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Zwaag SM, van den Hengel-Koot IS, Baker S, Druwé P, Elhadi M, Dufol AF, Forsberg S, Halacli B, Jung C, Laubner Sakalauskienė G, Lindqvist E, Moreno R, Rabe C, Reiter N, Rezar R, Țincu R, Topeli A, Wood DM, de Lange DW, Hunault CC. The INTOXICATE study: methodology and preliminary results of a prospective observational study. Crit Care 2024; 28:316. [PMID: 39334221 DOI: 10.1186/s13054-024-05096-7] [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: 06/22/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND There is currently no practice-based, multicenter database of poisoned patients admitted to intensive care units (ICUs). The INTOXICATE study, endorsed by the ESICM and EAPCCT, aimed to determine the rate of eventful admissions among acutely intoxicated adult ICU patients. METHODS Ethical approval was obtained for this multicenter, prospective observational study, and data-sharing agreements were signed with each participating center. An electronic case report form was used to collect data on patient demographics, exposure, clinical characteristics, investigations, treatment, and in-hospital mortality data. The primary outcome, 'eventful admission', was a composite outcome defined as the rate of patients who received any of the following treatments in the first 24 h after the ICU admission: oxygen supplementation with a FiO2 > 40%, mechanical ventilation, vasopressors, renal replacement therapy (RRT), cardiopulmonary resuscitation, antidotes, active cooling, fluid resuscitation (> 1.5 L of intravenous fluid of any kind), sedation, or who died in the hospital. RESULTS Seventy-eight ICUs, mainly from Europe, but also from Australia and the Eastern Mediterranean, participated. A total of 2,273 patients were enrolled between November 2020 and June 2023. The median age of the patients was 41 years, 72% were exposed to intoxicating drugs. The observed rate of patients with an eventful ICU admission was 68% (n = 1546/2273 patients). The hospital mortality was 4.5% (n = 103/2273). CONCLUSIONS The vast majority of patients survive, and approximately one third of patients do not receive any ICU-specific interventions after admission in an intensive care unit for acute intoxication. High-quality detailed clinical data have been collected from a large cohort of acutely intoxicated ICU patients, providing information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of these patients. TRIAL REGISTRATION OSF registration ID: osf.io/7e5uy.
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Affiliation(s)
- Samanta M Zwaag
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Stuart Baker
- Intensive Care Unit, Redcliffe Hospital, Redcliffe, QLD, Australia
| | - Patrick Druwé
- Intensive Care, Ghent University Hospital, Ghent, Belgium
| | | | - Ana Ferrer Dufol
- Unit of Clinical Toxicology, Clinic University Hospital, Saragossa, Spain
| | - Sune Forsberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden
| | - Burcin Halacli
- Medical Intensive Care Unit, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Christian Jung
- Klinik Für Kardiologie, Pneumologie Und Angiologie Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | - Elin Lindqvist
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden
| | - Rui Moreno
- Hospital de São José, Unidade Local de Saúde de São José, Lisboa, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Christian Rabe
- Department of Clinical Toxicology, Klinikum Rechts Der Isar, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Nanna Reiter
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Danish Poison Information Center, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Richard Rezar
- Department of Cardiology and Intensive Care, Clinic of Internal Medicine II, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Radu Țincu
- Bucharest Emergency Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Arzu Topeli
- Medical Intensive Care Unit, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners and King's College London, London, UK
| | - Dylan W de Lange
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Claudine C Hunault
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands.
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Salek A, Selmi M, Njim L, Umek P, Mejanelle P, Moussa F, Douki W, Hosni K, Baati T. Titanate nanotubes as an efficient oral detoxifying agent against drug overdose: application in rat acetaminophen poisoning. NANOSCALE ADVANCES 2023; 5:2950-2962. [PMID: 37260481 PMCID: PMC10228339 DOI: 10.1039/d2na00874b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/22/2023] [Indexed: 06/02/2023]
Abstract
Voluntary drug intoxication is mainly due to drug overdose or the interaction of several drugs. Coma and its associated complications such as hypoventilation, aspiration pneumopathy, and heart rhythm disorders are the main hallmarks of drug intoxication. Conventional detoxification treatments, including gastric lavage or vomiting, administration of ipecac or activated charcoal (CH), and the use of antidotes, have proven to be inefficient and are generally associated with severe adverse effects. To overcome these limitations, titanate nanotubes (TiNTs) are proposed as an efficient emerging detoxifying agent because of their tubular shape and high adsorption capacity. In the present study, the detoxifying ability of TiNTs was evaluated on paracetamol (PR)-intoxicated rats. Results indicate that the loading ability of PR into TiNTs (70%) was significantly higher than that recorded for CH (38.6%). In simulated intestinal medium, TiNTs showed a controlled drug release of less than 10% after 72 h of incubation. In PR-intoxicated rats, TiNTs treatment resulted in a 64% decrease of PR after 4 h of poisoning versus 40% for CH. Concomitantly, TiNTs efficiently reduced PR absorption by 90% after 24 h of poisoning, attenuated the elevated levels of biochemical markers (i.e., alanine aminotransferase, aspartate aminotransferase, creatinine, and TNF-α) and mitigated oxidative stress by increasing the activity of superoxide dismutase and reducing the oxidized glutathione/total glutathione ratio, suggesting a histoprotective effect of TiNTs against paracetamol-induced toxicity in rats. In addition to their safety and high stability in the entire gastro-intestinal tract, biodistribution analysis revealed that TiNTs exhibited low intestinal absorption owing to their large cluster size of compact aggregate nanomaterials across the intestinal villi hindering the absorption of paracetamol. Collectively, these data provide a new and promising solution for in vivo detoxification. TiNTs are expected to have great potential for the treatment of voluntary and accidental intoxication in emergency care.
