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Objective: To examine the use of OTC analgesics among dental patients. Methods: Patients reporting to an urban dental clinic were interviewed by trained research assistants using a standardized questionnaire. We recorded patient demographics, the types and amounts of OTC analgesics taken over the past 3 days, and perceptions of OTC analgesic safety. The study was completed over 8 non-consecutive days. We defined supratherapeutic as any dose greater than the total recommended daily dose stated on package labeling. We defined primary OTC analgesic as the medication taken in the greatest amount by the patient if a combination of analgesics was used. Results: We approached 194 patients, of which 127 participated. Analgesic use within the last 3 days was reported by 100 of 127 patients, most (82%) used an OTC analgesic. The mean age of participants was 28 years: 52% were male. OTC analgesics reported in the 82 patients included ibuprofen (39), acetaminophen (28), acetaminophen/aspirin (8), naproxen (4), and aspirin (3). Seventeen patients reported supratherapeutic use of their primary OTC analgesic: ibuprofen (12/39), acetaminophen (2/28), and naproxen (3/4). Of these 17 patients, 82% agreed that they 'could get sick [by taking] too much' OTC analgesic. Conclusion: OTC analgesic use was common in patients presenting to a safety net dental clinic (65%), as was OTC analgesic misuse (21%). Nonsteroidal anti-inflammatory drugs were the most frequently misused products. Although the study was limited by small sample size, it noted that analgesics requiring fewer total tablets per day for therapeutic dosing were more likely to be misused. Patient awareness of potential OTC analgesic toxicity did not prevent supratherapeutic use., Havey JM(1), Hill RE(1,3), Robins CW(3), Bogdan GM(1), Daly FFS(1), Zallen R(2), Dart RC(1,3). (1)Rocky Mountain Poison and Drug Center-Denver Health, (2)Denver Health Dental Clinic-Denver Health, (3)University of Colorado Health [...]

Objective: IV acyclovir is an effective treatment for herpes simplex encephalitis. Recently it has been increasingly used as an empiric therapy for patients with unexplained altered mentation. We reviewed all the patients who received IV acyclovir at an inner city, safety net hospital over a 6 month period to determine adverse sequelae associated with its use. Methods: Index case: a 35-year-old alcoholic with normal renal function empirically received 3 doses of IV acyclovir over 24 hr for unexplained confusion, despite a lack of focal neurologic deficits or abnormal LP results. Over the next 2 days the patient's serum creatinine rose from 0.6 to 6.4 mg/dL and he developed symptoms of psychosis, both attributed to the acyclovir. A chart review was then performed on all patients at our institution who had received IV acyclovir during the previous 6 months. Results: 36 patients were identified who had received IV acyclovir: 21 (58%) patients had no change in serum creatinine. Eleven (31%) had no serum creatinine measured during or soon after acyclovir therapy. Deterioration of renal function was discovered in 4 (11%) patients (the highest creatinine was 6.4 mg/dL), and 2 of these patients received acyclovir empirically despite a lack of focal neurologic findings or abnormal LP results. Both patients had extensive work-ups and prolonged hospital stays as a result of their renal injury, but eventually recovered within a week of stopping acyclovir. Conclusion: Despite serious potential adverse sequelae, empiric treatment with IV acyclovir is being used for patients with unexplained changes in mental status, even in the absence of focal neurologic deficits or an abnormal LP. Furthermore, many patients do not receive appropriate monitoring of renal function during therapy. Given the reported adverse effects of IV acyclovir, a careful risk/benefit analysis should be performed prior to empiric use., Erdman AE, Jolliff HA, Waksman JC, Earnest M, Dart RC. Rocky Mountain Poison and Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, [...]

Background: It has been suggested that an antivenom used for one species of Latrodectus (widow spiders) would be effective in treating envenomation by other Latrodectus species. Objective: To determine the efficacy of a Latrodectus mactans (black widow) antivenom, manufactured in Mexico, in neutralizing the lethality of L. hesperus (Western black widow) and L. mactans (Southern black widow) venom collected in the United States. Methods: A blinded, randomized, comparative, placebo-controlled trial in the mouse. Power analysis indicated that 7 animals per group conferred a 95% power to detect an 80% difference between the experimental groups with a two-tailed alpha of 0.05. The following were pre-mixed and incubated at 25 [degree] C for 1 hour prior to i.p. injection: 1) L. hesperus venom (at 5x [LD.sub.50]) + antivenom (calculated to neutralize 120 x [LD.sub.50]); 2) L. hesperus venom + protein control (non-specific equine IgG); 3) L. mactans venom (at 5x [LD.sub.50]) + antivenom; 4) L. mactans venom + protein control; 5) 0.9% saline + protein control; and 6) saline + antivenom. Survival curves were compared with a Log-rank test. Results: All mice in the venom + antivenom and non-venom control groups survived (mean survival time 1440 [+ or -] 0 minutes) and were different from the L. hesperus + protein control group (7/7 died; mean survival time 689.3 [+ or -] 212.7 minutes) and L. mactans venom + protein control group (6/7 died; mean survival time 265.4 [+ or -] 518.4 minutes) (p [is less than] 0.001). Conclusion: The imported antivenom effectively neutralized the lethality of the Latrodectus venoms in a murine model. While our study is limited by the premixing of antigen and antibody, it concurs with the hypothesis that one antivenom could be effective worldwide., Bogdan GM, Hill RE, Jolliff HA, Daly FFS, Dart RC. Rocky Mountain Poison and Drug Center--Denver Health, University of Colorado Health Sciences Center, Denver, [...]

Introduction: IL-18 is a novel pro-inflammatory cytokine that participates in hepatocyte apoptosis in mice after treatment with a variety of hepatotoxins. The normal apoptotic pathway commences with Fas/Fas Ligand interactions. The role of IL-18 in APAP-induced hepatic injury has not been previously reported. Objective: To explore the role of IL-18 in APAP-induced hepatic injury and determine if this mechanism is Fas/Fas Ligand mediated. Methods: C57BL/6 female mice (N = 10, 20-25g) were injected i.p. with 700 mg/kg APAP. Control mice (N = 10) received an equal volume of saline by the same route. Blood and liver were collected for ALT and IL-18 determinations at 1, 2, 4, 8, 24 hours following APAP injection. A second group (N = 25) was injected i.p. with neutralizing antibodies to IL-18 one hour prior to APAP injection. ALT and IL-18 levels were measured at 8 hours following APAP injection. Control mice (N = 25) received control protein followed one hour by APAP. Ten Fas deficient mice (Lpr/Lpr) were also injected i.p. with APAP to explore Fas/Fas Ligand participation. Results: IL-18 was detected in serum and liver one hour following APAP injection and peaked at 8 hours. Anti-IL18 antibodies significantly reduced hepatic injury: mean serum ALT ([+ or -] SD) was 523 [+ or -] 428 IU/L compared to 1653 [+ or -] 1043 IU/L for controls (p [is less than] 0.0001). Mean serum ALT for Lpr/ Lpr mice was not different from wild type mice. Conclusion: In this model liver IL-18 is involved in APAP-induced hepatotoxicity, but IL-18 antibodies do not completely prevent hepatic injury. The mechanism by which IL-18 is involved in APAP hepatotoxicity seems to be Fas independent., Waksman JC(1,3), Fantuzzi G(2), Bogdan GB(1), Dart RC(1,3), Dinarello C(2). (1) Rocky Mountain Poison and Drug Center--Denver Health, (2) Division of Infectious Diseases, (3) University of Colorado Health Sciences Center, [...]

