Abstracts of the 2006 North American Congress of Clinical Toxicology Annual Meeting

Figures & data

Table

	Prospective outcome N (%)			Retrospective outcome N (%)
Dose	Injury	Death	No injury/death	Injury	Death	No injury/death
Therap.	20 (0.1)	0 (0)	30,954 (99.9)	57 (0.6)	9 (0.1)	9,245 (99.3)
Suprather.	12 (1.0)	0 (0)	1,164 (99.0)	57 (19.5)	35 (11.9)	201 (68.6)
Unknown	0 (0)	0 (0)	2,911 (100.0)	14 (0.5)	23 (0.8)	2,708 (98.7)
Total	32 (0.1)	0 (0)	35,029 (99.9)	128 (1.0)	67 (0.5)	12,154 (98.4)

In vitro CroFab yield (grams/vial) with various mixing methods

Mixing method	Initial recovery	Residual in vial	Calculated yield after 2 extractions
manual	0.78	0.39	1.17
manual	0.80	0.37	1.18
rocking (30 min)	0.77	0.39	1.16
rocking (30 min)	0.76	0.37	1.13
lateral motion	0.78	0.38	1.15
lateral motion	0.73	0.36	1.09
rotatory mixer	0.70	0.35	1.06
rotatory mixer	0.68	0.38	1.06
lateral/rocking combo	0.72	0.38	1.10
lateral/rocking combo	0.81	0.27	1.08
rocking (60 minutes)	0.64	N/A	N/A
rocking (60 minutes)	0.68	N/A	N/A

*Each vial was mixed for 30 minutes unless otherwise noted. N/A: Not tested.

Results

Time (hrs)	AP (μg/mL)	MMP (μg/mL)	AP to MP ratio
0	607.400	13.170	46.11
14.48	206.200	4.087	50.45
28.66	9.370	0.196	47.80
57.88	13.920	0.260	53.53

Comparison of opioid proportions between dry and wet counties

	Human exposures N = 492	All pill identifications N = 3,444	Oxycodone pill ids N = 718	Hydrocodone pill ids N = 2,070
Dry N = 26	0.68	3.58	0.86	2.68
Wet N = 41	0.61	1.29	0.09	0.65
P value	0.62	<0.01	0.02	0.01

*median proportions.

Results

Parameter	Mean	Range	SD
Age (years)	39	18–68	8.8
Temperature °f	97.9	95.4–100	0.8
Systolic BP (mmHg)	134.5	216–70	21.6
Diastolic BP (mmHg)	87.4	142–40	14.4
Heart rate (beats/min)	82.7	164–42	16.4
Length of stay (HR:Min)	01:47	00:01–20:05	00:08

Calls from 911 centers (year/no. calls)

2001	1,505
2002	1,267
2003	1,139
2004	1,111
2005	848

Mercury-related calls to the illinois poison center

	Thermometer-related	Seafood-related	Other mercury-related
12/11/05–12/17/05	10	0	0
12/18/05–12/24/05	6	0	0
12/25/05–12/31/05	2	0	1
1/1/06–1/7/06	10	0	0
1/8/06–1/14/06	11	1	1
1/15/06–1/21/06	3	0	1
1/22/06–1/28/06	7	0	3
Mercury-related calls during same time period from the previous year
12/11/04–12/17/04	11	0	1
12/18/04–12/24/04	15	0	0
12/25/04–12/31/04	11	0	7
1/1/05–1/7/05	12	0	0
1/8/06–1/14/05	10	0	1
1/15/05–1/21/05	4	0	0
1/22/05–1/28/05	13	0	2

Table

Percent of responding hospitals stocking the antidote
Cyanide kit	63
Atropine	94
Pralidoxime	51
Benzodiazepine	100
Crotalinae snake antivenom	85
Digoxin antibodies	78
Mucomyst IV	36

Table

	TESS	AERS	X2	p value
Child <6 years old	185 (44%)	15 (4.4%)	159.9	<0.001
Route – ocular	19 (10.3%)	13 (86.7%)	28.5	<0.001
Route-oral	156 (84.3%)	2 (13.3%)	7.6	<0.01
Triage-ED	78 (42.2%)	–	–	–
Hospitalized	31 (16.8%)	15 (100%)	22.0	<0.001
Naloxone	18 (9.8%)	–	–	–

