CLINICAL TOXICOLOGY https://doi.org/10.1080/15563650.2018.1533727
NPDS REPORT 2017 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report
David D. Gummin MDa,b, James B. Mowry PharmDc, Daniel A. Spyker PhD, MDd,e, Daniel E. Brooks MDf, Krista M. Osterthaler MPHg and William Banner MD, PhDh aWisconsin Poison Center, Milwaukee, WI, USA; bDepartment of Emergency Medicine, Section of Medical Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA; cIndiana Poison Center, Indiana University Health, Indianapolis, IN, USA; dDepartment of Emergency Medicine, Oregon Poison Center, Oregon Health & Science University, Portland, OR, USA; eDepartment of Biopharmaceutical Sciences, University of California, San Francisco, CA, USA; fDepartment of Medical Toxicology, Banner University Medical Center - Phoenix, Phoenix, AZ, USA; gAmerican Association of Poison Control Centers, Alexandria, VA, USA; hOklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
Table of contents Introduction ...... 1 The NPDS products database...... 5 Methods ...... 5 Characterization of participating poison centers and population served ...... 5 Encounter management – specialized poison exposure emergency providers ...... 5 NPDS – near real-time data capture ...... 6 Annual report case inclusion criteria ...... 6 Statistical methods ...... 7 NPDS surveillance ...... 9 Emerging trends ...... 10 Fatality case review and abstract selection ...... 11 Pediatric fatality case review ...... 12 Results ...... 12 Informational contacts with poison centers ...... 12 Exposure cases logged at poison centers ...... 14 Age and gender distributions ...... 15 Caller site and exposure site ...... 17 Exposures in pregnancy...... 17 Chronicity ...... 17 Reason for exposure...... 17 Scenarios ...... 17 Reason by age...... 18 Route of exposure...... 18 Clinical effects ...... 18 Case management site ...... 18 Medical outcome ...... 19 Decontamination procedures and specific antidotes ...... 20 Top substances in human exposures ...... 21 Changes over time ...... 21 Emerging trends – drugs of abuse ...... 21 Distribution of suicides ...... 22 Plant exposures ...... 22 Deaths and exposure-related fatalities...... 22 All fatalities – all ages ...... 22 Pediatric fatalities – age 5 years ...... 25 Pediatric fatalities – ages 6–12 years ...... 25 Adolescent fatalities – ages 13–19 years ...... 25
CONTACT David Gummin [email protected] American Association of Poison Control Centers, 515 King Street, Suite 510, Alexandria, VA 22314, USA ß 2018 American Association of Poison Control Centers 2 D. D. GUMMIN ET AL.
Pregnancy and fatalities ...... 26 AAPCC surveillance results ...... 26 Discussion ...... 26 Summary ...... 28 Disclaimer ...... 28 Declaration of interest ...... 28 References ...... 28 Appendix A: Acknowledgments ...... 31 Poison centers (PCs) ...... 29 AAPCC fatality review team ...... 31 AAPCC NPDS steering committee ...... 31 AAPCC micromedex joint coding group ...... 31 AAPCC rapid coding team ...... 31 AAPCC surveillance team ...... 31 Regional poison center fatality awards ...... 31 Appendix B: Data definitions ...... 33 Reason for exposure...... 32 Medical outcome ...... 32 Relative contribution to fatality (RCF) ...... 33 Appendix C: Abstracts of selected cases ...... 43 Selection of abstracts for publication ...... 33 Abstracts ...... 33 Abbreviations & Normal Ranges ...... 43 APPENDIX D – Table 21. Listing of fatal nonpharmaceutical and pharmaceutical exposures ...... 46 APPENDIX E – Table 22(A) & Table 22(B), Demographic profile of SINGLE SUBSTANCE exposure cases by generic category Nonpharmaceuticals (Table 22(A))...172 Pharmaceuticals (Table 22(B))...188 ...... 172
List of Figures and Tables Figure 1. Human exposure cases, information contacts and animal exposure cases by day since 1 January 2000 ...... 9 Figure 2. All drug identification and law enforcement drug identification contacts by day since 1 January 2000 ...... 9 Figure 3. Health care facility (HCF) exposure cases and hcf information contacts by day since 1 January 2000 ...... 9 Figure 4. Substance categories with the greatest rate of exposure increase since 1 January 2000 for more severe outcomes (Top 4) ...... 10 Figure 5. Change in encounters by outcome from Year 2000 ...... 24 Figure 6. Deaths over time in the United States related to illicit use of drugs of abuse ...... 27 Figure 7. NPDS selected drugs of abuse over time ...... 27 Table 1A. AAPCC population served and reported exposures (1983–2017) ...... 6 Table 1B. Non-human exposures by animal type ...... 7 Table 1C. Distribution of information calls ...... 7 Table 2. Site of call and site of exposure, human exposure cases ...... 11 Table 3A. Age and gender distribution of human exposures ...... 11 Table 3B. Population-adjusted exposures by age group ...... 11 Table 4. Distribution of age and Gender for Fatalities ...... 12 Table 5. Number of substances involved in human exposure cases ...... 12 Table 6A. Reason for human exposure cases ...... 12 Table 6B. Scenarios for therapeutic errors by Age ...... 13 Table 7. Distribution of reason for exposure by age ...... 13 Table 8. Distribution of reason for exposure and age for fatalities ...... 13 Table 9. Route of exposure for human exposure cases ...... 14 Table 10. Management site of human exposures...... 14 Table 11. Medical outcome of human exposure cases by patient age...... 15 Table 12. Medical outcome by reason for exposure in human exposures ...... 15 Table 13. Duration of clinical effects by medical outcome ...... 15 Table 14. Decontamination and therapeutic interventions ...... 15 Table 15. Therapy provided in human exposures by age ...... 16 Table 16A. Decontamination trends (1985–2017) ...... 17 CLINICAL TOXICOLOGY 3
