphenhydramine alprazolam opiate Acetaminophen/diphenhydramine carbon monoxide Acetaminophen/diphenhydramine ethanol Acetaminophen/hydrocodone Acetaminophen/hydrocodone acetaminophen/propoxyphene ethanol Acetaminophen/hydrocodone
Chronicity
Route
Reason
A
Ingestion Int suicide
U A U U
Ingestion Ingestion Ingestion Ingestion
U
Ingestion Int suicide
32 IJg/mUI
A
Ingestion Int suicide
4 pg/mLI
A U A A
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
333 iJg/mLII 362 pg/mU 94 pg/mLtl 86 pg/mLIL
A
Ing/Inh
Int suicide
A/C
Ingestion
Int unknown
7 pg/mUI 3% 46 pg/mLtl
C A
Ingestion Int misuse Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
C A
Ingestion Unknown Ingestion Int suicide
37 pg/mLI
C
Ingestion Int misuse
U U A A/C C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int suicide Adv rxn Int suicide
252 pg/mUl 38 mg/dL 150 gg/mLtl
A/C
Ingestion
Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion Int suicide
A
Ingestion Int suicide
177 pg/mUL 265 mg/dL propoxyphene 0.24 pg/mL norpropoxyphene 0.37 pg/mL 290 mg/dL 190 #g/mUt
A
Ingestion Int suicide
130 pg/mLLi
A/C
Ingestion
567 pg/mLt]
Int suicide Int suicide Int suicide Int unknown
diazepam 230
46yr
231 232P
40 yr 38yr
233
43yr
234 235 236 237 238
39 yr 43 yr 44yr 88 yr 60 yr
239
39 yr
240P
36 yr
241
57 yr
242P
48 yr
243P
47 yr
244P
64 yr
245P
34 yr
246
42 yr
247
48 yr
Acetaminophen/hydrocodone temazepam Iorazepam Acetaminophen/oxycodone Acetaminophen/oxycodone propoxyphene ethanol Acetaminophen/oxycodone salicyIate Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene Acetaminophen/propoxyphene acetaminophen/codeine Acetaminophen/propoxyphene acetaminophen/codeine paroxetine Acetaminophen/propoxyphene acetaminophen/diphenhydramine ethanol Acetaminophen/propoxyphene alprazolam Acetaminophen/propoxyphene aspirin/butalbital nefazodone Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene ethanol Acetaminophen/propoxyphene hydroxyzine ethanol Acetaminophen/propoxyphene Iorazepam Acetaminophen/propoxyphene oxybutynin
Blood Levels 23 IJg/mL 3 pg/mL 4 mg/dL
72 h 72 h 72 h
103 pg/mLtt
>6 h
48 pg/mUI 248 pg/mUI
(Continued on following page)
-24 h 2d
130 mg/dL 36 pg/mLII hydrocodone 0.17 pg/mL§ 0.18 pg/mL nordiazepam 0.08 pg/mL 685 pg/mUI hydrocodone 0.35 pg/mL 0.34 pg/mL
44 pg/mLil 7 pg/mLH
272 pg/mUt 78 mg/dL
Int misuse
15 h
48 h
LITOVITZ ET AL •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
501
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
248
35 yr
249 a 250 251 252 253 254 255 256 a 257 258 259 260 261 262 263 264 265 266 267 268 269 270
2 yr 18 yr 19 yr 22 yr 25 yr 33 yr 35 yr 37 yr 37 yr 43 yr 50 yr 50 yr 55 yr 55 yr 56 yr 60 yr 69 yr 87 yr 88 yr 93 yr 95 yr 46 yr
271
15 yr
272
42 yr
273
22 yr
274
32 yr
275
33 yr
276
70 yr
277
33 yr
278
53 yr
279
71 yr
280
23 yr
281
35 yr
282
40 yr
283P
35 yr
284
68 yr
285
79 yr
286
37 yr
287
52 yr
Substances Acetaminophen/propoxyphene
temazepam Aspirin Aspirin Aspirin Aspirin Aspirin Aspirin Aspmn Aspmn Aspinn Aspirin Aspmn Aspmn Aspmn Aspirin Aspirin Aspirin Asptrin AspJnn Aspmn Aspmn Aspinn Aspmn acebutolol Aspirin acetaminophen Aspirin acetaminophen Aspirin acetaminophen brodifacoum Aspirin acetaminophen/diphenhydramine ethanol Aspirin acetaminophen/oxycodone Aspirin activated charcoal Aspirin amitriptyline Aspinn amitriptyline Aspirin amitriptyline/pe rphenazine amitriptyline Aspirin benztropine Iorazepam Aspirin bupropion haloperidol Aspirin carbamazepine Aspirin clonidine alprazolam Aspirin ethanol Aspirin ethanol Aspirin interferon Aspirin Iorazepam
Chrenicity
Route
Reason
U
Ingestion
Unknown
A A A A A A A A A A A/C C A C A A C A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Int suicide Unknown Int suicide Int suicide fnt suicide Int suicide Int suicide Int suicide Int suicide Ther error Int unknown Int suicide Ther error Int suicide Int suicide Unknown Int suicide Int suicide Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
U
Ingestion
Ther error
A
Ingestion
Int suicide
A
Ingestion
A
Blood Levels 320 #g/mL"§ propoxyphene 6.99 IJg/mL§ norproxyphene 4.03 IJg/mL§ 1.22 pg/mL§ 109 mg/dL 105 mg/dL 73 mg/dL 120 mg/dL 126 mg/dL 104 mg/dL 104 mg/dL 120 mg/dL 95 mg/dL 92 mg/dL 116 mg/dL 82 mg/dL 36 mg/dL 40 mg/dL 97 mg/dL 76 mg/dL 47 mg/dL 65 mg/dL 103 mg/dL 88 mg/dL 71 mg/dL 87 mg/dL§
6h
9h 5h 28 h 8h
2-3 d 9h
-22 h
130 mg/dL 103 IJg/mL 99 mg/dL 36 pg/mL 118 mg/dL 108 IJg/mL
7h 7h
Int suicide
73 mg/dL
1Oh
Ingestion
Int suicide
A
Asp/Ing
Int suicide
94 mg/dL 9 tJg/mL" 50 mg/dL
A
Ingestion
Int suicide
101 mg/dL
U
Ingestion
Int suicide
A
Ingestion
Int suicide
70 mg/dL 121 ng/mL 113 mg/dL
U
Ingestion
Unknown
210 ng/mL 69 mg/dL
A
Ingestion
Int suicide
86 mg/dL
A
Ingestion
Int suicide
91 mg/dL
U
Ingestion
Int suicide
116 mg/dL
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ing/Paren
A
Ingestion
42 h
10h
Int suicide
121 mg/dL 160 mg/dL 87 mg/dL
Int suicide
130 mg/dL
16h
(Continued on following page)
502
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
288
27 yr
289
43 yr
290
74yr
291 292p
15 yr >19 yr
293P
22 yr
Substances Aspirin phentermine phendimetrazine Aspirin temazepam Aspirin verapamil (Long-acting) Aspirin-containing sinus medication Aspirin/propoxyphene/caffeine flunitrazepam Codeine
Chronicity
Route
Reason
A
Ingestion
Int suicide
47 mg/dL§ 0.08 IJg/mL
A
Ingestion
Int suicide
119 mg/dL
A
Ingestion
Int suicide
73 mg/dL
A A
Ingestion Ingestion
Int suicide Int suicide
88 mg/dL 47 mg/dL¶
A
Ingestion
Int suicide
1.6 Ug/mL§ morphine 0.162 ug/mL§ 1,890 ng/mL§ norfluoxetine 2,270 ng/mL§
U
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U U
Ingestion Ingestion
Int unknown Int suicide
A A A A A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Unint gen Unint gen Int suicide Unknown Int suicide
fluoxetine 294 ip
295 a 296 297 a 298P 299P 300P 301 aip 302 ap 303 ~p 304p 305 Lp 306P
80 yr
Codeine oxycodone amitriptyline 38 yr Celchicine 48 yr Colchicine aspirin/carisoprodol 14 yr Colchicine trazodone 32 yr Hydrocodone alprazolam 49 yr Meperidine 32 yr Meperidine cocaine 19 me Methadone 2 yr Methadone 3 yr Methadone 20 yr Methadone 30 yr Methadone 39 yr Methadone amitriptyline
307p
30 yr
308P
21 yr
309n
23 yr
310P
28 yr
311 ap
47 yr
312P 313 314 ip
30 yr 75 yr 40 yr
315
69 yr
316 ip
33 yr
317 ~p
39 yr
318 ip
37 yr
319
61 yr
320 ~p
26 yr
Methadone amitriptyline chlordiazepoxide Methadone ethanol Methadone ethanol Methadone ethanol Methadone heroin Morphine (long-acting) Morphine (long-acting) Morphine acetaminophen/oxycodone diazepam Morphine alprazolam Morphine cocaine benzodiazepines Morphine ethanol benzodiazepines Morphine ethanol codeine Morphine hydromorphone metoprolol Morphine methamphetamine
Blood Levels
25 mg/dL¶
A/C
Ingestion
Int unknown
A
Ingestion
Int abuse
A
Ingestion
Int unknown
U
Ingestion
Unknown
A/C
Ingestion
Int abuse
U C U
Ingestion Ingestion Ing/Unk
Int abuse Ther error Int unknown
U
Ingestion
Int suicide
A/C
Ing/Inh/Par Int abuse
A
Ing/Paren
A/C
Ing/Inh/Par Int abuse
A
Ingestion
Int suicide
A/C
Parenteral
Int abuse
Int abuse
(Continued on following page)
186 ng/mL 33 ng/mL
0.5 pg/mL§
430 ng/mL nortriptyline 3,250 ng/mL 1.55 pg/mL§ 60 ng/mL§ nortriptyiine 120 ng/mL§ 0.2 pg/mL§ 5,010 pg/mL 59 mg/dL
0.29 pg/mL§ 200 mg/dL§
0.065 iJg/mL 27 mg/dL
0.056 pg/mL§ 0.30 pg/mL§
8h 6h
LITOVITZ ET AL •
TABLE 21.
Age
321~P
44yr
322 ~p
37 yr
323p 324p 325
34 yr 41 yr 22 yr
326P
41 yr
327P
46 yr
329P 330 a 331 332 ip 333 ~ 334P 335p
336 ip 337 ~p
338 ip
339
340
341 342 343
503
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
328
1995 A A P C C A N N U A L R E P O R T
Substances Morphine paroxetine thioridazine Morphine sertraline Opiates Opiates Opiates amphetamines Opiates chlordiazepoxide Opiates doxepin
benzodiazepines Opiates ethanol 46 yr Pentazocine/naloxone 40 yr Phenylbutazone 18 yr Propoxyphene 43 yr Propoxyphene 13-19 yr Propoxyphene 28 yr Propoxyphene acetaminophen 26 yr Propoxyphene acetaminophen fiuoxetine 31 yr Propoxyphene amitriptyline 38 yr Propoxyphene butalbital chlorpromazine 39 yr Propoxyphene cocaine benzodiazepines 82 yr Propoxyphene codeine benzodiazepine 41 yr Propoxyphene fentanyl carisoprodol 58 yr Salicylate 51 yr Salicylate >19 yr Salicylate 55 yr
Chronicity
Route
Reason
A/C
Ingestion
Int suicide
A/C
Ing/Unk
Int unknown
C A A
Unknown Ingestion Unknown
Int abuse Int misuse Int abuse
U
Unknown
Int unknown
U
Ingestion
Unknown
U
Unknown
Unknown
A U A/C A/C A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int unknown
Blood Levels
1,037 884 215 nordoxepin 84
ng/mL§ ng/mL ng/mL ng/mL
200 mg/dL
7.69 pg/mL >2,000 ng/mL 366 pg/mL 244 pg/mL
U
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
C A U
Ingestion Ingestion Ingestion
Int misuse Int suicide Unknown
71 mg/dL 166 mg/dL
See also cases 11, 12, 36, 53, 127, 271, 272, 273, 334, 335, 367, 390, 432, 476, 495, 542, 577, 611, 618, 643 (acetaminophen); 238, 239, 393, 578, 603 (acetaminophen/codeine); 13 (acetaminophen/decongestant); 202, 240, 274, 641 (aeetaminephen/diphenhydramine); 528, 543, 611 (aeetaminophen/hydreeodone); 275, 314 (acetaminophen/oxyeodone) ; 228, 368, 44& 647 (acetaminophen/propoxyphene) ; 64, 203, 214, 370, 430, 684 (aspirin); 242 (aspirin/butalbital); 172, 296 (aspirin/earisoprodol); 318, 339, 375, 404, 532, 698, 708 (codeine); 542 (eodeine/iodinated glycerol); 583 (diclofenac); 383 (etodoloc); 340 (fentanyl); 387, 449 (hydrocodone); 319 (hydromorphone); 431, 449, 458, 495, 496, 528, 585, 605 (ibuprofen); 452 (methadone); 19, 680 (morphine); 628 (naproxen); 224, 347, 474, 476, 648, 681, 682, 683 (opiate); 294, 389, 432, 468 (oxycodone); 589 (piroxicam); 20, 21, 22, 232, 590, 600, 707, 708 (propoxyphene); 233 (salicylate). Anesthetics 344 ap 345P 346 a 347
29yr 16 yr 28 yr 48 yr
Bupivacaine Halothane Isoflurane Udocaine opiates
A A/C U A
Parenteral Inhalation Inhalation Ingestion
Adv rxn Int abuse Int abuse Int suicide
A
Ingestion
Int suicide
benzodiazepines See also case 718 (ethyl ether). Anticholinergic drugs 348 35 yr Amantadine
See also cases 426 (amantadine); 280, 588, 628 (benztropine); 247 (oxybutynin); 621 (trihexyphenidyl). Anticoagulants 349 71 yr
Warfarin trimethoprim/sulfamethoxazole
C
Ingestion
Ther error
See also case 499 (warfarin). (Continued on following page)
145 IJg/mL§ 50 pg/mL
504
TABLE 21. Case
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Substances
Chronicity
Route
Reason
Anticonvulsants 350 30s yr Carbamazepine A/C Ingestion Int suicide 351 32 yr Valproic acid U Ingestion Int suicide See also cases 15, 16, 204, 282, 443, 477 (carbamazepine); 498 (phenytoin); 402 (valproate); 642 (valproic acid). Antidepressants 352~P 19 yr 353P 354 355 356 357P 358 359P 360p 361P 362P 363 364p
21 yr 22 yr 22 yr 24 yr 24 yr 27 yr 32 yr 32 yr 35 yr 36 yr 38 yr 41 yr
365 ip 366P 367P
57 yr >19 yr 58 yr
368P
35 yr
369
34 yr
370
41 yr
371P
36 yr
Blood Levels 40 IJg/mL 170.8 IJg/mL
Amitriptyline
A
Ingestion
Int misuse
Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline
A A/C A/C A/C A U A A U A A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int unknown Int suicide Int suicide
Amitriptyline Amitriptyline Amitriptyline acetaminophen ethanol Amitriptyline acetaminophen/propoxyphene ethanol Amitriptyline
A/C A A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Asp/Ing
Int suicide
3,283 ng/mL nortriptyline 351 ng/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
1,250 ng/mL#§ 88 mg/dL 4,680 ng/mL nortriptyline 1,320 ng/mL 14,880 ng/mL 6,000 ng/mL
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
activated charcoal Amitriptyline aspirin Amitriptyline
372P
35 yr
373
47 yr
374P
29 yr
375P
>19 yr
376P
42 yr
377 ip
42 yr
378
38 yr
clomipramine diphenhydramine Amitriptyline clonazepam Amitriptyline clonazepam baclofen Amitriptyline cocaine Amitriptyline codeine benzodiazepines Amitriptyline cyclobenzaprine diazepam Amitriptyline cyclobenzaprine ethanol Amitriptyline
379p
45 yr
diazepam ethanol Amitriptyline
380p
27 yr
381P
34 yr
382p
55 yr
383
48 yr
diphenhydramine Amitriptyline ethanol Amitriptyline ethanol Amitriptyline ethanol Amitriptyline etodolac
6,000 ng/mL nortriptyline 1,140 ng/mL
653 ng/mL
514 ng/mL 218 ng/mL nortriptyline 410 ng/mL
137 ng/mL 154 IJg/mL 586 mg/dL
4,100 ng/mL#
U
Ingestion
Int suicide
A
Ingestion
Int suicide
7,068 ng/mL§ nortriptyline 1,574 ng/mL§ 710 ng/mL
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
2,350 ng/mL nortriptyline 3,830 ng/mL 0.20 pg/mL 1,460 ng/mL§ 124 mg/dL§
U
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
(Continued on following page)
5,200 ng/mL§ 70 mg/dL§
LITOVITZ ET AL •
TABLE 21,
505
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
384
57yr
385
69 yr
386 ip
47yr
387
38 yr
388 ap
1995 A A P C C A N N U A L R E P O R T
9 yr
Substances Amitriptyline fluoxetine Amitriptyline fosinopril alprazolam Amitriptyline heroin Amitriptyline hydrocodone alprazolam Amitriptyline
Chronicity
Route
Reason
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
64 IJg/mL >5,000 ng/mL
A/C
Ingestion
Int suicide
279 ng/mL
A/C
Ingestion
Int suicide
U
Ingestion
Unknown
A/C
Ingestion
Int suicide
A
Ing/Inh
Int suicide
A
Ingestion
Int suicide
imipramine
389P
25 yr
390
64yr
391
57 yr
392
48 yr
393
41 yr
394p
26 yr
395P
32 yr
396
34 yr
397P
49 yr
methylphenidate Amitriptyline oxycodone Amitriptyline phenelzine acetaminophen Amitriptyline prochlorperazine Amitriptyline risperidone terfenadine Amitriptyline paroxetine acetaminophen/codeJne Amitriptyline phenobarbital Amitriptyline thioridazine Amitriptyline thiothixene natural gas Amitriptyline
Blood Levels
verapamil 398 399 ap
75 yr 27 yr
Amitriptyline/perphenazine Bupropion
A A
Ingestion Ingestion
Int suicide Int suicide
400 p 401
61 yr 35 yr
A A
Ingestion Ingestion
Int suicide Int suicide
402P
25 yr
A/C
Ingestion
Int suicide
403 404P
51 yr 50 yr
A A/C
Ingestion Ingestion
Int suicide Int suicide
405 a 406 a 407P 408 409 410 ip 411 412P 413P 414 415P
1 yr 3 yr 14 yr 15 yr 18 yr 18 yr 19yr 21 yr 21 yr 34 yr 44 yr
A U A A A/C A A U A A A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unint gen Unknown Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide
416
44 yr
Bupropion Bupropion sertraIine Bupropion valproate Iorazepam CIomipramine Clomipramine Ioxapine codeine Desipramine Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme Desipramme alprazolam Desipramine barbiturate, unknown type trazodone
A/C
Ingestion
Int suicide
(Continued on followingpage)
1,100 ng/mL nortriptyline 1,200 ng/mL
1,430 nortriptyline 600 696 desipramine 636
860 nortriptylilne 150 0.48 norverapamil 0.51
ng/mL ng/mL ng/mL ng/mL
ng/mL§ ng/mL§ tJg/mL§ IJg/mL§
446 ng/mL hydroxybupropion 3,217 ng/mL 10.5 pg/mL desmethylsertraline 1.5 tJg/mL
2,600 ng/mL
1,472 ng/mL 1,800 ng/mL 8,200 ng/mL§ 3,500 ng/mL
506
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Case
Age
417~P
47 yr
418p
29yr
419
22 yr
420
25 yr
421
42 yr
422P 423P 424P 425
40 yr 40 yr 43 yr 84 yr
426
33 yr
427P
46 yr
428
78 yr
429P
34 yr
430P
50 yr
Substances Desipramine benzodiazepines ethanol Desipramine fluoxetine Desipramine haloperidol Desipramine lithium chlorpromazine Desipramine Iorazepam Doxepin Doxepin Doxepin Doxepin alprazolam paroxetine Doxepin amantadine Doxepin buspirone indapamide Doxepin chlorzoxazone diphenhydramine Doxepin ethanol Doxepin
Chronicity
Route
Reason
A/C
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
A
Ingestion Int suicide
A NC A A/C
Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion Int suicide
NC
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Unknown
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A/C
Ingestion
Int suicide
Int suicide
Int suicide
431 i
30 yr
432P
42 yr
433P
30 yr
434ip
46 yr
435ip
50 yr
436P
12 yr
437
24 yr
Imipramine
A
Ingestion Int suicide
438 439P
29 yr 34 yr
Imipramine Imipramine
A A
Ingestion Int suicide Ingestion Int suicide
440
40 yr
Imipramine
A
Ingestion Int abuse
441
35 yr
Imiprarnine
A/C
Ingestion
Int suicide
442
43 yr
A/C
Ingestion
Int suicide
443P
39 yr
A
Ingestion Int suicide
444p
32 yr
U
Ingestion Int suicide
445P
29 yr
U
Ingestion Int suicide
446P
30 yr
A
Ingestion Int suicide
carbamazepine Imipramine cocaine Imipramine ethanol Imipramine ethanol
2,500 ng/mL
Int suicide
ethanol aspirin Doxepin ibuprofen Doxepin oxycodone acetaminophen Doxepin perphenazine Doxepin trazodone cannabinoids Fluoxetine isopropanol ethanol Imipramine
alprazolam Imipramine alprazolarn verapamil Imipramine
Blood Levels
(Continued on followingpage)
>3,000 ng/mL
2,900 ng/mL nordoxepin 1,200 ng/mL 32 pg/mL
1,300 ng/mL nordoxepin 90 ng/mL 220 mg/dL 6 mg/dL
3,600 ng/mL§ 0,3 pg/mL§
8,718 ng/mL desipramine 2,098 ng/mL 6,700 ng/mL desipramine 1,500 ng/mL 16,800 ng/mL§ desipramine 2,100 ng/mL§ 1,500 ng/mL desipramine 8,500 ng/mL 1,012 ng/mL§ desipramine 228 ng/mL
4,230 ng/mL§ desipramine 8,230 ng/mL§ 21.2 IJg/mL 8,168 ng/mL
1,934 ng/mL# 278 mg/dL
LITOVITZ ET AL •
TABLE 21.
