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Tang KB, Simpson MD, Burns MM. Evolving trends of pharmaceutical poisonings associated with QRS complex prolongation. Clin Toxicol (Phila) 2024; 62:574-582. [PMID: 39194962 PMCID: PMC11421585 DOI: 10.1080/15563650.2024.2390138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/23/2024] [Accepted: 08/03/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Tricyclic antidepressants often cause drug-induced QRS complex prolongation in overdose but are now less commonly prescribed. We sought to determine, among a contemporary cohort of patients, the pharmaceuticals independently associated with QRS complex prolongation in acute overdose. METHODS We performed secondary analysis of data from the Toxicology Investigators Consortium (ToxIC) Core Registry. We included adult patients presenting from January 2016 through March 2023 with acute or acute-on-chronic pharmaceutical exposures. The primary outcome was QRS complex prolongation >0.12 s. Secondary outcomes included cardiac arrest, death, ventricular dysrhythmia, intensive care unit admission, initiation of vasopressors, and treatment with sodium bicarbonate. We used a multivariable logistic regression model with QRS complex prolongation as the outcome and individual pharmaceuticals of interest as independent variables. We assessed yearly trends of the contribution of relevant pharmaceuticals to QRS complex prolongation since 2016. RESULTS Of 11,945 patients in the total cohort (median age 37 years, 6,652 [55.7%] female), 366 (3.1%) developed QRS complex prolongation. Of 9,417 patients included in the model, 290 (3.1%) developed QRS complex prolongation. Amitriptyline, nortriptyline, doxepin, imipramine, noxiptiline, bupropion, flecainide, carvedilol, propranolol, diphenhydramine, and lamotrigine poisonings were independent predictors of QRS complex prolongation. Flecainide poisoning conferred the greatest odds of QRS complex prolongation (OR 574.1; 95% CI: 88.3-12,747). The contribution of tricyclic antidepressants to QRS complex prolongation decreased from 38.8% to 17.6% of all patients with QRS complex prolongation from 2016 to 2022. In 2022, the proportion of QRS complex prolongation from diphenhydramine (20.6%) surpassed that of tricyclic antidepressants. DISCUSSION This study provides insights into contemporary pharmaceutical poisoning associated with QRS complex prolongation. Tricyclic antidepressants remain clinically relevant exposures but are no longer the most common cause of drug-induced QRS complex prolongation. CONCLUSIONS Bupropion, diphenhydramine, and antidysrhythmics are increasingly common causes of QRS complex prolongation, each associated with numerous severe outcomes in poisoning. Greater safety measures to protect patients from cardiovascular toxicity from these pharmaceuticals are warranted.
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Affiliation(s)
- Katherine B Tang
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael D Simpson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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2
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Foresteire NP, Howard C, Szustkiewicz K. Tricyclic Antidepressant and Antipsychotic Toxicity: Clomipramine and Ziprasidone Overdose. Cureus 2024; 16:e63691. [PMID: 39092392 PMCID: PMC11293789 DOI: 10.7759/cureus.63691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/04/2024] Open
Abstract
This case report details an intentional overdose attempt utilizing tricyclic antidepressants (TCAs) and atypical antipsychotics with significant neurologic, pulmonary, and cardiac toxicity. In conjunction with the local poison control center, progression of the clinical toxidrome was anticipated, aggressively managed, and successfully treated. This case highlights the dangers of significant TCA toxicity, peak onset of toxicity within six hours, and the amplification of clinical toxidromes with co-ingestions.
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Affiliation(s)
- Nikolas P Foresteire
- Emergency Medicine, Hospital Corporation of America (HCA) Brandon Hospital, Brandon, USA
- Emergency Medicine, Morsani College of Medicine, University of South Florida, Graduate Medical Education Consortium, Tampa, USA
| | - Cory Howard
- Emergency Medicine, Hospital Corporation of America (HCA) Brandon Hospital, Brandon, USA
- Emergency Medicine, Morsani College of Medicine, University of South Florida, Graduate Medical Education Consortium, Tampa, USA
| | - Kirk Szustkiewicz
- Emergency Medicine, Hospital Corporation of America (HCA) Brandon Hospital, Brandon, USA
- Emergency Medicine, Morsani College of Medicine, University of South Florida, Graduate Medical Education Consortium, Tampa, USA
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3
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Chan BS, Buckley NA. Common pitfalls in the use of hypertonic sodium bicarbonate for cardiac toxic drug poisonings. Clin Toxicol (Phila) 2024; 62:213-218. [PMID: 38597366 DOI: 10.1080/15563650.2024.2337028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Hypertonic sodium bicarbonate is advocated for the treatment of sodium channel blocker poisoning, but its efficacy varies amongst different sodium channel blockers. This Commentary addresses common pitfalls and appropriate usage of hypertonic sodium bicarbonate therapy in cardiotoxic drug poisonings. SODIUM BICARBONATE WORKS SYNERGISTICALLY WITH HYPERVENTILATION Serum alkalinization is best achieved by the synergistic effect of hypertonic sodium bicarbonate and hyperventilation (PCO2 ∼ 30-35 mmHg [0.47-0.6 kPa]). This reduces the dose of sodium bicarbonate required to achieve serum alkalinization (pH ∼ 7.45-7.55) and avoids adverse effects from excessive doses of hypertonic sodium bicarbonate. VARIABILITY IN RESPONSE TO SODIUM BICARBONATE TREATMENT Tricyclic antidepressant poisoning responds well to sodium bicarbonate therapy, but many other sodium channel blockers may not. For instance, drugs that block the intercellular gap junctions, such as bupropion, do not respond well to alkalinization. For sodium channel blocker poisonings in which the expected response is unknown, a bolus of 1-2 mmol/kg sodium bicarbonate can be used to assess the response to alkalinization. SODIUM BICARBONATE CAN EXACERBATE TOXICITY FROM DRUGS ACTING ON MULTIPLE CARDIAC CHANNELS Hypertonic sodium bicarbonate can cause electrolyte abnormalities such as hypokalaemia and hypocalcaemia, leading to QT interval prolongation and torsade de pointes in poisonings with drugs that have mixed sodium and potassium cardiac channel properties, such as hydroxychloroquine and flecainide. THE GOAL FOR HYPERTONIC SODIUM BICARBONATE IS TO ACHIEVE THE ALKALINIZATION TARGET (∼PH 7.5), NOT COMPLETE CORRECTION OF QRS COMPLEX PROLONGATION Excessive doses of hypertonic sodium bicarbonate commonly occur if it is administered until the QRS complex duration is < 100 ms. A prolonged QRS complex duration is not specific for sodium channel blocker toxicity. Some sodium channel blockers do not respond, and even when there is a response, it takes a few hours for the QRS complex duration to return completely to normal. In addition, QRS complex prolongation can be due to a rate-dependent bundle branch block. So, no further doses should be given after achieving serum alkalinization (pH ∼ 7.45-7.55). MAXIMAL DOSING FOR HYPERTONIC SODIUM BICARBONATE A further strategy to avoid overdosing patients with hypertonic sodium bicarbonate is to set maximum doses. Exceeding 6 mmol/kg is likely to cause hypernatremia, fluid overload, metabolic alkalosis, and cerebral oedema in many patients and potentially be lethal. RECOMMENDATION FOR THE USE OF HYPERTONIC SODIUM BICARBONATE IN SODIUM CHANNEL BLOCKER POISONING We propose that hypertonic sodium bicarbonate therapy be used in patients with sodium channel blocker poisoning who have clinically significant toxicities such as seizures, shock (systolic blood pressure < 90 mmHg, mean arterial pressure <65 mmHg) or ventricular dysrhythmia. We recommend initial bolus dosing of hypertonic sodium bicarbonate of 1-2 mmol/kg, which can be repeated if the patient remains unstable, up to a maximum dose of 6 mmol/kg. This is recommended to be administered in conjunction with mechanical ventilation and hyperventilation to achieve serum alkalinization (PCO2∼30-35 mmHg [4-4.7 kPa]) and a pH of ∼7.45-7.55. With repeated bolus doses of hypertonic sodium bicarbonate, it is imperative to monitor and correct potassium and sodium abnormalities and observe changes in serum pH and on the electrocardiogram. CONCLUSIONS Hypertonic sodium bicarbonate is an effective antidote for certain sodium channel blocker poisonings, such as tricyclic antidepressants, and when used in appropriate dosing, it works synergistically with hyperventilation to achieve serum alkalinization and to reduce sodium channel blockade. However, there are many pitfalls that can lead to excessive sodium bicarbonate therapy and severe adverse effects.
