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281 Pages·2013·4.76 MB·English

Clinical Toxicology (2013), 51, 949–1229
Copyright © 2013 Informa Healthcare USA, Inc.
ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.3109/15563650.2013.863906
ABSTRACTS
2012 Annual Report of the American Association of Poison
Control Centers ’ National Poison Data System (NPDS):
30th Annual Report
JAMES B. MOWRY , PHARMD; DANIEL A. SPYKER , PHD, MD; LOUIS R. CANTILENA , JR, MD, PHD;
J. ELISE BAILEY , MSPH; and MARSHA FORD , MD
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Address correspondence to: James B. Mowry, PharmD, DABAT, FAACT
American Association of Poison Control Centers, 515 King Street Suite
510 Alexandria, VA 22314. E-mail: [email protected]
949
950 J. B. Mowry et al.
Table of Contents
Abstract ..................................................................................................................................................................................955
Introduction ............................................................................................................................................................................955
The NPDS Products Database ............................................................................................................................................955
Methods ..................................................................................................................................................................................956
Characterization of Participating Poison Centers and Population Served ..........................................................................956
Call Management — Specialized Poison Exposure Emergency Providers ..........................................................................956
NPDS — Near Real-time Data Capture................................................................................................................................956
Annual Report Case Inclusion Criteria ...............................................................................................................................957
Statistical Methods ..............................................................................................................................................................957
NPDS Surveillance .............................................................................................................................................................957
Fatality Case Review and Abstract Selection......................................................................................................................957
Pediatric Fatality Case Review ...........................................................................................................................................958
Results ....................................................................................................................................................................................958
Information Calls to Poison Centers ...................................................................................................................................958
Exposure Calls to Poison Centers .......................................................................................................................................958
13 Age and Gender Distributions ............................................................................................................................................961
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2 Caller Site and Exposure Site .............................................................................................................................................962
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n 1 Exposures in Pregnancy ......................................................................................................................................................962
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6 Chronicity ...........................................................................................................................................................................962
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1.1 Reason for Exposure ...........................................................................................................................................................962
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2. Scenarios ..........................................................................................................................................................................962
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2. Reason by Age .................................................................................................................................................................963
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by Route of Exposure ..............................................................................................................................................................963
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Clinical Effects ....................................................................................................................................................................963
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hcare.only. C Maesdei cMala nOaugtecmomenet . .S..i..t.e. ................................................................................................................................................................................................................................................................................................................996646
mahealtnal use D Toepc oSnutbamstainnacteiso nin P Hroucmedaunr Eesx panodsu Srepse .c.i..fi. .c.. A...n..t.i.d..o..t..e.s.. ..................................................................................................................................................................................................................996677
nforerso Changes Over Time .............................................................................................................................................................968
d from iFor p D Pliasntrti bEuxtpioonsu orfe sS .u..i.c..i.d..e..s.. ............................................................................................................................................................................................................................................................................................................996699
de Deaths and Exposure-related Fatalities ...............................................................................................................................969
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nlo All fatalities — all ages .....................................................................................................................................................969
ow Pediatric fatalities — age (cid:2) 5 years ...................................................................................................................................975
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y Pediatric fatalities — ages 6 – 12 years ...............................................................................................................................975
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olo Adolescent fatalities — ages 13 – 19 years .........................................................................................................................975
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xi Pregnancy and Fatalities ..................................................................................................................................................976
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al T AAPCC Surveillance Results .............................................................................................................................................976
nic Discussion ..............................................................................................................................................................................979
Cli Summary ................................................................................................................................................................................980
Disclaimer ..............................................................................................................................................................................980
References ..............................................................................................................................................................................980
Appendix
APPENDIX A – Acknowledgments ....................................................................................................................................1201
Poison Centers (PCs) ........................................................................................................................................................1201
AAPCC Fatality Review Team .........................................................................................................................................1203
AAPCC Micromedex Joint Coding Group .......................................................................................................................1204
AAPCC Rapid Coding Team ............................................................................................................................................1204
AAPCC Surveillance Team ..............................................................................................................................................1204
Regional Poison Center (PC) Fatality Awards ..................................................................................................................1204
APPENDIX B – Data Defi nitions ........................................................................................................................................1204
Reason for Exposure .........................................................................................................................................................1204
Medical Outcome ..............................................................................................................................................................1205
Relative Contribution to Fatality (RCF) ...........................................................................................................................1206
Clinical Toxicology vol. 51 no. 10 2013
2012 NPDS Annual Report 951
APPENDIX C – Abstracts of Selected Cases ......................................................................................................................1206
Selection of Abstracts for Publication ..............................................................................................................................1206
Abstracts ..............................................................................................................................................................................1206
Abbreviations and Normal ranges for Abstracts ..................................................................................................................1227
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Copyright © Informa Healthcare USA, Inc. 2013
