Abstracts of the 2008 North American Congress of Clinical Toxicology Annual Meeting, September 11–16, 2008, Toronto, Canada

Figures & data

Summary of charges

Charges	Amount
Nursing Level 4	$924
Physician Level 4	$319
Pulse Ox	$112
Total	$1355

Table

	Citalopram (N = 316)		Escitalopram (N = 63)		Chi^2 p=
somnolence	138	44%	25	40%	0.56
vomiting	56	18%	9	14%	0.51
tachycardia	54	17%	7	11%	0.24
seizures	43	14%	1	2%	0.0065
prolonged QT-interval	27	9%	5	8%	0.87
tremor	26	8%	8	13%	0.26

Table

Outcome	# Patients with recorded dose	Mean and median dose (mg)	Range (mg)
Death	1	3,000
Major	20	1,410 and 1000	100–3,200
Moderate	68	629 and 200	50–4,900
Minor	329	415 and 100	25–3,000

LE DIDs 2003–2007

	2004	2005	2006	2007
LE DID calls	6,510	7,781	9,916	13,873

Characteristics of unmatched vs matches cases

	SMC (2006)			SFC (9/06)
	Unmatched (N=223)	Matched (N=179)		Unmatched (N=109)	Matched (N=15)
Mean age	39.5	33.9	p<.05	37.2	39.6	ns
% female	57.0%	63.1%	ns	41.3%	60.0%	ns
Top substances	EtOH (24%)	sedatives (17%)		EtOH (22%)	sedatives (27%)
	narcotics (13%)	household agt (13%)		illicits (19%)	APAP (27%)
Mean # subs percase	1.2	1.2	ns	1.1	1.2	ns

Acetaminophen level and liver function since admission

Time post-admission	0	6	14	23	29	35	41
APAP (umol/l)	3716	2923	2550	3128	3249	1938	1288
ALT (IU/L)	37	52	61	94	108	167	245
AST (IU/L)	34	32	40	87	62	89	135
INR	1.2	1.6	1.7	1.9	1.9	2	2.1

Ordinal logistic regression

Dose history	Prob [No Effect]	Prob [Minor Effect]	Prob [Moderate Effect]
10 mcg/kg	95.00%	4.62%	0.38%
1 mg/kg	91.17%	8.13%	0.70%
100 mg/kg	84.86%	13.86%	1.28%

Mistaken oral ingestions

Agent	2001	2002	2003	2004	2005	2006	2007
Foradil^†	104	403	509	417	648	696	671
Spiriva	*	*	*	1146	3915	5344	7169

*Not yet on market; ^†2000 cases = 0.

Table: Laboratory course over first 10 days

Hospital day	24 hour urine arsenic (mcg/L)	Creatinine (mg/dL)	Total bili (mg/dL)	ALT (U/L)	Chelation
Admission/#1		1.2	1.5	162	BAL IM q 6hrs
#2			4.3	131	“
#3			6.9	172	BAL IM q 12 hrs
#4	8605	2.1	7.9	289	“
#5	3037		11.6	369	“
#6	7818		17.8	350	“
#7			20	251	“
#8	6589		22.1	198	Succimer po
#9			18.7	154	“
#10			17.1	136	“

EG levels vs. time

Time PI (hr)	EG level (mg/dl)	EG level (mmol/L)
3	600	96.7
9.8	326	52.5
17.7	181	29.2
23.6	158	25.5
31.5	115	18.5
48.3	44	7.1
62.8	19	3.1

Table

	Analgesic with opiate	Antipsychotics	Sedative/hypnotic	Cardiovascular Meds	Anticonvulsants
2000	18,602	13,029	36,723	14,908	14,014
2007	39,372	31,401	65,650	26,207	22,920
% Increase	112%	141%	78%	76%	64%

Table

	2000	2001	2003	2005	2007
Number (%) of Copperhead treated	69 (9.8)	119 (15.6)	261 (26.23)	320 (30.53)	410 (35.8)
Number (%) of Crotaline-Unknown treated	51 (18.6)	56 (19.24)	121 (30.6)	129 (31.2)	195 (40.5)
Number (%) Rattlesnake treated	491 (48.7)	618 (54.6)	628 (50)	638 (50.8)	736 (55.3)
Number (%) of total snakebites treated	743 (19)	936 (22.6)	1257 (25.5)	1378 (27.2)	1617 (32.5)

