Acute poisoning: understanding 90% of cases in a nutshell

Accidental substance-related acute toxicity deaths among youth in Canada: a descriptive analysis of a national chart review study of coroner and medical examiner data

INTRODUCTION

Substance-related acute toxicity deaths (ATDs) are a public health crisis in Canada. Youth are often at higher risk for substance use due to social, environmental and structural factors. The objectives of this study were to understand the characteristics of youth (aged 12-24 years) dying of accidental acute toxicity in Canada and examine the substances contributing to and circumstances surrounding youth ATDs.

METHODS

Data from a national chart review study of coroner and medical examiner data on ATDs that occurred in Canada between 2016 and 2017 were used to conduct descriptive analyses with proportions, mortality rates and proportionate mortality rates. Where possible, youth in the chart review study were compared with youth in the general population and youth who died of all causes, using census data.

RESULTS

Of the 732 youth who died of accidental acute toxicity in 2016-2017, most (94%) were aged 18 to 24 years. Youth aged 20 to 24 who were unemployed, unhoused or living in collective housing were overrepresented among accidental ATDs. Many of the youth aged 12 to 24 who died of accidental acute toxicity had a documented history of substance use. Fentanyl, cocaine and methamphetamine were the most common substances contributing to death, and 38% of the deaths were witnessed or potentially witnessed.

CONCLUSION

The findings of this study point to the need for early prevention and harm reduction strategies and programs that address mental health, exposure to trauma, unemployment and housing instability to reduce the harms of substance use on Canadian youth.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Trends and profiles of acute poisoning cases: a retrospective analysis

Acute poisoning is a significant public health concern. This retrospective study investigates trends in acute poisoning cases and explores the clinical and sociodemographic profiles associated with this condition. Medical data from 859 hospitalized patients diagnosed with acute poisoning between January 2017 and December 2022 were comprehensively analyzed. The descriptive statistical analysis revealed that 360 patients had underlying diseases, with depression being the most prevalent among them. Furthermore, urban areas accounted for 87.2% of the acute poisoning cases, indicating a higher incidence compared to rural areas. The substances implicated in acute poisoning incidents varied, with drugs of abuse being the most common (53.2%), followed by pesticides (22.2%), carbon monoxide (11.8%), and alcohol (5.4%). Suicide attempt/suicide emerged as the leading cause of acute poisoning incidents, accounting for 75.9% of cases, while poisoning accidents predominantly occurred within the home setting. Through chi-square tests, it was determined that risk factors for suicide attempt/suicide included female gender and underlying medical conditions. Temporal analysis showed that the total number of acute poisoning cases increased from 2017 to 2019 and decreased from 2019 to 2022. Notably, suicide-related cases exhibited an upward trend, with suicide attempt/suicide accounting for over 80% of all acute poisoning cases after 2020. This study contributes valuable insights into the trends, profiles, and risk factors associated with acute poisoning cases.

Using a decision tree algorithm to distinguish between repeated supra-therapeutic and acute acetaminophen exposures

BACKGROUND

This study aimed to compare clinical and laboratory characteristics of supra-therapeutic (RSTI) and acute acetaminophen exposures using a predictive decision tree (DT) algorithm.

METHODS

We conducted a retrospective cohort study using the National Poison Data System (NPDS). All patients with RSTI acetaminophen exposure (n = 4,522) between January 2012 and December 2017 were included. Additionally, 4,522 randomly selected acute acetaminophen ingestion cases were included. After that, the DT machine learning algorithm was applied to differentiate acute acetaminophen exposure from supratherapeutic exposures.

RESULTS

The DT model had accuracy, precision, recall, and F1-scores of 0.75, respectively. Age was the most relevant variable in predicting the type of acetaminophen exposure, whether RSTI or acute. Serum aminotransferase concentrations, abdominal pain, drowsiness/lethargy, and nausea/vomiting were the other most important factors distinguishing between RST and acute acetaminophen exposure.

CONCLUSION

DT models can potentially aid in distinguishing between acute and RSTI of acetaminophen. Further validation is needed to assess the clinical utility of this model.

Outcome of burn injury and associated factor among patient visited at Addis Ababa burn, emergency and trauma hospital: a two years hospital-based cross-sectional study

BACKGROUND

Burn is one of the critical health problems worldwide. Developing countries with sub-Saharan and Asian populations are affected more. Its mortality and non-fatal complications depend on several factors including age, sex, residency, cause, the extent of the burn, and time and level of care given.

OBJECTIVE

The purpose of this study was to assess the outcome of burn injury and its associated factor among patients who visited Addis Ababa burn emergency and trauma hospital.