952 J. B. Mowry et al.
List of Figures and Tables
Figure 1. Human Exposure Calls, Information Calls, and Animal Exposure Calls by Day since January 1, 2000 ..............961
Figure 2. All Drug Identifi cation and Law Enforcement Drug Identifi cation Calls by Day since January 1, 2000 ..............961
Figure 3. HCF Exposure Calls and HCF Information Calls by Day since January 1, 2000 ..................................................962
Figure 4. Change in Encounters by Outcome from 2008 to 2012 .........................................................................................973
Figure 5. Substance Categories with the Greatest Rate of Exposure Increase (Top 4) ..........................................................974
Figure 6. Unit Dose Liquid Laundry Detergent Exposures, Jan 2012 — Sep 2013 ................................................................979
Table 1A. AAPCC Population Served and Reported Exposures (1983 – 2012) ...................................................................... 958
Table 1B. Non-Human Exposures by Animal Type ............................................................................................................... 958
Table 1C. Distribution of Information Calls .......................................................................................................................... 959
Table 2. Site of Call and Site of Exposure, Human Exposure Cases ..................................................................................... 962
Table 3A. Age and Gender Distribution of Human Exposures .............................................................................................. 963
Table 3B. Population-Adjusted Exposures by Age Group ..................................................................................................... 963
Table 4. Distribution of Age and Gender for Fatalities ..........................................................................................................964
Table 5. Number of Substances Involved in Human Exposure Cases ................................................................................... 964
Table 6A. Reason for Human Exposure Cases ...................................................................................................................... 964
13 Table 6B. Scenarios for Therapeutic Errors by Age ..............................................................................................................965
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2 Table 7. Distribution of Reason for Exposure by Age ........................................................................................................... 965
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n 1 Table 8. Distribution of Reason for Exposure and Age for Fatalities ....................................................................................966
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6 Table 9. Route of Exposure for Human Exposure Cases ....................................................................................................... 966
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1.1 Table 10. Management Site of Human Exposures ................................................................................................................. 967
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2. Table 11. Medical Outcome of Human Exposure Cases by Patient Age ............................................................................... 967
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2. Table 12. Medical Outcome by Reason for Exposure in Human Exposures ......................................................................... 968
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by Table 13. Duration of Clinical Effects by Medical Outcome................................................................................................. 968
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Table 14. Decontamination and Therapeutic Interventions ................................................................................................... 969
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hcare.only. T Taabbllee 1156.A T. hDeeracpoyn tPamroivniadteiodn i nT rHeunmdsa (n1 E98x5p –o 2su0r1e2s) b..y.. .A...g..e.. ........................................................................................................................................................................................................ 997701
mahealtnal use T Taabbllee 1167BA.. DSuebcostnatnacmei Cnaattieogno Trireesn Mdso: sTto Ftarel qHuuemntalyn Iannvdo lPveeddi aitnr iHc uEmxpaons Euxrepso (cid:2) su 5re Yse (aTros p.. .2..5..). .............................................................................................. 997722
nforerso Table 17B. Substance Categories with the Greatest Rate of Exposure Increase (Top 25) ..................................................... 973
d from iFor p T Taabbllee 1177DC.. SSuubbssttaannccee CCaatteeggoorriieess MMoosstt FFrreeqquueennttllyy IInnvvoollvveedd iinn APedduilatt r(i(cid:3) c ( 2(cid:2) 0 y 5e yaeras)r sE) xEpxopsousruerse (sT (oTpo 2p5 2)5 ..). .................................................... 9 97745
de Table 17E. Substance Categories Most Frequently Involved in Pediatric ((cid:2) 5 years) Deaths .............................................. 976
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nlo Table 17F. Substance Categories Most Frequently Identifi ed in Drug Identifi cation Calls (Top 25) .................................... 976
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o Table 17G. Substance Categories Most Frequently Involved in Pregnant Exposures (Top 25) ............................................977
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y Table 18. Categories Associated with Largest Number of Fatalities (Top 25) ......................................................................977
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olo Table 19A. Comparisons of Death Data (1985 – 2012) ...........................................................................................................978
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xi Table 19B. Comparisons of Direct and Indirect Death Data (2000 – 2012) ............................................................................978
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al T Table 20. Frequency of Plant Exposures (Top 25) .................................................................................................................979
nic Table 21. Listing of Fatal Nonpharmaceutical and Pharmaceutical Exposures .....................................................................981
Cli Table 22A. Demographic profi le of SINGLE-SUBSTANCE Nonpharmaceuticals
exposure cases by generic category .................................................................................................................................1147
Table 22B. Demographic profi le of SINGLE-SUBSTANCE Pharmaceuticals
exposure cases by generic category .................................................................................................................................1171
Clinical Toxicology vol. 51 no. 10 2013
2012 NPDS Annual Report 953
List of Cases
Case 57. Ethanol (non-beverage) ingestion: undoubtedly responsible. ...............................................................................1206
Case 107. Acute methanol ingestion: undoubtedly responsible. ..........................................................................................1206
Case 190. Acute methanol ingestion: undoubtedly responsible. ..........................................................................................1207
