TOXICOLOGY/SPECIAL CONTRIBUTION
Poisoning in the United States: 2012 Emergency Medicine Report of the National Poison Data System Richard C. Dart, MD, PhD*; Alvin C. Bronstein, MD; Daniel A. Spyker, PhD, MD; Louis R. Cantilena, MD, PhD; Steven A. Seifert, MD; Stuart E. Heard, PharmD, FCSHP; Edward P. Krenzelok, PharmD *Corresponding Author. E-mail: [email protected].
Deaths from drug overdose have become the leading cause of injury death in the United States, where the poison center system is available to provide real-time advice and collect data about a variety of poisonings. In 2012, emergency medical providers were confronted with new poisonings, such as bath salts (substituted cathinones) and Spice (synthetic cannabinoid drugs), as well as continued trends in established poisonings such as from prescription opioids. This article addresses current trends in opioid poisonings; new substances implicated in poisoning cases, including unit-dose laundry detergents, bath salts, Spice, and energy drinks; and the role of poison centers in public health emergencies such as the Fukushima radiation incident. [Ann Emerg Med. 2014;-:1-8.] 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.11.001
INTRODUCTION Deaths from drug overdose have become the leading cause of injury death.1 Each day in the United States, an average of 105 people die as a result of drug exposure.2 In 2012, drug misuse and abuse caused approximately 2.5 million emergency department (ED) visits.2 Drug-related deaths now exceed motor traffic accidents as the leading cause of accidental death in the United States.1 Emergency medical services and EDs are typically the first part of the health care system to encounter poisonings. Despite familiarity with acute resuscitation of the poisoned patient, the emergency physician is continually challenged by the emergence of new types of poisoning, which may require a new approach to diagnosis and management. For example, the emergency physician faces the challenge of new drugs such as Spice (synthetic cannabinoids) and bath salts (substituted cathinones) before other parts of the health care system. The National Poison Data System collects information from all poison centers and provides early recognition of emerging poison hazards. Despite the regular involvement of emergency medical providers in the management of poisoning and the source of much information in the system, to our knowledge these data have never been reported specifically for emergency physicians. This article provides a focused summary of information from poison centers about changes in therapeutics and new emerging chemicals and drugs that may confront the emergency medical personnel during out-of-hospital or ED care (eg, opioid analgesics, laundry detergent packets, bath salts, Volume
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Spice, energy drinks), as well as examples of the poison center’s role in disaster communication such as the Fukushima reactor disaster. Overview of Poison Center Operations The poison center system is composed of 55 poison centers that provide advice about poisoning exposures throughout the United States and its territories. A poison center is reached through a national toll-free number (800222-1222) that routes the caller to the center serving the caller’s geographic location. Callers include members of the public and health care providers. The case is managed without cost to the caller. Each case is uploaded and aggregated in the National Poison Data System, which is operated by the American Association of Poison Control Centers. The flow of a case through the poison center to the National Poison Data System is shown in Figure 1. Every poison center can provide advice at any time from a board-certified medical toxicologist. Poison center cases are spontaneous contacts involving either an exposed human or animal (termed an exposure call) or a request for information without exposure (termed an information call). An exposure is defined as any contact in which a person is reported to be exposed to the compound regardless of the amount or route of the exposure (oral, inhalation, dermal, and others). Each exposure case is received by a specialist in poison information, typically a nurse or pharmacist who has received training in toxicology and the management of emergencies. Every poison center uses a specialized electronic medical record that includes basic Annals of Emergency Medicine 1
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Figure 1. Flow of exposure case through a poison center to the National Poison Data System. HCF, Health care facility; NPDS, National Poison Data System.
quality-control checks (ie, required data fields ensure that the same core information is collected on all cases). Centers undergo a rigorous accreditation process and must be reaccredited periodically. For example, each poison center must have a board-certified medical director and nationally certified specialists in poison information. Further information on methods, definitions, and certification criteria is available from the American Association of Poison Control Centers (http://www.aapcc.org). National Poison Data System data involve spontaneous reporting; therefore, the number of exposures will be underestimated because many persons with an exposure do not contact a poison center. There is likely bias in reports that are received because callers may be more likely to contact a poison center when a child or other vulnerable person is affected. Similarly, the perceived severity of exposure may increase the likelihood of contacting a poison center. Publicity and other activities may transiently increase poison center contacts because of greater awareness among callers. Furthermore, although poison centers use specific interview techniques to solicit the specific identity of a poison, the identity may be unknown or misidentified by the caller. Subtle clinical effects such as electrocardiographic changes can be omitted or misinterpreted by health provider callers. In many cases, the exposure cannot be confirmed through blood or other tests. However, the data available 2 Annals of Emergency Medicine
suggest that poison centers are successful in accurately identifying the poisoning agent, and deaths in the National Poison Data System correlate well to the number of deaths reported to the national mortality database.3-5 In 2012, poison centers recorded 3.3 million total encounters, including 2.3 million human exposure cases (1 case every 13 seconds), 66,000 animal exposures, and 1 million information calls.6 The National Poison Data System database contains almost 58 million human exposure case records through 2012. A unique feature of poison centers is the extensive follow-up performed to collect additional information on the case, provide additional advice about management of the case, verify the poison center record with the caller or the health care provider, and determine outcome for the case. Cases that are referred to the ED are typically followed until the patient is discharged. In 2012, poison centers made 2.7 million follow-up contacts involving 45% of all human exposure cases. The annual number of human exposure cases increased consistently until 2007, when the upward trajectory leveled off and has since decreased slightly. Analysis reveals that the decreased case volumes primarily involve low-risk exposures in children, the main category responsible for cost savings.7 In contrast, more serious exposure cases such as those involving health care facilities have continued to increase. The number of poison center exposures managed in a health care facility (typically an ED) increased from 526,000 in 2003 to 613,412 in 2012 (Table 1). Because most health facility contacts are of higher severity and involve an ED, the acuity of poison center cases seems to be increasing despite the slight decrease in case volume. Table 1. Site of management in human exposure cases involving a poison center, 2012.* Site of Management Managed on site, non-HCF Managed in HCF Treated/evaluated and released Admitted to critical care unit Patient lost to follow-up/left against medical advice Admitted to non–critical care unit Admitted to psychiatric facility Subtotal: managed in HCF Other, refused referral, or unknown Total
Number of Cases
Percentage
1,574,362
69.2
291,414 100,455 94,284
12.8 4.4 4.1
67,847 59,412 613,412 87,367 2,275,141
3.0 2.6 27.0 3.8 100.0
*HCF is defined as any hospital-based patient care unit or ED, freestanding emergency medical clinic, first aid station, physician’s office, or clinic. The majority of these patients present to the ED. Each category is mutually exclusive. A patient can be in only 1 category. The highest level of care is rendered per the following prioritization in descending order: (1) admitted to critical care unit, (2) admitted to non–critical care unit, (3) admitted to psychiatric care facility, (4) treated or evaluated and released, (5) patient refused referral or did not arrive at HCF, (6) patient lost to follow-up or left against medical advice.
