2020 webPOISONCONTROL data summary.

INTRODUCTION: Increasing use of the internet for health information has decreased utilization of traditional telephone-based poison centers in the United States. webPOISONCONTROL®, a browser-based tool and app was launched to meet the growing demand for online, personalized recommendations for human poison exposures. This study was conducted to characterize webPOISONCONTROL cases and highlight its potential for real-time monitoring of poisoning. METHODS: Case data for all completed, nonduplicated public cases entered in 2020 were analyzed using a custom Qlik Sense dashboard. RESULTS: Of the 156,202 cases, 52.9% occurred in children younger than 4 years. Most cases (109,057, 69.8%) were initially triaged to home, 28.4% were advised to call Poison Control, and 1.7% were referred to the ED. Follow-up was available for 33.3% of home-triaged cases; 1.7% of those had a change in triage recommendation. Pharmaceuticals were implicated in 41.5% of cases (nonpharmaceuticals in 58.5%). Ingestion was the most common route (88.4%, 138,012). One-time double dose therapeutic error cases were implicated in 17,901 cases (27.6% of pharmaceutical cases). Cosmetics (13.9%) and cleaning substances (12.9%) were the most frequent substance categories. Melatonin was the most frequently implicated generic substance (4.5% of cases). Most (72.0%) cases had no effect (21.4%), a minor effect (3.9%) or were minimally toxic with unknown outcome (46.7%). There were no deaths, 17 major outcomes (0.01%), and 26.7% of cases had potentially toxic exposures with no outcome determination. In 2020, webPOISONCONTROL handled 7.3% as many human poison exposure cases as were reported to U.S. phone-based poison centers. Online cases are skewed towards younger ages (53% in children younger than 4 years vs 37% of phone-based cases) and towards nonpharmaceuticals (58.5% vs 43.5%). Near real-time data visualizations enabled detection of COVID-19-related increases in exposures to hand sanitizers and cleaners, illustrating the public health surveillance and hazard detection capabilities of webPOISONCONTROL. CONCLUSION: The webPOISONCONTROL tool provides a safe, quick and fully-automated alternative to those who are unable or unwilling to use the telephone to call a traditional poison center.

Time to perforation for button batteries lodged in the esophagus.

INTRODUCTION: New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations. METHODS: A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations. RESULTS: Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in <24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days. CONCLUSION: Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

webPOISONCONTROL: can poison control be automated?

BACKGROUND: A free webPOISONCONTROL app allows the public to determine the appropriate triage of poison ingestions without calling poison control. If accepted and safe, this alternative expands access to reliable poison control services to those who prefer the Internet over the telephone. This study assesses feasibility, safety, and user-acceptance of automated online triage of asymptomatic, nonsuicidal poison ingestion cases. METHODS: The user provides substance name, amount, age, and weight in an automated online tool or downloadable app, and is given a specific triage recommendation to stay home, go to the emergency department, or call poison control for further guidance. Safety was determined by assessing outcomes of consecutive home-triaged cases with follow-up and by confirming the correct application of algorithms. Case completion times and user perceptions of speed and ease of use were measures of user-acceptance. RESULTS: Of 9256 cases, 73.3% were triaged to home, 2.1% to an emergency department, and 24.5% directed to call poison control. Children younger than 6 years were involved in 75.2% of cases. Automated follow-up was done in 31.2% of home-triaged cases; 82.3% of these had no effect. No major or fatal outcomes were reported. More than 91% of survey respondents found the tool quick and easy to use. Median case completion time was 4.1 minutes. CONCLUSION: webPOISONCONTROL augments traditional poison control services by providing automated, accurate online access to case-specific triage and first aid guidance for poison ingestions. It is safe, quick, and easy to use.

Effect of cough and cold medication restriction and label changes on pediatric ingestions reported to United States poison centers.

