Causal factors of work-related chemical eye injuries reported to the Dutch Poisons Information Center.

This study investigated the circumstances of chemical occupational eye exposures reported to the Dutch Poisons Information Center. During a 1-year prospective study, data were collected through a telephone survey of 132 victims of acute occupational eye exposure. Victims were often exposed to industrial products (35%) or cleaning products (27%). Most patients developed no or mild symptoms. Organizational factors (such as lack of work instructions (52%)), and personal factors (such as time pressure and fatigue (50%), and not adequately using personal protective equipment (PPE, 14%), were the main causes of occupational eye exposures. Exposure often occurred during cleaning activities (34%) and personal factors were reported more often during cleaning (67%) than during other work activities (41%). Data from Poison Control Centers are a valuable source of information, enabling the identification of risk factors for chemical occupational eye exposure. This study shows that personal factors like time pressure and fatigue play a significant role, although personal factors may be related to organizational issues such as poor communication. Therefore, risk mitigation strategies should focus on technical, organizational, and personal factors. The need to follow work instructions and proper use of PPE should also have a prominent place in the education and training of workers.

Acute occupational exposures reported to the Dutch Poisons Information Center: a prospective study on the root causes of incidents at the workplace.

BACKGROUND: Hazardous substances at the workplace can cause a wide variety of occupational incidents. This study aimed to investigate the nature and circumstances of acute occupational intoxications reported to the Dutch Poisons Information Center. METHODS: During a one-year prospective study, data on the circumstances and causes of the incident, the exposure(s) and clinical course, were collected by a telephone survey with victims of an acute occupational intoxication. RESULTS: We interviewed 310 patients. Most incidents occurred in industry (25%), building and installation industry (14%) and agriculture (10%). Patients were often exposed via multiple routes. Inhalation was the most common route of exposure (62%), followed by ocular (40%) and dermal contact (33%). Acids and alkalis were often involved. Exposure often occurred during cleaning activities (33%). The main root causes of these accidents were: technical factors such as damaged packaging (24%) and defective apparatus (10%), organizational factors such as lack of work instructions (44%) and poor communication or planning (31%), and personal factors such as disregarding work instructions (13%), not (adequately) using personal protective equipment (12%) and personal circumstances (50%) such as inaccuracy, time pressure or fatigue. The majority of the patients only reported mild health effects and recovered quickly (77% within 1 week). CONCLUSIONS: Poison Center data on occupational exposures provide an additional source of knowledge and an important basis for poisoning prevention strategies related to hazardous substances at the workplace. These data are useful in deciding which risk mitigation measures are most needed in preventing future workplace injuries.

Estimation of the risk of local and systemic effects in infants after ingestion of low-concentrated weak acids from descaling products.

INTRODUCTION: The accidental ingestion of diluted household descaling products by infants is a phenomenon that poison control centers regularly encounter. Feeding infants with baby milk prepared with water from electric kettles still containing descaler is a common way of exposure. This study aimed to determine the risks related to ingestion of (diluted) descalers by infants. METHODS: pH measurements were performed using acetic acid and three different commercially available electric kettle descalers. The pH of different dilutions was measured in the absence or presence of baby milk powder. In addition, an overview was made of pH values of different electric kettle descalers as given by the product information of the manufacturer. Finally, a simple pharmacokinetic (PK) model was used to predict changes in blood pH in infants after ingestion of acetic acid, which is the most commonly used descaler. RESULTS: Several commercially available electric kettle descalers have a pH <2. Even after diluting such descalers up to 10 times the pH can remain low. The addition of milk powder increases the pH of descalers containing weaker acids, with a pH >1.5, while descalers with stronger acids and pH <1 show little pH increase after the addition of milk powder. Finally, a simple PBPK model for the ingestion of acetic acid predicted that the ingestion of larger amounts of acetic acid (>1000 mg) by an infant could result in relevant changes in blood pH. CONCLUSIONS: Commercially available electric kettle descaling products may pose a health risk to infants in case of accidental ingestion since the pH of some of these products can be very low, even when diluted 10-times or in the presence of baby milk powder. Oral exposure of infants to the common descaler acetic acid, after accidental preparation of baby milk with cleaning vinegar, will probably not result in serious local effects, but changes in blood pH cannot be excluded when larger amounts of acetic acid are ingested.

Is secondary chemical exposure of hospital personnel of clinical importance?

