Presentation of poisoned patients to accident and emergency departments in the north of England

Unravelling the mechanism of amitriptyline removal from water by natural montmorillonite through batch adsorption, molecular simulation and adsorbent characterization studies

Amitriptyline (AMI) is one of the most common tricyclic antidepressant personal care medications. Due to its environmental persistence and bioaccumulation, release of AMI into the environment via wastewater streams in elevated levels could lead to significant ecological and human health impacts. In this study, the adsorption of AMI by montmorillonite (SWy-2), a naturally abundant smectite clay with sodium ions as the main interlayer cations, was investigated. Maximum AMI adsorption (276 mg/g) occurred at pH 7-8. After adsorption, examination of the adsorbent's X-ray diffraction pattern indicated that interlayer expansion had occurred, where chemical stoichiometry confirmed cation exchange as the principal adsorption mechanism. AMI adsorption reached equilibrium within 4 h, with kinetic data best fitting the pseudo-second order kinetic model (R² = 0.98). AMI adsorption was unaffected by solution pH in the range 2-11, where adsorption was endothermic, and molecular simulations substantiated by Fourier transform infrared spectroscopy and thermogravimetric investigations indicated that the orientation of AMI molecules in the interlayer was via an amine group and a benzene ring. Overall this research shows that SWy-2 has significant potential as a low cost, effective, and geologically derived natural material for AMI removal in wastewater systems.

Incidence and profile of acute intoxication among adult population in Najran, Saudi Arabia: A retrospective study

Acute poisoning is considered one of the most important medical emergencies, resulting in severe morbidity and mortality, and is an economic burden on governments. This study aimed to determine the extent of acute adult intoxication among the population located in the Najran area, Saudi Arabia, over the last 3 years (from January 2017 to December 2019). The study is a hospital-based retrospective observational study. The data of all acutely intoxicated adult patients were collected from patients' files of King Khalid Hospital, the main hospital in the Najran area. In this study, the total number of intoxicated patients was 852. Patients were divided into three groups according to their age: 15-25 years, 26-35 years and >35 years. Accidental intoxication was predominant (64.6%), especially with therapeutic drugs (60.2%), predominantly acetaminophen and amphetamine, which intoxicated 24.5% and 23.4% of the patients, respectively. Moreover, this study showed that 10.6% of patients were intoxicated with overdoses of alcohol, mostly among patients aged over 35 years. Furthermore, the present study revealed that 23.9% of patients were intoxicated with household chemicals, especially Clorox bleach or Flash. Patients presented with a wide range of symptoms; some were even asymptomatic. Overall, patients' outcomes were good; mortalities were few (1.2%), and most fatalities were found in patients aged over 35 years (60%). The present study showed that pharmaceutical drugs constituted the most common causative agents in acute intoxication. Household chemicals, especially Clorox bleach, Flash and pesticides, are highly implicated in the acute toxicity problem. Drug abuse, especially amphetamine and alcohol, still represents a great threat facing people from the Najran region. It is crucial to deliver effective public health education programmes to increase community awareness about the predisposing risk factors of acute toxicity, whether as overdoses or suicide attempts.

Impact of Lockdown due to COVID-19 on the Modalities of Intoxicated Patients Presenting to the Emergency Room

INTRODUCTION

Coronavirus disease 2019 (COVID-19) pandemic influences health care facilities world-wide. The flow rate, type, and severity of cases presented to emergency departments varied during the pandemic in comparison to the past years. However, this change has not been well-described among the cases of hospital admission due to toxic exposure.

STUDY OBJECTIVE

Recognition of the pattern of toxic exposure among the cases refereed to Tanta Poison Control Center (TPCC; Tanta, Egypt) during the past five years, and furthermore, exploration of the impact of lockdown due to the COVID-19 pandemic on the pattern of presented cases.

METHODS

The current study is a five-year retrospective, comparative cross-sectional study carried out among acutely intoxicated patients admitted to TPCC during the spring months (March through May) of 2016-2020. A total of 1,916 patients with complete medical records were recruited. The type and manner of toxic exposure, demographic, clinical data, and outcomes were analyzed.

RESULTS

The current study noted that there were delays in time from toxic exposure to emergency services during the lockdown period. This was reflected in significant lower recovery rates (884.8/1,000 population; z = -3.0) and higher death rates (49.4/1,000 population; z = 2.1) despite the marked decrease in the total number of hospital admissions in comparison to the past four years. The lockdown period showed significantly higher phosphides (z = 3.5; χ2 = 34.295; P <.001) and antipsychotics exposure (z = 3.6; χ2 = 21.494; P <.001) than the previous years. However, predominance of female exposure and intentional self-poisoning was maintained over the past five years, including the lockdown.

CONCLUSION

COVID-19-associated lockdown greatly reformed the usual intoxication pattern of the cases admitted to emergency room. Also, it played a role in delaying time of hospital arrival, which was reflected as lower recovery rates and higher death rates.

Mental health in hospital emergency departments: cross-sectional analysis of attendances in England 2013/2014

Objective

To describe the population of patients who attend emergency departments (ED) in England for mental health reasons.

Methods

Cross-sectional observational study of 6 262 602 ED attendances at NHS (National Health Service) hospitals in England between 1 April 2013 and 31 March 2014. We assessed the proportion of attendances due to psychiatric conditions. We compared patient sociodemographic and attendance characteristics for mental health and non-mental health attendances using logistic regression.

Results

4.2% of ED attendances were attributable to mental health conditions (median 3.2%, IQR 2.6% to 4.1%). Those attending for mental health reasons were typically younger (76.3% were aged less than 50 years), of White British ethnicity (73.2% White British), and resident in more deprived areas (59.9% from the two most deprived Index of Multiple Deprivation quintiles (4 and 5)). Mental health attendances were more likely to occur ‘out of hours’ (68.0%) and at the weekend (31.3%). Almost two-thirds were brought in by ambulance. A third required admission, but around a half were discharged home.

Conclusions

This is the first national study of mental health attendances at EDs in England. We provide information for those planning and providing care, to ensure that clinical resources meet the needs of this patient group, who comprise 4.2% of attendances. In particular, we highlight the need to strengthen the availability of hospital and community care ‘out of hours.’

Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications

In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN^-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.

An epidemiological snapshot of toxicological exposure in children 12 years of age and younger in Riyadh

BACKGROUND

Poisoning among the pediatric population is an important public health concern that is responsible for frequent pediatric emergency department visits and hospital admissions. Surveillance of poisoning cases is essential for designing and implementing effective preventive strategies.

OBJECTIVE

Describe the characteristics of acute poison exposure and related therapeutic interventions in children aged 12 years and younger.

DESIGN

Prospective, descriptive cross-sectional study.

SETTING

Two pediatric emergency departments in Riyadh.

PATIENTS AND METHODS

We prospectively reviewed pediatric poisonings that presented to emergency departments over a period of two years.

MAIN OUTCOME MEASURES

Epidemiological aspects of pediatric poisoning Riyadh.

SAMPLE SIZE

1035 patients.