507
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
447
30 yr
448P
1995 A A P C C A N N U A L R E P O R T
>19 yr
449
30 yr
450
49 yr
451
46 yr
452P
31 yr
453
67 yr
454 455 456
41 yr 46 yr 37 yr
457
70 yr
458
19 yr
459 460 461P 462~P 463
>19 yr 17 yr 27 yr 31 yr 39 yr
464P
60 yr
465
43 yr
466
61 yr
467 468~P
39 yr 50 yr
469~p
37 yr
470
36 yr
471 ip
50 yr
472 473 474
54 yr 68 yr 31 yr
475p
59 yr
Substances Imipramine ethanol Imipramine fluoxetine acetaminophen/propoxyphene Imipramine hydrocodone ibuprofen Imipramine lithium Imipramine meclizine phenylpropanolamine/guaifenesin Imipramine methadone ethanol Imipramine thioridazine clonazepam Lithium Lithium Lithium fluphenazine Iorazepam Lithium theophylline thioridazine Lithium tricyclic antidepressants ibuprofen Loxapine Nortriptyline Nortriptyline Nortriptyline Nortriptyline atenolol venlafaxine Nortriptyline flurazepam Nortriptyline imipramine ethanol Nortriptyline trazodone Phenelzine Sertraline carisoprodol oxycodone Sertraline lithium propranolol Sertraline paroxetine Trazodone benzodiazepines ethanol Tricyclic antidepressant Tricyclicantidepressant Tricyclic antidepressant amphetamines opiates Tricyclic antidepressant
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int suicide
U
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int unknown
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
C C A
Ingestion Ingestion Ingestion
Ther error Ther error Int suicide
3.1 mEq/L 2.3 mEq/L
C
Ingestion
Int misuse
3.0 mEq/L 56 pg/mL
A/C
Ingestion
Int suicide
A A/C A A/C A/C
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
U U
Ingestion Ingestion
Unknown Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Ther error
A/C A/C A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Unknown
A
Ingestion
Int suicide
29,445 ng/mL
2,650 ng/mL desipramine 586 ng/mL 4.46 mEq/L
3,450 ng/mL§
2,423 ng/mL#
benzodiazepines 476P
28 yr
ethanol Tricyclicantidepressant opiate acetaminophen
246 pg/mL
(Continued on following page)
508
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
477a
30 yr
Substances
Chronicity
Route
Reason
Blood Levels
Venlafaxine A/C Ingestion Unknown 89 tJg/mL§ carbamazepine 19.2 IJg/mL§ See also cases 15, 218, 277, 278, 279, 294, 306, 307, 336, 669 (amitriptyline); 279 (amitriptyline/perphenazine); 14, 607 (antidepressant); 281 (bupropion); 371, 503, 642 (clomipramine); 621, 649 (desipramine); 327, 600 (doxepin); 16, 170, 209, 293, 335, 384, 418, 448, 595, 620 (fluoxetine); 388, 465, 534, 641 (imipramine); 420, 450, 469, 547, 629 (lithium); 404 (Ioxapine); 242 (nefazodone); 55, 504, 555 (nortriptyline); 239, 321,393,425, 470, 547 (paroxetine); 390 (phenelzine); 22, 322, 401,496, 612 (sertraline); 14, 297, 416, 434, 466 (trazodone); 458 (tricyclic antidepressant); 213, 463 (venlafaxine).
Antihistamines 478 48 yr Diphenhydramine A ingestion 479P 22 yr Diphenhydramine (OTC) sleep aid A Ingestion 480p 30 yr Diphenhydramine (OTC) sleep aid A Ingestion See also cases 371, 379, 428, 589 (diphenhydramine); 245, 609, 633 (hydroxyzine); 451
Int suicide Int suicide Int suicide (meclizine), 392 (terfenadine).
Antimicrobials 481 39 yr
Rifampin C Ingestion Adv rxn ethambutol clofazimine See also cases 481 (clofazimine); 481 (ethambutol); 583 (penicillin); 349 (trimethoprim/sulfamethoxazole).
Antineoplastics 482 81 yr
Doxerubicin
Asthma therapies 483 68 yr 484 48 yr 485 52 yr 486P 55 yr 487 65 yr 488 68yr 489 74 yr 490 74yr 491 76 yr 492 89 yr 493 >19yr 494 64yr
Aminophylline Theophylline Theophylline (long-acting) Theephylline Theophylline Theophylline Theophylline (long-acting) Theophylline Theophylline Theophylline Theophylline Theophylline (long-acting) alprazolam prednisone 495 18 yr Theophylline (long-acting) ibuprofen acetaminophen 496 20yr Theophylline ibuprofen sertraline 497 71 yr Theophylline isradipine 498 75 yr Theophylline phenytoin 499 71 yr Theophylline warfarin See also cases 214, 457, 577 (theophylline).
Cardiovascular drugs 500 28 yr Acebutolol enalapril 501 50 yr Amlodipine alprazolam verapamil 502 62 yr Amlodipine verapamil (long-acting) guanfacine 503 34yr Atenolol clonidine clomipramine 504 63 yr Atenolol trifluoperazine nortriptyline 505a 23 yr Cardiac glycoside extract from Bufo species (toad) sold as topical aphrodisiac
A
Parenteral Ther error
C C A/C A/C C C U C C C C A/C
Parenteral Ther error Ingestion Unknown Ingestion Int suicide Ingestion Int misuse Ingestion Int suicide Ing/Other Thererror Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Ther error Ingestion Int suicide
47 t4g/mL >100 pg/mL 180 pg/mL 69 pg/mL 36 pg/mL 46 pg/mL 46 pg/mL 75 pg/mL 40 pg/mL 57 pg/mL 49 pg/mL 119 pg/mL
A
Ingestion Int suicide
167 IJg/mL
A
Ingestion Int suicide
19 pg/mL 105 pg/mL
NC
Ingestion
Int suicide
72 pg/mL
A/C
Unknown Unknown
C
Ingestion Ther error
37 IJg/mL 51.4 pg/mL 64 IJg/mL
A
Ingestion Int suicide
A
Ingestion Int suicide
A/C
Ingestion
A
Ingestion Int suicide
A
Ingestion Int suicide
A
Ingestion Int misuse
Int suicide
(Continued on following page)
4,750 ng/mL§ digoxin 0.9 ng/mL
LITOVITZ ET AL •
TABLE 21.
509
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
506
40 yr
507 508 509 510P 511 ~ 512 513 514
1995 A A P C C A N N U A L R E P O R T
> 19 yr 63 yr 74 yr 83 yr 89 yr 89 yr 94 yr 81 yr
515
92 yr
516
30 yr
517 518 519P 520 521P 522 523 524
34 yr 38 yr 60 yr 68 yr 80 yr 86 yr 90 yr 29 yr
525
69 yr
526
42 yr
527
49 yr
528
65 yr
Substances Cardiac glycoside extract from Bufospecies (toad) sold as topical aphrodisiac cocaine ethanol Cionidine Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Digoxin Ioperamide Digoxin oxybutynin Digoxin verapamil Iorazepam Diltiazem (long-acting) Diltiazem Diltiazem (long-acting) Diltiazem (long-acting) Diltiazem Diltiazem (long-acting) Diltiazem (long-acting) Diltiazem captopril Diltiazem (long-acting) digoxin Diltiazem enalapril atenolol Diltiazem ethanol Diltiazem (long-acting) ibuprofen
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int misuse
digoxin 3.08 ng/mL
A A/C C A/C A/C A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int misuse Ther error Int suicide Ther error Int suicide Ther error Int unknown
>10 ng/mL >4.0 ng/mL 3.8 ng/mL§ 8 ng/mL 3.3 ng/mL
A/C
Ingestion
Int suicide
49.1 ng/mL
A/C
Ingestion
Int suicide
7.8 ng/mL
A A U A/C C A/C A/C A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Adv rxn Int suicide Int suicide Ther error Ther error Int suicide Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
5.0 ng/mL 3-4 h
>2,000 mg/dL§ 6.8 ng/mL
16.3 pg/mL§ 80 pg/mL[I
8h
acetaminophen/hydrocodone 529 530 a 531
17 yr 20 yr 53 yr
532P
40 yr
533P 534
25 yr 26 yr
535 a 536P
72 yr 31 yr
537P 538 539 540 a 541p 542
23 yr 47 yr 57 yr 57 yr >19yr 22 yr
543P
544
58 yr
38 yr
Disopyramide Flecainide Isradipine enalapril cisapdde Metoprolol nifedepine codeine Mexiletine Mexiletine imipramine ethanol Milrinone Nadolol verapamil benzodiazepines Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine (long-acting) Nifedipine Nifedipine (long-acting) acetaminophen codeine/iodinated glycerol Nifedipine acetaminophen/hydrocodone alprazolam Nifedipine diltiazem (long-acting) enalapril
A/C A U
Ingestion Ingestion Unknown
Int suicide Int suicide Unknown
A/C
Ingestion
Int suicide
A U
Ingestion Ingestion
Int suicide Int unknown
A A/C
Parenteral Ingestion
Ther error Int misuse
U U A/C A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Unknown Int suicide Int suicide Int misuse Unknown Int suicide
1.62 pg/mL
204 mg/dL
>200 ng/mL
123 pg/mL A/C
Ingestion
Int suicide 43,8 iJg/mLII
A
Ingestion
Int suicide
(Continued on following page)
10 h
510
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
TABLE 21. Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd) Case
Age
545
38 yr
546
36 yr
547
>19 yr
548
40 yr
549p
46 yr
550
35 yr
551 552 553
70 yr 37yr 79 yr
554~p
39 yr
555
26 yr
556 a
49 yr
557 558a
67 yr 50 yr
559 i 560 561P 562 563P 564P 565 566 567 568 569 570 571 572P 573 574P 575P 576 577
578
Substances
Chronicity
Route
Reason
Nifedipine (long-acting) ethanol Nifedipine (long-acting) glyburide methocarbamol Nifedipine (long-acting) lithium paroxetine Nifedipine (long-acting) verapamil (long-acting) Nifedipine (long-acting) verapamil (long-acting) Procainamide
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
NC
Ingestion
Int suicide
Procainamide Propranolol (long-acting) Propranolol (long-acting) calcium channel blocker, unknown type Propranolol ethanol Propranolol nortriptyline Propranolol verapamil (long-acting)
Quinidine Quinidine captopril 79 yr Unknown cardiovascular drug 15 yr Verapamil 16 yr Verapamil 26 yr Verapamil (long-acting) 28 yr Verapamil (long-acting) 37yr Verapamil (long-acting) 38yr Verapamil (long-acting) 41 yr Verapamil (long-acting) 44yr Verapamil (long-acting) 46yr Verapamil (long-acting) 48 yr Verapamil (long-acting) 50yr Verapamil (long-acting) 50 yr Verapamil (long-acting) 54yr Verapamil (long-acting) 64yr Verapamil (long-acting) 64 yr Verapamil 70syr Verapamil (long-acting) 87 yr Verapamil 69 yr Verapamil (long-acting) acetaminophen theophylline 60yr Verapamil (long-acting)
5.6 mEq/L A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
A/C
Ingestion
Unknown
A A C
Parenteral Ingestion Ingestion
Adv rxn Int suicide Adv rxn
A/C
Ingestion
Int suicide
A
Ingestion
Int suicide
C
Ingestion
Unknown
A A/C
Ingestion Ingestion
Int suicide Int suicide
A/C A A A A/C A A/C A A A U A/C A A A/C A/C A U A
Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Unknown Int unknown Int suicide Ther error Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Int suicide Ther error Int suicide Int suicide Int suicide Int suicide
A/C
Ingestion
Int suicide
A/C
Asp/Ing
Int suicide
A
Ingestion
Int unknown
A
Ingestion
Int suicide
A
Ingestion
Int suicide
A
Ingestion
Int suicide
acetaminophen/codeine
579
54 yr
580P
30 yr
581 p
19 yr
582
55 yr
583
15 yr
benazepril Verapamil activated charcoal Verapamil amphetamines/methamphetamine Verapamil atenolol Verapamil cyclobenzaprine alprazolam Verapamil (long-acting) diclofenac penicillin
Blood Levels
(Continued on following page)
74 pg/mL N-acetylprocainamide 80 pg/mL
600 pg/mL 668 pg/mL norverapamil 301 pg/mL 12 pg/mL
2.6 pg/mL§
1,681 pg/mL
18.4 pg/mL
404 pg/mL 26 pg/mL 2.55 pg/mL§ norverapamil 0.30 lJg/mL§ 19 lag/mUI codeine 0.38 IJg/mL§ 15,800 ng/mL§ 509 tJg/mL norverapami1236 pg/mL
LITOVITZ ET AL •
TABLE 21.
1995 A A P C C A N N U A L R E P O R T
511
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
584
61 yr
Substances
Chronicity
Route
Reason
Blood Levels
Verapamil (long-acting) A/C Ingestion Intsuicide ethanol 585n 52 yr Verapamil A Ingestion Int suicide ibuprofen 586 52 yr Verapamil (long-acting) A Ingestion Int suicide molindone clonazepam 587 61 yr Verapamil (long-acting) A Ingestion Int suicide temazepam clorazepate 588 53 yr Verapamil A/C Ingestion Int suicide thiothixene benztropine See also cases 270 (acebutolol); 463, 526, 581 (atenolol); 578 (benazepril); 553 (calcium channel blocker, unknown type); 524, 558 (captopril); 283, 503, 638 (clonidine); 525, 625 (digoxin); 544 (diltiazem); 500, 526, 531, 544 (enalapril); 385 (fosinopril); 502 (guanfacine); 497 (isradipine); 212 (lisinopril), 319 (metoprolol); 532 (nifedipine); 469 (propranolol); 290, 397, 442, 501, 502, 516, 536, 548, 549, 556 (verapamil). Cough and cold preparations 589 28 yr Clemastine/phenylpropanolamine diphenhydramine piroxicam 590ip 33 yr Dextromethorphan phenylpropanolamine propoxyphene 591alp 592P 593 a
A
Ingestion
Int misuse
A
Ingestion
Int unknown
9 pg/mL 1.11 pg/mL 0.83 pg/mL norpropoxyphene 1.6 IJg/mL
17 yr 22 yr 43 yr
Ephedrine A Ingestion Int unknown Ephedrine A Ingestion Int misuse Phenylpropanolamine/ A Ingestion Int suicide brompheniramine See also cases 542 (codeine/iodinated glycerol); 451 (phenylpropanolamine/guaifenesin).
Diuretics See cases 629 (hydrochlorothiazide/triamterene); 427 (indapamide). Electrolytes and minerals 594 a 22 mo Ferrous sulfate 595 52 yr Potassium fluoxetine See also case 211 (iron dextran). Gastrointestinal preparations 596 2 yr Bismuth subsalicylate 597 a 63 yr Sodium biphosphate/phosphate enema See also cases 531 (cisapride) ; 514 (Ioperamide).
A A
Ingestion Ingestion
Unint gen Int suicide
C A
Ingestion Other
Adv rxn Ther error
2,583 IJg/dL 9.4 mEq/L
Hormones and hormone antagonists 598 44 yr Insulin A/C Parenteral Int suicide 599 30 yr Insulin A Ing/Paren Int suicide chlordiazepoxide carisoprodol 600 66 yr Insulin A Ing/Paren Int suicide doxepin propoxyphene 601 67 yr Phenformin C Ingestion Adv rxn See also cases 546 (glyburide); 637 (levothyroxine); 213 (oral hypoglycemic); 494 (prednisone). Miscellaneous drugs 602 85 yr AIIopurinol C Ingestion Adv rxn See also cases 135 (carbidopa/levodopa); 675 (gamma hydroxy butyrate); 286 (interferon). Muscle relaxants 603 41 yr
Carisoprodol A/C Ingestion Int suicide acetaminophen/codeine 604ip 33 yr Carisoprodol A Ingestion Int suicide ethanol 605 35 yr Cyclobenzaprine U Ingestion Int suicide ibuprofen See also cases 373 (baclofen); 219, 220, 340, 468, 599 (carisoprodol); 428 (chlorzoxazone); 376, 377, 582 (cyclobenzaprine); 546 (methocarbamol).
Sedatives/hypnotics/antipsychotics 606 73 yr Alprazolam 607 35 yr AIprazolam antidepressant, unknown type
A A
Ingestion Ingestion
Int suicide Int suicide
(Continued on following page)
6.5 h
512
TABLE 21.
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, N u m b e r 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
608 ~
30yr
609P
610P 611P
612P 613 p 614P 615 616 a 617 618P
619 a 620
621
622 623 624 625
626 a 627P 628iP
629
630 631 632P 633P
634 635
636ip 637P 638 a 639 640 641
Substances
Alprazolam ethanol 42 yr Alprazolam hydroxyzine ethanol 17 yr Benzodiazepines 49 yr Benzodiazepines acetaminophen/hydrocodone acetaminophen 82 yr Benzodiazepines sertraline 41 yr Chloral hydrate 80yr Chloral hydrate 85 yr Chlorpromazine 31 yr Clozapine 37 yr Diazepam ethanol 45 yr Diazepam ethanol acetaminophen 30 yr Ethchlorvynol ethanol 32 yr Fluphenazine chlorpromazine fluoxetine 36 yr Fluphenazine trihexyphenidyl desipramine 50s yr Flurazepam 84 yr Flurazepam 37 yr Flurazepam alprazolam 80 yr Flurazepam Iorazepam digoxin 16 yr Haloperidol 51 yr Haloperidol 24 yr Haloperidol benztropine naproxen 70 yr Haloperidol hydrochlorothiazide/triamterene lithium 42 yr Haloperidol perphenazine 91 yr Lorazepam > 19 yr Lorazepam ethanol 46 yr Lorazepam hydroxyzine chlordiazepoxide 32 yr Phenobarbital 41 yr Phenobarbital amphetamines benzodiazepines 36 yr Phenobarbital benzodiazepines 21 yr Phenobarbital levothyroxine 66 yr Risperidone clonidine 66 yr Secobarbital 80 yr Temazepam 47 yr Thioridazine acetaminophen/diphenhydramine imipramine
Chronicity
Route
Reason
Blood Levels
A
Ingestion
Int abuse
0.031 pg/mL§ 60 mg/dL§
NC
Ingestion
Int suicide
A A
Unknown Ingestion
Int unknown Int suicide
A/C
Ingestion
Int suicide
A A A A A
Ingestion Ingestion Ingestion Ingestion Ingestion
Int suicide Int suicide Ther error Int suicide Int suicide
A/C
Ingestion
Int suicide
1,19 pg/mL§ 366 mg/dL
U
Ing/Paren
Int unknown
8.6 pg/mL§ 150 mg/dL
U
Ingestion
Int suicide
A/C
Ingestion
int suicide
A U A
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
A
Ingestion
Int suicide
C A U
Parenteral Ingestion Ingestion
Adv rxn Int suicide Int suicide
A/C
Ingestion
Int suicide
C
Parenteral
Adv rxn
A A
Ingestion Ingestion
Adv rxn Int suicide
A
Ingestion
Int suicide
A A/C
Ingestion Ingestion
Int suicide Int suicide
U
Ingestion
Int unknown
A/C
Ingestion
Int suicide
AJC
Ingestion
Int suicide
A/C A A/C
Ingestion Ingestion Ingestion
Int suicide Int suicide Int suicide
183 pg/mL
6-10 h
desalkylflurazepam 380 ng/mL N-desalkylflurazepam 189 ng/mL 5 ng/mL
2.7 ng/mL
0.3 mEq/L
(Continued on followingpage)
212 pg/mL
276.5 pg/mL
132 pg/mL 7 pg/mL 4,200 ng/mL 148 pg/mUI 230 ng/mL desipramine 1,300 ng/mL
18h 4h
TABLE 21.
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
642 ~p
31 yr
643
50 yr
644 ap
12 yr
Substances Thioridazine valproic acid clomipramine Trifluoperazine Iorazepam acetaminophen Trimethobenzamide
Chronicity
Route
Reason
C
Ingestion
Int misuse
A
Ingestion
Int suicide
C
Other
Adv rxn
Blood Levels
168 pg/mL 26.8 pg/mL
See also cases 224, 241, 283, 298, 315, 385, 387, 415, 425, 441, 442, 494, 501, 543, 582, 624, 669, 682 (alprazolam); 21, 316, 317, 327, 338, 339, 347, 375, 417, 471, 475, 536, 635, 636, 670, 683, 686, 695, 715 (benzodiazepines); 36, 416, 648 (barbiturates); 427 (buspirone); 337 (butalbital); 307, 326, 599, 633 (chlordiazepoxide); 55, 337, 420, 620 (chlorpromazine); 372, 373, 453, 586 (clonazepam); 229, 314, 376, 378, 671, 700 (diazepam); 292 (flunitrazepam); 456 (fluphenazine); 464 (flurazepam); 281, 419 (haloperidol); 230, 246, 280, 267, 402, 421, 456, 516, 625, 643 (Iorazepam); 433, 630 (perphenazine); 394 (phenobarbital); 391 (prochlorperazine); 392 (risperidone); 230, 248, 289, 587 (temazepam); 321, 395, 453, 457 (thioridazine); 396, 588 (thiothixene); 504 (trifluoperazine). Stimulants and street drugs 645n 43 yr Amphetamine 646 48 yr Amphetamine 647 51 yr Amphetamine acetaminophen/propoxyphene 6480 41 yr Amphetamine barbiturates opiates 649 60 yr Amphetamine desipramine 650 30 yr Amphetamines, hallucinogenic ethanol cannabinoids 651 35 yr Amphetamines marijuana 652an 11 mo Cocaine (crack) 653 18 yr Cocaine
A/C U A/C
Ingestion Unknown Ingestion
Int abuse Int unknown Int misuse
A/C
Unknown
Int abuse
U
Ingestion
Unint unk
U
Unknown
Int unknown
64 IJg/mUI
110 pg/m L 210 ng/mL§ 18 mg/dL A
Inhalation
Int abuse
A A
Ingestion Ingestion
Unint gen Int abuse
654P 655p 656 657p
25 yr 25 yr 27 yr 29 yr
Cocaine Cocaine Cocaine Cocaine
A A/C A A
Ing/Inh Ingestion Ingestion Ingestion
Int misuse Int misuse Int misuse Unknown
658~P 659 660 661p 662p 663 664 665P 666 667p 668p 669n
29 yr 30 yr 31 yr 31 yr 35 yr 35 yr 37 yr 38 yr 42 yr 42 yr 55 yr 34 yr
A AJC A A/C A A/C U A/C A U U A
Unknown Inhalation Unknown Inhalation Unknown Parenteral Unknown Inhalation Inhalation Unknown Inhalation Ing/Inh
Int abuse Int abuse Int abuse Int abuse Unknown Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int unknown
670
47 yr
A
Ing/Inh
Int abuse
671
29 yr
Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine (crack) Cocaine Cocaine Cocaine Cocaine amitriptyline alprazolam Cocaine benzodiazepines amphetamines Cocaine
U
Ingestion
Int abuse
672Jp
30 yr
C
Ing/Inh
Int abuse
673p
35 yr
A
Unknown
Int abuse
674
24 yr
C
Ing/Inh
Int abuse
675
23 yr
A
Ing/Unk
Int abuse
676P
46 yr
A/C
Ing/Paren
Int abuse
diazepam Cocaine ethanol Cocaine ethanol Cocaine ethanol methamphetamine Cocaine gamma hydroxy butyrate Cocaine heroin methamphetamine
1,000 ng/mL
(Continued on following page)
25.66 0.31 benzoylecgonine 6.9 ecgonine methyl ester 2.87
IJg/mL§ pg/mL§ pg/mL§ #g/mL§
0.52 #g/mL benzoylecgonine 3.43 IJg/mL 0.3 pg/mL benzoylecgonine 8.8 IJg/mL§ 2.0 ~Jg/mL
0.06 IJg/mL§ benzoylecgonine 2.28 IJg/mL§ ecgonine methyl ester 0.75 pg/mL§ 0.9 pg/mL§
0.03 pg/mL§ benzoylecgonine 1.4 pg/mL§
514
TABLE 21.
