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Shi Q, Ba G, Xia Z, Mao Z, Sun H, Zhang J. The value of toxicological analysis in acute poisoning patients with uncertain exposure histories: a retrospective and descriptive study from an institute of poisoning. World J Emerg Med 2024; 15:98-104. [PMID: 38476534 PMCID: PMC10925527 DOI: 10.5847/wjem.j.1920-8642.2024.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/23/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND In clinical practice, some patients might not be able or unwilling to provide a thorough history of medication and poison exposure. The aim of this study was to use toxicological analysis to examine the clinical characteristics of patients with acute poisoning whose exposure history was uncertain from a toxicological analysis perspective. METHODS This was a retrospective and descriptive study from an institute of poisoning. Patient registration information and test reports spanning the period from April 1, 2020 to March 31, 2022, were obtained. Patients with uncertain exposure histories and who underwent toxicological analysis were included. Clinical manifestations and categories of toxics were analyzed. RESULTS Among the 195 patients with positive toxicological analysis results, the main causes of uncertain exposure history was disturbance of consciousness (62.6%), unawareness (23.6%) and unwillingness or lack of cooperation (13.8%). The predominant clinical manifestations were disturbed consciousness (62.6%), followed by vomiting and nausea (14.4%) and liver function abnormalities (8.7%). A comparison of clinical manifestations between patients with positive and negative (n=99) toxicological analyses results revealed significantly different proportions of disturbances in consciousness (63% vs. 21%), dizziness (1.5% vs. 5.1%), multi-organ failure (1.5% vs. 7.1%), and local pain (0 vs 4%). The main categories of substances involved were psychiatric medications (23.1%), sedatives (20.5%), insecticides (13.8%), and herbicides (12.8%). CONCLUSION The clinical manifestations of acute poisoning in patients with an uncertain exposure history are diverse and nonspecific, and toxicological analysis plays a pivotal role in the diagnosis and differential diagnosis of such patients.
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Affiliation(s)
- Qifang Shi
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Gen Ba
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhenyu Xia
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhengsheng Mao
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Forensic Medicine, Nanjing Medical University, Nanjing 211166, China
| | - Hao Sun
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Jinsong Zhang
- Institute of Poisoning, Nanjing Medical University, Nanjing 211100, China
- Department of Emergency Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- The Key Laboratory of Modern Toxicology of Ministry of Education, Nanjing Medical University, Nanjing 211166, China
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Pai K, Buckley NA, Isoardi KZ, Isbister GK, Becker T, Chiew AL, Cairns R, Brown JA, Chan BS. Optimising alkalinisation and its effect on QRS narrowing in tricyclic antidepressant poisoning. Br J Clin Pharmacol 2021; 88:723-733. [PMID: 34312917 DOI: 10.1111/bcp.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS The objectives were to determine the effect of NaHCO3 and/or mechanical ventilation on the biochemical profile and serum alkalinisation in tricyclic antidepressant (TCA) poisoning and investigate the impact of effective alkalinisation therapy on the QRS interval in TCA poisoning. METHODS This was a retrospective review of TCA poisonings from three Australian toxicology units and a poisons information centre (Jan 2013 to Jan 2019). We included patients with TCA toxicity who ingested>10 mg/kg or had clinically significant toxicities consistent with TCA poisoning, and analysed patients' clinical, electrocardiogram and biochemical data. RESULTS Of 210 patients, 84 received NaHCO3 and ventilation (dual therapy), 12 NaHCO3 , 46 ventilation and 68 supportive care treatment. When compared with single/supportive groups, patients who received dual therapy had taken a significantly higher median dose of TCA (1.5 g vs1.3 g, P < .001), a longer median maximum QRS interval (124 ms, interquartile ranges [IQR] 108-138 vs106 ms, IQR 98-115, P < .001) and were more likely to have seizures (14% vs3%, P = .006) and arrhythmias (17% vs1%, P < .001). The dual therapy group demonstrated greater increases in serum pH (median 0.11, IQR 0.04-0.17) compared to the single/supportive therapy group (median 0.03, IQR -0.01-0.09, p < .001). A greater proportion of patients reached the target pH 7.45-7.55 in the dual therapy group (59%) compared to the single/supportive therapy group (10%) (P < .001). For each 100 mmol bolus of NaHCO3 given, the median increase in serum sodium was 2.5 mmol/L (IQR 1.5-4.0). QRS narrowing occurred twice as quickly in the dual therapy vs single/supportive therapy group. CONCLUSIONS A combination of NaHCO3 and mechanical ventilation was most effective in achieving serum alkalinisation and was associated with a more rapid narrowing of the QRS interval. We advise that the maximal dose of NaHCO3 should be <400 mmol (6 mmol/kg).