OBJECTIVE: To determine the impact of industry and Food and Drug Administration initiatives implemented to limit the use of over-the-counter (OTC) cough and cold medications in children younger than 6 years of age. STUDY DESIGN: This is a retrospective database study of OTC cough and cold medication ingestions reported to US poison centers between 2000 and 2010. Data analyzed from the National Poison Data System included the month and year of ingestion, reason for ingestion, health care utilization, and medical outcome. Ingestion frequencies were stratified by age and reason. Data were divided into pre- and postintervention periods for comparative analysis. RESULTS: Unintentional ingestions of OTC cough and cold medications decreased 33.4% and therapeutic errors by 46.0%. Health care facility referral declined for unintentional ingestions (28.9% <2 years of age, 19.9% 2-5 years of age, P < .0001) and therapeutic errors in children younger than 2 years of age (59.2%, P < .0001). Moderate and severe adverse outcomes decreased for unintentional ingestions in children younger than 2 years of age by 32.4% and by 21.3% in 2- to 5-year olds, P < .0001. CONCLUSIONS: The restriction of OTC cough and cold medications has led to a decline in unintentional ingestions, therapeutic errors, health care facility referral, and serious medical outcomes in children younger than 2 years of age. There has also been a decline in ingestions in 2- to 5-year-old children.

Severe ocular injury after button battery exposure.

BACKGROUND: Button batteries can cause local tissue necrosis within 2h of exposure due to hydrolysis of tissue fluid and generation of hydroxide ions. Tissue damage resulting from battery exposure has been associated with acute and chronic complications via several routes, however, previous experience with ocular battery exposures is predominantly limited to batteries that have exploded or penetrated the eye. OBJECTIVES: A case is presented of an intact battery causing significant damage after ocular exposure without penetrating the eye. CASE REPORT: An 18-year-old woman presented to the Emergency Department after a toy balloon propelled a button battery into the patient's eye. The battery did not penetrate the orbit and was intact upon removal from the inferior fornix in the operating room 4h later. The patient had severe conjunctival ulceration, subconjunctival hemorrhage, vitreous opacification, and a partially dilated pupil, with the greatest area of injury adjacent to the negative pole of the battery. The eye was extensively irrigated and the patient was treated with topical antibiotics, steroids, and a daily rodding procedure to prevent conjunctival adhesions. The eye ultimately healed over the subsequent 6 months, with normal visual acuity on follow-up. CONCLUSION: Prolonged ocular exposure to an intact battery can cause significant tissue necrosis, which may threaten sight. Early removal is critical to prevent significant ocular damage and visual compromise.

Management of button battery-induced hemorrhage in children.

OBJECTIVES: Button battery ingestions are potentially life threatening for children. Catastrophic and fatal injuries can occur when the battery becomes lodged in the esophagus, where battery-induced injury can extend beyond the esophagus to the trachea or aorta. Increased production of larger, more powerful button batteries has coincided with more frequent reporting of fatal hemorrhage secondary to esophageal battery impaction, but no recommendations exist for the management of button battery-induced hemorrhage in children. MATERIALS AND METHODS: We reviewed all of the reported pediatric fatalities due to button battery-associated hemorrhage. Our institution engaged subspecialists from a wide range of disciplines to develop an institutional plan for the management of complicated button battery ingestions. RESULTS: Ten fatal cases of button battery-associated hemorrhage were identified. Seven of the 10 cases have occurred since 2004. Seventy percent of cases presented with a sentinel bleeding event. Fatal hemorrhage can occur up to 18 days after endoscopic removal of the battery. Guidelines for the management of button battery-associated hemorrhage were developed. CONCLUSIONS: Pediatric care facilities must be prepared to act quickly and concertedly in the case of button battery-associated esophageal hemorrhage, which is most likely to present as a "sentinel bleed" in a toddler.

Button Battery Safety: Industry and Academic Partnerships to Drive Change.