Pregnancy outcomes

Order	Sex	Gestational age (weeks)	Birth weight(grams)	Apgar @ 1 and 5 min	Oxytocin used	Highest [ASA] (mg/dL)	Lowest [bicarb] (mmol/L)
1	M	40 1/7	3402	8/9	Yes	ND	NA
2	F	38	2977	ND	No	ND	NA
3	NA	5	NA	NA	NA	NA	NA
4	M	39 2/7	2835	9/9	Yes	ND	NA
5	M	37 0/7	3005	8/9	Yes	27	12
6	F	37 5/7	3175	8/9	Yes	24	19
7	M	36 2/7	2381	8/9	Yes	56	13

ND = not documented, NA = not available.

Table

	Negative Hx ethanol co-ingestion (n = 31)	Positive Hx ethanol co-ingestion (n = 15)	P value
Mean age	33.37 (15–29)	34.86 (17–85)	ns
Sex M:F (%)	7:24 (23:77)	5:10 (33:67)	ns
Mean time to presentation, hours (range)	8.68 (0.5–72)	8.50 (0.7–48)	ns
Mean reported acetaminophen dose g	21.43	19.2	ns
Mean initial plasma acetaminophen conc μg/mL (range)	181 (27–632)	141 (21–276)	ns
Mean pre-NAC INR (range)	1.09 (0.95–1.28)	1.02 (0.92–1.14)	<0.05
Mean increase in INR post-NAC	0.13	0.08	ns
No. of patients requiring ongoing Rx with IV NAC	6	0	<0.05

Coagulation profile and bromadiolone level

Day	PT (sec) #	aPTT (sec) #	Oral vit. K1 (mg)	FFP (unit)	Bromadiolone (ng/mL)
1	92.0	50.2	–	–	–
2	93.8	59.8	10	6	85
2	13.9	38.8	–	–	92
4	39.5	45.5	–	4	27
5	27.7	43.4	–	–	–
5	36.7	42.3	–	4	–
5	25.0	43.7	–	–	–
5	21.5	43.4	–	–	–
6	33.5	46.6	–	4	–
7	22.0	39.8	10	4	–
9	14.1	37.3	10	–	22
10	14.4	38.3	–	–	14
11	16.3	39.7	–	–	12
13	18.9	43.3	10	–	10
15	14.2	39.8	10	–	–
19	12.8	30.4	10	–	10
22	12.0	35.8	10	–	10
30	11.0	35.8	–	–	7.5
47	10.7	35.5	–	–	6.9
54	10.7	33.1	–	–	5.0
61	10.9	36.9	–	–	2.9

#: Reference range (sec) – PT: 10.0-13.0, aPTT: 24.0-35.0.

Delayed acetaminophen peak

Date	Time	APAP (mcg/mL)	AST (U/L)	ALT (U/L)
11/3/06	20:00	101
11/3/06	21:45	131	25	40
11/4/06	05:30	114.3	20	33
11/4/06	12:25	125.5
11/4/06	18:00	121
11/5/06	08:00	21.9	72	99
11/5/06	18:00	<6.7	199	231
11/6/06	05:00	2.3	456	565
11/7/06			442	942
11/8/06			191	596
11/9/06			98	455

Comparison of patients with elevated BLL on initial and repeat admission

	First admission	Re-admission
	n (%)	n (%)
Total	39 (100%)	14 (36%)
Male	22 (56%)	12 (86%)
African-American	31 (79%)	14 (100%)
Prior admission	0 (0%)	14 (100%)
BLL mcg/dL	49	54
Positive AbXr	22 (56%)	7 (50%)
FEP mcg/dL	173	196
FEPQuant mcg/dL	512	567
HCT (%)	32.7	34.1
MCV (fL)	72.5	72.4

BLL: blood lead level; FEP: free erythrocyte protoporphyrin.

