2017 Annual Report of The American Association of Poison Control Centers
2017 Annual Report of The American Association of Poison Control Centers
2017 Annual Report of The American Association of Poison Control Centers
https://doi.org/10.1080/15563650.2018.1533727
Table of contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The NPDS products database. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Characterization of participating poison centers and population served . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Encounter management – specialized poison exposure emergency providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
NPDS – near real-time data capture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Annual report case inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Statistical methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
NPDS surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Emerging trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Fatality case review and abstract selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Pediatric fatality case review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Informational contacts with poison centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Exposure cases logged at poison centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Age and gender distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Caller site and exposure site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Exposures in pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chronicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Reason for exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Reason by age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Route of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Clinical effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Case management site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Medical outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Decontamination procedures and specific antidotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Top substances in human exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Changes over time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Emerging trends – drugs of abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Distribution of suicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Plant exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Deaths and exposure-related fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
All fatalities – all ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Pediatric fatalities – age 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Pediatric fatalities – ages 6–12 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Adolescent fatalities – ages 13–19 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
CONTACT David Gummin [email protected] American Association of Poison Control Centers, 515 King Street, Suite 510, Alexandria, VA 22314, USA
ß 2018 American Association of Poison Control Centers
2 D. D. GUMMIN ET AL.
Table 16B. Decontamination trends: Total human and pediatric exposures 5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 16C. Human exposures to drugs of abuse by generic code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Table 17A. Substance categories most frequently involved in human exposures (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Table 17B. Substance categories with the greatest rate of exposure increase (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Table 17C. Substance categories most frequently involved in pediatric ( 5 years) exposures (Top 25) . . . . . . . . . . . . . . . . . . . . . 19
Table 17D. Substance categories most frequently involved in adult (>20 years) exposures (Top 25). . . . . . . . . . . . . . . . . . . . . . . . 20
Table 17E. Substance categories most frequently involved in pediatric ( 5 years) deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Table 17F. Substance categories most frequently identified in drug identification calls (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Table 17G. Substance categories most frequently involved in pregnant exposures (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Table 18. Categories associated with largest number of fatalities (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Table 19A. Comparisons of death data (1985–2017) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Table 19B. Comparisons of direct and indirect death data (2000–2017) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Table 20. Frequency of plant exposures (Top 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Table 21. Listing of fatal nonpharmaceutical and pharmaceutical exposures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category . . . . . . . . . . 172
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category . . . . . . . . . . . . . . 188
Case 1174.
Acute pregabalin and topiramate ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Case 1343.
Acute diphenhydramine ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Case 1369.
Acute tilmicosin parenteral: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1379.
Chronic: methotrexate ingestion: contributory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1439.
Acute-on-chronic: flecainide ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1456.
Acute-on-chronic amlodipine ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1632.
Acute nifedipine ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1634.
Acute benzonatate and meclizine ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Case 1643.
Acute iron ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Case 1646.
Acute iron ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Case 1649.
Acute loperamide, atropine/diphenoxylate, trazodone ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . 41
Case 1657.
Acute loperamide ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Case 1739.
Acute diazepam, gabapentin, citalopram ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Case 1879.
Acute U-47700, para-fluorobutyryl fentanyl and psycho-active benzodiazepines ingestion: undoubtedly
responsible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Case 1943. Unknown carfentanil, alprazolam and cocaine exposure: probably responsible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Case 2034. Acute mitragyna speciosa korthals exposure: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Case 2060. Acute methamphetamine ingestion: probably responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Case 2131. Acute-on-chronic: cocaine rectal: undoubtedly responsible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Case 2141. Unknown methamphetamine ingestion: undoubtedly responsible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Case 2615. Acute methamphetamine/amphetamine and hydrocarbon ingestion and aspiration: undoubtedly responsible. . . . . . . . .43
ABSTRACT
Introduction: This is the 35th Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison
Data System (NPDS). As of 1 January 2017, 55 of the nation’s poison centers (PCs) uploaded case data automatically to NPDS.
The upload interval was 8.07 [7.32, 12.65] (median [25%, 75%]) minutes, creating a near real-time national exposure and
information database and surveillance system.
Methods: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous
years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by
a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality
(RCF) of the exposure.
Results: In 2017, 2,607,413 closed encounters were logged by NPDS: 2,115,186 human exposures, 51,164 animal exposures, 435,540
information contacts, 5,424 human confirmed nonexposures, and 99 animal confirmed nonexposures. US PCs also made 2,680,625
follow-up calls in 2017. Total encounters showed a 3.79% decline from 2016, while health care facility (HCF) human exposure cases
increased by 3.06%. All information contacts decreased by 11.5%, medication identification (Drug ID) requests decreased by 30.2%,
and human exposure cases decreased by 2.03%. Human exposures with less serious outcomes have decreased 2.48% per year since
2008, while those with more serious outcomes (moderate, major or death) have increased 4.44% per year since 2000.
Consistent with the previous year, the top 5 substance classes most frequently involved in all human exposures were
analgesics (11.08%), household cleaning substances (7.43%), cosmetics/personal care products (6.76%), sedatives/
hypnotics/antipsychotics (5.74%), and antidepressants (5.02%). As a class, sedative/hypnotics/antipsychotics exposures
increased most rapidly, by 1962 cases/year (4.91%/year), over the last 17 years for cases with more serious outcomes. The
top 5 most common exposures in children age 5 years or less were cosmetics/personal care products (12.59%), household
cleaning substances (10.96%), analgesics (9.18%), foreign bodies/toys/miscellaneous (6.39%), and topical preparations
(4.84%). Drug identification requests comprised 22.1% of all information contacts. NPDS documented 3,208 human
exposures resulting in death; 2,682 (83.6%) of these were judged as related (RCF of 1-Undoubtedly responsible,
2-Probably responsible, or 3-Contributory).
Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information
to manage more serious exposures, despite a decrease in cases involving less serious exposures. Unintentional and intentional
exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents
a national public health resource to collect and monitor US exposure cases and information contacts. The continuing mission of
NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious,
venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS
is a model system for the near real-time surveillance of national and global public health.
NOTE: Comparison of exposure or outcome data from previous AAPCC Annual Reports is problematic. In particular, the identification
of fatalities (attribution of a death to the exposure) differed from pre-2006 Annual Reports (see Fatality Case Review – Methods).
Death cases were described as all cases resulting in death and those determined to be exposure-related fatalities. Likewise, Table 22
(Exposure cases by Generic Category) since year 2006 restricts the breakdown of included deaths to single-substance cases to
improve precision and avoid misinterpretation.
CLINICAL TOXICOLOGY 5
education curricula to allow them to be prepared for PC Table 1A. AAPCC population served and reported exposures (1983–2017).
patient management operations. These individuals must No. of Population Exposures per
receive significant additional training beyond their degree participating served Human thousand
Year centers (in millions) exposures population
programs to become (C)SPIs. Such training is only offered
1983 16 43.1 251,012 5.8
within the PCs. “Poison Information Providers” (PIPs) are 1984 47 99.8 730,224 7.3
allied healthcare professionals who are allowed to manage 1985 56 113.6 900,513 7.9
1986 57 132.1 1,098,894 8.3
information-type and lower acuity (non-hospital) cases 1987 63 137.5 1,166,940 8.5
while working under the supervision of a CSPI. Poison cen- 1988 64 155.7 1,368,748 8.8
ters undergo a rigorous accreditation process administered 1989 70 182.4 1,581,540 8.7
1990 72 191.7 1,713,462 8.9
by the AAPCC and must submit an annual accreditation 1991 73 200.7 1,837,939 9.2
report and an extensive reaccreditation application every 1992 68 196.7 1,864,188 9.5
7 years. 1993 64 181.3 1,751,476 9.7
1994 65 215.9 1,926,438 8.9
1995 67 218.5 2,023,089 9.3
1996 67 232.3 2,155,952 9.3
NPDS – near real-time data capture 1997 66 250.1 2,192,088 8.8
1998 65 257.5 2,241,082 8.7
Extensively enhanced over its predecessor, the Toxic 1999 64 260.9 2,201,156 8.4
Exposure Surveillance System (TESS), which began collecting 2000 63 270.6 2,168,248 8.0
2001 64 281.3 2,267,979 8.1
data in 1983 and near real-time data since 2003, NPDS was 2002 64 291.6 2,380,028 8.2
launched on 12 April 2006. NPDS is the data repository for 2003 64 294.7 2,395,582 8.1
all US PCs and includes all case information collected by its 2004 62 293.7 2,438,643 8.3
2005 61 296.4 2,424,180 8.2
predecessor. In 2017, all 55 US PCs uploaded case data auto- 2006 61 299.4 2,403,539 8.0
matically to NPDS in near real-time, making NPDS one of the 2007 61 305.6 2,482,041 8.1
few operational systems of its kind. Poison center staff record 2008 61 308.5b 2,491,049 8.1
2009 60 310.9b 2,479,355 8.0
cases contemporaneously in 1 of 4 electronic medical record 2010 60a 313.3b 2,384,825 7.6
systems. Each PC uploads case data automatically. The 2011 57c 315.7b 2,334,004 7.4
average time to upload data for all PCs is 8.07 [7.32, 12.65] 2012 57 318.0b 2,275,141 7.2
2013 57d 320.2e 2,188,013 6.8
(median [25%, 75%]) minutes creating a near real-time 2014 56d 322.9f 2,165,142 6.7
national exposure database and surveillance system. 2015 55g 325.4h 2,168,371 6.7
The web-based NPDS software facilitates the detection, 2016 55 327.0i 2,159,032 6.6
2017 55 330.4j 2,115,186 6.4
analysis, and reporting of surveillance anomalies. System Total 66,609,913
software offers a myriad of surveillance uses allowing a
As of 1 July 2010 there were 60 Participating Centers.
b
AAPCC, its member centers and public health agencies to AAPCC Total as of 1 July Mid Year US Census (2012 data for 50 United States,
utilize NPDS exposure data. Users can access regional data District of Columbia and Puerto Rico; 2011 data for Guam; 2010 data for
American Samoa, Federated States of Micronesia, and the US Virgin Islands).
for their own areas and view national aggregate data. c
As of 1 July 2011 there were 57 Participating Centers.
d
Custom surveillance definitions are available, along with ad One Participating Center closed in September 2013. Its data is included in
the 2013 totals but not in the 2014 data.
hoc reporting tools. Information in the NPDS database is e
AAPCC Total as of 1 July Mid Year US Census (2013 data for 50 United
dynamic. Each year the database is locked prior to extrac- States, District of Columbia and Puerto Rico, Guam, American Samoa,
tion of annual report data to prevent inadvertent changes Federated States of Micronesia, and the US Virgin Islands).
f
AAPCC Total as of 1 July Mid Year US Census (2014 data for 50 United States,
and ensure consistent, reproducible reports. Additional District of Columbia and Puerto Rico, Guam, American Samoa, Federated
information including autopsy data on fatalities may be States of Micronesia, and the US Virgin Islands) [2].
g
added after the lock date as an addendum to the fatality One Participating Center closed in July 2014. Its data is included in the 2014
totals but not in the 2015 data.
abstract. The 2017 database was locked on 1 August 2018 h
AAPCC Total as of 1 July Mid Year US Census (2015 data for 50 United
at 12:01 EDT. States, District of Columbia and Puerto Rico, Guam, American Samoa,
Federated States of Micronesia, and the US Virgin Islands) [2].
i
AAPCC Total as of 1 July Mid Year US Census (2016 data for 50 United States,
Annual report case inclusion criteria District of Columbia and Puerto Rico, Guam, American Samoa, Federated
States of Micronesia, and the US Virgin Islands) [2].
j
AAPCC Total as of 1 July Mid Year US Census (2017 data for 50 United States,
Note: In this and last years’ reports, human and animal District of Columbia and Puerto Rico, Guam, American Samoa, Federated
“EXPOSURE CALLs” have been renamed to human and States of Micronesia, and the US Virgin Islands) [2].
animal “EXPOSURE CASEs,” since a single call may result in
multiple cases and the NPDS database contains information
about individual exposure cases. The information in this involving complex hospitalized patients or resulting in death
report reflects only those cases that are not duplicates and may remain open for months while data continue to be
classified by the PC as CLOSED. A case is closed when the PC collected. Follow-up contacts provide a proven mechanism
has determined that no further follow-up/recommendations for monitoring the appropriateness of management recom-
are required or no further information is available. Exposure mendations, enabling continual updates of case information,
cases are followed to obtain the most precise medical out- augmenting patient guidelines, providing poison prevention
come possible. Depending on the case specifics, most cases education, and obtaining final medical outcomes to make
are “closed” within a few hours of the initial contact. Cases the data collected as accurate and complete as possible.
CLINICAL TOXICOLOGY 7
Horse 83 0.16
Sheep/goat 45 0.09 12.0.1 (SAS Institute, Cary, NC) and summary counts were
Cow 34 0.07 generated by the NPDS web-based application. The analysis
Aquatic 10 0.02
Other 261 0.51
for Figure 5 was done using Microsoft Excel 2016 (Microsoft,
Total 51,164 100.00 Redmond, WA).
Figure 1. Human exposure cases, information contacts and animal exposure Figure 3. Health care facility (HCF) exposure cases and hcf information contacts
cases by day since 1 January 2000. by day since 1 January 2000.
Smoothing spline fits using lambda ¼ 1200 for human exposures had associated Both linear and second order (quadratic) terms were statistically significant
RSqr ¼ 0.447, information contacts RSqr ¼ 0.904 and animal exposures RSqr ¼ 0.871. (p < 0.001) for regression of HCF human exposure with associated RSqr ¼ 0.766.
The quadratic coefficient is positive meaning the case counts are increasing
faster than linearly. Smoothing spline fit with lambda ¼ 1200 for HCF informa-
tion contacts had associated RSqr ¼ 0.369.
Figure 4. Substance categories with the greatest rate of exposure increase since 1 January 2000 for more severe outcomes (Top 4).
Solid lines show least-squares linear regressions for the human exposure cases per year for that category (w). Broken lines show 95% confidence interval on the regression.
week, from 1-Jul-2010 through 30-Jul-2018 by Generic Code and percentage of exposures may be relevant, so both
(GC) for: parameters were calculated and presented.
Table 4. Distribution of agea and Gender for Fatalitiesb. Table 6A. Reason for human exposure cases.
Cumulative Reason N % Human exposures
Age (y) Male Female Unknown Total (%) total (%) Unintentional
< 1 year 2 2 0 4 (0.3%) 4 (0.3%) Unintentional – General 1,072,789 50.7
1 year 1 0 0 1 (0.1%) 5 (0.4%) Unintentional – Therapeutic error 271,112 12.8
2 years 2 1 0 3 (0.2%) 8 (0.6%) Unintentional – Misuse 141,330 6.7
3 years 1 0 0 1 (0.1%) 9 (0.7%) Unintentional – Environmental 51,755 2.4
4 years 3 0 0 3 (0.2%) 12 (0.9%) Unintentional – Bite / sting 41,850 2.0
Child 6–12 years 8 4 1 13 (0.9%) 25 (1.8%) Unintentional – Occupational 29,834 1.4
Teen 13–19 years 19 27 0 46 (3.3%) 71 (5.1%) Unintentional – Food poisoning 16,181 0.8
20–29 years 123 81 1 205 (14.8%) 276 (19.9%) Unintentional – Unknown 4,525 0.2
30–39 years 148 95 0 243 (17.5%) 519 (37.4%) Subtotal 1,629,376 77.0
40–49 years 99 128 0 227 (16.4%) 746 (53.8%) Intentional
50–59 years 131 137 0 268 (19.3%) 1,014 (73.1%) Intentional – Suspected suicide 274,390 13.0
60–69 years 75 114 0 189 (13.6%) 1,203 (86.7%) Intentional – Misuse 57,085 2.7
70–79 years 43 61 0 104 (7.5%) 1,307 (94.2%) Intentional – Abuse 49,234 2.3
80–89 years 25 33 0 58 (4.2%) 1,365 (98.3%) Intentional – Unknown 19,452 0.9
> ¼ 90 years 5 12 0 17 (1.2%) 1,382 (99.6%) Subtotal 400,161 18.9
Unknown adult 3 1 0 4 (0.3%) 1,386 (99.9%) Adverse Reaction
Unknown age 0 1 1 2 (0.1%) 1,388 (100.0%) Adverse reaction – Drug 34,896 1.6
Total 688 697 3 1,388 (100.0%) 1,388 (100.0%) Adverse reaction – Other 11,033 0.5
a
Age includes cases with both actual and estimated ages as shown in Adverse reaction – Food 5,561 0.3
Table 21. Subtotal 51,490 2.4
b
Includes cases with RCF of 1-Undoubtedly responsible, 2-Probably Unknown
responsible, or 3-Contributory. This excludes reports with outcome of Unknown reason 17,986 0.9
Death INDIRECT. Subtotal 17,986 0.9
Other
Other – Contamination / tampering 7,262 0.3
Other – Malicious 7,151 0.3
Table 5. Number of substances involved in human exposure cases.
Other – Withdrawal 1,760 0.1
Human exposures Fatal exposuresa Subtotal 16,173 0.8
Total 2,115,186 100.0
No. of Substances N % N %
1 1,858,385 87.86 598 43.08
2 159,710 7.55 327 23.56 detail regarding law enforcement or child protective services
3 53,855 2.55 214 15.42 involvement, postmortem investigation, and the means by
4 22,485 1.06 97 6.99
5 9,764 0.46 74 5.33 which the child accessed the substances responsible for the
6 4,814 0.23 24 1.73 fatality. Poison Centers are encouraged to heed previously
7 2,504 0.12 22 1.59 published pediatric narrative guidelines to improve the deter-
8 1,427 0.07 9 0.65
> ¼9 2,242 0.11 23 1.66 mination of causality, and preventability, wherever possible.
Total 2,115,186 100.00 1,388 100.00
a
Includes cases with RCF of 1-Undoubtedly responsible, 2-Probably responsible, Results
or 3-Contributory. This excludes reports with outcome of Death INDIRECT.
Informational contacts with poison centers
exposure-related fatality as a death judged by the AAPCC
Fatality Review Team to be at least contributory to the Data from 435,540 information contacts to PCs in 2017
exposure. The definitions used for the Relative Contribution (Table 1C) was transmitted to NPDS, including contacts in
to Fatality (RCF) classification are defined in Appendix B and optional reporting categories such as prevention/safety/educa-
the methods to select abstracts for publications are described tion (20,000), administrative (20,245), and caller referral (48,600).
in Appendix C. For details of the AAPCC fatality review pro- Figure 2 shows that all Drug ID contacts have decreased
cess, see the 2008 annual report [1]. dramatically since mid-2008. Law enforcement Drug ID con-
tacts also showed a decline. The most frequent information
contacts was for Drug ID, comprising 96,221 contacts with
Pediatric fatality case review
PCs during the year. Of these, 52,093 (54.1%) were identified
A focused Pediatric Fatality Review team comprised of 6 as drugs with known abuse potential. However, these cases
pediatric toxicologists evaluated cases for patients under 19 were categorized based on the drug’s abuse potential with-
years of age. The panel reviewed the documentation of all out knowledge of whether abuse was actually intended.
such cases, with specific focus on the conditions behind the While the number of Drug information contacts decreased
poisoning exposure and finding commonalities which might 5.98% from 2016 (80,847 contacts) to 2017 (76,014 contacts),
inform efforts at prevention. The reviewed pediatric fatality the percentage of these slightly increased to 17.45% of all
cases exhibited a bimodal age distribution. Exposures causing information requests. The most common drug information
death in children 5 years of age were mostly coded as requests were about drug-drug interactions, followed by
“Unintentional-General,” while those in ages >13 years were other drug information, questions about dosage, inquiries of
mostly “Intentional.” As has been true for several years, the adverse effects (without a known exposure), and therapeutic
circumstances of the case are often not captured in the use and indications. Environmental inquiries comprised
reason code or the narrative. The pediatric fatality review 3.37% of all information contacts. Of these environmental
team continues to encourage the procurement of further inquiries, specific questions related to pesticides were most
CLINICAL TOXICOLOGY 13
common, followed by cleanup of mercury (thermometers Of all the information contacts, poison information com-
and other), and air quality. prised 11.4% of the requests with inquiries involving general
toxicity the most common followed by questions involving
14 D. D. GUMMIN ET AL.
Table 10. Management site of human exposures. up was performed in 47.0% of human exposure cases. One
Site of management N % follow-up contact was made in 21.8% of human exposure
Managed on site, nonhealth care facility 1,385,895 65.5 cases and multiple follow-ups (range 2-160) were performed
Managed in healthcare facility in 25.2% of cases. For human exposure cases in which
Treated/evaluated and released 309,330 14.6
Admitted to critical care unit 101,849 4.8 follow-up contacts were documented, an average of 2.62
Admitted to psychiatric facility 85,629 4.1 contacts per case were done.
Patient lost to follow-up/left AMA 82,448 3.9
Figure 3 shows a graphic summary and analyses of
Admitted to noncritical care unit 76,979 3.6
Subtotal (managed in HCF) 656,235 31.0 Health Care Facility (HCF) exposure and HCF information
Other 19,941 0.9 contacts. HCF exposure cases slightly departs from linearity
Refused referral 25,734 1.2
Unknown 27,381 1.3
but continues to increase at a steady rate, while the rate
Total 2,115,186 100.0 of HCF information contacts has declined since early 2005
but leveled off since late 2013. This increasing use of the
PCs for the more serious exposures (HCF cases)
food preparation handling practices, safe use of household is important in the face of the overall decline in exposure
products, and food poisoning. and information encounters.
Tables 22A (Nonpharmaceuticals) and 22B (Pharmaceuticals)
(in Appendix E) provide summary demographic data on patient
Exposure cases logged at poison centers
age, reason for exposure, medical outcome, and use of an
In 2017, the participating PCs logged 2,607,413 total HCF for all 2,115,186 human exposure cases, presented by
encounters including 2,115,186 closed human exposure cases substance categories. The Pharmaceuticals category includes
(Table 1A), 51,164 animal exposures (Table 1B), 435,540 both licit and illicit drugs.
information contacts (Table 1C), 5,424 human confirmed non- Column 1: Name of the major, minor generic categories and their
exposures, and 99 animal confirmed non-exposures. An add- associated generic substances (Alternate Names). Note that for
itional 170 cases were still open at the time the database pharmaceuticals, the generic category or generic substance listed is
was locked. The cumulative AAPCC database now contains for the initial FDA approved indication and may not reflect current
indications or uses for the pharmaceutical.
more than 68 million human exposure case records
(Table 1A). A total of 19,250,405 information contacts have Column 2: Number of Case Mentions (all exposures) in grey
shading, displays the number of times the specific generic code
been logged into the AAPCC database since the year 2000.
was reported in any human exposure case. If a human exposure
Figure 1 shows the human exposures, information case has multiple instances of a specific generic code it is only
contacts and animal exposures by day since 1 January 2000. counted once.
Smoothing spline fit of these data shows departure from
Column 3: Number of Single Exposures displays the number of
linearity (declining rate of cases since mid-2007) for Human human exposure cases that identified only 1 substance (1 case,
Exposure cases with some flattening over the last 2 years. 1 substance).
information contacts are declining more rapidly and are also The succeeding columns (Age, Reason, Treatment Site, and
described by a smoothing spline fit, and Animal Exposure Outcome) show selected detail from these single-substance
cases have likewise been declining since mid-2005. The 2 exposure cases. Death cases include both cases that have the
May 2006 exposure data spike on Figure 1 was the result of outcome of Death or Death (indirect report). These death
cases are not limited by the RCF.
602 children in a Midwest school reporting a noxious odor
which caused anxiety but resolved without sequelae. Tables 22A and 22B (Appendix E) restrict the breakdown
A hallmark of PC case management is the use of follow- columns to single-substance cases. Prior to 2007, when multi-
up contacts to monitor case progress and medical outcome. substance exposures were included, a relatively innocuous
US PCs made 2,680,625 follow-up contacts in 2017. Follow- substance could be mentioned in a death column when,
CLINICAL TOXICOLOGY 15
Table 13. Duration of clinical effects by medical outcome. Tables 22A and 22B (Appendix E) tabulate 2,541,728
Minor effect Moderate effect Major effect substance-exposures, of which 1,858,385 were single-
Duration of effect N % N % N % substance exposures, including 954,802 (51.4%) non-
<¼2 hours 99,733 29.55 7140 4.27 864 3.21 pharmaceuticals and 903,583 (48.6 %) pharmaceuticals.
>2 hours, <¼8 hours 97,644 28.93 33,495 20.01 1,786 6.63 In 23.2% of single-substance exposures that involved
>8 hours, <¼24 hours 65,138 19.30 61,298 36.63 5,897 21.88 pharmaceutical substances, the reason for exposure was
>24 hours, <¼3 days 20,725 6.14 34,855 20.83 9,171 34.03
>3 days, <¼1 week 3,915 1.16 8,236 4.92 5,019 18.62 intentional, compared to only 4.14% when the exposure
>1 week, <¼1 month 1,134 0.34 1,548 0.92 1,393 5.17 involved a nonpharmaceutical substance. Correspondingly,
>1 month 332 0.10 352 0.21 147 0.55 treatment in an HCF was provided in a higher percentage
Anticipated permanent 422 0.13 166 0.10 453 1.68
Unknown 48,452 14.36 20,264 12.11 2,219 8.23 of exposures that involved pharmaceutical substances
Total 337,495 100.00 167,354 100.00 26,949 100.00 (34.2%) compared with nonpharmaceutical substances
(17.4%). Exposures to pharmaceuticals also had more
Table 14. Decontamination and therapeutic interventions. severe outcomes. Of single-substance exposure-related
Therapy N % fatal cases, 1,009 (76.2%) were pharmaceuticals compared
Decontamination Only 1,012,714 47.9 with 315 (23.8%) nonpharmaceuticals.
Therapeutic Intervention Only 265,267 12.5
Decontamination and Therapeutic Intervention 118,881 5.6
Not Coded 718,324 34.0 Age and gender distributions
Total 2,115,186 100.0
The age and gender distribution of human exposures is out-
lined in Table 3A. Children younger than 3 years of age were
for example, the death was attributed to an antidepres- involved in 33.6% of exposures and children 5 years
sant, opioid, or cyanide. This subtlety was not always accounted for approximately half of all human exposures
appreciated by the user of this table. The restriction of the (45.2%). A male predominance was found among cases
breakdowns to single-substance exposures should increase involving children 12 years, but this gender distribution
precision and reduce misrepresentation of the results in was reversed in teenagers and adults, with females compris-
this unique by-substance table. Single substance cases
ing the majority of reported exposures. The overall rate
reflect the majority (87.9%) of all exposures. In contrast,
of poison exposures reported to PCs is 660/100,000 popu-
only 43.1% of fatalities are single substance exposures
lation (Table 3B). The highest rates of poison exposures are
(Table 5).
in 1-year-old children (8,083/100,000 population) and
16 D. D. GUMMIN ET AL.
Table 16B. Decontamination trends: Total human and pediatric exposures pregnancy duration (n ¼ 6,331), 37.1% occurred in the first
5 yearsa.
trimester, 34.9% in the second trimester, and 28.0% in the
Human Exposures
exposures children < ¼5 y third trimester. Most (72.5%) were unintentional exposures
and 21.0% were intentional exposures. There were 2 deaths
Therapy N % N %
in pregnant females in 2017.
Activated charcoal administered 39,985 1.89 5,743 0.60
Cathartic 5,134 0.24 327 0.03
Ipecac administered 64 0.00 12 0.00
Lavage 1,057 0.05 26 0.00 Chronicity
Other Emetic 14,534 0.69 6,727 0.70
Whole Bowel Irrigation 1,640 0.08 60 0.01 Most human exposures, 1,825,251 (86.3%), were acute cases
Total 62,414 2.95 12,895 1.35 (single, repeated or continuous exposure occurring over 8 hours
a
Human exposures ¼ 2,115,186; Pediatric exposures ¼ 956,871.
or less) compared to 1,018 (31.7%) acute cases among the
2-year-old children (7,675/100,000 population). Rates 3,208 fatalities. Chronic exposures (continuous or repeated
declined with age from 448/100,000 population in children exposures occurring over >8 hours) comprised 2.20% (46,611)
6-12 to 345/100,000 population in adults 20 years. of all human exposures. Acute-on-chronic exposures (single
exposure that was preceded by a continuous, repeated, or
Caller site and exposure site intermittent exposure occurring over a period greater than
8 hours) numbered 209,778 (9.92%).
As shown in Table 2, of the 2,115,186 human exposures
reported, 67.5% of of these encounters originated from a
residence (own or other) but 92.7% actually occurred at a Reason for exposure
residence (own or other). Another 24.4% were made from an The reason category for most human exposures was unintentional
HCF. Beyond residences, exposures occurred in the workplace (77.0%), including: unintentional general (50.7%), therapeutic error
(1.84% of cases), schools (1.45%), HCF (0.335%), and restau-
(12.8%), and unintentional misuse (6.68%) (Table 6A).
rants or food services (0.174%).
Exposures in pregnancy
Scenarios
Exposure during pregnancy occurred in 6,795 women Of the total 271,112 therapeutic errors, the most common
(0.321% of all human exposures). Of those with known scenarios for all ages included: inadvertent double-dosing
18 D. D. GUMMIN ET AL.
Table 17A. Substance categories most frequently involved in human exposures (Top 25).
Substance (Major Generic Category) All substances %a Single substance exposures %b
Analgesics 283,784 11.08 178,069 9.58
Cleaning Substances (Household) 190,319 7.43 170,676 9.18
Cosmetics/Personal Care Products 172,968 6.76 166,145 8.94
Sedative/Hypnotics/Antipsychotics 146,943 5.74 53,419 2.87
Antidepressants 128,546 5.02 53,934 2.90
Antihistamines 111,181 4.34 76,152 4.10
Cardiovascular Drugs 108,614 4.24 46,207 2.49
Foreign Bodies/Toys/Miscellaneous 89,368 3.49 86,290 4.64
Pesticides 84,031 3.28 77,999 4.20
Alcohols 72,090 2.82 22,239 1.20
Stimulants and Street Drugs 69,979 2.73 38,148 2.05
Topical Preparations 66,702 2.61 64,886 3.49
Anticonvulsants 65,941 2.58 26,066 1.40
Vitamins 59,761 2.33 49,937 2.69
Cold and Cough Preparations 56,757 2.22 38,457 2.07
Hormones and Hormone Antagonists 56,673 2.21 36,962 1.99
Antimicrobials 53,667 2.10 42,882 2.31
Dietary Supplements/Herbals/Homeopathic 51,653 2.02 42,645 2.29
Gastrointestinal Preparations 48,714 1.90 35,117 1.89
Plants 46,782 1.83 44,089 2.37
Bites and Envenomations 46,513 1.82 45,688 2.46
Chemicals 43,688 1.71 37,406 2.01
Fumes/Gases/Vapors 33,615 1.31 30,829 1.66
Electrolytes and Minerals 30,446 1.19 24,641 1.33
Other/Unknown Nondrug Substances 30,102 1.18 27,657 1.49
a
Percentages are based on the total number of substances reported in all exposures (N ¼ 2,560,308).
b
Percentages are based on the total number of single substance exposures (N ¼ 1,858,385).
(30.6%), wrong medication taken or given (16.7%), other (8.65%), and parenteral (7.20%) were the predominant exposure
incorrect dose (14.6%), doses given/taken too close together routes. Each exposure case may have more than one route.
(11.2%), and inadvertent exposure to someone else’s medica-
tion (9.03%). The types of therapeutic errors observed are dif-
ferent for each age group and are summarized in Table 6B. Clinical effects
The NPDS database allows for the coding of up to 131 indi-
Reason by age vidual clinical effects (signs, symptoms, or laboratory abnor-
Intentional exposures accounted for 18.9% of human malities) for each case. Each clinical effect can be further
exposures. Suicidal intent was suspected in 13.0% of cases, defined as related, not related, or unknown if related. Clinical
intentional misuse in 2.70%, and intentional abuse in 2.33%. effects were coded in 813,794 (38.5%) cases (17.7% had 1
Unintentional exposures outnumbered intentional exposures effect, 9.88% had 2 effects, 5.32% had 3 effects, 2.56% had 4
in all age groups with the exception of ages 13–19 years effects, 1.26% had 5 effects, and 1.75% had >5 effects
(Table 7). In contrast, of the 1,388 reported fatalities with RCF coded). Of clinical effects coded, 77.3% were deemed related
1-3, the major reason reported for children 5 years was to the exposure, 9.94% were considered not related, and
unintentional, while most fatalities in adults (20 years) were 12.8% were coded as unknown if related.
intentional (Table 8).
Case management site
Route of exposure The majority of cases reported to PCs were managed outside
Ingestion was the route of exposure in 83.4% of cases (Table 9), of a HCF (65.5%), usually at the site of exposure, primarily
followed in frequency by dermal (7.23%), inhalation/nasal the patient’s own residence (Table 10). Treatment in a HCF
(6.33%), and ocular routes (4.22%). For the 1,388 exposure-related was rendered in 31.0% of cases. Only 1.2% of cases were
fatalities, ingestion (76.7%), unknown (12.6%), inhalation/nasal referred to a HCF but refused referral.
CLINICAL TOXICOLOGY 19
Table 17B. Substance categories with the greatest rate of exposure increase (Top 25).
Increase in serious exposures per yeara
Substance (Major Generic Category) Mean 95% CIb All substances in 2016
Sedative/Hypnotics/Antipsychotics 1,962 [1601, 2322] 50,933
Analgesics 1,785 [1528, 2041] 50,064
Antidepressants 1,367 [1230, 1503] 42,476
Cardiovascular Drugs 984 [948, 1020] 22,835
Alcohols 931 [872, 990] 25,003
Stimulants and Street Drugs 913 [660, 1167] 26,499
Anticonvulsants 721 [655, 786] 18,538
Antihistamines 657 [563, 751] 17,301
Muscle Relaxants 423 [365, 481] 10,409
Unknown Drug 405 [337, 473] 9,554
Hormones and Hormone Antagonists 253 [242, 265] 6,944
Cold and Cough Preparations 224 [166, 281] 7,813
Gastrointestinal Preparations 102 [83, 121] 3,495
Miscellaneous Drugs 78.1 [51, 105] 2,227
Diuretics 52.4 [44, 60] 1,546
Anticoagulants 49.3 [44, 55] 1,179
Electrolytes and Minerals 40.0 [35, 45] 1,090
Vitamins 36.3 [30, 42] 1,053
Anticholinergic Drugs 31.1 [23, 40] 1,017
Other/Unknown Nondrug Substances 25.3 [3, 48] 1,158
Weapons of Mass Destruction 19.2 [12, 27] 363
Antimicrobials 13.7 [-4, 31] 2,713
Narcotic Antagonists 11.9 [9, 15] 310
Tobacco/Nicotine/eCigarette Products 11.9 [6, 17] 355
Essential Oils 11.0 [9, 13] 236
a
Serious exposures have outcomes of Moderate, Major or Death..
b
Increase and confidence intervals are based on least squares linear regression of the number of calls per year for 2000–2017..
Table 17C. Substance categories most frequently involved in pediatric ( 5 years) exposures (Top 25)a.
Substance (Major Generic Category) All substances %b Single substance exposures %c
Cosmetics/Personal Care Products 125,838 12.59 123,019 13.26
Cleaning Substances (Household) 109,563 10.96 105,275 11.35
Analgesics 91,741 9.18 83,438 8.99
Foreign Bodies/Toys/Miscellaneous 63,916 6.39 62,266 6.71
Topical Preparations 48,342 4.84 47,367 5.11
Antihistamines 46,936 4.70 42,435 4.57
Vitamins 42,553 4.26 38,215 4.12
Pesticides 34,303 3.43 33,211 3.58
Dietary Supplements/Herbals/Homeopathic 34,265 3.43 32,000 3.45
Plants 28,029 2.80 26,889 2.90
Gastrointestinal Preparations 26,808 2.68 24,204 2.61
Antimicrobials 23,090 2.31 21,609 2.33
Cardiovascular Drugs 20,983 2.10 13,318 1.44
Cold and Cough Preparations 20,536 2.05 18,537 2.00
Arts/Crafts/Office Supplies 20,449 2.05 19,779 2.13
Electrolytes and Minerals 18,785 1.88 16,994 1.83
Hormones and Hormone Antagonists 17,646 1.77 13,830 1.49
Deodorizers 17,214 1.72 16,985 1.83
Essential Oils 16,142 1.61 15,249 1.64
Other/Unknown Nondrug Substances 12,524 1.25 11,865 1.28
Antidepressants 11,667 1.17 8,459 0.91
Tobacco/Nicotine/eCigarette Products 11,207 1.12 11,119 1.20
Chemicals 11,026 1.10 10,023 1.08
Sedative/Hypnotics/Antipsychotics 9,825 0.98 7,525 0.81
Alcohols 9,402 0.94 9,153 0.99
a
Includes all children with actual or estimated ages 5 years old. Results do not include “Unknown Child” or “Unknown Age”..
b
Percentages are based on the total number of substances reported in pediatric exposures (N ¼ 999,529).
c
Percentages are based on the total number of single substance pediatric exposures (N ¼ 927,844).
Of the 656,235 cases managed in a HCF, 309,330 (47.1%) compared to 66.7% of teenagers (13–19 years) and 50.2% of
were treated and released, 101,849 (15.5%) were admitted adults (age 20 years).
to a critical care unit, 76,979 (11.7%) were admitted to
a noncritical unit, and 85,629 (13.0%) were admitted directly
to a psychiatric facility.
