Publications by authors named "Kent Olson"

66 Publications

Consensus statements on the approach to patients in a methanol poisoning outbreak.

Clin Toxicol (Phila) 2019 12 22;57(12):1129-1136. Epub 2019 Jul 22.

The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.

Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages. We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO. We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes. We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient. We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.
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http://dx.doi.org/10.1080/15563650.2019.1636992DOI Listing
December 2019

Patients with acute poisoning presenting to an urban emergency department of a tertiary hospital in Tanzania.

BMC Res Notes 2017 Sep 16;10(1):482. Epub 2017 Sep 16.

California Poison Control System, University of California, San Francisco, CA, USA.

Background: Poisoning is a major public health concern in sub-Saharan Africa, affecting patients of all age groups. Poisoned patients often present to the emergency department (ED) and prompt evaluation and appropriate management are imperative to ensure optimal outcomes. Unfortunately, little is known about the specific presentations of poisoned patients in East Africa. We describe the clinical and epidemiological features of patients presenting to the Muhimbili National Hospital (MNH) ED with suspected toxicological syndromes.

Methods: This prospective study enrolled a consecutive sample of ED patients who presented with a suspected toxicological syndrome from March 2013 to June 2013. Trained investigators completed a structured case report form (CRF) for each eligible patient, documenting the suspected poison, demographic information, the clinical presentation, and the ED outcome and disposition. The study data were analyzed and summarized with descriptive statistics.

Results: Of 8827 patients, who presented to ED-MNH, 106 (1.2%) met inclusion criteria, and all were enrolled. Among those enrolled, the median age was 28 years (interquartile range [IQR] 16 years), and 81 (76.4%) were male. Overall 55 (52%) were single, and 28 (26.4%) had professional jobs. 60 (56.6%) patients were referred from district hospitals, 86.8% of which were in Dar es Salaam. Only 13 (12.3%) of patients presented to the ED within 2 h of the toxic exposure. The etiology of poisoning included alcohol in 42 (50%), a mixture of different medications in 12 (14.3%), and snakebite in 6 (11.3%). Most exposures were intentional (63 [59.4%]) and were via the oral route (88 [83%]). The most common abnormal physical findings were altered mental status (66 [62.3%]) and tachypnoea (68 [64.2%]). One patient died in the ED and 98 (92.5%) required hospital admission.

Conclusions: Most patients presenting to the ED with a toxicological syndrome were adult males with intentional exposures. The most common toxic exposure was alcohol (ethanol) intoxication and the most common abnormal findings were altered mental status and tachypnoea. More than three-quarter of patients presented after 2 h of exposure. Almost all patients were admitted to the hospital.
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http://dx.doi.org/10.1186/s13104-017-2807-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602963PMC
September 2017

Safety and effectiveness of physostigmine: a 10-year retrospective review.

Clin Toxicol (Phila) 2018 02 13;56(2):101-107. Epub 2017 Jul 13.

b Department of Emergency Medicine , University of California San Francisco , San Francisco , CA , USA.

Background: Physostigmine has long been recognized as an antidote to reverse anticholinergic delirium. However, its effectiveness, safety profile, and dosing have been disputed.

Objectives: To describe effectiveness, adverse events, and dosing associated with the use of physostigmine to reverse anticholinergic delirium.

Methods: A retrospective cohort study of hospitalized patients reported to a regional poison center system between 2003 and 2012 who received physostigmine to reverse an anticholinergic toxidrome. Data extraction of a priori defined variables were recorded with concurrence of investigators. The cases were stratified by the primary ingestant as the presumed causative agent and associations for response were performed using odds ratios (ORs), 95% confidence intervals (CI's), and p values.

Results: Of the 1422 cases identified, 191 met the inclusion criteria. Patients exposed to non-diphenhydramine antihistamines (n = 14), antipsychotics (n = 4), and tricyclic antidepressants (n = 3) had 100% response to physostigmine, whereas anticholinergic plants (n = 46/67; 68.7%, OR: 0.70; CI: 0.36-1.35), diphenhydramine (n = 43/56; 64.2%, OR: 1.30; CI: 0.63-2.68), and combination products (n = 8/10; 80%, OR: 1.48; CI: 0.30-7.24) had partial response rates. Of the included patients, 142 (74.3%) were treated with physostigmine alone, and 16 (8.4%) of these patients were discharged directly from the emergency department (ED).