Table

Outcome	Mean dose(mg)	Median dose(mg)
Symptoms	5193	2700
No Symptoms	1587	750
Minor effect	4724	2100
Moderate effect	6776	3600
Major Effect	14500	18000

Table

Age, disposition, and outcome N = 695		Clinical effects N = 695
Age ≤1 month	21.2%	Drowsy/lethargy	11.9%
Age > 1 month and ≤1 year	73.4%	Agitation	11.2%
Age > 1 year and < 6 years	5.5%	Dystonia	10.9%
Treated at HCF	61.1%	Vomiting	2.3%
Admit critical care unit	5.9%	Tremor	1.7%
Admit non-critical unit	9.6%	Tachycardia	1.7%
No effect	42.6%	Diarrhea	1.6%
Minor effect	16.3%	Muscle rigidity	1.2%
Moderate effect	15.0%
Major effect	0.6%
Death	0.0%
Unknown outcome	24.8%

Breakdown of arsenic calls to regional poison center

Reason	2003	2004	2005	Subtotal
How to evaluate elevated As level in hair, urine or blood	15	8	10	33
Pediatric exposure to arsenic containing ant killer	6	10	6	22
Someone is poisoning me or someone I know	4	10	4	18
Chromated Copper Arsenate (CCA) treated wood	6	3	2	11
Occupational/school/dermal exposures	4	4	0	8
Arsenic in well water	3	5	0	8
Homeophathic medication exposure	0	1	2	3
Intentional ingestion	2	0	1	3
Accidental Ingestion	1	0	0	1
Total	41	41	25	107

Association of asthma admission with home proximity to a power plant

Home distance from power plant (miles)	N	% Admitted	OR (95% CI)
≤ 2.5	205	34.2	0.61 (0.42, 0.89)
>2.5 and ≤ 5	1,067	30.3	0.56 (0.43, 0.72)
>5 and ≤ 7.5	481	32.0	0.54 (0.40, 0.71)
>7.5 and ≤ 10	224	38.8	0.65 (0.40, 0.91)
>10	489	48.9	1.00

Adjusted for demographics, p < 0.001 for all OR.

Occurrence of documented clinical effects

Clinical Effect	n	%
Vomiting	347	33.8
Nausea	286	27.9
Diarrhea	126	12.3
Dizzy/vertigo	102	9.9
Drowsy/lethargy	79	7.7
Diaphoresis	76	7.4
Tremor	53	5.2
Bradycardia	51	5
Confusion	39	3.8
Abdominal pain	30	2.9
Hypertension	29	2.8
Muscle weakness	23	2.2

10-year TESS data of human exposure cases, TEs and ADRs

Year	# of Exposures	# of TEs	% of TEs	# of ADRs	% of ADRs
1995	2,023,089	110,038	5.4	28,296	1.4
1996	2,155,952	123,095	5.7	32,866	1.5
1997	2,192,088	131,872	6.0	31,896	1.5
1998	2,241,082	144,328	6.4	31,601	1.4
1999	2,201,156	154,422	7.0	32,742	1.5
2000	2,168,248	152,101	7.0	31,245	1.5
2001	2,267,979	167,014	7.4	35,646	1.6
2002	2,380,028	193,194	8.1	41,215	1.7
2003	2,395,582	215,052	9.0	41,335	1.7
2004	2,438,644	222,644	9.1	42,812	1.8

TABLE 1

	Amidoarone	Control	Log rank (p value)
Median time to VT (min)	79	62	0.0097
Median time to death (min)	65	63	0.14

Carbamazepine Serum and Dialysate Levels

Time	Serum level mcg/mL	Dialysate level mcg/mL	Clearance mL/min
1 hour	124.7	21.6	86.6
2 hours	93.4	16.5	88.3
3 hours	63.3	10.5	82.9

*Blood flow rate = 350 mL/min and Dialysate flow rate = 500 mL/min.

Recovery (grams of protein) after reconstitution, 4-hour storage, and IV tubing transfer of CroFab mixed in different solutions

Sample/step	Lactated ringers	Normal saline	1/2 normal saline
Vial A, initial	0.69	0.70	0.75
Vial B, initial	0.78	0.71	0.74
Vial C, initial	0.68	0.68	0.74
Vial A, 4 hrs	0.69	0.67	0.82
Vial B, 4 hrs	0.77	0.71	0.78
Vial C, 4 hrs	0.69	0.67	0.80
Vial A, tubing	0.68	0.66	0.83
Vial B, tubing	0.78	0.71	0.78
Vial C, tubing	0.66	0.69	0.79

*Mean Values; see Methods.