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Figure 2. Changes in use of decontamination in poison center cases, 1985 to 2012. 1: Publication date of the European Association of Poison Centres and Clinical Toxicologists’ ipecac position statement.10 2: Publication date of the American Academy of Clinical Toxicology’s ipecac position statement.11 3: Publication date of the American Academy of Pediatrics’ article about poison treatment in the home.12
Cost-effectiveness of Poison Centers Poison centers reduce the number of poisoning cases that enter the health care system. An independent analysis of costs and benefits associated with poison centers found that poison centers effectively reduce health care expenses. The total operating cost of all poison centers is approximately $160 million annually.8 The calculated total cost savings are more than $1.8 billion annually, with a return of investment of $13.39 for every dollar spent on a poison center. Savings occur in 4 categories: avoided medical use ($753 million), reduced hospital length of stay ($441 million), reduced health care use because of in-person outreach services ($24 million), and reduced work-loss days ($603 million).8 The largest component, reduced health care system expense, is created mainly by reducing the number of patients who enter the health care system. Most patients who contact a poison center are managed without involvement of a health care facility (69.2%), usually at the site of exposure and primarily in the patient’s residence. The proportion of patients treated in a health care facility varies with age. In 2012, only 11.6% of children younger than 5 years and only 14.0% of children aged between 6 and 12 years were managed in a health care facility compared with 51.2% of teenagers (aged 13 to 19 years) and 37.9% of adults (aged 20 years or older). The precise reasons for the increased rate of health facility use for the older patient groups is not known, but many of these cases involve more dangerous drugs such as cardiovascular medications or involve patients with self-harm attempts, who are typically referred to an ED for medical and psychiatric evaluation. Volume
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Another contributor is that contacts about young children may involve less toxic compounds (ie, household supplies of limited toxicity such as cosmetics, soaps, and air cleaners). More recently, another study documented that the involvement of a poison center in the care of hospitalized patients was associated with shorter stay and reduced charges.9 Evolution of Emergency Gastrointestinal Decontamination Techniques Once used in many poisoned patients, gastrointestinal decontamination techniques failed to improve patient outcomes, and their use has subsequently been discouraged. Several organizations such as the American Association of Poison Control Centers and the American Academy of Pediatrics have recommended the elimination of ipecac or cathartic agents for decontamination of poisoning. Similarly, the use of gastric lavage has been de-emphasized and more restricted use of activated charcoal for decontamination has been recommended.10-12 Data from the National Poison Data System indicate that use of gastrointestinal decontamination procedures has changed greatly. The use of cathartics, gastric lavage, and induced emesis has nearly vanished. The use of activated charcoal has declined substantially in recent years, although the relation between changes in practice and position statements from professional societies is not strong (Figure 2). Whatever the reason for the change in practice, it produced significant changes in emergency medical practice. Annals of Emergency Medicine 3
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Poisoning Mortality in the United States All poison center cases with an outcome of death undergo a standardized evaluation by the American Association of Poison Control Centers Fatality Case Review Team. The team is composed of approximately 40 medical and clinical toxicologists. Each case is reviewed by 4 team members. In accordance with an examination of case circumstances and the toxicology of each drug associated with the death, cases are rated on the likelihood of the substance’s being responsible for the death, using a defined classification scheme: undoubtedly responsible, probably responsible, contributory, probably not responsible, clearly not responsible, or unknown. In 2012, there were a total of 2,937 human exposures in the National Poison Data System with an outcome of death. The primary substance was a pharmaceutical product in 83% of cases. The most commonly implicated pharmaceuticals were prescription drugs of abuse, mainly opioid analgesics, followed by cardiovascular and antidepressant medications (Table 2). Although total deaths from antidepressants have decreased since the introduction of serotonin reuptakeinhibitor antidepressants, the cyclic antidepressants such as amitriptyline remain important causes of death. Bupropion is a common overdose agent and is also associated with a substantial number of deaths. Among the nonpharmaceutical agents, carbon monoxide is a perennial leading cause of death in the National Poison Data System; in 2012, it was involved in 54 deaths.6 Freon and other halocarbons are surprisingly frequent as a cause of death, considering their limited availability. In 2012, there were 16 deaths involving Freon or other propellants, generally during abuse of products containing a propellant (eg, keyboard duster spray). A listing of individual cases and case summaries are tabulated in an expanded National Poison Data System report.6 Opioid Analgesics The opioid analgesics have emerged during the past 15 years as a major cause of accidental death in the United States. The Drug Abuse Warning Network reported that ED visits in the United States for use of opioid pain relievers increased 153% from 2004 to 2011.2 The Centers for Disease Control and Prevention (CDC) reported that more than 16,000 people died because of prescription opioid analgesics in 2010.13 Trends involving prescription opioids in the National Poison Data System have mirrored the national toll associated with these products. The total number of human exposures managed by poison centers was stable, at 2.3 to 2.4 million, during the 10-year period ending 2012. In 4 Annals of Emergency Medicine
Table 2. Top causes of death related to pharmaceutical products in the National Poison Data System Database, 2012. Drug Category Analgesics
Stimulants/street drugs
Cardiovascular drugs
Antidepressants
Sedative/hypnotic/ antipsychotics
Active Pharmaceutical Ingredient
Number of Reports
Methadone Oxycodone Acetaminophen/hydrocodone Acetaminophen Morphine Fentanyl Salicylate Tramadol Acetaminophen/oxycodone Total Heroin
178 138 133 103 102 53 49 33 24 813 325
Methamphetamine Cocaine Amphetamines (hallucinogenic) Total Amlodipine Metoprolol Verapamil Diltiazem (immediate or extended release) Cardiac glycoside Atenolol Total Amitriptyline Bupropion (immediate or extended release) Citalopram Doxepin Venlafaxine Total Quetiapine
90 87 14 516 33 21 21 29 12 10 126 38 31 14 11 9 103 35
Alprazolam Benzodiazepine Clonazepam Diazepam Pentobarbital Total
27 9 8 7 5 91
contrast, the number of human exposures involving prescription opioid analgesics doubled, from 22,641 in 2003 to 44,381 in 2012.6,14 Methadone is well known for its long duration of action and propensity for lethal outcomes.15 It was the leading opioid as a cause of death in the National Poison Data System, with 178 cases in 2012.6 Many of the methadone cases reported involved the tablet formulation. Substance abuse treatment programs (methadone clinics) most commonly use the liquid or diskette formulations of methadone, but many of the serious cases managed by poison centers involve tablets; tablet cases appear to be prescribed outside the confines of an opioid abuse treatment program and arise out of use of methadone for pain. The fact that many fatal poison center cases associated Volume
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Figure 3. Number of cases of single use unit-dose laundry detergent packets and general laundry detergent cases, 2012 to 2013.
