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2010 Annual Report o the American Association

o Poison Control Centers National PoisonData System (NPDS): 28th Annual Report

ALVIN C. BRONSTEIN, MD; DANIEL A. SPYKER, MD, PHD; LOUIS R. CANTILENA, JR, MD, PHD; JODY L. GREEN, PHD;BARRY H. RUMACK, MD, and RICHARD C. DART, MD, PHD

Clinical Toxicology (2011), 49 , 910941Copyright 2011 In orma Healthcare USA, Inc.ISSN: 1556-3650 print / 1556-9519 onlineDOI: 10.3109/15563650.2011.635149

Address correspondence to Alvin C. Bronstein MD, FACEP, FACMT,American Association o Poison Control Centers, 515 King Street,Suite 510, Alexandria, VA 22314. E-mail: [email protected]


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Copyright In orma Healthcare USA, Inc. 2011

AAPCC 2010 Annual Report o the NPDS 911

Table o ContentsAbstract .................................................................................................................................................................................. 914Introduction ............................................................................................................................................................................ 914

Whats New in NPDS and the Annual Report ..................................................................................................................... 914The NPDS Application ........................................................................................................................................................ 915

Limitations and Plans ......................................................................................................................................................... 915Methods .................................................................................................................................................................................. 916

Characterization o Participating Poison Centers and Population Served ......................................................................... 916

Call Management Specialized Poison Exposure Emergency Providers........................................................................... 916 NPDS Near Real-time Data Capture ............................................................................................................................... 916 Annual Report Case Inclusion Criteria .............................................................................................................................. 917Statistical Methods .............................................................................................................................................................. 917

NPDS Surveillance ............................................................................................................................................................. 917Fatality Case Review and Abstract Selection ...................................................................................................................... 917Pediatric Fatality Case Review ........................................................................................................................................... 918

Results .................................................................................................................................................................................... 918 In ormation Calls to Poison Centers ................................................................................................................................... 918 Exposure Calls to Poison Centers ....................................................................................................................................... 919 Age and Gender Distributions ............................................................................................................................................ 922Caller Site and Exposure Site ............................................................................................................................................. 922

Exposures in Pregnancy ...................................................................................................................................................... 922Chronicity ............................................................................................................................................................................ 922

Reason or Exposure ........................................................................................................................................................... 922Scenarios .......................................................................................................................................................................... 923

Reason by Age .................................................................................................................................................................. 923 Route o Exposure ............................................................................................................................................................... 924Clinical E ects .................................................................................................................................................................... 924Case Management Site ........................................................................................................................................................ 925

Medical Outcome ................................................................................................................................................................ 925 Decontamination Procedures and Specifc Antidotes ......................................................................................................... 925Top Substances in Human Exposures ................................................................................................................................. 926Changes rom Last Year ...................................................................................................................................................... 926

Distribution o Suicides ....................................................................................................................................................... 927Plant Exposures .................................................................................................................................................................. 928

Deaths and Exposure-related Fatalities .............................................................................................................................. 928 All atalities all ages ..................................................................................................................................................... 929Pediatric atalities age 5 years .................................................................................................................................. 936Pediatric atalities ages 612 years .............................................................................................................................. 937

Adolescent atalities ages 1319 years ......................................................................................................................... 937Pregnancy and Fatalities ................................................................................................................................................. 937

AAPCC Surveillance Results .............................................................................................................................................. 9382010 Gul o Mexico Oil Spill .......................................................................................................................................... 939THC Homologs and Bath Salts ........................................................................................................................................ 940

Discussion .............................................................................................................................................................................. 940Summary ................................................................................................................................................................................ 940Re erences .............................................................................................................................................................................. 940

Disclaimer .............................................................................................................................................................................. 941

AppendixTable 21. Listing o Fatal Nonpharmaceutical and Pharmaceutical Exposures .......................................................................... iTable 22A. Demographic pro le o SINGLE SUBSTANCE Nonpharmaceuticals exposure cases

by generic category ..........................................................................................................................................................xcviiiTable 22B. Demographic pro le o SINGLE SUBSTANCE Pharmaceuticals exposure cases

by generic category ..........................................................................................................................................................cxviiiAppendix A Acknowledgments ............................................................................................................................................cxl

NPDS Toxicology Quote o the Day ......................................................................................................................................cxlPoison Centers (PCs) ............................................................................................................................................................cxl


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Clinical Toxicology vol. 49 no. 10 2011

912 A. C. Bronstein et al.

Fatality Review Team ......................................................................................................................................................... cxlii AAPCC Micromedex Joint Coding Group ........................................................................................................................ cxliii AAPCC Rapid Coding Team ............................................................................................................................................. cxliii AAPCC Surveillance Team ............................................................................................................................................... cxliii Regional Poison Center (PC) Fatality Awards .................................................................................................................. cxliii

Appendix B Data De nitions ............................................................................................................................................ cxliv Reason or Exposure ......................................................................................................................................................... cxliv Medical Outcome .............................................................................................................................................................. cxliv

Relative Contribution to Fatality (RCF) .............................................................................................................................cxlvAppendix C Abstracts o Selected Cases ............................................................................................................................cxlv

Selection o Abstracts or Publication ................................................................................................................................cxlv Abstracts .............................................................................................................................................................................cxlv Abbreviations & Normal ranges or Abstracts ................................................................................................................. clxix


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List o Figures and TablesFigure 1. Human Exposure Calls, In ormation Calls and Animal Exposure Calls by Day since 1 January 2000 ................ 919Figure 2. All Drug Identi cation and Law En orcement Drug Identi cation Calls by Day since 1 January 2000 ............... 921Figure 3. Health Care Facility (HCF) Exposure Calls and HCF In ormation Calls by Day since 1 January 2000 ............... 922Figure 4. Change in Encounters rom 2009 to 2010 with Graphical Breakdown o Exposure Calls .................................... 932Figure 5. Gul Oil Spill Encounters per Day ......................................................................................................................... 933Figure 6. Emerging Trends: Bath Salts and THC Homologs Exposures ............................................................................... 933Figure 7. Human Exposure Calls By Year 20002010 Top 4 Categories ........................................................................... 934

Table 1A. AAPCC Population Served and Reported Exposures (19832010) ...................................................................... 918Table 1B. Non-Human Exposures by Animal Type ............................................................................................................... 919Table 1C. Distribution o In ormation Calls .......................................................................................................................... 919Table 2. Site o Call and Site o Exposure, Human Exposure Cases ..................................................................................... 922Table 3A. Age and Gender Distribution o Human Exposures .............................................................................................. 923Table 3B. Population-Adjusted Exposures by Age Group ..................................................................................................... 923Table 4. Distribution o Age a and Gender or Fatalities b ....................................................................................................... 924Table 5. Number o Substances Involved in Human Exposure Cases ................................................................................... 924Table 6A. Reason or Human Exposure Cases ...................................................................................................................... 924Table 6B. Scenarios or Therapeutic Errors a by Age b ............................................................................................................ 925Table 7. Distribution o Reason or Exposure by Age ........................................................................................................... 926Table 8. Distribution o Reason or Exposure and Age or Fatalities a ................................................................................... 927Table 9. Route o Exposure or Human Exposure Cases ....................................................................................................... 927Table 10. Management Site o Human Exposures ................................................................................................................. 928Table 11. Medical Outcome o Human Exposure Cases by Patient Age a.............................................................................. 928Table 12. Medical Outcome by Reason or Exposure in Human Exposures a........................................................................ 929Table 13. Duration o Clinical E ects by Medical Outcome................................................................................................. 929Table 14. Decontamination and Therapeutic Interventions ................................................................................................... 930Table 15. Therapy Provided in Human Exposures by Age .................................................................................................... 930Table 16A. Decontamination Trends (19852009) ................................................................................................................ 931Table 16B. Decontamination Trends: Total Human and Pediatric Exposures 5 Years (2010) a .......................................... 932Table 17A. Substance Categories Most Frequently Involved in Human Exposures (Top 25) ............................................... 934Table 17B. Substance Categories with the Greatest Rate o Exposure Increase (Top 25) ..................................................... 935Table 17C. Substance Categories Most Frequently Involved in Pediatric ( 5 years) Exposures (Top 25) a ......................... 935Table 17D. Substance Categories Most Frequently Involved in Adult ( 20 years) Exposures (Top 25) a ............................ 936Table 17E. Substance Categories Most Frequently Involved in Pediatric ( 5 years) Deaths a ............................................. 936Table 17F. Substance Categories Most Frequently Identi ed in Drug Identi cation Calls (Top 25) .................................... 937Table 17G. Substance Categories Most Frequently Involved in Pregnant Exposures a (Top 25) ........................................... 937Table 18. Categories Associated with Largest Number o Fatalities (Top 25) a ..................................................................... 938Table 19A. Comparisons o Death Data (19852010) a ......................................................................................................... 938Table 19B. Comparisons o Direct and Indirect Death Data (20002010) a .......................................................................... 939Table 20. Frequency o Plant Exposures (Top 25) a................................................................................................................ 939

AppendixTable 21. Listing o Fatal Nonpharmaceutical and Pharmaceutical Exposures .......................................................................... iTable 22A. Demographic pro le o SINGLE SUBSTANCE Nonpharmaceuticals exposure cases

by generic category ..........................................................................................................................................................xcviiiTable 22B. Demographic pro le o SINGLE SUBSTANCE Pharmaceuticals exposure cases

by generic category ..........................................................................................................................................................cxviii