INTRODUCTION: There is increasing concern among hospital personnel about potential secondary exposure when treating chemically contaminated patients. OBJECTIVE: To assess which circumstances and chemicals require the use of Level C Personal Protective Equipment (chemical splash suit and air-purifying respirator), to prevent secondary contamination of hospital personnel treating a chemically contaminated patient. METHODS: The US National Library of Medicine PubMed database was searched for the years 1985 to 2020 utilizing combinations of relevant search terms. This yielded 557 papers which were reviewed by title and abstract. After excluding papers on biological or radiological agents, or those not related to hospital personnel, 38 papers on chemicals remained. After a full-text review, 13 papers without an in-depth discussion on the risk for secondary contamination were omitted, leaving 25 papers for review. The references of these papers were searched and this yielded another seven additional citations, bringing the total to 32 papers. INCIDENCE OF SECONDARY TOXICITY: Secondary toxicity in hospital personnel is rare: a large-scale inventory of 120,000 chemical incidents identified only nine cases, an occurrence of 0.0075%. SKIN CONTACT AS A SECONDARY EXPOSURE ROUTE: Skin exposure is rare under normal hygienic working conditions, reflected by the very small number of cases reported in the literature: two cases with corrosive effects due to unprotected contact and one case of presumed skin absorption. INHALATION AS A SECONDARY EXPOSURE ROUTE: Most case reports described secondary toxicity as a result of inhalation. The chemicals involved were irritating solid particles (capsaicin spray/CS), toxic gases formed in the stomach of patients (arsine/hydrazoic acid/phosphine) and vapours from volatile liquids (solvents). FEATURES OF SECONDARY TOXICITY: Reported symptoms after secondary inhalation were generally mild and reversible (mostly irritation of eyes and respiratory tract, nausea, headache, dizziness/light-headedness) and did not require treatment. In many cases, special circumstances increased exposure: treatment/decontamination of multiple patients, regurgitation of the chemical agent from the stomach, or inadequate room ventilation. USE OF MORE THAN STANDARD PERSONAL PROTECTIVE EQUIPMENT: Normal hygienic precautions prevent direct skin contact from exposure to common chemical agents. When solid particle contamination is extensive, a mask and eye protection should be applied. Splash proof outer clothing (splash suit) and eye protection is preferred if (partial) wet decontamination is performed on single patients. Adequate ventilation, careful removal of clothing in case of solid particles contamination and adequate disposal of gastric content reduces exposure. Hospital staff can be rotated if symptoms occur, which can be odour-mediated. The use of more elaborate personal protective equipment with an air-purifying respirator (Level C) is only necessary in exceptional cases of contamination with highly toxic volatile chemicals (e.g., sarin). It should also be considered when decontaminating a large number of patients. CONCLUSIONS: The risk of secondary contamination and subsequent toxicity in hospital personnel decontaminating or treating chemically contaminated patients is small. Normal hygienic precautions (gloves and water-resistant gown) will adequately protect hospital staff when treating the majority of chemically contaminated patients. More extensive protection is only necessary infrequently and there is no reason to delay critical care, even if more elaborate protection is not immediately available.

Profile of incidental exposures to e-cigarette liquids in Europe, 2018-2019.

BACKGROUND: Following the implementation of the European Union Tobacco Product Directive (EU TPD) regulations on e-cigarette products in 2016, we assessed the current profile of e-cigarette liquid exposure incidents and their associated health outcomes. METHODS: De-identified data were received from poison centers in eight EU Member States (Sweden, the Netherlands, Italy, Hungary Austria, Finland, Spain and Croatia) reporting on e-cigarette liquid exposure incidents between August 2018 to December 2019. Descriptive analysis was conducted to present incident characteristics and health outcomes. Chi-square tests and multivariable logistic regression analysis were used to test associations. RESULTS: Of the 223 e-liquid exposure incidents recorded by poison centers in multiple EU MS, 64.7% of the cases were unintentional exposures, ranging from 48.4% among adults aged ≥19 years to 100.0% among children aged 0-5 years (p < 0.05). The most frequent route of exposure was ingestion (73.5%) while55.2% experienced any clinical symptoms, including nausea (16.6%), vomiting (11.1%), and dizziness (9.0%). 57.8% of the cases were treated at the residence or on-site. CONCLUSION: Further monitoring is warranted, using uniform reporting requirements, to ensure the continued compliance to the EU TPD and assess its long-term impact on related incident characteristics.

A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study.

BACKGROUND: Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission. METHODS: For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect. RESULTS: We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%). CONCLUSIONS: The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.

Intoxication with Ornithogalum arabicum is a potential cause of visual impairment and irreversible blindness in dogs.

