Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care

STUDY OBJECTIVE

We developed recommendations for antidote stocking at hospitals that provide emergency care.

METHODS

An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote.

RESULTS

The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital.

CONCLUSION

The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.

Tricyclic antidepressant poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of U.S. poison center data for 2004 showed over 12,000 exposures to tricyclic antidepressants (TCAs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce healthcare costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate prehospital triage and management of patients with suspected ingestions of TCAs by 1) describing the manner in which an ingestion of a TCA might be managed, 2) identifying the key decision elements in managing cases of TCA ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of TCAs alone. Co-ingestion of additional substances could require different referral and management recommendations depending on their combined toxicities. This guideline is based on the assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with suspected self-harm or who are the victims of malicious administration of a TCA should be referred to an emergency department immediately (Grade D). 2) Patients with acute TCA ingestions who are less than 6 years of age and other patients without evidence of self-harm should have further evaluation including standard history taking and determination of the presence of co-ingestants (especially other psychopharmaceutical agents) and underlying exacerbating conditions, such as convulsions or cardiac arrhythmias. Ingestion of a TCA in combination with other drugs might warrant referral to an emergency department. The ingestion of a TCA by a patient with significant underlying cardiovascular or neurological disease should cause referral to an emergency department at a lower dose than for other individuals. Because of the potential severity of TCA poisoning, transportation by EMS, with close monitoring of clinical status and vital signs en route, should be considered (Grade D). 3) Patients who are symptomatic (e.g., weak, drowsy, dizzy, tremulous, palpitations) after a TCA ingestion should be referred to an emergency department (Grade B). 4) Ingestion of either of the following amounts (whichever is lower) would warrant consideration of referral to an emergency department: an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose. For all TCAs except desipramine, nortriptyline, trimipramine, and protriptyline, this dose is >5 mg/kg. For despiramine it is >2.5 mg/kg; for nortriptyline it is >2.5 mg/kg; for trimipramine it is >2.5 mg/kg; and for protriptyline it is >1 mg/kg. This recommendation applies to both patients who are naïve to the specific TCA and to patients currently taking cyclic antidepressants who take extra doses, in which case the extra doses should be added to the daily dose taken and then compared to the threshold dose for referral to an emergency department (Grades B/C). 5) Do not induce emesis (Grade D). 6) The risk-to-benefit ratio of prehospital activated charcoal for gastrointestinal decontamination in TCA poisoning is unknown. Prehospital activated charcoal administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grades B/D). 7) For unintentional poisonings, asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the initial call to a poison center is greater than 6 hours. These patients do not need referral to an emergency department facility (Grade C). 8) Follow-up calls to determine the outcome for a TCA ingestions ideally should be made within 4 hours of the initial call to a poison center and then at appropriate intervals thereafter based on the clinical judgment of the poison center staff (Grade D). 9) An ECG or rhythm strip, if available, should be checked during the prehospital assessment of a TCA overdose patient. A wide-complex arrhythmia with a QRS duration longer than 100 msec is an indicator that the patient should be immediately stabilized, given sodium bicarbonate if there is a protocol for its use, and transported to an emergency department (Grade B). 10) Symptomatic patients with TCA poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard ACLS guidelines (Grade D). 11) Administration of sodium bicarbonate might be beneficial for patients with severe or life-threatening TCA toxicity if there is a prehospital protocol for its use (Grades B/D). 12) For TCA-associated convulsions, benzodiazepines are recommended (Grade D). 13) Flumazenil is not recommended for patients with TCA poisoning (Grade D).

Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management

A review of US poison center data for 2004 showed over 48,000 exposures to selective serotonin reuptake inhibitors (SSRIs). A guideline that determines the conditions for emergency department referral and prehospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with a suspected ingestion of an SSRI by 1) describing the process by which an ingestion of an SSRI might be managed, 2) identifying the key decision elements in managing cases of SSRI ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of immediate-release forms of SSRIs alone. Co-ingestion of additional substances might require different referral and management recommendations depending on their combined toxicities. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department. This activity should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) Any patient already experiencing any symptoms other than mild effects (mild effects include vomiting, somnolence [lightly sedated and arousable with speaking voice or light touch], mydriasis, or diaphoresis) should be transported to an emergency department. Transportation via ambulance should be considered based on the condition of the patient and the length of time it will take the patient to arrive at the emergency department (Grade D). 3) Asymptomatic patients or those with mild effects (defined above) following isolated unintentional acute SSRI ingestions of up to five times an initial adult therapeutic dose (i.e., citalopram 100 mg, escitalopram 50 mg, fluoxetine 100 mg, fluvoxamine 250 mg, paroxetine 100 mg, sertraline 250 mg) can be observed at home with instructions to call the poison center back if symptoms develop. For patients already on an SSRI, those with ingestion of up to five times their own single therapeutic dose can be observed at home with instructions to call the poison center back if symptoms develop (Grade D). 4) The poison center should consider making follow-up calls during the first 8 hours after ingestion, following its normal procedure. Consideration should be given to the time of day when home observation will take place. Observation during normal sleep hours might not reliably identify the onset of toxicity. Depending on local poison center policy, patients could be referred to an emergency department if the observation would take place during normal sleeping hours of the patient or caretaker (Grade D). 5) Do not induce emesis (Grade C). 6) The use of oral activated charcoal can be considered since the likelihood of SSRI-induced loss of consciousness or seizures is small. However, there are no data to suggest a specific clinical benefit. The routine use of out-of-hospital oral activated charcoal in patients with unintentional SSRI overdose cannot be advocated at this time (Grade C). 7) Use intravenous benzodiazepines for seizures and benzodiazepines and external cooling measures for hyperthermia (>104 degrees F [>40 degrees C]) for SSRI-induced serotonin syndrome. This should be done in consultation with and authorized by EMS medical direction, by a written treatment protocol or policy, or with direct medical oversight (Grade C).