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Abstrac t

Background: This is the 28th Annual Report o the AmericanAssociation o Poison Control Centers (AAPCC) NationalPoison Data System (NPDS). All US poison centers upload casedata automatically with a median time interval o 19.0 [11.9,40.6] (median [25%, 75%]) minutes, creating a near real-timenational exposure and in ormation database and surveillance

system. Methodology: We analyzed the case data tabulating speci cindices rom NPDS. The methodology was similar to that o previous years. Where changes were introduced, the di erencesare identi ed. Poison center cases with medical outcomes o deathwere evaluated by a team o 33 medical and clinical toxicologistreviewers using an ordinal scale o 1 (Undoubtedly responsible)6(Unknown) to determine Relative Contribution to Fatality (RCF)o the exposure to the death. Results: In 2010, 3,952,772 closed encounters were logged byNPDS: 2,384,825, human exposures, 94,823 animal exposures,1,466,253 in ormation calls, 6537 human con rmed nonexposures,and 334 animal con rmed nonexposures. Total encounters showeda 7.7% decline rom 2009 while health care acility calls increased

by 2.7%. Human exposures with more serious outcomes (minor,moderate, major or death) increased 4.5% while those with lessserious outcomes (all other medical outcome categories) decreased5.9%. All in ormation calls decreased 12.6% and health care

acility (HCF) in ormation calls decreased 13.6%, Drug ID callsdecreased 10.9%, and human exposures decreased 3.8%. The top5 substance classes most requently involved in all human exposureswere analgesics (11.5%), cosmetics/personal care products(7.7%), household cleaning substances (7.3%), sedatives/hypnotics/ antipsychotics (6.0%), and oreign bodies/toys/miscellaneous(4.2%). Analgesic exposures as a class increased the most rapidly by32.8% over the last decade. The top ve most common exposures inchildren age 5 years or less were cosmetics/personal care products(13.2%), analgesics (9.4%), household cleaning substances (9.2%),

oreign bodies/toys/miscellaneous (7.2%), and topical preparations(6.8%). THC homolog and designer amphetamine (Bath Salts)exposures were identi ed as emerging public health threats. Drugidenti cation requests comprised 64.3% o all in ormation calls.NPDS documented 1730 human exposures resulting in death with1146 human atalities judged related with an RCF o 1-Undoubtedlyresponsible, 2-Probably responsible, or 3-Contributory. Conclusions: These data support the continued value o poisoncenter expertise and need or specialized medical toxicologyin ormation to manage the more severe exposures, despite adecrease in calls involving less severe exposures. Unintentionaland intentional exposures continue to be a signi cant cause o

morbidity and mortality in the US. The near real-time, alwayscurrent status o NPDS represents a national public health resourceto collect and monitor US exposure cases and in ormation calls.The continuing mission o NPDS is to provide a nationwidein rastructure or public health surveillance or all types o exposures, public health event identi cation, resilience responseand situational awareness tracking. NPDS is a model system orthe nation and global public health.

Introduction

This is the 28th Annual Report o the American Associationo Poison Control Centers (AAPCC; http://www.aapcc.org)National Poison Data System (NPDS). 1 On 1 January 2010,sixty regional Poison Centers (PCs) serving the entire popu-lation o the 50 United States, American Samoa, District o Columbia, Federated States o Micronesia, Guam, PuertoRico, and the US Virgin Islands submitted in ormation andexposure case data collected during the course o providingtelephonic patient tailored exposure management and poisonin ormation. On 17 December 2010, the Western New York

Poison Center (Bu alo) serving Western New York ceasedoperations. The Ruth A. Lawrence Poison Center (Roches-ter) closed on 30 December 2010. The Long Island RegionalPoison Control Center (Mineola) ceased operations on 31December 2010. New York State is now served by two poi-son centers based in New York City and Syracuse. Duringthis transition national coverage remained seamless.

NPDS is the data warehouse or the nations poisoncenters. Poison Centers (PCs) place emphasis on exposuremanagement, accurate data collection and coding, and thecontinuing need or poison related public and pro essionaleducation. The PCs health care pro essionals are available

ree o charge to all, 24-hours a day, every day o the year.

PCs respond to questions rom the public, health care pro-essionals, and public health agencies. The continuous sta

dedication at the regional PCs is mani est as the number o exposure and in ormation call encounters exceeds 3.9 millionannually. PC encounters either involve an exposed humanor animal (EXPOSURE CALL) or a request or in orma-tion (INFORMATION CALL) with no exposed person oranimal.

Whats New in NPDS and the Annual ReportSeveral enhancements were made to the tables and gures

or this report. Continuing goals o the writing team have

been to remove inconsistencies, improve the readers abil-ity to clearly understand the data, and provide additionaldata where appropriate. Two new tables have been added tothis years report: Table 3B Population-Adjusted Exposuresby Age Groups and Table 17G Substance Categories MostFrequently Involved in Pregnant Exposures (Top 25).

This year, the AAPCC Fatality Review team did not reviewdeath (indirect report) cases. Death (indirect report) casesare reports identi ed through other sources (news eeds,medical examiner data or other) about which no inquiry tothe PC was made. In previous years, both death and death(indirect report) cases were reviewed and included in the

WARNING: Comparison o exposure or outcome datarom previous AAPCC Annual Reports is problematic.

In particular, the identi cation o atalities (attribution o a death to the exposure) di ered rom pre-2006 AnnualReports (see Fatality Case ReviewMethods). Poisoncenter death cases are described as all cases resulting indeath and those determined to be exposure-related atali-ties. Likewise, Table 22 (Exposure Cases by Generic Cat-egory) since year 2006 restricts the breakdown includingdeaths to single-substance cases to improve precision and avoid misinterpretation.


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tables. This year, all the tables related to atalities containonly death cases with an AAPCC Relative Contribution o Fatality (RCF) o 1, 2,or 3, except Tables 11, 12, 19A, 19B,and 21 which also contain death (indirect report) casesseelist below:

Table Fatalities Included RCFNumber

o Deaths

4 Death only 1,2,3 1,1465 Death only 1,2,3 1,1468 Death only 1,2,3 1,1469 Death only 1,2,3 1,146

11 Death and Death (indirect report) All 1,73012 Death and Death (indirect report) All 1,730

17E Death and Death (indirect report) All 1,73018 Death only 1,2,3 1,366

19A Death and Death (indirect report) All 1,73019B Death and Death (indirect report) All 1,730

21 Death and Death (indirect report) 1,2,3 1,36622 Death and Death (indirect report) -

Single substance deaths onlyAll 764

Enhancements were added to the NPDS Fatality module toaid the atality team in per orming their review. The assign-ment o the Annual Report ID or the atality cases includedin Table 21 has now been automated. This will allow thecases in Table 21 to be easily identi ed when responding toAnnual Report questions or comments.

Throughout the year the AAPCC Micromedex Joint Cod-ing Group reviews the Generic Codes and responds to ques-tions and requests or new generic codes. The group consistso AAPCC members and editorial and lexicon sta romMicromedex Poisindex (Micromedex Healthcare Series[Internet database]. Greenwood Village, CO: ThomsonReuters [Healthcare] Inc.). New Product Codes and AAPCCGeneric Codes were added to NPDS to address emergingproducts. In 2010, new generic codes were added or the ol-lowing six product classes:

1. Electronic Cigarettes2. Energy Drinks3. Hand sanitizers4. Opioids5. Tetrahydrocannabinol (THC) Pharmaceuticals6. Tetrahydrocannabinol (THC) Homologs

At the time o this report, there were 965 active and 12 obso-

lete generic codes. The active codes are divided into Non-Pharmaceutical (541) and Pharmaceutical (424) groups.These two groups are urther divided into Major (67) andMinor (167) categories. New products associated withthese classes were also added by Micromedex. Addition o these generic codes provides enhanced report granularity asrefected in Table 22. Because the new codes were addedat di erent times during the year, the numbers in Table 22may not accurately refect all o the cases in these categories,and or completeness certain categories require customizeddata retrieval until these categories have been in place or aminimum o a ull year or more (2011 orward).

The NPDS ApplicationIn 2010, numerous enhancements were introduced in theNPDS web-based application. Many o these ocused onenhancing enterprise reports and surveillance unctions. Onehundred sixty-nine (169) enterprise reports now return multi-year results. The Case Log reports were expanded to supportany combination o 24 separate search parameters and nine(9) di erent result ormats. NPDS Case Log reports nowsupport a variety o outputs including case line listing, dailyand monthly counts, time series charts, and US maps. CaseLog Counts Reports were added that strati y the results basedon user de ned classi cations. To simpli y product selection

or reports, a new product selection unction was added thatdisplays products associated with a speci c AAPCC GenericCode. Finally, a new National Case Log report was addedthat allows Regional Poison Centers to use the power o theCase Log (Generic Code) report to execute a national caselisting without geographic or case identi ers.

New surveillance unctions were added to support in or-mation call and animal call volume surveillance. To aid theAAPCC Surveillance Team anomaly review, a PendingStatus indicator was added or all anomalies to allow users toidenti y anomalies that are in the process o being analyzed.In addition, a new Case Classi cation parameter was addedto the Case Based anomalies to allow users to classi y theanomaly.