with opioids involve the tablet formulation indicates that restriction of availability of the tablet formulation could be useful. To address this concern, the Food and Drug Administration (FDA) has included methadone in its longacting opioid Risk Evaluation and Mitigation Strategy program, which requires manufacturers to provide education and training about their products. Emergency physicians should be aware of the numerous difficulties involved in the use of methadone. Prescription opioids are also a danger to young children.16 For some formulations, a single pill can kill a small child. The total number of prescription opioid singlesubstance exposures involving children aged 5 years or younger more than doubled, from 2,591 to 5,541 annually, in the 10-year period ending in 2012. Similarly, child deaths associated with a prescription analgesic increased from 1 to 7 annually in the same period. As with adults, the most common drug involved in a pediatric death was methadone. It is prudent for emergency personnel to provide detailed and emphatic warnings when prescribing to a patient with small children at home. Laundry Detergent Packets An unexpected source of poisoning appeared in 2012: laundry detergent packets. Several manufacturers now provide a “unit-dose” delivery mechanism for laundry detergents. The user simply puts one packet in a load of laundry without the need for measuring. The packs contain concentrated liquid detergent within a water-soluble membrane that dissolves easily and can be bitten through. The most common exposure from a traditional open liquid Volume
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detergent container is a sip, which would amount to less than 5 mL. In contrast, a child ingesting 1 packet could receive a larger amount and potentially a large spray of detergent into the airway. As a class, laundry detergents are a common and relatively benign exposure among young children. The adverse event profile of these products is generally limited to local irritation, self-limited vomiting, and other mild effects. The number of cases increased considerably after the introduction of concentrated laundry packets in 2012 (Figure 3).6 Review of National Poison Data System data from 2011 and 2012 indicates that approximately 0.5% of patients experienced airway effects that were managed with intubation. Similar products have been available in Europe for several years. The National Poisons Information Service in the United Kingdom prospectively collected 1,486 exposures relating to liquid detergent capsules from 2009 to 2011. Nearly all patients were children younger than 5 years. The most common features reported after ingestion alone were nausea and vomiting, followed by coughing, drowsiness, or central nervous system depression and foamy oral secretions. After ocular exposure, features suggesting conjunctivitis and corneal ulceration developed. A few patients had skin exposure alone and developed erythema, rash, and burn. There were no fatalities.17 The emergency physician should consider laundry packet exposures more dangerous than open-container liquid exposures. Standard irrigation and follow-up are indicated for irritation of the eyes and mucous membranes. Typical airway management is sufficient to maintain the Annals of Emergency Medicine 5
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Figure 4. National Poison Data System human exposures per month for bath salts and analogues of tetrahydrocannabinol, 2011 to 2012. THC, Tetrahydrocannabinol.
airway. To date, toxicity has been evident relatively early in the course and should be present in the ED course. Patients are typically observed for 2 or 3 hours and discharged if symptoms resolve. Bath Salts Bath salts is the street name for a family of designer drugs with names such as Plant Food, Ivory Wave, Purple Wave, Vanilla Sky, and Bliss. The drug typically contains substituted cathinones (eg, mephedrone, methylenedioxypyrovalerone, methylone). A cathinone structure contains an amphetamine nucleus, which stimulates release of dopamine and produces stimulant effects similar to those of amphetamines or cocaine. These crystalline products vaguely resemble household products such as Epsom salts, but their intent is not therapeutic. They are often labeled as “not for human consumption” in an attempt to avoid government regulation. In the United States, they are readily available in head shops and convenience stores and are intended to be “legal stimulants.” Many of these compounds are no longer legal because the US Drug Enforcement Agency has classified some compounds as schedule I controlled substances, which makes them illegal for use in the United States. Unfortunately, manufacturers of illicit drugs can avoid such bans by making minor structural changes to the molecule, thereby creating a compound that is not explicitly illegal. Therefore, EDs can anticipate a steady supply of evolving stimulant exposures in the future. Although the data available are not comprehensive, mephedrone (4-methacathinone) is perhaps the most common compound marketed as a bath salt. It causes 6 Annals of Emergency Medicine
disorientation, perceptual distortions, and involuntary movements and has been associated with extreme paranoia and violent acts. The first cases of bath salts received by poison centers occurred in February 2010 and peaked in 2011, with 6,137 exposures and 31 deaths reported by poison centers (Figure 4). A slight decrease occurred in 2012, with 994 exposures and 16 deaths. The initial management of bath salt toxicity is the same as that of other causes of agitated delirium. However, because new structural versions are continually introduced to avoid federal regulations, patients with clinical effects should be observed closely, with unusual cases observed for longer periods. Involvement of a poison center can be useful to access emerging information and to include the case in the National Poison Data System. Homologs of Tetrahydrocannabinols (Spice) A group of synthetic cannabinoids (marijuana-like drugs that bind to the cannabinoid receptors), sometimes called Spice (one brand name product), is another developing trend in designer substances. Like bath salts, these products are sold at gas stations, convenience stores, and head shops, and on the Internet. Synthetic marijuana became available in 2010, with product names including Spice, K2, Genie, Yucatan Fire, Smoke, Skunk, Blaze, and Aroma. The clinical effects reported include disorientation, anxiety attacks, and sympathomimetic effects such as diaphoresis, agitation, psychosis, vomiting, tachycardia, hypertension, and convulsions. In 2012, poison centers recorded 5,225 cases in which a tetrahydrocannabinol homolog was mentioned as one of the substances in a human exposure Volume
