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Gill AS, Rai HK, Karunakaran A, Chaudhuri A. Suicide Attempt With Levothyroxine Overdose. Cureus 2023; 15:e36172. [PMID: 37065406 PMCID: PMC10103151 DOI: 10.7759/cureus.36172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Symptoms of levothyroxine overdose may vary depending on age, metabolism, etc. There are no specific guidelines for treating levothyroxine poisoning. Here, we present the case of a 69-year-old man with a history of panhypopituitarism, hypertension, and end-stage renal disease who attempted suicide by ingesting 60 tablets of 150 µg levothyroxine (9 mg). Upon presentation to the emergency room, he was asymptomatic despite the free thyroxine level above the range of the assay. During the hospital stay, he developed sinus tachycardia, which was controlled with propranolol. Mild elevations in liver enzymes were also noted. He received stress-dose steroids; hemodialysis was performed a day earlier, and cholestyramine was administered. Thyroid hormone levels started to improve by day seven and finally normalized in 20 days, after which the home dose of levothyroxine was resumed. The human body has several mechanisms to compensate for levothyroxine toxicity, including the conversion of excess levothyroxine to inactive reverse triiodothyronine, increased binding to thyroid-binding globulin, and hepatic metabolism. This case shows that it is possible to have no symptoms even with an overdose of up to 9 mg a day of levothyroxine. Signs and symptoms of levothyroxine toxicity may not appear for several days after ingestion, and, therefore, close observation preferably on a telemetry floor is recommended until the thyroid hormone levels start to decrease. Effective treatment options include beta-blockers preferably propranolol, early gastric lavage, cholestyramine, and glucocorticoids. While hemodialysis has a limited role, antithyroid drugs and activated charcoal are ineffective.
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Wendt S, Lübbert C, Begemann K, Prasa D, Franke H. Poisoning by Plants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:arztebl.m2022.0124. [PMID: 35140011 PMCID: PMC9453220 DOI: 10.3238/arztebl.m2022.0124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/26/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC). Over the years 2011-2020, plant poisoning was the subject of 15% of all inquiries to the joint poison information center in Erfurt, Germany (Gemeinsames Giftinformationszentrum Erfurt, GGIZ) that concerned poisoning in children (2.3% in adults). In this patient collective, plant poisoning occupied third place after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushroom poisoning (1.5%). METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed/TOXLINE on plant poisoning and on 12 epidemiologically and toxicologically relevant domestic species of poisonous plants in risk categories 2 and 3 (up to 2021). RESULTS Medical personnel should have basic toxicological knowledge of the following highly poisonous plants: wolfsbane (aconitum), belladonna, angel's trumpet, cowbane (cicuta virosa), autumn crocus, hemlock, jimson weed, henbane, castor bean (ricinus), false hellebore, foxglove (digitalis), and European yew. The intoxication is evaluated on the basis of a structured history (the "w" questions) and the clinical manifestations (e.g., toxidromes). Special analysis is generally not readily available and often expensive and time-consuming. In case of poisoning, a poison information center should be contacted for plant identification, risk assessment, and treatment recommendations. Specimens of plant components and vomit should be obtained, if possible, for further testing. Measures for the elimination of the poisonous substance may be indicated after a risk-benefit analysis. Specific antidotes are available for only a few types of plant poisoning, e.g., physostigmine for tropane alkaloid poisoning or digitalis antibodies for foxglove poisoning. The treatment is usually symptomatic and only rarely evidence-based. Individualized medical surveillance is recommended after the ingestion of large or unknown quantities of poisonous plant components. CONCLUSION The clinician should be able to recognize dangerous domestic species of poisonous plants, take appropriate initial measures, and avoid overdiagnosis and overtreatment. To improve patient care, systematic epidemiological and clinical studies are needed.
