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Reisinger AC, Schneider N, Schreiber N, Janisch M, Rauch I, Kaufmann P, Wünsch G, Eller P, Hackl G. Critical care management of acute intoxications, dynamics and changes over time: a cohort study. Intern Emerg Med 2024:10.1007/s11739-024-03570-2. [PMID: 38502464 DOI: 10.1007/s11739-024-03570-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
Abstract
Acute intoxications and poisonings are a relevant cause for ICU admission of critically ill patients. This study aimed to determine the characteristics of intoxicated patients in a tertiary center medical ICU in Austria over time and to investigate parameters associated with ICU mortality. This study was a retrospective data analysis including adult ICU patients from the years 2007 to 2021. In addition to ICU documentation, pre-hospital, and emergency department documents as well as autopsy reports were utilized. In an exploratory subanalysis, we compared these findings to a historical dataset from our facility from 1992 to 1996. We identified 581 cases admitted to the medical ICU because of acute poisoning (2007-2021), of which 45% were female and 46.6% were mixed intoxications. Suicidal intent was the primary cause of intoxication (48.2%) and ICU length of stay was median 1.2 days. The majority of deceased patients received pre-hospital mechanical CPR. Primary and secondary poison/toxin removal modalities were used in 29.9% and 11.7% of cases, whereas antidotes were administered in 54.4%. Comparing the data with a historical cohort (n = 168), we found a shift in primary detoxification away from gastric lavage and an increase in alternative secondary poison/toxin removal techniques. The ICU mortality was 4.1% and 4.2% in the present and historic cohort, respectively. Pre-existing psychiatric illnesses increased from 49% in the historic to 69% in the present cohort. Psychiatric illness predisposes patients to severe intoxications necessitating ICU care, thus increasing prevention measures seems warranted. Females did present with a different spectrum of intoxications compared to males. ICU mortality remained low over time and most deceased patients had a grim prognosis already on ICU arrival.
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Affiliation(s)
- Alexander Christian Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Nikolaus Schneider
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Nikolaus Schreiber
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Martina Janisch
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Ines Rauch
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Department of Anesthesiology, LKH Hochsteiermark, Bruck an der Mur, Austria
| | - Peter Kaufmann
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Gerrit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
| | - Gerald Hackl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
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Wiersma T, van den Oever HLA, van Hout FJHA, Twijnstra MJ, Mauritz GJ, van 't Riet E, Jansman FGA. The performance of COBRA, a decision rule to predict the need for intensive care interventions in intentional drug overdose. Eur J Emerg Med 2022; 29:126-133. [PMID: 34560700 DOI: 10.1097/mej.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND COBRA was developed as a decision rule to predict which patients visiting the emergency department (ED) following intentional drug overdose will not require intensive care unit (ICU) interventions. COBRA uses parameters from five vital systems (cardiac conduction, oxygenation, blood pressure, respiration, and awareness) that are readily available in the ED. COBRA recommends against ICU admission when all these parameters are normal. OBJECTIVE The primary aim of this study was to determine the negative predictive value (NPV) of COBRA in predicting ICU interventions. Secondary outcomes were the sensitivity, specificity and positive predictive value (PPV), and the observation time required for a reliable prediction. DESIGN Observational cohort study. SETTINGS AND PARTICIPANTS Patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function were included, and data necessary to complete the decision rule was collected. The attending physician in the ED made the actual admission decision, on the basis of clinical judgement. COBRA was measured 0, 3 and 6 h after arrival at the ED. OUTCOME MEASURES Need for ICU interventions (treatment of convulsion; defibrillation; mechanical or noninvasive ventilation; intravenous administration of vasopressive agents, antiarrhythmics, atropine, calcium, magnesium or sedation; continuous hemofiltration or administration of antagonist/antidote and fluid resuscitation). MAIN RESULTS Of 230 new cases (144 unique patients), 59 were immediately referred to the psychiatric services and/or sent home by the attending physician, 27 went to a regular ward, and 144 were admitted to the ICU. Of these 144 cases, 40 required one or more ICU interventions. By the time the first parameters were collected, the NPV of COBRA was 95.6%. After 3 h of observation, NPV was 100%, while sensitivity, specificity and PPV were 100, 61.1 and 35.1%, respectively. None of these values improved by prolonging the observation time to 6 h. CONCLUSION In patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function, the COBRA decision rule showed good performances in predicting the need for intensive care interventions, with a NPV of 100% after 3 h of observation.
