2022 Annual Report of the National Poison Data System® (NPDS) from America's Poison Centers®: 40th Annual Report.

INTRODUCTION: This is the 40th Annual Report of America's Poison Centers National Poison Data System (NPDS). As of 1 January, 2022, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 4.72 [4.40, 9.27] (median [25%, 75%]) minutes, effectuating 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 2022, 2,483,183 closed encounters were logged by NPDS: 2,064,875 human exposures, 50,381 animal exposures, 363,099 information requests, 4,790 human confirmed nonexposures, and 38 animal confirmed nonexposures. Total encounters showed a 12.9% decrease from 2021, and human exposure cases decreased by 0.771%, while health care facility (HCF) human exposure cases increased by 0.214%. All information requests decreased by 48.4%, medication identification (Drug ID) requests decreased by 21.2%, and medical information requests showed a 76.92% decrease, although these remain twice the median number before the COVID-19 pandemic. Drug Information requests showed a 52.4% decrease, due to declining COVID-19 vaccine calls to PCs but still comprised 5.55% of all information contacts. Human exposures with less serious outcomes have decreased 1.70% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.41% per year since 2000.Consistent with the previous year, the top 4 substance classes most frequently involved in all human exposures were analgesics (11.5%), household cleaning substances (7.23%), antidepressants (5.61%), and cosmetics/personal care products (5.23%). Antihistamines (4.81%) replaced sedatives/hypnotics/antipsychotics as the 5th substance class. As a class, analgesic exposures increased most rapidly, by 1,514 cases/year (3.26%/year) over the past 10 years for cases with more serious outcomes.The top 5 most common exposures in children age 5 years or less were household cleaning substances (10.3%), analgesics (9.54%), cosmetics/personal care products (9.49%), dietary supplements/herbals/homeopathic (6.65%), and foreign bodies/toys/miscellaneous (6.61%). NPDS documented 3,255 human exposures resulting in death; 2,622 (80.6%) 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 the need for specialized medical toxicology information to manage the increasing number of more 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 requests. 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.

Time to development of metformin-associated lactic acidosis.

Objective: Metformin-associated lactic acidosis (MALA) is a complication of metformin overdose. Recommendations for observation time after an acute ingestion to monitor for MALA vary. The aim of this study was to characterize the time to development of MALA after an acute metformin overdose.Methods: Utilizing Crystal Reports (Version 11.0), all metformin cases reported to the Illinois Poison Center (IPC) with a National Poison Data System (NPDS) clinical effects code of "acidosis" or "anion gap" were retrospectively queried over a 14-year period (2001-2014). Demographic data, time to MALA, co-ingestants, therapeutic modality use, and case outcome were extracted. Interrater reliability was assessed using kappa analysis.Results: A total of 88 cases were identified of which 44 met criteria for MALA; 40 were acute, acute on chronic, or unknown ingestions. The remaining four were chronic ingestions which were excluded. The mean age was 41 years (range 19-79 years). Most were female (55.0%) and over half (62.5%) were acute on chronic ingestions. Hypoglycemia was seen in three ingestions of metformin only. Of the 40 MALA cases, 18 developed MALA less than or equal to 6 h after ingestion, 9 between 6-12 h, 3 after 12 h, and 10 patients had an unknown time to MALA. The only death in the cohort had MALA detected beyond the typical 6-h observation period. Of the exposures when time to MALA was known, 40% (12/30) developed MALA greater than 6 h post ingestion.Conclusion: A 6-h observation period after a single acute ingestion of metformin may be inadequate, as a significant portion of exposures developed MALA beyond this time. We recommend a minimum of 12 h of observation following an acute overdose. Further study defining prospectively the time to development of MALA may improve management of this population.

An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticides.