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Affiliation(s)
- Sebastian Wendt
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, University Hospital, Leipzig
- University Hospital Leipzig, Interdisciplinary Centre for Infectious Diseases (ZINF)
- Postgraduate Study of Toxicology and Environmental Protection, Leipzig
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, University Hospital, Leipzig
- University Hospital Leipzig, Interdisciplinary Centre for Infectious Diseases (ZINF)
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig
| | - Kathrin Begemann
- German Federal Institute for Risk Assessment, Department Exposure,Berlin
| | - Dagmar Prasa
- *These authors share last authorship
- Joint Poison Information Center of Mecklenburg-Vorpommern, Sachsen, Sachsen-Anhalt und Thüringen c/o HELIOS Klinikum Erfurt
| | - Heike Franke
- *These authors share last authorship
- Postgraduate Study of Toxicology and Environmental Protection, Leipzig
- Rudolf-Boehm-Institute of Pharmacology and Toxicology, University of Leipzig
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Mix KA, Stafford J, Hofmeister E. Effect of single dose administration activated charcoal containing sorbitol on serum sodium concentration and hydration status in dogs. J Vet Emerg Crit Care (San Antonio) 2019; 29:616-621. [PMID: 31468696 DOI: 10.1111/vec.12887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 06/03/2017] [Accepted: 07/01/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the administration of a commercially available activated charcoal suspension with sorbitol (ACS) on serum sodium concentrations and hydration status in healthy dogs. DESIGN Prospective study. SETTING Private referral hospital. ANIMALS Nine healthy adult dogs. INTERVENTIONS Dogs were administered 1 mg/kg maropitant (Cerenia; Pfizer Animal Health, New York, NY) intravenously 1 hour prior to charcoal administration. Dogs were administered a single dose of 2 g/kg ACS. MEASUREMENTS AND MAIN RESULTS Blood samples and body weights were obtained prior to charcoal administration and 2, 4, 6, 8, 10, and 12 hours post ACS administration. Venous sodium, potassium, chloride, blood urea nitrogen, creatinine, lactate, packed cell volume, and total plasma protein were measured at each time interval. All dogs returned 2-4 weeks after ACS administration for a 12 hour period of water restriction and to serve as their own control group. The same measurements were repeated during water restriction period as following ACS administration. The increase in serum sodium concentration was significantly higher following ACS administration when compared to control period (P = 0.0002). All dogs administered ACS experienced a significant degree of weight loss (P = 0.0371) when compared to the control period. Following administration of ACS, the hematocrit of the dogs administered ACS was found to be significantly increased (P = 0.0001), when compared to the control period. CONCLUSION Patients that are administered a single dose of ACS are at risk of developing dehydration and secondary hypernatremia as observed in the dogs during the study period. Patients receiving ACS should have electrolytes monitored and would benefit from fluid therapy as previously recommended.
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Affiliation(s)
| | | | - Erik Hofmeister
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL
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Howard C. A New Source for Nicotine Exposures in Pediatric Patients: Electronic Cigarettes. J Emerg Nurs 2016; 42:451-3. [PMID: 27061488 DOI: 10.1016/j.jen.2016.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Koenigshof AM, Beal MW, Poppenga RH, Jutkowitz LA. Effect of sorbitol, single, and multidose activated charcoal administration on carprofen absorption following experimental overdose in dogs. J Vet Emerg Crit Care (San Antonio) 2015; 25:606-10. [PMID: 25891141 DOI: 10.1111/vec.12305] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 01/27/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the effectiveness of single dose activated charcoal, single dose activated charcoal with sorbitol, and multidose activated charcoal in reducing plasma carprofen concentrations following experimental overdose in dogs. DESIGN Randomized, four period cross-over study. SETTING University research setting. ANIMALS Eight healthy Beagles. INTERVENTIONS A 120 mg/kg of carprofen was administered orally to each dog followed by either (i) a single 2 g/kg activated charcoal administration 1 hour following carprofen ingestion (AC); (ii) 2 g/kg activated charcoal with 3.84 g/kg sorbitol 1 hour following carprofen ingestion (ACS); (iii) 2 g/kg activated charcoal 1 hour after carprofen ingestion and repeated every 6 hours for a total of 4 doses (MD); (iv) no treatment (control). MEASUREMENTS AND MAIN RESULTS Plasma carprofen concentrations were obtained over a 36-hour period following carprofen ingestion for each protocol. Pharmacokinetic modeling was performed and time versus concentration, area under the curve, maximum plasma concentration, time to maximum concentration, and elimination half-life were calculated and compared among the groups using ANOVA followed by Tukey's multiple comparisons test. Activated charcoal, activated charcoal with sorbitol (ACS), and multiple-dose activated charcoal (MD) significantly reduced the area under the curve compared to the control group. AC and MD significantly reduced the maximum concentration when compared to the control group. MD significantly reduced elimination half-life when compared to ACS and the control group. There were no other significant differences among the treatment groups. CONCLUSIONS Activated charcoal and ACS are as effective as MD in reducing serum carprofen concentrations following experimental overdose in dogs. Prospective studies are warranted to evaluate the effectiveness of AC, ACS, and MD in the clinical setting.
