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Nanah A, Abdeljaleel F, Matsubara JK, Garcia MVF. Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions. J Intensive Care Med 2024:8850666241275041. [PMID: 39150325 DOI: 10.1177/08850666241275041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. METHODS A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. RESULTS 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). CONCLUSION The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.
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Affiliation(s)
- Abdelrahman Nanah
- Cleveland Clinic Foundation, Fairview Hospital, Cleveland, Ohio, USA
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Sharif AF, Kasemy ZA, Alshabibi RA, Almufleh SJ, Abousamak FW, Alfrayan AA, Alshehri M, Alemies RA, Almuhsen AS, AlNasser SN, Al-Mulhim KA. Prognostic factors in acute poisoning with central nervous system xenobiotics: development of a nomogram predicting risk of intensive care unit admission. Toxicol Res (Camb) 2022; 12:62-75. [PMID: 36866212 PMCID: PMC9972822 DOI: 10.1093/toxres/tfac084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022] Open
Abstract
Background Acute intoxication with central nervous system (CNS) xenobiotics is an increasing global problem. Predicting the prognosis of acute toxic exposure among patients can significantly alter the morbidity and mortality. The present study outlined the early risk predictors among patients diagnosed with acute exposure to CNS xenobiotics and endorsed bedside nomograms for identifying patients requiring intensive care unit (ICU) admission and those at risk of poor prognosis or death. Methods This study is a 6-year retrospective cohort study conducted among patients presented with acute exposure to CNS xenobiotics. Results A total of 143 patients' records were included, where (36.4%) were admitted to the ICU, and a significant proportion of which was due to exposure to alcohols, sedative hypnotics, psychotropic, and antidepressants (P = 0.021). ICU admission was associated with significantly lower blood pressure, pH, and HCO3 levels and higher random blood glucose (RBG), serum urea, and creatinine levels (P < 0.05). The study findings indicate that the decision of ICU admission could be determined using a nomogram combining the initial HCO3 level, blood pH, modified PSS, and GCS. HCO3 level < 17.1 mEq/L, pH < 7.2, moderate-to-severe PSS, and GCS < 11 significantly predicted ICU admission. Moreover, high PSS and low HCO3 levels significantly predicted poor prognosis and mortality. Hyperglycemia was another significant predictor of mortality. Combining initial GCS, RBG level, and HCO3 is substantially helpful in predicting the need for ICU admission in acute alcohol intoxication. Conclusion The proposed nomograms yielded significant straightforward and reliable prognostic outcomes predictors in acute exposure to CNS xenobiotics.
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Affiliation(s)
- Asmaa F Sharif
- Corresponding author: Clinical Medical Sciences Department, College of Medicine, Dar AlUloom University, Riyadh, Al-Falah, 13314, Saudi Arabia.
| | - Zeinab A Kasemy
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin ElKom, Egypt
| | | | - Salem J Almufleh
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | | | | | - Muath Alshehri
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Rakan A Alemies
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Assim S Almuhsen
- College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - Shahd N AlNasser
- Poison Control Department, Emergency Medicine Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khalid A Al-Mulhim
- Emergency Medicine Department, King Fahad Medical City, Riyadh, 1125, Saudi Arabia
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[Acute intoxications in the intensive care unit: A 10-year analysis]. Med Klin Intensivmed Notfmed 2021; 117:129-136. [PMID: 34302193 DOI: 10.1007/s00063-021-00839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 04/15/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute intoxications play a special role in preclinical emergency medicine, in the emergency department, and in intensive care. This study characterizes cases of acute intoxications from an intensive care perspective. OBJECTIVES All cases of acute intoxications admitted to the intensive care units at the University Hospital Hamburg-Eppendorf between 01 January 2007 and 30 June 2017 were retrospectively analyzed. RESULTS During the study period, 587 patients with acute intoxications were admitted to the university hospital's intensive care units. Median age was 45 years (interquartile range [IQR] 31 years); 83.1% of patients were younger than 70 years. The most common cause of intoxication in the younger patients was a suicide attempt (55.1%), while in older patients it was an iatrogenic event (47.5%). Cases involving intoxications with psychotropic medication (48.7%), alcohol (32.9%), analgesics (23.3%), and drugs (17.0%) were most frequent. In 50.6% of cases, intoxication was due to more than one substance. Intoxication-specific therapy was performed in 40.0% of cases and intensive care therapy in 42.4% of cases. The median length of intensive care unit stay was 2 days (IQR 3). Hospital mortality was 5.5%. In older patients (≥ 70 years) compared with younger patients, the need for intensive care treatment (56.6% vs. 39.5% of cases, p = 0.002), the length of intensive care unit stay (3 days [IQR 5] vs. 2 days [IQR 3], p = 0.0004) and in-hospital mortality (17.2% vs. 3.1%, p < 0.001) were significantly higher. CONCLUSIONS Acute intoxications are part of the spectrum of disorders treated in the intensive care unit. In older patients, iatrogenic causes are frequently found, which is associated with an increased risk of death.
