The laboratory in the diagnosis and management of acetaminophen and salicylate intoxications

Toxic ingestions of acetaminophen and aspirin are clearly distinct in clinical presentations and in implications for laboratory medicine. In acetaminophen ingestion, the serum drug level is the single most important factor in the decision for or against therapy. In aspirin ingestion, the serum drug level is useful at its extremes--when so low as to indicate no need for therapy, and when so high as to indicate the need for dialysis. In the majority of infants and children with clinically significant salicylism, the serum drug level is in an intermediate range. For the management of these patients, the absolute level of salicylate in blood has much less significance than the laboratory assessment of the effects of salicylate on intermediary metabolism, acid-base status, and electrolyte and water balance.

Poisoning with enteric-coated acetylsalicylic acid complicating gastric outlet obstruction

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Effect of safety packaging on aspirin ingestion by children

The effectiveness of child-resistant closures, required under the Poison Prevention Packaging Act of 1970, in reducing the incidence of accidental ingestion of aspirin and aspirin-containing products among children less than 5 years of age has been investigated. Data from Poison Control Centers and the National Center for Health Statistics were analyzed to determine the ingestion level before and two to three years after safety closures were required. Baby aspirin and nonbaby aspirin products were analyzed separately. For baby aspirin. It is estimated that safety packaging has reduced the incidence of ingestions 45% to 55%. For nonbaby aspirin products, the reduction has been 40% to 45%.

Diffuse metanephric adenoma after in utero aspirin intoxication. A unique case of progressive renal failure

Diffuse persistent glomerular immaturity and focal proximal tubular ectasia were seen in bilateral open renal biopsy specimens for an infant with fluid and salt depletion and slowly progressive renal failure. Subsequently, diffuse tubulopapillary renal adenoma subtotally replaced each kidney, thereby, necessitating renal transplantation. Origin of diffuse metanephric adenoma from persistent primitive epithelium of the proximal nephron is postulated and partly substantiated. We propose that this case of persistent proximal nephronic epithelial immaturity and diffuse metanephric adenoma is a variant of nephroblastomatosis and that in this case, a first trimester suicide attempt with aspirin may have initiated the maturation defect that preceded neoplastic transformation.

Fixed-bed uncoated charcoal hemoperfusion in the treatment of intoxications: animal and patient studies

We examined the efficacy of a new, fixed-bed, uncoated charcoal device in experimentally intoxicated dogs and in drug-intoxicated as well as chemically poisoned patients. In the animal studies, 4 h of hemoperfusion resulted in a significant decrease in the blood level of phenobarbital, salicylate, pentobarbital and glutethimide. The drug clearances varied between 97 +/- 10 and 129 +/- 6 ml/min. However, the total amount of drug removed was higher for phenobarbital and salicylate which have a small apparent volume of distribution (AVD) than for pentobarbital and glutethimide which have an AVD greater than total body water. We next treated 14 patients suffering from a wide variety of intoxications. Patients intoxicated with phenobarbital, methsuximide, chlordane and Amanita muscaria all showed a significant improvement in their clinical status. Patients intoxicated with ethchlorvynol, glutethimide, methaqualone, podophyllin and fluoroacetamide did not improve. Charcoal hemoperfusion may be useful in patients poisoned with drugs characterized by an AVD smaller than total body water. No major complications were encountered during the hemoperfusions.

Salicylate intoxication and influenza in ferrets

A model of salicylate intoxication was developed in ferrets to permit the evaluation of the interaction with viruses isolated from patients with Reye's syndrome. Salicylate intoxication produced a mild elevation of the serum glutamic oxaloacetic transaminase and fatty changes in the liver, but these changes differed from those seen in Reye's syndrome on light and electron microscopy. Salicylates were associated with decreased activity of hepatic phosphorylase and a slight depression of activity or ornithine transcarbamylase, a mitochondrial urea cycle enzyme. Infection with influenza viruses produced mild fatty changes in the liver, but did not significantly potentiate the effects of salicylate intoxication on the over-all mortality, the degree of fatty changes, or the hepatic enzymes. Influenza infection alone was not associated with decreased hepatic phosphorylase activity, but was associated with decreased activity of ornithine transcarbamylase. Influenza A was isolated from the livers of two of four animals cultured in embryonated eggs.

