Human bromethalin exposures reported to a U.S. Statewide Poison Control System

Background: Bromethalin is an increasingly used alternative to long-acting anticoagulant and cholecalciferol rodenticides. There are few reports of human exposures, and no existing professional society guidelines on medical management of bromethalin ingestions. The aim of this retrospective data review is to characterize bromethalin exposures reported to the California Poison Control System (CPCS) between 1997 and 2014. Methods: This is an observational retrospective case review of our statewide poison control system’s electronic medical records. Following Institutional Board Review and Research Committee approvals, poison center exposures related to bromethalin were extracted using substance code and free text search strategies. Case notes of bromethalin exposures were reviewed for demographic, clinical, laboratory, and outcome information; inclusion criteria for the study was single-substance, human exposure to bromethalin. Results: There were 129 calls related to human bromethalin exposures (three cases met exclusion criteria). The age range of cases was 7 months–90 years old, with the majority of exposures (89 cases; 70.6%), occurring in children younger than 5 years of age (median age of 2 years). Most exposures occurred in the pediatric population as a result of exploratory oral exposure. One hundred and thirteen patients (89.7%) had no effects post exposure, while 10 patients (7.9%) had a minor outcome. Adverse effects were minor, self-limited, and mostly gastrointestinal upset. There were no moderate, major, or fatal effects in our study population. The approximate ingested dose, available in six cases, ranged from 0.067?mg/kg to 0.3?mg/kg (milligrams of bromethalin ingested per kilogram of body weight), and no dose-symptom threshold could be established from this series. Exposures were not confirmed through urine or serum laboratory testing. Discussion: The prognosis for most accidental ingestions appears to be excellent. However, bromethalin exposures may result in a higher number of symptomatic patients than long-acting anticoagulant agents. Parents, physicians and poison control specialists are encouraged to maintain a high index of suspicion for bromethalin-related complications in all cases of rodenticide exposures. Conclusions: Accidental bromethalin exposures in children appear to be self-limited in toxicity. Additional studies are warranted to determine whether more severe effects are precipitated when larger amounts are involved, particularly in suicidal ingestion.     

Evaluating exposures to plants

Most clinical problems due to plant exposures result from experimentation with or overt abuse of plant parts and extracts. Plant exposures may present as complex pharmacologic problems that challenge the diagnostic and therapeutic skills of the physician. Although specific physiologic antagonists (antidotes) may exist for specific intoxications, basic decontamination and supportive techniques are often all that may be offered.     

Selected topics related to occupational exposures

The auditory and nonauditory effects of noise can be quite profound, affecting approximately 15 to 20 million Americans. As with most occupational toxins, recognition and careful assessment of noise exposure are the foundation on which preventive measures and treatment are based. Dosimeters can measure noise exposure over specific time periods. Pure tone air conduction audiometric monitoring should be performed on an annual basis in workers at risk for significant noise exposure. Occupational infectious disease involves far more than hepatitis and tuberculosis. Periodic fever, dermatologic manifestations and other symptoms peculiar to a specific disease may be important clues to an occupationally related exposure. Whereas strict attention to hand washing and isolation are cornerstones of prevention, use of protective gear is mandated in certain situations. Zoonotic disease, agriculture exposure, water transmission, and biologic contaminants in buildings can be important but subtle exposures sources. Recognition of these infections often depends on the alertness of the primary care giver.     

Plant exposures: wilderness medicine

This article discusses poisonous plants, the symptoms that might arise if they are ingested, and the treatments that should be administered to patients.     

Sticky situations: cyanoacrylate exposures reported to a poison control system

Introduction: Cyanoacrylate (Super Glue^®) exposures are commonly reported to poison control centers, but little has been published in the medical literature regarding these exposures. We sought to characterize cyanoacrylate exposures reported to a poison control system.

Methods: We performed a retrospective review of a poison system’s database for all cases of single-substance human exposure to cyanoacrylate-containing products from 2005 to 2015. Data collected included age, gender, route of exposure, clinical effects, treatments recommended and medical outcome.

Results: There were a total of 893 patients, 505 (56.6%) of which were female. Patient ages ranged from 6 months to 88 years with a median of 11 years. The vast majority of exposures (n?=?871, 97.5%) were unintentional, but a small number of exposures (n?=?22, 2.5%) were due to intentional misuse (such as trying to stop a bleeding cut) or malicious intent (such as purposefully gluing a person's eyes shut as a prank). Routes of exposure included: ingestion, n?=?337 (37.7%); ocular, n?=?322 (36.1%); dermatologic, n?=?285 (31.9%); inhalation, n?=?16 (1.8%); nasal, n?=?1 (0.1%); and otic, n?=?1 (0.1%); some patients had multiple routes of exposure. Treatments recommended by the poison center included irrigation (n?=?411), petroleum jelly (n?=?143), mineral oil (n?=?131), topical antibiotic ointment (n?=?82), peanut butter (n?=?6), acetone (n?=?4) and WD-40^® (n?=?2). A total of 657 patients (73.6%) were managed on-site, while 236 (26.4%) were seen in a health care facility. Among all exposures, effects were classified as none (n?=?287), minor (n?=?529) and moderate (n?=?77). No major effects or deaths were reported.

Conclusions: In this case series, the majority of cases occurred in children and most exposures did not result in significant morbidity. Notably, there was wide variation in terms of recommended treatments; further study is needed to determine the optimal treatment method and to standardize poison center recommendations for treating patients with cyanoacrylate exposures.     

