2021 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System.

Introduction: This is the 2021 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. Methods: Encounters reported to the KSPCC from January 1, 2021 through December 31, 2021 were analyzed. Data recorded includes caller demographics, exposure substance, nature and route of exposure, interventions, medical outcome, disposition, and location of care. Results: The KSPCC logged 18,253 total encounters in 2021, including calls from every county in Kansas. A majority of human exposure cases (53.6%) were female. Approximately 59.8% were pediatric exposures (defined as 19 years of age or less). Most encounters occurred at a residence (91.7%) and most were managed there (70.5%). Unintentional exposures were the most common reason for exposures (70.5%). The most common reported substance in pediatric encounters was household cleaning products (n = 815) and cosmetics/personal care products (n = 735). For adult encounters, analgesics (n = 1,241) and sedative/ hypnotics/antipsychotics (n = 1,013) were the most frequently reported. Medical outcomes were 26.0% no effect, 22.4% minor effect, 10.7% moderate effect, and 2.7% major effects. There were 22 deaths. Conclusions: The 2021 KSPCC annual report demonstrated that cases were received from the entire state of Kansas. Pediatric exposures remained most common but cases with serious outcomes continued to increase. This report supported the continued value of the KSPCC to both public and health care providers in the state of Kansas.

2020 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System.

Introduction: This is the 2020 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC receives calls from the public, law enforcement, healthcare professionals, and public health agencies. Methods: Encounters reported to the KSPCC from January 1, 2020 through December 31, 2020 were analyzed for caller location, demographics, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, and location of care. Encounters were classified as human or animal exposure, confirmed non-exposure, or information call (no exposure). Results: There were 19,780 total encounters, including 18,492 human exposure cases. These cases were primarily female (53.6%, n = 9,911) and pediatric (19 years of age or less; 59.5%, n = 10,995). Acute cases (82.7%, n = 15,294), unintentional exposures (73.8%, n = 13,643), and ingestions (85.9%, n = 15,901) were most common. The most common reported substance was household cleaning products (n = 937) in pediatric (children ≤ 5) and analgesics (n = 1,335) in adults. An increase in exposures to disinfectants and household cleaning products was seen. Moderate (n = 1,812) or major (n = 482) clinical outcomes were seen in 12.4% of cases. There were 18 deaths in 2020 reported to the KSPCC. Conclusions: Over 18,400 exposures were managed by the KSPCC in 2020. Pediatric exposures remained the most common encounter. An increase in exposures to disinfectants and other household cleaning products was seen. This report supported the continued value of the KSPCC to both public and acute healthcare in the state of Kansas.

A different challenge with Benadryl: adolescent diphenhydramine ingestions reported to National Poison Database System, 2007-2020.

BACKGROUND: The US Food and Drug Administration released a warning related to potential adverse effects related to intentional misuse or abuse ingestions of diphenhydramine in September 2020. We sought to evaluate adolescent-aged (13-19 y) diphenhydramine ingestions reported to US poison control centers to characterize these exposures, adverse effects, outcomes, and trends in outcomes and reasons for ingestion. METHODS: The US National Poison Database System was queried for all exposures to diphenhydramine between January 1, 2007 and December 31, 2020. RESULTS: 47,644 ingestions were included for analysis. An increase in the number of ingestions, percentage of cases due to an intentional reason for ingestion and suspected suicide was observed. More serious outcomes, cardiac complications, seizures, and deaths were more common following intentional ingestions and specifically suspected suicide over misuse or abuse. CONCLUSIONS: Adolescent ingestions of diphenhydramine increased between 2007 and 2020. More serious outcomes, intentional reasons, and suspected suicide also increased over the study interval. Suspected suicide was associated with cardiac complications, seizures, coma, and death at higher rates than misuse or abuse. While misuse and abuse remain a concern, public health interventions focusing on the risk that diphenhydramine pose as an agent of suicide attempt may be of higher impact.

2019 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System.