Discussion: Most patients, 182 (95.3%), had no documented adverse effects. Four patients (2.1%) experienced emesis, two experienced QTc prolongation (1.0%), and two experienced seizures (1.0%). There was a single fatality 6 h after physostigmine administration. Average initial total doses of physostigmine ranged from 1.0 to 1.75 mg. Most patients were admitted to the ICU (n = 110; 57.6%), however, 36 (18.8%) patients were discharged directly from the ED.

Conclusions: In this retrospective cohort study, physostigmine administration to reverse anticholinergic delirium had a good safety profile, and often improved or resolved anticholinergic delirium when administered in doses less than 2 mg.
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http://dx.doi.org/10.1080/15563650.2017.1342828DOI Listing
February 2018

Amanita phalloides Mushroom Poisonings - Northern California, December 2016.

MMWR Morb Mortal Wkly Rep 2017 Jun 2;66(21):549-553. Epub 2017 Jun 2.

Amanita phalloides, colloquially known as the "death cap," belongs to the Phalloideae section of the Amanita family of mushrooms and is responsible for most deaths following ingestion of foraged mushrooms worldwide (1). On November 28, 2016, members of the Bay Area Mycological Society notified personnel at the California Poison Control System (CPCS) of an unusually large A. phalloides bloom in the greater San Francisco Bay Area, coincident with the abundant rainfall and recent warm weather. Five days later, CPCS received notification of the first human A. phalloides poisoning of the season. Over the following 2 weeks, CPCS was notified of an additional 13 cases of hepatotoxicity resulting from A. phalloides ingestion. In the past few years before this outbreak, CPCS received reports of only a few mushroom poisoning cases per year. A summary of 14 reported cases is presented here. Data extracted from patient medical charts revealed a pattern of delayed gastrointestinal manifestations of intoxication leading to dehydration and hepatotoxicity. Three patients received liver transplants and all but one recovered completely. The morbidity and potential lethality associated with A. phalloides ingestion are serious public health concerns and warrant medical provider education and dissemination of information cautioning against consuming foraged wild mushrooms.
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http://dx.doi.org/10.15585/mmwr.mm6621a1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657817PMC
June 2017

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey.

Clin Toxicol (Phila) 2017 Aug 2;55(7):670-673. Epub 2017 May 2.

b Department of Emergency Medicine , Chang Gung Memorial Hospital, Linkou Branch , Taoyuan , Taiwan.

Context: Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Case Details: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove.

Conclusions: The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.
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http://dx.doi.org/10.1080/15563650.2017.1317350DOI Listing
August 2017

Unintentional Pediatric Cocaine Exposures Result in Worse Outcomes than Other Unintentional Pediatric Poisonings.

J Emerg Med 2017 Jun 10;52(6):825-832. Epub 2017 Apr 10.

California Poison Control System, San Francisco Division, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, California.

Background: Unintentional pediatric cocaine exposures are rare but concerning due to potentially serious complications such as seizures, dysrhythmias, and death.

Objectives: The objectives were to assess the demographic and clinical characteristics of pediatric cocaine exposures reported to the California Poison Control System.

Methods: This is a retrospective study of all confirmed pediatric (< 6 years of age) cocaine exposures reported to the California Poison Control System from January 1, 1997-September 30, 2010. Case narratives were reviewed for patient demographics, exposure details, clinical effects, therapy, hospitalization, and final outcome.

Results: Of the 86 reported pediatric cocaine exposures, 36 had positive urine drug testing and were included in the study cohort. The median age at presentation was 18 months (range: 0-48 months), and 56% were male (n = 20). The most common clinical manifestations were tachycardia and seizures. The most common disposition was admission to an intensive care unit (n = 14; 39%). Eleven cases (31%) were classified as having a major effect as per American Association of Poison Control Centers case coding guidelines. One child presented in asystole with return of spontaneous circulation after cardiopulmonary resuscitation and multiple vasoactive medications. The proportion of cocaine exposures with serious (moderate or major) outcomes (66.7%; 95% confidence interval 50.3-79.8%) was higher than other pediatric poisonings reported to the American Association of Poison Control Centers during the study period (0.88%; 95% confidence interval 0.87-0.88).

Conclusions: Although pediatric cocaine exposures are rare, they result in more severe outcomes than most unintentional pediatric poisonings. Practitioners need to be aware of the risk of recurrent seizures and cardiovascular collapse associated with cocaine poisoning.
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http://dx.doi.org/10.1016/j.jemermed.2017.03.017DOI Listing
June 2017

Fatal Taxus baccata ingestion with perimortem serum taxine B quantification.