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Affiliation(s)
- Abir Salek
- Laboratoire des Substances Naturelles, Institut National de Recherche et d'Analyse Physico-chimique, Biotechpôle Sidi Thabet 2020 Tunisia +216 71 537 688 +216 71 537 666
| | - Mouna Selmi
- Laboratoire des Substances Naturelles, Institut National de Recherche et d'Analyse Physico-chimique, Biotechpôle Sidi Thabet 2020 Tunisia +216 71 537 688 +216 71 537 666
| | - Leila Njim
- Service d'Anatomie Pathologique, EPS Fattouma Bourguiba de Monastir, Faculté de Médecine de Monastir, Université de Monastir 5000 Monastir Tunisia
| | - Polona Umek
- Jožef Stefan Institute Jamova cesta 39 SI-1000 Ljubljana Slovenia
| | - Philippe Mejanelle
- Département de chimie, IUT d'Orsay, Université Paris-Saclay 91190 Gif-sur-Yvette France
| | - Fathi Moussa
- Institut de Chimie Physique, CNRS UMR 8000, Université Paris-Saclay 91190 Gif-sur-Yvette France
| | - Wahiba Douki
- Laboratoire de Biochimie et de Toxicologie, EPS Fattouma Bourguiba de Monastir, Université de Monastir 5000 Monastir Tunisia
| | - Karim Hosni
- Laboratoire des Substances Naturelles, Institut National de Recherche et d'Analyse Physico-chimique, Biotechpôle Sidi Thabet 2020 Tunisia +216 71 537 688 +216 71 537 666
| | - Tarek Baati
- Laboratoire des Substances Naturelles, Institut National de Recherche et d'Analyse Physico-chimique, Biotechpôle Sidi Thabet 2020 Tunisia +216 71 537 688 +216 71 537 666
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Wiersma T, van den Oever HLA, van Hout FJHA, Twijnstra MJ, Mauritz GJ, van 't Riet E, Jansman FGA. The performance of COBRA, a decision rule to predict the need for intensive care interventions in intentional drug overdose. Eur J Emerg Med 2022; 29:126-133. [PMID: 34560700 DOI: 10.1097/mej.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND COBRA was developed as a decision rule to predict which patients visiting the emergency department (ED) following intentional drug overdose will not require intensive care unit (ICU) interventions. COBRA uses parameters from five vital systems (cardiac conduction, oxygenation, blood pressure, respiration, and awareness) that are readily available in the ED. COBRA recommends against ICU admission when all these parameters are normal. OBJECTIVE The primary aim of this study was to determine the negative predictive value (NPV) of COBRA in predicting ICU interventions. Secondary outcomes were the sensitivity, specificity and positive predictive value (PPV), and the observation time required for a reliable prediction. DESIGN Observational cohort study. SETTINGS AND PARTICIPANTS Patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function were included, and data necessary to complete the decision rule was collected. The attending physician in the ED made the actual admission decision, on the basis of clinical judgement. COBRA was measured 0, 3 and 6 h after arrival at the ED. OUTCOME MEASURES Need for ICU interventions (treatment of convulsion; defibrillation; mechanical or noninvasive ventilation; intravenous administration of vasopressive agents, antiarrhythmics, atropine, calcium, magnesium or sedation; continuous hemofiltration or administration of antagonist/antidote and fluid resuscitation). MAIN RESULTS Of 230 new cases (144 unique patients), 59 were immediately referred to the psychiatric services and/or sent home by the attending physician, 27 went to a regular ward, and 144 were admitted to the ICU. Of these 144 cases, 40 required one or more ICU interventions. By the time the first parameters were collected, the NPV of COBRA was 95.6%. After 3 h of observation, NPV was 100%, while sensitivity, specificity and PPV were 100, 61.1 and 35.1%, respectively. None of these values improved by prolonging the observation time to 6 h. CONCLUSION In patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function, the COBRA decision rule showed good performances in predicting the need for intensive care interventions, with a NPV of 100% after 3 h of observation.