The pediatric button battery (BB) hazard has been recognized for several decades. In 2012, the National Button Battery Task Force was established, and most manufacturers have improved warning labels, more secure packaging, and made BB compartments in products are more secure. Tissue neutralization before BB removal (ie, honey or sucralfate/Carafate®) is an effective way to reduce the rate of BB injury. In absence of visible perforation, 0.25% sterile acetic acid esophageal tissue irrigation at time of BB removal is recommended as a neutralization strategy to mitigate injury progression. Future BB design changes could eliminate esophageal tissue injury.

The impact of poison control centers on poisoning-related visits to EDs--United States, 2003.

PURPOSE: This study analyzes the association between center usage rates and the rates of nonadmitted visits to emergency departments (EDs) for poisoning. BASIC PROCEDURES: With a log-normal regression model, we analyzed the association between the number of human exposure calls per hospitalized poisoning patient and the number of nonhospitalized ED visits. The data were from 14 states at county level. MAIN FINDINGS: A 1% higher poison control center (PCC) human exposure call rate for unintentional poisoning is associated, but not necessarily causally, with a 0.18% lower ED visit rate (P < .0001). If the observed association is causative, 15.5 PCC human poison exposure calls prevent one nonadmitted ED visit, yielding a $205 net cost saving and a benefit-cost ratio of 1.4. The savings ignore any reduction in hospital admissions. PRINCIPAL CONCLUSIONS: Increased PCC exposure calls appear to be associated with reduced ED use for unintentional poisoning and appear to reduce net medical spending.

Public health investigation after the discovery of ricin in a South Carolina postal facility.

OBJECTIVES: In October 2003, a package containing ricin and a note threatening to poison water supplies was discovered in a South Carolina postal facility, becoming the first potential chemical terrorism event involving ricin in the United States. We examined the comprehensive public health investigation that followed and discuss the lessons learned from it. METHODS: An investigation consisting primarily of environmental sampling for ricin contamination, performance of health assessments on affected personnel, and local, regional, and national surveillance for ricin-associated illness. RESULTS: Laboratory analysis of 75 environmental sampling specimens revealed no ricin contamination. Health assessments of 36 affected employees were completed. Local surveillance initially identified 3 suspected cases, and national surveillance identified 399 outliers during the 2-week period after the incident. No confirmed cases of ricin-associated illness were identified. CONCLUSIONS: A multifaceted and multidisciplinary approach is required for an effective public health response to a chemical threat such as ricin. The results of all of the described activities were used to determine that the facility was safe to reopen and that no public health threat existed.

Early detection of illness associated with poisonings of public health significance.

Since September 11, 2001, concern about potential terrorist attacks has increased in the United States. To reduce morbidity and mortality from outbreaks of illness from the intentional release of chemical agents, we examine data from the Toxic Exposure Surveillance System (TESS). TESS, a national system for timely collection of reports from US poison control centers, can facilitate early recognition of outbreaks of illness from chemical exposures. TESS data can serve as proxy markers for a diagnosis and may provide early alerts to potential outbreaks of covert events. We use 3 categories of information from TESS to detect potential outbreaks, including call volume, clinical effect, and substance-specific data. Analysis of the data identifies aberrations by comparing the observed number of events with a threshold based on historical data. Using TESS, we have identified several events of potential public health significance, including an arsenic poisoning at a local church gathering in Maine, the TOPOFF 2 national preparedness exercise, and contaminated food and water during the northeastern US blackout. Integration of poison control centers into the public health network will enhance the detection and response to emerging chemical threats. Traditionally, emergency physicians and other health care providers have used poison control centers for management information; their reporting to these centers is crucial in poisoning surveillance efforts.

Epidemiology of nonfatal deliberate self-harm in the United States as described in three medical databases.

