Washington Poison Center

Abstracts

Abstract Prepared by the Washington Poison Center staff

Bottled Water Bonanza!
Chemical Terrorists: Aren’t They Really Us?
Don’t Abandon Home Ipecac!
Poison Information Resources: 1953 VS 2004
Three Years Experiences With Syrup Of Ipecac (SOI) Induced Emesis
Washington’s Poison Antidotes Status - 2004
Washington’s Use Of IV NAC

Bottled Water Bonanza!

Robertson W; Washington Poison Center, Seattle, WA
Background: Over the past decade, bottled water use has boomed. FDA Consumer reports its combined sales for 2002 out-performed those of coffee, milk and beer in the US – more than $35 billion dollars per year – despite no substantiated health benefit – save for, perhaps, a better taste. Nonetheless, a recent Seattle happening served to stimulate sales even more. Case Report: In the fall of 2003, two parents of a school-aged child visited her school to sample the drinking water. Its purported orange color and “bad taste” saw them collect a sample for chemical analysis. It revealed a lead level just slightly in excess of EPA guidelines. Widely publicized in the local press, subsequent political pressure saw the Board of Education allocate $700,000 for the purchase of bottled water to distribute in the schools and encourage parents to send their kids to school with still more ‘pure’ bottled water – not simply water from home taps put into bottles. Amazingly, not a single child has had a blood lead level measured to assess the existence of any real risk. Even our “activist” newspapers admit our state has never documented a single case of lead poisoning due to drinking water. Conclusion: In early March 2004, the Wall Street Journal noted that 5 leading vendors of bottled water employ “expiration dates” to better market their products. Is it ever possible for science to trump such behavior? Don’t bet on it!

Chemical Terrorists: Aren’t They Really Us?

Robertson W; Washington Poison Center, Seattle, WA, USA
Background: After September 11, 2001, the term “terrorism” achieved worldwide fame. With the anthrax and ricin scares, “biological terrorists” were suspected of lurking behind every tree, bush and blade of grass. But, none was found. In truth, however, “chemical terrorists” have been thriving across the US for decades scaring our citizens about lead, mercury, DDT, PCB’s, dioxins, etc. on virtually a daily basis. Why does this happen? Method: MEDLINE was searched and Science Citation Index consulted. Results: Neither the chemicals themselves, their forms, nor their doses begin to explain this epidemic of chemical gloom; rather, scientists and government agencies infected with the ‘precautionary principle’ plus well-motivated, but misinformed, public speakers and the ‘media’ appear to be casual. Discussion: In 2002, Luberoff analyzed 1.08 million scientific and technical journal articles finding 92% of the modifiers of the word ‘chemical’ carried a negative connotation: bad, toxic, hazardous, etc. Clearly, the public deserves less negative hype concerning Love Canal, Agent Orange, silicon implants, Gulf War Syndrome, ad infinitum! Conclusion: Last year, the world’s worst biologic toxin BOTOX was stuck into >1 million foreheads to cure wrinkles without any problems. The dose – not the chemical – continues to make the poison!

Don’t Abandon Home Ipecac!

Ngu I, Robertson W; Washington Poison Center, Seattle, WA USA
Background: A year ago the American Academy of Pediatrics (AAP), after having committed to a joint action with the American Association of Poison Control Centers (AAPCC) unilaterally reversed its support of home use of Syrup of Ipecac (SOI). Home use of SOI skyrocketed in the early 60's - seeing more than 70% of Seattle homes with children less than 10 years of age having SOI on the premises. Still, the AAP remained divided about endorsing SOI’s use, finally agreeing to do so in 1983 but somehow failing to publicize that policy until 1989. Then, in the 1970's, emergency physicians began to champion the use of charcoal as the preferred gastric decontaminant - in their hospital ED’s, of course! But, in 1998, repeated documentation of prolonged delays in using charcoal appeared. Our 3 studies showed delays of 55, 62 and 69 minutes after the patient reached the ED. Now at least eight others confirm such delays nationwide. We decided to quantify “delays” with SOI again! Method: An opportunistic sample of 60 home SOI usages was reviewed; time lapses between toxin ingestion and SOI use were calculated. Results: A x of 9.4 +/- 6.6 minutes transpired between the ingestion and SOI consumption. No SOI was refused. Conclusion: Since “time” is the most significant contributor to the effectiveness of any “gastric decontamination”, our data “suggest” that home use of SOI clearly ought continue.