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cases (Figure 4). There were 6 deaths involving synthetic cannabinoid products alone. These products are not detectable in typical laboratory screens used clinically. The Synthetic Drug Abuse Prevention Act of 2012 bans synthetic compounds commonly found in synthetic cannabinoids by placing them in schedule I. Emergency physicians should be aware that these substances are still available and typically create clinical presentations much different from those of marijuana despite the similarity in names. As with bath salts, the initial management of synthetic cannabinoid toxicity is identical to that for agitated delirium. Emerging Exposure Trends: Energy Drinks In 2010, poison centers began tracking exposures to “energy drinks,” which generally contain caffeine and other ingredients (yerba mate, kola nut, guarana, taurine, etc); until its use was banned by the FDA, some contained ethanol. National Poison Data System data demonstrated that children younger than 6 years accounted for approximately half of the reported exposures. Major effects associated with caffeinated energy drink exposures included seizures and arrhythmias. Ingestion of products containing ethanol and caffeine resulted in a larger proportion of critical care admissions. An FDA ban on alcoholic energy drinks was followed by a sharp reduction in poison center exposure reports. Public educational campaigns were also associated with a reduction in poison center reports.18 Fukushima Nuclear Power Incident Regional poison centers can be used to guide the public health response in real time and thereby reduce ED visits and enhance system response and data collection during a public health emergency. In 2011, Japan was struck by a magnitude 9.0 earthquake and subsequent tsunami, which caused the release of radioactive materials. One consequence was drift of radioactive atmospheric plumes toward the United States, which created urgent public concern about radiation poisoning. Agencies such as the CDC were interested in targeting and evaluating risk communication messages and in tracking individual potential exposures to iodide products consumed as pharmaceutical countermeasures for radioactive iodine.19 The CDC and American Association of Poison Control Centers coordinated the efforts of public health agencies and poison centers. Calls about reported radiation exposures and potassium iodide (KI) or other products were categorized with regard to exposure likelihood according to follow-up information obtained from the poison center.19 Of 400 poison center cases related to the Volume
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radiation release, 60 reported putative exposures. Of the 60 exposure cases, KI was reported in 25 cases and potential radiation in 22 cases (16 cases were ultimately classified as suspect and 6 were classified as nonexposures), and other iodine or iodide products in 13 cases. No radiation exposures were classified as probable exposures.19 A small number of the probable exposures to KI and other iodide or iodine products reported adverse signs or symptoms (n¼9). These data identified a potential public health information gap about KI and other products, which was then addressed through public health messaging activities. DISCUSSION Poisoning continues to be a significant cause of morbidity and mortality in the United States. The near real-time nature of the National Poison Data System represents a national public health resource to collect and monitor poisoning data. Data from poison centers can be used to reveal the effects of changes in practice, as shown by the decontamination trends, to identify new and emergency clinical challenges such as Spice and synthetic cannabinoids and to reduce the burden on EDs by managing many poisonings with home care alone. Supervising editor: Michael L. Callaham, MD Author affiliations: From the Rocky Mountain Poison Center, Denver Health, and the University of Colorado School of Medicine, Denver, CO (Bronstein, Dart); the Department of Emergency Medicine, Oregon Poison Center, Oregon Health & Science University, Portland, OR (Spyker); the Division of Clinical Pharmacology and Medical Toxicology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD (Cantilena); the Department of Emergency Medicine, University of New Mexico School of Medicine, and New Mexico Poison and Drug Information Center, Albuquerque, NM (Seifert); the California Poison Control System, School of Pharmacy, University of California, San Francisco, San Francisco, CA (Heard); and the School of Pharmacy, University of Pittsburgh, Pittsburgh, PA (Krenzelok). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Dart reports receiving consulting and research support from McNeil Consumer Health Care. He is responsible for operating the RADARS System on behalf of Denver Health and Hospital Authority, which owns the RADARS System. Several manufacturers of controlled substances are subscribers to the RADARS System. He has no direct financial relationship with any of these companies. Publication dates: Received for publication October 12, 2013. Revisions received August 19, 2014; and October 10, 2014. Accepted for publication October 20, 2014. The American Association of Poison Control Centers (AAPCC; http://www.aapcc.org) maintains the national database of information logged by the country’s regional poison centers, Annals of Emergency Medicine 7
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Poisoning in the United States serving all 50 states, Puerto Rico, and the District of Columbia. Case records in this database are from self-reported calls: they reflect only information provided when the public or health care professionals report an actual or potential exposure to a substance (eg, an ingestion, inhalation, topical exposure) or request information or educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may remain unreported to poison centers, and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s). Dr. Callaham was the supervising editor on this article. Dr. Dart did not participate in the editorial review or decision to publish this article.