Characteristics and adsorption kinetics of AC preparations

	Surface area(m^2/g)	Pore volume(mL/g)	AcetaminophenQmax (mg/g)	AmitriptylineQmax (mg/g)
Charcodote (CD)	1497	1.34	81	372
Carbomix (CM)	1461	0.83	122	378
M60	1820	1.72	168	497

Qmax = Maximum adsorption capacity.

Mean electrolytes after lethal fluoride doses in mice

Treatment (n)	Potassium (mEq/L)	Calcium (mg/dL)	Bicarbonate (mEq/L)
Saline (4)	7.7	7.0	25
3 mM NaF (8)	14.2	1.8	12
3 mM HF (6)	10.8	5.8	12
1.5 mM NaF (6)	8.2	2.1	11
1.5 mM HF (6)	8.6	3.1	9

*p < 0.05 compared to saline controls.

Blood mercury concentration during surgical debridment

Minutes since beginning of debridement	0	30	60	90	120	180
Blood mercury concentration μg/dL	126	124	120	128	116	120

Age group and medical outcome by morphine formulation

Morphine formulation:		ER N (%)	IR N (%)	p value
Age group (years)	<13	31 (18)	122 (9)
	13–19	18 (11)	113 (8)
	20s	30 (18)	241 (17)
	30s	23 (13)	275 (19)	0.001
	40s	28 (16)	326 (23)
	≥50s	28 (16)	261 (18)
	Unknown	13 (8)	96 (7)
Medical outcome	No effect	25 (15)	176 (12)
	Minor	38 (22)	364 (25)
	Moderate	21 (12)	376 (26)	<0.001
	Major/death	9 (5)	144 (10)
	Other	78 (46)	374 (26)

*Not followed, nonexposure, unrelated, unknown.

Table

Poison knowledge
Heard of poison center	79%
Identify who answers calls	55%
Recognize core functions	54%
Believe poison to be anything	91%
Identify risk factors	64%
Identify proofing tips	53%

Table

	No effect	Minor	Moderate	Major	Death
PR	81.5%	17.1%	1.2%	0.18%	.02%
AR	89.7%	9.6%	0.6%	0.1%	.00%

Table

Year	No. of exposures ()	Age			Reason
		<6	6–19	>19	Unintentional	Intentional
2000	13,759 (30)	4,926	1,735	6,945	12,859	392
2001	17,294 (36)	5,828	2,138	9,174	16,094	427
2002	19,442 (38)	6,476	2,193	10,573	18,032	531
2003	21,135 (41)	6,787	2,353	11,661	19,607	507
2004	24,169 (45)	7,387	2,653	13,877	22,355	646

*Percentage of all insecticide incidents involving pyrethrins and/or pyrethroids.

Workplace CO fatalities 1992 to 2004 by month of they year

Months	Total fatalities	Mean US temp
Jan	44	32.50
Feb	29	36.53
Mar	22	43.83
Apr	23	52.45
May	16	62.88
Jun	19	69.54
Jul	11	74.57
Aug	24	73.40
Sep	8	65.93
Oct	22	54.58
Nov	22	42.84
Dec	36	34.64

Table

Initial results from patient 3
ABG (on face-mask oxygen)	7.277/27/105/ COHgB 1.3 %/ METHgB 0.8 %
Chemistry	Na 141; K 4.7; cl 97; HCO3 14; BUN 28; creat 2.3; Ca 9.3
Cardiac markers	CPK 399; troponin 0.06; BNP 34;
Chest radiograph	No infiltrates
EKG	Sinus tachydcardia
UA	1.030; 100 prot; trace kets; 25 blood; no cells.
LFTs, lipase, CBC	All normal
Acetaminophen, salicylates, EG, MeOH	All negative

Mercury levels

Patients	Whole blood (mcg/L)	House	mg/m^3	School	mg/m^3
16-year-old Male	18	Car seat	50.0	9 Classrooms	1.0 – 65.0
37-year-old female	6	Kitchen	10.0	3 Closets	>1.0
15-day-old infant	5	Bedroom	20.0	Office	7.0

TABLE 1

Clinical Grade Muscle Weakness	RNS
No weakness/MRC Grade 4	DI From 10 to 30 Hz
MRC Grade 3/2	DI From 1 to 30 Hz
Clinical IMS	Decremental reponse only