Table 16B. Decontamination trends: Total human and pediatric exposures 5 years ...... 17 Table 16C. Human exposures to drugs of abuse by generic code ...... 18 Table 17A. Substance categories most frequently involved in human exposures (Top 25) ...... 18 Table 17B. Substance categories with the greatest rate of exposure increase (Top 25) ...... 19 Table 17C. Substance categories most frequently involved in pediatric ( 5 years) exposures (Top 25) ...... 19 Table 17D. Substance categories most frequently involved in adult (>20 years) exposures (Top 25)...... 20 Table 17E. Substance categories most frequently involved in pediatric ( 5 years) deaths...... 20 Table 17F. Substance categories most frequently identified in drug identification calls (Top 25) ...... 21 Table 17G. Substance categories most frequently involved in pregnant exposures (Top 25) ...... 23 Table 18. Categories associated with largest number of fatalities (Top 25) ...... 24 Table 19A. Comparisons of death data (1985–2017) ...... 25 Table 19B. Comparisons of direct and indirect death data (2000–2017) ...... 25 Table 20. Frequency of plant exposures (Top 25) ...... 26 Table 21. Listing of fatal nonpharmaceutical and pharmaceutical exposures...... 46 Table 22A. Demographic profile of SINGLE SUBSTANCE nonpharmaceuticals exposure cases by generic category ...... 172 Table 22B. Demographic profile of SINGLE SUBSTANCE pharmaceuticals exposure cases by generic category ...... 188
Fatality Narrative Contents Case 133. Acute hydrofluoric acid ingestion: undoubtedly responsible ...... 43 Case 136. Acute methanol ingestion: undoubtedly responsible...... 33 Case 150. Acute Disc battery, ingestion: undoubtedly responsible ...... 33 Case 151. Acute Crotalinae envenomation: undoubtedly responsible ...... 34 Case 152. Acute Crotalinae envenomation: undoubtedly responsible ...... 34 Case 154. Acute fire ant bite/sting: contributory ...... 34 Case 155. Acute calcium hydroxide dermal: undoubtedly responsible...... 34 Case 156. Acute silicone parenteral: undoubtedly responsible ...... 34 Case158.Acuteparenteralcyanideexposure:undoubtedlyresponsible...... 34 Case 166. Acute tetramethyl ammonium hydroxide inhalation/nasal, ocular: undoubtedly responsible ...... 34 Case174.Acuteethylmethacrylateingestion:undoubtedlyresponsible...... 35 Case190.Acutehydrochloricacidingestion:undoubtedlyresponsible...... 35 Case 218. Acute deodorizer ingestion: probably responsible ...... 35 Case 220. Acute carbon monoxide inhalation/nasal: undoubtedly responsible ...... 35 Case230.Acutecarbonmonoxideinhalation:undoubtedlyresponsible...... 35 Case 268. Acute sulfur dioxide inhalation and ocular exposure: undoubtedly responsible ...... 35 Case 285. Acute arsenic and ethanol ingestion: probably responsible...... 36 Case 288. Acute arsenic, benzene and toluene ingestion: undoubtedly responsible...... 36 Case 311. Acute fluorinated hydrocarbon inhalation: undoubtedly responsible ...... 36 Case 323. Acute hydrocarbon, amphetamine, and methylenedioxymethamphetamine (MDMA) ingestion: undoubtedly responsible ...... 36 Case 325. Acute-on-chronic botulism parenteral: contributory ...... 36 Case 333. Acute-on-chronic aluminum phosphide exposure: undoubtedly responsible ...... 36 Case 335. Acute-on-chronic aluminum phosphide inhalation: undoubtedly responsible ...... 37 Case 345. Acute sulfuryl fluoride inhalation: undoubtedly responsible ...... 37 Case 347. Acute dinitrophenol ingestion: undoubtedly responsible ...... 37 Case 356. Acute paraquat ingestion: undoubtedly responsible ...... 37 Case 360. Acute Curcuma domestica parenteral: undoubtedly responsible ...... 37 Case 361. Acute plant (cardiac glycoside) ingestion: undoubtedly responsible ...... 37 Case 364. Acute-on-chronic nicotine inhalation/nasal: undoubtedly responsible ...... 38 Case 365. Acute nicotine parenteral: undoubtedly responsible ...... 38 Case 368. Acute methadone, chlorpheniramine and diphenhydramine ingestion: undoubtedly responsible ...... 38 Case 371. Acute ibuprofen ingestion: undoubtedly responsible ...... 38 Case 1038. Unknown salicylate ingestion: undoubtedly responsible ...... 38 Case 1063. Acute-on-chronic colchicine ingestion: undoubtedly responsible...... 39 Case 1091. Acute salicylate ingestion: undoubtedly responsible ...... 39 Case 1148. Acute lidocaine, cleaner (cationic): undoubtedly responsible ...... 39 Case 1151. Acute lidocaine inhalation: undoubtedly responsible ...... 39 4 D. D. GUMMIN ET AL.