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
Summary of Fatal Exposures Reported to TESS in 1995 (Cont'd)
Case
Age
677
41 yr
678P
26 yr
679
23yr
680~p
26 yr
6810
36yr
682
33yr
683P
51 yr
684
43yr
685ip
52 yr
6860
30 yr
687P 688P 689P 690 691P 692io 693P 694P 695iP
21 yr 34 yr 36 yr 42 yr 45 yr 46 yr 47yr 48 yr 43yr
696ip
32 yr
697i0
38yr
698P
39 yr
6990
47 yr
700P
28 yr
701 p
20yr
702P
30yr
703ip
34 yr
704P
37 yr
705P
46 yr
706ip
19 yr
707P
26 yr
708iP
26 yr
Substances Cocaine marijuana Cocaine methamphetamine heroin Cocaine (crack) methanol Cocaine morphine Cocaine opiates Cocaine opiates alprazolam Cocaine opiates benzodiazepines Cocaine phenylpropanolamine aspirin Cocaine (crack) plastic bag Fenfluramine ethanol benzodiazepmes Heroin, brown Heroin Heroin Heroin Heroin Heroin Heroin Heroin Heroin benzodiazepines Heroin cocaine Heroin cocaine Heroin cocaine codeine Heroin cocaine ethanol Heroin diazepam Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol Heroin ethanol cannabinoids Heroin propoxyphene cocaine Heroin propoxyphene codeine
Chronicity
Route
Reason
A
Inhalation
Int abuse
A
Parenteral
Int abuse
U
Ing/Inh
Int abuse
A/C
Parenteral
Int abuse
A
Unknown
Int unknown
A/C
Ing/Unk
Int abuse
A
Ingestion
Int unknown
A/C
Ingestion
Int suicide
U
Asp/ing
Int abuse
U
Ingestion
Int suicide
Blood Levels
0.02 IJg/mL cocaine metabolite 0.19 ug/mL 0.02 IJg/mL
0.06 ug/mL benzoylecgonine 1.4 pg/mL 0.06 Ug/mL
79 mg/dL
109 mg/dL§ U A/C A/C A/C A A/C A A/C A/C
Inhalation Parenteral Parenteral Parenteral Parenteral Parenteral Parenteral Parenteral Ing/Paren
Int abuse Int suicide Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse Int abuse
A/C
Inh/Paren
Int abuse
A/C
Inh/Paren
Int abuse
A/C
Unknown
Int abuse
A/C
Parenteral
Int abuse
NC
Ing/Paren
Int abuse
U
Ing/Paren
Int abuse
A/C
Ing/Paren
Int abuse
A/C
Ing/Paren
Int abuse
U
Ing/Paren
Int abuse
C
Parenteral
Int abuse
A/C
Ing/Inh/Par Int abuse
A
Parenteral
A
Ing/Inh/Unk Int abuse
morphine 0.028 pg/mL morphine 111 ug/mL
130 mg/dL
167 mg/dL
240 mg/dL
Int abuse
(Continued on following page)
LITOVITZ ET AL •
TABLE 21. Case 709 a 710 711a 712 713 714p
1995 A A P C C A N N U A L R E P O R T
515
S u m m a r y of Fatal Exposures Reported to TESS in 1995 (Cont'd) Age
Substances
Chronicity
Route
Reason
1d 27 yr 30 yr 36 yr 37 yr >19yr
Methamphetamine Methamphetamine Methamphetamine Methamphetamine Methamphetamine Methamphetamine
C A U A/C A/C U
Other Ingestion Ing/Inh Unknown Parenteral Unknown
Int abuse Int abuse Int abuse Int abuse Int abuse Unknown
715
40 yr
U
Ing/Unk
Int abuse
716
37 yr
Methamphetamine benzodiazepines ethanol Methamphetamine
U
Unknown
Int abuse
717p
31 yr
cannabinoids Methamphetamine
A
Unknown
Int abuse
Blood Levels
1.1 pg/mL amphetamine 0.16 pg/mL
474 mg/dL >5,000 ng/mL amphetamine 3,590 ng/mL 0.80 pg/mL amphetamine 0.11 IJg/mL benzoyfecgonine 0.28 pg/mL§
cocaine Methamphetamine A Inh/Unk Int abuse ethyl ether 719P 19 yr Methylenedioxymethamphetamine A Ingestion Int abuse 0.54 pg/mL§ 720P 23 yr Methylenedioxymethamphetamine A Ingestion Int abuse 721 18 yr Phencyclidine U Unknown Int abuse 722p 38 yr Phencyclidine A Ingestion Int abuse 0.62 pg/mL§ See also cases 325, 474, 635, 670 (amphetamine); 580 (amphetamines/methamphetamine); 434, 650, 706, 716 (cannabinoids); 128, 150, 205, 300, 316, 338, 374, 444, 506, 696, 697, 698, 699, 707, 717(cocaine); 17, 210, 311, 386, 676, 678 (heroin); 651, 677(marijuana); 16, 320, 674, 676, 678 (methamphetamine); 388 (methylphenidate); 288 (phendimetrazine); 288 (phentermine); 590, 684 (phenylpropanolamine). 718ap
25 yr
Topical preparations 723 44 yr Methyl saficylate (oil of wintergreen) iodine (2%) See also case 723 (iodine). Vitamins 724 a
1 yr
Prenatal vitamins with iron
A
Ingestion
Int suicide
124 mg/dL
1-2 h
A
Ingestion
Unint gen
6,000 pg/dL
12-14 h
NOTE: The term "long-acting" is used throughout for all sustained release, delayed release, or long-acting formulation. ABBREVIATIONS: C, chronic exposure; A, acute exposure; A/C, acute on chronic; U, unknown; Adv rxn, adverse reaction; Env, environmental; Int, intentional; Occ, occupational; Ther error, therapeutic error; Unint gen, unintentional general. pPrehospital (cardiac and/or respiratory) arrest. ~Reported to poison center indirectly (by coroner, medical examiner, or from other sou rce) after the fatality occurred. aAbstract provided in Appendix. § Level obtained postmortem. ilAcetaminophen level. I] Salicylate level. # Level includes metabolite and parent compound.
516
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A.
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals
Age (yr) Substance Implicated In the Exposure Adhesives/glues Cyanoacrylates Epoxy Toluene/xylene Nontoxic Unknown *Category totals Alcohols Ethanol (beverage) Ethanol (other) Higher alcohols Isopropanol Methanol Rubbing alcohol Ethanol, with methyl salicylate Ethanol, without methyl salicylate Isopropanol, with methyl salicylate Isopropanol, without methyl salicylate Unknown rubbing alcohol Other alcohol Unknown alcohol *Category totals Arts/crafts/office supplies Artist paints, non-watercolor Chalk Clay Crayon Glazes Office supplies: miscellaneous Pencil Pens/ink Typewriter correction fluid Water color Other Unknown *Category totals Auto/aircraftJboat products Ethylene glycol Glycols: other Glycol and methanol Hydrocarbons Methanol Nontoxic Other Unknown *Category totals Batteries Automotive batteries Disc batteries Alkaline (MnO=) Lithium Mercuric oxide Nickel cadmium Silver oxide Zinc-air Other Unknown Dry cell batteries Other batteries Unknown batteries
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
12,235 804 2,040 1,522 4,553 21,154
12,403 822 2,134 1,577 4,742 21,678
3,831 322 1,447 1,120 2,606 9,326
2,472 66 324 330 640 3,832
4,568 331 257 109 1,163 6,428
28,981 2,367 147 9,781 842
1,581 1,469 54 6,649 206
4,303 226 24 849 114
20,417 562 46 1,944 442
31
22
2
6
29
319
249
21
40
356
276
21
52
8,540 191 35 529 52,119
6,283 127 17 76 17,009
717 24 3 88 6,392
1,325 35 11 319 25,199
1,091 1,903 1,727 2,767 253
761 1,677 1,450 2,410 97
156 165 163 223 41
129 41 89 101 101
1,059 1,888 1,703 2,743 246
314 3,054 12,982 2,394 3,309 5,662 365 35,821
105 1,528 9,543 1,551 2,659 4,374 266 26,421
39 1,174 2,744 610 375 677 69 6,436
126 257 474 177 230 486 27 2,238
4,362 1,544 90 3,546 1,290 53 2,587 159 13,631
722 471 36 1,680 395 35 1,084 45 4,368
630 131 12 432 191 11 393 30 1,830
1,785
179
94 68 13 5 35 96 8 1,532 4,007 92 30
71 32 4 1 23 49 5 1,060 2,119 34 9
Int
Outcome None
Minor
Moderate Major Death
113 6 82 40 131 372
37 2 8 12 23 82
14 7 3 1 28 53
2,795 302 308 73 841 4,319
1,579 190 621 275 1,230 3,895
3,067 229 489 102 1,041 4,928
680 70 47 11 175 983
11 0 2 0 7 20
0 0 0 0 1 1
4,198 23,902 2,165 160 143 3 8,807 902 753 78
170 8 0 37 6
501 28 0 11 0
20,245 381 54 2,043 435
3,469 788 42 3,671 238
9,395 402 37 1,948 246
4,370 53 12 294 52
706 2 0 41 17
20 0 0 1 6
2
0
0
7
10
8
1
0
0
308
10
0
0
47
134
47
3
1
0
335
19
0
0
82
174
60
9
3
0
7,862 612 170 17 32 1 228 290 25,030 25,996
43 3 0 2 269
3 0 2 6 551
1,340 27 9 325 24,995
3,247 53 12 75 11,913
1,512 17 9 105 13,786
152 5 0 74 5,025
10 0 1 12 793
0 0 0 0 82
26 10 16 19 6
2 1 0 0 1
4 2 7 4 0
90 37 67 80 43
307 346 284 450 80
135 51 93 70 34
16 3 3 5 4
3 1 0 0 1
0 0 0 0 0
304 2,963 12,663 2,244 3,264 5,562 354 34,993
8 30 271 130 37 82 6 641
0 56 24 12 2 12 2 112
1 2 15 2 6 5 2 50
56 153 375 228 84 280 28 1,521
54 318 2,796 811 706 1,065 72 7,289
77 361 468 302 145 340 23 2,099
8 14 34 13 10 27 4 141
1 0 1 1 1 0 0 9
0 0 0 0 0 0 0 0
2,450 752 32 1,223 563 6 861 73 5,960
4,038 1,474 86 3,430 1,187 52 2,515 147 12,929
285 56 4 96 91 0 44 11 586
18 10 0 12 9 1 12 1 63
8 0 0 5 1 0 14 0 28
1,523 523 32 941 575 6 876 67 4,543
1,031 381 26 929 448 12 513 20 3,360
1,067 583 32 1,345 375 9 1,036 69 4,516
298 73 2 155 58 2 202 15 805
80 13 0 10 14 0 3 1 121
11 1 0 0 5 0 0 0 17
220
1,034
1,766
11
4
1
579
802
194
6
0
11 13 2 1 5 6 2 333 1,017 30 13
4 14 6 2 5 38 1 106 631 22 5
89 63 13 5 32 94 8 1,497 3,831 91 29
2
3
0
0
1 0 0 0 0 0 0 3 0 0
11 11 0 1 3 4 0 69 1,093 23 14
0
0 0 0 1 0 0 0 36 0 0
63 37 7 2 22 75 4 1,093 615 20 11
3
4 0 0 2 2 0 29 134 1 1
2 0 0 1 0 0 15 172 5 1
1 0 0 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0 0
(Continued on followingpage)
156 61 17 6 1 21 69 2 881 1,051 22 5
LITOVITZ ET A L •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
517
Demographic Profile of Exposure Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure *Category totals Bites and envenomations Coelenterate Fish Other/unknown marine animal Insects Ant/fire ant Bee/wasp/hornet Caterpillar Centipede/millipede Mosquito Scorpion Tick Other insect Mammals Bat Cat Dog Fox Human Raccoon Rodents/lagomorphs Skunk Other mammal Reptile other/unknown Snakes Copperhead Coral Cottonmouth Crotalid: unknown Rattlesnake Exotic snakes Poisonous Nonpoisonous Unknown if poisonous Nonpoisonous snake Unknown snake Spiders Black widow Brown recluse Other spider Tarantula Unknown insect or spider Other/unknown animal bite *Category totals Building and construction products Caulking compounds and putties Cement, concrete Insulation Asbestos Fiberglass Urea/formaldehyde Other Unknown Soldering flux Other construction product Unknown construction product *Category totals Chemicals Acetone
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
7,765
3,586
1,653
1,868
7,518
186
44
5
2,528
2,292
2,031
393
9
0
52 1,233
13 25
11 204
22 853
52 1,228
0 1
0 2
0 2
11 408
1 26
14 550
3 173
0 5
0 0
217
70
35
97
213
2
0
2
64
21
49
18
0
0
3,121 17,874 2,554 105 287 11,005 3,211 10,876
1,255 3,795 714 41 101 915 882 2,362
460 4,060 686 20 55 2,161 788 2,030
1,173 8,408 1,020 33 104 6,793 1,264 5,495
3,099 17,853 2,535 105 286 11,00t 3,202 10,676
6 11 8 0 0 3 2 22
13 2 4 0 1 0 0 136
2 8 6 0 0 1 3 29
358 1,771 217 9 46 761 644 1,976
78 206 81 8 1 122 195 394
1,232 7,706 979 38 101 5,917 698 3,384
184 947 86 3 19 733 55 669
6 22 1 0 2 21 2 3
0 2 0 0 0 0 0 0
180 744 1,407 27 62 103 1,703 233 964 1,342
18 131 261 7 18 9 453 27 168 509
39 176 530 5 19 19 652 63 335 445
93 357 514 14 16 67 455 102 356 296
176 740 1,407 27 53 101 1,685 231 957 1,313
1 1 0 0 0 1 1 0 1 9
0 0 0 0 9 0 13 1 1 9
1 2 0 0 0 0 2 1 2 8
110 359 851 19 27 61 383 26 365 188
21 12 17 1 2 5 63 19 55 153
38 160 233 2 14 25 512 78 218 431
3 23 39 0 7 4 28 11 21 37
0 1 2 0 0 0 0 0 3 0
0 0 0 0 0 0 0 0 0 1
467 45 81 5 817
29 4 2 1 55
103 9 18 1 158
302 31 52 3 533
467 44 81 5 811
0 0 0 0 4
0 0 0 0 1
0 1 0 0 1
406 38 68 3 708
9 6 3 1 26
185 19 30 0 201
167 5 24 2 355
10 1 2 0 74
0 0 0 0 1
104 237 1 2,044 1,957
11 26 0 243 213
14 80 0 937 651
63 110 1 715 971
101 237 1 2,040 1,956
1 0 0 0 1
0 0 0 1 0
1 0 0 1 0
84 69 1 444 1,130
5 4 O 79 118
21 77 0 867 946
28 12 0 43 225
8 0 0 1 22
0 0 0 0 0
2,080 2,003 6,687 107 12,672 1,021 87,628
184 180 944 17 2,076 101 15,860
336 301 1,343 41 2,320 463 19,568
1,400 1,239 3,854 38 6,172 415 43,431
2,076 1,997 6,668 106 12,648 1,019 87,197
3 2 8 0 5 1 94
1 1 2 0 13 0 210
0 1 8 1 4 1 88
689 1,051 1,118 16 2,681 142 17,302
130 43 135 2 189 14 2,245
950 570 2,400 56 5,280 328 34,309
321 493 372 2 1,025 66 6,203
14 25 4 0 13 0 242
0 0 0 0 0 0 4
3,428 1,455
2,563 361
222 116
461 779
3,379 1,430
28 14
4 3
15 7
252 618
1,057 200
321 400
45 303
2 16
0 0
200 1,503 119 246 60 463 1,875
28 586 44 103 32 190 1,014
36 252 20 34 5 70 184
95 515 38 80 19 159 534
195 1,448 116 240 56 454 1,851
1 15 1 2 0 3 13
0 19 0 0 2 3 4
1 12 2 4 2 2 6
65 214 29 38 16 154 347
31 200 16 59 9 100 361
25 380 24 41 3 148 375
5 48 8 6 3 40 80
0 0 0 0 0 3 0
0 0 0 0 0 0 0
64 9,413
12 4,933
7 946
35 2,715
62 9,231
0 77
0 35
2 53
22 1,755
5 2,038
23 1,740
7 545
0 21
0 0
1,197
439
139
508
1,124
47
8
7
369
248
384
67
3
0
(Continued on followingpage)
518
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A.
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Acids Hydrochloric Hydrofluoric Other Unknown Alkali Ammonia Borates/boric acid Chlorates Cyanide Dioxin Formaldehyde/formalin Glycol: ethylene Glycol: other Ketones Methylene chloride Nitrates and nitrites Phenol/creosote Strychnine Toluene diisocyanate Other chemicals Unknown chemicals *Category totals Cleaning substances (household) Ammonia cleaners (all purpose) Automatic dishwasher detergents Granules Liquids Rinse agents Other/unknown Bleaches Borate Hypechlorite Nonhypochlorite Other/unknown Carpet/upholstery cleaners Cleansers Anionic/nonionic Other/unknown Disinfectants Hypochlorite Phenol Pine oil Other/unknown Drain cleaners Acid Alkali Other/unknown Fabric softeners/antistatic agents Aerosol/spray Dry/powder Liquid Solid/sheet Other/unknown Glass cleaners Ammonia Anienic/nonionic Isopropanol Other/unknown Hand dishwashing Anionic/nonionic Other/unknown
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
2,968 1,435 4,895 484 4,958 5,653 3,622 76 287 16 1,572 660 1,210 986 697 970 1,349 29 430 15,565 2,449 51,506
176 105 656 57 1,181 1,627 2,074 29 15 1 246 122 475 261 101 255 204 7 66 4,881 1,159 14,137
576 84 716 84 806 704 358 10 15 0 309 70 231 85 65 355 172 8 36 2,117 376 7,316
1,750 954 2,680 267 2,241 2,713 999 30 200 13 772 361 390 512 415 281 756 9 241 6,388 657 23,137
2,883 1,410 4,771 456 4,831 5,416 3,417 73 251 14 1,493 546 1,162 974 684 889 1,313 13 422 14,272 2,341 48,755
56 14 74 14 60 182 152 3 20 1 48 99 29 5 6 51 18 9 4 441 19 1,352
15 5 22 13 38 31 30 0 11 0 15 3 5 2 3 21 2 3 1 476 59 763
8 2 20 0 18 18 13 0 1 0 7 1 11 5 2 5 16 2 2 264 24 426
1,174 1,095 2,184 209 2,339 1,918 559 44 181 14 674 319 450 496 360 253 546 16 172 4,960 402 18,734
267 135 475 34 622 640 950 12 49 2 215 128 297 147 77 250 126 7 56 2,971 426 8,134
1,288 573 1,980 189 1,700 2,209 361 13 91 5 517 137 353 385 292 239 480 2 120 3,928 354 15,600
439 367 728 93 908 622 45 5 18 2 114 63 71 113 84 43 178 1 42 986 52 5,041
20 25 35 3 41 21 1 1 9 0 7 44 6 4 3 2 7 0 2 63 2 299
3 0 5 0 0 0 0 0 2 0 0 9 0 0 0 0 0 0 0 4 0 23
3,643
1,687
360
1,375
3,505
112
18
5
679
789
1,092
200
2
0
4,930 2,182 1,171 803
4,114 1,744 1,094 621
279 108 33 53
429 266 37 91
4,890 2,159 1,170 791
25 15 1 4
10 0 0 6
1 8 0 2
244 137 22 55
2,121 873 342 322
942 372 155 143
54 34 3 11
0 1 1 0
0 0 0 0
806 47,495 822 314 4,207
379 19,837 446 156 3,191
56 5,052 65 25 276
306 18,967 251 112 558
773 45,615 794 290 4,135
14 1,430 19 15 24
3 309 4 6 7
15 94 4 2 39
99 8,937 133 55 388
184 7,938 194 63 1,223
254 16,911 270 106 806
30 2,396 16 17 71
1 51 1 0 2
0 0 0 0 0
7,755 1,085
5,904 675
551 96
1,036 273
7,507 1,031
163 43
39 5
35 3
728 186
2,403 326
1,447 268
149 41
1 0
0 0
5,657 4,793 10,802 1,847
2,730 3,282 7,500 862
667 489 853 256
1,894 801 2,107 560
5,525 4,546 10,337 1,716
75 188 375 87
25 39 54 27
31 13 16 14
1,139 687 1,959 499
1,319 1,197 3,801 442
1,959 1,317 2,522 635
425 106 256 87
8 5 19 1
0 0 0 0
938 3,447 397
96 653 105
80 368 60
594 1,969 192
911 3,199 370
20 220 22
4 22 1
2 0 3
341 1,240 84
90 483 71
373 1,252 139
187 497 21
7 26 1
1 2 1
61 6 1,158 366 26
37 5 939 313 20
4 1 64 25 0
18 0 120 21 5
60 6 1,109 348 25
0 0 16 2 1
1 0 2 1 0
0 0 31 14 0
8 0 89 8 4
13 2 398 108 6
18 2 149 32 3
1 0 11 0 2
0 0 0 0 0
0 0 0 0 0
2,702 30 4,400 4,479
2,083 12 3,446 3,499
229 5 403 408
291 10 452 405