Calls to Poison Centers for hookah smoking exposures

Over the past decade, smoking behaviors have changed in the US. Hookah or waterpipe smoking is increasing, especially among youth and young adults. Social media sites describe the “hookah high” or “buzz”, which may be related to nicotine, carbon monoxide, or other inhalants in hookah smoke. Most important is the risk of carbon monoxide poisoning. Case reports include a high number of victims presenting with loss of consciousness from either syncope or seizures. Anaphylaxis and a very rare respiratory hypersensitivity reaction, acute eosinophilic pneumonia, have also been reported from hookah smoking in previously healthy young adults. This article provides background information on hookah smoking, describes hookah-induced acute injuries that could precipitate poison center calls, and offers suggestions for exposure characterization.     

Adverse events associated with pediatric exposures to dextromethorphan

Study objective: Dextromethorphan is the most common over-the-counter (OTC) antitussive medication. We sought to characterize adverse events associated with dextromethorphan in children <12 years old from a surveillance program of OTC cough/cold medication exposures.

Methods: This is a retrospective case series of oral exposures to dextromethorphan with ≥1 adverse event from multiple U.S. sources (National Poison Data System, FDA Adverse Event Reporting System, manufacturer safety reports, news/media, medical literature) reported between 2008 and 2014. An expert panel determined the relationship between exposure and adverse events, estimated dose ingested, intent of exposure, and identified contributing factors to exposure.

Results: 1716 cases contained ≥1 adverse event deemed at least potentially related to dextromethorphan; 1417 were single product exposures. 773/1417 (55%) involved only one single-ingredient dextromethorphan product (dextromethorphan-only). Among dextromethorphan-only cases, 3% followed ingestion of a therapeutic dose; 78% followed an overdose. 69% involved unsupervised self-administration and 60% occurred in children <4 years old. No deaths or pathologic dysrhythmias occurred. Central nervous system [e.g., ataxia (N?=?420)] and autonomic symptoms [e.g., tachycardia (N?=?224)] were the most common adverse events. Flushing and/or urticarial rash occurred in 18.1% of patients. Dystonia occurred in 5.4%.

Conclusions: No fatalities were identified in this multifaceted surveillance program following a dextromethorphan-only ingestion. Adverse events were predominantly associated with overdose, most commonly affecting the central nervous and autonomic systems.     

Tramadol exposures reported to statewide poison control system

BACKGROUND: Tramadol is a unique analgesic that has been associated with seizures on overdose. OBJECTIVE: To determine the toxic effects associated with tramadol exposure. METHODS: A retrospective chart review of tramadol exposures reported to a multisite, state-wide poison control system over a 2.5-year period was performed. RESULTS: A total of 602 cases were retrieved; 190 had sufficient data for study evaluation. Cases with coingestants or unknown outcomes were eliminated. Of the 190 remaining cases, 55% were females. Acute ingestions represented 90.0%, chronic ingestions 7.9%, and acute on chronic 2.1% of the overdoses. Ages of the patients ranged from 9 months to 80 years. Suicide attempts represented the largest group of exposures. Main symptoms included central nervous system (CNS) depression (27.4%), nausea and vomiting (21.1%), tachycardia (17.4%), and seizures (13.7%). Dosage ranged from a taste amount to 5000 mg. The smallest amount of tramadol associated with seizure was 200 mg, and 84.6% of seizures occurred within 6 hours of time of ingestion. Logistic regression analysis showed an association between seizures and tramadol use in males, chronic use, suicide attempts, intentional abuse or misuse, and tachycardia (HR >100 beats/min). No effect was seen in 36.3% of patients, minor effects in 43.7%, moderate effects in 19.5%, and major effects in 0.5%. Symptoms resolved within 24 hours in 96.7% of the 121 patients who had symptoms. Naloxone improved CNS depression in 7 of 8 patients in whom a response was documented. CONCLUSIONS: Tramadol overdoses frequently cause CNS depression, nausea/vomiting, tachycardia, and seizures. Symptoms generally resolve within 24 hours. Accidental ingestions in children were well tolerated, primarily causing sedation.     

Gender-based differences in postural responses to seated exposures

Background. Individuals may respond differently to various chair designs and the factors that influence these sitting behaviours are not well understood. There is very little information in the scientific literature regarding the observation and documentation of gender differences in seated postures. In particular, anecdotal observations of potential gender-specific sitting behaviours led us to test the influence of gender on the postural responses to different seated conditions.

Methods. Sixteen healthy university students (8 males and 8 females) were tested on four different chair configurations. Upper body kinematics (spine angles and centre of mass) and seat pressure profiles (centre of pressure, peak pressure) were obtained during each testing session.

Findings. Regardless of the chair used or the task performed, average lumbar and trunk angles were significantly more flexed for males than for females (P = 0.047 and P = 0.0026, respectively). Males exhibited average lumbar spine and trunk angles of 65.4° (SD 16.2°) and 29.8° (SD 28.3°), respectively, while female lumbar spine and trunk angles were 49.6° (SD 23.1°) and −3.3° (SD 20.4°), respectively. The pelvis was posteriorly rotated for males (7.6° (SD 8.2°)) and anteriorly rotated for females (−5.5° (SD 9.3°)) (P = 0.0008). Significant gender * chair interactions of the location of the individual on the chair seat were most marked for the pivoting chair with a back rest. Females positioned their centre of mass and hip joints anterior to the chair pivot point while males’ centre of mass (P = 0.0003) and hip joints (P = 0.0039) were located posterior to the pivot point. Females also sat with their centre of mass closer to the seat pan centre of pressure than males when a back rest was present (P = 0.0012).

Interpretation. Males and females may be exposed to different loading patterns during prolonged sitting and may experience different pain generating pathways. Therefore, gender-dependent treatment modalities and/or coaching should be implemented when considering methods of reducing the risk of injury or aggravation of an existing injury.