Case 201. Acute antifreeze (ethylene glycol) ingestion: undoubtedly responsible. ............................................................1207
Case 233. Acute hydrochloric acid ingestion: undoubtedly responsible. ............................................................................1207
Case 234. Acute cyanide ingestion: undoubtedly responsible .............................................................................................1208
Case 235. Acute ammonia ingestion and dermal: contributory. ..........................................................................................1208
Case 243. Acute drain cleaner ingestion: undoubtedly responsible. ....................................................................................1208
Case 260. Acute hydrogen peroxide ingestion: undoubtedly responsible ...........................................................................1208
Case 261. Acute formaldehyde/methanol ingestion: undoubtedly responsible. ..................................................................1208
Case 285. Acute hydrogen sulfi de inhalation/nasal, dermal: undoubtedly responsible. ......................................................1209
Case 302. Acute helium inhalation/nasal: undoubtedly responsible. ...................................................................................1209
Case 303. Acute hydrogen sulfi de inhalation: undoubtedly responsible. ............................................................................1209
Case 308. Carbon monoxide inhalation: undoubtedly responsible. .....................................................................................1210
Case 315. Acute nitrogen gas inhalation: undoubtedly responsible ....................................................................................1210
13 Case 384. Chronic lead ingestion: undoubtedly responsible. ..............................................................................................1210
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2 Case 402. Acute freon and marijuana exposure: undoubtedly responsible.. ........................................................................1210
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n 1 Case 405. Acute Freon inhalation/nasal: undoubtedly responsible. ....................................................................................1210
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6 Case 413. Acute mushroom (cyclopeptides) ingestion: undoubtedly responsible. ..............................................................1211
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1.1 Case 417. Acute mushroom (cyclopeptides) ingestion: undoubtedly responsible. ..............................................................1211
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2. Case 418. Acute mushroom (cyclopeptides) ingestion: undoubtedly responsible. ..............................................................1211
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2. Case 421. Acute malathione ingestion: contributory. ..........................................................................................................1212
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by Case 424. Acute borate ingestion: undoubtedly responsible. ..............................................................................................1212
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Case 431. Acute selenous acid ingestion: undoubtedly responsible. ...................................................................................1212
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hcare.only. C Caassee 443420.. AAccuettaem niincootpihneen p ianrgenestetiroanl:: uunnddoouubbtteeddllyy rreessppoonnssiibbllee.. ....................................................................................................................................................................................11221123
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nforerso Case 496. Unknown, salicylate, doxylamine, acetaminophen, ibuprofen ingestion:
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de Case 563. Acute salicylate ingestion: probably responsible. ...............................................................................................1214
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nlo Case 629. Acute colchicine and omeprazole ingestion: undoubtedly responsible. ..............................................................1214
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o Case 689. Acute ibuprofen ingestion: undoubtedly responsible. .........................................................................................1215
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y Case 710. Fentanyl (transdermal) ingestion: probably responsible. ....................................................................................1215
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olo Case 727. Acute-on-chronic fentanyl (transdermal), diazepam, gabapentin ingestion, dermal:
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xi undoubtedly responsible. .................................................................................................................................................1216
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al T Case 827. Acute acetaminophen/diphenhydramine ingestion: undoubtedly responsible ....................................................1216
nic Case 946. Acute-on-chronic, colchicine ingestion: undoubtedly responsible. ....................................................................1216
Cli Case 958. Acute colchicine ingestion: undoubtedly responsible. ........................................................................................1217
Case 1247. Acute salicylate ingestion: probably responsible. .............................................................................................1217
Case 1389. Chronic dabigatran ingestion: probably responsible. ........................................................................................1217
Case 1418. Acute-on-chronic, carbamazepine, cyclic antidepressant, unknown ingestion:
undoubtedly responsible ..................................................................................................................................................1217
Case 1425. Bupropion (extended release), aripiprazole ingestion: undoubtedly responsible. ............................................1218
Case 1437. Acute-on-chronic bupropion (extended release), methylphenidate, polyethylene glycol
ingestion: probably responsible .......................................................................................................................................1218
Case 1531. Acute bupropion (extended release), ethanol, venlafaxine ingestion: undoubtedly
responsible .......................................................................................................................................................................1218
Case 1542. Acute-on-chronic vilazodone, alprazolam, salicylate, escitalopram, and duloxetine
ingestion: undoubtedly responsible. .................................................................................................................................1219
Case 1605. Acute hydroxychloroquine, metformin, acetaminophen/diphenhydramine,
hydroxyzine, cocaine, alprazolam, and pregabalin ingestion: undoubtedly responsible. ................................................1219
Case 1614. Acute-on-chronic theophylline ingestion: probably responsible. ......................................................................1219
Case 1622. Acute fl ecainide, clonidine, fl uoxetine, potassium chloride, ethanol, lorazepam,
cocaine, clonazepam, lisinopril, and furosemide ingestion: undoubtedly responsible ....................................................1220