2,612 26 4,262 4,329
70 2 107 100
15 0 24 31
4 1 3 13
219 6 351 340
820 7 1,375 1,328
541 9 1,015 1,045
21 2 43 44
2 0 1 3
0 0 0 0
7,877 1,373
4,963 764
776 150
1,682 361
7,521 1,272
104 29
88 29
156 42
480 107
1,587 181
2,322 335
108 20
4 0
0 0
(Continued on following page)
LITOVITZ ET AL •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
519
Demographic Profile of E x p o s u r e Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Laundry additives Bluing/brightening agent Detergent booster Enzyme/microbiological additive Water softener Other/unknown Laundry detergents Granules Liquids Soaps Other/unknown Laundry prewash/stain removers Dry solvent-based Liquid solvent-based Spray solvent-based Other/unknown solventbased Dry surfactant-based Liquid surfactant- based Spray surfactant- based Other/unknown surfactant-based Other/unknown Miscellaneous cleaner Acid Alkali Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Phenol Other/unknown Oven cleaner Acid Alkali Detergent type Other/unknown Rust remover Alkali Anionic/nonionic Hydrofluoric acid Acid other Other/unknown Spot removers/dry cleaning agent Anionic/nonionic Glycol Carbon tetrachloride PerChloroethylene Other halogenated hydrocarbon Isopropanol Other nonhalogenated hydrocarbon Other/unknown Starch/fabric finishes~sizing Toilet bowl cleaner Acid Alkali Other/unknown Wall~floor~tilecleaner Acid Alkali
No, of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
62 34
41 21
13 3
7 5
60 31
1 2
0 1
0 0
4 6
19 6
3 11
0 0
0 0
0 0
47 141 89
27 31 50
4 10 6
12 91 22
45 131 78
1 0 0
0 3 2
0 7 9
7 23 29
16 40 15
8 28 29
1 5 10
0 0 0
0 0 0
8,271 3,481 172 136
6,939 2,468 117 89
470 263 12 13
700 615 34 30
8,046 3,256 169 132
95 82 2 2
10 6 0 0
115 130 0 2
983 442 13 28
2,378 714 35 43
2,312 974 36 38
195 64 3 5
4 1 0 t
0 0 0 0
88 376 536
79 292 399
4 20 27
5 49 76
88 373 528
0 2 2
0 0 0
0 1 6
6 44 100
20 115 122
10 82 174
1 14 30
0 1 0
0 0 0
72 657 2,315 383
42 553 1,912 304
5 25 113 25
18 43 199 42
71 646 2,277 376
1 4 23 3
0 0 4 3
0 7 11 1
11 32 287 47
25 179 610 76
13 103 590 161
1 5 99 9
0 0 2 0
0 0 0 0
20 40
15 23
0 2
1 10
20 39
0 0
0 0
0 1
3 13
3 8
4 14
1 2
0 0
0 0
701 6,585 8,675 3,798 454 1,915 1,464 50 16 2,918
272 3,258 5,822 2,056 280 1,234 983 30 2 1,613
52 645 702 457 34 184 224 4 7 325
284 2,074 1,661 970 108 395 198 15 7 737
684 6,366 8,414 3,617 433 1,865 1,419 49 15 2,766
10 142 155 126 14 27 26 0 1 76
3 52 37 23 2 11 15 1 0 38
3 23 62 24 5 8 4 0 0 33
205 2,115 1,173 835 72 278 201 17 3 580
174 1,602 2,192 969 128 599 476 13 5 758
243 2,177 2,203 1,039 121 465 398 19 8 804
49 585 201 161 16 47 28 1 0 112
1 19 5 6 0 1 0 0 0 3
1 2 0 1 0 0 0 0 0 0
13 3,419 26 280
2 815 12 65
4 430 3 36
3 1,660 11 146
11 3,313 25 273
2 55 0 2
0 32 1 2
0 12 0 2
5 1,477 3 108
1 312 9 22
4 1,277 3 93
2 595 1 29
0 19 0 1
0 0 0 0
31 1 1,563 209 312
11 0 113 64 55
3 1 109 13 30
11 0 1,217 112 197
30 1 1,531 199 302
1 0 29 6 2
0 0 3 2 1
0 0 0 1 6
t0 1 969 74 61
9 0 155 42 55
10 1 807 79 115
3 0 389 21 37
0 0 17 0 1
0 0 1 0 0
495 108 0 73
389 77 0 36
35 6 0 5
54 16 0 26
492 104 0 69
2 3 0 4
0 0 0 0
1 1 0 0
61 12 0 25
146 37 0 16
123 33 0 14
12 2 0 6
0 0 0 0
0 0 0 0
136 33
41 23
11 2
62 7
132 31
2 1
0 0
2 1
24 4
18 12
43 8
5 0
0 0
0 0
153 51 1,180
96 25 956
10 5 118
35 19 83
149 49 1,126
4 1 47
0 0 2
0 0 3
30 15 55
57 15 284
42 14 172
5 2 9
0 0 1
0 0 0
3,445 545 2,696
1,257 335 2,036
322 28 123
1,444 153 381
3,288 537 2,645
128 7 32
15 1 6
9 0 12
990 76 227
758 191 804
1,315 122 333
342 29 51
19 0 1
5 0 0
3,054 8,506
1,242 4,970
257 758
1,228 2,373
2,986 8,283
43 136
8 38
15 38
755 1,811
674 2,212
1,263 3,188
249 524
3 13
0 1
(Continued on following page)
520
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22A.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Anionic/nonionic Cationic Ethanol Glycols Isopropanol Methanol Other/unknown *Category totals Industrial cleaners Acids Alkali Anionic/nonionic Cationic Other/unknown *Category totals Cosmetics/personal care products Bath oil, bubble bath Creams, lotions, make-up Dental care products False teeth cleaning Toothpaste with fluoride Toothpaste without fluoride Other Deodorants Depilatories Douches Eye products Hair care products Coloring agents Rinses, conditioners, relaxers Shampoos Sprays Other Lipsticks/balms, with camphor Lipsticks/balms, without camphor Mouthwash Ethanol Nonethanol Fluoride Unknown Nail products Polish Polish removers: acetone Polish removers: other Polish removers: unknown Other miscellaneous Perfume, cologne, aftershave Peroxide Powders: talc Powders: without talc Soaps Suntan/sunscreen products *Category totals Deodorizers Air fresheners Diaper pail deodorizers Toilet bowl deodorizers Other Unknown *Category totals
No. of Exposures
<6
6-19
819 526 70 2,094 1,442 172 8 2 2 1,643 1,138 143 63 43 5 1 0 1 424 193 34 200,449 116,073 18,177 1,823 2,909 1,137 761 1,764 8,394
427 541 642 150 499 2,259
8,955 16,195
Treated in Health Care Other Adv Rxn Facility
Reason >19 162 390 0 302 13 0 148 53,844
Unint
Int
788 21 2,051 25 7 0 1,598 29 62 1 1 0 405 13 193,316 4,676
Outcome None
Minor
Moderate Major Death
6 6 0 8 0 0 4 1,116
4 11 1 7 0 0 1 1,130
126 222 1 257 9 1 125 34,315
198 645 0 473 23 0 96 48,610
202 582 2 429 14 0 124 58,913
25 56 0 55 1 1 31 8,980
1 0 0 1 0 0 1 259
0 0 0 0 0 0 0 15
227 453 134 149 224 1,187
910 1,426 278 325 799 3,738
1,777 2,780 1,104 714 1,686 8,061
37 93 20 36 48 234
8 18 6 5 23 60
1 13 7 4 4 29
778 1,664 262 321 728 3,753
274 375 263 104 278 1,294
765 1,170 352 326 690 3,303
234 523 48 81 211 1,097
5 19 0 5 1 30
0 1 0 1 0 2
8,172 12,089
444 1,031
239 2,504
8,799 14,825
32 183
5 49
114 1,118
247 746
2,535 3,424
1,169 1,385
37 110
0 2
0 0
1,242 4,499
235 3,417
73 326
842 547
1,207 4,026
19 39
7 24
4 393
95 246
380 1,272
144 825
8 24
0 0
0 0
252 1,350 11,235 646 272 1,425
177 835 8,920 206 171 1,076
25 165 971 125 24 73
44 289 1,016 246 69 213
231 1,291 10,163 493 243 1,368
7 24 158 24 7 10
1 0 26 13 0 1
13 33 885 116 20 45
12 121 445 133 41 103
55 357 2,574 111 69 323
45 289 1,592 208 40 165
3 9 65 63 4 20
0 0 1 1 0 2
0 0 1 0 0 0
1,632
700
143
622
1,473
12
2
143
405
349
542
110
1
0
3,840 8,515 3,843 3,144
2,831 6,657 2,500 2,048
336 733 599 306
474 937 579 613
3,646 8,153 3,366 2,893
52 237 387 89
10 12 27 12
129 103 59 147
974 587 512 588
1,047 2,088 989 894
964 1,775 1,020 660
251 t01 85 136
1 7 5 7
0 0 1 0
630
561
34
27
621
3
1
5
23
149
65
2
0
0
2,374
2,183
110
66
2,345
8
1
18
50
447
94
4
0
0
9,682 431 1,263 249
3,598 244 938 47
1,975 91 265 136
3,435 80 53 51
8,719 386 1,248 212
828 36 4 12
62 0 2 22
52 6 9 2
996 71 38 29
2,665 194 457 25
1,159 57 77 127
153 2 1 9
19 0 0 0
0 0 0 0
8,354 3,335 2,111
7,402 2,625 1,645
505 294 205
353 351 219
8,266 3,244 2,065
59 69 31
14 13 2
14 8 11
545 377 158
2,442 1,284 794
1,682 677 435
50 33 33
1 0 1
0 1 0
6,748 4,295
5,110 2,560
725 655
738 848
6,533 4,216
170 41
33 3
8 34
748 1,163
2,211 978
1,315 1,286
53 288
2 7
0 0
29,038 2 6 , 0 9 1 1,586 14,362 7,632 1,502 3,839 3,338 242 1,225 1,119 67 12,033 8,843 1,016 4,412 3,449 498 171,426 127,419 15,280
1,157 4,274 209 33 1,743 377 23,248
28,556 349 13,911 317 3,782 36 1,206 8 11,130 176 4,211 23 162,828 3,450
79 40 4 2 65 5 537
45 79 17 9 648 168 4,455
1,704 1,014 376 36 665 282 13,530
4,797 2,659 1,154 262 2,129 1,543 30,341
142 176 51 13 105 57 2,198
1 6 2 0 0 3 69
0 0 0 0 0 0 3
50 0 0 12 1 63
77 1 3 84 1 166
1,000 24 87 512 26 1,649
3,733 23 95 800 40 4,691
138 1 7 66 1 213
7 0 0 1 0 8
5 0 1 0 0 6
15,031 632 998 3,725 142 20,528
12,413 593 884 2,606 96 16,592
1,338 23 53 326 17 1,757
802 13 52 517 24 1,408
14,687 631 986 3,572 137 20,013
210 0 9 51 2 272
(Continued on followingpage)
10,614 3,286 1,044 226 2,927 756 46,986 4,044 292 400 1,029 46 5,811
LITOVITZ ET A L •
TABLE 22A.
1995 A A P C C A N N U A L R E P O R T
521
D e m o g r a p h i c Profile of Exposure C a s e s by Generic C a t e g o r y of Substances and Products: Nonpharmaceuticals ( C o n r d )
Age (yr) Substance Implicated In the Exposure Dyes Fabric Food dye (eg, Easter egg) Leather Other Unknown *Category totals Essential oils Fertilizers Household plant food Outdoor fertilizers Plant hormones Other Unknown *Category totals Fire extinguishers Food products/food porsoning Foreign bodies/toys/ miscellaneous Ashes Bubble blowing solutions Charcoal Christmas ornaments Coins Desiccants Feces/urine Glass Incense, punk Soil Thermometer Toys Other Unknown *Category totals
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
790 1,076 141 604 72 2,683 3,451
634 897 113 388 50 2,082 2,354
75 122 11 146 5 359 452
65 40 13 52 14 184 509
777 1,038 137 585 68 2,605 3,236
6 23 3 7 0 39 129
1 3 0 3 3 10 26
5 10 1 9 1 26 58
68 26 16 52 9 171 476
275 258 40 201 25 799 808
36 58 11 54 7 166 1,287
5 2 1 5 2 15 73
0 0 0 0 1 1 2
0 0 0 0 0 0 2
4,964 2,840 118 324 1,756 10,002 2,954 67,084
3,248 1,878 48 189 1,097 6,460 273 17,677
659 293 13 41 242 1,248 829 10,857
877 459 41 76 319 1,772 1,347 31,875
4,911 2,805 117 318 1,715 9,866 2,744 62,063
33 13 1 1 19 67 61 540
11 4 0 3 7 25 130 959
7 14 0 2 13 36 7 3,387
145 159 23 30 175 532 846 6,571
1,296 765 32 76 447 2,616 439 7,121
206 232 19 24 244 725 1,149 12,929
6 22 6 5 31 70 153 2,893
2 0 0 1 0 3 4 79
0 0 0 0 0 0 0 0
626 3,833 842 1,317 3,731 20,537 3,329 2,212 259 2,098 12,919 5,553 17,529 236 75,021
554 3,542 606 1,115 3,004 18,230 2,667 729 224 1,778 6,908 3,888 10,581 146 53,972
32 202 71 111 620 1,487 204 289 19 129 3,522 1,489 4,350 44 12,569
30 69 142 68 82 567 363 940 11 159 1,772 125 1,996 29 6,353
618 3,814 813 1,304 3,690 20,376 3,263 1,913 255 2,080 12,827 5,479 16,543 209 73,184
4 8 20 9 34 120 10 19 3 11 63 58 298 3 660
1 6 3 0 3 34 53 267 0 3 18 8 572 21 989
3 4 6 3 1 1 0 10 1 3 6 7 100 2 147
35 104 59 83 1,311 497 113 308 9 68 708 313 1,672 36 5,316
124 727 205 322 1,188 3,375 663 352 70 422 2,501 1,177 3,576 52 14,754
75 1,028 84 81 417 148 190 300 18 118 248 819 2,361 32 5,919
10 17 18 11 37 7 13 20 2 6 13 19 183 4 360
0 0 5 0 1 2 0 1 0 0 0 1 4 1 15
0 0 3 0 0 0 0 0 0 0 0 0 1 0 4
409 19,253 3,089
39 2,655 110
109 3,147 192
196 10,500 2,305
389 18,797 2,977
17 394 107
1 5 0
1 18 2
90 7,719 829
40 1,904 112
125 6,673 1,472
29 1,856 383
0 187 2
0 47 0
1,163 5,400 1,407 4,081 5
29 424 140 640 2
171 1,057 150 700 1
797 3,133 714 2,081 2
1,148 5,270 1,400 4,017 5
12 81 3 47 0
2 13 4 9 0
1 32 0 3 0
333 1,925 482 1,202 1
47 261 164 509 0
547 2,645 423 1,393 0
196 936 134 223 1
4 20 12 6 0
0 0 0 1 0
2,852 2,748 1,898 42,305
241 257 162 4,699
694 387 264 6,872
1,464 1,652 1,042 23,886
2,602 2,621 1,867 41,093
236 48 10 955
4 53 11 102
1 17 4 79
992 1,166 489 15,228
285 296 150 3,768
961 975 809 16,023
283 302 114 4,457
20 15 0 267
0 0 0 48
290 16 425 271 566 1,568
93 10 77 142 148 470
25 3 40 40 42 150
124 3 192 62 198 579
283 15 399 257 541 1,495
5 1 7 8 4 25
0 0 1 1 0 2
1 0 17 5 19 42
77 8 138 38 129 390
62 3 66 57 91 279
69 4 114 35 131 353
14 3 22 4 23 66
0 0 2 0 0 2
0 0 0 0 0 0
743
362
82
231
723
6
5
7
99
146
68
24
2
0
569 19 61 925 15 3 3,039
52 4 9 171 11 1 1,459
33 3 6 311 3 0 500
392 10 34 339 0 1 827
405 15 53 846 15 3 2,902
28 2 3 31 0 0 44
77 0 1 24 0 0 31
3 2 0 18 0 0 9
347 9 35 273 3 0 1,250
87 4 9 152 2 0 619
76 3 12 268 1 0 206
31 2 1 69 0 0 81
7 0 2 2 0 0 7
2 0 0 0 0 0 0
Fumes~gases~vapors Carbon dioxide Carbon monoxide Chloramine Chlorine: acid mixed with hypochlorite Chlorine: other Hydrogen sulfide Methane and natural gas Polymer fume fever Propane/simple asphyxiants Other Unknown *Category totals Fungicides Carbamate fungicide Mercurial fungicide Nonmercurial fungicide Phthalimide fungicide Other/unknown *Category totals Heavy metals Aluminum Arsenic (excluding pesticides) Barium Cadmium Copper Fireplace flame colors Gold Lead
(Continued on following page)
522
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 •
TABLE 22A,
September 1996
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Manganese Mercury Metal fume fever Selenium Thallium Other Unknown *Category totals Herbicides Carbamate herbicide 2,4-D or 2,4,5-T Diquat Paraquat Paraquat/diquat Triazine herbicide Urea herbicide Other Unknown *Category totals Hydrocarbons Benzene Carbon tetrachloride Diesel fuel Freon and other propellants Gasoline Halogenated hydrocarbon: other Kerosene Lighter fluid/naphtha Lubricating oil/motor oil Mineral seal oil Mineral spirits/varsol Toluene/xylene Turpentine Other Unknown *Category totals Insecticides/pesticides (excluding rodenticides) Arsenic pesticides Borates/boric acid Carbamate only Carbamate with other pesticide Chlorinated hydrocarbon only Chlorinated hydrocarbon with other pesticide Metaldehyde Nicotine Organophosphate only With carbamate With chlorinated hydrocarbon With other pesticide With carbamate & chlorinated hydrocarbon Piperonyl butoxide only Piperonyl butoxide/pyrethrin Pyrethrins only Repellants (insect) Rotenone Veterinary insecticide
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
43 2,157 1,078 93 106 796 29 9,676
4 762 24 31 33 270 6 3,199
14 459 62 8 8 123 5 1,617
19 702 851 46 22 308 18 3,800
37 1,970 1,071 76 94 709 22 8,941
4 119 2 11 3 40 0 293
0 23 0 1 1 4 6 173
1 27 5 5 7 37 1 122
22 443 330 27 14 290 7 3,149
5 599 17 21 7 155 9 1,832
10 121 351 23 8 137 4 1,286
7 39 195 6 2 47 1 505
1 3 2 0 0 1 1 28
0 0 0 0 0 0 0 2
65 2,712 319 231 2 517 62 5,127 306 9,341
9 762 81 6 0 99 7 1,373 89 2,426
4 300 28 28 1 51 5 481 38 936
27 949 171 112 1 224 39 2,418 143 4,084
64 2,603 307 220 1 490 60 4,844 290 8,879
0 17 6 6 1 5 1 40 3 79
0 6 0 2 0 1 0 23 8 40
1 79 4 3 0 19 1 204 5 316
26 576 133 127 2 172 25 1,229 85 2,375
11 433 75 22 1 59 6 1,104 54 1,765
20 564 90 44 0 118 15 1,271 74 2,196
1 99 27 32 1 27 3 174 13 377
1 6 1 2 0 0 1 9 0 20
0 0 1 0 0 0 0 0 0 1
105 46 1,034 7,195 21,284
19 3 214 643 7,004
9 6 139 919 4,338
56 26 525 4,190 8,187
95 46 1,000 6,933 20,039
4 0 23 226 1,133
6 0 6 19 80
0 0 3 10 10
61 16 229 1,526 3,435
9 9 161 1,249 4,449
32 13 423 1,971 9,427
10 4 45 382 728
1 0 0 11 34
0 0 0 5 1
1,097 3,072 4,256 4,159 258 5,661 1,894 1,182 6,456 7,444 65,143
195 1,901 2,431 2,841 222 2,768 318 483 3,092 4,569 26,723
151 335 518 378 19 805 207 195 804 709 9,532
577 646 1,029 712 13 1,675 1,114 420 1,889 1,636 22,695
1,034 2,987 4,024 4,072 255 5,405 1,704 1,021 6,174 7,210 61,999
40 54 184 48 2 201 169 143 210 150 2,587
9 19 33 33 1 31 9 10 38 46 340
12 3 10 2 0 19 6 3 26 28 132
469 963 1,293 593 28 1,258 943 334 1,698 1,916 14,762
123 472 806 1,074 1,250 1,351 1,583 766 131 36 1,497 1,803 251 741 274 360 1,784 1,703 2,219 2,133 15,795 22,305
113 202 241 85 4 255 240 41 395 401 3,146
8 11 17 0 0 14 18 3 21 27 165
0 0 2 0 0 0 2 0 4 0 14
442 3,534 5,750
307 2,856 2,602
71 191 535
50 398 1,853
424 3,458 5,510
16 60 151
2 10 20
0 5 61
80 355 1,101
183 1,101 1,287
25 190 962
8 16 222
0 1 14
0 0 2
1,319
408
138
567
1,242
43
11
21
265
222
372
50
2
0
3,002
1,237
523
1,009
2,709
122
4
150
1,063
965
681
109
25
0
162 325 7 16,586 1,088
52 228 4 5,678 364
20 33 0 1,335 105
56 44 3 6,326 425
159 321 6 15,895 1,028
0 1 1 350 38
0 1 0 50 7
3 1 0 261 12
25 48 3 3,903 192
34 114 3 3,189 205
32 20 1 3,340 249
7 6 1 702 38
0 1 0 67 2
0 0 0 7 0
260 1,940
59 551
23 193
107 794
248 1,840
4 55
4 7
4 36
61 390
44 366
56 488
16 92
2 5
0 0
44 109
17 40