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[Acute intoxications: markers for screening, diagnosis and therapy monitoring]. Med Klin Intensivmed Notfmed 2019; 114:302-312. [PMID: 30944942 DOI: 10.1007/s00063-019-0566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/21/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Abstract
Acute poisonings account for a significant proportion of the patient population presenting to intensive care units, whereby mixed drug overdoses and prescription drug overdoses predominate. The aim of this article was to describe indications for screening, diagnosis and therapy monitoring in acute overdoses in the intensive care unit. To conduct this work, a literature search was carried out and a review was written based on guidelines, case reports, expert opinions and scientific publications. Toxidromes are a useful tool for classification of clinical characteristics when the causative agent is initially unknown. Especially in critical care medicine, identifying and quantifying of the causative toxin by enzyme immunoassays, chromatography and mass spectrometry should be attempted. Intensive care treatment of patients with acute overdoses includes not only monitoring and support of vital functions but also methods for primary and secondary elimination of toxins. The indication for the use of extracorporeal procedures should be carefully evaluated and the method should be chosen based on protein binding and molecular size. Lipid emulsion therapy, high-dose insulin euglycaemia therapy and hyperbaric oxygenation are also increasingly used.
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Nguyen TL, Boudemaghe T, Leguelinel-Blache G, Eiden C, Kinowski JM, Le Manach Y, Peyrière H, Landais P. Identifying Life-Threatening Admissions for Drug Dependence or Abuse (ILIADDA): Derivation and Validation of a Model. Sci Rep 2017; 7:44428. [PMID: 28290530 PMCID: PMC5349588 DOI: 10.1038/srep44428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/07/2017] [Indexed: 12/23/2022] Open
Abstract
Given that drug abuse and dependence are common reasons for hospitalization, we aimed to derive and validate a model allowing early identification of life-threatening hospital admissions for drug dependence or abuse. Using the French National Hospital Discharge Data Base, we extracted 66,101 acute inpatient stays for substance abuse, dependence, mental disorders or poisoning associated with medicines or illicit drugs intake, recorded between January 1st, 2009 and December 31st, 2014. We split our study cohort at the center level to create a derivation cohort and a validation cohort. We developed a multivariate logistic model including patient's age, sex, entrance mode and diagnosis as predictors of a composite primary outcome of in-hospital death or ICU admission. A total of 2,747 (4.2%) patients died or were admitted to ICU. The risk of death or ICU admission was mainly associated with the consumption of opioids, followed by cocaine and other narcotics. Particularly, methadone poisoning was associated with a substantial risk (OR: 35.70, 95% CI [26.94-47.32], P < 0.001). In the validation cohort, our model achieved good predictive properties in terms of calibration and discrimination (c-statistic: 0.847). This allows an accurate identification of life-threatening admissions in drug users to support an early and appropriate management.
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Affiliation(s)
- Tri-Long Nguyen
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA2415, University of Montpellier, Montpellier, France.
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, University of Montpellier, Montpellier, France.
- Department of Pharmacy, Nîmes University Hospital, Nîmes, France.
| | - Thierry Boudemaghe
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA2415, University of Montpellier, Montpellier, France.
- Department of Biostatistics, Epidemiology, Public Health and Medical Informatics, Nîmes University Hospital, Nîmes, France.
| | - Géraldine Leguelinel-Blache
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA2415, University of Montpellier, Montpellier, France.