INTRODUCTION: This is the 2019 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. The KSPCC receives calls from the public, law enforcement, health care professionals, and public health agencies. All calls to the KSPCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS) which is the data repository for all poison control centers in the United States. METHODS: All encounters reported to the KSPCC from January 1, 2019 through December 31, 2019 were analyzed. Data recorded for each exposure includes caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care. Encounters were classified as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported). RESULTS: The KSPCC logged 20,589 total encounters in 2019, including 19,406 human exposure cases. The KSPCC received calls from every county in Kansas. A slim majority of human exposure cases (50.5%, n = 9,790) were female. Approximately 61% (n = 11,876) of human exposures involved a child (defined as 19 years of age or less). Most encounters occurred at a residence (91.6%, n = 17,780) and most cases (64.9%, n = 12,599) originated from a residence. The majority of human exposures (85.5%, n = 16,589) were acute cases (exposures occurring over 8 hours or less). Ingestion was the most common route of exposure documented (85.3%, n = 16,548). The most commonly reported substance in pediatric (children ≤ 5) encounters was cosmetics/personal care products (n = 959) followed closely by household cleaning products (n = 943). For adult encounters, analgesics (n = 1,296) and sedative/hypnotics/antipsychotics (n = 1,084) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (75.4%, n = 14,634). Most encounters (65.9%, n = 12,780) were managed in a non-healthcare facility (i.e., a residence). Among human exposures, 14,591 involved exposures to pharmaceutical agents while 9,439 involved exposure to non-pharmaceuticals. Medical outcomes were 26.4% (n = 5,116) no effect, 18.8% (n = 3,652) minor effect, 9.3% (n = 1,813) moderate effect, and 3.1% (n = 603) major effects. There were 14 deaths in 2019 reported to the KSPCC. Cases from healthcare facilities and cases with moderate or major medical outcomes increased in 2019 compared to 2018. The number of deaths reported to the KSPCC increased in 2019 to 14 from 7 in 2018. CONCLUSIONS: The results of the 2019 Kansas Poison Control Center's annual report demonstrated that cases were received from the entire state of Kansas totaling over 19,400 human exposures per year. While pediatric exposures remained the most common encounter, there continued a trend of increasing number of cases from healthcare facilities and for cases with serious outcomes. The experience of the KSPCC is comparable to national data. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

A Retrospective Review of Morbidity and Mortality Associated with Acute Benzodiazepine Withdrawal at a Midwestern Academic Medical Center.

INTRODUCTION: There is concern that acute benzodiazepine (BZD) withdrawal may result in morbidity and mortality. However, there is a paucity of medical literature regarding clinical characteristics and outcomes of acute BZD withdrawal. We sought to characterize acute BZD withdrawal and its associated clinical outcomes and treatment at a midwestern academic medical center. METHODS: This was a retrospective study. The medical records of the University of Kansas Hospital, a tertiary academic medical center, were queried for patients with a diagnosis of BZD withdrawal, drug withdrawal, sedative-hypnotic withdrawal, or withdrawal-NOS from January 1, 2009 to January 1, 2016. Data collected included age, sex, month/year of encounter, initial vital signs, type of drug withdrawal (alcohol, opioid, BZD, or other), type of BZD withdrawing from, disposition, duration of hospitalization, seizures, endotracheal intubation, mortality, and pharmacological treatment. RESULTS: Eighty-two cases were identified. Cases per year increased over the study period. Thirty-one (38%) cases involved concurrent drug withdrawal with opioids most common (n = 25). Alprazolam (n = 32) was the most common BZD implicated in BZD withdrawal. Thirty-nine cases (47%) were admitted including seven to the ICU. Seizures were reported in 8 (10%) cases. Endotracheal intubation occurred in three (3.6%). Sixty-seven patients (81%) were treated with a BZD, with lorazepam (n = 42) most used. There were no deaths. Upon discharge, 40 (49%) patients received a prescription for a benzodiazepine. CONCLUSIONS: Cases of acute BZD withdrawal increased over the study period but were associated with only occasional morbidity and no mortality. Further multi-center studies are warranted to characterize the incidence and characteristics of acute BZD withdrawal better.

Massive Iatrogenic Pediatric Ketamine Overdose With Serial Levels and Minimal Morbidity.

ABSTRACT: Ketamine is a dissociative anesthetic commonly used for procedural sedation owing to its perceived favorable safety profile. Despite its frequent use, overdoses of ketamine are rarely reported, and no cases with serum levels of ketamine or its metabolite have previously been reported. We report a case of an iatrogenic pediatric ketamine 20 mg/kg intramuscular overdose with serial ketamine and norketamine levels that resulted in minimal toxicity.

Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system.

OBJECTIVE: We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them. METHODS: The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of "amphetamine and related compounds" or "methylphenidate" and specific product name containing XR, CD, ER, LA, and SR. RESULTS: A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent. CONCLUSION: Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.