4 10
20 48
43 103
1 3
0 1
0 2
17 34
12 22
9 28
1 8
1 0
0 0
7,396 6,576 6,745 134 4,396
2,285 2,108 4,332 49 2,639
941 787 1,168 13 514
2,586 2,806 792 57 1,005
6,813 6,123 6,243 131 4,245
196 156 66 1 77
37 29 37 0 9
336 250 388 2 60
1,523 1,628 895 22 576
1,157 1,107 1,569 32 1,365
1,730 1,705 1,691 32 975
398 338 158 6 100
10 11 11 0 2
0 0 1 0 0
(Continued on following page)
LITOVITZ ET A L •
1995 A A P C C A N N U A L R E P O R T
523
TABLE 22A. Demographic Profile of Exposure Cases by Generic C a t e g o r y of S u b s t a n c e s and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Other Unknown *Category totals Lacrimators Capsicum/peppers Lacrimators: CN Lacrimators: CR Lacrimators: CS Lacdmators: DM Other Unknown *Category totals Matches/fireworks/explosives Eplosives Fireworks Matches Other Unknown *Category totals Moth repellants Naphthalene Paradichlorobenzene Other Unknown *Category totals Mushrooms Copdne Cyclopeptide Gastrointestinal irritants Hallucinogenic Ibotenic acid Miscellaneous, nontoxic Monomethylhydrazine Muscarine Orellanine Other potentially toxic Unknown *Category totals Paints and stripping agents Paint: antialgae Paint: anticorrosion Paint: oil-base Paint: water-base Stains Stripping agents Methylene chloride Other Unknown Varnishes, lacquers Wood preservatives Other paint/varnish/lacquer Unknown paint/varnish/ lacquer *Category totals Photographic products
No. of Exposures
<6
6-19
Treated in HeaFth Care Other Adv Rxn Facility
Reason >19
3,984 3,360 67,159
2,461 983 29,250
263 429 7,296
913 1,508 21,367
1,313 7,743 0 528 1 109 3,346 13,040
394 2,212 0 204 0 23 877 3,710
459 2,829 0 192 1 27 1,142 4,650
334 1,868 0 78 0 41 1,014 3,335
275 581 1,561 54 4 2,475
125 474 1,398 28 3 2,028
91 78 99 10 0 278
2,008 119 51 2,868 5,046
1,576 85 40 2,218 3,919
10 41 304 515 37 190 79 11 0 32 7,904 9,123
Unint 3,876 3,121 63,538
Int
Outcome None
Minor
Moderate Major Death
40 90 1,473
10 74 313
50 60 1,702
521 911 13,613
1,042 571 14,590
464 753 13,793
86 141 2,503
6 9 169
0 3 13
1,123 6,639 0 471 0 101 2,877 11,211
39 137 0 5 0 5 66 252
120 855 0 50 1 3 361 1,390
22 17 0 1 0 0 9 49
177 1,149 0 100 0 33 518 1,977
33 329 0 29 0 5 118 514
805 4,565 0 363 0 60 1,952 7,745
39 246 0 10 0 11 171 477
0 3 0 1 0 1 3 8
0 0 0 0 0 0 0 0
38 17 50 11 1 117
240 562 1,540 48 4 2,394
16 8 17 5 0 46
18 6 2 0 0 26
0 2 0 0 0 2
66 40 57 21 0 184
67 195 496 17 2 777
68 88 37 9 0 202
11 12 7 6 1 37
0 1 0 2 0 3
0 0 0 0 0 0
141 7 4 198 350
222 21 5 331 579
1,971 117 51 2,813 4,952
26 2 0 25 53
7 0 0 20 27
2 0 0 6 8
445 11 3 557 1,016
1,028 48 24 1,223 2,323
163 15 5 198 381
18 0 1 34 53
3 0 0 1 4
0 0 0 0 0
8 11 130 65 2 78 4 6 0 19 5,875 6,198
1 5 60 244 18 30 7 1 0 3 1,140 1,509
1 22 90 165 17 72 56 3 0 9 745 1,180
10 28 269 122 16 169 67 9 0 31 7,277 7,998
0 7 26 383 21 3 2 1 0 1 536 980
0 0 1 5 0 0 0 0 0 0 13 19
0 5 7 4 0 18 10 1 0 0 72 117
1 31 103 322 29 36 35 10 0 17 2,024 2,608
8 10 71 56 4 61 10 6 0 20 4,974 5,220
0 9 61 97 4 37 32 2 0 3 758 1,003
1 9 38 155 15 5 11 3 0 4 235 476
0 4 1 6 1 0 1 0 0 0 9 22
0 0 0 0 0 0 0 0 0 0 0 0
6 76 4,409 4,102 1,100
0 24 1,244 2,982 451
0 13 942 267 117
5 34 1,747 578 449
6 75 4,085 4,042 1,070
0 1 270 26 9
0 0 17 8 6
0 0 30 26 12
2 21 1,084 310 206
1 9 721 939 249
1 26 1,483 380 283
1 7 303 46 46
0 0 10 1 1
0 0 0 0 0
1,422 665 431 986 641 1,234
260 139 127 312 169 538
146 48 57 133 66 158
784 363 188 430 305 404
1,382 650 417 961 624 1,191
33 9 8 15 9 24
0 1 2 6 0 2
5 4 4 3 7 15
507 257 143 235 159 267
119 76 72 155 81 233
699 264 131 295 192 308
152 76 53 60 34 77
6 1 4 4 1 2
0 0 0 0 0 0
10,354 25,426
6,049 12,295
1,155 3,102
2,342 7,629
10,081 24,584
184 588
28 70
41 147
1,547 4,738
2,042 4,697
1,560 5,622
270 1,125
10 40
1 1
460 2 331 15 808
58 1 191 1 251
153 0 32 4 189
183 1 94 8 286
450 2 325 14 791
5 0 2 1 8
1 0 2 0 3
4 0 2 0 6
145 1 52 9 207
54 0 71 1 126
193 1 51 7 252
41 0 6 1 48
0 0 0 0 0
0 0 0 0 0
2,592 1,052
1,970 241
378 584
186 168
2,518 470
29 560
8 14
35 6
138 586
779 162
103 242
17 318
2 24
0 0
Developers~fixing~stop baths Photographic coating fluids Other Unknown *Category totals Plants Amygdalin/cyanogenic glycosides Anticholinergic
(Continued on following page)
524
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22A.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Nonpharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Cardiac glycosides Colchicine Depressants Dermatitis Gastrointestinal irritants Hallucinogenic Nicotine Nontoxic plant Oxalate Solanine Stimulants Toxalbumins Other Unknown *Category totals Polishes and waxes Radioisotopes Rodenticides ANTU Anticoagulant: standard Anticoagulant: long-acting Barium carbonate Cyanide Monofluoroacetate Strychnine Vacor Other Unknown *Category totals Sporting equipment Fishing bait Fishing products, other Golf balls Golf products, other Gun bluing Hunting products, other Other Unknown *Category totals Swimming pool/aquarium Tobacco products Other/unknown nondrug substances Total number of nonpharmaceutical substances % of nonpharmaceutical substances % of all substances
No. of Exposures 2,437 19 54 20,373 18,521 278 270 19,485 14,586 1,691 604 203 3,211 18,811 104,187 7,911 181
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
1,713 421 228 15 3 1 30 4 13 9,914 3,603 5,133 14,678 1,852 1,577 137 83 46 72 84 89 16,311 1,836 1,014 12,494 1,363 567 1,357 150 155 311 106 160 105 33 50 2,270 427 387 13,211 2,644 2,210 74,829 13,571 11,984 5,942 633 870 25 24 103
2,325 94 19 0 43 9 19,185 214 17,923 370 181 80 254 6 19,160 122 14,443 113 1,654 19 464 69 187 14 3,016 85 18,145 278 99,987 2,062 7,708 137 165 2
2 0 0 244 25 1 1 13 1 1 2 0 7 77 396 19 1
15 0 2 685 191 13 8 179 22 16 65 1 93 285 1,616 43 10
362 6 17 1,700 1,169 84 107 485 530 233 192 115 331 1,616 7,671 958 64
1,054 10 18 2,830 6,297 69 57 3,250 5,404 856 234 73 1,039 5,764 27,896 2,989 18
176 1 6 5,839 1,745 28 100 835 2,364 137 98 51 360 1,887 13,972 1,441 17
28 1 1 573 180 26 30 79 85 16 37 13 45 237 1,686 156 10
2 0 0 5 3 1 0 2 6 1 6 0 11 10 73 8 1
0 0 0 1 0 0 0 0 0 0 0 0 1 0 2 0 0
0 1,287 13,423 0 19 1 158 5 978 1,316 17,187
0 1,139 12,028 0 0 1 29 2 732 969 14,900
0 36 536 0 0 0 17 0 65 69 723
0 94 673 0 17 0 85 3 134 206 1,212
0 1,234 12,962 0 16 1 69 5 910 1,152 16,349
0 44 392 0 1 0 52 0 57 115 661
0 6 46 0 2 0 26 0 8 39 127
0 1 6 0 0 0 3 0 3 2 15
0 428 5,051 0 16 1 94 3 272 595 6,460
0 542 5,869 0 7 1 33 2 313 468 7,235
0 27 226 0 5 0 14 0 51 57 380
0 5 80 0 5 0 21 1 12 19 143
0 3 8 0 0 0 3 0 4 2 20
0 0 1 0 0 0 1 0 2 1 5
111 39 68 0 54 419 195 0 886 7,100 9,733
78 25 9 0 21 262 111 0 506 3,490 7,917
26 8 39 0 4 81 56 0 214 1,188 600
4 2 15 0 26 60 10 0 117 1,806 1,038
108 37 62 0 52 387 180 0 826 6,949 8,963
1 2 6 0 1 19 8 0 37 49 231
1 0 0 0 0 8 1 0 10 8 330
1 0 0 0 0 2 6 0 9 91 196
5 11 19 0 33 117 38 0 223 1,172 2,037
20 11 7 0 13 185 64 0 300 1,617 3,450
8 8 26 0 19 41 19 0 121 2,201 2,542
0 2 1 0 12 8 2 0 25 421 200
0 0 0 0 0 0 0 0 0 9 8
0 0 0 0 0 0 0 0 0 0 0
15,846
5,638
2,487
5,957
13,219
585
1,118
390
4,607
2,876
3,281
755
77
0
649,216 166,611 347,878 1,176,764 50,535 10,007
15,787
226,295
51,854
2,908
245
1.3% 0.7%
18.0% 10.4%
1,255,696
57.9%
51.7% 30.0%
13.3% 7.7%
27.7% 16.0%
93.7% 54.3%
4.0% 2.3%
0.8% 0.5%
268,471 293,550 21.4% 12.4%
NOTE: Patients with unknown age, reason, or medical outcome were omitted from the respective tabulations. ABBREVIATIONS:Adv rxn, adverse reaction: Int, intentional: Unint, unintentional.
23.4% 13.5%
4.1% 2.4%
0.2% 0.0% 0.1% 0.0%
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals
Age (yr) Substance Implicated In the Exposure Analgesics Acetaminophen only Adult formulations Pediatric formulations Unknown formulations Acetaminophen in combination with: Aspirin (with other ingredients) Aspirin (no other ingredients) Codeine Oxycodone Propoxyphene Other narcotics Other drugs, adult formulations Other drugs, pediatric formulations Aspirin alone Adult formulations Pediatric formulations Unknown formulations Aspirin in combination with: Codeine Oxycodone Propoxyphene Other narcotics Other drugs (adult formulations) Other drugs (pediatric formulations) Narcotics Codeine Meperidine Methadone Morphine Oxycodone Pentazoeine Propoxyphene Other/unknown Nonaspirin salicylates Other nensteroidal antiinflammatory drugs Colchicine Ibuprofen, OTC Ibuprofen, Rx Ibuprofen, unknown if OTC or Rx Indomethaein Other Unknown Phenacetin Phenazopyridine Salicylamide Other analgesic Unknown analgesic *Category totals Anesthetics Inhalation anesthetics Nitrous oxide Other/unknown Ketamine and analogs Local and topical anesthetic Other anesthetic Unknown anesthetic
Treated in Health Care Other AdvRxn Facility
Reason
No. of Exposures
<6
6-19
>19
Unint
27,566 36,106 9,197
6,760 32,858 2,618
10,429 2,788 3,152
9,329 390 2,993
11,998 15,200 35,555 402 3,897 5,128
2,621
1,024
779
713
1,455
26 7,108 2,853 5,180 7,878
12 1,346 384 734 956
6 1,425 355 669 1,222
5 3,817 1,826 3,380 5,021
12,401
2,259
2,956
219
36
33
4,965 628 9,955
1,653 521 2,067
1,622 83 3,826
714 328 64 46
119 51 14 10
104 39 7 5
2,374
509
9
Int
18 8 10
292 127 103
1,062
3
93
1,195
14 2,686 1,038 1,622 2,721
12 3,870 1,538 3,268 4,449
0 2 0 3 2
0 518 256 244 654
6,378
4,300
7,661
1
127
81
122
2,336 586 3,298
448 204 36 25
488
7
1,458 603 534 795 127 292 686 3,181 1,152
631 72 54 94 12 26 73 512 575
171 17,553 11,688
45 9,051 7,138
10,120 822 15,891 4 4 715 112 464 175 196,805
Outcome None
Minor
4,268 774 1,499
1,464 58 688
308 4 189
35 0 20
853
532
103
4
2
15 4,201 1,619 3,505 4,458
8 1,732 588 1,240 1,605
5 1,698 737 1,456 2,220
2 519 240 529 625
0 85 55 104 97
0 7 5 16 6
383
7,833
3,209
3,249
1,072
144
11
0
15
135
61
66
19
5
1
2,469 32 6,423
5 0 8
132 8 159
2,723 129 6,798
1,531 279 2,698
878 30 2,212
471 10 1,296
34 1 129
11 0 37
226 122 27 18
449 181 33 24
1 0 0 0
36 23 4 4
469 187 34 18
156 67 20 11
228 91 16 11
79 17 4 3
15 11 0 0
0 0 1 0
1,237
894
1,371
1
93
1,436
575
619
255
33
3
2
0
7
2
0
0
6
4
2
0
0
0
317 92 35 84 15 35 78 387 173
410 372 397 514 82 197 466 1,979 347
961 238 169 340 37 90 186 1,303 790
391 292 303 370 71 154 458 1,331 307
1 0 2 3 0 1 1 1 0
97 70 46 68 15 45 33 502 49
497 359 395 468 76 159 481 1,734 441
413 112 24 139 20 43 148 542 379
264 166 116 147 31 98 193 884 203
64 73 113 93 12 31 70 394 69
10 12 30 38 1 4 34 110 7
4 2 12 13 3 1 17 16 0
24 4,509 1,711
83 3,442 2,527
101 11,233 8,626
44 5,957 2,824
25 317 215
107 6,098 3,263
47 6,306 4,077
37 1,995 1,123
14 375 242
1 21 22
3 2 2
4,956 4,858 395 336 8 , 2 5 1 6,677 1 2 2 1 613 70 93 16 173 206 46 114 111,485 78,478
92
27I 89 919 1 1 30 3 83 13 6,036
4,806 386 7,157 3 3 231 34 240 109 88,585
3,555 249 5,327 2 1 320 66 88 33 59,407
1,567 171 2,642 1 1 93 8 102 37 30,670
372 51 676 0 1 16 2 42 13 10,177
3,525 3,119 226 129 4,933 3,673 1 1 2 0 534 68 87 11 87 58 27 71 81,643 44,580
1,481 21 3,515
2,925 409 6,273 2 2 101 12 282 66 61,834
1 6 , 6 1 1 9,096 4,433 10,931 5,733 2,852
Moderate Major Death
37 2 4 0 47 3 0 0 0 0 1 0 0 0 16 0 0 0 1,613 235
204 180 66
13 32 1
78 26 15
79 89 41
80 149 14
104 18 50
1 4 1
19 9 0
104 72 5t
26 22 5
43 74 19
21 13 10
5 6 7
0 3 0
5,797 16 3
4,14t 7 2
544 1 0
863 8 1
5,387 12 2
155 3 0
19 0 0
228 1 1
1,139 6 0
2,461 3 0
813 3 1
88 1 0
16 1 0
2 0 0
(Continued on folio wing page)
526
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Substance Implicated In the Exposure *Category totals Anticholinergic drugs Anticoagulants Heparin Warfarin (excluding rodenticides) Other Unknown *Category totals Anticonvulsants Carbamazepine Phenytoin Succinimides Valproic acid Other Unknown *Category totals Antidepressants Cyclic antidepressants Amitrintyline Amoxapine Desipramine Doxepin Imipramine Maprotiline Nortriptyline Protriptyline Other cyclic antidepressant Unknown cyclic antidepressant Cyclic antidepressant formulated with a benzodiazepine Cyclic antidepressant formulated with a phenothiazine Lithium MAO inhibitors Trazodone Other antidepressant Unknown antidepressant *Category totals Antihistamines H 2 receptor antagonists Diphenhydramine, unknown if OTC or Rx Diphenhydramine, Rx Diphenhydramine, OTC Other *Category totals Antimicrobials Antibiotics: systemic Antibiotics: topical Antibiotics: unknown Antifungals: systemic Antifungals: topical Antifungals: unknown Anthelmintics: diethylcarbamazine Anthelmintics: piperazine Anthelmintics: other Anthelmintics: unknown Antiparasitics: antimalarial
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason
Age (yr) >19
Unint
Int
Outcome None
Minor
Moderate Major Death
5,644 2,020
330 1,987
25 12
258 236
1,372 2,729
2,517 1,235
953 965
133 670
35 100
5 6
32
51
4
0
2
24
15
8
8
3
0
475 60 1 568
890 109 11 1,061
185 8 2 199
1 0 0 1
37 7 0 46
525 49 11 609
425 50 9 499
62 13 0 83
81 3 0 92
21 1 0 25
2 0 0 2
1,333 416 41 945 73 1 2,809
2,918 2,584 35 2,195 326 3 8,061
3,809 2,266 108 1,912 405 8 8,508
2,461 1,613 20 1,981 113 1 6,189
3 7 0 1 1 0 12
265 289 4 223 42 0 823
4,356 2,849 39 2,580 247 5 10,076
1,681 1,126 46 1,256 164 2 4,275
1,756 999 23 971 129 3 3,881
1,032 619 3 437 41 0 2,132
283 92 1 88 7 0 471
6 1 0 3 0 0 10
987 15 174 175 764 11 227 3
942 13 227 272 1,161 4 401 3
5,313 76 590 2,188 1,396 48 1,411 24
2,069 40 390 564 1,512 23 675 10
5,466 69 611 2,216 1,816 38 1,428 26
5 0 0 4 1 0 2 0
156 3 49 61 144 3 91 0
6,358 89 774 2,402 2,480 50 1,666 26
1,291 22 235 405 999 13 443 11
1,903 25 222 801 782 14 554 9
1,849 23 190 677 555 16 387 1
822 8 69 290 216 7 128 3
54 0 17 15 21 0 9 0
993
65
153
678
256
687
1
40
754
212
290
174
41
5
155
8
24
105
18
127
3
3
141
16
28
41
29
5
147
24
17
97
49
93
0
3
107
27
39
30
9
0
87 53 376 1,093 50 17 433 847 3,156 5,574 4 4 6,559 10,805
326 3,457 307 4,758 13,576 37 34,387
155 322 1,570 3,205 166 162 1,404 4,964 6,894 15,955 8 42 15,803 37,227
0 8 0 1 13 0 38
14 429 87 304 1,386 1 2,774
394 4,122 293 5,094 17,086 38 41,874
102 1,187 82 1,436 7,309 8 13,798
126 1,455 79 2,369 6,124 16 14,836
101 925 99 804 2,393 3 8,268
42 168 28 116 365 1 2,342
2 9 2 4 23 2 168
1,172
2
378
1,631
1,673
574
185
17
0
3,260 2,997 119 119 10,513 5,433 9,475 5,026 26,730 14,747
14 0 4 6 26
209 10 307 622 1,526
3,424 129 6,654 6,743 18,581
1,576 56 4,829 5,054 13,188
1,587 57 3,819 2,915 8,952
783 28 1,209 1,057 3,262
83 2 108 107 317
3 0 1 4 8
6,215 62 542 116 63 0
25 1 1 0 8 0
4,597 120 286 87 142 2
8,703 247 616 189 321 0
11,173 1,490 345 260 1,960 5
4,684 353 337 92 650 2
853 36 67 20 35 0
70 1 8 2 2 0
1 0 0 0 0 0
1 21 9 4 50
0 0 0 0 0
0 1 46 1 29
15 61 175 4 139
244 239 206 14 108
15 27 131 1 41
1 8 30 1 23
0 1 0 0 3
0 0 0 0 0
6,266 4,297
4,196 1,228
664 536
57
18
1
1,118 126 13 1,314
541 58 10 627
61 1 1 64
6,602 4,258 132 41149 563 9 15,713
2,044 978 52 741 121 5 3,941
7,784 113 1,061 2,874 3,491 64 2,213 36
496 5,313 420 6,716 24,358 51 56,285
678
1,081 2,296
4,933
2,010
1,991
6,523 250 16,292 15,193 43,191
2,187 74 8,281 5,778 18,330
1 , 3 8 1 2,636 45 114 2 , 5 4 1 4,908 3,464 5,228 8,109 14,877
43,904 6,357 1,711 940 7,953 18
25,226 4,789 501 514 6,257 11
7,264 476 493 125 418 1
640 635 711 37 271
442 480 364 22 92
29 66 73 2 37
3,363
9,523 32,964 859 6,168 583 878 250 737 1,001 7,739 5 16 148 77 198 10 118
639 612 653 32 191
(Continued on following page)
LITOVITZ ET AL •
TABLE 22B.