RESULTS

The median (IQR) age at the time of exposure was 27 (23-42) months. The most frequently involved substance class was toxic household products in children younger than 6 years and pesticides in children 6 years or older. A frequently involved single agent was paracetamol in younger and older children. The majority of patients (78.7%) were completely asymptomatic at the time of presentation and during the observation period. Almost half of the exposure incidents (47.8%) needed no intervention. Most exposure incidents (95%) did not require any pharmacological support and most (87%) did not require nonpharmacological intervention. Eight (0.7%) patients required intubation and mechanical ventilation. Activated charcoal was administered for 27% of cases. Gastric lavage, whole bowel irrigation, and ipecac were used in a few cases (1%, 0.3%, and 0.1%, respectively). Enhanced elimination interventions were performed for only 0.5% of exposure cases. Only two patients died.

CONCLUSIONS

Household products were the commonest reason for pediatric poisonings in Saudi Arabia and most of them were asymptomatic. Our results suggest a need for strategic plans for prevention and care.

LIMITATIONS

May not be representative of the experiences and practices of smaller hospitals in remote regions of the country.

CONFLICT OF INTEREST

None.

Analysis of Patients with Acute Toxic Exposure between 2009 and 2013: Data from the Korea Health Insurance Review and Assessment Service and the National Emergency Department Information System

BACKGROUND

According to domestic studies, patients visiting the emergency departments (ED) with acute toxic exposure comprise 0.68%-5.5% of all ED patients, with various causes and motives. The purpose of this study is to investigate the clinical and social characteristics of patients with toxic exposure visiting the ED.

METHODS

This study spanned a period of five years, from January 1, 2009 to December 31, 2013. The data were extracted using the National Emergency Department Information System (NEDIS) and The Korea Health Insurance Review and Assessment Service (HIRA).

RESULTS

From the HIRA database, during the study period (2009-2013); 310,159 (2009), 289,829 (2010), 288,906 (2011), 285,514 (2012), and 279,575 (2013) patients, respectively, visited EDs with diagnoses related to exposure to toxic substances. The number of patients who presented with acute toxic exposure compared to all ED visits significantly decreased consistently (7.8%, 6.9%, 6.0%, 5.0%, 4.1%) over 5 years. Regarding the cause of toxic exposure, substances other than drugs accounted for the largest percentage, and increased annually. Acetylcysteine was the most commonly prescribed antidote, and patients in their 40s and 50s showed the most frequent visits. The monthly distribution was highest in July-September, and higher in January than in other months.

CONCLUSION

This study found that the percentage of patients visiting the ED is decreasing, the exposure to quasi-drugs was the most common, and the exposure to antipsychotic drugs was the most frequent.

Acute poisoning in Shenyang, China: a retrospective and descriptive study from 2012 to 2016

OBJECTIVES

Up-to-date information on the patterns of acute poisoning is crucial for the proper management of poisoning events. The objectives of this study were to analyse the characteristics of patients suffering from acute poisoning admitted to the emergency department (ED) in a tertiary medical centre in Northeast China and to compare these characteristics with those of a previous comparable study.

DESIGN

Retrospective and descriptive study.

SETTING

Data were collected from the hospital information system in Shengjing Hospital, China, from January 2012 to December 2016.

PARTICIPANTS

All cases aged ≥11 years old with a diagnosis of acute poisoning.

RESULTS

In total, 5009 patients aged ≥11 years presented to the ED with acute poisoning during the study period. The average age of the patients was 36.0±15.1 years and over half (52.7%) were in the 20-39age group. The female to male ratio was 1.2:1. Patients with acute poisoning mainly lived in rural areas rather than in urban areas. The majority of patients consumed poison as suicide attempts (56.7%). Men were more commonly poisoned by drug abuse than women, but women outnumbered men in suicidal poisoning. The most common form of poison intake was ingestion (oral intake; 86.2%). The five most common toxic agent groups, in descending order, were therapeutic drugs (32.6%), pesticides (26.9%), alcohol (20.7%), fumes/gases/vapours (11.4%) and chemicals (3.6%). Sedatives/hypnotics in the therapeutic drugs group and paraquat in the pesticides group were the most common toxic agents, respectively. The mortality rate of study participants was 1.3%, with 64 deaths.

CONCLUSIONS

The results of this study indicate the need to strengthen education on the rational and safe use of drugs in Shenyang.

Hospital usage of TOXBASE in Great Britain: Temporal trends in accesses 2008 to 2015

AIM

To examine temporal trends in accesses to the UK's National Poison Information Service's TOXBASE database in Britain.

METHODS

Generalized additive models were used to examine trends in daily numbers of accesses to TOXBASE from British emergency departments between January 2008 and December 2015. Day-of-the-week, seasonality and long-term trends were analysed at national and regional levels (Wales, Scotland and the nine English Government Office Regions).

RESULTS

The long-term trend in daily accesses increases from 2.8 (95% confidence interval (CI): 2.6-3.0) per user on 1 January 2008 to 4.6 (95% CI: 4.3-4.9) on 31 December 2015, with small but significant differences in population-corrected accesses by region ( p < 0.001). There are statistically significant seasonal and day of the week patterns ( p < 0.001) across all regions. Accesses are 18% (95% CI: 14-22%) higher in summer than in January and at the weekend compared to weekdays in all regions; there is a 7.5% (95% CI: 6.1-8.9%) increase between Friday and Sunday.

CONCLUSIONS

There are consistent in-year patterns in access to TOXBASE indicating potential seasonal patterns in poisonings in Britain, with location-dependent rates of usage. This novel descriptive work lays the basis for future work on the interaction of TOXBASE use with emergency admission of patients into hospital.

Complex refractive index spectra of whole blood and aqueous solutions of anticoagulants, analgesics and buffers in the mid-infrared

Mid-infrared (MIR) spectroscopy is a powerful tool for characterising the vibrations of molecular bonds and is therefore ideal for label-free detection of chemical species. Recent research into thin-film deposition and etching techniques for mid-infrared materials shows potential for realising miniaturised bedside biosensors for clinical diagnostics exploiting MIR spectroscopy, to replace laboratory based-techniques. However, lack of refractive index information for commonly encountered biological media and analytes hampers optimisation of biosensor performance for maximum sensitivity, especially for devices exploiting evanescent spectroscopy. Here we present refractive index data for human whole blood and several aqueous solutions of general interest to the clinical community: anticoagulants, analgesics and buffers. The refractive indices are generally dominated by the water content of each sample and the whole blood spectra exhibit additional strong features due to protein content. Furthermore, we present a generalised method for extracting complex refractive indices of aqueous solutions in the mid-infrared region using conventional attenuated total reflection Fourier transform spectroscopy (ATR-FTIR) without the need for collimated or polarised incident light, as is required for existing methods.