Introduction: Acute phase reaction is a coordinated protective response to tissue injury and inflammation including the synthesis of acute phase proteins that are IL-6 dependent. C-reactive protein (CRP) belongs to this group and is considered a surrogate for IL-6. Animal studies have shown that inflammation plays a role in APAP induced liver damage. Objective: To explore serum IL-6 levels in patients following acute APAP overdose. Methods: Between May and December 2000, we conducted a prospective cohort study of patients who presented to an emergency department after an acute single overdose of APAP. We collected information on patient demographics, current ingestion including coingestants, past medical history, and current medication use. Serum AST, ALT, basic chemistry panel, INR, and IL-6 levels were performed. Hepatic injury was defined as AST or ALT [is greater than] 50 IU/L and positive serum IL-6 was defined as greater than 40 pg/mL. Groups were compared with Fisher's exact test. Results: Thirteen patients were studied (male: 2, mean age: 26.8 yrs, range: 16-56). No one presented later than 24 hrs from reported ingestion. Serum IL-6 was statistically associated with hepatic injury (p = 0.014): Hepatic Injury No Hepatic Injury Total Positive serum IL-6 0 (0%) 9 (69%) 9 (69%) Negative serum IL-6 3 (23%) 1 (8%) 4 (31%) Conclusion: Hepatic injury is associated with decreased serum IL-6 levels. Measuring IL-6 levels or the more clinically feasible CRP, may serve as a prognostic factor in APAP overdose. Waksman JC(1,3), Fantuzzi G(2), Bogdan GM(1), Dart RC(1,3), Dinarello C(2). (1) Rocky Mountain Poison and Drug Center-Denver Health, (2) Division of Infectious Diseases, (3) University of Colorado Health Sciences Center, Denver, CO, Waksman JC(1,3), Fantuzzi G(2), Bogdan GM(1), Dart RC(1,3), Dinarello C(2). (1) Rocky Mountain Poison and Drug Center-Denver Health, (2) Division of Infectious Diseases, (3) University of Colorado Health Sciences Center, [...]

Background: EG levels are not readily available in most hospitals. The presence of an OG has therefore been proposed as a surrogate measure of serum EG. Some authors even suggest that absolute serum EG levels in mg/dL may be estimated by multiplying the OG by a conversion factor of 6.2. We report a patient with severe EG poisoning in whom serial measurements of OG were used to estimate EG levels and guide treatment decisions. Case Report: A 40-year-old alcoholic man drank 0.5 gallons of antifreeze in a suicide attempt. He was treated at a facility where 12-24 hrs were required to obtain serum EG results. The patient's initial OG was markedly elevated and this was used to justify the need for dialysis. There was no ethanol detectable. The OG was then followed serially to guide the timing and duration of dialysis treatments. The patient was dialyzed a total of 3 times until his OG was normal. Serial OG and EG measurements were: Hours after ingestion OG EG (mg/dL) Calculated EG (mg/dL) 8 161.3 676.0 1,000.1 44 15.4 80.7 95.5 68 2.4 47.2 14.9 No further dialysis was performed after the OG reached 2.4, and the creatinine subsequently rose from 2.6 to 3.6 mg/ dL. A month later it was 1.2 mg/dL. Conclusion: Although an elevated OG may be helpful in deciding to initiate therapy for EG ingestions, the OG may not accurately predict actual EG levels. Moreover, a normal OG does not exclude a potentially toxic EG level. Erdman AE(1), Mallea MC(2), Jolliff HA(1), Waksman JC(1), Dart RC(1). (1) Rocky Mountain Poison and Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, CO; (2) Idaho Nephrology Associates, Boise, ID, Erdman AE(1), Mallea MC(2), Jolliff HA(1), Waksman JC(1), Dart RC(1). (1) Rocky Mountain Poison and Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, CO; (2) Idaho Nephrology Associates, [...]

Objective: Oxcarbazepine (Trileptal) is a new antiepileptic drug derived from carbamazepine. It is approved for use in the United States for treating partial seizures and trigeminal neuralgia. It is reported to be better tolerated and have fewer adverse effects than carbamazepine. Adverse cardiac effects and tinnitus have not previously been reported with ingestion of oxcarbazepine. We report the first case of bradycardia, hypotension, and tinnitus after overdose of oxcarbazepine. Case Report: A 38-year-old female with a history of simple partial seizures presented to the emergency department four hours after accidental oxcarbazepine overdose. The patient's normal dose was 2100 mg/day. Due to a prescription refill error, the patient consumed 3300 mg of oxcarbazepine that day (900 mg that morning and 2400 mg that evening). The recommended maximum daily dose is 2400 mg. Two hours after the evening ingestion, the patient developed diplopia, somnolence and fell asleep. She awoke 90 minutes later, with burning of her throat, vertigo, tinnitus, and was noted to be lethargic. In the waiting room of the hospital, she had a brief witnessed partial seizure and was brought into the treatment area of the emergency department. Her initial vital signs were: blood pressure 142/84 mm Hg, heart rate 60 beats per minute (bpm), respiratory rate 15 breaths per minute, temperature 37 degrees C and pulse oximetry 95% on room air. Glasgow Coma Scale was 13 and she was oriented. Ten minutes after her initial assessment, she was described as more lethargic, with a systolic blood pressure of 60 mm Hg by palpation and a heart rate of 27 bpm. Administration of IV fluids and atropine 1 mg increased her heart rate to 108 bpm and her blood pressure to 130/ 78 mm Hg. The patient was more alert and had no residual ECG abnormalities. A 6 hour post-ingestion serum oxcarbazepine level (10-hydroxy metabolite) was 45.6 [micro]g/mL (therapeutic range 10-35 [micro]g/mL). A comprehensive urine toxicologic screen was negative except for 'carbamazepine and metabolites,' however her serum carbamazepine level was non-detectable. The patient was taking no other seizure medications, had no previous cardiac history or adverse events with oxcarbazepine. The patient was discharged symptom free from the hospital within 24 hours without further episodes of bradycardia or hypotension. Conclusion: This is the first report of adverse cardiac effects and tinnitus with oxcarbazepine. The manufacturer notes oxcarbazepine has a narrow therapeutic index in regards to adverse CNS effects. This case demonstrates oxcarbazepine doses greater than 2400 mg/day, may cause such adverse effects as bradycardia, hypotension and tinnitus., Jolliff HA, Fehrenbacher N, Dart RC. Rocky Mountain Poison and Drug Center, Denver Health, University of Colorado Health Sciences Center, Denver, [...]