Medical outcome
The percentage of patients treated in a HCF varied consid-
erably with age. Only 12.9% of children 5 years and 18.4% Table 11 displays the medical outcome of human exposure
of children between 6 and 12 years were managed in a HCF cases distributed by age. Older age groups exhibit a greater
number of severe medical outcomes. Table 12 compares
20 D. D. GUMMIN ET AL.
Table 17D. Substance categories most frequently involved in adult (>20 years) exposures (Top 25)a.
Substance (Major Generic Category) All substances %b Single substance exposures %c
Analgesics 129,917 11.18 58,799 8.95
Sedative/Hypnotics/Antipsychotics 114,212 9.83 35,663 5.43
Antidepressants 83,753 7.21 29,034 4.42
Cardiovascular Drugs 74,293 6.40 26,036 3.96
Cleaning Substances (Household) 63,329 5.45 50,384 7.67
Alcohols 55,752 4.80 10,449 1.59
Anticonvulsants 49,298 4.24 16,881 2.57
Pesticides 41,807 3.60 37,492 5.71
Stimulants and Street Drugs 41,266 3.55 18,872 2.87
Antihistamines 38,228 3.29 17,761 2.70
Hormones and Hormone Antagonists 33,006 2.84 19,369 2.95
Bites and Envenomations 31,090 2.68 30,547 4.65
Cosmetics/Personal Care Products 30,454 2.62 27,662 4.21
Chemicals 25,213 2.17 20,840 3.17
Fumes/Gases/Vapors 24,378 2.10 22,260 3.39
Antimicrobials 21,769 1.87 15,364 2.34
Cold and Cough Preparations 20,913 1.80 11,171 1.70
Muscle Relaxants 20,550 1.77 7370 1.12
Hydrocarbons 17,304 1.49 15,868 2.42
Gastrointestinal Preparations 16,570 1.43 7,744 1.18
Unknown Drug 15,129 1.30 9,340 1.42
Topical Preparations 14,179 1.22 13,557 2.06
Other/Unknown Nondrug Substances 13,038 1.12 11,604 1.77
Foreign Bodies/Toys/Miscellaneous 12,256 1.06 11,222 1.71
Miscellaneous Drugs 12,235 1.05 6,219 0.95
a
Includes all adults with actual or estimated ages 20 years old. Results also include “Unknown Adult” but do not include “Unknown Age”.
b
Percentages are based on the total number of substances reported in adult exposures (N ¼ 1,161,585).
c
Percentages are based on the total number of single substance adult exposures (N ¼ 656,790).
Table 17E. Substance categories most frequently involved in pediatric ( 5 years) deathsa.
Substance (Major Generic Category) All substances %b Single substance exposures %c
Analgesics 7 20.59 5 26.32
Unknown Drug 4 11.76 4 21.05
Antihistamines 3 8.82 0 0.00
Fumes/Gases/Vapors 3 8.82 1 5.26
Alcohols 2 5.88 1 5.26
Stimulants and Street Drugs 2 5.88 0 0.00
Anesthetics 1 2.94 0 0.00
Antidepressants 1 2.94 0 0.00
Batteries 1 2.94 1 5.26
Cardiovascular Drugs 1 2.94 1 5.26
Cosmetics/Personal Care Products 1 2.94 1 5.26
Deodorizers 1 2.94 1 5.26
Dietary Supplements/Herbals/Homeopathic 1 2.94 1 5.26
Electrolytes and Minerals 1 2.94 1 5.26
Gastrointestinal Preparations 1 2.94 0 0.00
Hydrocarbons 1 2.94 0 0.00
Pesticides 1 2.94 1 5.26
Sedative/Hypnotics/Antipsychotics 1 2.94 0 0.00
Weapons of Mass Destruction 1 2.94 1 5.26
Total 34 100.00 19 100.00
a
Includes all children with actual or estimated ages 5 years old. Results do not include “Unknown Child” or “Unknown Age”. Includes death and death, indirect
regardless of RCF.
b
Percentages are based on the total number of substances reported in pediatric fatalities (N ¼ 34).
c
Percentages are based on the total number of single substance pediatric fatalities (N ¼ 19).
medical outcome and reason for exposure and shows a greater measures to enhance elimination in the treatment of patients
frequency of serious outcomes in intentional exposures. reported in the NPDS database. These should be interpreted
The duration of effect is required for all cases which as minimum frequencies because of the limitations of tele-
report at least 1 clinical effect and have a medical outcome phone data gathering.
of minor, moderate or major effect (n ¼ 531,798; 25.1% of Ipecac-induced emesis for poisoning continues to decline
exposures). Table 13 demonstrates an increasing duration of as shown in Tables 16A and 16B. Ipecac was administered
the clinical effects observed with more severe outcomes. in only 12 (0.00125%) pediatric exposures in 2017. The
continued decrease in ipecac syrup use over the last 2
decades was likely a result of ipecac use guidelines issued
Decontamination procedures and specific antidotes
in 1997 by the American Academy of Clinical Toxicology and
Tables 14 and 15 outline the use of decontamination the European Association of Poisons Centres and Clinical
procedures, specific physiological antagonists (antidotes), and Toxicologists and updated in 2004 [5,6]. In a separate report,
CLINICAL TOXICOLOGY 21
Table 17F. Substance categories most frequently identified in drug identifica- the change over time and linear regressions for the top 4
tion calls (Top 25).
increasing categories in Table 17B.
Substance (Major Generic Category) All substances %a Tables 17C and 17D present exposure results for
Analgesics 38,765 33.78 children and adults, respectively, and show the differences
Sedative/Hypnotics/Antipsychotics 20,449 17.82
Unknown Drug 8,271 7.21 between substance categories involved in pediatric and
Cardiovascular Drugs 6,916 6.03 adult exposures.
Antidepressants 5,704 4.97
Table 17E reports the 25 categories of substances most
Muscle Relaxants 5,069 4.42
Anticonvulsants 4,919 4.29 frequently involved in pediatric (5 years) fatalities in 2015.
Stimulants and Street Drugs 4,271 3.72 Table 17F reports the 25 Drug ID categories most
Antihistamines 4,251 3.70
Antimicrobials 4,028 3.51
frequently queried in 2017, highlighting the value of Drug ID
Hormones and Hormone Antagonists 2,593 2.26 information to the AAPCC, public health, public safety, and
Information Calls 2,514 2.19 regulatory agencies. Internet based resources do not afford
Gastrointestinal Preparations 2,349 2.05
Diuretics 1,351 1.18 the caller the option to speak with a health care professional,
Miscellaneous Drugs 927 0.81 if needed. Proper resources to continue this vital public
Cold and Cough Preparations 525 0.46 service are essential, especially since the top 10 substance
Anticholinergic Drugs 293 0.26
Vitamins 267 0.23 categories include antibiotics and drugs with widespread use
Anticoagulants 262 0.23 and abuse potential, such as opioids and benzodiazepines.
Asthma Therapies 261 0.23 Table 17G reports the 25 substance categories most
Electrolytes and Minerals 249 0.22
Dietary Supplements/Herbals/Homeopathic 70 0.06 frequently reported in exposures involving pregnant patients.
Other/Unknown Nondrug Substances 69 0.06
Narcotic Antagonists 56 0.05
Antineoplastics 55 0.05 Changes over time
a
Percentages are based on the total number of substances reported in all
drug identification calls (N ¼ 114,760). Total encounters peaked in 2008 at 4,333,012 including
2,491,049 human exposure cases and 1,703,762 information
contacts. Total encounters decreased 3.79% from 2,710,042 in
the American Academy of Pediatrics concluded not only 2016 to 2,607,413 in 2017. information contacts decreased by
that ipecac should no longer be used routinely as a home 11.2% from 490,215 in 2016 to 435,540 in 2017, with a 30.2%
decrease in drug identification contacts and a 0.264 %
treatment strategy, but also recommended disposal of home
decrease in HCF information contacts. Human exposures
ipecac stocks [7]. A decline was also observed since the early
decreased by 2.03% from 2,159,032 to 2,115,186 cases over
1990s for reported use of activated charcoal. While not
the same time period.
as dramatic as the decline in use of ipecac, reported use of Figure 5 shows the year-to-year change through 2017
activated charcoal decreased from 3.66% of pediatric cases in as a percentage of year 2000 for human exposure cases
1993 to just 0.600% in 2017. broken down into cases with more serious outcomes (death,
major effect, and moderate effect) and less serious outcomes
(minor effect, no effect, not followed (non-toxic), not
Top substances in human exposures
followed (minimal toxicity possible), unable to follow (poten-
Table 17A presents the 25 most common substance catego- tially toxic), and unrelated effect). Since 2000, cases with
ries, listed by frequency of human exposure for cases with more serious outcomes have increased by 4.44% (95% CI
more serious outcomes (moderate, severe, and death). This [4.15%, 4.73%]) per year from 108,148 cases in 2000 to
ranking provides an indication where prevention efforts 196,135 cases in 2017. However, cases with less serious out-
might be focused, as well as the types of serious exposures comes have decreased since 2008 by 2.48% [2.96%,
PCs regularly manage. It is relevant to know whether 1.99%] per year from 2,339,460 in 2008 to 1,917,675 cases
exposures to these substances are increasing or decreasing. in 2017. This decrease in less serious exposures has driven
To better understand these relationships, we examined the overall decrease in human exposures since 2008. Thus
exposures with more serious outcomes per year over the last we see a consistent increase in exposure cases from HCFs
17 years for the change over time for each of the 68 major (Figure 3) and for more severe exposures (Figure 5), despite
generic categories via least squares linear regression. The a decrease in cases involving less severe exposures.
serious outcome exposure cases per year over this period
were increasing for 34, static for 5, and decreasing for 29 of
Emerging trends – drugs of abuse
the 68 categories with data for the entire time period. The
change over time for the 17 yearly values was statistically Cocaine-related mortality is increasing in the US. The same
significant (p < 0.05) for 48 of the 68 categories with data for appears true for methamphetamine and other stimulants
the entire time period. Table 17B shows the 25 categories (Figure 6). Likewise, data from NPDS show the recent steady
which were increasing the most rapidly. Statistical signifi- rise in poison center contacts leading up to and throughout
cance of the linear regressions can be verified by noting 2017 (Figure 7).
the 95% confidence interval on the rate of increase excludes Documented exposures to heroin continue to rise in
zero for all but 1 of the 25 categories. Figure 4 shows NPDS data. Methamphetamine exposures steadily increased
22 D. D. GUMMIN ET AL.
in recent years, while cocaine dropped quickly and then Table Fatalities Included RCF N
plateaued. Other hallucinogenic amphetamine exposures 4 Death only 1,2,3 1,388
appear to be downtrending. Interestingly, despite the cre- 5 Death only 1,2,3 1,388
ation of an active generic code in March, 2017 the 8 Death only 1,2,3 1,388
9 Death only 1,2,3 1,388
Historical GC search strategy revealed that kratom shows 11 Death and Death (indirect report) All 3,208
steady activity preceding a marked increase in the number 12 Death and Death (indirect report) All 3,208
of cases late in this 10-year period. Synthetic cathinones 17E Pediatric Death and Death (indirect report) All 25
18 Death only 1,2,3 1,388
showed early peaks, likely reflecting emergence as abused 19A Death and Death (indirect report) All 3,208
drugs with secondary peaks during outbreaks involving 19B Death and Death (indirect report) All 3,208
novel compounds with unique toxicities. Synthetic trypt- 21 Death and Death (indirect report) 1,2,3 2,682
22 Death and Death (indirect report) - All 1,324
amines show a very small presence in the NPDS database Single substance deaths only
while synthetic opioids show a subtle increase toward the
end of the period (Figure 7).
of the exposure (exposure-related fatalities). Tables 11, 12,
Table 16C details the increase in exposures for the 52-
and 19 consider all deaths, irrespective of the RCF. Beginning
week period ending 30 Jul 2018 by linear regression. Of the
in 2010, deaths recorded as Indirect Report were no longer
8 GC’s examined over these 52 weeks, all were increasing (5
reviewed by the AAPCC fatality review team and the RCF
of 8 with p < 0.05), 3 of 8 at >100%/year. Trends in these
was determined by the reporting PC.
data do not seem to reflect the timing of activation of GCs.
There were 1,376 deaths, indirect and 1,832 deaths. Of
Rather, peaks appear to reflect the emergence of new classes
these 3,208 cases, 2,682 were judged exposure-related fatal-
of abused drugs directly resulting in the development of
ities (RCF ¼ 1 - Undoubtedly responsible, 2 - Probably respon-
new GCs. This highlights the value and timeliness of utilizing
NPDS data to identify new trends as they emerge. sible, or 3 - Contributory). The remaining 526 cases were
Moving forward, the Historical GC search should facilitate judged as follows: 122 as RCF ¼ 4 - Probably not responsible,
the identification of new, potentially harmful substances. 70 as RCF ¼ 5 - Clearly not responsible, and 334 as RCF ¼ 6
- Unknown.
Deaths are sorted in Table 21 (Appendix D) according to
Distribution of suicides the category, then substance deemed most likely responsible
for the death (Cause Rank), and then by patient age. The
Table 19A shows a modest variation in the distribution
Cause Rank permits the PC to judge 2 or more substances as
of suicides and pediatric deaths over the past 2 decades
indistinguishable in terms of cause, for example, 2 substances
as reported to the NPDS national database. Within the last
which appear equally likely to have caused the death could
decade, the percent of exposures determined to be suspected
have Substance Rank of 1,2 and Cause Rank of 1,1. Additional
suicides ranged from 29.7 to 50.5% and the percent of
agents implicated in the death are listed below the primary
pediatric cases has ranged from 0.8 to 3.18%. The relatively
agent in the order of their contribution to the fatality.
large changes seen for 2011, 2012 and 2017 reflects the large
As shown in Table 5, a single substance was implicated in
increase in indirect death reports in those years (e.g. 1,376
87.9% of reported human exposures, and 12.1% of patients
in 2017). Analyses of suicides and pediatric deaths for Direct
were exposed to 2 or more drugs or products. The exposure-
and Indirect reports are shown in Table 19B.
related fatalities involved a single substance in 598 cases
(43.1%), 2 substances in 327 cases (23.6%), 3 in 214 cases
Plant exposures (15.4%), and 4 or more in the balance of cases.
In Table 21 (Appendix D), the Annual Report ID number
Table 20 provides the number of times a specific plant was
[bracketed] indicates that the abstract for that case is included
reported to NPDS (N ¼ 46,782). The 25 most commonly
in Appendix C. The letters following the Annual Report ID
involved plant species and categories account for 40.6% of
number indicate: i ¼ Death, Indirect report (occurred in 1,294,
all reported plant exposures. Three of the top 5 categories in
48.25% of cases), p ¼ prehospital cardiac and/or respiratory
the table are essentially synonymous for unknown plant and
arrest (occurred in 560, 20.9% of cases), h ¼ hospital records
comprise 10.6% (4,951/46,782) of all plant exposures. For
reviewed (occurred in 1,007, 37.6% of cases), a ¼ autopsy report
a variety of reasons, it was not possible to make a precise
reviewed (occurred in 1,690, 63.0% of cases). The distribution of
identification in these 3 groups. The most frequent plant
NPDS RCF was: 1 ¼ Undoubtedly responsible in 1,397 cases
exposures where positive plant identification was made were
(52.1%), 2 ¼ Probably responsible in 982 cases (36.6%),
(descending order): Cherry (species unspecified), Phytolacca
3 ¼ Contributory in 303 cases (11.3%). The denominator for
americana, Spathiphyllum species, Ilex species, Malus species,
these Table 21 percentages is 2,682.
Solanum nigrum, and Caladium species.
Table 17G. Substance categories most frequently involved in pregnant exposuresa (Top 25).
Substance (Major Generic Category) All substances %b Single substance exposures %c
Analgesics 846 10.84 514 8.50
Cleaning Substances (Household) 660 8.46 485 8.02
Fumes/Gases/Vapors 539 6.91 503 8.32
Pesticides 505 6.47 479 7.92
Bites and Envenomations 375 4.80 337 5.57
Sedative/Hypnotics/Antipsychotics 296 3.79 139 2.30
Antidepressants 284 3.64 160 2.65
Antihistamines 282 3.61 181 2.99
Vitamins 275 3.52 217 3.59
Cosmetics/Personal Care Products 214 2.74 202 3.34
Chemicals 203 2.60 164 2.71
Foreign Bodies/Toys/Miscellaneous 203 2.60 191 3.16
Antimicrobials 199 2.55 157 2.60
Infectious and Toxin-Mediated Diseases 191 2.45 152 2.51
Hydrocarbons 180 2.31 174 2.88
Stimulants and Street Drugs 174 2.23 96 1.59
Hormones and Hormone Antagonists 155 1.99 139 2.30
Alcohols 132 1.69 53 0.88
Plants 131 1.68 117 1.93
Electrolytes and Minerals 122 1.56 88 1.46
Cold and Cough Preparations 117 1.50 79 1.31
Cardiovascular Drugs 115 1.47 66 1.09
Other/Unknown Nondrug Substances 114 1.46 103 1.70
Gastrointestinal Preparations 105 1.35 79 1.31
Paints and Stripping Agents 97 1.24 93 1.54
a
Includes all patient classified as pregnant and all female patients with a ‘duration of pregnancy’ greater than 0.
b
Percentages are based on the total number of substances reported in pregnant exposures (N ¼ 7,805).
c
Percentages are based on the total number of single substance pregnant exposures (N ¼ 6,047).
to 2016, with 71 cases representing 5.1% of fatalities. This (SSRIs). Note that Table 18 is sorted by all substances to
was an absolute decrease of 2 fatalities (2.74% decrease) in which a patient was exposed (i.e., a patient exposed to an
that age group. The age distribution of reported fatalities in opioid may have also been exposed to 1 or more other prod-
adults ( 20 years) was similar to prior years with 1,315 of ucts) and shows single substance exposures in the right-
1,388 (94.7%) fatal cases occurring in that age group actual hand column.
percent 2 (0.144%) occurring in Unknown Age patients. The first ranked substance (Appendix D, Table 21) was
While children 5 years old were involved in 45.2% of expo- a pharmaceutical in 2,314 (86.3%) of the 2,682 fatalities.
sures, the 12 deaths in this group comprised just 0.865% of These 2,314 first ranked pharmaceuticals included:
the exposure-related fatalities. The number of deaths in this 788 stimulants/street drugs (345 methamphetamine, 290 heroin,
age group decreased by 12 from 2016. Most (67.9%) of the 90 cocaine, 25 amphetamine, 10 methylenedioxymethamphe-
fatalities occurred in 20 to 59-year-old individuals, a slightly tamine (MDMA))
increased percentage from prior years. 778 analgesics (215 fentanyl, 116 acetaminophen, 94 oxycodone,
Table 21 (Appendix D) lists each of the 2,682 human fatal- 58 morphine, 56 methadone, 42 acetaminophen/hydrocodone, 30
ities (including death, indirect) along with all of the substan- salicylate, 27 acetaminophen/oxycodone, 25 narcotic, other/
ces involved for each case. Please note, the substance listed unknown, 21 tramadol, 14 carfentanil, 13 acetaminophen/
diphenhydramine, 10 hydrocodone, 10 hydromorphone)
in column 3 of Table 21 (alternate name) was chosen to be
the most specific generic name based upon the Micromedex 254 cardiovascular drugs (80 amlodipine, 28 metoprolol, 21
PoisindexV product name and generic code selected for that diltiazem, 17 digoxin, 17 verapamil, 12 diltiazem [extended
R
Table 18. Categories associated with largest number of fatalities (Top 25)a.
Substance (Minor Generic Category) All substances %b Single substance exposures %c
Miscellaneous Sedative/Hypnotics/Antipsychotics 404 12.38 14 2.34
Opioids 315 9.65 48 8.03
Miscellaneous Stimulants and Street Drugs 299 9.16 71 11.87
Miscellaneous Alcohols 202 6.19 15 2.51
Calcium Antagonist 170 5.21 31 5.18
Acetaminophen Combinations 142 4.35 28 4.68
Acetaminophen Alone 140 4.29 61 10.20
Beta Blockers 118 3.62 12 2.01
Miscellaneous Antidepressants 87 2.67 9 1.51
Miscellaneous Unknown Drug 87 2.67 26 4.35
Selective Serotonin Reuptake Inhibitors (SSRI) 84 2.57 1 0.17
Miscellaneous Antihistamines 82 2.51 14 2.34
Hypoglycemic, Single Agent 74 2.27 14 2.34
Tricyclic Antidepressants (TCA) 73 2.24 9 1.51
Miscellaneous Muscle Relaxants 72 2.21 11 1.84
Anticonvulsants: Gamma Aminobutyric Acid and Analogs 64 1.96 3 0.50
Miscellaneous Cardiovascular Drugs 60 1.84 17 2.84
Miscellaneous Fumes/Gases/Vapors 53 1.62 32 5.35
Acetylsalicylic Acid Alone 47 1.44 20 3.34
Miscellaneous Anticonvulsants 45 1.38 3 0.50
Nonsteroidal Antiinflammatory Drugs 42 1.29 6 1.00
Serotonin Norepinephrine Reuptake Inhibitors (SNRI) 40 1.23 2 0.33
Angiotensin Converting Enzyme Inhibitor 38 1.16 1 0.17
Cannabinoids and Analogs 37 1.13 2 0.33
Miscellaneous Chemicals 35 1.07 20 3.34
a
Numbers represent total exposures associated with 1,388 fatalities (with RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory); each
fatality may have had exposure to more than one substance.
b
Percentages are based on the total number of substances reported in fatal exposures (N ¼ 3,263).
c
Percentages are based on the total number of single substance fatal exposures (N ¼ 598).
methamphetamine, 32 methadone, 31 morphine (free), Route of exposure was: Ingestion only in 1,030 cases
27 amphetamine, 26 carboxyhemoglobin, 25 oxycodone, (38.4%), Inhalation/nasal in 118 cases (4.40%), and Parenteral
24 amlodipine, 21 7-aminoclonazepam, 20 morphine, 19 in 97 cases (3.62%). Parenteral only cases increased by 22.8%
gabapentin, 19 ethylene glycol, 18 cocaine, 18 bupropion, 17 from 2016. Most other exposures recorded a combination of
diphenhydramine, 17 methanol, 16 nortriptyline, 16 digoxin, routes or an unknown route.
and 16 clonazepam. The Intentional exposure reason was: Abuse in 1206
cases (45.0%), Suspected suicide in 829 cases (30.9%), Misuse
CLINICAL TOXICOLOGY 25
in 97 cases (3.62%), and Unknown in 89 cases (3.32%). Pediatric fatalities – age 5 years
Unintentional exposure reasons were: Environmental in 44 Although children younger than 6 years were involved in
cases (1.64%), General in 30 cases (1.12%), Therapeutic error 45.2% of exposures, they comprised only 25 (0.779%) of the
in 28 cases (1.04%), and Misuse in 27 cases (1.01%). Adverse 3,208 fatalities. These numbers are similar to those reported
drug reaction was the reason in 45 cases (1.68%). since 1985 (Table 19A, all RCFs and includes indirect deaths).
Table 8 (RCF 1, 2 or 3, excludes indirect deaths) shows the
percentage of fatalities in children 5 years related to total
Table 19A. Comparisons of death data (1985–2017)a. pediatric exposures was 12/956,871 (0.00125%). By compari-
Total fatalities Suicides Pediatric deathsb son, 1,315/836,306 (0.157%) of all adult exposures involved a
Year N % of cases N % of deaths N % of deaths fatality. Of the 12 pediatric fatalities in which reason for
1985 328 0.036 174 53.0 20 6.1 exposure was documented, 9 (75.0%) were reported as unin-
1986 406 0.037 223 54.9 15 3.7 tentional, 1 (8.3%) as unknown, 1 (8.3%) as other – malicious,
1987 398 0.034 227 57.0 22 5.5
1988 544 0.040 296 54.4 30 5.5 and 1 was coded as other – contamination/tampering (8.3%)
1989 590 0.037 323 54.7 24 4.1 (Table 8).
1990 553 0.032 320 57.9 21 3.8 The 14 fatalities in children 5 years detailed in Appendix
1991 764 0.042 408 53.4 44 5.8
1992 705 0.038 395 56.0 29 4.1 D (Table 21) (includes death, indirect reports and RCF 1-3)
1993 626 0.036 338 54.0 27 4.3 included 10 pharmaceuticals and 4 nonpharmaceuticals. The
1994 766 0.040 410 53.5 26 3.4
1995 724 0.036 405 55.9 20 2.8
first ranked substances associated with these fatalities
1996 726 0.034 358 49.3 29 4.0 included: analgesics (4), fumes/gases/vapors (2), batteries
1997 786 0.036 418 53.2 25 3.2 (disc/button; 1), deodorizers (1), antihistamines (1), cardiovas-
1998 775 0.035 421 54.3 16 2.1
1999 873 0.040 472 54.1 24 2.7
cular drugs (1), electrolytes and minerals (1), sedative/hyp-
2000 921 0.042 477 51.8 20 2.2 notics/antipsychotics (1), stimulants and street drugs (1), and
2001 1,085 0.048 553 51.0 27 2.5 unknown drug (1).
2002 1,170 0.049 635 54.3 27 2.3
2003 1,109 0.046 592 53.4 35 3.2
2004 1,190 0.049 642 53.9 27 2.3
2005 1,438 0.059 674 46.9 32 2.2 Pediatric fatalities – ages 6–12 years
2006 1,515 0.063 705 46.5 39 2.6 In the age range 6 to 12 years, 16 fatalities are listed in
2007 1,597 0.064 737 46.1 47 2.9
2008 1,756 0.070 797 45.4 39 2.2
Appendix D (Table 21) (includes death, indirect reports and
2009 1,544 0.062 779 50.5 37 2.4 RCF 1-3) included: fumes/gases/vapors (7), pesticides (3), anti-
2010 1,730 0.072 779 45.0 55 3.2 depressants (2), analgesics (1), anesthetics (1), cardiovascular
2011 2,765 0.118 865 31.3 42 1.5
2012 2,937 0.129 890 30.3 46 1.6
drugs (1) and sedative/hypnotics/antipsychotics (1). For those
2013 2,477 0.113 785 31.7 51 2.1 in whom reason for exposure was recorded, there were 13
2014 1,835 0.085 790 43.1 34 1.9 cases: 7 were unintentional – environmental, 3 were inten-
2015 1,831 0.084 814 44.5 42 2.3
2016 1,977 0.091 906 45.8 44 2.2 tional - suspected suicide, 2 were unknown reason, and 1
2017 3,208 0.151 954 29.7 25 0.8 was unintentional – therapeutic error (Table 8).
a
Human exposures with medical outcome of death or death, indirect regard-
less of RCF.
b
Includes all children with actual or estimated ages 5 years old. Results do Adolescent fatalities – ages 13–19 years
not include “Unknown Child” or “Unknown Age”. Includes death and death,
indirect regardless of RCF.
In the age range 13 to 19 years, there were 46 reported fatal-
ities with documented reason for exposure, an increase of 4
(9.52%) from 2016, and included 38 intentional, 3 uninten- 330,000 anomalies have been detected and reported. Close
tional, 3 unknown reason, 1 other, and 1 adverse reaction to 2,300 were confirmed as representing public health signifi-
(Table 8). The 84 fatalities listed in Appendix D (Table 21) cance with PCs working collaboratively with local health
(includes death, indirect reports and RCF 1-3) included 72 departments and, in some instances the CDC, on the identi-
pharmaceuticals and 12 nonpharmaceuticals. The first ranked fied issues.
pharmaceuticals associated with these fatalities included: At the time of this report, 583 surveillance definitions run
analgesics (32), stimulants and street drugs (12), antidepres- continuously, monitoring case and clinical effects volumes
sants (9), antihistamines (4), cardiovascular drugs (4), cold and a variety of case-based definitions from food poisoning
and cough preparations (2), hormones and hormone antago- to nerve agents. These definitions represent the surveillance
nists (2), sedative/hypnotics/antipsychotics (2), antimicrobials work by many PCs, health departments, the AAPCC, the
(1), dietary supplements/herbals/homeopathic (1), gastro- Health Studies Branch (Division of Environmental Hazards
intestinal preparations (1), narcotic antagonists (1) and and Health Effects, National Center for Environmental
unknown drug (1). The first ranked nonpharmaceutical associ- Health), and CDC. NPDS has also been used for surveillance
ated with these fatalities included: fumes/gases/vapors (4), during mass gathering events, such as the Super Bowl.
hydrocarbons (2), pesticides (2), alcohols (1), chemicals (1), The methodology for automating surveillance continues
plants (1), and tobacco/nicotine/e-cigarette products (1). to be improved in efforts to detect the index case of any
relevant public health event. Algorithms for identifying the
Pregnancy and fatalities index case vary greatly regarding the substance to be identi-
There were 2 deaths in pregnant women reported to NPDS fied. No individual algorithm works for every application [8].
in 2017. A total of 45 deaths of pregnant women have The magnitude and penetrance of NPDS are critical to
been reported between 2000 and 2017. The majority (37 of epidemiologic surveillance and to the ability to substantiate
45, 82.2%) were intentional exposures (misuse, abuse or situational awareness for clinicians, policymakers, and
suspected suicide). public health officials nationwide. Typically, NPDS surveillance
detects the response to an event, rather than predicting an
event. This fosters situational awareness and resilience during
AAPCC surveillance results and after a public health event. Situational awareness is
Key components of the NPDS surveillance system include the undoubtedly beneficial to public health surveillance.
automated monitoring tools available to the NPDS user com-
munity. In addition to AAPCC national surveillance defini- Discussion
tions, 30 PCs utilize NPDS as part of their surveillance
programs. The CDC, FDA, 6 state health departments, 1 The exposure cases and information requests reported by
county health department and 1 state police department run PCs in 2017 do not reflect the full extent of PC efforts, which
surveillance definitions in NPDS. Since Surveillance Anomaly also include poison prevention activities and public and
1, generated at 2:00 pm EDT on 17 September 2006, over health care professional education programs.
CLINICAL TOXICOLOGY 27
Figure 6. Deaths over time in the United States related to illicit use of drugs of abuse.
Source: CDC WONDER [7].
NPDS exposure data may be considered “numerator data” 5 years of age), increasing use of text rather than voice
in the absence of a true denominator; that is, we do not communication, and increasing use of and reliance on inter-
know the number of actual exposures that occur in the net resources. To meet our public health goals, PCs will need
population. NPDS data covers only those exposures which to understand and provide access via the public’s 21st
are reported to PCs since poison exposures and poisoning century communication preferences. We are concerned that
deaths are not currently reportable events. failure to respond to these changes may result in a retro-shift
NPDS 2000-2017 encounter volume data clearly demon- with more people seeking medical care at HCFs for
strate a continuing decrease in exposure cases. This decline exposures that could have been managed on-site by a PC.
has been apparent and increasing since mid-2007 and Likewise, minor exposures may progress to more serious
reflects the decreasing use of the PC for less serious expo- morbidity and mortality because of incorrect internet infor-
sures. However, during this same period, exposures with mation or the absence of PC management. The net effect
a more serious outcome (death, major, moderate) and HCF could be more serious poisoning outcomes because fewer
cases have continued to increase. Possible contributors to people took advantage of PC services, with a resultant
the declining PC utilization include: declining US birth rate increased burden on the national healthcare infrastructure as
(especially since exposure rates are much higher in children
28 D. D. GUMMIN ET AL.
may be reflected in the increased number of cases managed The Historical GC search, a newly available NPDS tool,
in a HCF this year. should facilitate the identification of new, potentially
NPDS statistical analyses indicate that all analgesic expo- harmful products.
sures, including opioids, and sedatives are increasing year
over year. This trend is shown in Table 17B and Figure 4. These data support the continued value of PC expertise
NPDS data mirrors CDC data that demonstrates similar find- and need for specialized medical toxicology information to
ings [9]. Thus NPDS provides a near real-time view of these manage the more severe exposures, despite a decrease in
public health issues without the need for data source cases involving less severe exposures. In addition to tele-
extrapolations. phonic services, PCs must consider newer communication
One of the limitations of NPDS data has been the per- approaches that match current, and future, public preferen-
ceived lack of fatality cases compared to other reporting ces. The continuing mission of NPDS is to provide a nation-
sources. However, when change over time is studied, NPDS is wide infrastructure for public health surveillance for all types
clearly consistent with other public health fatality analyses. of exposures, public health event identification, resilience,
One of the issues leading to this concern is the fact that response and situational awareness tracking. NPDS is a model
medical record systems seldom have common output system for the nation and global public health.
streams. This is particularly apparent with the various
electronic medical record systems available. It is important
Disclaimer
to build a federated approach similar to the one modeled
by NPDS to allow data sharing, for example, between The American Association of Poison Control Centers (AAPCC;
hospital emergency departments and other medical record http://www.aapcc.org) maintains the national database of
systems, including medical examiner offices, nationwide. information logged by the country’s regional Poison Centers
Enhancements to NPDS can promote interoperability (PCs) serving all 50 United States, Puerto Rico, and the
between NPDS and electronic medical records systems to District of Columbia. Case records in this database are from
better trend poison-related morbidity and mortality in the US self-reported encounters: they reflect only information pro-
and internationally. vided when the public or healthcare professionals report an
actual or potential exposure to a substance (e.g., an inges-
tion, inhalation, or topical exposure, etc.) or request informa-
Summary tion/educational materials. Exposures do not necessarily
Unintentional and intentional exposures continue to be represent a poisoning or overdose. The AAPCC is not able to
a significant cause of morbidity and mortality in the US. The verify the accuracy of every report made to member centers.
near real-time status of NPDS represents a national public Additional exposures may go unreported to PCs and data ref-
health resource to collect and monitor US exposure cases erenced from the AAPCC should not be construed to
and information contacts. represent the complete incidence of national exposures to
Changes in 2017 encounters are shown in Figures 1, 3, any substance(s).
and 4, and include:
Declaration of interest
Total encounters (all exposure and information contacts)
decreased by 3.79%. The authors report no declarations of interest.
All information contacts decreased 11.2%, Drug ID con-
tacts decreased 30.2%, and human exposures References
decreased 2.03%.
HCF information requests decreased 0.264% although [1] National Poison Data System: Annual reports 1983–2016
[Internet]. Alexandria (VA): American Association of Poison
managed exposure cases reported from an HCF increased
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Human exposures with less serious outcomes decreased [2] US Census Bureau: International Data Base (IDB) Mid-Year
2.57% while those with more serious outcomes (moder- Population by Single Year Age Groups – Custom Region
ate, major or death) increased 2.87% compared to an (American Samoa, Federated States of Micronesia, Guam, Puerto
Rico, United States, US Virgin Islands). Accessed at https://www.
overall 4.44% yearly increase since 2000.
census.gov/data-tools/demo/idb/informationGateway.php Sep 30,
The categories of substance exposures, resulting in more
2018.
serious outcomes, most rapidly increasing was sedative/ [3] Botticelli MP. National Drug Control Strategy. Executive office of
hypnotics/antipsychotics, followed by analgesics, antide- the President of the United States. Data Supplement, 2017.
pressants, and cardiovascular drugs. Accessed at https://obamawhitehouse.archives.gov/sites/default/
All 8 of the drugs of abuse examined under emerging files/ondcp/policy-and-research/2016_ndcs_data_supplement_
20170110.pdf Sep 30, 2018.
trends (cocaine, hallucinogenic amphetamines, heroin,
[4] US Department of State: Bureau for International Narcotics and
kratom, synthetic cathinones, synthetic opioids, and syn- Law Enforcement Affairs. International Narcotics Control Strategy
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weeks (ending 30-Jul-2018). March 2018, pg 16.
CLINICAL TOXICOLOGY 29
[5] American Academy of Clinical Toxicology; European Association California Poison Control System – Fresno/Madera Division
of Poisons Centres and Clinical Toxicologists. Position statement: Richard J. Geller, MD, MPH
ipecac syrup. J Toxicol Clin Toxicol. 1997;35:699–709. Rais Vohra, MD
[6] American Academy of Clinical Toxicology; European Association California Poison Control System – Sacramento Division
of Poisons Centres and Clinical Toxicologists. Position paper: ipe- Timothy Albertson, MD, PhD
cac syrup. J Toxicol Clin Toxicol. 2004;42: 133–143. Justin Lewis, PharmD, DABAT
[7] American Academy of Pediatrics Policy Statement. Poison treat- Kelly Owen, MD
ment in the home. Pediatrics. 2003;112:1182–1185. Jonathan Ford, MD
[8] Savel TG, Bronstein A, Duck M, et al. Using secure web services to Daniel Colby, MD
visualize poison center data for nationwide biosurveillance: a case James Chenoweth, MD
study. Online J Public Health Inform. 2010; 2:1–9. Accessed at California Poison Control System – San Diego Division
Richard F. Clark, MD
http://ojphi.org/article/view/2920/4722 Sep 30, 2018.
Lee Cantrell, PharmD, DABAT
[9] Overdose Death Rates. National Institute on Drug Abuse. Accessed
Adam Koch, MD
at https://www.drugabuse.gov/related-topics/trends-statistics/
Cliff Masom, MD
overdose-death-rates Sep 30, 2018.
