Abstracts of the 2007 North American Congress of Clinical Toxicology Annual Meeting, October 19–24, 2007, New Orleans, Louisiana

Figures & data

Influence of METIS therapy on FA intoxication in rats

FA dose (mg/kg) and (therapy)	Lethal frequency	Probit Analysis
1.5 (none)	1/4	LD16 = 1.26
2.0 (none)	2/4	LD50 = 1.87
2.5 (none)	4/4	LD84 = 2.78
3.0 (none)	3/4
7.5 (METIS)	3/7	LD16* = 6.42
8.0 (METIS)	5/8	LD50* = 7.87
9.0 (METIS)	4/8	LD84* = 9.66
10.0 (METIS)	4/4
K(LD16) = 5.1
K(LD50) = 4.2
K(LD84) = 3.5

Table

	APAP at presentation (hrs post-ingestion)	AST Peak 1 (hrs post-ingestion)	AST Trough (hrs post-ingestion)	AST Peak 2 (hrs post-ingestion)
Case 1	30.7 mg/L (24 h)	3467 IU/L (37 h)	1958 IU/L (48 h)	7518 IU/L (65 h)
Case 2	0 mg/L (43 h)	507 IU/L (43 h)	390 IU/L (51 h)	1488 IU/L (69 h)

Table

	All pts. (n = 101)	Prior (n = 61) 1985–2001	Current (n = 40) 2002–2007
Age (mos.)	107+/−146	54+/−87	164+/−171
ECMO duration (hrs.)	222+/−172	255+/−167	186+/−166
Survival (%)	58/101 (57%)	34/61 (56%)	24/40 (60%)
Hydrocarbons, % (% survival)	40/101,40% (67%)	32/61,52% (67%)	8/40,20% (87%)
Noxious gases, % (% survival)	33/101,33% (54%)	22/61,36% (50%)	17/40,42% (63%)
Pharmaceuticals, % (% survival)	21/101, 21% (52%)	4/61,7% (75%)	11/40,27% (47%)

Fentanyl Deaths April 2005-December 2005

	N (%)
Deaths	338
Male	284 (84)
Black	201 (59.5)
Caucasian	137 (40.5)
Death in Chicago	271 (80.2)
Death in a Residence	162 (47.9)
Age, y (mean, range)	40.5 (17–68)
Fentanyl level, ng/mL (mean, range)	22.9 (0.8–164)

Table

Outocme	Mean Dose (mg)	Median Dose (mg)
Symptoms	135	50
No Symptoms	88	30
Mild Symptoms	132	50
Moderate Symptoms	106	40
Major Symptoms	N/A	N/A

MDAVB Antivenin in Antivenin Index

Not Available	Not Listed	Only Expired
Brown Snake	SAIMR Boomslang	FAVIREPT
Polyvalent Snake	SAIMR Scorpion	Polyvalent African
Soro Anti-Arachnidico	SCORPIFAV	Soro Anti-Botropico-Laquetico
Soro Anti-Botropico-Crotalico	Thai Cobra	Suero Antilachesico Monovalente
Soro Anti-Elapidico	Tiger Snake	Taipan
Suero Antibotropico Polivalente
Suero Anticrotalico Monovalente
Suero Antiofidico Anti-Coral
Suero Antiofidico Polyvalent

% treated, Odds Ratio relative to TOX, (95% CI)

Scenario	TOX	EP	CARD
SYM	91.5%	82.0%,0.50(0.27,0.95)	66.9%,0.22(0.12, 0.38)
ASYM	1.2%	1.8%,1.49(0.25,9.05)	2.1%,2.93(0.63,13.57)
PJ	24.2%	16.2%,0.83(0.50,1.37)	9.0%,0.43(0.26,0.70)
UD	17.0%	17.4%,1.26(0.74,2.16)	10.7%,0.71(0.43,1.19)
Any Senario	92.1%	83.2%,0.43(0.21,0.85)	67.8%,0.18(0.10,0.33)

Websites Ranked by Expert Opinion

Category/N(%)	A	B	C	D	E
MD	14 (17)	37 (44)	14 (17)	06 (07)	13 (15)
Pharm D	08 (10)	30 (35)	26 (31)	12 (14)	08 (10)
RN/SPI	28 (33)	26 (31)	11 (13)	08 (10)	11 (13)

A = highest rank of scientific evidence.