METHODS

The institutional-based, retrospective cross-sectional study design was conducted from April 1, 2019, to March 30, 2021. After checking the data for its consistency the data were entered and analyzed by using SPSS version 25. A total of 241 patients who had visited Addis Ababa burn, emergency and trauma Hospitals after sustained burn injury were recruited through convenience sampling method for final analysis. Model goodness-of-fit was checked by Hosmer and Lemeshow test (0.272). After checking multi-collinearity both the bi-variable and multivariable logistic regression model was fitted and variables having a p-value less than or equal to 0.05 at 95% CI in the multivariable analysis were considered statistically significant.

RESULT

Adults (age 15 to 60 years) are the most affected groups accounting for 55.2% followed by pediatric age groups (age <15 years) (43.6%) and the elderly (age > 60 years) (1.2%). Scald burn was the major cause accounting for 39 % followed by Flame burn (33.6%), Electrical burn (26.6%), and chemical burn (0.8%). The mean TBSA% was 15.49%, ranging from1% to 64%. Adult males are more affected by electrical burns while adult females and the elderly encounter flame burn. 78.4% of patients were discharged without complications, 14.9% were discharged with complications and 6.6% died. The commonest long-term complication is the amputation of the extremity (19, 7.9%). Age greater than 60 years and TBSA% greater than 30% is a strong predictors of mortality with odds of 2.2 at 95% CI of [1.32, 3.69] and 8.7 at 95% CI of [1.33, 57.32] respectively.

CONCLUSION AND RECOMMENDATION

The mortality rate show decrement from previous studies. Overall scald burn is common in all age groups but electrical burns and flame burns affected more adult and elderly age groups. Extremities were by far, the commonest affected body parts. The extent of burn injury and the age of the patient independently predict mortality. Early intervention will reduce mortality and complications.

Strategies for the treatment of acute benzodiazepine toxicity in a clinical setting: the role of antidotes

INTRODUCTION

Although not a potentially life-threatening poisoning, benzodiazepine (BZD) intoxication may be life-threatening in special situations/populations or those with background diseases.

AREAS COVERED

The aim of this review is to evaluate all possible treatment options available in the literature for the management of benzodiazepine poisoning with special attention to antidote administration. We conducted a literature search using PubMed, Google Scholar, EMBASE, and Cochrane central register from 1 January 1980 to 10 November 2021 using keywords 'benzodiazepine,' 'poisoning,' 'toxicity,' 'intoxication,' and 'treatment.'

EXPERT OPINION

Careful patient selection, ideally by a clinical toxicologist, may decrease the complications of flumazenil and add to its efficacy. The cost-to-benefit ratio should be considered in every single patient who is a candidate for flumazenil administration. In case a decision has been made to administer flumazenil, careful consideration of the possible contraindications is essential. We recommend slow administration of low doses of flumazenil (0.1 mg/minute) to avoid complications or withhold the administration with development of first signs of adverse effects. The main treatment of benzodiazepine toxicity is conservative with administration of activated charcoal, monitoring of the vital signs, prevention of aspiration and development of deep vein thrombosis due to prolonged immobilization, and respiratory support.

Toxico-epidemiology of acute poisoning; an exploratory study from a tertiary care hospital in South India along with global comparisons and solutions

BACKGROUND

Poisoning has been and still is a major problem faced throughout the globe. But its patterns are different and changing in different parts of the world due to local influences. This calls for a study to explore the issue in this unique South Indian state.

METHODS

A cross-sectional exploratory study was conducted to analyse the patterns of poisoning and the socio-demographic characteristics of the patients. Subgroups were compared using Fisher-Freeman-Halton exact test and further analysed by multivariate logistic regression.

RESULTS

48% of cases were of pharmaceutical drug poisoning. 27.5% of these cases involved polymedication and Paracetamol (Acetaminophen) turned out to be the single most drug used. Suicide was the most common circumstance. 10% of patients had co-diagnoses of psychiatric disorders. Univariate analysis separately showed that females (p < 0.001), higher educated (p = 0.149), higher socioeconomic strata (p = 0.136) and non-addicts (p = 0.002) were more exposed to drugs whereas males, lower educated, lower socioeconomic strata and addicts are skewed to pesticides for poisoning. Most repeat suicide attempts were with the same poisonous agent. 70% of patients with a diagnosed psychiatric disorder have attempted suicide before using some drugs (p < 0.001).

CONCLUSION

Our study highlights the importance of a region-wise, targeted approach in policymaking to curb poisoning.

Epidemiology of Self-poisoning with Drug in the Central Anatolian Region in Turkey

Aim: Deliberate self-poisoning (DSP) is a common cause of intensive care hospitalization among young adults and a serious health problem worldwide. Demographic data vary according to geographical and sociocultural characteristics of the regions. In recent years, studies investigating epidemiological features and prognosis of these patients have increased. In our study, we retrospectively examined patients who committed suicide with drugs and were treated in the ICU of our hospital.