Long-acting anticoagulant rodenticide poisoning: An evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposure to long-acting anticoagulant rodenticides (LAAR). An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the doses reported (Grade D). 2) Patients with symptoms of LAAR poisoning (e.g., bleeding, bruising) should be referred immediately to an emergency department for evaluation regardless of the doses reported (Grade C). 3) Patients with chronic ingestion of LAAR should be referred immediately to an emergency department for evaluation of intent and potential coagulopathy (Grade B). 4) Patients taking anticoagulants therapeutically and who ingest any dose of a LAAR should have a baseline prothrombin time measured and then again at 48-72 hours after ingestion (Grade D). 5) Patients with unintentional ingestion of less than 1 mg of LAAR active ingredient can be safely observed at home without laboratory monitoring. This includes practically all unintentional ingestions in children less than 6 years of age (Grade C). 6) Pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED or clinic is not required (Grade D). 7) Patients with unintentional ingestion of 1 mg or more of active ingredient and are asymptomatic should be evaluated for coagulopathy at 48-72 hours after exposure (Grade B). 8) Physicians' offices or outpatient clinics must be able to obtain coagulation study results in a timely manner, preferably in less than 24 hours, for patients who require outpatient monitoring (Grade D). 9) Gastrointestinal decontamination with ipecac syrup or gastric lavage is not recommended (Grade D). 10) Transportation to an emergency department should not be delayed for administration of activated charcoal (Grade D). 11) Patients with dermal exposures should be decontaminated by washing the skin with mild soap and water (Grade D). 12) The administration of vitamin K is not recommended prior to evaluation for coagulopathy (Grade D).

Dextromethorphan poisoning: An evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected ingestion of dextromethorphan by 1) describing the process by which an ingestion of dextromethorphan might be managed, 2) identifying the key decision elements in managing cases of dextromethorphan ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to the ingestion of dextromethorphan alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) Patients who exhibit more than mild effects (e.g., infrequent vomiting or somnolence [lightly sedated and arousable with speaking voice or light touch]) after an acute dextromethorphan ingestion should be referred to an emergency department (Grade C). 3) Patients who have ingested 5-7.5 mg/kg should receive poison center-initiated follow-up approximately every 2 hours for up to 4 hours after ingestion. Refer to an emergency department if more than mild symptoms develop (Grade D). 4) Patients who have ingested more than 7.5 mg/kg should be referred to an emergency department for evaluation (Grade C). 5) If the patient is taking other medications likely to interact with dextromethorphan and cause serotonin syndrome, such as monoamine oxidase inhibitors or selective serotonin reuptake inhibitors, poison center-initiated follow-up every 2 hours for 8 hours is recommended (Grade D). 6) Patients who are asymptomatic and more than 4 hours have elapsed since the time of ingestion can be observed at home (Grade C). 7) Do not induce emesis (Grade D). 8) Do not use activated charcoal at home. Activated charcoal can be administered to asymptomatic patients who have ingested overdoses of dextromethorphan within the preceding hour. Its administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grade D). 9) For patients who have ingested dextromethorphan and are sedated or comatose, naloxone, in the usual doses for treatment of opioid overdose, can be considered for prehospital administration, particularly if the patient has respiratory depression (Grade C). 10) Use intravenous benzodiazepines for seizures and benzodiazepines and external cooling measures for hyperthermia (>104 degrees F, >40 degrees C) for serotonin syndrome. This should be done in consultation with and authorized by EMS medical direction, by a written treatment protocol or policy, or with direct medical oversight (Grade C). 11) Carefully ascertain by history whether other drugs, such as acetaminophen, were involved in the incident and assess the risk for toxicity or for a drug interaction.

Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management

The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposures to elemental mercury. An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses.