Alicia Minns, MD
[10] Table SR12-1 Selected Examples of Laboratory Critical Values,
Matt Riddle, MD
Harrison’s Principles of Internal Medicine 20e. McGraw-Hill
Christie Sun, MD
Professional, 2018. Available from: http://www.accessmedicine.com/. California Poison Control System – San Francisco
[11] Goldfrank’s Toxicologic Emergencies, Tenth Edition, McGraw-Hill Raymond Ho, PharmD, DABAT
Companies, 2015. Robert Goodnough, MD
[12] Dart RC, editor. Medical Toxicology, Third Edition. Philadelphia, Susan Kim-Katz, PharmD
Lippincott, Williams & Wilkins, 2004. Kai Li, MD
Anita Ma, PharmD
Appendix A: Acknowledgments Beth Manning, PharmD
Kathryn Meier, PharmD, DABAT
The compilation of the data presented in this report was supported in Freda Rowley, PharmD
part through the US Centers for Disease Control and Prevention AAPCC Craig Smollin, MD
Cooperative Agreement 1UE1EH001314-02. Ben Tsutaoka, PharmD, DABAT
The authors wish to express their profound appreciation to the fol- Carolinas Poison Center
lowing individuals who assisted in the preparation of the manuscript: Michael C. Beuhler, MD
Katherine W. Dibert and Laura J. Rivers. Anna Rouse Dulaney, PharmD
The authors express their sincere gratitude to the staff at the AAPCC Dalia Alwasiyah, MD
Central Office for their support during the preparation of the manuscript: Christine M. Murphy, MD
Stephen Kaminski, JD, Executive Director, and the entire staff. Sara K. Lookabill, PharmD
Matt Stripp, MD
Poison centers (PCs) Kathy Kopec, DO
William Kerns II, MD
We gratefully acknowledge the extensive contributions of each partici- Central Ohio Poison Center
pating PC and the assistance of the many health care providers who Hannah L Hays, MD, FACEP
report comprehensive data to the PCs for inclusion in this database. We Jason Russell, DO
especially acknowledge the dedicated efforts of the Specialists in Poison Marcel J. Casavant, MD, FACEP, FACMT, FAACT
Information (SPIs) who meticulously managed and coded 2,607,413 Henry Spiller, MS, DABAT, FAACT
encounters at US PCs in 2017. Kimberly Smitley
As in previous years, the initial review of reported fatalities and Central Texas Poison Center
development of the abstracts and case data for NPDS was the responsi- Ryan Morrissey, MD
bility of the staff at the 55 participating PCs. Many individuals at each S. David Baker, PharmD, DABAT
center participated in the fatality case preparation. These toxicology pro- Children’s Hospital of MI Regional Poison Center
fessionals and their centers are: Cynthia Aaron, MD
Lydia Baltarowich, MD
Arizona Poison and Drug Information Center Mirjana Dimovska, MD
Keith J. Boesen, PharmD, CSPI, FAzPA Bram Dolcourt, MD
F. Mazda Shirazi, MS, MD, PhD, FACEP, FAMCT Matthew Hedge, MD
Nicholas B. Hurst, MD, MS Andrew King, MD
Denise Holzman, PharmD, CSPI Denise Kolakowski
Matthew Andrews, PharmD Keenan Bora, MD
Steven Dudley, PharmD Eric Malone, MD
Arkansas Poison & Drug Information Center Luke Bisoski, MD
Henry F. Simmons, Jr., MD Cincinnati Drug and Poison Information Center
Pamala R. Rossi, PharmD Shan Yin, MD, MPH
Howell Foster, PharmD, DABAT Sara Pinkston, RN, CSPI
Banner Poison & Drug Information Center Deborah Donald, RN, CSPI
Daniel Brooks, MD Shannon Staton-Growcock, RN, CSPI
Rebecca Hilder, RN, CSPI Connecticut Poison Center
Maureen Roland, RN, CSPI Suzanne Doyon, MD, MPH
Belinda Sawyers, RN, CSPI Dana Bartlett, MSN, MA, CSPI
Kim Schmid, MSN, CSPI Florida/USVI Poison Information Center – Jacksonville
Daniel Thole RN, CSPI Thomas Kunisaki, MD, FACEP, ACMT
Blue Ridge Poison Center Florida Poison Information Center – Miami
Christopher P. Holstege, MD Jeffrey N. Bernstein, MD
Jennifer R Horn, BSN Richard S. Weisman, PharmD
30 D. D. GUMMIN ET AL.
Florida Poison Information Center – Tampa Mississippi Poison Control Center Regina R. Padilla
Tamas Peredy, MD, FAACT, FACMT Tanya Calcote, RN, CSPI Caitlin Bonney, MD
Alfred Aleguas, PharmD, DABAT, FAACT Robert Cox MD, PhD, DABT, FACMT Nick Brandehoff, MD
Szilvia Boos, PharmD, CSPI Missouri Poison Center at SSM Health Keith Baker, MD
Kiet Ngo, PharmD, CSPI Cardinal Glennon Children’s Hospital Michael Marlin, MD
Maria T Reyes, RN, CSPI Rebecca Tominack, MD Thomas Nappe, MD
Judy Turner, RN, CSPI Theresa Matoushek, PharmD, CSPI Patrick Ng, MD
Charisse Webb, RN, CSPI National Capital Poison Center Jonathan Schimmel, MD
Georgia Poison Center Cathleen Clancy, MD, FACMT South Texas Poison Center
Brent W. Morgan, MD Nicole Reid, BSN, MEd, CSPI, DABAT Veronica Stoller, MPA
Robert J. Geller, MD Nebraska Regional Poison Center Rick Hernandez, MD, RN, CSPI
Ziad Kazzi, MD Ronald I. Kirschner, MD Alfredo Gonzalez, DNP, MSN, RN, CSPI
Gaylord P. Lopez, PharmD New Jersey Poison Information and Darelle Hinson, MSN, RN, CSPI
Stephanie Hon, PharmD Education System Maria Hinojosa, PharmD, CSPI
Alaina Steck, MD Bruce Ruck, PharmD Robert Miller, PharmD, CSPI
Ezaldeen Numur, MD Diane P. Calello, MD Vivian Rivera, RN, CSPI
Jessica Weiland, MD New Mexico Poison and Drug Cynthia Teter, PharmD, CSPI
Cynthia Santos, MD Information Center Douglas Cobb, RPh, CSPI
Lindsay Schaack, PharmD Steven A. Seifert, MD, FAACT, FACMT George Layton, MD, CSPI
Sara Miller, PharmD Brandon J. Warrick, MD Shawn Varney, MD, FACEP, FACMT
Alexandra King, PharmD Susan C. Smolinske, PharmD, DABAT, FAAC Southeast Texas Poison Center
Diane Hindman, MD New York City Poison Control Center Wayne R. Snodgrass, MD, PhD, FACMT
Tharwat El-Zahran, MD Maria Mercurio-Zappala, MS, RPh Jean L. Cleary, PharmD, CSPI
Samuel A. Ralston, DO Mark K Su, MD, MPH Tennessee Poison Center
Joseph Carpenter, MD Stephen Alex Harding. MD Donna Seger, MD
Brian P. Murray, DO Jonathan De Olano, MD Nena Bowman, PharmD, DABAT
Camille Dunkley, MD Elie Harmouche. MD Denese Britt, MS, BSN, CSPI
Illinois Poison Center Madeline Renny, MD Justin Loden, PharmD, CSPI
Michael Wahl, MD North Texas Poison Center Texas Panhandle Poison Center
Sean Bryant, MD Kelly Hogue, RN, MSN Cristie Johnston, RN, CSPI
Indiana Poison Center Brett Roth MD, ACMT, FACMT Thomas Martin, MD
Gwenn Christianson, MSN, CSPI Donna Abron, RN, BSN, CSPI Jeanie E. Jaramillo, PharmD
Adam Overberg, PharmD Anelle Menendez, CSPI The Poison Control Center at the
Daniel E. Rusyniak, MD Melody Gardner, MSN, MHA Children’s Hospital of Philadelphia
Blake Froberg, MD Northern New England Poison Center Fred Henretig, MD
James B. Mowry, PharmD Karen E. Simone, PharmD, DABAT, FAACT Kevin Osterhoudt, MD, MSCE, FAAP,
Iowa Poison Control Center Tammi H. Schaeffer, DO, FACEP, FACMT FAACT, FACMT
Sue Ringling, RN, CSPI Oklahoma Poison Control Center Jeanette Trella, PharmD, BCPPS
Linda B. Kalin, RN, CSPI William Banner, Jr., MD, PhD, ABMT The University of Kansas Health System
Edward Bottei, MD Scott Schaeffer, RPh, DABAT Poison Control Center
Kentucky Regional Poison Control Center Oregon Poison Center Tama Sawyer, PharmD, DABAT
George M. Bosse, MD Zane Horowitz, MD Stephen Thornton, MD
Ashley N. Webb, MSc, PharmD, DABAT Sandra L. Giffin, RN, MS Upstate NY Poison Center
Louisiana Poison Center Palmetto Poison Center Brett Cherrington, MD
Mark Ryan, PharmD William H. Richardson, MD Jeanna M. Marraffa, PharmD
Thomas Arnold, MD Jill E. Michels, PharmD Christine M. Stork, PharmD
Maryland Poison Center Lewis S. Hardison, DO William Eggleston, PharmD
Hong Kim, MD Pittsburgh Poison Center Utah Poison Control Center
Lisa Booze, PharmD, CSPI Michael Lynch, MD B. Zane Horowitz, MD
Jacquelyn Goodrich, BSN, CSPI Amanda Korenoski, PharmD, MHA Virginia Poison Center
Angel Bivens, RPh, CSPI Puerto Rico Poison Center S. Rutherfoord Rose, PharmD
Kevin Simmons, BSN, CSPI Jose Eric D^ıaz-Alcala, MD Kirk Cumpston, DO
Eric Schuetz, BSPharm, CSPI Andres Britt, MD Brandon Wills, DO
Lisa Aukland, PharmD, CSPI Elba Hernandez, RN Michelle Troendle, MD
Michael Hiotis, BSPharm, CSPI Regional Center for Poison Control and Washington Poison Center
Michael Joines, BSPharm, CSPI Prevention Serving Massachusetts and Erica L. Liebelt MD
Randall Goldberg, RN, CSPI Rhode Island Curtis Elko PharmD
Denise Couch, BSN, CSPI Michele M. Burns, MD, MPH David Serafin
Jeanne Wunderer, RPh, CSPI Rebecca E. Bruccoleri, MD West Texas Regional Poison Center
Jennifer Malloy, PharmD, CSPI Takuyo Chiba, MD Hector L. Rivera, RPh, CSPI
Laura Hignutt, PharmD, CSPI Regional Poison Control Center – Children’s Stephen W. Borron, MD, MS, FACEP, FACMT
Christopher Wolff, PharmD, CSPI of Alabama Salvador H. Baeza, PharmD, DABAT
Elizabeth Millwee, RN, CSPI Justin Arnold, DO, MPH West Virginia Poison Center
Minnesota Poison Control System Sherrel Kirkland, RN, CSPI Mike Abesamis, MD, ABEM-MT
Deborah L. Anderson, PharmD LaDonna Gaines, RN, CSPI Elizabeth J. Scharman, PharmD, DABAT,
Jon B. Cole, MD Janet Fowler, RN, CSPI BCPS, FAACT
Samantha Lee, PharmD, DABAT Rocky Mountain Poison & Drug Center Wisconsin Poison Center
Ben Orozco, MD Shireen Banerji, PharmD, DABAT David D. Gummin, MD
Jill Topeff, PharmD, CSPI Christopher Hoyte, MD Jillian L. Theobald, MD, PhD
Laurie Willhite, PharmD, CSPI Carol Hesse RN, CSPI Amy E. Zosel, MD
CLINICAL TOXICOLOGY 31
AAPCC fatality review team Robert Goetz, PharmD, DABAT, Cincinnati Drug and Poison Information
Center, Cincinnati, OH
The Lead and Peer review of the 2017 fatalities was carried out by the Ron Kirschner, MD, Nebraska Regional Poison Center, Omaha, NE
47 individuals listed here including 6 who reviewed the pediatric cases Salvador Baeza, PharmD, DABAT, West Texas Regional Poison Center, El
[Peds]. The authors and the AAPCC wish to express our appreciation for Paso, TX
their volunteerism, dedication, hard work and good will in completing Sara Miller, PharmD, DABAT, Grady Health System, Atlanta, GA
this task in a limited time. Serena Huntington, PharmD, CSPI, California Poison Control System-
Madera, Madera, CA
Alexandra King, PharmD, DABAT, Georgia Poison Center, Atlanta, GA Sophia Sheikh, MD, Department of Emergency Medicine, University of
Alfred Aleguas Jr†, PharmD, DABAT, FAACT, Florida Poison Information Florida College of Medicine-Jacksonville, Jacksonville, FL
Center, Tampa, FL Stephanie Hon, PharmD, DABAT, Georgia Poison Center, Atlanta, GA
Alice Lugo, PharmD, CSPI, California Poison Control System-Sacramento, Steven M Marcus, MD, Newark, NJ [Peds]
Sacramento, CA Susan Smolinske†, PharmD, New Mexico Poison Center, Albuquerque, NM
Amberly R. Johnson, PharmD, DABAT, Utah Poison Control Center, Timothy Wiegand, MD, University of Rochester, Medical Center and
Salt Lake City, UT Strong Memorial Hospital; SUNY Upstate Poison Center
Anna Rouse Dulaney, PharmD, DABAT, FAACT, Carolinas Poison Center,
Charlotte, NC [Peds] † These reviewers served as associate managers during final review
Annette Lopez, MD, Oregon Poison Center, Portland, OR wrap up.
Ann-Jeannette Geib, MD, FACEP, FACMT, Rutgers Robert Wood Johnson These reviewers further volunteered to read the top ranked 200
Medical School, New Brunswick, NJ abstracts and judged to publish or not publish each.
Bernard C Sangalli, MS, DABAT, Connecticut Poison Center, Farmington, CT
Christine Murphy, MD, Carolinas Medical Center, Charlotte, NC [Peds]
Curtis Elko†, PharmD, CSPI, Washington Poison Center, Seattle, WA AAPCC NPDS steering committee
Denese Britt †, MS, BSN, CSPI, Tennessee Poison Center,
Nashville, TN Chair: David D. Gummin, MD
Diane Calello, MD, FAAP, FACMT, New Jersey Poison Information and James B. Mowry, PharmD, DABAT, FAACT, DPNAP
Education System, Newark, NJ [Peds] Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT
Ed Bottei, MD, Iowa Statewide Poison Control Center, Sioux City, IA Jonathan Colvin, MS, BSN, CSPI
Elizabeth Hines, MD, Clinical Fellow, Medical Toxicology, NYU School Alvin C. Bronstein, MD, FACEP, FACMT
of Medicine, NY, NY
Elizabeth J Scharman, PharmD, DABAT, BCPS, FAACT, West Virginia
Poison Center, Charleston, WV AAPCC micromedex joint coding group
Frank LoVecchio, DO, Banner Poison and Drug and Information Center,
Phoenix, AZ Chair: Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT
Gar Chan, MD, FACEM, Calvary Hospital, Lenah Valley, Tasmania, Australia Alvin C. Bronstein, MD, FACEP, FACMT
Hannah Hays, MD, FACEP, Central Ohio Poison Center, Columbus, OH Anna Rouse Dulaney, PharmD, DABAT, FAACT
Henry Spiller, MS, DABAT, FAACT, Central Ohio Poison Center, Sandy Giffin, RN, MS
Columbus OH Susan C. Smolinske, PharmD, DABAT, FAACT
Jan Scaglione, PharmD, DABAT, Cincinnati Drug and Poison Information
Center, Cincinnati, OH
Jeffrey S Fine, MD, NYU School of Medicine/Perelman Emergency AAPCC rapid coding team
Department/Bellevue Hospital Center, New York, NY [Peds]
Jennifer Lowry, MD, Division of Clinical Pharmacology, Toxicology, and Chair: Alvin C. Bronstein, MD, FACEP, FACMT
Therapeutic Innovations, Children’s Mercy Hospital, Kansas City, MO [Peds] Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT
Jill E Michels, PharmD, DABAT, Palmetto Poison Center, Columbia, SC Jay L. Schauben, PharmD, DABAT, FAACT
Justin Lewis, PharmD, DABAT, California Poison Control System- Susan C. Smolinske, PharmD, DABAT, FAACT
Sacramento, Sacramento, CA
Justin Loden, PharmD, CSPI, Tennessee Poison Center, Vanderbilt
University Medical Center, Nashville, TN AAPCC surveillance team
Kaitlyn Brown, PharmD, DABAT, Utah Poison Control Center, Salt Lake
NPDS surveillance anomalies are analyzed daily by a team of 10 medical
City, UT
and clinical toxicologists working across the country in a distributed sys-
Lindsay Schaack Rothstein, PharmD, DABAT, Georgia Poison Center,
Atlanta, GA tem. These dedicated professionals interface with the Health Studies
Maria Mercurio-Zappala, RPh, MS, DABAT, FAACT, New York City Poison Branch, National Center for Environmental Health, Centers for Disease
Control Center, New York, NY Control and Prevention (HSB/NCEH/CDC) and the PCs on a regular basis
Mark J. Neavyn, MD, Division of Medical Toxicology, UMass Memorial to identify anomalies of public health significance and improve NPDS
Medical Center, Worcester, MA surveillance systems:
Mark Su, MD, MPH, FACEP, FACMT, New York City Poison Control Center, Alvin C. Bronstein, MD, FACEP, FACMT - Director
New York, NY Alfred Aleguas, PharmD, DABAT
Michael Levine, MD, Banner Good Samaritan Medical Center, Phoenix, Douglas J. Borys, PharmD, DABAT
AZ; University of Southern California, Los Angeles, CA John Fisher, PharmD, DABAT, FAACT
Nathanael McKeown†, DO, Oregon Poison Center, Portland, OR Jeanna M. Marraffa, PharmD, DABAT
Nena Bowman, PharmD, DABAT, Tennessee Poison Center Maria Mercurio-Zappala, RPH, MS, DABAT, FAACT
Nima Majlesi, DO, Staten Island University Hospital, NY Henry A. Spiller, MS, DABAT, FAACT
Paul Starr, PharmD, DABAT, Sykesville, MD Richard G. Thomas, PharmD, DABAT
Rachel Gorodetsky, PharmD, DABAT, Upstate New York Poison Center,
Syracuse, NY
Rachel Schult, PharmD, DABAT, Upstate New York Poison Center, Regional poison center fatality awards
Syracuse, NY
Each year the AAPCC and the Fatality Review team recognizes several
regional PCs for their extra effort in their preparation of fatality reports
32 D. D. GUMMIN ET AL.
and prompt responses to reviewer queries. The awards are presented Contaminant/tampering: The patient is an unintentional victim of a sub-
each year at the North American Congress of Clinical Toxicology stance that has been adulterated (either maliciously or unintention-
Annual meeting. ally) by the introduction of an undesirable substance.
Malicious: Patients who are victims of another person’s intent to
First Center to Complete all Cases (12/15/17, 21 cases): Utah Poison harm them.
Control Center (Salt Lake City) Withdrawal: Inquiry about or experiencing of symptoms from a decline
Largest Number with Autopsy Reports (52 of 72 cases; 72%): Carolinas in blood concentration of a pharmaceutical or other substance after
Poison Center (Charlotte) discontinuing therapeutic use or abuse of that substance.
Highest Percentage with Autopsy Reports (79% of 39 cases): Banner Adverse Reaction Drug: Unwanted effects due to an allergic, hyper-
Poison Control Center (Phoenix) sensitivity, or idiosyncratic response to the active ingredient(s),
Largest Number of Indirect cases (n ¼ 1226; 96% of all Indirect cases): inactive ingredient(s) or excipient of a drug, chemical, or other drug
Banner Poison Control Center (Phoenix) substance when the exposure involves the normal, prescribed, labeled
Highest Overall Quality of Reports (5.38 out of possible 12 for 29 cases): or recommended use of the substance.
Wisconsin Poison Center (Milwaukee) Adverse Reaction Food: Unwanted effects due to an allergic, hypersensi-
Greatest improvement in Overall Quality of Reports (1.69 increase from tivity, or idiosyncratic response to a food substance.
last year) :West Virginia Poison Center (Charleston) Adverse Reaction Other: Unwanted effects due to an allergic, hyper-
Most Abstracts Published in the 2017 Annual report (5 of the 57 pub- sensitivity, or idiosyncratic response to a substance other than drug
lished narratives): Carolinas Poison Center (Charlotte) or food.
Most Helpful Regional Poison Center Staff (based on survey of AAPCC Unknown Reason: Reason for the exposure cannot be determined or no
review team): Washington Poison Center (Seattle) other category is appropriate.
Honorable mention: Wisconsin Poison Center (Milwaukee)
Endurance Award (consistently great cases with the most autopsies and
most published abstracts for the last 6 years): Carolinas Poison Medical outcome
Center (Charlotte)
No effect: The patient did not develop any signs or symptoms as a result
of the exposure.
Appendix B: Data definitions Minor effect: The patient developed some signs or symptoms as a result
of the exposure, but they were minimally bothersome and generally
Reason for exposure resolved rapidly with no residual disability or disfigurement. A minor
effect is often limited to the skin or mucus membranes (e.g., self-
NPDS classifies all encounters as either EXPOSURE (concern about an limited gastrointestinal symptoms, drowsiness, skin irritation, first-
exposure to a substance) or INFORMATION (no exposed human or ani- degree dermal burn, sinus tachycardia without hypotension, and
mal). A contact may provide information about one or more exposed transient cough).
person or animal (receptors). Moderate effect: The patient exhibited signs or symptoms as a result of
SPIs coded the reasons for exposure reported by callers to PCs
the exposure that were more pronounced, more prolonged, or more
according to the following definitions:
systemic in nature than minor symptoms. Usually, some form of treat-
Unintentional general: All unintentional exposures not otherwise ment is indicated. Symptoms were not life-threatening, and the
defined below. patient had no residual disability or disfigurement (e.g., corneal abra-
Environmental: Any passive, non-occupational exposure that results from
sion, acid-base disturbance, high fever, disorientation, hypotension
contamination of air, water, or soil. Environmental exposures are usu-
that is rapidly responsive to treatment, and isolated brief seizures that
ally caused by manmade contaminants.
respond readily to treatment).
Occupational: An exposure that occurs as a direct result of the person
Major effect: The patient exhibited signs or symptoms as a result of the
being on the job or in the workplace.
exposure that were life-threatening or resulted in significant residual
Therapeutic error: An unintentional deviation from a proper therapeutic
disability or disfigurement (e.g., repeated seizures or status epilepticus,
regimen that results in the wrong dose, incorrect route of administra-
respiratory compromise requiring intubation, ventricular tachycardia
tion, administration to the wrong person, or administration of the
with hypotension, cardiac or respiratory arrest, esophageal stricture,
wrong substance. Only exposures to medications or products used as
medications are included. Drug interactions resulting from uninten- and disseminated intravascular coagulation).
Death: The patient died as a result of the exposure or as a direct compli-
tional administration of drugs or foods which are known to interact
are also included. cation of the exposure.
Unintentional misuse: Unintentional, improper or incorrect use of Not followed, judged as nontoxic exposure: No follow-up calls were
a nonpharmaceutical substance. Unintentional misuse differs from made to determine the outcome of the exposure because the sub-
intentional misuse in that the exposure was unplanned or not fore- stance implicated was nontoxic, the amount implicated was insignifi-
seen by the patient. cant, or the route of exposure was unlikely to result in a
Bite/sting: All animal bites and stings, with or without envenomation, clinical effect.
are included. Not followed, minimal clinical effects possible: No follow-up calls were
Food poisoning: Suspected or confirmed food poisoning; ingestion made to determine the patient’s outcome because the exposure was
of food contaminated with microorganisms is included. likely to result in only minimal toxicity of a trivial nature. (The patient
Unintentional unknown: An exposure determined to be unintentional, was expected to experience no more than a minor effect.).
but the exact reason is unknown. Unable to follow, judged as a potentially toxic exposure: The patient was
Suspected suicidal: An exposure resulting from the inappropriate use of lost to follow-up, refused follow-up, or was not followed, but the
a substance for reasons that are suspected to be self-destructive or exposure was significant and may have resulted in a moderate, major,
manipulative. or fatal outcome.
Intentional misuse: An exposure resulting from the intentional improper Unrelated effect: The exposure was probably not responsible for
or incorrect use for reasons other than the pursuit of a psycho- the effect.
tropic effect. Confirmed nonexposure: This outcome option was coded to designate
Intentional abuse: An exposure resulting from the intentional improper cases where there was reliable and objective evidence that an expos-
or incorrect use where the patient was likely attempting to gain ure initially believed to have occurred actually never occurred (e.g., all
a high, euphoric effect or some other psychotropic effect, including missing pills are later located). All cases coded as confirmed nonexpo-
recreational use of a substance for any effect. sure are excluded from this report.
CLINICAL TOXICOLOGY 33
Death, indirect report: Death, indirect report are deaths that the poison Abstracts
center acquired from medical examiner or media, but did not
manage nor answer any questions about the death. Abstracts of the cases were selected (see Selection of Abstracts for
Publication, above) from the human fatalities judged related to an
exposure as reported to US PCs in 2017. A structured format for
Relative contribution to fatality (RCF) abstracts was required in the PC preparation of the abstracts and was
used in the abstracts presented. Abbreviations, units and normal ranges
The Case Review Team (CRT) includes the Author and Reviewer from the omitted from the abstracts are given at the end of this appendix.
RPC, The AAPCC Lead Reviewer, Peer Reviewer and Manager.
The definitions used for the Relative Contribution to Fatality (RCF) Case 133. Acute hydrofluoric acid ingestion: undoubtedly
classification were as follows: responsible
Scenario/Substances: A 53y/o developmentally delayed male was
1. Undoubtedly responsible: In the opinion of the CRT the Clinical Case doing glass etching in a workshop when he swallowed 3 oz of glass
Evidence establishes beyond a reasonable doubt that the etching cream containing ammonium bifluoride and hydrofluoric acid.
SUBSTANCES actually caused the death. He vomited within 15 min and was transported to the ED.
2. Probably responsible: In the opinion of the CRT the Clinical Case Past Medical History: Developmental delay, deaf, mute, history of pica,
Evidence suggests that the SUBSTANCES caused the death, but seizures, hypothyroidism.
some reasonable doubt remained. Physical Exam: In the ED he was alert but vomiting; BP 126/91, HR 86,
3. Contributory: In the opinion of the CRT the Clinical Case Evidence RR 18, T 37 C, O2 sat 94% (RA).
establishes that the SUBSTANCES contributed to the death, but did Laboratory/Diagnostic Findings: Na 146/K 5.2/Cl 112/CO2 17/BUN 12/
not solely cause the death. That is, the SUBSTANCES alone would Cr 1.68/Glu 215, AG 217. ABG- pH 7.09. Mg 1.7, Ca 6.9, Ca (ionized) 2.1,
not have caused the death, but combined with other factors, were troponin 2.67 (peak 89.5). ECHO: severely reduced RV systolic function;
partially responsible for the death. LV ejection fraction was25-30%. ECG: new RBBB and prolonged QTc.
4. Probably not responsible: In the opinion of the CRT the Clinical Case Clinical Course: Attempt to place an NG failed due to patient agita-
Evidence establishes to a reasonable probability, but not conclu- tion. One h later he was sedated with haloperidol, lorazepam and
sively, that the SUBSTANCES associated with the death did not cause diphenhydramine and an NGT was placed with clear aspirate obtained.
the death He was then intubated for respiratory distress and became hypotensive.
5. Clearly not responsible: In the opinion of the CRT the Clinical Case EKG: QRS widening with a new RBBB. He received Ca (4 g) and Mg (4 g),
Evidence establishes beyond a reasonable doubt that the sodium bicarbonate and norepinephrine drips; BP 73/56, HR 111.
SUBSTANCES did not cause this death. Endoscopy was not performed because of concern for esophageal per-
6. Unknown: In the opinion of the CRT the Clinical Case Evidence is foration and hemodynamic instability. Ceftriaxone and omeprazole were
insufficient to impute or refute a causative relationship for the administered. CT chest: negative for perforation, airspace disease and
SUBSTANCES in this death. multiple air fluid levels in the gut. Patient remained hypotensive at 60/
40, HR 122. Ca <5 despite 12g of Ca. He had a VF cardiac arrest and
died, despite resuscitation efforts, 10 h after ED arrival.
Appendix C: Abstracts of selected cases Autopsy Findings: Cause of death: alkalinizing (barium-containing) tox-
icity; manner of death: accidental. Esophageal and gastric hemorrhage
Selection of abstracts for publication and perforations; barium staining of the peritoneum and mediastinum;
microscopic evidence of myocardial infarction. Toxicologic report: barium
The abstracts included in Appendix C were selected for publication in
in gastric contents and peripheral blood. [MSDS: product contained 1-2%
a 3-stage process consisting of qualifying, ranking, and reading. Changes
hydrofluoric acid, 21-27% ammonium bifluoride and a small amount of
in place since the 2014 report for the selection of the top 200 cases:
barium sulfate. The PCC contacted the ME office and provided product
include all pregnant subjects, include all children (0-2 y/o) subjects,
information and that the death was likely due to hydrofluoric acid/
increase (double) the weight on the autopsy report, add a weighting
ammonium bifluoride toxicity; their report was not edited.]
for Age of subject (1/age in years), add a weighting for infrequency of
substance category (Generic Code).
Qualifying cases were thus: Age 0-2 y/o, Pregnant, or RCF ¼ Case 136. Acute methanol ingestion: undoubtedly responsible
1-Undoubtedly Responsible, 2-Probably Responsible or 3-Contributory. Scenario/Substances: A 35 y/o male ingested 1 gallon of windshield
Fatalities by Indirect report were excluded beginning with the 2008 deicer over the course of the day.
annual report. The ranking was based on Final Case Weighting (FCW). Past Medical History: Alcoholism.
Physical Exam: Unresponsive; SBP 170s, HR 120s, T 101 F.
FCW ¼ f ½1=ðnum substances in this caseÞ; WCS; 1=Age ðyearsÞ; Laboratory/Diagnostic Findings: ABG- pH 7.1/pCO2 13/pO2 227. Na
1=ðnum cases in that generic code this yearÞ 140/K 4.9/Cl 100/CO2 < 5/BUN 19/Cr 1.27/Glu 132/AG >35. AST 192, ALT
Where: 200, INR 1.0; WBC 4.8/Hgb 16.5. Serum osmolality >500, methanol:
Weighted Case Score ðWCSÞ ¼ 620 mg/dL. Serum ethylene glycol, APAP, ethanol and salicylate not
Hospital records 8:8 þ Postmortem 15:2 detected. UDS was negative.
þ Blood levels 6:9 þ Quality=Completeness 6:4 Clinical Course: He was intubated in the ED, given metoprolol and
þ Novelty=Educational value 13:2 started on fomepizole. HD was initiated within 4 h; repeat methanol lev-
WCS Scores were normalized (z-score) within each AAPCC els were 57, 19 and then 11 mg/dL. CT head showed infarcted basal gan-
reviewer before the final weighting: 25% for each (1/ glia and diffuse cerebral edema. EEG showed suppressed brainwave
NumSubstances, WCS, 1/Age, 1/NumCodes). activity. Diabetes insipidus with polyuria developed with hypotension
The WCS weighting factors were the averages of review team recom- requiring multiple vasopressors. Cerebral perfusion scan showed absent
mendations gathered in 2006. intracranial blood flow. Based on the prognosis, the family opted for
The top ranked abstracts (200 þ ties) were each read by individual institution of comfort measures and he died on Day 7.
reviewers who volunteered (See Appendix A) and the 2 managers (DAS Autopsy Findings: No autopsy results were provided.
and DEB). Each reader judged each abstract as “publish” or “omit” and
all abstracts receiving 8 or more of 12 publish votes were selected, fur- Case 150. Acute Disc battery, ingestion: undoubtedly responsible
ther edited, cross-reviewed by the 2 managers and JBM, and published Scenario/Substances: A 2 y/o female ingested a button battery
in this report. 36 h prior.
34 D. D. GUMMIN ET AL.
Clinical Course: She presented at the ED following an episode of Past Medical History: Alcoholism.
hematemesis at home. CxR: battery was in the esophagus. Endoscopic Physical Exam: HR 100, RR 18, T 36 C; alert but confused, GCS 14. Full
retrieval was unsuccessful, the child exsanguinated and died. thickness burns to back and all extremities.
Autopsy Findings: No autopsy results were provided. Laboratory/Diagnostic Findings: WBC 7.4/Hgb 13.9/Hct 41.5%/PLT 117.
CT head: unremarkable.
Case 151. Acute Crotalinae envenomation: undoubtedly responsible Clinical Course: On Day 2 he developed alcohol withdrawal and was
Scenario/Substances: A 29 y/o male was bitten on the forearm by an treated with benzodiazepines and oral alcohol. Nutrition and burn care
unknown snake. were initiated; skin grafts were performed. On Day 14 he developed
Physical Exam: 2 noticeable puncture wounds were visible on the tachydysrhythmias (ST, AF, SVT) and was treated with adenosine, meto-
forearm with edema to his axilla. He complained of abdominal pain. prolol and amiodarone. On Day 29 he required intubation and norepin-
Clinical Course: At Day 2 he developed rhabdomyolysis and hemocon- ephrine for presumed sepsis. Based on the prognosis, comfort measures
centration; INR 1.4, CK 30,000, WBC 50/Hgb 21/PLT 162.Swelling did not were instituted and he died on Day40.
improve with the initial 6 vials of Fab antivenom, INR increased to 1.7. Autopsy Findings: Not performed.
Pulses were only detectable on Doppler. Extremity was elevated, cortico-
steroids and another 6 vials of antivenom were given but the edema Case 156. Acute silicone parenteral: undoubtedly responsible
progressed into his torso and back. Urine output decreased. WBC 56/ Scenario/substance: A 19 y/o female injected silicone into her but-
Hgb 22/Hct 65.1/PLT 15, CK 6,604, INR 2.3, PTT 38.9, lactate 3.48. CxR: tocks 3 d prior to hospital admission.
pulmonary edema. The patient was intubated, 12 more vials of anti- Past Medical History: Cocaine abuse, transgender on estro-
venom were given and CRRT was initiated. On Day 2: PT 13.3, PTT 43.5, gen therapy.
fibrinogen 159, PLT 100, BUN 24, Cr 3.3; FFP was given. On Day3: INR Physical Exam: Palpable injection sites. BP 73/46, HR 132, RR 40s.
2.1, PTT >200, PLT 92, ABG- pH 6.93/pCO2 23/HCO3 5. He continued to Laboratory/Diagnostic Findings: Na 146/K 4.2/Cl 104/CO2 15/BUN 14/
deteriorate and died on Day 3. Cr 1.7, AST 3,317, ALT 2,741. ECG: HR 136, QRS 79, QTc 440.
Autopsy Findings: No autopsy results were provided. Clinical Course: Patient was admitted for possible alcohol withdrawal
but then had ‘bleeding’ and two cardiac arrests. She was intubated and
Case 152. Acute Crotalinae envenomation: undoubtedly responsible developed right ventricular strain, ARDS, diffuse alveolar hemorrhage
Scenario/Substances: 31 y/o male was hiking when he was bitten and multiple seizures. She was treated with levetiracetam and albumin
by a rattlesnake on his left leg. He rapidly developed dyspnea with and started on norepinephrine, vasopressin and sodium bicarbonate
throat swelling and then became unresponsive. Bystander CPR was per- drips. She remained hypotensive; aminocaproic acid was given for pul-
formed; EMS arrived 30 min later. He had intermittent ROSC during monary hemorrhage. Based on her prognosis, comfort measures were
ED transport. initiated, and she died on Day 2.
Clinical Course: He arrived at the ED in cardiac arrest, was intubated Autopsy Findings: No autopsy results were provided.
and ACLS was continued. Ultrasound showed no cardiac activity and he
was pronounced dead 2 h after being envenomated. Case 158. Acute parenteral cyanide exposure: undoubtedly responsible
Autopsy Findings: Two puncture wounds on the left lower leg with Scenario/Substances: A 35 y/o female was reportedly injected into her
marked hemorrhage and edema. Diffuse petechiae and hemorrhage of gluteal area by her estranged husband. She was flaccid and unrespon-
epicardium and endocardium, visceral pleurae of the lungs, intercostal sive when EMS arrived.
muscles and diffuse tissues. Cause of death: complications following Physical Exam: Upon ED arrival she was unresponsive, BP 130/83,
rattlesnake envenomation. HR 102.
Laboratory/Diagnostic Findings: ABG- pH 6.95, lactate 7.7.
Case 154. Acute fire ant bite/sting: contributory Clinical Course: She was immediately intubated, repeat VS: SBP 72, HR
Scenario/substance: A 53 y/o male was bitten by fire ants and col- 40s.Norepinephrine, hydroxocobalamin and sodium thiosulfate were
lapsed soon after. He was given a dose of epinephrine via auto-injector given. Repeat ABG- pH 7.37/PCO2 25/PO2 357/HCO3 15.5, lactate 3.3.
but lost consciousness. EMS found the patient in PEA cardiac arrest; Vasopressin, sodium bicarbonate drips and CRRT were started. On Day 2
40 min resuscitation before ROSC. she remained unresponsive with no corneal reflexes. She was declared
Past Medical History: Hymenoptera (fire ant) hypersensitivity, last reac- brain dead and died.
tion 8 y prior. Autopsy Findings: Examination revealed dermal puncture in the glu-
Physical Exam: Unresponsive; bloody NGT fluids. Foot lesions consist- teal area, cerebral ischemia with edema and uncal herniation. Blood
ent with ant bites. 91/77, HR 104, RR 24, O2 sat 92%. cyanide was 3.4 mg/L.
