Hepatotoxicity induced by acute and chronic paracetamol overdose in adults. Where do we stand?

Paracetamol (Acetaminophen) poisoning data can reveal the potential deficiencies of paracetamol poisoning management guidelines. We conducted a retrospective cohort study of patients >18years who were attended in the emergency department (ED) of a Spanish tertiary hospital, from 2005 to 2010 for suspected paracetamol overdose and who had measurable paracetamol concentrations. 208 patients suspected of paracetamol poisoning were identified. The annual incidence in the ED increased from 2.0 (95%-CI: 0.2-7.2) cases per 10,000 patients in 2005 to 3.4 (95%-CI: 1.1-8.8) in 2010. Only 7 of 98 patients (7.14%) with acute poisoning at toxic doses showed hepatotoxicity signs, 4 (57.1%) of whom presented acute liver failure (ALF) criteria, while 8 of 10 patients (80%) with chronic paracetamol poisoning at toxic doses presented hepatotoxicity and 3 (37.5%) with ALF criteria. The time required to find medical care was 9.0h for acute poisoning and 49.6h for chronic poisoning (p<0.001). We conclude that the incidence of suspected cases of paracetamol poisoning at our hospital is increasing. The majority of toxicity cases, including ALF, associated with the ingestion of paracetamol were due to chronic poisoning. This finding constitutes an important warning regarding paracetamol chronic poisoning, and clinicians should have a higher index of clinical suspicion for this entity.

Clinical manifestations of elderly patients with digitalis intoxication in the emergency department

This study aimed to determine the clinical characteristics of elderly patients diagnosed with digitalis intoxication, on the Emergency Department, University Hospital Complex, A Coruña, Spain. During the study period (January-September 2008) cases were included in which digitalis intoxication was confirmed by plasma digoxin levels. We collected data on age, gender, base-line diseases, therapeutic indications for digoxin, functional classification, ejection fraction, plasma digoxin levels, creatinine clearance, ions, gasometry, electrocardiogram, concomitant medication, symptomatology and treatment. The results were: mean age 82.0 ± 6.6 years, predominantly female subjects (83.7%). The most prevalent pathologies were cardiac valvulopathy (81.0%), hypertension (68.3%) and ischemic cardiopathy (46.3%), 95.1% had a background of cardiac insufficiency, and 52.6% were in functional grade III. The mean digoxin level was 2.7 ± 0.69 ng/ml, 23.1% of the patients had a creatinine clearance of less than 60 ml/min/1.73 m(2) and 2.6% had a severely reduced glomerular filtration rate (GFR) (clearance<30 ml/min/1.73 m(2)). A negative correlation was found between digoxin levels and clearance (r = -0.22; p = 0.18) and between the levels and cardiac frequency (r = -0.35; p = 0.026). Of the patients, 47.5% presented bradycardia and 87.8% arrhythmias, most frequently auricular fibrillation. The most frequent symptoms were nausea (54.8%), fatigue (42.9%), vomiting (33.3%) and anorexia (28.6%). We conclude that clinical digestive symptoms in elderly women who are taking digitalis, with bradycardia and impaired renal functioning, should lead us to suspect digitalis intoxication.