2015 Annual Meeting of the North American Congress of Clinical Toxicology (NACCT)

Figures & data

Table

	2012 (10/1–12/31)	2013	2014	2015 (1/1–12/31)
Average page views per month	1,032	4,768	14,342	24,555
Mobile device (% of page views)	35%	63%	74%	78%
Arrive by organic search	Not available	70%	87%	87%
Traffic from within RPC region	40%	11%	7%	7%
Average clicks on 1–800-222–1222 per month	Not available	102	234	414

Table 1. Comparison of discharges, charges and payments between facilities with and without medical toxicology treatment services. *P values < 0.05.

	917 MedTox	917 No MedTox	918 MedTox	918 No MedTox
Average annual covered discharges per facility	24	20*	29	21*
Average covered charges per visit	$ 47,307	$ 40,527	$ 19,573	$ 17,757
Average total payment per visit	$ 14,801	$ 10,770*	$ 6,080	$ 4,483*
Average Medicare payment per visit	$ 13,609	$ 9,540*	$ 5,066	$ 3,527*

Table

	New (n = 179)	Old (n = 70)	Unknown (n = 13)
Average Dose (mg/kg) + STD	76.79 + 54.34	106.73 + 61.12	110.99 + 61.70
Max Individual Dose ≥ 150 mg/kg	19/179 (10.6%)	16/70 (22.9%)	5/13 (38.5%)

Table

	Estimated 2006 Rate (CI)	Estimated 2014 Rate (CI)	Start of Decline in Rate
Midwest	5.03 (4.56, 5.54)	7.55 (6.97, 8.18)	1Q2012
Northeast	3.83 (3.45, 4.26)	5.52 (5.09, 5.98)	3Q2011
South	5.08 (4.54, 5.68)	6.57 (5.96, 7.25)	1Q2011
West	4.18 (3.77, 4.65)	7.87 (7.26, 8.53)	3Q2012

Table

Initial snake ID	# of Identifications	# Correct	% Correct
Copperhead	36	20	56%
Moccasin	5	5	100%
Rattlesnake	3	2	67%
Unknown	4	0	0%
Nonvenomous	2	2	100%
All	50	29	58%

Table

	Sample A (5 min)	Sample A (30 min)	Sample B (5 min)	Sample B (30 min)	Sample C (5 min)	Sample C (30 min)
Hb (control)	14.2 g/dl	14.3 g/dl	15.4 g/dl	15.4 g/dl	16.1 g/dl	16.2 g/dl
COHb (control)	1.0%	0.8%	1.4%	1.5%	1.5%	1.2%
MetHb (control)	0.2%	0.3%	0.1%	0.2%	0.2%	0.3%
Hb (N-OH-PAPA)	16.3 g/dl	16.4 g/dl	15.7 g/dl	16.3 g/dl	17.4 g/dl	18.1 g/dl
COHb (N-OH-PABA)	23.6%	33.7%	5.8%	9.1%	19.2%	26.8%
MetHb (N-OH-PABA)	41.1%	44.9%	21.4%	34.3%	32.5%	42.5%

Table

PSFS Correlation	Absolute Correlation (ρ)
LEFS	0.9076
DASH	0.8300
NPRS	0.7374
NSS	0.7026
SF-36 PCS	0.6621
PGIC	0.3422
SF-36 MCS	0.1151

Table 1. Characteristics and Statistically Significant Differences.

	PCP positive	Drug Free	Other Drugs
% Black (n)	76 (119)*#	18 (28)	22 (34)
Mean ISS [SD]	7.64 [8.18]*#	9.74 [9.55]	10.839 [12.32]
Mean GCS [SD]	13.73 [2.68]*	14.37 [2.35]	13.03 [3.94]
% Intubated (n)	17 (26)*	6 (10)	20 (31)
% Admitted to ICU (n)	39 (61)#	44 (68)	54 (84)
Mean Serum Ethanol (mg/dL) [SD]	58 [91.67]#	0 [NA]	103 [116.79]

* = p < 0.05 between PCP positive and Drug free group.

# = p < 0.05 between PCP positive and Other drug group.

Table 1. Serum and urine mitragynine concentrations.