Materials and Methods: The files of 148 patients who took drugs or substances for committing suicide and who were hospitalized in the ICU of Aksaray Training and Research Hospital between 2015 and 2019 were examined. Demographic data of the patients, type of the agent used in the suicide, time to reach hospital, treatment methods applied, length of hospital stay, vital signs, complications, need for intubation, and mortality rates were recorded.

Results: Mean age of the 148 patients who took drugs for suicide was 26.7. Female rate was 73%. The most frequently used drug for suicide was paracetamol (34.4%). Antidepressants took the second place and were followed by drugs in the NSAID group. The duration of admission in the hospital after taking the medicine ranged from 1 to 6 h, while it was less than 3 h in 68.2% of the patients. In most suicide patients, the treatment method was in the form of intravenous fluid and supportive therapy (95%). N-acetyl cysteine (paracetamol intoxication) was used in 7% of the patients, an intubation requirement developed in 2.7%, and three patients taking organophosphate died.

Conclusion: In studies conducted in developing countries such as Turkey, female sex (63%-71%) and 25 years of age have been found to be the proportion of the patients (56%-63%), whereas our study found even higher ratios compared to those (73%-66%). In studies conducted in developed countries, most commonly used agents for suicide were benzodiazepines and tricyclic antidepressants, while the most common suicide agent was paracetamol in our study. We believe that the reason for this could be the possibility of accessing the agent without a prescription.

Comparing Logistic Regression Models with Alternative Machine Learning Methods to Predict the Risk of Drug Intoxication Mortality

(1) Medical research has shown an increasing interest in machine learning, permitting massive multivariate data analysis. Thus, we developed drug intoxication mortality prediction models, and compared machine learning models and traditional logistic regression. (2) Categorized as drug intoxication, 8,937 samples were extracted from the Korea Centers for Disease Control and Prevention (2008-2017). We trained, validated, and tested each model through data and compared their performance using three measures: Brier score, calibration slope, and calibration-in-the-large. (3) A chi-square test demonstrated that mortality risk statistically significantly differed according to severity, intent, toxic substance, age, and sex. The multilayer perceptron model (MLP) had the highest area under the curve (AUC), and lowest Brier score in training and validation phases, while the logistic regression model (LR) showed the highest AUC (0.827) and lowest Brier score (0.0307) in the testing phase. MLP also had the second-highest AUC (0.816) and second-lowest Brier score (0.003258) in the testing phase, demonstrating better performance than the decision-making tree model. (4) Given the complexity of choosing tuning parameters, LR proved competitive when using medical datasets, which require strict accuracy.

Toxicological exposures reported to a telephonic consultation service at a tertiary care hospital in Lebanon

Introduction: This study aims to describe the epidemiology of toxicological exposures reported to a telephonic medical toxicology service at a tertiary care center in Lebanon during a 46-months period.Methods: This study is a secondary analysis of a database for a telephonic medical toxicology service at a tertiary care center in Lebanon. Clinical information from all pediatric and adult patients, presenting with intentional or unintentional toxicological exposure, was entered into the database by the medical toxicology team.Results: Four hundred and seventy-seven exposures were recorded from 1 March 2015 to 31 December 2018. Female patients were involved in 60.2% of cases. Children less than 5 years old constituted 23.5% of cases and adults aged 20-49 constituted 48.6%. Up to 51.6% of cases were intentional, with 37.7% resulting from suicidal attempts. The majority of patients displayed no effects (33.1%) or minor effects (39.2%). Almost half of patients were treated and discharged from the Emergency Department (ED) without further hospitalization, and another 18.9% of patients left the ED against medical advice. The most common pharmaceutical agents involved were sedative/hypnotics/antipsychotics (14.7%), analgesics (12.6%) and antidepressants (11.3%). The most common non-pharmaceutical agents involved were household cleaning substances (8.0%), pesticides (5.2%) and bites and envenomations (3.8%).Conclusions: The results of this study suggest that sedative/hypnotics/antipsychotics, analgesics, antidepressants and household cleaning substances are the most common agents involved. Adult women and children ≤5 years old constitute a large portion of patients with toxicological exposures. Prevention strategies and policies should be implemented to mitigate these hazards.

Assessment of knowledge and practice of nurses on initial management of acute poisoning in Dessie referral hospital Amhara region, Ethiopia, 2018

Introduction

Poisoning is a major health problem worldwide, and it causes significant morbidity and mortality. It is estimated that 350,000 people died worldwide from unintentional poisoning. The purpose of this study is to assess nurses’ knowledge and practice on the initial management of acute poisoning among nurses in Dessie referral hospital, Amhara region, Ethiopia.