Clin Toxicol (Phila) 2016 Nov 20;54(9):878-880. Epub 2016 Jul 20.

b San Francisco Division , California Poison Control System , San Francisco , CA , USA.

Introduction: Common yew (Taxus baccata) is a common decorative evergreen shrub with potentially fatal toxicity hallmarked by seizure, arrhythmia and cardiovascular collapse if ingested. Taxine B has been identified as one of the most cardiotoxic taxine alkaloids in Taxus spp, and another alkaloid, 3,5-dimethoxyphenol (3,5-DMP), is used as a marker of ingestion. We present a fatal case of ingestion of yew with perimortem serum and gastric taxine B, and 3,5-DMP concentrations.

Case Presentation: A 22-year-old woman was brought to the emergency department (ED) from a nearby botanical garden after she was found apneic and pulseless after a witnessed generalized tonic clonic seizure. The patient was found to have a wide complex rhythm with persistent cardiovascular collapse and expired despite maximal supportive care in the ED. A baggie of plant material was found on the patient, identified as Taxus baccata. Perimortem serum and gastric samples were analyzed to quantify serum and gastric taxine B and 3,5-DMP concentrations.

Results: Perimortem serum showed a 3,5-DMP concentration of 86.9 ng/mL, and taxine B of 80.9 ug/mL.

Conclusion: We report a perimortem serum and gastric taxine B and 3,5-DMP concentrations in a fatal case of T. baccata toxicity.
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http://dx.doi.org/10.1080/15563650.2016.1209765DOI Listing
November 2016

Methemoglobinemia from frozen-dried mudfish contaminated with sodium nitrite.

Clin Toxicol (Phila) 2016 Nov 1;54(9):892. Epub 2016 Jul 1.

b California Poison Control System-San Francisco Division , University of California , San Francisco , CA , USA.

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http://dx.doi.org/10.1080/15563650.2016.1201677DOI Listing
November 2016

Treatment of cocaine cardiovascular toxicity: a systematic review.

Clin Toxicol (Phila) 2016 Jun 26;54(5):345-64. Epub 2016 Feb 26.

f Department of Internal Medicine, Division of Cardiology , Texas Tech University Health Sciences Center , El Paso , TX , USA.

Introduction: Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death.

Objective: The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse.

Methods: MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine.

Conclusions: High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.
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http://dx.doi.org/10.3109/15563650.2016.1142090DOI Listing
June 2016

Clenbuterol causing non-ST-segment elevation myocardial infarction in a teenage female desiring to lose weight: case and brief literature review.

Am J Emerg Med 2016 Aug 6;34(8):1739.e5-7. Epub 2016 Jan 6.

San Francisco Division of the California Poison Control System, University of California San Francisco, San Francisco, CA 94143-1369. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2015.12.086DOI Listing
August 2016

Treatment of drug-induced seizures.

Br J Clin Pharmacol 2016 Mar 17;81(3):412-9. Epub 2015 Sep 17.

California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.

Seizures are a common complication of drug intoxication, and up to 9% of status epilepticus cases are caused by a drug or poison. While the specific drugs associated with drug-induced seizures may vary by geography and change over time, common reported causes include antidepressants, stimulants and antihistamines. Seizures occur generally as a result of inadequate inhibitory influences (e.g., gamma aminobutyric acid, GABA) or excessive excitatory stimulation (e.g. glutamate) although many other neurotransmitters play a role. Most drug-induced seizures are self-limited. However, status epilepticus occurs in up to 10% of cases. Prolonged or recurrent seizures can lead to serious complications and require vigorous supportive care and anticonvulsant drugs. Benzodiazepines are generally accepted as the first line anticonvulsant therapy for drug-induced seizures. If benzodiazepines fail to halt seizures promptly, second line drugs include barbiturates and propofol. If isoniazid poisoning is a possibility, pyridoxine is given. Continuous infusion of one or more anticonvulsants may be required in refractory status epilepticus. There is no role for phenytoin in the treatment of drug-induced seizures. The potential role of ketamine and levetiracetam is promising but not established.
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http://dx.doi.org/10.1111/bcp.12720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767205PMC
March 2016

Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review.

Drug Alcohol Depend 2015 May 18;150:1-13. Epub 2015 Feb 18.

