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2014 ACMT Annual Scientific Meeting Research Abstracts 21-40 

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21. Hemodialysis for Salicylate Toxicity during Therapeutic Hypothermia

Boyle KL, Church RJ, Babu KM
University of Massachusetts, Worcester, MA, USA

Background: Hemodialysis is a well-established method of rewarming after hypothermia. Less is known about the effect of hemodialysis on temperature in the setting of hypothermia after cardiac arrest (HACA).

Hypothesis: When indicated for the treatment of overdose, hemodialysis can be performed during HACA without adverse event.

Methods: This is a single patient chart review. A 57 year-old woman presented to a Level 1 trauma center with a self-inflicted stab wound to her left chest. Imaging revealed a pneumothorax, which was treated with tube thoracostomy. Ten hours later, the patient became unresponsive. Arterial blood gas showed a pH of 7.4, PaCO2 35, PaO2 88. The patient was intubated, and ten minutes later became aystolic. She was treated with chest compressions, epinephrine and sodium bicarbonate, leading to ventricular tachycardia. ROSC was achieved with defibrillation. Post arrest, venous blood gas revealed a pH of 7.18 and PaCO2 of 73. Labs sent at the time of the arrest were significant for a serum aspirin level of 100 mg/dL. Hemodialysis was indicated for treatment of the salicylate overdose, however, concerns arose regarding dialysis catheter placement and temperature maintenance during active cooling. After discussions with toxicology, hemodialysis was initiated. The patient improved and was discharged to inpatient psychiatry on hospital day 46.

Results: The patient was actively cooled to goal temperature within three hours of initiating the hypothermic protocol despite placement of the dialysis catheter and preparing to start hemodialysis.

Discussion: Although our results are based on a single patient, hemodialysis for treatment of salicylate toxicity does not appear to impair active cooling. We do not believe that hemodialysis or HACA should delay or contraindicate each other in the rare cases where both are required. More data needs to be collected to determine the relationship between cooling times and hemodialysis parameters.

Conclusion: Hemodialysis for the treatment of salicylate toxicity does not interfere with HACA.


22. A Retrospective Analysis of Antiretroviral Agents and Outcomes from a Regional Poison Center

Braden BR1, Bronstein AC1, Waldstein MM2
1Rocky Mountain Poison and Drug Center, Denver, CO, USA; 2Creighton University, Omaha, NE, USA 

Background: Antiretroviral (ARV) agents used in the treatment of Human Immunodeficiency Virus (HIV) have a well described toxicity described in chronic use. However, the frequency of toxicity from overdose has not been investigated.

Hypothesis: The objective of this study was to quantify the number of reported cases of toxicity from ARV to a regional poison center and to determine if any patients developed clinical manifestations of toxicity.

Methods: We conducted a retrospective review of poison center records between January 1, 2000 and December 31, 2012. All single formula and combination formula products were searched. We screened all cases for number of exposures and clinical outcome

Results: Our poison center received 17 calls with 8 confirmed exposures to ARV. We had 6 intentional exposures and 2 unintentional exposures. No patients with either intentional or unintentional exposures developed toxicity. One patient with intentional exposure developed dehydration from diarrhea and required intravenous fluids in a health care facility.

Discussion: There are 56,000 new cases of Human Immunodeficiency Virus (HIV) reported each year. In 2010 the CDC stated that there were more than 1.1 million people living with HIV in the United States of America. Our poison center covers four states and according to each state’s department of health statistics, serves an HIV population of 23,037. Our analysis shows that ARV exposures were infrequently reported to our regional poison center. Of the cases that were reported, toxicity from intentional exposure was not found. In order to determine whether toxicity from intentional exposures does occur, a national investigation of poison center data should be undertaken.

Conclusions: ARV drug toxicity from intentional exposure reported to our poison center does not seem to cause toxicity.


23. Fomepizole Clearance with Continuous Renal Replacement Therapy

Braden BR1, Hurlbut KM1, McMartin KE2, Latimer B2, Linas SL3, Adebiyi OO4, Waldstein MM5
1Rocky Mountain Poison and Drug Center, Denver, CO, USA; 2Louisiana State University, Baton Rouge, LA, USA; 3Denver Health and Hospital Authority, Denver, CO, USA; 4University of Colorado, Boulder, CO, USA; 5Creighton University, Omaha, NE, USA

Background: When patients become hemodynamically unstable from the acidosis of toxic alcohol metabolites many nephrologists will prefer to place patients on continuous renal replacement therapy (CRRT). While fomepizole dosing has been studied in patients undergoing hemodialysis, there have not been any studies that have measured fomepizole clearance in patients undergoing CRRT. In this case report we measured fomepizole clearance from a single patient who was treated with intravenous fomepizole and underwent CCRT.

Case Report: A 63 year old male presented to a tertiary metropolitan emergency department with severe intoxication and acidosis. Initial laboratory findings included pH, 7.18, pCO2, 14 mmHg, pO2, 125 mmHg, bicarbonate, 4 mEq/L, anion gap, 39 mEq/L, BUN, 31 mg/dL, creatinine, 3.0 mg/dL. These findings were essentially unchanged following administration of 2 liters normal saline and 100 mEq sodium bicarbonate. Because toxic alcohol ingestion was suspected, 15 mg/kg IV fomepizole was administered. The patient was placed on CRRT and fomepizole concentrations were measured prior to beginning CRRT and every four hours thereafter. When the ethylene glycol and methanol concentrations returned below limits of detection 6 hours later, no additional fomepizole dosing was administered.