Methods

Hospital based cross sectional study was conducted from January 2018 to June 2018. Simple Random sampling technique was used to select the samples. Data was collected by using self-administered structured questioners. Data were cleansed, checked for completeness and entered into SPSS version 20 for analyses. Statistical measures of Central tendency, T-test and ANOVA were used in determining the association between independent and dependent variables.

Results

Based on the given 13 items to assess the general knowledge of nurses on poisoning, the score ranges from 2 to 9 with the range of 7 with the mean score of 7.48(SD-0. 0.839) for the entire respondents that was 57.5% for the given items that was less than 75% which was unsatisfactory level of knowledge. The mean score of general knowledge on poisoning was high among nurses who had training on initial management of poisoning than those nurses who had not the training.

Conclusion and recommendation

All Dessie referral nurses that participated in this study had unsatisfactory general knowledge on poisoning, knowledge on initial management of acute poisoning and self-reported practice. The major implication of these study findings on the health system is the importance of ensuring support to nurses’ health care services for early detection and management of poisoning.

The healthcare costs of intoxicated patients who survive ICU admission are higher than non-intoxicated ICU patients: a retrospective study combining healthcare insurance data and data from a Dutch national quality registry

Background

The aim of this study was to describe the healthcare costs of intoxicated ICU patients in the year before and the year after ICU admission, and to compare their healthcare costs with non-intoxicated ICU patients and a population based control group.

Methods

We conducted a retrospective cohort study, combining a national health insurance claims database and a national quality registry database for ICUs. Claims data in the timeframe 2012 until 2014 were combined with the clinical data of patients who had been admitted to an ICU during 2013. Three study populations were compared and matched according to socioeconomic status, type of admission, age and gender: an “ICU population”, an “intoxication population” and a “control population” (who had never been on the ICU).

Results

2591 individual “intoxicated ICU patients” were compared to 2577 general “ICU patients” and 2591 patients from the “control population”. The median and interquartile ranges (IQR) healthcare costs per day alive for the “intoxicated ICU patients” were higher during the year before ICU admission (€20.3 (IQR €3.6–€76.4)) and the year after ICU admission (€23.9 (IQR €5.1–€82.4)) compared to the ICU population (€6.1 (IQR €0.9–€29.3) and €13.6 (IQR €3.3–€54.9) respectively) and a general control population (€1.1 (IQR €0.3–€4.6) and €1.1 (IQR €0.4–€4.9) respectively). The healthcare associated costs in intoxicated ICU patients were correlated with the number of chronic conditions present prior ICU admission (p < 0.0001).

Conclusions

Intoxicated patients admitted to the ICU had in the year before and after ICU admission much higher median healthcare costs per day alive compared to other ICU patients and a general population control group. Healthcare costs are greatly influenced by the number of psychiatric and other chronic conditions of these intoxicated patients.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0224-7) contains supplementary material, which is available to authorized users.

Patterns and outcome of acute poisoning among children in rural Sri Lanka

Background

The burden of poisoning among children is largely underexplored in rural Sri Lanka. This study describes the patterns of demographic characteristics, poison related factors, clinical management and outcome following acute poisoning among children (9 months- 12 years) in rural Sri Lanka.

Method

This hospital based multi-center study included Anuradhapura Teaching hospital, Polonnaruwa District General hospital, and 34 regional hospitals within Regional Director of Health Services in North Central province of Sri Lanka. The study assessed clinical profiles, poison related factors, clinical management, complications, harmful first aid practices, reasons for delayed management, complications and outcomes following acute poisoning over 7 years.

Results

Among 1621 children with acute poisoning, the majority were in preschool age group. Household chemicals were accountable for 489 acute poisonings (30.2%). The most common poison was kerosene oil, followed by paracetamol. Most events occurred within their own domestic premises. Potentially harmful first aid measures were practiced by approximately one third of care givers. Reasons for delayed presentation at emergency center included lack of concern by family members regarding the urgency of the situation and lack of knowledge regarding possible complications. Complications were observed in 12.5% and the most common complication was chemical pneumonitis.

Conclusions

Children with acute poisoing in rural Sri Lanka were predominantly preschoolers. They are poisonined mostly within their own housing premises. Kerosene oil, in addition to being the most common poison, had additional risks of aspiration pneumonia following potentially hazadrous first aid measures practised by the care givers. Complications though rare were potentially preventable by community education and awareness on timely attention to seek medical care, and avoidance of harmful first aid practices.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1246-0) contains supplementary material, which is available to authorized users.

Acute poisonings during pregnancy and in other non-pregnant women in emergency departments of four government hospitals, Addis Ababa, Ethiopia: 2010-2015

OBJECTIVE

To characterise acute poisonings in pregnant and non-pregnant women treated at emergency departments of government hospitals in Addis Ababa, Ethiopia, between 2010 and 2015.