Laboratory/Diagnostic Findings: ABG- pH 7.04/pCO2 62/pO2 86/CO2 16/BE
-13. Na 143/K 3.9/Cl 104/CO2 17/BUN 16/Cr 1.48/Glu 254, AG 22, AST 374 Case 166. Acute tetramethyl ammonium hydroxide inhalation/nasal,
(12,700 peak), ALT 237 (5,600 peak), bilirubin 0.8 (peak 3.1). INR 1.9, CK ocular: undoubtedly responsible
(peak) 6,472, troponin (peak) 14.75. WBC 14.8 (peak 40.8)/Hgb 17.7/Hct 55/ Scenario/Substances: A 39 y/o male contractor was working on a job
PLT 226. CT chest: bilateral aspiration; ECG: HR 117, QRS 84, QTc 477. site when a pipe containing tetramethyl ammonium hydroxide burst and
Clinical Course: In the ED he was intubated, cooled, placed on norepin- sprayed on him for 20 sec. He showered immediately but then collapsed
ephrine, vasopressin and epinephrine drips with fentanyl and midazolam with cardiac arrest; he was noted to be apneic in PEA. On site CPR was
for sedation. He had a second cardiac arrest after ICU arrival; antibiotics, performed for 5 min. He was intubated and received epinephrine by
bicarbonate, hydrocortisone and albumin were given. On Day 2, CRRT was EMS, with ROSC, and was then transported to the ED.
started for acidosis and renal failure (Cr peaked at 4.46 on Day 6). He devel- Past Medical History: Healthy, no medical problems.
oped coagulopathy (fibrinogen <60, INR 2.5) and was given cryoprecipitate Physical Exam: HR 90, SBP 110, O2sats 90%. Pt was initially combative
and vitamin K. MRI brain (Day 5) was consistent with severe hypoxic injury; and given midazolam. Skin was slightly red with petechiae and superfi-
he was unresponsive off sedation. Based on the prognosis, comfort meas- cial erythema (partial thickness burns) but no blisters. Pupils were minim-
ures were instituted and he died on Day 6. ally reactive without corneal injury.
Autopsy Findings: No autopsy results were provided. Laboratory Data: Electrolytes, Cr, INR and ABG ‘normal.’ Lactate 1.2,
transaminases in the 100s. EKG: inferior ischemia. CxR: “fluffy” with pul-
Case 155. Acute calcium hydroxide dermal: undoubtedly responsible monary congestion.
Scenario/Substances: 59 y/o male sustained 50% TBSA chemical burn Clinical Course: The patient was transferred to a tertiary care center and
after falling into pit filled with fresh cement. He was extricated 2 h later; started on cooling protocol for post cardiac arrest. HR varied from 46 to 62,
he was confused and combative. EMS decontaminated him prior to BP 98/60 then 124/88. 24 h later he was rewarmed, and sedation was
ED transfer. weaned. He developed jerking motions which raised concern about anoxic
CLINICAL TOXICOLOGY 35
brain injury. Patient developed seizures without neurological improvement TBSA (35% partial, 18% full thickness burns). After ROSC: BP 75/40, HR
on Day 12, placed on comfort care, and died on Day 13. 120, RR 30.
Autopsy Findings: Cause of death: anoxic encephalopathy, hydroxide Laboratory/Diagnostic Findings: Glu 262, lactate 22.8, CO2 10, ALT 885,
exposure, burn exposure 16% TBSA. Manner of death: accident; tetra- AST 1285, lipase 244, CK 16,091. VBG-pH <6.8, COHb 26%. CxR: extensive
methyl ammonium hydroxide exposure. lung opacities, left > right. EKG: NSR with septal ST depression. CT head:
diffuse cerebral and cerebellar edema.
Case 174. Acute ethyl methacrylate ingestion: undoubtedly responsible Clinical Course: ROSC was obtained after 20 min of CPR, intubation,
Scenario/Substances: A 52 y/o male, owner of a nail salon, was found epinephrine and sodium bicarbonate. Sodium thiosulfate was given. On
unresponsive in his yard with an empty liter bottle of ethyl methacrylate. burn center arrival (on epinephrine and norepinephrine) BP 103/91, HR
He was intubated by EMS prior to transport to an ED. Of note, he was 8, O2 sat 86%. Escharotomy was performed for pulse less left leg with
recently arrested for a felony charge. circumferential burn. His BP and oxygenation decreased, acidosis
Physical Exam: BP 73/49, HR 84, RR 14, O2sats 86% (100% FiO2). increased. Based on the prognosis, comfort measures were instituted
Pupils were fixed and dilated, he had no brainstem reflexes. and he died 7 h after arrival.
Laboratory/Diagnostic Findings: ABG- pH 6.74/pCO2 51/pO2 71/HCO3 6/ Autopsy Findings: 50% TBSA burns, cerebral edema, bilateral pulmon-
BE -35. Lactate 4.7, Ca 4.3, Na 141/K 5.7/Cl 120/CO2 9/BUN 9/Cr 1.2/Glu 197/ ary consolidation, airway inhalation injuries. Cause of death: medical
AG 12. UDS was negative. WBC 22.4; CxR: bilateral infiltrates. complications of thermal and inhalation injures. COHb 24%.
Clinical Course: He was treated with IV boluses of lactated ringers and
drips of norepinephrine, vasopressin and sodium acetate, but died within Case 230. Acute carbon monoxide inhalation: undoubtedly responsible
4 h of presentation. Prior to cardiac arrest his BP 30/14, HR 40 and O2 sat Scenario/Substances: A 16 y/o male was found in cardiac arrest inside
<70% on 100% FiO2. a mobile home that had a generator running for heat. CPR was initiated
Autopsy Findings: No autopsy results were provided. with ROSC and he was transported to the ED. Two other adults were
also found unconscious but survived.
Case 190. Acute hydrochloric acid ingestion: undoubtedly responsible Physical Exam: His pupils fixed and dilated; GCS 3.
Scenario/Substances: A 68 y/o female intentionally ingested 16 oz of Laboratory/Diagnostic Findings: Initial COHb 32.6% (then 7.5%), O2 sat
64.8%. Na 146/K 3.4/Cl 103/CO2 14.8/BUN 12/Cr 1.8/Glu 414, AG 28, Ca
hydrochloric acid-containing toilet bowel cleaner. She arrived in the ED
9.7, bilirubin 0.4, ALP 105, AST 235, ALT 228, lactate 25.2, troponin 86
2 h later with hematemesis and respiratory distress.
(then 30.6), CK 2,700. WBC 17.8/Hgb 15.4/Hct 47.1/PLT 233, PTT 37.1, INR
Past Medical History: Anxiety, bipolar disorder, chronic pain.
Physical Exam: In the ED: BP 185/86, HR 71, T 36 C, RR 30 (NRB). She 1.3. Serum APAP, ethanol and salicylate not detected. ABG- (after 6 amps
of sodium bicarbonate) pH 7.25/pCO2 60.2/HCO3 26.2.
was alert and oriented with bloody secretions in oropharynx. There were
Clinical Course: He was intubated and placed on 100% FIO2, started
coarse wet rales throughout all lung fields; abdomen was dif-
on norepinephrine, epinephrine (and then amiodarone) drips for hypo-
fusely tender.
tension and a hypothermia protocol. He was transferred to a tertiary
Laboratory/Diagnostic Findings: ABG- pH 6.92/pO2 184/pCO2 43/HCO3
care center for HBO therapy, but the chamber was malfunctioning. He
8. Na 143/K 5.1/Cl 118/CO2 15/BUN 14/Cr 0.95/Glu 221, AG 22. AST 173,
remained unresponsive with fixed and dilated pupils on Day 1. HR 106,
ALT 57, bilirubin 1.6, INR 1.5, WBC 26/Hgb 16.2/Hct 50.7/PLT 186. Serum
BP 104/67 on vasopressors that were slowly weaned. On Day 2 his pupils
APAP, ethanol and salicylate not detected. CxR: right lung opacification.
were 8mmand fixed; VS with re-warming: HR 83, BP 106/39, RR 29
ECG: sinus rhythm at 82.
(breathing slightly over the ventilator rate), O2 sat 88%. He died on the
Clinical Course: She was intubated in the ED and had dark-brown
evening of Day 2.
aspirate from the ETT and NGT. Antibiotics were given. Upper endoscopy
Autopsy Findings: No autopsy results were provided.
demonstrated ulceration in hypopharynx, severe esophagitis with necro-
sis, diffuse gastric necrosis. She received IVFs, vasopressors and CRRT but
Case 268. Acute sulfur dioxide inhalation and ocular exposure:
died 12 h after admission.
undoubtedly responsible
Autopsy Findings: Cause of death: complications from cleaning chem-
Scenario/Substances: 64 y/o male became trapped in a smelting area
ical ingestion; manner of death: suicide. Findings included hemorrhage
with high concentrations of sulfur dioxide. He became disoriented, took
and necrosis of esophagus, stomach and small intestine. Toxicology
off his protective mask and was exposed for 10 min.
screens were negative for drugs of abuse.
Physical Exam: In the ED he complained on bilateral eye pain. BP
125/53, HR 82, RR 20, T 36.3 C, O2 sat 89 % (RA).
Case 218. Acute deodorizer ingestion: probably responsible Laboratory/Diagnostic Findings: ABG- pH 7.26/pCO2 47. Na 145/K 3.9/
Scenario/Substances: A 4 w/o 4 kg male was fed a bottle containing Cl 112/CO2 22. CxR: mild infiltrate.
formula accidentally mixed with an industrial deodorizer (containing Clinical Course: In the ED his eyes were irrigated with 2 L NSS;
lemon verbena). He reportedly only took 1 drink and then started crying. conjunctival pH after irrigation was 7.0. Eye exam showed mild corneal
MSDS lists nonyl phenol and propylene glycol ether. haziness with diffuse fluorescein uptake. He became progressively short
Physical Exam: In the ED he was lethargic, HR 70s, O2 sat 70% (RA). of breath and deteriorated despite albuterol. He was intubated and
Laboratory/Diagnostic Findings: ABG- pH <6.8/pCO2 92/pO2 31/HCO3 2. transported to a burn unit. Bronchoscopy showed friable, edematous
Na 153/K 5.4/Cl 124/BUN 7/Cr 0.26/Glu 45, AST 137, ALT 45, bilirubin 0.2. and erythematous bronchopulmonary segments. CxR: diffuse patchy con-
WBC 12.9/Hgb 8.5/Hct 30/PLT 118. CxR: atelectasis and lung opacities. solidation in all lung fields. BP 95/55, HR 120, T 37.4 C, BUN 32, Cr 3.47,
Clinical Course: Within 1 h he developed lethargy, hypoxia and periods lactate 4.0. He was started on veno-venous ECMO and CRRT, received
of apnea. He was intubated and received CPR, epinephrine and atropine sodium bicarbonate and an esmolol drip. Bedside ECHO showed normal
with initial improvement. He was reintubated at the tertiary care center and ejection fraction. On Day 2 he developed severe acidosis, hematemesis,
placed on an epinephrine drip but had cardiac arrest and died. and abdominal distension with concern for ischemic bowel; Cr 4.26, BUN
Autopsy Findings: No autopsy results were provided. 38, lactate 12.7. He developed hypoxia and hypotension; repeat ECHO
showed cardiogenic shock. Dobutamine was added. INR 2.1, PTT >150.
Case 220. Acute carbon monoxide inhalation/nasal: undoubtedly Based on the prognosis, the family opted for institution of comfort meas-
responsible ures and he died on Day 3.
Scenario/Substances: A 4 y/o male was found in cardiac arrest after Autopsy Findings: Pathologic findings: diffuse alveolar damages,
being extricated from a house fire. He had ROSC after 40 min of ACLS on corneal burns bilateral, peritoneal effusion, occlusive CAD 60 - 90 %
scene but arrested again prior to ED arrival. RCA/LAD/L circumflex. Toxicology (premortem blood): amphetamine
Physical Exam: Unresponsive in cardiac arrest. Soot in mouth and 0.146 mcg/mL, ketamine 0.144 mcg/mL (ketamine presumed from hos-
nasal passages, coarse lung sounds. Cyanosis of hands and feet; 53% pital anesthetic).
36 D. D. GUMMIN ET AL.
Case 285. Acute arsenic and ethanol ingestion: probably responsible Laboratory/Diagnostic Findings: Arterial pH 7.1. ECG: ST with depres-
Scenario/Substance: A 36 y/o male was brought to the ED after drink- sions in inferior leads, QTc 525.
ing alcohol and an unlabeled bottle with “the appearance of an antique Clinical Course: Pt was intubated in the ED and transferred to a burn
bottle of Clorox.” EMS found him confused, vomiting and incontinent of unit. She had VF arrest during debridement; ACLS was initiated, includ-
urine and feces. His blood glucose was 60 and he received D50. ing defibrillation, with intermittent ROSC. She received epinephrine,
Past Medical History: Drug abuse, recent suicidal ideation. amiodarone, esmolol and overdrive pacing. Her QTc remained prolonged
Physical Exam: BP 56/27, HR 126, RR 40 O2 sats72% (on 94% NRB), T (506 ms). She died shortly after burn unit arrival.
35.1 C rectal. He was lethargic, pupils 3 mm and sluggishly reactive Autopsy Findings: Postmortem blood toxicology: 1,1-difluoroethane,
bilaterally. 35 mcg/ml; hydromorphone free 4.3 ng/ml; COHb 2%. No evidence of
Laboratory/Diagnostic Findings: ABG- pH 7.21/pCO2 24/pO2 185/HCO3 thermal injury or acute inflammation to upper and lower airway. Cause
9/BE -17, Na 140/K 2.6/Cl 106/CO2 13/BUN 26/Cr 1.75/Glu 255/AG 22. of death: complications of inhalant toxicity (cardiac arrhythmia) due to
Lactate 8.9, Ca 9.4. Serum ethanol 10 mg/dL. Serum salicylate and APAP “huffing.” Manner of death: accidental.
not detected. Serum osmolality 312, CK 246, ammonia 190, troponin
0.26, Hgb 14.9, PLT 130. EKG: ST at 125, QRS 109, QTc 485, inferolateral Case 323. Acute hydrocarbon, amphetamine, and methylenedioxy-
ST depression. methamphetamine (MDMA) ingestion: undoubtedly responsible
Clinical Course: On arrival to the ED he was drowsy but arousable, Scenario/Substances: A 27 y/o male was found unconscious next to a
complained of feeling cold. He was transiently responsive to IVFs and truck with a hose inside the fuel tank (apparently siphoning fuel into a
oxygen but remained tachypneic and tachycardic. He was started on container). There was fuel on and around the patient. He was trans-
norepinephrine and received both bolus doses and drip of sodium bicar- ported to the ED with CNS and respiratory depression.
bonate. His mental status declined. During intubation, he vomited and Physical Exam: On arrival in ED: BP 45/33, HR 124, RR 20, O2 Sat 85%
went into VF requiring defibrillation and ACLS. Electrolytes (Mg, K Ca) (RA), T 37 C. Pupils 3 mm and reactive, gasping respirations, GCS 7,
were replaced but he died 3.5 h after presentation. superficial burns to abdomen and hip.
Autopsy Findings: Not performed. Of note: after death the antique Laboratory/Diagnostic Findings: Na 143/K 3.9/Cl 108/CO2 27/BUN 13/
bottle was obtained. Testing of a chalky gray residue, via water distilla- Cr 1.4/Glu 185. ABG- pH 7.17/pCO2 72.4/pO2 62/BE -4.6, COHb 0.3%. AST
tion and mass spectrometry, revealed 6,755 ppm arsenic. 25, ALT 27, WBC 12.9/Hgb 14.9/Hct 43.8/PLT 341.Serum APAP, ethanol
and salicylate not detected. UDS was positive for amphetamines, MDMA
Case 288. Acute arsenic, benzene and toluene ingestion: undoubt- and THC. ECG: unremarkable. CxR: bilateral opacities. CT head:
edly responsible. unremarkable.
Scenario/Substances: A 59 y/o male presented to the ED 19 h after Clinical Course: On arrival in the ED he was intubated and admitted
ingesting 4 oz of an arsenic solution in either benzene or toluene. He was to the ICU. He developed hypotension, acidosis and hypoxia requiring
reportedly working with chemicals (which he had access to via employ- multiple vasopressors, then became difficult to oxygenate (PEEP 24, FIO2
ment) in his basement and confused the liquid with his orange juice. 1.0) and was paralyzed. His condition deteriorated and he developed
Past Medical History: No reported depression but admitted to being renal failure and shock liver. He was started on CRRT. Despite these
stressed from caring for his father-in-law. interventions, he became more hypoxic, went into cardiac arrest and
Physical Exam: Anxious with profuse vomiting, flank pain and dizzi- died on Day 2.
ness. BP 90/73, HR 111, RR 24, O2 sat 94% (RA), T 36 C. Autopsy Findings: Postmortem lungs showed evidence of pneumonitis
Laboratory/Diagnostic Findings: ABG- pH 7.24/pCO2 35/pO2 85/HCO3 with red-brown parenchyma and copious amounts of blood tinged fluid.
14.9/BE -11.04, Na 134/K 3.8/Cl 93/BUN 44/Cr 3.6/Glu 236, AG 21. AST 52, Antemortem blood testing: d-methamphetamine 0.30 mg/L and d-
ALT 43, bilirubin0.6, INR 0.9, WBC 17.7/Hgb 16.8/Hct 48.3/PLT 321, tropo- amphetamine 0.03 mg/L. Tolmetin was detected. Cause of death: chem-
nin 0.465. Serum APAP 2, salicylate 1.7. UDS was positive for opiates. ical pneumonitis due to inhalation of gasoline
ECG: HR 100, QRS 84, QT/QTc 400/516. CxR: unremarkable. Specimens
sent on Day 1 showed a 24 h urine arsenic of 19,418 ng/mL and a serum Case 325. Acute-on-chronic botulism parenteral: contributory
arsenic of 160 ng/mL. Scenario/Substances: A 52 y/o male developed wound botulism after
Clinical Course: He presented with muscle cramps and emesis, he skin-popping. His initial symptoms included dysphagia, double vision
vomited 1.5 L and had no urine output. On Day 2 he developed 1st and generalized weakness.
degree heart block. DMSA was initiated at 500 mg for arsenic poisoning, Past Medical History: Drug abuse.
but the patient was switched to BAL on Day 3 as his condition contin- Physical Exam: Generalized weakness; scab on chest; nodules
ued to deteriorate. NAC was added when AST and ALT increased (378 under skin.
and 201, respectively). On Day 3 he had several episodes of bloody diar- Clinical Course: The patient was intubated and admitted to the ICU.
rhea that tested positive for C. difficile. The patient developed sepsis He received botulism antitoxin, propofol, fentanyl, benzodiazepines, anti-
with multiple organ dysfunction. His lactate was 5.9 (increasing to 17), biotics, n-acetylcysteine tablets and corticosteroids. On Day 12, he
troponin 1.22, AST 854, ALT 408. He was given IV metronidazole and became agitated, extubated himself and was put on BiPAP. On Day 13,
vancomycin for suspected abdominal infection. He underwent an emer- the patient died from respiratory arrest.
gent open colectomy and acute blood loss post-surgery required treat- Autopsy Findings: No autopsy results were provided.
ment with packed RBCs. He developed renal failure, sepsis, GI bleeding
and coagulopathy (INR 4.4). He received phenylephrine, norepinephrine, Case 333. Acute-on-chronic aluminum phosphide exposure:
epinephrine and vasopressin. On Day 5 he developed asystole, with undoubtedly responsible
ROSC after 1 h of CPR. Based on the prognosis, the family opted for com- Scenario/Substances: [See case 10] A 9 y/o male involved in a mass
fort measures and he died on Day 5. casualty incident after her father placed large quantity of aluminum
Autopsy Findings: No autopsy results were provided. phosphide tablets under their home as a pesticide. Most household
members had developed adverse GI effects and had been scene previ-
Case 311. Acute fluorinated hydrocarbon inhalation: undoubtedly ously at a local hospital (history of chemical exposure was not provided)
responsible and the family members were diagnosed with gastroenteritis. That night
Scenario/Substances: A 36 y/o female was in a car when there was an the father attempted to get rid of the tablets by dissolving them with
explosion. Police found 8 cans of (fluorinated hydrocarbon-containing) water from a garden hose.
keyboard duster, 1 of which exploded, at the scene. Physical Exam: He presented to the ED awake but lethargic, initial VS:
Past Medical History: Illicit drug abuse including huffing. BP 112/80, HR 90.
Physical Exam: Presented with respiratory difficulty and 30% TBSA Laboratory/Diagnostic Findings: ABG- pH of 6.8/pC02 62/p02 25/HCO3
burns, including full thickness burns to face. SBP 110, HR 130s. 10/BE -24. CO2 8, Mg 3.5, Glu 405, BUN 30, Cr. 1.64, CPK 48, AST 92, ALT
CLINICAL TOXICOLOGY 37
130, AG 36, troponin 0.14, BNP 196. CxR: (1 h after PICU admission) air sodium bicarbonate and Ca. Bedside echo showed no cardiac activity; he
bronchograms and densities in both lungs. died 2 h after presentation.
Clinical Course: In the ED he patient quickly became obtunded and Autopsy Findings: Blood 2, 4 dinitrophenol 91mg/L. Death classified
hypotensive (BP 72/60). He was intubated but developed atrial flutter as suicide.
and lost pulses. He received CPR, IVFs and sodium bicarbonate with
ROSC. In the PICU, he developed frothy pulmonary secretions and Case 356. Acute paraquat ingestion: undoubtedly responsible
required increased ventilatory support. He developed acidosis (pH <6.5), Scenario/Substances: A71 y/o male brought paraquat home from work
hypercarbia (pCO2> 130), hypoxemia (pO221) and shock. Despite aggres- in a drink bottle to spray on his flower. He left the paraquat in his
sive resuscitation efforts (IVFs, multiple doses of epinephrine, sodium refrigerator and accidentally drank it, vomited and immediately pre-
bicarbonate, Ca, vasopressors and CPR) he died 2h after PICU admission. sented to the ED.
Autopsy Findings: Pulmonary edema with pleural effusions. Cause of Laboratory/Diagnostic Findings: In the ICU: Cr 1.7, BUN 11, CO2 22.
death: accidental phosphine gas poisoning. CxR was unremarkable. Repeat labs on Day 2: AST increased from 30 to
175, Cr 3.5, lactate 3.1, CO2 19. Solution was confirmed as being
Case 335. Acute-on-chronic aluminum phosphide inhalation: 30% paraquat.
undoubtedly responsible Clinical Course: In the ED he was diaphoretic with blue/green emesis.
Scenario/Substances: A17 y/o female was involved in a mass casualty He refused activated charcoal or NG tube placement. He was transferred
incident after her father placed large quantity of aluminum phosphide to a tertiary care HCF; cyclophosphamide, methylprednisolone and IV
tablets under their home as a pesticide. Most household members devel- NAC were started. On Day 2 he was alert and oriented; BP 123/62, HR
oped adverse GI effects and had been seen previously at the ED (history 93, RR 21, O2 sat >92%. CRRT was started for worsening renal function
of chemical exposure was not provided) and the family members were but complicated by clotting issues. He complained of odynophagia, and
diagnosed with gastroenteritis. That night the father attempted to get became agitated, uncooperative and hypoxic (O2 sat 85%) He was intu-
rid of the tablets by dissolving them with water from a garden hose. bated on Day 3 and started on vasopressin, norepinephrine and phenyl-
Early the next morning, an older sibling awoke and found some family ephrine drips. Based on the prognosis, the family opted for comfort
members to be quite ill. EMS was called and found 2 children in cardiac measures and he died on Day 5.
arrest. One was declared dead at the scene; the second failed to respond Autopsy Findings: Not performed.
to ACLS interventions and was pronounced in the ED. A third sibling
died 2 h after PICU arrival. Case 360. Acute Curcuma domestica parenteral: undoubtedly
Physical Exam: In the ED she was lethargic with nausea, abdominal responsible
pain and dyspnea. BP 77/55, HR 107, RR 16, T 36 C, O2 sat 100% Scenario/Substances: A 30 y/o female received an infusion of turmeric
(on oxygen). in her naturopathic doctor’s office. Within minutes she was unresponsive.
Laboratory/Diagnostic Findings: K 3.1, CO2 14, AG 25, Mg 2.0, PO4 7.5, The infusion was stopped, CPR was initiated and epinephrine IM admin-
BUN 20, Cr 1.33, bilirubin 1.4, WBC 3.1, BNPT 161, troponin 0.05, ABG- istered while awaiting EMS.
pH 7.22/CO2 25/O2 49, COHb 0.8%, MetHgb 0.7%. Subsequent ABG- pH Past Medical History: Eczema, hypothyroidism, obesity, pre-diabetes,
7.0/CO2 29.8/O2 83 (intubated on 100% FiO2). and food allergies to soy protein, lactose and gluten.
Clinical Course: Ondansetron and IVFs were given, then norepineph- Physical Exam: In the ED: BP 119/83, HR 58, O2 sat 100% (intu-
rine, phenylephrine and dopamine for hypotension. She was intubated bated), T 35 C.
and received potassium, sodium bicarbonate and Mg. CxR: pulmonary Laboratory/Diagnostic Findings: BMP ‘normal’, Phos 1.8, Mg 1.8.
edema. EKG: ST at 108, mild ST depression in inferior lateral leads. She Clinical Course: In the ED she was intubated with ROSC and placed
went into cardiac arrest and died 3.5 h after arrival. her on a hypothermia protocol. CT head: edema. In the ICU she exhib-
Autopsy Findings: Gastric mucosal hemorrhage and superficial ulcer- ited decerebrate posturing. Based on the prognosis, comfort measures
ation, focal cerebral subarachnoid hemorrhages, pericardial, pleural and were instituted and she died on Day 5.
peritoneal effusions. Autopsy Findings: Toxicology (antemortem blood): diphenhydramine
0.22 mg/L, presumptive positive for cannabinoids. Cause of death: anoxic
Case 345. Acute sulfuryl fluoride inhalation: undoubtedly encephalopathy due to prolonged cardiopulmonary arrest due to
responsible adverse reaction to tumeric solution. Manner of death: accidental. No
Scenario/Substances: A 36 y/o male was found altered inside a resi- turmeric testing was performed on her blood or urine.
dential structure which had been tented and fumigated with sulfuryl
fluoride. Estimated time of exposure was 1-2 h. Case 361. Acute plant (cardiac glycoside) ingestion: undoubtedly
Past Medical History: Polysubstance abuse. responsible
Physical Exam: In the ED, he was alert and conversant; BP 128/9, HR Scenario/Substances: A 33 y/o female ingested an herbal supplement
115-120, RR 29, T 36 C. (“pong-pong” a nut from the Cerbera odollam tree) purchased on the
Laboratory/Diagnostic Findings: Cr 1.24, BUN 13. Ca 4.0, WBC 19.3, internet for weight loss. She developed AMS and vomiting, and was
Hgb and Hct ‘normal.’ UDS was positive for methamphetamine. transported to the ED.
Clinical Course: He gradually developed shortness of breath, was diag- Past Medical History: Depression, eating disorder, no reported sui-
nosed with pulmonary edema and treated with BiPAP; he also received cidal ideation.
calcium. On Day 3, he was intubated after developing pneumonia and Physical Exam: In the ED she was diaphoretic and pale with contin-
ARDS; liver function tests increased. He developed hypotension requiring ued nausea and vomiting. She soon became agitated and required
vasopressors and died on Day 8. restraints. SBP 90, HR 30-40.
Autopsy Findings: Cause of death: complications of ARDS secondary Laboratory/Diagnostic Findings: K 8.9, ECG: wide complexes with no p
to sulfuryl fluoride fumigant exposure; manner of death: accidental. waves. Serum digoxin was 3.1 ng/mL.
Clinical Course: She was resuscitated with IVFs and vasopressors, was
Case 347. Acute dinitrophenol ingestion: undoubtedly responsible intubated and receive 10 vials of digoxin Fab fragments. Despite these
Scenario/Substances: 42 y/o male took 30 dinitrophenol (200 mg) efforts she died 3 h after presentation.
tablets. He was found unresponsive by EMS. Autopsy Findings: Cause of death: “cardiac glycoside toxicity (cerberin
Physical Exam: In the ED 3 h after ingestion he was disoriented, anx- and neriifolin); manner of death: accidental. Post mortem toxicology
ious, diaphoretic, and became rigid. Initial BP 120/58, HR 117, RR 32, O2 screening was positive for neriifolin and cerberin (2 cardiac glycosides)
sat 98% (2 L/min O2), T 36.8 C. but negative for drugs of abuse. “Plants which contain these glycosides
Laboratory/Diagnostic Findings: Initial blood pH 6.7, K 5, CK 600s. include Cerbera odollam and Cerbera manghas.” Liver tissue extract
Clinical Course: In the ED he was intubated, developed rigor and showed 3 peaks on LC/MS suggestive of cardiac glycosides; neriifolin
hyperthermia (T 38 C), then went into asystole. He received epinephrine, and cerberin were confirmed but no quantification data were reported.
38 D. D. GUMMIN ET AL.
Case 364. Acute-on-chronic nicotine inhalation/nasal: undoubtedly Clinical Course: Minimal response to naloxone; he was intubated,
responsible then started on IVFs and antibiotics. On Day 2 he became hypotensive
Scenario/Substances: A 19 y/o male was vaping at a mall using a 0.3% (40/20) and started on a naloxone drip. He had multiple episodes of car-
nicotine solution when he lost consciousness. EMS found patient in VF diac arrest, received IVF boluses, and dopamine and epinephrine drips.
arrest. He received ACLS with ROSC after a 40-min downtime. Pupils became fixed and dilated. An exterior ventricular drain was placed
Physical Exam: In the ED he was intubated, cyanotic with pupils that and he received 3% saline for cerebral edema, but died on Day 2.
were 6mm and sluggish; HR 160, T 38 C. Autopsy Findings: Toxicology report: naloxone positive; antemortem
Laboratory/Diagnostic Findings: Na 143/K 3.7/Cl 100/CO2 19/BUN 15/ peripheral blood: methadone 400 ng/mL, EDDP 83 ng/mL, chlorphenir-
Cr 1.4/Glu 274, Mg 2.4, AST 245, ALT 348. ABG- pH 6.93/pCO2 69/pO2 98. amine 41 ng/mL, diphenhydramine 180 ng/mL. Cause of Death: diffuse
Lactate 8.9, WBC 5.5/Hct47.9/PLT 223. Serum APAP, ethanol and salicyl- anoxic encephalopathy with diffuse cerebral edema and herniation due
ate not detected. UDS was negative. CxR: right mainstem intubation, to combined effects of methadone, chlorpheniramine and diphenhydra-
complete opacification of left lung, areas of patchy infiltrates. ECG: ST at mine; manner of death: homicide.
124, right axis deviation, possible anterolateral infarct, QRS 96, QTc 459.
CT head: anoxic injury. CT chest: ground glass consolidations and patchy Case 371. Acute ibuprofen ingestion: undoubtedly responsible
infiltrates bilaterally. ECHO: moderate hypokinesis of LV. Scenario/Substances: A 13 y/o female intentionally ingested an
Clinical Course: Patient was resuscitated and started on pressors unknown amount of ibuprofen. She was discovered unresponsive with
and cooling protocol. He rapidly developed evidence of pulmonary emesis and bloody stool, 10 h after last being seen at baseline. EMS
edema with difficulty oxygenating; a chest tube was placed. He was administered naloxone, without effect, and transported her to the ED
resuscitated after a PEA arrest. Metoprolol was given for persistent Physical Exam: BP 101/32, HR 91, RR 10.
tachycardia in the 160s. Nitric oxide inhalation was started and he Laboratory/Diagnostic Findings: Arterial pH 7.3, lactate >20, Cr 1.9, Ca
was transferred for ECMO. On arrival at the tertiary care center <2, K 6.4, HCO3 8, AG 30, BUN 22, Cr 1.8, Glu 82, WBC 38, AST 198, ALT
a bronchoscopy showed inflamed lung with bloody irritation of the 62. Post-transfusion Hgb 9.8/Hct 30. Serum APAP and salicylate not were
mainstem bronchi and sloughed mucosa. He was unresponsive off detected. Repeat labs on Day 2: Na 173/K 2.6/Cl 110/CO2 31/BUN 39/Cr
sedation. On Day 3, CT head: cerebral edema with loss of grey-white 2.3, lactate 15.4. ABG- pH 7.55/pCO2 38/pO2 43/HCO3 33.8/BE 12, Ca
matter distinction. On Day 5, he was declared brain dead, died and (ionized) 2.0, CPK 23,000. Day 3: Arterial pH 7.35, K 4.8, Cr 3.5, AST 999,
underwent organ donation. ALT 240, INR 3.0, PTT 42, CPK 43,123.
Autopsy Findings: Cause of death: sudden cardiac death while vap- Clinical Course: In the ED she was intubated and received sodium
ing nicotine, acute aspiration pneumonia, pulmonary thrombosis with bicarbonate, calcium, antibiotics and NAC. CT head: unremarkable. She
infarction, splenic infarction; manner of death: accidental. The vaping was transferred to a tertiary care center where she became hypotensive,
liquid was analyzed and found to have nicotine and carrier oils. MSDS bradycardic and then developed asystole. CPR was performed, and she
stated that ingredients were nicotine 0.3%, glycerin and propylene received dopamine, norepinephrine and epinephrine drips. She received
glycol. Excipients for scent and taste were not listed. Because of 2 units of FFP and 1 unit of PRBCs for rectal bleeding; BP 90/50, HR 137.
public health concerns, state public health agency and police On Day 2 she remained unresponsive; BP 99/47 and HR 86 on 3 vaso-
were notified. pressors. She was cooled for hyperthermia. On Day 3 she had no pur-
poseful movements, BP 80/30, HR 120, O2 sat 80%. She died on Day 4
Case 365. Acute nicotine parenteral: undoubtedly responsible from a reported anoxic brain injury.
Scenario/Substances: 20 y/o female was found by EMS in cardiac Autopsy Findings: Cause of death: ibuprofen intoxication; manner of
arrest after reportedly injecting a liquid nicotine product 50 min prior. death: suicide. Hospital blood ibuprofen level was 500 mcg/mL. The pul-
She was intubated and received CPR, naloxone (no response) and IVFs monary parenchyma was erythematous and congested, brain showed
prior to ED arrival. hypoxic ischemia.
Past Medical History: Asthma, thyroid disease, depression.
Physical Exam: Unresponsive; incontinent of stool. Pupils fixed and Case 1038. Unknown salicylate ingestion: undoubtedly responsible
dilated. SBP 112, HR 190. Scenario/Substances: A 65 y/o male was brought to the ED by family
Laboratory/Diagnostic Findings: ABG- pH 7.09/pCO2 38/pO2 114/HCO3 for altered mental status.
11.2. Na 142/K 3.7/Cl 104/CO2 12/BUN 14/Cr 1.6/Glu 129. Mg 2.2, Phos Past Medical History: COPD, bipolar disorder, alcohol abuse, and
4.3, AST 140, ALT 102, bilirubin 1.0, INR 1.2, WBC 19/Hgb12.7/Hct 39.2/ chronic liver disease. Home medications: alprazolam, baclofen, flutica-
PLT 400. Serum APAP, ethanol and salicylate not detected. UDS was sone, lamotrigine, meloxicam, tamsulosin, tiotropium and zolpidem.
positive for amphetamine metabolites. Lactate 13.2, CK 200, troponin Physical Exam: BP 135/75, HR 92, RR 34, O2 sat 99% (RA), T 37 C.
<0.015. CT brain: unremarkable. Day 3 blood: nicotine 1,000 ng/mL, coti- Alert and oriented but was diaphoretic and appeared distressed.
nine 510 ng/mL. Laboratory/Diagnostic Findings: Na 145/K 5.5/Cl 117/CO2 15/BUN 25/
Clinical Course: The patient’s HR decreased to 109 after more IVFs, Cr 1.43/Glu 117, AG 13, VBG-pH 7.41/pCO2 31.8/pO2 22/HCO3 26.2/BE -4.
she remained unresponsive with posturing and myoclonic jerks. She CK 175, lactate 0.7, AST 29, ALT 11, bilirubin 0.2. WBC 23.4/Hgb 16.7/Hct
began cooling protocol. On Day 2 she remained unresponsive with 50.1/PLT 289. Serum ethanol not detected. UDS was positive for benzo-
mydriasis and increased muscle tone. Off sedation her pupils were2mm diazepines. CxR: left lower lobe opacity and effusion. CT head: unremark-
and unreactive, she received antibiotics for presumed pneumonia. On able. ECG: HR 90, QRS 80, QTc 555.
Day 6 she received benzodiazepines, valproate, levetiracetam and lacosa- Clinical Course: In the ED the suspected sepsis was treated with broad
mide for repeated seizures. On Day 8, MRI showed diffuse hypoxia brain spectrum antibiotics. After 5 h with RR 30 to 34 he became obtunded
injury. Based on the prognosis, the family opted for of comfort measures and was intubated, then became bradycardic and hypotensive. 45 min
and she died on Day 20. later he had a cardiac arrest; resuscitation efforts (CPR, atropine, epi-
Autopsy Findings: No autopsy results were provided. nephrine and naloxone) were unsuccessful and he died within 8 h after
ED arrival.
Case 368. Acute methadone, chlorpheniramine and diphenhydra- Autopsy Findings: Premortem serum lamotrigine from the ED was sub-
mine ingestion: undoubtedly responsible therapeutic (1.5 mcg/mL), salicylate was 112 mg/dL. Cause of death: sali-
Scenario/Substances: A 2 y/o male was put down for a nap and then cylate toxicity with intra-alveolar hemorrhage.
found unresponsive 5.5 h later. Medications found in the home included:
metoprolol, lisinopril, meloxicam, amlodipine, promethazine, tizanidine Case 1063. Acute-on-chronic colchicine ingestion: undoubtedly
and baclofen. responsible
Physical Exam: Lethargic in respiratory distress at ED arrival. Scenario/Substances: A 68 y/o female ingested 86 tabs of colchicine in
Laboratory/Diagnostic Findings: UDS was positive for methadone. a suicide attempt. When EMS arrived she was lethargic, vomiting and
Serum APAP, salicylate and ethanol not detected. incontinent.