Results: The average clearance of fomepizole during CRRT in this case was 12µmol/L/h. The R2 value for clearance was 0.993.

Discussion: In our patient undergoing CRRT, clearance of fomepizole was 12µmol/L/h, which is double the healthy volunteer rate of 6µmol/L/h. Despite the apparent increase in fomepizole clearance, all concentrations obtained for 16 hours after the intial dose of fomepizole during CRRT were above the assumed therapeutic concentration in humans.

Conclusion: While this case report suggests that fomepizole dosing does not need to be adjusted during CRRT, a formal clinical trial would need to determine the best dosing of fomepizole during CRRT.


24. Respiratory Failure, QTc Prolongation and Myoclonic Movements after Massive Pediatric Ondansetron Oral Dissolving Tablet Ingestion

Cao D1, Wang GS1,2, Bronstein AC1,2
1Rocky Mountain Poison and Drug Center, Denver, CO, USA; 2University of Colorado School of Medicine, Aurora, CO, USA

Background: Ondansetron, a centrally acting 5-HT3 receptor antagonist when used for preventing emesis, has a well-established safety profile. Large, pediatric symptomatic ingestions have not been well described.

Hypothesis: Ondansetron mediated 5-HT3 antagonism may cause severe toxicity in massive overdose.

Methods: This is a case report. The hospital consulted the regional poison center. Clinical course and laboratory data were obtained as a result of this consultation.

Results: A previously healthy 2-year old female presented after suspected consumption of 58 (36 mg/kg) ondansetron 8 mg oral dissolving tablets (ODT) out a bottle of 60. Only two tablets were found. Within one hour of ingestion, the child demonstrated difficulty ambulating, nystagmus, tremors, and sleepiness. At the initial healthcare facility, the patient had emesis and worsening CNS depression, requiring intubation and mechanical ventilation. Heart rate was 152, and blood pressure was 138/87 with lowest at 80/38. EKG showed sinus tachycardia with QTC prolongation of 507 ms. Exam was significant for myoclonic jerks with unequal but reactive pupils. Laboratory evaluation and head CT scan were normal. On the following day, the patient became more responsive, and the QTC prolongation resolved with her recovering without sequalae.

Discussion: By history, this patient ingested a massive overdose. Ondansetron has a well described safety profile with a large therapeutic margin. In the US, ondansetron ODT is typically dispensed in blister packs. Because of hyperemesis gravidarum, the child’s mother obtained a bottle of 60 ondansetron ODT without blister pack packaging from a foreign pharmacy. The ODT formulation has a flavoring agent in the tablet making them palatable to children. The mechanism of toxicity is uncertain but has been attributed to increase of synaptic serotonin concentrations as a result of 5-HT3 receptor antagonism and decreased receptor selectivity. Ondansetron may also be a weak antagonist of 5-HT1A, 5-HT1B, and α1-adrenergic receptors.

Conclusion: Because of flavoring and rapid oral dissolution, ondansetron ODT can be attractive to children and result in severe consequences. Appropriate packaging such as blister packs may deter children from significant ingestion. In our patient, toxicity manifested as CNS depression requiring intubation, QTc prolongation, hypotension, and symptoms of serotonin excess.


25. Medical Toxicology Education in Medical Schools in the United States

Carey JC1, Halliday M2, Nelson LN3, Wax PM4
1University of Massachusetts Medical School, Worcester, MA, USA; 2Emory University, Atlanta, GA, USA; 3New York University School of Medicine, New York, NY, USA; 4University of Texas Southwestern Medical Center, Dallas, TX, USA

Background: Exposure to medical toxicology (MT) early in training may be important to educate medical students in caring for poisoned patients and may encourage interest in the specialty. The availability of MT education in US medical schools has not previously been described.

Research Question:The purpose of this study is to describe the prevalence of MT rotations, MT faculty, and poison center (PC) access in US medical schools.

Methods:A listing of allopathic US medical schools was obtained from the American Association of Medical Colleges (AAMC) website. Each school was evaluated for the presence of a MT student clerkship by searching the AAMC Visiting Student Application Service, medical school clerkship websites, and personal communications with MT faculty. Medical toxicologists’ affiliations were identified through the ACMT database, MT fellowship websites, and the AAMC online faculty database. Lastly, medical school affiliated PCs were identified using the American Association of Poison Control Center’s (AAPCC) website.

Results: MT clerkships are available at 47/141 (33%) of US medical schools. 89/141 (63%) have MT faculty, 34/141 (24%) of these have three or more medical toxicologists. Of schools with MT faculty, 45/89 (51%) have MT clerkships. 48/141 (34%) of medical schools are affiliated with PCs (the remaining 8 PCs do not have medical school affiliations). 31/48 (65%) of schools with PC affiliations have MT clerkships. 32/141(23%) have MT fellowships, 29/32(91%) of fellowships have an associated MT clerkship.

Discussion: Identifying medical schools without formal MT education and/or faculty will help target future MT educational efforts. The goal is to improve clinical understanding of poisoning and awareness of the specialty at the medical student level. Finding ways to improve medical student education and assessing the impact is an important next step.

Conclusion: While nearly 2/3 of US allopathic medical schools have MT faculty, only 1/3 have MT clerkships.