Objective: To describe a large regional poison center's experience managing an outbreak of long-acting anticoagulant rodenticide (LAAR) poisoning associated with synthetic cannabinoid (SC) use.Methods: This is a retrospective review of exposures reported to the Illinois Poison Center between March 10 and August 1, 2018. All cases coded as exposure to Δ9-tetrahydrocannabinol homologs were identified. Patients with suspected SC use, positive LAAR testing, and coagulopathy (signs or symptoms of bleeding or international normalized ratio [INR] > 2) were included. If confirmatory LAAR testing was performed and resulted as negative, the patient was excluded from this analysis. In the absence of LAAR testing, patients with suspected SC use, an INR >2, and no alternative explanation of coagulopathy were included. Suspected SC use was defined as use suspected by a member of the treating team or reported by the patient. Presenting signs and symptoms, laboratory findings, management, healthcare utilization, outcomes, and disposition of patients affected by this outbreak were reported.Results: One hundred seventy-eight cases met inclusion criteria. Most patients were male (73%) and young to middle-aged (median age 32, IQR 25-40). Most presented to hospitals in Peoria (35%) and Cook (31%) counties. Median hospitalization was three days (IQR 2-4). Eighty-eight percent of patients presented with an INR >10. Eighteen cases had qualitative anticoagulant testing, all of which were positive for brodifacoum. Other identified LAARs included difenacoum (10/18) and bromadiolone (1/18). Sixty-three percent of patients had back, flank or abdominal pain; 70% of patients presented with hematuria. One hundred six cases received IV vitamin K1; no adverse or anaphylactoid reactions were reported. Forty-one (22%) patients left AMA. Thirty-eight patients (21%) were re-hospitalized during the study period. Patients leaving AMA were 1.6 times more likely to be re-hospitalized than patients with other dispositions. Intracranial hemorrhage, present in 3% of total cases, was present in 4 of 5 fatalities.Conclusions: We describe an outbreak of multiple LAARs contaminating SCs. Patients presented with bleeding from varied sites, often required blood products, factor replacement, and high dose vitamin K1 for stabilization.

Cocaine: history, social implications, and toxicity: a review.

The amount of positive cocaine results in an urban emergency department are staggering. The ages of use are becoming more common in older age groups. Most of these patients have underlying medical conditions, including end-stage renal disease (on hemodialysis) and heart and lung disease. Most of their visits to the emergency department are for cocaine exacerbation of underlying chronic condition, adding exponentially to health care dollars. This article describes the history and pharmacology of illicit cocaine use.

Hospitalization for caffeine abuse is associated with abuse of other pharmaceutical products.

STUDY OBJECTIVE: The aim of this study was to examine the characteristics and outcomes of patients seeking treatment for abuse of supplemental caffeine. METHODS: This was a 3-year analysis conducted of all consecutive cases involving caffeine abuse in patients 10 years and older reported to a regional poison center. Excluded were suicide attempts, therapeutic errors, and cases involving only a coffee or tea product. RESULTS: Two hundred fifty-four cases met inclusion criteria. Mean age was 20.5 years, 50% were women. Caffeine was in the form of a nondietary medication in 201 cases, a dietary supplement in 35 cases, and a caffeine-enhanced beverage in 35 cases. Caffeine was abused alone in 174 (68%), with alcohol in 7, illegal drugs in 6 cases, and with other pharmaceutical products in 81 (29%) cases. Thirty-four patients (13% of total) were hospitalized for medical complications from caffeine. Only concomitant abuse of other pharmaceutical products was associated with hospitalization (odds ratio, 3.8; 95% CI, 1.8-8.8; P = .0004). CONCLUSION: In this cohort, supplemental caffeine was abused primarily by young adults. Concomitant recreational abuse of other pharmaceuticals was associated with hospitalization and warrants further investigation.

Management of severe bupropion poisoning with intravenous lipid emulsion.

BACKGROUND: Bupropion toxicity is characterized by central nervous system and cardiovascular toxicity. Intravenous lipid emulsion (ILE) has been suggested as a treatment by some for the treatment of refractory bupropion toxicity. This recommendation is based largely on published case reports and cases presented at scientific meetings. The objective of this study is to characterize the outcomes of patients with suspected bupropion toxicity in which ILE was administered and the indications for its use. METHODS: Electronic records from one regional poison center were searched for intentional bupropion ingestions from 1 January 2009 through 31 December 2015. Cases in which ILE was administered or death was listed as the outcome were further analyzed. RESULTS: There were 1274 cases of suspected bupropion ingestion reported during the study period with 14 reported deaths. Nine cases of ILE administration were identified. Of these, four patients expired and five survived. One of the survivors had neurologic sequelae necessitating placement in a long-term care facility. Patient complications after ILE administration were common and included continued hypotension in 7 cases, recurrent seizures in 3 patients, ARDS in two patients, and renal failure in one patient. CONCLUSIONS: The high mortality and complication rate after ILE in this study sample does not reflect the positive outcome benefit seen in previous published case reports. Further characterization of the efficacy and complications of ILE in bupropion toxicity is needed.

Retrospective review of SGLT2 inhibitor exposures reported to 13 poison centers.