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Affiliation(s)
- Betty S Chan
- Discipline of Critical Care, School of Clinical Medicine, University of New South Wales, Sydney, Australia
- New South Wales Poisons Information, Sydney, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information, Sydney, Australia
- Clinical Pharmacology, Faculty of Medicine and Health, Sydney University, Sydney, Australia
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4
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Simon M, Kaplan S, Muschler K, Hoyte C, Brent J. The role of QRS complex prolongation in predicting severe toxicity in single-xenobiotic overdose. Clin Toxicol (Phila) 2024; 62:32-38. [PMID: 38329803 DOI: 10.1080/15563650.2024.2307356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The QRS complex duration is commonly used to prognosticate severity, predict outcomes, and indicate treatment in overdose. However, literature to support this practice is mixed in tricyclic antidepressant overdoses and absent in non-tricyclic antidepressant overdoses. Our objective was to assess the validity of QRS complex duration as a prognostic marker in overdose. METHODS This was a secondary analysis of cases reported to the Toxicology Investigators Consortium between January 1, 2010, and December 31, 2022. Cases were assessed to determine the six xenobiotics most associated with QRS complex prolongation. All cases involving these six xenobiotics, regardless of QRS complex duration, constituted the study cohort. Inclusion criteria were cases of patients older than 12 years old with single-xenobiotic exposures. Clinical outcomes evaluated were seizure, ventricular dysrhythmia, metabolic acidosis, and death. RESULTS Of 94,939 total cases, diphenhydramine, amitriptyline, bupropion, quetiapine, nortriptyline, and cocaine were most associated with QRS complex prolongation. Inclusion criteria were met by 4,655 cases of exposure to these xenobiotics. QRS complex prolongation was associated with increased odds ratio of seizure in all included xenobiotics, of ventricular dysrhythmia in all included xenobiotics except nortriptyline, and of metabolic acidosis or death in all included xenobiotics except nortriptyline and quetiapine. A normal QRS complex duration had a negative predictive value of greater than or equal to 93.0 percent of developing metabolic acidosis and 98.0 percent of developing a ventricular dysrhythmia or death from the xenobiotics studied. DISCUSSION This study demonstrates that patients with QRS complex prolongation from all six xenobiotics studied had an increased prevalence and odds of developing severe outcomes. Furthermore, patients who did not develop QRS complex prolongation were unlikely to develop a ventricular dysrhythmia, metabolic acidosis, or death. These findings were noted in six xenobiotics that mechanistically can cause QRS complex prolongation through sodium channel or gap junction inhibition. CONCLUSION Identification of patients at risk for severe outcomes after overdose can be aided by measuring the QRS complex duration. If prospectively validated, these outcomes have implications on risk stratification, disposition level of care, and appropriateness of treatments.
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Affiliation(s)
- Mark Simon
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sabrina Kaplan
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Karen Muschler
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
| | - Jeffrey Brent
- Department of Emergency Medicine, University of CO, Aurora, CO, USA
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Keenan M, Rice S, Frawley E, Jacques C, Wojcik S, Marraffa J. Rate of Adverse Outcomes During 6-Hour Observation for Asymptomatic Patients with Select Ingestions. J Med Toxicol 2023; 19:288-292. [PMID: 37294525 PMCID: PMC10293546 DOI: 10.1007/s13181-023-00954-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Michael Keenan
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA.
- Upstate New York Poison Control Center, 750 East Adams St, Syracuse, NY, 13210, USA.
| | - Stephen Rice
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Emma Frawley
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Chelsie Jacques
- Department of Surgery, New York Medical College at Metropolitan Hospital Center, 1901 1st Ave., New York, NY, 10029, USA
| | - Susan Wojcik
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Jeanna Marraffa
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
- Upstate New York Poison Control Center, 750 East Adams St, Syracuse, NY, 13210, USA
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6
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Feng C, Fay KE, Burns MM. Toxicities of herbal abortifacients. Am J Emerg Med 2023; 68:42-46. [PMID: 36924751 PMCID: PMC10192026 DOI: 10.1016/j.ajem.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND In the post-Roe era, barriers to facility-based abortions may lead to an increased incidence of self-managed abortions. While misoprostol-based medication abortions have significant literature supporting its safety profile, there is a knowledge deficit within the medical community regarding the toxicities of commonly used herbal abortifacients. METHODS This is a narrative review, based on a MEDLINE and HOLLIS database search, of self-managed abortion methods with herbal abortifacients and their associated toxicities. RESULTS Common herbal abortifacients with significant morbidity and mortality implications include pennyroyal, blue cohosh, rue, and quinine. Other commonly reported abortifacients considered to be less toxic also are discussed in brief. Special considerations for hepatic, cardiac, renal, and hematologic toxicities are important in patients with significant exposures to these herbal substances. CONCLUSION There is an anticipated increase in the utility of herbal xenobiotics for self-managed abortions with post-Roe restrictions to standard mifepristone-misoprostol protocols. Frontline providers should be aware of the associated toxicities and have special considerations when treating a poisoned patient in this population.