Table

Age	Reason	Drug/Dose	Sx
2 mo	Therapeutic Error	Sumatriptan 100mg	“fussy” per family but appropriate per ED staff
4 yr	Unintentional	Sumatriptan 400mg	Vomit × 6 PTA, remained asx in HCF
3 yr	Unintentional	Zolmitriptan 2.5mg	Vomit × 1 after excess water given by parent
2 yr	Unintentional	Zolmitriptan 1.5mg	Vomit × 2

Table

Drug Group	Median [min, max]	Doubling time [95% CI]	R-squared
Angiotensin receptor blocker MMD	383 [152, 636]	1.45 [1.20, 1.82]	0.960
Antihyperlipidemic MMD	1469 [1163, 1895]	4.16 [3.60, 4.92]	0.968
ACE inhibitor MMD	582 [273, 892]	1.82 [1.54, 2.22]	0.972
Clonidine MMD	1554 [1291, 1790]	8.00 [5.42, 15.3]	0.976
Calcium antagonist MMD	1185 [763, 1634]	3.04 [2.6, 3.67]	0.815
Beta blocker MMD	2316 [1445, 3313]	1.94 [1.58, 2.5]	0.990
CV Category MMD	9290 [6591, 12588]	3.35 [3.17, 3.55]	0.997
All Exposure Calls/1000	2400 [2168, 2439]	49.4 [29.3, 159]	0.678

Table 1. Factors associated with PRF

Factors:	OR (CI):
Historical
Suicidal	2.9 (1.6–5.0)
All intentional	2.3 (1.2–4.5)
PCC-Data
Noncompliance with PCC Antidote Rec	9.7 (1.2–78)
Presentation >24h	6.3 (2.5–15)
Late PCC Consult	4.8 (1.6–14)
Clinical
RR ≥ 25	13.8 (4.0–47)
MAP < 65	10.6 (2.4–46)
QTc ≥ 500 ms	9.8 (1.8–52)
Temp ≥ 101.5	5.1 (1.1–24)
Coma	5.1 (2.5–10)
HR < 60	3.5 (1.1–11)
Any AMS	3.3 (1.9–5.8)
HR ≥ 100	2.5 (1.4–4.4)
Laboratory
K^+ ≥ 5.5	∞
Ca^2+ ≥ 10.5	∞
HCO3 < 20	48.9 (17.7–135)
Cr > 1.5	26.9 (9.7–74)
Ca^2+ < 9.0	13.4 (3.7–48)
Anion gap > 12	6.1 (2.9–13)
Glucose < 65	5.4 (1.4–21)

Table 1. Self-report outcomes for intervention vs. control

Principal Outcomes	Intervention (n = 1043)	Control (n = 1070)	Statistic
Suicidal Ideation	n (%)	n (%)
Yes	302 (29.0)	446 (41.7)
No	741 (71.0)	624 (58.3)	Chi square 37.41 (1) p <. 001
Suicide Attempt
Yes	31 (3.0)	55 (5.1)
No	1012 (97)	1015 (94.9)	Chi square 6.36 (1) p = 0.01
Self cutting (mutilation)
Yes	42 (4.0)	50 (4.7)
No	1001 (96.0)	1020 (95.3)	Chi square 0.53 (1) p = 0.47

Patients with clinical effects

Patient	Age (years)	Weight (kg)	Dose (mg)	Tablet Number	Effect
1	2	13.5	1.0	1	V
2	2	15.0	3.0	3	D, L, V
3	3	14.3	0.5	1	V (see text)

D = drowsiness, L = lethargy, V = vomiting.

Table 1: Comparison of survey responses

Question	2006 Agree	2007 Agree
Prepared to do motivational interviewing	1/9	1/10
A designated Drug ID service would/did help relieve workload	7/9	10/10
Amount of time devoted to exposure calls is adequate	7/9	10/10
Satisfied with job (including tablet identification)	8/9	10/10

Caller type by substance by year

Substance	Year	Health Professional	Law Enforcement	Public	Other
Amphetamines (%)	2005	27 (16)	23 (14)	97 (59)	17 (10)
	2006	36 (19)	47 (25)	104 (55)	1 (1)
	2007	32 (18)	67 (38)	78 (44)	0 (0)
Buprenorphine (%)	2005	1 (2)	23 (40)	28 (48)	0 (0)
	2006	8 (5)	85 (57)	54 (36)	1 (1)
	2007	2 (1)	158 (79)	40 (20)	0 (0)
Oxycodone (%)	2005	59 (3)	262 (11)	1,843 (79)	161 (7)
	2006	102 (4)	480 (18)	2,095 (77)	42 (2)
	2007	97 (3)	639 (21)	2,333 (76)	5 (0)
Total (%)	2005	87 (3)	308 (12)	1,968 (77)	184 (7)
	2006	146 (5)	612 (20)	2,253 (74)	44 (1)
	2007	131 (4)	864 (25)	2,451 (71)	5 (0)