Sample	Time	Mitragynine Concentration (ng/mL)
HD#1 Serum	1736H	13.0
HD#2 Serum	2038H	7.4
HD#3 Serum	1535H	< LOQ (3.5 ng/mL)
HD#1 Urine	1830H	356.3

Table 1. Best GT Predictors of NPDS Suicidal Exposures 2004–2014 *p < 0.0001.

NPDS Exposures Reason = Suicide	Mean Exposures/ Week	Increase in Exposures/Week [95% CI]	Best model (stepwise) # of GT Predictors	R^2
13–19 Y	962	0.448 [0.378,0.517]	10	0.583*
All ages	4146	1.63 [1.54, 1.73]	7	0.750*
Acetaminophen	345	0.0105 [–0.006, 0.027]	10	0.268*
Antidrepressant	747	0.230 [0.205, 0.256]	8	0.529*
Antihistamine	384	0.278 [0.025, 0.295]	7	0.739*
Aspirin	145	–0.010 [–0.017, –0.002]	6	0.154*
Cough and cold	37.6	0.0541 [0.050, 0.058]	8	0.659*

Table

Gestational age	pH	HCO3	Anion gap	Methanol (mmol/L)	Treatment
34^0	7.27	9	27	9.5	Fomepizole + dialysis
34^4	7.43	19	18	10	Fomepizole × 1
35^3	7.33	11	20	11.9	Fomepizole × 8
37^5	7.35	13	16	8.5	Fomepizole × 1

Table

Procedure	Qty	Charges	% of Coding Denial
99358-Prolonged Inpt Serv, No Contact, 1st Hr	14	$4,760	52.5%
99291-Critical Carem E/M 30–74 Minutes	3	$1,741	19.2%
93042-Rhythm ECG, Report	48	$1,440	15.9%
99173-Visual Screening Test, Bilat	10	$820	9.0%
99215- Office/Outpt	1	$308	3.4%
Grand Total Coding Denials	76	$9,069	100.0%

Table 1. depicts his platelet count trend.

Day Post Envenomation	Platelet Count (per mm^3)
0	13,000
1	140,000
2	142,000
3	92,000
7	51,000
13	160,000

Table

Group	N	Mean observed Tmax (hours) (99% CI)
APAP-only	148	3.51 (3.11, 3.91)
APAP+ Antihistamine	111	2.99 (2.58, 3.40)
APAP+ Opioid	47	4.15 (3.36, 4.94)

Table

Neurologic Symptoms	Number of Patients
Coma/CNS depression	24
Agitation	20
Delirium/Toxic Psychosis	16
Seizure	8
Hallucination	7
Weakness/paralysis/numbness/parasthesia	4
EPS/dystonia	1

Table

Commercial Interest	What Was Received	For What Role?
Cumberland Pharmaceuticals	Research Grant	Research Grant

Table

	Results in Percentile		Degree of Impairment
Testing Parameters	Day 70	Day 92	Day 70	Day 92
Attention, Concentration, and Orientation	5^th	25^th	Mild-moderate	None
Language	< 1^st	22^nd	Moderate-severe	Mild
Visual-spatial	1^st	22^nd	Moderate-severe	Below average
Problem solving	Failed	Normal	Severe	Normal- mild
Memory	2^nd (average)	19^th (average)	Severe	Mild
Wechsler Adult Intelligence Scale	5^th	37^th	Severe	None

Table

	Rivaroxaban n = 198	Apixaban n = 25
Patients PT recorded	49 (25%)	6 (24%)
PT elevated (% with recorded PT)	7 (17%) (PT range 22.5 to 126.3)	0 (0%)
Patient INR recorded	61 (31%)	5 (20%)
INR elevated (% with recorded INR)	13 (21%) (INR range 1.4 to 12.47)	0 (0%)
Patients with PTT recorded	49 (25%)	6 (24%)
PTT elevated (% with PTT recorded)	5 (10%) (Ptt range 44.2 to 114.9)	0 (0%)

Table. Frequency of clinical effects single substance oral baclofen overdose.

Clinical Effects	Count (%)
Coma/CNS depression	24 (57)
Sedative-Hypnotic Toxidrome	12 (29)
Agitation	7 (17)
Respiratory Depression	6 (14)
Bradycardia (P < 50)	5 (12)
Hyperreflexia/Myoclonus/Clonus/Tremor	5 (12)
Delirium/Toxic Psychosis	4 (10)
Seizures	3 (7)
Hypertension (SBP > 200 and/or DBP > 120)	2 (5)

Table

	Day 3	Day 5	Day 6	Day 7	Day 8
Time (24 hr)	06:25	08:50	07:40	07:43	07:23
APAP-CYS (uM)	1.79	4.81	2.92	1.31	0.95

Table.