26. Mortal Questions: The Prevalence of Care Withdrawal after Intentional Self-poisoning

Carey JL1, Felton D2, Boyer EW1, Neavyn MJ1
1University of Massachusetts, Worcester, MA, USA; 2Boston Children’s Hospital, Boston, MA, USA

Background: Suicidal patients often refuse life-saving care, but emergency physicians still intervene under the pretense that capacity to refuse care is lost in actively suicidal patients. Treatment may, however, be withdrawn later as futility of treatment become apparent. Although withdrawal of care after suicide (WOCAS) requires significant ethical considerations, no studies report the prevalence of this phenomenon.

Objective: To identify the prevalence of WOCAS among regional poison control center cases.

Methods: This is a cross-sectional survey of all adult deaths reported to a regional poison control center (PCC) between 1/1/2003 – 6/30/2013. Records were retrieved retrospectively from Toxicall. Three unblinded data abstractors recorded cases and inter-rater reliability (kappa) was calculated.  Age, gender, suspected suicide (SS), and documented withdrawal of care (WOC) were abstracted. The categorization of SS was based on the suspicion of the healthcare provider requesting consultation with PCC, and was recorded as yes, no, or unknown. Only cases with a documented decision to discontinue life-saving therapies or refrain from escalation in care were considered WOC.

Results: 259 cases met inclusion criteria. There were 70 cases (27%) of WOC which represented 27.5% of all suicide deaths and 23.4% of all non-suicide deaths (p=0.16). The average age of suicide deaths was 45(IQR 37-58) versus 50 (IQR 34-66) (NS) in non-suicide deaths. The average age of patients with WOCAS was 53 (IQR 37-58) versus 67 (IQR 59-84) for WOC in non-suicide patients (p<0.05). Kappa was >0.7.

Discussion: This study documents prevalence of WOCAS among PCC deaths. The primary limitation in this study is the use of PCC charts, which may have underestimated the amount of suspected suicides and/or WOC cases due to under documentation.  This is supported by prior studies documenting WOC rates in ICU patients ranging from 50-90%. A prospective case-control study incorporating additional information, such as a comorbidity index, severity of illness, and time from presentation to WOC would improve our understanding of this problem.

Conclusion: The prevalence of withdrawal of care after suicide suggests that prospective studies are needed to highlight the major influences on this mortal question.


27. Portable Biosensors to Detect Physiologic Changes in Opioid Use: A Pilot Study

Carreiro S, Boyer EW
University of Massachusetts, Worcester, MA, USA

Background: Portable biosensors have been used to monitor physiologic variables in natural environments and have been shown to be useful in the monitoring of cocaine addiction by identifying craving and relapse. Similarly, biosensor technology could provide critical information in opioid addiction and treatment. However, there are no data on the changes measured by biosensors after opioid exposure.

Research Question: Do biosensor-monitored parameters change after therapeutic opioid administration?

Methods: This is an IRB-approved, observational study of four emergency department patients receiving parenteral opioids. Exclusion criteria were as follows: age 90, pregnancy, trauma related chief complaint, upper extremity amputation, and inability to consent. After enrollment, patients were asked about prior opioid exposure, home medications, and dominant handedness. The patient's electronic medical record was also evaluated for history of opioid prescriptions or use. A portable biosensor (Q sensor, Affectiva) was placed on the inner wrist of each subject, which continuously measured electrodermal activity (EDA), skin temperature, and locomotion. Data were continuously recorded for five minutes prior to opioid administration, during administration, and for thirty minutes after administration. Data were analyzed for overall trends in biometric parameters following administration.

Results: Individual results are presented in the Table.

Discussion: In this pilot study, opioid injection was associated with a rise in EDA. Previous opioid use seemed to be associated with a blunted response. In one patient, apparent drug seeking behavior correlated with lack of change in EDA. Laterality seemed to be an important factor, as magnitude of response varied between dominant and non-dominant wrists. Biometric changes should be further explored as a marker of opioid use in various clinical scenarios. Limitations: Larger application across varying ages, demographics, and range of opioid tolerance will be required to further delineate the expected biometric parameter changes.

Conclusion: Changes in EDA occur with administration of opioids, may vary depending on opioid use history, and can be easily measured by portable biosensors. 


28. Misuse of Pregabalin, Gabapentin and Baclofen in UK Men who Have Sex With Men Clubbers

Chan WL1, Wood DM2, Wood T2, Vermette AE3, Dargan PI2
1Tan Tock Seng Hospital, Singapore; 2Guy's and St Thomas' NHS Foundation Trust, London, UK; 3McGill University, Montreal, QC, Canada

Introduction: Pregabalin, gabapentin and baclofen produce central nervous system effects by interaction with GABA and/or GABA receptors. There has been interest in internet discussion fora and in recent anecdotal reports to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) of pregabalin misuse. Baclofen is used in the treatment of GHB withdrawal and there are reports of users buying baclofen off the internet to self-treat withdrawal. There is no data on the prevalence of misuse of these drugs. The aim of this survey was to investigate misuse of these drugs in a clubbing cohort that have previously been shown to have a high prevalence of use of recreational drugs.

Methods: We surveyed adults attending nightclubs catering for men who have sex with men (MSM) in South London in June 2013. Basic demographic data (age, sex, whether they had sex with men, women or both), together with data on whether individuals had heard of pregabalin, gabapentin and baclofen and if so, whether they had ever misused them were collected. Participants were classified MSM if they were male and had sex with men or both men and women.