Respiratory depression following medications for opioid use disorder (MOUD)-approved buprenorphine product oral exposures; National Poison Database System 2003-2019.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine is recommended for patients with opioid use disorders. We sought to evaluate the frequencies of respiratory depression, intubation, and naloxone administration, and clinical outcomes among patients reported to the National Poison Database System (NPDS) following single-substance and multiple-substance buprenorphine oral exposures. METHODS: NPDS was queried for all MOUD-approved buprenorphine product exposures between 1 January 2003 and 31 December 2019. Data abstracted included year, route, gender, age, site of exposure, management site, medical outcome, recorded "related" respiratory depression ("respiratory rate <10 breaths/min and/or a SpO2 (pulse oximetry)≤90%), reported administration of naloxone and intubation in oral exposure cases followed to known outcome. Concomitant products were also recorded in multiple-substance buprenorphine cases. RESULTS: 27,275 (11,010 multiple and 16,265 single) buprenorphine oral exposures were identified and followed to known outcome. A 65-fold increase in reported cases was reported over the study interval. A steady increase in the frequency of more serious outcomes by year was also observed. Respiratory depression occurred at a frequency of 11.8% (pediatric single-substance), 11.2% (pediatric multiple-substance), 11.3% (adult single-substance), and 11.9% (adult multiple-substance). Among oral exposures of buprenorphine and only one other product, benzodiazepines, opioids, ethanol, and amphetamines were most common. CONCLUSIONS: Oral exposures have increased substantially between 2003 and 2019. More serious outcomes including deaths following oral exposures to buprenorphine have also increased over the same interval for both adult and pediatric patients. Clinically significant rates of respiratory depression in both adult and pediatric patients when taken alone and with additional substances were observed.

2018 Annual Report of the University of Kansas Health System Poison Control Center.

INTRODUCTION: This is the 2018 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System (KSPCC). The KSPCC serves the state of Kansas 24-hours per day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. METHODS: All encounters reported to the KSPCC from January 1, 2018 through December 31, 2018 were analyzed. Data recorded for each exposure included caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care. RESULTS: There were 21,072 total encounters, including 20,031 human exposure cases. Calls were received from every county and hospital in Kansas. Most of the exposures involved females (51.5%, n = 10,320) and a child less than 19 year of age (64%, n = 12,865). Medical outcomes were 24.5% (n = 4,912) no effect, 17.7% (n = 3,542) minor effect, 9.1% (n = 1,830) moderate effect, and 2.4% (n = 476) major effect. Seven deaths were reported in 2018. The number of exposure calls from healthcare facilities and severity of medical outcomes increased in 2018 compared to 2017. CONCLUSION: The 2018 KSPCC annual report demonstrated that the center receives calls from the entire state of Kansas totaling over 20,000 human exposures. While pediatric exposures remain the most common encounter, a trend continued of an increasing number of calls from healthcare facilities and for cases with serious outcomes. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

Patch Problems? Characteristics of Transdermal Drug Delivery System Exposures Reported to the National Poison Data System.

BACKGROUND: Transdermal drug delivery systems (TDDS) pose special risks considering a large amount of drug they contain and their modified release properties. We sought to characterize TDDS exposures reported to the National Poison Data System (NPDS). METHODS: NPDS was searched for all human exposures to a TDDS from 1/1/2006 to 12/31/2015. Only single-substance TDDS exposures followed to a known medical outcome were included for final analysis. Specific data analyzed was date, sex, age, TDDS product, exposure reason, route of exposure, medical outcome, management site, level of health care facility care, clinical effects, and interventions. RESULTS: Over that 10-year period, 6746  adults and 1917 pediatric exposures were identified. Exposures declined over the study period. The most common exposure reason in adults was intentional abuse (n = 1622) compared to unintentional-general (n =1 070) in pediatric cases. TDDS ingestion was reported in 4519 adults and 2825 pediatric cases. Fentanyl was the most common substance encountered in adult (n = 4656) and pediatric cases (n = 474). No or minor effect were the most common medical outcomes in both groups. In fentanyl cases, moderate or major outcomes were seen in 54 % (n = 1062) of adult and 26 % (n = 54) of pediatric cases. Naloxone was given in 1080 cases. Ninety-seven deaths (91 adults, 6 pediatrics) were reported, all involving ingestion of the TDDS. Fentanyl was associated with 80 adult and 5 pediatric deaths. CONCLUSION: Overall, single-substance TDDS exposures decreased over the duration of this study and typically resulted in no or mild effects. However, exposures involving fentanyl resulted in higher rates of major or moderate medical outcomes and were associated with multiple deaths.