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Affiliation(s)
| | | | | | | | - Gert-Jan Mauritz
- Department of Emergency Medicine, Rijnstate Teaching Hospital, Arnhem
| | | | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Deventer
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Groningen, The Netherlands
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Park SY, Kim K, Woo SH, Park JT, Jeong S, Kim J, Hong S. Artificial neural network approach for acute poisoning mortality prediction in emergency departments. Clin Exp Emerg Med 2021; 8:229-236. [PMID: 34649411 PMCID: PMC8517465 DOI: 10.15441/ceem.20.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/20/2020] [Accepted: 10/29/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The number of deaths due to acute poisoning (AP) is on the increase. It is crucial to predict AP patient mortality to identify those requiring intensive care for providing appropriate patient care as well as preserving medical resources. The aim of this study is to predict the risk of in-hospital mortality associated with AP using an artificial neural network (ANN) model. METHODS In this multicenter retrospective study, ANN and logistic regression models were constructed using the clinical and laboratory data of 1,304 patients seeking emergency treatment for AP. The ANN model was first trained on 912/1,304 (70%) randomly selected patients and then tested on the remaining 392/1,304 (30%). Receiver operating characteristic curve analysis was used to evaluate the mortality prediction of the two models. RESULTS Age, endotracheal intubation status, and intensive care unit admission were significant predictors of mortality in patients with AP in the multivariate logistic regression model. The ANN model indicated age, Glasgow Coma Scale, intensive care unit admission, and endotracheal intubation status were critical factors among the 12 independent variables related to in-hospital mortality. The area under the receiver operating characteristic curve for mortality prediction was significantly higher in the ANN model compared to the logistic regression model. CONCLUSION This study establishes that the ANN model could be a valuable tool for predicting the risk of death following AP. Thus, it may facilitate effective patient triage and improve the outcomes.
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Affiliation(s)
- Seon Yeong Park
- Department of Emergency Medicine, Daejeon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | | | - Seon Hee Woo
- Department of Emergency Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Jung Taek Park
- Department of Emergency Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Sikyoung Jeong
- Department of Emergency Medicine, Daejeon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Jinwoo Kim
- Department of Emergency Medical Service, Daejeon Health Institute of Technology, Daejeon, Korea
| | - Sungyoup Hong
- Department of Emergency Medicine, Daejeon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
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Elgazzar FM, Afifi AM, Shama MAE, Askary AE, El-Sarnagawy GN. Development of a risk prediction nomogram for disposition of acute toxic exposure patients to intensive care unit. Basic Clin Pharmacol Toxicol 2021; 129:256-267. [PMID: 34117718 DOI: 10.1111/bcpt.13619] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022]
Abstract
Early risk stratification of acutely poisoned patients is essential to identify patients at high risk of intensive care unit (ICU) admission. We aimed to develop a prognostic model and risk-stratification nomogram based on the readily accessible clinical and laboratory predictors on admission for the probability of ICU admission in acutely poisoned patients. This retrospective cohort study included adult patients with acute toxic exposure to a drug or a chemical substance. Patients' demographic, toxicologic, clinical and laboratory data were collected. Among the 1260 eligible patients, 180 (14.3%) were admitted to the ICU. We developed a generalized prognostic model for predicting ICU admission in patients with acute poisoning. The predictors included the Glasgow coma scale, oxygen saturation, diastolic blood pressure, respiratory rate and blood bicarbonate concentration. The model displayed excellent discrimination and calibration (optimistic-adjusted area under the curve = 0.924 and optimistic-adjusted Hosmer and Lemeshow test = 0.922, respectively) when internally validated. Additionally, we developed prognostic models that determine ICU admission in patients with specific poisonings. Furthermore, we constructed risk-stratification nomograms that rank the probability of ICU admission in these patients. The developed risk-stratification nomograms help decision-making regarding ICU admission in acute poisonings. Future external validation in independent cohorts is necessary before clinical application.
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Affiliation(s)
- Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed M Afifi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abd Elhady Shama
- Emergency Medicine and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmad El Askary
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Ghada N El-Sarnagawy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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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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Resiere D, Kallel H, Oxybel O, Chabartier C, Florentin J, Brouste Y, Gueye P, Megarbane B, Mehdaoui H. Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes. TOXICS 2020; 8:toxics8020028. [PMID: 32283693 PMCID: PMC7356022 DOI: 10.3390/toxics8020028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/27/2022]
Abstract
The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients. METHODS A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité. RESULTS During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients. CONCLUSIONS Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.
