Acute perchloroethylene intoxication in an elderly woman: a case report

Background

Perchloroethylene is a colorless, strong-smelling substance commonly used for dry cleaning. Liver and kidney toxicities and carcinogenicity are well-known occupational hazards caused by chronic perchloroethylene exposure. Acute intoxication by ingestion of nondiluted perchloroethylene is rare in the adult population owing to its strong smell and taste. Very few data are available to physicians managing patients in this situation.

Case presentation

An 89-year-old Caucasian woman accidentally drank perchloroethylene while visiting her laundry, leading to a coma within a few minutes. The poison control center provided little information about perchloroethylene toxicity after ingestion, including an estimated long biological half-life (144 hour) and detrimental effects to liver and kidneys. A long intensive care unit stay was thus expected, potentially leading to several complications. After intubation, transitory hypoxemia appeared and rapidly resolved, while mild hemodynamic instability was managed with fluid resuscitation and anti-arrhythmic drugs. Twelve hours after perchloroethylene ingestion, the patient suddenly woke up and self-extubated. Less than 24 hours after ingestion, she was discharged from the intensive care unit, and 4 days later she was discharged home.

Conclusion

The patient drank perchloroethylene from a bottle, which prevented her from smelling it, and owing to its taste, only a small sip was likely drunk. However, a much larger intake was presumed, given her rapid and profound central nervous system depression. This case was challenging owing to the paucity of information available regarding acute perchloroethylene ingestion and the duration and magnitude of its effect. The present report will hopefully be of support for clinicians managing patients with this rare acute intoxication.

Epidemiology of cannabidiol related cases reported in the National Poison Data System - 2019-2020

INTRODUCTION

Cannabidiol (CBD) has become a popular supplement in consumer products in recent years, resulting in part from normalization of the cultivation of low THC cannabis in 2018. However, the actual content of CBD-labeled products is frequently uncertain, as oversight of such products is minimal. To date, there is little pragmatic knowledge regarding exposures to products labeled as containing CBD.

METHODS

Cases reported to Poison Control Centers from April 1, 2019 and March 31, 2020, the first year in which CBD was identified uniquely as a substance in the National Poison Data System, were analyzed for demographic, temporal, and clinical trends.

RESULTS

Poison Control Centers handled 1581 cases exposures to CBD-containing products between April 1, 2019 and March 31, 2020. There was a significant trend of over 5 additional cases related to this substance per month (linear regression coefficient = 5.2, 95% CI: 1.52-8.98). Patients under age 13 years made up 44.0% of reported exposures. Mild CNS depression (10.3%), tachycardia (5.7%), dizziness/vertigo (5.3%), vomiting (4.9%), nausea (4.5%), and agitation (4.4%) were the most frequently reported symptoms. 13% of cases were coded as having "moderate" or "severe" medical outcomes. There were no fatalities.

CONCLUSIONS

Cases reported to Poison Control Centers regarding exposures to CBD-labeled products have been increasing, representing an emerging trend of interest to Poison Control Center professionals, clinicians, and public health officials. Further monitoring of this trend is recommended.

[Poisoning inquiries from Berlin and Brandenburg from 1999-2018: an urban-rural comparison]

Hintergrund und Ziel

Der Berliner Giftnotruf ist seit 1963 die zentrale Anlaufstelle beim Thema „Vergiftungen“ für die Berliner und Brandenburger Bevölkerung. Ferner nimmt die Einrichtung eine wichtige Funktion im Bereich der Vergiftungsprävention wahr. Ziel dieser Arbeit ist es, die Entwicklung des Beratungsaufkommens und der Inhalte von 1999 bis 2018 zu beschreiben. Unterschiede bei städtischer und ländlicher Herkunft der Anrufenden sowie bei privatem oder beruflichem Hintergrund der Anfragen werden betrachtet. Die Ergebnisse sollen der Verbesserung der Präventionsarbeit dienen.

Methoden

Die Falldaten des Giftnotrufs (1999–2018) wurden aufbereitet und einer explorativen Datenanalyse unterzogen. Über Verfahren der deskriptiven Statistik wurden die Daten ausgewertet und analysiert. Zusammenhänge zwischen der „Herkunft des Anrufs“ (Stadt oder Land), dem „Hintergrund“ (privat oder beruflich) und der jeweiligen „Noxenkategorie“ wurden mittels Pearsons Chi-Quadrat-Test analysiert.

