Gastric emptying. Risk versus benefit in the treatment of acute poisoning

Drug and Chemical Poisoning Patterns in Makkah Region, Saudi Arabia

This research reveals that drugs and chemicals poisoning have been reported to have severe and fetal side effects on health provided by doctors in statistics and periodical records. This work aimed to explore the interaction among drug and chemical poisoning patterns concerning risk factors, especially gender, age, exposure circumstances, and outcomes in the Makkah region. A retrospective analysis was of clinical drug and chemical poisoning cases (2014-2015). The data were retrieved from the Department of Environmental and Occupational Health, Ministry of Health, Makkah, Saudi Arabia. The Saudi Arabia Ministry of Health received 1216 reports of drug and chemical poisoning during 2014-2015 in Makkah. This study has found that, the most affected gender was that of males (65%). The most affected age category with drug poisoning was over 15 years old (67%), but under 5 years for chemical poisoning (60%). The majority of drug poisoning cases are unknown drugs (42%), which accidental poisoning was a minority compared with other drug causes (27%). Chemical poisoning accidents were the majority causes of the recorded cases (63%). We reported healthy recovered without complications for most patients from drug and chemical poisoning (85-95%). Antidotes were administered in only (5%) of cases, and fatalities were reported (0.5% of cases). We have shown a flagrant increase in the number of people poisoned by drugs and chemical agents during 2015. Increases poisoning cases involved both genders and all studied age categories, especially males over 15 years up to 25 (drugs) and < 5 years (chemicals). Most cases were accidental (chemicals) and reported healthy recovery for most patients.

Management of pharmaceutical and recreational drug poisoning

BACKGROUND

Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.

METHODS

A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

A learning-based method for online adjustment of C-arm Cone-beam CT source trajectories for artifact avoidance

PURPOSE

During spinal fusion surgery, screws are placed close to critical nerves suggesting the need for highly accurate screw placement. Verifying screw placement on high-quality tomographic imaging is essential. C-arm cone-beam CT (CBCT) provides intraoperative 3D tomographic imaging which would allow for immediate verification and, if needed, revision. However, the reconstruction quality attainable with commercial CBCT devices is insufficient, predominantly due to severe metal artifacts in the presence of pedicle screws. These artifacts arise from a mismatch between the true physics of image formation and an idealized model thereof assumed during reconstruction. Prospectively acquiring views onto anatomy that are least affected by this mismatch can, therefore, improve reconstruction quality.

METHODS

We propose to adjust the C-arm CBCT source trajectory during the scan to optimize reconstruction quality with respect to a certain task, i.e., verification of screw placement. Adjustments are performed on-the-fly using a convolutional neural network that regresses a quality index over all possible next views given the current X-ray image. Adjusting the CBCT trajectory to acquire the recommended views results in non-circular source orbits that avoid poor images, and thus, data inconsistencies.

RESULTS

We demonstrate that convolutional neural networks trained on realistically simulated data are capable of predicting quality metrics that enable scene-specific adjustments of the CBCT source trajectory. Using both realistically simulated data as well as real CBCT acquisitions of a semianthropomorphic phantom, we show that tomographic reconstructions of the resulting scene-specific CBCT acquisitions exhibit improved image quality particularly in terms of metal artifacts.

CONCLUSION

The proposed method is a step toward online patient-specific C-arm CBCT source trajectories that enable high-quality tomographic imaging in the operating room. Since the optimization objective is implicitly encoded in a neural network trained on large amounts of well-annotated projection images, the proposed approach overcomes the need for 3D information at run-time.

Adjuncts and Alternatives to Oxime Therapy in Organophosphate Poisoning—is There Evidence of Benefit in Human Poisoning? A Review

Organophosphate poisoning is common in developing countries. The morbidity and mortality with organophosphate poisoning is relatively high despite the use of atropine as specific antidotal therapy and oximes to reactivate acetylcholinesterase. Several adjunct and alternative therapies have been explored in animal and human studies. We reviewed the literature to ascertain if there was evidence of benefit of such therapies. Adjunct and alternative therapies included treatments to reduce poison absorption by topical application of creams, enhance toxin elimination by haemoperfusion or bioremediation and neutralise the poison by scavenging free organophosphate with cholinesterase-rich human plasma. In addition, magnesium, clonidine, diazepam, N-acetyl cysteine and adenosine receptor agonists have also been used to counteract poison effects. Detailed assessment was limited by the paucity of trials on adjunct/alternative therapies. The limited evidence from the review process suggested potential benefit from the use of human plasma infusion, early initiation of haemoperfusion and intravenous magnesium, in addition to standard therapy with atropine and pralidoxime. There appeared to be no additional benefit with alkalinisation or use of glycopyrrolate instead of atropine in human trials. Diazepam administration has been advocated by military authorities if symptoms developed following exposure to organophosphate. Bioremediation, clonidine, N-acetyl cysteine and adenosine receptor agonists have been evaluated only in animal models. The impact of adjunct and alternate therapies on outcomes in human poisoning needs to be further explored before implementation as standard treatment.