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Affiliation(s)
- Amy M Koenigshof
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI
| | - Matthew W Beal
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI
| | - Robert H Poppenga
- the Department of Molecular Biosciences, California Animal Health and Food Safety Laboratory, University of California-Davis, Davis, CA
| | - L Ari Jutkowitz
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI
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Moon J, Chun B, Song K. An exploratory study; the therapeutic effects of premixed activated charcoal-sorbitol administration in patients poisoned with organophosphate pesticide. Clin Toxicol (Phila) 2015; 53:119-26. [PMID: 25608917 DOI: 10.3109/15563650.2014.1001516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The effects of activated charcoal (AC) mixed with cathartics for gastric decontamination in the management of organophosphate (OP) poisoning remain unknown due to limited clinical evidence. This exploratory study assessed the effectiveness of premixed AC-sorbitol as a treatment for OP poisoning. MATERIALS AND METHODS This retrospective observational case study included patients who either did not receive AC-sorbitol or received a single dose of AC-sorbitol within 24 h after OP ingestion. The patients were divided into three groups: no AC-sorbitol treatment, patients who received AC-sorbitol within 1 h of OP ingestion, and patients who received AC-sorbitol more than 1 h after OP ingestion. Mortality, the development of respiratory failure, and the duration of mechanical ventilation were used as outcome measurements for effectiveness, whereas aspiration pneumonia and electrolyte imbalance were employed as safety measurements. RESULT Among 262 patients with OP poisoning, 198 were included. Of these, 133 patients did not receive AC-sorbitol, whereas 14 and 51 patients received AC-sorbitol within 1 h or more than 1 h after ingestion, respectively. The time from ingestion to hospital arrival and time from ingestion to administration of atropine and pralidoxime differed among the groups, whereas other characteristics, including age, amount ingested, and type of ingested OP, were similar among the groups. Univariate and multivariate analysis demonstrated that the administration of AC-sorbitol was not associated with outcome measures for effectiveness and did not significantly increase either aspiration pneumonia or electrolyte imbalances during hospitalization. DISCUSSION AND CONCLUSION The administration of AC-sorbitol exerted neither beneficial nor harmful effects on the outcomes of OP-poisoned patients regardless of the time from OP ingestion to administration, compared with those of patients who did not receive AC-sorbitol. However, this study enrolled a small number of patients who received AC-sorbitol; further qualified trials with a sufficient number of patients are therefore needed.