Table

Max-AST	Patients (%)		Proportion with Max-AST > Max-ALT (%)		Max-AST to Max-ALT Ratio: Median [10^th, 90^th %-iles]
Normal range (≤ 40 IU/L)	534	63.0%	396	74.2%	1.38	[0.714, 2.71]
41–1,000 IU/L	235	27.7%	159	67.7%	1.40	[0.610, 4.80]
> 1,000 IU/L	79	9.32%	35	44.3%	0.902	[0.568, 3.25]
All pts with AST & ALT data	848	100%	590	69.6%	1.33	[0.646, 3.00]

Table

PK Parameter	Population Mean (%SE)^a		Between-subject variability^b (%SE)
dka (hr^−1)^c	0.068	15.8%	47.1%	24.1%
ke (hr^−1)	0.357	1.7%	33.0%	6.7%
FEH (%)	3.38	7.9%	116%	9.4%
kt (hr^−1)	0.339	7.3%	67.8%	14.4%

^aPercent standard error of parameter estimate; ^bPercent coefficient of variation; ^ck_a = k_e + dk_a to avoid flip-flop phenomenon.

Desirable simulant characteristic scores

	CM-FC	O-FC	CS	K	C
global*	9.25	6.38	7.30	6.93	3.80
visibility*	9.15	8.43	8.95	8.88	5.58
removal*	7.5	7.55	5.75	2.28	1.55
stain	n	y	n	n	n

*mean VAS score.

3 year mushroom data-set analysis

	2005 (n = 28)	2006 (n = 9)	2007 (n = 15)
Annulus present?	64%	88%	93%
Cup present?	57%	88%	87%
Gill color?	71%	88%	87%
Gills attached?	43%	88%	80%
Patches on the cap?	11%	88%	87%
Digital photo possible?	0%	78%	60%
Time of Ingestion?	43%	56%	100%
S/Sx?	96%	100%	100%
Location found?	39%	44%	80%

Table

Serum APAP mcg/ml	AR ≤ 59 min	AR ≥ 60 min
Overall	5/47 (10.6%)	23/178 (12.9%)
0	0/10 (0.0%)	2/34 (5.9%)
1–20	2/4 (50.0%)	4/26 (15.4%)
21–70	3/12 (25.0%)	10/50 (20.0%)
≥ 71	0/21 (0.0%)	7/68 (10.3%)

Frequency of different age groups among patients with seizure

Age group	Number of patients
10–20 years old	77
21–30 years old	70
31–40 years old	11
41–50 years old	3
51–60 years old	1
>60 years old	7

Eligible patients=169.

Table

	No effect	Minor	Moderate	Major
All patients (n=108, 79% of total group)	51 (47%)	44 (40%)	13 (12%)	1 (1%)
Mean and median dose	528 mg, 200mg	1272 mg, 600 mg	1808 mg, 1200 mg	6000 mg
Patients < 6 years (n=32, 74% of age group)	27 (84%)	4 (13%)	1 (3%)	0
Mean and median dose	125mg, 100 mg	250 mg, 250 mg	400 mg

Table 1: Comparison of the farmers and the control group

	farmers (n=38) Mean(SD)	controls (n=38) mean(SD)	significance (p)	mean difference (95% CI)
age (years)	49.5 (7.7)	48.9 (7.3)	0.714	0.6 (−2.8–4.1)
N100 latency (ms)	103.5 (15.9)	99.4 (10.7)	0.197	4.1 (−2.1–10.3)
P200 latency (ms)	188.2 (18.3)	178.8 (21.4)	0.046	4.6 (0.2–18.6)
N200 latency (ms)	243.0 (26.4)	226.3 (24.3)	0.006	16.7 (5.0–28.4)
P300 latency (ms)	399.6 (45.5)	368.6 (29.1)	0.0007	31.0 (13.5–48.4)
P300 amplitude: Cz (μV)	14.80 (8.83)	12.95 (9.03)	0.371	1.85 (−2.25–5.92)
P300 amplitude: Pz (μV)	10.77 (4.7)	11.37 (5.04)	0.590	0.60 (−2.83–1.62)