Time (hr after HDI stopped)	0	5.5	12	18	24	30	37	44	52	58	65	89	107	114	134	139	157
[Insulin] (μIU/mL)	> 1000	> 1000	301	220	160	135	129	59	80	18.1	53	78	22.7	73	26.1	39.8	20.3

Table

Hours after ingestion	serum total VPA (mg/L)	Apparent t1/2 (hours)
6.8	298
10	268	21
16.6	226	26.7
21	207	34.7
25.3	189	33
27.9	146	7.2
32.3	82	5.3
38.9	39	6.1
41.8	33	12
46.2	28	18.7
50.2	25	24.8

Renal values.

Creatinine [μmol/l] (normal 52–117)/ urea [mmol/l] (normal 3.3–10.8)
	30.11.	1.12.	2.12.	3.12.	4.12.	5.12.	8.12.	9.12.	11.12.	12.12.	23.12.
Dog 1	1151/28	1014/52*	830/36*	727/25*	–	771/24*	758/28*	571/26*	429/32	391/36*	122/14
Dog 2	757/30	–/40	1347/45	1083/58*	882/36*	565/22*	593/29	650/34*	458/30*	440/29	154/13
Dog 3	364/26	510/36	674/41	846/44	971/46

*Subsequent hemodialysis.

Table 1. Deaths involving antipsychotics.

Year	2008		2009		2010		2001
Total Poisoning Deaths	258		248		235		213
Antipsychotics	n	(%)	n	(%)	n	(%)	n	(%)
Quetiapine	1	(0.4)	5	(2.0)	5	(2.1)	10	(4.7)
Clozapine	4	(1.6)	11	(4.4)	2	(0.9)	5	(2.3)
Olanzapine	5	(1.9)	4	(1.6)	7	(3.0)	4	(1.9)
Risperidone	1	(0.4)	0	(0.0)	2	(0.9)	4	(1.9)
Chlorpormazine	1	(0.4)	1	(0.4)	1	(0.4)	0	(0.0)
Total* (% of Deaths)	12	(4.7)	21	(8.5)	17	(7.2)	23	(10.8)

*Note that three deaths involved two antipsychotic drugs.

Table 1. Deaths involving sedative-hypnotics.

Year	2008		2009		2010		2011
Total Poisoning Deaths	258		248		235		213
Sedative-Hypnotic	n	(%)	n	(%)	n	(%)	n	(%)
Zopiclone	19	(7.4)	28	(11.3)	28	(11.9)	34	(16.0)
Diazepam	8	(3.1)	15	(6.0)	15	(6.4)	12	(5.6)
Clonzepam	1	(0.4)	9	(3.6)	5	(2.1)	5	(2.3)
Benzodiazepine	3	(1.2)	3	(1.2)	3	(1.3)	5	(2.3)
Lorazepam	2	(0.8)	3	(1.2)	6	(2.6)	2	(0.9)
Triazolam	1	(0.4)	4	(1.6)	5	(2.1)	3	(1.4)
Temazepam	2	(0.8)	1	(0.4)	5	(2.1)	3	(1.4)
Alprazolam	1	(0.4)	0	(0.0)	2	(0.9)	0	(0.0)
Nitrazepam	2	(0.8)	1	(0.4)	0	(0.0)	0	(0.0)
Oxazepam	0	(0.0)	1	(0.4)	2	(0.9)	0	(0.0)
Total* (%)	39	(15.1)	65	(26.2)	71	(30.2)	64	(30.0)

*Note that 39 deaths involved two sedative-hypnotic agents and in 5 cases three

Table 1. Deaths involving toxic/asphyxiating gases.

Year	2008		2009		2010		2011
Total Poisoning Deaths*	258		248		235		213
Gases	n	(%)	n	(%)	n	(%)	n	(%)
Carbon Monoxide	74	(28.9)	54	(21.8)	56	(23.8)	47	(22.1)
Butane	5	(2.0)	3	(1.2)	5	(2.1)	5	(2.3)
Helium	3	(1.2)	3	(1.2)	4	(1.7)	5	(2.3)
Total (% of total deaths)	82	(32.0)	60	(24.2)	65	(27.7)	57	(26.8)

*Deaths due to all forms of poisoning.

