Efficacy of abdominal computed tomography and nasogastric tube in acute poisoning patients

Thermal desorption ambient ionization mass spectrometry for emergency toxicology

In the emergency department, it is important to rapidly identify the toxic substances that have led to acute poisoning because different toxicants or toxins cause poisoning through different mechanisms, requiring disparate therapeutic strategies and precautions against contraindicating actions, and diverse directions of clinical course monitoring and prediction of prognosis. Ambient ionization mass spectrometry, a state-of-the-art technology, has been proved to be a fast, accurate, and user-friendly tool for rapidly identifying toxicants like residual pesticides on fruits and vegetables. In view of this, developing an analytical platform that explores the application of such a cutting-edge technology in a novel direction has been initiated a research program, namely, the rapid identification of toxic substances which might have caused acute poisoning in patients who visit the emergency department and requires an accurate diagnosis for correct clinical decision-making to bring about corresponding data-guided management. This review includes (i) a narrative account of the breakthrough in emergency toxicology brought about by the advent of ambient ionization mass spectrometry and (ii) a thorough discussion about the clinical implications and technical limitations of such a promising innovation for promoting toxicological tests from tier two-level to tier one level.

An analysis of reports concerning overdose evaluated by abdominal computed tomography

Recently, there have been a number of reports concerning the utility of abdominal computed tomography (CT) for diagnosing overdose (OD). We herein report the summary and results of an analysis of these reports to assess the significance of CT for patients with OD. Searches of Ichushi (Japana Centra Revuo Medicine) and PubMed were carried out to identify articles from 1983 to 2019 using the key words "poisoning" and "abdominal computed tomography". Forty-eight cases across 15 articles were defined as subjects in this report. The average age of subjects was 46 years old, and there were 28 women. Forty-five of the 48 subjects (93.8%) had positive findings of residual drugs on CT. The finding of a high-density fluid level in the stomach was the most frequent (60.4%), followed by ill-defined high-density material in the stomach (12.5%) and high-density tablets in the stomach (10.4%). One prospective study suggested the merits of decontamination for patients with positive findings on CT even if more than 60 min had elapsed since the ingestion of drugs. Computed tomography could aid in the diagnosis of OD in comatose patients who cannot talk or who present without any other evidence of OD. In addition, a recent study revealed the merits of decontamination for patients with positive findings on the CT even if more than 60 min had elapsed since the ingestion of drugs.

The usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach of patients with acute drug overdose

Objectives: If clinicians can know that there are many life-threatening drugs left in the stomach through a non-invasive method over 60 min after drugs ingestion, it may be preferable to minimize absorption of remnant drugs through various methods according to the characteristic of the drug. Computed tomography (CT) has gained wide acceptance in the detection of drug mules. Therefore, we evaluated the prevalence of drugs in the gastric lumen using abdominal non-contrast CT, performed over 60 min after acute drug poisoning. Materials and methods: This was a prospective cohort study of patients with acute drug poisoning who were admitted to the emergency department (ED) between March 2017 and February 2018. If the patient visited the ED over 60 min after ingestion of life-threatening or unknown drugs, non-contrast CT scan was performed. "Presence of drugs" was defined in the non-contrast CT as a round-shaped lesion with higher density than the gastric mucosa. In addition, "positive radiodense image" was defined as that with higher density than the gastric mucosa regardless of drug appearance in the non-contrast CT scan. Results: Among a total of 482 patients with drug poisoning, 140 were finally included in the study. Residual drugs were detected in 36 patients (25.7%). Further, regardless of the presence of drugs, 58 patients (41.4%) showed positive radiodense image in the stomach. The median Hounsfield unit of drugs was 131.5 and that of food materials in the stomach was 34.5. Total duration of hospital stay was significantly longer in the "absence of drug" group and sustained-release drugs were detected more frequently in the "presence of drugs" group. Conclusions: Detection rate of drugs and presence of positive radiodense image, regardless of drug appearance, were as high as 25.7% and 41.4%, respectively. Sustained-release drugs were detected more frequently in the "presence of drugs" group.

Successful retrieval using ultrathin transnasal esophagogastroduodenoscopy of a significant amount of residual tricyclic antidepressant following serious toxicity: a case report

Background

In Japan, ultrathin transnasal esophagogastroduodenoscopy (EGD) with a 4.9-mm diameter endoscope (Olympus XP260) is routinely used to examine the upper gastrointestinal tract. This procedure does not require sedation and does not affect vital signs. Gastric lavage is not empirically employed in the management of all poisoning patients. It is considered only for potentially life-threatening overdoses when the procedure can be performed within 1 h of ingestion of the poison. However, there are no absolute indications for gastric lavage. EGD may increase the indications, efficiency and safety of gastric lavage in poisoning patients.

Findings

A 35-year-old female was admitted to our emergency department 2 h after ingesting multiple drugs, including a critical dose of the tricyclic antidepressant (TCA) amitriptyline, at which time she was confused and had a Glasgow Coma Scale score of 8 (E1V2M5). Endotracheal intubation was performed. To confirm the type of TCA and in order to determine whether gastric lavage was required, we decided to perform EGD. Endoscopy demonstrated adherence of residual drugs to the stomach wall, in a soluble form and not as a mass. Hence, gastric lavage was performed via the EGD to avoid passage of these drugs into the small bowel. The patient was extubated on day 2, without the development of complications such as aspiration pneumonia, and was discharged on day 5.

Conclusion

EGD may be useful in poisoning patients for determining the amount of residual drug in the stomach, also allowing direct observation of the effectiveness of gastric lavage.