Factors associated with ACVE in ED patients with SAP

Factors:	Univariate p Value:	Adjusted OR (95% CI):
Clinical Factors:
Age ≥ 55	<0.001	4.2 (1.4–12.6)
Multi-drug OD	0.02	3.4 (1.4–8.4)
HTN	<0.001	2.1 (0.7–6.5)
ECG Factors:
Non-sinus rhythm	0.001	3.6 (1.2–10.6)
Ectopy	0.001	3.3 (0.8–14.1)
QTc ≥ 500 ms	0.02	3.0 (1.1–8.4)
Ischemia	0.002	2.9 (1.0–8.2)
QTD ≥ 50 ms	0.02	2.0 (0.7–5.7)
Exposures:
CV Meds	0.045	3.3 (1.0–10.9)
Opioids	0.025	3.0 (1.1–8.0)

Table

Age	21–30 yrs	31–41 yrs	41–50 yrs	51–60 yrs	61–70 yrs	71–80 yrs
SPIs/PIPs	76	116	222	170	13	0
Man.Directors	0	7	14	12	4	0
Med.Directors	1	7	14	11	4	0

Table

	Day 0	Day 4	Day 7	Day 9	Day 11	Day 14	Follow-up
n	29	25	25	25	25	24	8
Mean ALT U/L	25.4	25.9	41.3	46.3	41.8	36.1	20
ALT Range	12–45	14–52	15–136	16–124	18–120	14–77	11–34
n with ALT>ULN (%)	1(3)	4(16)	14(56)	13(52)	12(48)	11(46)	0
Total Mean Bilirubin	0.52	0.46	0.45	0.51	0.48	0.52	ND
Total Bilirubin Range	0.2–1.8	0.1–1.2	0.1–1.3	0.1–1.2	0.2–1.1	0.2–1.4	ND

Substance abuse related mortality among 15–69 years residents of Iran, 2004

Age (population %)	Sex	Num	Per 10^5
15–49 year (54.4)	M	1936	10.28
	F	79	0.44
	M & F	2015	5.48
50–69 year (5.5)	M	222	11.65
	F	23	1.27
	M & F	245	6.60
Total (59.9)	M	2158	10.40
	F	102	0.52
	M & F	2260	5.59

Buprenorphine exposures, 2003–2007

Year	Reported Ingestions, Children Under 12	State Medicaid Patients Prescribed Buprenorphine
2003	0	195
2004	4	1,522
2005	9	2,988
2006	14	3,284
2007	25	4,642

Table

Year	2003	2004	2005	2006	2007
Total Cases	342	416	378	386	363
HCF Referral Rate (%)	8.2	5.5	3.2	0.8	1.7

Age-specific penetrance

	0–5	6–12	13–19	adult	0–99
1999	45.19	5.14	5.68	3.42	6.76
2007	40.33	4.39	5.5	3.48	6.47

Cases with GBP: 3% hydrogen peroxide ingestion with significant or prolonged symptoms

Years Old and Gender	Quantity (mL)	Symptoms	Symptom Duration	Treatment
45 F	120	GI pain, emesis, fever, leukocytosis, infection, computed tomography-imaged bowel wall thickening, localized perforation, ischemic bowel	6 days	IV fluids, antibiotics, IV analgesic
42 M	30–45	Emesis, epigastric pain	2–3 days	Oral fluids
63 F	15	Nausea, abdominal pain	1.5 days	Antacids, antiemetics
44 F	30	GI pain, gastric burns, emesis, necrotizing mucosal gastritis, endoscopic-visualized severe mucosal abnormalities with hemorrhagic appearance, ulceration of the jejunum	5 days	Oral fluids, GI cocktail, IV protonix, IV analgesic

The values of PB, HCO3 and K

Days	2	3	4	5	6
PB (mcg/ml)	32	29.6	28.1	22.9	11.2
HCO3(meq/L)	14	14	12	16	17
K (meq/L)	3.8	3.6	2.6	3.4	3.1

Percent of children answering “No” to each question; C =control, I = intervention

	Touch it? C	Touch it? I	Smell it? C	Smell it? I	Drink or eat it? C	Drink or eat it? I
Mouthwash	57.4	75.7	53.1	78.9	73.3	75.9
Pills	73.5	74	71.7	80.8	86.2	85.1
Fruit	15.6	28.9	23.3	36.1	27.9	37.3
Holly	60.3	77.7	57.9	76	75.5	83.9
Cleaner	70.3	78.4	69.4	82.2	86.2	86.8

Post intervention comparison of control and intervention groups ( n=513).