Copyright © Informa Healthcare USA, Inc. 2013
954 J. B. Mowry et al.
Case 1637. Acute verapamil ingestion: undoubtedly responsible. ......................................................................................1220
Case 1651. Acute fl ecainide, bupropion (extended release), and ethanol ingestion: undoubtedly responsible. ..................1220
Case 1674. Acute diltiazem (extended release) and amlodipine ingestion: undoubtedly responsible. ................................ 1220
Case 1731. Acute-on-chronic sitagliptin, citalopram, alprazolam, diltiazem (extended release), metoprolol (extended
release) ingestion: undoubtedly responsible. ...................................................................................................................1221
Case 1757. Chronic cardiac glycoside ingestion: probably responsible. .............................................................................1221
Case 1795. Acute nifedipin ingestion: undoubtedly responsible. ........................................................................................1221
Case 1812. Acute yohimbine ingestion: contributory. .........................................................................................................1222
Case 1815. Acute calcium parenteral: undoubtedly responsible. ........................................................................................1222
Case 1816. Acute atropine/diphenoxylate ingestion: undoubtedly responsible. ..................................................................1222
Case 1824. Acute metformin ingestion: undoubtedly responsible. ......................................................................................1223
Case 1845. Chronic metformin ingestion: contributory. ......................................................................................................1223
Case 1873. Acute baclofen ingestion: undoubtedly responsible. .........................................................................................1223
Case 1922. Acute-on-chronic clozapine ingestion: undoubtedly responsible. ....................................................................1224
Case 1993. Hallucinogenic amphetamine ingestion: probably responsible. ........................................................................1224
Case 2014. Chronic cocaine, promethazine ingestion, inhalation/nasal: probably responsible ..........................................1224
Case 2040. THC homolog inhalation, unknown: undoubtedly responsible. .......................................................................1225
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3/ Case 2063. Acute amphetamine (hallucinogenic), morphine ingestion: undoubtedly responsible. ....................................1225
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2/ Case 2085. Acute amphetamine (hallucinogenic) unknown: undoubtedly responsible .......................................................1225
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n Case 2149. Acute methamphetamine exposure: undoubtedly responsible. .........................................................................1225
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86 Case 2240. Cocaine ingestion, inhalation/nasal: undoubtedly responsible. ........................................................................1226
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1. Case 2506. Acute-on-chronic methamphetamine inhalation: probably responsible. ...........................................................1226
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92. Case 2542. Hallucinogenic amphetamine, cocaine, marijuana, and gabapentin exposure: undoubtedly responsible. ........1226
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Clinical Toxicology vol. 51 no. 10 2013
2012 NPDS Annual Report 955
Abstract identifi cation requests comprised 54.4% of all information
calls. NPDS documented 2,937 human exposures resulting
in death with 2,576 human fatalities judged related (RCF
Background: This is the 30 th Annual Report of the of 1-Undoubtedly responsible, 2-Probably responsible, or
American Association of Poison Control Centers ’ (AAPCC) 3-Contributory).
National Poison Data System (NPDS). As of July 1, 2012, Conclusions: These data support the continued value of
57 of the nation ’ s poison centers (PCs) uploaded case data PC expertise and need for specialized medical toxicology
automatically to NPDS. The upload interval was 7.58 [6.30, information to manage the more severe exposures, despite a
11.22] (median [25%, 75%]) min, creating a near real-time decrease in calls involving less severe exposures. Uninten-
national exposure and information database and surveillance tional and intentional exposures continue to be a signifi cant
system. cause of morbidity and mortality in the US. The near real-
Methodology: We analyzed the case data tabulating time, always current status of NPDS represents a national
specifi c indices from NPDS. The methodology was similar public health resource to collect and monitor US exposure
to that of previous years. Where changes were introduced, cases and information calls. The continuing mission of NPDS
the differences are identifi ed. Poison center cases with is to provide a nationwide infrastructure for public health
medical outcomes of death were evaluated by a team of surveillance for all types of exposures, public health event
34 medical and clinical toxicologist reviewers using an identifi cation, resilience response, and situational awareness
3
3/1 ordinal scale of 1 – 6 to assess the Relative Contribution to tracking. NPDS is a model system for the nation and global
2
2/ Fatality (RCF) of the exposure to the death. public health.
1
n Results: In 2012, 3,373,025 closed encounters were
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86 logged by NPDS: 2,275,141 human exposures, 66,440
1 Introduction
1. animal exposures, 1,025,547 information calls, 5,679 human
2
92. confi rmed nonexposures, and 218 animal confi rmed nonex- This is the 30t h Annual Report of the American Association
2.
7 posures. Total encounters showed a 6.9% decline from 2011, of Poison Control Centers ’ (AAPCC; http://www.aapcc.