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Affiliation(s)
- Jeongmi Moon
- Department of Emergency Medicine, Chonnam National University Medical School , Gwangju , South Korea
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Zyoud SH, Al-Jabi SW, Bali YI, Al-Sayed AM, Sweileh WM, Awang R. Availability of treatment resources for the management of acute toxic exposures and poisonings in emergency departments among various types of hospitals in Palestine: a cross-sectional study. Scand J Trauma Resusc Emerg Med 2014; 22:13. [PMID: 24555427 PMCID: PMC3939642 DOI: 10.1186/1757-7241-22-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 02/17/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Poisoning exposures continue to be a significant cause of morbidity and mortality worldwide. The lack of facilities, treatment resources, and antidotes in hospitals may affect the treatments provided and outcomes. This study aimed to determine the availability of gastrointestinal (GI) decontamination, stabilisation, elimination enhancement resources, and antidotes for the management of acute toxic exposures and poisonings in emergency departments (EDs) among various types of governmental and private hospitals in Palestine. METHODS A cross-sectional study using semi-structured questionnaire was performed. Data were collected based on hospital resources; GI decontamination, stabilisation, elimination enhancement resources and antidotes from Palestinian hospitals. RESULTS Eighteen hospitals (94.7%) have responded. Among them, paracetamol poisoning was the most frequently reported cases by EDs (mean frequency score = 7.6 ± 2.1), followed by bee stings (mean = 6.9 ± 2.7) and organophosphate poisoning (mean = 6.7 ± 2.7). The availabilities of most resources related to GI decontamination items varied substantially with hospital type, but these differences were not statistical significant. The availability of stabilisation resources was not significantly different between hospitals types. For the availability of techniques used to enhance the elimination of toxic substances, there were variations between the hospitals types. However, these differences were not statistical significant, except for haemodialysis (p = 0.003) which was more available in governmental hospitals. For the availability of antidotes, none of the hospitals had sufficient stock of all antidotes listed. In relation to hospital type, there was variability in the availability of antidotes, but this did not reach statistical significance, except for deferoxamine (p < 0.001), which was available in all governmental hospitals but none of the private hospitals. CONCLUSIONS The availability of treatment resources and antidotes in Palestinian hospitals was not adequate except for stabilisation resources. The availability of such resources acts as a marker for the level of readiness of hospital EDs in Palestine for the management of acute toxic exposure and poisoning. The implementation of a minimum list of antidotes and treatment resources would be useful to increase the level of resources. Coordination between Palestinian poison control and drug information centre and hospitals is also important.
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Affiliation(s)
- Sa’ed H Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia
| | - Samah W Al-Jabi
- Department of Clinical and Comunity Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Yara I Bali
- PharmD Program, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Afnan M Al-Sayed
- PharmD Program, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Waleed M Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Rahmat Awang
- WHO Collaborating Centre for Drug Information, National Poison Centre, Universiti Sains Malaysia (USM), Penang, Malaysia
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Müller D, Desel H. Common causes of poisoning: etiology, diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:690-9; quiz 700. [PMID: 24194796 DOI: 10.3238/arztebl.2013.0690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/31/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND In 2011, German hospitals treated approximately 205 000 patients suffering from acute poisoning. Change is seen over time both in the types of poisoning that occur and in the indications for specific treatment. METHODS This article is based on a selective review of the literature, with special attention to the health reports of the German federal government, the annual reports of the GIZ-Nord Poisons Center (the poison information center for the four northwestern states of Germany, i.e. Bremen, Hamburg, Lower Saxony and Schleswig-Holstein), and the recommendations of international medical associations. RESULTS From 1996 to 2011, the GIZ-Nord Poisons Center answered more than 450 000 inquiries, most of which involved exposures to medical drugs, chemicals, plants, foods, or cosmetics. Poisoning was clinically manifest in only a fraction of these cases. Ethanol intoxication is the commonest type of acute poisoning and suicide by medical drug overdose is the commonest type of suicide by poisoning. Death from acute poisoning is most commonly the result of either smoke inhalation or illegal drug use. Severe poisoning is only rarely due to the ingestion of chemicals (particularly detergents and cleaning products), cosmetics, or plant matter. Medical procedures that are intended to reduce the absorption of a poison or enhance its elimination are now only rarely indicated. Antidotes (e.g., atropine, 4-dimethylaminophenol, naloxone, toluidine blue) are available for only a few kinds of poisoning. Randomized clinical trials of treatment have been carried out for only a few substances. CONCLUSION Most exposures to poisons can be treated with general emergency care and, if necessary, with symptomatic intensive-care measures. Poison information centers help ensure that cases of poisoning are dealt with efficiently. The data they collect are a useful aid to toxicological assessment and can serve as a point of departure for research projects.