To provide centers with more in ormation on public healthevents, a Special Projects report was added to the NPDSenterprise reporting system. This report provides geocentricreporting o AAPCC de ned products or real time eventmonitoring. For example, the NPDS report was utilized byregional poison centers to access national cases related to theGul o Mexico Oil spill in real-time.

NPDS aggregate and case detail web services oper-ate continuously, allowing external systems or viewers toanalyze NPDS data in ways not otherwise possible in theNPDS application. The aggregate web service providestotal call volume, human exposure call volume, or clinicale ects counts allowing an external system such as RODS(Realtime Outbreak and Disease Surveillance, University o Pittsburgh, Department o Biomedical In ormatics) to createtime-series or GIS displays. Unique to NPDS, the aggregatecase count web service is not only accessible by externalcomputer systems but also directly by system users to createtheir own time series without the need or external systemso tware. Two state health departments utilize the case detailweb service to analyze data rom their PCs. Four state healthdepartments access the aggregate count web service or data.The web services allow NPDS data to be provisioned in a

ederated manner where the data is always current in NPDSand can be readily accessed as needed without the need orcostly cloning and warehousing. 2

Limitations and PlansAs outlined above, the encounters (exposure reports and in or-mation questions) which comprise NPDS are collected romspontaneous, sel -reported calls made to US PCs. Exposures


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in NPDS comprise a portion o the total number o incidentsthat occurred. These refect the limitations o this type o passive reporting system (see DISCLAIMER).

Most o the 390,000 proprietary and non-proprietarydrugs, chemicals, and biological agents including ood poi-soning agents in the NPDS products data base are classi edby their primary active ingredient into one o 965 AAPCCgeneric codes. Some multiple ingredient products are coded

to multiple product generic codes (e.g., acetaminophen withhydrocodone). Table 22 and other tables reporting in orma-tion by generic category are organized by this system. Thusour current review and reporting methods do not necessarilydistinguish between the individual components o a combi-nation product.

Nonetheless, the scope and immediacy o these data havemuch to o er. In particular, the 28-years history o ers aunique opportunity to assess the long term (secular) trendsin exposures and in ormation calls.

There are a number o plans to improve the data systemand reporting or 2010 and beyond including:

Enhancements to NPDS real-time geographic in orma-tion system (GIS) with more data display options orappropriate data analyses;

Enhancements to case-based surveillance systems; Continued improvements in data quality edits; Implement security paradigm enhancements to support

speci c product access or reports and surveillance; Enterprise report enhancements; New auto-upload requirements and improved solution; Lexicon based analysis o the current generic code

system to better meet current exposure tracking andsurveillance needs;

Review and analysis o NPDS clinical e ect codingterminology.

These and other initiatives are under continuous reviewby the AAPCC Board, NPDS Steering Committee, andCDC.

Methods

Characterization o Participating PoisonCenters and Population Served Sixty participating centers submitted data to AAPCC through17 December 2010, 59 participating centers submitted data

to AAPCC through 30 December 2010, 58 participating cen-ters submitted data to AAPCC through 31 December 2010,with the total center count decreasing to 57 or the remain-der o 2010. Fi ty-seven centers (95%) were accredited byAAPCC as o 1 July 2010. The entire population o the 50states, American Samoa, the District o Columbia, FederatedStates o Micronesia, Guam, Puerto Rico, and the US VirginIslands was served by the US PC network in 2010. 3,4

The average number o human exposure cases managedper day by all US PCs was 6,534. Similar to other years,higher volumes were observed in the warmer months, witha mean o 6,950 cases per day in June compared with 6,305

per day in January. On average, US PCs received a call aboutan actual human exposure every 13.2 sec.

Call Management Specialized Poison Exposure Emergency ProvidersMost PC operations management, clinical education, andinstruction are directed by Managing Directors (most are

PharmDs and RNs with American Board o Applied Toxi-cology [ABAT] board certi cation). Medical direction isprovided by Medical Directors who are board-certi ed phy-sician medical toxicologists. At some PCs, the Managing andMedical Director positions are held by the same person.

Calls received at US PCs are managed by healthcarepro essionals who have received specialized training intoxicology and managing exposure emergencies. These pro-viders include medical and clinical toxicologists, registerednurses, doctors o pharmacy, pharmacists, chemists, hazard-ous materials specialists, and epidemiologists. Specialists inPoison In ormation (SPIs) are primarily registered nurses,PharmDs, and pharmacists. They work under the supervi-

sion o a Certi ed Specialist in Poison In ormation (CSPI).SPIs must log a minimum o 2,000 calls over a 12-monthperiod to become eligible to take the CSPI examination

or certi cation in poison in ormation. Poison In ormationProviders (PIPs) are allied healthcare pro essionals. Theymanage in ormation-type and low acuity (non-hospital) callsand work under the supervision o a CSPI. O note is the

act that no nursing or pharmacy school o ers a toxicologycurriculum designed or PC work and SPIs must be trainedin programs o ered by their respective PC. Centers areaccredited by the AAPCC meeting strict standards and mustbe reaccredited every 5 years.

NPDS Near Real-time Data CaptureLaunched on 12 April 2006, NPDS is the data repository orall o the US regional PCs. In 2010, all 60 o the 60 USPCs uploaded case data automatically to NPDS through17 December 2010. The center count decreased to 59 as o 17 December 2010, to 58 as o 30 December 2010 and to 57as o 31 December 2010. All centers submitted data in nearreal-time making NPDS one o the ew operational systems o its kind. PC sta record calls contemporaneously in 1 o 4 casemanagement systems. Each center uploads case data periodi-cally as it is entered. The time to upload data or all PCs is 19.9

[9.7, 58.7] (median [25%, 75%]) minutes creating a real-timenational exposure database and surveillance system.

The web-based NPDS so tware acilitates detection, analy-sis, and reporting o NPDS surveillance anomalies. Systemso tware o ers a myriad o surveillance uses allowingAAPCC, its member centers and public health agencies toutilize NPDS US exposure data. Users are able to accesslocal and regional data or their own areas and view nationalaggregate data. The application allows or increased drill-down capability and mapping via a geographic in ormationsystem (GIS). Custom surveillance de nitions are availablealong with ad hoc reporting tools. In ormation in the NPDS


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database is dynamic. Each year the database is locked priorto extraction o annual report data to prevent inadvertentchanges and ensure consistent, reproducible reports. The 2010database was locked on 9 October 2011 at 0930 hr EDT.

Annual Report Case Inclusion CriteriaThe in ormation in this report refects only those cases

that are not duplicates and classi ed by the regional PC asCLOSED. A case is closed when the PC has determinedthat no urther ollow-up/recommendations are required orno urther in ormation is available. Exposure cases are ol-lowed to obtain the most precise medical outcome possible.Depending on the case speci cs, most calls are closedwithin the rst hours o the initial call. Some calls regard-ing complex hospitalized patients or cases resulting in deathmay remain open or weeks or months while data continuesto be collected. Follow-up calls provide a proven mechanism

or monitoring the appropriateness o management recom-mendations, augmenting patient guidelines, and providingpoison prevention education, enabling continual updates o

case in ormation as well as obtaining nal/known medicaloutcome status to make the data collected as accurate andcomplete as possible.

Statistical MethodsAll tables except Tables 3B and 17B were generated directlyby the NPDS web-based application and can thus be repro-duced by each center. The gures and statistics in Tables 3Band 17B were created using SAS JMP version 9.0.0 (SASInstitute, Cary, NC) on summary counts generated by theNPDS web-based application.

NPDS SurveillanceAs previously noted, all o the active US PCs upload casedata automatically to NPDS. This unique near real-timeupload is the oundation o the NPDS surveillance system.This makes possible both spatial and temporal case volumeand case based surveillance. NPDS so tware allows creationo volume and case based de nitions. De nitions can beapplied to national, regional, state, or ZIP code coverageareas. Geocentric de nitions can also be created. This unc-tionality is available not only to the AAPCC surveillanceteam, but to every regional PC. PCs also have the ability toshare NPDS real-time surveillance technology with external

organizations such as their state and local health departmentsor other regulatory agencies. Another NPDS eature is theability to generate system alerts on adverse drug events andother products o public health interest like contaminated

ood or product recalls. NPDS can thus provide real-timeadverse event monitoring and surveillance or resilienceresponse and situational awareness.