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Affiliation(s)
- Chris Feng
- Harvard Medical Toxicology, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Kathryn E Fay
- Department of Obstetrics, Gynecology and Reproductive Medicine, Harvard Medical School, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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7
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Current Evidence Surrounding the Use of Sodium Bicarbonate in the Critically Ill Patient. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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8
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Restrepo JA, MacLean R, Celano CM, Huffman JC, Januzzi JL, Beach SR. The assessment of cardiac risk in patients taking lamotrigine; a systematic review. Gen Hosp Psychiatry 2022; 78:14-27. [PMID: 35763920 DOI: 10.1016/j.genhosppsych.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The Food and Drug Administration (FDA) warned about lamotrigine's arrhythmogenicity based on in vitro data. This systematic review investigates lamotrigine's effect on cardiac conduction and risk of sudden cardiac death (SCD) in individuals with and without cardiovascular disease. METHODS We searched Web of Science and PubMed from inception through August 2021. We included studies measuring electrocardiogram (ECG) changes, laboratory abnormalities, or SCD among patients taking lamotrigine. Studies examining sudden unexpected death in epilepsy were excluded for scope. Two reviewers assessed articles and extracted data. We used the Effective Public Healthcare Panacea Project tool to evaluate confidence in evidence. RESULTS Eight randomized controlled trials, 9 nonrandomized observational studies, and 24 case reports were identified, with >3054 total participants, >1606 of whom used lamotrigine. One randomized trial of older patients found an average QRS increase of 3.5 +/- 13.1 ms. Fifteen studies reported no changes in ECG parameters. Case reports documented QRS widening (13), Brugada syndrome (6), QTc prolongation (1) and SCD (2), though many ingested toxic quantities of lamotrigine and/or other medications. CONCLUSIONS Evidence is insufficient to support the breadth of the FDA warning concerning lamotrigine's cardiac risk. Lamotrigine at therapeutic doses may be associated with modest, non-dangerous QRS widening.
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Affiliation(s)
- Judith A Restrepo
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Rachel MacLean
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jeffery C Huffman
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Baim Institute for Clinical Research, 930 Commonwealth Avenue #3, Boston, MA 02215, United States of America
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Al-Daghastani T, Naser AY. Hospital admission profile related to poisoning by, adverse effect of and underdosing of psychotropic drugs in England and Wales: An ecological study. Saudi Pharm J 2022; 30:1262-1272. [PMID: 36249944 PMCID: PMC9561178 DOI: 10.1016/j.jsps.2022.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/24/2022] [Indexed: 11/09/2022] Open
Abstract
Background Drug poisoning is considered as one of the main principal reasons for acute care hospitals admissions, and it places a significant burden on emergency medical services resources. The aim of this study is to examine the trend of hospital admission due to poisoning by psychotropic drugs and prescriptions of psychotropic medications in England and Wales in the past 21 years. Method Hospital admission data from the Hospital Episode Statistics database in England and the Patient Episode Database in Wales were used in this ecological study. For the period from April 1999 to March 2020, hospital admissions data relating to poisoning by, classified by adverse effects of, and underdosing of psychiatric medications were extracted. Data on CNS drug prescriptions was collected for the time period 2004–2020. Results During the study period, hospital admission rate increased by19.9% [from 39.94 (95% CI 39.40–40.48) in 1999 to 47.90 (95% CI 47.34–48.45) in 2020 per 100,000 persons, trend test, p < 0.05]. The most common reason of poisoning by psychotropic drugs that lead to hospital admissions was unspecified poisoning by antidepressants (accidental (unintentional), intentional self-harm, assault, as adverse effect, and under-dosing), which accounted for 48.9% of the total number of admissions. CNS medications prescription rates increased by 56.4% [from 247629.78 (95% CI 247593.18–247666.39) in 2004 to 387372.48 (95% CI 387333.41–387411.55) in 2020 prescriptions per 100,000 persons, trend test, p < 0.001]. The most commonly prescribed CNS medications prescriptions were analgesics, antidepressant, antiepileptic, and hypnotics and anxiolytics, which accounted for: 35.0%, 28.7%, 10.0%, and 9.5%, respectively. During the study. period between 2004 and 2020, the overall medications prescribing rate showed to be very strongly and positively correlating the hospital admissions rate with the overall poisoning by psychotropic drugs (r = 0.799; p ≤ 0.001). Conclusion Over the last two decades, there has been a parallel increase in the hospitalization rate for psychotropic drug poisoning and the prescription rate for CNS medications. Future research should focus on identifying high-risk populations who are more prone to psychotropic drug poisoning.
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McCabe D, Radke JB, Wilson BZ. Disposition, outcomes, and lengths of stay due to bupropion overdose at a tertiary care center with a medical toxicology service. Am J Emerg Med 2022; 54:269-273. [DOI: 10.1016/j.ajem.2022.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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12
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Littmann L. Electrocardiographic Findings in an Unresponsive Patient-Found Down. JAMA Intern Med 2021; 181:856-858. [PMID: 33871568 DOI: 10.1001/jamainternmed.2021.0930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
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13
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Shastry S, Ellis J, Loo G, Vedanthan R, Richardson LD, Manini AF. In Response: Don't Throw the Sodium Bicarbonate Out with the Correlation. J Med Toxicol 2021; 17:319-320. [PMID: 33886089 DOI: 10.1007/s13181-021-00840-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave Levy Place, Box 1620, New York, NY, 10029, USA.
| | | | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave Levy Place, Box 1620, New York, NY, 10029, USA.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rajesh Vedanthan
- Department of Population Health, New York University, New York, NY, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave Levy Place, Box 1620, New York, NY, 10029, USA.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine, Elmhurst Hospital Center, New York, NY, USA
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14
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Don't Throw the Sodium Bicarbonate Out with the Correlation. J Med Toxicol 2021; 17:317-318. [PMID: 33852108 DOI: 10.1007/s13181-021-00838-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/06/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022] Open
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Haring B, Weismann D. [Taxus poisoning: an unusual cause of acute heart failure]. Dtsch Med Wochenschr 2021; 146:331-334. [PMID: 33648002 DOI: 10.1055/a-1239-5316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Taxines are the active, poisonous constituents in yew plants (Taxus spp.) and can result in life-threatening cardiac toxicity. Rapid elimination of yew plant material and administration of active charcoal can limit absorption of toxins. Treatment is confined to supportive care. Therapeutic interventions such as utilization of digoxin immune fab, hemodialysis and temporary cardiac pacing may be utilized. Extracorporeal life support should be considered for severe cases.
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Affiliation(s)
- B Haring
- Medizinische Klinik und Poliklinik I, Schwerpunkt Internistische Notfall- und Intensivmedizin, Universitätsklinikum Würzburg
| | - D Weismann
- Medizinische Klinik und Poliklinik I, Schwerpunkt Internistische Notfall- und Intensivmedizin, Universitätsklinikum Würzburg
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Grautoff S, Fessele K, Fandler M, Gotthardt P. Hypothermia und Intoxication in der EKG-Diagnostik. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00732-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shastry S, Ellis J, Loo G, Vedanthan R, Richardson LD, Manini AF. Antidotal Sodium Bicarbonate Therapy: Delayed QTc Prolongation and Cardiovascular Events. J Med Toxicol 2021; 17:27-36. [PMID: 32737857 PMCID: PMC7785762 DOI: 10.1007/s13181-020-00799-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sodium bicarbonate therapy (SBT) is currently indicated for the management of a variety of acute drug poisonings. However, SBT effects on serum potassium concentrations may lead to delayed QTc prolongation (DQTP), and subsequent risk of adverse cardiovascular events (ACVE), including death. Emergency department (ED)-based studies evaluating associations between SBT and ACVE are limited; thus, we aimed to investigate the association between antidotal SBT, ECG changes, and ACVE. METHODS This was a secondary data analysis of a consecutive cohort of ED patients with acute drug overdose over 3 years. Demographic and clinical data as well as SBT bolus dosage and infusion duration were collected, and outcomes were compared with an unmatched consecutive cohort of patients with potential indications for SBT but who did not receive SBT. The primary outcome was the occurrence of ACVE, and secondary outcomes were delayed QTc (Bazett) prolongation (DQTP), and death. Propensity score and multivariable adjusted analyses were conducted to evaluate associations between adverse outcomes and SBT administration. Planned subgroup analysis was performed for salicylates, wide QRS (> 100 ms), and acidosis (pH < 7.2). RESULTS Out of 2365 patients screened, 369 patients had potential indications for SBT, of whom 31 (8.4%) actually received SBT. In adjusted analyses, SBT was found to be a significant predictor of ACVE (aOR 9.35, CI 3.6-24.1), DQTP (aOR 126.7, CI 9.8-1646.2), and death (aOR 11.9, CI 2.4-58.9). Using a propensity score model, SBT administration was associated with ACVE (OR 5.07, CI 1.8-14.0). Associations between SBT and ACVE were maintained in subgroup analyses of specific indications for sodium channel blockade (OR 21.03, CI 7.16-61.77) and metabolic acidosis (OR: 6.42, 95% CI: 1.20, 34.19). CONCLUSION In ED patients with acute drug overdose and potential indications for SBT, administration of SBT as part of routine clinical care was an independent, dose-dependent, predictor of ACVE, DQTP, and death. This study was not designed to determine whether the SBT or acute overdose itself was causative of ACVE; however, these data suggest that poisoned patients receiving antidotal SBT require close cardiovascular monitoring.