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Affiliation(s)
- Dieter Müller
- GIZ-Nord Poisons Center, University Medical Center Göttingen-Georg-August-Universität
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Mégarbane B. Décontamination digestive et épuration extrarénale en toxicologie: des recommandations internationales pour la pratique médicale. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Awang R, Al-Sohaim SI, Zyoud SH, Khan HRM, Hashim S. Availability of decontamination, elimination enhancement, and stabilization resources for the management of acute toxic exposures and poisonings in emergency departments in Malaysia. Intern Emerg Med 2011; 6:441-8. [PMID: 21750875 DOI: 10.1007/s11739-011-0662-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/29/2011] [Indexed: 02/07/2023]
Abstract
Acute poisoning is a common medical emergency in Malaysia. Life can be saved if the patient is diagnosed properly and receives the appropriate treatment such as gastrointestinal decontamination techniques and resources to increase poison elimination according to clinical guidelines at a reasonable time. The aims of this study were to determine the availability of decontamination, elimination enhancement, and stabilization resources for the management of acute toxic exposures and poisonings in accident and emergency departments in Malaysia, and to compare the availability of such facilities among various types of hospitals. A comparative, descriptive cross-sectional study was conducted using a structured questionnaire. Seventy-four (58.3%) out of the targeted 127 hospitals replied and completed the questionnaire. The availabilities of most items related to stabilization resources were far better in general hospitals compared to district hospitals with specialists and district hospitals without specialists. These items were mechanical ventilators (p = 0.011), non-invasive positive pressure ventilators (0.024), pacemakers (p = 0.019), and transcutaneous cardiac pacing (p < 0.001). The availability of decontamination resources varied substantially with hospital type. Nevertheless, these differences did not reach statistical significance in any of the cases, whereas sodium sulphate, sorbitol, and polyethylene glycol were almost never available. The availabilities of most items related to elimination enhancement resources were far better in general hospitals and district hospitals with specialists compared to district hospitals without specialists. These items were haemodialysis (p = 0.046), haemoperfusion (p = 0.002), haemofiltration (p = 0.002), acid diuresis (p = 0.04), peritoneal dialysis (p < 0.001), and exchange transfusion (p < 0.001). Most Malaysian hospitals have certain important immediate interventions such as gastrointestinal decontamination techniques and resources to increase poison elimination. The availabilities of most facilities were far better in the general hospitals. Coordination between the National Poison Centre in Malaysia and hospitals should be established regarding the emergency facilities for effective management of poisoning cases in each hospital in order to direct the poisoned patients to the hospital where the appropriate management resources is available.
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Affiliation(s)
- Rahmat Awang
- WHO Collaborating Centre for Drug Information, Clinical Toxicology Program, National Poison Centre, Universiti Sains Malaysia (USM), 11800 Penang, Malaysia.
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Abstract
Clinicians are frequently confronted with toxicological emergencies and challenged with the task of correctly identifying the possible agents involved and providing appropriate treatments. In this review article, we describe the epidemiology of overdoses, provide a practical approach to the recognition and diagnosis of classic toxidromes, and discuss the initial management strategies that should be considered in all overdoses. In addition, we evaluate some of the most common agents involved in poisonings and present their respective treatments. Recognition of toxidromes with knowledge of indications for antidotes and their limitations for treating overdoses is crucial for the acute care of poisoned patients.
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Affiliation(s)
- Simon W Lam
- Cleveland Clinic, Department of Pharmacy, Cleveland, OH 44195, USA.
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Benson BE, Spyker DA, Troutman WG, Watson WA, Bakhireva LN. Amlodipine toxicity in children less than 6 years of age: a dose-response analysis using national poison data system data. J Emerg Med 2009; 39:186-93. [PMID: 19535212 DOI: 10.1016/j.jemermed.2009.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 12/18/2008] [Accepted: 02/06/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Amlodipine is a long-acting calcium channel blocker capable of producing hypotension and dysrhythmia in overdose. The toxic doses of amlodipine in children are unclear. OBJECTIVES The purposes of this study were to describe amlodipine poisoning in children and to determine whether a dose-response relationship could be detected in this population using standardized call data from United States (US) poison centers. PATIENTS AND METHODS 1251 amlodipine-only ingestions in children < 6 years of age were reviewed. Cases with doses coded as "Exact" or "Estimated" and with dose, age, and medical outcome were analyzed (n = 678). Ingestions reported as a "taste or lick" (n = 53) were included as a dose of 1/10 of the dosage form involved. A clinically important response was defined as bradycardia, hypotension, dysrhythmia, conduction disturbance, or hyperglycemia. The risk of such responses was examined over four dosage intervals (< 2.5 mg, 2.5-5 mg, 5.1-10 mg, and > 10 mg). RESULTS The median estimated dose ingested was 5 mg (range 0.25-200 mg). Clinically important responses developed in 27 patients (3.98%), and the prevalence of such response significantly increased from 0% for the lowest to 11.1% for the highest dose interval (p = 0.001). The smallest dose to produce a clinically important response was 2.5 mg (0.15 mg/kg). Children who ingested > 10 mg were 4.4 times more likely to develop clinically important responses than those ingesting < or = 5 mg. CONCLUSION Hypotension may occur in children with amlodipine doses as low as 2.5 mg. The National Poison Data System might provide useful insights regarding dose-response.