Urine RICN Levels

Time post ingestion(hrs)	RICN(ng/ml)	Cr corrected RICN(μg/g-cr)
14	1400	591
26	190	674
40	550	511
49	330	226
63	130	135

Brewing time

Patch Strength	2.5 min	5 min	10 min	20 min
25 mcg/hr	0.62	0.98	2	2.9
50 mcg/hr	1	2.4	3.4	5.4
75 mcg/hr	1.1	3.5	5.3	8.1
100 mcg/hr	2.9	2.3	5.1	6.3

*All fentanyl concentrations in mcg/mL.

Contenst of herbal N-Acetylcysteine poducts

Product	Amount per capsuleon label	Presence of NAC	Mean concentration ofNAC per capsule by LC/MS/MS
A = GNC	600 mg	Yes	510 mg
B = Vitamin world	600 mg	Yes	500 mg
C = Wild oats	600 mg	Yes	555 mg
D = Biochem	750 mg	Yes	735 mg

Laboratory Values of Chronic Inhalational Exposure to Methanol

Four exposures to one individual	Maximum detected methanol concentration	Mean methanol concentration	Lowest serum bicarbonate	Mean serum bicarbonate	Lowest pH	Mean pH	Antidotes/ dialysis
Case 1	76 mg/dL	49.3 mg/dL	8.0 mEq/L	13.7 mEq/L	7.22	7.37	Yes/yes
Case 2	73 mg/dL	36.5 mg/dL	8.0 mEq/L	20.0 mEq/L	7.25	7.38	Yes/yes
Case 3	57 mg/dL	30.5 mg/dL	8.0 mEq/L	18.8 mEq/L	None recorded	0	Yes/yes
Case 4	87 mg/dL	43.7 mg/dL	6.0 mEq/L	19.5 mEq/L	7.57	7.57	Yes/yes
Total mean	73.25 mg/dL	40 mg/dL	7.5 mEq/L	18.0 mEq/L	7.34	7.44	Yes/yes

Clinical toxicology assessment scores

Total = 42	Mean pre-test % correct	Mean post-test % correct	Mean difference	SD difference	CI of difference	p value
EM = 16	62.06	84.67	22.60	13.00	29.56–15.69	0.0001
IM = 11	49.27	77.45	28.10	19.88	41.54–14.83	0.0008
FP = 2	54.50	80.50	26.00	7.00	89.53–37.53	0.12
CC = 5	58.80	90.40	31.60	15.50	50.74–12.46	0.01
MS = 8	45.75	86.50	40.75	10.32	49.38–32.12	0.0001

Table

Snake Type	REC	CREC	TREC
RS	6/32 (19%)	5/31 (16%)	2/31 (7%)
UK	17/37 (46%)	11/36 (31%)	10/37 (27%)
Total	23/81 (28%)	16/79 (20%)	12/78 (15%)

The venom concentration in patient’s samples at varied & indicated time

Sample \ time	24 hrs	30 hrs	44 hrs	68 hrs	72 hrs
Serum (ng/ml)	26.6	ND	3.2
Blister fluid (ng/ml)			1391	1062
Necrotic tissue (ng/gm)					135

ND: non-detectable.

Key clinical findings (humans)

Age(yr)	Symptom	Duration	CXR	Pulse Ox	Treatment
N = 180	N = 191	N = 171	N = 64	N = 48	N = 165
Range	Cough	Range	Positive	Range	Albuterol
0.5–69.5	(79.6%)	0.25–504	16 (30%)	61–100	36%
Median	Dyspnea	Median	Negative	Median	Steroids
31.5	(60.7%)	19 hrs	37 (58%)	96	16%
	Chest pain		None		Oxygen
	(28.8%)		11		24%
	Throat irritation		Unk
	(18.8%)		126
	Tachypnea
	(6.3%)

WNV and DEET exposure data

Year	WNV cases	DEET exposures	Outcome severity
			No Effect	Minor	Moderate	Major
			N (%)	N (%)	N (%)	N (%)
2003	3244	293	70 (28)	97 (38)	6 (2)	0 (0)
2004	323	348	137 (42)	136 (42)	8 (2)	0 (0)

*p < 0.05.