Characteristics of acute adult poisoning cases admitted to a university hospital in Istanbul

Background: The aim of this retrospective study was to analyse the characteristics of acute adult poisoning cases admitted to a university hospital in Istanbul, Turkey. Patients and methods: All cases admitted to the Emergency Unit of the Istanbul University Cerrahpaşa Medical Faculty Hospital, between January 2001 and December 2001, were included in this study. We analysed the clinical charts for aetiological and demographical characteristics of the acutely poisoned patients. Results: There were 284 poisoning cases (207 females and 77 males) among 11 834 patients admitted to the Emergency Unit. This was 2.4% of all emergency admissions. The female-to-male ratio was 3:1. The mean age was 27±12 years (age range 15–87) and the majority of the patients (73.94%) were below the age of 30 years. The median age was 24 years. Medicinal drugs were the major cause (69.37%) of the cases, followed by inhalation of gases (14.44%), alcohol (5.99%), alcohol together with illicit drugs (4.23%), food (3.17%), corrosives (1.76%) and pesticides (1.06%). The route of administration was as follows: 84.51% orally, 14.44% by inhalation and 1.06% by intravenous injection. Seventy-one per cent of acute poisonings were self-inflicted and 88% occurred at home. The most frequently involved medicinal drugs were antidepressants and analgesics. In 32.04% of cases, there was more than one medicinal drug responsible for the poisoning. The seasonal distribution in poisoning patients suggested a peak in summer (31.7% of presentations) and winter (30.9%) and lower numbers in spring (22.9%) and autumn (14.5%). The follow-up period of the patients were 1–12 hours for 42 cases (15%), 13–24 hours for 134 cases (47%) and more than 24 hours for 108 cases (38%). Two of the 284 cases with acute poisonings were fatal. This was a university hospital-based study, so these results may not be representative of the general population. Despite this drawback, these data still provide important information about the characteristics of poisoning in the largest city of the country.

Demographical, aetiological and clinical characteristics of poisonings in Mersin, Turkey

Background: As acute poisoning continues to be an important public health problem, and represents a frequent cause of admission in emergency departments, there is a constant need to have up to date information about it. The aim of this retrospective study was to evaluate the demographical, aetiological and clinical characteristics of acute poisonings who were admitted to a university hospital in the south part of Turkey. Methods: The data of 195 acute poisoning patients who were admitted to the Emergency Department of Mersin University were retrospectively studied. Results: Most poisonings occurred in the age range 0–6 years (57.5%) for children and 17–25 year (46.7%) for adults. The overall female to male ratio was 1.26. Drugs were the most common cause of poisonings (55.4%). Among the drug poisonings, psychotropics (41.7%) were the most frequent agent, followed by analgesics (20.4%). 67.7% of the cases presented to the emergency department within 3 hours of poisoning and the procedures for elimination of poison were performed in most of them. The clinical status of the patients on arrival was generally good. 69.2% of the patients were hospitalized. The mean duration of hospitalization was 2.49±2.8 days. 41.8% of the suicidal cases had a history of psychiatric disorders; 92.8% of the patients were discharged home after toxicological treatment; 2.6% of the cases died. Conclusion: Further studies are necessary to collect more data and these data will be helpful not only for determining risk factors of acute poisonings but also for developing education and prevention programmes.

Acute intoxication cases admitted to the emergency department of a university hospital

BACKGROUND

This study aimed to describe the clinical and socio-demographic aspects of acute poisoning in 2010 in Duzce City, Northwest Anatolian Region of Turkey.

METHODS

Acute poisoning was due to the intentional ingestion of drugs in young and adult people (≥16), who were treated at the Emergency Service of Duzce University Medical Hospital, Turkey from January 1, 2010 to December 31, 2010. In this retrospective and descriptive study, 95 patients were diagnosed with intoxications and 30 of them intentionally ingested drugs to commit suicide. Records of the patients diagnosed with intoxication were obtained from the Clinical Archive of the hospital. Their diagnoses were established according to the International Statistical Classification of Diseases and Related Health Problems. Codes X60-X84 of this classification were used to classify self-infringed drug injuries and drug poisoning.

RESULTS

In this series, 35 (36.8%) patients were male and 60 patients (63.2%) female. The male/female ratio was 1.0/1.7. The mean age of the patients was 33.1±14.2 years; 17 (17.9%) patients were below 20 years old and 9 (9.5%) were older than 50 years. Of these patients, 29 (30.5%) were single, 7 (7.4%) divorced or separated, and 59 (62.1%) married. Their mean time for admission to the emergency service after the incident was 208±180 (15-660) minutes. The mean time for admission to the emergency service for patients with food intoxication after the incident was 142±160 minutes, for those with drug intoxication 173±161 minutes, for those with carbon monoxide (CO) intoxication 315±209 minutes, and for those with undefined intoxication 289±166 minutes (P=0.005). Most of the intoxication cases occurred in winter (41.1%, 39 of 95 patients). Admissions to the emergency service were most common in December and April (21 and 16 of 95 patients, respectively). Sixty-five (68.4%) cases were involved in non-deliberate poisoning, whereas 30 (31.6%) were involved in deliberate poisoning. Twenty-six of the 95 patients with acute poisonings had mortality risk at admission, however only one died from CO intoxication in the emergency service (1.1%). Suicide attempts were more common in females than in males (21 of 30 patients, 70%, P<0.05).

CONCLUSION

In Duzce City of Turkey, most intoxication cases occurred in winter, especially in December. They had non-deliberate poisoning, but deliberate poisoning in suicide attempts was more common in females than in males.

The predictive value of hospital admission serum alanine transaminase activity in patients treated for paracetamol overdose

BACKGROUND

Paracetamol is a major cause of poisoning. Treatment decisions are predominately based on the dose ingested and a timed blood paracetamol concentration because most patients present to hospital soon after overdose, before hepatotoxicity can be confirmed/excluded using serum alanine transaminase (ALT). Nonetheless, ALT is measured at hospital presentation; we investigated its value in predicting hepatotoxicity.

METHODS

From March 2011 to May 2012, patients admitted to the Royal Infirmary of Edinburgh for paracetamol overdose treatment were identified. We determined the value of admission ALT (below or above our upper limit of normal-50 IU/l) at predicting three endpoints: 1-doubling of ALT; 2-peak ALT >1000 IU/l; 3-peak international normalized ratio (INR) >2.

RESULTS

From 500 patients, 410 met the entry criteria; 264 presented within 8 h of overdose, 54 between 8 and 24 h, 53 after 24 h and 39 were staggered ingestions. Admission ALT was increased in 71. For endpoint 1 (ALT doubling), the positive predictive value (PPV) of admission ALT was 19% [95% confidence interval (CI) 12-30] with a negative predictive value (NPV) of 98% (95% CI 96-99); endpoint 2 (ALT >1000 IU/l: PPV 23% (95% CI 14-34) and NPV 100% (95% CI 99-100) and for endpoint 3 (INR >2): PPV 14% (95% CI 7-25) and NPV of 100% (95% CI 99-100). The NPV remained high when only late presenters were included.

CONCLUSION

Admission ALT within the normal range has a high NPV and could be used, alone or in combination with newer biomarkers, to identify lower risk patients at hospital presentation.

A dosing regimen for immediate N-acetylcysteine treatment for acute paracetamol overdose

CONTEXT

Current treatment of paracetamol (acetaminophen) poisoning involves initiating a 3-phase N-acetylcysteine (NAC) infusion after comparing a plasma concentration, taken ≥ 4 h post-overdose, to a nomogram. This may result in dosing errors, a delay in treatment, or possibly more adverse effects - due to the use of a high dose rate for the first infusion when treatment is initiated.

OBJECTIVE

Our aim was to investigate a novel dosing regimen for the immediate administration of NAC on admission at a lower infusion rate.