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m b while healthcare facility (HCF) exposure calls increased by org) National Poison Data System (NPDS). (1) On January
co 1.2%. All information calls decreased by 14.8% and HCF 1, 2012, 57 regional poison centers (PCs) serving the entire
care.nly. information calls decreased by 1.7%, medication identifi ca- population of the 50 United States, American Samoa, District
d from informahealthFor personal use o teebo4ixxuy.o6pps n%3 oo o.ssr 7uuuep%tqrreceeuro ss epmy sereteewrass pr iy o(t(sehDmriat nerorcud ldeesg e sit 2nrosIa0 c Dt0Uees) 0,eS 2 .rmd 0iPeo0acCu8jros,se r a,wd sooeheurcdi tlrdc eeeob aamtysht eheo2d)ss 2 ehb. a0hywv%a e2ivt, .eh i5n a %cmndrd.eeo acHrhesruuee sadmmes breaaiydnn- oRetienxfilf pceCo NooproP,shm luDoauarnnmSetdii cobc i tnsiapha .sta e,he t Fi eUed endaSdtat e atVtra aaci irwtolegoladilrnere Sec dIhtt seaeoldxtaue pnsdsoed uos srffu io snrMrueg bt imhctmhera oeinnt ntacaeegotdsieuo imairnns, ’ eef sGon o5rutm f7aa mpnaPrdtC,oi opPvsno.iu d iPeasirCnnotdgnos
e
ad The top fi ve substance classes most frequently involved place emphasis on exposure management, accurate data
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wnl in all human exposures were analgesics (11.6%), cosmet- collection and coding, and responding to the continuing
Do ics/personal care products (7.9%), household cleaning sub- need for poison-related public and professional education.
gy stances (7.2%), sedatives/hypnotics/antipsychotics (6.1%), The PC ’ s health care professionals are available free of
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col and foreign bodies/toys/miscellaneous (4.1%). Analgesic charge to users, 24-hours a day, every day of the year. PCs
oxi exposures as a class increased the most rapidly (8,780 respond to questions from the public, healthcare profession-
T
al calls/year) over the last 12 years. The top fi ve most com- als, and public health agencies. The continuous staff dedica-
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Clini mon exposures in children aged 5 years or less were cos- tion at the PCs is manifest as the number of exposure and
metics/ personal care products (13.9%), analgesics (9.9%), information call encounters exceeds 3.3 million annually.
household cleaning substances (9.7%), foreign bodies/toys/ Poison center encounters either involve an exposed human
miscellaneous (7.0%), and topical preparations (6.3%). Drug or animal (EXPOSURE CALL) or a request for informa-
tion with no person or animal exposed to any foreign body,
viral, bacterial, venomous, or chemical agent or commercial
WARNING: Comparison of exposure or outcome data product (INFORMATION CALL).
from previous AAPCC Annual Reports is problematic.
In particular, the identifi cation of fatalities (attribution of
The NPDS Products Database
a death to the exposure) differed from pre-2006 Annual
Reports (see Fatality Case Review — Methods). Poison The NPDS products database contains over 400,000 prod-
center death cases are described as all cases resulting ucts ranging from viral and bacterial agents to commer-
in death and those determined to be exposure-related cial chemical and drug products. The products database is
fatalities. Likewise, Table 22 (Exposure Cases by Generic maintained and continuously updated by data analysts at
Category) since year 2006 restricts the breakdown includ- the Micromedex Poisindex ® System (Micromedex Health-
ing deaths to single-substance cases to improve precision care Series [Internet database]. Greenwood Village, CO:
and avoid misinterpretation. Truven Health Analytics. A robust generic coding system
categorizes the product data into 1014 generic codes. These
Copyright © Informa Healthcare USA, Inc. 2013
956 J. B. Mowry et al.
generic codes collapse into Nonpharmaceutical (558) and Call Management — Specialized Poison Exposure
Pharmaceutical (456) groups. These two groups are divided Emergency Providers
into Major (68) and Minor (176) categories. The generic
Most PC operations management, clinical education,
coding schema undergoes continuous improvement through
and instruction are directed by Managing Directors (most
the work of the AAPCC – Micromedex Joint Coding Group.
are PharmDs and RNs with American Board of Applied
The group consists of AAPCC members and editorial and
Toxicology [ABAT] board certifi cation). Medical direction
lexicon staff working to meet best terminology practices.
is provided by Medical Directors who are board-certifi ed
The generic code system provides enhanced report granular-
physician medical toxicologists. At some PCs, the Manag-
ity as refl ected in Table 22. The following 19 generic codes
ing and Medical Director positions are held by the same
were introduced in 2012:
person.