The absence of validated U.S. rates of nonfatal suicidal behavior places risk management and injury prevention programs at danger of being poorly informed and inadequately conceptualized. In this study we compare estimated rates of intentional self-harm from two ongoing surveys (National Electronic Injury Surveillance System-All Injury Program-NEISS-AIP; National Hospital Ambulatory Medical Care Survey-NHAMCS) to data from the Toxic Exposure Surveillance System. Results suggest that, for every 2002-2003 suicide, there were 12 (NEISSAIP) or 15 (NHAMCS) self-harm-related emergency department visits, and for every intentional self-poisoning death there were 33 intentional overdoses reported to poison control centers, of which two ultimately went untreated.

The Toxic Exposure Surveillance System (TESS): risk assessment and real-time toxicovigilance across United States poison centers.

The Toxic Exposure Surveillance System (TESS) is a uniform data set of US poison centers cases. Categories of information include the patient, the caller, the exposure, the substance(s), clinical toxicity, treatment, and medical outcome. The TESS database was initiated in 1985, and provides a baseline of more than 36.2 million cases through 2003. The database has been utilized for a number of safety evaluations. Consideration of the strengths and limitations of TESS data must be incorporated into data interpretation. Real-time toxicovigilance was initiated in 2003 with continuous uploading of new cases from all poison centers to a central database. Real-time toxicovigilance utilizing general and specific approaches is systematically run against TESS, further increasing the potential utility of poison center experiences as a means of early identification of potential public health threats.

The severity of toxic reactions to ephedra: comparisons to other botanical products and national trends from 1993-2002.

OBJECTIVE: Ephedra is a botanical product widely used to enhance alertness, as a weight loss aide, and as a decongestant. Its reported adverse effects led the Food and Drug Administration (FDA) to ban ephedra-containing products in the United States in 2004. This study's purpose was to compare toxicity from botanical products containing ephedra to nonephedra products. METHODS: The Toxic Exposure Surveillance System (TESS), a national poison center database, was utilized to determine the number and outcomes of cases involving botanical products reported from 1993-2002. Cases listing both a botanical product and any other drugs or chemicals were excluded a priori. Ten-year hazard rates (moderate outcomes + major outcomes + deaths per 1000 exposures) were used to compare botanical product categories. RESULTS: There were 21,533 toxic exposures with definitive medical outcomes reported over the 10 yrs where a botanical product was the only substance involved. Of these, 4306 (19.9%) had moderate or major medical outcomes and there were two deaths, for an overall hazard score of 200 per 1000 exposures. The number of ephedra reports to poison centers increased 150-fold over the 10-yr period. The hazard rate for products that contained only ephedra was 250 per 1000 exposures and 267 per 1000 exposures for products that contained ephedra and additional ingredients; whereas the hazard score for only nonephedra botanical products was 96 per 1000 exposures. The rate ratios for multibotanical products with ephedra (RR 1.33; 95% C.I. 1.27-1.40) and for single-ingredient ephedra products (RR 1.25; 95% C.I. 1.11-1.40) were both two to six times higher than those of other common botanical products. Yohimbe-containing products had the highest hazard score (417) and rate ratio (2.08; 95% C.I. 1.59-2.80). CONCLUSION: Ephedra-containing botanical products accounted for a significant number of toxic exposures with severe medical outcomes reported to poison centers. Hazard rate analysis suggests poison center-reported events involving ephedra-containing botanical products were much more likely to result in severe medical outcomes than those involving nonephedra-containing botanical products. These data support recommendations by policymakers that the sale of ephedra should be prohibited to protect consumers. Our data suggest that the botanical product, yohimbe, may also be associated with unacceptably high risks of toxicity and should receive close scrutiny from health policymakers.

Pediatric button battery injuries: 2013 task force update.

Over the last 10 years, there has been a dramatic rise in the incidence of severe injuries involving children who ingest button batteries. Injury can occur rapidly and children can be asymptomatic or demonstrate non-specific symptoms until catastrophic injuries develop over a period of hours or days. Smaller size ingested button batteries will often pass without clinical sequellae; however, batteries 20mm and larger can more easily lodge in the esophagus causing significant damage. In some cases, the battery can erode into the aorta resulting in massive hemorrhage and death. To mitigate against the continued rise in life-threatening injuries, a national Button Battery Task Force was assembled to pursue a multi-faceted approach to injury prevention. This task force includes representatives from medicine, public health, industry, poison control, and government. A recent expert panel discussion at the 2013 American Broncho-Esophagological Association (ABEA) Meeting provided an update on the activities of the task force and is highlighted in this paper.

