The OPQ: a proposed instrument for predicting poisoning accident recurrence in young children.

A 26-item self-report questionnaire for parents/guardians was constructed for potential use with first-exposure childhood poisoning victims to predict high risk for subsequent poisoning episodes. Data were obtained from 185 subjects served by 1 of 5 US regional poison control centers. The resulting device was labeled the OPQ. Its retrospective validity (R = 0.71) and test-retest reliability (0.81) are viewed as sufficient. The test itself, with accompanying scoring key and norms, are provided here in the hope that other clinicians and researchers will join in subjecting the OPQ to prospective validity studies and other forms of Scale refinement.

Rapid onset of seizures following aspiration of viscous lidocaine.

A 2 year-old drank from a bottle of viscous lidocaine. Coughing and choking were prompt, and seizures began within 10 to 15 seconds. Intraosseous phenobarbital 40 mg/kg stopped seizures temporarily, 30 mg/kg more plus lorazepam 20 mg/kg were needed for complete control. Suctioning of the airway revealed viscous material compatible with the drug. Bilateral hilar pneumonia ensued rapidly. The syndrome of inappropriate antidiuretic hormone secretion occurred and was countered appropriately. Intubation, performed on admission, could not be discontinued. The adult respiratory distress syndrome, characterized by a typical diffuse X-ray pattern and poor oxygenation, developed. Bilateral pneumothoraces complicated care. The patient required 14 days of extracorporeal membrane oxygenation before recovery. A lidocaine level was obtained at 4 h post-ingestion and was 0.5 micrograms/mL (2 mumol/L). The rapid onset of seizures suggests that the drug was absorbed from the pulmonary bed. This possibility is supported by the finding of viscous-lidocaine-like material in the trachea, the rapid development of aspiration pneumonia, and the development of adult respiratory distress syndrome, which has been observed in adults when lidocaine was used in the trachea for procedures.

A multicenter, prospective study of fetal outcome following accidental carbon monoxide poisoning in pregnancy.

We report the results of the first prospective, multicenter study of acute carbon monoxide (CO) poisoning in pregnancy. We collected and followed cases of CO poisoning occurring during pregnancy between December 1985 and March 1989. The sources of CO were malfunctioning furnaces (n = 16), hot water heaters (n = 7), car fumes (n = 6), and methylene chloride inhalation (n = 3). Pregnancy outcome was adversely affected in 3 of 5 pregnancies with severe toxicity; two stillbirths, and one cerebral palsy with tomographic findings consistent with ischemic damage. All adverse outcome occurred in cases treated with high flow oxygen, whereas the 2 cases of severe toxicity with normal outcomes followed hyperbaric oxygen therapy. All 31 babies exposed in utero to mild or moderate CO poisoning exhibited normal physical and neurobehavioral development. Severe maternal CO toxicity was associated with significantly more adverse fetal cases when compared to mild maternal toxicity (P less than 0.001). It is concluded that while severe CO poisoning poses serious short- and long-term fetal risk, mild accidental exposure is likely to result in normal fetal outcome. Because fetal accumulation of CO is higher and its elimination slower than in the maternal circulation, hyperbaric oxygen may decrease fetal hypoxia and improve outcome.

Acid and alkaline diuresis. When are they of value in the treatment of poisoning?

The utility of both acid and alkaline diuresis has been brought into question because of the ability to increase the elimination rate of many toxins by less care-intensive methods such as repeated-dose charcoal. Alkaline diuresis is a technique which uses a common drug, but acid diuresis is not a technique known to most physicians. The former is currently the best therapy for quinine poisoning. Phencyclidine elimination is increased by 10%, but most patients recover with only supportive care. Acidification has been effective in some hands; data suggest that renal elimination is not the only mechanism of action of this therapy. In deeply comatose patients with hypotension, acidification should be considered. Alkalinisation, the mainstay of therapy for salicylate and phenobarbital poisoning over many decades, is effective, although no more so than charcoal, and less than dialysis.

Physical change, time of day, and child characteristics as factors in poison injury.

In a study of 85 children under 6 y whose mothers called the poison center, information regarding the physical surroundings of the substance ingested at the time of the incident was obtained along with ratings of maternal stress and child behavior problems. In 51% of the incidents, the substance had recently been moved from a usual storage site or was in use at the time of the ingestion. Environmental changes occurred in 1/3 of those poisoned between 4 and 6 pm which was the 2-h period of the greatest incidence. Poisoning in children 1 and 2 y were more likely to have followed physical environmental change. Children with higher child behavior problem score were more likely to be poisoned in the morning.

Extracorporeal bypass for the treatment of verapamil poisoning.