Table

Manifestations (cases with data)	Definition	Cases meeting criteria
Metabolic acidosis (n=102)	pH ≤ 7.20	74	72.5%
Hepatotoxicity (n=135)	AST > 1,000 IU/L	95	70.3%
Hypotension (n=155)	SBP < 90 mmHg, or vasopressors used	107	69.0%
Rhabdomyolysis (n=42)	CK > 1,000 IU/L	27	64%
Fever (n=61)	T ≥ 101°F	27	44%

Clonidine dose-effect relationship

Clinical Effect	n	Usual dose (mcg/kg)	Added Dose (x usual dose)
All Cases	158	4.44 (0.917–15.2)	0.2–10
No Effect	32	4.37 (1.12–12.6)	0.5–2
Minimal Effect	120	4.55 (0.917–15.2)	0.2–6
Moderate Effect	6	3.53 (1.96–5.5)	2–10
Major Effect	0

Clinical signs & symptoms

Clinical Features	Hornet	Yellow jacket	Honey bee	Wasp
	N=60 (%)
Local pain	38 (63.3)	11 (1.3)	8 (13.3)	3 (5)
Local necrosis	23 (38.3)	2 (3.3)	1 (1.6)	2 (3.3)
Rhabdomyolysis	19 (31.6)	2 (3.3)	0	0
Acute renal failure (ARF)	13 (21.6)	0	0	2 (3.3)
Urticaria	6 (10)	3 (5)	3 (5)	1 (1.6)
Hypertension	5 (8.3)	1 (1.6)	0	1 (1.6)
Coma	1 (1.6)	1 (1.6)	0	0
Anaphylaxis	1 (1.6)	1 (1.6)	0	0
Acute pulmonary edema	1 (1.6)	0	0	0
Death	1 (1.6)	0	0	2 (3.3)

Opioid analgesics listed in order of highest proportion of deaths

Opioid	DEA Schedule	Proportion of deaths to all KMOs	P value (compared to propoxyphene)	% of deaths in children <5 yr
Methadone	2	0.0435	<0.0002	1.4%
Morphine	2	0.0225	<0.0002	0.4%
Hydromorphone	2	0.0133	0.04	0
Oxycodone	2	0.0126	<0.0002	0.6%
Buprenorphine	2	0.0114	0.24	0
Propoxyphene	4	0.0103	-----------	0
Hydrocodone	3	0.0075	<0.0002	1.5%

Count of common substance ID'd by year

Substance	Year	Count
Oxycodone	2005	2,325
	2006	2,719
	2007	3,074
Hydrocodone	2005	1,117
	2006	1,122
	2007	1,176
Methadone	2005	275
	2006	478
	2007	464
Benzodiazepines	2005	2,092
	2006	2,213
	2007	2,448

Table

CASE	Cl 1	ASA 1	Cl 2	ASA 2	Cl 3	ASA 3
1	174	81	186	89	131	34
2	146	45	138	42	120	28
3	127	33	125	30	108	18

Questionnaire results

	Yes	No	Don't Know
Has your ED staff received radiation emergency training in the last 5 years?	3.6 % (n=1)	89.3 % (n=25)	7.1 % (n=2)
Has your ED treated a radiation emergency in the past 5 years?	57.1 % (n=16)	39.3 % (n=11)	3.6 % (n=1)
Radiation emergency training planned in the next 6 months?	25 % (n=7)	67.9 % (n=19)	7.1 % (n=2)
How capable is your ED in treating radiation emergencies?	0% reported “very capable”

Table

Mild Symptoms		Moderate Symptoms		Severe Symptoms
somnolence	53 (64%)	coma (GCS8–9)	7 (8%)	coma (GCS≤7)	9 (11%)
restlessness	2 (2%)	agitation	6 (7%)	multiple seizures	1 (1%)
dysarthria	5 (6%)	tachycardia (140–179bpm)	3 (4%)	sat O2≤85%	1 (1%)
mild prolonged QTc interval	12 (15%)	hypotension BP syst. 55–79 mmHg	2 (2%)
tachycardia (100–139bpm)	35 (42%)	sat O2 86–90%	1 (1%)
hypotension BP syst. <100mmHg	15 (18%)
sat O290–94%	3 (4%)
other minor sympt.	27 (33%)