Results: There were 313 respondents: 282(90.1%) male, 30(9.6%) female, 1(0.3%) transgender, mean±SD age 31.3 ±7.6years. 248 (79.2%) were MSM. Amongst MSM, 28(11.3%) had heard of pregabalin, 26(10.5%) of gabapentin and 32(12.9%) of baclofen. Of these, 6(21.4%) had misused pregabalin, 1(3.8%) gabapentin and 8(25%) baclofen. Overall, 11(4.4%) had misused one or more of these drugs in their lifetime. 7(63.6%) obtained these drugs from dealers, 4 (36.4%) from friends, 4(36.4%) from a primary-care doctor, 3(27.3%) from the internet, 3(27.3%) from family. 8 (72.7%) obtained the drugs from multiple sources. Last month use of recreational drugs was high in the MSM cohort: mephedrone 67.3%, GHB 50.4%, cocaine 43.2%.

Conclusion: The results suggest that there is misuse of pregabalin, gabapentin and baclofen in a small, but significant proportion of this high drug-using MSM population. Further work is required to determine whether this is more widespread and to further understand the routes of supply and motivations for use so that appropriate preventive strategies can be implemented.

29. Qsymia Induced Bilateral Acute Angle-Closure Glaucoma

Cheema B1, Collings J1, Cheema N2
1Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 2Toxikon Consortium, Chicago, IL, USA

Background: Obesity has reached epidemic proportions with about one third of North American considered to be obese. Qsymia, a combination of phentermine and extended release topiramate, was approved by the FDA in 2012 making it one of the first weight loss medications approved since fenfluramine/phentermine.

Methods: This is a single patient chart review. A 38 year-old obese woman presented to the emergency department with bilateral blurry vision for one day. In addition, she reported bilateral eye pain and flashes of light.  She denied headaches, nausea, vomiting, or eye trauma. She had been taking Qsymia for seven days as a weight loss aid. She had normal vitals and basic labs. Her eye exam demonstrated bilateral conjunctival injection, 4 mm reactive pupils, visual acuity 20/200 OD and 20/100 OS, intact extra-ocular movements, and normal retinas and ocular nerves on fundoscopic exam. She was found to have bilateral acute angle closure glaucoma (BAACG) with intraocular pressures (IOP) of 48 mmHg OU.

Results: The patient was treated with brominodine, metoprolol, mannitol, solumedrol, and homatropine.  Her IOP improved to 21 mmHg OS and 22 mmHg OD prior to discharge 24 hours later.

Discussion: Our patient experienced BAACG secondary to her use of once daily Qsymia, which contains 3.75mg of phentermine and 23mg of topiramate. While BAACG has been described in relation to topiramate in the ophthalmology literature, to our knowledge, it has not been described for Qysmia or in the toxicology literature. The mechanism of the development of BAACG from topiramate is hypothesized to be a uveal effusion leading to anterior displacement of the lens-iris diaphragm, resulting in miopization and reduction of anterior chamber depth. Phentermine has not been reported to cause BAACG. Our patient was instructed to discontinue the Qsymia.

Conclusion: This case report highlights the potential of a new FDA approved weight loss medication Qsymia to cause bilateral acute angle-closure glaucoma.


30. Fentanyl Patch Ingestion in an Infant with Endoscopic Retrieval

Chenoweth JA1,2, Radke JB1,2, Ford JB1, Sutter ME1, Albertson TE1,2
1University of Caifornia, Davis, Sacramento, CA, USA; 2Veterans Administration Northern California Health Care System, Mather, CA, USA

Background: Transdermal fentanyl patches are frequently used for prolonged analgesia in chronic pain syndromes.  Previous cases of intentional fentanyl patch ingestion resulting in clinical opioid toxicity have been reported.  There are no prior reports of management of fentanyl patch ingestion in an infant.

Hypothesis: Fentanyl patch ingestion by an infant may be amenable to endoscopic removal. 

Methods: This is a single patient chart review.  An 8-month old female was sleeping on her grandmother’s chest when she suddenly lost postural tone.  She was noted to be apneic with perioral cyanosis.  Following a blind finger sweep, mouth to mouth resuscitation was performed.  On arrival at a local hospital she was noted to have agonal respirations and decreased muscle tone so she was intubated.  On exam she was noted to have pinpoint pupils and when her grandmother looked for the 75mcg/hr fentanyl patch she had been wearing on her chest, she was unable to find it.  The patient was given a trial of naloxone (0.05mg) with return or muscle tone and pupillary response.  After 2 hours she once again was noted to have decreased muscle tone and pinpoint pupils which again responded to naloxone (0.086mg).  A pediatric gastroenterologist was consulted and endoscopy was performed to attempt fentanyl patch retrieval. 

Results: A single 75 mcg fentanyl patch was retrieved from the esophagus resulting in gradual resolution of opioid toxicity. 

Discussion: The amount of fentanyl contained in a single trans-dermal patch can cause significant morbidity and mortality.  In our case, we calculated a total of 12.375mg of fentanyl was contained in a single 75mcg patch.  Ingestion of the patch can result in prolonged opioid toxicity.  Treatment with naloxone can dramatically reduce the respiratory, neurologic, and gastrointestinal effects of fentanyl, but enhanced elimination techniques could also be considered.  Endoscopic removal can be attempted, particularly in younger patients where the patch may become entrapped in the esophagus or stomach.  In patients older than 9 months, whole bowel irrigation could also be considered. 

Conclusion: Endoscopic retrieval is an effect means of removing ingested sustained release patches in infants.