The hazards of gastric lavage for intentional self-poisoning in a resource poor location

OBJECTIVE

The 10-20% case fatality found with self-poisoning in the developing world differs markedly from the 0.5% found in the West. This may explain in part why the recent movement away from the use of gastric lavage in the West has not been followed in the developing world. After noting probable harm from gastric lavage in Sri Lanka, we performed an observational study to determine how lavage is routinely performed and the frequency of complications.

CASE SERIES

Fourteen consecutive gastric lavages were observed in four hospitals. Lavage was given to patients unable or unwilling to undergo forced emesis, regardless of whether they gave consent or the time elapsed since ingestion. It was also given to patients who had taken non-lethal ingestions. The airway was rarely protected in patients with reduced consciousness, large volumes of fluid were given for each cycle (200 to more than 1000 ml), and monitoring was not used. Serious complications likely to be due to the lavage were observed, including cardiac arrest and probable aspiration of fluid. Health care workers perceived lavage as being highly effective and often life-saving; there was peer and relative pressure to perform lavage in self-poisoned patients.

CONCLUSIONS

Gastric lavage as performed for highly toxic poisons in a resource-poor location is hazardous. In the absence of evidence for patient benefit from lavage, (and in agreement with some local guidelines), we believe that lavage should be considered for few patients - in those who have recently taken a potentially fatal dose of a poison, and who either give their verbal consent for the procedure or are sedated and intubated. Ideally, a randomized controlled trial should be performed to determine the balance of risks and benefits of safely performed gastric lavage in this patient population.

Does gastric lavage really push poisons beyond the pylorus? A systematic review of the evidence

Classically, treatment of acute self-poisoning involves resuscitation and supportive care, followed by gastric emptying, administration of activated charcoal, and use of specific antidotes. Recently, however, the practice of gastric emptying has fallen out of favor in the West because physicians have recognized its complications and the lack of evidence for clinical benefit from its practice. Authoritative position statements have stated that forced emesis should not be used and that gastric lavage should be used in restricted settings. One commonly cited complication of gastric lavage is propulsion of poison beyond the pyloric sphincter into the small bowel. We have carried out a systematic search for studies addressing this issue and found only 2. The first, a randomized controlled trial of patients presenting to an emergency department, reported propulsion of poison into the small bowel and has been widely cited as showing evidence for such a complication. However, analysis of the data presented in this article shows no significant difference in the number of radio-opaque marker pellets present in the small bowel after gastric lavage, ipecac-induced forced emesis, or no intervention. The second, an observational study using human volunteers, showed significantly less poison in the small bowel after gastric lavage than after no intervention. In conclusion, it seems that no published data support the statement that gastric lavage forces poison into the small bowel.

Single-dose oral activated charcoal in the treatment of the self-poisoned patient: a prospective, randomized, controlled trial

Oral activated charcoal (OAC) is a universally accepted treatment of the overdose patient. Although the benefits of OAC have been suggested, there are no conclusive clinical data indicating that OAC affects outcome in overdose patients. This study was a prospective, randomized, controlled trial to determine the effects of OAC treatment in the self-poisoned adult patient. Adult patients presenting to the emergency department (ED) with a history of oral overdose were assigned to treatment with OAC (50 g) or supportive care only on an even-odd day protocol. Patients did not undergo gastric evacuation procedures in the ED. The outcome measures were clinical deterioration, length of stay in the ED or hospital, and complication rate. Over a 24-month period, 1479 patients were entered into the study. There were no significant differences in outcome parameters between the OAC treatment group and controls when comparing the length of intubation time, length of hospital stay, and the complication rates associated with the overdose. There was a higher incidence of vomiting and longer length of ED stay associated with OAC treatment. The results of this study indicated that oral drug overdose patients do not require gastric evacuation or charcoal administration. OAC provided no additional benefit to supportive care alone, was associated with a higher incidence of vomiting and a longer length of ED stay, and did not improve clinical outcome.

Gastric emptying in acute overdose: a prospective randomised controlled trial

OBJECTIVE

To test the hypothesis that administration of activated charcoal is as efficacious and safe as the combination regimen of gastric emptying plus charcoal in adults after acute oral overdose.

DESIGN

Prospective randomised controlled trial, with subjects presenting on odd-numbered dates allocated to the emptied group (E), and those on even-numbered dates to the not-emptied group (NE).

SETTING

Princess Alexandra Hospital, Brisbane (a tertiary referral hospital), which serves an adult urban community, between 4 January 1988 and 11 June 1990.