CLINICAL TOXICOLOGY 39
Past Medical History: Anxiety and depression, asthma and HTN. Scenario/Substances: A 33 y/o male was inhaling lidocaine powder
Medications: colchicine, meloxicam, escitalopram, omeprazole, metopro- (imported from China) to treat GERD. He was found unresponsive sur-
lol, quetiapine, furosemide and fluticasone. rounded by white powder.
Physical Exam: In the ED 4 h after ingestion she was lethargic but Past Medical History: GERD.
arousable. BP 112/100, HR 118, RR 16, O2 sat 100% (RA), T 37 C. Physical Exam: He was in cardiac arrest upon ED arrival, pupils 8mm
Laboratory/Diagnostic Findings: ABG- pH 7.09/pO2 20.8/HCO3 9.1/BE and unresponsive.
-20.3. Na 149/K 3.3/Cl 105/CO2 21/BUN 17/Cr 1.5/Glu 172. AST 464, ALT Laboratory/Diagnostic Findings: ABG- pH< 6.8/pCO2 98/pO2 181/HCO3
131; WBC 29.5/Hgb 15.7/Hct 49.6/PLT 256. Serum APAP, salicylate and 8.9. Na 143/K 4.4/Cl 106/CO2 14/BUN 17/Cr 1.3/Glu 375. AG 28, AST 334,
ethanol not detected. UDS was negative. ALT 204, bilirubin 3.0. INR 0.9.WBC 9.4/Hgb 11.6/Hct 40.1/PLT 205. Serum
Clinical Course: In the ED she received activated charcoal and IVFs. APAP, ethanol and salicylate not detected. UDS was positive for benzo-
Her BP dropped to 96/52 then 49/29, HR 110. ECG: accelerated junctional diazepines. EKG: NSR, QRS 148, QTc 485. CxR: widened mediastinum, dis-
rhythm, QRS 82, QT 652. She was intubated and started on norepineph- tended stomach.
rine, and sodium bicarbonate drips. She developed renal dysfunction (Cr Clinical Course: After ROSC: BP 64/34, HR 73, RR 14, O2 sat 92%. He
3.5) and worsening hypotension; she died 24 h after admission. was intubated and started on norepinephrine and dopamine drips for
Autopsy Findings: Cardiomegaly, pulmonary edema, hepatomegaly, hypotension. He received sodium bicarbonate for QRS prolongation and
and nephrosclerosis. Cause of death: colchicine intoxication; manner of ILE. The patient’s BP stabilized to 104/52 and QRS narrowed to 120 ms,
death: suicide. but he remained unresponsive with fixed and dilated pupils. CT head
showed anoxic brain injury with edema and herniation. He was declared
Case 1091. Acute salicylate ingestion: undoubtedly responsible brain dead and died on Day 2. The product involved tested positive for
Scenario/Substances: A 71 y/o female presented to an ED after taking lidocaine (via gas chromatography/mass spectroscopy). Serum lidocaine
handfuls of ASA, intermittently, for 3 h. was >12 mcg/mL.
Past Medical History: Hypertension, diabetes. Autopsy Findings: Cause of death: lidocaine toxicity; manner of death:
Physical Exam: In the ED: BP 179/103, HR 107, RR 23, O2 sat 92% (RA), accidental. Antemortem blood sample: lidocaine 18 mcg/mL; monoethyl-
T 36.3 C. glycinexylidide (MEGX): 11 mcg/mL.
Laboratory/Diagnostic Findings: Initial salicylate level was 70 mg/dL.
ABG- pH 7.40/pCO2 33/pO2 182/HCO3 22.2. Na 138/K 4.8/Cl 166/CO2 15/
Case 1174. Acute pregabalin and topiramate ingestion: undoubtedly
BUN 18/Cr 0.9/Glu 186, AG 43, AST 116, ALT 172, bilirubin 0.2, CK 150,
responsible
WBC 19.9/Hgb 15.8/Hct 47.6. Serum APAP and ethanol not detected.
Scenario/Substances: A 63 y/o male who had been taking extra prega-
ECG: HR 108, QRS 114, QTc 479. CxR: atelectasis.
balin to sleep (per family) was found in cardiac arrest and transported to
Clinical Course: In the ED she was alert and diaphoretic, complaining
the ED. 90 pregabalin tablets were later found to be missing.
of nausea (with emesis) and fuzzy vision. Within several hours she devel-
Past Medical History: Seizure disorder. Medications: topiramate, pregabalin.
oped tinnitus and her QTc prolonged to 500; she received IV Mag and K.
Physical Exam: Intubated, sedated, unresponsive. BP 117/70,
Salicylate level increased to 105 mg/dL and CRRT was started. Repeat
HR 120, T 37 C.
ABG- pH 7.64/pCO2 23/pO2 91/HCO3 28.9, bicarbonate drip was discon-
Laboratory/Diagnostic Findings: UDS was positive for opioids. EKG:
tinued. ASA level decreased to 75 mg/dL and CRRT was stopped. BP 135/
incomplete RBBB, QRS 98, QTc 407. Day 2: Na 131/K 4.9/Cl 112/CO2 19/
75, HR 121, RR 28, O2 sat 95% (2 LPM). 4 h after stopping HD: Salicylate
BUN 13/Cr 0.63/Glu 134, ABG-pH 7.45/pCO2 27/pO2 124/HCO3 18.
was 102, CO2 21, Cr 1.34, AG 29. She had increased agitation, confusion,
Clinical Course: BP 105/92, HR 88, RR 20, T 32 C (on hypothermia
diaphoresis and dry mucus membranes. ASA increased to 104 and HD
protocol). Remained intubated in the ICU, opened eyes to external rub
was resumed; 1 h later she had a ventricular arrhythmia then asystole.
She was intubated with CPR (achieved ROSC) and received sodium bicar- and had myoclonic jerking without seizure activity. Day 2: BP 140/84, HR
bonate (boluses and drip), epinephrine, calcium, vasopressin, norepin- 113, RR 23, T 36.1 C, patient was being rewarmed. Patient went into car-
ephrine and mannitol for unequal pupils. CT head: no acute changes, K diac arrest and died on Day 3.
5.9, CO219, Cr 1.81, Ca 7.2, and Glu 212. She was given sodium polystyr- Autopsy Findings: Cause of death: acute mixed drug intoxication (pre-
ene sulfonate. HD was performed 2 more times which decreased salicyl- gabalin and topiramate). Blood toxicology: pregabalin 43 mcg/mL, topira-
ate level to 18. She received antibiotics for hyperthermia (T 41.3 C) and mate 6,300 ng/mL.
pantoprazole for coffee-ground emesis. EEG: no seizure activity. Repeat
CT head: diffuse anoxic injury. Based on the prognosis, comfort measures Case 1343. Acute diphenhydramine ingestion: undoubtedly
were instituted and she died on Day 3. responsible
Autopsy Findings: No autopsy results were provided. Scenario/Substances: A 29 y/o female texted friends saying she
wanted to harm herself and was then found unconscious in a car with a
Case 1148. Acute lidocaine, cleaner (cationic): undoubtedly bottle diphenhydramine. There were 64 (50 mg) tablets missing. EMS
responsible found her to be tachycardic with seizure-like activity. She developed PEA
Scenario/substance: An 11 y/o male did not have his usual solution to enroute to the ED but had ROSC after CPR and epinephrine.
flush his cecal port, so his father asked the pharmacist for a saline solu- Laboratory/Diagnostic Findings: Glu 274, ABG- pH 6.7 (then 7.4 after 7
tion that was not in stock. The father asked for a wound wash and was amps of sodium bicarbonate); pO2 350, Na 130, Hgb 14.4 PLT 326. UDS was
referred to topical solutions. He purchased a solution (2.5% lidocaine, negative. Serum salicylate, APAP and ethanol not detected. EKG: QRS 240,
0.013% benzalkonium chloride) and instilled 177 mL into the port. He QTc 520.
rapidly developed a seizure; EMS arrived, transported him to the ED, he Clinical Course: She was intubated upon ED arrival; BP 116/60, HR 120
developed cardiac arrest enroute and they intubated him. (then 180). She received calcium and sodium bicarbonate and was then
Past Medical History: Spina bifida with chronic constipation, with a apparently hallucinating and picking at things in the air. QTc increased
right lower quadrant cecal port (flushed daily with a combination saline from 520 to 615.She received a total of 10 amps of sodium bicarbonate,
and glycerin solution). Prescribed amphetamines. 3 gm MgSO4 and 280 ml 3% saline; Na 158, 3 h later BP 112/82, HR 99.
Clinical Course: He was in cardiac arrest upon ED arrival. PALS was EKG: QRS 40, QTc 601. Patient received piperacillin/tazobactam, albumin
performed, he received naloxone and ILE without response. He was pro- and potassium replacement. Day 2 her pupils were 6 mm and nonreac-
nounced dead shortly after arrival. tive. She was weaned from sedation for several hours and her exam
Autopsy Findings: Femoral blood contained amphetamine 0.13 mg/L, became notable for gaze deviation up and to the left, no cough, gag or
lidocaine 15 mg/L, MEGX 2.7 mg/L. The cause of death: lidocaine toxicity; corneal reflexes, and pupils fixed and dilated. EEG was negative for seiz-
manner of death: accidental. ures. Day 3 she was hypertensive, tachycardic and completely flaccid.
Day 4 cerebral perfusion study confirmed brain death. She died on Day
Case 1151. Acute lidocaine inhalation: undoubtedly responsible 5 and underwent organ donation.
40 D. D. GUMMIN ET AL.
Autopsy Findings: Cause of death: complications of acute diphen- Past Medical History: Hypertension. Medications: amlodipine 5 mg.
hydramine toxicity. Antemortem blood toxicology: diphenhydramine Physical Exam: In the ED she was alert, oriented x 3. BP 80/40, HR
level: 5400 mcg/L. 110, RR 20, O2 sat 96% (RA).
Laboratory/Diagnostic Findings: Na 133/K 3.4/Cl 98/CO2 10/BUN 10/Cr
Case 1369. Acute tilmicosin parenteral: undoubtedly responsible 1.6/Glu 355, AG 25, Ca 9.6, ABG- pH 7.2/pCO2 20/pO2 64/HCO3 8. Lactate
Scenario/Substances: A 54 y/o female injected herself with tilmicosin 8.6, INR 1.02, WBC 54. Serum APAP, ethanol and salicylate not detected.
in a suicide attempt. A coworker at a bovine facility reported a dispute UDS was negative. CxR: left lower lobe infiltrate, ECG: HR 100, QRS 83,
with the woman and the saw her holding a syringe and applying a tour- QTc 369. CT head: unremarkable.
niquet on her arm, stating she was going to kill herself. The woman was Clinical Course: 5 h after ED arrival she was started on an epineph-
soon found unresponsive and bystander CPR was started. She was trans- rine drip and HIE (D10 and insulin at 104 U/h) for an MAP of 51.
ported to an ED by EMS, but was pronounced dead. Police found bottles Epinephrine and insulin were increased, she developed respiratory dis-
of tilmicosin and syringes at the scene. tress 15 h after arrival and was intubated. She had persistent lactic acid-
Past Medical History: Depression with suicidal ideation. osis, decreasing urine output, and hypotension (BP 75/39, HR 102).
Physical Exam (postmortem): Tourniquet on right arm with bruising Pulmonary embolus was suspected and heparin was started. Ca, sodium
and marks on arm, not consistent with IV attempts by EMS. EMS rhythm bicarbonate and norepinephrine were administered. On Day 2 CRRT was
strip showed ‘dysrhythmia.’ started for oliguric renal failure and fluid overload; BP 98/59, HR 83. She
Autopsy: Blood positive for tilmicosin (qualitative analysis only); cause became hypoglycemic (Glu69) and was started on D50 with HIE. Day 3:
of death: Intentional overdose of tilmicosin. BP 95/49, HR 92, lactate 10, on insulin and D50 drips. She remained
unresponsive. Day 10: surgery evaluated her for a possible bowel perfor-
Case 1379. Chronic: methotrexate ingestion: contributory ation but due to critical illness did not recommend surgery. Based on
Scenario/Substances: A 96 y/o female mistakenly received 1 tab the prognosis, comfort measures were instituted and she died on
(2.5mg) of methotrexate daily for 27 days (instead of 5 tablets once a Day 10.
week) at her nursing home. Autopsy Findings: Cause of death: amlodipine overdose; manner of
Past Medical History: Rheumatoid arthritis, Alzheimer’s disease, atrial death: suicide. Toxicology: amlodipine 840 ng/mL.
fibrillation, cardiovascular disease.
Physical Exam: She presented with generalized weakness, nausea and Case 1632. Acute nifedipine ingestion: undoubtedly responsible
confusion. Stomatitis with large wounds on her lips and buttocks. HR 62, Scenario/Substances: An 11 m/o female was found with an open bot-
RR 16, O2 sat 96% (RA), afebrile. tle of nifedipine (30 mg tabs; at least one partially dissolved pill in her
Laboratory/Diagnostic Findings: Glomerular filtration rate 23 ml/min, mouth) 1 h prior to ED arrival.
AST 30, ALT 20, ALP 44, WBC 1.5/Hct 34/PLT 99. Initial methotrexate level Clinical Course: The patient was given a dose of activated charcoal
0.08 mmol/L. but subsequently vomited (including 1 intact pill). She was asymptomatic
Clinical Course: Patient received leucovorin, renal support and sodium for 2 h but then developed atrial block, bradycardia and cardiac arrest.
bicarbonate. MTX level decreased to <0.04 mmol/L over 72 h; WBC nadir 50 min of resuscitation efforts were unsuccessful and she died.
was 0.6. Her renal function improved over the next 4 d; bicarbonate drip Autopsy Findings: Peripheral blood: nifedipine concentration: 870 ng/
was stopped, leucovorin was continued. She received antibiotics for a mL. Visible pill residue within the stomach, duodenum, and proximal
UTI. On Day 6 her WBC increased to 0.8 and PLT 31. She received blood jejunum; petechial hemorrhages of the gastrointestinal mucosa. Cause of
and platelet transfusions. Patient died on Day 16. The chronic MTX tox- death: acute nifedipine toxicity; manner of death: accidental.
icity was thought to have contributed to her death along with her pre-
existing medical conditions. Case 1634. Acute benzonatate and meclizine ingestion: undoubtedly
Autopsy Findings: Per forensic pathologist, clinical symptoms, labora- responsible
tory findings (myelosuppression) and underlying co-morbidities, the dos- Scenario/Substances: A 17 y/o female was found seizing, several
ing error of methotrexate played a contributing role in the decedent’s minutes after locking herself in a bathroom. EMS found her drowsy and
death. No post-mortem toxicology testing was performed. shaking; benzonatate and meclizine bottles were found at the scene.
Laboratory/Diagnostic Findings: K 2.4, HCO3 15.6, BUN 11, Cr 1.35, Glu
Case 1439. Acute-on-chronic: flecainide ingestion: undoubtedly 367, AST 400, ALT 376, bilirubin 0.8.
responsible Clinical Course: The patient was pulseless and apneic upon ED arrival;
Scenario/Substances: A 47 y/o female was found with an empty bottle pupils were fixed and dilated. She was intubated, and resuscitated with
of flecainide. EMS performed cardioversion enroute to the ED. CPR, defibrillation X 5, and sodium bicarbonate boluses with ROSC.
Past Medical History: Atrial fibrillation, mitral valve prolapse and psy- BP 81/47, HR 85, O2 sat 100% (100% FiO2). ILE was given; gastric lavage
chiatric disorder (NOS). Medications: flecainide, metoprolol, cyanocobala- returned pill fragments and she received activated charcoal and placed
min, oxycodone and ranitidine on hypothermic protocol. NAC was started for elevated LFTs. On Day 2
Laboratory/Diagnostic Findings: Na 156/K 2.8/CO2 36/BUN 11/Cr 0.9, hepatic function improved but she remained comatose with decerebrate
AG 18, Ca 7.1, AST 416, ALT 195. Serum ethanol 170. Serum APAP and posturing. Levetiracetam was given for seizure activity on EEG. On Day 3
salicylate not were detected. UDS was negative. ECG: multiple PVCs. she received phenobarbital for increased seizure activity but then again
Clinical Course: In the ED she was responsive to verbal stimuli; SBP showed decerebrate posturing. Based on the poor prognosis, comfort
90s, HR 130s with multiple PVCs. She was given multiple amps of measures and organ donation were instituted, and she died on Day 10.
sodium bicarbonate, atropine, magnesium, vasopressors, ILE and was Autopsy Findings: Cause of death: complications of meclizine and
transcutaneously paced. She had repeated cardiac arrests. EKG: HR 75, benzonatate toxicity; manner of death: suicide. Blood toxicology (pre-
QRS 152 and QTC 625. She was taken to the catheterization lab for pace- mortem, 2.2 h post ingestion): benzonatate 680 mcg/L; meclizine
maker placement and transferred to the ICU. She continued to have VF/ 150 mcg/L.
VT and died early on Day 2.
Autopsy Findings: Cause of death: flecainide and ethanol intoxication. Case 1643. Acute iron ingestion: undoubtedly responsible
Hospital blood flecainide 3.82 mcg/mL. Scenario/Substances: A 47 y/o female ingested a large (unknown)
number of iron tablets in a suicide attempt. She began vomiting and
Case 1456. Acute-on-chronic amlodipine ingestion: undoubtedly presented to the ED.
responsible Physical Exam: Initial BP 133/94, HR 102, RR 20, O2 sat 98% (RA).
Scenario/Substances: A 50 y/o female took 90 (5 mg) tablets of amlo- Laboratory/Diagnostic Findings: Na 138/K 3.9/Cl 103/CO2 18.4/BUN 11/
dipine over several hours in a suicide attempt. She vomited multiple Cr 0.68/Glu 98. ABG- pH 7.07/pCO2 20/pO2 127. WBC 9.2. Serum iron
times and then presented to an ED 45 min later. 562 mcg/dL (then >6,000 on Day 2).
CLINICAL TOXICOLOGY 41
Clinical Course: She was vomiting on ED arrival. Abdominal radiograph brain injury, acute bronchopneumonia with diffused alveolar damage,
showed a radio-opaque mass but individual tablets were not visualized. bilateral, intrapulmonary arterial thromboembolism; recent organ/tissue
She was treated with a sodium bicarbonate drip and deferoxamine (1 g IV procurement.
then 1.5 g 5 h later). She developed shortness of breath, tachypnea and
generalized body pain. The patient unwilling to drink PEG solution for WBI. Case 1657. Acute loperamide ingestion: undoubtedly responsible
She became hypotensive, was started on vasopressors, deferoxamine (2 g/ Scenario/Substances: A 41 y/o female presented to the ED with weak-
h) and WBI. CRRT was initiated for worsening liver and kidney failure. She ness, dizziness and dyspnea.
developed asystole requiring CPR with ROSC. Iron levels were decreasing Past Medical History: Depression, anxiety, opioid and cocaine abuse.
but lactic acidosis increased and hypotension persisted despite vasopres- Medications: mirtazapine, buspirone and gabapentin.
sors. She died in the ICU on Day 3. Physical Exam: Unresponsive, pupils 2 mm and sluggish, myoclonus in
Autopsy Findings: No autopsy results were provided. extremities. BP 97/61, HR 90, RR 20, O2 sat 94% (100% FiO2), T 37 C.
Laboratory/Diagnostic Findings: ABG- pH 7.39/pCO2 53/pO2 61/HCO3
Case 1646. Acute iron ingestion: undoubtedly responsible 31. Na 144/ K 4.0/Cl 105/CO2 31/BUN 23/Cr 1.6/Glu 151. AST 308, ALT
Scenario/Substances: A 10 m/o male was taken by his mother to 340, CK 11,112, lactate 8.5. Serum APAP, ethanol and salicylate not
urgent care after a suspected ingestion of ferrous sulfate tablets; max- detected. ECG: HR 108, QRS 176, QTc 477.
imum exposure was 79 tablets of 325 mg. Clinical Course: She went into cardiac arrest in the ED, had ROSC with
Physical Exam: Lethargic, withdrawing to pain. BP 96/72, HR 136, RR ACLS but then lost pulses again, several times, over the next half hour.
42, O2 sat 98% (RA), T 35.8 C, Thrombolytic was administered for presumptive pulmonary embolus. LE
Laboratory/Diagnostic Findings: VBG- pH 7.27/pCO2 36/pO2 70. Glu U/S was negative for deep vein thrombosis. Myoclonic jerking was
199, fibrinogen 60, INR 4.3. Serum ethanol, APAP and salicylate noted, EEG revealed burst suppression. Bicarbonate drip was initiated
not detected. (for QRS of 214 ms) and antibiotics were started. Her brother then
Clinical Course: The child was immediately transferred to a PICU reported that she was recently using ‘a laxative’ to get high, mother
where he was intubated. Abdominal x-ray showed 55 visible pills. An reportedly found empty loperamide boxes at home; a loperamide level
NGT was placed for WBI; IV deferoxamine was started at 15 mg/kg/hr. was ordered (send out). On Day 2, myoclonus continued, QRS 120, QTc
The child was taken for emergent endoscopy; 26 tablets were removed 594. On Day 3 MRI revealed diffuse ischemic injury and cerebral edema.
(4 from the esophagus, 22 from the stomach). His pH dropped to 6.81; a Based on the prognosis, the family opted for comfort measures and she
central line was placed for fluid resuscitation. ECG showed a bundle died on Day 11.
branch block. The deferoxamine drip was increased to 45 mg/kg/hr; he Autopsy Findings: Cause of death: anoxic encephalopathy due to
was started on exchange transfusion. The first serum iron concentration loperamide intoxication. Loperamide and metabolite concentrations
returned at 931 mcg/mL, repeated level was 7,739 mcg/mL. While prepar- returned ‘elevated.’
ing for ECMO the child went into cardiac arrest. He was resuscitated
with CPR and ACLS, then cooled and started on dopamine (20 mcg/kg/ Case 1739. Acute diazepam, gabapentin, citalopram ingestion:
min) and epinephrine (0.4 mcg/min) drips. ECMO was started along with undoubtedly responsible
CRRT for anuria; deferoxamine was continued. WBI was stopped due to Scenario/substance: A 12 y/o female was found unresponsive by fam-
oral secretions and decreased bowel sounds. He developed coagulop- ily after last being seen normal the previous evening. She received 4 mg
athy (d-dimer 69,000, PTT 70.8, fibrinogen 78) and acidosis (lactate 4.8). naloxone by EMS without response and was intubated on scene.
Serum iron concentration decreased to 1,175 mcg/ml, and then 475 mcg/ Medications available at home: lorazepam, tramadol, gabapentin, losar-
mL (after 80 % exchange transfusion). He developed abdominal compart- tan, hydrochlorothiazide, APAP, ibuprofen, atomoxetine, fluoxetine, mon-
ment syndrome and underwent abdominal fasciotomy. On Day 3 his telukast and eszopiclone.
repeat serum iron concentration was 246 mcg/ml; BP 75/40 and HR Physical Exam: BP 68/28, HR 98, RR 21, O2 sat 31% on BVM, T 36.3 C.
145.Visual inspection of bowel and liver showed edema; arterial pH was She was unresponsive, pupils were 2 mm and sluggish. She had clonus
6.096. Based on his poor prognosis the family opted for comfort measure in lower extremities with normal reflexes.
and he died. Laboratory/Diagnostic Findings: ABG- pH 7.11/pCO2 53/pO2 92/HCO3
Autopsy Findings: Not performed. 17/BE -13. Na 141/K 3.4/Cl 107/CO2 19/BUN 19/Cr 1.72/Glu 243, AG 15.
Lactate 7.3, AST 34, ALT 27, bilirubin 1.2. INR 1.3, ammonia 74. WBC
Case 1649. Acute loperamide, atropine/diphenoxylate, trazodone 27.7/Hgb 12.5/Hct 37/PLT 424. Serum APAP, ethanol and salicylate not
ingestion: undoubtedly responsible detected, UDS was positive for benzodiazepines. CxR and CT head were
Scenario/Substances: A 23 y/o female was found unresponsive and unremarkable. ECG: HR 120 with peaked T waves, QRS 84, QTc 497.
cyanotic by her mother who started CPR and called 911. EMS trans- Clinical Course: The patient presented to the ED unresponsive and
ported to the ED. hypotensive with the ETT in her esophagus. She was re-intubated and
Past Medical History: Anxiety, depression, hypertension. Patient was in started on vasopressors and IVFs, then transferred to a PICU. On arrival,
the ED the day before for using high quantities of loperamide and the patient’s HR was in the 140s; she was given sodium bicarbonate and
diphenoxylate/atropine for opioid dependency. She was discharged antibiotics and placed on an EEG monitor. On Day 3, she developed epi-
home with clonidine patches. sodes of bigeminy, increased oxygen requirements, fevers, acute kidney
Laboratory/Diagnostic Findings: Na 140/K 4.5/Cl 104/CO2 13/Cr 0.9, AG injury. The EEG was initially abnormal and then showed no brain activity.
23, Mg 2.4, ALT 82, bilirubin 0.3. Serum APAP and salicylate not detected. Brain MRI revealed severe anoxic brain injury. She was declared brain
CxR: pulmonary edema. CT head: diffuse ischemic injury with edema. dead and died on Day 4.
Repeat labs: AST 227, ALT 1188, ALP 169, K 2.5. Autopsy Findings: Urine collected in the ED showed diazepam 20 ng/
Clinical Course: She arrived in the ED with a wide complex tachycar- ml, nordiazepam 68 ng/ml, oxazepam 32 ng/ml and temazepam 410 ng/
dia (HR 100s, QRS 120) and “good” BP. She was intubated and received ml. ED blood demonstrated gabapentin 1.5 mcg/ml. Antemortem periph-
naloxone (no response), 2 amps of sodium bicarbonate, magnesium and eral blood drawn 2 h from being found demonstrated citalopram
amiodarone. She became hypotensive (72/39). Almost 15 h later she 0.42 mg/L, diazepam 0.98 mg/L, gabapentin 24 mg/L, nordiazepam
remained unstable on epinephrine, norepinephrine and vasopressin 0.067 mg/L; urine demonstrated benzodiazepines, caffeine, citalopram,
drips; she was unresponsive off sedation. On Day 3 the patient was gabapentin/pregabalin and ondansetron. Autopsy demonstrated cerebral
declared brain dead and she was transferred to the OR for edema with herniation, pulmonary edema and acute pneumonia. Cause
organ donation. of death: hypoxic ischemic encephalopathy due to respiratory failure due
Autopsy Findings: Cause of death: mixed drug toxicity. Post-mortem to diazepam and gabapentin toxicity.
blood toxicology: desmethylloperamide 58 ng/ml, mCPP 65 ng/ml, trazo-
done 2.4 mcg/ml. Post-mortem urine toxicology positive for trazodone. Case 1879. Acute U-47700, para-fluorobutyryl fentanyl and psycho-
Autopsy: acute transmural myocardial infarction, global hypoxic-ischemic active benzodiazepines ingestion: undoubtedly responsible
42 D. D. GUMMIN ET AL.
Scenario/Substances: A 23 y/o male was seen somnolent and intermit- Clinical Course: He was treated with lorazepam 2 mg, haloperidol
tently snoring. Later that day he was found apneic and cyanotic. CPR 8 mg and labetalol 20 mg IV. Just prior to transfer he was intubated with
was started; EMS found him to be in PEA arrest. He was intubated, etomidate and rocuronium; received dextrose for a Glu of 7. He was
successfully resuscitated, and transported to the ED. transferred to a tertiary care center where he arrived with T 38.3 C, BP
Past Medical History: 2 recent ED visits for headaches and back pain; he 84/50, HR 148 on norepinephrine drip at 4 mcg/h after 3 L NS. He also
was discharged with prescriptions for hydrocodone and cyclobenzaprine. received activated charcoal, high dose insulin, methylene blue, Ca,
Physical Exam: In the ED he was unresponsive, pupils were fixed and sodium bicarbonate, vasopressin, epinephrine and phenylephrine, cryo-
dilated. He had a frontal abrasion and hematoma. BP 60/40, HR 84, O2 precipitate, fresh frozen plasma, PLTs and antibiotics. He developed
sat 100% (intubated), T 34 C. acute respiratory failure with persistent hypotension, anuria, rhabdo-
Laboratory/Diagnostic Findings: VBG- pH 7.12/pCO2 58/pO2 67. Lactate myolysis and DIC. He was resuscitated from 2 cardiac arrests. Based on
9.4, NA 146/K 6.7/CL 107/CO2 25/BUN 22/Cr 3.14/Glu 85, AG 14, AST 1,192, the prognosis, the family opted for institution of comfort measures and
ALT 1,348, bilirubin 0.4, WBC 12.7/Hgb 11.6/HCT 39.4/PLT 225, troponin 1.9. he died after a third cardiac arrest.
UDS was positive for opiates, benzodiazepines and tricyclic antidepressants. Autopsy Findings: A small (empty) plastic bag was found in the stom-
CxR: aspiration pneumonia. CT head: cerebral edema with herniation. ach. Cerebral and pulmonary edema were noted. Post mortem blood:
Clinical Course: He was admitted to the ICU and required aggressive methamphetamine 5.29 mg/L, amphetamines and etomidate detected,
fluid resuscitation and vasopressors for hypotension. He was placed alprazolam 0.016 mg/L, midazolam 0.017 mg/L. Cause of death: metham-
on a hypothermia protocol; his brainstem reflexes remained absent and phetamine toxicity.
he was declared brain dead. Based on the prognosis, comfort measures
were instituted and he died on Day 2.
Case 2131. Acute-on-chronic: cocaine rectal: undoubtedly responsible
Autopsy Findings: Antemortem blood analysis: U-47700 5.2 ng/mL, flubro-
Scenario/Substances: A 37-year-old male placed a bag containing
mazepam 450 ng/mL, etizolam 29 ng/mL, delorazepam 82 ng/mL, diclazepam
1 g of cocaine into his rectum to evade police discovery. 6 h later, he
33 ng/mL, para-fluorobutyryl fentanyl/fluoroisobutyryl fentanyl 5.8 ng/mL,
tore the bag upon attempted removal and reported the event to
oxycodone (free) 15 ng/mL. Cause of death: “U-47700 and para-fluorobutyryl
fentanyl/FIBF intoxication [and] psycho-active benzodiazepines.” authorities.
Past Medical History: Substance abuse.
Physical Exam: He was alert, calm and following commands upon ED
Case 1943. Unknown carfentanil, alprazolam and cocaine exposure:
arrival, with a surgery scar over his abdomen. Initial VS: BP 166/90, HR
probably responsible
86, RR 18, O2 sat 96%, T 37 C.
Scenario/ Substances: A 26 y/o female was found in asystole by EMS.
Laboratory/Diagnostic Findings: Na 146/K 5.0/Cl 100/CO2 22/BUN 14/
CPR, naloxone, epinephrine and bicarbonate were administered with
Cr 1.57/Glu 71 /AG 24, AST 187, ALT 117.
ROSC prior to ED transport.
Clinical Course: He initially refusal a rectal exam; received Mg citrate
Past Medical History: Bipolar disorder, drug abuse.
and remained asymptomatic. He was sleeping with normal VS 5 h later;
Physical Exam: She was intubated with no spontaneous activity. Initial
no bowel movement. 2 h later, while on the commode, he was noted to
VS in the ICU: BP 105/92, HR 83, RR 22, O2 Sat 100%, (FIO2 30%), T 31 C
be agitated with mumbling speech and spastic movements. He fell, strik-
(prior to cooling).
ing his head, and developed repetitive seizures; he was treated with lor-
Laboratory/ Diagnostic Findings: ABG- pH 7.22/pO2 291/pCO2 35/HCO3
14. Na 142/K 4.8/Cl 97/CO2 15/BUN 16/Cr 1.7/Glu 478, AG 30, AST 320, azepam. He developed wide complex PEA. He was intubated, received
ALT 220, WBC 39/Hgb 10.8/Hct 35/PLT 348. Serum APAP, ethanol and CPR, amiodarone, dextrose, calcium, bicarbonate and epinephrine, with
salicylate not detected. UDS was negative. ECG: HR 99, QRS 90, QTc 439. ROSC after 20 minutes. He remained in status epilepticus and was
CxR: bilateral pleural effusions and perihilar opacities. treated with propofol, fosphenytoin and lorazepam. Numerous pieces of
Clinical Course: The patient was intubated upon arrival and started on a while chunky substance was removed from his rectum. He developed
hypothermia protocol in the ICU. She received IVFs, sodium bicarbonate, pulseless VT and died, 15 h after insertion, despite resuscitation efforts.
analgesics, antibiotics and vasopressors. On Day 3 rewarming was com- Autopsy Findings: Two plastic bag fragments in lower bowel with
pleted. A brain perfusion scan was consistent with brain death. Based on white material adherent to rectal mucosa were found. Post mortem heart
the prognosis, comfort measures were instituted and she died on Day 4. blood demonstrated benzodiazepines, cocaine metabolite, and
Autopsy Findings: Cause of death: anoxic encephalopathy from levamisole. Post mortem iliac vein blood showed cocaine >2 mg/L,
carfentanil intoxication; manner of death: accidental. Antemortem urine benzoylecgonine >4.0 mg/L, and lorazepam 0.067 mg/L. Cause of death:
was positive for alpha-hydroxyalprazolam, benzoylecgonine and carfenta- cocaine toxicity; manner of death: accidental.
nil. Antemortem blood testing was positive for alprazolam 15 ng/ml.
Case 2141. Unknown methamphetamine ingestion: undoubtedly
Case 2034. Acute mitragyna speciosa korthals exposure: undoubt- responsible
edly responsible Scenario/Substances: A 37 y/o male ingested a large amount
Scenario/Substances: A 31 y/o male reportedly purchased Kratom of methamphetamine for unknown reasons. Friends called EMS, who
capsules and poured the powder into cups. He was found dead by found him combative, diaphoretic and hyperthermic.
Sheriff’s deputies. Past Medical History: Bipolar disorder, substance abuse, pancreatitis,
Autopsy Findings: Post-mortem toxicology found: mitragynine: 990 ng/ GI bleed.
mL; positive for cyclobenzaprine, tramadol, quetiapine, 7-aminoclonaze- Physical Exam: BP 96.57, HR 180, RR 30, O2 sat 90% (nasal catheter,
pam, morphine/codeine/laudanoside. 4L/min), T 40 C.
Laboratory/Diagnostic Findings: ABG- pH 7.24/pCO2 50/pO2 64/HCO3
Case 2060. Acute methamphetamine ingestion: probably responsible 22. K 7.3, CO2 18, BUN 23, Cr 2.88, AST 437, ALT 206, CK >22,000. UDS
Scenario/Substances: A 33 y/o male swallowed 3 g of methampheta- was positive for amphetamines and benzodiazepines.
mine to evade police detection. 2 d later he presented to the ED. Clinical Course: In the ED he was intubated and sedated with
Past Medical History: Chronic substance abuse, prior overdose. benzodiazepines, paralyzed and actively cooled, and received IVFs and
Physical Exam: He presented with paranoid ideation and agitated empiric antibiotics. He developed multiple organ failure, rhabdomyolysis
delirium. BP 128/86, HR 126, RR 24, T 37 C. and shock liver (transaminases >1,000) and hypotension requiring
Laboratory/Diagnostic Findings: WBC 15, lactate 2.9, CK 215. UDS was vasopressors. CRRT was initiated for renal failure. Brain imaging demon-
positive for amphetamines, methamphetamines and benzodiazepines. strated herniation and he died on Day 6.
Serum ethanol, salicylate and APAP were not detected. Subsequent labs: Autopsy Findings: Blood analyses revealed the following: metham-
lactate 9.6, troponin 4.87, Cr 3.54, AST 815, ALT 326, CK 45,219, PLTs 43, phetamine 4,600 ng/mL, amphetamine 170 ng/mL, lorazepam 22 ng/mL
fibrinogen <60, PTT >250, PT >120. EKG: ST at 128, QTc 580. CT head: and lamotrigine 1.2 mcg/mL. Cause of death: “complications of metham-
negative. CxR: RUL infiltrate. phetamine abuse.”
CLINICAL TOXICOLOGY 43
Case 2615. Acute methamphetamine/amphetamine and hydrocarbon BE base excess, ¼ base excess [±2mEq/L or mmol/L]
ingestion and aspiration: undoubtedly responsible bicarbonate [22–26] mmol/L
Scenario/Substances: A 13 m/o male (7.7 kg) was found agitated bili (direct) direct bilirubin [0.1, 0.4] mg/dL
and crying, with liquid on his face. Parents reported that he bili (indirect) indirect bilirubin [0.2, 0.9] mg/dL
ingested aftershave. bilirubin total [0.3–1.3] mg/dL
Physical Exam: He presented to the ED somnolent with his eyes rolled BiPAP bilevel positive airway pressure, pressure support with
back into his head. Initial VS: HR 132, RR 20, O2 sat 98% (RA), T 36 C. 2 levels of continuous positive airway pressure
Laboratory/Diagnostic Findings: Na 133/K 4/CO2 20/BUN 6/Cr 0.2/Glu BLQ below the limit of quantitation
194, AST 38, ALT 13, ALP 320. WBC 15/Hgb 11/Hct 33. Serum ethanol BMI body mass index
not detected. CxR: bilateral infiltrates. BNPT prohormone with a 76 amino acid N-terminal inactive
Clinical Course: Upon arrival to the ED, he was tachypneic, foaming protein that is cleaved from the molecule to release
from his mouth, and developed multiple seizures unresponsive brain natriuretic peptide. CHF is likely if
to lorazepam. He was intubated but became hypotensive and then BNPT >125 pg/mL (<75 y/o), > 450 pg/mL (>75 y/o),
went into cardiac arrest. He received CPR, IVFs, sodium bicarbonate body packing insertion of drugs into body orifices to evade law
and vasopressors. Resuscitation was unsuccessful and the patient died enforcement
on Day 1. body stuffing the ingestion of drugs in order to evade law enforcement
Autopsy Findings: Blood toxicology: amphetamine 590 ng/mL, BP Blood Pressure, systolic/diastolic, (Torr)
methamphetamine >1,000 ng/mL, lorazepam positive. No history of BPH benign prostatic hypertrophy
amphetamine prescription or exposure was reported by the parents. BUN see Urea nitrogen
C degrees Centigrade
Ca (ionized) ionized calcium, [4.5–5.6] mg/dL
Abbreviations & normal ranges for narratives. Disclaimer – all
Ca calcium [8.7–10.2] mg/dL
laboratories are different and provide their own normal ranges. Units
CABG coronary artery bypass graft
and normal ranges are provided here for general guidance only. These
CAD coronary artery disease
values were taken from Harrison’s [10], Goldfrank [11] or Dart [12].