Ergebnisse

Das jährliche Beratungsvolumen stieg tendenziell an. Insbesondere Anfragen zu Expositionen von Erwachsenen und Senioren nahmen zu. Häufigste Themen waren Vergiftungen mit Medikamenten und Publikumsmitteln. Anfragen zu illegalen Drogen nahmen am stärksten zu (durchschnittliche jährliche Wachstumsrate 6,3 %). Anfragenden Privatpersonen kann in den meisten Fällen direkt geholfen werden (86,8 %), sodass nur selten eine medizinische Behandlung empfohlen wird. Privatpersonen rufen häufiger aus der Stadt an, auf dem Land überwiegen Anrufe von medizinischem Personal. Im ländlichen Raum wurden Anfragen zu Schädlingsbekämpfungsmitteln, Pilzen, Tieren und Pflanzen häufiger gestellt. Anrufe zu Lebensmitteln, Fremdkörpern, Genussmitteln oder illegalen Drogen gingen hingegen vermehrt aus dem städtischen Raum ein.

Recommendation for the establishment of a poison control center at the Korea Disease Control and Prevention Agency

There is currently no governmental body in South Korea resembling the type of poison center (PC) recommended by the World Health Organization (WHO). All Organization for Economic Cooperation and Development (OECD) member countries except for South Korea maintain such a PC tasked with both preventing poisoning accidents and supporting the prompt treatment of poisoned patients. Such a PC could very possibly have allowed the country to more promptly recognize the widespread wave of humidifier disinfectant (HD) associated health effects, including fatal lung injury and death, that lasted started roughly in 2000 and continued through 2011. Despite this chemical poisoning tragedy, South Korea still lacks a surveillance system to monitor health effects caused by the use and consumption of materials that include products containing chemicals, foodborne pathogens, drugs, pesticides, etc. There have been no legal procedures for examining the potential risk of products or materials manufactured by industry. The reporting of national poisoning data or causes of poisoning, which is near ubiquitous in advanced countries with a PC, has not taken place We recommend that a PC should be established within the Korea Disease Control and Prevention Agency (KDCA). In addition, in order to perform surveillance of poisoning cases across the country, a certain number of regional PCs, including at large hospitals, will also be necessary.

Legal aspects of information sharing and communication by poison centers in the United States

To keep pace with changing technology and to provide better treatment to the public, U.S. poison control centers have increasingly implemented new ways of communicating with healthcare providers and with patients, including electronic transfer of patient information. Innovation in communication and information sharing raises concerns over patient privacy and compliance with applicable laws. This narrative review analyzes both typical activities and emerging innovations of PCCs in relation to U.S. law and regulation regarding privacy, specifically the Health Insurance Portability and Accountability Act, the Substance Abuse and Mental Health Treatment Act, and the Federal Trade Commission Act. PCCs that are "covered entities" under HIPAA may exchange patient health information with other providers by telephone for purposes of treatment, and certainly during the emergency management of poisonings. SAMHSA regulations, however, limit information that can be shared outside of emergencies without patient consent. The FTC Act prohibits unfair or deceptive trade practices which may in some circumstances involve privacy violations. Text message exchanges between PCCs and patients present particularly difficult privacy challenges under these laws.

An interprofessional clinical toxicology advanced pharmacy practice experience

BACKGROUND AND PURPOSE

Clinical toxicology is a blend of science, research, and patient management practices involving human poisonings from exposure to natural and synthetic toxins. The objective of this study was to describe the components of an elective advanced pharmacy practice experience (APPE) in clinical toxicology at California Poison Control System (CPCS).

EDUCATIONAL ACTIVITY AND SETTING

The APPE requirements included a mix of active participation in case management and supplemental educational exercises, case presentations and consultations, and a structured self-study component consisting of readings and on-line modules. In addition, there were two active learning activities, high acuity poisoning simulation scenarios utilizing a high-fidelity mannequin, and an antidote tasting session.