Comparison of citalopram and other selective serotonin reuptake inhibitor ingestions in children.

CONTEXT: In adults, citalopram is more likely to cause seizures and ECG changes than other selective serotonin reuptake inhibitors (SSRIs). Data in children are lacking, yet the 2007 American Association of Poison Control Centers out-of-hospital citalopram consensus guideline mirrors the guideline for other SSRIs. OBJECTIVE: To compare the clinical effects and hazard index of citalopram with other SSRIs in pediatric ingestions. METHODS: An 11-year retrospective analysis of national poison center data was conducted. Acute, known-type SSRI ingestions in children younger than 6 years with known outcome were included. Clinical effects and hazard index (number of major or fatal outcomes/1000 SSRI ingestions) were compared. Citalopram dose-response was evaluated. RESULTS: The 35 296 included cases by SSRI type were citalopram (3747), escitalopram (4815), fluoxetine (5946), fluvoxamine (273), paroxetine (7157), and sertraline (13 358). The overall hazard index was 0.340. The hazard index for citalopram (0.801) was 2.8-fold higher than for non-citalopram SSRIs (0.285). Comparing seizures (single or multiple discrete) and cardiac effects (conduction disturbances, other ECG changes or other dysrhythmia) of citalopram with the other SSRIs, pediatric citalopram ingestions were more likely to develop seizures (5 of 3747 [0.13%] vs. 10 of 31 549 [0.03%], OR = 4.2; 1.4-12.3) and cardiac toxicity (9 of 3747 [0.24%] vs. 25 of 31 549 [0.08%], OR = 3.0; 1.4-6.5). Clinical effects occurring more frequently with other SSRIs included tachycardia (p = 0.0236), oral irritation (p = 0.0412), vomiting (p = 0.0036), agitation/irritability (p = 0.0104), and hyperthermia (p = 0.0314). There was a dose response only for single or multiple discrete seizures, mydriasis and clinically significant responses (a predetermined subset of CNS and cardiopulmonary clinical effects). Meaningful triage thresholds for citalopram could not be determined due to the low frequency of significant clinical effects. CONCLUSION: Children develop minimal toxicity with SSRI ingestions. Seizures and ECG changes, while uncommon, occur more frequently with citalopram. Doses associated with significant outcomes suggest that the triage guideline for citalopram does not need to be modified.

Monitoring trends in dextromethorphan abuse using the National Poison Data System: 2000-2010.

CONTEXT: Dextromethorphan (DXM) abuse persists among US youth and should be closely monitored because of the risks of severe medical complications, addiction, and psychiatric sequelae. Prior investigations have demonstrated DXM to be an emerging drug of abuse with increasing national prevalence through 2004. OBJECTIVE: To extend existing substance abuse survey results by describing demographic, geographic, product, and outcome trends in medically significant DXM abuse cases (those reported to US poison centers). METHODS: National Poison Data System (NPDS) data are collected and compiled in real time by all 57 US poison centers. Demographic, geographic, product, and outcome data for all intentional DXM abuse cases reported to the NPDS between 2000 and 2010 were analyzed. RESULTS: A total of 44,206 DXM abuse cases met inclusion criteria, 34,755 of which were single-substance exposures. The mean annual prevalence of DXM cases reported to poison control centers was 13.4 cases per million population for all ages and 113.0 cases per million for 15-19 year olds. The prevalence of DXM cases for all ages increased steadily (p = 0.002, Cochran-Armitage trend test) until 2006 to a peak of 17.6 calls/million and has subsequently plateaued at 15.7 cases per million in 2010. This trend is also seen in the most commonly abused brand of DXM products, Coricidin(®). A preponderance of male adolescents was noted throughout the study period. The odds of a severe outcome are increased for a multi-substance exposure (OR: 2.53; 95% CI: 2.14-2.99, logistic regression); odds were not significantly increased for any of the most commonly abused product brands. CONCLUSION: The increasing trend of DXM abuse cases noted in the first half of the decade by previous studies seems to have peaked at 17.6 calls per million population in 2006. It is likely that a combination of legislative, educational, and economic initiatives are responsible for the observed plateau.

