Barbara I. Crouch

Pulmonary toxicity following exposure to waterproofing grout sealer

IntroductionWe report a large number of cases of pulmonary toxicity from 6 regional poison control centers associated with the use of a waterproofing-grout sealer. The identification of this illness occurred by means of the poison control center (PCC) national automated toxicosurveillance.Materials and MethodsThis is a retrospective case review of all cases of pulmonary toxicity following exposure to a waterproofing grout sealer from 6 regional PCCs including Michigan, Kentucky, Utah, Maine, Arizona, and Nebraska. The study period extended from June 1, 2005 to December 1, 2005.ResultsThe vast majority of patients used the product at home (80%). Over half the patients presented within 3 hours of exposure. The most common presenting symptoms were shortness of breath (63%), cough (60%), and chest pain (44%). Wheezing (33%) and rales (23%) were the most common signs of clinical toxicity. One patient required endotracheal intubation. Thirty-seven percent of patients had signs of acute pneumonitis on initial chest x-ray. The mean presenting oxygen saturation was 89.5%. The most common treatment measures used were supplemental oxygen, bronchodilator therapy, oral steroids, and antibiotics. Over half of the study group required hospital admission.ConclusionThe majority of patients in this study were adults using the product at home. Over one-third of patients had an abnormal x-ray upon presentation. Over half of the study group required hospital admission following exposure to this product. Medical professionals should be aware of the potential for pulmonary toxicity due to waterproofing aerosols.

Cyclizine abuse by teenagers in Utah

Substance abuse by teenagers is common, often involving use of alcohol and illicit drugs. Ingestion of cyclizine hydrochloride, a nonprescription medication, was noted to occur frequently in Utah for abuse reasons. A retrospective review was conducted of patients younger than 18 years of age over a 3-year period who intentionally ingested cyclizine identified from Utah Poison Control Center records. Eighty patients were included; 42 patients underwent hospital record review. Abuse accounted for 89% of cyclizine ingestions; hallucinations (70%) and confusion/disorientation (40%) were the most notable symptoms. Tachycardia (52%) and systolic hypertension (69%) were frequently present in patients who presented to a hospital. No serious complications occurred. This study illustrates teenage abuse of one nonprescription antihistamine presumably to induce hallucinations. Abuse of over-the-counter medications by adolescents may be more appealing than illicit drug use for numerous reasons, and may be more common than appreciated.

Benzonatate overdose associated with seizures and arrhythmias

BACKGROUND Benzonatate is an antitussive with a unique chemical structure. It can contain as many as 8 structural analogs. Therefore, laboratory analysis of benzonatate is difficult. We report 2 cases of benzonatate poisoning with seizures and cardiac arrest and an analytical method to identify and quantify benzonatate in human plasma. CASE REPORTS Case 1: A 12-month-old male presented to the emergency department of a rural hospital following ingestion of an unknown amount of benzonatate. Upon arrival, the child was seizing and in full cardiac arrest. Resuscitative measures were unsuccessful and the child died shortly after arriving at the emergency department. Case 2: A 39-year-old male ingested 36 benzonatate capsules in a suicide attempt. Enroute to the health care facility, the patient experienced a seizure, had a cardiac arrest, and was cardioverted. Upon arrival at the emergency department, the patient was acidotic with a pH of 6.8. Gastric lavage was performed followed by the administration of activated charcoal. Six hours after arrival at the emergency department, the patient was alert, oriented, and hemodynamically stable. The patient was observed for 24 hours and subsequently discharged. Laboratory confirmation of benzonatate in the plasma of the patient was performed using high-pressure liquid chromatography with tandem mass spectrometry (MS/MS). The benzonatate concentration was estimated to be 2.5 micrograms/mL. CONCLUSION Seizures and cardiac arrest are possible following an acute ingestion. Quantitative analysis of benzonatate is possible using high-pressure liquid chromatography with tandem mass spectrometry. Routine analysis for benzonatate is not common.

Exploring Challenges to Telehealth Communication by Specialists in Poison Information

The use of the telephone for providing health care is growing. A significant amount of social meaning is derived from visual information, and the absence of visual stimuli provides unique barriers to communication and increases the risks for misunderstandings and distractions. Understanding challenges to telephone communication can provide insight into training opportunities for overcoming these difficulties and improving patient care. The purpose of this research was to explore through focus groups the challenges of phone communication perceived by specialists in poison information. General types of challenges to effective phone communication included developing new communication skills to compensate for lack of visual information, difficulty assessing caller understanding, difficulty managing caller misunderstandings, maintaining distinctive assessments for routine calls, and managing the multifaceted aspects of job stress. The desire for training to enhance telehealth and cultural competency skills was also mentioned, and these findings might provide guidance for the development of training opportunities for telehealth professionals.

Prospective observational multi-poison center study of ziprasidone exposures

Background. Ziprasidone is an atypical antipsychotic associated with QTc prolongation during therapeutic use. We characterized the clinical manifestations associated with ziprasidone overdoses, in particular the incidence and severity of QTc prolongation. Methods. Four regional poison centers prospectively collected ziprasidone overdose data from August 1, 2003 to October 1, 2005. Cases were included if they were followed to known medical outcome and comprised single-substance ziprasidone exposures or with co-ingestants not associated with prolongation of the QTc interval. Results. Fifty-six ziprasidone exposures met inclusion criteria. The most common clinical effects were drowsiness (N=38, 67.9%) and tachycardia (N=19, 33.9%). QTc prolongation (>0.500 second) occurred in only one patient. Seven patients had QTc intervals of 0.450 to 0.500 second. Medical outcomes were coded as no effect (13, 23.2%), minor effect (21, 35.5%), moderate effect (20, 35.7%), or major effect (2, 3.4%). Conclusion. Common clinical effects following ziprasidone overdose are drowsiness and tachycardia. Clinically significant QTc prolongation occurs infrequently.