Table

	Marijuana	Heroin	Cocaine
Total Cases Reported	99	349	252
Cases Meeting Inclusion Criteria	20	79	38
Age Range in Years (Mean)	1–55 (20)	14–64 (32)	19–60 (37)
Male	15	55	21
Female	5	24	17
Number Receiving Toxicological Treatment	11	66	28

Table

Day	PT (seconds)	aPTT (seconds)	INR	Rivaroxaban Concentration (ng/mL)
1	60.2	55.7	7.2
2	46.3	47.1	5.2
3	31.0	40.0	3.1	160
4	26.7	39.7	2.5	120
5	17.7	31.6	1.5

Table

Hyperkalemic Patients	N	[median dig], (IQR) ng/mL	[median K+], (IQR) mEq/L
No Fab, survived	15	3.1 (2.5–3.5)	6.0 (5.7–7.0)
Fab, survived	24	4.3 (3.4–5.4)	6.1 (5.9–6.8)
No Fab, death	1	4.0	6.3
Fab, death	2	6.0, 3.1	6.1, 6.3

Table

Time (min)	2	22	24	29	32	85	91	100	101	106	110	124	143	188	198	207
MAP (mmHg)	59	57	54	55	59	63	61	62	58	59	60	63	57	57	56	64
StO2 (%)		67	63	70	71	70	72	71	69	74	74	72	74	72	73	73

Table

Hours post-ingestion	10	32	50	62	74
Serum ibuprofen level (mcg/mL)	570	171	327	138	62

Table

Day post-ingestion	INR	Factor VII (%)	Daily vitK (mg)
1	2.6	32	200
2	3.0		300
7	1.1	88	240
12	1.1	88	200
15	1.1	92	160
17	1.1	84	140
21	1.1		100
23	1.2	78	20
30	7.5	2	100
32	1.3	80	100
33	1.3	68	80
35	1.3	66	80
41	1.1	65	80
60	1.2–1.3		70–80
90	1.2–1.4		50–60
120	1.2–1.4		50–60
150	1.2–1.4		30–60
180	1.2–1.6		30–40
210	1.2–3.0		30–50
240	1.1
270			5–10
285	1.1		0

Table

Na (meq/L)	137	CO2 (meq/L)	18
K (meq/L)	5.1	Glucose (mg/dl)	67
Cl (meq/L)	102	Osmolality (mOsm/Kg)	404
Methanol (mg/dl)	153	Ethylene Glycol (mg/dl)	330

Table

	Methanol (mg/dl)	Ethylene Glycol (mg/dl)
2 h post 1st dialysis	63	120
2 h post 2nd dialysis	< 10	< 10

Table

Time after adminstration	Ketamine level (ng/mL)
97 minutes	3800
6 hours	350
12 hours	160

Table 1. Adverse Effects of Phenybut Exposures.

Clinical Effects	Cases (N = 25)
Nausea/Vomiting	7
Diarrhea	1
Dizziness	1
Sedation	13
Agitation	4
Confusion	4
Hallucinations	0
Seizures	1
Tremors	2
Tachycardia	2
Bradycardia	4
Hypotension	2
Hypertension	3
Respiratory Depression	3

Table

	Suburban ED (n = 100)
Rx Storage: Bathroom	60
Bedroom	28
Kitchen	5
Other	8
Expiration Date Awareness	66 (Rx = 88, OTC = 76)
Rx Disposal: Garbage	38
Toilet	29
Do not dispose Rx	21
Gave Rx away	4
Insulin Syringe Disposal	8/8 (5 container, 3 sharps box)
Rx Drop-off site	41 (41%)

Table

Sample	Hours from Presentation	Chemical Detected	Concentration
Serum	0	AB-PINACA	42 ng/mL
Serum	0	AB-PINACA N-pentanoic acid	345 ng/mL
Serum	12	AB-PINACA N-pentanoic acid	232 ng/mL
Urine	16	AB-PINACA N-pentanoic acid	1.7 ug/mL

Table 1. Antidote Stocking at FECs and PHs.