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Affiliation(s)
- Dabor Resiere
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
- Correspondence: ; Tel.: +1-(596)-6-9620-3184
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital; 97300 Cayenne, French Guiana,
| | - Odile Oxybel
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Cyrille Chabartier
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
| | - Jonathan Florentin
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Yannick Brouste
- Department of Emergency Medicine, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (J.F.); (Y.B.)
| | - Papa Gueye
- Emergency Medical Services (Service d’aide médicale d’urgence 972), 97261 Martinique, France;
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMR-S 1144, 75013 Paris, France;
| | - Hossein Mehdaoui
- Intensive Care Unit, University Hospital of Martinique, Fort-de-France, 97261 Martinique, France; (O.O.); (C.C.); (H.M.)
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 1: epidemiology, methodology and general overview. Biomarkers 2019; 25:9-19. [PMID: 31735069 DOI: 10.1080/1354750x.2019.1694994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute intoxications account for a significant proportion of the patient population in intensive care units and sedative medications, ethanol, illicit drugs, inhalable poisons and mixed intoxications are the most common causes. The aim of this article is to describe biomarkers for screening and diagnosis of acute intoxications in critically ill patients. For this purpose, a survey of the relevant literature was conducted, and guidelines, case reports, expert assessments, and scientific publications were reviewed. In critical care, it should always be attempted to identify and quantify the poison or toxin with the assistance of enzyme immunoassay (EIA), chromatography, and mass spectrometry techniques and this section is critically appraised in this publication. The principles for anion gap, osmol gap and lactate gap and their usage in intoxications is shown. Basic rules in test methodology and pre-analytics are reviewed. Biomarkers in general are presented in part one and biomarkers for specific intoxications including ethanol, paracetamol, cardiovascular drugs and many others are presented in part two of these publications.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, Laribi S, N-Gueye P, Joly LM, Dumas F, Beaune S. Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France. Intern Emerg Med 2019; 14:981-988. [PMID: 31104303 DOI: 10.1007/s11739-019-02108-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.
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Affiliation(s)
- Maxime Maignan
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France.
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Nathan Vejux
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Eric Wiel
- Emergency Department and SAMU 59, Lille University Hospital, Inserm UMR1011 and UDSL, Institut Pasteur de Lille, EGID, Lille, France
| | - Laurent Jacquin
- Emergency Department, Hospices Civiles de Lyon, Lyon, France
| | - Said Laribi
- Emergency Department, Tours University Hospital, 37044, Tours, France
- INSERM, U942, BIOmarkers in CArdioNeuroVAScular Diseases, Paris, France
| | - Papa N-Gueye
- Emergency Department, APHP Hôpital Lariboisière, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Charles Nicolle Hospital, Rouen, France
| | - Florence Dumas
- Emergency Department, APHP Hôpital Cochin, Sudden Death Expertise Center, Paris Cardiovascular Research Center, INSERM Unit 970, Paris, France
| | - Sebastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, APHP, University Paris Diderot, INSERM UMR-S 1144, Paris, France
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Parish S, Carter A, Liu YH, Humble I, Trott N, Jacups S, Little M. The impact of the introduction of a toxicology service on the intensive care unit. Clin Toxicol (Phila) 2019; 57:778-783. [PMID: 30729819 DOI: 10.1080/15563650.2019.1566553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.