CHF congestive heart failure
CIWA Clinical Institute Withdrawal Assessment for Alcohol
Typical laboratory panels: ABG-pH/pCO2/pO2/HCO3/BE CK creatinine kinase (CPK), total: [39–238] U/L females,
Basic metabolic panel: Na/K/Cl/CO2/BUN/Cr/Glu/AG, [51–294] U/L males
Complete blood count: WBC/Hgb/Hct/platelets, CKMB MB fraction of CK [0.0–5.5 mcg/L ¼ 0.0–5.5 ng/mL]
Fraction of total CK activity [0–0.04 ¼ 0–4.0%]
Cl chloride [102–109] mEq/L
ABBREVIATIONS & NORMAL RANGES CMV cytomegalovirus
CNS central nervous system
approximately ABG-pH/pCO2/pO2/HCO3/BE
COHb carboxyhemoglobin (RR < 3%)
ABG arterial blood gases
COPD chronic obstructive pulmonary disease
pH hydrogen ion concentration [7.38–7.42 mmHg]
CPAP continuous positive airway pressure
pCO2 partial pressure of carbon dioxide [38–42 mmHg]
CPR cardio pulmonary resuscitation
pO2 partial pressure of oxygen [90–100 mmHg]
Cr creatinine [0.5–0.9] mg/dL females, [0.6–1.2] males,
HCO3 bicarbonate [22–28 mEq/L]
CRRT continuous renal replacement therapy
BE base excess [±2mEq/L or mmol/L]
CSF cerebrospinal fluid
ACLS advanced cardiac life support, protocol for the provision
CT computed tomography (CAT scan)
of cardiac resuscitation
CVA cerebrovascular accident
ADHD attention deficit hyperactivity disorder
CVVH continuous venovenous hemodiafiltration
AF atrial fibrillation
CxR chest radiograph, chest xray
AG anion gap Na – (Cl þ HCO3) [12 ± 4 mEq/L or mmol/L]
D10W 10% dextrose in water
AICD automatic implanted cardiodefibrillator
D50W 50% dextrose in water
AKI acute kidney injury
D5NS 5% dextrose in normal saline
ALP alkaline phosphatase [13–100] U/L
D5W 5% dextrose in water
ALT Alanine aminotransferase [7–41] U/L ¼ (SGPT)
Day when capitalized, Day ¼ hospital day, i.e., days since
AMA against medical advice
admission to the initial hospital admission for
ammonia [25–80] mcg/dL
this exposure
[15–47] mcmol/L
DIC disseminated intravascular coagulation
amp ampoule
DM diabetes mellitus
amphetamines
DNI do not intubate
(hallucinogenic) one or more of the products (6-APB, bath salts, plant
DNR do not resuscitate
food, Bliss, Ivory Wave, Purple Wave, Vanilla Sky,
drip intravenous infusion
et al) or chemicals (3,4 methylenedioxypyrovalerone
Dx diagnosis
[MDPV], 6-(2-aminopropyl)benzofuran [6-APB], butylone,
ECG electrocardiogram (EKG), leads ¼ I, II, III, aVR, aVL, aVF,
desoxypipradrol [2-DPMP], ethylone, flephedrone, V1, V2, V3, V4, V5, V6
naphyrone, mephedrone, methylenedioxypyrovalerone, ECHO echocardiogram
methylone, methcathinone, et al) ECMO extracorporeal membrane oxygenation
AMS altered mental status ED emergency department, in these abstracts refers to the
APAP acetaminophen (acetyl-para-aminophenol), therapeutic initial health care facility
[10–20] mcg/mL EDDP principal methadone metabolite, 2-ethylidene-1,5-
APLS advanced pediatric life support, protocol for the provision dimethyl-3,3-diphenylpyrrolidine
of cardiac resuscitation EEG electroencephalogram
aPTT activated partial thromboplastin time [30–40] sec EGD esophagogastroduodenoscopy
ARDS acute respiratory distress syndrome ELISA enzyme-linked immunosorbent assay
AST Aspartate aminotransferase [12–38] U/L ¼ (SGOT) EMS emergency medical services, paramedics, the
AV block atrio-ventricular block first responders
BAL British anti-Lewisite
44 D. D. GUMMIN ET AL.
THC Homolog one or more of the products (Blaze, Dawn, herbal WBI whole bowel irrigation
incense, K2, Red X, spice, et al) or chemicals (cannabicyclo- WNL within normal limits
hexanol, CP-47,497, JWH-018, JWH-073, JWH-200, et al) y/o year old
TPN total parenteral nutrition
Tprot total protein
troponin troponin I, normal range [0–0.08] ng/mL, Cut-off for APPENDIX D
MI > 0.04 ng/mL
TTE transthoracic echocardiogram
U units
U/dL units per deciliter
U/L units per liter
U/mL units per milliliter
UA urinalysis
UDS urine drug screen
Urea nitrogen
(BUN) [6–17] mg/dL
VBG venous blood gases
VF ventricular fibrillation
VSD ventricular septal defect
VT ventricular tachycardia
WBC white blood cell (leukocyte) count [3.54–9.06]
10 3 /mm 3
46 D. D. GUMMIN ET AL.
APPENDIX E
Automotive/Aircraft/Boat Products
134h 28 y M A Ingst Int-S 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 1408 mg/L In Serum @ Unknown
135 32 y M A Ingst Int-S 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 1000 mg/dL In Blood (unspecified) @
34 h (pe)
ethanol 2 2
[136h] 35 y M A Ingst Int-A 1
ethylene gylcol/methanol 1 1 methanol 620 mg/dL In Blood (unspecified)
@ Unknown
137pa 36 y M U Ingst Unk 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 0 mg/dL In Blood (unspecified) @
1 h (pe)
138h 44 y M A Ingst Int-S 2
ethylene glycol (antifreeze) 1 1
139pai 48 y F U Ingst Int-S 1
ethylene glycol (antifreeze) 1 1
140ph 50 y M A Ingst Int-S 2
ethylene glycol (antifreeze) 1 1
141h 53 y M A/C Ingst Unk 3
ethylene glycol (antifreeze) 1 1 ethylene glycol 13 mg/dL In Serum @ Unknown
acetaminophen 2 2
142 54 y F A Ingst Int-S 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 36 mg/dL In Blood (unspecified)
@ Unknown
143ha 55 y M A Ingst Int-M 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 72 mg/dL In Blood (unspecified)
@ Unknown
methanol 2 2 methanol 289 mg/dL In Blood (unspecified)
@ Unknown
144 57 y M C Ingst Int-S 2
methanol 1 1
ethanol (non-beverage) 2 2
145 65 y M A Ingst Unk 2
ethylene glycol (antifreeze) 1 1
146ha 68 y M A Ingst Int-S 2
ethylene glycol (antifreeze) 1 1
147 68 y M A Ingst Int-S 2
ethylene glycol (antifreeze) 1 1
venlafaxine 2 2
ethanol 3 3 ethanol 236 mg/dL In Serum @ Unknown
glyphosate 4 4
drain cleaner (alkali) 5 5
148h 69 y F A Ingst Int-S 1
ethylene glycol (antifreeze) 1 1 ethylene glycol 225 mg/dL In Blood (unspecified)
@ Unknown
149h 91 y F A Ingst Unt-G 3
ethylene glycol (antifreeze) 1 1 ethylene glycol 11 mg/dL In Blood (unspecified) @
1 h (pe)
See Also case 305
Batteries
[150h] 2yF A Ingst Unt-G 1
battery, disc 1 1
Chemicals
[156ha] 19 y M A Par þ Oth Int-M 1
silicone 1 1
157 31 y F A Ingst Int-S 2
ethylene glycol 1 1
ethanol 2 2
[158a] 35 y F A Par Oth-M 1
cyanide 1 1 cyanide 3.4 mcg/mL In Blood (unspecified) @
1 h (pe)
cyanide 1 1 cyanide 4.053 mg/L In Blood (unspecified) @
4 h (pe)
159ai 35 y M U Unk Int-S 1
sodium azide 1 1
160h 36 y M A Ingst Int-S 1
sulfuric acid 1 1
(continued)
52 D. D. GUMMIN ET AL.
Fumes/Gases/Vapors
219pha 4yM A Inhal Unt-E 1
carbon monoxide 1 1
carbon monoxide 2 1 ethanol 0 mg/dL In Blood (unspecified)
@ Autopsy
carbon monoxide 2 1 carboxyhemoglobin 46 % In Blood (unspecified) @ Autopsy
[220pha] 4yM A Inhal Unt-E 1
carbon monoxide 1 1
221pha 6yM A Inhal Unt-E 1
carbon monoxide 1 1 ethanol 0 mg/dL In Blood (unspecified)
@ Autopsy
carbon monoxide 1 1 carboxyhemoglobin 49% In Blood (unspecified) @ Autopsy
carbon monoxide 2 2 carboxyhemoglobin 49 % In Blood (unspecified) @ Autopsy
222pi 6yM A Inhal Unt-G 2
carbon monoxide 1 1
223ph 7yF A Inhal Unt-E 1
carbon monoxide 1 1
224p 7yM A Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 20 % In Whole Blood @ Unknown
225p 7yM A Inhal Unt-E 2
carbon monoxide 1 1
226pa 8yM A Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 27 % In Blood (unspecified)
@ Unknown
227pi 10 y F C Inhal Unt-E 1
carbon monoxide 1 1
228pi 13 y M A Inhal Unt-E 1
carbon monoxide 1 1
229pi 16 y M A Inhal Unt-E 1
carbon monoxide 1 1
[230ph] 16 y M U Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 0.3 % In Blood (unspecified)
@ Unknown
carbon monoxide 1 1 carboxyhemoglobin 32.6 % In Blood (unspecified)
@ Unknown
carbon monoxide 1 1 carboxyhemoglobin 7.5 % In Blood (unspecified)
@ Unknown
231pa 19 y F A Inhal Oth-M 1
carbon monoxide 1 1 carboxyhemoglobin 60.001 % In Blood (unspecified)
@ Autopsy
232pa 21 y F A Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 43 % In Blood (unspecified) @ Autopsy
233pi 21 y M A Inhal Unt-G 2
carbon monoxide 1 1
234pa 23 y M A Ingst Int-S 1
nitrogen 1 1
clonazepam 2 2 clonazepam 0.1 mg/L In Blood (unspecified)
@ Autopsy
235pi 24 y M A Inhal Unt-O 1
hydrogen sulfide 1 1
methane 2 2
236pha 24 y M A Inhal Int-S 1
propane 1 1
237p 24 y F A Inhal Unt-E 2
carbon monoxide 1 1
238p 24 y M A Inhal Unt-E 1
carbon monoxide 1 1
hurricane related 2 2
239pa 25 y F A Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 54 % In Blood (unspecified) @ Autopsy
240pi 27 y F A Inhal Unt-G 2
carbon monoxide 1 1
241ph 28 y M A Inhal Unk 2
carbon monoxide 1 1
242pi 29 y M U Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 47 % In Blood (unspecified) @ Autopsy
243pi 34 y M A Inhal Unt-O 1
hydrogen sulfide 1 1
methane 2 2
244pi 34 y F A Inhal Unt-E 2
carbon monoxide 1 1
245pi 34 y F U Inhal Unt-E 1
carbon monoxide 1 1
246p 35 y M A Inhal Int-S 1
helium 1 1
247ph 37 y M A Inhal Unt-E 1
carbon monoxide 1 1 carboxyhemoglobin 75.4 % In Blood (unspecified)
@ Unknown
248pa 40 y M A Inhal Oth-M 1
(continued)
CLINICAL TOXICOLOGY 55
Hydrocarbons
289ai 17 y M U Inhal Int-A 1
hydrocarbon (fluorinated) 1 1
290i 17 y M U Unk Unt-U 2
hydrocarbon (fluorinated) 1 1
291ai 20 y M C Inhal Int-A 3
hydrocarbon (fluorinated) 1 1
292h 23 y F A Inhal Unk 2
hydrocarbon (fluorinated) 1 1
293pha 25 y M A Inhal Int-A 2
hydrocarbon (fluorinated) 1 1
294ha 26 y M C Inhal Int-A 1
hydrocarbon (fluorinated) 1 1
295pha 27 y M A/C Unk Int-S 1
hydrocarbon (fluorinated) 1 1 1,1-difluoroethane 19 mcg/mL In Blood (unspecified)
@ Autopsy
cocaine 2 2
nitric oxide 3 3
alprazolam 4 4
acetaminophen/hydrocodone 5 5
296ph 27 y F A/C Inhal Int-A 1
hydrocarbon (fluorinated) 1 1
297 30 y F A Inhal Int-M 1
hydrocarbon (fluorinated) 1 1
298 31 y M A Inhal Int-A 1
hydrocarbon (fluorinated) 1 1
299pa 32 y M C Inhal Int-A 1
hydrocarbon (fluorinated) 1 1 1,1-difluoroethane 51 mcg/mL In Blood (unspecified)
@ Unknown
hydrocarbon (inhalation) 2 1
300ph 32 y M A Inhal Int-A 1
(continued)
CLINICAL TOXICOLOGY 57
Pesticides
332pa 7yM C Inhal Unt-E 1
aluminum phosphide 1 1
[333ha] 9yM U Unk Unk 1
aluminum phosphide 1 1
334pha 11 y U C Inhal Unt-E 1
aluminum phosphide 1 1
[335ha] 17 y F C Inhal Unt-E 1
aluminum phosphide 1 1
336ha 19 y M A Ingst Int-A 1
dinitrophenol 1 1
337h 20 y M A Ingst Int-S 1
dinitrophenol 1 1
338p 22 y M A Ingst Int-S 1
phosphine 1 1
339ha 26 y M A Ingst Int-S 1
dinitrophenol 1 1
340pha 27 y M A Ingst Int-S 1
dinitrophenol 1 1
341h 27 y M U Ingst Int-S 2
dinitrophenol 1 1
342h 30 y M A Ingst þ Unk Unk 2
glyphosate 1 1
methamphetamine 2 2
343h 31 y M A Inhal Unt-O 2
methyl bromide 1 1
344ha 35 y M A Ingst Int-S 1
glyphosate 1 1
[345ha] 36 y M A Inhal Unt-E 1
sulfuryl fluoride 1 1
346h 42 y M A Ingst Int-S 2
chlorfenapyr 1 1
ethanol 2 2 ethanol 238 mg/dL In Blood (unspecified)
@ Unknown
[347ha] 42 y M A Ingst Int-S 1
dinitrophenol 1 1
348p 47 y M C Inhal þ Derm Unt-E 2
pesticide, unknown 1 1
349h 47 y M A Ingst Int-S 1
organophosphate 1 1
350pa 50 y M A Ingst Int-U 3
glyphosate 1 1 amphetamine 31 ng/mL In Serum @ Autopsy
glyphosate 1 1 methamphetamine 407 ng/mL In Serum @ Autopsy
351 55 y M A Ingst Int-S 2
organophosphate 1 1
352h 59 y M U Ingst Int-S 2
rodenticide (antocoagulant) 1 1
drug, unknown 2 2
353pha 63 y M A Ingst Int-U 3
cyhalotrhin/prallethrin 1 1
354h 69 y M A Ingst Int-S 2
pesticide, unknown 1 1
355h 70 y M A Ingst Int-S 2
glyphosate 1 1
ethanol 2 2
[356h] 71 y M A Ingst Unt-M 1
paraquat 1 1
357h 84 y M A Inhal Unt-E 3
organophosphate 1 1
phosmet 2 2
captan 3 3
See Also case 147
Plants
358a 18 y M U Ingst Int-S 1
plant, cardiac glycoside 1 1
ethanol 3 2
methamphetamine 2 2
359h 22 y F A Ingst Int-S 1
plant, cardiac glycoside 1 1
[360pha] 30 y F A Par AR-D 1
(continued)
CLINICAL TOXICOLOGY 59
Gastrointestinal Preparations
1648ai 19 y M U Ingst þ Unk Int-A 1
loperamide 1 1
clonazepam 2 2
ethanol 3 3
[1649pha] 23 y F A Ingst Int-U 1
loperamide 1 1 desmethylloperamide 56 ng/mL In Blood (unspecified)
@ Unknown
atropine/diphenoxylate 2 2
trazodone 3 3 trazodone 2.4 mcg/mL In Blood (unspecified)
@ Unknown
trazodone 3 3 mcpp (meta- 65 ng/mL In Blood (unspecified)
chlorophenylpiperazine) @ Unknown
1650ph 30 y F A Ingst þ Aspir Int-A 1
loperamide 1 1 desmethylloperamide 160 ng/mL In Serum @ Unknown
loperamide 1 1 loperamide 54 ng/mL In Serum @ Unknown
1651h 30 y M A Ingst Int-S 1
loperamide 1 1
gabapentin 2 2
ethanol 3 3 ethanol 210 mg/dL In Serum @ 1 h (pe)
1652pha 31 y M A Ingst Int-S 2
(continued)
CLINICAL TOXICOLOGY 127
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Nonpharmaceuticals
Adhesives/Glues
Miscellaneous Adhesives/Glues
D. D. GUMMIN ET AL.
Cyanoacrylates (Superglues, etc) 4,381 4,316 1,887 354 265 1,424 15 322 49 4,141 117 21 23 1,185 634 858 130 2 0
Epoxy 630 583 164 14 18 317 2 62 6 556 8 4 12 182 87 141 55 1 0
Non-Toxic Adhesives/Glues (White Glue, 1,224 965 560 247 70 60 4 21 3 890 63 6 3 48 95 51 5 0 0
Paper Glue, etc)
Toluene/Xylene (Adhesives Only) 253 236 103 7 10 97 0 15 4 219 13 0 3 48 33 45 8 0 0
Unknown Types of Adhesive, Glue, 4,248 3,868 1,603 407 205 1,207 8 394 44 3,605 163 34 52 583 585 556 101 7 0
Cement or Paste
Category Total: 10,736 9,968 4,317 1,029 568 3,105 29 814 106 9,411 364 65 93 2,046 1,434 1,651 299 10 0
Alcohols
Miscellaneous Alcohols
Ethanol (Beverages) 54,446 8,151 1,976 196 941 4,513 13 418 94 2,628 4,850 328 159 4,449 979 2,059 1,300 253 66
Ethanol (Non-Beverage, 3,067 2,244 1,442 119 94 520 2 55 12 1,922 259 33 14 326 402 243 62 14 0
Non-Rubbing)
Higher Alcohols (Butanol, Amyl Alcohol, 120 92 37 6 3 40 0 6 0 84 6 0 0 30 16 18 10 0 0
Propanols, etc)
Isopropanol (Excluding Rubbing Alcohols 3,935 3,409 1,439 146 194 1,420 3 187 20 2,557 770 30 25 1,026 626 677 311 40 0
and Cleaning Agents)
Methanol (Excluding Automotive Products 675 551 105 8 40 342 1 48 7 477 52 8 4 224 120 97 24 12 7
and Cleaning Agents)
Other Types of Alcohol 189 168 107 7 7 40 0 5 2 156 9 0 3 31 46 15 4 1 0
Unknown Types of Alcohol 1,032 277 63 9 34 141 3 17 10 112 131 5 7 127 25 56 34 22 5
Rubbing Alcohols
Rubbing Alcohols: Ethanol with 5 4 2 0 0 2 0 0 0 4 0 0 0 1 2 1 1 0 0
Methyl Salicylate
Rubbing Alcohols: Ethanol without 181 169 105 6 8 48 0 2 0 154 11 1 2 20 43 26 3 0 0
Methyl Salicylate
Rubbing Alcohols: Isopropanol 204 198 148 9 2 36 0 3 0 179 15 3 1 66 65 37 4 0 0
with Methyl Salicylate
Rubbing Alcohols: Isopropanol without 7,624 6,908 3,703 261 327 2,257 14 314 32 5,692 1,094 64 22 1,578 1,389 1,121 371 28 0
Methyl Salicylate
Rubbing Alcohols: Unknown 87 68 26 1 6 31 0 4 0 50 16 0 0 30 10 14 7 2 0
Category Total: 71,565 22,239 9,153 768 1,656 9,390 36 1,059 177 14,015 7,213 472 237 7,908 3,723 4,364 2,131 372 78
Arts/Crafts/Office Supplies
Miscellaneous Arts/Crafts/
Office Supplies
Artist Paints (Non-Water Color) 3,502 3,405 2,549 264 139 370 7 67 9 3,288 77 14 25 116 375 143 13 4 0
Artist Paints (Water Color) 1,578 1,538 1,281 141 41 59 5 9 2 1,494 36 5 2 24 160 26 4 0 0
Chalks 1,662 1,622 1,519 52 19 22 4 5 1 1,601 16 1 2 36 192 37 3 0 0
Clays 2,475 2,415 2,008 238 66 83 12 6 2 2,348 50 4 7 113 228 94 4 2 0
Crayons 1,811 1,733 1,464 137 32 81 11 6 2 1,691 40 1 0 47 137 42 1 0 0
Glazes 106 105 44 22 16 18 0 5 0 93 6 6 0 7 14 9 0 0 0
Office Supplies: Miscellaneous 87 84 48 12 4 18 0 2 0 81 3 0 0 7 13 8 1 0 0
Other Types of Arts/Crafts/ 6,702 6,300 4,499 766 249 583 44 139 20 6,001 227 36 25 284 826 265 21 2 1
Writing Products
Pencils 1,229 1,170 541 442 102 54 11 14 6 1,029 111 17 4 42 109 41 3 0 0
Pens or Inks 8,687 8,445 5,442 1,870 649 302 43 108 31 7,907 440 40 41 255 1,018 209 16 2 0
Typewriter Correction Fluids 530 516 319 71 45 64 2 9 6 468 39 6 1 50 111 34 5 0 0
Unknown Types of Arts/Crafts/ 113 109 65 31 6 6 0 1 0 106 3 0 0 8 20 8 0 0 0
Writing Products
Category Total: 28,482 27,442 19,779 4,046 1,368 1,660 139 371 79 26,107 1,048 130 107 989 3,203 916 71 10 1
Automotive/Aircraft/Boat Products
Automotive Products
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Automotive Products: 922 844 209 10 51 489 3 73 9 784 47 6 1 306 139 240 37 5 1
Brake Fluids
Automotive Products: Ethylene Glycol 6,144 5,583 485 120 458 3,968 11 469 72 4,601 772 139 9 2,270 1,086 998 417 112 10
(Including Antifreeze)
Automotive Products: Glycol and 137 127 33 6 6 71 0 9 2 116 8 1 0 37 35 19 4 1 1
Methanol Mixtures
Automotive Products: Hydrocarbons 1,980 1,853 573 47 100 966 2 150 15 1,732 88 11 11 616 353 564 103 3 0
(Transmission
Fluids, Power Steering Fluids, etc)
Automotive Products: Methanol (Dry Gas, 1,220 1,149 173 32 91 709 2 130 12 1,054 75 13 0 359 286 233 34 7 0
Windshield Washing Solutions, etc)
Automotive Products: 161 153 63 8 5 65 1 9 2 147 2 4 0 35 30 21 4 1 0
Other Glycols
Miscellaneous Automotive/Aircraft/
Boat Products
Automotive/Aircraft/Boat Products: 13 10 5 0 0 4 0 1 0 9 0 1 0 3 2 1 0 0 0
Non-Toxic
Automotive/Aircraft/Boat Products: Other 1,336 1,274 451 43 77 598 0 94 11 1,215 31 8 15 402 227 347 78 3 0
Automotive/Aircraft/Boat 194 175 35 8 21 89 0 17 5 161 8 4 1 82 29 51 16 1 0
Products: Unknown
Category Total: 12,107 11,168 2,027 274 809 6,959 19 952 128 9,819 1,031 187 37 4,110 2,187 2,474 693 133 12
Batteries
Disc Batteries
Disc Batteries: Alkaline (MNO2) 480 466 266 51 25 101 1 19 3 443 12 2 8 329 221 56 16 0 0
Disc Batteries: Lithium 255 185 85 22 15 61 0 2 0 133 34 1 13 152 62 33 46 7 0
Disc Batteries: Mercuric Oxide 4 4 3 0 0 1 0 0 0 4 0 0 0 3 4 0 0 0 0
Disc Batteries: Nickel Cadmium 7 5 3 0 0 2 0 0 0 4 1 0 0 1 1 0 0 0 0
Disc Batteries: Other 9 7 4 1 1 1 0 0 0 7 0 0 0 5 4 0 0 0 0
Disc Batteries: Silver Oxide 42 42 20 5 0 15 0 1 1 39 1 1 0 25 25 3 0 0 0
Disc Batteries: Unknown 2,398 2,331 1,487 299 67 424 14 35 5 2,231 72 15 5 1,791 1,101 148 42 7 1
Disc Batteries: Zinc-Air 328 314 127 21 2 158 0 6 0 309 4 1 0 193 208 16 3 5 0
Miscellaneous Batteries
Automotive/Aircraft/Boat Batteries 565 556 30 16 32 392 2 76 8 540 8 3 4 208 65 156 52 1 0
Other Types of Battery 358 336 49 12 98 112 3 56 6 309 23 0 4 52 125 40 13 0 0
Penlight/Flashlight/Dry Cell Batteries 5,176 4,989 2,914 494 278 1,014 19 244 26 4,487 414 62 11 1,000 1,233 500 91 2 0
Unknown Types of Battery 87 81 30 11 10 27 0 3 0 67 7 4 1 23 19 14 3 0 0
Category Total: 9,709 9,316 5,018 932 528 2,308 39 442 49 8,573 576 89 46 3,782 3,068 966 266 22 1
Bites and Envenomations
Aquatic
Fish Stings 572 566 22 41 65 384 1 46 7 553 3 2 8 268 15 197 84 3 0
Jellyfish and Other Coelenterate Stings 189 188 25 46 28 70 1 17 1 187 0 0 1 43 3 66 18 0 0
Other or Unknown Marine Animal Bites 259 252 121 30 13 72 1 14 1 239 6 3 2 45 26 34 12 0 0
and/or Envenomations
Exotic Snakes
Exotic Snake: Unknown 1 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 1 0 0
If Poisonous
Exotic Snakes: Non-Poisonous 19 19 0 0 2 16 0 0 1 19 0 0 0 13 0 6 3 0 0
Exotic Snakes: Poisonous 54 50 2 1 4 39 0 3 1 50 0 0 0 35 3 10 17 2 0
Insects
Ant or Fire Ant Bites 534 493 169 39 29 194 0 58 4 476 0 16 1 69 10 116 27 2 1
Bee, Wasp, or Hornet Stings 3,629 3,542 592 342 169 2,018 11 358 52 3,535 3 3 1 628 29 1,172 261 8 1
Caterpillars 2,114 2,110 517 288 154 973 11 141 26 2,064 16 3 24 328 41 660 105 0 0
Centipede or Millipede Bites 497 492 120 31 25 277 0 33 6 491 0 1 0 75 18 160 28 0 0
Mosquito Bites 252 112 27 5 4 65 0 10 1 112 0 0 0 21 2 25 3 0 0
Other Insect Bites and/or Stings 4,810 4,648 1,039 311 246 2,448 16 531 57 4,524 18 73 23 890 157 999 290 2 0
CLINICAL TOXICOLOGY
Scorpion Stings 12,669 12,645 1,394 1,380 952 8,319 12 457 131 12,642 1 1 0 1,526 73 8,319 569 26 0
Tick Bites 871 837 210 88 35 367 15 115 7 831 2 1 1 158 36 115 18 2 0
Mammals
Bat Bites 685 675 83 81 65 361 5 73 7 672 1 0 0 441 116 83 11 0 0
173
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
174
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
176
Ammonia Cleaners (All Purpose) 669 489 147 24 25 240 2 42 9 429 45 6 9 126 83 118 25 3 0
Carpet, Upholstery, Leather, 3,176 2,954 2,049 86 60 651 1 99 8 2,860 40 17 33 382 528 478 46 4 0
or Vinyl Cleaners
(continued)
177
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
178
Acrylic Nail Adhesives 915 909 341 147 117 253 7 38 6 883 19 1 5 394 90 254 69 0 0
Acrylic Nail Primers 219 212 159 2 18 31 0 1 1 207 1 0 4 65 45 51 10 0 0
Acrylic Nail Removers 10 10 8 0 0 2 0 0 0 10 0 0 0 4 2 2 1 0 0
(continued)
179
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
180
Deodorizers
Air Freshener
Air Fresheners: Aerosols 2,095 2,053 1,334 165 86 360 5 89 14 1,942 59 23 28 161 378 342 20 4 0
Air Fresheners: Liquids 9,352 9,228 8,126 237 147 571 10 124 13 9,063 91 55 15 615 1,722 1,266 41 0 0
Air Fresheners: Solids 1,968 1,945 1,696 91 31 108 2 16 1 1,912 23 9 0 169 370 120 11 0 0
Air Fresheners: Unknown Form 1,732 1,711 1,451 58 29 139 6 25 3 1,670 20 9 11 168 348 207 12 0 0
Miscellaneous Deodorizers
Diaper Pail Deodorizers 12 11 9 0 0 2 0 0 0 11 0 0 0 0 1 1 0 0 0
(Excluding Moth Repellants)
Other Types of Deodorizer 5,703 5,442 3,906 234 156 937 12 174 23 5,230 122 58 23 548 1,105 738 49 5 1
(Not For Personal Use)
Toilet Bowl Deodorizers 488 473 403 8 7 41 1 10 3 465 7 1 0 52 112 42 6 0 0
Unknown Types of Deodorizer 80 79 60 4 1 11 0 3 0 76 2 1 0 8 19 9 0 0 0
(Not for Personal Use)
Category Total: 21,430 20,942 16,985 797 457 2,169 36 441 57 20,369 324 156 77 1,721 4,055 2,725 139 9 1
Dyes
Miscellaneous Dyes
Dyes: Fabrics 369 357 246 38 14 49 0 9 1 344 4 3 5 23 90 14 2 0 0
Dyes: Foods (Including 870 781 639 89 19 27 6 1 0 743 34 0 4 21 122 33 2 0 0
Easter Egg)
Dyes: Leathers 70 67 44 4 4 9 0 5 1 65 1 0 0 5 17 2 0 0 0
Dyes: Other 488 455 200 90 90 54 2 15 4 423 20 3 8 35 73 23 4 0 0
Dyes: Unknown 53 45 30 4 5 5 0 1 0 40 4 0 1 7 11 3 1 0 0
Category Total: 1,850 1,705 1,159 225 132 144 8 31 6 1,615 63 6 18 91 313 75 9 0 0
Essential Oils
Miscellaneous Essential Oil
Cinnamon Oil 642 575 374 60 23 95 0 21 2 491 41 5 37 56 55 174 6 0 0
Clove Oil 605 556 356 14 12 146 1 25 2 505 19 0 32 101 109 139 10 1 0
Eucalyptus Oil 1,502 1,341 864 54 27 325 6 56 9 1,274 35 6 18 254 286 207 19 1 0
Miscellaneous Essential Oils 16,020 15,248 11,458 587 283 2,347 29 504 40 14,516 291 80 333 1,113 2,940 2,375 104 2 0
Pennyroyal Oil 24 22 5 2 1 12 0 2 0 15 3 0 4 6 6 2 1 1 0
Tea Tree Oil 4,597 4,326 2,192 136 207 1,478 3 283 27 3,980 208 22 90 530 983 453 38 1 0
Category Total: 23,390 22,068 15,249 853 553 4,403 39 891 80 20,781 597 113 514 2,060 4,379 3,350 178 6 0
Fertilizers
Miscellaneous Fertilizers
Household Plant Foods 1,391 1,338 720 91 44 405 4 68 6 1,298 26 12 1 62 214 49 7 1 0