Calls received at US PCs are managed by healthcare
Table: Generic Codes Added in 2012. professionals who have received specialized training in
1 Laundry Detergents: Granules (Unit Dose) toxicology and managing exposure emergencies. These pro-
2 Laundry Detergents: Liquids (Unit Dose) viders include medical and clinical toxicologists, registered
3 Laundry Detergents: Granules with Liquids (Unit Dose) nurses, doctors of pharmacy, pharmacists, chemists, hazard-
4 Automatic Dishwasher Detergents: Granules (Unit ous materials specialists, and epidemiologists. Specialists in
Dose)
3 Poison Information (SPIs) are primarily registered nurses,
1 5 Automatic Dishwasher Detergents: Liquids (Unit Dose)
3/ PharmDs, and pharmacists who direct the public to the most
2 6 Automatic Dishwasher Detergents: Granules with
12/ Liquids (Unit Dose) appropriate level of care while also providing the most up-
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o 7 Fabric Softeners/Antistatic Agents: Dry or Powder to-date management recommendations to healthcare provid-
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18 (Unit Dose) ers caring for exposed patients. They may work under the
21. 8 Fabric Softeners/Antistatic Agents: Liquid (Unit Dose) supervision of a Certifi ed Specialist in Poison Information
72.92. 9 F(Uabnriitc D Soosfet)eners/Antistatic Agents: Powder with Liquid (CSPI). SPIs must log a minimum of 2,000 calls over a
by 10 Levamisole 12-month period to become eligible to take the CSPI exami-
m 11 Fosphenytoin nation for certifi cation in poison information. Poison Infor-
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mahealthnal use o 111456 LTLoaevpmeirotaitrmraigcaietnetaem afancdt twhoatr kn ou nnduerrs inthge osru pphearvrmisiaocny oscf hao oCl SoPffIe. rOs fa ntooxteic oisl otghye
nforerso 17 Oxcarbazepine curriculum designed for PC work and SPIs must be trained
ed from iFor p 1189 ZOotAhnenisrt aiTcmyoipndveesu losfa nGtamma Aminobutyric Acid iraning dpo rrmooguurssa ta mbcesc rroeefdaficetcraerteidod nbit yep drto heceveiers rsry e a5sdp myeeciantirivsse.t e PreCd. bPyC tsh ue nAdAerPgCo Ca
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w Because the new codes were added at different times dur-
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D ing the year, the numbers in Table 22 for these generic codes NPDS — Near Real-time Data Capture
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olog do not refl ect the entire year. For completeness certain of Launched on 12 April 2006, NPDS is the data repository for
xic these categories require customized data retrieval until these all of the US PCs. In 2012, all 57 US PCs uploaded case data
To categories have been in place for a year or more. automatically to NPDS. All PCs submitted data in near real-
al
nic time, making NPDS one of the few operational systems of its
Cli Methods kind. Poison center staff record calls contemporaneously in
1 of 4 case data management systems. Each PC uploads case
Characterization of Participating PCs data automatically. The time to upload data for all PCs is
and Population Served 7.58 [6.30, 11.22] (median [25%, 75%]) min creating a real-
Fifty-seven participating centers submitted data to AAPCC time national exposure database and surveillance system.
through December 31, 2012. Fifty-four centers (95%) The web-based NPDS software facilitates detection,
were accredited by AAPCC as of July 1, 2012. The entire analysis, and reporting of NPDS surveillance anomalies.
population of the 50 states, American Samoa, the District System software offers a myriad of surveillance uses allow-
of Columbia, Federated States of Micronesia, Guam, Puerto ing AAPCC, its member centers, and public health agen-
Rico, and the US Virgin Islands was served by the US PC cies to utilize NPDS US exposure data. Users are able to
network in 2012.(2,3) access local and regional data for their own areas and view
The average number of human exposure cases managed national aggregate data. The application allows for increased
per day by all US PCs was 6,216. Similar to other years, “ drill-down ” capability and mapping via a geographic infor-
higher volumes were observed in the warmer months, with a mation system. Custom surveillance defi nitions are available
mean of 6,576 cases per day in July compared with 5,583 per along with ad hoc reporting tools. Information in the NPDS
day in December. On average, US PCs received a call about database is dynamic. Each year the database is locked prior
an actual human exposure every 13.9 sec. to extraction of annual report data to prevent inadvertent
Clinical Toxicology vol. 51 no. 10 2013
2012 NPDS Annual Report 957
changes and ensure consistent, reproducible reports. The constructed using volume or case-based defi nitions with a
2012 database was locked on 24 October 2013 at 17:24 variety of mathematical options and historical baseline
EDT. periods from 1 to 13 years. NPDS surveillance tools include
the following:
Annual Report Case Inclusion Criteria • Volume Alert Surveillance Defi nitions
The information in this report refl ects only those cases that • Total Call Volume
are not duplicates and classifi ed by the PC as CLOSED. • Human Exposure Call Volume
A case is closed when the PC has determined that no further • Animal Exposure Call Volume
follow-up/recommendations are required or no further infor- • Information Call Volume
mation is available. Exposure cases are followed to obtain • Clinical Effects Volume (signs and symptoms, or
the most precise medical outcome possible. Depending on laboratory abnormalities)
the case specifi cs, most calls are “ closed ” within a few hours • Case-Based Surveillance Defi nitions utilizing vari-
of the initial call. Some calls regarding complex hospital- ous NPDS data fi elds linked in Boolean expressions
ized patients or cases resulting in death may remain open (cid:2) Substance
for weeks or months while data continues to be collected. (cid:2) Clinical Effects
Follow-up calls provide a proven mechanism for monitor- (cid:2) Species
13 ing the appropriateness of management recommendations, (cid:2) Medical Outcome and others
3/
2/2 augmenting patient guidelines, and providing poison pre- Incoming data is monitored continuously and anomalous
1
n vention education, enabling continual updates of case infor- signals generate an automated email alert to the AAPCC ’ s
o
86 mation as well as obtaining fi nal/known medical outcome surveillance team or designated PC or public health agency
1
1. status to make the data collected as accurate and complete staff. These anomaly alerts are reviewed daily by the AAPCC
2
92. as possible. surveillance team, the PC, or the public health agency that
2.