Poisoning in Older Adults: A 5-Year Experience of US Poison Control Centers

BACKGROUND Poisoning in older adults has received relatively little attention. OBJECTIVE To describe poison exposures in older adults reported to US poison centers and identify substances that pose a unique risk to this population. METHODS: A retrospective review of human exposures for patients aged 60 years reported to the American Association of Poison Control Centers Toxic Exposure Surveillance System from 1993 to 1997 was performed. Frequencies and cross-tabulations were used to describe the data. Hazard factor analysis was conducted to identify medications that pose risk in this population. Statistical analysis included χ2 and Fishers exact test for hazard factors. RESULTS A total of 298 713 poison exposure cases were reported to US poison centers involving individuals aged 60 years between 1993 and 1997. The proportion of cases in this age group also steadily increased from 2.5% of all cases in 1993 to 3.4% of all cases in 1997. The mean age of the patients was 64.7 years, and 34.1% were males. Hazard factor analysis was conducted on unintentional exposures and adverse reactions to pharmaceutical agents to determine medications that posed increased risk to older adults. The substance categories that had the highest hazard factor were radiopharmaceuticals, asthma therapies, anticoagulants, anesthetics, and antidepressants. CONCLUSIONS Therapeutic errors and adverse reactions to medications are common reasons for major effects and fatal outcomes among older adults reported to poison centers. Understanding poisoning issues specific to this population may help direct future outreach education efforts.

Fatal Accidental Dibucaine Poisoning in Children

Dibucaine is a potent amide anesthetic available in over-the-counter preparations. Compared with lidocaine, substantially lower doses of dibucaine may result in seizures, dysrhythmias, and death. We present three fatal cases of accidental dibucaine ingestion in children and discuss the toxicity, treatment, and prevention of such ingestions.

Poison control center communication and impact on patient adherence

Objective. This project explored the communication processes associated with poison control center calls. Methods. In this preliminary study, we adapted the Roter Interaction Analysis System to capture staff-caller dialogue. This involved case selection, wherein adherence and non-adherence cases were selected; call linkage to medical records, where case records were linked with voice recordings; and application of Roter Interaction Analysis System to calls. Results. Results indicate that communications are predominantly provider-driven. Patient age and percentage of staff partnership statements were significantly associated with adherence at the 0.05 level. Increases in age were associated with decreases in adherence to recommendations (p < 0.001). Increases in percentage of staff partnership statements (over all staff talk) were associated with increases in adherence (p = 0.013). Conclusion. This line of research could lead to evidence-based guidelines for effective staff-caller communication, increased adherence rates, and improved health outcomes.

Data standards to support health information exchange between poison control centers and emergency departments.

OBJECTIVE Poison control centers (PCCs) routinely collaborate with emergency departments (EDs) to provide care for poison-exposed patients. During this process, a significant amount of information is exchanged between EDs and PCCs via telephone, leading to important inefficiencies and safety vulnerabilities. In the present work, we identified and assessed a set of data standards to enable a standards-based health information exchange process between EDs and PCCs. MATERIALS AND METHODS Based on a reference model for PCC-ED health information exchange, we (1) mapped PCC-ED information exchange events to clinical documents specified in the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) Standard, and (2) mapped information types routinely exchanged in PCC-ED telephone conversations to C-CDA sections. RESULTS Four C-CDA document types were necessary to support the PCC-ED information exchange process: History & Physical Note, Consultation Note, Progress Note, and Discharge Summary. Information types that are commonly exchanged between PCCs and EDs can be reasonably well represented within these C-CDA documents. CONCLUSIONS A standards-based health information exchange process between PCCs and EDs appears to be feasible given a set of clinical data standards that are required for EHR certification in the USA, although the proposed approach still needs to be validated in actual system implementations. Such a process has the potential to improve the safety and efficiency of PCC-ED communication, ultimately resulting in improved patient care outcomes.

Electronic information exchange between emergency departments and poison control centers: A Delphi study

Context. The US emergency departments and poison control centers use telephone communication to exchange information about poison exposed patients. Electronically exchanged patient information could better support care for poisoned patients by improving information availability for decision making and by decreasing unnecessary emergency department telephone interruptions. As federal initiatives push to increase clinical health information exchange (HIE), it is essential to assess the readiness of US poison control centers. We conducted a nationwide Delphi study to determine consensus on legal, operational, and clinical considerations that are important for electronic information exchange between emergency departments and poison control centers. Materials and methods. A national panel of US experts (n = 71) in emergency medicine and poison control participated in a Delphi study, September–December 2010. Panelists rated statements describing concepts related to implementation, adoption, or potential outcomes of electronic information exchange between emergency departments and poison control centers. The statements reflected panelist responses to initial open-ended questions and literature-based concepts. Results. A total of 71 panelists agreed to participate. The response rate for each round ranged from 0.73 to 0.77. Most (114/121) statements reached consensus. Seven statements failed to reach consensus. Panelists indicated that user involvement in the design of systems and tools is important. Workflow integration, safety, evidence of benefit, and outcomes are high-importance issues. Discussion/conclusions. Future research and development related to electronic information exchange should address high-importance issues: safety, patient outcomes, workflow integration, and evidence of benefit. It should also address key barriers: initial and ongoing costs associated with electronic information exchange, the absence of software and tools to facilitate exchange, and the need for training. Users should be involved in the design of an electronic information exchange process, and the process should support, not replace, verbal communication.