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

A survey of the antidote preparedness in Norwegian hospitals

OBJECTIVES

Antidotes are an important part of the emergency preparedness in hospitals. In the case of a major chemical accident or a fire, large quantities of antidotes may be needed within a short period of time. For time-critical antidotes it is therefore necessary that they be immediately available. We wanted to evaluate the antidote preparedness in Norwegian hospitals as regards the national recommendations and compare this with other international guidelines.

METHODS

A digital survey was sent to the 50 hospitals in Norway that treat acute poisonings. Of these, four hospitals are categorised as regional hospitals, 15 as large hospitals and 31 as small hospitals. Each hospital was asked which antidotes they stockpiled from a list of 35 antidotes. The financial costs (low, moderate, high) were added to an established efficacy scale to illustrate the cost-effectiveness of the different antidotes.

RESULTS

The response rate was 100%. Eleven of fifty (22%) hospitals stockpiled all antidotes recommended for their hospital size. All four regional hospitals had all the recommended antidotes. Large hospitals which were not regional hospitals had the least availability of antidotes, and only one large hospital stockpiled all antidotes recommended for this hospital size.

CONCLUSIONS

We found varying compliance with the national recommendations for antidote storage in hospitals. To strengthen antidote preparedness, we recommend standardised European guidelines to support national guidelines.

A sabbath in the emergency room or a case of anticholinergic toxicity?

We report the case of a 32-year-old Italian man admitted to our emergency room for visual disturbances with blurred vision, anisocoria and temporal headache suddenly occurred in absence of other neurological symptoms. A diagnosis of Datura stramoniuminduced anticholinergic toxicity was done. With our work, we want to highlight the importance of a meticulous clinical examination, including papillary diameter and reflexes, combined with a detailed history of the patient in the emergency room. Anticholinergic toxicity is a medical emergency. The diagnosis is always clinical, and it can represent a challenge for the emergency clinicians because it can mimic several neurological diseases, including acute stroke and seizures, but early diagnosis is crucial to avoid severe complications and management errors.

The emerging therapeutic role of some pharmacological antidotes in management of COVID-19

Background

A novel RNA coronavirus was identified in January 2020 as the cause of a pneumonia epidemic affecting the city of Wuhan; it rapidly spread across China.

Aim of the review

The aim is to discuss the potential efficacy of some pharmacologically known pharmacological antidotes (N-acetylcysteine; hyperbaric oxygen; deferoxamine; low-dose naloxone) for the management of COVID-19-associated symptoms and complications.

Method

An extensive search was accomplished in Medline, Embase, Scopus, Web of Science, and Central databases until the end of April, 2021. Four independent researchers completed the screening, and finally, the associated studies were involved.

Conclusion

The current proof hinders the experts for suggesting the proper pharmacological lines of treatment of COVID-19. Organizations, for example, WHO, should pursue more practical actions and design well-planned clinical trials so that their results may be used in the treatment of future outbreaks.

Availability of Essential Antidotes and the Role of Community Pharmacists in the Management of Acute Poisoning: A Cross-Sectional Study in Ethiopia

Background

Morbidity and mortality related to acute poisoning is a major public health issue in both developing and developed countries. Community pharmacists have a crucial role in ensuring drug availability, increasing drug safety, counseling patients, overdose risk reduction and management, and provision of appropriate drug information. This study aimed to assess the availability of necessary antidotes in community pharmacies in Gondar and Bahir-Dar cities, Ethiopia, and the role of community pharmacists in the management of acute poisoning.

Methods

A cross-sectional survey was conducted in Gondar and Bahir-Dar cities. A self-administered, structured questionnaire was used for data collection and Statistical Package for Social Sciences (SPSS) version 24.0 was used for data analysis. Chi-square analysis was computed to identify the associated factors with a confidence interval of 95% and a P value less than .05 was used as a cut-point for statistical significance.