A 25-month-old boy ingested six sustained-release verapamil tablets, each containing 240 mg of drug. Charcoal and cathartic were given but were never passed per rectum. Third-degree heart block, hypotension, and hypocalcemia were only transiently responsive to calcium infusions, inotropic agents, and epicardial pacing. Cardiopulmonary arrest with electromechanical dissociation ensued. Standard cardiopulmonary bypass was used to allow sufficient time for liver detoxication. Serum levels of verapamil fell during the bypass procedure, and the patient's cardiac status improved. However, continued absorption of drug after bypass resulted in a level of 4 mg/L, unresponsive circulatory failure, and death. Early, aggressive gut decontamination and the potential value of cardiopulmonary bypass procedures in poisoning that lead to cardiac depression are emphasized.

Development of phenobarbital glucosidation in the human neonate.

Phenobarbital-N-glucoside (PNG) has recently been identified as a significant metabolite of phenobarbital (PB). Five neonates treated with PB alone for seizures were studied. Serum concentration of PB ranged from 30 to 80 mg/l. Serial single daily voided specimens were analyzed for PB, PNG, and total p-hydroxyphenobarbital (PHPB). PNG was detected on the 14th day of life in 1 patient, who was the oldest by gestational age. On the 20th day of life, PNG accounted for 50% of the dose excreted in the urine. No PNG was detected in other patients by the 12th, 15th, or 16th day of life. PHPB was found on day 4, in the first urine examined, in the patient who made PNG. In other patients, PHPB was first excreted on the 4th day of life in 2 patients and on the 10th day in 2. It appears that N-glucosidation, when activated, rapidly becomes a significant route for PB metabolism in the neonate.

Poisoning with the North American Jack O'Lantern mushroom, Omphalotus illudens.

Ingestion of Jack O'Lantern mushrooms by fourteen people led to vomiting in 8, diarrhea in 5, weakness in 2. Tiredness, the feeling of weakness and being cold occurred in 8. Recovery was complete within 18 hours.

Acute manic psychosis following the dermal application of N,N-diethyl-m-toluamide (DEET) in an adult.

Extensive animal testing and 30 years of human experience have established the general safety of DEET when applied episodically to skin or bedclothes. Local and systemic toxic and allergic reactions to DEET have been observed in man. Three weeks prior to admission, for the purpose of self-medication, a 30 year old man began daily applications of the insect repellant, DEET followed by a 1-2 hour period in a light-bulb heated box. Sedation and incoherence were noted for short periods following each application session. Aggressiveness and psychotic ideation led to hospital admission where he displayed psychomotor hyperactivity, rapid and pressured speech, tangentiality, flight of ideas, and grandiose delusions. Treatment was begun with haloperidol. Clinical improvement was complete within 6 days, atypical for classic endogenous mania. Drug and metabolites were identified in the urine more than 2 weeks after the last drug application.

Posttraumatic stress disorder from pentaborane intoxication. Neuropsychiatric evaluation and short-term follow-up.

Fourteen individuals briefly exposed to a toxic industrial compound, pentaborane, were evaluated for neuropsychiatric abnormalities four to 12 weeks after exposure. Results of physical, neurological, and routine laboratory evaluations were normal. Initial and persistent psychiatric symptoms, neuropsychological deficits, electroencephalographic changes, elevated central nervous system neurotransmitter levels, and ventricular brain ratios (computed tomographic scan) provide evidence of central nervous system damage. Seven patients met diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, ed 3, for posttraumatic stress disorder, and seven patients had neuropsychological test evidence of mild brain dysfunction. No statistically significant relationship was found between neuropsychiatric test results and psychiatric diagnoses. These results contradict previous literature that reports most symptom resolution within the first week after exposure to pentaborane. Results suggest that patients suffered a combination of organic brain insult and psychological trauma.

Perception of toxicity and dose by 3- and 4-year-old children.

Three and 4-year-old children from two suburban preschools were individually interviewed to assess their knowledge of the effects of ingesting a household product, a candy, and a common drug. Most children understood that scouring cleanser was toxic. Children reported that candy was safe to eat, even in large amounts. However, vitamins were not perceived by all children as having a dose-related toxicity. This understanding developed with age, and boys were better than girls at differentiating between a usual and an excessive dose of vitamins. One overdose occurred, perhaps because of an increase in the child's interest in vitamins after the interview. More research is needed to broaden our understanding of children's knowledge of the toxicity of poisons. The results of the present study provided information needed for the formulation of educational objectives for a preschool poison prevention program. We believe the primary message is that nothing should be eaten unless it is approved by an adult.

Falls in children and youth.

Falls account for considerable morbidity in childhood. The importance of the surface that the child strikes is highlighted as well as the parents' perceptions of the seriousness of the fall. Recommendations for prevention are made.

Severe central nervous system damage and profound acidosis in persons exposed to pentaborane.

Three cases of pentaborane intoxication resulting from a common exposure are presented. These cases were characterized by the rapid onset of seizures and opisthotonic spasms accompanied by severe metabolic acidosis without respiratory compensation. Rhabdomyolysis occurred, serum transaminase levels were elevated, and liver damage was demonstrated histologically. One patient died and another sustained severe neurologic damage. These poisonings are unique with respect to the rapid and devastating neurologic consequences. Pentaborane is an extremely toxic compound and a major hazard not only to exposed workers but also to the medical personnel dealing with them.