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REFERENCES 1. Substance Abuse and Mental Health Services Administration. Results From the 2011 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse & Mental Health Services Administration; 2012; NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. 2. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. The DAWN Report. Rockville, MD: US Dept of Health & Human Services, Substance Abuse & Mental Health Services Administration; 2013. Available at: http:// www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm. Accessed April 25, 2014. 3. Hoyt BT, Rasmussen R, Giffin S, et al. Poison center data accuracy: a comparison of rural hospital chart data with the TESS database. Acad Emerg Med. 1999;6:851-855. 4. Reynolds KM, Green JL, Dart RC, et al. Accuracy of poison center data improves after targeted training. Clin Toxicol. 2012;50:620. 5. Dasgupta N, Davis J, Jonsson Funk M, et al. Using poison center exposure calls to predict methadone poisoning deaths. PLoS ONE. 2012;7:e41181. 6. Mowry JB, Spyker DA, Cantilena LR Jr, et al. 2012 Annual report of the American Association of Poison Control Centers’ National Poison
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Data System (NPDS): 30th annual report. Clin Toxicol. 2013;51: 949-1229. Bronstein AC, Spyker DA, Cantilena LR, et al. 2011 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th annual report. Clin Toxicol. 2012;50:911-1164. Lewin Group. Final Report on the Value of the Poison Center System. Falls Church, VA: Lewin Group; 2012. Available at: http://production-aapcc. dotcloud.com/about/lewin-group-report/. Accessed April 25, 2014. Friedman LS, Krajewski A, Vannoy E, et al. The association between US poison center assistance and length of stay and hospital charges. Clin Toxicol. 2014;52:198-206. Position statement: ipecac syrup. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1997;35:699-709. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: ipecac syrup. J Toxicol Clin Toxicol. 2004;42:133-143. American Academy of Pediatrics policy statement. Poison treatment in the home. Pediatrics. 2003;112:1182-1185. Centers for Disease Control and Prevention. QuickStats: number of poisoning deaths involving opioid analgesics and other drugs or substances—United States, 1999-2007. MMWR Morb Mortal Wkly Rep. 2010;59:1026. Watson W, Litovitz TL, Klein-Schwartz W, et al. 2003 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Clin Toxicol. 2004;22:335-404. Centers for Disease Control and Prevention. Vital signs: risk of overdose from methadone used for pain relief—United States, 19992010. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6126a5.htm?s_cid¼mm6126a5_w. Accessed April 25, 2014. Bailey JE, Campagna E, Dart RC, et al. The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med. 2009;53:419-424. Williams H, Moynss E, Bateman DN, et al. Hazard of household cleaning products: a study undertaken by the UK National Poisons Information Service. Clin Toxicol. 2012;50:770-775. Seifert SM, Seifert SA, Schaechter JL, et al. An analysis of energy-drink toxicity in the National Poison Data System. Clin Toxicol. 2013;51(7):566-574. Law RK, Schier JG, Martin CA, et al. National surveillance for radiological exposures and intentional potassium iodide and iodine product ingestions in the United States associated with the 2011 Japan radiological incident. Clin Toxicol. 2013;51:41-46.
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Poisoning in the United States: 2012 Emergency Medicine Report of the National Poison Data System Richard C. Dart, MD, PhD*; Alvin C. Bronstein, MD; Daniel A. Spyker, PhD, MD; Louis R. Cantilena, MD, PhD; Steven A. Seifert, MD; Stuart E. Heard, PharmD, FCSHP; Edward P. Krenzelok, PharmD *Corresponding Author. E-mail: [email protected].
Deaths from drug overdose have become the leading cause of injury death in the United States, where the poison center system is available to provide real-time advice and collect data about a variety of poisonings. In 2012, emergency medical providers were confronted with new poisonings, such as bath salts (substituted cathinones) and Spice (synthetic cannabinoid drugs), as well as continued trends in established poisonings such as from prescription opioids. This article addresses current trends in opioid poisonings; new substances implicated in poisoning cases, including unit-dose laundry detergents, bath salts, Spice, and energy drinks; and the role of poison centers in public health emergencies such as the Fukushima radiation incident. [Ann Emerg Med. 2014;-:1-8.] 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.11.001
INTRODUCTION Deaths from drug overdose have become the leading cause of injury death.1 Each day in the United States, an average of 105 people die as a result of drug exposure.2 In 2012, drug misuse and abuse caused approximately 2.5 million emergency department (ED) visits.2 Drug-related deaths now exceed motor traffic accidents as the leading cause of accidental death in the United States.1 Emergency medical services and EDs are typically the first part of the health care system to encounter poisonings. Despite familiarity with acute resuscitation of the poisoned patient, the emergency physician is continually challenged by the emergence of new types of poisoning, which may require a new approach to diagnosis and management. For example, the emergency physician faces the challenge of new drugs such as Spice (synthetic cannabinoids) and bath salts (substituted cathinones) before other parts of the health care system. The National Poison Data System collects information from all poison centers and provides early recognition of emerging poison hazards. Despite the regular involvement of emergency medical providers in the management of poisoning and the source of much information in the system, to our knowledge these data have never been reported specifically for emergency physicians. This article provides a focused summary of information from poison centers about changes in therapeutics and new emerging chemicals and drugs that may confront the emergency medical personnel during out-of-hospital or ED care (eg, opioid analgesics, laundry detergent packets, bath salts, Volume
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Spice, energy drinks), as well as examples of the poison center’s role in disaster communication such as the Fukushima reactor disaster. Overview of Poison Center Operations The poison center system is composed of 55 poison centers that provide advice about poisoning exposures throughout the United States and its territories. A poison center is reached through a national toll-free number (800222-1222) that routes the caller to the center serving the caller’s geographic location. Callers include members of the public and health care providers. The case is managed without cost to the caller. Each case is uploaded and aggregated in the National Poison Data System, which is operated by the American Association of Poison Control Centers. The flow of a case through the poison center to the National Poison Data System is shown in Figure 1. Every poison center can provide advice at any time from a board-certified medical toxicologist. Poison center cases are spontaneous contacts involving either an exposed human or animal (termed an exposure call) or a request for information without exposure (termed an information call). An exposure is defined as any contact in which a person is reported to be exposed to the compound regardless of the amount or route of the exposure (oral, inhalation, dermal, and others). Each exposure case is received by a specialist in poison information, typically a nurse or pharmacist who has received training in toxicology and the management of emergencies. Every poison center uses a specialized electronic medical record that includes basic Annals of Emergency Medicine 1
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Figure 1. Flow of exposure case through a poison center to the National Poison Data System. HCF, Health care facility; NPDS, National Poison Data System.