METHODS

All data for acutely poisoned women were retrospectively collected from patient medical charts at the emergency departments of Saint Paul's Hospital Millennium Medical College, Ras Desta Memorial Hospital, Yekatit 12 Hospital Medical College and Zewditu Memorial Hospital. Data were collected by extraction questionnaire and analysed using SPSSv. 20 statistical software.

RESULTS

During the study period, 998 cases of acutely poisoned women were listed in the hospital registries. Of these, complete data for inclusion in the study were available for 592. 36.3% of the study participants were in the age group of 20-24, with a mean (±SD) age of 23.03 (±6.3) years. 80.9% were from Addis Ababa; 4.6% were pregnant. The mean arrival time of all cases was 4.14 h. 85.5% of all study cases were due to intentional self-poisoning, of whom 42.1% were discharged without complications. The most common poisons were bleach and organophosphates; 25.9% of pregnant cases and 32.6% of non-pregnant cases were poisoned by bleach; and 18.5% of pregnant cases and 18.9% of non-pregnant cases had organophosphate poisoning. 0.7% had a history of poisoning; all were non-pregnant women. The common route of poison exposure was oral, and the case fatality rate of organophosphate poisoning in pregnant and non-pregnant women was 20 and 1.87%, respectively. The pre-hospital intervention for the majority of the women was milk, in 12.0% of cases.

CONCLUSION

Acute poisoning remains a public health problem in our community. Bleach is the most common poisons. Our present findings indicate the necessity of educational programmes on preventable reasons of acute poisonings and their outcomes on pregnant and non-pregnant women.

Poisoning cases and their management in emergency centres of government hospitals in northwest Ethiopia

Introduction

With the widespread availability of a vast number of chemicals and drugs, acute poisoning is a common medical emergency worldwide. In spite of the success of interventions to prevent toxic ingestions, acute poisoning continues to be an important public health problem. Because of weak regulations and limited health care services in developing countries, adverse outcomes from poisoning are more prevalent than in the developed world. Due to the limited Ethiopian literature on this topic, the primary objective of this study was to evaluate and report poisoning cases, their management and outcome in northwest Ethiopia.

Methods

This is a retrospective study of all poisoning cases admitted and managed in the emergency centres of Gondar Teaching Referral Hospital and Metema and Debark district hospitals, from September 2010 to December 2014. Data was collected through retrospective chart review of patients who were admitted due to poisoning.

Results

There were 543 registered poisoning cases listed in the registry during the study period, of which 344 cases (63.4%) had complete data and were included in the final analysis. There were 48,619 emergency centre visits during the study period, with poisoning cases accounting for 1.1%. Females (60%) were predominant among intentional as well as unintentional poisoning cases. Patients between 15 and 24 years of age accounted for 55% of the cases. Patients poisoned with organophosphate and bleaching agents accounted for 35% and 25%, respectively. Among the poisoning patients, 74% were treated with decontamination, while those exposed to organophosphate were treated with atropine 45.5% (55/121) of the time.

Discussion

Young females comprise a group at increased risk for suicidal poisonings. As a developing nation, pesticide and bleaching agents remain a significant cause of acute poisonings in Ethiopia. Intentional poisoning remains the most significant identified cause of poisoning overall.

Pattern of acute organophosphorus poisoning at University of Gondar Teaching Hospital, Northwest Ethiopia

Background

Despite the apparent benefits of organophosphate compounds (OPCs) acute organophosphate (OP) pesticide poison is an increasing problem worldwide. In a country like Ethiopia, where agriculture is a major component of the economy, these compounds are readily available to the general public. There is paucity of evidence from Ethiopia showing the pattern of organophosphate poisoning (OPP) in healthcare facilities. The objective of this study was to evaluate retrospectively the pattern of acute OPP at the University of Gondar Teaching Hospital in northwest Ethiopia, during September 2010 through December 2014 was conducted. Data was collected through chart review of patients who were admitted due to poisoning. Data was analysed using SPSS 20.

Results

Organophosphate poisoning in University of Gondar teaching hospital accounts for about 38.46% of all emergency room admissions for poisoning. Out of the 90 cases studied 60% (54) were women, with male to female ratio of 1:1.5. The mean age of the patients was 25.5 with a standard deviation of 9.45. 56.7% of the cases studies lived in an urban environment compared to 43.3% who lived rurally. In the vast majority of patients, 90% (81) patients had ingested OP as an act of suicide. Regarding the route of exposure, oral ingestion was most common in suicidal cases (88.9%). The elapsed time between the time of poison ingestion and the start of the treatment, ranged from 13 min to 1 day. Health care professionals’ useds decontamination methods such as gastric lavage and activated charcoal (45.6%) and 36.7% use atropine for OPP treatment. The mean hospital stay was 0.74 days. In the present study family problems were a leading cause of suicides and accounted for 45.8% of all cases.