(Generally for Indoor Plants)
Other Types of Fertilizer 1,502 1,370 853 104 40 291 3 67 12 1,323 19 10 17 124 233 95 16 0 0
Outdoor Fertilizers 1,835 1,722 1,096 114 40 390 7 69 6 1,666 22 8 23 119 315 122 16 0 0
Plant Hormones 59 50 18 1 0 26 0 5 0 47 0 0 3 3 8 4 0 0 0
Unknown Types of Fertilizer 106 97 38 11 4 34 0 8 2 93 2 2 0 10 13 8 0 1 0
Category Total: 4,893 4,577 2,725 321 128 1,146 14 217 26 4,427 69 32 44 318 783 278 39 2 0
Fire Extinguishers
Miscellaneous Fire Extinguisher
Miscellaneous Fire Extinguishers 2,772 2,701 239 395 325 1,040 95 313 294 2,406 65 195 15 639 562 726 121 0 0
Category Total: 2,772 2,701 239 395 325 1,040 95 313 294 2,406 65 195 15 639 562 726 121 0 0
Foreign Bodies/Toys/Miscellaneous
Miscellaneous Foreign Bodies/Toys/
Miscellaneous
Ashes 323 293 236 11 2 31 0 12 1 286 3 2 2 15 45 17 2 0 0
Bubble Blowing Solutions 3,292 3,242 2,928 184 51 61 2 12 4 3,190 45 2 2 157 371 474 16 1 0
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Charcoals 738 616 417 29 30 108 0 24 8 556 21 4 30 53 79 38 10 0 0
Christmas ornaments 269 265 207 13 5 25 2 13 0 258 6 0 1 19 50 16 1 0 0
Coins 2,749 2,679 2,182 402 34 41 4 12 4 2,615 57 3 0 960 664 260 27 1 0
Desiccants 18,718 18,559 15,256 1,248 342 1,265 76 310 62 18,156 245 122 17 924 2,203 162 7 1 0
Feces/Urine 5,417 4,708 3,687 152 90 540 19 186 34 4,553 30 93 23 184 573 138 14 1 0
Glass 3,839 3,752 880 209 189 1,514 39 836 85 3,605 40 70 31 251 560 180 13 1 0
Glow Products 15,491 15,459 11,881 2,829 309 268 52 93 27 15,279 160 9 4 716 1,618 2,838 50 0 0
Incense (Punk) 191 186 140 4 6 19 1 14 2 178 2 4 1 13 35 11 2 0 0
Other Types of Foreign Body, Toy, or 23,875 22,646 15,251 2,519 792 2,904 86 959 135 21,425 663 288 216 1,956 3,563 973 125 6 0
Miscellaneous Substance
Oxygen Absorbers 494 488 208 100 38 112 3 26 1 451 28 6 2 33 95 17 0 0 0
Soil 2,325 2,060 1,379 134 37 398 2 99 11 1,982 27 11 36 176 229 139 24 0 1
Toys 8,214 8,122 6,213 1,434 201 176 18 68 12 7,845 190 34 47 538 1,226 506 24 1 0
Unknown Types of Foreign Body, Toy, or 1,462 1,418 959 224 61 136 4 32 2 1,348 47 9 7 100 179 69 11 3 0
Miscellaneous Substance
Thermometers
Thermometers: Mercury 1,032 1,020 211 127 74 330 17 232 29 996 9 7 4 75 170 14 1 0 0
Thermometers: Other 682 669 211 93 44 204 8 96 13 649 8 8 3 39 128 30 1 0 0
Thermometers: Unknown 108 108 20 10 10 48 0 18 2 107 0 1 0 9 12 1 0 0 0
Category Total: 89,219 86,290 62,266 9,722 2,315 8,180 333 3,042 432 83,479 1,581 673 426 6,218 11,800 5,883 328 15 1
Fumes/Gases/Vapors
Miscellaneous Fumes/Gases/Vapors
Carbon Dioxide 425 403 32 34 55 212 3 56 11 367 24 2 7 96 69 101 26 0 0
Carbon Monoxide 12,846 11,508 1,479 917 852 6,425 148 1,418 269 11,003 341 46 29 5,751 2,273 3,166 1,237 203 44
Chloramine Gas 2,230 2,115 80 40 119 1,529 7 316 24 2,000 96 7 11 370 241 664 152 4 0
Chlorine Gas 4,305 4,039 328 286 275 2,544 36 525 45 3,869 114 10 37 1,130 355 1,331 488 9 1
Chlorine Gas (When 2,284 2,166 102 68 123 1,561 7 293 12 2,074 85 0 3 479 313 816 236 5 0
Household Acid is Mixed with
Hypochlorite)
Hydrogen Sulfide (Sewer Gas) 739 646 45 29 26 411 3 116 16 632 7 2 2 283 61 197 81 7 1
Methane and Natural Gas 4,738 4,467 895 361 266 2,129 50 681 85 4,430 15 13 0 973 1,171 804 134 3 3
Other Types of Fume, Gas or 1,551 1,426 174 62 83 826 11 249 21 1,325 62 11 22 364 245 307 104 6 1
Vapor
Polymer Fume Fever 5 5 0 1 0 2 1 1 0 5 0 0 0 1 0 1 0 0 0
Simple Asphyxiants 2,618 2,357 221 279 201 1,298 23 305 30 2,104 209 15 13 810 376 615 182 12 3
Unknown Types of Fume, Gas or Vapor 1,776 1,697 96 56 65 917 21 446 96 1,618 15 34 12 471 154 352 123 5 0
Category Total: 33,517 30,829 3,452 2,133 2,065 17,854 310 4,406 609 29,427 968 140 136 10,728 5,258 8,354 2,763 254 53
Heavy Metals
Miscellaneous Heavy Metals
Aluminum 762 690 417 33 34 157 0 46 3 647 14 12 13 48 91 44 9 0 0
Arsenic (Excluding Pesticides) 837 737 127 21 19 462 1 94 13 467 13 114 19 376 113 58 37 9 1
Barium, Soluble Salts 23 15 0 1 6 7 0 1 0 11 0 2 2 5 3 2 1 0 0
Cadmium 91 62 3 1 2 48 0 7 1 45 2 4 0 36 5 7 3 1 0
Copper 657 545 85 42 88 244 4 74 8 486 24 16 13 166 62 147 30 1 0
Fireplace Flame Colors 18 18 7 3 2 5 0 1 0 16 0 2 0 3 1 3 0 0 0
Gold 2 2 1 0 0 1 0 0 0 2 0 0 0 0 1 0 0 0 0
Lead 2,397 2,219 1,099 179 97 606 29 184 25 2,032 28 56 13 1,052 585 144 78 4 1
Manganese 55 38 8 6 3 17 0 4 0 33 0 1 2 17 3 4 1 0 0
Mercury (Other) 150 136 17 3 7 88 0 16 5 101 6 11 14 41 24 15 2 1 0
Mercury, Elemental (Excluding 1,045 973 85 75 76 498 8 193 38 827 45 30 46 250 227 39 18 1 0
Thermometer)
Metal Fume Fever 307 279 16 3 16 217 0 25 2 252 11 1 15 112 13 78 36 0 0
Other Types of Heavy Metal 3,527 2,297 910 143 100 920 5 195 24 1,847 175 51 196 407 335 193 65 6 0
Thallium 27 18 0 1 0 11 0 6 0 5 0 9 0 10 1 3 1 0 0
Unknown Types of Heavy Metal 62 59 7 5 5 29 0 11 2 36 2 8 6 36 4 1 7 0 0
CLINICAL TOXICOLOGY
Category Total: 9,960 8,088 2,782 516 455 3,310 47 857 121 6,807 320 317 339 2,559 1,468 738 288 23 2
Hydrocarbons
Miscellaneous Hydrocarbons
(continued)
181
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
182
Lighter Fluids and/or Naphtha 2,191 2,038 1,049 58 98 693 11 117 12 1,877 95 48 8 723 387 547 129 10 0
Lubricating Oils and/or Motor Oils 3,494 3,267 1,780 161 133 1,023 5 150 15 3,107 90 60 5 625 833 513 79 4 0
Mineral Seal Oil 24 24 11 0 3 6 0 3 1 22 1 1 0 5 4 4 1 0 0
Mineral Spirits 1,546 1,428 398 35 84 789 4 107 11 1,327 59 27 12 533 233 407 108 7 0
Other Types of Halogenated Hydrocarbon 219 187 32 5 13 117 0 19 1 167 13 3 4 81 21 64 13 2 0
Other Types of Hydrocarbon 3,984 3,625 1,674 164 146 1,375 12 233 21 3,451 117 30 16 1,010 696 764 178 13 1
Toluene and/or Xylene 620 525 75 11 16 351 0 46 26 489 21 5 7 230 73 170 49 3 1
(Excluding Adhesives)
Turpentine 331 290 46 9 20 172 1 39 3 219 54 10 3 94 52 52 20 1 0
Unknown Types of Hydrocarbon 467 411 136 14 22 204 0 28 7 362 35 2 6 141 79 98 38 5 0
Category Total: 29,520 27,613 8,392 1,295 1,692 13,505 83 2,363 283 24,856 2,168 368 110 8,209 4,782 7,043 1,715 111 29
Industrial Cleaners
Miscellaneous Industrial Cleaners
Industrial Cleaner: Disinfectants 2,164 1,991 142 81 159 1,306 3 265 35 1,802 149 17 16 634 194 643 171 7 0
Industrial Cleaner: Other or Unknown 1,466 1,337 352 40 93 716 4 119 13 1,227 56 38 12 514 200 415 101 9 0
Industrial Cleaners: Acids 1,819 1,521 357 28 65 915 2 130 24 1,443 44 22 8 501 188 438 124 9 1
Industrial Cleaners: Alkalis 2,785 2,609 470 70 164 1,670 2 208 25 2,466 82 39 18 1,409 259 917 452 22 0
Industrial Cleaners: Anionics or Nonionics 624 550 219 22 32 225 2 45 5 521 26 3 0 134 69 123 19 0 0
Industrial Cleaners: Cationics 731 691 125 40 64 396 2 55 9 612 60 11 4 258 101 236 32 1 0
Category Total: 9,589 8,699 1,665 281 577 5,228 15 822 111 8,071 417 130 58 3,450 1,011 2,772 899 48 1
Infectious and Toxin-Mediated Diseases
Botulinum Toxins
Botulism 262 241 55 7 2 131 2 37 7 158 4 2 68 88 31 17 15 15 1
Ichthyosarcotoxins
Ciguatera Poisoning 151 145 2 3 6 120 0 8 6 108 1 1 35 69 2 32 27 3 0
Clupeotoxic Fish Poisoning 19 17 0 2 0 15 0 0 0 15 0 0 1 2 0 1 1 0 0
Other Types of Seafood Poisoning 192 171 4 4 12 132 0 17 2 140 2 1 24 65 3 40 23 1 0
Paralytic Shellfish Poisoning 114 109 4 8 8 75 0 11 3 86 1 0 21 32 11 17 20 3 0
Scombroid Fish Poisoning 191 181 12 5 8 112 1 37 6 126 0 5 50 48 8 50 26 1 0
Tetrodon Poisoning 135 130 23 27 9 62 0 7 2 118 7 1 3 17 17 14 4 1 0
Infectious Diseases
Bacterial Diseases 397 376 93 27 23 154 3 70 6 317 1 17 35 66 30 51 26 3 0
Fungal Diseases 2,445 2,370 674 229 153 1,043 10 240 21 2,076 8 150 135 42 275 87 7 0 0
Other Types of Bacterial Food Poisoning 49 47 16 4 2 20 0 5 0 40 1 3 3 4 3 4 3 0 0
(Salmonella, Shigella, Vibrio,
Staphylococcus, Streptococcus, etc)
Parasitic Diseases 17 13 1 1 0 8 0 3 0 12 1 0 0 1 2 0 0 0 0
Prion Diseases 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Unknown Types of Bacterial 171 166 22 7 9 111 0 17 0 155 0 5 5 22 3 19 9 0 0
Food Poisoning
Unknown Types of Suspected 9,700 9,458 1,713 680 611 5,163 32 1,132 127 8,810 41 114 460 848 521 1,460 320 8 0
Food Poisoning
Viral Diseases 309 160 16 10 4 95 0 27 8 136 1 11 7 70 7 7 4 0 0
Category Total: 14,153 13,584 2,635 1,014 847 7,241 48 1,611 188 12,297 68 310 847 1,374 913 1,799 485 35 1
Information Calls
Food Information Calls
Information Calls About Food Products, 7,485 5,485 2,774 416 257 1,518 25 451 44 4,510 275 309 357 535 732 703 80 5 0
Additives or
Supplements
Information Calls About Possibly 4,854 4,737 1,182 433 295 2,198 9 568 52 4,295 18 128 280 184 461 298 66 1 0
Spoiled Foods
Category Total: 12,339 10,222 3,956 849 552 3,716 34 1,019 96 8,805 293 437 637 719 1,193 1,001 146 6 0
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Lacrimators
Miscellaneous Lacrimators
Lacrimators: Capsicum Defense Sprays 3,320 3,277 608 794 608 892 45 231 99 2,615 128 377 31 833 191 1,584 141 4 0
Lacrimators: CN (Chloroacetophenone) 497 488 95 104 106 147 3 26 7 381 19 65 9 125 13 226 31 0 0
Lacrimators: CS (O-Chlorobenzylidene 12 12 2 0 0 10 0 0 0 9 0 2 0 11 0 9 1 1 0
Malonitrile)
Lacrimators: Other 66 36 4 3 1 23 0 5 0 34 1 1 0 13 2 9 3 0 0
Lacrimators: Unknown 112 102 22 12 12 46 0 7 3 75 7 11 3 33 3 48 10 0 0
Category Total: 4,007 3,915 731 913 727 1,118 48 269 109 3,114 155 456 43 1,015 209 1,876 186 5 0
Matches/Fireworks/Explosives
Miscellaneous Matches/Fireworks/Explosives
Explosives 175 162 92 14 16 30 0 9 1 140 16 5 0 47 35 25 7 1 0
Fireworks 883 878 756 61 21 27 0 6 7 858 12 3 1 90 257 61 12 0 0
Matches 436 433 380 12 6 26 1 7 1 425 7 0 1 23 72 8 1 0 0
Other Types of Match, 83 82 56 11 5 9 0 1 0 79 2 1 0 12 21 9 6 0 0
Firework, or Explosive
Unknown Types of Match, 10 10 6 0 0 3 0 0 1 9 1 0 0 1 4 0 1 0 0
Firework, or Explosive
Category Total: 1,587 1,565 1,290 98 48 95 1 23 10 1,511 38 9 2 173 389 103 27 1 0
Miscellaneous Foods
Foods
Capsicum Peppers 2,229 2,121 511 261 367 718 27 205 32 1,516 232 42 300 215 40 858 81 5 0
Food Additives 441 403 154 35 27 149 1 33 4 298 14 7 81 51 50 55 22 0 0
Food Products 8,553 7,890 3,723 663 342 2,194 48 781 139 6,210 238 247 1,159 570 831 668 132 1 0
Other Adverse Reactions to Food 1,153 1,078 183 95 84 511 6 177 22 446 18 44 554 182 49 235 93 2 0
Category Total: 12,376 11,492 4,571 1,054 820 3,572 82 1,196 197 8,470 502 340 2,094 1,018 970 1,816 328 8 0
Mushrooms
Miscellaneous Mushrooms
Group 1 Mushrooms: 58 56 16 1 4 31 0 2 2 38 12 0 5 38 18 12 7 3 0
Cyclopeptides
Group 2 Mushrooms: Muscimol 34 31 9 0 3 19 0 0 0 17 12 1 1 23 4 5 12 2 0
(Ibotenic Acid)
Group 3 Mushrooms: 26 24 2 3 2 16 0 0 1 19 3 0 2 15 7 5 3 1 0
Monomethylhydrazine (MMH)
Group 4 Mushrooms: 36 36 1 0 2 31 0 2 0 25 5 0 6 26 1 24 2 0 0
Muscarine and Histamine
Group 5 Mushrooms: Coprine 10 9 5 1 0 3 0 0 0 8 1 0 0 5 2 2 0 0 0
Group 6 Mushrooms: Hallucinogenics 446 296 23 4 96 151 1 16 5 54 231 1 8 229 10 61 128 6 0
(Psilocybin and Psilocin)
Group 7 Mushrooms: 189 178 64 6 13 90 0 5 0 131 36 1 10 84 36 54 30 0 0
Gastrointestinal Irritants
Mushrooms: Miscellaneous, 119 107 50 12 4 34 0 7 0 85 5 0 16 25 26 16 3 1 0
Non-Toxic
Mushrooms: Other Potentially 148 133 45 12 11 52 0 12 1 103 6 0 23 34 37 26 9 2 0
Toxic
Mushrooms: Unknown 5,070 4,911 3,229 405 226 905 23 96 27 4,187 529 13 148 1,528 1,920 630 254 19 2
Category Total: 6,136 5,781 3,444 444 361 1,332 24 140 36 4,667 840 16 219 2,007 2,061 835 448 34 2
Other/Unknown Nondrug Substances
Miscellaneous Other/Unknown
Nondrug Substances
Other Non-Drug Substances 23,732 21,666 10,724 2,035 892 5,937 127 1,569 382 19,542 736 645 506 3,180 4,128 3,282 523 32 3
Unknown Substances Unlikely 6,243 5,991 1,141 272 230 3,334 30 764 220 4,453 167 858 177 1,577 561 670 250 54 8
to be Drug Products
Category Total: 29,975 27,657 11,865 2,307 1,122 9,271 157 2,333 602 23,995 903 1,503 683 4,757 4,689 3,952 773 86 11
Paints and Stripping Agents
Miscellaneous Paints and Stripping Agents
CLINICAL TOXICOLOGY
Other Types of Paint, Varnish or Lacquer 435 416 176 19 17 158 4 37 5 391 5 1 19 80 74 74 14 1 1
Unknown Types of Paint, 4,894 4,615 3,018 219 151 922 19 254 32 4,445 79 29 50 543 670 319 67 3 0
Varnish or Lacquer
(continued)
183
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
184
Stripping Agents
Methylene Chloride Stripping Agents 350 340 51 14 13 231 0 31 0 319 12 2 6 152 24 126 46 5 0
Other Types of Stripping Agent 486 445 90 11 19 287 1 35 2 423 8 4 8 191 38 132 78 1 0
Unknown Types of Stripping 64 59 7 1 8 41 0 2 0 59 0 0 0 24 3 22 9 0 0
Agent
Category Total: 12,475 11,811 6,212 543 452 3,634 48 820 102 11,308 217 66 195 1,832 1,672 1,603 381 14 2
Pesticides
Fumigants
Aluminum Phosphide 81 74 3 3 9 49 0 10 0 67 3 1 1 55 7 27 7 3 6
Methyl Bromide 21 18 1 0 0 17 0 0 0 18 0 0 0 10 1 4 4 0 1
Other Fumigants 42 38 4 1 1 22 0 9 1 35 0 0 3 12 5 9 1 0 0
Sulfuryl Fluoride 308 278 31 33 16 163 0 28 7 260 1 9 8 38 27 34 4 0 1
Unknown Fumigants 112 109 16 2 6 73 0 12 0 97 6 1 3 40 10 29 10 0 0
Fungicides (Non-medicinal)
Carbamate Fungicides 80 54 15 2 4 31 1 1 0 51 1 0 2 21 8 15 5 0 0
Copper Compound Fungicides 84 81 6 3 2 59 0 11 0 80 1 0 0 12 13 17 1 0 0
Mercurial Fungicides 1 1 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0
Other Types of Non-Medicinal Fungicide 604 474 109 24 14 270 1 50 6 455 8 2 9 72 87 73 19 2 0
Phthalimide Fungicides 35 23 8 3 2 9 0 1 0 22 0 0 1 4 5 4 0 0 0
Unknown Types of Non- 50 31 9 1 0 19 0 2 0 28 1 1 0 9 4 6 3 0 0
Medicinal Fungicide
Wood Preservatives 138 132 20 7 2 90 1 11 1 131 1 0 0 24 12 18 3 0 0
Herbicides (Including Algaecides, Defoliants,
Desiccants, Plant Growth Regulators)
Carbamate Herbicides (Excluding 3 3 0 0 0 3 0 0 0 3 0 0 0 2 0 2 0 0 0
Metam Sodium)
Chlorophenoxy Herbicides 1,828 1,557 394 58 27 896 6 157 19 1,484 22 11 35 276 315 349 36 2 0
Diquat 447 408 99 8 4 246 2 42 7 382 9 6 11 61 103 73 13 0 1
Glyphosate 3,550 3,167 645 110 72 1,954 6 355 25 3,001 40 34 79 561 624 719 82 4 4
Other Types of Herbicide 1,430 1,131 249 34 30 694 2 112 10 1,071 19 14 22 224 205 272 28 1 2
Paraquat 122 105 2 0 5 80 0 14 4 94 1 3 0 54 20 24 10 3 1
Triazine Herbicides 207 145 29 6 3 91 1 13 2 139 2 0 4 41 26 35 7 0 0
Unknown Types of Herbicide 492 409 87 30 10 227 2 45 8 369 16 9 11 107 47 83 14 1 1
Urea Herbicides 38 22 7 2 0 12 0 1 0 19 3 0 0 3 7 3 0 0 0
Insecticides (Including Insect Growth
Regulators, Molluscicides, Nematicides)
Carbamate Insecticides Alone 1,485 1,378 425 84 47 654 9 140 19 1,263 63 27 21 310 292 221 50 2 0
Carbamate Insecticides in Combination 189 181 27 6 9 106 0 26 7 173 2 1 3 27 22 30 6 0 0
with Other Insecticides
Chlorinated Hydrocarbon 163 147 55 4 2 64 0 19 3 130 10 1 5 44 27 23 2 2 0
Insecticides Alone
Chlorinated Hydrocarbon Insecticides in 188 183 42 5 10 95 0 27 4 165 3 0 15 37 21 52 11 0 0
Combination with Other Insecticides
Insect Growth Regulators 182 91 34 3 1 37 0 13 3 86 2 0 3 12 12 12 1 0 0
Metaldehyde 42 41 17 0 1 22 0 1 0 39 0 2 0 6 12 7 1 0 0
Nicotine (Excluding Tobacco Products) 32 27 14 0 3 6 0 4 0 24 2 0 0 4 3 7 0 0 0
Organophosphate Insecticides Alone 2,326 2,126 623 96 65 1,089 19 208 26 1,954 88 14 50 585 524 374 109 24 4
Organophosphate Insecticides in 35 28 7 0 0 14 0 6 1 26 0 0 2 5 9 3 1 0 0
Combination with Carbamate Insecticides
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Organophosphate Insecticides in 493 472 85 21 17 287 3 53 6 448 13 3 6 87 69 125 17 0 0
Combination with Non-Carbamate
Insecticides
Other Types of Insecticide 9,717 9,019 4,659 379 205 2,943 22 672 139 8,667 108 42 179 902 1,679 930 95 6 4
Piperonyl Butoxide & Pyrethrins (without 2 2 0 0 1 1 0 0 0 2 0 0 0 1 0 0 0 0 0
Carbamate or O.P.)
Pyrethrins 5,813 5,493 1,616 387 213 2,654 26 541 56 5,039 178 29 228 1,209 620 1,398 278 9 0
Pyrethroids 23,081 21,732 5,487 1,113 764 11,744 80 2,232 312 19,965 715 184 795 4,091 3,014 5,713 814 28 3
Rotenone 32 31 5 0 1 15 0 10 0 28 2 0 1 7 4 9 1 0 0
Unknown Types of Insecticide 4,848 4,408 1,073 229 164 2,216 20 616 90 3,885 144 174 146 1,238 536 897 206 16 4
Veterinary Insecticide/Pesticide Product 3 3 1 0 0 2 0 0 0 3 0 0 0 0 0 0 0 0 0
(For Pets-Flea
Collars, Etc.)
Miscellaneous Pesticides
Arsenic Pesticides 17 17 8 0 1 6 0 2 0 16 0 1 0 0 4 1 0 0 0
Borates and/or Boric Acid 6,805 6,705 5,832 155 56 511 9 119 23 6,618 36 24 20 457 1,210 175 23 0 0
Pesticides (Excluding Other Uses)
Metam Sodium 2 2 0 0 0 2 0 0 0 2 0 0 0 2 0 1 1 0 0
Repellents
Animal Repellents 467 446 121 33 11 218 0 56 7 422 8 4 12 68 52 97 9 0 0
Insect Repellents with DEET 3,960 3,893 2,012 535 184 915 13 200 34 3,553 83 43 206 363 532 1,028 76 3 0
Insect Repellents without DEET 1,456 1,417 1,034 110 29 197 4 33 10 1,362 10 7 38 94 225 239 17 0 0
Naphthalene Moth Repellants (Excluding 1,202 1,180 725 63 19 268 5 95 5 1,136 27 3 13 193 307 83 27 1 0
Deodorizing Products)
Other Types of Moth Repellant 5 4 1 0 0 2 0 1 0 4 0 0 0 1 2 1 0 0 0
Paradichlorobenzene Moth Repellants 122 122 76 4 2 28 0 9 3 115 5 0 2 22 30 9 1 1 0
(Excluding Deodorizing Products)
Unknown Types of Insect 177 167 98 13 8 34 1 11 2 159 3 1 4 31 19 26 7 0 0
Repellent
Unknown Types of Moth 1,965 1,930 1,092 69 37 506 11 196 19 1,844 54 9 19 285 473 161 30 0 0
Repellant
Rodenticides
Bromethalin Rodenticides 1,198 1,132 856 25 17 172 2 44 16 1,065 49 11 4 446 433 38 4 1 0
Cholecalciferol Rodenticides 4 3 1 1 0 1 0 0 0 3 0 0 0 0 0 0 0 0 0
Cyanide Rodenticides 2 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0
Long-Acting Anticoagulant Rodenticides 4,990 4,810 3,850 143 46 575 8 144 44 4,612 106 55 22 1,356 1,260 93 18 2 1
Other Types of Rodenticide 622 599 393 31 8 119 4 38 6 572 17 4 4 107 115 36 16 0 0
Strychnine Rodenticides 48 43 6 2 3 26 0 4 2 29 4 6 1 19 15 2 3 1 0
Unknown Types of Rodenticide 1,746 1,602 1,029 42 30 353 7 104 37 1,368 107 89 10 585 422 64 15 2 1
Warfarin Type Anticoagulant Rodenticides 196 187 143 7 2 28 1 4 2 179 5 3 0 52 54 2 0 0 0
Zinc Phosphide Rodenticides 124 117 29 7 2 64 0 11 4 108 5 2 1 43 51 18 2 1 0
Category Total: 83,412 77,999 33,211 3,894 2,165 30,979 266 6,513 971 72,871 1,983 830 1,999 14,317 13,575 13,671 2,088 115 34
Photographic Products
Miscellaneous Photographic Products
Developers, Fixing Baths, Stop Baths 93 83 23 0 25 30 0 4 1 78 3 0 2 16 15 14 2 0 0
Other Types of Photographic Product 274 252 164 25 7 43 0 9 4 243 8 0 1 16 47 21 3 0 0
Photographic Coating Fluids 6 6 4 1 0 1 0 0 0 6 0 0 0 1 0 1 0 0 0
Unknown Types of Photographic Product 2 2 0 0 0 1 0 1 0 2 0 0 0 2 0 0 0 0 0
Category Total: 375 343 191 26 32 75 0 14 5 329 11 0 3 35 62 36 5 0 0
Plants
Miscellaneous Plants
Plants: Amygdalin and/or 4,902 4,812 2,428 620 195 1,223 14 286 46 4,411 169 28 194 316 849 186 22 2 0
Cyanogenic Glycosides
Plants: Anticholinergics 563 528 290 43 23 143 3 19 7 431 63 12 19 107 137 53 38 4 0
Plants: Cardiac Glycosides (Excluding Drugs) 1,691 1,642 854 204 68 423 5 77 11 1,489 105 2 35 270 397 112 26 7 3
CLINICAL TOXICOLOGY
Plants: Colchicine 20 17 7 3 0 6 0 0 1 13 2 0 2 5 4 4 1 0 0
Plants: Depressants 225 174 113 9 8 38 0 6 0 131 20 2 19 36 43 15 4 0 0
Plants: Gastrointestinal Irritants (Excluding 6,629 6,335 4,531 608 170 814 12 180 20 5,867 247 14 194 506 1,231 542 56 4 0
Oxalate Containing Plants)
185
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
186
Plants: Skin Irritants (Excluding Oxalate 5,286 4,865 1,893 442 245 1,788 31 423 43 4,379 159 22 288 852 474 807 238 3 1
Containing Plants)
Plants: Solanine 1,787 1,746 1,111 138 33 367 1 90 6 1,578 55 7 103 138 438 109 13 0 0
Plants: Stimulants 467 436 105 51 18 201 2 53 6 379 45 2 8 105 122 35 7 1 0
Plants: Toxalbumins 275 262 92 17 15 119 0 18 1 205 40 10 4 105 72 41 13 2 0
Plants: Unknown Toxic Types or Unknown 9,912 9,370 6,310 1,119 247 1,270 58 301 65 8,656 399 20 260 739 1,670 725 116 5 0
if Toxic
Category Total: 46,579 44,089 26,889 5,005 1,474 8,404 170 1,877 270 39,917 2,242 163 1,625 4,679 7,732 4,394 843 62 5
Polishes and Waxes
Miscellaneous Polishes and Waxes
Floor Waxes, Polishes, or Sealers 363 341 201 9 10 92 3 25 1 325 9 2 4 49 63 46 3 1 0
Furniture Polishes 1,307 1,254 1,050 35 19 114 2 32 2 1,224 16 11 3 97 348 163 10 1 0
Miscellaneous Polishes and Waxes 1,883 1,808 1,272 56 39 340 7 72 22 1,734 40 9 22 185 351 168 28 0 0
(Excluding Mineral Seal Oils)
Category Total: 3,553 3,403 2,523 100 68 546 12 129 25 3,283 65 22 29 331 762 377 41 2 0
Radiation
Ionizing Radiation
Gamma Radiation 1 1 0 0 0 1 0 0 0 1 0 0 0 1 0 1 0 0 0
Ionizing Radiation: Type Unknown 59 58 7 1 0 29 0 19 2 49 0 1 5 21 6 3 1 0 0
Radon 93 72 9 8 1 38 1 11 4 70 0 1 1 15 14 3 0 0 0
Specific Nonpharmaceutical Radionuclides 86 56 5 2 1 22 0 21 5 43 4 5 3 30 12 7 0 0 1
X-ray Radiation 17 17 1 1 1 7 0 7 0 14 0 0 3 4 3 1 0 0 0
Miscellaneous Radiation
Nonpharmaceutical Radiation: 3 3 0 0 0 1 0 1 1 3 0 0 0 2 0 0 0 0 0
Type Unknown
Non-ionizing Radiation
Extremely Low-frequency 3 3 1 0 1 1 0 0 0 3 0 0 0 3 0 0 2 0 0
Radiation
Infrared Radiation 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
Microwave Radiation 21 21 0 0 0 16 0 3 2 18 3 0 0 1 4 1 0 0 0
Non-ionizing Radiation: Type Unknown 14 14 0 0 0 12 0 1 1 12 0 0 1 9 3 0 0 0 0
Radio Frequency Radiation 10 10 0 0 0 8 0 2 0 8 0 0 1 8 0 4 1 0 0
Ultraviolet Radiation 12 11 1 0 0 8 0 2 0 10 0 0 1 6 0 4 1 0 0
Visible Light Radiation (Lasers) 7 7 1 1 0 5 0 0 0 6 1 0 0 0 2 1 0 0 0
Category Total: 327 274 26 13 4 148 1 67 15 238 8 7 15 100 44 25 5 0 1
Sporting Equipment
Miscellaneous Sporting Equipment
Fishing Baits 50 50 36 5 4 5 0 0 0 46 3 1 0 0 8 0 0 0 0
Fishing Products, Miscellaneous 25 24 14 4 3 2 0 1 0 21 2 1 0 0 1 1 1 0 0
Golf Balls (Including 3 3 0 0 1 2 0 0 0 2 1 0 0 0 0 2 0 0 0
Liquid Center of Golf Balls)
Gun Bluing Compounds 14 13 6 1 0 5 0 1 0 12 0 1 0 3 4 2 0 0 0
Hunting Products, Miscellaneous 284 272 150 22 16 69 2 10 3 238 16 12 3 81 76 34 4 0 0
Other Types of Sporting 10 10 3 2 0 3 0 1 1 10 0 0 0 3 0 4 0 0 0
Equipment
Unknown Types of Sporting Equipment 1 1 0 0 0 1 0 0 0 1 0 0 0 1 0 0 1 0 0
Category Total: 387 373 209 34 24 87 2 13 4 330 22 15 3 88 89 43 6 0 0
Swimming Pool/Aquarium
Miscellaneous Swimming
Pool/Aquarium
Algicides 1,073 1,026 300 122 57 458 1 77 11 988 20 3 15 220 116 332 67 0 0
Aquarium Products, Miscellaneous 1,029 973 738 48 26 121 3 32 5 950 11 8 4 64 220 57 2 1 0
(continued)
Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category. – Continued.