quality-control checks (ie, required data fields ensure that the same core information is collected on all cases). Centers undergo a rigorous accreditation process and must be reaccredited periodically. For example, each poison center must have a board-certified medical director and nationally certified specialists in poison information. Further information on methods, definitions, and certification criteria is available from the American Association of Poison Control Centers (http://www.aapcc.org). National Poison Data System data involve spontaneous reporting; therefore, the number of exposures will be underestimated because many persons with an exposure do not contact a poison center. There is likely bias in reports that are received because callers may be more likely to contact a poison center when a child or other vulnerable person is affected. Similarly, the perceived severity of exposure may increase the likelihood of contacting a poison center. Publicity and other activities may transiently increase poison center contacts because of greater awareness among callers. Furthermore, although poison centers use specific interview techniques to solicit the specific identity of a poison, the identity may be unknown or misidentified by the caller. Subtle clinical effects such as electrocardiographic changes can be omitted or misinterpreted by health provider callers. In many cases, the exposure cannot be confirmed through blood or other tests. However, the data available 2 Annals of Emergency Medicine
suggest that poison centers are successful in accurately identifying the poisoning agent, and deaths in the National Poison Data System correlate well to the number of deaths reported to the national mortality database.3-5 In 2012, poison centers recorded 3.3 million total encounters, including 2.3 million human exposure cases (1 case every 13 seconds), 66,000 animal exposures, and 1 million information calls.6 The National Poison Data System database contains almost 58 million human exposure case records through 2012. A unique feature of poison centers is the extensive follow-up performed to collect additional information on the case, provide additional advice about management of the case, verify the poison center record with the caller or the health care provider, and determine outcome for the case. Cases that are referred to the ED are typically followed until the patient is discharged. In 2012, poison centers made 2.7 million follow-up contacts involving 45% of all human exposure cases. The annual number of human exposure cases increased consistently until 2007, when the upward trajectory leveled off and has since decreased slightly. Analysis reveals that the decreased case volumes primarily involve low-risk exposures in children, the main category responsible for cost savings.7 In contrast, more serious exposure cases such as those involving health care facilities have continued to increase. The number of poison center exposures managed in a health care facility (typically an ED) increased from 526,000 in 2003 to 613,412 in 2012 (Table 1). Because most health facility contacts are of higher severity and involve an ED, the acuity of poison center cases seems to be increasing despite the slight decrease in case volume. Table 1. Site of management in human exposure cases involving a poison center, 2012.* Site of Management Managed on site, non-HCF Managed in HCF Treated/evaluated and released Admitted to critical care unit Patient lost to follow-up/left against medical advice Admitted to non–critical care unit Admitted to psychiatric facility Subtotal: managed in HCF Other, refused referral, or unknown Total
Number of Cases
Percentage
1,574,362
69.2
291,414 100,455 94,284
12.8 4.4 4.1
67,847 59,412 613,412 87,367 2,275,141
3.0 2.6 27.0 3.8 100.0
*HCF is defined as any hospital-based patient care unit or ED, freestanding emergency medical clinic, first aid station, physician’s office, or clinic. The majority of these patients present to the ED. Each category is mutually exclusive. A patient can be in only 1 category. The highest level of care is rendered per the following prioritization in descending order: (1) admitted to critical care unit, (2) admitted to non–critical care unit, (3) admitted to psychiatric care facility, (4) treated or evaluated and released, (5) patient refused referral or did not arrive at HCF, (6) patient lost to follow-up or left against medical advice.
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Figure 2. Changes in use of decontamination in poison center cases, 1985 to 2012. 1: Publication date of the European Association of Poison Centres and Clinical Toxicologists’ ipecac position statement.10 2: Publication date of the American Academy of Clinical Toxicology’s ipecac position statement.11 3: Publication date of the American Academy of Pediatrics’ article about poison treatment in the home.12
Cost-effectiveness of Poison Centers Poison centers reduce the number of poisoning cases that enter the health care system. An independent analysis of costs and benefits associated with poison centers found that poison centers effectively reduce health care expenses. The total operating cost of all poison centers is approximately $160 million annually.8 The calculated total cost savings are more than $1.8 billion annually, with a return of investment of $13.39 for every dollar spent on a poison center. Savings occur in 4 categories: avoided medical use ($753 million), reduced hospital length of stay ($441 million), reduced health care use because of in-person outreach services ($24 million), and reduced work-loss days ($603 million).8 The largest component, reduced health care system expense, is created mainly by reducing the number of patients who enter the health care system. Most patients who contact a poison center are managed without involvement of a health care facility (69.2%), usually at the site of exposure and primarily in the patient’s residence. The proportion of patients treated in a health care facility varies with age. In 2012, only 11.6% of children younger than 5 years and only 14.0% of children aged between 6 and 12 years were managed in a health care facility compared with 51.2% of teenagers (aged 13 to 19 years) and 37.9% of adults (aged 20 years or older). The precise reasons for the increased rate of health facility use for the older patient groups is not known, but many of these cases involve more dangerous drugs such as cardiovascular medications or involve patients with self-harm attempts, who are typically referred to an ED for medical and psychiatric evaluation. Volume
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Another contributor is that contacts about young children may involve less toxic compounds (ie, household supplies of limited toxicity such as cosmetics, soaps, and air cleaners). More recently, another study documented that the involvement of a poison center in the care of hospitalized patients was associated with shorter stay and reduced charges.9 Evolution of Emergency Gastrointestinal Decontamination Techniques Once used in many poisoned patients, gastrointestinal decontamination techniques failed to improve patient outcomes, and their use has subsequently been discouraged. Several organizations such as the American Association of Poison Control Centers and the American Academy of Pediatrics have recommended the elimination of ipecac or cathartic agents for decontamination of poisoning. Similarly, the use of gastric lavage has been de-emphasized and more restricted use of activated charcoal for decontamination has been recommended.10-12 Data from the National Poison Data System indicate that use of gastrointestinal decontamination procedures has changed greatly. The use of cathartics, gastric lavage, and induced emesis has nearly vanished. The use of activated charcoal has declined substantially in recent years, although the relation between changes in practice and position statements from professional societies is not strong (Figure 2). Whatever the reason for the change in practice, it produced significant changes in emergency medical practice. Annals of Emergency Medicine 3