Results

Out of 101 community pharmacies invited to participate in the study, 80 of them completed the survey with a response rate of 79.2%. The overall mean antidote availability score was .59 (SD = .837), which falls within the definition of Poor availability. None of the pharmacies had kept all of the antidotes, and the maximum number of an antidote kept by a single pharmacy was 7 out of nineteen essential antidotes surveyed. The most commonly reported reason for the unavailability of essential antidotes was stock was not ordered (56.3%) followed by stock ordered but not delivered from suppliers (wholesalers) (20.0%). More than 3 fourth of the respondents (83.8%) had poor knowledge about the antidotes for the common poisonings.

Conclusion

There was a significantly very low availability of essential antidotes in the community pharmacies. Strategies should be implemented to improve pharmacist’s knowledge about antidotes, and management of poisoning emergencies through on-job training and provision of reference materials.

The Use of Physostigmine in the Diagnosis and Treatment of Anticholinergic Toxicity After Olanzapine Overdose: Literature Review and Case Report

BACKGROUND

Second-generation antipsychotic agents are commonly used by clinicians for the treatment of various psychiatric and medical conditions. Despite their presumed safety, an overdose with olanzapine may lead to the development of anticholinergic toxicity. The anticholinergic toxidrome is characterized by both central and peripheral physical findings. Central anticholinergic syndrome, a term used to describe the symptoms that arise from reduced cholinergic activity in the central nervous system, is characterized primarily by signs and symptoms consistent with hyperactive delirium. Signs of peripheral anticholinergia include mydriasis and blurred vision, tremors, ataxia, fever/hyperthermia, flushed and dry skin, dry oral mucosa, decreased bowel sounds, constipation, and urinary retention, among other symptoms. In extreme cases, central anticholinergic syndrome can be associated with seizures, coma, respiratory failure, and cardiovascular collapse.

OBJECTIVE

To provide scientific evidence regarding the efficacy and safety of physostigmine use in cases of anticholinergic toxicity.

METHODS

We conducted a comprehensive review of the published literature on the symptoms, diagnosis, and treatment of anticholinergic toxicity.

RESULTS

Currently the recommended treatment for olanzapine overdose, as is the case of most severe anticholinergic toxicity cases, involves supportive care, along with cardiac, neurological, and respiratory status monitoring. In addition, we detail the symptoms characteristic of anticholinergic toxicity, using the case of a patient experiencing central anticholinergic syndrome after an overdose with olanzapine.

CONCLUSION

Physostigmine, a tertiary acetylcholinesterase inhibitor, can be used to assist in the both the diagnosis and management of severe anticholinergic toxicity associated with an olanzapine overdose, which might be applicable to the antimuscarinic toxidrome associated with the ingestion of agents with significant anticholinergic activity.

An Appraisal of Antidotes' Effectiveness: Evidence of the Use of Phyto-Antidotes and Biotechnological Advancements

Poisoning is the greatest source of avoidable death in the world and can result from industrial exhausts, incessant bush burning, drug overdose, accidental toxication or snake envenomation. Since the advent of Albert Calmette’s cobra venom antidote, efforts have been geared towards antidotes development for various poisons to date. While there are resources and facilities to tackle poisoning in urban areas, rural areas and developing countries are challenged with poisoning management due to either the absence of or inadequate facilities and this has paved the way for phyto-antidotes, some of which have been scientifically validated. This review presents the scope of antidotes’ effectiveness in different experimental models and biotechnological advancements in antidote research for future applications. While pockets of evidence of the effectiveness of antidotes exist in vitro and in vivo with ample biotechnological developments, the utilization of analytic assays on existing and newly developed antidotes that have surpassed the proof of concept stage, as well as the inclusion of antidote’s short and long-term risk assessment report, will help in providing the required scientific evidence(s) prior to regulatory authorities’ approval.

Availability of antidotes in 70 hospitals in Catalonia, Spain

BACKGROUND AND OBJECTIVE

Antidotes may have a relevant role in acute intoxication management and the time until its administration can influence patient survival.

PATIENTS AND METHOD

Study conducted by a questionnaire sent in early 2015 to 70 hospitals in Catalonia providing emergency services. Qualitative availability on each antidote was considered adequate when present in at least 80% of hospitals. The quantitative availability was considered adequate when at least 80% of hospitals had the number of units of antidote recommended.