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Affiliation(s)
- Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA.
| | | | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA
| | - Rajesh Vedanthan
- Department of Population Health, New York University, New York, NY, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 3 East 101st Street, 2nd Floor, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine, Elmhurst Hospital Center, New York, NY, USA
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19
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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20
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Angel-Isaza AM, Bustamante-Cristancho LA, Uribe-B FL. Successful Outcome Following Intravenous Lipid Emulsion Rescue Therapy in a Patient with Cardiac Arrest Due to Amitriptyline Overdose. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922206. [PMID: 32447341 PMCID: PMC7274498 DOI: 10.12659/ajcr.922206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The management of patients with tricyclic antidepressant drug overdose can be a challenge for the emergency department physician. Tricyclic antidepressants block alpha-adrenergic receptors and the anticholinergic effects may lead to cardiotoxicity, resulting in arrhythmias and hypotension that can lead to patient mortality. This report is of a case of a 28-year-old woman who presented with cardiac arrest due to amitriptyline overdose and who responded to intravenous lipid emulsion (ILE) therapy. CASE REPORT A 28-year-old woman was admitted to the emergency department with amitriptyline overdose. She suffered a cardiac arrest followed by cardiovascular and neurological complications. Hypotension and lack of a pulse did not respond to treatment with high-dose sodium, but she stabilized following treatment with ILE. The prompt response from the emergency team guaranteed rapid intervention that may have influenced the successful results. CONCLUSIONS Despite the frequency and severity of poisoning with tricyclic antidepressants, there is little consensus among physicians regarding patient management. This case showed the successful use of ILE as rescue therapy in a patient in cardiac arrest following amitriptyline overdose. However, the successful outcome obtained in this case is not a recommendation for the use of ILE as a first-line treatment for the management of patients with tricyclic antidepressant drug overdose. Controlled clinical studies are required to evaluate the safety and efficacy of ILE in the management of tricyclic antidepressant drug overdose.
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Affiliation(s)
| | - Luis Alfonso Bustamante-Cristancho
- Emergency Department, Fundación Valle del Lili, Santiago de Cali, Colombia.,Intensive Care Unit, Fundación Valle del Lili, Santiago de Cali, Colombia
| | - Francisco L Uribe-B
- Clinical Research Center (Centro de Investigaciones Clínicas), Fundación Valle del Lili, Santiago de Cali, Colombia
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Jansen T, Hoegberg LCG, Eriksen T, Dalhoff KP, Belhage B, Johansen SS. Amitriptyline accumulation in tissues after coated activated charcoal hemoperfusion-a randomized controlled animal poisoning model. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2019; 392:1285-1292. [PMID: 31187186 DOI: 10.1007/s00210-019-01669-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
Abstract
Amitriptyline poisoning (AT) is a common poisoning, and AT possess the ability to promote life-threatening complications by its main action on the central nervous and cardiovascular systems. The pharmacokinetic properties might be altered at toxic levels compared to therapeutic levels. The effect of coated activated charcoal hemoperfusion (CAC-HP) on the accumulation of AT and its active metabolite nortriptyline (NT) in various tissues was studied in a non-blinded randomized controlled animal trial including 14 female Danish Land Race piglets. All piglets were poisoned with amitriptyline 7.5 mg/kg infused in 20 min, followed by orally instilled activated charcoal at 30 min after infusion cessation. The intervention group received 4 h of CAC-HP followed by a 1-h redistribution phase. At study cessation, the piglets were euthanized, and within 20 min, vitreous fluid, liver tissue, ventricle and septum of the heart, diaphragm and lipoic and brain tissues were collected. AT and NT tissue concentrations were quantified by UHPLC-MS/MS. A 4-h treatment with CAC-HP did not affect the tissue accumulation of AT in the selected organs when tested by Mann-Whitney U test (p values between 0.44 and 0.73). For NT concentrations, p values were between 0.13 and 1.00. Although not significant, an interesting finding was that data showed a tendency of increased tissue accumulation of AT and NT in the CAC-HP group compared with the control group. Coated activated charcoal hemoperfusion does not significantly alter the tissue concentration of AT and NT in the AT-poisoned piglet.
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Affiliation(s)
- Tejs Jansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, Building 7A, NV, 2400, Copenhagen, Denmark.
| | - Lotte C G Hoegberg
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, Building 7A, NV, 2400, Copenhagen, Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical Sciences, University Hospital for Companion Animals, Faculty of Health and Medical Sciences, University of Copenhagen, Dyrlægevej 16, 1870, Frederiksberg, Denmark
| | - Kim P Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, Building 20C, NV, 2400, Copenhagen, Denmark
| | - Bo Belhage
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, Building 7A, NV, 2400, Copenhagen, Denmark
| | - Sys S Johansen
- Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Frederik V's Vej 11, 2100, Copenhagen, Denmark
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22
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Tay E, Sotiriou A, Graham GG, Wilhelm K, Snowden L, Day RO. Restarting antidepressant and antipsychotic medication after intentional overdoses: need for evidence-based guidance. Ther Adv Psychopharmacol 2019; 9:2045125319836889. [PMID: 30956788 PMCID: PMC6444415 DOI: 10.1177/2045125319836889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 02/13/2019] [Indexed: 11/16/2022] Open
Abstract
Intentional drug overdoses with antidepressant and antipsychotic medications are an increasingly common problem. Currently, there is little guidance with regard to reintroduction of these medications after intentional overdoses. We have used published toxicological and pharmacokinetic data to obtain factors which control the recovery from overdoses. From such data, we have proposed guidance regarding their reintroduction, provided there are no adverse effects or contraindications. Tentatively, we suggest that when adverse effects from the overdose are lost, treatment could recommence after a further mean half-life of elimination. Most antidepressant and antipsychotic drugs are metabolized by cytochrome P450 enzymes and, where cytochrome P450 inhibitors are co-ingested, serial plasma concentrations should optimally be obtained in order to assess a suitable time for reintroduction of the psychoactive drugs. We hope the proposals presented will stimulate research and discussion that lead to better guidance for clinicians concerning reintroduction of psychoactive medication after intentional overdose.