Objective: Serum ethylene glycol (EG) levels are not readily available in most hospitals in the United States. In these cases, the development of a metabolic acidosis may indicate an occult toxic EG ingestion. This concept has never been validated using an evidence-based approach. We utilized the medical literature, to test the hypothesis that all patients who ingest EG will develop a significant metabolic acidosis (serum [HCO.sub.3] [is less than or equal to] 20 mEq/L or base deficit [is greater than or equal to] 4) unless the resulting serum EG [is less than] 20 mg/dL. Methods: A systematic analysis was performed using a predefined search procedure of the following electronic databases: MEDLINE, EMBASE, CINAHL, Best Evidence and the Cochrane Databases of Systematic Reviews. Using the Ovid search engine, all English and non-English language articles regarding human ethylene glycol ingestion from 1960-1999 were reviewed. Bibliographies, personal files, poison center physician consults from 1997-1999, and extensive communications with authors identified additional cases. Structured data collection extracted time of ingestion, EG levels, serum [HCO.sub.3], base deficit and ethanol levels. Results: 262 articles (413 patients), 11 consults, and 23 unpublished cases were reviewed; 52 review articles were excluded as they provided no patient information. A total of 447 patients were analyzed, of which, 213 (48%) were excluded due to lack of patient data on acidosis and EG levels. Of the remaining 234 patients, 213 (91%) were acidotic and 21 (9%) were not acidotic at presentation. Therefore, most patients would have been detected due to an abnormal serum bicarbonate level or base deficit. Of the 21 patients without acidosis, 12 had ingested ethanol (thereby blocking alcohol dehydrogenase), 8 presented within 4 hours of the ingestion (before acidosis would be expected to develop), and one patient was treated with a Na[HCO.sub.3] infusion prior to assessment. Kappa scores for intra-rater and inter-rater reliability were 0.95 and 0.93 respectively. Conclusion: Although this study is limited by its retrospective nature, all untreated patients with significant EG ingestion manifested acidosis unless alcohol dehydrogenase was blocked or they presented prior to 4 hours of the ingestion. Decreasing [HCO.sub.3] levels or increasing base deficits at least 4 hours after ingestion may be a sensitive indicator of significant EG ingestion when serum EG levels are not available., Jolliff HA, Megarbane B, Waksman JC, Dart RC. Rocky Mountain Poison & Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, Colorado, USA; Hopital Lariboisiere, Paris, [...]

Objective: Repeated supratherapeutic dosing accounts for 9% of APAP-related deaths and has not been studied systematically. We hypothesize that AST/ALT at presentation identifies patients at risk for APAP-induced hepatotoxicity following repeated supratherapeutic dosing. Methods: A prospective cohort study of poison center patients presenting with repeated supratherapeutic APAP dosing (ingestion of [is greater than] 4 g/24 h; pediatric [is greater than] 90 mg/kg) was performed using structured data collection. Patients were managed by standing poison center protocol (presentation with abnormal AST/ALT or APAP level [is greater than] 10 mcg/mL prompted treatment with N-acetylcysteine-NAC) and followed for 48 hours, or until resolution of symptoms and laboratory abnormalities. Results: 44,689 calls were screened; 2,335 were APAP exposures. 114 cases (5%) were repeated supratherapeutic ingestions and 92 consented to enrollment. AST/ALT at Median Presentation n (%) APAP (g/d) Normal AST/ALT 41 (44.6) 10 AST/ALT >50 IU/L 40 (43.5) 12 No laboratory data 11 (11.9) 7.5 AST/ALT at Hepatotoxicity Lost to Presentation (AST > 1000 IU/L) Follow Up Normal AST/ALT 0 (15 treated with NAC) 7 AST/ALT >50 IU/L 13 (4 deaths, 1 transplant) 2 No laboratory data 0 (3 well at follow-up) 8 The likelihood ratio for patients with normal AST/ALT at presentation developing hepatotoxicity was zero. This study is limited by small numbers, administration of NAC to patients with normal AST, and 18% lost to follow-up rate. Conclusion: Patients who present after repeated supratherapeutic APAP ingestions with normal AST/ALT may not need treatment with NAC. The role of an APAP level in directing treatment and predicting outcome is not clear. Daly FFS, Dart RC, Bogdan GM, Jolliff HA, Waksman JC. Rocky Mountain Poison & Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, CO, Daly FFS, Dart RC, Bogdan GM, Jolliff HA, Waksman JC. Rocky Mountain Poison & Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, [...]

Objective: Serum EG and osmolality values are not available in many regions. In such cases, the development of acidosis may indicate significant EG ingestion. This concept has never been validated using an evidence based approach. We test the hypothesis that all patients who ingest EG will develop an acidosis (serum [HCO.sub.3] [is less than] 20 mEq/L or base deficit [is greater than or equal to] 41) unless the resulting serum EG [is less than] 20 mg/dL. Methods: A systematic analysis was performed using a predefined search procedure of MEDLINE and the Cochrane Databases (Ovid) for English language articles (1960-1999). Bibliographies, personal files, poison center consults (1997-1999), and extensive communications with authors identified additional cases. Structured data collection extracted time of ingestion, EG levels, serum [HCO.sub.3], and ethanol levels. Results: 162 articles (367 patients) and 11 consults were reviewed; 27 articles and 2 consults were excluded due to lack of patient data on acidosis and EG levels. Overall, 135 articles and 9 consults provided data on a total of 220 patients. Of these, 199 (90%) were acidotic and 21 (10%) were not acidotic at presentation. However, of these 21 patients, 12 had ingested ethanol, 8 presented within 4 hours (before acidosis would develop) and one patient was treated with a [HCO.sub.3] infusion prior to assessment. Kappa scores for intra-rater and inter-rater reliability were 0.95 and 0.93 respectively. Conclusion: Although this study is limited by its retrospective nature, all patients with significant EG ingestion manifested acidosis unless alcohol dehydrogenase was blocked or they presented prior to 4 hours of ingestion. Decreasing [HCO.sub.3] levels at least 4 hours after ingestion may be a sensitive indicator of significant EG ingestion when serum EG levels are not available., Jolliff HA, Dart RC, Bogdan GM, Daly FFS. Rocky Mountain Poison & Drug Center-Denver Health, University of Colorado Health Sciences Center, Denver, [...]