BACKGROUND: SGLT2 inhibitors are a new class of oral antidiabetics prescribed in the United States since 2013. They act by inhibiting reabsorption of glucose in the proximal convoluted tubule of the kidney, allowing excess glucose to be excreted. Little has been reported regarding effects of non-therapeutic exposure to this class of medication. METHODS: Retrospective records from 13 poison centers were examined for human exposures to SGLT2 inhibitors between 1st January 2013 and 31st December 2016. Exclusion criteria included multi-substance exposures and exposures without any follow-up call. Data examined included patient age, chronicity of exposure, clinical effects, management site, treatments administered, duration of follow-up, and outcome. RESULTS: Eighty-eight cases met inclusion criteria. Patient age ranged from 1 to 75 years; 49 were evaluated in a health care facility with 18 admissions. No symptoms developed in 80 (91%) patients, 6 (7%) developed minor symptoms, and 2 (2%) developed moderate symptoms. Hypoglycemia was not observed. Mean time to final follow-up was 9.3 h, ranging from 1 to 42 h; median was 6 h. Of the two patients who developed moderate symptoms, one was a 65 year old male who developed metabolic acidosis and hypokalemia while taking canagliflozin therapeutically; the other a 43-year-old female who developed tachycardia and mild hypertension following the intentional ingestion of 6000 mg of canagliflozin. DISCUSSIONS: The number of patients evaluated in a health care facility is most likely reflective of a cautious approach to dealing with a new class of drug. Exposures were generally well-tolerated and managed with minimal intervention. CONCLUSIONS: In this retrospective series, acute ingestions of SGLT2 inhibitors were well-tolerated with no hypoglycemia and only minor effects. For young children with unintentional ingestions, a reasonable approach to home management would include at least one follow-up for signs and symptoms of possible toxicity including mental status changes, polyuria, or tachypnea.

Nutmeg poisonings: a retrospective review of 10 years experience from the Illinois Poison Center, 2001-2011.

Nutmeg is a commonly consumed spice. The toxic effects of nutmeg have been purported to be due mainly to myristicin oil. Prior poison center series of nutmeg exposures show very few unintentional exposures of nutmeg to children younger than 13. Case series from these centers did not record drug exposures combined with nutmeg. This study is a review of Illinois Poison Center (IPC) data regarding nutmeg exposures from January of 2001 to December 2011. The goal of this study was to compare the Illinois data to the literature as well as look for current trends in nutmeg poisonings. The data were extracted using the code for hallucinogenic plants in the IPC database, and poisonings unrelated to nutmeg exposure were eliminated. Medical outcomes were noted as recorded. Thirty-two cases of nutmeg ingestion were reported. Of the 17 (53.1 %) unintentional exposures, 10 subjects (58.8 %) were under the age of 13. Four of the exposures in children under the age of 13 were ocular exposures. Fifteen exposures (46.9 %) were intentional exposures. Of these intentional exposures, five (33.3 %) were recorded to have combined drug intoxication. All of these were between the ages of 15 and 20. One patient with polypharmaceutical exposure required ventilatory support in the hospital. Our study shows an unexpected percentage of unintentional exposures in juveniles under the age of 13, out of the total exposures to nutmeg. Mixing of nutmeg with other drugs was seen and required more intervention in adolescents. More education about these two factors, i.e., nutmeg exposures as intentional polypharmacy in adolescents and unintentional exposures in young children, is advised.

Compliance with poison center fomepizole recommendations is suboptimal in cases of toxic alcohol poisoning.

We sought to examine hospital compliance with poison center antidotal alcohol dehydrogenase inhibition recommendations in cases of ethylene glycol (EG) and methanol (ME) ingestion. A 2-year analysis of all potential EG and ME ingestion cases reported to a regional poison center was conducted. Excluded from analysis were exposures without an ingestion, without a confirmatory EG or ME serum assay, or without complete medical charting. During the study period, 579 EG or ME exposures were reported to the poison center: 133 cases met study eligibility as an ingestion. Of the 133 cases, 102 (77%) had complete data and were included in the analysis. Immediate alcohol dehydrogenase inhibition was recommended by the poison center in 79 of the 102 cases. Fomepizole was recommended in 61/79 (77%); ethanol was recommended as an alternative therapeutic choice in 32/61 (52%) of these cases if fomepizole was not immediately available. Ethanol alone was recommended in 18/79 (23%). Fomepizole was eventually administered in 39/61 (64%) cases where recommended. The mean time to antidote administration was 3 times longer in cases where a choice in antidote was given [57 min (95% confidence interval, 43-70) vs. 146 min (95% confidence interval, 93-200)]. Despite its ease of administration, fomepizole is used less frequently than recommended by poison center staff. Delays to antidote administration occurred more commonly in cases where the poison center gave a choice in antidotal therapy.

Atypical poisonings with botanicals raise suspicion of malicious activity.

Heightened toxicovigilance since the terrorist actions of 9/11 has raised concerns for malicious use of highly toxic botanicals, as the 3 cases reported illustrate.