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Affiliation(s)
- Blaine E Benson
- New Mexico Poison & Drug Information Center, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA
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Ballesteros S, Ramón MF, Martínez-Arrieta R. Ingestions of benzydamine-containing vaginal preparations. Clin Toxicol (Phila) 2009; 47:145-9. [DOI: 10.1080/15563650801938670] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Acutely poisoned children remain a common problem facing pediatricians working in acute care medicine in the United States and worldwide. The management of such children continues to be challenging, and their care has evolved throughout the years. The concept of gastric decontamination in acute poisoning has significantly changed over the past 10 years, and many of the previously used techniques have been abandoned or fallen out of favor for lack of evidence to their benefit or unacceptable serious risks and side effects. Supportive care continues to be the cornerstone in managing most poisoned children. Only a few patients benefit from antidotes or specific interventions.
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Affiliation(s)
- Usama A Hanhan
- Division of Pediatrics, Department of Critical Care Medicine, University Community Hospital, 3100 East Flecher Ave., Tampa, FL 33613, USA.
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Abstract
Toxicologic conditions are encountered in critically ill patients due to intentional or unintentional misuse of or exposure to therapeutic or illicit drugs. Additionally, toxicities related to medical interventions may develop in hospitalized patients. This review focuses on recent developments in the field of critical care toxicology. Early interventions to decrease absorption or enhance elimination of toxins have limited value. Specific interventions to manage toxicities due to analgesics, sedative-hypnotics, antidepressants, antipsychotics, cardiovascular agents, alcohols, carbon monoxide, and cholinergic agents are reviewed. Hospital-acquired toxicities due to methemoglobinemia, propylene glycol, and propofol should be recognized and treated. The clinician is continually required to incorporate clinical judgment along with available scientific data and clinical evidence to determine the best therapy for toxicologic conditions.
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Abstract
Gastrointestinal decontamination has been a historically accepted modality in the emergency management of oral intoxicants. Theoretically, gastric and whole-bowel emptying procedures hinder absorption, remove toxic substances, prevent clinical deterioration, and hasten recovery. This article presents a current overview of gastrointestinal decontamination. It challenges the accepted precepts of gut decontamination and assesses the utility of syrup of ipecac-induced emesis, orogastric lavage, single-dose-activated charcoal, cathartics, and whole-bowel irrigation.
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Bailey B. To Decontaminate or Not to Decontaminate? The Balance Between Potential Risks and Foreseeable Benefits. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2008. [DOI: 10.1016/j.cpem.2007.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Zimmerman JL, Rudis M. Poisonings. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249-81; abstract vii. [PMID: 17482020 DOI: 10.1016/j.emc.2007.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Toxic overdose can present with various clinical signs and symptoms. These may be the only clues to diagnosis when the cause of toxicity is unknown at the time of initial assessment. The prognosis and clinical course of recovery of a patient poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency setting. Usually the drug or toxin can be quickly identified by a careful history, a directed physical examination, and commonly available laboratory tests. Once the patient has been stabilized, the physician must consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary.
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Affiliation(s)
- Timothy B Erickson
- Department of Emergency Medicine, Division of Clinical Toxicology, University of Illinois at Chicago, Toxikon Consortium, Chicago, IL 60612, USA.
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Abstract
Patients presenting to the emergency department (ED) after medication overdose are often given activated charcoal initially for gastrointestinal decontamination. Complications of charcoal are rare, but do occur. The following case describes a patient with pre-existing undiagnosed diverticular disease who developed sigmoid perforation after a single dose of activated charcoal, given without cathartic for a drug overdose. A literature search revealed no other cases of bowel perforation associated with single-dose activated charcoal. This case report discusses adverse effects associated with activated charcoal and the role of cathartics in gastrointestinal decontamination.