We describe two dogs with persistent visual impairment after initially mild intoxication signs following ingestion of Ornithogalum arabicum plant material. Additionally, a 12-year analysis of the Dutch Poisons Information Centre database additionally reveals that ingestion of Ornithogalum plant material can be potentially life-threatening to companion animals. Further studies are necessary to confirm the involvement of cardiac glycoside-like toxins present in Ornithogalum arabicum and the toxicity of these substances to the retina.

New legal requirements for submission of product information to poisons centres in EU member states.

INTRODUCTION: In the past eight years, the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) has been intensively involved in a European Commission led process to develop EU legislation on the information of hazardous products that companies have to notify to EU Poisons Centres (or equivalent "appointed bodies"). As a result of this process, the Commission adopted Regulation (EU) No 2017/542, amending the CLP Regulation by adding an Annex on harmonised product submission requirements. Harmonised mixture information requirements: Detailed and consistent information on the composition of the hazardous product will become available to EU Poisons Centres (PC). The information will be submitted by companies to PCs (or equivalent "appointed bodies") using a web-based software application or in-house software. Two new important features are introduced. Firstly, to be able to rapidly identify the product formula, a Unique Formula Identifier (UFI) on the product label links to the submitted information. Secondly, for better comparability of reports on poisonings between EU member states, a harmonised Product Categorisation System will specify the intended use of a product. Rapid product identification and availability of detailed composition information will lead to timely and adequate medical intervention. This may lead to considerable reduction in healthcare costs. Additionally, for companies trading across the EU, costs of submission of this information will be reduced significantly. Next steps: From 2017, an implementation period has started, consisting of a three-year period for stakeholders to implement the new requirements, followed by a gradual applicability for consumer products (2020), professional products (2021) and industrial use-only products (2024). Technical tools to generate the electronic format and the UFI together with guidance documents are expected to be made available by the end of 2017 by the European Chemicals Agency (ECHA). Guidance on interpretation of legal text and ECHA helpdesk support are planned to be ready at the end of 2018.

Fatalities, Cerebral Hemorrhage, and Severe Cardiovascular Toxicity After Exposure to the New Psychoactive Substance 4-Fluoroamphetamine: A Prospective Cohort Study.

STUDY OBJECTIVE: We study adverse health effects after use of the new psychoactive substance 4-fluoroamphetamine. METHODS: All patients who reported 4-fluoroamphetamine exposure and for whom the Dutch Poisons Information Center was consulted by their physician in 2016 were included in a prospective cohort study. The clinical course was investigated through telephone interviews with the physician and/or patient, using standardized questionnaires. 4-Fluoroamphetamine was analyzed in remaining drug material and biological samples with liquid and gas chromatography-mass spectrometry techniques. RESULTS: We included 45 patients, and follow-up with the physician and/or patient was performed in 33 cases. All patients experienced adverse effects after 4-fluoroamphetamine use. Severe toxicity was reported in 8 patients. In 5 of these patients, 4-fluoroamphetamine exposure was confirmed in biological specimens. Severe toxicity that was reported included 2 fatalities, 4 patients with cerebral hemorrhage (1 fatal), 2 patients with inverted Takotsubo's cardiomyopathy, 1 patient with myocardial infarction, 1 patient with acute heart failure, and an overall high prevalence of pronounced hypertension and tachycardia. CONCLUSION: Since the introduction of 4-fluoroamphetamine to the Dutch drug market in 2007, its use continues to increase, possibly because users perceive it as "ecstasy light" and thus relatively safe. However, the proportion of patients with severe toxicity after 4-fluoroamphetamine use is relatively large in our study population. Therefore, users should be warned about the risks of 4-fluoroamphetamine.

Characteristics and outcomes of e-cigarette exposure incidents reported to 10 European Poison Centers: a retrospective data analysis.