Trends and characteristics of cases when serial carboxyhemoglobins are obtained.

BACKGROUND: Carboxyhemoglobin (COHb) levels are obtained when there is suspicion for carbon monoxide (CO) exposure. Serial COHb levels are sometimes obtained despite the well-established half-life of COHb with oxygen supplementation. We sought to evaluate the trends and characteristics associated with obtaining serial carboxyhemoglobin levels. METHODS: A retrospective review was performed at an academic medical center for all inpatient and emergency department cases with either single COHb or serial COHb levels from 1 April 2010 through 31 March 2015. Data collected included age, gender, pregnancy status, smoking history, encounter month, admission status, oxygen administration, fire or burn history, vital signs, presenting symptoms, hyperbaric oxygen (HBO2) therapy use, initial pH, troponin, lactate, and COHb levels. The time and change in values between serial levels were also obtained. RESULTS: 624 cases were identified, with 106 (17%) having multiple carboxyhemoglobin levels. A mean of 2.6 (range 2 - 9) serial COHb levels were obtained. The average initial COHb was 8.9%. Subsequent serial levels were obtained on average at 353, 663 and 1,095 minutes and averaged 2.8%, 1.8% and 1.1% respectively. Serial COHb levels were obtained more commonly in burn patients, those admitted to the ICU and those who had HBO2 therapy. Four patients had an increase in COHb level on serial testing. The largest increase of these was from 2.0% to 3.9%. CONCLUSION: Serial COHb levels were not infrequent in this study. No clinically significant increase in COHb was identified by serial testing. Further studies should examine the clinical utility of such practices.

2017 Annual Report of the University of Kansas Health System Poison Control Center.

INTRODUCTION: This is the 2017 Annual Report of the University of Kansas Health System Poison Control Center (PCC). The PCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year. The PCC receives calls from the public, law enforcement, health care professionals, and public health agencies, which are answered by trained and certified specialists in poison information with the immediate availability of medical toxicology back up. All calls to the PCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS), which is the data repository for all poison control centers in the United States. METHODS: All encounters reported to the PCC from January 1, 2017 to December 31, 2017 were analyzed. Data recorded for each exposure included caller location, age, weight, gender, substance exposed to, nature of exposure, route of exposure, interventions, medical outcome, disposition and location of care. Encounters were classified further as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported). RESULTS: The PCC logged 21,431 total encounters in 2017, including 20,278 human exposure cases. Cases came from every county in Kansas. Most of the human exposure cases (51.4%, n = 10,430) were female. Approximately 66% (n = 13,418) of human exposures involved a child (defined as age less than 20 years). Most encounters occurred at a residence (94.0%, n = 19,018) and most calls (69.5%, n = 14,090) originated from a residence. Almost all human exposures (n = 19,823) were acute cases (exposures occurring over eight hours or less). Ingestion was the most common route of exposure documented (80.5%, n = 17,466). The most common reported substance in pediatric encounters was cosmetics/personal care products (n = 1,255), followed by household cleaning products (n = 1,251). For adult encounters, analgesics (n = 1,160) and sedatives/hypnotics/antipsychotics (n = 1,127) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (78.6%, n = 15,947). Most encounters (69.4%, n = 14,073) were managed in a non-health care facility (i.e., a residence). Among human exposures, 14,940 involved exposures to pharmaceutical agents, while 9,896 involved exposure to non-pharmaceuticals. Medical outcomes were 28% (n = 5,741) no effect, 18% (n = 3,693) minor effect, 9% (n = 1,739) moderate effect, and 2% (n = 431) major effect. There were 16 deaths in 2017 reported to the PCC. Number of exposures, calls from health care facilities, cases with moderate or major medical outcomes, and deaths increased in 2017 compared to 2016, despite a decrease in total exposures. CONCLUSIONS: The results of the 2017 University of Kansas Health System Poison Control annual report demonstrated that the center continues to receive calls from the entire state of Kansas, totaling over 20,000 human exposures per year. While pediatric exposures remain the most common, a trend of increasing number of calls remains from health care facilities and for cases with serious outcomes. The 2017 PCC data reflected current national trends. This report demonstrated the continued importance of the PCC to both the public and health care providers in the state of Kansas.

Characteristics of Laboratory Confirmed Ethylene Glycol and Methanol Exposures Reported to a Regional Poison Control Center.

