The Role of a Regional Poison Center in Assessing and Managing Disaster Risk.

The United States constantly faces the threat of large-scale disasters caused by natural and human factors. Emergency medical services, other first responders, and emergency department professionals are responsible for triaging and caring for victims of mass casualty incidents that include biological, chemical, and radiological agents. These providers need immediate access to individuals with expertise in infectious disease, medical toxicology, and biological, chemical, and radiological exposure who are readily available or easily accessible in the event of an emergency. Poison centers play a key public health role during disasters, in part because of the specialized training staff-including medical toxicologists-receive in all facets of toxic exposure risk identification, assessment, and management, which are foundational areas critical to disaster health response. Integrating poison centers into the public health infrastructure and public health surveillance is crucial for disaster response. Through enhanced partnerships with public health agencies, poison centers have leveraged their readily accessible expertise and surveillance capabilities to expand their roles in disaster planning and response. This paper highlights the pivotal role the Nebraska Regional Poison Center plays in preparing for and responding to disasters and other public health emergencies at local, state, and regional levels. With an emphasis on its role in risk assessment and management in partnership with healthcare coalitions and public health departments, we recommend the Nebraska Regional Poison Center as a model to inform other poison centers across the United States.

Nomogram line crossing after acetaminophen combination product overdose.

BACKGROUND: The Rumack-Matthew nomogram predicts the risk of hepatotoxicity following acute acetaminophen overdose based on a serum concentration obtained ≥ 4-hour post-ingestion. Some patients with low-risk concentrations at 4 hours may have subsequent values indicating increased risk (above the nomogram treatment line), especially if coingestants that slow gastrointestinal motility are involved. The treatment line currently used to identify low risk patients in the United States, Canada, and Australia begins at 150 mcg/mL (993 µmol/L) and intersects at 18.75 mcg/mL (124.1 µmol/L) 16 hours post-ingestion. OBJECTIVE: To determine the incidence of nomogram line crossing after acute overdose of acetaminophen combination products containing an opioid or antihistamine. METHODS: This was a prospective cohort study of hospitalized patients reported to a regional poison center (RPC) after acute overdose of a combination product containing an opioid or antihistamine. If a 4-hour acetaminophen concentration was detectable but below the nomogram treatment line, the RPC recommended repeat concentrations. Patients were entered into the study if at least one subsequent concentration was available. During follow-up calls hospital providers were queried regarding clinical features, treatment, and indicators of liver injury. RESULTS: Over a 4-year period 76 patients met entry criteria. 5/76 (6.6%) had measureable acetaminophen concentrations below the treatment line at or close to 4-hour post-ingestion followed by values above the line obtained at 6.5-12.5 hours. Four of the five were treated with acetylcysteine and none developed hepatotoxicity. Four of the five had clinical features reported to the RPC suggesting toxicity from the opioid or antihistamine component. CONCLUSION: After acute overdose of acetaminophen combination products, patients with detectable but non-toxic 4-hour acetaminophen concentrations should have repeat concentrations obtained in a time frame that would allow providers to initiate acetylcysteine treatment, if needed, without undue delay.