7 created the surveillance defi nition. When reports of potential
y
m b Statistical Methods public health signifi cance are detected, additional informa-
co tion is obtained via the NPDS surveillance correspondence
hcare.only. Abyll tThaeb NlePs DexSc ewpetb T-abbalseesd 3 aBp panlidc a1t7ioBn wanerde cgaenn ethrautse db ed irreepcrtoly- system or phone as appropriate from reporting PCs. The PC
d from informahealtFor personal use daINnnuPsdctDe it1dSu7 t bBwey, e weCba-eacbrrhaey s ,c ceeNrdne Caatetp)er p.do lT inuch asestiu infiom ggn mu.S rAaersSy a JncModu sPnt atvstie sgrtseiicnosen ri na9t .Te0da.b 0bl e(ySs At3hBSe tPSCCfheuteDaeubntndCult iiear)ceer.l s seh T o rBehftfasofri lesartt rhnhueDec ndiihsii rssq,b e uruyNaeee ssNsa epn ta PieeorCcDaentro iSab vnrlr ee taorCa nuosledt-glat n hittatmehten etreodo Pr ft toPrClhaorrec secE .kvaa nietlnt vnhegitner iaooatiblnnoti mhnl(i tHedoynefS itptsBaha lae/r N tH uHmCneeeaiEaqnlltHutthshe/,.
e
d NPDS Surveillance
a AAPCC Surveillance Team clinical and medical toxicol-
o
wnl As previously noted, all of the active US PCs upload case ogists review surveillance defi nitions on a regular basis to
o
D data automatically to NPDS. This unique near real-time fi ne-tune the queries. CDC, as well as State and local health
y
g upload is the foundation of the NPDS surveillance system. departments with NPDS access as granted by their respec-
o
col This makes possible both spatial and temporal case volume tive PCs, also have the ability to create surveillance defi ni-
xi
o and case-based surveillance. NPDS software allows creation tions for routine surveillance tasks or to respond to emerging
T
al of volume and case-based defi nitions. Defi nitions can be public health events.
c
Clini applied to national, regional, state, or ZIP code coverage
areas. Geocentric defi nitions can also be created. This func-
Fatality Case Review and Abstract Selection
tionality is available not only to the AAPCC surveillance
team, but also to every PC. PCs also have the ability to share NPDS fatality cases can be recorded as DEATH or DEATH
NPDS real-time surveillance technology with external orga- (INDIRECT REPORT). Medical outcome of death is by
nizations such as their state and local health departments direct report. Deaths (indirect reports) are deaths that the
or other regulatory agencies. Another NPDS feature is the PC acquired from medical examiners or media, but did not
ability to generate system alerts on adverse drug events and manage nor answer any questions related specifi cally to that
other drug or commercial products of public health interest death.
like contaminated food or product recalls. Thus NPDS can Although PCs may report death as an outcome, the death
provide real-time adverse event monitoring and surveillance may not be the direct result of the exposure. We defi ne
for resilience response and situational awareness. exposure-related fatality as a death judged by the AAPCC
Surveillance defi nitions can be created to monitor a Fatality Review Team to be at least contributory to the expo-
variety of volume parameters or case-based defi nitions on sure. The defi nitions used for the Relative Contribution to
any desired substance or commercial product in the Micro- Fatality (RCF) classifi cation are defi ned in Appendix B and
medex Poisindex products database and/or set of clinical the methods to select abstracts for publications is described
effects or other parameters. The products database con- in Appendix C. For details of the AAPCC fatality review
tains over 400,000 entries. Surveillance defi nitions may be process, see the 2008 annual report.(1)
Copyright © Informa Healthcare USA, Inc. 2013
958 J. B. Mowry et al.
Pediatric Fatality Case Review Table 1A. AAPCC Population Served and Reported Exposures
(1983 – 2012).