Table 1. Characteristics at Medical Toxicology Program Directors

PD Academic rank	n	EM as primary specialty	Service as PD > 3 years	Hours required to work in ED (average for rank)	Average salary stipend for PD role	In favor of national in-service exam for fellows	In favor of national matching for fellow slots
Full Professor	4	4	4	5	$86,250	4 (100%)	3 (75%)
Associate Professor	12	11	6	10	$43,500	10 (83.3%)	6 (50%)
Assistant Professor	7	6	4	12	$20,140	7 (100%)	3 (42.7%)
Instructor	0	N/A	N/A	N/A	N/A	N/A	N/A
No rank	2	2	0	19	0	1 (50%)	2 (100%)

Table

Variable	AV Group	Control Group	P-Value
Mean ΔVAS (SD)	55 (27)	29 (41)	.043
# of TFs (%)	3 (23)	6 (60)	.086
# of Subjects With a Related AE (%)	6 (46)	4 (36)	.697

FDA Approved & Most Common Antivenin Listed

	Unexpired	Expired
CroFab	4/40	5/72
Antivenin Crotalidae Polyvalent^§	1/10	22/294
Antivipmyn Polyvalent	22/338	23/417
Black Widow Spider	1/1	1/1
Antivenin Micrurus fulvius^§	0/0	7/33
Coralmyn Anticoral Serum	4/45	7/90
SAIMR Polyvalent	12/210	18/1,036
King Cobra	12/255	14/676
Green Pit Viper	13/139	4/65

Institutions/Vials, *Production ceased 2001, §FDA

Table

age gp	N	Long QTc	VA	Death
<7 yr	13	2	0	0
7–16 yr	21	1	0	1
>16 yr	166	31	2	10

IR Application Evaluation

Application	N	Accuracy	Mean Score	Preferred?
FAQ Library	28	96%	4.5	Yes
ZCSM	36	100%	4.3	No
Drug ID	26	100%	4.3	No

Table

Patient Outcomes
No Effect	380	21.7%
Minor Effect	563	32.1%
Moderate Effect	87	5%
Not Followed (non-toxic)	77	4.4%
Not Followed (minimal toxicity)	560	31.9%
Unable to Follow	53	3%
Unrelated Effect(s)	31	1.8%
Confirmed Non-exposure	2	0.1%

2002–2006 data.

Urine Hg Values

Group:	0	1	2	p Value
mcgHg/gCr pre-DMSA	0.614	1.009	1.520	.368
mcgHg/gCr post-DMSA	3.149	8.855	11.358	.051
Rise in Hg (mcgHg/gCr)	2.467	7.344	9.485	.042

*median.

Table

Concentration of Diphenhydramine	One Step Multi-Drug, Multi-Line Screen Test Device
10 mcg/mL	Color reduction but clearly negative
25 mcg/mL	More color reduction but negative
50 mcg/mL	Further color reduction; potential positive
100 mcg/mL	Positive interpretation

Selected Prescription Drug Behaviors

Drug Name	Indication	Motivation
Amphetamine/Dextroamphetamine	Enhanced test performance	Scholastic
Amphetamine/Dextroamphetamine	Improved study habits	Scholastic
Amphetamine/Dextroamphetamine	Longer party endurance	Recreational
Amphetamine/Dextroamphetamine	Stay awake in school	Scholastic
Amphetamine/Dextroamphetamine	Used to “feel good”	Recreational
Hydrocodone	Better pain tolerance during football game	Scholastic
Hydrocodone	Continued football participation despite prior injury	Scholastic
Hydrocodone	“Chill out” at parties	Recreational
Hydrocodone/Oxycodone	Getting “high”	Recreational
Trazadone	Experience “crazy dreams”	Recreational
Butalbital	Escape stress	Recreational
Clonazepam	Getting “a buzz”	Recreational

Identifying Mushrooms

Level of Familiarity	Cap	Stem	Gills	Ring	Cup/volva	ID toxic species?
Little or none (N = 87)	80 (92%)	83 (95%)	77 (89%)	21 (24%)	21 (24%)	5 (6%)
Low (N = 9)	8 (89%)	8 (89%)	8 (89%)	6 (67%)	3 (33%)	1 (11%)
Moderate (N = 5)	5 (100%)	5 (100%)	5 (100%)	3 (60%)	2 (40%)	0 (0%)
High (N = 3)	3 (100%)	3 (100%)	3 (100%)	2 (67%)	1 (33%)	1 (33%)

Drug-Related Deaths in Philadelphia 2004–2006

	2004	2005	2006
January	31	46	32
February	37	33	30
March	30	36	35
April	30	28	63
May	44	38	55
June	31	36	53
July	20	34	62
August	30	46	78
September	29	49	54
October	33	32	35
November	38	48	35
December	38	36	26
Total number of drug-related deaths	391	462	558
Number of drug-related deaths which tested positive for fentanyl	19	22	239
Percentage of drug-related deaths tested positive for fentanyl	4.8%	4.8%	42.8%

Rate Pressure Product, Fraction of Baseline

	5 min	10 min
L	0.23+/−.03	0.63+/−.07
E	0.20+/−.05	0.31+/−.04
V	0.07+/−.02	0.07+/−.01

Kappa Scores for Clincal Effects

CE	Mean Kappa Score	95% CI
Constipation	0.76	(0.57, 0.95)
Dysphagia	0.50	(0.19, 0.81)
Nausea	0.84	(0.78, 0.91)
Vomiting	0.94	(0.78, 0.91)
Agitated	0.96	(0.85, 0.99)
Coma	0.67	(0.58, 0.77)
Confusion	0.26	(−0.002, 0.52)
Drowsiness	0.74	(0.60, 0.88)
Muscle Weakness	0.57	(0.40, 0.74)
Paralysis	0.80	(0.55, 0.99)
Tremor	0.92	(0.84, 0.99)
Blurred Vision	0.84	(0.87, 0.92)
Acidosis	0.81	(0.70, 0.92)
Hematemesis	0.70	(0.41, 0.99)
Visual Defect	0.09	(−0.10, 0.28)