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Poisoning Mortality in the United States All poison center cases with an outcome of death undergo a standardized evaluation by the American Association of Poison Control Centers Fatality Case Review Team. The team is composed of approximately 40 medical and clinical toxicologists. Each case is reviewed by 4 team members. In accordance with an examination of case circumstances and the toxicology of each drug associated with the death, cases are rated on the likelihood of the substance’s being responsible for the death, using a defined classification scheme: undoubtedly responsible, probably responsible, contributory, probably not responsible, clearly not responsible, or unknown. In 2012, there were a total of 2,937 human exposures in the National Poison Data System with an outcome of death. The primary substance was a pharmaceutical product in 83% of cases. The most commonly implicated pharmaceuticals were prescription drugs of abuse, mainly opioid analgesics, followed by cardiovascular and antidepressant medications (Table 2). Although total deaths from antidepressants have decreased since the introduction of serotonin reuptakeinhibitor antidepressants, the cyclic antidepressants such as amitriptyline remain important causes of death. Bupropion is a common overdose agent and is also associated with a substantial number of deaths. Among the nonpharmaceutical agents, carbon monoxide is a perennial leading cause of death in the National Poison Data System; in 2012, it was involved in 54 deaths.6 Freon and other halocarbons are surprisingly frequent as a cause of death, considering their limited availability. In 2012, there were 16 deaths involving Freon or other propellants, generally during abuse of products containing a propellant (eg, keyboard duster spray). A listing of individual cases and case summaries are tabulated in an expanded National Poison Data System report.6 Opioid Analgesics The opioid analgesics have emerged during the past 15 years as a major cause of accidental death in the United States. The Drug Abuse Warning Network reported that ED visits in the United States for use of opioid pain relievers increased 153% from 2004 to 2011.2 The Centers for Disease Control and Prevention (CDC) reported that more than 16,000 people died because of prescription opioid analgesics in 2010.13 Trends involving prescription opioids in the National Poison Data System have mirrored the national toll associated with these products. The total number of human exposures managed by poison centers was stable, at 2.3 to 2.4 million, during the 10-year period ending 2012. In 4 Annals of Emergency Medicine
Table 2. Top causes of death related to pharmaceutical products in the National Poison Data System Database, 2012. Drug Category Analgesics
Stimulants/street drugs
Cardiovascular drugs
Antidepressants
Sedative/hypnotic/ antipsychotics
Active Pharmaceutical Ingredient
Number of Reports
Methadone Oxycodone Acetaminophen/hydrocodone Acetaminophen Morphine Fentanyl Salicylate Tramadol Acetaminophen/oxycodone Total Heroin
178 138 133 103 102 53 49 33 24 813 325
Methamphetamine Cocaine Amphetamines (hallucinogenic) Total Amlodipine Metoprolol Verapamil Diltiazem (immediate or extended release) Cardiac glycoside Atenolol Total Amitriptyline Bupropion (immediate or extended release) Citalopram Doxepin Venlafaxine Total Quetiapine
90 87 14 516 33 21 21 29 12 10 126 38 31 14 11 9 103 35
Alprazolam Benzodiazepine Clonazepam Diazepam Pentobarbital Total
27 9 8 7 5 91
contrast, the number of human exposures involving prescription opioid analgesics doubled, from 22,641 in 2003 to 44,381 in 2012.6,14 Methadone is well known for its long duration of action and propensity for lethal outcomes.15 It was the leading opioid as a cause of death in the National Poison Data System, with 178 cases in 2012.6 Many of the methadone cases reported involved the tablet formulation. Substance abuse treatment programs (methadone clinics) most commonly use the liquid or diskette formulations of methadone, but many of the serious cases managed by poison centers involve tablets; tablet cases appear to be prescribed outside the confines of an opioid abuse treatment program and arise out of use of methadone for pain. The fact that many fatal poison center cases associated Volume
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Figure 3. Number of cases of single use unit-dose laundry detergent packets and general laundry detergent cases, 2012 to 2013.
with opioids involve the tablet formulation indicates that restriction of availability of the tablet formulation could be useful. To address this concern, the Food and Drug Administration (FDA) has included methadone in its longacting opioid Risk Evaluation and Mitigation Strategy program, which requires manufacturers to provide education and training about their products. Emergency physicians should be aware of the numerous difficulties involved in the use of methadone. Prescription opioids are also a danger to young children.16 For some formulations, a single pill can kill a small child. The total number of prescription opioid singlesubstance exposures involving children aged 5 years or younger more than doubled, from 2,591 to 5,541 annually, in the 10-year period ending in 2012. Similarly, child deaths associated with a prescription analgesic increased from 1 to 7 annually in the same period. As with adults, the most common drug involved in a pediatric death was methadone. It is prudent for emergency personnel to provide detailed and emphatic warnings when prescribing to a patient with small children at home. Laundry Detergent Packets An unexpected source of poisoning appeared in 2012: laundry detergent packets. Several manufacturers now provide a “unit-dose” delivery mechanism for laundry detergents. The user simply puts one packet in a load of laundry without the need for measuring. The packs contain concentrated liquid detergent within a water-soluble membrane that dissolves easily and can be bitten through. The most common exposure from a traditional open liquid Volume
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detergent container is a sip, which would amount to less than 5 mL. In contrast, a child ingesting 1 packet could receive a larger amount and potentially a large spray of detergent into the airway. As a class, laundry detergents are a common and relatively benign exposure among young children. The adverse event profile of these products is generally limited to local irritation, self-limited vomiting, and other mild effects. The number of cases increased considerably after the introduction of concentrated laundry packets in 2012 (Figure 3).6 Review of National Poison Data System data from 2011 and 2012 indicates that approximately 0.5% of patients experienced airway effects that were managed with intubation. Similar products have been available in Europe for several years. The National Poisons Information Service in the United Kingdom prospectively collected 1,486 exposures relating to liquid detergent capsules from 2009 to 2011. Nearly all patients were children younger than 5 years. The most common features reported after ingestion alone were nausea and vomiting, followed by coughing, drowsiness, or central nervous system depression and foamy oral secretions. After ocular exposure, features suggesting conjunctivitis and corneal ulceration developed. A few patients had skin exposure alone and developed erythema, rash, and burn. There were no fatalities.17 The emergency physician should consider laundry packet exposures more dangerous than open-container liquid exposures. Standard irrigation and follow-up are indicated for irritation of the eyes and mucous membranes. Typical airway management is sufficient to maintain the Annals of Emergency Medicine 5
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Figure 4. National Poison Data System human exposures per month for bath salts and analogues of tetrahydrocannabinol, 2011 to 2012. THC, Tetrahydrocannabinol.