RESULTS

Lower complexity hospitals (level A) showed a percentage of adequate qualitative and quantitative availability of 66.7 and 42.9% respectively. In higher complexity hospitals (level B) qualitative and quantitative availability was adequate in 64.5 and 38.7% of the antidotes respectively. Data showed no differences between the different health regions as well as a positive correlation (p<.05) between the number of emergencies attended and the percentage of adequate qualitative availability.

CONCLUSIONS

The availability of antidotes in Catalonia hospitals is generally low and shows differences across health regions and depending on level of complexity.

Distribution of Problems, Medications and Lab Results in Electronic Health Records: The Pareto Principle at Work

BACKGROUND: Many natural phenomena demonstrate power-law distributions, where very common items predominate. Problems, medications and lab results represent some of the most important data elements in medicine, but their overall distribution has not been reported. OBJECTIVE: Our objective is to determine whether problems, medications and lab results demonstrate a power law distribution. METHODS: Retrospective review of electronic medical record data for 100,000 randomly selected patients seen at least twice in 2006 and 2007 at the Brigham and Women's Hospital in Boston and its affiliated medical practices. RESULTS: All three data types exhibited a power law distribution. The 12.5% most frequently used problems account for 80% of all patient problems, the top 11.8% of medications account for 80% of all medication orders and the top 4.5% of lab result types account for all lab results. CONCLUSION: These three data elements exhibited power law distributions with a small number of common items representing a substantial proportion of all orders and observations, which has implications for electronic health record design.

A system-wide solution to antidote stocking in emergency departments: the Nova Scotia antidote program

OBJECTIVE

Inadequate stocking of essential antidotes in hospitals is an internationally documented problem. A concrete and sustainable system-wide solution for easy access to antidotes in emergency departments (EDs) was developed and implemented in Nova Scotia, Canada.

METHODS

Antidote stocking guidelines and a systemwide antidote management strategy were established. A standardized collection of antidotes housed in highly visible containers in provincial EDs was implemented for timely access. Antidote-specific online administration guidelines were developed. Using the poison centre for surveillance, the antidote program maintained a database of antidote utilization patterns; 11 years of data were available for analysis.

RESULTS

2/2 (100%) tertiary care, 9/9 (100%) regional EDs, and 21/25 (84%) community EDs in Nova Scotia stock antidote kits, for an overall compliance rate of 32/36 (89%). A total of 678 antidotes (excluding N-acetylcysteine) were used for 520 patients. The distribution of antidote use by hospital type was 99/678 (14.6%) at community hospitals, 379/678 (55.9%) at regional hospitals, and 200/678 (29.5%) at tertiary care hospitals. The five most commonly used antidotes were: naloxone 143/678 (21.1%), fomepizole 111/678 (16.4%), glucagon 94/678 (13.9%), calcium 70/678 (10.3%), and sodium bicarbonate 67/678 (9.9%). Of the 520 patients in whom antidotes were used, death occurred in 3% (15/520), major outcomes in 35% (183/520), and moderate outcomes in 39% (205/520).

CONCLUSION

The Nova Scotia Antidote Program demonstrates that a solution to inadequate antidote stocking is achievable and requires a system-wide approach with ongoing maintenance and surveillance. The frequency and distribution of antidote usage documented in this program supports the need for enhancement of emergency preparedness. The poison centre and hospital pharmacies are crucial to surveillance and maintenance of this program.

International Variability in Gastrointestinal Decontamination With Acute Poisonings

BACKGROUND AND OBJECTIVES

Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings to emergency departments.

METHODS

This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists' recommendations. Multivariate logistic regression was performed to identify independent risk factors for performing GID procedures.

RESULTS

We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1%-22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5%-51.2%), the GID procedure was considered appropriate, with significant differences between regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region where the intoxication occurred (P < .001).

CONCLUSIONS

Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented.

National study on the adequacy of antidotes stocking in Lebanese hospitals providing emergency care

Background

Antidotes stocking is a critical component of hospital care for poisoned patients in emergency. Antidote stocking represents a major health challenge worldwide and in Lebanon. Systematic data monitoring of antidote stocking in Lebanese hospitals is lacking. The objective of this study is to assess the adequacy of antidotes stocking in Lebanese hospitals according to type and quantity and explore the characteristics associated with their differential availability.