Surveillance de nitions can be created to monitor a varietyo volume parameters, any desired substance or commercialproduct in the Micromedex Poisindex products database.The database contains over 390,000 entries. Surveillancede nitions may be constructed using volume or case based

de nitions with a variety o mathematical options andhistorical baseline periods rom 1 to 11 years. NPDS surveil-lance tools include the ollowing:

Volume Alerts Surveillance De nitions Total Call Volume Human Exposure Call Volume Animal Exposure Call Volume In ormation Call Volume Clinical E ects Volume (signs and symptoms, or

laboratory abnormalities) Case Based Surveillance De nitions utilizing various

NPDS data elds linked in Boolean expressionsSubstanceClinical E ectsSpeciesMedical Outcome and others

Incoming data is monitored continuously and anomaloussignals generate an automated email alert to the AAPCCssurveillance team or designated regional PC or public health

agency. These anomaly alerts are reviewed daily by theAAPCC surveillance team and/or the regional PC that cre-ated the surveillance de nition. When reports o potentialpublic health signi cance are detected, additional in orma-tion is obtained via the NPDS surveillance correspondencesystem or phone as appropriate rom reporting PCs. Theregional PC then alerts their respective state or local healthdepartments. Public health issues are brought to the attentiono the Health Studies Branch, Division o EnvironmentalHazards and Health E ects, National Center or Environ-mental Health, Centers or Disease Control and Prevention(CDC). This unique near real-time tracking ability is a unique

eature o ered by NPDS and the regional PCs.AAPCC Surveillance Team clinical and medical toxicol-

ogists review surveillance de nitions on a regular basis tone-tune the queries. CDC, as well as State and local health

departments with NPDS access as granted by their respec-tive regional PCs, also have the ability to create surveillancede nitions or routine surveillance tasks or to respond toemerging public health events.

Fatality Case Review and Abstract SelectionNPDS atality cases can be recorded as DEATH or DEATH(INDIRECT REPORT). Medical outcome o death is bydirect report. Death (indirect reports) are deaths that the

PC acquired rom medical examiners or media, but did notmanage nor answer any questions related speci cally to thatdeath.

Although PCs may report death as an outcome, the deathmay not be the direct result o the exposure. We de neexposure-related atality as a death judged by the AAPCCFatality Review Team to be at least contributory to the expo-sure. The de nitions used or the Relative Contribution toFatality (RCF) classi cation are de ned in Appendix B andthe methods to select abstracts or publications is describedin Appendix C. For details o the AAPCC atality reviewprocess, see the 2008 annual report. 1


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Pediatric Fatality Case ReviewA ocused Pediatric Fatality Review team, comprised o 3pediatric toxicologists, was assembled this year to evaluatecases in patients under 18 years o age. The panel reviewedthe documentation o all such cases, with speci c ocus onthe conditions behind the poisoning exposure and on nd-ing commonality which might in orm e orts at prevention.Seventy-one cases were reviewed and ound to have a bimodalage distribution. Exposures causing death in children age5 years were mostly coded as Unintentional-General whilethose in ages over 12 years were mostly Intentional. O tenthe Reason Code did not capture the complexities o the case.For example, there were ew mentions o details such as theinvolvement o law en orcement or child protective services.While there were some complete and in ormative reports,in many narratives the circumstances which preceded theexposure thought responsible or the death was unclear orabsent. In response to these ndings, the pediatric atalityreview team will develop Pediatric Narrative Guidelines orthe upcoming year, with speci c attention to the root causeo these cases. As a result, poison centers will be requestedto implement guidelines recommending the most in-depthcausality investigation possible.

Results

In 2010, the participating PCs logged 3,952,772 total encoun-ters including 2,384,825 closed human exposure cases(Table 1A), 94,823 animal exposures (Table 1B), 1,466,253in ormation calls (Table 1C), 6,537 human con rmed non-exposures, and 334 animal con rmed non-exposures. Anadditional 449 calls were still open at the time o databaselock. The cumulative AAPCC database now contains nearly

51 million human exposure case records (Table 1A). A totalo 13,357,650 in ormation calls have been logged by NPDSsince the year 2001.

Figure 1 shows the human exposures, in ormation callsand animal exposures by day since 2001. Second order (qua-dratic) least squares regression or 20002010 has shown astatistically signi cant departure rom linearity (decliningrate o calls since mid-2007) or Human Exposure Calls.In ormation Calls are declining more rapidly than the qua-dratic regression this year, and Animal Exposure Calls havelikewise been declining since mid-2005.

A hallmark o PC case management is the use o ol-low-up calls to monitor case progress and medical outcome.US PCs made 2,841,477 ollow-up calls in 2010. Follow-upcalls were done in 46.0% o human exposure cases. One

ollow-up call was made in 22.4% o human exposure cases,and multiple ollow-up calls (range 2666) were placed in23.6% o cases.

In ormation Calls to Poison CentersData rom 1,466,253 in ormation calls to PCs in 2010 (Table1C) was transmitted to NPDS, including calls in optionalreporting categories such as prevention/sa ety/education(31,656), administrative (23,546) and caller re erral (65,652).

Table 1A. AAPCC Population Served and Reported Exposures(19832010)

Year

No. o participating

centers

Populationserved (inmillions)

Humanexposures

Exposuresper

thousandpopulation

1983 16 43.1 251,012 5.81984 47 99.8 730,224 7.31985 56 113.6 900,513 7.91986 57 132.1 1,098,894 8.31987 63 137.5 1,166,940 8.51988 64 155.7 1,368,748 8.81989 70 182.4 1,581,540 8.71990 72 191.7 1,713,462 8.91991 73 200.7 1,837,939 9.21992 68 196.7 1,864,188 9.51993 64 181.3 1,751,476 9.71994 65 215.9 1,926,438 8.91995 67 218.5 2,023,089 9.31996 67 232.3 2,155,952 9.31997 66 250.1 2,192,088 8.81998 65 257.5 2,241,082 8.71999 64 260.9 2,201,156 8.42000 63 270.6 2,168,248 8.02001 64 281.3 2,267,979 8.12002 64 291.6 2,380,028 8.22003 64 294.7 2,395,582 8.12004 62 293.7 2,438,643 8.32005 61 296.4 2,424,180 8.22006 61 299.4 2,403,539 8.02007 61 305.6 2,482,041 8.12008 61 308.5 b 2,491,049 8.12009 60 310.9 b 2,479,355 8.02010 60 a 313.3 b 2,384,825 7.6Total 50,935,385aAs o 1 July 2010 there were 60 Participating Centers.bAs o 1 July Mid Year US Census (50 United States, American Samoa,District o Columbia, Federated States o Micronesia, Guam, Puerto Rico,and the US Virgin Islands). 3,4

Figure 2 shows that All Drug ID calls decreased dra-matically in mid-2009, and again in late-2010 (no regressionwas t to these data). En orcement Drug ID Calls showeda declining rate o increase. The most requent in orma-tion call was or Drug ID, comprising 942,614 calls to PCsduring the year. O these, 566,543 (60.1%) were identi edas drugs with known abuse potential; however, these caseswere categorized based on the drugs abuse potential without

knowledge o whether abuse was actually intended.While the number o Drug In ormation calls decreased

9.4% rom 2009 (239,943 calls) to 2010 (217,286), the DrugIn ormation calls as a percentage o all in ormation calls was14.3% and 14.8%, respectively. O these, the most commonrequests were in regards to therapeutic use and indications,

ollowed by drugdrug interactions, questions about dosageand inquiries o adverse e ects. Environmental inquiriescomprised 1.6% o all in ormation calls. O these environ-mental inquiries, questions related to cleanup o mercury(thermometers and other) remained the most common ol-lowed by questions involving pesticides.


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0

2000

4000

6000

8000

10000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

E n c o u n

t e r s

P e r

D a y

Human Exposures = -150366 + 78.3*Year - 20.4*Year^2

Information Calls = -515029 + 259*Year - 25.84*Year^2

Animal Exposures = 14.3 + 0.180*Year - 4.14*Year^2

Fig. 1. Human Exposure Calls, In ormation Calls and Animal Exposure Calls by Day since 1 January 2000.Black lines show least-squares second order regression both linear and second order (quadratic) terms were statistically signi cant or each o the 3 regressions.(See colour version o this gure online).

Table 1B. Non-Human Exposures by Animal TypeAnimal N %

Dog 85,804 90.49Cat 7,936 8.37Horse 259 0.27Bird 238 0.25Rodent/lagomorph 185 0.20Cow 70 0.07Sheep/goat 64 0.07Aquatic 30 0.03Other 237 0.25Total 94,823 100.00

Table 1C. Distribution o In ormation Calls

In ormation call type N

% o In o.calls

Drug identifcationPublic inquiry: Drug sometimes

involved in abuse462,128 31.52

Public inquiry: Drug not known tobe abused

192,972 13.16

Public inquiry: Unknown abusepotential

5,416 0.37

Public inquiry: Unable to identi y 86,201 5.88HCP inquiry: Drug sometimes

involved in abuse6,819 0.47

HCP inquiry: Drug not known tobe abused

12,317 0.84

HCP inquiry: Unknown abusepotential

458 0.03

HCP inquiry: Unable to identi y 5,056 0.34Law En . Inquiry: Drug

sometimes involved in abuse97,596 6.66

Law En . Inquiry: Drug not knownto be abused

51,007 3.48

Law En . Inquiry: Unknown abusepotential

1,726 0.12

Law En . Inquiry: Unable toidenti y

14,121 0.96

Other drug ID 6,797 0.46Subtotal 942,614 64.29

Drug in ormationAdverse e ects (no known

exposure)13,893 0.95

Brand/generic name clari cations 3,710 0.25Calculations 213 0.01Compatibility o parenteral

medications309 0.02

Compounding 617 0.04Contraindications 1,824 0.12Dietary supplement, herbal, and

homeopathic792 0.05

Dosage 13,506 0.92Dosage orm/ ormulation 2,865 0.20

(Continued)

O all the in ormation calls, poison in ormation com-

prised 4.8% o the requests with inquiries involving generaltoxicity the most common ollowed by questions involvingood preparation practices, plant toxicity, and sa e use o

household products.