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Affiliation(s)
- Emma Tay
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Andreas Sotiriou
- University College London Medical School, University College London, London, UK
| | - Garry G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia Department of Pharmacology, University of New South Wales, Sydney, Australia
| | - Kay Wilhelm
- Department of Liaison Psychiatry, St Vincent's Hospital, Sydney, Australia Department of Psychiatry, University of New South Wales, Sydney, Australia
| | - Leone Snowden
- NSW Medicines Information Centre, Darlinghurst, NSW, Australia
| | - Richard O Day
- Department of Pharmacology, University of New South Wales, Sydney, Australia
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Rasimas JJ, Sachdeva KK, Donovan JW. Revival of an antidote: bedside experience with physostigmine. TOXICOLOGY COMMUNICATIONS 2018. [DOI: 10.1080/24734306.2018.1535538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- J. J. Rasimas
- PinnacleHealth Toxicology Center, Harrisburg, PA, U.S.A
- Department of Emergency Medicine, Penn State College of Medicine, Hershey, PA, U.S.A
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA, U.S.A
| | | | - J. Ward Donovan
- PinnacleHealth Toxicology Center, Harrisburg, PA, U.S.A
- Department of Emergency Medicine, Penn State College of Medicine, Hershey, PA, U.S.A
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24
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Farkas AN, Marcott M, Yanta JH, Pizon AF. Bicarbonate refractory QRS prolongation and left bundle‐branch block following escitalopram and lamotrigine overdose: A case report and literature review of toxic left bundle‐branch block. J Clin Pharm Ther 2018; 43:717-722. [DOI: 10.1111/jcpt.12698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- A. N. Farkas
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
| | - M. Marcott
- University of Pittsburgh School of Medicine Pittsburgh PA USA
| | - J. H. Yanta
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
| | - A. F. Pizon
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of Pittsburgh School of Medicine Pittsburgh PA USA
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25
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Goldstein JN, Dudzinski DM, Erickson TB, Linder G. Case 12-2018: A 30-Year-Old Woman with Cardiac Arrest. N Engl J Med 2018; 378:1538-1549. [PMID: 29669228 DOI: 10.1056/nejmcpc1800322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Joshua N Goldstein
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - David M Dudzinski
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - Timothy B Erickson
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
| | - Grace Linder
- From the Departments of Emergency Medicine (J.N.G.), Medicine (D.M.D.), and Pathology (G.L.), Massachusetts General Hospital, the Department of Emergency Medicine, Brigham and Women's Hospital (T.B.E.), and the Departments of Emergency Medicine (J.N.G., T.B.E.), Medicine (D.M.D.), and Pathology (G.L.), Harvard Medical School - all in Boston
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26
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Giwa A, Oey E. The return of an old nemesis: Survival after severe tricyclic antidepressant toxicity, a case report. Toxicol Rep 2018; 5:357-362. [PMID: 29854605 PMCID: PMC5977411 DOI: 10.1016/j.toxrep.2018.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 11/19/2022] Open
Abstract
Tricyclic antidepressants (TCAs) were first approved by the Food and Drug Administration (FDA) for use as antidepressants in the 1950s. Although their function as an antidepressant in the U.S. has largely been replaced by newer and safer alternatives, they are still prescribed for various conditions, including chronic pain and intractable depression. We will discuss a case of a TCA overdose presenting with generalized tonic-clonic seizures and multiple recurrent cardiac arrests. This is a case of a 34 year-old female who was brought in by Emergency Medical Services (EMS) with generalized tonic clonic seizure, status post intentional ingestion of multiple drugs. Her vital signs were: Temperature-38.8 °C, Heart Rate-140 beats per minute, Respiratory Rate (RR)-25 breaths per minute, Blood Pressure (BP)-139/77 mmHg, Oxygen Saturation (SaO2)-99% on 100% nonrebreather facemask (NRB). Her electrocardiogram (EKG) showed a widened ventricular tachyarrhythmia and she was immediately given an ampule of sodium bicarbonate. Over the span of the subsequent 2 h, she had recurrent pulseless ventricular tachycardic arrest 5 times in the emergency department (ED). After 5 days of further stabilization, the patient had a subsequent complete recovery with normal neurological function at discharge from the medical unit. In the ED it is imperative that we understand the now uncommon presentation of a TCA overdose in order to initiate immediate treatment. It is also important to understand the optimal treatment choices in patients that presents with TCA toxicity, especially arrhythmias that are refractory to initial treatment choices. Overall, severe TCA poisoning is often fatal; however, we demonstrated that with high quality resuscitative efforts, despite multiple arrests, survival to discharge with normal neurological outcome is possible.
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Jansen T, Hoegberg LCG, Eriksen T, Haarmark C, Dalhoff K, Belhage B. Advanced Electrocardiogram Analysis in the Amitriptyline-poisoned Pig Treated with Activated Charcoal Haemoperfusion. Basic Clin Pharmacol Toxicol 2017; 122:442-447. [DOI: 10.1111/bcpt.12931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Tejs Jansen
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Lotte C. G. Hoegberg
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Thomas Eriksen
- Department of Veterinary Clinical Sciences; Faculty of Health and Medical Sciences; University Hospital for Companion Animals; University of Copenhagen; Copenhagen Denmark
| | - Christian Haarmark
- Department of Clinical Physiology and Nuclear Medicine; Copenhagen University Hospital Herlev and Gentofte; Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Bo Belhage
- Department of Anaesthesiology; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
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28
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Abstract
Tricyclic antidepressant remains widely prescribed despite its dangerous cardiovascular and neurological effects in overdosed patients. We present a case of lethal dothiepin overdose and discuss the major complications and its management strategies.
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Affiliation(s)
| | | | - Cw Kam
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
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29
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Sogut O, Yalcin S, Kaya H, Gokdemir MT, Sezen Y. Opipramol Overdose Presented with Wide-Complex Tachycardia to the Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791201900207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Opipramol is an antidepressant and anxiolytic drug similar in structure to tricyclic antidepressants (TCAs) but it is primarily used for the treatment of generalized anxiety disorders. Unlike many TCAs, opipramol has no reuptake-inhibiting properties. Opipramol acts as a high affinity sigma receptor agonist. Opipramol acts as a low to moderate affinity antagonist for the dopamine-2 (D2), 5-hydroxtryptamine (5-HT2), histamine 1 (H1), histamine 2 (H2), and muscarinic acetylcholine receptors accounting for its antihistamine effects, and muscarinic anticholinergic properties. Here, we report a rare case of opipramol overdose case involving a 18-year-old woman, presenting to our emergency department (ED) with loss of consciousness and wide-complex tachycardia. A firm diagnosis of opipramol overdose was made on the basis of clinical, laboratory and electrocardiogram findings.