Methods

Data collection to assess antidote availability and its correlate was undertaken through a self-administered questionnaire. The questionnaires were distributed by the unit of surveillance at the Ministry of Public Health to eligible hospitals providing emergency care services. The list of essential antidotes was adapted from the World Health Organization (WHO) list and the British Columbia Drug and Poison Information Centre.

Results

Among the 85 Lebanese hospitals surveyed none had in stock all the 35 essential antidotes required. The frequency of stocking by type of antidote varied from a minimum of 1.2 % of the hospitals having a (cyanide kit) to 100 % availability of (atropine and calcium gluconate). Teaching hospitals and those with a large bed-capacity reported a higher number of available antidotes for both immediate and non-immediate use than non-teaching hospitals while controlling for the hospital geographical region and public vs private sector.

Conclusion

The Lebanese hospitals have a suboptimal stock of essential antidotes supply. It is recommended that the Lebanese Ministry of Public Health monitors closely on the hospital premises the adequacy and availability of essential antidotes stock.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-016-0092-7) contains supplementary material, which is available to authorized users.

The mastery of antidotes: A survey of antidote knowledge and availability among emergency physicians in registered hospitals in China

AIM

To describe various types of Chinese hospitals' emergency department (ED) physicians' knowledge of antidotes and the comparative availability of toxicological treatments at these hospitals.

METHODS

We emailed a written survey to the ED doctors of 900 hospitals in China. The hospitals' names and addresses were obtained and randomly selected from the 6214 hospitals registered by the Chinese Medical Association. The survey included 23 questions on antidotes to commonly seen poisonings as well as questions on the availability of antidotes and decontamination techniques at each hospital.

RESULTS

Six hundred and fifty three hospital emergency directors responded to the survey 72.6% response rate). Overall knowledge of antidotes is not high and varied depending on antidote. Physicians in Eastern China, those working in tertiary-level hospitals and those working in hospitals with higher numbers of beds performed significantly better. On average, only 35.6% of the 23 antidotes were available in all reporting hospitals; 54.1% can get these antidotes from nearby hospitals and 42.0% can get them from a local CDC poison control center. However, only 57.3% can get a requested antidote within two hours. Gastric lavage is the most widely used decontamination procedure, and the availability of extracorporeal decontamination techniques is between 67.2% and 79.6% (depending on type).

CONCLUSION

Knowledge of specific antidotes correlated significantly with size, type, and region of hospital in China rather than with individual physician characteristics. Significant antidotes remain unavailable or unavailable within 2 h in about half of all hospitals surveyed, although all major acute decontamination treatments and techniques seem quite prevalent.

Flumazenil, naloxone and the 'coma cocktail'

Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.

Who gets antidotes? choosing the chosen few

An understanding of mechanisms, potential benefits and risks of antidotes is essential for clinicians who manage poisoned patients. Of the dozens of antidotes currently available, only a few are regularly used. These include activated charcoal, acetylcysteine, naloxone, sodium bicarbonate, atropine, flumazenil, therapeutic antibodies and various vitamins. Even then, most are used in a minority of poisonings. There is little randomized trial evidence to support the use of most antidotes. Consequently, decisions about when to use them are often based on a mechanistic understanding of the poisoning and the expected influence of the antidote on the patient's clinical course. For some antidotes, such as atropine and insulin, the doses employed can be orders of magnitude higher than standard dosing. Importantly, most poisoned patients who reach hospital can recover with supportive care alone. In low risk patients, the routine use of even low risk antidotes such as activated charcoal is unwarranted. In more serious poisonings, decisions regarding antidote use are generally guided by a risk/benefit assessment based on low quality evidence.

Taking stock: UK national antidote availability increasing, but further improvements are required

Background

A 2010/2011 audit of the Royal College of Emergency Medicine (RCEM) National Poisons Information Service (NPIS) UK guidelines on antidote availability demonstrated variable stocking of antidotes for the management of poisoned patients; the guidelines were updated and republished in 2013.

Aim

To assess if antidote stocking has improved since the 2010/2011 audit and introduction of the 2013 guidelines.