Exposure Calls to Poison CentersFigure 3 shows a graphic summary and analyses o HealthCare Facility (HCF) Exposure and HCF In ormation calls .HCF Exposure Calls did not depart rom linearity (contin-ued to increase at a steady rate) while the rate o HCFIn ormation Calls has been declining since early 2005.This linearly increasing use o the PCs or the more seri-

ous exposures (HCF calls) is important in the ace o thedeclining growth o all exposure and in ormation calls.The 2 May 2006, exposure data spike on the gure wasthe result o 602 children in a Midwest school reporting anoxious odor which caused anxiety, but resolved withoutsequelae.

Tables 22A (Nonpharmaceuticals) and 22B (Pharma-ceuticals) provide summary demographic data on patientage, reason or exposure, medical outcome, and use o a health care acility or all 2,384,825 human exposurecases, presented by substance categories.


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% o In o.calls

Drug use during breast- eeding 4,644 0.32Drug-drug interactions 29,050 1.98Drug- ood interactions 1,659 0.11Foreign drug 638 0.04

Generic substitution 1,108 0.08Indications/therapeutic use 71,864 4.90Medication administration 5,383 0.37Medication availability 2,209 0.15Medication disposal 4,907 0.33Pharmacokinetics 2,615 0.18Pharmacology 2,044 0.14Regulatory 13,808 0.94Stability/storage 3,446 0.24Therapeutic drug monitoring 938 0.06Other drug in o 35,244 2.40Subtotal 217,286 14.82

Environmental in ormationAir quality 1,995 0.14Carbon monoxide - no known

patient(s)

847 0.06

Carbon monoxide alarm use 507 0.03Chem/bioterrorism/weapons

(suspected or con rmed)22 0.00

Clari cation o media reports o environmental contamination

26 0.00

Clari cation o substancesinvolved in a HAZMATincident - no known victim(s)

104 0.01

General questions aboutcontamination o air and/or soil

559 0.04

HAZMAT planning 150 0.01Lead - no known patient(s) 671 0.05Mercury thermometer cleanup 2,453 0.17Mercury (excluding

thermometers) cleanup

2,996 0.20

Noti cation o a HAZMATincident - no known patient(s)

357 0.02

Pesticide application by apro essional pest control operator

680 0.05

Pesticides (other) 3,017 0.21Potential toxicity o chemicals in

the environment1,352 0.09

Radiation 70 0.00Sa e disposal o chemicals 1,740 0.12Water purity/contamination 945 0.06Other environmental 5,251 0.36Subtotal 23,742 1.62

Medical in ormationDental questions 132 0.01

Diagnostic or treatment recom-mendations or diseases orconditions - non-toxicology

9,633 0.66

Disease prevention 742 0.05Explanation o disease states 1,448 0.10General rst-aid 1,418 0.10Interpretation o non-toxicology

laboratory reports185 0.01

Medical terminology questions 72 0.00Rabies no known patient(s) 373 0.03Sunburn management 119 0.01Other medical 17,502 1.19Subtotal 31,624 2.16

Table 1C. (Continued) Table 1C. (Continued)


% o In o.calls

Occupational in ormationOccupational treatment/ rst-aid

guidelines - no known patient(s)39 0.00

In ormation on chemicals in the

workplace

150 0.01

MSDS interpretation 71 0.00Occupational MSDS requests 1,359 0.09Routine toxicity monitoring 30 0.00Sa e handling o workplace

chemicals117 0.01

Other occupational 216 0.01Subtotal 1,982 0.14

Poison in ormationAnalytical toxicology 805 0.05Carcinogenicity 94 0.01Food poisoning - no known

patient(s)2,815 0.19

Food preparation/handlingpractices

7,374 0.50

General toxicity 31,765 2.17Mutagenicity 46 0.00Plant toxicity 4,105 0.28Recalls o non-drug products

(including ood)856 0.06

Sa e use o household products 3,743 0.26Toxicology in ormation or legal

use/litigation213 0.01

Other poison 18,640 1.27Subtotal 70,456 4.81

Prevention/Sa ety/EducationCon rmation o poison center

number15,051 1.03

General (non-poison) injuryprevention requests

677 0.05

Media requests 390 0.03Poison prevention materialrequests

13,046 0.89

Poison prevention week dateinquiries

59 0.00

Pro essional educationpresentation requests

407 0.03

Public education presentationrequests

567 0.04

Other prevention 1,459 0.10Subtotal 31,656 2.16

Teratogenicity in ormationTeratogenicity 3,058 0.21Subtotal 3,058 0.21

Other in ormation

Other 45,538 3.11Subtotal 45,538 3.11

Substance AbuseDrug screen in ormation 7,165 0.49E ects o illicit substances no

known patient(s)335 0.02

New trend in ormation 386 0.03Withdrawal rom illicit substances

- no known patient(s)207 0.01

Other substance abuse 1,006 0.07Subtotal 9,099 0.62

AdministrativeExpert witness requests 37 0.00

(Continued) (Continued)


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% o In o.calls

Faculty activities 51 0.00Funding 47 0.00Personnel issues 462 0.03Poison center record request 211 0.01

Product replacement/mal unction(issues intended or themanu acturer)

2,350 0.16

Scheduling o poison centerrotations

143 0.01

Other administration 20,245 1.38Subtotal 23,546 1.61

Caller Re erredImmediate re erral - animal poison

center or veterinarian16,083 1.10

Immediate re erral - drugidenti cation

15,704 1.07

Immediate re erral - drugin ormation

931 0.06

Immediate re erral - healthdepartment

5,958 0.41

Immediate re erral - medicaladvice line

1,117 0.08

Immediate re erral - pediatrictriage service

60 0.00

Immediate re erral - pesticidehotline

319 0.02

Immediate re erral - pharmacy 2,620 0.18Immediate re erral - poison center 3,550 0.24Immediate re erral - private

physician2,442 0.17

Immediate re erral - psychiatriccrisis line

167 0.01

Immediate re erral - teratologyin ormation program

162 0.01

Other call re erral 16,539 1.13Subtotal 65,652 4.48

Total 1,466,253 100.00

Table 1C. (Continued)

0

1000

2000

3000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

E n c o u n

t e r s

P e r

D a y

All Drug Identification Calls

Law Enforcement Drug ID Calls= -85072 + 42.6*Year - 1.43*(Year-2006.5)^2

Fig. 2. All Drug Identifcation and Law En orcement Drug Identifcation Calls by Day since 1 January 2000.Black line shows least-squares second order regression both linear and second order (quadratic) terms were statistically signi cant or the Law En orcement DrugID Calls. (See colour version o this gure online).

Column 1: Name o the major, minor generic categories andtheir associated generic codes.Column 2: No. o Case Mentions (all exposures) in greyshading and displays the number o times the speci c genericcode was reported in all human exposure cases. I a humanexposure case has multiple instances o a speci c genericcode it is only counted once.Column 3: No. o Single Exposures this column was previ-ously named No. o Single Exposures and was renamedin the 2009 report or clarity. This column displays thenumber o human exposure cases that identi ed only onesubstance (one case, one substance).The succeeding columns (Age, Reason, Treatment Site,and Outcome) show selected detail rom these single-substance exposure cases. Death cases include both casesthat have the outcome o Death or Death, (indirect report).These death cases are not limited by the relative contributionto atality.

Tables 22A and 22B restrict the breakdown columns tosingle-substance cases. Prior to 2007, when multi-substance

exposures were included, a relatively innocuous substancecould be mentioned in a death column when, or example,the death was attributed to an antidepressant, opioid, or cya-nide. This subtlety was not always appreciated by the usero this table. The restriction o the breakdowns to single-substance exposures should increase precision and reducemisrepresentation o the results in this unique by-substancetable. Single substance cases refect the majority (90%) o allexposures yet 41% o atalities (Table 5).

Tables 22A and 22B tabulate 2,759,287 substance-exposures, o which 2,147,248 were single-substance expo-sures, including 1,125,336 (52.4%) nonpharmaceuticalsand 1,021,909 (47.6%) pharmaceuticals. The remaining 4exposure cases (3 single exposures cases) did not speci yi the substance was pharmaceutical or nonpharmaceutical(invalid generic codes).


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0

500

1000

1500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

E n c o

u n

t e r s

P e r

D a y

HCF Human Exposures= -65672 + 33.2*Year

HCF Information Calls= 1457 - 0.672*Year - 0.973*(Year-2005.5) 2

Fig. 3. Health Care Facility (HCF) Exposure Calls and HCF In ormation Calls by Day since 1 January 2000.Black lines show least-squares rst and second order regressions linear regression or HCF Exposure Calls (second order term was not statistically signi cant) and secondorder regression or HCF In ormation Calls. All terms shown were statistically signi cant or each o the 2 regressions. (See colour version o this gure online).