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Affiliation(s)
| | - S Yalcin
- Harran University, Medical Faculty, Department of Anesthesiology and Reanimation, Sanliurfa, Turkey
| | | | | | - Y Sezen
- Harran University, Medical Faculty, Department of Cardiology, Sanliurfa, Turkey
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30
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Abstract
Pharmaceutical ingestions comprise an important part of pediatric toxicology. Based on the 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System, coupled with recent epidemiology articles on the topic of pediatric toxicology, it is apparent that poison prevention education has not been completely successful in decreasing exposures to toxic drugs. From the unintentional ingestion in a toddler due to unsafe storage to the intentional adolescent ingestion for misuse and abuse, pharmaceutical medications continue to cause harm. Access to adult prescription drugs in the home accounted for most of the exposures in children age ≤5 years as well as adolescents age 13 to 19 years. Ingestions resulting from more common pharmaceutical exposures are discussed with the hope of increasing awareness about the need for added vigilance. [Pediatr Ann. 2017;46(12):e459-e465.].
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31
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Affiliation(s)
| | - Michele M Burns
- Harvard Medical Toxicology Program and.,Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA
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32
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Abstract
The most important diagnostic factor in uncovering a toxic etiology for delirium or critical illness is the clinician's openness to the possibility of its existence. Therefore, a consulting psychiatrist, already prepared to perform the detail-oriented work of sorting out behavioral manifestations of disease, can be a vital asset at the bedside if also attuned to the role of purposeful, accidental, and iatrogenic exposures in the intensive care unit. This article summarizes the presentation, evaluation, and treatment of toxidromes relevant to the work of acute psychosomatic medicine.
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33
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Liu Z, Zhu Y, Liu X, Yeung K, Wu S. Construction of poly (vinyl alcohol)/poly (lactide-glycolide acid)/vancomycin nanoparticles on titanium for enhancing the surface self-antibacterial activity and cytocompatibility. Colloids Surf B Biointerfaces 2017; 151:165-177. [DOI: 10.1016/j.colsurfb.2016.12.016] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 01/11/2023]
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34
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Manini AF, Nair AP, Vedanthan R, Vlahov D, Hoffman RS. Validation of the Prognostic Utility of the Electrocardiogram for Acute Drug Overdose. J Am Heart Assoc 2017; 6:e004320. [PMID: 28159815 PMCID: PMC5523748 DOI: 10.1161/jaha.116.004320] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND While it is certain that some emergency department patients with acute drug overdose suffer adverse cardiovascular events (ACVE), predicting ACVE is difficult. The prognostic utility of the ECG for heterogeneous drug overdose patients remains to be proven. This study was undertaken to validate previously derived features of the initial ECG associated with ACVE in this population. METHODS AND RESULTS We performed a prospective validation cohort study to evaluate adult emergency department patients with acute drug overdose at 2 urban university hospitals over 5 years in whom an emergency department admission ECG was performed. Exclusion criteria were alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. ACVE was defined as any of the following: circulatory shock, myocardial injury, ventricular dysrhythmia, or cardiac arrest. Blinded cardiologists interpreted ECGs for previously derived predictors of ACVE (ectopy, QT prolongation, nonsinus rhythm, ischemia/infarction), QT dispersion, and prominent R wave in lead AVR. Of 589 patients who met inclusion criteria (48% male, mean age 42), there were 95 ACVEs (39 shock, 64 myocardial injury, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were as follows: benzodiazepines, opioids, and acetaminophen. Previously derived criteria were highly predictive of ACVE, with QT correction >500 ms as the highest risk feature (OR 11.2, CI 4.6-27). CONCLUSIONS This study confirms that early ECG evaluation is essential to assess the cardiovascular prognosis and medical clearance of emergency department patients with acute drug overdose. Furthermore, this study validates previously derived high-risk features of the admission ECG to risk stratify for ACVE in this patient population.
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Affiliation(s)
- Alex F Manini
- Division of Medical Toxicology, Elmhurst Hospital Center, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ajith P Nair
- Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Rajesh Vedanthan
- Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - David Vlahov
- Office of the Dean, School of Nursing, University of California, San Francisco, CA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY
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35
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Poisoning. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Abstract
Sodium bicarbonate is a well-known antidote for tricyclic antidepressant (TCA) poisoning. It has been used for over half a century to treat toxin-induced sodium channel blockade as evidenced by QRS widening on the electrocardiogram (ECG). The purpose of this review is to describe the literature regarding electrophysiological mechanisms and clinical use of this antidote after poisoning by tricyclic antidepressants and other agents. This article will also address the literature supporting an increased serum sodium concentration, alkalemia, or the combination of both as the responsible mechanism(s) for sodium bicarbonate's antidotal properties. While sodium bicarbonate has been used as a treatment for cardiac sodium channel blockade for multiple other agents including citalopram, cocaine, flecainide, diphenhydramine, propoxyphene, and lamotrigine, it has uncertain efficacy with bupropion, propranolol, and taxine-containing plants.
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37
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Odigwe CC, Tariq M, Kotecha T, Mustafa U, Senussi N, Ikwu I, Bhattarcharya A, Ngene JI, Ojiako K, Iroegbu N. Tricyclic antidepressant overdose treated with adjunctive lipid rescue and plasmapheresis. Proc (Bayl Univ Med Cent) 2016; 29:284-7. [PMID: 27365872 DOI: 10.1080/08998280.2016.11929437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Tricyclic antidepressant poisoning remains a major cause of morbidity and mortality, particularly in the setting of suicidal attempts. The current standard of care for treatment is the administration of sodium bicarbonate infusion. Adjunctive lipid emulsion therapy and plasmapheresis have received attention recently. We report an 18-year-old patient who was successfully managed with lipid emulsion and plasmapheresis as adjuncts to sodium bicarbonate treatment and review some of the recent literature.
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Affiliation(s)
| | - Madiha Tariq
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
| | - Tulsi Kotecha
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
| | - Usman Mustafa
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
| | - Nizar Senussi
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
| | - Isaac Ikwu
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
| | | | | | - Kizito Ojiako
- Department of Medicine, St. Joseph Hospital, Chicago, Illinois
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38
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Abstract
Tricyclic antidepressants (TCAs) are one of the most commonly prescribed classes of antidepressant medica tions, and they may account for more than 25% of all serious drug overdoses for persons admitted to adult intensive care units (ICUs). TCA overdose is the most common life-threatening drug ingestion in the United States, with an in-hospital mortality ranging from 0.6 to 15%. Manifestations of a significant overdose include anticholinergic effects (fever, mydriasis, tachycardia, and urinary retention), central nervous system toxicity (confusion, agitation, coma, hallucinations, and grand mal seizures), respiratory depression, and cardiovascu lar toxicity (ventricular tachycardia or fibrillation, hypotension, and conduction defects). The principal cardiovascular findings associated with therapeutic doses of TCAs are discussed and grouped into three categories: (1) electrocardiographic changes—sinus tachycardia, repolarization abnormalities, conduction disturbances, and ventricular arrhythmias; (2) mild depression of myocardial contractility; and (3) sudden cardiac death. The therapeutic feasibility and selection of a TCA for patients with preexisting cardiovascular disease is discussed, and current recommendations on the diagnosis and management of TCA overdoses are reviewed.