FINDINGS

From April 2012 to October 2017, 82 student pharmacists completed this APPE. Pharmacy students completed 85 pre-simulation surveys and 80 post-simulation surveys. Survey results showed an increase in pharmacy student beliefs that a clinical pharmacist should be involved in the differential diagnosis and management of patients (60% pre-simulation vs. 78.8% post-simulation, p = 0.009). APPE pharmacy students completed an evaluation of the preceptors(s), site, and learning experience. The average score for all areas on the preceptor and site evaluations was >4.5 on a 5-point Likert scale. Qualitative data themes included student satisfaction with opportunities, feedback, and the interprofessional and collaborative environment.

SUMMARY

An APPE in the CPCS was successfully designed and implemented. The APPE provides an interprofessional collaborative learning environment that allows student pharmacists to understand the unique role of the pharmacist in this setting.

Trends in types of calls managed by U.S. poison centers 2000-2015

AIM

The number of cases reported to poison centers has decreased since 2008 but there is evidence that the complexity of calls is increasing.

OBJECTIVES

The objectives are to evaluate national poison center data for trends in reason and how these changes effect management site, medical outcomes, and poison center workload.

METHODS

Data regarding reason, age, management site, and medical outcome were extracted from annual reports of the National Poison Data System from 2000 to 2015. The proportion of cases by year were determined for unintentional and intentional exposures. Analysis of data from a single poison center from 2005 to 2015 compared the number of interactions between poison center staff and callers for unintentional versus intentional reasons.

RESULTS

Trend analyses found that from 2000 to 2015 the percent of unintentional cases decreased (from 85.9 to 78.4%, p < .0001) and the percent of intentional cases increased (from 11.3 to 17.6%, p < .0001). Age distribution changed with a decrease in children <13 years of age and increase in adolescents and adults. In these latter two age groups, the proportion due to intentional exposure increased while unintentional declined. The distribution of management sites changed over the 16-year period, with a decrease in non-HCF cases and significant increase in percent of cases treated in a HCF. The frequencies of moderate effect, major effect, and death were significantly higher for intentional exposures than for unintentional exposures. Analysis of data entry notes from a single center showed that the mean number of notes per unintentional case (1.61 ± 0.08) was significantly different from the mean number of notes per intentional case (9.23 ± 0.68) (p < .0001).

DISCUSSION

Poison centers are managing more intentional exposures and fewer unintentional exposures. Intentional exposures require more poison center staff expertise and time.

CONCLUSION

Looking only at poison center total call volume may not be an adequate method to gauge productivity.

Non-health Care Facility Medication Errors Associated with Hormones and Hormone Antagonists in the United States

INTRODUCTION

Hormones and hormone antagonists are frequently associated with medication errors and may result in important adverse outcomes. The purpose of this study is to investigate non-health care facility (non-HCF) medication errors associated with hormones and hormone antagonists in the United States (US).

METHODS

A retrospective analysis of National Poison Data System data was conducted to identify characteristics and trends of unintentional non-HCF therapeutic errors involving hormones and hormone antagonists among individuals of all ages from 2000 to 2012.

RESULTS

From 2000 to 2012, US poison control centers received 169,695 calls regarding unintentional non-HCF therapeutic errors associated with hormone therapies, averaging 13,053 medication error calls annually. The rate of reported errors increased significantly by 162.6% (p < 0.001), from 2.24 per 100,000 US residents in 2000 to 5.89 per 100,000 in 2012. Two thirds of the errors (65.2%) occurred among females. The medications most commonly associated with errors were thyroid preparations (23.2%), corticosteroids (21.9%), and insulin (20.0%). All nine deaths and 93.2% of major effects were attributed to hypoglycemic agents. Sulfonylureas alone accounted 43.9% of major effects. The number and rate of therapeutic errors increased significantly for all medication categories except estrogen and thiazolidinediones. Most errors were managed at the site of exposure (82.9%) and did not result in serious medical outcomes (95.6%).

CONCLUSIONS

This study provides an overview of non-HCF medication errors associated with hormones and hormone antagonists in the US. While most errors did not result in adverse outcomes, their increasing frequency places a greater burden on the health care system.

An Increase in Dietary Supplement Exposures Reported to US Poison Control Centers

INTRODUCTION

The objective of this study was to investigate the epidemiology of dietary supplement exposures in the USA.