INTRODUCTION: Ethylene glycol (EG) and methanol (MET) exposures are rare but can cause significant morbidity and mortality. Though frequently treated similarly, EG and MET exposures have characteristics that are not well differentiated in the literature. We sought to describe the clinical characteristics of EG and MET exposures, confirmed with quantitative serum levels. METHODS: An IRB-approved retrospective review of the University of Kansas Health System Poison Control Center database from July 2005 to July 2015 identified all EG/MET exposures evaluated at a health care facility. Initial measurements were EG/MET levels, serum pH, serum creatinine, anion gap, serum ethanol level, max anion gap, max osmolar gap, therapy performed (hemodialysis, fomepizole, ethanol) and death. RESULTS: The search identified 75 cases, with 59 cases having only detectable EG levels and 15 cases having only detectable MET levels. The average EG level was 126 mg/dL (range 5 - 834). The average detectable methanol level was 78 mg/dL (range 5 - 396). The average maximum anion gap of the EG positive group was 20 mEq/L (range 8 - 35). The average maximum anion gap of the MET positive group was 14 mEq/L (range 6 - 34). One death was reported in the EG positive group, with an initial level of 266 mg/dL. CONCLUSIONS: In this study of EG/MET exposures, EG exposures were more common than MET exposures, but they had similar demographics, laboratory findings, and interventions. Continued studies are warranted to characterize these uncommon exposures further.

2016 Annual Report of the University of Kansas Health System Poison Control Center.

INTRODUCTION: This is the 2016 Annual Report of the University of Kansas Health System Poison Control Center (PCC). The PCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year, with certified specialists in poison information and medical toxicologists. The PCC receives calls from the public, law enforcement, health care professionals, and public health agencies. All calls to the PCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS), which is the data repository for all poison control centers in the United States. METHODS: All encounters reported to the PCC from January 1, 2016 to December 31, 2016 were analyzed. Data recorded for each exposure includes caller location, age, weight, gender, substance exposed to, nature of exposure, route of exposure, interventions, medical outcome, disposition and location of care. Encounters were classified further as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported). RESULTS: The PCC logged 21,965 total encounters in 2016, including 20,713 human exposure cases. The PCC received calls from every county in Kansas. The majority of human exposure cases (50.4%, n = 10,174) were female. Approximately 67% (n = 13,903) of human exposures involved a child (defined as age 19 years or less). Most encounters occurred at a residence (94.0%, n = 19,476) and most calls (72.3%, n = 14,964) originated from a residence. The majority of human exposures (n = 18,233) were acute cases (exposures occurring over eight hours or less). Ingestion was the most common route of exposure documented (86.3%, n = 17,882). The most common reported substance in pediatric encounters was cosmetics/personal care products (n = 1,362), followed by household cleaning product (n = 1,301). For adult encounters, sedatives/hypnotics/antipsychotics (n = 1,130) and analgesics (n = 1,103) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (81.3%, n = 16,836). Most encounters (71.1%, n = 14,732) were managed in a non-healthcare facility (i.e., a residence). Among human exposures, 14,679 involved exposures to pharmaceutical agents while 10,176 involved exposure to non-pharmaceuticals. Medical outcomes were 32% (n = 6,582) no effect, 19% (n = 3,911) minor effect, 8% (n = 1,623) moderate effect, and 2% (n = 348) major effects. There were 15 deaths in 2016 reported to the PCC. Number of exposures, calls from healthcare facilities, cases with moderate or major medical outcomes, and deaths all increased in 2016 compared to 2015. CONCLUSION: The results of the 2016 University of Kansas Health System Poison Control annual report demonstrates that the center receives calls from the entire state of Kansas totaling over 20,000 human exposures per year. While pediatric exposures remain the most common, there is an increasing number of calls from healthcare facilities and for cases with serious outcomes. The experience of the PCC is similar to national data. This report supports the continued value of the PCC to both public and acute health care in the state of Kansas.

Seizures, Systemic Inflammatory Response, and Rhabdomyolysis Associated With Laboratory-Confirmed 2C-I and 25-I Exposure.