Preventing battery ingestions: an analysis of 8648 cases.

OBJECTIVES: Outcomes of pediatric button battery ingestions have worsened substantially, predominantly related to the emergence of the 20-mm-diameter lithium cell as a common power source for household products. Button batteries lodged in the esophagus can cause severe tissue damage in just 2 hours, with delayed complications such as esophageal perforation, tracheoesophageal fistulas, exsanguination after fistulization into a major blood vessel, esophageal strictures, and vocal cord paralysis. Thirteen deaths have been reported. The objective of this study was to explore button battery ingestion scenarios to formulate prevention strategies. METHODS: A total of 8648 battery ingestions that were reported to the National Battery Ingestion Hotline were analyzed. RESULTS: Batteries that were ingested by children who were younger than 6 years were most often obtained directly from a product (61.8%), were loose (29.8%), or were obtained from battery packaging (8.2%). Of young children who ingested the most hazardous battery, the 20-mm lithium cell, 37.3% were intended for remote controls. Adults most often ingested batteries that were sitting out, loose, or discarded (80.8%); obtained directly from a product (4.2%); obtained from battery packaging (3.0%); or swallowed within a hearing aid (12.1%). Batteries that were intended for hearing aids were implicated in 36.3% of ingestions. Batteries were mistaken for pills in 15.5% of ingestions, mostly by older adults. CONCLUSIONS: Parents and child care providers should be taught to prevent battery ingestions. Because 61.8% of batteries that were ingested by children were obtained from products, manufacturers should redesign household products to secure the battery compartment, possibly requiring a tool to open it.

Determinants of U.S. poison center utilization.

CONTEXT: High poison center utilization has been associated with decreased emergency department usage and hospitalization rates. However, utilization requires awareness of the poison center. Penetrance, defined as the number of human poison exposures reported to a poison center per 1,000 population, has been used as a marker of poison center awareness. OBJECTIVES: To identify factors that influence poison center penetrance to optimize the life- and cost-saving benefits of poison control centers. METHODS: Human poison exposures that were reported to the National Poison Data System in 2001 were analyzed to identify and rank factors affecting poison center penetrance. RESULTS: Overall penetrance correlated with pediatric penetrance (R(2) = 0.75, p < 0.01). As pediatric penetrance increased, there was a significant decline in the percent of children reported to a poison center that were already in or en route to a healthcare facility at the time of the call to the poison center (R(2) = 0.41, p < 0.01). Larger poison center service populations were associated with lower penetrance (R(2) = 0.23, p < 0.01). Inverse predictors of penetrance included inability to speak English well, Black/African American race, and distance from the poison center (multiple regression). Positive predictors included the percentage of the population younger than 5 years, the percentage of the adult population with a bachelor's degree, poison center certification, poison center educator FTEs (full time equivalents), Asian population percentage, and population density. DISCUSSION: The inverse correlation between pediatric penetrance and healthcare facility utilization supports prior observations of excessive healthcare utilization when a poison center is not called. Since race, language and distance are barriers to poison center utilization, and since healthcare utilization increases when poison center penetrance declines, low penetrance suggests a lack of awareness of the poison center rather than a low incidence of poisonings. CONCLUSION: Strategies to raise penetrance should be informed by an understanding of the barriers to utilization - language, Black/African American race, distance from the poison center, poverty, and lower education levels.