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Affiliation(s)
- Shaun Parish
- a Royal North Shore Hospital, formerly Cairns Hospital , Saint Leonards , Sydney , Australia
| | - Angus Carter
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia.,c DonateLife QLD.,d School of Medicine and Dentistry, James Cook University , Cairns , Australia
| | - Yu-Hsuan Liu
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Ian Humble
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Nicholas Trott
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Susan Jacups
- e The Cairns Institute, James Cook University (JCU) , Cairns , Australia
| | - Mark Little
- f Department of Emergency Medicine, Cairns Hospital , Cairns , Australia.,g NSW Poisons Information Centre , Sydney , Australia
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Patel MM, Travers CD, Stockwell JA, Numur EA, Geller RJ, Kamat PP, Grunwell JR. Reducing Childhood Admissions to the PICU for Poisoning (ReCAP2) by Predicting Unnecessary PICU Admissions After Acute Intoxication. Pediatr Crit Care Med 2018; 19:e120-e129. [PMID: 29227437 PMCID: PMC6298737 DOI: 10.1097/pcc.0000000000001410] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To derive and validate clinical prediction models to identify children at low risk of clinically significant intoxications for whom intensive care admission is unnecessary. DESIGN Retrospective review of data in the National Poison Data Systems from 2011 to 2014 and Georgia Poison Center cases from July to December 2016. SETTING United States PICUs and poison centers participating in the American Association of Poison Control Centers from 2011 to 2016. PATIENTS Children 18 years and younger admitted to a United States PICU following an acute intoxication. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary study outcome was the occurrence of clinically significant intoxications defined a priori as organ system-based clinical effects that require intensive care monitoring and interventions. We analyzed 70,364 cases. Derivation (n = 42,240; 60%) and validation cohorts (n = 28,124; 40%) were randomly selected from the eligible population and had similar distributions of clinical effects and PICU interventions. PICU interventions were performed in 1,835 children (14.1%) younger than 6 years, in 374 children (15.4%) 6-12 years, and in 4,446 children (16.5%) 13 years and older. We developed highly predictive models with an area under the receiver operating characteristic curve of 0.834 (< 6 yr), 0.771 (6-12 yr), and 0.786 (≥13 yr), respectively. For predicted probabilities of less than or equal to 0.10 in the validation cohorts, the negative predictive values were 95.4% (< 6 yr), 94.9% (6-12 yr), and 95.1% (≥ 13 yr). An additional 700 patients from the Georgia Poison Center were used to validate the model and would have reduced PICU admission by 31.4% (n = 110). CONCLUSIONS These validated models identified children at very low risk of clinically significant intoxications for whom pediatric intensive care admission can be avoided. Application of this model using Georgia Poison Center data could have resulted in a 30% reduction in PICU admissions following intoxication.
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Affiliation(s)
- Meral M Patel
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Curtis D Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Emory+Children's Pediatric Research Biostatistics Core, Atlanta, GA
| | - Jana A Stockwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Ezaldeen A Numur
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Georgia Poison Center, Atlanta, GA
| | - Robert J Geller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Georgia Poison Center, Atlanta, GA
| | - Pradip P Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Jocelyn R Grunwell
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
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Lindqvist E, Edman G, Hollenberg J, Nordberg P, Ösby U, Forsberg S. Intensive care admissions due to poisoning. Acta Anaesthesiol Scand 2017; 61:1296-1304. [PMID: 28990178 DOI: 10.1111/aas.13005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 09/11/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients. METHOD A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register). RESULTS The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P < 0.01). CONCLUSION In Sweden, patients treated in the ICU due to poisoning represent a fifth of all poisoned patients seeking medical care. Older men with no previous poisoning were considered a high-risk group.
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Affiliation(s)
- E. Lindqvist
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - G. Edman
- Department of Clinical Sciences; Danderyd Hospital; Karolinska Institutet; Stockholm Sweden
- Department of Psychiatry; Norrtälje Hospital; Norrtälje Sweden
| | - J. Hollenberg
- Karolinska Institutet; Department of Medicine; Centre for Resuscitation Science; Stockholm Sweden
| | - P. Nordberg
- Karolinska Institutet; Department of Medicine; Centre for Resuscitation Science; Stockholm Sweden
| | - U. Ösby
- Center for Molecular Medicine; Karolinska University Hospital Solna; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Center for Family Medicine; Karolinska Institutet; Stockholm Sweden
| | - S. Forsberg
- Department of Anaesthesiology and Intensive Care; Norrtälje Hospital; Norrtälje Sweden
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
- Swedish Poisons Information Centre; Stockholm Sweden
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13
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Abstract
OBJECTIVES Acute intoxications in children account for 4.6% of annual admissions to the PICU. We aimed to describe the interventions and monitoring required for children admitted to the PICU following intoxications with the ultimate goal of determining patient and intoxication characteristics associated with the need for PICU interventions. DESIGN Retrospective review of prospectively collected data from Virtual Pediatric Systems, LLC. SETTING United States PICUs participating in the Virtual Pediatric Systems database from 2011 to 2014. PATIENTS Less than or equal to 18 years old admitted to a PICU with a diagnostic code for poisoning, ingestion, intoxication, or overdose. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 12,021 patients were included with a median PICU length of stay of 0.97 days (interquartile range, 0.67-1.60). Seventy-eight percent of the intoxications were intentional. The top five classes of medications ingested were unknown substances (21.6%), antidepressants (11.5%), other chemicals (10.7%), analgesics (7.3%), and antihypertensives (6.2%). Seventy-six (0.61%) patients died. Any of the interventions reported in the Virtual Pediatric Systems database were performed in only 29.1% of the total cases. CONCLUSIONS The majority of cases (70.9%) admitted to the PICU following an intoxication did not undergo any significant intervention. Future studies should focus on distinguishing patient and intoxication characteristics associated with need for PICU intervention to optimize patient safety and minimize resource burden.