31. Wide Variation in Naloxone Dosing Recommendations for Acute Opioid Toxicity

Connors NC, Nelson LS
New York University School of Medicine, New York, NY, USA

Background: Opioid intoxication is an increasingly common reason for an Emergency Department visit. Naloxone, a competitive mu-opioid receptor antagonist, can be used judiciously to reverse hypoventilation, but in excess, can precipitate opioid withdrawal syndrome (OWS) in opioid dependent patients. The optimal dose of naloxone remains controversial, particularly in this latter group.

Research Question: What naloxone dose do authoritative sources recommend to treat opioid-induced hypoventilation?

Methods: A convenience sample of textbooks, study guides, and internet resources published within the last ten years in the fields of Emergency Medicine (EM) (4), Anesthesiology (4), Medical Toxicology (MT) (4), Pediatrics (2), Internal Medicine (IM) (2), and general medicine (ACLS, pharmacology reference, and internet resources) (6) were reviewed for their recommended naloxone initial dosing, dose range, and titration protocol for opioid toxicity. 

Results: 22 resources were identified that provided a naloxone dose recommendation. Of these, 12/22 (55%) recommended an initial dose of 0.04 or 0.05 mg IV and 9/22 (41%) suggested 0.4 or 0.5 mg IV. The maximum dose by titration recommended by source was: 2 mg in 6, 10 mg in 8, and 20 mg in 2. No trend towards lower recommended dosage was noted based on year of publication (R^2 = 0.012). An initial dosage less than 0.1 mg recommended by source was: 3/4 MT, 3/4 Anesthesia, 4/6 general medicine, and 2/4 EM. No IM or Pediatric sources recommended an initial dose less than 0.4 mg.

Discussion: Low-dose naloxone is highly effective in reversing ventilatory depression, and though it is slower in onset than higher doses, OWS is less concerning. The increase in chronic opioid therapy for pain and an increase prevalence of opioid abuse raises the likelihood of OWS following naloxone. Recent data suggests an initial naloxone dose of 0.04 mg IV is preferred.

Conclusion: Wide variation in the naloxone dose recommended for acute opioid toxicity is noted in sources with the potential for patient harm due to OWS. Clinical studies are needed to evaluate whether lower doses are efficacious and provide greater safety for opioid intoxicated patients.

32. Severe Mercury Poisoning in a Pediatric Patient Due to Mexican Facial Cream Use

Daubert GP1, Usedom EJ2, Offerman SR1
1Kaiser Permanente South Sacramento, Sacramento, CA, USA; 2Drexel University College of Medicine, Philadelphia, PA, USA

Background: We report a case of severe mercury (Hg) poisoning in a pediatric patient due to Mexican facial cream use.

Hypothesis: Hg poisoning in pediatric patients can occur with topical use of facial creams containing inorganic Hg.

Methods: A healthy 17 year-old boy presented with insomnia, lower extremity muscle weakness, extremity tingling, and low back pain. He reported a loss of balance and coordination while playing soccer. Later he developed hypertension (148/84 mmHg) and extremity fasciculations.  Initial workup revealed: normal CBC, CK, UA, serum electrolytes, Ca, Mg, CRP, TSH, AST, and MRI of the spine. An EMG revealed diffuse myopathic fasciculations. Prednisone resulted in no significant improvement. His symptoms worsened including severe fasciculations, hallucinations, ataxia, hypertension (170/90 mmHg) and tachycardia (150 bpm). He was admitted to the PICU due to hyperadrenergic signs and hallucinations. Initial working diagnosis was pheochromoctyoma. Morvan’s Fibrillary Chorea was then presumed and a 5-day course of IVIG was administered. 3 generalized seizures developed.  A medical toxicology consultation was then requested.

Results: Toxicology lab testing revealed elevated blood Hg levels of 208 mcg/L. Home inspection revealed unlabeled jars of acne facial cream from Mexico containing mercurous chloride (96,00-210,000 ppm Hg). Lumex measurements in the patient’s room were 2.6 mcg/mm3. The patient used facial cream daily for 6 weeks and stopped 1 month prior to the first Hg level.  Treatment included a full course of succimer. Hypertension was managed with diltiazem. Sleep and pain were managed with amitriptyline. Fasciculations, back pain, insomnia were present at 3 months. At 6 months follow-up he had rejoined his soccer team but continued on diltiazem for persistent hypertension and tachycardia.

Discussion: It is important to obtain a full medication history in adolescents using various acne treatments. Hg poisoning in pediatric patients is most commonly confused with pheochromocytoma and Kawasaki’s disease. Patients presenting with similar symptoms yet an incomplete picture should prompt an evaluation for Hg poisoning.

Conclusion: Determination of Hg toxicity may be challenging. Awareness of acne treatment facial products may prompt an early diagnosis of Hg poisoning. This case demonstrates collaboration between local and state health departments and a toxicology service.


33. Food-borne Poisonings and Infectious Diseases from Survivor Program Copycat Behaviors

Diaz JH
LSU Schools of Medicine and Public Health, New Orleans, LA, USA

Background: Popular Survivor television programs feature outdoorsmen recommending that novices survive wilderness experiences by consuming edible raw animals and plants.

Research Question: Do Survivor copycat behaviors result in potentially fatal food-borne infections and poisonings?

Methods: In case-series analyses, internet searches identified poisonings and infections following consumption of raw plants and animals with poisonings confirmed by positive chromatography and infections defined by positive microscopic, serologic, or molecular diagnostics. Statistical significance was defined by p-values ≤ 0.05 with continuous variables analyzed by t-tests and categorical variables by Chi-squares (Χ2).

