Rising incidence and high mortality in intentional sodium nitrite exposures reported to US poison centers.

INTRODUCTION: Sodium nitrite is an oxidizing agent capable of producing profound methemoglobinemia. Large quantities of sodium nitrite can be purchased online, and recent literature has identified several cases of intentional self-poisoning, including multiple cases of mortality. This has raised concern that intentional sodium nitrite poisoning and resultant severe methemoglobinemia may be increasing in incidence and could represent a substantial public health threat. MATERIALS AND METHODS: This study used data obtained from the National Poison Data System (NPDS) to evaluate the incidence and mortality rate of intentional sodium nitrite poisoning of suicidal intent reported to US poison centers over a five-year period. Patient demographics, exposure characteristics, treatments administered, and patient outcomes were analyzed. Temporal patterns in exposure were also investigated. RESULTS: Forty-seven cases were identified in the NPDS database, of which three were excluded due to lack of outcome data. Median patient age was 23 years, 52% of patients were female and 86% of exposures occurred at the patient's residence. Serious outcomes were observed in 84% of cases, 77% of patients included were treated with methylene blue and 30% of patients died. No intentional sodium nitrite exposures were reported in the first two years studied, but we observed an increase in the incidence of exposures reported through the remainder of the investigation period. DISCUSSION/CONCLUSIONS: The incidence of intentional self-poisoning with sodium nitrite has been increasing since 2017. Many of these exposures result in toxicity requiring antidotal therapy, and a high mortality rate was observed. Recent literature indicates that this trend may be the result of ready access to this poison through online vendors combined with recommendations shared in online communities that sodium nitrite be used as an effective method of suicide. Further study is needed to better characterize this phenomenon and develop public health interventions to prevent future morbidity and mortality.

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.

Direct comparison of 20-hour IV, 36-hour oral, and 72-hour oral acetylcysteine for treatment of acute acetaminophen poisoning.

There is no general consensus among clinicians on the superior route or duration of treatment with N-acetylcysteine (NAC) for acute acetaminophen (APAP) poisoning, and head-to-head studies comparing intravenous (IV) and oral NAC have not been done. Recent 20-hour IV NAC protocol failures in the United States prompted some to question its safety. Our objective was to determine if treatment with the 20-hour IV NAC protocol results in clinical outcomes different from the longer 36-hour oral or 72-hour oral NAC protocols in cases of acute APAP poisoning. We performed a retrospective analysis of all consecutive cases of acute APAP overdose where NAC treatment was initiated within 8 hours of ingestion between January 1, 2002, and December 31, 2007. Outcomes were survival, transplant, and death; secondary outcomes were based on King's College Criteria; interrater reliability was calculated with a kappa score. Out of 4642 cases of APAP overdose, 795 met study inclusion criteria: 213 were treated with 20-hour IV protocol, 213 with the 36-hour oral protocol, and 369 with the 72-hour oral protocol. The mean age in these groups was 25 years [95% confidence interval (CI): 22-26], 26 years (95%CI: 23-29), and 27 years (95%CI: 25-28), respectively. The mean 4-hour APAP concentration was 199 µg/mL (95%CI: 188-211), 174 µg/mL (95%CI: 164-184), and 205 µg/mL (95%CI: 195-216), respectively. No cases of transplant or death occurred, and secondary outcomes were rare. When administered within 8 hours of acute APAP poisoning, the 20-hour IV treatment protocol was as effective as the longer 36-hour oral and 72-hour oral treatment protocols. Further study is needed to determine outcome differences between IV and oral NAC when treatment is initiated >8 hours after overdose or in cases of coingestion with other drugs.

Can a poison center overdose guideline safely reduce pediatric emergency department visits for unintentional ß-blocker ingestions?

Poisoning is a leading cause cause for injury and death in pediatric patients. For this reason, ß-blocker ingestion has been an indication for emergency department (ED) referral and evaluation in pediatric patients even though significant clinical effects are uncommonly reported. We sought to determine whether an evidence-based triage guideline developed jointly by the American Association of Poison Control Centers, American Academy of Clinical Toxicology, and American College of Medical Toxicology safely reduces unnecessary pediatric ED visits after unintentional small dose ß-blocker overdose. This was a prospective study of patients aged 0-6 years with a ß-blocker ingestion managed by a regional poison center pre and postimplementation of the triage guideline. One hundred fifty-three cases met inclusion criteria. Before implementation of an evidence-based triage guideline for out-of-hospital management, 52 (67%) cases were referred for ED evaluation, and 26 (33%) cases were recommended for home observation. After guideline implementation, 38 (51%) cases were referred for ED evaluation, and 37 (49%) were recommended for home observation. No deaths occurred in either group. The triage guideline was accurately followed by poison center staff in 96% of cases after implementation. An out-of-hospital triage guideline for pediatric ß-blocker overdose was accurately followed by poison center staff and safely reduced unnecessary ED referrals with a 50% increase in home observation.