Comparison of understocked antidotes 1998 and 2005

	% Understocked1998 study	% Understocked2005 study	P value
Fomepizole (4 vials)	93.8%	88.5%	0.56
Pyridoxine (5 grams)	83.3%	92.3%	0.28
Digoxin Immune Fab (10 vials)	79.2%	90.4%	0.19
Ethanol (70 grams)	62.5%	75.0%	0.26
Pralidoxime (2 grams)	41.7%	63.5%	0.05
Deferoxamine (1 gram)	35.4%	55.8%	0.07
Cyanide Antidote Kit (1 kit)	25.0%	46.2%	0.05
Wyeth Antivenin Crotalidae (5 vials)	16.7%	44.2%	<0.01
Naloxone (>2 mg)	2.1%	0%	0.96

Physiologic and biochemical data during first 24 hours in 6 patients with CCA overdose treated with HDI

Drugs Ingested	Presentation BP (mmHg)	Mean insulin infusion rate (units/hr)	Max insulin infusion rate (units/hr)	Total potassium administered (mEq)	Total dextroseadministered(g)	Blood sugarrange mg/dL(mean)	Recovered
Verapamil 2000mg	90/50	62.5	75	60	12.5	77–158 (95)	Yes
Amlodipine, sotalol	90/55	25	85	0	35	74–255 (171)	No
Diltiazem 10080mg, doxasozin 40mg	55/30	45	60	80	240	119–500 (333)	Yes
Diltiazem, diazepam	70/30	75	150	80	58	81–232	Yes
Amlodipine 280mg,doxasozin	60/40	147	280	40	230	43–464 (335)	Yes
Amlodipine 300mg, atenolol 2000mg	70/30	146	160	0	0	106–409 (224)	Yes

Table

Year	1998	1999	2000	2001	2002	2003	2004
Total enquiries	30031	31337	33433	36010	35852	32034	26164
Quetiapine calls	6	9	34	80	89	114	144
Quetiapine calls (%)	002	0.029	0.102	0.222	0.248	0.356	0.55

Table

Time	03:10	03:55	05:00	06:00	07:00	08:18	11:07
pH	7.17	6.97	7.21	7.21	7.19	7.34	7.42
pCO2 (mm Hg)	14.3	31.5	18.4	25.3	39.8	46.7	44.3
HCO3 (mM)	5	6.8	7.1	9.7	14.6	24.6	28.7
Base deficit (mM)	22.9	24.8	19	16.8	12.7	0.8	−4.2
Lactate (mM)	22	21	21	19	17	7.8	2
Bicarbonate given (mM)			50	100	100

Table

Most common substances		Age, disposition, and outcome
Cimetidine/other H2 antagonist	23.5%	Age ≤ 1 month	19.7%
Metoclopramide	17.8%	Age > 1 month and ≤ 1 year	55.2%
Dextromethophan w/o ppa	6.8%	Age > 1 year and < 6 years	25.1%
Antibiotic: systemic	5.4%	Treated at HCF	43.5%
Antihistamine w/o opioid, w/o ppa	4.6%	Admitted to hospital	12.2%
Gastrointestinal prep: other	4.1%	No effect	34.5%
Albuterol	3.9%	Minor effect	16.7%
Acetaminophen: pediatric	2.6%	Moderate effect	7.0%
Iron (excluding vitamins with iron)	2.2%	Major effect	0.9%
Antispasmotic: anticholinergic	2.1%	Death	0.1%

% of 3894 exposures.

QA tool scores

	Communication skills	Active listening skills	Completeness of poison management	Documentation
Average scorepre-QA tool	98.6%	92.4%	94.4%	94.2%
Average score post-QA tool	100%	92.6%	88.4%	84.9%

QT prolongation liabilities of CNS drugs

Drug	Indication	QT prolongation	Patch clamp	Rb efflux	Binding
Bromopride	Nausea	No	ND	>20	>20
Imipramine	Depression	Yes	3.4	12.2	7.4
Risperidone	Depression	Yes	0.17	8.5	0.77
Amitriptyline	Depression	Yes	10	8.3	13
Pimozide	Psychosis	Yes	0.018	0.011	0.031

Values in μM; ND: not determined.