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Affiliation(s)
- Jason P Green
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
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24
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Aggarwal C, Gupta S. Case 24-2006: a woman with hypotension after an overdose of amlodipine. N Engl J Med 2006; 355:1936; author reply 1937-8. [PMID: 17079775 DOI: 10.1056/nejmc062395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chen ML, Straughn AB, Sadrieh N, Meyer M, Faustino PJ, Ciavarella AB, Meibohm B, Yates CR, Hussain AS. A Modern View of Excipient Effects on Bioequivalence: Case Study of Sorbitol. Pharm Res 2006; 24:73-80. [PMID: 17048115 DOI: 10.1007/s11095-006-9120-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 07/12/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE To examine the effect of common excipients such as sugars (sorbitol versus sucrose) on bioequivalence between pharmaceutical formulations, using ranitidine and metoprolol as model drugs. METHODS Two single-dose, replicated, crossover studies were first conducted in healthy volunteers (N=20 each) to compare the effect of 5 Gm of sorbitol and sucrose on bioequivalence of 150 mg ranitidine or 50 mg metoprolol in aqueous solution, followed by a single-dose, nonreplicated, crossover study (N=24) to determine the threshold of sorbitol effect on bioequivalence of 150 mg ranitidine in solution. RESULTS Ranitidine Cmax and AUC0-infinity were decreased by approximately 50% and 45%, respectively, in the presence of sorbitol versus sucrose. Similarly, sorbitol reduced metoprolol Cmax by 23% but had no significant effect on AUC0-infinity. An appreciable subject-by-formulation interaction was found for ranitidine Cmax and AUC0-infinity, as well as metoprolol Cmax. Sorbitol decreased the systemic exposure of ranitidine in a dose-dependent manner and affected bioequivalence at a level of 1.25 Gm or greater. CONCLUSIONS As exemplified by sorbitol, some common excipients have unexpected effect on bioavailability/bioequivalence, depending on the pharmacokinetic characteristics of the drug, as well as the type and amount of the excipient present in the formulation. More research is warranted to examine other 'common' excipients that may have unintended influence on bioavailability/bioequivalence.
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Affiliation(s)
- M-L Chen
- Office of Pharmaceutical Science, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Avenue Building 21, Rm. 3644, Silver Spring, Maryland 20993-0002, USA.
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Soar J, Deakin CD, Nolan JP, Abbas G, Alfonzo A, Handley AJ, Lockey D, Perkins GD, Thies K. European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resuscitation 2006; 67 Suppl 1:S135-70. [PMID: 16321711 DOI: 10.1016/j.resuscitation.2005.10.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kreislaufstillstand unter besonderen Umständen. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mikhalovsky S, Nikolaev V. Chapter 11 Activated carbons as medical adsorbents. INTERFACE SCIENCE AND TECHNOLOGY 2006. [DOI: 10.1016/s1573-4285(06)80020-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Abstract
Pediatric toxic ingestions are treated commonly by pediatricians and emergency physicians. Significant injury after these ingestions is infrequent, but identifying the dangerous ingestion is sometimes a difficult task. By performing a detailed history, focused physical examination, and directed laboratory evaluation, an estimation of risk can be developed. This article introduced the term "toxic triage" to describe this process. The toxic triage estimation allows the clinician to make thoughtful decontamination and treatment decisions. Familiarity with the literature supporting or refuting each decontamination method allows educated decisions to be made. Supportive care is an integral part of treatment for all poisonings, from asymptomatic to life-threatening. Most antidotes are used rarely in clinical practice, but familiarity with common antidotes benefits those patients with specific hazardous ingestions. Prevention efforts have the potential to decrease the incidence of pediatric poisonings. The universal poison control center number provided should be distributed and posted in homes, clinics, and emergency departments.
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Affiliation(s)
- J Dave Barry
- Medical Toxicology Consulation Service, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA.
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Brent J. 2005 Louis Roche Lecture, Professional Societies and Evidence-Based Clinical Toxicology Delivered at the XXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists Berlin, Germany. Clin Toxicol (Phila) 2005; 43:881-6. [PMID: 16440519 DOI: 10.1080/15563650500357644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jeffrey Brent
- Toxicology Associates/NewFields, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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