RECOMMENDATIONS

1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the exposure reported (Grade D). 2) Patients with symptoms of acute elemental mercury poisoning (e.g., cough, dyspnea, chest pain) should be referred immediately to an emergency department for evaluation regardless of the reported dose. Patients with symptoms of chronic toxicity (rash, tremor, weight loss, etc.) should be referred for healthcare evaluation, the timing and location of which is guided by the severity of illness and circumstances of the exposure (Grade C). 3) If the elemental mercury was recently heated (e.g., from stove top, oven, furnace) in an enclosed area, all people within the exposure area should be evaluated at a healthcare facility due to the high risk of toxicity (Grade C). 4) If the elemental mercury was vacuumed or swept with a broom, the health department should be contacted to perform an environmental assessment for mercury contamination. Consider healthcare referral for those exposed to documented high air mercury concentrations (Grade C). 5) Patients ingesting more mercury than in a household fever thermometer or those with abdominal pain after ingestion should be referred to an emergency department for evaluation (Grade C). Do not induce emesis or administer activated charcoal. 6) Asymptomatic patients with brief, unintentional, low-dose vapor exposures can be observed at home. Asymptomatic patients can be evaluated as non-urgent outpatients if there is concern for exposures to high doses (e.g., more than contained in a thermometer) or for chronic duration (Grade D). 7) Pregnant patients unintentionally exposed to elemental mercury and who are asymptomatic should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED is not required (Grade D). 8) Patients with elemental mercury deposited or injected into soft tissue should be referred for evaluation of surgical removal (Grade C). 9) All elemental mercury spills should be properly cleaned up, including the small amount of mercury from a broken thermometer. Brooms and vacuum cleaners should not be used to clean up elemental mercury. The clean-up of any spill larger than a broken thermometer should be performed by a professional company, state health department, or the EPA. Detailed instructions are provided on the EPA website: www.epa.gov/epaoswer/hazwaste/mercury/faq/spills.htm (Grade D). 10) Patients with dermal exposures should remove all jewelry and wash the affected area with mild soap and water. Remove all contaminated clothing and place these items in a sealed plastic double-bag for proper disposal (Grade D). 11) Do not discard elemental mercury in household trash, plumbing drains, or sewer systems. Consult local authorities for the proper disposal of low-level elemental mercury-contaminated household items and thermometers (Grade D).

Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior

OBJECTIVE

Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used and frequently lead to serious adverse events. Little is known about NSAID-related ethnic/racial disparities. We focused on differences in patient NSAID risk awareness, patient-doctor NSAID risk communication, and NSAID risk-avoidance behavior.

METHODS

We performed a cross-sectional analysis of survey data from the Alabama NSAID Patient Safety Study. Eligible patients were > or = 65 years old and currently taking prescription NSAIDs (Rx NSAIDS). Generalized linear latent and mixed models accounted for nesting of patients within physicians.

RESULTS

Of all 404 participants, 32% were African American and 73% were female. The mean +/- SD age was 72.8 +/- 7.5 years, and 64% reported an annual household income <$20,000. African American patients were less likely than white patients to recognize any risk associated with over-the-counter (OTC) NSAIDs (13.3% versus 29.3%; P = 0.001) and Rx NSAIDs (31.3% versus 49.6%; P = 0.001), report that their doctor discussed possible NSAID-related gastrointestinal problems (38.0% versus 52.4%; P = 0.007), and take medications to reduce ulcer risk (30.5% versus 50.2%; P = 0.001). Patients with lower income and education reported significantly less risk awareness for OTC and Rx NSAIDs. Racial/ethnic differences persisted after adjusting for multiple confounders.

CONCLUSION

In this community-based study of low income elderly individuals receiving NSAIDs, we identified important racial/ethnic differences in risk awareness, communication, and behavior. Additional efforts are needed to promote safe NSAID use and reduce ethnic/racial disparities.

Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management

A review of U.S. poison center data for 2004 showed over 40,000 exposures to salicylate-containing products. A guideline that determines the conditions for emergency department referral and pre-hospital care could potentially optimize patient outcome, avoid unnecessary emergency department visits, reduce health care costs, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the lead author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected exposure to salicylates by 1) describing the process by which a specialist in poison information should evaluate an exposure to salicylates, 2) identifying the key decision elements in managing cases of salicylate exposure, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses: 1) Patients with stated or suspected self-harm or who are the victims of a potentially malicious administration of a salicylate, should be referred to an emergency department immediately. This referral should be guided by local poison center procedures. In general, this should occur regardless of the dose reported (Grade D). 2) The presence of typical symptoms of salicylate toxicity such as hematemesis, tachypnea, hyperpnea, dyspnea, tinnitus, deafness, lethargy, seizures, unexplained lethargy, or confusion warrants referral to an emergency department for evaluation (Grade C). 3) Patients who exhibit typical symptoms of salicylate toxicity or nonspecific symptoms such as unexplained lethargy, confusion, or dyspnea, which could indicate the development of chronic salicylate toxicity, should be referred to an emergency department (Grade C). 4) Patients without evidence of self-harm should have further evaluation, including determination of the dose, time of ingestion, presence of symptoms, history of other medical conditions, and the presence of co-ingestants. The acute ingestion of more than 150 mg/kg or 6.5 g of aspirin equivalent, whichever is less, warrants referral to an emergency department. Ingestion of greater than a lick or taste of oil of wintergreen (98% methyl salicylate) by children under 6 years of age and more than 4 mL of oil of wintergreen by patients 6 years of age and older could cause systemic salicylate toxicity and warrants referral to an emergency department (Grade C). 5) Do not induce emesis for ingestions of salicylates (Grade D). 6) Consider the out-of-hospital administration of activated charcoal for acute ingestions of a toxic dose if it is immediately available, no contraindications are present, the patient is not vomiting, and local guidelines for its out-of-hospital use are observed. However, do not delay transportation in order to administer activated charcoal (Grade D). 7) Women in the last trimester of pregnancy who ingest below the dose for emergency department referral and do not have other referral conditions should be directed to their primary care physician, obstetrician, or a non-emergent health care facility for evaluation of maternal and fetal risk. Routine referral to an emergency department for immediate care is not required (Grade C). 8) For asymptomatic patients with dermal exposures to methyl salicylate or salicylic acid, the skin should be thoroughly washed with soap and water and the patient can be observed at home for development of symptoms (Grade C). 9) For patients with an ocular exposure of methyl salicylate or salicylic acid, the eye(s) should be irrigated with room-temperature tap water for 15 minutes. If after irrigation the patient is having pain, decreased visual acuity, or persistent irritation, referral for an ophthalmological examination is indicated (Grade D). 10) Poison centers should monitor the onset of symptoms whenever possible by conducting follow-up calls at periodic intervals for approximately 12 hours after ingestion of non-enteric-coated salicylate products, and for approximately 24 hours after the ingestion of enteric-coated aspirin (Grade C).

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data

PURPOSE

The severity of hazards posed by medications implicated in poisoning in older adults was characterized.

METHODS

Toxic Exposure Surveillance System (TESS) cases from 1993 through 2002 involving a single substance in patients age 60 years or older and coded as an adverse drug reaction (ADR) or therapeutic error were analyzed. Hazard factors were determined for each exposure reason by calculating the sum of the major effects and deaths for each substance category and subcategory and dividing this by the total number of exposures for the respective category or subcategory.

RESULTS

Hazard factors were calculated for 12,737 ADRs and 51,846 therapeutic errors. The overall rates of major effects and deaths were 7.5% and 1.6% in the ADR and therapeutic error groups, respectively. In the ADR group, five TESS categories had a hazard factor of > or =2.0: anesthetics, anticoagulants, antineoplastics, cardiovascular drugs, and radiopharmaceuticals. In the therapeutic error group, five drug categories also had a hazard factor of > or =2.0: anesthetics, anticoagulants, antineoplastics, asthma therapies, and serums/toxoids/vaccines. Six pharmaceutical categories were associated with hazard factors of > or =2.0 in both the ADR and therapeutic error groups.

CONCLUSION

An analysis of ADRs and therapeutic errors involving older adults and reported to poison control centers from 1993 through 2002 revealed overall rates of major effects and death of 7.5% and 1.6% in the ADR and therapeutic error groups, respectively. Antineoplastics, aminophylline or theophylline, cardiac glycosides, heparin, morphine, and warfarin were implicated in more than 50 cases and associated with hazard factors of > or =2.0 for both exposure groups.

Hydrocarbon toxicity: an analysis of AAPCC TESS data

INTRODUCTION

Human hydrocarbon exposures have the potential to cause significant morbidity and mortality. To determine which hydrocarbons were associated with the most severe adverse outcomes, human exposure data reported to American poison information centers were analyzed.

METHODS

Outcome data for single-substance, hydrocarbon exposures reported to the American Association of Poison Control Centers Toxic Exposure Surveillance System from 1994 through 2003 were analyzed. Only cases with definitive medical outcomes were included. Analyses were stratified by five age groups: <6 years, 6-12 years, 13-19 years, 20-59 years, >59 years. Hazard factors were determined by calculating the sum of the major effects and fatalities for each hydrocarbon category and dividing this by the total number of exposures for that category. To normalize the data, the overall rate of major effects and deaths for each age group was assigned hazard factor value of 1. Hydrocarbon categories with a HF of > or = 1.5 were included in the final analyses. Estimated rates of major effect and fatal outcomes (outcomes/1000 people) were also calculated.

RESULTS

318,939 exposures were analyzed. Exposures to benzene, toluene/xylene, halogenated hydrocarbons, kerosene and lamp oil resulted in the highest hazard factor values.

CONCLUSIONS

These data demonstrate that hydrocarbons that are absorbed systemically and those with low viscosities are associated with higher hazard factors. The risks associated with hydrocarbons often implicated in abuse by older children and adolescents are also confirmed.

Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management

A review of national poison center data from 1990 through 2003 showed approximately 10,000 annual ingestion exposures to camphor-containing products. A guideline that determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create the guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected exposures to camphor-containing products by 1) describing the manner in which an exposure to camphor might be managed, 2) identifying the key decision elements in managing cases of camphor exposure, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to camphor exposure alone. Co-ingestion of additional substances, such as in commercial products of camphor combined with other ingredients, could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline, and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are the recipients of malicious administration of a camphor-containing product should be referred to an emergency department immediately, regardless of the amount ingested (Grade D). 2) Patients who have ingested more than 30 mg/kg of a camphor-containing product or who are exhibiting symptoms of moderate to severe toxicity (e.g., convulsions, lethargy, ataxia, severe nausea and vomiting) by any route of exposure should be referred to an emergency department for observation and treatment (Grade D). 3) Patients exhibiting convulsions following a camphor exposure should be transported to an emergency department by pre-hospital emergency medical care providers (Grade D). A benzodiazepine should be used to control convulsions (Grade C). 4) Patients who have been exposed to a camphor product and who remain asymptomatic after 4 hours can be safely observed at home (Grade C). 5) Induction of emesis with ipecac syrup should not be performed in patients who have ingested camphor products (Grade C). 6) Activated charcoal administration should not be used for the ingestion of camphor products. However, it could be considered if there are other ingredients in the product that are effectively adsorbed by activated charcoal or if other substances have been co-ingested. (Grade C). 7) For asymptomatic patients with topical exposures to camphor products, the skin should be thoroughly washed with soap and water and the patient can be observed at home for development of symptoms (Grade C). 8) For patients with topical splash exposures of camphor to the eye(s), the eye(s) should be irrigated in accordance with usual poison center procedures and that referral take place based on the presence and severity of symptoms (Grade D). 9) Patients with camphor inhalation exposures should be moved to a fresh air environment and referred for medical care based on the presence and severity of symptoms. It is unlikely that symptoms will progress once the patient is removed from the exposure environment (Grade D).

Guideline on the use of ipecac syrup in the out-of-hospital management of ingested poisons

The use of gastric emptying techniques, including ipecac-induced emesis, in the management of poisoned patients has declined significantly in recent years. Historically, poison centers used ipecac syrup in two ways. Ipecac syrup was administered to patients prior to referral to the emergency department in attempts to start the gastric emptying process as early as possible. Additionally, poison centers used ipecac syrup in attempts to keep patients from requiring referral to medical facilities. In these situations, ipecac syrup was administered in the home and poison center staff performed follow-up telephone calls to gauge progress and outcome. Studies to determine the effectiveness of ipecac syrup demonstrate that it induces vomiting in a high percentage of people to whom it is administered and that it decreases the gastrointestinal absorption of ingested substances in a time-dependent fashion. However, the effectiveness of ipecac syrup in affecting patient outcome has not been studied in adequate clinical trials. Its effectiveness in preventing drug absorption has only been documented for a limited number of substances and is substantially reduced if it is given more than 30-90 minutes following ingestion of the toxic material. There are potentially significant contraindications, adverse effects and related problems associated with the use of ipecac syrup. It is the consensus of the panel that the circumstances in which ipecac-induced emesis is the appropriate or desired method of gastric decontamination are rare. The panel concluded that the use of ipecac syrup might have an acceptable benefit-to-risk ratio in rare situations in which: there is no contraindication to the use of ipecac syrup; and there is substantial risk of serious toxicity to the victim; and there is no alternative therapy available or effective to decrease gastrointestinal absorption (e.g., activated charcoal); and there will be a delay of greater than 1 hour before the patient will arrive at an emergency medical facility and ipecac syrup can be administered within 30-90 minutes of the ingestion; and ipecac syrup administration will not adversely affect more definitive treatment that might be provided at a hospital. In such circumstances, the administration of ipecac syrup should occur only in response to a specific recommendation from a poison center, emergency department physician, or other qualified medical personnel. The panel decided not to address the issue of whether ipecac should remain a nonprescription, over-the-counter product. The panel does not support the routine stocking of ipecac in all households with young children but was unable to reach consensus on which households with young children might benefit from stocking ipecac. Instead, the panel concluded that individual practitioners and poison control centers are best able to determine the particular patient population, geographic and other variables that might influence the decision to recommend having ipecac on hand.

Should home ipecac-induced emesis be routinely recommended in the management of toxic berry ingestions?