Methods

Questionnaires were sent to Chief Pharmacists at all 215 acute hospitals in England, Wales and Northern Ireland in October 2014. Data were collected on the timing of availability (category A antidotes should be available immediately, category B within 1 h and category C can be held supraregionally) and stock levels.

Results

169 (78.6%) responses were received. Atropine, calcium gluconate and flumazenil (category A) were the only antidotes available in all hospitals within the recommended time and stock levels. Forty-one (24.3%) hospitals held every category A antidote; this increased to 81 (47.9%) for those holding at least one cyanide antidote and all other category A antidotes. The proportion of hospitals stocking category A/B antidotes within the recommended time increased for 20 (90.9%) category A/B antidotes. Fomepizole (category B) availability increased to 62.1% of hospitals from 11.4% in 2010/2011. Other than penicillamine (63.3% hospitals), there was poor availability (2.4%-36.1%) of category C antidotes.

Conclusions

Availability of category A and B antidotes has improved since the 2010/2011 audit and 2013 guidelines. However, there remains significant variability particularly for category C antidotes. More work is required to ensure that those treating poisoned patients have timely access to antidotes focusing particularly on category C antidotes.

Drug shortages: Implications for medical toxicology

CONTEXT

Drug shortages have significantly increased over the past decade. There are limited data describing how shortages impact medical toxicology of drugs.

OBJECTIVE

To characterize drug shortages affecting the management of poisoned patients.

MATERIALS AND METHODS

Drug shortage data from January 2001 to December 2013 were obtained from the University of Utah Drug Information Service. Shortage data for agents used to treat poisonings were analyzed. Information on drug type, formulation, reason for shortage, shortage duration, marketing, and whether the drug was available from a single source was collected. The availability of a substitute therapy and whether substitutes were in shortage during the study period were also investigated.

RESULTS

Of 1,751 shortages, 141 (8.1%) impacted drugs used to treat poisoned patients, and as of December 2013, 21 (14.9%) remained unresolved. New toxicology shortages increased steadily from the mid-2000s, reaching a high of 26 in 2011. Median shortage duration was 164 days (interquartile range: 76-434). Generic drugs were involved in 85.1% of shortages and 41.1% were single-source products. Parenteral formulations were often involved in shortages (89.4%). The most common medications in shortage were sedative/hypnotics (15.6%). An alternative agent was available for 121 (85.8%) drugs; however, 88 (72.7%) alternatives were also affected by shortages at some point during the study period. When present, the most common reasons reported were manufacturing delays (22.0%) and supply/demand issues (17.0%). Shortage reason was not reported for 48.2% of drugs.

DISCUSSION

Toxicology drug shortages are becoming increasingly prevalent, which can result in both suboptimal treatment and medication errors from using less familiar alternatives.

CONCLUSION

Drug shortages affected a substantial number of critical agents used in the management of poisoned patients. Shortages were often of long duration and for drugs without alternatives. Providers caring for poisoned patients should be aware of current shortages and implement mitigation strategies to safeguard patient care.

Intentional and inadvertent chemical contamination of food, water, and medication

Numerous examples of chemical contamination of food, water, or medication have led to steps by regulatory agencies to maintain the safety of this critical social infrastructure and supply chain. Identification of contaminant site is important. Environmental testing and biomonitoring can define the nature and extent of the event and are useful for providing objective information, but may be unavailable in time for clinical care. Clinical diagnosis should be based on toxidrome recognition and assessment of public health implications. There are several resources available to assist and these can be accessed through regional poison control centers or local/state public health departments.

Kind and estimated stocking amount of antidotes for initial treatment for acute poisoning at emergency medical centers in Korea

Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide estimation of the antidotes stocking amount in Korea. This study tried to estimate the quantities of stocking antidotes at emergency department (ED). An expert panel of clinical toxicologists made a list of 18 emergency antidotes. The quantity was estimated by comparing the antidote utilization frequency in a multicenter epidemiological study and the nation-wide EDs' data of National Emergency Department Information System (NEDIS). In an epidemiological study of 11 nationwide EDs from January 2009 to December 2010, only 92 (1.9%) patients had been administered emergency antidotes except activated charcoal among 4,870 cases of acute adult poisoning patients. Comparing with NEDIS data, about 1,400,000 patients visited the 124 EDs nationwide due to acute poisoning and about 103,348 adult doses of the 18 emergency antidotes may be required considering poisoning severity score. Of these, 13,224 (1.9%) adult doses of emergency antidotes (575 of atropine, 144 of calcium gluconate or other calcium salts, 2,587 of flumazenil, 3,450 of N-acetylcysteine, 5,893 of pralidoxime, 287 of hydroxocobalamin, 144 of sodium nitrite, and 144 of sodium thiosulfate) would be needed for maintaining the present level of initial treatment with emergency antidotes at EDs in Korea.