The 2C drugs are hallucinogenic phenethylamines. They and their n-benzyloxymethyl analogs have become popular as "legal highs," and significant toxicity has been attributed to their use. We report on a case of seizures, systemic inflammatory response, and rhabdomyolysis associated with laboratory-confirmed 4-iodo-2,5-dimethoxyphenethylamine and 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl) phenethylamine exposure. A 17-year-old male teenager developed seizures after taking "2 strips of acid." The seizures resolved with midazolam, but he became apneic and was intubated. His head computed tomography was unremarkable. Initial creatinine level was 1.5 mg/dL, with a creatine kinase of 112 U/L. His urine immunoassay drug screen was negative. He was extubated within 12 hours but had elevated temperatures for 48 hours. He was treated with antibiotics, but no source of infection was identified. His creatinine level peaked at 2.46 mg/dL. His creatine kinase peaked 72 hours later at 14579 U/L. He was treated with intravenous fluids and did not require renal replacement therapy. He recovered fully and was discharged after 5 days. Serum and urine samples were tested using liquid chromatography time-of-flight mass spectrometry. We detected 4-iodo-2,5-dimethoxyphenethylamine and 4-iodo-2,5-dimethoxy-N-(2-methoxybenzyl) phenethylamine in both serum and urine. No other substances were detected. The 2C drugs and their n-benzyloxymethyl analogs are potent serotonergic agents. Their use has been associated with multiple adverse effects including seizures, rhabdomyolysis, and death. They should be considered in differential diagnosis for drug-induced seizures and as a cause for systemic inflammatory response. This case highlights the significant toxicity seen with these compounds.

Do rapid comprehensive urine drug screens change clinical management in children?

CONTEXT: Multiple studies have concluded that urine drug screens rarely change clinical management. The rapid comprehensive urine drug screen (RCUDS) at our institution detects over 300 substances using a combination of EIA and GC/MS and typically takes 2-5 h for completion. OBJECTIVE: We sought to determine whether this RCUDS altered management in the pediatric population. METHODS: All patients >1 month and <18 years of age in which a RCUDS was completed from 1 January 2012 to 31 December 2012 were eligible for the study. Assuming that clinical management would not be altered in at least 90% of cases with a confidence interval of 95%, an alpha error of 5%, we calculated a sample size of 122 cases to ensure adequate study power. Four board-certified medical toxicologists reviewed 160 cases. Cases were assigned to the toxicologists based on a random-number generator. In addition, each toxicologist reviewed 12 random cases from the other three toxicologist's cases to determine inter-rater reliability. All four toxicologists reviewed any case in which a RCUDS was believed to have changed management. RESULTS: A total of 908 RCUDS were performed during the study period, and 160 were selected for study. Mean age was 10.5 years; male = 83, female = 77. Most were ordered from the ED (101/160 = 63%), followed by the inpatient unit (36/160 = 23%), outpatient (14/160 = 9%), and ICU (9/160 = 6%). 111/160 (69%) had a history of ingestion. Of the 160 randomly chosen cases, only three cases were found in which overall clinical management was altered based on the results of the RCUDS. All three cases were children <3 years old with a RCUDS positive for amfetamines. In all the three cases, police, Division of Family Services (DFS), and social work were involved. In no case did the acute clinical management change occurred due to the results of the RCUDS. CONCLUSIONS: The RCUDS rarely changed management in patients at our institution. Further study is warranted.

A Case of 3,4-Dimethoxyamphetamine (3,4-DMA) and 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity with Possible Metabolic Interaction.

We present a case of "ecstasy" ingestion revealing 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-dimethoxyamphetamine (3,4-DMA) and absence of cytochrome P450 (CYP)-2D6 MDMA metabolites. CASE REPORT: A 19-year-old presented following a seizure. Initial vital signs were normal. Laboratories were normal with the exception of sodium 127 mEq/L and urine drugs of abuse screen positive for amphetamines. Twelve hours later, serum sodium was 114 mEq/L and a second seizure occurred. After receiving hypertonic saline (3%), the patient had improvement in mental status and admitted to taking "ecstasy" at a rave prior to her initial presentation. Liquid chromatography-time-of-flight mass spectrometry (LC-TOF/MS) of serum and urine revealed MDMA, 3,4-DMA, and the CYP-2B6 MDMA metabolites 3,4-methylendioxyamphetamine (MDA) and 4-hydroxy-3-methoxyamphetamine (HMA). The CYP2D6 metabolites of MDMA, 3,4-dihydromethamphetamine (HHMA) and 4-hydroxy-3-methoxymethamphetamine (HMMA), were detected at very low levels. CONCLUSION: This case highlights the polypharmacy which may exist among users of psychoactive illicit substances and demonstrates that concurrent use of MDMA and 3,4-DMA may predispose patients to severe toxicity. Toxicologists and other healthcare providers should be aware of this potential toxicity.