Department of Emergency Medicine, Oregon Health Sciences University, Oregon Poison Center, Portland, OR, United States.

Background: Overdose of amphetamine, related derivatives, and analogues (ARDA) continues to be a serious worldwide health problem. Patients frequently present to the hospital and require treatment for agitation, psychosis, and hyperadrenegic symptoms leading to pathologic sequelae and mortality.

Objective: To review the pharmacologic treatment of agitation, psychosis, and the hyperadrenergic state resulting from ARDA toxicity.

Methods: MEDLINE, PsycINFO, and the Cochrane Library were searched from inception to September 2014. Articles on pharmacologic treatment of ARDA-induced agitation, psychosis, and hyperadrenergic symptoms were selected. Evidence was graded using Oxford CEBM. Treatment recommendations were compared to current ACCF/AHA guidelines.

Results: The search resulted in 6082 articles with 81 eligible treatment involving 835 human subjects. There were 6 high-quality studies supporting the use of antipsychotics and benzodiazepines for control of agitation and psychosis. There were several case reports detailing the successful use of dexmedetomidine for this indication. There were 9 high-quality studies reporting the overall safety and efficacy of β-blockers for control of hypertension and tachycardia associated with ARDA. There were 3 high-quality studies of calcium channel blockers. There were 2 level I studies of α-blockers and a small number of case reports for nitric oxide-mediated vasodilators.

Conclusions: High-quality evidence for pharmacologic treatment of overdose from ARDA is limited but can help guide management of acute agitation, psychosis, tachycardia, and hypertension. The use of butyrophenone and later-generation antipsychotics, benzodiazepines, and β-blockers is recommended based on existing evidence. Future randomized prospective trials are needed to evaluate new agents and further define treatment of these patients.
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http://dx.doi.org/10.1016/j.drugalcdep.2015.01.040DOI Listing
May 2015

Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California.

Am J Cardiovasc Drugs 2015 Feb;15(1):43-50

California Poison Control System, San Francisco Division, University of California, San Francisco, USA,

Background: Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented.

Objective: The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes.

Methods: We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP).

Results: Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs.

Conclusions: Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.
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http://dx.doi.org/10.1007/s40256-014-0104-1DOI Listing
February 2015

Symptomatic Exposures Among California Inmates 2011-2013.

J Med Toxicol 2015 Sep;11(3):309-16

Department of Internal Medicine, Tulane University Medical Center, New Orleans, LA, USA,

Prisoners have a high prevalence of substance misuse and abuse, but few studies have examined symptomatic exposures among incarcerated populations. We sought to further characterize the nature of these exposures among this population using the California Poison Control System data. Keyword searches identified inmate cases in 2011-2013 for patients 20+ years old exposed to a single substance and taken to hospital from jail, prison, or police custody. Comparisons were made with non-inmate cases during the same period, using similar limitations. Body stuffers and body packers were analyzed as a subgroup. Seven hundred four inmate cases were compared to 106,260 non-inmate cases. Inmates were more likely to be younger, male, and to have engaged in drug misuse or abuse. They most commonly ingested methamphetamine, heroin, acetaminophen, and anticonvulsants. Inmates were more likely to receive activated charcoal (OR 9.87, 8.20-11.88), whole bowel irrigation (OR 44.50, 33.83-58.54), undergo endotracheal intubation (OR 4.09, 2.91-5.73), and to experience a major clinical outcome or death (OR 1.41, 1.05-1.89). When body stuffers and packers were removed, clinical findings were similar, though the odds of a major outcome or death became statistically non-significant. Body stuffers and body packers primarily used methamphetamine and heroin, and compared with other inmates had significantly higher odds of both adverse clinical effects and poor outcome. This large series provides a profile of symptomatic exposures among inmates, a little-studied population. The potential for high morbidity among body stuffers and packers suggests that a high index of suspicion of such ingestions be maintained when evaluating patients prior to incarceration.
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http://dx.doi.org/10.1007/s13181-014-0456-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547960PMC
September 2015

Unintentional pediatric ophthalmic tetrahydrozoline ingestion: case files of the medical toxicology fellowship at the University of California, San Francisco.

J Med Toxicol 2014 Dec;10(4):388-91

California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA, USA,

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http://dx.doi.org/10.1007/s13181-014-0400-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4252297PMC
December 2014

Unintentional pediatric ophthalmic tetrahydrozoline ingestion: case files of the medical toxicology fellowship at the University of California, San Francisco.