SUBJECTS

Consecutive patients (13 years or older) who presented to the Emergency Department after ingesting an overdose of one or more compounds able to be adsorbed by activated charcoal.

INTERVENTIONS

All patients received charcoal by the oral or nasogastric route. Those in the E group also had gastric emptying by ipecac-induced emesis or gastric lavage.

OUTCOME MEASURES

Clinical course during the first six hours after treatment began, length of hospital stay, complications.

RESULTS

876 patients were eligible for the study. There were no significant differences between the E and NE groups in age and sex distribution, severity of the overdose or other characteristics, except the mean interval between presentation and administration of charcoal (91 min [SD, 52] for E group and 55 [SD, 41] for NE group; P = 0.0001). There were no significant differences between the E and NE groups in outcome, even when the groups were stratified for severity of the overdose or into subgroups that presented sooner or later than one hour after ingestion.

CONCLUSIONS

Gastric emptying can be omitted from the treatment protocol for adults after acute oral overdose.

Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage

A rare complication of gastric decontamination occurred in a young woman undergoing treatment for tricyclic ingestion. After orogastric intubation and lavage, she developed an acute abdomen and underwent laparotomy. Charcoal was discovered throughout the peritoneum, but concurrent and subsequent efforts failed to localize a specific perforation site. Her hospital course was protracted and complicated by tenacious peritoneal charcoal deposition, persistent peritonitis, and adhesion and abscess formation. She underwent both percutaneous and open abscess drainage, oophorectomy, and small-bowel resection. She required total parenteral nutrition in addition to feeding jejunostomy. This present case constitutes the first report of the clinical consequences of charcoal peritoneum. Outright viscus perforation should be considered among potential complications of orogastric intubation and lavage in the poisoned patient. Methods to minimize risks of its occurrence are suggested.

Changes in arterial oxygen tension after gastric lavage for drug overdose

1. Changes in arterial oxygen tension after gastric lavage were investigated in a prospective study of 55 patients admitted for drug overdose. 2. A significantly greater decrease was observed in smokers compared to non-smokers. 3. A correlation was found between the tricyclic antidepressant serum level and the observed oxygen tension decrease. 4. The usefulness, as well as the safety of the lavage procedure, in managing tricyclic antidepressants overdoses is controversial.

A review of the management of oral drug overdose in the Accident and Emergency Department of the Royal Brisbane Hospital

Two-hundred and eighty-nine patients who made a total of 323 presentations to the Royal Brisbane Hospital Accident and Emergency Department with a known or suspected oral drug overdose were reviewed. The majority of patients (76%) could be managed in a 24 h Accident and Emergency observation unit. Activated charcoal given orally or via a nasogastric tube was the recommended method of preventing further absorption of an ingested drug. The use of syrup of ipecac was not encouraged and orogastric lavage was used in only specific situations. The morbidity and mortality of these patients when compared with other studies, was not adversely affected by this protocol which dramatically reduced the indications for the use of orogastric lavage and syrup of ipecac.

Recovery of cyclic antidepressants with gastric lavage

The role of lavage fluid volume in recovery of cyclic antidepressant with gastric lavage was determined in 13 patients treated for moderate to severe cyclic antidepressant intoxication. An orogastric tube was placed, gastric contents aspirated, and gastric lavage performed with 60 to 180 mL aliquots of tap water or 0.9% NaCl for irrigation. A volume of 12.8 +/- 4.4 liters of lavage fluid was instilled, and 97.6 +/- 6.9% of this volume was recovered. The recovered aspirate and lavage fluid were inspected for the presence of particulate matter and saved in 4 to 5 liter collections. Determination of cyclic antidepressant and metabolite concentrations was performed using gas chromatography-mass spectrometry, and the amount of cyclic antidepressant recovered was calculated. The mean total amount recovered was 110 mg and ranged from 2.4 mg to 342 mg. Of the total amount recovered, 88% +/- 13% was recovered in the first 4 to 5 liters of lavage fluid. An estimate of the dose ingested was available in 7 patients, with 8.7% (0.4% to 21.7%) of the estimated dose recovered by lavage. There were no cases of significant drug recovery in clear lavage fluid. We conclude that if gastric lavage is undertaken in cyclic antidepressant intoxications, it should utilize 5 liters initially and then continue only if particulate matter is seen.