Hospital preparedness for chemical and radiological disasters

Hospital planning for chemical or radiological events is essential but all too often treated as a low priority. Although some other types of disasters like hurricanes and tornadoes may be more frequent, chemical and radiological emergencies have the potential for major disruptions to clinical care. Thorough planning can mitigate the impact of a chemical or radiological event. Planning needs to include all 4 phases of an event: mitigation (preplanning), preparation, response, and recovery. Mitigation activities should include the performance of a hazards vulnerability analysis and identification of local subject-matter experts and team leaders.

Availability of treatment resources for the management of acute toxic exposures and poisonings in emergency departments among various types of hospitals in Palestine: a cross-sectional study

BACKGROUND

Poisoning exposures continue to be a significant cause of morbidity and mortality worldwide. The lack of facilities, treatment resources, and antidotes in hospitals may affect the treatments provided and outcomes. This study aimed to determine the availability of gastrointestinal (GI) decontamination, stabilisation, elimination enhancement resources, and antidotes for the management of acute toxic exposures and poisonings in emergency departments (EDs) among various types of governmental and private hospitals in Palestine.

METHODS

A cross-sectional study using semi-structured questionnaire was performed. Data were collected based on hospital resources; GI decontamination, stabilisation, elimination enhancement resources and antidotes from Palestinian hospitals.

RESULTS

Eighteen hospitals (94.7%) have responded. Among them, paracetamol poisoning was the most frequently reported cases by EDs (mean frequency score = 7.6 ± 2.1), followed by bee stings (mean = 6.9 ± 2.7) and organophosphate poisoning (mean = 6.7 ± 2.7). The availabilities of most resources related to GI decontamination items varied substantially with hospital type, but these differences were not statistical significant. The availability of stabilisation resources was not significantly different between hospitals types. For the availability of techniques used to enhance the elimination of toxic substances, there were variations between the hospitals types. However, these differences were not statistical significant, except for haemodialysis (p = 0.003) which was more available in governmental hospitals. For the availability of antidotes, none of the hospitals had sufficient stock of all antidotes listed. In relation to hospital type, there was variability in the availability of antidotes, but this did not reach statistical significance, except for deferoxamine (p < 0.001), which was available in all governmental hospitals but none of the private hospitals.

CONCLUSIONS

The availability of treatment resources and antidotes in Palestinian hospitals was not adequate except for stabilisation resources. The availability of such resources acts as a marker for the level of readiness of hospital EDs in Palestine for the management of acute toxic exposure and poisoning. The implementation of a minimum list of antidotes and treatment resources would be useful to increase the level of resources. Coordination between Palestinian poison control and drug information centre and hospitals is also important.

A fatal case of thallium toxicity: challenges in management

BACKGROUND

Thallium is a highly toxic compound and is occasionally involved in intentional overdoses or criminal poisonings. Accidental poisonings also occur, but are increasingly rare owing to restricted use and availability of thallium. We report a fatal suicidal ingestion of thallium sulfate rodenticide in which multi-dose activated charcoal (MDAC) and Prussian Blue (PB) were both used without changing the outcome.

CASE REPORT

A 36 year old man ingested an unknown amount of thallium sulfate grains from an old rodenticide bottle. He presented to an emergency department (ED) 45 minutes later with abdominal pain and vomiting. On examination he was agitated with a blood pressure of 141/60 mmHg and a heart rate of 146 beats per minute (bpm). He received MDAC during his initial ED management and was started on PB 18 hours post arrival; he was intubated on the following day for airway protection. The patient continued to be tachycardic and hypertensive and subsequently developed renal failure. On hospital day three, the patient developed hypotension that did not respond to fluids. The patient required vasopressors and was transferred to a tertiary care center to undergo continuous renal replacement therapy (CRRT). The patient died shortly after his transfer. His last blood thallium concentration was 5369 mcg/L, a spot urine thallium >2000 mcg/L, and a 24- hour urine thallium was >2000 mcg/L.