METHODS

We used a published population pharmacokinetic model of NAC to simulate a scenario where a patient presents to the hospital 2 h post-overdose. The conventional regimen is commenced 6 h post-overdose when the 4-h plasma paracetamol concentration is available. We investigated an NAC infusion using a lower dosing rate initiated immediately on presentation. We determined a dosing rate that gave an area under the curve (AUC) of the concentration-time curve that was the same or greater than that from the conventional regimen on 90% of occasions.

RESULTS

Lower dosing rates of NAC initiated immediately resulted in a similar exposure to NAC. An infusion of 110 mg/kg over the first 5 h (22 mg/kg/h) followed by the last two phases of the conventional regimen, or 200 mg/kg over 9 h (22.6 mg/kg/h) followed by the last phase of the conventional regimen could be used.

CONCLUSION

The novel dosing regimen allowed immediate treatment of a patient using a lower dosing rate. This greatly simplifies the current dosing regimen and may reduce NAC adverse effects while ensuring the same amount of NAC is delivered.

Epidemiology of acute drug poisoning in a tertiary center from Iasi County, Romania

The aim of this retrospective epidemiological study was to investigate the demographical, etiological and clinical characteristics of acute drug poisonings in Iasi County, Romania. All patients were referred and admitted in the Toxicology Clinic of “Sf. Ioan” Emergency Clinic Hospital Iasi, Romania. Between 2003 and 2009, 811 cases of acute drug poisonings were recorded, counting for 28.43% from the total number of poisonings. The majority of these poisonings resulted in mild (51.94%) and medium (28.35%) clinical forms, while 19.71% were coma situations. In all, 63.51% of patients originated from urban areas, 39.94% were unemployed and the patients were predominantly women (66.46%). A high percentage (97.27%) were suicide attempts, using only one type of drug (65.88%) and the 21–30 years group (29.8%) records the highest incidence, for both women and men. The most frequently involved drugs were benzodiazepines 13.69%, anticonvulsive drugs 8.63%, barbiturates 8.51% and cardiovascular drugs 5.92%. Drugs combinations were recorded in 32.92% of cases and 1.2% were combinations between drugs and other substances. Mortality was the outcome in 0.3% of the total registered number of acute drug poisonings. This study underlines that in order to provide a proper management of these situations, a Regional Poison Information Center is absolutely necessary.

Acute adult poisoning cases admitted to a university hospital in Tabriz, Iran

The aim of our study was to investigate the etiological and demographical characteristics of acute adult poisoning cases admitted to a university hospital in Tabriz, Iran. This retrospective study was performed on 1342 poisoning admissions to a university hospital from 2003 to 2005, by data collection from the medical records of patients. Poisonings were 5.40% of the total admissions. There was a predominance of female patients (55.7%) compared to male patients (44.3%) with a female-to-male ratio of 1.2:1. Most poisonings occurred in the age range of 11–20 years (38.9%). Drugs were the most common cause of poisonings (60.8%). Among the drug poisonings, benzodiazepines (40.31%) were the most frequent agents, followed by antidepressants (31.98%). The seasonal distribution in poisoning patients suggested a peak in spring (28%) and summer (27.5%). In 9.8% of cases accidental and in 90.2% intentional poisonings were evident. Most suicide attempts were made by women (58.51%) and unmarried people (51.4%).The mean duration of hospitalization was 3.02 ± 2.8 days. There were 28 (2.3%) deaths; the majority (13 cases) was due to pesticides. This was a university hospital-based study, so these results may not be representative of the general population. Despite this drawback, these data still provide important information on the characteristics of the poisoning in this part of Iran. To prevent such poisonings, the community education about the danger of central nervous system-acting drugs and reducing the exposure period of people to pesticides are recommended.

Adverse reactions associated with acetylcysteine

INTRODUCTION

Paracetamol (acetaminophen) is one of the most common agents deliberately ingested in self-poisoning episodes and a leading cause of acute liver failure in the western world. Acetylcysteine is widely acknowledged as the antidote of choice for paracetamol poisoning, but its use is not without risk. Adverse reactions, often leading to treatment delay, are frequently associated with both intravenous and oral acetylcysteine and are a common source of concern among treating physicians.

METHODS

A systematic literature review investigating the incidence, clinical features, and mechanisms of adverse effects associated with acetylcysteine.

RESULTS

A variety of adverse reactions to acetylcysteine have been described ranging from nausea to death, most of the latter due to incorrect dosing. The pattern of reactions differs with oral and intravenous dosing, but reported frequency is at least as high with oral as intravenous. The reactions to the intravenous preparation result in similar clinical features to true anaphylaxis, including rash, pruritus, angioedema, bronchospasm, and rarely hypotension, but are caused by nonimmunological mechanisms. The precise nature of this reaction remains unclear. Histamine now seems to be an important mediator of the response, and there is evidence of variability in patient susceptibility, with females, and those with a history of asthma or atopy are particularly susceptible. Quantity of paracetamol ingestion, measured through serum paracetamol concentration, is also important as higher paracetamol concentrations protect patients against anaphylactoid effects. Most anaphylactoid reactions occur at the start of acetylcysteine treatment when concentrations are highest. Acetylcysteine also affects clotting factor activity, and this affects the interpretation of minor disturbances in the International Normalized Ratio in the context of paracetamol overdose.

CONCLUSION

This review discusses the incidence, clinical features, underlying pathophysiological mechanisms, and treatment of adverse reactions to acetylcysteine and identifies particular "at-risk" patient groups. Given the commonality of adverse reactions associated with acetylcysteine, it is important to ensure that any adverse event does not preclude patients from receiving maximal hepatic protection, particularly in the context of significant paracetamol ingestion. Further work on mechanisms should allow specific therapies to be developed.

Demographics of toxic exposures presenting to three public hospital emergency departments in Singapore 2001-2003

Background

The demographics of poisoned patients and the circumstances of toxic exposure have not been evaluated in Singapore for the last 10 years.

Aim

This study aims to give an estimate of the burden of poisoning in Singapore from the emergency department’s (ED) perspective.

Method

A retrospective study of toxic exposure was conducted over a period of 3 years from 2001 to 2003 at the ED of three public hospitals, one being a paediatric hospital.

Results

There were 9,212 cases of toxic exposures during the study period, which constituted 0.94% of total ED attendances. The poison exposure rate was 1.7 per 1,000 population and the estimated case fatality rate was 0.8 per 1,000 ED attendances for poisoning. The mean age of patients was 29 years and the majority were male (63.3%). Non-accidental injuries constituted 60% of the cohort. Alcohol was the commonest toxin involved (26%), but paracetamol (acetaminophen) was the most common pharmaceutical agent (33%). The mean time of exposure to ED presentation was 3.3 h. About one third of the patients were admitted of whom 157 patients (4.7% of admitted cases) required intensive care management.

Conclusion

The patients were predominantly young adults. This may suggest a need for poison prevention and chemical safety education to reduce the impact on this high-risk group. Although poisoning accounts for only 1% of the total ED attendance, a sizable proportion of them required inpatient care (36.1%) with a significant proportion requiring intensive care management. However, it was also noted that a third of those who were admitted stayed for less than 24 h, and hence a short-stay ward in the ED might be a cost-effective strategy to consider.