Results: 38 cases of neuroangiostrongyliasis (NAS) with eosinophilic meningoencephalitis and 16 cases of paragonimiasis (PG) with hemorrhagic pneumonitis followed consumption of raw animals infected with causative parasites, rat lungworms (Angiostrongylus cantonensis) and American lung flukes (Paragonimus kellicotti) respectively. The mean age of NAS cases was 21.5 years, mostly males (P = 0.039, Χ2) from Hawaii (P = 0.039, Χ2) who consumed raw snails or frogs (P = 0.003, Χ2). The mean age of the PG patients was 27.3 years with 1 death, mostly males from Missouri (P < 0.0001, Χ2) who consumed raw crayfish (P < 0.0001, Χ2) while intoxicated (P = 0.028, Χ2). 6 cases of plant poisonings were reported in 5 males with mean age 26.4 years and 1 female (age 14). 4 plant poisonings with 3 fatalities followed consumption of water hemlock (Cicuta maculata). 2 fatalities followed consumption of poison hemlock (Conium maculatum). In fatal plant poisonings, hemlocks were misidentified as either wild carrot or ginseng. There were more infections then poisonings, but plant poisonings caused more fatalities than parasitic infections (P < 0.0001, Χ2).

Discussion: Risk factors for infectious diseases from Survivor copycat behaviors included male gender and consumption of raw animals while intoxicated outdoors. Risk factors for plant poisonings from Survivor copycat behaviors included male gender and misidentification of poisonous plants as non-poisonous. Recommended preventive interventions included proper preparation of self-harvested natural foods, wilderness survival training, and alcohol avoidance.

Conclusion: Survivor copycat behaviors resulted in significant risks for parasitic infections and fatal plant poisonings in young males consuming raw animals and plants during outdoor experiences when intoxicated.


34. Succimer Chelation Therapy Safely Used for Lead Poisoning in Pregnancy

Dissanayake VL1, Binns HJ2, Lank PM3, Mycyk MB1
1Toxikon Consortium, Chicago, IL, USA; 2Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; 3Northwestern University Feinberg School of Medicine, Chicago, IL, USA

Background: The 2008 National Health and Nutrition Examination Survey suggested that ~1% of women of childbearing age have elevated blood lead levels (BLL). Although research is lacking, edetate calcium disodium is the preferred chelating agent because of its familiarity in this setting. There is a paucity of cases utilizing succimer (DMSA) during pregnancy, one case demonstrated no improvement in maternal BLL.

Methods: 19-year-old female (G1P0) at 27 weeks gestation (WG) presents to her obstetrician with bone pain reminiscent of elevated BLL. She was first diagnosed with lead poisoning at 2 and received DMSA repeatedly. At 15, her levels had plateaued near “normal” after removal of a tongue stud verified to contain lead. Her BLL at 28 WG is 42.9 mcg/dL. Medical toxicology is contacted when her BLL is 101 mcg/dL at 34 WG. The patient denies pica and refuses hospital admission. After negotiation, the patient starts DMSA at home at 500 mg every 8 hours (5 days) and then every 12 hours (2 weeks). After she completes DMSA and removes 2 new tongue studs, her BLL is 32 mcg/dL. She is induced at 37 WG, and a 2,790 gram baby boy is vaginally delivered with APGAR scores of 9 at both 1 and 5 minutes. Cord and neonate BLL are 46 and 50 mcg/dL respectively. After he takes DMSA for 19 days, his BLL is 33 mcg/dL.

Discussion: The tongue studs are not verified lead sources, however the patient’s home revealed no source. Pica remains a common source of lead in pregnancy.  Although chelating agents may cause teratogenicity in animals due to loss of essential nutrients, in most cases of prenatal chelation, infants develop normally in the short-term. A case of DMSA prenatal chelation (maternal BLL: 44 mcg/dL at 7 months gestation) resulted in cord BLL of 126 mcg/dL at 37 WG, but infant was “normal” per pediatrician at 6-month follow-up.

Conclusion: Although one prior case report lacked significant improvement in maternal BLL after DMSA chelation, our case demonstrates that DMSA is a viable and safe option in pregnancy. Source removal remains most important in lead poisoning management.


35. Phencyclidine Intoxication Observational Survey

Dominici P1, Kopec KT2, Rowden A1
1Einstein Medical Center, Philadelphia, PA, USA; 2Duke University, Durham, NC, USA

Background: Phencyclidine (PCP) is a synthetic compound derived from piperdine and used as an anesthetic and hallucinogenic. Little has been published regarding the clinical presentation of PCP intoxication. PCP use as a recreational drug is resurging.

Objective: To quantify the incidence of clinical and behavioral findings in patients presenting to the emergency department (ED) under the influence of PCP.

Methods: A prospective, observational study was conducted in a tertiary care center with an annual census of 90,000 patients/year. Physicians and research assistants identified patients with possible PCP intoxication, along with bystander/EMS and self-reported ingestions. A structured data collection form was completed obtaining both clinical and behavioral events observed during the ED visit.

