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Goldfrank's Manual of Toxicologic Emergencies

Goldfrank's Manual of Toxicologic Emergencies


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Published by Kang Kyu Choi
Goldfrank's Manual of Toxicologic Emergencies
Goldfrank's Manual of Toxicologic Emergencies

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Published by: Kang Kyu Choi on Jul 10, 2011
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In 1950, the American Academy of Pediatrics created a Committee on Ac-
cident Prevention to explore methods to reduce injuries in young children.
A survey by that committee demonstrated that injuries resulting from unin-
tentional poisoning were a significant cause of childhood morbidity. Simul-
taneously came the realizations that a source of reliable information on the
active ingredients of common household products was lacking and that
there were few accepted methods for treating poisoned patients. In response
to this void, the first poison center was created in Chicago in 1953. The poi-
son center of today is charged with many of the same mandates as the orig-
inal centers, including maintaining a database; providing information to
public and health professionals, collecting epidemiologic data on the inci-
dence and severity of poisoning; preventing unnecessary hospitalizations
following exposure; and educating healthcare professionals on the diagno-
sis and treatment of poisoning. However, a crucial test of the usefulness of
poison centers will be their ability to demonstrate a reduction in poison-
related mortality.


With the evolution of information technology, poison centers are no longer
perceived as the sole guardians of toxicology information. Although these
services are still essential for the public at large, and those professionals
away from their computers, a predictable decline in poison center use has
paralleled growth in information availability. A study demonstrated that
82.6% of emergency physicians who had POISINDEX available in their
institutions did not routinely consult the poison center. An initial analysis
might suggest that this is an acceptable trend in that it both allows physi-
cians to respond more rapidly to patient needs and poison information cen-
ters to be more available to those individuals who do not have access to
this information system. However, this practice of “not calling” under-
mines the efforts of poison information centers to gather epidemiologic
data. Also, because most databases are designed to provide information
about known entities, they perform poorly when dealing with unknown
and unclear scenarios. Thus, although originally designed as providers of
information, poison centers must now be considered valued consultants,
with staff who not only provide content information but also interpret clin-
ical material and link both to appropriate management strategies. An illus-
trative example of the value of poison centers can be drawn from the use of
flumazenil for benzodiazepine overdose. Although it may easily be deter-
mined by anyone capable of using an index that flumazenil is an antidote
for benzodiazepine overdoses, many subtle characteristics of the patient or
the overdose often contraindicate its use. A prospective study determined
that when flumazenil was used before consultation with the poison infor-
mation center, contraindications were present in 10 (71%) of 14 cases, re-
sulting in one serious adverse event.

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Recent data demonstrate that poisoning is the third leading cause of injury-
related fatalities, ranking behind motor vehicle crash and firearm use. Un-
derstanding the evolving trends in poisoning is essential to the development
of enhanced surveillance, prevention, and education programs designed to
reduceunintentional poisoning. Although data can be analyzed from numerous
sources, such as death certificates, hospital discharge coding records, and
poison information centers, it is essential to recognize the biases that are in-
herent in each of these reports. Because not all significant poisoning results
in either hospitalization or fatality, data from poison centers appear to offer a
unique perspective.

Unfortunately, the data collected and disseminated by poison centers is de-
fined by the term “exposures.” Many exposures are of no clinicalconsequence
because of the properties of the xenobiotic involved, the magnitude or dura-
tion of the exposure, or uncertainty as to whether an actual exposure has oc-
curred; therefore, data collected by poison information centers represent a lim-
ited and ill-defined measure of poisoning. The situation is further confounded
by multiple biases that are introduced by the actual reporting process, which
first and foremost is voluntary and passive. Because the majority of calls con-
cern self-reported data that come from the home and are never subsequently
confirmed, a significant percentage of existing data may actually represent po-
tential or possible exposures, with the potential for resultant large statistical er-
rors introduced into the database. Reporting biases serve as another clear exam-
ple of problems with poison center data.

Fatal Poisoning

A 4-year study compared deaths from poisoning reported to the Rhode Is-
land medical examiner with those reported to the area poison center. Not
surprisingly, the medical examiner reported many more deaths: 369 com-
pared to 45 reported by the poison center. Although the majority of the cases
not reported to the poison center were victims who died at home, were pro-
nounced dead on arrival to the hospital, or those in whom poisoning was not
suspected until the postmortem analysis, 79 patients who subsequently be-
came unreported fatalities were actually admitted to the hospital with a sus-
pected poisoning. In ten of these cases, the authors concluded that a toxicol-
ogy consultation might have altered the outcome. Similar studies confirm
these findings.

Nonfatal Poisoning

A 1-year retrospective review demonstrated that only 26% (123/470) of poisoned
patients who were treated in a particular emergency department were reported to
the poison center. Interestingly, only 3% of inhalational exposures were reported,
compared with 95% of cyclic antidepressant ingestions. Similarly, in a survey,
physicians reported that they would “almost never” contact the poison center for
asymptomatic exposures (62.9%), chronic toxicity (50.4%), or simply to assist in
establishing a reliable database (90.2%).