Etiology and outcome of patients presenting for poisoning to the emergency department in Taiwan: a prospective study

Poisoning is one of the most common reasons for visiting the emergency department in many countries, and the pattern varies from countries to countries and time to time. To compare the etiology and outcome of poisoning patients in different gender and age groups, we conducted a prospective study at the emergency departments of two medical centers in southern Taiwan between January 2001 and December 2002. All cases of poisoning, excluding patients diagnosed as cases of alcohol or food poisoning, were included, and relevant information was collected. There were 1512 cases of poisoning observed with a male to female ratio of 1:1.2 (684/828). Overall, drugs (49.9%) were the main agents involved, and a suicidal attempt (66.1%) was the predominant etiology. A total of 63 fatalities (4.2%) were observed and pesticides, especially paraquat, resulted in most fatalities. Patients aged 19–30 years constituted the most cases, and significant differences in exposure agents, causes, and fatality rates were found among different age and gender groups. The results are compatible with the trend reported by other Asian countries. This study also shows important differences existing in poisoning patients of different age and gender groups. Therefore, different poisoning-prevention strategies should be applied to different groups.

Presentations of patients of poisoning and predictors of poisoning-related fatality: findings from a hospital-based prospective study

BACKGROUND

Poisoning is a significant public health problem worldwide and is one of the most common reasons for visiting emergency departments (EDs), but factors that help to predict overall poisoning-related fatality have rarely been elucidated. Using 1512 subjects from a hospital-based study, we sought to describe the demographic and clinical characteristics of poisoning patients and to identify predictors for poisoning-related fatality.

METHODS

Between January 2001 and December 2002 we prospectively recruited poisoning patients through the EDs of two medical centers in southwest Taiwan. Interviews were conducted with patients within 24 hours after admission to collect relevant information. We made comparisons between survival and fatality cases, and used logistic regressions to identify predictors of fatality.

RESULTS

A total of 1512 poisoning cases were recorded at the EDs during the study period, corresponding to an average of 4.2 poisonings per 1000 ED visits. These cases involved 828 women and 684 men with a mean age of 38.8 years, although most patients were between 19 and 50 years old (66.8%), and 29.4% were 19 to 30 years. Drugs were the dominant poisoning agents involved (49.9%), followed by pesticides (14.5%). Of the 1512 patients, 63 fatalities (4.2%) occurred. Paraquat exposure was associated with an extremely high fatality rate (72.1%). The significant predictors for fatality included age over 61 years, insufficient respiration, shock status, abnormal heart rate, abnormal body temperature, suicidal intent and paraquat exposure.

CONCLUSION

In addition to well-recognized risk factors for fatality in clinical settings, such as old age and abnormal vital signs, we found that suicidal intent and ingestion of paraquat were significant predictors of poisoning-related fatality. Identification of these predictors may help risk stratification and the development of preventive interventions.

Variations in time of hospital presentation for deliberate self-harm and their implications for clinical services

BACKGROUND

Variation in number, characteristics and management of deliberate self-harm (DSH) patients presenting to hospital during the 24-h cycle and day of the week may have implications for patient services. We have investigated how patient characteristics and clinical management of DSH episodes vary according to hour and day of presentation.

METHODS

Time of presentation was studied in 5348 DSH patients who presented to a general hospital following 9101 episodes during a 6-year period. Patient characteristics were identified through routine clinical monitoring.

RESULTS

Presentations varied markedly during the 24-h cycle, ranging from a peak between 8 pm and 3 am (average hourly rate of 6.6% of all episodes) to a low between 4 am and 10 am (1.4%). The majority (72.0%) occurred outside office hours. DSH associated with alcohol use and interpersonal problems was more frequent during the late evening or night, and at the weekend. A greater proportion of daytime presentations involved high suicide intent (although a larger number of high intent acts presented at other times), and more were admitted and assessed.

LIMITATIONS

This study was based on DSH presentations to one hospital. Time and date of presentation and of psychosocial assessment, not time of DSH, were available for analysis.

CONCLUSIONS

Peak times for DSH presentations are at night and the weekend, suggesting that specialist DSH services in general hospitals should be available 24 h a day, 7 days a week. Time of presentation should not be used as a proxy measure of suicide intent.

Tricyclic antidepressant poisoning : cardiovascular toxicity

Tricyclic antidepressants remain a common cause of fatal drug poisoning as a result of their cardiovascular toxicity manifested by ECG abnormalities, arrhythmias and hypotension. Dosulepin and amitriptyline appear to be particularly toxic in overdose. The principal mechanism of toxicity is cardiac sodium channel blockade, which increases the duration of the cardiac action potential and refractory period and delays atrioventricular conduction. Electrocardiographic changes include prolongation of the PR, QRS and QT intervals, nonspecific ST segment and T wave changes, atrioventricular block, right axis deviation of the terminal 40 ms vector of the QRS complex in the frontal plane (T 40 ms axis) and the Brugada pattern (downsloping ST segment elevation in leads V1-V3 in association with right bundle branch block). Maximal changes in the QRS duration and the T 40 ms axis are usually present within 12 hours of ingestion but may take up to a week to resolve. Sinus tachycardia is the most common arrhythmia due to anticholinergic activity and inhibition of norepinephrine uptake by tricyclic antidepressants but bradyarrhythmias (due to atrioventricular block) and tachyarrhythmias (supraventricular and ventricular) may occur. Torsade de pointes occurs uncommonly. Hypotension results from a combination of reduced myocardial contractility and reduced systemic vascular resistance due to alpha-adrenergic blockade. Life-threatening arrhythmias and death due to tricyclic antidepressant poisoning usually occurs within 24 hours of ingestion. Rapid deterioration is common. Level of consciousness at presentation is the most sensitive clinical predictor of serious complications. Although a QRS duration >100 ms and a rightward T 40 ms axis appear to be better predictors of cardiovascular toxicity than the plasma tricyclic drug concentration, they have at best moderate sensitivity and specificity for predicting complications.

Paracetamol and salicylate testing: routinely required for all overdose patients?

OBJECTIVES

To determine whether it is necessary to routinely measure serum salicylate levels in addition to serum paracetamol levels in alert overdose patients who deny ingestion of that substance.

METHODS

Prospective observational study of overdose patients attending an urban emergency department.

RESULTS

A total of 171 patients attended with an alleged overdose. Thirty-seven patients were excluded; 24 patients had a reduced conscious level (Glasgow Coma Scale <15), nine patients could not recall the time of overdose and four patients had a staggered overdose. In all, 47.0% (63/134) claimed to have taken paracetamol and 5.2% (7/134) claimed to have taken salicylate. No patient who denied taking paracetamol or salicylate subsequently tested positive for them. In all, 51.5% (69/134) of patients reported that they had taken alcohol at the time of their overdose.

CONCLUSION

Given the relatively low clinical risk and evident symptoms and signs from salicylate overdose, routine testing may not be required for fully conscious asymptomatic patients who deny taking it. The risks of delayed toxicity and lack of initial symptoms in those ingesting paracetamol suggests that continued routine testing is necessary.