airway. To date, toxicity has been evident relatively early in the course and should be present in the ED course. Patients are typically observed for 2 or 3 hours and discharged if symptoms resolve. Bath Salts Bath salts is the street name for a family of designer drugs with names such as Plant Food, Ivory Wave, Purple Wave, Vanilla Sky, and Bliss. The drug typically contains substituted cathinones (eg, mephedrone, methylenedioxypyrovalerone, methylone). A cathinone structure contains an amphetamine nucleus, which stimulates release of dopamine and produces stimulant effects similar to those of amphetamines or cocaine. These crystalline products vaguely resemble household products such as Epsom salts, but their intent is not therapeutic. They are often labeled as “not for human consumption” in an attempt to avoid government regulation. In the United States, they are readily available in head shops and convenience stores and are intended to be “legal stimulants.” Many of these compounds are no longer legal because the US Drug Enforcement Agency has classified some compounds as schedule I controlled substances, which makes them illegal for use in the United States. Unfortunately, manufacturers of illicit drugs can avoid such bans by making minor structural changes to the molecule, thereby creating a compound that is not explicitly illegal. Therefore, EDs can anticipate a steady supply of evolving stimulant exposures in the future. Although the data available are not comprehensive, mephedrone (4-methacathinone) is perhaps the most common compound marketed as a bath salt. It causes 6 Annals of Emergency Medicine
disorientation, perceptual distortions, and involuntary movements and has been associated with extreme paranoia and violent acts. The first cases of bath salts received by poison centers occurred in February 2010 and peaked in 2011, with 6,137 exposures and 31 deaths reported by poison centers (Figure 4). A slight decrease occurred in 2012, with 994 exposures and 16 deaths. The initial management of bath salt toxicity is the same as that of other causes of agitated delirium. However, because new structural versions are continually introduced to avoid federal regulations, patients with clinical effects should be observed closely, with unusual cases observed for longer periods. Involvement of a poison center can be useful to access emerging information and to include the case in the National Poison Data System. Homologs of Tetrahydrocannabinols (Spice) A group of synthetic cannabinoids (marijuana-like drugs that bind to the cannabinoid receptors), sometimes called Spice (one brand name product), is another developing trend in designer substances. Like bath salts, these products are sold at gas stations, convenience stores, and head shops, and on the Internet. Synthetic marijuana became available in 2010, with product names including Spice, K2, Genie, Yucatan Fire, Smoke, Skunk, Blaze, and Aroma. The clinical effects reported include disorientation, anxiety attacks, and sympathomimetic effects such as diaphoresis, agitation, psychosis, vomiting, tachycardia, hypertension, and convulsions. In 2012, poison centers recorded 5,225 cases in which a tetrahydrocannabinol homolog was mentioned as one of the substances in a human exposure Volume
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cases (Figure 4). There were 6 deaths involving synthetic cannabinoid products alone. These products are not detectable in typical laboratory screens used clinically. The Synthetic Drug Abuse Prevention Act of 2012 bans synthetic compounds commonly found in synthetic cannabinoids by placing them in schedule I. Emergency physicians should be aware that these substances are still available and typically create clinical presentations much different from those of marijuana despite the similarity in names. As with bath salts, the initial management of synthetic cannabinoid toxicity is identical to that for agitated delirium. Emerging Exposure Trends: Energy Drinks In 2010, poison centers began tracking exposures to “energy drinks,” which generally contain caffeine and other ingredients (yerba mate, kola nut, guarana, taurine, etc); until its use was banned by the FDA, some contained ethanol. National Poison Data System data demonstrated that children younger than 6 years accounted for approximately half of the reported exposures. Major effects associated with caffeinated energy drink exposures included seizures and arrhythmias. Ingestion of products containing ethanol and caffeine resulted in a larger proportion of critical care admissions. An FDA ban on alcoholic energy drinks was followed by a sharp reduction in poison center exposure reports. Public educational campaigns were also associated with a reduction in poison center reports.18 Fukushima Nuclear Power Incident Regional poison centers can be used to guide the public health response in real time and thereby reduce ED visits and enhance system response and data collection during a public health emergency. In 2011, Japan was struck by a magnitude 9.0 earthquake and subsequent tsunami, which caused the release of radioactive materials. One consequence was drift of radioactive atmospheric plumes toward the United States, which created urgent public concern about radiation poisoning. Agencies such as the CDC were interested in targeting and evaluating risk communication messages and in tracking individual potential exposures to iodide products consumed as pharmaceutical countermeasures for radioactive iodine.19 The CDC and American Association of Poison Control Centers coordinated the efforts of public health agencies and poison centers. Calls about reported radiation exposures and potassium iodide (KI) or other products were categorized with regard to exposure likelihood according to follow-up information obtained from the poison center.19 Of 400 poison center cases related to the Volume
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radiation release, 60 reported putative exposures. Of the 60 exposure cases, KI was reported in 25 cases and potential radiation in 22 cases (16 cases were ultimately classified as suspect and 6 were classified as nonexposures), and other iodine or iodide products in 13 cases. No radiation exposures were classified as probable exposures.19 A small number of the probable exposures to KI and other iodide or iodine products reported adverse signs or symptoms (n¼9). These data identified a potential public health information gap about KI and other products, which was then addressed through public health messaging activities. DISCUSSION Poisoning continues to be a significant cause of morbidity and mortality in the United States. The near real-time nature of the National Poison Data System represents a national public health resource to collect and monitor poisoning data. Data from poison centers can be used to reveal the effects of changes in practice, as shown by the decontamination trends, to identify new and emergency clinical challenges such as Spice and synthetic cannabinoids and to reduce the burden on EDs by managing many poisonings with home care alone. Supervising editor: Michael L. Callaham, MD Author affiliations: From the Rocky Mountain Poison Center, Denver Health, and the University of Colorado School of Medicine, Denver, CO (Bronstein, Dart); the Department of Emergency Medicine, Oregon Poison Center, Oregon Health & Science University, Portland, OR (Spyker); the Division of Clinical Pharmacology and Medical Toxicology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD (Cantilena); the Department of Emergency Medicine, University of New Mexico School of Medicine, and New Mexico Poison and Drug Information Center, Albuquerque, NM (Seifert); the California Poison Control System, School of Pharmacy, University of California, San Francisco, San Francisco, CA (Heard); and the School of Pharmacy, University of Pittsburgh, Pittsburgh, PA (Krenzelok). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Dart reports receiving consulting and research support from McNeil Consumer Health Care. He is responsible for operating the RADARS System on behalf of Denver Health and Hospital Authority, which owns the RADARS System. Several manufacturers of controlled substances are subscribers to the RADARS System. He has no direct financial relationship with any of these companies. Publication dates: Received for publication October 12, 2013. Revisions received August 19, 2014; and October 10, 2014. Accepted for publication October 20, 2014. The American Association of Poison Control Centers (AAPCC; http://www.aapcc.org) maintains the national database of information logged by the country’s regional poison centers, Annals of Emergency Medicine 7
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Poisoning in the United States serving all 50 states, Puerto Rico, and the District of Columbia. Case records in this database are from self-reported calls: they reflect only information provided when the public or health care professionals report an actual or potential exposure to a substance (eg, an ingestion, inhalation, topical exposure) or request information or educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may remain unreported to poison centers, and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s). Dr. Callaham was the supervising editor on this article. Dr. Dart did not participate in the editorial review or decision to publish this article.
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