Poison center (PC) management of toxic berry ingestions may include recommendations to administer syrup of ipecac (SI) regardless of the number of berries ingested. We investigated whether the routine use of SI in the home management of asymptomatic single or few (< 6) berry ingestions may be unnecessary. A prospective, randomized clinical trial compared SI + home observation (HO) to HO alone for management of pediatric toxic berry ingestions. Subjects were children 9 mo to 5 y who ingested a small number (< 6) of Taxus sp (yew), Solanum americanus (nightshade), Ilex sp (holly) or unknown potentially toxic berries. Exclusions were symptomatic subjects, ingestion of more than 1 type of berry or other plant part, or contraindication to SI. Outcome variables consisting of symptom assessment and disposition were assessed 24 h following the ingestion. Over a 27-mo period 103 subjects were entered into the study; 45 received SI/HO and 51 received only HO. While 100% of the SI/HO group experienced vomiting, none of the HO group vomited. Diarrhea and sedation were more common in the SI/HO group. Use of SI in the home management of young children who ingest fewer than 6 toxic berries (yew, nightshade, holly or unknown) and who are asymptomatic when the PC is contacted may be responsible for the majority of symptoms. Ingestion of small amounts of berries may require no intervention beyond observation. Methodological limitations of this study included the lack of confirmed identification of the berries and the inability to confirm ingestion and absorption.

A comparison of the bioavailabilities of oral and intravenous ethanol in healthy male volunteers

OBJECTIVES

Ethanol (EtOH), the antidote for methanol and ethylene glycol, is administered by the oral (PO) and intravenous (IV) routes. Serum concentrations (SCs) of 100 mg/dL or more are targeted for clinical effect. This study was completed to validate the assumption that there are minimal differences in SC achieved between these two routes.

METHODS

Twenty healthy male volunteers were randomized to receive either PO or IV EtOH. Subjects abstained from EtOH for 48 hours before each phase. After a seven-day washout period, the subjects crossed over to the other group. Inclusion criteria were no history of medical problems, age between 21 and 40 years, and actual body weight within 10% of ideal weight. Baseline EtOH SCs were obtained before participation in each phase. Two hours after a standard breakfast, the subjects received 700 mg/kg of PO or IV EtOH. PO EtOH was administered as a 20% solution in juice over 10 minutes. IV EtOH, controlled by an infusion pump, was administered as a 10% solution over 30 minutes. Blood was drawn for EtOH SCs at 45, 75, 105, 135, 165, 225, 285, and 345 minutes after start of the dose.

RESULTS

All initial EtOH SCs were 0. EtOH SCs were higher after IV administration. Mean peak SC was 103.6 mg/dL after IV administration and 71.3 mg/dL after PO administration (p<0.0001). Mean time to peak was 46.5 minutes after IV administration and 103.5 minutes after PO administration (p<0.0001). Total area under the curve was 17,440 min-mg/dL after IV administration and 13,875 min-mg/dL after PO administration (p<0.003). The order of treatments did not affect results (p>0.1).

CONCLUSION

Significant differences exist between the SCs of EtOH as well as the times to peak SC after PO and IV administrations.

Toxicology training of paramedic students in the United States

A 16-item survey was mailed to the directors of 618 paramedic training programs in the United States to determine (1) the number of lecture hours devoted to toxicology topics and (2) how often paramedic training includes a rotation in a poison control center. The response rate was 82%. Toxicology accounts for approximately 2% of paramedic students' total training. Cardiovascular drug toxicity and hazardous materials are discussed for over 60 minutes by more than 50% of paramedic training programs. Four paramedic programs have no lecture time on cyclic antidepressant overdoses and one program has no lecture time on carbon monoxide poisoning. Eighty-one percent (377 of 467) have access to a regional poison control center; 11% (42 of 377) use the poison control center as a paramedic training site. Some US paramedic training programs spend insufficient time covering topics that have significant out-of-hospital morbidity. Although poison control centers are often available, they are underutilized for paramedic training.

Home observation for asymptomatic coin ingestion: acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group

OBJECTIVES

To obtain preliminary estimates of the acceptance rate and the frequency of adverse outcomes, and to identify issues related to acceptance, associated with management of asymptomatic pediatric coin ingestion by home observation, in preparation for a large-scale prospective study.

METHODS

Scripted telephone follow-up of callers who had reported asymptomatic pediatric coin ingestions to one of five poison control centers six to 36 months previously, which had been managed by home observation.

RESULTS

Of the 67 callers enrolled, 41 (67%) reported contacting a physician regarding the coin ingestion, despite home observation instruction by poison control center personnel. Those who did not recall being instructed in home observation were more likely to have contacted a physician than those who did. Nearly all, however, were satisfied with the advice they had been given. One child developed subsequent symptoms; as per the instructions that had been given by poison control center personnel, his parent sought physician evaluation, revealing an esophageal coin, which was removed uneventfully. No other child developed complications.

CONCLUSIONS

Although all of the 67 children managed by home observation did well, most of their caretakers had not accepted this management strategy. Acceptance, while unrelated to satisfaction, may be related to comprehension of the instructions caregivers are given. A prospective study of home observation for asymptomatic pediatric coin ingestion would be safe and would allow further examination of factors affecting acceptance.

Experimental tricyclic antidepressant toxicity: a randomized, controlled comparison of hypertonic saline solution, sodium bicarbonate, and hyperventilation

STUDY OBJECTIVE

We sought to compare the effects of hypertonic sodium chloride solution (HTS), sodium bicarbonate solution, and hyperventilation (HV) on severe tricyclic antidepressant (TCA) toxicity in a swine model.