Acute poisoning cases admitted to a university hospital emergency department in Diyarbakir, Turkey

AIM

This study was conducted to determine the biological effects of acute poisoning, the nature of agents involved and the pattern of poisoning in Diyarbakir City, in the Southeast Anatolian region of Turkey, during 2000.

METHOD

Hospital records of all admissions to the Emergency Department (ED) of Dicle University Hospital following acute poisoning were revised and all data from January to December 2000 were analysed. The present study included 44 (25.9%) male (M) and 126 (74.1%) female (F), a total of 170 patients. The M/F ratio was 1.0/3.5.

RESULTS

The mean age of patients was 23.3+/-6.3 years; 63 (37.1%) of them were under 20 years of age and 147 (86.5%) were under 30 years of age. Most intoxication cases occurred during the summer season (93 of 170 patients). On a monthly basis, admissions during April, May and July were most common (24, 26 and 30 patients, respectively). Sixty-two (36.5%) cases involved accidental poisoning while 108 (63.5%) involved deliberate poisoning. In suicide attempts, intoxications were more common in females (77 cases, 71.3%, P < 0.05), and in unmarried persons (74 cases, 68.5%, P < 0.05). There were only two deaths (1.2%) among the 170 admissions of acute poisonings. One of the deaths was due to pesticide poisoning and the other was due to medical drug abuse. Tachycardia (59, 34.7%), vomiting (55, 32.4%) and loss of consciousness (42, 24.7%) were frequently observed, whereas hypersecretion (15, 8.8%), bradycardia (5, 2.9%), convulsion (8, 4.7%) and hypertension (2, 1.2%) were less frequent. Among pesticide poisoning cases the incidence of convulsion (6, 10.2%), miosis (6, 10.2%), and hypersecretion (12, 20.3%) were significantly higher when compared to other cases (P=0.018, P <0.0001 and P <0.0001, respectively).

CONCLUSION

In the Southeast Anatolian region of Turkey, pesticide intoxication is common especially among young, unmarried females and most of these intoxications are intentional self-poisonings. The annual rate of poisoning-related ED visits and mortality were found to be within expected ranges; psychoactive agents being the most common cause.

Characteristics of acute adult poisoning in Gaziantep, Turkey

BACKGROUND

The objective of this prospective hospital-based study was to evaluate the rate and characteristics of acute human poisoning in our province (Gaziantep City, Turkey).

METHODS

All cases of acute human poisonings admitted to the emergency department of the Gaziantep University Hospital, Gaziantep, Turkey, between January 2000 and December 2001, were included in the study. The rate and causes of mortality from poisoning as well as demographic data of the patients were investigated.

RESULTS

There were 179 (0.7%) poisoning cases among 25,605 patients who admitted to the emergency department. Of the poisoning cases, 64.3% were female and 35.6% were male patients. The poisoning made a peak between the ages of 16 and 25. The majority of poisonings resulted from oral ingestion with deliberate intake accounting for 78.7% of the cases. Most of the suicide attempt cases were also females. Analgesics were the most common agents (42.4%) among the drugs incriminated in poisoning. Twenty-four patients (13.7%) were admitted to intensive care unit, of whom 42% were female and 58% were male patients. Drugs for suicide attempts were the main cause of poisoning in the patients who admitted to intensive care unit. Five patients (2.8% of all cases) died in the intensive care unit.

CONCLUSIONS

These data provide important preliminary information on the pattern of symptomatic poisonings in this south-east part of our country.

Web based information on clinical toxicology for the United Kingdom: uptake and utilization of TOXBASE in 2000

AIMS

To examine the use and uptake of TOXBASE, an Internet database for point of care provision of poisons information in the United Kingdom during its first calendar year of web-based access.

METHODS

Interrogation of the database software to examine: use by different types of user and geographical origin; profile of ingredient and product access; time of access to the system; profile of access to other parts of the database.

RESULTS

Registered users of the system increased in the first full year of operation (1224 new users) and usage of the system increased to 111 410 sessions with 190 223 product monograph accesses in 2000. Major users were hospitals, in particular accident and emergency departments. NHS Direct, a public access information service staffed by nurses, also made increasing use of the system. Usage per head of population was highest in Northern Ireland and Scotland, and least in southern England. Ingredients accessed most frequently were similar in all four countries of the UK. Times of use of the system reflect clinical activity, with hospitals making many accesses during night-time hours. The most popular parts of the database other than poisons information were those dealing with childhood poisoning, information on decontamination procedures, teratology information and slang terms for drugs of abuse.

CONCLUSIONS

This Internet system has been widely used in its first full year of operation. The provision of clinically relevant, up to date, information at the point of delivery of patient care is now possible using this approach. It has wide implications for the provision of other types of therapeutic information in clinical areas. Web-based technology represents an opportunity for clinical pharmacologists to provide therapeutic information for clinical colleagues at the bedside.

Paracetamol overdose: an evidence based flowchart to guide management

A flowchart for the management of patients with paracetamol poisoning is presented to help clinicians in the emergency department.

TOXBASE: poisons information on the internet

OBJECTIVES

To assess the uptake, usage and acceptability of TOXBASE, the National Poisons Information Service internet toxicology information service.

METHODS

An observational study of database usage, and a questionnaire of users were undertaken involving users of TOXBASE within the UK between August 1999, when the internet site was launched, and May 2000. The main outcome measures were numbers of registered users, usage patterns on the database, responses to user satisfaction questionnaire.

RESULTS

The number of registered users increased from 567 to 1500. There was a 68% increase in accident and emergency departments registered, a 159% increase in general practitioners, but a 324% increase in other hospital departments. Between January 2000 and the end of May there had been 60 281 accesses to the product database, the most frequent to the paracetamol entry (7291 accesses). Ecstasy was the seventh most frequent entry accessed. Altogether 165 of 330 questionnaires were returned. The majority came from accident and emergency departments, the major users of the system. Users were generally well (>95%) satisfied with ease and speed of access. A number of suggestions for improvements were put forward.

CONCLUSIONS

TOXBASE has been extensively accessed since being placed on the internet (http://www.spib.axl.co.uk). The pattern of enquiries mirrors clinical presentation with poisoning. The system seems to be easily used. It is a model for future delivery of treatment guidelines at the point of patient care.

Parasuicidal poisoning treated in a Greek medical ward: epidemiology and clinical experience

OBJECTIVE

To study the epidemiology of acute poisoning patients presenting to an acute medical service ward in a Greek hospital between January 1998 and December 2000.

DESIGN

Prospective case series.