Objective: Serotonin syndrome has not been reported following the use of St. John's Wort. We report a patient who developed serotonin syndrome after using St. John's Wort and paroxetine, a selective serotonin reuptake inhibitor (SSRI). Case Report: A previously healthy 61-year-old female presented to an emergency department complaining of restlessness and uncontrollable movements of all four extremities. She discontinued St. John's Wort (600 mg per day) 3 days prior to presentation and commenced paroxetine on the day of presentation. The patient noted agitation and marked akathisia 8 hours after ingesting a single dose of 20 mg of paroxetine. On admission blood pressure (BP), heart rate (HR) and temperature were normal. The patient was alert and diaphoretic. Neurologic examination revealed involuntary movements of all extremities. Hyperreflexia and rigidity was noted in all extremities (legs greater than arms). Fasciculation was not observed. The initial creatine kinase was 212 U/L and later peaked at 1024 U/L. Thyroid function tests and other laboratory values were normal. Following admission, her BP increased to 200/116 mmHg and her HR increased to 145 BPM. The patient was managed with supportive care and lorazepam. She was discharged 2 days after presentation. Conclusion: Concomitant administration of a SSRI and St. John's Wort may cause serotonin syndrome. Given the prolonged elimination half-life of St. John's Wort, physicians may be advised to wait at least one week following discontinuation of St. John's Wort before initiating SSRI therapy., Waksman JC, Heard K, Jolliff H, Daly FFS, Bogdan GM, Dart RC. Rocky Mountain Poison and Drug Center-Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Background: Digibind reverses the cardiovascular effects of digoxin, but efficacy of a new digoxin-specific Fab (DigiTAb) has not been demonstrated. Objective: To compare the efficacy of DigiTAb and Digibind in reversing digoxin cardiotoxicity in a rat model. Methods: Baseline (0 minutes) measurements were recorded. Digoxin toxicity was induced in 4 groups of 10 rats by IV administration of 1.0 mg/kg digoxin over 5 minutes. At 30 minutes postinfusion (time of toxicity), each rat was randomized to one of the following treatments: DigiTAb, Digibind, nondigoxin specific Fab control, and NaCl/Sorbitol control. Fab doses were equimolar to amount of digoxin infused. ECG recordings and serum potassium levels were determined at pre-defined intervals from 0-210 minutes and were the primary variables used to compare efficacy. Results: The following table summarizes mean values for variables ([+ or -] SD) at pre-defined intervals: PTQ index = [PR interval (sec) x T score]/[QT.sub.c] (sec). An (*) indicates groups that did not differ from each other (p [is greater than] 0.05), but differed from controls (p [is less than] 0.05). Conclusions: There were no differences between DigiTAb and Digibind in reversing digoxin-induced increases in PTQ index and serum potassium levels. The primary limitation of the study was the use of an animal model. PTQ Index Treatment Baseline Toxicity 210 min Digibind 0.20 (0.02) 1.97 (0.90) 0.48 (0.20)(*) DigiTAb 0.19 (0.03) 1.83 (1.04) 0.66 (0.39)(*) Sorbitol 0.18 (0.02) 1.74 (1.06) 1.00 (0.52) Fab control 0.19 (0.02) 1.71 (0.50) 0.91 (0.43) Serum Potassium Levels (mEq/L) Treatment Baseline Toxicity 210 min Digibind 3.5 (0.54) 7.4 (0.85) 4.6 (0.28)(*) DigiTAb 3.6 (0.60) 7.3 (0.92) 4.7 (0.67)(*) Sorbitol 3.5 (0.44) 7.3 (0.90) 5.8 (1.10) Fab control 3.8 (0.45) 7.6 (1.43) 6.4 (1.00) Hill RE, Bogdan GM, Dart RC. Rocky Mountain Poison and Drug Center, Denver Health Authority, University of Colorado Health Sciences Center, Denver, CO, Hill RE, Bogdan GM, Dart RC. Rocky Mountain Poison and Drug Center, Denver Health Authority, University of Colorado Health Sciences Center, Denver, [...]

Objective: To test the effectiveness of redback spider (L. hasseltii) antivenom in neutralizing the lethal effects of L. hesperus and L. mactans (North American black widows) venoms. Methods: [LD.sub.50] values for the L. hesperus and L. mactans venom preparations were determined in preliminary studies. A prospective, randomized, double blind experiment was then performed for each venom using a murine envenomation model. Power analysis determined that 7 animals per group conferred a 95% power to detect an 80% difference between the experimental groups with a two-tailed alpha of 0.05. The following treatments were pre-mixed and incubated at 25 [degrees] C for 1 hour prior to intraperitoneal injection: 1) saline control + protein control (nonspecific equine IgG with a concentration equal to the antivenom) 2) saline control + L. hasseltii antivenom 3) venom (at 5 x [LD.sub.50]) + protein control and 4) venom + L. hasseltii antivenom. The study endpoints were elapsed time until death and survival at 24 hours. Comparison of survival curves was performed with Log-rank and Wilcoxon tests. Results: The murine [LD.sub.50] values for L. hesperus and L. mactans venoms were 0.64 mg/kg and 0.26 mg/kg, respectively. All mice in the L. hesperus or L. mactans venom and nontoxic protein control groups died. All mice in group 4 in both experiments survived (p [is less than] 0.0001). Conclusion: Redback spider antivenom is effective in neutralizing the lethal effects of L. hesperus and L. mactans venoms in a murine envenomation model. While our study is limited by the (optimized) premixing of antigen and antibody, it generates the hypothesis that redback antivenom would be effective in the treatment of latrodectism in humans caused by the North American widow spiders., (*) Winner of the American Academy of Clinical Toxicology 1999 Research Award. Daly FFS, Hill RE, Bogdan GM, Dart RC. Rocky Mountain Poison and Drug Center, Denver Health Authority, University [...]

Background: TriTAb[R] TCA immune Fab (ovine) is effective in neutralizing and redistributing TCA in a mouse poisoning model. We report the serum and urine concentrations of free and total TCA for 4 patients treated with Fab for TCA intoxication. Methods: Patients with TCA overdose and a QRS interval of [is greater than] 100 msec were treated within a forced titration dose finding study. Patients 1-3 received 7 g (as 1, 2 and 4 g infusions), while patient 4 received 14 g (as 2, 4 and 8 g infusions). Serum samples were collected at baseline, after each Fab infusion and 0, 0.5, 1, 2, 4, 8, 12, and 24 hours following final Fab infusion. Urine samples were collected at baseline and 0, 4, 12, and 24 hours following final Fab infusion. Samples were analyzed for free and total levels of each TCA using HPLC. Results: Total and free drug levels (parent + active metabolite) for serum and urine obtained at baseline and after final Fab infusion (0 hr) are shown. Conclusions: 1) TCA immune Fab effectively binds TCA in overdose patients. 2) Following Fab administration, total TCA serum and urine levels increase while free TCA levels show inconsistent and inconclusive reductions. 3) This suggests that Fab administration redistributes TCA from tissue into serum., Serum TCA Concentrations (ng/ml) Total (Free) Patient No.-TCA Baseline 0 Hr 1-Imipramine 450 (ND) 4,500 (ND) 2-Amitriptyline 510 (20) 3,100 (15) 3-Nortriptyline 1,600 (130) 5,300 (120) 4-Amitriptyline 1,330 (59) 7,200 [...]