Results: We enrolled 179 patients, two patients were excluded secondary to lost data. The mean age was 32 years old (20-53) and 64% were male. Approximately half (47%) self-reported PCP use. On arrival 78% of patients were awake and alert, and 48% were oriented to self, time/date, and place. Mean physiological parameters were: HR 101 bpm, RR 18 bpm, BP 146/86 mmHg, 36.9C, pulse oxymetry 98%. Clinical findings were: amnesia 73%, horizontal nystagmus 64%, vertical nystagmus 52%, hypertension 50%, and agitation 40%. Co-ingestions were reported 35% of the time, 25% with marijuana and 21% with ETOH. Out of 177 patients, 153 had positive urine drug screens (UDS). PCP was positive in 152 (99%), 63 positive for THC (41%), 39 positive for benzodiazepines (BZD) (25%), and 19 positive for opiates (12%). The mean length of stay was 266 minutes, with 86% discharged, 8% admitted, and 6% transferred to psychiatry.

Conclusion: Patients with PCP intoxication tended to be young males. Prevalent clinical signs and symptoms were: amnesia, nystagmus, hypertension and agitation. Co-ingestions were the norm, however 25% of patients with a positive UDS received BZD in the ED, therefore it may not represent a co-ingestant. The majority of patients had minimal alteration in vital signs and were discharged once their symptoms resolved. The increasing prevalence of PCP use as a recreational drug requires a better understanding of its clinical presentation.


36. High Dose, Variable Length, N-acetylcysteine (HINAC) Therapy for Late-presenting Acetaminophen Poisoning

Eygnor J1, Dorai S1, Moore PW2, Donovan JW2, Burkhart KK3
1Lehigh Valley Health Network, Allentown, PA, USA; 2PinnacleHealth, Harrisburg, PA, USA; 3Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD, USA

Introduction: Two previous studies have demonstrated a decreased mortality from 58-80% to 37-52% for patients with late-presenting acetaminophen poisoning who were treated with Prescott’s N-acetylcysteine protocol. Since 1998, we have utilized a high dose, intravenous, variable length, N-acetylcysteine (HINAC) regimen for patients with acetaminophen poisoning described as a 140 mg/kg loading dose of N-acetylcysteine followed by 70 mg/kg every 4 hours until the transaminases begin to decline.

Objective: To describe our clinical experience of HINAC therapy for the treatment of late presenting acetaminophen poisoned patients.

Methods: A retrospective, observational chart review of an institutionally approved HINAC protocol from 1998 to 2013 at two toxicology centers. Inclusion criteria included HINAC administration >24 hours post-ingestion and/or initial transaminases twice the upper limit of normal with history of >8 gms of ingested acetaminophen. Patients were excluded by inadequate data, dosing deviation from HINAC protocol >25%, and chronic ingestion (>2 ingestions, separated by >8 hours). Our primary outcome was death. Secondary outcomes included liver failure (defined by transaminases >1000 IU/L), King’s College laboratory criteria for poor prognosis and anaphylactoid reactions. Outcomes were compared to previously published NAC regimens.

Results: There were 74 patients who presented after 24 hours with median age 31 yrs (range 1-71). Forty-nine (66%) were female, 18 (24%) had history of chronic ethanol abuse and 4 had history of hepatic disease. 65 (88%) of the ingestions were suicidal and the average time from ingestion to presentation was 34 hours (range 24-88). 47 had detectable acetaminophen levels with median 80.5 mcg/ml (range 2-516). The median number of doses of HINAC received was 7 (range 2-26). Forty-five (61%) had peak AST>1000 U/L and the median peak AST was 2756 U/L with range 18-23,470. Forty-three (58%) had peak ALT>1000 U/L and the median peak ALT was 3184 with range 11-17,658. Fourteen patients met at least 1 King’s college criteria (2 with protime >100 secs, 16 with creatinine >3.3 mg/dl, 9 with pH<7.3) and there were 5 deaths (2 non-acetaminophen). 4 (0.5%) patients had anaphylactoid reactions.

Conclusions: Patients with late-presenting acetaminophen poisoning who are treated with HINAC have decreased mortality compared to previous studies (p<0.0001)


37. Bedside Evaluation of Adverse Drug Events by Medical Toxicologists

Farmer BM1, Nelson LS2, Perrone J3, On behalf of the ACMT Toxicology Investigators Consortium (ToxIC)
Weill-Cornell Medical College, New York, NY, USA; 2New York University School of Medicine/Bellevue Hospital Center, New York, NY, USA; 3Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

Background: ADEs are defined as untoward outcomes associated with the use of a drug, including adverse reactions and medication errors. ADEs contribute significantly to iatrogenic morbidity and mortality and are generally preventable. Medical toxicologists (MTs) may be consulted in the care of patients with ADEs due to severity of symptoms and their expertise in antidote use, drug interactions, and care of poisoned patients.

Research Question: We sought to describe the clinical characteristics of ADEs leading to bedside toxicology consultation.

Methods: The ToxIC registry from January 2010 to October 2013 was examined to identify ADEs as the primary reason for consultation. These cases were analyzed for patient demographics, classes of drugs involved, presence of toxidromes, and clinical findings.

Results:A total of 309 ADEs were identified involving 166 women, 143 men. Patients were between the ages of 19-65 (206), age >65 years old (64), and age

Discussion/Conclusions: MTs consult on a wide range of ADEs in patients of all ages. Toxidromes or organ-specific findings are often present and may lead clinicians to seek expert advice. Further analysis of this and similar cohorts may generate ADE prevention strategies.  

38. Characteristics of Patients Presenting to a Medical Toxicologist for Exposure to Heavy Metals

Farrugia LA, Rhyee SH, On behalf of the ACMT Toxicology Investigators Consortium (ToxIC)
UMass Memorial Medical Center, Worcester, MA, USA

Background: Adult patients commonly present to medical toxicologists for evaluation of potential heavy metal exposure, but are poorly characterized in the toxicology literature.