BACKGROUND: The use of e-cigarettes has increased during the past few years. Exposure to e-cigarette liquids, whether intentional or accidental, may lead to adverse events our aim was to assess factors associated with e-cigarette exposures across European Union Member States (EU MS). METHODS: A retrospective analysis of exposures associated with e-cigarettes reported to national poison centers was performed covering incidents from 2012 to March 2015 from 10 EU MS. De-identified and anonymous raw data was acquired. RESULTS: In total, 277 incidents were reported. Unintentional exposure was the most frequently cited type of exposure (71.3%), while e-cigarette refill vials were responsible for the majority of the reported incidents (87.3%). Two-thirds of all exposures (67.5%) occurred as ingestion of e-liquids, which was more frequent among children (≤ 5 years, 6-18 years) compared to adults (87.0% vs. 59.3% vs. 57.6%, p < 0.001 respectively), exposure via the respiratory (5.4% vs. 22.2% vs. 22.2%, p < 0.001) were more frequent among paediatric patients while ocular routes (2.2% vs. 3.7% vs. 11.4%, p = 0.021) were more frequent among adults. Logistic regression analyses indicated that paediatric incidents (≤ 5 years) were more likely to be through ingestion (adjusted Odds Ratio [aOR] = 4.36, 95% Confidence Interval [C.I.]: 1.87-10.18), but less likely to have a reported clinical effect (aOR = 0.41, 95% C.I.: 0.21-0.82). CONCLUSIONS: Our study highlighted parameters related to e-cigarette exposure incidents in 10 EU MS, the results of which indicate that consideration should be given to the design features which may mitigate risks, thereby protecting users, non-users and especially children.

Modeling the effect of succimer (DMSA; dimercaptosuccinic acid) chelation therapy in patients poisoned by lead.

CONTEXT: Kinetic models could assist clinicians potentially in managing cases of lead poisoning. Several models exist that can simulate lead kinetics but none of them can predict the effect of chelation in lead poisoning. Our aim was to devise a model to predict the effect of succimer (dimercaptosuccinic acid; DMSA) chelation therapy on blood lead concentrations. MATERIALS AND METHODS: We integrated a two-compartment kinetic succimer model into an existing PBPK lead model and produced a Chelation Lead Therapy (CLT) model. The accuracy of the model's predictions was assessed by simulating clinical observations in patients poisoned by lead and treated with succimer. The CLT model calculates blood lead concentrations as the sum of the background exposure and the acute or chronic lead poisoning. The latter was due either to ingestion of traditional remedies or occupational exposure to lead-polluted ambient air. The exposure duration was known. The blood lead concentrations predicted by the CLT model were compared to the measured blood lead concentrations. RESULTS: Pre-chelation blood lead concentrations ranged between 99 and 150 µg/dL. The model was able to simulate accurately the blood lead concentrations during and after succimer treatment. The pattern of urine lead excretion was successfully predicted in some patients, while poorly predicted in others. CONCLUSIONS: Our model is able to predict blood lead concentrations after succimer therapy, at least, in situations where the duration of lead exposure is known.

Modelling dimercaptosuccinic acid (DMSA) plasma kinetics in humans.

CONTEXT: No kinetic models presently exist which simulate the effect of chelation therapy on lead blood concentrations in lead poisoning. OBJECTIVE: Our aim was to develop a kinetic model that describes the kinetics of dimercaptosuccinic acid (DMSA; succimer), a commonly used chelating agent, that could be used in developing a lead chelating model. MATERIAL AND METHODS: This was a kinetic modelling study. We used a two-compartment model, with a non-systemic gastrointestinal compartment (gut lumen) and the whole body as one systemic compartment. The only data available from the literature were used to calibrate the unknown model parameters. The calibrated model was then validated by comparing its predictions with measured data from three different experimental human studies. RESULTS: The model predicted total DMSA plasma and urine concentrations measured in three healthy volunteers after ingestion of DMSA 10 mg/kg. The model was then validated by using data from three other published studies; it predicted concentrations within a factor of two, representing inter-human variability. CONCLUSIONS: A simple kinetic model simulating the kinetics of DMSA in humans has been developed and validated. The interest of this model lies in the future potential to use it to predict blood lead concentrations in lead-poisoned patients treated with DMSA.

Clinical presentation and management of an Aruban rattlesnake bite in the Netherlands.

Bites by Aruban Rattlesnake (Crotalus durissus unicolor) are rare and not known to induce severe envenomations. Here, we present a case of a 57 year-old man bitten by his pet Aruban Rattlesnake (Crotalus durissus unicolor). He was admitted to hospital within 15 min. Three and a half hours later his fibrinogen concentration decreased to 0.6 g/L (normal: 2.0-4.0). Nine hours post-bite, he was treated with polyvalent snake antivenom covering Crotalus durissus. Three hours later his fibrinogen became undetectable while at that time clotting times were prolonged (PT 38.7 s (normal: 12.5-14.5) and aPTT 40 s (normal: 25-35)). His platelet count remained within normal limits. Creatine kinase (CK) concentrations reached a maximum of 1868 U/L (normal: <200) 16 h post-bite. After a second antivenom dose, 10.5 h after the first antivenom administration, clotting times returned to normal. Fibrinogen was restored to normal within three days. He was discharged from hospital on day five. In conclusion, administration of polyvalent snake antivenom covering Crotalus durissus snakebites shows cross-neutralization and is effective in the treatment of patients bitten by Crotalus durissus unicolor.