	Sufficient Inventory
Antidote	Quantity 1h (100 kg)	Quantity 8h (100 kg)	FEC Adequate 1h TX	PH Adequate 1h TX	PH Adequate 8h TX
Acetylcysteine	15g	28g	2	5	3
Crotalidae Polyvalent Immune Fab	4 vials	12 vials	0	1	0
Sodium thiosulfate/nitrite or hydroxycobalamin (cyanide kit)	300mg/25g or 5g	600mg/50g or 10g	5	5	5
Deferoxamine mesylate	1.5g	12g	2	5	2
Digoxin Immune fab	10 vials	15vials	1	3	2
Fomepizole	1.5g	1.5g	4	5	5
Glucagon hydrochloride	20mg	90mg	2	4	2
Methylene blue	200mg	400mg	0	4	4
Naloxone hydrochloride	6mg	20mg	4	5	5
Octreotide acetate	75mcg	75mcg	1	3	3
Physostigmine salicylate	2mg	4mg	1	4	4
Pralidoxime chloride	2g	7g	0	1	1
Pyridoxine hydrochloride	5g	8g	1	3	2

Table

Period	Average Quarterly Change % (95% CI)	Average Quarterly Change p-value	Difference In Slopes Compared to Active p-value
Pre	5.69 (4.01, 7.41)	<.001	0.034
Active	2.64 (1.22, 4.08)	<.001	–
Post	–0.34 (–0.69, 0.01)	0.053	<.001

Table 1. Drug or drug category detected on urinalysis listed by trimester.

Drug or Drug category	All Trimester Use number (%)	First Trimester Use number (%)	Second Trimester Use number (%)	Third Trimester Use number (%)
Marijuana	12 (4)	2 (1)	1 (1)	9 (5)
Cocaine	1 (< 1)	0	1 (1)	0
Ethanol	18 (6)	2 (1)	3 (3)	13 (7)
Opioids	13 (4)	0	2 (2)	11 (6)
Sedative Hypnotics	3 (1)	0	1 (1)	2 (1)

Table

Variable Mean (95% CI)	Non-Hemodialysis (n = 95)	Hemodialysis (n = 8)	p-value
Age, yrs	40.6 (37.4–43.8)	49.3 (40.6–53.3)	0.13
Female, no. (%)	52 (54%)	2 (25%)	0.10
Initial Serum Creatinine, mg/dL	1.39 (1.18–1.6)	3.56 (0.78–6.34)	< 0.001
Initial Lithium level, meq/L	2.42 (2.21–2.63)	5.13 (3.49–8.41)	< 0.001
Peak Lithium level, meq/L	2.72 (2.51–2.93)	5.27 (3.63–6.91)	< 0.001
Length of Stay, days	4.41 (3.58–5.24)	13 (3.91–22.1)	< 0.001

Table

Drug Category	Public N (%)*	Private N (%)*	Odds Ratio	P-value
Any Drug	5,705 (33.1)	1,635 (28.4)	0.85	< 0.0001
Opioids	3,130 (18.1)	896 (15.6)	0.88	0.005
Sleeping Aid	1,508 (8.74)	439 (7.63)	0.89	0.079
Stimulant	1,930 (11.2)	562 (9.77)	0.90	0.091
Muscle Relaxer	1,847 (10.7)	502 (8.73)	0.91	0.146
Anti-Depressant	1,521 (8.82)	471 (8.19)	0.97	0.686
Anti-Anxiety	1,779 (10.3)	564 (9.81)	0.99	0.893
Any Illicit Drugs	1,796 (10.4)	552 (9.60)	1.01	0.842

*Multiple endorsements are possible between categories.

Table

Hotline	Days in Operation	Total Calls
H1N1	246	4,063
MERS	19	36
EVD	30	664

Call type.