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Affiliation(s)
- Kieran Pai
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Mater Department of Clinical Toxicology and Pharmacology, Calvary Mater Hospital, Waratah, New South Wales, Australia
| | - Therese Becker
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Angela L Chiew
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jared A Brown
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Betty S Chan
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Department of Clinical Toxicology, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Lee MJ, Cho JW, Jung H, Park J, Kim YJ, Seo JS, Chang H, Won S. Analytical toxicology service model at the subregional center level for severe acute poisoning. TOXICOLOGY COMMUNICATIONS 2021. [DOI: 10.1080/24734306.2021.1913913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Mi Jin Lee
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae Wan Cho
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Haewon Jung
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jungbae Park
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yun Jeong Kim
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jun Seok Seo
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Seoul, Republic of Korea
| | - Hanseok Chang
- National Emergency Medical Center, National Medical Center, Seoul, Republic of Korea
| | - Sinae Won
- National Emergency Medical Center, National Medical Center, Seoul, Republic of Korea
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Thromboelastography with Platelet Studies (TEG® with PlateletMapping®) After Rattlesnake Envenomation in the Southwestern United States Demonstrates Inhibition of ADP-Induced Platelet Activation As Well As Clot Lysis. J Med Toxicol 2019; 16:24-32. [PMID: 31407209 DOI: 10.1007/s13181-019-00729-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Hematologic effects of North American rattlesnake envenomation can include fibrinogenolysis and thrombocytopenia, depending on species, geography, and other variables. During treatment, these effects are routinely monitored through assessment of fibrinogen concentrations and platelet counts. However, these tests provide no information about fibrinolysis or platelet dysfunction, both of which can also occur with venom from some species. METHODS This was a retrospective chart review of patients admitted to a quaternary care academic hospital (Banner - University Medical Center Phoenix) in the southwestern United States for treatment of rattlesnake envenomation, over an approximately 1-year period from March 2017 through April 2018. Patients who had thromboelastography with platelet studies (TEG® with PlateletMapping®) during their care were included. RESULTS Twelve patients were identified for this study. Four patients exhibited inhibition of ADP-induced platelet activation: one had normal fibrinogen and platelet count, two had concurrent hypofibrinogenemia, and one had concurrent thrombocytopenia. Crotalidae polyvalent immune Fab (ovine) reversed platelet inhibition in the single patient for whom serial thromboelastographs were available. Fibrinolysis was present in seven patients and resolved in the two patients with serial thromboelastographs. CONCLUSIONS Inhibition of ADP-induced platelet aggregation and fibrinolysis occurred independent of hypofibrinogenemia and thrombocytopenia, indicating fibrinogen concentration (or protime) and platelet count monitoring alone is insufficient to assess the extent of hematologic toxicity in rattlesnake envenomation. Crotalidae polyvalent immune Fab (ovine) reversed platelet inhibition in one case, suggesting platelet inhibition could also be used in treatment decisions. Fibrinolysis could also be reversed, although the timing to antivenom administration was less clear.
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Hondebrink L, Rietjens SJ, Donker DW, Hunault CC, van den Hengel-Koot I, Verputten PM, de Vries I, Kaasjager KAH, Dekker D, de Lange DW. A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study. Eur J Intern Med 2019; 66:41-47. [PMID: 31113710 DOI: 10.1016/j.ejim.2019.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/13/2019] [Accepted: 05/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission. METHODS For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect. RESULTS We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%). CONCLUSIONS The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.
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Affiliation(s)
- Laura Hondebrink
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma van den Hengel-Koot
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pauline M Verputten
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma de Vries
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Douwe Dekker
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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Huang HS, Ho CH, Weng SF, Hsu CC, Wang JJ, Su SB, Lin HJ, Huang CC. Long-term mortality of acetaminophen poisoning: a nationwide population-based cohort study with 10-year follow-up in Taiwan. Scand J Trauma Resusc Emerg Med 2018; 26:5. [PMID: 29310687 PMCID: PMC5759248 DOI: 10.1186/s13049-017-0468-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022] Open
Abstract
Background The long-term mortality of acetaminophen (APAP) poisoning has not yet been well studied; hence, we conducted this study to gain understanding of this issue. Methods We conducted a nationwide population-based cohort study by identifying 3235 participants with APAP poisoning and 9705 participants without APAP poisoning in Taiwan between 2003 and 2012 in the Nationwide Poisoning Database and Longitudinal Health Insurance Database 2000. Participants with APAP poisoning and control subjects were compared for the risk of all-cause mortality by follow-up until 2013. Results Two hundred forty-one participants with APAP poisoning (7.5%) and ninety-four control subjects (1.0%) died during the follow-up. Participants with APAP poisoning had a higher risk of all-cause mortality than the control subjects (incidence rate ratio [IRR], 8.1; 95% confidence interval [CI], 6.3–10.2), especially in the subgroup aged 20 years and younger (IRR, 27.3; 95% CI, 3.5–215.5) and in the first 12 months after poisoning (IRR, 16.0; 95% CI, 9.9–25.7). The increased risk of all-cause mortality was found even up to 2 years after the index poisoning. Conclusion APAP poisoning was associated with increased long-term mortality. Early referral for intensive aftercare and associated interventions are suggested; however, further studies of the method are needed for clarification.
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Affiliation(s)
- Hung-Sheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Department of Occupational Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Shih-Feng Weng
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Shih-Bin Su
- Department of Occupational Medicine, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Leisure, Recreation, and Tourism Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan.,Department of Medical Research, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan. .,Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan City, 710, Taiwan. .,Department of Occupational Medicine, Chi-Mei Medical Center, Tainan, Taiwan. .,Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology, Tainan, Taiwan. .,Department of Geriatrics and Gerontology, Chi-Mei Medical Center, Tainan, Taiwan.
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most widely used classes of medications in children. Despite a reported positive safety profile, NSAIDs have been associated with toxicities in both overdose and routine use. Most children with NSAID overdoses are asymptomatic and should be managed conservatively, whereas a small number may present with severe symptoms. We review NSAID exposures in children and strategies for their clinical evaluation and management.
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