Age Reason Outcome
No. of Case No. of Unknown Unknown Unknown Adv Treated in
Mentions Single Child Adult Age Rxn Health
5 6–12 13–19 20 Unint Int Other Care None Minor Moderate Major Death
Exposure
Facility
Bromine Shock Treatments 52 47 19 8 2 15 0 3 0 45 1 0 1 6 10 17 1 0 0
Chlorine Shock Treatments 2,608 2,476 490 339 158 1,273 14 188 14 2,379 47 5 42 772 148 880 299 8 0
Other Types of Swimming Pool or 1,293 1,193 357 152 70 508 3 78 25 1,119 20 3 51 267 171 427 58 4 0
Aquarium Product
Swimming Pool and Aquarium 118 107 53 5 14 31 0 3 1 103 2 2 0 13 21 18 2 0 0
Test Kits
Category Total: 6,173 5,822 1,957 674 327 2,406 21 381 56 5,584 101 21 113 1,342 686 1,731 429 13 0
Tobacco/Nicotine/eCigarette Products
eCigarettes: Nicotine Containing
eCigarettes: Nicotine Device 255 249 162 10 22 42 0 11 2 208 27 1 13 83 84 39 10 2 0
Flavor Unknown
eCigarettes: Nicotine Device With 105 103 76 3 9 15 0 0 0 94 7 0 1 28 37 21 4 0 0
Added Flavors
eCigarettes: Nicotine Device Without 1,029 995 685 46 93 140 0 23 8 885 75 5 28 374 343 188 37 1 0
Added Flavors
eCigarettes: Nicotine Liquid 628 611 408 14 48 118 2 18 3 551 43 7 10 271 211 142 17 0 0
Flavor Unknown
eCigarettes: Nicotine Liquid With 292 289 216 10 11 47 1 3 1 271 17 0 1 90 121 66 3 1 0
Added Flavors
eCigarettes: Nicotine Liquid Without 161 157 109 3 8 30 1 5 1 146 7 2 2 54 60 26 6 0 0
Added Flavors
Miscellaneous Tobacco Products
Chewing Tobacco 1,535 1,514 1,388 30 24 59 4 9 0 1,482 22 5 5 317 442 415 23 1 0
Cigarettes 6,697 6,536 6,168 43 41 225 15 35 9 6,403 69 28 34 797 2,107 943 45 2 0
Cigars 179 167 130 4 7 22 0 3 1 150 7 0 10 21 52 23 5 0 0
Dissolvable Tobacco 9 7 7 0 0 0 0 0 0 7 0 0 0 2 2 1 0 0 0
Filter Tips Only (i.e. Butts) 63 60 56 0 0 2 0 2 0 60 0 0 0 5 30 4 0 0 0
Other Types of Tobacco Product 152 137 88 1 7 32 0 8 1 113 15 0 9 37 23 30 10 0 0
Snuff 509 498 428 7 12 44 1 6 0 471 18 1 7 88 150 133 6 0 0
Unknown Types of Tobacco 1,902 1,801 1,198 55 104 346 5 78 15 1,567 136 9 78 589 492 357 85 6 2
Product
Category Total: 13,516 13,124 11,119 226 386 1,122 29 201 41 12,408 443 58 198 2,756 4,154 2,388 251 13 2
Waterproofers/Sealants
Miscellaneous Waterproofers/Sealants
Waterproofers/sealants: aerosols 191 182 85 11 15 62 1 8 0 167 3 3 8 33 35 34 11 0 0
Waterproofers/sealants: liquids 81 75 43 1 2 25 0 2 2 71 0 0 4 19 15 17 6 0 0
Waterproofers/sealants: solids 3 3 1 0 0 2 0 0 0 3 0 0 0 0 0 0 0 0 0
Waterproofers/sealants: unknown form 41 38 19 1 1 13 0 4 0 37 1 0 0 10 7 8 0 0 0
Category Total: 316 298 148 13 18 102 1 14 2 278 4 3 12 62 57 59 17 0 0
Weapons of Mass Destruction
Miscellaneous Weapons of Mass Destruction
Anthrax 6 5 0 0 0 4 0 1 0 4 0 1 0 2 1 0 0 0 0
Nerve Gases 3 2 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0
Other Biological Weapons 4 3 2 0 0 0 0 1 0 3 0 0 0 0 0 0 0 0 0
Other Chemical Weapons 30 29 1 1 2 20 0 0 5 7 0 21 1 27 5 1 21 0 0
Other Suspicious Powders 206 191 30 17 8 107 1 26 2 119 15 48 2 83 35 33 16 2 0
Other Suspicious Substances 2,387 2,198 485 126 118 1,018 12 372 67 1,314 119 432 76 868 196 365 185 41 7
(Non-Powder)
Suspicious Powders in 60 57 7 9 0 28 0 12 1 36 2 14 2 31 23 11 3 0 0
Envelope or Package
Category Total: 2,696 2,485 525 153 128 1,178 13 413 75 1,483 136 517 81 1,011 260 410 225 43 7
Nonpharmaceuticals Total: 1,068,976 954,802 514,962 64,426 42,389 269,371 3,122 52,480 8,052 883,748 39,504 11,743 15,510 166,414 152,063 158,141 31,679 2,335 315
CLINICAL TOXICOLOGY
187
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category
188
Acetaminophen in Combination with Other 5,812 3,235 794 116 1,223 1,039 1 47 15 1,189 1,928 5 67 2,182 805 845 451 48 2
Drugs, Adult Formulations
Acetaminophen in Combination with Other 42 32 25 6 1 0 0 0 0 31 0 0 1 3 9 1 0 0 0
Drugs, Pediatric Formulations
Acetaminophen with Codeine 3,782 1,742 246 68 315 1,024 2 76 11 696 871 0 147 1,045 433 383 172 26 0
Acetaminophen with Diphenhydramine 6,908 4,070 593 93 828 2,412 1 114 29 1,146 2,822 1 43 2,999 772 974 949 136 11
Acetaminophen with 15,202 6,431 1,047 216 837 4,009 12 259 51 2,934 3,064 16 305 3,766 1,696 1,379 659 149 15
Hydrocodone
Acetaminophen with Other Narcotics or 376 183 31 4 15 124 0 8 1 72 94 1 11 124 47 41 27 6 4
Narcotic Analogs
Acetaminophen with Oxycodone 7,611 3,282 519 68 282 2,216 2 165 30 1,334 1,658 14 195 2,150 772 767 509 123 5
Acetaminophen with 55 26 5 1 3 14 0 2 1 11 12 1 2 14 8 4 1 1 0
Propoxyphene
Acetylsalicylic Acid Alone
Acetylsalicylic Acid Alone, Adult Formulations 5,562 3,175 1,355 138 645 982 0 47 8 1,764 1,322 3 50 1,752 809 467 437 47 6
Acetylsalicylic Acid Alone, 689 372 230 31 36 67 0 8 0 280 82 0 7 131 102 33 22 1 0
Pediatric Formulations
Acetylsalicylic Acid Alone, 11,838 5,596 1,800 258 1,136 2,272 0 101 29 2,557 2,763 6 106 3,521 1,287 918 1,099 152 17
Unknown if Adult or Pediatric Formulations
Acetylsalicylic Acid Combinations
Acetylsalicylic Acid in 1,240 840 243 55 85 434 0 19 4 432 362 1 29 458 160 168 138 25 0
Combination with Other Drugs, Adult
Formulations
Acetylsalicylic Acid in 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Combination with Other Drugs, Pediatric
Formulations
Acetylsalicylic Acid with Carisoprodol 10 1 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0
Acetylsalicylic Acid with Codeine 49 25 7 0 1 17 0 0 0 7 15 0 2 17 5 3 4 3 0
Acetylsalicylic Acid with Other Narcotics or 1 1 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0
Narcotic Analogs
Acetylsalicylic Acid with 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Oxycodone
Acetylsalicylic Acid with Propoxyphene 1 1 0 0 0 1 0 0 0 0 1 0 0 1 0 1 0 0 0
Miscellaneous Analgesics
Non-Aspirin Salicylates (Excluding Topicals 202 154 88 4 11 47 2 2 0 130 12 0 11 39 31 14 10 0 0
and/or Gastrointestinal Drugs)
Other Analgesics 832 578 220 20 65 244 1 23 5 350 202 2 21 231 106 126 52 7 0
Phenacetin 1 1 0 0 1 0 0 0 0 1 0 0 0 1 0 1 0 0 0
Phenazopyridine 1,084 897 613 32 31 204 1 16 0 800 47 0 48 225 278 79 32 2 0
Salicylamide 1 1 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0
Unknown Analgesics 179 75 14 1 21 27 0 7 5 24 42 1 6 44 16 12 12 0 1
Nonsteroidal Antiinflammatory Drugs
Colchicine 356 245 50 2 8 168 1 16 0 185 30 1 24 124 61 41 31 3 3
Cyclooxygenase-2 Inhibitors 772 382 124 9 18 195 1 32 3 341 28 0 12 62 93 13 6 0 0
Ibuprofen 81,129 61,547 41,138 3,481 8,069 7,924 49 687 199 49,029 11,862 20 490 14,318 14,024 4,258 1,007 88 4
Ibuprofen with Diphenhydramine 2,737 1,706 374 43 327 898 0 57 7 844 835 0 16 897 347 335 239 22 0
Ibuprofen with Hydrocodone 86 46 7 5 8 22 1 2 1 25 18 0 2 24 11 12 5 1 0
Indomethacin 416 230 68 10 19 117 0 14 2 148 56 0 24 82 65 29 5 0 0
Ketoprofen 39 16 7 1 5 3 0 0 0 11 5 0 0 8 8 2 0 0 0
Naproxen 13,321 7,501 2,361 270 1,866 2,635 8 309 52 4,326 2,928 2 211 3,092 2,019 1,073 245 9 1
Other Types of Nonsteroidal 7,392 3,913 1,362 180 306 1,814 7 215 29 3,168 576 3 148 902 970 319 54 4 0
Antiinflammatory Drug
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
No. of Age Reason Treated in Outcome
No. of Single Unknown Unknown Unknown Adv Health
Case Exposure 5 6–12 13–19 20 Child Adult Age Unint Int Other Rxn Care None Minor Moderate Major Death
Mentions Facility
Unknown Types of Nonsteroidal 8 6 5 0 0 1 0 0 0 5 0 0 1 2 2 0 0 0 0
Antiinflammatory Drug
Opioids
Alfentanil 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Buprenorphine 3,885 2,243 1,068 36 72 915 3 116 33 1,358 649 58 131 1,742 374 665 442 67 1
Butorphanol 54 34 8 0 2 20 0 3 1 24 9 0 1 19 3 8 3 0 0
Codeine 1,652 1,107 352 143 109 458 1 39 5 872 183 5 35 304 268 123 38 1 1
Dihydrocodeine 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Fentanyl 1,780 793 58 6 32 648 0 45 4 225 496 12 38 588 96 116 193 121 41
Hydrocodone Alone or in Combination 1,810 740 153 42 67 405 2 59 12 432 231 2 52 311 158 125 66 6 1
(Excluding Combination Products with
Acetaminophen, Acetylsalicylic Acid
or Ibuprofen)
Hydromorphone 1,205 468 41 11 17 358 0 36 5 244 182 3 30 275 90 102 72 16 2
Levorphanol 10 5 1 0 0 4 0 0 0 3 1 0 1 3 1 1 1 0 0
Meperidine 85 34 10 0 1 19 0 4 0 17 12 0 5 22 8 8 3 2 0
Methadone 2,611 1,054 173 19 39 764 2 47 10 426 465 39 69 862 143 178 304 149 16
Morphine 2,959 1,352 173 11 54 996 0 106 12 755 493 9 66 838 310 211 207 66 16
Nalbuphine 17 11 1 1 0 9 0 0 0 4 2 0 5 10 0 2 4 0 0
Other or Unknown Narcotics 2,525 1,014 65 2 40 815 2 72 18 179 660 72 37 866 72 143 333 215 25
Oxycodone Alone or in Combination 7,437 3,168 595 131 197 2,034 6 172 33 1,576 1,328 31 150 1,974 621 679 491 177 19
(Excluding Combination Products with
Acetaminophen or Acetylsalicylic Acid)
Oxymorphone 387 164 16 2 6 123 1 15 1 57 94 2 9 111 29 37 33 11 0
Pentazocine 24 16 2 0 2 12 0 0 0 7 7 0 2 12 2 5 4 0 0
Propoxyphene 15 2 1 0 1 0 0 0 0 0 0 0 0 2 0 1 1 0 0
Remifentanil 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tapentadol 274 146 13 5 7 114 0 7 0 81 44 2 13 89 33 32 17 2 0
Tramadol 10,932 4,903 907 120 525 3,128 4 193 26 2,153 2,390 33 249 3,294 1,249 1,106 765 152 5
Other Acetaminophen and Acetylsalicylic Acid
Combinations
Acetaminophen and Acetylsalicylic Acid with 6,729 4,345 1,547 169 1,162 1,346 3 91 27 2,211 2,000 1 110 2,253 1,030 913 464 18 0
Other Ingredients
Acetaminophen and Acetylsalicylic Acid 205 136 37 4 13 80 0 2 0 59 67 1 7 80 19 23 34 4 0
without Other Ingredients
Serotonin 5-HT 1B,1D Receptor Agonists
Serotonin 5-HT 1B,1D Receptor Agonists: 338 167 64 18 19 60 0 6 0 130 21 0 15 58 50 26 8 0 0
Other or Unknown
Serotonin 5-HT 1B,1D Receptor Agonists: 947 503 152 35 66 224 1 21 4 352 84 0 65 194 137 67 48 1 0
Sumatriptan
Category Total: 282,784 178,069 83,438 8,394 26,441 54,740 156 4,059 841 115,759 56,598 375 3,598 73,949 42,362 22,006 12,618 2,672 283
Anesthetics
Inhalation Anesthetics
Nitrous Oxide 259 205 18 26 34 114 1 11 1 62 110 2 23 141 24 46 47 5 0
Other Types of Inhalation Anesthetic 98 81 8 2 4 50 1 15 1 70 8 0 3 43 8 23 9 1 1
Unknown Types of Inhalation Anesthetic 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
Local and/or Topical Anesthetics
Dibucaine 31 26 23 1 0 2 0 0 0 24 0 0 2 7 10 0 0 0 0
Lidocaine 1,636 1,410 536 80 82 593 2 99 18 1,135 95 8 157 348 318 197 71 13 1
Other or Unknown Local and/or 3,450 3,232 1,991 152 112 822 8 137 10 2,838 130 13 244 487 828 362 81 27 0
Topical Anesthetic
Miscellaneous Anesthetics
Ketamine and Analogs 250 129 11 3 12 90 0 11 2 40 70 6 11 110 4 24 53 12 0
Other Types of Anesthetic 27 20 7 0 0 9 0 4 0 17 0 0 3 3 7 3 0 0 0
Unknown Types of Anesthetic 6 6 2 0 1 1 0 1 1 2 0 2 1 2 1 1 1 0 0
Category Total: 5,758 5,110 2,597 264 245 1,681 12 278 33 4,188 413 31 445 1,141 1,200 656 262 58 2
CLINICAL TOXICOLOGY
Anticholinergic Drugs
Miscellaneous Anticholinergic Drugs
Anticholinergic Drugs (Excluding Cough and 6,761 4,394 232 58 108 3,470 6 487 33 3,958 285 13 110 583 593 216 167 12 0
Cold Preparations, and Plants)
189
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
190
Intravenous, Intramuscular)
Topical Antifungal Preparations (Dermal, Otic, 6,875 6,540 4,312 224 112 1,504 16 341 31 6,283 60 14 170 405 948 435 34 0 0
Ophthalmic, Nasal)
(continued)
191
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
192
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
194
Antihistamine
Non-Acetylsalicylic Acid Salicylates and Opioid 1 1 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0
with Decongestant
(continued)
195
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
196
Opioid
Non-Acetylsalicylic Acid Salicylates with 3 2 2 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0
Decongestant without Opioid
Obsolete: Non-Acetylsalicylic Acid Salicylates 1 1 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0
with Decongestant and/or Antihistamine
without Phenylpropanolamine and Opioid
Phenylpropanolamine Containing Preparations
Acetaminophen and Phenylpropanolamine 34 25 12 2 5 6 0 0 0 14 10 0 1 11 7 3 3 1 0
Combinations with Decongestant and/or
Antihistamine without Opioid
Acetaminophen, Acetylsalicylic Acid, and 9 7 6 0 0 0 0 1 0 7 0 0 0 1 2 0 0 0 0
Phenylpropanolamine Combinations with
Decongestant and/or Antihistamine
without Opioid
Acetaminophen, Acetylsalicylic Acid, 22 18 7 4 1 6 0 0 0 13 2 0 3 6 3 1 0 0 0
Phenylpropanolamine, and Dextromethorphan
Combinations with Decongestant and/or
Antihistamine
Acetaminophen, Phenylpropanolamine, and 37 30 19 4 3 4 0 0 0 25 3 0 0 3 2 3 1 0 0
Dextromethorphan Combinations with
Decongestant and/or Antihistamine
Acetaminophen, Phenylpropanolamine, and 1 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0
Other Opioid Combinations with Decongestant
and/or Antihistamine
Acetylsalicylic Acid and Phenylpropanolamine 17 13 8 1 3 1 0 0 0 11 2 0 0 3 3 1 1 0 0
Combinations with Decongestant and/or
Antihistamine without Opioid
Acetylsalicylic Acid, Phenylpropanolamine, and 4 4 4 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0
Dextromethorphan Combinations with
Decongestant and/or Antihistamine
Antihistamine and/or Decongestant with 5 4 2 0 1 1 0 0 0 4 0 0 0 0 1 0 0 0 0
Phenylpropanolamine and Codeine
Antihistamine and/or Decongestant with 164 131 89 21 5 16 0 0 0 117 11 0 3 22 20 11 2 0 0
Phenylpropanolamine and Dextromethorphan
Antihistamine and/or Decongestant with 4 4 3 1 0 0 0 0 0 4 0 0 0 1 2 0 0 0 0
Phenylpropanolamine and Other Opioid
Antihistamine and/or Decongestant with 192 129 88 21 11 8 0 1 0 114 14 0 0 38 41 11 2 0 0
Phenylpropanolamine without Opioid
Other Phenylpropanolamine Preparations 226 195 100 1 5 80 0 9 0 194 1 0 0 12 65 2 3 0 0
(Excluding Street Drugs and Diet Aids)
Category Total: 56,305 38,457 18,537 3,848 4,748 10,353 30 818 123 28,042 8,948 32 1,160 11,994 7,869 5,027 3,330 203 4
Diagnostic Agents
Miscellaneous Diagnostic Agents
Diagnostic Tablets for Glucose or Ketones 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0
Other Types of Diagnostic Agent 353 298 56 15 11 173 2 32 9 252 4 0 41 125 58 52 12 4 0
Unknown Types of Diagnostic Agent 6 4 0 0 1 3 0 0 0 2 0 0 2 3 0 1 0 0 0
Category Total: 360 303 57 15 12 176 2 32 9 255 4 0 43 128 58 53 12 4 0
Dietary Supplements/Herbals/Homeopathic
Amino Acids
Creatine 171 124 75 5 12 30 0 2 0 98 7 0 19 38 29 11 10 1 0
Other Amino Acid Dietary Supplements 683 464 268 23 21 133 1 15 3 370 37 1 54 86 86 45 16 2 0
Botanical Products
Citrus Aurantium (Single Ingredient) 27 19 8 1 2 6 0 2 0 16 2 0 1 3 2 2 0 0 0
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
No. of Age Reason Treated in Outcome
No. of Single Unknown Unknown Unknown Adv Health
Case Exposure 5 6–12 13–19 20 Child Adult Age Unint Int Other Rxn Care None Minor Moderate Major Death
Mentions Facility
Echinacea 136 102 67 14 2 14 0 4 1 91 6 0 5 13 24 6 0 0 0
Ginkgo Biloba 85 52 23 5 2 18 0 4 0 38 8 0 6 9 10 4 3 0 0
Ginseng 79 50 27 1 2 18 0 0 2 37 6 0 6 13 12 4 4 0 0
Kava Kava 106 75 17 2 4 48 0 2 2 28 26 0 19 40 11 16 9 1 0
Ma Huang/Ephedra (Single Ingredient) 16 12 1 0 2 8 0 1 0 3 4 0 4 8 0 4 4 0 0
Multi-Botanicals with Citrus Aurantium 48 40 21 2 2 14 0 1 0 27 7 0 6 17 6 6 4 1 0
Multi-Botanicals with Ma Huang 66 49 24 0 6 17 0 2 0 29 16 0 3 22 10 9 10 1 0
Multi-Botanicals without Ma Huang or 1,584 1,271 766 74 65 335 3 23 5 934 134 5 191 316 239 141 87 4 0
Citrus Aurantium
Other Single Ingredient Botanicals 3,208 2,465 1,394 101 89 710 7 152 12 2,025 161 7 261 369 418 253 50 5 1
St. John’s Wort 219 140 84 4 13 34 0 4 1 111 18 0 10 22 35 10 2 0 0
Valerian 215 100 28 10 15 44 0 3 0 57 25 0 16 35 22 14 3 0 0
Yohimbe 140 99 15 3 4 72 0 5 0 28 18 0 52 70 9 15 41 1 0
Cultural Medicines
Asian Medicines 107 92 43 8 6 34 0 1 0 61 5 1 23 46 14 15 7 0 0
Ayurvedic Medicines 10 7 4 0 0 3 0 0 0 6 0 1 0 3 3 1 1 0 0
Hispanic Medicines 8 8 4 2 0 2 0 0 0 4 0 0 4 5 1 1 3 0 0
Other Cultural Medicines 83 64 31 5 2 25 0 1 0 44 12 0 8 29 5 10 6 3 0
Energy Products
Energy Drinks: Caffeine Containing (From Any 1,193 966 572 79 109 186 0 19 1 708 137 2 118 210 186 167 69 0 0
Source Including Guarana, Kola Nut, Tea,
Yerba Mate, Cocoa, etc)
Energy Drinks: Caffeine Only (Without Guarana, 886 665 427 65 54 108 1 8 2 522 81 4 53 99 118 78 29 0 0
Kola Nut, Tea, Yerba Mate, Cocoa, etc)
Energy Drinks: Ethanol and Caffeine Containing 150 39 8 0 10 17 0 4 0 10 18 0 9 15 4 8 9 0 0
(From Any Source Including Guarana, Kola Nut,
Tea, Yerba Mate, Cocoa, etc)
Energy Drinks: Ethanol and Caffeine Only 2 1 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0
(Without Guarana, Kola Nut, Tea, Yerba Mate,
Cocoa, etc)
Energy Drinks: Ethanol Containing Without 1 1 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0
Caffeine (From Any Source)
Energy Drinks: No Caffeine (From Any Source) 26 25 17 3 1 4 0 0 0 21 2 0 2 2 5 2 0 0 0
Energy Drinks: Unknown 464 335 157 42 56 67 1 10 2 221 64 0 45 91 56 74 28 0 1
Energy Products: Other 293 230 110 12 27 75 0 6 0 136 41 0 50 96 46 50 24 2 0
Hormonal Products
Androgen or Androgen Precursor Dietary 123 95 62 2 2 27 0 2 0 74 6 1 14 20 20 4 6 0 0
Supplements
Glandular Dietary Supplements 48 40 29 3 1 5 0 1 1 37 1 0 2 4 2 3 1 0 0
Melatonin 27,799 23,627 18,611 2,505 1,393 944 25 113 36 21,385 2,022 17 136 3,319 5,071 2,272 52 1 1
Phytoestrogen Dietary Supplements 59 48 24 1 3 17 0 2 1 34 5 0 7 9 9 2 2 1 0
Miscellaneous Dietary Supplements/Herbals/
Homeopathic
Homeopathic Agents 8,603 8,034 7,117 322 86 420 12 66 11 7,758 92 5 166 628 1,393 251 33 7 0
Unknown Dietary Supplements or 1,938 1,553 914 92 62 415 1 58 11 1,181 80 4 270 340 285 177 65 13 0
Homeopathic Agents
Other Dietary Supplements
Blue-Green Algae 358 347 73 61 41 126 9 36 1 334 2 3 6 68 69 80 6 0 0
Fatty Acid Supplements 2 2 1 1 0 0 0 0 0 2 0 0 0 0 2 0 0 0 0
Glucosamine (with or without Chondroitin) 591 405 302 9 7 71 0 13 3 384 8 1 11 30 83 14 2 0 0
Other Single Ingredient Non-Botanical Dietary 1,834 999 674 63 32 188 2 35 5 871 49 1 71 112 175 59 12 3 0
Supplements
Category Total: 51,361 42,645 32,000 3,520 2,133 4,235 62 595 100 37,687 3,100 53 1,648 6,187 8,462 3,808 598 46 3
Diuretics
Miscellaneous Diuretics
Furosemide 3,324 1,038 380 25 23 571 0 37 2 949 67 1 21 273 238 124 40 1 0
CLINICAL TOXICOLOGY
Other Types of Diuretic 2,555 940 332 56 53 453 0 40 6 800 97 0 40 244 231 74 35 1 0
Thiazide 4,214 1,423 568 80 58 675 0 41 1 1,265 128 2 25 371 367 81 39 1 0
Unknown Types of Diuretic 256 92 38 3 10 39 0 1 1 74 14 0 3 30 28 8 3 1 1
(continued)
197
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
198
Antidotes
Miscellaneous Antidote Drugs 4 3 1 1 0 1 0 0 0 2 1 0 0 1 1 0 0 0 0
Other Miscellaneous Drugs
(continued)
199
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
200
Nicotine Pharmaceuticals 1,582 1,496 947 150 27 319 4 45 4 1,357 68 1 60 261 422 203 39 0 0
Other Types of Miscellaneous Prescription 15,473 9,870 3,761 552 482 4,481 13 513 68 8,552 665 26 566 2,429 2,051 1,208 446 45 7
or Over the Counter Drug
Parkinson Drugs
Decarboxylase Inhibitor, Alone 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Levodopa (Alone or with Decarboxylase 1,473 809 169 5 6 591 0 35 3 708 67 0 26 245 184 124 54 6 0
Inhibitor)
Levodopa and Carbidopa with Other Drugs 1 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0
Other Parkinson Drugs (Including 19 8 4 0 0 4 0 0 0 6 1 0 1 2 1 2 0 0 0
Combinations)
Category Total: 19,745 12,602 5,043 722 523 5,603 17 616 78 10,979 824 31 684 3,032 2,754 1,562 554 57 7
Muscle Relaxants
Miscellaneous Muscle Relaxants
Baclofen 5,200 2,200 270 55 213 1,613 0 40 9 652 1,301 24 114 1,792 290 457 736 241 12
Carisoprodol (Formulated Alone) 2,236 901 49 3 43 785 0 15 6 145 713 1 12 794 82 347 252 50 2
Cyclobenzaprine 10,429 4,248 1,008 219 472 2,381 4 132 32 2,089 2,034 1 66 2,642 929 1,040 731 97 1
Metaxalone 412 205 27 3 21 135 1 18 0 113 84 0 6 104 37 48 30 3 0
Methocarbamol 2,253 904 116 13 130 610 0 26 9 403 464 0 27 550 214 267 100 8 0
Other Types of Muscle Relaxant 574 228 35 5 20 158 0 6 4 102 110 0 13 141 48 59 31 4 0
Tizanidine 4,577 1,889 274 44 125 1,356 2 74 14 829 921 16 92 1,288 274 413 584 74 0
Unknown Types of Muscle Relaxant 219 30 5 0 3 18 0 3 1 6 22 0 0 22 2 9 5 2 0
Category Total: 25,900 10,605 1,784 342 1,027 7,056 7 314 75 4,339 5,649 42 330 7,333 1,876 2,640 2,469 479 15
Narcotic Antagonists
Miscellaneous Narcotic Antagonists
Miscellaneous Narcotic Antagonist 991 410 31 14 18 294 1 48 4 203 72 21 105 188 51 74 64 6 2
Category Total: 991 410 31 14 18 294 1 48 4 203 72 21 105 188 51 74 64 6 2
Radiopharmaceuticals
Miscellaneous Radiopharmaceutical
Specific Pharmaceutical Radionuclides 47 38 6 3 2 21 0 6 0 29 0 0 9 15 4 5 1 0 0
Category Total: 47 38 6 3 2 21 0 6 0 29 0 0 9 15 4 5 1 0 0
Sedative/Hypnotics/Antipsychotics
Barbiturates
Long Acting Barbiturates 1,462 850 214 30 32 532 2 35 5 631 172 1 25 303 191 119 67 24 2
Short or Intermediate Acting Barbiturates 152 61 3 3 3 43 0 8 1 34 22 0 4 34 6 13 10 3 0
Unknown Types of Barbiturate 31 8 1 0 2 4 0 0 1 1 5 0 0 7 0 0 2 0 0
Miscellaneous Sedative/Hypnotics/Antipsychotics
Atypical Antipsychotics 44,251 17,121 1,713 895 3,151 10,781 9 456 116 5,399 10,697 47 724 13,258 2,921 5,001 4,192 547 9
Benzodiazepines 69,506 25,070 3,990 652 3,346 15,898 13 912 259 7,438 16,429 336 395 18,884 4,958 8,929 3,519 416 14
Buspirone 6,218 1,914 329 67 369 1,072 0 62 15 749 1,071 1 74 1,228 597 517 159 6 1
Chloral Hydrate 13 9 7 0 1 1 0 0 0 5 1 1 2 6 2 4 1 0 0
Ethchlorvynol 2 2 0 0 0 2 0 0 0 1 1 0 0 2 0 1 1 0 0
Glutethimide 1 1 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0
Meprobamate 24 12 0 0 4 8 0 0 0 0 12 0 0 10 1 3 5 0 0
Methaqualone 4 3 0 0 0 3 0 0 0 0 2 0 1 3 0 0 1 0 0
Other Types of Sedative/Hypnotic/Anti-Anxiety 13,579 5,356 587 270 456 3,836 5 160 42 1,894 3,212 30 113 3,812 814 1,999 813 90 5
or Anti-Psychotic Drug
Phenothiazines 4,333 1,655 182 44 167 1,172 1 80 9 679 761 5 180 1,168 332 359 439 20 2
Sleep Aids, Over the Counter Only (Excluding 1,939 1,254 494 20 202 515 0 18 5 591 648 0 5 733 319 250 233 22 0
Diphenhydramine)
Unknown Types of Sedative/Hypnotic/Anti- 292 103 5 1 28 57 1 7 4 12 86 1 1 89 12 24 30 0 0
Anxiety or Anti-Psychotic Drug
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
No. of Age Reason Treated in Outcome
No. of Single Unknown Unknown Unknown Adv Health
Case Exposure 5 6–12 13–19 20 Child Adult Age Unint Int Other Rxn Care None Minor Moderate Major Death
Mentions Facility
Category Total: 141,807 53,419 7,525 1,982 7,761 33,925 31 1,738 457 17,434 33,120 422 1,524 39,537 10,153 17,219 9,472 1,128 33
Serums, Toxoids, Vaccines
Miscellaneous Serums, Toxoids, Vaccines
Miscellaneous Serums, Toxoids and Vaccines 1,562 1,389 241 89 108 791 7 128 25 1,104 3 1 277 458 114 302 83 2 0
Category Total: 1,562 1,389 241 89 108 791 7 128 25 1,104 3 1 277 458 114 302 83 2 0
Stimulants and Street Drugs
Cannabinoids and Analogs
eCigarettes: Marijuana Device Flavor Unknown 15 14 2 0 4 6 0 2 0 6 8 0 0 8 2 7 0 0 0
eCigarettes: Marijuana Device With Added 1 1 0 0 1 0 0 0 0 0 1 0 0 1 0 1 0 0 0
Flavors
eCigarettes: Marijuana Device Without 1 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0
Added Flavors
eCigarettes: Marijuana Liquid Flavor Unknown 13 13 7 0 2 3 1 0 0 10 3 0 0 6 2 6 0 0 0
eCigarettes: Marijuana Liquid With Added 2 2 2 0 0 0 0 0 0 2 0 0 0 0 1 0 0 0 0
Flavors
eCigarettes: Marijuana Liquid Without 2 1 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0
Added Flavors
Marijuana: Concentrated Extract (Including Oils 292 216 31 7 65 98 0 14 1 58 105 16 34 149 16 80 54 7 0
and Tinctures)
Marijuana: Dried Plant 7,333 2,891 681 166 753 1,108 10 143 30 1,146 1,313 98 237 2,053 237 889 654 59 2
Marijuana: Edible Preparation 714 624 202 75 99 217 0 22 9 357 182 16 60 417 73 244 107 7 0
Marijuana: Oral Capsule or Pill Preparation 18 12 2 1 1 8 0 0 0 4 2 0 6 8 1 6 2 0 0
Marijuana: Other or Unknown Preparation 214 80 18 3 18 37 1 2 1 23 48 1 5 70 4 32 30 1 0
Marijuana: Pharmaceutical Preparation 68 45 14 1 5 22 0 3 0 23 13 1 8 26 9 14 9 0 0
Marijuana: Topical Preparation 6 5 2 0 0 3 0 0 0 4 1 0 0 3 2 2 0 0 0
Marijuana: Undried Plant 26 10 0 0 4 4 0 2 0 4 2 1 2 5 3 5 1 0 0
Synthetic Cannabinoids, Analogs and Precursors 1,959 1,295 13 12 269 961 2 28 10 60 1,151 19 18 1,183 63 418 500 103 5
Diet Aids
Diet Aids: Phenylpropanolamine and Caffeine 5 4 1 1 0 1 0 1 0 2 2 0 0 2 0 0 0 0 1
Combinations
Diet Aids: Phenylpropanolamine Only 4 2 0 0 0 2 0 0 0 2 0 0 0 1 0 0 1 0 0
Other Types of Diet Aid, Over the Counter Only 160 118 64 1 11 38 0 3 1 83 14 0 21 48 28 17 14 0 0
Other Types of Diet Aid, Prescription Only 23 15 6 0 0 7 0 2 0 9 4 0 2 9 3 2 3 1 0
Unknown Types of Diet Aid 47 30 14 1 5 8 0 2 0 17 9 0 4 13 7 2 3 1 0
Miscellaneous Stimulants and Street Drugs
Amphetamines and Related Compounds 16,569 10,162 3,531 1,835 1,862 2,691 7 184 52 6,926 2,748 46 279 5,274 2,469 1,739 1,756 124 3
Amyl or Butyl Nitrites (Street Drugs) 154 130 24 3 4 95 0 3 1 61 68 0 0 63 20 25 21 2 1
Caffeine 3,765 2,842 1,173 114 399 1,028 1 106 21 1,731 650 14 416 887 451 534 301 11 0
Cocaine 6,008 1,427 74 15 73 1,130 2 93 40 152 1,191 27 10 1,229 224 241 426 94 30
Ephedrine 149 105 52 5 5 37 0 4 2 71 27 3 2 38 26 13 16 3 0
gamma-Hydroxybutyric Acid including Analogs 519 323 6 3 18 270 0 16 10 56 208 26 7 273 21 55 123 66 0
or Precursors
Hallucinogenic Amphetamines 1,908 871 35 2 188 594 0 38 14 93 738 20 7 745 60 173 350 68 6
Heroin 8,784 4,923 23 6 141 4,583 0 119 51 158 4,564 124 18 4,419 377 819 1,828 1,087 66
Kratom 372 240 9 1 13 210 0 6 1 27 167 15 27 196 18 63 89 20 1
Lysergic acid diethylamide (LSD) 1,018 594 10 5 343 208 1 18 9 51 513 14 3 518 27 112 323 29 1
Mescaline/Peyote 48 35 7 4 2 21 0 1 0 22 9 1 3 12 1 7 8 1 0
Methamphetamines 7,519 3,503 239 50 163 2,779 4 206 62 526 2,770 87 32 2,904 324 645 1,199 256 191
Methylphenidate 9,589 6,562 1,630 2,602 1,421 820 8 64 17 5,258 1,140 12 106 2,241 1,628 944 689 25 0
Other Hallucinogens 102 70 0 0 25 43 0 2 0 5 61 1 2 62 2 11 41 4 0
Other Stimulants (Excluding Amphetamines) 458 258 74 5 16 148 0 15 0 156 55 2 41 117 56 44 36 2 0
Other Street Drugs 509 294 18 3 27 225 1 15 5 30 243 11 1 248 10 36 137 29 3
Other Synthetic Street Drugs 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Phenylcyclohexylpiperidine (PCP) 540 220 11 3 14 172 0 12 8 32 160 5 4 193 11 43 101 16 1
Synthetic Cathinones, Analogs and Precursors 7 4 0 0 0 4 0 0 0 0 3 1 0 4 1 1 1 0 0
CLINICAL TOXICOLOGY
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
202
Calamine (Including All Caladryl Type Products) 1,962 1,901 1,328 63 23 436 7 41 3 1,885 12 0 2 125 259 170 4 0 0
Camphor 10,211 9,975 8,252 229 159 1,107 12 199 17 9,742 135 20 67 1,142 2,635 1,089 65 8 0
Camphor and Methyl Salicylate Combinations 1,195 1,175 948 26 15 170 1 14 1 1,130 15 1 27 129 323 143 2 1 0
Diaper Care and Rash Products 21,969 21,562 20,475 208 142 585 39 100 13 21,490 19 12 31 472 2,703 591 15 0 0
Hexachlorophene Containing Antiseptics 20 17 10 2 0 3 0 2 0 13 1 0 2 1 2 3 0 0 0
Hydrogen Peroxide 3% 5,879 5,612 1,906 302 272 2,667 7 425 33 5,342 174 32 47 545 575 905 71 0 0
Iodine or Iodide Containing Antiseptics 1,007 888 195 48 62 501 13 59 10 736 79 5 63 179 171 171 26 2 0
Mercury Containing Antiseptics 33 28 14 1 0 10 0 3 0 23 1 0 4 7 5 6 0 0 0
Methyl Salicylate 5,971 5,875 4,118 253 116 1,131 6 240 11 5,668 47 16 135 582 1,175 818 40 3 0
Minoxidil, Topical 166 159 59 2 2 85 0 11 0 141 7 2 8 41 30 12 7 1 0
Other Types of Rubefacient or Liniment 3,463 3,385 2,433 94 55 664 7 120 12 3,140 29 8 205 188 532 503 28 1 0
(Excluding Camphor and Methyl Salicylate)
Other Types of Topical Antiseptic 2,001 1,932 945 74 88 688 2 121 14 1,804 70 8 43 265 298 220 33 3 0
Podophyllin 46 41 12 5 0 22 0 2 0 34 2 0 5 7 3 5 0 0 0
Silver Nitrate 103 87 21 3 25 25 0 12 1 65 2 4 15 24 8 20 3 0 0
Topical Steroids (Including Otic, Ophthalmic, 8,515 8,285 4,573 639 180 2,364 13 481 35 8,159 38 2 82 177 1,002 285 9 1 0
and Dermal Preparations)
Topical Steroids in Combination with 798 774 364 55 16 285 4 46 4 738 6 2 27 56 103 120 2 0 0
Antibiotics (Including Otic, Ophthalmic, and
Dermal Preparations)
Wart Preparations and Other Keratolytics 1,179 1,164 682 91 38 288 3 60 2 1,086 17 6 51 177 204 186 32 3 0
Category Total: 66,632 64,886 47,367 2,222 1,461 11,511 115 2,046 164 63,078 704 121 904 4,257 10,359 5,467 356 24 0
Unknown Drug
Miscellaneous Unknown Drug
Miscellaneous Unknown Drugs 25,411 17,075 4,310 720 2,287 8,536 75 804 343 6,344 6,786 778 575 12,867 3,088 2,843 3,799 1,383 130
Category Total: 25,411 17,075 4,310 720 2,287 8,536 75 804 343 6,344 6,786 778 575 12,867 3,088 2,843 3,799 1,383 130
Veterinary Drugs
Miscellaneous Veterinary Drugs
Miscellaneous Veterinary Drugs without 5,792 5,359 1,123 124 132 3,410 4 503 63 5,243 48 9 49 554 1,244 516 82 3 0
Human Equivalent
Category Total: 5,792 5,359 1,123 124 132 3,410 4 503 63 5,243 48 9 49 554 1,244 516 82 3 0
Vitamins
Miscellaneous Vitamins
Other Types of Vitamin 699 518 394 40 15 58 2 8 1 479 20 1 16 63 120 20 3 0 0
Unknown Types of Vitamin 700 491 358 63 18 41 3 6 2 451 28 0 10 48 96 19 3 0 0
Multiple Vitamin Liquids: Adult Formulations
Multiple Vitamin Liquids: Adult Formulations 10 8 6 1 1 0 0 0 0 7 1 0 0 1 0 0 0 0 0
with Fluoride (No Iron)
Multiple Vitamin Liquids: Adult Formulations 172 133 79 7 4 38 0 5 0 116 8 0 9 15 27 11 0 0 0
with Iron (No Fluoride)
Multiple Vitamin Liquids: Adult Formulations 8 5 3 0 0 2 0 0 0 5 0 0 0 0 0 1 0 0 0
with Iron and Fluoride
Multiple Vitamin Liquids: Adult Formulations 444 349 254 43 10 38 0 2 2 310 31 0 8 34 57 9 3 0 0
without Iron or Fluoride
Multiple Vitamin Liquids: Pediatric Formulations
Multiple Vitamin Liquids: Pediatric Formulations 86 83 77 5 0 1 0 0 0 81 1 0 0 1 13 1 0 0 0
with Fluoride (No Iron)
Multiple Vitamin Liquids: Pediatric Formulations 431 410 387 16 2 4 0 1 0 397 5 2 6 27 81 19 0 0 0
with Iron (No Fluoride)
Multiple Vitamin Liquids: Pediatric Formulations 27 26 26 0 0 0 0 0 0 26 0 0 0 0 5 3 0 0 0
with Iron and Fluoride
(continued)
Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category – Continued.
No. of Age Reason Treated in Outcome
No. of Single Unknown Unknown Unknown Adv Health
Case Exposure 5 6–12 13–19 20 Child Adult Age Unint Int Other Rxn Care None Minor Moderate Major Death
Mentions Facility
Multiple Vitamin Liquids: Pediatric Formulations 808 771 632 116 8 10 1 3 1 742 25 2 1 35 120 19 1 0 0
without Iron or Fluoride
Multiple Vitamin Tablets: Adult Formulations
Multiple Vitamin Tablets: Adult Formulations 121 111 91 11 2 6 0 1 0 108 3 0 0 7 20 1 1 0 0
with Fluoride (No Iron)
Multiple Vitamin Tablets: Adult Formulations 5,005 4,096 3,156 120 105 613 7 78 17 3,867 167 4 54 396 858 156 17 1 0
with Iron (No Fluoride)
Multiple Vitamin Tablets: Adult Formulations 24 16 13 1 0 1 0 1 0 15 1 0 0 5 2 0 0 0 0
with Iron and Fluoride
Multiple Vitamin Tablets: Adult Formulations 77 64 38 6 4 15 0 0 1 56 6 0 2 14 17 3 0 0 0
with Iron Carbonyl (No Fluoride)
Multiple Vitamin Tablets: Adult Formulations 6,768 5,527 4,022 660 218 524 10 86 7 5,091 314 5 114 373 1,083 186 13 1 0
without Iron or Fluoride
Multiple Vitamin Tablets: Pediatric Formulations
Multiple Vitamin Tablets: Pediatric Formulations 169 163 146 17 0 0 0 0 0 162 0 1 0 11 32 4 0 0 0
with Fluoride (No Iron)
Multiple Vitamin Tablets: Pediatric Formulations 4,076 3,892 3,481 317 50 30 6 5 3 3,823 59 1 7 388 748 243 16 0 0
with Iron (No Fluoride)
Multiple Vitamin Tablets: Pediatric Formulations 23 23 23 0 0 0 0 0 0 23 0 0 0 4 4 1 0 0 0
with Iron and Fluoride
Multiple Vitamin Tablets: Pediatric Formulations 21 20 17 2 1 0 0 0 0 18 2 0 0 1 1 3 0 0 0
with Iron Carbonyl (No Fluoride)
Multiple Vitamin Tablets: Pediatric Formulations 19,516 18,811 14,824 3,370 367 182 38 25 5 18,027 745 4 20 819 3,001 354 9 0 0
without Iron or Fluoride
Multiple Vitamins, Unspecified Adult
Formulations
Multiple Vitamins, Unspecified Adult 10 9 5 3 0 1 0 0 0 8 0 0 1 1 1 1 0 0 0
Formulations with Fluoride (No Iron)
Multiple Vitamins, Unspecified Adult 1,267 866 623 39 39 135 0 25 5 807 42 0 15 93 149 42 4 0 0
Formulations with Iron (No Fluoride)
Multiple Vitamins, Unspecified Adult 7 4 4 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0
Formulations with Iron and Fluoride
Multiple Vitamins, Unspecified Adult 457 400 306 56 8 27 0 2 1 367 30 0 3 18 65 7 0 0 0
Formulations without Iron or Fluoride
Multiple Vitamins, Unspecified Pediatric
Formulations
Multiple Vitamins, Unspecified Pediatric 15 14 11 3 0 0 0 0 0 14 0 0 0 0 4 0 0 0 0
Formulations with Fluoride (No Iron)
Multiple Vitamins, Unspecified Pediatric 82 77 68 6 0 2 1 0 0 72 3 0 2 8 10 8 0 0 0
Formulations with Iron (No Fluoride)
Multiple Vitamins, Unspecified Pediatric 8 8 8 0 0 0 0 0 0 8 0 0 0 2 4 0 0 0 0
Formulations with Iron and Fluoride
Multiple Vitamins, Unspecified Pediatric 857 824 650 150 18 2 1 1 2 781 38 0 1 23 186 16 1 0 0
Formulations without Iron or Fluoride
Other Vitamins
Other B Complex Vitamins 5,901 4,047 3,244 218 101 394 10 70 10 3,815 137 1 88 282 714 63 8 0 0
Vitamin A 422 343 202 27 6 89 0 17 2 311 15 2 13 35 49 20 5 0 0
Vitamin B3 (Niacin) 1,188 939 311 28 76 463 0 54 7 483 183 1 268 263 65 299 74 1 0
Vitamin B6 (Pyridoxine) 377 206 144 12 4 39 0 6 1 183 11 0 11 20 40 6 2 0 0
Vitamin C 1,505 978 720 106 24 110 2 13 3 886 65 0 26 56 121 54 6 0 0
Vitamin D 7,544 5,292 3,581 323 171 1,036 9 161 11 5,035 123 2 114 510 843 174 27 3 1
Vitamin E 622 413 311 16 10 62 0 13 1 380 14 0 15 31 75 9 0 0 0
Category Total: 59,447 49,937 38,215 5,782 1,262 3,923 90 583 82 46,958 2,077 26 804 3,584 8,611 1,752 193 6 1
Pharmaceuticals Total: 1,472,752 903,583 412,882 59,730 90,429 307,725 1,065 27,214 4,538 653,569 209,392 3,243 27,934 308,955 187,259 115,821 71,447 11,453 1,009
Grand Total 25,41,728 18,58,385 927,844 124,156 132,818 577,096 4,187 79,694 12,590 1,537,317 248,896 14,986 43,444 475,369 339,322 273,962 103,126 13,788 1,324
(Nonpharmaceuticals þ Pharmaceuticals):
CLINICAL TOXICOLOGY
203