RESULTS

A total of 273 patients with self-poisoning were included in the study. This represented 3.8% of the overall admissions to the unit. The mean age of patients was 33, the most frequent age group being that aged 20-30 years (36.2% of total) with a male-to-female ratio of 1:1.97. Sixty per cent of patients was admitted within 4 h. Those from urban areas comprised 76.2% and 23.8% from rural areas. The most frequently ingested agents were psychopharmaceuticals (37.4%) and analgesics/anti-rheumatics (32.6%). Pesticides (7.7% of total) were most frequently used by patients coming from rural areas (32.3% of patients from rural areas). Alcohol was included in the overdose in 8.4%. Of the patients, 16.2% had a previous history of overdose. In this case series, psychiatric assessment suggested that 52% of the patients had a formal psychotic diagnosis, 21% had personality disorder and 27% had taken an overdose in response to stress. The most frequently documented precipitating factors were family problems and disputes (37%). Unusually, the seasonal distribution in these patients suggested a peak in summer (37.5% of presentations) with lower numbers in spring (30.2%), autumn (17.7%) and winter (14.6%). Of the patients, 23.7% presented in July. A total of 73.5% of patients was conscious, 16.4% was somnolent, 4.5% was in precoma and 5.6% was in coma (GCS <8). Patients who received antidotal therapy comprised 17.9%. Evidence of hepatic dysfunction was observed in 8.9% of patients and renal dysfunction in 3.6%. Extracorporeal techniques for drug removal (hemodialysis and hemoperfusion) were used in 2.2% of patients. Intensive care therapy was required in 11.4% of patients. The mean overall hospitalization time was 3.3 days. The mortality rate was 2.9%.

CONCLUSIONS

This study shows that the epidemiology of self-harm by overdose in Greece is significantly different in terms of the seasonal presentation from other parts of Europe. The agents ingested and other features are similar to northern Europe. Psychiatric diagnoses are more common in our group than in those reported from northern Europe.

Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: does it change outcome?

OBJECTIVE

To assess whether measuring plasma paracetamol concentrations in all patients with drug overdose or collapse (altered consciousness) changes outcome.

METHOD

A retrospective survey was performed of all patients attending the Accident and Emergency Department at Guy's Hospital, London over a 12 month period who had plasma paracetamol concentrations measured (it is hospital policy that patients presenting after any drug overdose, or with a collapse/altered consciousness have a plasma paracetamol concentration).

RESULTS

A total of 440 patients were identified who had plasma paracetamol concentrations measured, of whom 411 were eligible for the study. Altogether 115 patients presented after a collapse and paracetamol was detected in four of these. A total of 296 patients presented after a drug overdose-136 denied overdose with a paracetamol containing product and paracetamol was not detected in any of these 136 cases. Of the remaining 160 patients who gave a positive history for overdose with paracetamol, 122 presented within 24 hours and 94 had detectable paracetamol values with 16 cases above the treatment line, 12 presented more than 24 hours after ingestion, and 26 presented with a staggered overdose. One patient died as a result of paracetamol overdose.

CONCLUSIONS

This is the first study in the United Kingdom to evaluate the clinical value of routine paracetamol levels in patients presenting to the emergency department after any overdose or a collapse. Taking blood samples for plasma paracetamol estimation in patients who deny taking paracetamol is of little clinical value. However, there is the potential for missing significant paracetamol poisoning in patients presenting with collapse and so screening with a plasma paracetamol concentration is clinically justified in these patients. Such an approach can only be justified in a country in which paracetamol poisoning is prevalent, such as the United Kingdom.

Etiologic and demographic characteristics of poisoning: a prospective hospital-based study in Oman

BACKGROUND

The health care system in Oman is characterized by its rapid development and free medical services for all its nationals although traditional medicine still plays a major role in daily life. Epidemiological data on poisoning are scanty.

OBJECTIVE

To determine the annual rate of poisoning-related Accident & Emergency Department visits at Sultan Qaboos University Hospital in Oman and to evaluate, in both children and adults, the etiologic and demographic characteristics of poisoning cases. The poisoning pattern is contrasted to that of other countries.

METHODS

A prospective observational study included all symptomatic and asymptomatic poisoning-related Accident & Emergency Department visits over 4 years (1996-1999). Data were recorded on a specifically designed poison reporting form.

RESULTS

Two hundred and four poisoning-related Accident & Emergency Department visits were recorded corresponding to an average annual rate of 1.8/1000 Accident & Emergency Department visits. Therapeutic agents were most commonly involved (50% of all cases). Accidental poisoning in toddlers was most commonly caused by drugs. Intentional poisoning in adults involved mainly therapeutic agents (50%), particularly analgesics, followed by industrial and environmental agents (25%). Animal poisoning (14%) was most commonly encountered in adult males. Traditional remedies constituted 7% of all poisoning cases. A total of 148 patients (73%) were admitted for 1 to 175 days.

CONCLUSIONS

Compared to studies performed in urban hospitals in other countries, (1) the annual rate of poisoning-related Accident & Emergency Department visits was substantially lower, (2) psychoactive drugs were less frequently incriminated in intentional ingestions, and (3) we found a significantly higher frequency of poisoning by animals and traditional remedies than reported by urban hospitals in other Middle Eastern countries. The limitations of our study (Accident & Emergency Department-based data collection in an urban hospital) do not permit extrapolation to the rest of the country.

Deliberate self-harm and antidepressant drugs. Investigation of a possible link

BACKGROUND

It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs.

AIMS

To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event.

METHOD

This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant.

RESULTS

Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P<0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline.

CONCLUSIONS

Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.

Reduction in incidence of severe paracetamol poisoning

We report substantial reductions in the frequency of severe paracetamol hepatotoxicity locally and nationally after legislative limitations on its sale. These reductions were not explained by changes in referral patterns or use of N-acetylcysteine.

Effectiveness of delayed activated charcoal administration in simulated paracetamol (acetaminophen) overdose

AIMS

Oral activated charcoal is used to treat drug overdose and is effective at reducing drug absorption when administered within 1 h of drug ingestion. There are fewer data on efficacy when the delay is longer, as is the case in most drug overdoses. This study investigated the efficacy of activated charcoal at preventing paracetamol (acetaminophen) absorption after simulated overdose when administration was delayed between 1 and 4 h.

METHODS

An open randomized-order four-way crossover study was performed in healthy volunteers comparing the effect of activated charcoal 50 g on the absorption of 3 g paracetamol tablets when administered after an interval of 1, 2 or 4 h or not at all. Plasma paracetamol concentrations were measured over 9 h after paracetamol ingestion using h.p.l.c. and areas under the curve between 4 and 9 h (AUC(4,9 h)) calculated as a measure of paracetamol absorption.

RESULTS

Activated charcoal significantly reduced paracetamol AUC(4,9 h) when administered after 1 h (mean reduction 56%; 95% Confidence intervals 34, 78; P<0.002) or 2 h (22%; 6, 39; P<0.03) but not after 4 h (8%; -8, 24). When administered after 1 h activated charcoal reduced individual plasma paracetamol concentrations significantly at all times between 4 and 9 h after paracetamol administration. Administration at 2 or 4 h had no significant effect.

CONCLUSIONS

These results in healthy volunteers cannot be extrapolated directly to poisoned patients. However, they provide no evidence of efficacy for activated charcoal when administered after an interval of more than 2 h.