Determination of brain death via pulsatile echoencephalography

For cerebral death to occur there must be many levels of cerebral function destroyed. Cortical and subcortical irreversible damage is evident by unresponsiveness to any stimuli. Brain stem and basal ganglia damage is indicated by absence of spontaneous respirations, cephalic reflexes, and thus cerebral circulation. All elements of the criteria for cerebral death must be met. The decision should be made by the attending physician in consultation with his peers. The life support mechanisms should be discontinued after the diagnosis of cerebral death has been made. Absence of pulsatile echoes means absence of cerebral circulation and cerebral function, or a definitive diagnosis of cerebral death. It is a final parameter in the criteria and allows definite measures to be taken. But it behooves one to remember that this phenomenon of cerebral death makes organ donation and transplantation possible. It has not been created in order to supply the needs for organ transplant!

Adult respiratory distress syndrome precipitated by massive salicylate poisoning

Pulmonary oedema has been reported in severe cases of acetyl salicylic acid (ASA) poisoning. Liberal use of intravenous fluids, to establish a forced diuresis, is usually thought to be the precipitating cause. A case of severe ASA poisoning and respiratory failure was found to have increased pulmonary vascular resistance and signs of intravascular hypercoagulability. The patient recovered rapidly on mechanical ventilation with a positive endexpiratory pressure of 18 cm H2O and systemic steroids.

Aspirin overdosage: incidence, diagnosis, and management

The importance of aspirin as a cause of poisoning in children has declined dramatically with safety packaging and reductions in the dose of flavored children's aspirin per package. Although flavoring entices children to ingest more tablets, the increment is less than the dose differential between the children's and adults' preparations, and so the latter pose the greater hazard in the individual case. Chronic poisoning of children during therapy with aspirin is aggravated by the peculiar kinetics of the drug, but is preventable and constitutes no essential basis for the substitution of acetaminophen, which may not be devoid of risk factors in sick children. Salicylate levels are essential in the diagnosis and management of intoxication. In treatment, emphasis should be on trapping salicylate in the plasma and eventually the urine--through ionization to prevent its entry into the brain.

Pathophysiology of aspirin overdosage toxicity, with implications for management

The principal pathophysiologic effect of toxic doses of salicylates are characterized by (1) stimulation of the respiratory center of the brain, leading to hyperpnea and respiratory alkalosis; (2) uncoupling of oxidative phosphorylation, leading to increased oxygen utilization and glucose demand, increased oxygen utilization and glucose demand, increased glyconeogenesis, and increased heat production; (3) inhibition of Krebs cycle enzymes, leading to decreased glucose availability and increased organic acids; (4) alterations in lipid metabolism and amino acid metabolism, enhancing metabolic acidosis; and (5) increased fluid and electrolyte losses, leading to dehydration, sodium depletion, potassium depletion, and loss of buffer capacity. The principal toxic manifestations of respiratory alkalosis and metabolic acidosis, altered glucose availability and depletion, fluid and electrolyte losses, and hypermetabolism result in serious morbidity and are potentially fatal. Therapy of salicylate intoxication should be aimed principally at replacement of fluid electrolytes, correction of acidemia, administration of glucose, and prevention of further salicylate absorption and enhancement of salicylate elimination.

Profiles in altered metabolism. II.--Accumulation of homogentisic acid in serum and urine following acetylsalicylic acid ingestion

Homogentisic acid elevations have been found in urine and serum of patients on long term heavy salicylate therapy and those acutely intoxicated with acetylsalicylic acid. Loading of two normal volunteers with single oral acetylsalicylate doses produced transient elevations in urinary homogentisic acid excretion. These findings suggest that heavy salicylate use results in the partial inhibition of homogentisic acid oxidase in vivo.

Unusual abdominal complications of a suicidal overdose of analgesic and psychotropic drugs in an elderly patient

A suicidal 67-year-old woman with manic-depressive psychosis took an overdose of asprin, amitriptyline and diazepam. The initial effects were pyrexia, tachycardia, hyperpnea, metabolic acidosis, electrocardiographic changes, hypoprothrombinemia, gastritis, and pancreatitis. Four to six weeks later, she was examined because of persistent abdominal pain with mausea, anorexia anemia, and possibly a malabsorption syndrome. An exploratory laparotomy was performed. The surgeon found several previous adhesions, a small intestinal volvulus, and a nodular pancreas. This suggested previous perforation of the small bowel from enteritis, causing a "blind-loop" syndrone. The invilved section of the small bowel was resected. With appropriate treatment, the patient is well three months after operation.