METHODS

Twenty-four mixed-breed, domestic swine of either sex were given an intravenous infusion of nortriptyline (NT) until development of both a QRS duration longer than 120 ms and a systolic blood pressure (SBP) less than or equal to 50 mm Hg. Animals were randomly assigned to 1 of 4 groups. On reaching toxicity, the control group received 10 mL/kg of 5% dextrose in water (D5W); the HTS group received 10 mL/kg of 7.5% NaCl solution (15 mEq Na+/kg); the NaHCO3 group received 3 mEq/kg of 8.4% sodium bicarbonate solution followed by enough D5W solution to equal 10 mL/kg of total volume; and the HV group was mechanically hyperventilated to maintain arterial pH between 7.50 and 7.60 and given 10 mL/kg of D5W.

RESULTS

The mean SBP 10 minutes after treatment was 54+/-18 mm Hg in the control group, 134+/-21 mm Hg in the HTS group, 85+/-19 mm Hg in the NaHCO3 group, and 60+/-12 mm Hg in the HV group (P<.05). Mean QRS duration 10 minutes after treatment was 144+/-38 ms in the control group, 80+/-14 ms in the HTS group, 105+/-38 ms in the NaHCO3 group, and 125+/-46 ms in the HV group (P<.05).

CONCLUSION

In this model of TCA, toxicity HTS was more effective than sodium bicarbonate. Hyperventilation had little effect. Sodium loading may be the most important factor in reversing TCA toxicity.

Gatekeepers: a missed opportunity for safe transport

OBJECTIVE

To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain.

METHODS

A convenience sample of adults > or =40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angioplasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation.

RESULTS

Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by ambulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile.

CONCLUSION

Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.

Prehospital gastrointestinal decontamination of toxic ingestions: a missed opportunity

The purpose of this study was to determine if emergency medical services (EMS) providers routinely initiate field gastrointestinal decontamination of adult drug overdose patients transported to the emergency department (ED). A retrospective prehospital chart review was performed on adult patients identified as drug overdose who were transported by EMS. ED charts on patients transported to a university hospital were reviewed for follow-up data. Prehospital care records showed that gastrointestinal decontamination was initiated in only 6 of 361 (2%) patients, all of whom received ipecac. No patient received activated charcoal. The median transport time was 25 minutes (range, 5 to 66 minutes). Follow-up data on patients transported to the university hospital revealed that 30 of 43 (70%) patients who might have been suitable candidates for prehospital activated charcoal actually received activated charcoal in the ED. Median time to activated charcoal in the ED was 82 minutes (range, 32 to 329 min). Use of activated charcoal in the field appears to be deferred despite its known loss of efficacy over time. The failure to start activated charcoal in the field contributes to the delay in initiating activated charcoal therapy.

Cocaine balloon aspiration: successful removal with bronchoscopy

Ingestion of balloons containing illicit substances along with the potential toxic sequelae associated with these ingestions have been described in the literature. This report describes the successful bronchoscopic retrieval of a cocaine balloon after aspiration. A 39-year-old man was witnessed swallowing several balloons that were thought to contain heroin. Shortly after ingestion, the patient became unconscious and required nasotracheal intubation. Before intubation, several balloons were removed from the oropharynx. Naloxone 4 mg was administered en route to the emergency department (ED). Following naloxone, the patient awoke and became agitated and combative. On arrival in the ED, midazolam, succinylcholine, and vecuronium were required to manage his combativeness. Vital signs were: heart rate, 130 beats/min; blood pressure, 128/86 mm Hg; respirations, 12 breaths/min; temperature, 96.5 degrees F. A balloon and balloon tip were removed during lavage. Whole bowel irrigation with a polyethylene glycol electrolyte solution was initiated. A right upper lobe infiltrate was identified on chest X-ray and aspiration of a balloon was suspected. At bronchoscopy, a small yellow, intact balloon visualized in the basilar segment of the right lower lobe was removed. Toxicologic analysis of the balloon contents found cocaine. The rest of the patient's hospital course was unremarkable and he was discharged 5 days after admission. This case brings to light the potential concerns, such as respiratory compromise, associated with aspiration of small balloons in the body stuffer. Additionally, the potential for the development of toxicity if the balloon ruptures and toxin absorption occurs through through the lungs should be considered. Emergency physicians and toxicologists should be aware of this significant complication of packet ingestion in the body packer or stuffer and be prepared to intervene early during the course of the patient's treatment.

Assessment of learning by emergency medicine residents and pharmacy students participating in a poison center clerkship

An AAPCC-designated poison center developed and validated an objective testing instrument to evaluate learning during a poison center clinical rotation for 2nd-year emergency medicine residents and 5th-year pharmacy students. The examination contained multiple-choice, true-false, and fill-in questions pertaining to basic clinical toxicology. A pretest was administered prior to the rotation and a post-test was administered upon completion of the rotation. Overall pre-test mean was 56.2%; physician pre-test mean was 73.8%, and student pre-test mean was 43.9%. Overall post-test mean was 78.7%; physician post-test mean was 85.7%, and student post-test mean was 81%. Pre-test scores ranged from 21 to 86% for the group, and post-test scores ranged from 68 to 96%. The mean difference in pre-test to post-test score was 26.9%. These data suggest that a poison center rotation can result in significant increases in post-test scores in comparison to pre-test scores.