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14
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Ichikura K, Okumura Y, Takeuchi T. Associations of Adverse Clinical Course and Ingested Substances among Patients with Deliberate Drug Poisoning: A Cohort Study from an Intensive Care Unit in Japan. PLoS One 2016; 11:e0161996. [PMID: 27560966 PMCID: PMC4999209 DOI: 10.1371/journal.pone.0161996] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/16/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives Some patients with deliberate drug poisoning subsequently have an adverse clinical course. The present study aimed to examine whether the type of drugs ingested and psychiatric diagnoses were related to an adverse clinical course. Methods We conducted a cohort study of patients with deliberate drug poisoning admitted to the intensive care unit of a university hospital located in Tokyo, Japan, between September 2006 and June 2013. Intensive care unit (ICU) stay of ≥4 days was used as a primary outcome measure, while the incidence of aspiration pneumonitis was used as a secondary outcome measure. Ingested substances and psychiatric diagnoses were used as explanatory variables. Results Of the 676 patients with deliberate drug poisoning, 88% had a history of psychiatric treatment and 82% had ingested psychotropic drugs. Chlorpromazine-promethazine-phenobarbital combination drug (Vegetamin®) ranked fifth among the most frequently ingested substances in cases of deliberate drug poisoning and had the highest incidence of prolonged ICU stay (20%) and aspiration pneumonitis (29%). The top three major classes consisted of benzodiazepines (79%), new-generation antidepressants (25%), and barbiturates/non-barbiturates (23%). Barbiturate overdose was independently associated with increased odds of both prolonged ICU stay (8% vs. 17%; odds ratio [OR], 2.97; 95% confidence interval [CI], 1.60–5.55) and aspiration pneumonitis (8% vs. 24%; OR, 3.83; 95% CI, 2.18–6.79) relative to those associated with overdose of only other sedative-hypnotics (i.e., benzodiazepines). Conclusion These results suggest that judicious prescribing of barbiturates by psychiatrists could reduce the risk of an adverse clinical course when a patient attempts an overdose.
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Affiliation(s)
- Kanako Ichikura
- Section of Liaison Psychiatry and Palliative Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | - Yasuyuki Okumura
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
- * E-mail:
| | - Takashi Takeuchi
- Section of Psychiatry and Behavioral Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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15
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Lionte C, Sorodoc V, Tuchilus C, Cimpoiesu D, Jaba E. Biomarkers, lactate, and clinical scores as outcome predictors in systemic poisons exposures. Hum Exp Toxicol 2016; 36:651-662. [PMID: 27457800 DOI: 10.1177/0960327116660866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute exposure to systemic poisons represents an important challenge in clinical toxicology. We aimed to analyze the potential role of cardiac biomarkers, routine laboratory tests, and clinical scores as morbidity and in-hospital mortality predictors in patients intoxicated with various systemic poisons. We conducted a prospective study on adults acutely exposed to systemic poisons. We determined the PSS, Glasgow Coma Scale (GCS), and we performed electrocardiogram, laboratory tests, lactate and cardiac biomarkers (which were reassessed 4 h, respectively 6 h later). Of 120 patients included, 45% developed complications, 19.2% had a poor outcome, and 5% died. Multivariate logistic regression sustained lactate (odds ratio (OR) 1.58; confidence interval (CI) 95%: 0.97-2.59; p 0.066), MB isoenzyme of creatine kinase (6h-CKMB; OR 1.08; CI 95%: 1.02-1.16; p 0.018) as predictors for a poor outcome. A GCS < 10 (OR 0.113; CI 95%: 0.019-0.658; p 0.015) and 4h-lactate (OR 4.87; CI 95%: 0.79-29.82; p 0.087) predicted mortality after systemic poisons exposure. Receiver operating characteristic analysis showed that brain natriuretic peptide (area under the curve (AUC), 0.96; CI 95%: 0.92-0.99; p < 0.001), lactate (AUC, 0.91; CI 95%: 0.85-0.97; p < 0.001), and 6h-CKMB have good discriminatory capacity for predicting a poor outcome. In conclusion, these biomarkers, lactate, and GCS can be used to predict morbidity and mortality after systemic poisons exposure.