A focused Pediatric Fatality Review team, comprised of four
pediatric toxicologists, evaluated cases in patients under No. of Population Exposures
18 years of age. The panel reviewed the documentation of participating served Human per thousand
all such cases, with specifi c focus on the conditions behind Year centers (in millions) exposures population
the poisoning exposure and on fi nding commonality which
1983 16 43.1 251,012 5.8
might inform efforts at prevention. The pediatric fatality 1984 47 99.8 730,224 7.3
cases reviewed exhibited a bimodal age distribution. Expo- 1985 56 113.6 900,513 7.9
sures causing death in children (cid:2) 5 years of age were mostly 1986 57 132.1 1,098,894 8.3
1987 63 137.5 1,166,940 8.5
coded as “ Unintentional-General ” , while those in ages over
1988 64 155.7 1,368,748 8.8
12 years were mostly “ Intentional ” . Often the Reason Code
1989 70 182.4 1,581,540 8.7
did not capture the complexities of the case. For example,
1990 72 191.7 1,713,462 8.9
there were few mentions of details such as the involvement 1991 73 200.7 1,837,939 9.2
of law enforcement or child protective services. While there 1992 68 196.7 1,864,188 9.5
were some complete and informative reports, in many narra- 1993 64 181.3 1,751,476 9.7
1994 65 215.9 1,926,438 8.9
tives the circumstances which preceded the exposure thought
1995 67 218.5 2,023,089 9.3
13 responsible for the death were unclear or absent. In response 1996 67 232.3 2,155,952 9.3
23/ to these fi ndings, the pediatric fatality review team developed 1997 66 250.1 2,192,088 8.8
12/ and distributed Pediatric Narrative Guidelines, with specifi c 1998 65 257.5 2,241,082 8.7
on attention to the root cause of these cases. PCs are requested 1999 64 260.9 2,201,156 8.4
186 to heed these guidelines and the need for a more in-depth 2000 63 270.6 2,168,248 8.0
1. 2001 64 281.3 2,267,979 8.1
2 investigation of “ causality. ”
2. 2002 64 291.6 2,380,028 8.2
9
2. 2003 64 294.7 2,395,582 8.1
7
y 2004 62 293.7 2,438,643 8.3
b
m RESULTS 2005 61 296.4 2,424,180 8.2
o
c 2006 61 299.4 2,403,539 8.0
care.nly. Information Calls to PCs 2007 61 305.6 2,482,041 8.1
ho 2008 61 308.5 2,491,049 8.1
ed from informahealtFor personal use D(oerTedpafaute Ftibacroilr agneatfu ailro rl1o( enC5m r22)e ,(ps021who68,or0a1,tw0s2)i n.15s tg9, r5t )ah4,nc a7sata mtAdeinigmltlfot oeiDrndrieirm sustta gorta siItouNDivncP eh cD acla(Sal2lss,l8 sd i,p6netrc3coerl8 vue)Pead, nsCinetasidgon nddicn/ rsa aaclm2lfas0ela tl1tiyei2nr-/ 22 T22 a A0000os1101t oa1290fl July 1, 255660177000 ac there were 6333301111 3580Pa....3709rt bb bic ipating 5 C22272e,,,,,33294nt83727e44599rs,,,,,.80133 2045554155 7778....6420
d
a cally in mid 2009, again in late 2010 and late 2011 and con- b AAPCC Total as of July 1, Mid Year US Census (2012 data for 50 United
o
wnl tinue to decrease in 2012. Law enforcement Drug ID Calls States, District of Columbia and Puerto Rico; 2011 data for Guam; 2010
o data for American Samoa, Federated States of Micronesia, and the US Virgin
D also showed a decline. The most frequent information call
y Islands) (2, 3)
g was for Drug ID, comprising 558,117 calls to PCs during c As of July 1, 2011 there were 57 Participating Centers.
o
col the year. Of these, 328,858 (58.9%) were identifi ed as drugs
xi
o with known abuse potential; however, these cases were
T Exposure Calls to PCs
al categorized based on the drug ’ s abuse potential without
c
Clini knowledge of whether abuse was actually intended. Itenr 2s 01in2c, ltuhdei pnagr ti2c,i2p7a5ti,n1g4 1P Ccsl loosgegde dh 3u,m37a3n, 0e2x5p toostaulr een ccoausnes-
While the number of Drug Information calls decreased
(Table 1A), 66,440 animal exposures (Table 1B), 1,025,547
by 17.0% from 2011 (173,904 calls) to 2012 (144,267
information calls (Table 1C), 5,679 human confi rmed non-
calls), the distribution of these call types remained steady
exposures, and 218 animal confi rmed non-exposures. An
at 14.5% and 14.1%, respectively, of all information request
calls. The most common drug information requests were in
regards to therapeutic use and indications, followed by drug – Table 1B. Non-Human Exposures by Animal Type.
drug interactions, questions about dosage, and inquiries of
Animal N %
adverse effects. Environmental inquiries comprised 2.1% of
all information calls. Of these environmental inquiries, ques- Dog 60,083 90.43
tions related to cleanup of mercury (thermometers and other) Cat 5,644 8.49
Bird 187 0.28
remained the most common followed by questions involving
Rodent/lagomorph 133 0.2
pesticides.
Horse 107 0.16
Of all the information calls, poison information com- Sheep/goat 47 0.07
prised 6.2% of the requests with inquiries involving general Cow 32 0.05
toxicity the most common followed by questions involving Aquatic 18 0.03
food preparation practices, safe use of household products, Other 189 0.28
Total 66,440 100
and plant toxicity.
Clinical Toxicology vol. 51 no. 10 2013