Frequent users of the emergency department: can we intervene?

OBJECTIVE

To determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users.

METHODS

The authors performed a prospective, randomized clinical trial of the impact of a care plan on ED use by adults with frequent ED visits. Patients with > 10 ED visits to a university hospital in 1993 were identified. Patients were matched for age, sex, and number of visits and then randomized into 2 groups. The control group received standard emergency care. The treatment group was managed by a multidisciplinary team and treated in the ED according to individualized care plans. ED use was tracked at the university hospital and at the other 5 community hospitals in the city.

RESULTS

Of the 70 enrolled patients, 25 of 37 control patients and 27 of 33 treatment patients made visits to the university hospital during the 1-year study period. Only those patients with follow-up visits were included in the data analysis. Patients remaining in the control group made 247 total visits (range 1-65) to the university hospital and 179 total visits (range 0-38) to the community hospitals during the study period. Patients in the treatment group made 320 total visits (range 1-72) to the university hospital and 254 total visits (range 0-135) to the community hospitals during the study period. There was no significant difference in the median number of visits made to either the university hospital or the community hospitals by the patients in the control group and those in the treatment group.

CONCLUSIONS

The use of individualized care plans and case management did not significantly decrease ED utilization by frequent ED users. However, the impact of individualized care plans and case management on other quality-of-care measures (e.g., patient satisfaction, ED length of stay, hospitalizations, primary care visits, and health care costs) remains to be determined.

Research subject enroller program: a key to successful emergency medicine research

OBJECTIVE

To describe the successful use and impact of individuals paid to enroll clinical research subjects in support of emergency medicine (EM) research.

PROGRAM DESCRIPTION

Paramedics and college students were hired to identify/enroll subjects in EM research studies 14 hours/day, 7 days/week. Potential subjects were identified by monitoring emergency medical services radios, routine rounding in the ED, and communication with the ED attending and charge nurse. Enrollers were trained in phlebotomy, obtaining ECGs, obtaining consent in appropriate studies, and post-ED follow-up. They supported ED prospective studies and multicenter clinical trials, as well as departmental surveys and retrospective studies. Survey support included mailing list development, mailing completion, survey database design, and data entry.

PROGRAM OUTCOMES

Over 18 months, 17 prospective studies and 8 surveys/retrospective studies were completed. 2,175 subjects were enrolled in prospective studies and 6,500 surveys/retrospective reviews were completed. In the year prior to enroller program initiation, < 100 subjects were enrolled in 3 departmental studies.

CONCLUSION

Use of paid, clinical research subject enrollers supports successful recruitment of study subjects and the completion of EM research studies.

Valerian overdose: a case report

We present the first reported case of valerian (Valeriana officianalis) overdose. This herb is popular as a sedative but little is known about its toxic effects. The patient presented with mild symptoms, all of which resolved within 24 h. Valerian overdose, at approximately 20 times the recommended therapeutic dose, appears to be benign.

Recovery from severe cyclic antidepressant overdose with hypertonic saline/dextran in a swine model

OBJECTIVE

To determine the effect of a hypertonic saline and dextran (HSD) solution on blood pressure and QS duration during severe cyclic antidepressant (CA) toxicity in swine.

METHODS

Ten domestic swine weighing 20-24 kg were anesthetized and placed on mechanical ventilation. Nortriptyline solution was infused intravenously to achieve hypotension (systolic blood pressure equal to 50% of baseline) and a QRS duration of 120 msec. After reaching toxicity, the animals received in a randomized fashion either 10 mL/kg of a 7.5% saline/6% dextran solution or an equal volume of 0.9% saline as a rapid intravenous bolus. The animals were observed for one hour or until they died. Blood pressure and ECG were recorded continuously. Arterial pH was maintained in the physiologic range by controlled ventilation.

RESULTS

Mean systolic blood pressure 10 minutes after treatment was 45 +/- 8 torr in the normal- saline group compared with 115 +/- 12 torr in the HSD group (p < 0.05). Mean QRS duration 10 minutes after treatment was 180 +/- 8 msec in the normal-saline group; it was 88 +/- 13 msec in the HSD group (p < 0.05). All normal-saline--group animals died within 20 minutes, and four of the five animals in the HSD group survived to 60 minutes (p < 0.05). The mean peak sodium concentration was 157 mmol/dL (mEq/dL) in the HSD group, and this was transient.

CONCLUSION

In this swine model of severe CA toxicity, a solution of 7.5% saline/6% dextran significantly reversed hypotension and QRS prolongation. HSD also improved survival to 60 minutes.