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Affiliation(s)
- C Lionte
- 1 Second Medical Clinic, "Sf. Spiridon" Emergency Clinical County Hospital, Iasi, Romania.,2 "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - V Sorodoc
- 1 Second Medical Clinic, "Sf. Spiridon" Emergency Clinical County Hospital, Iasi, Romania.,2 "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - C Tuchilus
- 2 "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,3 Central Laboratory, "Sf. Spiridon" Emergency Clinical County Hospital, Iasi, Romania
| | - D Cimpoiesu
- 2 "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,4 Department of Emergency Medicine, "Sf. Spiridon" Emergency Clinical County Hospital, Iasi, Romania
| | - E Jaba
- 5 Department of Statistics, FEAA, "Al. I. Cuza" University, Iasi, Romania
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Sorge M, Weidhase L, Bernhard M, Gries A, Petros S. Self-poisoning in the acute care medicine 2005-2012. Anaesthesist 2016; 64:456-62. [PMID: 25951922 DOI: 10.1007/s00101-015-0030-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the trend of acute self-poisoning in the emergency and intensive care. METHODS Electronic charts of adults who presented to the emergency department of the University Hospital Leipzig with self-poisoning following a suicide attempt (suicide group), intoxication (intoxication group), drug overdose for relief of pain or discomfort (drug overdose group) between 2005 and 2012 were analyzed. RESULTS 3533 adults (62.6% males) were identified, with the yearly admissions increasing from 305 in 2005 to 624 in 2012. The admission rate in relation to the total emergency department admissions also increased, from 1.2% in 2005 to 1.9% in 2012. 31.7% of the patients were younger than 25 years. The reasons for self-poisoning were suicide attempt (18.1%), intoxication (76.8%) and drug overdose (2.9%). The reason could not be clearly classified in 80 patients. Psychotropic drugs were used in 71.6% of suicide attempts, while alcohol was the sole cause of intoxication in 80.1% of cases in the intoxication group. Self-poisoning using at least two substances was observed in 52.0% of the suicide attempts, 10.3% of those with intoxication and 29.7% of those with drug overdose. While alcohol remains the most common cause of intoxication, there was a drastic increase in the consumption of cannabinoids, Crystal Meth and gamma-hydroxybutyrate in the years 2011 and 2012. ICU admission was necessary in 16.6% of the cases. There were 22 deaths (0.6% of the study population), of whom 15 were in the suicide group (2.3%), four (0.15%) in the intoxication group, and three in the not clearly classified group (3.8%). CONCLUSION Acute self-poisoning is an increasing medical issue. Psychotropic drugs remain the most common means of suicide attempt. Although alcohol intoxication is very frequent, intake of illicit drugs as the cause of emergency admission is increasing.
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Affiliation(s)
- M Sorge
- Medical Intensive Care Unit, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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17
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Viglino D, Bourez D, Collomb-Muret R, Schwebel C, Tazarourte K, Dumanoir P, Paquier C, Danel V, Debaty G, Maignan M. Noninvasive End Tidal CO2 Is Unhelpful in the Prediction of Complications in Deliberate Drug Poisoning. Ann Emerg Med 2016; 68:62-70.e1. [PMID: 26810758 DOI: 10.1016/j.annemergmed.2015.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE We study the performance of capnometry in the detection of early complications after deliberate drug poisoning. METHODS This was a prospective cohort study of self-poisoned adult patients who presented at an emergency department (ED) between April 20, 2012, and May 6, 2014. Patients who ingested at least 1 neurologic or respiratory depressant drug were included. The primary outcome was the predictive value of an end tidal CO2 (etco2) measurement greater than or equal to 50 mm Hg for the detection of early complications defined a priori by hypoxia requiring oxygen greater than or equal to 3 L/min, bradypnea less than or equal to 10 breaths/min, or ICU admission after intubation or antidote administration because of unresponsiveness to pain or respiratory arrest. Consciousness scales and clinical data were recorded at admission and every 30 minutes. Noninvasive etco2 was continuously measured for 2 hours after inclusion unless the patient was admitted to the ICU. Patients and physicians were blinded to etco2 values. RESULTS Two hundred one patients were included, 35 of whom exhibited at least 1 complication. An etco2 measurement greater than or equal to 50 mm Hg predicted the onset of a complication, with a sensitivity of 46% (95% confidence interval [CI] 29% to 63%) and a specificity of 80% (95% CI 73% to 86%), leading to a positive predictive value of 33% (95% CI 20% to 48%) and a negative predictive value of 88% (95% CI 81% to 92%). etco2 was less able to predict complications than the Glasgow Coma Scale score at inclusion. CONCLUSION Capnometry in isolation does not provide adequate prediction of early complications in self-poisoned patients referred to the ED. A dynamic minute-by-minute assessment of etco2 could be more predictive.
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Affiliation(s)
- Damien Viglino
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; INSERM U1042, HP2 Laboratory, University Grenoble Alps, Grenoble, France
| | - Delphine Bourez
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Roselyne Collomb-Muret
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Carole Schwebel
- University Grenoble Alps-Medical Intensive Care Unit, CHU Michallon, Grenoble, France
| | | | - Perrine Dumanoir
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Carole Paquier
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Vincent Danel
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France
| | - Guillaume Debaty
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; CNRS UMR 5525, TIMC-IMAG Laboratory, Team PRETA, University Grenoble Alps, Grenoble, France
| | - Maxime Maignan
- University Grenoble Alps-Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; CNRS UMR 5525, TIMC-IMAG Laboratory, Team PRETA, University Grenoble Alps, Grenoble, France.