Objective: To illustrate the prevention and treatment of recurrence of local symptoms in patients with crotalid envenomation treated with an initially controlling dose of affinity purified, mixed monospecific crotalid antivenom, ovine Fab for injection. Methods: Patients (n = 31) were enrolled in a multi-center clinical trial. Patients received up to 12 vials of antivenom for initial control and then were randomized into one of two groups: 1) Scheduled doses of 2 vials at 6, 12 and 18 hours after initial control, with additional antivenom as needed (SCHED-AV); or 2) 2 vials as needed (PRN-AV). Local recurrence after initial control (local recurrence) was defined as increasing local symptoms requiring nonscheduled antivenom. Results: Of 31 patients, 16 were in the PRN-AV group and 15 in the SCHED-AV group. Eight of 16 patients (50%) in the PRN-AV group developed local recurrence, (mean time to first recurrence = 9.72 hours, range 3.5-23.5). Zero of 15 patients (0%) in the SCHED-AV group developed local recurrence (p = 0.0024, Fisher's Exact, two-tailed). Additional antivenom was effective in re-achieving control of symptoms, at least temporarily, in each instance. Six of the eight had additional recurrences after re-achieving local control. There were no local recurrences beyond 24 hours. Conclusions: Local recurrence of symptoms was seen in 50% of patients with crotalid envenomation treated with an initially controlling dose of ovine, Fab antivenom. Re-dosing of antivenom in the first 24 hours was effective in re-achieving control of local symptoms. Scheduled antivenom in the first 24 hours prevented local recurrence., Seifert SA, Dart RC, Boyer LV, Clark RF, Hall EL, Kitchens CS, Bogdan GM, McNally J, and the CroTAb Investigative Group. Arizona Poison Center, Tucson, AZ; Rocky Mountain Poison Center, [...]

Background: There have been anecdotal reports of intra-articular crotalid envenomation but no studies have addressed this problem or provided treatment recommendations. Objectives: 1) To establish a model for crotalid venom-induced histopathologic changes in mammalian joints; and 2) To determine if intra-articular irrigation or systemic antivenom administration will prevent those changes. Methods: New Zealand White rabbits of both sexes, weighing 1.5-4.5 kg, were given intra-articular injections of 0.25 mL (20 mg/mL) Crotalus atrox venom to the right knee and 0.25 mL of 0.9% normal saline to the left knee (negative control). In phase one, envenomated knees without intervention were harvested at 20, 24, 30, and 96 hours. In phase two, envenomated knees were either irrigated with 3 mL of 0.9% normal saline 5 minutes after injection of venom or systemic antivenom was administered at 10 or 60 minutes prior to the intra-articular venom injection. These joints were harvested at 48 hours. Histopathologic changes were analyzed via microscopic examination and quantified by a blinded pathologist using a modified established scale for arthritis research. Results: In phase one, histopathological effects were apparent by 20 hours in envenomated knees and included the following: necrosis of muscle and soft tissue, inflammation and hemorrhage of the subsynovium, denuded cartilage surface with 100% proteoglycan loss and increased eosinophil density. Saline control knees had normal joint architecture with no signs of disruption or proteoglycan loss. In phase two, therapeutic interventions qualitatively reduced, but did not prevent venom induced structural damage. Irrigation did reduce synovial inflammation. Joints of rabbits treated with antivenom showed reduced soft tissue and synovial hemorrhage, as well as a reduction in the percentage of proteoglycan loss (60 min). Conclusion: This is the first report of a model to study intra-articular crotalid envenomation. The preliminary results indicated that joint irrigation and systemic antivenom could help reduce damage though future studies are required to further evaluate these therapeutic interventions., Hill RE, O'Malley GF, Bogdan GM, Heard K, Lear K, Huffer W, Dart RC. Rocky Mountain Poison & Drug Center, Denver Health, Denver, CO; University of Colorado Health Sciences Center, [...]

Background: A preliminary study of 60 alcoholic patients showed no difference between patients treated with acetaminophen (APAP) and those treated with placebo. Our study sought to increase the power to detect hepatotoxicity. Methods: A prospective, double-blind, randomized, placebo-controlled trial of alcoholics was conducted at an alcohol detoxification center. Alcoholism was confirmed by two methods. Baseline serum APAP, AST, ALT and INR were determined. Exclusion criteria included a recent history of ingesting [is greater than] 4 grams of APAP, serum APAP [is greater than] 20 mcg/mL, AST or ALT [is greater than] 120 IU/L or INR [is greater than] 1.5. Patients were randomized to receive APAP, 1 g every four hours for 4 doses on day 1 and day 2 or placebo on the same schedule. AST, ALT and INR were measured on days 2 and 4. Results: A total of 200 patients completed the trial: 102 received APAP and 98 received placebo. Patient groups were not different based upon demographics, severity of alcoholism, nutritional status or baseline AST, ALT or INR. Four patients in the APAP group and three patients in the placebo group developed an AST or ALT [is greater than] 120 IU/L. There was no statistical difference between the two groups at any time with respect to AST, ALT or INR means. Fisher's Exact test (p [is greater than] 0.05 two-tailed) was used to compare categorical data and an Unpaired Student t test (p [is greater than] 0.05 two-tailed) was used to compare continuous numerical data. There was a 95% probability of detecting a 15 IU/L difference between AST or ALT means. Conclusion: Alcoholic patients treated with the maximal therapeutic doses of acetaminophen did not develop hepatotoxicity. Our study does not support the concept of reducing acetaminophen dose in the alcoholic patient., Kuffner E, Dart RC, Bogdan GM, Mlakar P, Casper E, Darton L. Rocky Mountain Poison & Drug Center and Department of Psychiatry, Denver Health, Denver, [...]