[A potentially fatal intoxication with colchicine]. / Een levensbedreigende intoxicatie met colchicine.

BACKGROUND: Approximately ten times a year the Dutch National Poisons Information Centre (NVIC) is consulted regarding a colchicine intoxication or overdose. CASE DESCRIPTION: An 18-year old woman was admitted to the intensive care unit after a suicide attempt with a potentially lethal dosage of colchicine tablets (0.5 mg/kg body weight). After a few hours the patient developed abdominal pain and vomited. Over subsequent days she developed anaemia, thrombocytopenia and a paralytic ileus. Treatment mainly comprised intensive supportive care, including sedation, ventilation and repeated administration of activated charcoal. After a week she gradually began to recover and was able to leave IC 10 days after ingestion. CONCLUSION: Early recognition and treatment of colchicine intoxication is crucial to preventing a fatal outcome. Complete recovery is possible if extensive supportive treatment is given.

Methylphenidate intoxications in children and adults: exposure circumstances and evidence-based dose threshold for pre-hospital triage.

CONTEXT: Methylphenidate intoxications mostly have a relatively mild course, although serious complications can occur. OBJECTIVE: We aimed to characterize methylphenidate exposures and reassess our current dose threshold for hospital referral (2 mg/kg). METHODS: In a prospective follow-up study, we analysed 364 consecutive methylphenidate exposures that were reported to the Dutch Poisons Information Center. Patients and/or physicians were surveyed by telephone using standardized questionnaires. Three physicians independently scored the observed severity of the intoxication of each patient as 'no/mild' (observation at home) or 'moderate/severe' (hospital referral necessary). RESULTS: Unintentional exposures (40%) mostly occurred at home involving the patients' own medication or those from a family member. Compared to unintentionally exposed patients, intentionally exposed patients were exposed to relatively high methylphenidate doses (3.1 vs 1.6 mg/kg), more often used immediate release methylphenidate formulations (62 vs 34%) and more frequently had concomitant exposures (71 vs 17%). Severe symptoms like convulsions or coma were reported only in patients with concomitant exposures. Following exposure to methylphenidate only (i.e. no concomitant exposures), the most commonly reported symptoms were dry mucosa, headache, agitation, sleepiness and tachycardia. Our results show that the reported methylphenidate dose is predictive of the observed severity of the intoxication and can therefore aid in pre-hospital triage. CONCLUSION: We increased our current dose threshold for hospital referral from 2 to 3 mg/kg. In addition, we will refer patients at lower doses when clinical symptoms indicate the need for hospital referral. Application of this new dose threshold optimizes triage, thereby reducing unnecessary hospital referral and thus costs, without jeopardising patient safety.

Acute subjective effects after smoking joints containing up to 69 mg Δ9-tetrahydrocannabinol in recreational users: a randomized, crossover clinical trial.

RATIONALE: An increase in the potency of the cannabis cigarettes has been observed over the past three decades. OBJECTIVES: In this study, we aimed to establish the impact of Δ9-tetrahydrocannabinol (THC) on the rating of subjective effects (intensity and duration of the effects), up to 23 % THC potency (69 mg THC) among recreational users. METHODS: Recreational users (N = 24) smoked cannabis cigarettes with four doses of THC (placebo 29, 49 and 69 mg of THC) on four separate test days in a randomized, double-blind, placebo-controlled, crossover study. The participants filled in three different questionnaires measuring subjective effects during the exposure up to 8 h post-smoking. The 'high' feeling, heart rate, blood pressure and THC serum concentrations were also regularly recorded during these 8 h. RESULTS: THC significantly increased the high feeling, dizziness, dry-mouthed feeling, palpitations, impaired memory and concentration, and 'down', 'sedated' and 'anxious' feelings. In addition, THC significantly decreased alertness, contentment and calmness. A cubic relationship was observed between 'feeling the drug' and 'wanting more'. The THC-induced decrease in 'feeling stimulated' and increase in anxiety lasted up to 8 h post-smoking. Sedation at 8 h post-smoking was increased by a factor of 5.7 with the highest THC dose, compared to the placebo. CONCLUSIONS: This study shows a strong effect of cannabis containing high percentages of THC on the rating of subjective effects. Regular users and forensic toxicologists should be aware that the THC-induced increase in 'feeling sedated' continues longer with a 69 mg THC dose than with a 29 mg THC dose.