1995 A A P C C A N N U A L REPORT
527
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Substance Implicated In the Exposure
No. of Exposures
<6
6-19
Treated in Health Care Other Adv Rxn Facility
Reason
Age(y0
Outcome
>19
Unint
558 62 198 26 17 0 386 18 18 14 2 14,071 393
620 175 220 43 17 2 590 52 53 64 2 52,467 710
256 16 256 11 7 0 274 3 9 8 3 7,926 72
0 0 0 0 1 0 0 0 0 0 0 36 0
230 29 38 12 7 0 66 2 4 6 0 5,705 55
348 38 397 29 15 0 385 3 22 20 2 11,729 284
270 69 121 15 10 0 298 9 23 36 0 16,895 283
180 31 76 12 2 0 116 8 4 14 2 6,778 111
46 3 71 2 1 0 44 1 1 1 0 1,244 23
3 1 93 0 1 0 3 1 0 0 0 189 5
0 0 0 1 1 0 0 0 0 0 0 3 2
808
681
103
19
Int
None
Minor
Moderate Major Death
Antiparasitics:
metronidazole Antiparasitics: other Antituberculars: isoniazid Antituberculars: rifampin Antituberculars: other Antituberculars: unknown Antivirals: systemic Antivirals: topical Antivirals: unknown Other antimicrobial Unknown antimicrobial *Category totals Antineoplastics Asthma therapies Aminophylrine/theophylline Terbutaline and other beta-2 agonists Other beta agonists Other Unknown *Category totals Cardiovascular drugs Alpha blockers Antiarrhythmics Antihypertensives Beta blockers Calcium antagonists Cardiac glycosides Hydralazine Long-acting nitrates Nitroglycerin Nitroprusside Other vasodilator Unknown types of vasodilators Vasopressor Other cardiovascular drug Unknown cardiovascular drug *Category totals Cough and cold preparations Diagnostic agents Diuretics Furosemide Thiazide Other Unknown *Category totals Electrolytes and minerals Calcium Fluoride Iron Magnesium Potassium Sodium Zinc Other Unknown *Category totals
1,116 221 521 67 32 2 932 57 66 78 5 66,274 840
294 118 106 25 10 0 346 31 33 57 0 39,718 295
171 30 193 13 2 2 133 4 12 7 1 9,552 61
3,683
785
851
1,913
2,110
1,313
1
225
2,388
927
12,168 1,982 1,601 12 19,446
9,401 553 1,097 4 11,840
1,619 760 249 5 3,484
967 585 225 2 3,692
11,081 858 1,263 7 15,319
699 1,039 299 4 3,354
14 5 4 1 25
351 69 30 0 675
4,380 1,121 420 8 8,317
4,564 487 551 2 6,531
2,374 532 191 1 3,906
956 296 102 2 2,037
15 9 2 0 129
0 1 0 0 20
392 1,069 9,648 6,524 8,396 2,557 204 773 2,174 17 364
146 220 4,068 1,920 2,258 1,003 70 341 1,443 0 187
28 50 1,765 744 630 121 20 37 141 1 23
194 721 3,417 3,466 5,028 1,347 108 363 518 14 139
285 916 7,406 4,490 6,178 2,099 159 691 1,885 4 321
80 104 1,923 1,789 1,973 313 39 67 246 0 36
0 0 5 5 6 0 0 0 1 0 0
27 44 273 209 207 129 6 15 33 13 6
213 418 4,941 3,660 4,747 1,343 85 275 671 17 122
174 441 3,860 2,729 3,468 1,045 85 362 1,146 2 170
48 112 1,607 701 948 196 31 83 216 4 39
38 58 1,023 690 846 297 12 34 51 3 16
3 21 130 133 227 83 1 4 6 1 3
0 8 12 13 69 11 0 0 0 0 0
13 24 884
5 8 258
1 1 210
5 12 363
7 22 772
5 1 77
0 0 2
1 1 32
11 14 296
6
3
2 230
9 186
1 3 66
0 1 5
0 1 0
55 33,094 105,947 383
23 11,950 70,862 92
5 3,777 17,887 26
21 15,716 15,141 179
38 25,273 90,987 322
13 6,666 11,457 13
0 19 44 1
4 1,000 3,270 46
27 16,840 23,058 152
23 13,743 34,865 74
1 4,184 19,126 91
3 3,141 3,147 26
0 618 134 0
1 115 7 0
1,437 1,281 1,330 266 4,314
780 585 656 133 2,154
111 151 130 30 422
493 483 480 95 1,551
1,236 1,013 1,074 205 3,528
165 216 204 47 632
0 2 0 2 4
30 47 50 11 138
496 412 422 98 1,428
533 514 550 103 1,700
199 104 137 34 474
67 54 63 8 192
1 4 7 2 14
0 1 0 0 1
2,134 3,611 4,528 323 1,006 2,485 1,072 121 26 15,306
1,730 3,186 3,026 109 543 1,713 557 79
156 292 674 52 112 417 122 5
22
2
10,965
1,832
198 112 710 122 312 263 309 32 2 2,060
2,037 3,539 3,562 281 826 2,326 993 112 25 13,701
56 38 875 26 139 103 41 1 0 1,279
0 3 5 1 1 29 1 1 0 41
39 29 73 14 38 18 34 7 1 253
161 234 2,215 114 301 357 222 24 1 3,629
464 1,321 1,920 85 367 736 232 27 1 5,173
123 468 775 53 85 453 189 10 2 2,158
21 14 195 29 39 42 58 4 0 402
0 0 25 3 3 1 2 0 0 34
0 0 2 0 1 0 0 0 0 3
64 2,673 432 17
50 1,504 307 6
6 268 29 3
6 741 68 5
1 76 7 0
0 7 0 0
2 106 6 0
29 580 18 3
38 1,133 103 5
9 419 64 5
1 50 3 0
0 1 0 0
0 0 0 0
Eye~ear~nose~throat preparations Nasal preparations Tetrahydrazoline Other decongestant Other Unknown
61 2,480 419 17
(Continued on following page)
528
A M E R I C A N J O U R N A L OF E M E R G E N C Y MEDICINE • Volume 14, Number 5 • September 1996
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated Inthe Exposure Ophthalmic preparations Contact lens products Glaucoma therapies Tetrahydrazoline Other ophthalmic sympathomimetics Other Unknown Otic preparations Combination products Other Unknown Steroids-topical for eye/nose/throat Throat preparations Lozenges without local anesthetics Lozenges with local anesthetics Other Unknown *Category totals Gastrointestinal preparations Antacids: salicylate-containing Antacids: other Antidiarrheals: diphenoxylate Antidiarrheals: nonnarcotic Antidiarrheals: paregoric Antidiarrheals: other narcotic Antispasmodics: anticholinergic Antispasmodics: other Laxatives Other Unknown *Category totals Hormones and hormone antagonists Androgens Corticosteroids Estrogens Insulin Oral contraceptives Oral hypoglycemics Progestins Thyroid preparations Other hormones Other hormone antagonists Unknown hormones or antagonists *Category totals Miscellaneous drugs AIIopurinol L-dopa and related drugs Disulfiram Ergot alkaloids Homeopathic preparations Methylsergide Neuromuscular blocking agent Other *Category totals
No. of Exposures
<6
6-19
Treated in Health Care Other AdvRxn Facility
Reason >19
Unint
Int
Outcome None
Minor
Moderate Major Death
3,782 152 1,882
2,176 52 1,337
314 10 181
995 72 293
3,721 130 1,717
26 4 58
10 0 83
14 17 15
519 30 818
708 39 1,033
725 40 217
156 8 27
5 0 3
0 0 0
290 598 18
168 318 5
31 63 3
72 177 6
250 536 14
9 19 0
0 2 1
30 41 1
91 58 5
117 91 3
44 98 3
10 13 0
0 2 0
0 0 0
987 1,886 44
719 1,052 20
103 220 7
132 505 14
978 1,863 44
3 6 0
0 0 0
6 17 0
108 181 7
366 420 9
220 589 15
14 29 1
0 0 0
0 0 0
1,004
530
164
246
907
37
0
59
86
187
177
16
0
0
705
536
75
74
665
18
2
20
40
172
63
5
1
0 0
293 427 5 15,259
189 252 4 9,225
67 113 1 1,658
30 46 0 3,482
273 381 4 14,460
10 39 0 313
0 0 0 105
9 7 1 351
15 94 0 2,682
78 156 1 4,659
22 73 0 2,783
3 7 0 343
0 2 0 14
0 0 0
2,562 18,931
2,155 17,228
207 720
166 813
2,406 18,559
67 199
1 26
88 140
223 507
892 4,363
131 496
12 38
1 2
1 0
1,390 644 122
720 508 94
184 48 6
432 73 17
1,023 598 102
231 19 11
4 2 0
124 24 7
676 52 46
565 137 50
239 32 23
66 8 4
5 2 0
1 0 0
4
2
2
0
4
0
0
0
1
3
0
0
0
0
1,539 9 13,614 4,278 912 44,005
591 4 9,843 3,287 490 34,922
307 2 1,426 315 58 3,275
570 3 1,991 574 296 4,935
878 7 12,292 3,786 688 40,343
568 1 857 320 137 2,410
0 0 168 10 0 211
82 1 276 153 83 978
819 1 1,933 773 221 5,252
514 2 2,917 1,233 316 10,992
342 1 2,774 325 61 4,424
146 1 275 110 8 668
19 0 7 9 4 49
1 0 1 0 0 4
198 6,396 2,805 1,118 7,795 2,815 1,254 5,338 322 232
41 3,833 2,050 75 6,596 1,381 706 3,385 120 95
50 741 188 78 753 230 178 525 50 26
88 1,511 483 856 339 1,084 318 1,224 124 95
88 5,539 2,560 780 7,271 2,214 1,058 4,853 226 188
87 398 168 309 431 518 110 410 57 35
0 2 1 5 12 2 1 2 0 1
21 443 72 17 67 65 84 67 35 8
84 783 314 485 567 2,067 187 1,069 125 67
23 1,446 803 388 1,657 1,264 320 1,658 96 85
20 424 116 105 272 291 60 236 71 14
13 84 22 180 19 527 17 85 25 8
2 7 1 21 1 51 1 5 2 0
0 0 0 3 0 3 0 1 0 0
22 28,295
9 18,291
3 2,822
5 6,127
14 24,791
2 2,525
0 26
2 881
8 5,756
3 7,743
0 1,609
2 982
0 91
0 7
349 421 526 631 2,968 5
214 163 24 267 1,980 3
30 11 19 92 256 1
95 221 388 240 602 1
294 365 149 387 2,372 3
44 36 297 174 262 2
0 0 4 1 4 0
11 17 70 66 316 0
90 140 302 365 633 2
144 151 52 218 1,006 1
20 64 133 159 340 1
5 21 96 52 73 0
3 3 4 1 7 0
1 1 0 0 1 0
7 9,400 14,307
1 4,345 6,997
0 1,069 1,478
4 3,391 4,942
6 7,081 10,657
0 1,672 2,487
0 24 33
1 585 1,066
3 2,796 4,331
2 2,757 4,331
2 1,653 2,372
0 534 781
0 73 91
0 0 3
(Continued on following page)
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Muscle relaxants Cyclobenzaprine Methocarbamol Other Unknown *Category totals Narcotic antagonist Radiopharmaceuticals Sedative/hypnotics/ antipsychotics Barbiturates: long-acting Barbiturates: short-acting Barbiturates: unknown type Benzodiazepines Chloral hydrate Ethchlorvynol Glutethimide Meprobamate Methaqualone Phenothiazines Sleep aids (OTC) Other Unknown *Category totals Serum, toxoids, vaccines Stimulants and street drugs Amphetamines Amyl/butyl nitrites Caffeine Cocaine Diet aids: phenylpropanolamine Diet aids: phenylpropanolamine and caffeine Diet aids: other, OTC Diet aids: other, Rx Diet aids: unknown Heroin LSD Marijuana Mescaline/peyote Phencyclidine Phenylpropanolamine look-alike drugs Other stimulants Other hallucinogens Unknown hallucinogens Other street drugs Unknown stimulant/street drugs *Category totals Topical preparations Acne preparations Boric acid/borates Calamine Camphor Camphor/methyl salicylate Diaper products Hexachlorophene antiseptic Hydrogen peroxide Iodine or iodide antiseptics Mercury antiseptics Methyl salicylate Podophyllin Silver nitrate Topical steroids
No. of Exposures
<6
6-19
>19
Unint
3,641 1,112 5,444 38 10,235 103 14
657 134 565 1 1,357 6 0
588 209 624 12 1,433 5 1
2,142 664 3,826 23 6,655 77 11
3,475 1,481 2O 37,044 480 161 19 274 6o 11,577 2,498 5,874 308 63,271 1,455
798 146 1 4,522 121 13 2 26 4 1,441 159 461 19 7,713 370
379 183 4 3,272 37 9 4 21 18 1,679 428 685 50 6,769 155
2,057 1,020 13 25,935 292 127 13 211 29 7,566 1,698 4,180 192 43,333 696
12,981 92 7,655 3,875
3,634 12 1,174 135
5,177 18 4,335 496
3,514 46 1,782 2,847
7,345 35 2,600 325
1,703
515
701
429
332 261 280 187 1,156 1,708 1,734 189 426
81 125 127 51 9 32 90 57 19
139 70 29 65 69 1,142 888 49 154
97 1,032 3 13 24
12 207 0 0 1
53 408 2 5 13
81 33,829
Treated in Health Care Other Adv Rxn Facility
Reason
None
Minor
2,289 709 3,738 31 6,767 51 0
0 1 4 0 5 1 0
81 33 201 1 316 30 3
2,617 740 3,862 25 7,244 71 5
847 254 960 4 2,065 10 3
1,766 1,562 418 987 1 19 8,879 27,103 159 277 29 124 2 17 72 193 6 50 3,775 6,976 385 2,072 1,515 3,997 39 250 17,046 43,627 1,013 17
5 2 0 48 4 1 0 0 2 17 8 7 1 95 1
87 58 0 760 36 4 0 6 0 701 22 301 14 1,989 416
2,116 1,051 20 27,566 364 135 15 215 46 8,719 1,940 4,216 223 46,626 468
823 271 2 6,602 68 12 0 50 3 2,627 491 1,119 36 12,104 120
5,122 53 4,704 3,440
81 1 24 39
349 1 292 16
6,925 44 3,627 3,422
758
878
0
57
99 61 114 58 964 409 598 70 220
147 159 179 73 88 153 254 139 49
171 66 71 91 1,030 1,467 1,409 42 353
0 1 0 0 18 74 21 3 8
28 353 1 8 9
23 288 0 1 6
69 716 3 8 17
7 64 12,629 19,774
3 38 33 6,284 13,851 11,643
1,255 358 1,460 5 3,078 20 10
Int
Outcome
527 89 724 2 1,342 15 1
99 18 167 0 284 0 0
4 0 6 0 10 0 0
847 452 8 12,844 175 53 4 57 17 3,016 731 1,979 94 20,277 368
466 179 4 4,265 82 40 3 50 7 2,192 356 687 33 8,364 82
160 54 2 837 30 16 3 18 3 355 43 117 1 1,639 3
5 4 1 55 2 1 0 0 0 25 1 3 0 97 0
3,568 15 1,070 468
2,676 25 2,538 837
1,781 4 1,021 1,014
189 1 18 250
27 0 0 49
1,001
536
350
258
6
0
12 33 27 23 9 8 28 5 0
213 91 163 108 1,001 1,240 1,184 62 375
70 82 104 39 70 104 132 10 22
74 38 51 50 197 377 432 61 99
43 14 31 22 294 566 322 37 144
2 0 4 0 157 19 41 0 38
0 0 1 0 26 0 3 0 2
1 3 0 4 1
4 16 0 0 0
68 676 1 9 15
18 228 0 0 2
28 278 1 1 5
23 195 0 7 4
0 9 0 0 2
0 0 0 0 0
7 286
5
6,543
17 5,797
0
20,291
27 8,145
2
882
738
108
2
66
1,078 331 1,831 11 3,251 27 4
Moderate Major Death
1,732 381 4,838 8,914 1,273 19,164
847 256 3,853 7,101 995 17,747
453 24 242 575 68 701
327 90 638 1,029 187 576
1,545 365 4,781 8,684 1,216 19,109
23 10 34 152 17 35
3 0 1 15 2 4
158 3 22 58 38 16
206 39 268 1,314 167 256
367 103 1,161 3,850 518 4,179
416 50 332 1,374 235 673
76 4 14 76 11 17
0 0 1 5 1 1
0 0 0 0 0 0
124 7,195 1,588 480 9,820 64 161 6,625
65 3,648 608 384 7,101 24 19 4,850
13 764 246 37 873 6 58 425
36 2,339 592 51 1,510 27 62 1,064
109 7,011 1,355 457 9,667 55 147 6,499
9 139 171 17 54 3 4 39
0 9 8 1 16 0 0 2
4 26 46 4 82 6 9 80
31 469 392 58 953 24 37 189
37 1,484 427 195 3,005 15 18 1,193
23 1,552 371 32 2,232 12 61 447
1 78 52 6 80 9 8 28
0 3 5 0 4 0 0 1
0 0 1 0 1 0 0 0
(Continued on following page)
TABLE 22B.
Demographic Profile of Exposure Cases by Generic Category of Substances and Products: Pharmaceuticals (Cont'd)
Age (yr) Substance Implicated In the Exposure Topical steroid with antibiotics Wart preparations Other liniment Other topical antiseptic *Category totals Veterinary drugs Vitamins Multiple vitamins tablets: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with flouride Multiple vitamin tablets: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamin liquids: pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified adult formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Multiple vitamins, unspecified pediatric formulations No iron, no fluoride With iron, no fluoride With iron, with fluoride No iron, with fluoride Other vitamins Vitamin A Niacin (B3) Pyridoxine (B6) Other B complex vitamins Vitamin C Vitamin D Vitamin E Other Unknown *Category totals Unknown drugs Total number of pharmaceutical substances % of pharmaceutical substances % of all substances
No. of Exposures
<6
6-19
1,583 1,654 1,975 4,553 72,124 3,614
1,225 1,084 1,070 2,998 53,875 2,057
2,223 4,934 99 122
1,498 3,414 82 119
260 605 10 2
8,138 15,419 618 1,478
7,138 13,810 592 1,402
57 91 3 2
Treated in Health Care Other Adv Rxn Facility
Reason >19
Unint
None
Minor
Moderate Major Death
1,534 1,583 1,814 4,387 70,318 3,568
17 35 16 94 869 32
3 6 1 13 84 1
27 27 142 58 806 10
85 191 178 516 5,373 312
384 462 420 1,536 19,354 1,114
163 343 629 702 9,647 559
9 49 29 55 602 47
1 0 0 4 26 5
0 0 0 0 2 0
393 775 5 0
1,835 4,089 89 121
212 649 9 1
3 4 0 0
169 177 1 0
306 1,209 25 6
636 1,963 44 46
220 457 12 7
24 51 0 0
1 4 0 0
0 1 0 0
936 1,486 21 66
38 93 3 6
6,002 15,144 613 1,473
101 218 2 5
1 1 0 0
29 45 0 0
254 2,223 50 56
2,675 6,646 164 494
270 1,199 42 50
3 74 2 0
0 2 0 0
0 0 0 0
33 46 2 2
8 11 0 0
14 33 0 0
47 71 3 2
2 13 0 0
0 1 0 0
8 6 0 0
9 20 1 0
12 29 0 1
13 5 0 1
0 1 0 0
0 0 0 0
0 0 0 0
260 472 98 460
244 460 97 429
11 7 1 26
4 5 0 5
256 458 98 459
1 4 0 0
0 3 0 0
3 7 0 1
19 44 5 19
62 155 40 178
19 27 6 20
0 2 0 0
0 0 0 0
0 0 0 0
45 1,688 9 4
34 1,219 8 3
2 245 0 0
8 188 1 1
38 1,461 8 3
3 175 0 0
0 3 0 0
3 41 1 1
3 447 1 1
11 699 2 1
2 163 0 1
1 20 0 0
0 2 0 0
0 0 0 0
47 74 6 14
41 64 5 13
6 8 1 1
0 1 0 0
44 73 5 14
2 1 1 0
0 0 0 0
0 0 0 0
2 14 1 0
12 44 1 8
4 5 1 0
0 0 0 0
0 0 0 0
0 0 0 0
947 2,260 321
690 446 220
76 275 31
150 1,325 55
856 1,030 264
44 136 41
0 2 1
40 1,089 14
117 247 55
261 103 97
58 1,081 21
13 80 8
1 2 5
0 0 0
1,318 2,193 141 1,207 609 595 45,952 9,918
871 1,710 86 976 414 385 36,553 3,624
86 257 6 84 54 87 4,669 1,910
294 183 40 112 121 99 3,952 3,462
1,082 2,017 120 1,115 509 493 41,892 5,394
105 123 13 60 39 58 2,018 3,590
0 3 0 1 2 3 28 221
124 45 8 28 57 38 1,935 474
147 103 26 80 116 125 5,731 5,600
293 609 32 347 158 162 15,985 2,625
137 119 11 39 87 62 4,139 1,597
22 6 3 3 10 12 335 809
1 0 1 0 1 0 20 171
0 0 0 0 0 0 1 1
618,777255,036
1,473
32,978
339,005
261,831 156,370
55,114
9,157
818
0.2% 0.1%
3.6% 1.5%
37.2% 15.6%
6.0% 2.5%
1.0% 0.1% 0.4% 0.0%
911,856
42.1%
124 187 228 277 161 599 503 864 5,501 10,455 280 1,038
Int
Outcome
445,674 146,415 276,735 48.9% 20.6%
16.3% 6.8%
30.3% 12.8%
67.9% 28.5%
28.0% 11.8%
28.7% 12.1%
NOTE: Patients with unknown age, reason, or medical outcome were omitted from the respective tabulations. ABBREVIATIONS:Adv Rxn, adverse reaction; Int, intentional; Unint, unintentional.
17.1% 7.2%
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
REFERENCES 1. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1984;2:420-443 2. Litovitz TL, Veltri JC: 1984 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1985;3:423-450 3. Litovitz TL, Normann SA, Veltri JC: 1985 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1986;4:427-458 4. Litovitz TL, Martin TG, Schmitz B: 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1987;5:405-445 5. Litovitz TL, Schmitz BF, Matyunas N, et al: 1987Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1988;6:479-515 6. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989;7:495-545 7. Litovitz TL, Schmitz BF, Bailey KM: 1989 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1990;8:394-442 8. Litovitz TL, Bailey KM, Schmitz BF, et al: 1990Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1991;9:461-509 9. Litovitz TL, Holm KC, Bailey KM, et al: 1991 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1992; 10:452-505 10. Litovitz TL, Holm KC, Clancy C, et al: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993; 11:494-555 11. Litovitz TL, Clark LR, Soloway RA: 1993 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-584 12. Litovitz TL, Felberg L, Soloway RA, et al: 1994 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1995; 13:551-597
APPENDIX Drug and chemical levels provided in these abstracts were obtained on blood, serum, or plasma unless otherwise indicated. Case 31. A 46-year-old man presented 3 days after an exposure to antifreeze with nausea, vomiting, and abdominal cramping of 2 days' duration. He stated that some of the chemical had been ingested when he was "splashed" with radiator fluid while working. There were no witnesses to corroborate the exposure history. Clinical findings included a diminished urine output and intractable vomiting. Initial laboratory results were as follows: arterial pH, 7.39; creatinine, 10.8 mg/dL; blood urea nitrogen (BUN), 78 mg/dL; and white blood cell count, 20,500/pL. The urinalysis showed amorphous crystals, sloughed renal cells, 3+ leukocyte esterase, 4 + proteinuria, moderate blood, mad >50 white blood cells. The patient became dialysis-dependent and was discharged from the hospital. Three weeks later, he presented with seizure activity, decorticate posturing, and deficits of cranial nerves V, VII, and IX. Computed tomography (CT) of the head showed white matter changes, and the cerebrospinal fluid (CSF) was remarkable for elevated protein. The patient died 26 days after the exposure. Case 32. A 57-year-old man with a history of Parkinson's disease, chronic obstructive pulmonary disease (COPD), sleep apnea, right heart failure, chronically elevated creatine phosphokinase, and previous myocardial infarction was found stumbling and disoriented by his wife. There was no initial history of overdose. Four hours later in the emergency department (ED), his mental status further deteriorated and he was intubated. CT of the head was negative. Laboratory study results showed the following: ethylene
531
glycol, 177 mg/dL; lactate, 4.8 retool/L; osmolal gap, 35 rnosm/L; anion gap, 40 mEq/L; sodium, 147 mEq/L; potassium, 3.8 mEq/L; chloride, 100 mEq/L; bicarbonate, 7 mEq/L; BUN, 15 mg/dL; creatinine, 2.4 mg/dL; calcium, 7.6 mg/dL; white blood cell count, 35,900/gL; ionized calcium, 0.6 mmol/L; arterial pH, 7.01; Pco2, 29.3 mm Hg; and Po2, 224 mm Hg. The urinalysis showed more than 50 red blood cells/high-powered field (HPF), 26 white blood cells/HPF, and hippuric acid crystals. The electrocardiogram showed ST elevations in leads V~ to V3 with ST depressions in the anterolateral leads. Subsequent treatment included intravenous ethanol, 4-methylpyrazole, large doses of sodium bicarbonate, and hemodialysis. The patient suffered a myocardial infarction and developed refractory hypotension, unresponsive to dopamine, norepinephrine, and epinephrine. He died 36 hours postingestion. Case 44. A 66-year-old man with a history of prostate cancer with liver and bone metastases was attacked by a swarm of bees while reading the newspaper in his backyard. On initial evaluation, 25 stingers were noted on his head with additional stings noted about the shoulders, chest, back, and upper and lower extremities. One bee was found inside his mouth. Initial vital signs included: blood pressure, 160/100 mm Hg; pulse, 100 beats/min; and respirations, 18 breaths/min. En route to the hospital, the patient became light-headed and vomited. He was hypertensive on arrival to the hospital, and except for multiple stings, the physical examination was unremarkable. In all, 120 stingers were removed from his body. Over the next 24 hours, he developed disseminated intravascular coagulation (DIC), rhabdomyolysis, renal dysfunction, elevated liver function tests, and pulmonary edema. He died from renal failure 5 days after admission. Case 45. An 88-year-old woman with a history of chronic abdominal pain treated with oral meperidine opened the door to a shed in her backyard and was suddenly enveloped in a swarm of bees. She collapsed at the scene after sustaining several hundred bee stings. The patient's initial vital signs were as follows: pulse, 100 beats/min; blood pressure, unobtainable; respirations, 28 breaths/min. Initial therapy included intravenous fluids, diphenhydramine, methylprednisolone, and military antishock trousers (MAST). At the hospital, blood pressure increased to 194/90 mm Hg and the patient complained of increasing abdominal pain. Laboratory studies were remarkable for a platelet count that decreased from an initial 232,000/~L to 32,000/pL and a decreasing hematocrit over the next 48 hours. Transfusions of platelets and packed red blood cells were required. Myoglobinuria developed, and she was treated with intravenous fluids, sodium bicarbonate, and furosemide. After the patient developed rebound and guarding, a laparotomy was performed. Findings included diffuse necrosis of the entire small and large intestine and complete necrosis of the colon. Supportive care was withdrawn and the patient died on the 4th hospital day. Case 46. A 35-year-old man sustained a bite to the region of the right radial artery while playing with a Crotalus horridus atricaudatus (canebrake rattlesnake). The patient was asystolic when emergency medical services (EMS) arrived 30 minutes later. The bite area was swollen and discolored. Resuscitative efforts were not successful. At autopsy, no tissue necrosis was noted. The postmortem blood ethanol level was 250 mg/dL. No other drugs were detected. Case 48. A 53-year-old woman ingested an unknown amount of cyanide in the hospital shortly after seeing her psychiatrist. She was found in respiratory arrest, with a junctional rhythm, hypotension (systolic blood pressure 80 to 90 mm Hg by palpation), and acidosis. The cyanide antidote kit was administered without significant improvement. Seizure activity developed. Dopamine and second doses of cyanide antidote medications were administered, with improvement in the blood pressure and restoration of the cardiac rhythm. The patient remained unresponsive and was declared brain dead 21 hours postingestion. The heart, liver, and
532
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
both kidneys were harvested for organ transplantation. Pertinent laboratory studies were: initial arterial pH, 7.12; Pco2, 20 mm Hg; Po2 300 mm Hg; repeat arterial pH, 7.48; Pco2, 25 mm Hg; Po2, 364 mm Hg; creatine phosphokinase, 1,500 IU/L; MB fraction, 5%; lithium, 0.55 mEq/L; toxicology screen, negative. Serial plasma cyanide levels were: 15 minutes postingestion, 6.75 ~g/mL; 2.3 hours postingesfion, 17.4 pg/mL; 14 hours postingestion, 0.99
~,g/mL. Case 60. A 24-year-old graduate student, found by paramedics in the hallway of his research building, admitted to the ingestion of rat poison (later identified as sodium azide). At the scene, he was lethargic and hypotensive. On arrival to the ED, vital signs were: blood pressure, 107/46 mm Hg; pulse, 133 beats/min; respirations, 32 hreaths/min; temperature, 36.2°C. He was diaphoretic with clenched teeth and upward, rightward ocular deviation. He withdrew to pain with only the right hand. Initial treatment included gastric lavage, activated charcoal, and sodium thiosulfate 5 grams intravenously. Within 1 hour, hypotension (blood pressure 60/40 mm Hg) and a junctional escape rhythm developed. Minutes later, the patient was asystolic and did not respond to atropine, epinephrine, sodium bicarbonate, dopamine, or external pacing. Initial laboratory results were as follows: arterial pH, 7.49; Pco2, 17 mm Hg; sodium, 143 mEq/L; potassium, 3.1 mEq/L; chloride, 102 mEq/L; bicarbonate, 22 mEq/L; anion gap 19 mEq/L. Autopsy findings included acute parahippocampal focal neuronal necrosis, mild cerebral edema, diffuse congestion of the lungs, liver, spleen, and kidneys, acute tubular necrosis, and early myocardial necrosis. Postmortem blood sodium azide level was 5.58 mg/mL. Case 62. A 43-year-old man was the victim of a sodium azide explosion at the work site. He suffered burns over 60% of his body and multiple fractures. At the scene, he was noted to have pulmonary edema and hypotension, and was treated with intubation, neuromuscular paralysis, and epinephrine. Multiple boluses of caicium and magnesium were administered. In the ED, twitching was noted, although the patient was still partially paralyzed. The initial carboxyhemoglobin level was 14%. Hemodynamic instability worsened with blood pressure and pulse rate fluctuations from 30 to 100 mm Hg systolic and 110 to 140 beats/rain, respectively. Pulmonary edema, renal failure, and severe metabolic acidosis persisted, despite treatment with epinephrine and sodium bicarbonate infusions. The patient died approximately 24 hours after the explosion. Case 73. A 40-year-old woman with a history of renal, thyroid, and psychiatric disease ingested three ounces of rust stain remover (6% to 8% hydrofluoric acid) in a suicide attempt. She presented to the ED 90 minutes after ingestion, after six episodes of spontaneous emesis. She denied throat irritation, abdominal pain, or shortness of breath. Physical findings were remarkable for the absence of oral burns, drooling, respiratory distress, or chest or abdominal abnormalities. Vital signs were as follows: pulse rate, 124 beats/rain; blood pressure, 102/63 mm Hg; and respirations, 20 breaths/min. The electrocardiogram showed sinus tachycardia with a QTc interval of 0.35 seconds, and nonspecific T wave flattening in the lateral leads. The patient later developed ventricular fibrillation only minutes after appropriately conversing with a nurse. Defibrillation, calcium gluconate, magnesium sulfate, and cardiac pacing were not effective. The serum calcium at the time of cardiac arrest was 7.2 mg/dL. Case 88. A 75-year-old man with a history of diabetes and emphysema intentionally ingested Pomswnon Oil (a liniment containing cinnamon oil, peppermint oil, tea tree oil, licorice, dragon's blood, and skullcap) along with another reportedly identical herbal liniment preparation. Within 1 hour, he developed vomiting and was taken to the ED. On arrival, his systolic blood pressure was 86 mm Hg and his pulse rate was 140 beats/rain. The patient then seized and suffered a cardiac arrest. Resuscitative efforts were unsuccessful and he died within I hour.