Conclusion

As a developing nation who economy relies heavily on agriculture, Ethiopia continues to have OP compounds remain a common cause of acute poisonings. This is particularly concerning for younger generation who have high rates of OPP and whose numbers continue to raise. This data suggests that it is essential to strengthen Ethiopians regulatory policy concerning the availability of OPCs. Additionally, it will be important to design an appropriate health education program for the prevention of both suicidal and accidental OPPs for the benefit of the public at large.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2464-5) contains supplementary material, which is available to authorized users.

Acute salicylate poisoning: risk factors for severe outcome

CONTEXT

Salicylate poisoning remains a significant public health threat with more than 20,000 exposures reported annually in the United States.

OBJECTIVE

We aimed to establish early predictors of severe in-hospital outcomes in Emergency Department patients presenting with acute salicylate poisoning.

METHODS

This was a secondary data analysis of adult salicylate overdoses from a prospective cohort study of acute drug overdoses at two urban university teaching hospitals from 2009 to 2013. Patients were included based on confirmed salicylate ingestion and enrolled consecutively. Demographics, clinical parameters, treatment and disposition were collected from the medical record. Severe outcome was defined as a composite occurrence of acidemia (pH <7.3 or bicarbonate <16 mEq/L), hemodialysis, and/or death.

RESULTS

Out of 1997 overdoses screened, 48 patients met inclusion/exclusion criteria. Patient characteristics were 43.8% male, median age 32 (range 18-87), mean initial salicylate concentration 28.1 mg/dL (SD 26.6), and 20.8% classified as severe outcome. Univariate analysis indicated that age, respiratory rate, lactate, coma, and the presence of co-ingestions were significantly associated with severe outcome, while initial salicylate concentration alone had no association. However, when adjusted for salicylate concentration, only age (OR 1.13; 95% CI 1.02-1.26) and respiratory rate (OR 1.29; 95% CI 1.02-1.63) were independent predictors. Additionally, lactate showed excellent test characteristics to predict severe outcome, with an optimal cutpoint of 2.25 mmol/L (78% sensitivity, 67% specificity).

CONCLUSIONS

In adult Emergency Department patients with acute salicylate poisoning, independent predictors of severe outcome were older age and increased respiratory rate, as well as initial serum lactate, while initial salicylate concentration alone was not predictive.

Identification of incident poisoning, fracture and burn events using linked primary care, secondary care and mortality data from England: implications for research and surveillance

BACKGROUND

English national injury data collection systems are restricted to hospitalisations and deaths. With recent linkage of a large primary care database, the Clinical Practice Research Datalink (CPRD), with secondary care and mortality data, we aimed to assess the utility of linked data for injury research and surveillance by examining recording patterns and comparing incidence of common injuries across data sources.

METHODS

The incidence of poisonings, fractures and burns was estimated for a cohort of 2 147 853 0-24 year olds using CPRD linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality data between 1997 and 2012. Time-based algorithms were developed to identify incident events, distinguishing between repeat follow-up records for the same injury and those for a new event.

RESULTS

We identified 42 985 poisoning, 185 517 fracture and 36 719 burn events in linked CPRD-HES-ONS data; incidence rates were 41.9 per 10 000 person-years (95% CI 41.4 to 42.4), 180.8 (179.8-181.7) and 35.8 (35.4-36.1), respectively. Of the injuries, 22 628 (53%) poisonings, 139 662 (75%) fractures and 33 462 (91%) burns were only recorded within CPRD. Only 16% of deaths from poisoning (n=106) or fracture (n=58) recorded in ONS were recorded within CPRD and/or HES records. None of the 10 deaths from burns were recorded in CPRD or HES records.

CONCLUSIONS

It is essential to use linked primary care, hospitalisation and deaths data to estimate injury burden, as many injury events are only captured within a single data source. Linked routinely collected data offer an immediate and affordable mechanism for injury surveillance and analyses of population-based injury epidemiology in England.

Transporting children with toxicological emergencies

OBJECTIVE

Each year, the Newborn and Paediatric Emergency Transport Service (NETS) receives over 3600 calls from health professionals regarding the management and transportation of critically ill children across New South Wales, with toxicological emergencies making up 1.5% of these calls. The aim of the present study is to describe the characteristics of patients transported for toxicological emergencies and their retrieval management.

METHODS

A retrospective review of patients referred for management of a toxicological emergency between 2007 and 2011. Extracted data included patient demographics, substances involved, consultation with toxicological expertise, interventions performed and major adverse outcomes.