Research Question: To characterize patients who present to a medical toxicologist for evaluation of heavy metal exposure.

Methods: An advanced search of the ToxIC database was performed from the dates 1/1/2010 through 10/10/2013 for exposure to heavy metals (see Table 1 for individual metals). Exclusion criteria were age less than 18 or age range not recorded. Additionally, acute iron exposures were excluded. The following data were collected: demographics, source of referral, reported signs or symptoms, and therapy provided.

Results: Fifty-four adult patients were identified. Of these, 55.5% of patients were male, with an average age of 52 (SD 16.2). Reasons for referral were predominantly interpretation of prior lab data (31, 57.4%), unintentional non-pharmaceutical exposures (17, 31.5%), and organ dysfunction (7, 13%). The most common exposures were cobalt (21, 38.9%), chromium, and mercury (13, 24.1% each). Fifteen patients reported exposures to more than one metal. Thirty-seven (68.5%) patients had symptoms reported. The most frequent were numbness/paresthesias (8, 21.6%), rash (4, 10.8%), nausea/vomiting (2, 5.4%), peripheral neuropathy (2, 5.4%), and hemolysis (2, 5.4%). Only 6 patients (11.1%) were judged to have symptoms most likely related to a toxicological exposure. Eight patients (14.8%) received toxicological treatment, including 4 of the 6 patients with symptoms likely related to a toxicological exposure. Three patients received chelation with succimer, while one also received vitamin C, and another received dimercaprol, gastric lavage, whole bowel irrigation, and intravenous fluids. The fourth was treated with intravenous fluids.

Conclusion: This review of database information on adult patients presenting to a medical toxicologist for evaluation of heavy metal exposure finds that these patients are more often men referred by a primary care doctor or other outpatient physician. The most common exposures were cobalt, chromium, and mercury. Limitations include reliance on providers to enter information, resultant incomplete data entry, or potential reporting bias towards more unusual cases. 


39. Does Patient Education in the Emergency Department Increase Awareness that Acetaminophen is Contained in Percocet?

Fil LF1, Sattler S2, Dvorkin R2, Yens D3
1North Shore University Hospital, Manhasset, NY, USA; 2Good Samaritan Hospital Medical Center, West Islip, NY, USA; 3New York Institute of Technology College of Osteopthic Medicine, Old Westbury, NY, USA

Background: Acetaminophen overdose is a commonly reported overdose in the United States. There are multiple opioid-acetaminophen combination medications on the market. The percentage of people with acute liver failure associated with unintentional acetaminophen overdose is increasing. Patients may be unaware that acetaminophen is contained in certain prescription medications.

Study Objectives: Our study will assess if patients in the emergency department are aware that acetaminophen is contained in Percocet®. It will also evaluate if educating patients about their prescribed medication will increase their knowledge that Percocet contains acetaminophen.

Materials and Measure: We performed a prospective randomized study on patients ages 19 years and older, who presented to the Emergency Department Fast Track, and were being discharged with an outpatient prescription for Percocet (or its generic equivalent). Upon discharge patients in both the control and intervention groups were given a questionnaire to complete. Prior to answering the questionnaire, the intervention group was read a script with information about Percocet and acetaminophen. A percentage of patients were contacted after their encounter for a repeat phone questionnaire.

Results: A total of 55 patients were enrolled. The intervention group answered significantly more correct questions than the control group. A majority of patients in the control group were unaware that Percocet contains acetaminophen. At a four month follow up, patient scores in the intervention group decreased while those in the control group increased.

Conclusion: Many patients do not know acetaminophen is contained in Percocet and even if educated, they may not retain this information.


40. Naloxone Administration in the Pediatric Population According to ToxIC Database Reporting

Fil LF1, Nelson LN2, Olsen D3, On behalf of the ACMT Toxicology Investigators Consortium (ToxIC)
1North Shore University Hospital, Manhasset, NY, USA; 2New York University Hospital, New York, NY, USA; 3New York City Poison Control Center, New York, NY, USA

Background: In 2009 ACMT established the Toxicology Investigators Consortium (ToxIC). This network was constituted to promote multi-center research in toxicology and enable the nationwide collection of important toxicological data from patients at the bedside.  We used the ToxIC database to investigate characteristics of pediatric patients receiving naloxone over one year.

Research Question: What are the characteristics of patients age 18 years and younger that received naloxone? 

Methods: We searched the ToxIC database for all cases of patients who received naloxone from October 1, 2012 to September 30, 2013. Patients ages 18 years and younger were examined and divided in four groups: age < 2 years, 2-6 years, 7-12 years and 13-18 years. Patients were evaluated for sex, type of exposure and indication for naloxone administration and specific xenobiotic implicated.

Results:557 patients were recorded as given naloxone during the study period. Sixty-eight (12.2%) of patients were 18 years and younger, of these 14 (2.5%) were < 2 years, 17 (3.1%) were 2-6 years, 4 (0.7%) were 7-12 years and 33 (5.7%) were 13-18 years. The number of males were greater than females in all groups except the 7-12 year group (males=females). For ages

Discussion: The prescription opioid abuse epidemic results in increased availability of opioids in the home. The ToxIC database shows that naloxone use in children is mostly due to unintentional pharmacologic exposures which supports this. The most common xenobiotic implicated was buprenorphine.

Conclusion: According to the ToxIC database, the most common cause for naloxone administration in the pediatric population was unintentional pharmacologic exposure.


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