J Med Toxicol 2014 Dec;10(4):388-91

California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA, USA,

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http://dx.doi.org/10.1007/s13181-014-0400-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4252297PMC
December 2014

Predictors of Death and Prolonged Renal Insufficiency in Ethylene Glycol Poisoning.

J Intensive Care Med 2015 Jul 26;30(5):270-7. Epub 2013 Dec 26.

California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA.

Background: We assessed the predictive value of selected factors on the outcomes of death and prolonged renal insufficiency (RI) from ethylene glycol poisoning.

Methods: Retrospective, observational California Poison Control System study, over a 10-year period (1999-2008). We compared 2 groups. The first group (D/RI) included 59 patients who died (9 patients) or had prolonged RI (50 patients). Prolonged RI was defined as kidney injury in which dialysis was required for greater than 3 days after presentation. The second group (RECOV) of 62 patients had an uncomplicated recovery. Secondarily, we evaluated the association of time to antidote (ethanol and/or fomepizole) and time to dialysis with these outcomes.

Results: The D/RI group was more likely than the RECOV group to present comatose, have seizures, and require intubation. The D/RI group had a lower mean initial arterial pH of 7.03 (standard deviation [SD] 0.20), compared to 7.27 (SD 0.14) for the RECOV group. The D/RI group had a higher initial creatinine (1.7 mg/dL, SD 0.71) than that of the RECOV group (1.0 mg/dL, SD 0.33). Patients with a time to antidote greater than 6 hours had a higher odds of dying or having prolonged RI (OR 3.34, 95% CI : 1.21-9.26) Patients with a time to dialysis greater than 6 hours had a lower odds of dying or having prolonged RI (OR 0.36, 95% CI : 0.15-0.87).

Conclusion: Compared to survivors with an uncomplicated recovery, patients poisoned with ethylene glycol who died or had prolonged RI were more likely to exhibit clinical signs such as coma, seizures, and acidosis. Antidote administration within 6 hours is associated with better outcomes, unlike earlier time to dialysis.
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http://dx.doi.org/10.1177/0885066613516594DOI Listing
July 2015

Investigating the reliability of substance toxicity information found on the Internet in pediatric poisonings.

Pediatr Emerg Care 2013 Dec;29(12):1249-54

From the *California Poison Control System, San Francisco Division; †Department of Clinical Pharmacy, University of California, San Francisco; ‡Natividad Medical Center, Salinas; §Kaiser Permanente, Downey Medical Center, Downey; and ∥Department of Medicine, University of California, San Francisco, CA.

Objectives: The Internet may be the first source of information used by parents during a suspected poisoning of their children. Our primary aim was to assess the reliability of the Internet as a resource for information for parents to initially manage a suspected poisoning involving their child without outside consultation.

Methods: We distributed a self-administered survey to English-speaking parents to evaluate their Internet access behaviors so we could emulate their search strategies for a poisoning. A panel of clinical toxicologists performed an evaluation of Websites to determine the proportion that provided accurate and adequate information on common substances involved in poisonings.

Results: Of 21 parents surveyed, 15 (71%) used the Internet daily, with Google and Yahoo being the most commonly used search engines. Seven parents (39%) were somewhat to very likely to utilize the Internet during a poisoning scenario with prescription medications involving their child. Overall, only 27 (38%) of the Websites reviewed advised the user to call the poison center with the proper 800 telephone number, whereas no Website provided adequate information to manage the poisoning without outside consultation. Few Websites provided information on the toxic dose (13%), how to determine whether to manage the poisoning at home or in a hospital (22%), or first aid (28%).

Conclusions: The information provided on the Internet for substances involved in poisonings is variable and often incomplete. Reliance on the Internet for poisonings could create needless delays and inappropriate assessments and actions to manage a pediatric poisoning incident.
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http://dx.doi.org/10.1097/PEC.0000000000000022DOI Listing
December 2013

Baking soda can settle the stomach but upset the heart: case files of the Medical Toxicology Fellowship at the University of California, San Francisco.

J Med Toxicol 2013 Sep;9(3):255-8

California Poison Control System, San Francisco Division, University of California, San Francisco, UCSF Box 1369, San Francisco, CA, 94143-1369, USA.

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http://dx.doi.org/10.1007/s13181-013-0300-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770998PMC
September 2013

What is the best treatment for acute calcium channel blocker overdose?

Authors:
Kent R Olson

Ann Emerg Med 2013 Sep 6;62(3):259-61. Epub 2013 Apr 6.