In-state public callers
General EVD	271
Travel concern	62
Verify number	45
Exposure worry	29
Policy Issue	28
Other	28
Rumor	16
False claims	15
Media	14
Monitored traveler	3
Local health department	3
Calls from HCPs	84
Out of state callers	66
Total	664

Table

	Day 1	2	3	4	6	8	12
Creatinine (mg/dL)	1.69	3.23	4.19	4	8.05	7.04	6.92
AST (U/L)	78	236	187	174	107	79	26
ALT (U/L)	7	36	41	71	82	71	40
Bilirubin (mg/dL)	3.1	10.1	10	10.6	12.6	4.8	1.8
Hemoglobin (g/dL)	11.9	8.3	8.7	8	8.4	6.2	7
Platelets (x10^9/L)	136	81	56	25	43	109	126
Methemoglobin (%)	18	22	16	4.5	1.2
Serum Cu (mcg/dL)	> 500		88			161	137
Ceruloplasmin (mg/dL)	30		49
Dialysate Cu (mcg/dL)			0

Table

	Commercial Interest	What Was Received	For What Role?
DePuy Orthpaedics	Stipend	Stipend

Table

Phenibut dose	Co-ingestants	Symptoms	Treatment	Medication history
“10x usual dose”	None reported	Agitation,drowsiness, confusion, hallucinations, elevated creatine kinase and muscle stiffening	Lorazepam, haloperidol	Testosterone, Creatine
Unknown	Quetiapine, Unknown drug	Elevated creatine kinase, hypertension, agitated, diaphoresis, tachycardia, muscle rigidity, confusion, drowsiness	Lorazepam, Precede, Diazepam, Naloxone, oxygen, sodium bicarbonate, intravenous fluids	Unknown
9 grams	Alcohol	Nausea, bloating, anxious, insomnia, agitated	Unknown	None
Unknown	None reported	Agitated, confusion, lethargy, drowsiness	Unknown	Unknown
9.5 grams	Wine	Hypertension, tachycardia, vomiting, agitated, confusion, miosis	Lorazepam, intravenous fluids	Lithium Seroquel, flomax
Unknown	None reported	Hypertension, agitation, confusion, drowsiness, benign cyst on head CT	Unspecified benzodiazepine	None

Table 1. Association between Peripheral Blood Eosinophil Count and Urinary Phthalate Metabolites.

Phtalate metabolites (mcg/g creatinine)	Smokers or respiratory disease (n = 11,627)		Non-Smokers and no respiratory disease (n = 16,554)
	≥ 18 yrs (n = 9,669)	2–17 yrs (n = 1,958)	≥ 18 yrs (n = 8,375)	2–17 yrs (n = 8,179)
MiBP	–	–	–	β = 6 × 10–4*
∑HMWPH	–	β = 1 × 10–3*	–	–
MBzP	–	–	–	β = 4 × 10–4*
MCOP	–	β = 2 × 10–3**	–	–
MiNP	–	β = 6.6 × 10–3**	–	–

*p < .05, **p < .001; β = slope of linear regression line

Table

Source	State A	State B	State C	Outside states	Total (%)
Internet	109	36	97	26	268 (42.5)
Educational materials	96	17	16	9	138 (21.9)
Product packaging	13	6	8	3	30 (4.8)
Physician office	15	1	15	4	35 (5.5)
Hospital	10	2	8	2	22 (3.5)
Pharmacy	11	2	5	0	18 (2.9)
Friend	10	0	2	0	12 (1.9)
Programmed on phone	16	7	18	3	44 (7.0)
911	0	0	3	1	4 (0.6)
Phone book	19	4	11	3	37 (5.9)
Other	11	3	8	0	22 (3.5)
Total	310 (49.2)	78 (12.4)	191 (30.3)	51 (8.1)	630 (100)

Table 1. Adverse Effects of Bromethalin Exposure.

	Human (N = 136)	Canine (N = 282)	Feline (N = 10)	Rabbit (N = 1)
Gastrointestinal^a	10	5	0	0
Neruological^b	7	15	0	0
Cardiac	0	0	0	0
Pulmonary^c	2	1	0	0
Other Effects^d	14	10	0	0

^anausea, vomiting, diarrhea

^bHUMANS: headache, agitation, drowsiness CANINE: CNS depression, coma, weakness, ataxia, paralysis, tremors, seizures

^cHUMANS: shortness of breath, choking; CANINE: labored breathing

^dHUMANS: Fever, loss of appetite, ocular irritation CANINE: shivering, dermal bumps, decrease appetite, increase drinking, urination on floor

Table

Occupation	Number of Patients
Landscaper	6
Snake handler/caretaker	3
Construction worker	2
Snake remover	1
Venomous animal educator	1
Camp counselor	1
Engineer	1
Mechanic	1
Truck driver	1
Medicine man	1