Table 2. Site o Call and Site o Exposure, Human Exposure Cases

Site o caller Site o exposure

Site N % N %

ResidenceOwn 1,736,145 72.80 2,172,987 91.12Other 42,813 1.80 61,635 2.58

Workplace 28,429 1.19 37,707 1.58Health care acility 418,412 17.54 7,381 0.31School 10,901 0.46 29,568 1.24Restaurant/ oodservice

566 0.02 5,741 0.24

Public area 8,166 0.34 22,793 0.96Other 131,067 5.50 26,020 1.09Unknown 8,326 0.35 20,993 0.88

In 17.6% o single-substance exposures that involved

pharmaceutical substances, the reason or exposure wasintentional, compared to only 3.5% when the exposureinvolved a nonpharmaceutical substance. Correspond-ingly, treatment in a health care acility was provided in ahigher percentage o exposures that involved pharmaceuti-cal substances (27.5%) compared with nonpharmaceuticalsubstances (14.7%). Exposures to pharmaceuticals also hadmore severe outcomes. O single-substance exposure-related

atal cases, 521 (0.05%) were pharmaceuticals comparedwith 242 (0.02%) nonpharmaceuticals.

Age and Gender Distributions

The age and gender distribution o human exposures isoutlined in Table 3A. Children younger than 3 years o agewere involved in 37.7% o exposures and children youngerthan 6 years accounted or approximately hal o all humanexposures (50.5%). A male predominance was ound amongcases involving children younger than 13 years, but thisgender distribution was reversed in teenagers and adults,with emales comprising the majority o reported exposures.Table 3B shows population-adjusted exposures or the sameage groups.

Caller Site and Exposure Site

As shown in Table 2, o the 2,384,825 human exposuresreported, 74.6% o calls originated rom a residence (ownor other) but 93.7% actually occurred at a residence (own orother). Another 17.5% o calls were made rom a health care

acility. Beyond residences, exposures occurred in the work-place in 1.6% o cases, schools (1.2%), health care acilities(0.3%), and restaurants or ood services (0.2%).

Exposures in PregnancyExposure during pregnancy occurred in 7,849 women (0.33% o all human exposures). O those with known pregnancy duration

(n 7,193), 31.6% occurred in the rst trimester, 37.5% in thesecond trimester, and 30.9% in the third trimester. Most (72.2%)were unintentional exposures and 20.4% were intentional expo-sures. Medical outcome was No e ect in 16.9%, Minor e ect in20.3%, Moderate e ect in 5.76%, and Major E ect in 0.542%.There was one death in a pregnant emale in 2010.

ChronicityMost human exposures, 2,136,572 (89.6%) were acute cases(single, repeated, or continuous exposure occurring over8 hr or less) compared to 869 acute cases o 1730 atali-ties (50.2%). Chronic exposures (continuous or repeatedexposures occurring over 8 hr) comprised 2% (47,700) o

all human exposures. Acute-on-chronic exposures (singleexposure that was preceded by a continuous, repeated, orintermittent exposure occurring over a period greater than 8hr) numbered 174,777 (7.3%).

Reason or ExposureThe reason category or most human exposures was unin-tentional (81.4%) with unintentional general (57.3%),


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Table 3A. Age and Gender Distribution o Human Exposures

Male Female Unknown gender Total Cumulative total

Age (y) N

% o agegrouptotal N

% o agegrouptotal N

% o agegrouptotal N

% o totalexposures N %

Children (< 20) 1 61,837 51.96 56,779 47.71 401 0.34 119,017 4.99 119,017 4.991 196,460 51.83 182,070 48.03 539 0.14 379,069 15.90 498,086 20.892 209,515 52.29 190,541 47.55 629 0.16 400,685 16.80 898,771 37.693 96,889 54.90 79,231 44.90 358 0.20 176,478 7.40 1,075,249 45.094 46,270 55.91 36,300 43.86 187 0.23 82,757 3.47 1,158,006 48.565 26,281 56.46 20,098 43.18 167 0.36 46,546 1.95 1,204,552 50.51Unknown 5 1,414 46.77 1,290 42.67 319 10.55 3,023 0.13 1,207,575 50.64Child 612 83,114 57.95 59,525 41.50 785 0.55 143,424 6.01 1,350,999 56.65Teen 1319 72,506 46.43 83,122 53.23 536 0.34 156,164 6.55 1,507,163 63.20Unknown Child 2,054 39.36 1,991 38.16 1,173 22.48 5,218 0.22 1,512,381 63.42Subtotal 796,340 52.65 710,947 47.01 5,094 0.34 1,512,381 63.42 1,512,381 63.42

Adults ( 20)2029 90,853 46.19 105,622 53.70 198 0.10 196,673 8.25 1,709,054 71.663039 65,446 43.03 86,511 56.88 135 0.09 152,092 6.38 1,861,146 78.044049 58,233 41.49 82,024 58.45 85 0.06 140,342 5.88 2,001,488 83.935059 46,214 39.83 69,769 60.13 51 0.04 116,034 4.87 2,117,522 88.796069 27,166 37.60 45,046 62.35 34 0.05 72,246 3.03 2,189,768 91.827079 15,075 34.97 28,022 65.00 17 0.04 43,114 1.81 2,232,882 93.638089 9,110 32.96 18,515 66.99 12 0.04 27,637 1.16 2,260,519 94.79

90 1,530 28.60 3,816 71.34 3 0.06 5,349 0.22 2,265,868 95.01Unknown adult 41,761 39.59 61,333 58.14 2,401 2.28 105,495 4.42 2,371,363 99.44Subtotal 355,388 41.37 500,658 58.29 2,936 0.34 858,982 36.02 2,371,363 99.44

OtherUnknown age 4,718 35.05 5,954 44.23 2,790 20.73 13,462 0.56 2,384,825 100.00

Total 1,156,446 48.49 1,217,559 51.05 10,820 0.45 2,384,825 100.00 2,384,825 100.00

Table 3B. Population-Adjusted Exposures by Age Group

Age Group Exposures/100k population Number o Exposures a Population b

Children (< 20)1 2,760 119,017 4,312,097

1 8,858 379,069 4,278,3942 9,287 400,685 4,313,4443 4,057 176,478 4,349,1334 1,953 82,757 4,236,3335 1,110 46,546 4,193,338Child 612 502 143,424 28,575,574Teen 1319 533 156,164 29,262,563Subtotal 1,813 1,512,381 83,520,876

Adults ( 20)2029 451 196,673 43,608,697

3039 753 152,092 20,183,8724049 220 140,342 63,820,0325059 279 116,034 41,553,4086069 251 72,246 28,800,3047079 261 43,114 16,502,5088089 288 27,637 9,580,266

90 260 5,349 2,059,452Subtotal 380 858,982 226,108,539

Overall Total 761 2,384,825 313,306,729aNumber o Exposures excludes UNKNOWN ages rom the individual agecategories, but includes them in the Subtotals and Overall Total (see Table 3A).bAs o 1 July Mid Year US Census (50 United States, American Samoa,District o Columbia, Federated States o Micronesia, Guam, Puerto Rico,and the US Virgin Islands). 3,4

therapeutic error (11.3%) and unintentional misuse (5.4%)o all exposures (Table 6A).

ScenariosO the total 285,277 therapeutic errors, the most commonscenarios or all ages included: inadvertent double-dosing(29.1%), wrong medication taken or give (14.7%), otherincorrect dose (12.9%), doses given/taken too close together(9.5%), and inadvertent exposure to someone elses medi-cation (9.0%). The types o therapeutic errors observedare di erent or each age group and are summarized inTable 6B.

Reason by AgeIntentional exposures accounted or 14.7% o humanexposures. Suicidal intent was suspected in 9.2% o cases,intentional misuse in 2.5% and intentional abuse in 2.2%.Unintentional exposures outnumbered intentional expo-sures in all age groups with the exception o ages 1319years (Table 7). Intentional exposures were more requentlyreported than unintentional exposures in patients aged1319 years. In contrast, o the 1,146 reported atalitieswith RCF 13, the majority reason reported or children 5years was unintentional while most atalities in adults ( 20years) were intentional (Table 8).


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Table 4. Distribution o Age a and Gender or Fatalities b

Age (y) Male Female Unknown Total (%)Cumulative

total (%)

1 year 1 2 0 3 (0.3%) 3 (0.3%)1 year 4 5 0 9 (0.8%) 12 (1.1%)2 years 1 5 0 6 (0.5%) 18 (1.6%)3 years 4 2 0 6 (0.5%) 24 (2.1%)4 years 2 3 0 5 (0.4%) 29 (2.5%)5 years 1 2 0 3 (0.3%) 32 (2.8%)Child 612 years 2 1 0 3 (0.3%) 35 (3.1%)Teen 1319 years 30 26 0 56 (4.9%) 91 (7.9%)2029 years 95 77 0 172 (15.0%) 263 (23.0%)3039 years 80 104 0 184 (16.1%) 447 (39.0%)4049 years 103 134 0 237 (20.7%) 684 (59.7%)5059 years 113 110 1 224 (19.6%) 908 (79.2%)6069 years 61 58 0 119 (10.4%) 1,027 (89.6%)7079 years 25 29 0 54 (4.7%) 1,081 (94.3%)8089 years 23 27 0 50 (4.4%) 1,131 (98.7%)

90 years 4 5 0 9 (0.8%) 1,140 (99.5%)Unknown adult 1 2 0 3 (0.3%) 1,143 (99.7%)Unknown age 2 0 1 3 (0.3%) 1,146 (100.0%)Total 552 592 2 1,146 (100.0%) 1,146 (100.0%)aAge includes cases with both actual and estimated ages as shown in Table 21.bIncludes cases with relative contribution to atality o 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory. This excludes reports with

outcome o Death INDIRECT.