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http://dx.doi.org/10.1016/j.annemergmed.2013.03.026DOI Listing
September 2013

Multiple MDMA (Ecstasy) overdoses at a rave event: a case series.

J Intensive Care Med 2013 Jul-Aug;28(4):252-8. Epub 2012 May 28.

Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA 93701, USA.

Twelve patients with 3,4-methylenedioxymethamphetamine (MDMA) toxicity from a single rave event presented to multiple San Francisco Bay area hospitals with various life-threatening complications including seizures and hyperthermia. Eight required emergent endotracheal intubation and six had hypotension. Hyperkalemia, acute kidney injury, and rhabdomyolysis were present in most of the patients. In all, 2 patients died, 4 survived with permanent neurologic, musculoskeletal, and/or renal sequelae, and 6 survived without any apparent lasting deficits. Hyperthermia was present in 10 patients and was severe (40.9-43° C) in 7. Using multiple cooling methods, the average time to achieve cooling was 2.7 hours. Serum drug analysis was performed on 3 patients, demonstrating toxic MDMA concentrations without the presence of other xenobiotics. Two capsules confiscated by police at the event contained 82% and 98% MDMA, respectively, without other pharmacologically active compounds. Capsule #2 contained 270 mg MDMA, which is more than twice the amount of MDMA usually contained in 1 dose. The MDMA-induced hyperthermia significantly contributed to the morbidity and mortality in this case series. Factors contributing to the severity of the hyperthermia include ingestion of large doses of MDMA, a warm ambient environment, and physical exertion.
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http://dx.doi.org/10.1177/0885066612445982DOI Listing
August 2014

Hypoglycemia in pediatric sulfonylurea poisoning: an 8-year poison center retrospective study.

Pediatrics 2011 Jun 23;127(6):e1558-64. Epub 2011 May 23.

Department of Clinical Pharmacy, University of California, San Francisco, California, USA.

Objective: The goal of this study was to describe the clinical effects and time of onset of hypoglycemia in pediatric sulfonylurea poisoning.

Methods: This was a retrospective, descriptive study of pediatric (<6 years old) sulfonylurea exposures with hypoglycemia (glucose concentration <60 mg/dL) that were consulted on by the California Poison Control System for the 8-year period between January 1, 2002, and December 31, 2009.

Results: Of the 1943 consultations for pediatric sulfonylurea exposure in the study period, 300 children developed hypoglycemia. Ten percent had hypoglycemia occurring or persisting ≥ 12 hours after ingestion despite receiving treatment. All 5 children with seizures experienced these before hospital presentation. The mean (SD) time to onset of hypoglycemia in children not given any prophylactic treatment was 2.0 (1.2) hours. The mean (SD) times in children receiving prophylactic food only, intravenous glucose only, and both food and intravenous glucose were 5.9 (3.9), 5.7 (2.5), and 8.9 (3.6) hours, respectively. Ranges were 1 to 18, 1.5 to 9, and 2.5 to 15 hours. Seven of 40 patients (18%) receiving prophylactic food only had an onset of hypoglycemia >8 hours after sulfonylurea ingestion.

Conclusions: Pediatric sulfonylurea exposure can result in significant poisoning. Severe effects such as seizures occurred only in cases of unrecognized sulfonylurea ingestion. The onset of hypoglycemia after pediatric sulfonylurea ingestion can be delayed by as much as 18 hours by either free access to food or administration of intravenous glucose.
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http://dx.doi.org/10.1542/peds.2010-3235DOI Listing
June 2011

Serum verapamil concentrations before and after Intralipid® therapy during treatment of an overdose.

Clin Toxicol (Phila) 2011 Apr;49(4):340-4

Department of Laboratory Medicine, University of California San Francisco, USA.

CONTEXT. Intralipid® infusion is useful in reversing cardiac and central nervous system toxicity of local anesthetic drugs, and recent reports suggest utility in other drug overdoses. CASE DETAILS. A 47-year-old man presented to the emergency department with hypotension and complete heart block 3 h after a sustained-release verapamil overdose. He was given supportive care including calcium and hyperinsulinemia/euglycemia therapy. Nineteen and 29 h post-ingestion, Intralipid® was administered as a bolus, followed by an infusion. OBJECTIVE. The objective of this study was to determine the serum verapamil concentrations before and after Intralipid® administration and to ascertain its clinical effects. DISCUSSION. It was found that administration of Intralipid® was followed by a decrease in verapamil concentration once the lipid had been removed from the sample, demonstrating that Intralipid® was effective in sequestering verapamil, effectively removing it from the serum, and supporting its use in the treatment of verapamil overdose. Intralipid® administration was associated with an increase in the patient's blood pressure, but because other vasoactive drugs were given at the same time, it was difficult to determine its relative contribution to clinical improvement.
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http://dx.doi.org/10.3109/15563650.2011.572556DOI Listing
April 2011

Risk factors for complications of drug-induced seizures.