Poison Information Resources: 1953 VS 2004

Heathman J, Robertson W; Washington Poison Center, Seattle, WA, USA
Background: Some 1.2 million chemicals had been identified by 1952 when Poison Centers began; last year that number passed 50 million. Today, we still rely on “informatics” to provide answers to diagnostic and treatment questions. How has the process changed over the past half century? Methods: Both published literature and administrative files were scanned; findings were documented and compared. Results: In 1952-3, the American Academy of Pediatrics’ some 1,000 5x8 management cards were mimeographed by the Surgeon General and made available to State Health Officers to start today’s nationwide network of Poison Centers. By 1956, the FDA’s “National Clearinghouse of Poison Control Centers” began to update that Kardex system; it “helped” out with more than 75% of calls. Then, in 1973, microfiche technology arrived increasing the coverage to some 35,000 items with a boost in “hits” to more than 90%. Poisindex converted us to CD-ROM in the mid-80’s – with >900,000 items. By 1993, we found it provided >98% hits – as it did again in the spring of 2003. Conclusion: Appropriate informatics provides remarkably rapid (11 seconds) and thorough retrieval of poison management “information and advice” (98%) to the Poison Center scene. Access to information – not memorized facts – is what counts.

Three Years Experiences With Syrup Of Ipecac (SOI) Induced Emesis

Von Derau K , Robertson W; Washington Poison Center, Seattle, WA, USA
Background: When Poison Centers appeared 50 years ago, any child’s ingestion of a “possible” toxic chemical saw him/her rushed to hospital for gastric lavage. Then, SOI emerged on the scene and SOI home management burgeoned – with up to 30% of children being so treated. As experience grew, over-employment of SOI declined; simple home observation followed. Then, the specialty of emergency medicine began to advocate using activated charcoal – in their ED’s, of course – and SOI’s use declined even more. We decided to review our most recent three year’s use of SOI. Method: Records of all of Ipecac’s use (N=1099) were analyzed. Results: Our Center – as with others – continued to see a decline in SOI’s use – now only 1% of calls re: kids <5. Of note, one third of its use is initiated by the caregiver without contacting the Poison Center – but, over those 3 years, not a single untoward consequence was documented. Of those following our advice, no problems either. Conclusion: Assuming 1,100 ambulance (911) rides and ED visits (total cost = circa $600 a trip) $660,000 of costs were avoided – more than enough to place three bottles of SOI in every toddler’s home in the state. Does AAP’s policy of banishing ipecac look a bit ‘ludicrous’? We think so.

Washington’s Poison Antidotes Status - 2004

Bobbink S, Cropley J, Peterson T, Robertson W; Washington Poison Center, Seattle, WA
Background: For a decade, our Washington Poison Center (WPC) had sought to maintain a centralized listing of “who has what antidote” for our State – enabling sharing to take place. Last spring, we again updated our annualized database. Method: Our mail survey re: 20 antidotes was again dispatched to the state’s hospitals’ pharmacy directors. Tardy returns prompted follow-up letters. Results: This year, we sampled 94 of our states’ 120 +/- hospitals - exempting highly specialized or very small units. More than 85% responded. SOI was still 100% available (are we biased?) with naloxone, atropine and charcoal being close behind - >95%. Methylene blue, flumazenil and physostigmine were in > 80% of hospitals with N-Acetyl Cysteine (NAC), cyanide kits and Digibind in > 70%, but only 29% carried any chelating agents because heavy metals poisonings have virtually disappeared – and, apparently, chelation “therapy” for atherosclerosis has yet to catch on. All except two of our Eastern Washington hospitals (where rattlesnakes thrive) maintained CroFab (anti-venom) on their premises, but far less stocked 2-PAM for pesticide poisoning because it is reserved for bioterrorism. Conclusion: Our results provide a useful database for any “disaster planning”. This year, not a single new antidote was recommended by any of our respondents.

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Washington’s Use Of IV NAC

Yen C, Robertson W; Washington Poison Center, Seattle, WA, USA
Background: Acetaminophen (APAP) replaced phenacetin in Europe in the 50’s and 60’s because of phenacetin’s renal toxicity. A first metabolite of phenacetin, APAP migrated here in the 60’s just in time to replace aspirin – thoroughly “discredited” for any use in children because it caused (?) Reye’s Syndrome. By the 70’s, APAP became a popular “poison”. Fortunately, sulfhydryl donors – methionine, cysteine and N-acetyl cysteine (NAC) – were all found to be effective antidotes. By the late 80’s, the UK was successfully using NAC intravenously but, we, here in the US, were still plodding along with the oral form that caused so much vomiting. By the 90’s, however, “off-label” IV use had begun. We sought to document our decade of IV experience. Method: Telephone calls were made to 30 Washington hospital pharmacy directors about NAC’s IV use. Results: All 30 had already used IV NAC on more than one occasion – most with our encouragement. While we still have no precise number of patients so treated across Washington – we know >200! – neither we, nor the pharmacy directors, recalled a single clinically significant adverse event associated with IV NAC’s use. Moreover, all 5 Tacoma hospitals adopted a policy to abandon use of oral NAC. Conclusion: In our State, “off-label” IV NAC use has burgeoned. Still, we welcome Cumberland Labs’ FDA approved IV NAC product which just arrived this past May.