Toxicological features of deliberate self-poisonings

A Tissue Distribution Study of Propafenone in an Intentional Fatal Poisoning Case

Propafenone (PPF) belongs to the class 1C antiarrhythmics and can cause electrocardiogram-associated adverse/toxic effects. Cases of PPF intoxication are rarely investigated. We developed a novel and selective GC-MS/MS method for the determination of PPF and its tissue distribution in an intentional fatal poisoning case, which is applicable to PPF quantification in the range of therapeutic to lethal concentrations in complex post-mortem samples. A simple and effective sample pretreatment was applied to all analyzed samples. PPF was determined without the need for dilution, even in highly complex samples containing a wide range of analyte concentrations. Quantification was performed using the standard addition method, developed and validated according to the ICH M10 guidelines. The obtained results indicated that the PPF concentration in the serum from blood taken while alive, before therapy, was the highest ever reported in the literature. Despite the intensive therapy after the patients' admission, the PPF concentrations in the lungs, spleen, femoral blood and cardiac blood were fatal or abnormally high. On the other hand, the concentrations in the liver and skeletal muscle were lower or approximately the same as observed in cases with therapeutic doses. To the best of our knowledge, the distribution of PPF has not been investigated in fatal intoxication cases and can be helpful in clinical or forensic toxicology.

Paracetamol toxicity in mild overdose in combination with opioids: A retrospective observational study

AIMS

Toxicity in paracetamol overdose with opioid co-ingestion is poorly understood. We compared outcomes in both paracetamol-only and paracetamol-opioid overdoses to determine whether toxicity differed significantly between the groups, and to assess the utility of the ratio of measured plasma paracetamol concentration relative to the 4-hour nomogram-adjusted level (APAP_pl /APAP_t ).

METHODS

We conducted a retrospective observational study of all patients (n = 1159) presenting to 2 large UK hospitals between 2005 and 2013 with acute single-dose ingestion paracetamol overdose, with (n = 221) or without (n = 938) opioid co-ingestion. Adverse outcomes included biomarkers of hepatotoxicity and the need for extended treatment. Several outcomes were assessed in relation to the APAP_pl /APAP_t ratio.

RESULTS

Median ingested dose of paracetamol was low in both groups (10 g). Statistical comparison of the median APAP_pl /APAP_t ratios showed a significant difference (0.65 vs. 0.56 for the paracetamol-only and paracetamol-opioid groups respectively, P = .0329). Although there was a trend towards a lower risk of predefined toxic outcomes with opioid co-ingestion, statistical analysis did not show a significant difference, with outcomes for the paracetamol-only and paracetamol-opioid groups including the following: alanine transaminase >2× upper limit of normal, 7.7 vs. 5.7% (P = .6480); alanine transaminase >1000 IU/L, 2.4 vs. 0% (P = .2145); international normalised ratio > 1.3, 8.6 vs. 4.4% (P = .2774); and transfer to tertiary liver unit, 0.2 vs. 0% (P nonsignificant).

CONCLUSION

Our study does not support a change in current clinical practise beyond standard testing at 4 hours or longer post ingestion for mixed low dose paracetamol-opioid overdose.

Validation of the Poisoning Severity Score (PSS) in suicidal behavior by self-poisoning

Intentional self-poisoning is the leading method of suicidal behavior leading to medical attention worldwide. The medical severity of self-poisoning events has major treatment, prognostic, and medico-legal implications, yet measures of severity are limited. The Poisoning Severity Score (PSS) is a widely used scale but validation data are limited, particularly in the study of suicidal behavior per se. The sample was a consecutive series of intentional self-poisoning patients aged 13 to 65 treated at a large university medical center (n = 673). PSS scores, with a range 0 (none) to 4 (death), were calculated along with other structured clinical data and analyzed in a series of linear regressions adjusted for age and sex. Higher PSS scores were consistently associated with greater medical morbidity and more intensive acute medical treatments, and nearly all effect sizes were large. Results support the validity of the PSS in hospital-treated self-poisoning patients.

Poison exposures in young Israeli military personnel: a National Poison Center Data analysis

CONTEXT

To characterize poison exposures in young Israeli military personnel as reported to the national poison center.

METHODS

Retrospective poison center chart review over a 14-year period. Cases included were Israeli soldiers aged 18-21 years, the compulsory military service age required by the Israeli law.