Table 6A. Reason or Human Exposure Cases

Reason N% Humanexposures

UnintentionalUnintentional - General 1,367,682 57.3Unintentional - Therapeutic error 269,889 11.3Unintentional - Misuse 128,923 5.4Unintentional - Bite/sting 61,584 2.6Unintentional - Environmental 57,384 2.4Unintentional - Food poisoning 26,221 1.1Unintentional - Occupational 24,546 1.0Unintentional - Unknown 4,619 0.2Subtotal 1,940,848 81.4

IntentionalIntentional - Suspected suicide 219,934 9.2Intentional - Misuse 58,568 2.5Intentional - Abuse 51,715 2.2Intentional - Unknown 19,837 0.8Subtotal 350,054 14.7

Adverse ReactionAdverse reaction - Drug 42,201 1.8Adverse reaction - Other 13,612 0.6Adverse reaction - Food 5,775 0.2Subtotal 61,588 2.6

UnknownUnknown reason 14,332 0.6Subtotal 14,332 0.6

OtherOther - Malicious 8,351 0.4Other - Contamination/tampering 8,191 0.3Other - Withdrawal 1,461 0.1Subtotal 18,003 0.8

Total 2,384,825 100.0

Route o ExposureIngestion was the route o exposure in 83.5% o cases(Table 9), ollowed in requency by dermal (7.2%), inhala-tion/nasal (5.7%), and ocular routes (4.5%). For the 1,146exposure-related atalities, ingestion (87.5%), inhalation/nasal

(7.7%), and parenteral (3.1%) were the predominant exposureroutes. Each exposure case may have more than one route.

Clinical E ectsThe NPDS database allows or the coding o up to 131di erent clinical e ects (signs, symptoms, or laboratory

Table 5. Number o Substances Involved in Human Exposure Cases

Human exposures Fatal exposures a

No. o Substances N % N %

1 2,147,248 90.04 474 41.362 151,642 6.36 270 23.563 48,575 2.04 159 13.874 19,666 0.82 97 8.465 8,773 0.37 67 5.856 3,913 0.16 31 2.717 2,130 0.09 20 1.758 1,152 0.05 12 1.05

9 1,726 0.07 16 1.40Total 2,384,825 100.00 1,146 100.00aIncludes cases with relative contribution to atality o 1-Undoubtedlyresponsible, 2-Probably responsible, or 3-Contributory. This excludesreports with outcome o Death INDIRECT.


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Table 6B. Scenarios or Therapeutic Errors a by Age b

Scenario N 5 y

(Row %)612 y

(Row %)1319 y(Row %)

20 y(Row %)

Unknownchild

(Row %)

Unknownadult

(Row %)

Unknownage

(Row %)

Inadvertently took/givenmedication twice

83,140 20.11 12.49 5.88 55.04 0.08 6.13 0.26

Wrong medication taken/given 41,794 16.20 12.01 6.52 58.69 0.07 6.19 0.33Other incorrect dose 36,942 31.76 11.83 6.94 44.62 0.09 4.53 0.23Medication doses given/taken

too close together27,233 19.53 10.15 7.12 56.66 0.06 6.29 0.18

Inadvertently took/given someoneelses medication

25,542 20.48 18.80 6.94 49.03 0.07 4.54 0.13

Other/unknown therapeutic error 16,361 21.26 10.70 7.26 53.85 0.20 6.19 0.54Incorrect dosing route 16,056 8.84 4.02 3.10 72.14 0.14 11.02 0.74Con used units o measure 10,496 56.98 17.24 4.89 18.90 0.06 1.82 0.11Incorrect ormulation or

concentration given6,135 46.36 16.45 4.74 29.54 0.10 2.62 0.20

Health pro essional/iatrogenic error(pharmacist/nurse/physician)

5,684 28.20 10.38 6.33 47.59 0.48 5.96 1.06

More than 1 product containing sameingredient

5,589 15.80 14.96 14.17 48.77 0.05 6.07 0.18

Dispensing cup error 5,395 62.65 18.78 4.54 13.01 0.11 0.83 0.07Drug interaction 1,701 8.47 7.94 6.88 66.67 0.06 9.64 0.35Incorrect ormulation or

concentration dispensed1,656 43.90 15.16 4.95 31.28 0.30 4.17 0.24

10- old dosing error 1,444 55.89 7.62 4.36 29.36 0.14 2.35 0.28Exposure through breast milk 109 88.99 0.92 0.00 5.50 2.75 1.83 0.00aAll cases with a scenario category o therapeutic error regardless o reason.bO the human exposure cases reported to U.S. Poison Centers in 2010, 425,655 (17.8%) were coded to 1 or more o 54 scenarios.

abnormalities) or each case. Each clinical e ect can be ur-ther de ned as related, not related, or unknown i related.Clinical e ects were coded in 849,516 (35.6%) cases. (17.9%had 1 e ect, 9.3% had 2 e ects, 4.9% had 3 e ects, 2% had 4e ects, 0.8% had 5 e ects, and 0.9% had 5 e ects coded).

O clinical e ects coded, 79.2% were deemed related to theexposure(s), 9.3% were considered not related, and 11.5%were coded as unknown i related.

The duration o e ect is required or all cases that reportat least one clinical e ect and have a medical outcome o minor, moderate, or major e ect (n 514,203; 21.6% o exposures). Table 13 demonstrates an increasing duration o the clinical e ects observed with more severe outcomes.

Case Management SiteThe majority o cases reported to PCs were managed in anon-health care acility (71.3%), usually at the site o expo-

sure, primarily the patients own residence (Table 10). 1.8%o cases were re erred to a health care acility but re usedre erral. Treatment in a health care acility was rendered in25.2% o cases.

O the 601,197 cases managed in a health care acility,292,289 (48.6%) were treated and released, 97,650 (16.2%)were admitted or critical care (intensive care or monitoredunit), and 62,346 (10.4%) were admitted to a noncriticalunit.

The percentage o patients treated in a health care acilityvaried considerably with age. Only 11.1% o children 5years or younger and only 12.7% o children between 6 and

12 years were managed in a health care acility comparedto 48.6% o teenagers (1319 years) and 40.1% o adults(age 20 years).

Medical OutcomeTable 11 displays the medical outcome o human exposurecases distributed by age. A greater number o severe medi-cal outcomes is observed in the older age groups. Table 12compares medical outcome and reason or exposure andshows a greater requency o serious outcomes in intentionalexposures.

Decontamination Procedures and Specifc AntidotesTables 14 and 15 outline the use o decontamination proce-dures, speci c antidotes, and measures to enhance elimina-tion in the treatment o patients reported in the NPDS data-

base. These must be interpreted as minimum requenciesbecause o the limitations o telephone data gathering.Ipecac-induced emesis or poisoning continues to decline

as shown in Tables 16A and 16B. Ipecac was administeredin only 163 (0.01%) pediatric exposures in 2010. The con-tinued decrease in ipecac syrup use over the last two decadeswas likely a result o ipecac use guidelines issued in 1997by the American Academy o Clinical Toxicology, EuropeanAssociation o Poisons Centres, and Clinical Toxicologistsand updated in 2004. 5,6 In a separate report, the AmericanAcademy o Pediatrics concluded not only that ipecac shouldno longer be used routinely as a home treatment strategy,