Background: Insufficient stocking of emergency antidotes in hospital pharmacies is a well documented problem. Objective: Determine whether insufficient stocking of emergency antidotes can be improved by regional poison center recommendations. Methods: A written survey of pharmacy directors of all hospitals with emergency departments in Colorado, Montana, Idaho and Nevada was completed. Regional poison center antidote stocking recommendations were then distributed to all hospital pharmacies. Three months later, an identical written survey was repeated. For each survey, respondents reported the amount currently in stock of 10 different antidotes. Insufficient antidote stocking was defined as an amount inadequate to initiate treatment of one 70-kg patient: crotalid antivenin (5 vials), cyanide kit (1 kit), deferoxamine (1 g), digoxin immune Fab (20 vials), ethanol (70 g), fomepizole (2 vials), naloxone (2 mg), methylene blue (140 mg), pralidoxime (2 g), and pyridoxine (5 g). Results: Questionnaires were mailed to hospital pharmacy directors: 159 of 207 (77%) responded to the first and 122 of 203 (60%) to the second. One hospital in both surveys ([is less than] 0.5%) stocked all 10 antidotes in adequate amounts. Rate of insufficient stocking for antidotes ranged from 3% (naloxone) to 98% (digoxin immune Fab) in both surveys. There was significant improvement in the stocking of only 1 antidote, fomepizole, which increased by 13.4% (p [is less than] 0.05 by two-tailed Fisher's Exact testing). There was no change in the stocking of the other 9 antidotes. However, the proportion of hospitals with any amount of all 10 antidotes significantly increased from 4% to 14% (p [is less than] 0.05 by two-tailed Fisher's Exact testing). Conclusions: Insufficient stocking of antidotes continues to be a widespread problem in Colorado, Montana, Idaho and Nevada despite the distribution of stocking recommendations by a certified regional poison center., Bogdan GM, Hill RE, Dart RC. Rocky Mountain Poison & Drug Center, Denver Health, Denver, CO; University of Colorado Health Sciences Center, Denver, [...]

Background: Neuroleptic malignant syndrome (NMS) entails a spectrum of disease, and is an idiosyncratic reaction to neuroleptic medication. We report a case of acute IV overdose of haloperidol. Case Report: An 84 y.o. man was hospitalized for a heparin window. His pertinent medical history included coronary disease and chronic AFib. He had never before received a neuroleptic or lithium. On day 3 post-op, he was noted to be confused and slightly agitated. Haloperidol 0.5 mg IV was ordered, but 25 mg IV was administered. Within 1-2 hrs, he became increasingly agitated and confused. 4 hrs after the dose, he also displayed rigid extremities and cogwheeling, with a fever to 39.4 C. He was administered benztropine (1 mg), diphenhydramine (25 mg), and dantrolene (2 mg/kg x 1). His rigidity resolved over several hrs. Low-grade fever persisted another day. He had intermittent tachycardia with normal blood pressures. Serum chemistries, LFTs, ECG, CT head, LP, cultures, and CBC were all normal. His peak CK was only 179 U/L. He remained delirious, had pronounced dyskinesia, and spoke only in garbled, incomprehensible speech for approximately 72 hrs. He then returned to his baseline. Haloperidol serum concentrations were 5.9 ng/ml at 6 hrs and 1.2 ng/ml at 41 hrs (serum half-life = 15 hrs). A CSF haloperidol level at 43 hrs was 0.8 ng/ml (therapeutic range for serum and CSF is 0.8-33 ng/ml). Conclusion: This case provides the first reported example of a severe reaction to haloperidol after intravenous overdose with serum and CSF concentrations of the drug. His reaction appears to be a variant of NMS, with minimally elevated CK values. The rapidity of onset and persistence of symptoms may have been more related to the abrupt manner in which these drug concentrations were reached, rather than the levels themselves., Kostic MA, Palmer RB, Dart RC. Rocky Mountain Poison & Drug Center-Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Objective: Hydrazine (N[H.sub.2]N[H.sub.2]) is a liquid propellant used in emergency power units (EPU) of jet fighters. It undergoes catalytic decomposition to produce hot gas, which provides emergency thrust and power. No human exposure to combusted hydrazine has been reported in the literature. We describe several patients who were exposed to the combustion products of aqueous hydrazine. Case Series: Eleven members of the Colorado Air National Guard ground crew were working 100 yards downwind of an F-16 aircraft taxiing down the runway, when they all noticed an irritating ammonia-like smell. After leaving the area, respiratory symptoms (cough, dyspnea, chest discomfort) and mucous membrane irritation developed. Five patients were brought to a university hospital where they were evaluated. All but one was asymptomatic on arrival. This patient continued to experience throat irritation and chest discomfort. An investigation revealed that the pilot had accidentally activated the EPU containing a mixture of 70% hydrazine and 30% water. The patients were exposed to the exhaust plume generated by catalytic decomposition of this mixture. Exhaust products include ammonia, hydrogen, and nitrogen gases, and small amounts of unburned hydrazine, water, aniline, and carbon dioxide. The patient's chest radiograph was normal, his oxygen saturation was 94% and his peak flow exceeded 800 L/min. He was admitted for observation and discharged the following day without further symptoms. The other four patients had normal oxygen saturation and peak flow measurements. They were discharged after 6 hours of observation. One week later, all patients were asymptomatic. Conclusion: While hydrazine itself is toxic after inhalation, its catalytic decomposition products appear to cause only respiratory and mucous membrane irritation., Erdman AE, Dart RC, Cetaruk EW. Rocky Mountain Poison & Drug Center-Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Background: In 1998 & 1999, only 30% of hospitals had sufficient amounts of antivenom on-hand to treat one envenomation patient. In 2002, the supply of new antivenom may be lower than expected. Methods: In 1998, 1999, and 2002, we surveyed acute care hospital pharmacies in Colorado, Montana, Idaho and Clark County, Nevada for in-stock amounts of antivenom: Antivenin (Crotalidae) Polyvalent [Wyeth] and CroFab [Protherics]. Results: Survey response rates/year averaged 72%. The amount of antivenom vials on-hand are summarized in the table. In 2002, there was a 38% decrease in rattlesnake antivenom in our service area compared to 1998. It takes approximately 18 vials of either antivenom to treat one patient. Therefore, our treatment capacity has decreased from 71 to 44 patients during this period. Conclusions: Existing and new production of antivenom have decreased. Furthermore, 32% of current antivenom stock is located at larger hospitals in and around major urban areas. In the face of continued rattlesnake antivenom shortages, this affords poison centers the opportunity to take proactive measures to identify the location and amounts of antivenom in their service areas. Wyeth-1998 Wyeth-1999 Wyeth-2002 CroFab-2002 Hospitals (n) 160 161 205 205 NV 143 144 80 48 ID 212 188 47 91 MT 312 291 186 40 CO 614 585 289 164 Totals 1281 1208 602 193 Abstract 184. Masias TJ, Bogdan GM, Dart RC. Rocky Mountain Poison & Drug Center--Denver Health; University of Colorado Health Sciences Center, Denver, CO, Masias TJ, Bogdan GM, Dart RC. Rocky Mountain Poison & Drug Center--Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Background: Ingestion of ethylene glycol (EG) from antifreeze can lead to metabolic acidosis, renal injury and death. The yellow-green dye, fluorescein, is added to antifreeze to facilitate detection of cooling system leaks and help deter ingestion. Gas chromatography is the best method for quantitating serum EG concentrations but the method is difficult and few hospital laboratories perform this assay. A rapid and reliable diagnostic test to evaluate potential antifreeze poisoning victims is needed. Methods: A fluorometric assay for the detection of fluorescein in plasma was developed using a Hitachi F2000 fluorescence spectrophotometer. Blank human plasma from a date-expired banked single donor unit was spiked with fluorescein concentrations from 2.0-200ng/mL. The low concentration is over an order of magnitude less than calculated peak fluorescein concentration in a 70 kg adult with a 30 mL antifreeze ingestion. Results: A seven point calibration curve including a blank for these data was linear with [r.sup.2] = 0.999 using the average of triplicate determinations of each point. The limit of detection was determined to be 0.5 ng/mL with a limit of quantitation of 2.0 ng/mL. Previous reports examining fluorescence using a Wood's lamp suffered from light contamination as a result of the broad wavelength range of the light. We solved this problem by use of specific excitation (494nm) and emission (516nm) wavelengths. Analysis of blank samples demonstrated that typical plasma components did not interfere with the assay. Conclusions: A fluorometric assay can detect fluorescein in plasma as a surrogate marker for EG ingestion. The preliminary results obtained with this assay are promising and support further investigation of the use of this assay in actual antifreeze exposures., Palmer RB (1,2), O'Campo Y (2), Dart RC (1). (1) Rocky Mountain Poison & Drug Center Denver Health, Denver, CO; (2) Dept. Chemistry & Biochemistry, University of Northern Colorado, Greeley, [...]