Etiological and demographical characteristics of acute adult poisoning in Ankara, Turkey

1. The aim of this retrospective study was to evaluate etiological and demographical characteristics of acute adult poisoning patients during 1 year at a university hospital in Ankara, Turkey. 2. Two-hundred and twenty-eight adults (of which 180 were suicidal poisoning cases) were admitted to the emergency center with acute poisonings. This was 0.7% of all emergency admissions. The female-to-male ratio was 3:1, and the majority of patients (63.6%) were below the age of 25 years. 3. Drugs were the major cause in 75. 9% of the cases, followed by inhalation of gases (17.6%), food (2. 6%), corrosives (2.2%), pesticides (0.9%), and alcohol (0.9%). Analgesics were the most common cause of drug poisoning (29.7% of all substances). There were no fatalities. 4. It is important to realize that this study is a hospital-based study, and hence it may be considered difficult to draw conclusions for the whole population of Turkey. However, we consider that the reason for such a high ratio of analgesic poisoning is probably due to the habit of extensive analgesic prescribing in Ankara, which is the capital of Turkey.

Effect of activated charcoal alone or given after gastric lavage in reducing the absorption of diazepam, ibuprofen and citalopram

AIMS

The efficacy of activated charcoal alone, and gastric lavage followed by charcoal in reducing the absorption of diazepam, ibuprofen and citalopram was studied in healthy volunteers.

METHODS

In a randomized cross-over study with three phases, nine healthy volunteers were administered single oral doses of 5 mg diazepam, 400 mg ibuprofen and 20 mg citalopram, taken simultaneously after an overnight fast. Thirty minutes later, the subjects were assigned to one of the following treatments: 200 ml water (control), 25 g activated charcoal as a suspension in 200 ml water or gastric lavage followed by 25 g charcoal in suspension given through the lavage tube. Plasma concentrations of diazepam, ibuprofen and citalopram were determined up to 10 h.

RESULTS

The AUC(0,10 h) of diazepam was reduced by 27% (P<0.05) by both charcoal alone and charcoal combined with lavage. The increase in plasma diazepam concentration from 0.5 h onwards was prevented by both interventions (P</=0.05), whereas the Cmax of diazepam was not significantly affected by either treatment. The AUC(0, 10 h) of ibuprofen was reduced by 49% (P<0.05) after the combination treatment and by 30% (P<0.05) after charcoal alone, but there was no significant difference between these two treatments. Both charcoal alone and the combination treatment were equally effective in preventing the increase in plasma ibuprofen from 0.5 h onwards (P<0.01). The Cmax of ibuprofen was reduced by 45% (P<0.05) and by 21% (P=NS), respectively. The AUC(0,10 h) of citalopram was reduced by 51% (P<0.05) after both charcoal alone and charcoal combined with lavage, and the Cmax by 52% (P<0.05) and 54% (P<0.05), respectively. The increase in plasma citalopram concentration from 0.5 h onwards was reduced by about 50% (P<0.01) by both interventions.

CONCLUSIONS

Activated charcoal alone and charcoal combined with lavage showed similar efficacy in preventing the absorption of diazepam, ibuprofen and citalopram. These results suggest that gastric lavage needs not be routinely performed before administration of charcoal.

A prospective study of acute poisonings in Finnish hospital patients

1. We have carried out a prospective study of all adult patients presenting with acute poisoning during one month to the Helsinki University Central Hospital (Meilahti Hospital). 2. Two hundred and twenty-six cases of acute poisoning (113 males and 113 females) presented to the emergency department. Most cases in both men (66%) and women (67%) involved alcohol. As to drugs, psychotropic agents predominated in both men and women. The frequency of patient presentation peaked between 7 p.m. and 9 p.m. and was lowest between 8 a.m. and 10 a.m. In most cases, the delay from ingestion of the poison to presentation was longer than 4 h. 3. The clinical status of the patients on arrival was generally good; more than half (55%) of them were fully awake. Serious symptoms (e.g. unconsciousness, insufficient respiration necessitating intubation, aspiration, convulsions or hypotension) occurred in 15% of the presentations. There were no fatalities. 4. One hundred and thirty-five patients (60%) received at least one 50-g dose of activated charcoal. However, charcoal was given in 86% of the cases of drug poisoning. Gastric lavage was performed in 112 cases (50%), and 106 cases (47%) involved both gastric lavage and administration of charcoal. Twenty-one patients received antidotes (flumazenil, calcium gluconate or naloxone) and three patients were hemodialysed. 5. Of the 226 cases, 142 (63%) were managed solely in the emergency department. Of the 84 cases admitted to the hospital, eight had to be managed in the intensive care unit. Almost all patients (94%) were discharged within 24 h. 6. In this survey on 226 consecutive cases of acute poisoning, about two-thirds of the cases involved alcohol, while the most common drugs taken were psychotropic agents. The poisoning was mild in the great majority of the cases. Activated charcoal was generally administered in all but trivial cases of drug poisoning.

Paracetamol poisoning in the north east of England: presentation, early management and outcome

1. Paracetamol is increasingly involved in self-poisoning in the United Kingdom and remains a common cause of fatal poisoning. 2. To document the epidemiology and early management of paracetamol poisoning data were collected on consecutive patients with suspected paracetamol poisoning presenting to 6 hospitals in the North East of England over 12 weeks in 1994. 3. There were 400 presentations (attendance rate 1.14/10(3) population/yr) involving 343 persons (45% male). Paracetamol concentrations at 4 h correlated weakly with reported paracetamol dose (R = 0.49, P < 0.0001) and were similar comparing those treated and not treated by gastric decontamination. 4. In 38 (9%) cases paracetamol concentrations were above the appropriate nomogram treatment line, including 3% and 20% of patients who reported ingesting less than and more than 12 g respectively. In 21 patients acetylcysteine treatment was deferred until admission to the ward, the mean delay involved was 2.8 h. 5. One patient died, from arrhythmias caused by co-ingested dothiepin. 6. Paracetamol poisoning is common. Most cases do not have potentially toxic plasma paracetamol concentrations, but those who do often present late and antidotal treatment may be delayed inappropriately.

Factors affecting hospital admission and length of stay of poisoned patients in the north east of England

1. Poisoning is a common reason for presentation to hospital and hospital admission but there is no agreed policy for managing these patients. This study examined the management of patients presenting with poisoning and the factors affecting the probability of hospital admission and prolonged stay. 2. Data on all cases of poisoning presenting to six Accident and Emergency departments in the North East of England over 12 weeks in 1994 was collected prospectively from A&E notes. Length of stay and outcome were recorded from hospital computer records. 3. Overall, 73% of patients were admitted to a medical ward. Probability of admission was not independently affected by age or gender but was increased in those with intentional poisoning (Odds Ratio (OR) 3.3 [95% CI 1.8, 6.1]), a history of self harm (OR 1.7, [1.0, 2.9]) or potentially hazardous poisoning (OR 3.7 [2.1, 6.6]). There were significant variations between hospitals (50-80%) which could not be attributed to case mix. 4. Prolonged stay (> 2 nights) was more common in patients over 65 years (OR 6.8 [2.9, 16.1]), those with intentional poisoning (OR 2.7 [1.1, 6.6]) and those with potentially hazardous poisoning (OR 2.6 [1.4, 4.9]). Mean hospital stay was 1.5 days and varied significantly between hospitals from 0.8 to 2.1 days and this was independent of case mix. 5. There are appreciable variations in the management of poisoning between hospitals which are not explained by patient characteristics. Savings would occur if rates of admission and duration of stay were reduced by those hospitals where admission is more frequent or hospital stay is longer. However, the impact of this on long term morbidity is unknown.