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T a b l e

7 . D i s t r i b u t

i o n o f

R e a s o n f o r

E x p o s u r e

b y A g e

5

y

6 1 2 y

1 3 1

9 y

2

0 y

U n k n o w n c h

i l d

U n k n o w n a d u l

t

U n k n o w n a g e

T o t a l

R e a s o n

N

R o w

%

N

R o w

%

N

R o w

%

N

R o w

%

N

R o w

%

N

R o w

%

N

R o w

%

N

%

U n i n t e n

t i o n a

l

1 , 1 9 8 , 9 7 2

6 4 . 5

5

1 2 7 , 6 1 2

6 . 8 7

6 7 , 4

8 7

3 . 6 3

4 5 5 , 8 9 7

2 4 . 5

4

4 , 5 7 7

0 . 2 5

7 8 , 7

6 8

4 . 2 4

7 , 5 3 5

0 . 4 1

1 , 9 4 0 , 8 4 8

8 1 . 3

8

I n t e n t

i o n a

l

1 , 0 1 4

0 . 3

0

9 , 9 9 9

2 . 9 9

8 0 , 1

3 9 2 3 . 9 9

2 3 9 , 1 5 1

7 1 . 5

8

2 7 6

0 . 0 8

1 5 , 6

9 6

4 . 7 0

3 , 7 7 9

1 . 1 3

3 5 0 , 0 5 4

1 4 . 6

8

A d v e r s e r e a c

t i o n

4 , 5 4 3

8 . 3

9

3 , 1 0 2

5 . 7 3

4 , 6 3 2

8 . 5 5

4 0 , 8

3 3

7 5 . 4

0

1 6 2

0 . 3 0

7 , 2 7 4

1 3 . 4

3

1 , 0 4 2

1 . 9 2

6 1 , 5

8 8

2 . 5 8

O t h e r

2 , 2 4 8

1 4 . 4

4

1 , 8 8 5

1 2 . 1

1

2 , 0 3 9 1 3 . 1 0

9 , 1 0 9

5 8 . 5

3

1 4 9

0 . 9 6

2 , 2 9 1

1 4 . 7

2

2 8 2

1 . 8 1

1 8 , 0

0 3

0 . 7 5

U n k n o w n

7 9 8

6 . 2

3

8 2 6

6 . 4 5

1 , 8 6 7 1 4 . 5 7

8 , 4 9 7

6 6 . 3

2

5 4

0 . 4 2

1 , 4 6 6

1 1 . 4

4

8 2 4

6 . 4 3

1 4 , 3

3 2

0 . 6 0

T o t a l

1 , 2 0 7 , 5 7 5

5 3 . 1

0

1 4 3 , 4 2 4

6 . 3 1

1 5 6 , 1 6 4

6 . 8 7

7 5 3 , 4 8 7

3 3 . 1

3

5 , 2 1 8

0 . 2 3

1 0 5 , 4 9 5

4 . 6 4

1 3 , 4

6 2

0 . 5 9

2 , 3 8 4 , 8 2 5

1 0 0 . 0 0 but also recommended disposal o home ipecac stocks. 7 A

decline was also observed since the early 1990s or reporteduse o activated charcoal. While not as dramatic as the declinein use o ipecac, reported use o activated charcoal decreased

rom 3.7% o pediatric cases in 1993 to just 1.4% in 2010.

Top Substances in Human Exposures

Table 17A presents the most common 25 substance catego-ries, listed by requency o human exposure. This rankingprovides an indication where prevention e orts might be

ocused, as well as the types o exposures PCs regularlymanage. It is relevant to know whether exposures to thesesubstances are increasing or decreasing.

To better understand these relationships, we examinedexposures per year over the last 11 years or the changeover time or each o the 67 major generic categories vialeast squares linear regression. Despite an overall decreasein human exposure calls (3.8%) or this year, the calls peryear increased or 42 and decreased or 25 o the 67 majorcategories. The change over time or the 11-yearly values

was statistically signi cant (p 0.05) or 49 o the 67categories. Table 17B shows the 25 categories which wereincreasing the most rapidly. Statistical signi cance o the25 regressions can be veri ed by noting the 95% con denceinterval on the rate o increase excludes zero. Figure 7 showsthe linear regressions or the top 4 increasing categories inTable 17B. Tables 17C and 17D present exposure results orchildren and adults, respectively, and show the di erencesbetween substance categories involved in pediatric and adultexposures.

Table 17E reports the 25 categories o substances mostrequently involved in pediatric ( 5 years) atalities in

2010.Table 17F reports the 25 Drug ID categories most re-

quently identi ed in 2010. The most o ten identi ed drugcategory is miscellaneous and unknown; this categoryincludes medications which could not be identi ed. DrugID in ormation is o value to AAPCC, public health, publicsa ety, and regulatory agencies. Internet based resources donot allow data capture nor do they a ord the caller the abilityto speak with a specialist in poison in ormation i the inquiryis more than a drug identi cation question. Proper resourcesto continue this vital public service are essential, especiallysince the top 10 substance categories include antibiotics aswell as drugs with widespread use and abuse potential such

as opioids and benzodiazepines.Table 17G (new this year) reports the 25 substance cat-egories most requently reported in exposures involvingpregnant patients.

Changes rom Last YearFigure 4 shows the year-to-year changes or 20092010 orall encounters and or several major categories.

The graphic breaks down the change in exposure callsby outcome category. Although overall exposure calls havedecreased by 94,530 calls ( 3.8%), there is a consistentincrease in the exposures with a more serious outcome


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Table 9. Route o Exposure or Human Exposure Cases

Human exposures Fatal exposures a

Route N% o AllRoutes

% o AllCases N

% o AllRoutes

% o AllCases

Ingestion 1,990,244 79.51 83.45 1,003 80.82 87.52Dermal 172,318 6.88 7.23 18 1.45 1.57Inhalation/nasal 136,799 5.47 5.74 88 7.09 7.68Ocular 107,374 4.29 4.50 0 0.0 0Bite/sting 61,606 2.46 2.58 5 0.40 0.44Parenteral 16,865 0.67 0.71 35 2.82 3.05Unknown 8,944 0.36 0.38 69 5.56 6.02Other 3,016 0.12 0.13 4 0.32 0.35Otic 2,519 0.10 0.11 0 0.0 0Aspiration (with ingestion) 1,624 0.06 0.07 19 1.53 1.66Vaginal 1,106 0.04 0.05 0 0.0 0Rectal 736 0.03 0.03 0 0.0 0Total Number o Routes 2,503,151 100.00 104.96 1,241 100.00 108.29 b

aIncludes cases with relative contribution to atality o 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory. This excludes reports withoutcome o Death INDIRECT.bEach exposure case may have more than one route.

Table 8. Distribution o Reason or Exposure and Age or Fatalities a

Reason 5 y 612 y 1319 y 20 yUnknown

childUnknown

adultUnknown

age Total

UnintentionalUnintentional - General 15 0 0 24 0 0 0 39Unintentional - Environmental 6 0 2 21 0 0 0 29Unintentional - Occupational 0 0 2 11 0 0 0 13Unintentional - Therapeutic error 3 0 1 22 0 0 0 26Unintentional - Misuse 0 1 0 16 0 0 0 17Unintentional - Bite/sting 2 0 0 3 0 0 0 5Unintentional - Food poisoning 0 0 0 1 0 0 0 1Unintentional - Unknown 0 0 0 4 0 0 0 4

Subtotal 26 1 5 102 0 0 0 134Intentional

Intentional - Suspected suicide 0 0 31 603 0 3 0 637Intentional - Misuse 1 0 1 44 0 0 0 46Intentional - Abuse 0 1 9 88 0 0 1 99Intentional - Unknown 0 0 5 93 0 0 0 98Subtotal 1 1 46 828 0 3 1 880

OtherOther - Contamination/tampering 0 0 0 1 0 0 0 1Other - Malicious 2 0 1 3 0 0 0 6Other - Withdrawal 0 0 1 1 0 0 0 2Subtotal 2 0 2 5 0 0 0 9

Adverse reactionAdverse reaction - Drug 1 0 0 25 0 0 0 26Adverse reaction - Other 0 0 0 2 0 0 0 2Subtotal 1 0 0 27 0 0 0 28

UnknownUnknown reason 2 1 3 87 0 0 2 95Subtotal 2 1 3 87 0 0 2 95

Total 32 3 56 1,049 0 3 3 1,146aIncludes cases with relative contribution to atality o 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory. This excludes reports withoutcome o Death INDIRECT.

(minor, moderate, major or death) and as a group increased by 22,175 encounters (4.5%).

Thus we see a consistent increase in exposure calls romHCFs and or the more severe exposures, despite a decreasein calls involving less severe exposures.

Distribution o Suicides

Table 19A shows the modest variation in the distributiono suicides and pediatric deaths over the past two decadesas reported to the NPDS national database. Within the lastdecade, the percent o exposures determined to be suspected


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Table 10. Management Site o Human Exposures

Site o management N %

Managed on site, nonhealth careacility

1,700,736 71.3

Managed in healthcare acilityTreated/evaluated and released 292,289 12.3Admitted to critical care unit 97,650 4.1Patient lost to ollow-up/le t AMA 96,226 4.0Admitted to noncritical care unit 62,346 2.6Admitted to psychiatric acility 52,686 2.2Subtotal (managed in HCF) 601,197 25.2

Other 29,417 1.2Re used re erral 42,497 1.8Unknown 10,978 0.5Total 2,384,825 100.0

T a b l e

1 1 . M

e d i c a l

O u t c o m e o f

H u m a n

E x p o s u r e

C a s e s

b y P a t

i e n t

A g e

a

5 y

6 1 2 y

1 3 1

9 y

2

0 y

U n k n o w n

c h i l d

U n k n o w n a d u l

t

U n k n o w n

a g e

T o t a l

O u t c o m e

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N o e f

f e c t

3 0 2 , 6 5 9

2 5 . 0

6

2 5 , 6

6 0 1 7

. 8 9

2 5 , 0

1 4

1 6 . 0

2

9 3 , 3

1 1

1 2 . 3

8 1 , 0 1 8

1 9 . 5

1

1 0 , 4

1 8

9 . 8 8

1 , 1 9 9

8 . 9

4 5 9 , 2 7 9

1 9 . 2

6

M i n o r e f

f e c t

9 5 , 1

0 5

7 . 8 8

2 2 , 0

1 5 1 5

. 3 5

4 0 , 1

2 5

2 5 . 6

9 1 7 9 , 6 4 0

2 3 . 8

4

5 1 9

9 . 9 5

1 5 , 4

4 4

1 4 . 6

4

1 , 9 3 0

1 4 . 3

3 5 4 , 7 7 8

1 4 . 8

8

M o d e r a t e e f

f e c t

1 0 , 7

5 7

0 . 8 9

4 , 0 9 0

2 . 8 5

2 0 , 6

5 5

1 3 . 2

3

9 9 , 5

0 4

1 3 .

bronstein clintox 2011 npds

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