RESULTS

1770 records of poison exposures in young military personnel were identified. Most exposed individuals involved males (n = 1268, 71.6%). Main routes of exposure were ingestion (n = 854, 48.3%), inhalation (n = 328, 18.6%) and ocular (n = 211, 11.9%). Accidents or misuse (n = 712, 40.2%) were the most frequently reported circumstances, followed by suicide attempts (370, 20.9%), and bites and stings (161, 9.1%). More than half of the cases involved chemicals (n = 939, 53.1%); hydrocarbons, gases and corrosives were the main causative agents. Pharmaceuticals (mainly analgesics) were involved in 519 (29.3%) cases, venomous animals (mainly scorpions, centipedes, and snakes) in 79 (4.5%). Clinical manifestations were reported in 666 (37.6%) cases, mostly gastrointestinal, neurologic, and respiratory. The vast majority of cases (1634, 92.3%) were asymptomatic or mildly affected; no fatalities were recorded. In 831 (46.9%) cases the clinical toxicologist recommended referral to an emergency department; ambulatory observation was recommended in 563 (31.8%) cases, and hospitalization in 86 (4.9%).

CONCLUSIONS

Our data show that poison exposures among young soldiers involve mainly males, accidents, misuse and suicides, oral route and chemicals; most exposures were asymptomatic or with mild severity. Repeated evaluations of poison center data pertaining to military personnel is advised for identifying trends in poison exposure and characteristics in this particular population.

Self-poisoning in the acute care medicine 2005-2012

OBJECTIVE

To describe the trend of acute self-poisoning in the emergency and intensive care.

METHODS

Electronic charts of adults who presented to the emergency department of the University Hospital Leipzig with self-poisoning following a suicide attempt (suicide group), intoxication (intoxication group), drug overdose for relief of pain or discomfort (drug overdose group) between 2005 and 2012 were analyzed.

RESULTS

3533 adults (62.6% males) were identified, with the yearly admissions increasing from 305 in 2005 to 624 in 2012. The admission rate in relation to the total emergency department admissions also increased, from 1.2% in 2005 to 1.9% in 2012. 31.7% of the patients were younger than 25 years. The reasons for self-poisoning were suicide attempt (18.1%), intoxication (76.8%) and drug overdose (2.9%). The reason could not be clearly classified in 80 patients. Psychotropic drugs were used in 71.6% of suicide attempts, while alcohol was the sole cause of intoxication in 80.1% of cases in the intoxication group. Self-poisoning using at least two substances was observed in 52.0% of the suicide attempts, 10.3% of those with intoxication and 29.7% of those with drug overdose. While alcohol remains the most common cause of intoxication, there was a drastic increase in the consumption of cannabinoids, Crystal Meth and gamma-hydroxybutyrate in the years 2011 and 2012. ICU admission was necessary in 16.6% of the cases. There were 22 deaths (0.6% of the study population), of whom 15 were in the suicide group (2.3%), four (0.15%) in the intoxication group, and three in the not clearly classified group (3.8%).

CONCLUSION

Acute self-poisoning is an increasing medical issue. Psychotropic drugs remain the most common means of suicide attempt. Although alcohol intoxication is very frequent, intake of illicit drugs as the cause of emergency admission is increasing.

Perfil das exposições a medicamentos por mulheres em idade reprodutiva atendidas por um Centro de Informações Toxicológicas

O objetivo deste artigo é descrever os dados epidemiológicos referentes às exposições a medicamentos por mulheres em idade fértil atendidas por um Centro de Informações Toxicológicas. Realizou-se um estudo com mulheres em idade fértil, expostas a medicamentos entre 2007 e 2011. Foram estudadas variáveis relacionadas às pacientes, à ocorrência e ao medicamento envolvido, totalizando 777 notificações. Os dados foram obtidos do Sistema de Informação de Agravos de Notificação e processadas com o uso do programa Epi Info. A maioria das ocorrências (90,5%) foi intencional, em 33,7% dos casos foram utilizados de dois a três medicamentos e a frequência de hospitalização foi de 35,6%. Os medicamentos com atuação no Sistema Nervoso Central foram responsáveis por 59,9% das ocorrências, destacando-se os antiepilépticos (21,2%) e os antidepressivos (20,7%). Os principais fatores associados à hospitalização das pacientes foram: demora no atendimento após a ocorrência da exposição, pacientes com nível superior, contato com dois ou mais medicamentos e exposições a antiepilépticos e antidepressivos. Os resultados obtidos mostraram que as exposições a medicamentos representam um grave problema à saúde de mulheres em idade fértil e contribuem para o aumento das internações hospitalares.