Oral activated charcoal in the treatment of intoxications. Role of single and repeated doses

Activated charcoal has an ability to adsorb a wide variety of substances. This property can be applied to prevent the gastrointestinal absorption of various drugs and toxins and to increase their elimination, even after systemic absorption. Single doses of oral activated charcoal effectively prevent the gastrointestinal absorption of most drugs and toxins present in the stomach at the time of charcoal administration. Known exceptions are alcohols, cyanide, and metals such as iron and lithium. In general, activated charcoal is more effective than gastric emptying. However, if the amount of drug or poison ingested is very large or if its affinity to charcoal is poor, the adsorption capacity of activated charcoal can be saturated. In such cases properly performed gastric emptying is likely to be more effective than charcoal alone. Repeated dosing with oral activated charcoal enhances the elimination of many toxicologically significant agents, e.g. aspirin, carbamazepine, dapsone, dextropropoxyphene, cardiac glycosides, meprobamate, phenobarbitone, phenytoin and theophylline. It also accelerates the elimination of many industrial and environmental intoxicants. In acute intoxications 50 to 100g activated charcoal should be administered to adult patients (to children, about 1 g/kg) as soon as possible. The exceptions are patients poisoned with caustic alkalis or acids which will immediately cause local tissue damages. To avoid delays in charcoal administration, activated charcoal should be a part of first-aid kits both at home and at work. The 'blind' administration of charcoal neither prevents later gastric emptying nor does it cause serious adverse effects provided that pulmonary aspiration in obtunded patients is prevented. In severe acute poisonings oral activated charcoal should be administered repeatedly, e.g. 20 to 50g at intervals of 4 to 6 hours, until recovery or until plasma drug concentrations have fallen to non-toxic levels. In addition to increasing the elimination of many drugs and toxins even after their systemic absorption, repeated doses of charcoal also reduce the risk of desorbing from the charcoal-toxin complex as the complex passes through the gastrointestinal tract. Charcoal will not increase the elimination of all substances taken. However, as the drug history in acute intoxications is often unreliable, repeated doses of oral activated charcoal in severe intoxications seem to be justified unless the toxicological laboratory has identified the causative agent as not being prone to adsorption by charcoal. The role of repeated doses of oral activated charcoal in chronic intoxication has not been clearly defined.(ABSTRACT TRUNCATED AT 400 WORDS)

Role of extracorporeal drug removal in acute theophylline poisoning. A review

Theophylline, with its narrow therapeutic margin, is a common cause of iatrogenic and deliberate overdose. Most cases of self-poisoning are with sustained release preparations, with peak concentrations occurring up to 12 or more hours after overdose. Toxic symptoms are often seen at concentrations above 15 mg/L. Theophylline is metabolised within the cytochrome P-450 system, with an average total body clearance of 50 to 60 ml/min. Clearance is, however, affected by many factors such as other drugs or disease, and in overdose zero order kinetics may result in prolonged half-lives. Toxicity is characterised by agitation, tremor, nausea, vomiting, abdominal pains, seizures, and tachyarrhythmias. Hypokalaemia and metabolic acidosis are more profound in acute toxicity, and hypercalcaemia is usually present. Seizures occur at lower concentrations after chronic over-medication than after acute overdose. Gastric lavage should be performed in all patients presenting early, and an oral multiple dose charcoal regimen started with 50 to 100g charcoal, repeating with 50g doses and checking theophylline concentrations at 2- to 4-hour intervals. Multiple dose charcoal can be expected to double the clearance of theophylline, being as effective as a haemodialysis. Of the invasive techniques available, charcoal haemoperfusion is the most effective, increasing clearance 4- to 6-fold. Supportive care is particularly important. The aggressive supplementation of potassium, treatment of emesis with droperidol and ranitidine, and treatment of tachyarrhythmias and hypotension (possibly with propranolol), together with oral multiple dose charcoal may obviate the need for haemoperfusion. Seizures suggest increased morbidity and mortality. Charcoal haemoperfusion should be considered if plasma concentrations are greater than 100 mg/L in an acute intoxication or greater than 60 mg/L in a chronic intoxication. The decision to haemoperfuse should not be based on plasma concentrations alone, but an overall evaluation of the patient's laboratory and clinical status.

Physical assessment and differential diagnosis of the poisoned patient

The rapid diagnosis and immediate intervention required in patients with serious drug overdose or poisoning makes toxicological screening of limited value to the emergency department physician. Instead, a careful clinical evaluation using the history, physical examination, and the more readily available laboratory tests may allow a tentative diagnosis and the initiation of life-saving treatment. Laboratory tests should include serum osmolality, electrolytes, glucose, BUN and an estimation of the anion and osmolar gaps. The ECG can also provide useful information. Clinical findings of important include altered blood pressure, pulse, respiration and body temperature, the presence of coma, agitation, delirium or psychosis, and muscular weakness. An ophthalmological examination is also of importance in the acutely poisoned patient. Oral burns or dysphagia may occur following ingestion of any strongly reactive substance, but the absence of oral burns does not preclude the possibility of oesophageal or stomach injury. Odours and skin colour may also contribute to the diagnosis. Comprehensive toxicology screening may not be immediately available, or may be inaccurate, thus adding little to the information obtained during the initial evaluation of the poisoned patient.