- Department of Pharmacy, Nîmes University Hospital, Nîmes, France.
| | - Céline Eiden
- Department of Medical Pharmacology and Toxicology, Addictovigilance Centre, Montpellier University Hospital, Montpellier University Hospital, Montpellier, France.
| | - Jean-Marie Kinowski
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA2415, University of Montpellier, Montpellier, France.
- Department of Pharmacy, Nîmes University Hospital, Nîmes, France.
| | - Yannick Le Manach
- Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
- The Perioperative Research Group, Population Health Research Institute, Hamilton, Ontario, Canada.
| | - Hélène Peyrière
- Laboratory of Clinical Pharmacy, Faculty of Pharmacy, University of Montpellier, Montpellier, France.
- Department of Medical Pharmacology and Toxicology, Addictovigilance Centre, Montpellier University Hospital, Montpellier University Hospital, Montpellier, France.
| | - Paul Landais
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA2415, University of Montpellier, Montpellier, France.
- Department of Biostatistics, Epidemiology, Public Health and Medical Informatics, Nîmes University Hospital, Nîmes, France.
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El-Sarnagawy GN, Hafez ASAF. Comparison of different scores as predictors of mechanical ventilation in drug overdose patients. Hum Exp Toxicol 2016; 36:539-546. [DOI: 10.1177/0960327116655389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The decision of intubation and mechanical ventilation in poisoned patients with impaired consciousness can be a difficult task. The present study aimed to evaluate the power of Glasgow Coma Scale (GCS), acute physiology and chronic health evaluation (APACHE II), rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS) at admission in predicting the need of intubation and mechanical ventilation in drug overdose patients with disturbed consciousness level (DCL). This prospective observational study was conducted on 104 poisoned patients who were admitted to Tanta Toxicological Unit with a DCL. Four scoring systems (GCS, APACHE II, RAPS and REMS) were recorded for all patients on admission. Discrimination was evaluated using receiver operating characteristics curve and calculating the area under the curve (AUC). Twenty-four cases required mechanical ventilation. The mechanically ventilated patients had significantly lower value of GCS and higher values of APACHE II, REMS and RAPS than other group ( p < 0.001). Although the APACHE II score has the best AUC value (0.796) in predicting mechanical ventilation, there was no statistically significant difference between the four scores. GCS > 8 had 100% negative predictive value, while REMS > 8 had 100% positive predictive value.
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Affiliation(s)
- Ghada N El-Sarnagawy
- Department of Forensic Medicine and Clinical Toxicology, Tanta Faculty of Medicine, Tanta University, Egypt
| | - Amal SAF Hafez
- Department of Forensic Medicine and Clinical Toxicology, Tanta Faculty of Medicine, Tanta University, Egypt
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In-Hospital Mortality and Long-Term Survival of Patients With Acute Intoxication Admitted to the ICU*. Crit Care Med 2014; 42:1471-9. [DOI: 10.1097/ccm.0000000000000245] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mokhlesi B, Leiken JB, Murray P, Corbridge TC. Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest 2003; 123:577-92. [PMID: 12576382 DOI: 10.1378/chest.123.2.577] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Intensivists are confronted with poisoned patients on a routine basis, with clinical scenarios ranging from known drug overdose or toxic exposure, illicit drug use, suicide attempt, or accidental exposure. In addition, drug toxicity can also manifest in hospitalized patients from inappropriate dosing and drug interactions. In this review article, we describe the epidemiology of poisoning in the United States, review physical examination findings and laboratory data that may aid the intensivist in recognizing a toxidrome (symptom complex of specific poisoning) or specific poisoning, and describe a rational and systematic approach to the poisoned patient. It is important to recognize that there is a paucity of evidence-based information on the management of poisoned patient. However, the most current recommendations by the American Academy of Clinical Toxicology and European Association of Poisons Centers and Clinical Toxicologists will be reviewed. Specific poisonings will be reviewed in the second section of these review articles.
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Affiliation(s)
- Babak Mokhlesi
- Division of Pulmonary and Critical Care Medicine, Cook County Hospital/Rush Medical College, Chicago, IL 60612, USA.
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