J Med Toxicol 2011 Mar;7(1):16-23

Department of Emergency Medicine, Orlando Regional Medical Center, Orlando Health, Orlando, FL 32806, USA.

The purpose of this study is to determine clinical factors associated with complications of drug-induced seizures. This prospective observational study was conducted at an American Association of Poison Control Centers-certified regional poison control center (PCC) over a 1-year period. All consecutive cases reported to a PCC involving seizures were forwarded to investigators, who obtained standardized information including the specific drug or medication exposure, dose, reason for exposure, vital signs, laboratory data, treatment, and outcome. Patients were monitored by daily telephone follow-up until death or discharge. Subjects were excluded if the seizure was deemed to be unrelated to exposure. Odds ratios were used to analyze variables for associations with admission to the hospital for >72 h, endotracheal intubation, status epilepticus, anoxic brain injury, or death. One hundred twenty-one cases met inclusion criteria. Sixty-three (52%) were male, and the mean age was 30 (SD14) years. Common exposures included: antidepressants (33%), stimulants (15%), and anticholinergics (10%). One hundred and three (85%) of the exposures were intentional, of which 74 were suicide attempts and 16 were drug abuse or misuse. Forty-nine (40%) patients required endotracheal intubation, 12(10%) had status epilepticus, 50(41%) were hospitalized for more than 72 h, and one patient died. Median hospital stay was 3 days. Variables significantly associated with complications included stimulant exposure (odds ratios, OR=11 [95% confidence intervals (CI) 1.9-52]), suicide attempt (OR=2.2 [95% CI 1.02-4.7]), initial hypotension (OR=11.2 [95% CI 1.4-89.3]), admission glucose >130 mg/dL (OR=5.4 [95% CI 1.6-18.1]), and admission HCO(3) <20 mEq/L (OR=4.0 [95% CI 1.4-11.3]). Significant clinical factors associated with complications of drug-related seizures include stimulant exposure, suicide attempt, initial hypotension, and admission acidosis or hyperglycemia.
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http://dx.doi.org/10.1007/s13181-010-0096-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056005PMC
March 2011

Phenelzine-induced myocardial injury: a case report.

J Med Toxicol 2010 Dec;6(4):431-4

Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.

Introduction: Phenelzine is an irreversible monoamine oxidase inhibitor (MAOI). Hypertensive reactions after ingestion of tyramine-rich foods such as cheese are well known. However, a review of the available medical literature found no previous reports of myocardial infarction resulting from the ingestion of cheese by a patient taking a MAOI.

Case Report: A 34-year-old female taking phenelzine for depression developed severe chest pain 1 h after eating cheese. She was hypertensive and the electrocardiography showed ischemic changes in the antero-lateral chest leads. The chest pain and elevated blood pressure were relieved with intravenous morphine and nitroprusside. The initial serum troponin I level was normal, but serial repeat levels showed a rising trend with a peak at 4.89 ug/L (reference range <0.05 ug/L) 6 h after the initial blood draw, suggestive of a non-ST elevation myocardial infarction. The patient subsequently developed hypotension 4 h after another therapeutic dose of phenelzine was served to the patient 4 h after her admission to the ED. This was corrected with at least 2 L of intravenous normal saline boluses. Subsequent EKGs and Sestamibi scan showed no evidence of cardiac ischemia. She was discharged home after a hospital stay of 3 days.

Discussion: We believe this to be the first reported case of myocardial infarction resulting from ingestion of cheese in a patient taking a MAOI. It might be expected that hypertensive crisis could lead to a myocardial infarction, but a review of the medical literature found no such cases reported.
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http://dx.doi.org/10.1007/s13181-010-0101-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550457PMC
December 2010

Activated charcoal for acute poisoning: one toxicologist's journey.

Authors:
Kent R Olson

J Med Toxicol 2010 Jun;6(2):190-8

California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA 94143-1369, USA.