CONCLUSION

Though extremely rare, thallium intoxication can be lethal despite early administration of MDAC and use of Prussian blue therapy. Rapid initiation of hemodialysis can be considered in cases of severe thallium poisoning, to remove additional thallium, to correct acid-base disturbance, or to improve renal function.

Insufficient stocking of cyanide antidotes in US hospitals that provide emergency care

Objective:

To identify the influence of catchment area, trauma center designation, hospital size, subspecialist employment, funding source, and other hospital characteristics on cyanide antidote stocking choice in US hospitals that provides emergency care.

Materials and Methods:

A web-based survey was sent out to pharmacy managers through two listservs; the American Society of Health-Systems Pharmacists and the American College of Clinical Pharmacy. A medical marketing company also broadcasted the survey to 2,659 individuals. We collected data on hospital characteristics (size, state, serving population, etc.,) to determine what influenced the hospital's stocking choice.

Results:

The survey response rate was approximately 10% (n = 286). Thirty-eight hospitals (16%) stocked at least 4 antidote kits. Safety profile, recommendations from a poison control center, and ease of use had the strongest influence on stocking decisions.

Conclusions:

Survey of 286 US hospital pharmacy managers, 38/234 (16%) hospitals had sufficient stocking of cyanide antidotes. Antidote preference was based on safety, ease of use, and recommendations by the local poison center, over cost.

Antídotos e medicamentos utilizados para tratar intoxicações no Brasil: necessidades, disponibilidade e oportunidades

Antídotos e determinados medicamentos são essenciais ao tratamento de algumas intoxicações e não podem sofrer falhas no abastecimento, sob o risco de prejudicar a saúde e a segurança da população. O objetivo deste trabalho foi avaliar a disponibilidade de antídotos e medicamentos recomendados para o tratamento de intoxicações no Brasil. A partir de consensos internacionais, foram selecionados 41 antídotos para análise, todos sem patente em vigência. Desses, 27 são registrados, porém 11 estão disponíveis em formas inadequadas ao tratamento de intoxicações, restando 16 medicamentos comercialmente disponíveis. Somente um terço dos medicamentos necessários para o tratamento de intoxicações está incluído na relação de medicamentos essenciais do país. Em adição, é apresentada proposta de suprimento das demandas a um dos antídotos, anticorpo antidigoxina, considerando a capacidade de produção nacional de imunobiológicos. Os resultados demonstram limitação da assistência adequada aos pacientes intoxicados no país e reforçam a necessidade urgente de políticas públicas na área.

[Antidotes: use guidelines and minimun stock in an emergency department]

OBJECTIVE

To develop a guide for antidotes and other medications used to counteract poisoning, and define the stock in an emergency department, as a safety priority for the part-time pharmacist assigned to the unit.

METHOD

A search of specialist databases and web portals of the Spanish Society of Toxicology and the British National Poisons Information Service, as well as toxicology databases, TOXICONET, information from other hospitals, tertiary sources, Micromedex and Medline.

RESULTS

The Guide contains 42 active ingredients and is accessible to the Pharmacy and Emergency departments in electronic format. A minimum emergency stock was agreed based on the daily treatment of a 100 kg patient. This information, including updated expiry dates, is available at the emergency department antidote stock facilities and in electronic format. On a monthly basis, the pharmacist reviews the need to replace any drugs, due to their expiry date or lack of use.

DISCUSSION

The lack of evidence from high quality antidote studies, the variability due to the difficulties of updating sources and some geographical differences in their use means that decision-making can be difficult. It would be useful to have minimum quantity recommendations from societies of toxicology, regulatory agencies and organisations such as the Joint Commission on the Accreditation of Healthcare Organisations. It would also be useful to have a suprahospital risk assessment to optimise management and ensure the availability of antidotes which are expensive, have a limited shelf life, or of which demand is difficult to forecast.