Case 1174. Acute pregabalin and topiramate ingestion: undoubtedly responsible ...... 39 Case 1343. Acute diphenhydramine ingestion: undoubtedly responsible ...... 39 Case 1369. Acute tilmicosin parenteral: undoubtedly responsible...... 40 Case 1379. Chronic: methotrexate ingestion: contributory ...... 40 Case 1439. Acute-on-chronic: flecainide ingestion: undoubtedly responsible ...... 40 Case 1456. Acute-on-chronic amlodipine ingestion: undoubtedly responsible ...... 40 Case 1632. Acute nifedipine ingestion: undoubtedly responsible ...... 40 Case 1634. Acute benzonatate and meclizine ingestion: undoubtedly responsible ...... 40 Case 1643. Acute iron ingestion: undoubtedly responsible ...... 41 Case 1646. Acute iron ingestion: undoubtedly responsible ...... 41 Case 1649. Acute loperamide, atropine/diphenoxylate, trazodone ingestion: undoubtedly responsible ...... 41 Case 1657. Acute loperamide ingestion: undoubtedly responsible ...... 41 Case 1739. Acute diazepam, gabapentin, citalopram ingestion: undoubtedly responsible...... 41 Case 1879. Acute U-47700, para-fluorobutyryl fentanyl and psycho-active benzodiazepines ingestion: undoubtedly responsible...... 42 Case 1943. Unknown carfentanil, alprazolam and cocaine exposure: probably responsible...... 42 Case 2034. Acute mitragyna speciosa korthals exposure: undoubtedly responsible ...... 42 Case2060.Acutemethamphetamineingestion:probablyresponsible...... 42 Case2131.Acute-on-chronic:cocainerectal:undoubtedlyresponsible...... 42 Case 2141. Unknown methamphetamine ingestion: undoubtedly responsible ...... 42 Case2615.Acutemethamphetamine/amphetamineandhydrocarboningestionandaspiration:undoubtedlyresponsible...... 43
ABSTRACT Introduction: This is the 35th Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS). As of 1 January 2017, 55 of the nation’s poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 8.07 [7.32, 12.65] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. Methods: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. Results: In 2017, 2,607,413 closed encounters were logged by NPDS: 2,115,186 human exposures, 51,164 animal exposures, 435,540 information contacts, 5,424 human confirmed nonexposures, and 99 animal confirmed nonexposures. US PCs also made 2,680,625 follow-up calls in 2017. Total encounters showed a 3.79% decline from 2016, while health care facility (HCF) human exposure cases increased by 3.06%. All information contacts decreased by 11.5%, medication identification (Drug ID) requests decreased by 30.2%, and human exposure cases decreased by 2.03%. Human exposures with less serious outcomes have decreased 2.48% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.44% per year since 2000. Consistent with the previous year, the top 5 substance classes most frequently involvedinallhumanexposureswere analgesics (11.08%), household cleaning substances (7.43%), cosmetics/personal care products (6.76%), sedatives/ hypnotics/antipsychotics (5.74%), and antidepressants (5.02%). As a class, sedative/hypnotics/antipsychotics exposures increased most rapidly, by 1962 cases/year (4.91%/year), over the last 17 years for cases with more serious outcomes. The top 5 most common exposures in children age 5 years or less were cosmetics/personal care products (12.59%), household cleaning substances (10.96%), analgesics (9.18%), foreign bodies/toys/miscellaneous (6.39%), and topical preparations (4.84%). Drug identification requests comprised 22.1% of all information contacts. NPDS documented 3,208 human exposures resulting in death; 2,682 (83.6%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage more serious exposures, despite a decrease in cases involving less serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information contacts. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health.
NOTE: Comparison of exposure or outcome data from previous AAPCC Annual Reports is problematic. In particular, the identification of fatalities (attribution of a death to the exposure) differed from pre-2006 Annual Reports (see Fatality Case Review – Methods). Death cases were described as all cases resulting in death and those determined to be exposure-related fatalities. Likewise, Table 22 (Exposure cases by Generic Category) since year 2006 restricts the breakdown of included deaths to single-substance cases to improve precision and avoid misinterpretation. CLINICAL TOXICOLOGY 5