RESULTS

Two hundred and thirty patients, with 307 toxicological exposures, were referred to NETS, of whom 169 (73.5%) were subsequently transported. Pharmaceutical poisonings (223, 72.6%) were the most common, followed by non-pharmaceutical poisonings (61, 19.9%) and envenomation (23, 7.5%). Psychotropics, analgesics and chemicals were the most frequently ingested substances. The most common source of accidentally ingested pharmaceuticals was a family member. The most frequently given therapies were specific antidotes, in particular naloxone and N-acetylcysteine. Nearly half (43.2%) of transported children required only non-invasive monitoring. There was one death during the retrieval process.

CONCLUSIONS

Many children with toxicological emergencies require only non-invasive monitoring, which could be provided by trained ambulance crews in select scenarios. Involvement of a toxicologist in the initial consultation to identify these patients might reduce retrieval numbers and costs. Children on regular medication and those living with family members on psychotropic or cardiac drugs were identified as high-risk groups that should be targeted for medication safety education.

Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample

OBJECTIVE

To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders.

METHOD

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850-E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning.

RESULTS

Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs.

CONCLUSIONS

SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.

Antifreeze on a freezing morning: ethylene glycol poisoning in a 2-year-old

This case report describes the presentation and management of a 2-year-old child who ingested a potentially fatal amount of ethylene glycol (EG). There are few published cases worldwide of EG poisoning in children managed with fomepizole. All cases described in the literature were managed in a paediatric intensive care unit. In this case, the child presented irritable, pale and confused with high anion gap metabolic acidosis. As there were no paediatric intensive care beds available in the region, the child was successfully managed in a high dependency area in our district general hospital. The child fully recovered and was discharged home in 7 days. The authors believe that multi-disciplinary team management and the use of fomepizole contributed to the positive outcome and this case raised many useful learning points.

Transdermal opioid patches for pain treatment in ancient Greece

Pain treatment in ancient Greece, and through the middle ages in Europe, was to a great extent based on the expertise of the Greek physician Galen (c. 129-200 A.D.). Galen makes particular reference to "Olympic Victor's Dark Ointment" (OVDO), which is listed with a number of collyria. Galen states that OVDO can be useful for treating extreme pain and swellings, forming one of the best eye salves. Olympic Victor's Dark Ointment, an opium-based treatment, forms a "patch" when applied externally as an ointment, because it quickly dries to cover a localized region but still retains its elastic properties. This study has recreated OVDO and applied the ointment to abdominal mouse skin, in vitro. To assess the efficacy of OVDO, the transdermal transfer of morphine was measured when given as OVDO and compared to morphine administered in the form of a solution of Opium + PBS (ringer). Olympic Victor's Dark Ointment showed a transdermal transfer of morphine over time comparable to 25% of the most efficient modern transdermal opioid patches, while hardly any morphine was able to penetrate the skin when applied mixed in PBS. We conclude that OVDO is very efficient in its composition and may carry some forgotten abilities in terms of drug delivery, which could be transferred to modern medicine. Indeed, this may lead to a better choice of morphine use and controlled management in individual patient cases, taking both pain relief and anti-inflammatory aspects into account.

Mephedrone use and associated adverse effects in school and college/university students before the UK legislation change

BACKGROUND

Mephedrone is a synthetic cathinone that is commonly used as a recreational drug among those who attend nightclubs. There have been increasing reports of toxicity associated with its use and it was controlled as a Class B drug under the Misuse of Drugs Act (1971) in the UK on 16 April 2010. There has been a suggestion from media reports that mephedrone use is common in children/students but there is no data on the prevalence of its use among the general population. The aim of this study was to determine the prevalence and frequency of use of mephedrone among school and college/university aged individuals and to collect data on the sources of mephedrone and acute harm related to its use.

METHODS

Data was collected using a questionnaire survey in schools, colleges and universities in the Tayside area of Scotland, UK in February 2010.

RESULTS

A total of 1006 individuals completed the survey [501 (49.8%) males and 505 (50.2%) females], of whom 349 classified their educational institute as a school and 657 as a college/university. Among them 205 (20.3%) reported previous use of mephedrone; 23.4% reported using only using mephedrone on one occasion previously, although 4.4% reported daily use. A total of 56% of those who had used mephedrone, reported at least one unwanted effect associated with its use. A total of 17.6% of users reported 'addiction or dependence' symptoms associated with their mephedrone use. A total of 48.8% of users sourced mephedrone from street level dealers, 10.7% from the Internet.