Antidotes for toxicological emergencies: a practical review

PURPOSE

Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use.

SUMMARY

Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability.

CONCLUSION

Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.

Safety and cost-effectiveness of a clinical protocol implemented to standardize the use of Crotalidae polyvalent immune Fab antivenom at an academic medical center

STUDY OBJECTIVE

To evaluate the safety and cost-effectiveness of a clinical protocol adopted in June 2006 that included a comprehensive, objective assessment of snake bite envenomations and standardized the use of Crotalidae polyvalent immune Fab antivenom (FabAV).

DESIGN

Retrospective medical record review.

SETTING

Academic medical center that serves as the regional level I trauma center.

PATIENTS

Seventy-five adults treated with FabAV for snake envenomations in the emergency department between June 1, 2003, and June 1, 2009; 30 patients received treatment according to the protocol (treatment group), and 45 patients received treatment that did not adhere to the protocol (control group).

MEASUREMENTS AND MAIN RESULTS

Demographic and envenomation characteristics, as well as treatment details, were collected for all patients. In addition, information on quantity of FabAV vials required, length of hospital stay, and length of intensive care unit stay were compared between the treatment and control groups. In the treatment group, significantly fewer vials of FabAV were used (2.5 vs 4.727 vials, p=0.007). This decreased in usage correlated to a cost savings of approximately $2000/patient. Despite no significant difference in the severity of the envenomations between the two groups (p=0.379), the treatment group experienced a significantly shorter hospital length of stay (1.933 vs 2.791 days, p=0.030). No significant difference in the progression to fasciotomy or the development of allergic reactions was noted between the two groups.

CONCLUSION

Use of a clinical protocol related to snake envenomations resulted in approximately two fewer vials of FabAV required for each patient. In addition, the treatment group experienced a shorter hospital length of stay without a corresponding increase in adverse events or envenomation progression. Data show that use of the protocol was cost-effective. The development of institution-specific multidisciplinary protocols regarding snake bite envenomations is recommended. Clinical pharmacists can play a vital role in the protocol development to ensure that optimal care is provided for this distinct patient population.

Preparing for chemical terrorism: a study of the stability of expired pralidoxime (2-PAM)

OBJECTIVES

Oximes such as pralidoxime (2-PAM) are essential antidotes for life-threatening organophosphate poisoning. Unfortunately, oximes are expensive, have limited use, and have short shelf lives. As such, maintaining large stockpiles in preparation for terrorist activity is not always possible. We have demonstrated that atropine is stable well beyond its labeled shelf life and that recently expired 2-PAM was clinically efficacious in a series of poisoned patients. Because 2-PAM is often dosed empirically, clinical improvement does not guarantee pharmacological stability. We therefore chose to analyze the chemical stability of expired 2-PAM.

METHODS

Samples of lyophylized 2-PAM were maintained according to the manufacturer's recommendations for 20 years beyond the published shelf life. We studied 2-PAM contained in a MARK I autoinjector that was stored properly for 3 years beyond its expiration date. An Agilent LC/MSD 1100 with diode-array detector and an Agilent Sorbax SB-C-18, 4.6 × 150-mm, 5-μm column were used with the following solvent systems: water with 0.01% trifluoroacetic acid and methanol with 0.01% trifluoroacetic acid. Fresh reagent grade 2-PAM was used as a standard. Results were repeated for consistency.

RESULTS

Lyophylized 2-PAM was a white powder that was clear and colorless in solution. Liquid chromatography was identical to the standard and resulted in 2 isolated peaks with identical mass spectra, suggesting that they are stereoisomers. The autoinjector discharged a clear, yellowish solution. In addition to the 2 peaks identified for lyophylized 2-PAM, a small third peak was identified with a mass spectra corresponding to the reported N -methyl pyridinium carboxaldehyde degradation product.

CONCLUSIONS

When properly stored, lyophylized 2-PAM appears to be chemically stable well beyond its expiration date. Although the relative amount of degradation product found in solubilized (autoinjector) 2-PAM was small, it is unclear whether this may be toxic and therefore is of concern. Further studies performed with lots of drug stored under varied conditions would be required to fully determine the stability of expired 2-PAM.