Epidemiology of Poisoning and Antidotes Used In Toxicology

Link to companion PowerPoint Occurrence Unintentional In 2005, 23,618 (72%) of the 32,691 poisoning deaths in the United States were unintentional, and 3,240 (10%) were of undetermined intent (CDC 2008). Unintentional poisoning death rates have been rising steadily since 1992. Unintentional poisoning was second only to motor vehicle crashes as a cause of unintentional injury death in 2005 (CDC 2008). Among people 35 to 54 years old, unintentional poisoning caused more deaths than motor vehicle crashes. In 2006, unintentional poisoning caused about 703,702 emergency department (ED) visits (CDC 2008). Almost 25% of these unintentional ED visits resulted in hospitalization or transfer to another facility (CDC 2008). In 2006, poison control centers reported about two million unintentional poisoning or poison exposure cases (Bronstein et al. 2007). Intentional In the United States in 2005, 5,833 (18%) of the 32,691 poisoning deaths were intentional; 5,744 were suicides and 89 were homicides (CDC 2008). In 2006, intentional poisoning led to about 220,924 emergency department (ED) visits; 216,358 involved self-harm and 3,982 were assaults (CDC 2008). o Among the self-harm poisoning ED visits, 162,096 (75%) resulted in hospitalization or transfer to another facility.

Marc Imhotep Cray,M.D. Last Updated 09-02-13 1

 Self-harm poisoning was the second-leading cause of ED visits for intentional injury in 2006 (CDC 2008). That same year, poison control centers reported 198,578 cases where the reason for poison exposure was a suspected suicide attempt (Bronstein et al. 2007). Most common poisons Unintentional In 2004, 95% of unintentional and undetermined poisoning deaths were caused by drugs (WONDER 2007). Opioid pain medications were most commonly involved, followed by cocaine and heroin (Paulozzi et al. 2006). Among those treated in EDs for nonfatal poisonings involving intentional, nonmedical use (such as misuse or abuse) of prescription or over-the-counter drugs in 2004, opioid pain medications and benzodiazepines were used most frequently (SAMHSA 2006). Intentional In 2004, 75% of poisoning suicides were caused by drugs both legal and illegal. The most commonly used drugs identified in drug-related suicides were psychoactive drugs, such as sedatives and antidepressants, followed by opiates and prescription pain medications (WONDER 2007). Most (93%) nonfatal, poison-related suicide attempts involved pharmaceuticals. Among the 132,582 drug-related suicide attempts in the United States in 2005, sedatives and hypnotics, pain medications, and antidepressants were the most common drugs taken. Among pain medications, opioids were the most widely used, while benzodiazepines were the most common sedatives (SAMHSA 2007).

Costs In 2000, poisonings led to $26 billion in medical expenses and made up 6% of the economic costs of all injuries in the United States. Males accounted for 75% of the total costs of poisoning injuries ($19 billion). Females accounted for 25% of the total costs of poisoning injuries (almost $7 billion) (Finkelstein et al. 2006).

Marc Imhotep Cray,M.D. Last Updated 09-02-13 2

Groups at Risk Unintentional Among those who died from unintentional poisoning in 2005: men were 2.1 times more likely than women; Native Americans had the highest death rate; whites and blacks had comparable rates; the peak age was 45-49 years of age; and the lowest mortality rates were among children less than 15 years old (CDC 2008). Among people who unintentionally poisoned themselves, received treatment in emergency departments and survived in 2006: men were 1.5 times more likely than women; the highest rates were in the 40-49 year old age group (CDC 2008). Intentional Among those who committed suicide by poisoning in 2005: men were 1.3 times more likely than women; whites were 3.6 times more likely than blacks; and the peak age was 45-49 years old (CDC 2008). Among those who intentionally harmed themselves with poison, received treatment in emergency departments, and survived in 2006: women were 1.6 times more likely than men; and the peak age was 15-19 years old, with a secondary peak in the 40-44 age group (CDC 2008). Reference: http://www.cdc.gov/ncipc/factsheets/poisoning.htm

Marc Imhotep Cray,M.D. Last Updated 09-02-13 3

Antidotes Used In Toxicology

Antidote Atropine Atropine Pralidoxime/2-Pam Special Notes Primarily for treatment of muscarinic effects. Organophosphates For treatment of muscarinic effects. For treatment of nicotinic effects. Black Widow Spider Reserved for severe cases. Not always readily available. Botulism Given for confirmed cases. Several types available. Must obtain from CDC. Lead/Other Heavy Metals Based on levels and symptomatology. Can not be given to patient with peanut allergy. Must monitor LFTs with this therapy. Hydrofluoric Acid Case specific, dermal/IV for systemic toxicity. Coral Snake Different types, match antivenin to correct coral snake. Pit Viper Snake Requires skin test. Antivenin not always indicated. Pit Viper Snake No skin test required. Antivenin not always indicated. Cyanide Three components to kit amyl/sodium nitrite and sodium thiosulfate). For symptomatic patients. Hydroxocobalamin Iron Based on levels and symptomatology. Digoxin Used for severe toxicity. Ethylene Glycol Oral or IV. May shorten hospital stay. An adjunct to other therapies. An adjunct to other therapies. Methanol Oral or IV. May shorten hospital stay. Given IV. Toxin Carbamates

Black Widow Antivenin

Botulinum Antitoxin

Calcium EDTA BAL (dimercaprol) DMSA (Succimer)

Calcium Coral Snake Antivenin

Crotalidae Polyvalent Antivenin

Cro-Fab

Cyanide Antidote Kit CyanoKit

Deferoxamine Digibind/Digoxin Fab Fragments Ethanol Fomepizole Pyridoxine Thiamine Ethanol Fomepizole Folinic Acid, Folic Acid
Marc Imhotep Cray,M.D. Last Updated 09-02-13 4

Flumazenil Glucagon Methylene Blue

Benzodiazepines Beta Blockers Methemoglobinemia

NAC/Mucomyst/N-Acetylcysteine Naloxone Nalmefene Octreotide Physostigmine Protamine Sulfate Pyridoxine Scorpion Antivenin

Acetaminophen Opiates, Clonidine Sulfonylureas Anti-cholinergics Heparin Isoniazid Scorpion

Vitamin K 1

Anticoagulants/Rat Poisons/Warfarin

Use with caution, many contraindications. Used with significant symptoms. Based on methemoglobin levels. Several toxins can induce this condition. Given diluted orally. IV route not FDA approved. Short- acting. Longer-acting. Inhibits growth hormone and insulin secretion. Used only in rare and severe poisonings. In severe overdose and marked lab indications. Dose often dependent on amount INH ingested. No FDA approved antivenin available. An intrastate one used in Arizona. Many types, not all poisonous. Given

For more Toxicology see : IVMS General Priniples of Toxiology Folder (Public) External Resources: Agency for Toxic Substances and Disease Registry (ATSDR) American College of Medical Toxicology European Centre for Ecotoxicology and Toxicology of Chemicals Department of Health and Human Services National Toxicology Program (NTP) American Association of Poison Control Centers (AAPCC) Info. Tox. International Inc.

Marc Imhotep Cray,M.D. Last Updated 09-02-13 5