Consequences of Not Gaining Control

	Control (n = 180)	No Control (n = 46)
Total Vials	11.2 vials	15 vials
Time of Treatment	17.7 hours	35.2 hours
Length of Stay	50.5 hours	83 hours
Recurrence (n = 23)	16/180 (8.8%)	7/46 (15.2%)
Fasciotomy (n = 10)	6/180 (3.3%)	4/46 (8.7%)
Wyeth Antivenin (n = 10)	3/180 (1.6%)	7/46 (15.2%)

Table

time post NAC (hr)	Hepatotoxic death	Survived
0	706 [176, 1510]	15.2 [6.4, 32.1]
12	342 [73, 1330]	2.3 [0.8, 6.5]
24	325 [54, 1450]	0.8 [0.3, 3.1]

Spider Bite Enquires

Year	1997	1998	1999	2000	2001	2002	2003
% Spider Enquiries	0.033	0.033	0.044	0.045	0.069	0.081	0.072

Table

	Day 3	Day 4	Day 5	Day 7
APAP (mcg/ml)	15.8	33.1	37.7	34.0
AST/ALT (IU/L)	163/146	122/145	126/171	122/168
Bilirubin (mg/dl)	62.6	64.0	64.5	67.6

¶Days since the last Tylenol tablet was administered *N –Acetyl cysteine was started.

Clinical Characteristics of Pediatric Heroin/Tylenol PM® (Cheese) Abusers

Age(yrs)	Sex	Complications	Narcan	Intubation	APAP (mg/dL)	Transaminases	ED Disposition
11	M	AMS	+	−	<8	AST 25 ALT 25	Home
13	M	AMS	+	−	<8	ND	Home
14	M	AMS, RD, Cardiac Arrest, arrhythmia, pneumothorax, renal failure, liver injury	+	+	1	AST 546 ALT 638	ICU
15	F	AMS, RD, Seizure	+	+	<1	AST 72 ALT 72	ICU
15	M	AMS, RD	+	−	ND	AST 20 ALT 17	Home
16	F	AMS, RD, Pulmonary Edema, ARDS, anemia	+	+	2.2	AST 24 ALT 18	ICU
16	M	Withdrawal	−	−	<8	AST 65 ALT 49	Inpatient Psych
17	M	AMS	−	−	<8	AST 26 ALT 16	Rehab
17	M	Withdrawal	−	−	ND	ND	Home

AMS: Altered Mental Status; RD: Respiratory Depression; ND: not done.

Table

	+2.5 hours	+8.5 hours	+20 hours	+32 hours	+38 days	+64 days	+ 8 months
Sodium (mmol/L)	139	140	138	142	138	140	138
Potassium (mmol/L)	4.2	5.2	4.3	5.2	4.7	4.8	4.3
Chloride (mmol/L)	107	111	108	112	108	110	103
Bicarbonate (mmol/L)	21	19	23	22	23	23	25
BUN (mg/dL)	5	3	2	3	11	4	7
Creatinine (mg/dL)	0.3	0.4	0.3	0.4	0.5	0.2	0.3
Calcium (mg/dL)	10.2	10.0	10.2	10.1	8.8	9.4	10.0
Phosphorus (mg/dL)	5.2	−	−	6.4	−	5.9	6.7

ABX Use By Snake Type

Snake Type	ABX Use (%)	Significance
Copperhead (n = 5151)	23.4	OR 2.219; 95%CI 2.038 - 2.417
Coral snakes (n = 400)	2.6	OR 0.1925; 95%CI 0.1026 - 0.3611
Cottonmouth (n = 865)	13.8	NS
Rattlesnakes (n = 5981)	9.3	OR 0.6395; 95%CI 0.5780 - 0.7076
Unknown, venomous (n = 11338)	11.3	OR 0.7639; 95%CI 0.7049 - 0.8279

All significance results with p < 0.0001 unless noted.

Table

	Control	Methanol	Ethanol	Ethylene Glycol	Diethylene Glycol
Sodium	142	140	141	141	141
BUN	16	15	15	15	15
Glucose	99	100	100	100	93
Calculated Osm	295	291	293	293	293
Measured Osm	299	375	349	370	384
Osm Gap	4	84	56	77	91
Estimated Toxic Alcohol		269	258	477	965
Measured Toxic Alcohol		197	199	380	764
Error (% > measured)		36	29	25	26

Table

Hours post presentation	4	13	20	26	66
Troponin I	3.58 ng/mL	7.1	4.6	3.57	0.62
CK	643 U/L	1850	1335	1163	283
CK-MB	24 ng/mL	45.2	30.9	21.6	2.8
Index	4%	2%	2%	2%	1%