Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement.

Importance: The US and Canada currently have no formal published nationwide guidelines for specialists in poison information or emergency departments for the management of acetaminophen poisoning, resulting in significant variability in management. Objective: To develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada. Evidence Review: Four clinical toxicology societies (America's Poison Centers, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association of Poison Control Centers) selected participants (n = 21). Led by a nonvoting chairperson using a modified Delphi method, the panel created a decision framework and determined the appropriate clinical management of a patient with acetaminophen poisoning. Unique to this effort was the collection of guidelines from most poison centers in addition to systematic collection and review of the medical literature. Comments from review by external organizations were incorporated before the guideline was finalized. The project began in March 2021 and ended in March 2023. Findings: The search retrieved 84 guidelines and 278 publications. The panel developed guidelines for emergency department management of single or repeated ingestion of acetaminophen. In addition, the panel addressed extended-release formulation, high-risk ingestion, coingestion of anticholinergics or opioids, age younger than 6 years, pregnancy, weight greater than 100 kg, and intravenous acetaminophen use. Differences from current US practice include defining acute ingestion as an ingestion presentation from 4 to 24 hours after overdose was initiated. A revised form of the Rumack-Matthew nomogram was developed. The term massive ingestion was replaced with the term high-risk ingestion and denoted by a specific nomogram line. Other recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters, defining the role of gastrointestinal decontamination, detailed management of acetylcysteine treatment, associated adverse effects, and stopping criteria for acetylcysteine treatment, as well as criteria for consultation with a clinical toxicologist. Finally, specific treatment considerations, including acetylcysteine dosing, fomepizole administration, and considerations for extracorporeal elimination and transplant evaluation, were addressed. Conclusions and Relevance: This qualitative study provides a consensus statement on consistent evidence-based recommendations for medical, pharmacy, and nursing education and practice to optimize care of patients with acetaminophen poisoning.

Per- and polyfluoroalkyl substance (PFAS) exposure assessment in a community exposed to contaminated drinking water, New Hampshire, 2015.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in manufacturing that resist environmental degradation, can leach into drinking water, and bioaccumulate in tissues. Some studies have shown associations with negative health outcomes. In May 2014, a New Hampshire public drinking water supply was found to be contaminated with PFAS from a former U.S. Air Force base. OBJECTIVES: We established a serum testing program to assess PFAS exposure in the affected community. METHODS: Serum samples and demographic and exposure information were collected from consenting eligible participants. Samples were tested for PFAS at three analytical laboratories. Geometric means and 95% confidence intervals were calculated and analyzed by age and exposure variables. RESULTS: A total of 1578 individuals provided samples for PFAS testing; >94% were found to have perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorohexane sulfonic acid (PFHxS) detectable in serum. Geometric mean serum concentrations of PFOS, PFOA, and PFHxS were 8.6 µg/L (95% CI:8.3-8.9), 3.1 µg/L (95% CI: 3.0-3.2), and 4.1 µg/L (95% CI: 3.9-4.3), respectively, which were statistically higher than the general U.S. POPULATION: Significant associations were observed between PFAS serum concentrations and age, time spent in the affected community, childcare attendance, and water consumption. CONCLUSIONS: PFOS, PFOA, and PFHxS were found in significantly higher levels in the affected population, consistent with PFAS drinking water contamination. Given increased recognition of PFAS contamination in the U.S, a coordinated national response is needed to improve access to biomonitoring and understand health impacts.

Poison center surveillance data: the good, the bad and ... the flu.

BACKGROUND: Poison center data are increasingly used by state health departments and the Centers for Disease Control and Prevention for public health surveillance. Forrester and colleagues evaluated the ability of 6 Texas poison centers covering a population of 24 million to accurately code and report the number of H1N1 calls received over a 5-month period. DISCUSSION: The Texas poison centers generated new coding and began work within 24 h of notification of the surveillance need. No additional staff were added for call management, coding, or quality assurance, and no H1N1 training was provided ahead of time. A triple-redundancy coding method was used to prevent underreporting of calls. This allowed the Texas poison centers to accurately flag over 90% of H1N1 cases. Results were available in real time, allowing day-to-day monitoring by poison centers and the state public health department for surges, location, ages of callers and/or patients, and type of question. CONCLUSION: The accuracy of poison center near real-time toxicosurveillance data coding was sufficient to monitor emerging trends. The data generated by poison centers are flexible, immediate, unique from other data sources, and useful for trend monitoring. As health departments and other collaborative partners rely more on the data from poison centers, consideration must be given to appropriate funding to support coding training, monitoring, and quality assurance to further enhance this valuable system.

Arsenic poisoning caused by intentional contamination of coffee at a church gathering--an epidemiological approach to a forensic investigation.

An outbreak of apparent food-borne illness following a church gathering was promptly reported to the Maine Bureau of Health. Gastrointestinal symptoms among church attendees were initially attributed to consumption of leftover sandwiches that had been served the previous day. However, a rapid epidemiological and laboratory assessment revealed the etiology of illness, including the death of an elderly gentleman, was not food-borne in origin. A criminal investigation determined that deliberate arsenic contamination of the brewed coffee by one of the church members was the source of the outbreak. Public health officials and criminal investigators must be aware that intentional biologic aggression can initially present as typical unintentional disease outbreaks. Practitioners must also consider the need to properly maintain and preserve potential forensic evidence. This case demonstrates the key role public health practitioners may play in criminal investigations.

Pulmonary toxicity following exposure to waterproofing grout sealer.

INTRODUCTION: We report a large number of cases of pulmonary toxicity from 6 regional poison control centers associated with the use of a waterproofing-grout sealer. The identification of this illness occurred by means of the poison control center (PCC) national automated toxicosurveillance. MATERIALS AND METHODS: This is a retrospective case review of all cases of pulmonary toxicity following exposure to a waterproofing grout sealer from 6 regional PCCs including Michigan, Kentucky, Utah, Maine, Arizona, and Nebraska. The study period extended from June 1, 2005 to December 1, 2005. RESULTS: The vast majority of patients used the product at home (80%). Over half the patients presented within 3 hours of exposure. The most common presenting symptoms were shortness of breath (63%), cough (60%), and chest pain (44%). Wheezing (33%) and rales (23%) were the most common signs of clinical toxicity. One patient required endotracheal intubation. Thirty-seven percent of patients had signs of acute pneumonitis on initial chest x-ray. The mean presenting oxygen saturation was 89.5%. The most common treatment measures used were supplemental oxygen, bronchodilator therapy, oral steroids, and antibiotics. Over half of the study group required hospital admission. CONCLUSION: The majority of patients in this study were adults using the product at home. Over one-third of patients had an abnormal x-ray upon presentation. Over half of the study group required hospital admission following exposure to this product. Medical professionals should be aware of the potential for pulmonary toxicity due to waterproofing aerosols.