Background: There is concern across the United States about opioid abuse. The media have focused on OxyContin, a continuous-release oxycodone formulation. However, there is a need to define and understand the extent of opioid abuse, specifically OxyContin. We hypothesized that calls to poison centers (PCs) represent one indicator of misuse and abuse. Methods: We searched for all exposure and information calls related to four opioids (oxycodone--excluding OxyContin, hydrocodone, morphine, and fentanyl) and compared them to OxyContin calls at two PCs (A and B), one urban and one combined rural and urban, for 2001. Results: Call rates for these opioids per 100,000 population are given in the table. There are differences in call type rates between the geographic areas. Furthermore, the information and exposure calls for Center A have increased for all of the opioids over the past two years. Conclusions: The rates of oxycodone calls are 3- to 5-fold greater than the other opioids. Calls about OxyContin constitute 7 to 10% of all opioid information calls and 20 to 25% of all opioid exposure calls. Information Call Rates OxyContin Oxycodone Hydrocodone Center A 2.23 15.30 2.69 Center B 3.30 29.09 5.28 Exposure Call Rates OxyContin Oxycodone Hydrocodone Center A 1.67 4.70 1.23 Center B 0.40 0.63 0.29 Information Call Rates Morphine Fentanyl Center A 1.99 0.08 Center B 8.26 0.37 Exposure Call Rates Morphine Fentanyl Center A 0.76 0.20 Center B 0.18 0.11 Abstract 137. Hughes AA, Bogdan GM, Bond R, Dart RC. Rocky Mountain Poison Center, Denver Health, Denver, CO. Cincinnati Drug & Poison Information Center, Cincinnati, OH, Hughes AA, Bogdan GM, Bond R, Dart RC. Rocky Mountain Poison Center, Denver Health, Denver, CO. Cincinnati Drug & Poison Information Center, Cincinnati, [...]

Background: Numerous case reports have associated acute liver failure in alcoholics with therapeutic doses of acetaminophen (APAP) in a condition termed `alcohol--acetaminophen syndrome' (AAS). However, AAS does not appear to be a prominent malady in studies involving alcoholics taking APAP. Methods: A systematic review of the worldwide literature (all languages) in which alcoholics received [greater than or equal to] 1 therapeutic doses ([less than or equal to] 4g/d) of APAP was undertaken. MEDLINE and EMBASE were searched using the broad search criteria of the CAS registry number for APAP, 'human' and 'alcohol'. Trained abstractors performed standardized data abstraction of patient demographics, dose, liver function, pathology and outcome. Results: The initial search yielded 910 papers. Of these, 45 papers in 10 languages reported a total of 669 alcoholic patients that received at least one therapeutic dose of APAP. Class I and Class II (prospective) studies yielded 620 alcoholic patients that received APAP with no evidence of subsequent liver injury, including 172 patients that received multiple maximal therapeutic doses. Class III (retrospective) studies provided 49 alcoholic patients with evidence of liver injury attributed to AAS. All Class III cases were compromised by at least one serious deficiency: 1) conflicting data, 2) incomplete evaluation of other diagnoses or 3) a major plausible alternative diagnosis. Conclusions: AAS is a diagnosis of exclusion. Prospective data provide no indication for increased susceptibility to therapeutic doses. Retrospective data associate liver injury in selected cases, but include conflicting data or inappropriate assessment of causation. A comprehensive systematic review of the medical literature located no case of hepatic injury that could be reasonable attributed to the therapeutic use of APAP in an alcoholic patient., Palmer RB, Bogdan GM, Dart RC. Rocky Mountain Poison & Drug Center--Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Background: In a previous study of urban dental clinic (DC) patients, OTC analgesic use was common (82/127), as was supratherapeutic misuse (17/82). Analgesics requiring fewer total tablets per day for therapeutic dosing were more likely to be misused. We surveyed emergency department (ED) patients to characterize their OTC analgesic use and to compare the two patient populations. Methods: Patients reporting to an urban ED were interviewed by trained research assistants using a standardized questionnaire. We recorded patient demographics, the types and amounts of OTC analgesics taken over the past 3 days, and safety perceptions. The study was completed over 8 consecutive days. We defined supratherapeutic as a daily cumulative dose greater than the recommended daily dosage on the package. We defined primary OTC analgesic as the medication taken in the greatest amount if a combination of analgesics was used. Results: Only 5% of ED patients misused OTC analgesics compared to 21% of DC patients in the same hospital (p < 0.05). Primary OTC analgesic in ED patients was acetaminophen (29/60) with 3% reporting misuse and in DC patients was ibuprofen (39/82) with 31% reporting misuse (see table). Conclusion: OTC analgesic use differed significantly among ED and DC patient populations of an urban medical center. Efforts to educate specific patient populations about the potential dangers of supratherapeutic OTC analgesic use should reflect these differences. # Patients: Approached Surveyed Mean Age ED 225 194 40 DC 194 127 28 # Patients: % Males Using OTC Misusing OTC ED 57 60 3 DC 52 82 17 Abstract 101. Havey JM, Phelan S, Bogdan GM, Pons P, Dart RC. Rocky Mountain Poison & Drug Center and Denver Health Medical Center--Denver Health; Univ. CO Health Sciences Center, Denver, CO, Havey JM, Phelan S, Bogdan GM, Pons P, Dart RC. Rocky Mountain Poison & Drug Center and Denver Health Medical Center--Denver Health; Univ. CO Health Sciences Center, Denver, [...]