Tinnitus as a measure of salicylate toxicity in the overdose setting.

INTRODUCTION: The development of tinnitus and/or hearing loss (THL) in patients receiving chronic salicylate therapy has been demonstrated. However, to date, little scientific data validates this relationship in the large single overdose setting. OBJECTIVE: To correlate salicylate levels in patients with the subjective complaint of THL, following an acute salicylate overdose. METHODS: A retrospective chart review of cases of acute salicylate toxicity and THL reported to the Illinois Poison Control Center (IPC) from 2001-2002 was performed. Data abstracted included age, gender, ingestion time, salicylate levels, and arterial blood gases. RESULTS: Ninety-nine cases of THL were reviewed and analyzed with mean age of 23.7 years (SD: 10.9), 30.3% male, and 82.2% intentional overdoses. The average dose ingested was 20.0 grams (SD:20.2) and the mean time from ingestion to medical care was 12.4 hours (SD: 11.1). The mean initial ASA level was 48.3 mg/dl (SD: 16.4) with 86.9% having initial level >/=30mg/dl and 40.4% >/=50 mg/dl. 85.9% of cases presented to the hospital with their ASA level at or past peak. The mean pH was 7.45, pO2 = 108, pCO2 = 28.0, and HCO3 = 19.9. CONCLUSION: In this limited study, 85.9% of patients presenting with tinnitus and/or hearing loss following a single salicylate ingestion had initial salicylate levels at or past their peak and 86.9% were in the toxic range.

Universal versus selective iron supplementation for infants and the risk of unintentional poisoning in young children: a comparative study of two populations.

BACKGROUND: Iron continues to be a common cause of poisoning in young children, in part due to its widespread use and easy accessibility. OBJECTIVE: To determine differences in the epidemiology and outcome of unintentional iron ingestion by young children in populations practicing selective (eg, US) versus universal (eg, Israel) iron supplementation to infants. METHODS: All cases of unintentional iron ingestion in children younger than 7 years in a one year period were identified through the poison control center databases of 2 sites (Illinois and Israel). Parameters compared include patient sex and age; type, form, and dose of iron preparation; circumstances and clinical manifestations; management; and outcome. RESULTS: A total of 602 children were identified: 459 in Illinois and 143 in Israel. The majority of Illinois children ingested multivitamin preparations (94%), whereas Israeli children ingested single-ingredient iron preparations (78%) (p < 0.001). Iron doses ingested were higher in Israel (median 14.5 vs 6.6 mg/kg; p < 0.001) but remained within the nontoxic range for most children. No deaths or severe poisonings were reported, and 93% of children in both groups were asymptomatic. The majority of ingestions in both locations were due to unintentional self-ingestion. However, parental miscalculation occurred more frequently in Israel (16%) than in Illinois (1%). CONCLUSIONS: Universal iron supplementation to infants was not associated with a negative impact on the outcome of pediatric unintentional ingestions. Low-dose exposures were safely managed by on-site observation.

Digital imaging: a promising tool for mushroom identification.

Mushroom poisoning is a diagnostic and treatment dilemma for health care professionals. Decisions regarding treatment following ingestions are usually made without a firm identification of the fungus and tend to be more aggressive than necessary. The identification of mushrooms is beyond the scope of health care professionals, and a mycologist is essential to make an accurate identification. Telemedicine and digital imaging is an emerging technology that can assist in mushroom identification and facilitate patient care. The efficacy of using digital images sent over the Internet was tested in a pilot project. This article describes three cases in which digital images and verbal descriptions assisted in mushroom identification. When the actual specimen was sent to a mycologist, a definitive identification was obtained and compared with the presumptive identification. Digital images alone do not permit definitive identification; however, they often contain sufficient information to help the clinician rule out the possibility of a severely toxic species. Data accumulated to date indicate that digital imaging can be an important tool in the diagnosis and treatment of mushroom ingestion, and possibly other biologicals such as plants, insects, and reptiles.