METHODS

A retrospective analysis was conducted of out-of-hospital dietary supplement exposures reported to the National Poison Data System from 2000 through 2012.

RESULTS

There were 274,998 dietary supplement exposures from 2000 through 2012. The annual rate of dietary supplement exposures per 100,000 population increased by 46.1% during 2000-2002, decreased 8.8% during 2002-2005, and then increased again by 49.3% from 2005 to 2012. These trends were influenced by the decrease in ma huang exposures starting in 2002. Miscellaneous dietary supplements accounted for 43.9% of all exposures, followed by botanicals (31.9%), hormonal products (15.1%), and other supplements (5.1%). The majority of dietary supplement exposures (70.0%) occurred among children younger than 6 years old and were acute (94.0%) and unintentional (82.9%). Serious medical outcomes accounted for 4.5% of exposures and most (95.0%) occurred among individuals 6 years and older. Ma huang products, yohimbe, and energy products were the categories associated with the greatest toxicity.

CONCLUSIONS

There was an overall increase in the rate of dietary supplement exposures from 2000 through 2012. Although the majority of these exposures did not require treatment at a health care facility or result in serious medical outcomes, exposures to yohimbe and energy products were associated with considerable toxicity. Our results demonstrate the success of the FDA ban on ma huang products and the need for FDA regulation of yohimbe and energy products in the USA.

The value of a poison control center in preventing unnecessary ED visits and hospital charges: A multi-year analysis

OBJECTIVE

The purpose of this study is to determine the economic value of the Utah Poison Control Center (UPCC) by examining its contribution to the reduction of unnecessary emergency department (ED) visits and associated charges across multiple years.

METHODS

A multi-year (2009-2014) analysis of cross-sectional data was performed. Callers were asked what they would do for a poison emergency if the UPCC was not available. Healthcare charges for ED visits averted were calculated according to insurance status using charges obtained from a statewide database.

RESULTS

Of the 10,656 survey attempts, 5018 were completed. Over 30,000 cases were managed on-site each year. Using the proportion of callers who noted they would call 911, visit an ED, or call a physician's office, between 20.0 and 24.2 thousand ED visits were potentially prevented each year of the survey. Between $16.6 and $24.4 million dollars in unnecessary healthcare charges were potentially averted annually.

CONCLUSIONS

Compared to the cost of operation, the service UPCC provides demonstrates economic value by reducing ED visits and associated charges. As the majority of patients have private insurance, the largest benefit falls to private payers.

Recreational phenethylamine poisonings reported to a French poison control center

OBJECTIVES

Over the last decade, use of phenethylamines has become increasingly prevalent. This study aimed to describe typical aspects of phenethylamine poisoning in order to better inform patient care.

METHODS

Phenethylamine poisoning cases reported to the Poison Control Center of Angers, France, from January, 2007 to December, 2013 were examined. Clinical findings were examined in 105 patients, including phenethylamine used, symptoms and final outcome. Patients were predominantly male (80%), with mean age 26±8 years.

RESULTS

MDMA (38%), amphetamine (18%) and methamphetamine (14%) were the most commonly reported. Synthetic cathinones (10%) and the 2C series (7%) were also found. Substances most commonly associated with phenethylamine poisoning were cannabis (27%), ethanol (20%) and cocaine (9%). The most frequently reported symptoms included anxiety and hallucinations (49%), mydriasis and headache (41%), tachycardia (40%) and hypertension (15%). Complications such as seizures (7%), cardiac arrest (5%), toxic myocarditis (1%) and hemorrhagic stroke (1%) were also observed. Of the cases, the Poison Severity Score was: null or low, 66%, moderate, 21%, severe or fatal, 13%. Of the patients, 77% received hospital care and 12.4% were admitted to an intensive care unit. Analytical confirmations were obtained for all severe cases. While 93% of patients recovered, there were 5 deaths and 2 patients presented with neurological sequelae.

CONCLUSIONS

Phenethylamine poisonings may be severe in young and healthy individuals. Physicians, toxicologists and analysts should be aware of new phenethylamine consumption trends in order to inform management of patient care and to contribute to a more responsive drug policy.