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Ahuja H, Mathai AS, Pannu A, Arora R. Acute Poisonings Admitted to a Tertiary Level Intensive Care Unit in Northern India: Patient Profile and Outcomes. J Clin Diagn Res 2015; 9:UC01-4. [PMID: 26557594 PMCID: PMC4625313 DOI: 10.7860/jcdr/2015/16008.6632] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/28/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Poisoning is becoming a real health care burden for developing countries like India. An improved knowledge of the patterns of poisonings, as well as the clinical course and outcomes of these cases can help to formulate better preventive and management strategies. AIM To study the demographic and clinical profiles of patients admitted to the ICU with acute poisoning and to study the factors that predict their mortality. MATERIALS AND METHODS Retrospective two years (September 1, 2010 to August 31, 2012) study of all consecutive patients admitted to the Intensive Care Unit (ICU) with acute poisoning at a tertiary care hospital in Northern India. RESULTS Out of the 67 patients admitted to the ICU during the study period, the majority were young (median age 29 years) males (69%) who had consumed poison intentionally. Pesticides were the most commonly employed poison, notably organophosphorus compounds (22 patients, 32.8%) and aluminium phosphide (14 patients, 20.9%). While the overall mortality from all poisonings was low (18%), aluminium phosphide was highly toxic, with a mortality rate of 35%. The factors at ICU admission that were found to be associated with a significant risk of death were, high APACHE II and SOFA scores (p =0.0001 and p=0.006, respectively), as well as the need for mechanical ventilation and drugs for vasoactive support (p=0.012 and p= 0.0001, respectively). CONCLUSION Use of pesticides for intentional poisoning continues to be rampant in Northern India, with many patients presenting in a critical condition to tertiary level hospitals. Pesticide regulations laws, educational awareness, counseling and poison information centers will help to curtail this public health problem.
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Affiliation(s)
- Hemani Ahuja
- Assistant Professor, Department of Anesthesia and Critical Care, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Ashu Sara Mathai
- Professor, Department of Anesthesia and Critical Care, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Aman Pannu
- Biostatistician, Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Rohit Arora
- Consultant Eye Surgeon, Department of Ophthalmology, Dr Rohit Eye Care Hospital, Jagraon, India
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Beaune S, Curis E, Casalino E, Juvin P, Mégarbane B. Do serotonin reuptake inhibitors worsen outcome of patients referred to the emergency department for deliberate multi-drug exposure? Basic Clin Pharmacol Toxicol 2014; 116:372-7. [PMID: 25154631 DOI: 10.1111/bcpt.12311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 08/05/2014] [Indexed: 11/30/2022]
Abstract
Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is considered low, but its actual impact in multi-drug poisonings remains unclear. Our objective was to evaluate the consequences of SRI exposure in patients referred to the emergency department (ED) for deliberate multi-drug exposure. Patients admitted for multi-drug exposure involving at least one SRI were matched with patients who did not ingest any SRI, according to age, gender, type of drug and ingested doses. Features of serotonin syndrome according to Sternbach's criteria and Hunter's serotonin toxicity criteria were evaluated from records. In 4 years, 148 SRI-exposed patients were included and compared to 296 matched controls. The SRIs mainly involved were escitalopram (22%), venlafaxine (20%), fluoxetine (19%), citalopram (15%) and paroxetine (11%). Serotonin syndrome was diagnosed in one patient, but actually occurred in five SRI-exposed patients based on the retrospective evaluation of records. Twenty patients (14%) exhibited one or more serotonin syndrome criteria. At least two of 11 of Sternbach's criteria and two of nine of Hunter's serotonin toxicity criteria were missing in each chart. Using a conditional logistic regression analysis, seizures (p = 0.04) and serotonin syndrome (p = 0.01 based on Sternbach's criteria and p = 0.004 based on Hunter's serotonin toxicity criteria) more frequently occurred in SRI-exposed patients. Requirement for mechanical ventilation was significantly increased (p = 0.03), although admission to the intensive care unit was not. In multi-drug-poisoned patients admitted to the ED, exposure to SRIs significantly increases the risk of seizures and requirement for mechanically ventilation. Diagnosis of serotonin syndrome remains insufficient justifying improved training.
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Affiliation(s)
- Sébastien Beaune
- Inserm, U1144, Paris, France; Paris-Descartes University, UMR-S 1144, Paris, France; Paris-Diderot University, UMR-S 1144, Paris, France; Emergency Department, Ambroise Pare University Hospital, Boulogne, France; Emergency Department, Beaujon University Hospital, Clichy, France
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