Occupational Exposures

A number of federal and state government-funded agencies, such as National
Institute for Occupational Safety and Health (NIOSH), Occupational Safety



and Health Administration (OSHA), and Agency for Toxic Substances and
Disease Registry (ATSDR), exist to prevent occupational illness, to educate
the public, and to collect data on exposures to occupational toxins. Discrep-
ancies exist between poison information data and the data collected by gov-
ernmental agencies. A 6-month survey in California noted that only 15.9% of
the occupational cases reported to the poison center were captured by a state
reporting system.

Adverse Drug Events and Medication Errors

The ease of 24-hour telephone access, combined with the ability to con-
sult with a health professional, make poison centers ideal resources for
reporting of adverse drug events (ADEs). Yet, more than 76% of physi-
cians surveyed stated that they would “almost never” contact the poison
center regarding adverse drug reactions. Moreover, in one study, 53.6% of
poison centers stated that they had not submitted any of their ADE data to
the Food and Drug Administration’s MedWatch program.

Drugs of Abuse

Poison centers also collect data on exposures to drugs of abuse and misuse.
Because most substance abuse does not result in immediate interactions with
the healthcare system, other databases such as the National Institute on Drug
Abuse (NIDA) Household Survey (now referred to as the Monitoring the Fu-
ture Study) might better reflect substance abuse trends.

Grossly Underreported Xenobiotics

There is little doubt that alcohol and tobacco are the most common xenobi-
otics intentionally used and misused in our society. Although their toxico-
logic manifestations can be acute and severe, chronic subclinical poison-
ing often goes unnoticed for many years. Similarly, more than 1 million
American children have lead concentrations above 10 µg/dL and elevated
concentrations of polychlorinated biphenyls (PCBs) can be found in
countless adults and children. We must remain cognizant of these facts
when we read that plants, cleaning products, and cosmetics are the most
common exposures to xenobiotics. These are only the most common “re-
ported” exposures.

Using the Existing Data

With the current limitations of the Toxic Exposure Surveillance System
(TESS) data, it should be clear that neither the numerator nor the denomi-
nator of poisoning can be easily appreciated. Analysis of these data for
trends may be more useful because the inherent biases involved in TESS
reporting are probably consistent over many years. Despite its limitations,
TESS data have significant usefulness. It is often an exposurerather than
an actual poisoningthat provides the impetus for contact with healthcare.
For those exposures that are unlikely to be clinically consequential, the
poison center can intervene to prevent potentially harmful attempts at
home decontamination and costly unnecessary visits to healthcare provid-
ers. Interactions with parents at a time of perceived crisis also provides a
“teachable moment” that may help prevent a more consequential exposure
in the future.




When visits to pediatric emergency departments for acute poisoning were ana-
lyzed, one study demonstrated that 95% of parents had not contacted the poison
center before coming to the hospital. Sixty-four percent of those children re-
quired no hospital services. In contrast, when parents called the poison center
first, fewer than 1% sought emergency services. When 589 callers to one poi-
son center were surveyed, 464 (79%) stated that they would have used the
emergency care system if the poison center was unavailable. Suggesting simple
techniques or reassurance can successfully reduce hospital visits. The national
average cost to the poison center for a single human exposure call is less than
$35. A federally funded study concluded that in 1 year, poison centers reduced
the number of patients who were treated and not hospitalized by 350,000 and
reduced hospitalizations by an additional 40,000 patients. Each call to a poison
center prevented at least $175 in subsequent medical costs, providing strong
theoretical evidence to support the cost efficacy of poison centers.


Poison center staff work closely with physicians, community health educa-
tors, community support groups, and parent–teacher associations to develop
poison-prevention activities. Table 130–1lists common strategies advocated
to prevent poisoning.


The initial public health efforts of poison centers focused on attempts to alter
product concentration and to enhance product labeling and packaging. Cur-
rent events have also increased poison center activities in preparedness for di-

TABLE 130–1.Common Strategies Advocated to Help Prevent Poisoning

•All xenobiotics should be kept in their original containers. Food and drink
containers should never be used for the excess of a xenobiotic.
•Never store xenobiotics in unlocked cabinets under the sink.
•Apply locks to medicine cabinets that are within the reach of a child.
•In the absence of a lock, the more toxic xenobiotics should be stored on the
highest shelves.
•Xenobiotics should never be left in the glove compartment of the family car.
•Parents should buy or accept medication only if it is in a child-resistant con-


•Medication should be considered as medicine, not a plaything and certainly

not candy.

•Adults should not take their medications in front of children: This will limit
exposure to drug-taking role models that may become objects of imitative

•Unused portions of prescription medications should be discarded by flush-
ing the excess down the toilet at the completion of drug therapy.
•Activated charcoal should be readily available in the home for use if directed
by a poison information specialist or clinician.
•Since it should be anticipated that about 10% of children who have ingested
a poison will do so again within a year, these children should receive an
enhanced level of supervision.



sasters resulting from radiologic, biologic, and chemical terrorism. Addi-
tional collaboration with governmental agencies such as the Centers for
Disease Control and Prevention (CDC) and ATSDR continually expand the
role of medical toxicology in community health.


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