Cases 111 and 120. A 75-year-old woman was found dead in bed at home. The postmortem carboxyhemoglobin level was 45%. (Her 47-year-old daughter was also found dead inside a vehicle in the attached garage. A hose was found connected to the exhaust pipe and the driver's window of the car. The daughter had a history of depression and had left a suicide note). Case 135. A 34-year-old man with a history of narcotic and ethanol abuse and Parkinson's disease was brought to the El) with altered mental status. Two hours earlier, he had reportedly ingested 8 ounces of a liquid from an unmarked bottle, thought initially to contain the herbicide glyphosate, along with his antiparkinsonian medications, carbidopa/levodopa. Initial vital signs were: pulse, 120 beats/rain; blood pressure, 156/116 mm Hg; and respirations, 18 breaths/rain. He was noted to have mydriasis and hyperreflexia. Initial treatment included gastric lavage and activated charcoal. Within 8 hours, hyperpyrexia, seizures, and hypotension developed. Respiratory failure, hemodynamic instability, and renal failure developed. The patient died 37 hours after ingestion. Of note, the family later brought a bottle which contained the black liquid that had been ingested. It was identified as diquat. Serum and gastric diquat levels were 4.9 pg/mL and 1.1 lag/mL respectively, 23.7 hours postingestion. The paraquat assay was negative. Case 140. An 18-month-old boy was left unattended outside. His parents had borrowed charcoal lighter fluid from the neighbors to start a fire, and left the unused portion outdoors in a bowl. Following ingestion of the lighter fluid, the child developed vomiting and seizure activity. Initial treatment included lorazepam and intnbation, with high pressure ventilation. The initial chest X-ray showed a possible infiltrate in the left lower lobe. Clinical and radiographic deterioration occurred. On hospital day 2, extracorporeal membrane oxygenation (ECMO) therapy was initiated. The chest X-ray showed bilateral "white out." Life support was removed on hospital day 4. Autopsy findings included diffuse alveolar damage, pneumonia, and diffuse ischemic neuronal injury. Case 144. A 12-year-old boy was found face down in the bathtub, in cardiopulmonary arrest by his father. He had not been seen for a prolonged period of time. Along with the patient, a rubber hose and spray can containing an unknown substance were found in the water. The presenting cardiac rhythm was asystole which did not respond to prolonged resuscitative efforts. Autopsy findings included nasal injury consistent with inhalant abuse and blood and lung samples positive for difluoroethane. The patient's older brother later admitted to teaching him how to "huff" a few weeks earlier. Case 147. A 13-month-old girl ingested an unknown quantity of lighter fluid. Initial symptoms included coughing and difficulty breathing. In the ED, the child developed seizures and cyanosis. Despite intubation, she died within 3 hours of arrival. Case 151. A 74-year-old man inhaled a spray cleaner (sodium hydroxide >0.5%) for most of an entire day while cleaning his boat in an enclosed garage. That evening, he developed dyspnea, which became progressively worse over the next 5 days. On presentation to the hospital, intubation, intravenous steroids, and high concentrations of oxygen (FIo2, 0.70) were required to support respirations. Later, multiple attempts at weaning were unsuccessful and he died on hospital day 15. An open lung biopsy showed acute lung injury consistent with toxic pneumonitis. Case 156. A 31-year-old farmer who had been spraying disod i m methyl arsonate for 2 weeks presented with diarrhea, weakness, and inability to walk. The patient was admitted for dehydration and developed progressive renal failure, coagulopathy, fluid overload, and hypotension. Despite treatment with 3 to 4 doses of dimercaprol (5 mg/kg), the patient died approximately 5 days later. Case 160. A 73-year-old man was found unconscious in his back yard. An empty container of earharyl was found nearby. Further search of the area suggested that the patient may have also ingested
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malathion. He was intubated at the scene. In the ED, vital signs were: pulse, 80 to 100 beats/rain; respirations, 40 breaths/min, and temperature, 33.3°C. Copious diarrhea and respiratory secretions, miosis, and fasciculations of the eyelids and chest wall were noted. Atropine was administered to decrease secretions. Pralidoxime bolus and infusion therapy were initiated. Fluids and dopamine were given for hypotension and a Swan-Ganz catheter was placed. His mental status remained depressed, although he would occasionally respond to verbal or painful stimuli. The patient developed renal failure and hypotension that was refractory to fluids and increasing doses of vasopressors. By day 4 he was flaccid with fixed pupils and metabolic acidosis. He expired on the 6th hospital day. An initial plasma cholinesterase level was 0.3 KU/L (reference range 4.5 to 10.3 KU/L). Case 166. An 11-month-old girl presented with cold symptoms and a productive cough of unknown duration culminating in a seizure episode just prior to arrival to the ED. Home therapy included steam and topical and oral administration of cayenne pepper and ground garlic in oil. The child was limp and unresponsive with the following vital signs: pulse, 220 beats/min; respirations 52 breaths/min; temperature, 40.8°C. The skin, face, and oropharynx were covered with cayenne pepper. Treatment included intubation, antibiotics, vasopressors, lorazepam, and phenobarbital. Thirty-six hours later, hypertension, bradycardia, and fixed, dilated pupils were noted. CT of the head showed cerebral edema. The child was declared brain dead on hospital day 3. Pertinent laboratory results included: sodium, 142 mEq/L; potassium, 7.7 mEq/L; chloride, 109 mEq/L; BUN, 32 mg/dL; bicarbonate, 15 mEq/L; creatinine, 1.5 mg/dL; glucose, 44 mg/dL; white blood cell count, 28,800/gL; platelets, 419,000/gL; hemoglobin, 12.7 gm/dL; with no CSF red or white blood cells. The chest X-ray showed fight upper lobe atelectasis and bilateral perihilar infiltrates. Autopsy findings included localized edema of the trachea. Case 167. A 39-year-old man drank an herbal tea made from an unknown root from the Dominican Republic and developed vomiting, increased salivation, and incontinence. Physical findings included pinpoint pupils, fasciculations, a blood pressure of 200/100 mm Hg and a pulse rate of 98 beats/rain. Treatment included intubation, naloxone (8 mg without response), and atropine (10 mg). Despite the above therapy, the patient developed hypotension and suffered a cardiac arrest. Depressed plasma cholinesterase levels were subsequently reported. Case 168. A 12-week-old Hispanic boy had a history of rhinorrhea and mild cough for 3 days. No bowel or bladder changes were noted and adequate oral intake was maintained. One evening before admission, he was treated with acetaminophen, an antihistamine/decongestant (brompheniramine/phenylpropanolamine), and 4 ounces of tea made from 3 to 4 leaves from a plant growing in the aunt's yard. The following morning the child was found to be floppy, in respiratory distress, with "eyes rolled back." On arrival to the ED, the child had a respiratory rate of 80 breaths/rain. The arterial pH was 7.22 and the blood glucose was 29 mg/dL. Treatment included intubation, 15% dextrose, normal saline, and albumin. Subsequent laboratory studies included: pH, 7.02; Pco2, 65 mm Hg; PTT, >150 seconds; international normalized ratio (INR), 4.7; fibrin split products, >80 ~tg/mL; d-dimers, >200; fibrin monomer, positive; hematocrit, 21.5%; total bilirnbin, 1.1 mg/dL; aspartate transaminase (AST), 3,225 IU/L; alkaline phosphatase, 351 IU/L; potassium, 7.7 mEq/L; BUN, 23 mg/dL; creatinine, 2.1 mg/dL. Drug screens were negative for acetaminophen and salicylates. Hypocalcemia was also noted. Additional testing revealed cerebral edema on CT scan, left ventricular hypokinesis on echocardiogram, pulmonary edema, and oliguria. Subsequent treatment included blood transfusions, sodium polystyrene sulfonate, glucose, insulin, furosemide, ampicillin, cefotaxime, clindamycin, ganciclovir, ranitidine, vitamin K, and N-
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acetylcysteine. Fulminant hepatic failure developed, and liver transplantation was considered. Metabolic acidosis and renal and hepatic dysfunction progressed with the following laboratory results: BUN, 25 mg/dL; creatinine, 1.8 mg/dL; ammonia, 173; INR, 5.2; total bilirubin, 4.4 mg/dL; AST, >4500 IU/L; and alkaline phosphatase, 309 IU/L. The child died before liver transplantation. Antemortem blood was qualitatively positive for pulegone (pennyroyal) at approximately 2.5 days postingestion (limit of detection, 20 pg/mL). Case 169. A 74-year-old woman was found unresponsive and was suspected to have suffered a stroke. On physical examination, there were multiple ecchymotic skin lesions and a teal color staining of her teeth. In her pockets were several teal colored pellets later identified as brodifaenum. In addition to hypoglycemia and elevated liver function tests, initial laboratory results included a PT of 21 seconds and platelet count of 8,000/i.tL. Treatment included activated charcoal, vitamin K, platelet and fresh frozen plasma transfusions. She died 28 hours later. Postmortem blood revealed a brodifacoum level of 9.5 ng/mL. Case 171. An 83-year-old man with a history of lymphoma admitted to the ingestion of rat poison 30 to 45 minutes earlier. After an apparent seizure, he was found by paramedics to be diaphoretic and not responding verbally, with a blood pressure of 160/70 mm Hg and a pulse rate of 116 beats/rain. On arrival to the ED, he was lethargic, answered questions, and exhibited intermittent periods of screaming, neck extension, and "shaking." While being interviewed by a physician, the patient had a seizure followed by bradycardia and then pulselessness. Treatment included CPR, epinephrine, atropine, and sodium bicarbonate. The patient died after 10 minutes. Laboratory results included: arterial pH, 7.03; Pco2, 32 mm Hg; sodium, 134 mEq/L; potassium, 5.2 mEq/L; chloride, 104 mEq/L; bicarbonate, 9 mEq/L; BUN, 20 mg/dL; creatinine, 1.0 mg/dL; glucose, 248 mg/dL; and anion gap 30 mEq/L. The patient's wife revealed that he had threatened to take strychnine which was stored in an old container in their garage. Autopsy findings included acute pulmonary edema, visceral congestion, lymphoma with generalized lymphadenopathy and splenomegaly, generalized atherosclerosis, emphysema, and benign prostatic hypertrophy. A postmortem blood strychnine level was 0.35 ~tg/mL. Case 173. A previously healthy, premature 9-month-old, 9-kg girl presented with hyperpyrexia and respiratory distress. The child had evidence of septic shock and hepatic and renal failure. Upper respiratory symptoms had been present for about 3 days before arrival. The child's mother was treating her with aeetaminophen infant drops. After running out, she switched to chewable acetarninophen, and finally crushed adult strength acetaminophen tablets mixed into the child's formula. The total amount of acetaminophen administered was unknown. Treatment included vasopressors, intubation, plasmapheresis, and hemodialysis. The patient died the same day. Laboratory studies included: acetaminophen, 60 ~tg/mL; AST, 13,000 IU/L; alanine transaminase (ALT), 8,000 IU/L; PT, >90 seconds; ammonia, 384 gmol/L; CSF studies were normal. Autopsy findings were indicative of acetaminophen toxicity. Case 182. A 26-year-old woman with a history of schizophrenia and ethanol abuse ingested an unknown amount of aeetaminophen 1 hour before arrival to the ED. The patient had a prior history of acetaminophen overdose 1 month earlier with resultant hepatotoxicity. On this admission, serial acetaminophen levels were: at 1 hour postingestion, 133 lag/mL; 4 hours postingestion, 70 ~ag/mL; and 8 hours postingestion, 26 ~tg/mL. Liver function tests were not performed and the patient was transferred to a psychiatric unit. Three days later, fuhninant hepatic failure developed. There was no acetaminophen detectable in the serum at that time. In addition to acidemia, the patient had multiple laboratory abnormalities: PT, >100 seconds; creatinine, 2.0 mg/dL; AST, 12,000 IU/L. The oral N-acetylcysteine formulation was administered intravenously ev-
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ery 4 hours, along with intensive supportive care. Renal failure worsened over the next day with the creatinine level increasing to 4.5 mg/dL. The patient was not considered a candidate for liver transplantation and died 11 days postingestion. Case 249. A 2-year-old girl presented with tachypnea, nausea, and vomiting following the ingestion of an unknown number of 325-mg aspirin tablets. The initial vital signs were: temperature, 38.0°C; and respirations, 48 breaths/min. When seizures developed, the patient was transported to another facility. Subsequent therapy included intubation, activated charcoal with cathartic, and urinary alkalinization. The 6-hour salicylate level was 109 mg/dL. Other laboratory results included: initial arterial pH, 7.36; Pco2, 17 mm Hg; Po2, 120 mm Hg; PT, 14 seconds; and PTT, 39 seconds. Refractory seizures were treated with phenobarbital, lorazepam, and hemodialysis. The child remained comatose, with reactive pupils, an adequate urine output (urine pH, 7.0), and a repeat salicylate level of <5.0 mg/dL on the second hospital day. A C T scan of the head at that time showed cerebral edema. The patient suffered an intracranial hemorrhage, and was pronounced brain dead on hospital day 5. Case 256. A 37-year-old woman made a slurry using brandy plus 150 to 250 unknown strength aspirin tablets. She then drank one half of the mixture. Two hours later, she developed vomiting and called 911. Charcoal with cathartic were administered en route to the ED by prehospital personnel. Five and one half hours postingestion she was awake and alert with the following vital signs: pulse rate, 93 beats/rain; blood pressure, 199/85 mm Hg; respirations, 24 breaths/rain; temperature, 36.6°C. The initial salicylate level was 62 mg/dL. Other laboratory results were: sodium, 145 mEq/L; potassium, 3.4 mEq/L; chloride, 109 mEq/L; bicarbonate, 22 mEq/L; arterial pH, 7.43; Pco2, 27 mm Hg; and Po2, 121 mm Hg. A repeat salicylate level drawn 6 hours later was 41 mg/dL. Initial treatment included sodium bicarbonate boluses, potassium chloride, and two additional doses of activated charcoal with sorbitol. Fifteen hours after ingestion the patient had stable vital signs and was transferred to the psychiatric division. At 22 hours after ingestion, she complained of stomach upset and had multiple episodes of emesis which precluded the administration of oral medications. At 28 hours postingestion she was found lying on the floor, disoriented, diaphoretic, with the following vital signs: respirations, 24 breaths/min; pulse rate, 80 beats/rain; blood pressure, 158/78 mm Hg; and temperature, 36°C. Shortly thereafter, she had a grand mal seizure and developed ventricular fibrillation. Resuscitative efforts were not successful. A salicylate level drawn during CPR was 120 mg/dL, with a postmortem level of 85.8 mg/dL. Case 295. A 38-year-old man ingested 25, 0.5 mg eolehieine tablets, five hours prior to presentation. A British Textbook of Suicide was found in the patient's home. He was noted to complain of severe abdominal pain, hematemesis, and hematochezia. The patient's vital signs were: blood pressure, 158/80 mm Hg; pulse rate, 118 beats/min; temperature, 38.3°C; respirations, 20 breaths/ rain. Orthostatic pulse and blood pressure changes were noted. The electrocardiogram showed a normal sinus rhythm without ectopy or abnormal intervals. The initial blood gas analysis on room air showed: arterial pH, 7.38; Pco2, 33 mm Hg; and Po2, 83 mm Hg. Volume resuscitation was successful using six units of whole blood and 3 liters of lactated ringers. Multiple dose activated charcoal therapy was initiated. Twenty-three hours after ingestion the patient was talking to the nurse when he developed ventricular tachycardia followed by ventricular fibrillation. Defibrillation, lidocaine, epinephrine, magnesium, atropine, and sodium bicarbonate therapy were unsuccessful. Case 297. A 14-year-old girl ingested eolehieine and trazodone within 3 days of arrival to the ED. Initial symptoms included multiple episodes of vomiting and diarrhea. She was treated with activated charcoal and sorbitol, prophylactic antibiotics and fresh
frozen plasma. Laboratory results included: white blood cell count, 40,000/pL; AST, 320 IU/L; ALT, 280 IU/L; LDH, 7,300 IU/L; PT, 16 seconds; PTT, 30 seconds, BUN, 8 mg/dL; creatinine, 0.9 mg/dL; acetarninophen, <10 lag/mE The urine toxicology screen was negative. One day later, respiratory distress, refractory hypotension, and bradycardia developed. An agonal ventricular rhythm developed, which was unresponsive to prolonged advanced cardiac life support (ACLS) measures. Case 301. A 19-month-old boy was found comatose by his mother. Severn bottles of methadone elixir were found in the home. Both the mother and her boyfriend were in methadone treatment programs. The amount of methadone ingested was never determined. On arrival to the ED, the child was in cardiac arrest. Treatment included ACLS measures and naloxone. Resuscitative efforts were not successful. Autopsy findings included a postmortem blood methadone concentration of 0.5 gg/mL, and death was attributed to methadone intoxication. Case 302. A 2-year-old boy was given an uncertain amount of his uncle's methadone by his 4-year-old sibling. Seven hours later, his mother noted bizarre movements with "eyes rolling back into his head." She placed him in bed. One hour later, she checked on him, noting that he had persistently abnormal extremity and ocular movements. Four to five hours later he was apneic. On arrival to the ED, the child was pronounced dead. Case 311. A 47-year-old man on methadone maintenance intentionallyingested additional methadone to get high. On arrival to the hospital, he was comatose with hypoventilation. Treatment included naloxone boluses and infusion and admission to a critical care setting. The patient left the unit against medical advice and was found dead in the hospital chapel 4 hours later. A white powder, presumed to be heroin, was found in his pockets. Case 330. A 40-year-old woman ingested an unknown amount of phenylbutazone. On arrival to the ED, she was seizing, unresponsive, hypotensive and had severe acidosis (arterial pH, 6.3). After intubation, diazepam and phenobarbital were administered to control the seizures. Additional therapy included gastric lavage, multiple dose activated charcoal, cathartic, and bicarbonate. A repeat arterial pH was 7.3. The patient became more awake, but was agitated, tachycardic, and required neuromuscular paralysis. Subsequent laboratory studies included: glucose, 325 mg/dL; AST, 346 IU/L; ALT, 240 IU/L; lactic dehydrogenase (LDH), 381 IU/L; calcium, 7.6 mg/dL; and arterial pH, 7.47. The patient died 24 hours later. Autopsy findings included mild cerebral edema and unidentified white, grainy material in the small bowel. Case 344. A 29-year-old woman received a 40-mL injection of bupivaeaine 0.5% into the knee joint at her physician's office. Within 2 minutes, she seized and suffered a respiratory arrest. Prehospital CPR was initiated. On EMS arrival, the patient was noted to be bradycardic, but rapidly deteriorated to ventricular fibrillation. During transport, seizures continued. In the ED, seizures were controlled with lorazepam and phenytoin, and the acidosis was corrected with bicarbonate. After resuscitation, the patient's pupils were fixed and dilated, and she remained comatose. The bilirubin was noted to be elevated at 1.9 mg/dL on hospital day 4. Two days later, she died. Case 346. A 28-year-old male hospital housekeeper was found unconscious with an empty bottle of isoflurane and cotton balls strapped to his face. Pulseless electrical activity was noted and treatment included sodium bicarbonate, atropine, and epinephrine. Despite pacemaker placement, progressive tachyarrhythmias and, finally, asystole developed. Autopsy findings were negative. A postmortem isoflurane blood level was 145 gg/mL. Case 388. A 9-year-old boy was noted to have an unsteady gait prior to developing a seizure and cardiorespiratory arrest. Paramedics arrived approximately 10 minutes later and noted empty bottles of imipramine, amitriptyline, and methylphenidate nearby, On arrival to the ED, the patient was hypotensive with a wide complex
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