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http://dx.doi.org/10.1007/s13181-010-0046-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2919687PMC
June 2010

Case files of the California poison control system, San Francisco division: blue thunder ingestion: methanol, nitromethane, and elevated creatinine.

J Med Toxicol 2010 Mar;6(1):67-71

California Poison Control System, San Francisco Division, University of California, 2789 25th Street, Suite 2022, San Francisco, CA 94110, USA.

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http://dx.doi.org/10.1007/s13181-010-0042-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861177PMC
March 2010

Massive acetaminophen ingestion with early metabolic acidosis and coma: treatment with IV NAC and continuous venovenous hemodiafiltration.

Clin Toxicol (Phila) 2010 Feb;48(2):156-9

Department of Medicine and Emergency Medicine, Maine Medical Center and Northern New England Poison Center, 901 Washington Avenue, Portland, ME 04102, USA.

Context: We report the extraction of acetaminophen by continuous venovenous hemodiafiltration (CVVHD) during treatment of an acute ingestion of 200 g with a peak recorded serum acetaminophen level of 1,614 mg/L (10,652 micromol/L).

Case Details: The patient presented with early onset of coma, metabolic acidosis, and hypotension in the absence of significant hepatic injury. In addition to N-acetylcysteine (NAC) therapy, CVVHD was performed to manage the acid-base disturbance. Flow rate, effluent volume, and serum and effluent drug concentrations were obtained at hourly intervals. During 16 h of CVVHD the acetaminophen level dropped from 1,212 to 247 mg/L.

Discussion: The average clearance of acetaminophen by CVVHD was 2.53 L/h, with removal of 24 g of acetaminophen over 16 h. As NAC is effective in preventing hepatic injury after acute acetaminophen overdose, the role of dialysis or CVVHD is limited.
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http://dx.doi.org/10.3109/15563650903524142DOI Listing
February 2010

Carbon monoxide poisoning (acute).

BMJ Clin Evid 2010 Oct 12;2010. Epub 2010 Oct 12.

California Poison Control System, San Francisco Division and The University of California, California, USA.

Introduction: Carbon monoxide is an odourless, colourless gas, and poisoning causes hypoxia, cell damage, and death. Exposure to carbon monoxide is measured either directly from blood samples and expressed as a percentage of carboxyhaemoglobin, or indirectly using the carbon monoxide in expired breath. Carboxyhaemoglobin percentage is the most frequently used biomarker of carbon monoxide exposure. Although the diagnosis of carbon monoxide poisoning can be confirmed by detecting elevated levels of carboxyhaemoglobin in the blood, the presence of clinical signs and symptoms after known exposure to carbon monoxide should not be ignored.

Methods And Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of oxygen treatments for acute carbon monoxide poisoning? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results: We found 12 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: 100% hyperbaric oxygen, oxygen 28%, and oxygen 100% by non-re-breather mask.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217756PMC
October 2010

Tretinoin overdose: a first case report.

J Med Toxicol 2009 Jun;5(2):73-5

Department of Emergency Medicine, Singapore General Hospital, Singapore.

Introduction: Tretinoin (Vesanoid) is an all-trans-retinoic acid, and is related to retinol (Vitamin A). To date, there have been several case reports on overdose with its isomer isotretinoin, but none involving overdose of tretinoin. We report the first known case of a patient who ingested a massive overdose of tretinoin.

Case Report: A 31-year-old man ingested 1000 mg of tretinoin (100 pills of Vesanoid 10 mg) in a suicide attempt. He developed nonbloody diarrhea, but otherwise had no complaints. Clinical examination was normal. The patient was treated with activated charcoal and was hydrated. The patient's blood results did not show any deterioration on the third consecutive day. He was discharged well on the third day, but was subsequently lost to follow-up.

Discussion: Although there has been no reported experience with acute tretinoin overdose in humans, our patient took a dose approximately 3 times the recommended maximum tolerated daily dose in patients with myelodysplastic syndrome or solid tumors (195 mg/m2 per day). Overdose with other retinoids such as isotretinoin have been associated with only minor symptoms that resolved quickly. Our patient had diarrhea, which also resolved quickly with symptomatic treatment and hydration.

Conclusion: We believe this to be the first case report of an acute oral overdose of tretinoin. The patient developed diarrhea, but was otherwise asymptomatic.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550323PMC
http://dx.doi.org/10.1007/BF03161091DOI Listing
June 2009