CONCLUSION

We have shown in this study that the use of mephedrone among school and college/university students is common and that users found it easy to obtain. There was a high prevalence of unwanted effects associated with its use. Further work is needed to determine the impact of the recent changes in the UK legislation relating to mephedrone and other related cathinones and whether this has been effective in reducing the prevalence of mephedrone use.

Management of cocaine-induced cardiac arrhythmias due to cardiac ion channel dysfunction

Cocaine use is common in many areas of the world, particularly the United States and Western Europe. Toxicity following the use of cocaine is associated with a wide range of clinical features. In this review, we will focus on the cocaine-associated cardiac arrhythmias and, in particular, some of the controversies in their etiology and management. Cocaine can produce arrhythmias either through the production of myocardial ischemia or as a direct result of ion channel alterations. Excessive catecholamines, combined with sodium and potassium channel blockades, give rise to a wide variety of supra-ventricular and ventricular rhythms. The animal and human evidence for ion channel dysfunction is reviewed, and the effects of catecholamines are followed from the cardiac action potential to the development of arrhythmias. Finally, theoretical constructs are combined with existing evidence to develop a rational treatment strategy for patients with cocaine-induced cardiac arrhythmias. In particular, we review the evidence concerning the controversies relating to the use of lidocaine in comparison with sodium bicarbonate, in terms of QRS prolongation secondary to sodium channel blockade.

Can medical students identify recreational drugs by name?

BACKGROUND

Recreational drug toxicity is a common reason for presentation to the Emergency Department. Knowledge of recreational drug names is important to allow targeted assessment of patients presenting with recreational drug toxicity.

AIMS

To assess final year medical student knowledge of proper and street names for recreational drugs.

DESIGN

Questionnaire survey of final year medical students attending a revision lecture.

METHODS

There were two questionnaires used in this study. The first contained either proper names of recreational drugs or names sounding similar to recreational drugs or licensed pharmaceutical products; students were asked to identify which of these were recreational drugs. The second contained street names of recreational drugs and the students were asked to identify which recreational drug the street name referred to.

RESULTS

One hundred and thirty-five students completed the questionnaire 1. The mean total score (+/-SD) of correct answers was 7.15 +/- 2.26 (range 2-13) out of a maximum of 15. One hundred and fifteen students completed questionnaire 2. The mean total score (+/-SD) of correctly identified street names was 11.0 +/- 2.6 (range 0-17) out of a maximum of 24. No individual student was able to correctly identify all the street names for the recreational drugs listed in the survey.

CONCLUSION

We have shown that final year medical students have variable knowledge of both the proper and street names of recreational drugs. There is a need for improved education of medical students in the names of recreational drugs and the sources of information available to assist them in identifying what drugs an individual has taken.

The poisoned child in the pediatric intensive care unit

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.

Slow the ticking clock of toxicity

Time is a crucial element in preventing the most severe consequences of overdose.

Long circulating lipid nanocapsules for drug detoxification

Uncoated and poly(ethylene glycol) (PEG)-decorated lipid nanocapsules (NC) prepared from medium chain triglycerides were investigated both in vitro and in vivo as parenteral detoxifying colloids for their ability to sequester haloperidol, docetaxel and paclitaxel. In vitro studies showed that the uptake depended on the nature of the drug and the composition of NC core and shell. In the case of haloperidol, maximal affinity was achieved upon incorporation of a complexing fatty acid. In plasma lipoprotein distribution studies, the association of both haloperidol and docetaxel into triglyceride-rich lipoprotein fraction was significantly increased in the presence of NC. The ability of the NC to lower the free drug concentrations in incubation medium was confirmed by cytotoxicity studies, where the antiproliferative activity of docetaxel was significantly decreased in the presence of NC. Using docetaxel as drug model, the NC were finally evaluated for their uptake potential in mice by one of the following administration sequences between the drug solution (Taxotere, DTX) and NC: NC-DTX, PEG(NC)-DTX and DTX-PEG(NC). Irrespective of the administration sequence, the NC increased the blood levels of docetaxel due to the in situ sequestration of drug by the circulating carrier. These findings suggest that lipid NC could be used as a non-specific mode to deal with the sequestration of molecules with high affinity for oils.

An Ancient Greek Pain Remedy for Athletes

While Hippocratic writings make no reference to the actual Olympics, there is frequent mention of diet, exercise, and the treatment of injuries sustained by the athletic participants. Indeed, Galen in his Composition of Medicines gives details of a remedy prescribed for the relief of pains and swellings, which was reserved for use by the winners of Olympic events, the so-called "Fuscum Olympionico inscriptum"--(ointment) entitled "dark Olympic victor's." In a time when the Olympic games have recently returned to their homeland, we examine the potential efficacy of this ancient remedy in terms of pain relief, the novelty of transdermal pain management, and the ability of ancient physicians to attend to the sports-related needs of highly tuned athletes.