bradycardia. Treatment included intravenous fluids and sodium bicarbonate (arterial pH maintained at 7.45 to 7.48) and multiple dose activated charcoal. The cardiac conduction delay improved with a subsequent QRS duration of 0.10 seconds. Continuous squinting activity was observed. Electroencephalogram (EEG) tracings were consistent with seizure activity, CT of the head was negative, and the patient was treated with phenytoin. His clinical condition gradually deteriorated, and the patient died on hospital day 3. The antemortem blood analysis showed: amitriptyline, 1,430 ng/mL; nortriptyline, 600 ng/mL; imipramine, 696 ng/mL; and desipramine, 636 ng/mL. Case 399. A 27-year-old man called a crisis hotline stating that he had taken some medications and had only 2 hours to live. A first responder found him to be lethargic and attempted to walk him around at the scene to increase his alertness. He subsequently seized. A second seizure occurred en route to the hospital and was followed by a cardiac arrest. He was treated with CPR, intravenous fluids, and sodium bicarbonate. In the ED, a pulseless idioventricular rhythm and apnea were noted. Subsequent therapy with epinephrine, atropine, and intubation resulted in the return of spontaneous circulation, and the following vital signs were noted: pulse rate, 118 beats/min; blood pressure, 82/25 rnm Hg; respirations, 15 breaths/min. Dopamine and norepinephrine were required to support the blood pressure. Initial laboratory results included; arterial pH, 6.75; Pco2, 33 mm Hg; Po2, 244 mm Hg; and bicarbonate, 16.9 mEq/L. Life support was withdrawn 5 days later when an EEG showed no evidence of brain activity. Blood bupropion and hydroxybupropion levels taken 21 hours after admission were 446 ng/mL and 3,217 ng/mL respectively. Case 405. A 1-year-old girl ingested an unknown quantity of desipramine and was taken by ambulance to the ED. The child had a widened QRS of more than 0.12 seconds, and was treated with gastric lavage, activated charcoal, and intravenous sodium bicarbonate. Deterioration occurred, with a respiratory arrest, bradycardia, and acidosis (arterial pH, 7.06). Despite additional therapy including epinephrine, atropine, cardioversion, dopamine, and CPR, the patient died within 3 hours of arrival. Case 406. A 3-year-old boy with a history of attention deficit disorder was brought by ambulance to the ED following a 1-minute shaking spell at home. Earlier, he had received his usual bedtime dose of desiprarnine, 100 rag. Both the patient and his 6-year-old sibling were chronically treated with desipramine. It was determined that at most, two to three tablets from either prescription were missing. In the ED, a second tonic clonic seizure was followed by asystole. The patient was resuscitated with CPR, intubation, epinephrine, sodium bicarbonate, calcium, and atropine. A wide-complex tachycardia and persistent seizure activity led to the administration of additional sodium bicarbonate, benzodiazepines, and phenobarbital. After transfer to a tertiary care center, refractory seizures were treated with phenytoin and pentobarbital coma. The patient remained hemodynamically stable for 26 hours and then required fluid boluses and d0Pamine for hypotension. EEGs performed at 28 and 36 hours were flat line without evidence of brainstem activity. Life support was discontinued at approximately 47 hours. Laboratory results included: glucose, 308 mg/dL; serum desipramine on arrival, 1,472 ng/mL; and repeat antemortem desipranline, 215 ng/mL. The urine drug screen was positive for barbiturates, caffeine, imipramine, desipramine, and phenytoin. Autopsy findings included cerebral edema and bilateral diffuse bronchopneumonia. Case 477. A 30-year-old woman ingested an unknown quantity of venlafaxine and carbamazepine. She presented with the following vital signs: pulse rate, 160 beats/min; respirations, 28 breaths/min; and blood pressure, 148/82 mm Hg. To control the tachycardia, overdrive pacing was attempted. The patient's pulse rate steadily decreased to asystole. Prolonged resuscitative efforts were not successful. The initial urine drug screen was positive for
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benzoylecgonine. Postmortem results were: serum venlafaxine, 89 lag/mL; liver venlafaxine, 132 tag/mL; total gastric venlafaxine, 800 mg; serum carbamazepine 19.2 ~tg/mL; serum benzoylecgonine, none detected. Autopsy findings were remarkable only for the presence of alveolar fluid. Case 505. A 23-year-old man ingested a topical aphrodisiac called "Love Stone" purchased in a "smoke shop." Thirty minutes later he developed vomiting and diarrhea that persisted until his arrival to the ED the next day. On physical exam, the patient's vital signs were: pulse rate, 76 beats/min; respirations, 28 breaths/min; temperature, 33.8°C; and blood pressure, 98/60 mm Hg. He was noted to be alert, in respiratory distress, with diaphoresis and midrange, reactive pupils. A chest X-ray showed evidence of pulmonary edema. During intubation, the patient's heart rate decreased to 20 beats/min. He was treated with atropine, and the heart rate increased to 150 beats/min. Three hours after ED presentation, ventricular fibrillation developed. Despite Fab fragment therapy, the patient died. Antemortem laboratory results included: digoxin, 0.9 ng/mL; sodium, 139 mEq/L; potassium, 4.3 mEq/L; chloride, 100 mEq/L; bicarbonate, 2l mEq/L; BUN, 14 mg/dL; creatinine, 1.0 mg/dL; glucose, 104 mg/dL; arterial pH, 7.44; Pco2, 23 mm Hg; Po2, 41 mm Hg (on room air). A right bundle branch block pattern was noted on the electrocardiogram. The product was identified as an extract from the Bufo species of toad, known to contain a number of cardiac glycosides. Case 530. A drowsy 20-year-old woman admitted to the ingestion of naproxen and ethanol in a suicide attempt. (Later, police also discovered an empty bottle of her father's flecainide in the home). Prehospital providers found the patient to be lethargic, cool and clammy, with sluggishly reactive pupils and some purposeful movements. The pulse rate was 20 to 40 beats/min and the systolic blood pressure was 70 mm Hg by palpation. Intubation was performed at the scene. Ventricular fibrillation converted to pulseless electrical activity with defibrillation and lidocaine therapy. Atropine and epinephrine were then administered. Widened QRS complexes did not respond to 150 mEq of intravenous sodium bicarbonate. Hypotension persisted despite glucagon, calcium chloride, transvenous pacing, dopamine, norepinephrine, and isoproterenol. Additional complications included adult respiratory distress syndrome (ARDS) and renal failure. The patient was placed on ECMO for 2 days and developed a refractory coagulopathy. Death occurred shortly after removal from ECMO. An antemortem flecainide level was 1.62 lag/mL. Case 535. A 72-year-old man with an extensive cardiac history, an indwelling pacemaker, and renal failure was administered 50 mg of milrinone intravenously as a loading dose, instead of 3 mg. He became hypotensive (blood pressure, 60 mm Hg), and developed cardiogenic shock and anuria. High doses of vasopressor agents, including dopamine, norepinephfine, and phenylephrine, were administered for blood pressure support. The patient failed to respond to the above therapy and succumbed to a cardiac arrest 18 hours after exposure. Case 540. A 57-year-old man with a history of hypertension, asthma, peripheral vascular disease, and alcohol abuse presented to the ED after ingesting 15 of his own long.acting nifedipine for chest pain. Initial findings included hypotension, third degree heart block, ST elevations on electrocardiogram, acidosis, and lethargy. He was treated with gastric lavage, charcoal, cathartic, norepinephfine, dopamine, and calcium chloride. Whole bowel irrigation was initiated but discontinued upon the development of an ileus. Subsequent therapy for persistent hypotension and bradycardia included glucagon, calcium chloride infusion, epinephrine, transvenous cardiac pacing, and theophylline. Nonetheless, the patient died. Laboratory studies included: arterial pH, 7.28; Po2, 76 mm Hg (Fio2, 0.8); Pco2, 30 mm Hg; sodium, 136 mEq/L; potassium 3.5 mEq/L; chloride, 97 mEq/L; bicarbonate, 8 mEq/L; BUN, 15 mg/dL; creatinine, 2.7 mg/dL; glucose, 216 mg/dL; calcium, 13.1
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
mg/dL (after bolus); ionized calcium, 2.41 mmol/L; and creatine phosphokinase, 2,200 IU/L (100% MM fraction). The serum drug screen was negative for ethylene glycol, methanol, salicylates, and acetone. The urine drug screen was positive for opiates. Serum nifedipine levels were greater than 200 ng/mL by dilution. Case 556. A 49-year-old woman with a history of adult onset diabetes, hypertension, and hemorrhagic stroke presented with acute dyspnea. The family denied a history of suicide attempt or symptoms of depression. Her only medication was sustained release verapamil. Initial physical examination revealed confusion, agitation, bradycardia at 20 beats/min, poor skin perfusion, and a systolic blood pressure of 60 mm Hg by palpation. The electrocardiogram revealed a junctional bradycardia with QRS duration of •108 seconds and normal T wave appearance. Resuscitative efforts included rapid sequence intubation, atropine, isoproterenol, dobutamine, calcium chloride, norepinephrine, sodium bicarbonate, crystalloid infusion, insulin infusion and transvenous pacemaker placement. Despite 3 hours of aggressive resuscitation, the patient developed progressive bradycardia and hypotension, and died. Pertinent laboratory findings were: hemoglobin, 13.9 gm/dL; white blood cell count, 9,000/pL; glucose, 562 mg/dL; creatinine, 1.3 mg/dL; sodium, 137 mEq/L; potassium, 6.7 mEq/L; bicarbonate, 21 mEq/L; anion gap, 10 mEq/L. Autopsy findings revealed biventricular hypertrophy, diffuse coronary stenosis without acute coronary thrombus, and hepatic cirrhosis. Toxicologic blood analysis revealed the following: propranoiol, 600 ~tg/mL; verapamil, 668 tag/mL; norverapamil, 301 ~tg/mL; and the presence of diphenhydramine. Case 558. A 50-year-old man with a history of cardiac disease and hypertension ingested a mixture of 50 tablets of eaptopril and quinidlne. Prehospital intubation was performed and vital signs included a pulse of 52 beats/rain and a systolic blood pressure of 50 mm Hg. In the ED, treatment included gastric lavage, charcoal, cathartic, norepinephrine, isoproterenol, dopamine, atropine, and sodium bicarbonate. The electrocardiogram showed a QRS duration of 0.21 seconds (right bundle branch block pattern) and first degree AV block• The patient developed seizures, pulmonary edema, and dysrhythmias. His neurological status improved slightly prior to the onset of refractory hypotension and bradycardia on the third hospital day. Laboratory results included: quinidine, 12 ~tg/mL; initial digoxin, 1.8 ng/mL; sodium, 134 mEq/L; and potassium, 3.4 mEq/L. Case 591. A 17-year-old man reportedly ingested approximately 40 ephedrine tablets and then fell asleep. Later that evening, and early the next morning, friends heard him snoring. He was found unresponsive at noon the following day. On arrival to the ED, ventricular fibrillation was noted and was treated with defibrillation, fluids, and pacemaker placement. His body temperature was greater than 37.8°C. Resuscitative efforts were not successful. The initial laboratory results included: arterial pH, 6.53; Pco2, 29 mm Hg; Poe, 151 mm Hg; bicarbonate, 3.3 mEq/L, potassium, 11.03 mEq/L. The urine drug screen was positive for ephedrine, and negative for other drugs of abuse. A quantitative urine ephedrine level was 140/ag/mL. Autopsy findings included an intracerebral hemorrhage, cerebral edema, severe hemorrhagic gastritis, and bilateral pulmonary edema. Case 593. A 43-year-old woman with a history of hypertension intentionally ingested an unknown number of antihistamine/ decongestant tablets (75 mg phenylpropanolamine with 12 mg brompheniramine per tablet). On presentation, she was alert and oriented and complained of dizziness. Physical findings included diaphoresis, small to midrange pupils, normal bowel sounds, and good urine output• Vital signs were: pulse rate, 60 beats/rain; respirations, 20 breaths/rain; blood pressure, 165/125 mm Hg; temperature, 36.2°C. Over the course of several hours, the patient's blood pressure and pulse rate decreased to 150/90 mm Hg and 50 beats/rain, respectively. She became increasingly lethargic. A
subsequent CT scan revealed a large intracerebral bleed. Progressive coma, hypotension, and multiple organ failure resulted in death 3 days after ingestion. Case 594. A 22-month-old boy ingested 96 325-mg ferrous sulfate tablets (549 mg/kg elemental iron) 15 minutes before to arrival to the ED. Initial therapy included endoscopy, gastric lavage, and deferoxamine. Early laboratory results included: hemoglobin, 10.8 gm/dL; white blood cell count, 8,100//aL; serum iron, 50 lag/dL. After transfer to a second facility, the patient was somnolent and mildly combative with the following vital signs: pulse rate, 190 beats/rain; respirations, 30 breaths/rain; and blood pressure, 131/106 mm Hg. Repeat laboratory analysis included: serum iron (6½ hours postingestion), 2,583 /ag/dL; glucose, 393 mg/dL; white blood cell count, 26,800/pL; bicarbonate 13 mEq/L; PT, 27.1 seconds; PTT, 92 seconds; arterial pH, 7.24; Pco2, 22 mm Hg; and Po2, 99 mm Hg. Subsequent treatment included intubation, albumin, crystalloids, activated charcoal with cathartic, exchange transfusions, vasopressors, and a continuous deferoxamine infusion. A v i n r o s e urinary color change was noted. Repeat endoscopy showed corrosive changes in the cervical esophagus with retained charcoal and pill fragments in the gastric fundus. On hospital day 2, deterioration occurred with the development of ARDS, worsened coagulopathy, and acidosis. Multiple organ failure and hemodynamic instability ensued and the patient died that day. Blood cultures were positive for pneumococcus and pseudomonas. Case 597. A 63-year-old man with a history of colon cancer was being prepared for repair of stenosis of his colostomy. Ten enemas (each containing sodium biphosphate, 19 grams, and sodium phosphate, 7 grams per 118 mL) were administered into the ostomy. Three to four hours later he suffered a cardiac arrest. The patient was initially resuscitated with intubation and cardiac pacing. Vital signs were: blood pressure, 90/30 mm Hg; pulse rate, 96 beats/min; and temperature, 34.9°C. Laboratory results 1 hour after cardiac arrest were as follows: ionized calcium, 0.3 mg/dL; phosphorus, 10.8 mg/dL. Repeat laboratory results 3 hours later showed: sodium, 157 mEq/L; potassium, 8.2 mEq/L; chloride, 93 mEq/L; bicarbonate, 8 mEq/L; arterial pH, 7.17. Despite peritoneal dialysis, the patient died 12 hours after enema administration. Case 616. A 31-year-old man presented to the ED 3.5 hours after ingesting 14 tablets of 100 mg elozapine. He was awake, alert and in no distress with the following vital signs: blood pressure, 132/90 mm Hg; pulse rate, 100 beats/min. The initial electrocardiogram showed a QRS duration of 0.08 seconds. Five to six hours postingestion, the patient became uncooperative, pulled off the cardiac monitor lead wires and ran around the ED. Shortly thereafter, his level of consciousness became depressed and intnbation was performed. The QRS duration had increased to 0.24 seconds at that time. No seizure activity was noted. Treatment, including sodium bicarbonate, physostigmine (2 mg), epinephrine, atropine, and dopamine, was unsuccessful, and the patient died. Case 619. A 30-year-old man with a history of cocaine, marijuana, heroin, and ethanol abuse injected ethehlorvynol intravenously prior to arriving to the ED with complaints of shortness of breath. Initial physical findings included cyanosis, tachypnea, tachycardia, and hypotension. Treatment included intubation, 100% oxygen, positive end expiratory pressure of 15 cm H20, fluid restriction, vasopressor therapy, and invasive hemodynamic monitoring. The central venous pressure was 5 to 7 cm H20 and the systemic vascular resistance was low. Hemodialysis was attempted, but was aborted after 30 minutes because of hemodynamic instability. The patient died within 12 hours of arrival. Laboratory studies included: arterial pH, 7.21; Pco2, 58 mm Hg; Poe, 42 mm Hg; ethanol, 150 mg/dL; methanol, salicylate, ethylene glycol, and acetaminophen levels were below detection limits. Autopsy findings included acute pulmonary edema, early pneumonia, passive congestion of the liver, kidneys, spleen, and viscera,
LITOVITZ ET AL • 1995 AAPCC ANNUAL REPORT
and bilateral hydrothoraces. A postmortem ethchlorvynol level was 8.6 pg/mL. Case 626. A 16-year-old boy with a history of viral meningitis/ encephalitis complicated by seizures and agitation was being treated in a pediatric intensive care unit. In addition to anticonvulsants, haloperidol was given in escalating doses for 2 weeks. After receiving haloperidol 8 mg three times daily for 24 hours, dystonia was noted. Benztropine 2 mg was given. Thereafter, hyperkinesis, hyperthermia (temperature, 41.7°C), and cardiac arrest occurred. The patient was resuscitated, but developed DIC and generalized bleeding, and died within 12 hours. Pertinent laboratory results at the time of the cardiac arrest included creatine phosphokinase, 2,000 IU/L and potassium, 8.0 mEq/L. Case 638. A 66-year-old man with a history of angina, hypertension, psychosis, and previous suicide attempts intentionally ingested an 8-day supply of risperidone, 240 mg of nifedipine, 400 mg of sertraline, 1.6 mg of elonidine, and 10 to 15 mg of clonazepam. In the ED, the patient was arousable with slightly labored respirations. Treatment included cardiac monitoring, gastric lavage, activated charcoal, sorbitol, naloxone, and flumazenil. The patient seized, became apneic and was intubated. Recurrent seizures required diazepam and phenobarbital therapy. Later that day, his temperature rose to 41.7°C. He was treated with antipyretics and dantrolene. He deteriorated and developed persistent seizures and ultimately ventricular fibrillation. Resuscitation attempts were unsuccessful. Case 644. A 12-year-old autistic boy presented with a 40-hour duration of vomiting and poor oral intake. There was no history of diarrhea or fever. The diagnosis of gastroenteritis was made, and the patient was treated with trimethobenzamide suppositories. Over the next 24 hours, vomiting decreased, but the child was anuric and continued to complain of abdominal pain. Later, he was found flaccid, cyanotic, pulseless, and apneic by his brother. Prehospital CPR, intubation, epinephrine, and bicarbonate therapy was administered. ACLS measures continued in the ED with the return of spontaneous circulation. The patient suffered anoxic encephalopathy and subsequently died. Autopsy findings included hepatic microvesicular fatty change and axonal changes. Both urine and blood (26.8 pg/mL) trimethobenzamide levels were elevated. The cause of death was anoxic encephalopathy secondary to cardiopulmonary arrest. Case 652. Paramedics were called to transport an 11-month-old girl to the ED after the alleged ingestion of an unknown rat poison. En route, the child developed seizures and ventricular tachycardia. In the ED, she was treated with intubation, gastric lavage, and naioxone. The electrocardiogram showed a wide-complex tachycardia and a prolonged QTc. Deterioration of the cardiac rhythm occurred, and the patient was treated with atropine, epinephrine, and defibrillation. Despite initial stabilization, the child died because of refractory ventricular fibrillation. Laboratory results included: arterial pH, 6.51; Po2, 105 mm Hg; Pco2, 94 mm Hg; glucose, "normal." The urine drug screen was positive for cocaine metabolites. On autopsy, crack cocaine particles were noted in the duodenum. Postmortem toxicologic analysis revealed the following cocaine levels: heart, 17.74 ~g/mL; blood, 25.66 ~g/mL; liver, 11.56 mg/kg; brain, 29.55 mg/kg. The parents later admitted that they had Seen the child's 2-year-old sibling feeding her crack cocaine.
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Case 709. A 1-day-old girl born to a mother with a history of methamphetamine abuse developed tonic-clonic seizures. The mother admitted to methamphetamine use 3 days before delivery. The patient had agitation, fluctuating temperature, poor urine output, and intermittent apnea. Seizure control necessitated intubation and phenobarbital therapy. The patient remained sedated and died on the 6th hospital day. Autopsy findings included bilateral cerebral artery infarction with brain stem hemorrhage and herniation. Case 711. A 30-year-old man presented to the ED a few hours after snorting and ingesting crank (methamphetamine). He complained of sweating, chills, weakness, shakiness, and chest pain radiating to the neck. Flushing, tachycardia, hypotension, oliguria, and hyperkalemia were noted. Treatment included dopamine, norepinephrine, and hemodialysis. Swan-Ganz catheter insertion revealed a very low cardiac index and systemic vascular resistance. Shortly thereafter, the patient deteriorated further. Ventricular fibrillation progressed to asystole, and then to refractory pulseless electrical activity despite intubation and aggressive resuscitation. Death occurred within 1 hour. Autopsy findings included cystic medial necrosis of the ascending aorta with dissection and rupture into the pericardial sac (50 mL fluid); two vessel coronary atherosclerosis; pulmonary congestion and edema; renal congestion; and acute erosive hemorrhagic gastritis. The toxicology screen was positive for amphetamines. Case 718. A 25-year-old woman was found unconscious and in respiratory arrest in a hotel room. A young male was found dead in the same room, which smelled strongly of ethyl ether. Equipment and chemicals used to produce methamphetamine were found in the bathroom, and paraphernalia for smoking methamphetamine along with large amounts of the drug were seen on a table. The patient was transported to the ED after intubation. Resuscitative efforts were not successful, and she was pronounced dead approximately l hour after arrival. The cause of death was determined to be from methamphetamine poisoning with ethyl ether as a possible contributing factor. Case 724. A 1-year-old boy was unresponsive and cyanotic, with shallow respirations on presentation to the ED 12 to 14 hours after the ingestion of an unknown number of prenatal vitamins with iron. The initial vital signs were blood pressure, 40/29 mm Hg; and respirations, 28 breaths/min. The patient was treated with fluids and fresh frozen plasma through internal jugular and left ankle cutdown sites. A continuous infusion of deferoxamine was started (19 mg/kg/h). Two hours after arrival, the child was semicomatose and had evidence of disseminated intravascular coagulopathy. Further treatment included epinephrine, dopamine, dobutamine, and blood transfusions. Despite resuscitative efforts and transfer to a tertiary care facility, the patient died 11 hours after arrival. (Of note, the patient's sibling was evaluated for a possible iron ingestion one night earlier. It was not known at that time that the younger child had also ingested the prenatal vitamins). Laboratory results included: serial serum iron levels, 5,900 pg/dL, 6,000 pg/dL, 5,927 pg/dL; serial total iron binding capacity, 9,195 pg/dL, 2,196 pg/dL; PT, 27.3 seconds; PTT, 150 seconds; sodium, 145 mEq/L; potassium, 2.5 mEq/1; chloride, 109 mEq/L; bicarbonate, 17 mEq/L; BUN, 20 mg/dL; creatinine, 0.7 mg/dL; ALT 100 IU/L; AST 291 IU/L; LDH, 3,512 IU/L. Abdominal X-ray showed one tablet visible in the gastric region.