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Affiliation(s)
- G. William Dec
- Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Theodore A. Stern
- Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston, MA
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39
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Abstract
Although newer cyclic antidepressants have been introduced over the past several years, the tricyclic antidepressants (TCAs) continue to be the leading cause of morbidity from drug overdose in the United States. Overdose features depend on the particular cyclic antidepressant ingested and its pharmacological properties, and can include CNS depression, cardiac arrhythmias, hypotension, seizures, and anticholinergic symptomatology. Life-threatening symptomatology almost always begins within 2 hours, and certainly within 6 hours, after arrival to the emergency department. Plasma TCA levels are unreliable predictors of TCA toxicity and are not recommended. An ECG with a prolonged QRS complex more than 100 msec seems to be the best indicator of serious sequelae with TCAs. Management consists of stabilization of vital signs, gastrointestinal decontamination, intravenous sodium bicarbonate, and supportive care. Agents once thought to be useful for the treatment of cardiac dysrhythmias and seizures such as phenytoin and physostigmine should be avoided. The future of TCA antibody fragments in the treatment of TCA overdose seems promising. Newer and, to some degree, safer antidepressants in overdose have recently been introduced, and they include fluoxetine, trazodone, and sertraline. Amoxapine, bupropion, and maprotiline seem to be as toxic as the TCAs. A significant interaction between cyclic antidepressants and monoamine-oxidase inhibitors exists. Management includes supportive care and basic poison management. Prevention of poisoning seems to be the most logical and effective method of maintaining patient safety. TCAs should be avoided in children younger than 6 years old. All adults with suicidal ideations should receive no more than a 1-week supply (about 1 g) of drug. Finally consideration should be given to using one of the newer, safer antidepressants in all patients with suicidal ideations.
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Affiliation(s)
- Henry Cohen
- Arnold and Marie Schwartz College of Pharmacy, Long Island University, Bellevue Hospital Center
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40
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Betten DP, Vohra RB, Cook MD, Matteucci MJ, Clark RF. Antidote Use in the Critically Ill Poisoned Patient. J Intensive Care Med 2016; 21:255-77. [PMID: 16946442 DOI: 10.1177/0885066606290386] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.
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Affiliation(s)
- David P Betten
- Department of Emergency Medicine, Sparrow Health System, Michigan State University College of Human Medicine, Lansing, Michigan 48912-1811, USA.
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41
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Kang KS, Kim HI, Kim OH, Cha KC, Kim H, Lee KH, Hwang SO, Cha YS. Clinical outcomes of adverse cardiovascular events in patients with acute dapsone poisoning. Clin Exp Emerg Med 2016; 3:41-45. [PMID: 27752614 PMCID: PMC5051622 DOI: 10.15441/ceem.15.088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 10/26/2015] [Accepted: 12/19/2015] [Indexed: 11/23/2022] Open
Abstract
Objective Adverse cardiovascular events (ACVEs) account for a large proportion of the morbidities and mortalities associated with drug overdose emergencies. However, there are no published reports regarding outcomes of ACVEs associated with acute dapsone poisoning. Here, the authors retrospectively analyzed ACVEs reported within 48 hours of treatment in patients with acute dapsone poisoning and assessed the significance of ACVEs as early predictors of mortality. Methods Sixty-one consecutive cases of acute dapsone poisoning that were diagnosed and treated at a regional emergency center between 2006 and 2014 were included in the study. An ACVE was defined as myocardial injury, shock, ventricular dysrhythmia, cardiac arrest, or any combination of these occurring within the first 48 hours of treatment for acute dapsone poisoning. Results Nineteen patients (31.1%) had evidence of myocardial injury (elevation of serum troponin-I level or electrocardiography signs of ischemia) after dapsone overdose, and there were a total of 19 ACVEs (31.1%), including one case of shock (1.6%). Fourteen patients (23.0%) died from pneumonia or multiple organ failure, and the incidence of ACVEs was significantly higher among non-survivors than among survivors (64.3% vs. 21.3%, P=0.006). ACVE was a significant predictor of mortality (odds ratio, 5.690; 95% confidence interval, 1.428 to 22.675; P=0.014). Conclusion The incidence of ACVE was significantly higher among patients who died after acute dapsone poisoning. ACVE is a significant predictor of mortality after dapsone overdose, and evidence of ACVE should be carefully sought in these patients.
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Affiliation(s)
- Kyung Sik Kang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyung Il Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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42
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Abeyaratne DDK, Liyanapathirana C, Gamage A, Karunarathne P, Botheju M, Indrakumar J. Survival after severe amitriptyline poisoning with prolonged ventricular tachycardia and cardiac arrest. BMC Res Notes 2016; 9:167. [PMID: 26980525 PMCID: PMC4791788 DOI: 10.1186/s13104-016-1963-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 02/06/2016] [Indexed: 11/10/2022] Open
Abstract
Background Tricyclic antidepressants (TCA) are becoming one of the most frequently used substances in self poisoning. Significant morbidity and mortality associated with TCA overdose are often related to and refractory hypotension. We report the first case of survival after severe amitriptyline poisoning, leading to prolonged cardiac arrest and ventricular tachycardia (VT), resuscitated with 3 h of uninterrupted cardiac massage and Direct current (DC) shocks. Case presentation A 25 year old girl presented with severe amitriptyline poisoning causing pulseless VT and prolonged cardiac arrest. After 3 h of uninterrupted external cardiac massage, together with nine DC shocks and intra venous bicarbonate injections the rhythm reverted to a nodal tachycardia, initial 2D echocardiogram showed left ventricular dysfunction, which recovered to normal after 2 weeks and the patient had a complete recovery subsequently. Conclusion Our case highlights the importance of continued resuscitation in patients presenting with TCA poisoning and resistant arrhythmia, especially in young and otherwise healthy patients.
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Affiliation(s)
| | | | - Anushka Gamage
- Professorial Medical Unit, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | | | - Medhini Botheju
- Professorial Medical Unit, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
| | - Jegarajah Indrakumar
- Professorial Medical Unit, Colombo South Teaching Hospital, Kalubowila, Sri Lanka.,Department of Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
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O'grady J, Anderson S, Pringle D. Successful treatment of severe atenolol overdose with calcium chloride. CAN J EMERG MED 2015; 3:224-7. [PMID: 17610789 DOI: 10.1017/s1481803500005601] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTAtenolol, a selective β1-adrenergic antagonist, is commonly used to treat hypertension, ischemic heart disease and cardiac dysrhythmias. Few cases of severe atenolol intoxication have been described, and only one of these reports discussed the use of calcium chloride as a treatment. We present a case of atenolol overdose associated with shock and first-degree heart block, in which administration of calcium chloride led to dramatic improvement after failure of conventional treatment. In addition, we discuss the pharmacokinetics, toxicology and management of β-blocker overdose, focusing on the possible role of calcium chloride.