[Salicylate poisoning. Determination of the free fraction using the ultrafiltration method]

Seventeen infants under one year of age admitted to the Emergency Service of the General Hospital of the Medical Center La Raza during the year 1976 were included in this study with the diagnosis of salicylate poisoning. Determination of plasma salicylate by the ultrafiltrate method was practiced to all patients. A direct relationship between total plasmatic salicylate and its free fraction was found together with an inverse proportion between percentage of total free--salicylate and plasma pH and a lineal correlation between plasma free--salicylate and salicylate obtained in spinal fluid. It is concluded that determination of the free fraction of plasma salicylate is an easy diagnostic method for the better evaluation of salicylate acid poisoning in the infant.

Evaluation of a charcoal-sorbitol mixture as an antidote for oral aspirin overdose

The preparation of charcoal in a 70% sorbitol solution results in a suspension that is more palatable and less gritty than an aqueous slurry of charcoal. Although the charcoal-sorbitol mixture may be slightly less effective in reducing the extent of aspirin absorption compared with a charcoal slurry, it may prove to be of particular value in those cases where acceptance of a charcoal slurry presents a problem.

Acute acetylsalicylic acid poisoning: treatment with forced alkaline diuresis and diuretics

101 patients were treated for acute acetylsalicylic acid (ASA) poisoning in the Nephrological Unit Trondheim between 1971-1975. On admission 33 of them had a serum salicylic acid (SA) concentration greater than 400 microgram/ml (mean 588 +/- 40 microgram/ml). This group was compared with a group of 11 children less than 5 years old with ASA poisoning and a mean serum SA on admission of 550 +/- 34 microgram/ml. Blood pH on admission was normal or elevated in all patients more than 12 years old (mean 7.43 +/- 0.01), whereas 7 of the 11 children suffered from metabolic acidosis. The results of forced alkaline diuresis produced by loop diuretics (bumetanide, furosemide) in ASA poisoned patients older than 12 years are reported. The mean T 1/2 of SA was 9.6 h in the treated group as compared to 18-22 h in untreated patients. There was no apparent difference between the diuretic effect of bumetanide and furosemide.

Child-resistant packaging and accidental child poisoning

From Jan. 1, 1976, all children's aspirin and paracetamol preparations were required to be presented either in child-resistant containers or in dark-tinted unit packaging. In two areas hospital admissions of children under 5 years for accidental ingestion of aspirin were monitored from 1974 to 1976 to assess the effectiveness of this measure. There was a highly significant fall in admissions for accidental salicylate poisoning (129 in 1975 to 48 in 1976, P less than 0-001). Admissions fell throughout 1976 as old stocks were used up. Further analysis of cases in one area suggests that the fall in admissions from accidental salicylate poisoning was due to the packaging of one preparation of junior aspirin in child-resistant containers.

Childhood poisoning: a community hospital experience

We reviewed medical records of 53 children who ingested poison and were treated as inpatients and 107 who were treated as outpatients in a Southeastern community hospital. Findings included a much higher incidence of petroleum distillate poisoning than is found nationally, and a low frequency of aspirin ingestions. Data on packaging of the poisons indicate that one third was stored in food containers. Of the products encountered, 33% currently require safety packaging but were found in obsolete containers.

Treatment of severe drug overdosage with charcoal hemoperfusion

Mortality from severe poisoning remains excessively high in patients managed conservatively. In this report, charcoal hemoperfusion was used as a therapeutic aid to active drug removal in 10 patients (9 of whom were in Grade IV coma) intoxicated with a variety of drugs and a further 3 patients poisoned with the highly lethal herbicide, paraquat. All 10 patients who ingested drugs recovered. One of the 3 patients ingesting paraquat survived. The hemoperfusion treatments were associated with demonstrated drug removal. Complications associated with hemoperfusion were minor. Decreases in platelet levels were observed but were not accompanied by clinically important bleeding. The technique of hemoperfusion is simple and provides a therapeutic aid in the care of the severely poisoned patient.