Objectives: The potential toxicity of acetaminophen (paracetamol) in the setting of therapeutic use or 'low dose' overdose ingestion has generated intense controversy. If rare cases of fulminant hepatic failure occur [...]

Background: Crotalinae envenomations are an infrequent occurrence in pregnant women but have been associated with a high incidence of maternal death (10%) and fetal demise (43%). CroFab[R] [Crotalidae Polyvalent Immune Fab (Ovine)] was recently approved for use in the US. We present the first known use of CroFab[R] in a pregnant patient. Case Report: A 29 y.o. eight month pregnant woman presented to a central California hospital ED 30 minutes after a rattlesnake bite to her right thumb. There were two puncture marks on the digit. Initially she had only local swelling and hemorrhage. The snake was described as a baby rattler that had to be physically removed from the digit. Within one hour, her swelling had progressed to involve the entire hand and she complained of pain and perioral numbness. At this point antivenom use was considered. The treating hospital had a few vials of Wyeth Antivenin (Crotalidae) Polyvalent[R] (Equine) in stock, but the treating physician wanted to transfer the patient to a larger health care facility. Because of this, the higher risk of anaphylaxis and other potential consequences to the mother and fetus from the use of horse serum antivenom, she was transferred to a nearby hospital with CroFab[R] in stock. The first four vials of CroFab[R] were given within the first four hours. She received a total of 22 vials of CroFab[R] over the next two days. Swelling and ecchymosis involved the entire extremity to the shoulder. The prothrombin time, platelet count and fibrinogen level remained normal. She was discharged after 3 days. No complications with the pregnancy have occurred to date. Conclusions: To our knowledge this is the first reported use of CroFab[R] during pregnancy in a rattlesnake victim., Mullen WM (1), Dart RC (2), Olson KR (1). (1) California Poison Control System, San Francisco Division, Department of Clinical Pharmacy, UC San Francisco, and (2) Rocky Mountain Poison and [...]

Background: The September 11, 2001 terrorist attacks and the intentional distribution of anthrax spores through the United States Postal Service stunned the Nation. Our poison center and nurse advice line (Center) collectively managed over 40 cases per day related to anthrax concerns. This represented a 10% increase in daily call volume although no incidents occurred in our service region. Had an event actually occurred in our region, demand for our services would have surged, thus overwhelming existing Center and other public health emergency systems. To optimize limited resources, we implemented a role-based incident management process to provide a coordinated response to an emergency. Method: Center management was trained to utilize the role-based management process, Hospital Emergency Incident Command System (HEICS), and participated in a tabletop exercise. The management strategies were then tested in conjunction with an unannounced citywide exercise involving a chemical agent release. Results: February 22, 2002, 'injured' patients began contacting the Center. Available management personnel assembled within minutes of notification via text paging. Using the HEICS model, the team organized, assigned roles and implemented an action plan to prepare us for a surge in call volume. Within 60 minutes, additional phone lines were operational with specific information for those calling about the chemical agent release. Staff evaluations indicated that our Incident Command was established quickly and efficiently with the use of HEICS. Conclusions: Using HEICS enabled us to maintain normal operations while rapidly and effectively addressing the increased demand for services due to a simulated emergency despite the absence of key management personnel., Scherger D, Hintzen-Schmidt YP, Bogdan GM, Dart RC. Rocky Mountain Poison & Drug Center--Denver Health; University of Colorado Health Sciences Center, Denver, [...]

Background: In June 1999, a utility company severed our poison center's telephone lines. Service was restored to the building nearly seven hours later. Alternate telephone routing allowed calls to be re-directed which prevented loss of access to critical poison emergency services. However, our disaster plan was revised to address the need to maintain telecommunications systems and ensure rapid business recovery. Method: To minimize the impact of an outage, our telephone switch contains redundant processors, critical operations are balanced between the processors, and emergency power is available. In addition, three local and three long distance T1 circuits connect via a Sonet ring with primary and secondary paths entering the building from different locations to provide redundancy. Our disaster recovery plan has three levels of escalation. Level One involves the loss of long distance T1 circuits, whereby toll-free numbers on that circuit are re-routed to a local T1 circuit to restore service. Level Two involves loss of the telephone switch and T1 circuits, whereby all numbers are re-routed to an off-site switch but can still be answered at an on-site location. Level Three involves evacuation of the building, whereby all calls are rerouted to an off-site switch and answered at an off-site location. In addition, our poison information lines can be routed to other centers through pre-arranged agreements. Results: In January 2002, we performed a Level Two test which involved re-routing a test toll-free number to an off-site switch yet managing calls at an on-site location. Emergency telephones were deployed, the toll-free number was re-routed, and calls were received on-site within 30 minutes. Conclusions: All poison centers need to prepare and plan for multiple levels of telecommunications disasters in order to ensure that patients have uninterrupted access to life-saving poison emergency services., Scherger DL, Wruk KM, Hotton KJ, Dart RC. Rocky Mountain Poison & Drug Center, Denver Health Medical Center, Denver Health, Denver, [...]

Background: A hotline was established to address public health concerns related to the 17-year remediation of a major chemical weapons site. Despite on-site and perimeter air monitoring, surrounding communities had great anxiety and demanded a system for sentinel event detection and a means to report health concerns. Methods: A 24-hr toll-free hotline was established in 1998 and publicized in these communities. Recorded messages in English and Spanish provide information for odor concerns and clean up activities. Callers with health concerns speak with poison center staff who complete a standardized panel of questions to assess the potential agent, route and duration of exposure, health concerns (signs, symptoms) and other factors (occupation, lifestyle). Callers are urged to seek medical evaluation from their primary care provider (PCP) and evaluation by a medical toxicologist is available. Toxicologists review each case and assess likelihood of relationships to known site chemicals and air monitoring data for these agents. Assessments are part of the state health department's overall monitoring system. Results: In 40months we received 676 calls; 41 (6%) spoke to staff with only 27 related to site remediation concerns. Of the 27 callers, 11 reported specific medical concerns they attributed to the site and 16 wanted general information on environmental exposures. Case assessments indicated that reported medical concerns were likely due to smoking or normal aging processes. No PCP contacted us concerning a patient. During this period, no chemical releases across perimeter were indicated from air monitoring data. Conclusions: Passive surveillance mechanisms for reporting of environmental health concerns can alleviate public apprehension of community hazards and can potentially detect sentinel events if environmental releases were to occur., Bogdan GM, Dart RC. Rocky Mountain Poison & Drug Center--Denver Health; University of Colorado Health Sciences Center, Denver, [...]