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Affiliation(s)
- J O'grady
- Department of Emergency Medicine, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
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44
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Paksu MS, Zengin H, Ilkaya F, Paksu S, Guzel H, Ucar D, Uzun A, Alacam H, Duran L, Murat N, Guzel A. Can empirical hypertonic saline or sodium bicarbonate treatment prevent the development of cardiotoxicity during serious amitriptyline poisoning? Experimental research. Cardiovasc J Afr 2015; 26:134-9. [PMID: 25939777 PMCID: PMC4538909 DOI: 10.5830/cvja-2015-014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/27/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The aim of this experimental study was to investigate whether hypertonic saline or sodium bicarbonate administration prevented the development of cardiotoxicity in rats that received toxic doses of amitriptyline. METHOD Thirty-six Sprague Dawley rats were used in the study. The animals were divided into six groups. Group 1 received toxic doses of i.p. amitriptyline. Groups 2 and 3 toxic doses of i.p. amitriptyline, plus i.v. sodium bicarbonate and i.v. hypertonic saline, respectively. Group 4 received only i.v. sodium bicarbonate, group 5 received only i.v. hypertonic saline, and group 6 was the control. Electrocardiography was recorded in all rats for a maximum of 60 minutes. Blood samples were obtained to measure the serum levels of sodium and ionised calcium. RESULTS The survival time was shorter in group 1. In this group, the animals' heart rates also decreased over time, and their QRS and QTc intervals were significantly prolonged. Groups 2 and 3 showed less severe changes in their ECGs and the rats survived for a longer period. The effects of sodium bicarbonate or hypertonic saline treatments on reducing the development of cardiotoxicity were similar. The serum sodium levels decreased in all the amitriptyline-applied groups. Reduction of serum sodium level was most pronounced in group 1. CONCLUSION Empirical treatment with sodium bicarbonate or hypertonic saline can reduce the development of cardiotoxicity during amitriptyline intoxication. As hypertonic saline has no adverse effects on drug elimination, it should be considered as an alternative to sodium bicarbonate therapy.
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Affiliation(s)
- Muhammet Sukru Paksu
- Paediatric Intensive Care Unit, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Halit Zengin
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - Fatih Ilkaya
- Department of Pharmacology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sule Paksu
- Department of Paediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Guzel
- Department of Pharmacology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Durmus Ucar
- Department of Physiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Adem Uzun
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Alacam
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Latif Duran
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Naci Murat
- Department of Industrial Engineering, Faculty of Engineering, Ondokuz Mayis University, Samsun, Turkey
| | - Ahmet Guzel
- Department of Paediatric Emergency, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. Am J Cardiovasc Drugs 2015; 15:43-50. [PMID: 25567789 DOI: 10.1007/s40256-014-0104-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented. OBJECTIVE The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes. METHODS We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP). RESULTS Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs. CONCLUSIONS Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.
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46
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Poisoning. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_55-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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47
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Toxicologic emergencies in the intensive care unit: management using reversal agents and antidotes. Crit Care Nurs Q 2014; 36:335-44. [PMID: 24002424 DOI: 10.1097/cnq.0b013e3182a10cbd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the most common drugs implicated in overdoses admitted to the intensive care unit focusing on antidotes and reversal agents used in their management. SUMMARY Poisonings and overdoses due to pharmaceutical agents result in more than 100 000 critical care unit admissions each year. Ingestion of toxic alcohols, calcium channel blockers, beta-adrenergic antagonists, benzodiazepines, opioids, acetaminophen, tricyclic antidepressants, and salicylates are associated with a high rate of morbidity and mortality. Reviewing the mechanism of toxicity due to specific agents along with the mechanism of action, dosing, and adverse effects of appropriate antidotes is important for the successful management of these patients within the critical care unit. CONCLUSION Understanding the most prevalent overdoses and their management using reversal agents and antidotes is essential to the overall treatment of these critically ill patients.
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48
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Yates C, Galvao T, Sowinski KM, Mardini K, Botnaru T, Gosselin S, Hoffman RS, Nolin TD, Lavergne V, Ghannoum M. Extracorporeal treatment for tricyclic antidepressant poisoning: recommendations from the EXTRIP Workgroup. Semin Dial 2014; 27:381-9. [PMID: 24712820 PMCID: PMC4282541 DOI: 10.1111/sdi.12227] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The Extracorporeal Treatments In Poisoning (EXTRIP) workgroup was formed to provide recommendations on the use of extracorporeal treatments (ECTR) in poisoning. Here, the workgroup presents its results for tricyclic antidepressants (TCAs). After an extensive literature search, using a predefined methodology, the subgroup responsible for this poison reviewed the articles, extracted the data, summarized findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Blinded votes were compiled, returned, and discussed in person at a meeting. A second vote determined the final recommendations. Seventy-seven articles met inclusion criteria. Only case reports, case series, and one poor-quality observational study were identified yielding a very low quality of evidence for all recommendations. Data on 108 patients, including 12 fatalities, were abstracted. The workgroup concluded that TCAs are not dialyzable and made the following recommendation: ECTR is not recommended in severe TCA poisoning (1D). The workgroup considers that poisoned patients with TCAs are not likely to have a clinical benefit from extracorporeal removal and recommends it NOT to be used in TCA poisoning.
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Affiliation(s)
- Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
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Paksu S, Duran L, Altuntas M, Zengin H, Salis O, Ozsevik SN, Albayrak H, Murat N, Guzel A, Paksu MS. Amitriptyline overdose in emergency department of university hospital: evaluation of 250 patients. Hum Exp Toxicol 2014; 33:980-90. [PMID: 24505046 DOI: 10.1177/0960327113520019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the patients with acute amitriptyline poisoning and investigate predictive factors for the development of life-threatening complications. METHODS Demographics, clinical, laboratory, and electrocardiographic (ECG) findings of 250 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied. RESULTS Median age of patients was 14.6 years, of which, 70% of patients were female and 66% were in pediatric age group. The most common pathological clinical finding and laboratory abnormality were alteration of consciousness and hyponatremia. The rate of convulsive seizure, arrhythmia, and respiratory depression were 17 (6.8%), 16 (6.4%), and 11 (4.4%), respectively. These complications were more seen in pediatric patients than adults (15.8% and 1.2%). The incidence of hyponatremia was more in pediatric patients and severe poisoning groups (38.8 and 53.4%, respectively). The levels of amitriptyline and nortriptyline were significantly higher in the group with complications than the group without complications (p < 0.05). All adult patients were discharged with good prognosis. In pediatric age group, one patient was discharged with severe neurological sequelae and one patient died. QRS duration >100 ms, long corrected QT duration interval, and low Glasgow Coma Score (GCS) at admission were identified as independent risk factors for the development of life-threatening complications (odds ratio: 69.4, 1.9, and 1383, respectively; p < 0.05). CONCLUSION Amitriptyline poisoning may be associated with life-threatening complications, especially in pediatric age group and in patients with hyponatremia. Low GCS, presence of hyponatremia, high serum drug levels, and pathological ECG findings on admission may be helpful in predicting the development of complications and poor prognosis.
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Affiliation(s)
- S Paksu
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - L Duran
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M Altuntas
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - H Zengin
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - O Salis
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - S N Ozsevik
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - H Albayrak
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - N Murat
- Department of Industrial Engineering, Faculty of Engineering, Ondokuz Mayis University, Samsun, Turkey
| | - A Guzel
- Department of Pediatric Emergency, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M S Paksu
- Pediatric Intensive Care Unit, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Abstract
Treating patients with psychiatric problems can present numerous challenges for clinicians. The deliberate self-ingestion of antidepressants is one such challenge frequently encountered in hospitals throughout the United States. This review focuses on 1) the classes of antidepressants, their pharmacologic properties, and some of the proposed mechanism(s) for antidepressant overdose-induced seizures; 2) the evidence for seizures caused by antidepressants in overdose; 3) management strategies for patients who have intentionally or unintentionally overdosed on an antidepressant, or who have experienced an antidepressant overdose-induced seizure.
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Affiliation(s)
- Bryan S Judge
- Grand Rapids Medical Education Partners/Michigan State University Emergency Medicine Residency, 100 Michigan NE, MC 49, Grand Rapids, MI 49403, USA.
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