Acetaminophen intoxication is associated with decreased serum paraoxonase and arylesterase activities and increased lipid hydroperoxide levels

BACKGROUND

Acetaminophen is at present one of the most commonly used analgesics and antipyretics. Recent evidence has suggested that oxidative stress is involved in the mechanism of acetaminophen intoxication. Paraoxonase-1 (PON1) plays an important role as an endogenous free-radical scavenging molecule. The aim of this study was to evaluate the influence of serum PON1 activity and oxidative stress in patients with acetaminophen intoxication.

METHODS

A total of 20 patients with acetaminophen intoxication and 25 healthy controls were enrolled. Serum total antioxidant capacity (TAC), lipid hydroperoxide (LOOH) levels, and paraoxonase and arylesterase activities were measured spectrophotometrically.

RESULTS

The serum TAC levels and the paraoxonase and arylesterase activities were significantly lower in patients with acetaminophen intoxication compared with controls (all, p < 0.001), while the serum LOOH levels were significantly higher (p < 0.001).

CONCLUSIONS

Our results suggest that decreased PON1 activity seems to be associated with increased oxidative stress in patients with acetaminophen intoxication. Measuring serum PON1 activity may be useful in assessing the development of toxicity risk in acetaminophen toxicity. It would be useful to recommend vitamins with antioxidant effects such as vitamins C and E along with medical treatments.

Suicide attempts by deliberate self-poisoning in children and adolescents

AIM

The objective of the study was to examine the toxicological characteristics of suicide attempts by deliberate self-poisoning in children and adolescents.

METHOD

From the Toxicological Information Centre's database, the inquiries due to the suicide attempts in children (9-13 years old) and adolescents (14-18 years old) were evaluated.

RESULTS AND CONCLUSIONS

From 10,492 calls concerning suicide attempts, 2393 concerned children and adolescents. Most suicide attempts were attempted in spring (31.3%). Among the toxic agents, drugs were used in 97.8% cases. The most frequent ingestions appeared using drugs affecting the nervous system and anti-inflammatory non-steroids. The dose was evaluated as toxic in 73.4%, severely toxic in 3.0% and unknown in 11.2% cases. Only one in 10 children used a non-toxic dose. Girls, more frequently than boys (13.2% vs. 8.9%), used non-toxic doses. The symptoms of moderate and severe intoxications were present in 10.5% of the cases. Poison centre consultation was accessed within the first hour after the ingestion in one-fifth of the patients. In both age groups, the severity of the intoxication was greater among elder males who reached the medical facilities later than 4 h after the poisoning. The combinations of three or more drugs affecting central nervous system were present in the most severe cases.

Perfil das tentativas de suicídio por sobredose intencional de medicamentos atendidas por um Centro de Controle de Intoxicações do Paraná, Brasil

Este trabalho apresenta o perfil das tentativas de suicídio atendidas pelo Centro de Controle de Intoxicações da cidade de Londrina, Paraná, Brasil. Foi realizado um estudo retrospectivo dos casos atendidos entre 1997-2007. As tentativas de suicídio foram significativas entre homens desempregados e mulheres donas-de-casa/aposentadas, e houve associação com outras substâncias em 51,5% dos casos, sendo a freqüência maior entre os homens. 51,1% dos homens associaram o medicamento com bebida alcoólica, e entre as mulheres, 84,8% das associações se referiram a medicamentos. Os grupos farmacológicos de maior freqüência foram os tranqüilizantes (25,5%), antidepressivos (17%), anticonvulsivos (15%) e AINES (11,9%), respectivamente. Os prescritores devem avaliar corretamente o paciente antes de receitar psicofármacos, uma vez que esse é o grupo farmacológico mais freqüente nas tentativas de suicídio. Campanhas de conscientização para o uso racional de medicamentos, juntamente com programas sociais de atendimento ao paciente suicida, também poderiam contribuir na diminuição da freqüência desses casos.

Reliability of history of acetaminophen ingestion in intentional drug overdose patients

The objective of this study was to determine the reliability of denial of acetaminophen ingestion in intentional drug overdose patients. All intentional drug overdose patients admitted to an emergency department who were able to provide a history were included. A detailed history was obtained on names, timing and number of medications ingested, and serum acetaminophen was assayed. Multidrug ingestion was defined as the reporting of ≥2 medications. Patients were considered ‘reliable’ if they reported acetaminophen ingestion and had detectable acetaminophen levels or the other way around. Validity parameters of acetaminophen history were assessed by sensitivity, specificity and positive and negative predictive values. A total of 154 patients were included. History was significantly more reliable in patients who denied ingestion of acetaminophen (n = 107) compared with patients who reported it (n = 47; 95.3% vs 65.9%, respectively; p < 0.0001, 95% CI of the difference 17.5%—41.2%). No suicidal patient who denied both acetaminophen and multidrug ingestions had a detectable acetaminophen level (negative predictive value 1, 95% CI 0.93—1.0). It is suggested that denial of both acetaminophen and multidrug ingestions by intentional drug overdose patients after a thorough history taking can be considered reliable for acetaminophen history. In facilities with limited resources, these patients may not require routine acetaminophen screening.

Illicit cathinone (“Hagigat”) poisoning

INTRODUCTION

Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200 mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported.

METHODS

Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed.

RESULTS

Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was (1/2)-6 capsules (ingestion-32, sniffing-2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery.

CONCLUSION

Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Recovery from a psychotropic drug overdose tends to depend on the time from ingestion to arrival, the Glasgow Coma Scale, and a sign of circulatory insufficiency on arrival

PURPOSE

The aim of this study was to investigate which factors on arrival correlate with the duration of unconsciousness induced by a psychotropic drug overdose.

BASIC PROCEDURE

Patients were 175 consecutive intubated patients unconscious due to psychotropic drug overdose. They were divided into 2 groups, an "early" group in which the patients were extubated within 2 days from hospitalization, and a "delayed" group who were not extubated within 2 days.

MAIN FINDINGS

Glasgow Coma Scale (P = .001) scores in the early group were higher than those in the delayed group. The estimated time from ingestion to admission (P < .0001), creatine kinase level (P < .01), number of cases demonstrating shock (P < .05), shock index (P < .0001), and heart rate (P = .001) in the early group were smaller than those in the delayed group. Two subjects in the delayed group died of pneumonia and pulmonary embolism.

PRINCIPAL CONCLUSIONS

Delayed arrival from ingestion, a low level of unconsciousness, and a sign of circulatory insufficiency in a patient with a psychotropic drug overdose were risk factors of a delayed recovery and death.

Multiresidue analysis of seven anticoagulant rodenticides by high-performance liquid chromatography/electrospray/mass spectrometry

Mice and rat populations are commonly controlled by two classes of rodenticide anticoagulants, coumarins and indandiones. However, poisoning of nontarget animals also often occurs. For cases such as these, a rapid, multiresidue method, which provides positive confirmation for both classes of anticoagulant rodenticides, is needed by diagnostic laboratories. A method was developed for the determination of seven anticoagulant rodenticides, coumafuryl, pindone, warfarin, diphacinone, chlorophacinone, bromadiolone, and brodifacoum, in diverse matrices, animal feed, cooked beef, and fruit-flavored beverages using high-performance liquid chromatography/electrospray/mass spectrometry. Detection was by MS/MS with electrospray ionization in negative mode. Confirmation was by retention time, m/z of molecular ion, and two parent-daughter transitions. Recoveries from selected the matrices ranged from 61 to 117%. Limits of quantitation were as low as 1.5-4.5 ng g-1. The developed method was rapid and provided the simultaneous confirmation and quantification of the seven anticoagulant rodenticides.

Newer antidepressants: evaluation of fatal toxicity index and interaction with alcohol based on Finnish postmortem data

Finnish postmortem toxicology data from 1995 to 2002 was analyzed to obtain improved estimates of fatal toxicity indices for the newer antidepressants and to evaluate their interaction with alcohol. Altogether 284 fatal poisonings were attributed to 12 different newer antidepressants. Venlafaxine, mianserin, moclobemide, and mirtazapine were responsible for significantly more deaths than expected from their sales. Their fatal toxicity indices were higher than those of selective serotonin reuptake inhibitors (SSRIs) but lower than those of tricyclic antidepressants. In fatal poisonings involving alcohol in combination with venlafaxine, mianserin, moclobemide, or mirtazapine, the median blood alcohol concentration (BAC) ranged from 2.35 to 2.7 mg/g, whereas in those involving alcohol in combination with citalopram or fluoxetine the median BAC was 2.9 and 3.4 mg/g, respectively. The BAC was significantly lower in venlafaxine-related deaths than in those involving fluoxetine or citalopram. We conclude that among the newer antidepressants differences are present both in toxicity and in interaction potential with alcohol. The SSRIs appear to present a low risk of fatal poisoning when taken alone or in combination with alcohol, whereas venlafaxine is associated with an elevated risk.