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Affiliation(s)
| | | | | | | | - Gert-Jan Mauritz
- Department of Emergency Medicine, Rijnstate Teaching Hospital, Arnhem
| | | | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Deventer
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Groningen, The Netherlands
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3
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HyperCKemia and rhabdomyolysis in the neuroleptic malignant and serotonin syndromes: A literature review. Neuromuscul Disord 2020; 30:949-958. [PMID: 33250373 DOI: 10.1016/j.nmd.2020.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022]
Abstract
Neuroleptic malignant syndrome and serotonin syndrome are two syndromes whose molecular bases remain poorly understood. The phenotypes of both syndromes overlap with other syndromes that have a clear genetic background, in particular RYR1-related malignant hyperthermia. Through a literature review, performed according to the PRISMA guidelines, we aimed to report the clinical features of both syndromes, and the results of genetic testing performed. 10 case series and 99 case reports were included, comprising 134 patients. A male predominance of 58% was found. The median age was 35 (range 4-84) years. Eight patients experienced recurrent episodes of rhabdomyolysis. Genetic analysis was performed in eleven patients (8%), revealing four RYR1 variants, three likely benign (p.Asp849Asn, p.Arg4645Gln, p.Arg4645Gln) and one variant of uncertain significance (p.Ala612Thr). This review underlines that a subset of patients with neuroleptic malignant syndrome and serotonin syndrome develop recurrent episodes of rhabdomyolysis. This recurrent pattern suggests a possible underlying (genetic) susceptibility. However, the genetic background of neuroleptic malignant syndrome and serotonin syndrome has only been investigated to a very limited degree so far. The increasing availability of next generation sequencing offers an opportunity to identify potentially associated genetic backgrounds, especially in patients with recurrent episodes or a positive family history.
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Kruijt N, van den Bersselaar LR, Kamsteeg EJ, Verbeeck W, Snoeck MMJ, Everaerd DS, Abdo WF, Jansen DRM, Erasmus CE, Jungbluth H, Voermans NC. The etiology of rhabdomyolysis: an interaction between genetic susceptibility and external triggers. Eur J Neurol 2020; 28:647-659. [PMID: 32978841 PMCID: PMC7821272 DOI: 10.1111/ene.14553] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/09/2020] [Indexed: 01/04/2023]
Abstract
Background and purpose Rhabdomyolysis is a medical emergency characterized by acute skeletal muscle breakdown with a sudden rise and subsequent fall of serum creatine kinase (CK) levels. Rhabdomyolysis events are provoked by exposure to external triggers, possibly in combination with an increased genetic susceptibility. We aimed to describe comprehensively the external triggers and potentially pathogenic genetic variants possibly implicated in increased rhabdomyolysis susceptibility. Methods We performed a retrospective single‐center study, including a total of 1302 patients with an acute CK level exceeding 2000 IU/l. Results Anoxia was the most frequently reported trigger (40%). A subset of 193 patients were clinically suspected of an underlying genetic disorder (recurrent episodes, a positive family history, very high or persistently increased CK levels). In 72 of these patients, an unequivocal genetic defect was identified. A total of 22 genes with pathogenic variants were identified, including 52 different variants. Of those, 11 genes have been previously associated with rhabdomyolysis (ACADVL, ANO5, CPT2, DMD, DYSF, FKRP, HADHA, PGM1, LPIN1, PYGM, RYR1). Eleven genes are probably implicated in increased susceptibility (including AGL, CAPN3, CNBP, DMPK, MAGT1, ACADM, SCN4A, SGCA, SGCG, SMPD1, TANGO2). Conclusion These findings suggest that the spectrum of genetic susceptibility for rhabdomyolysis has not yet been completely clarified. With the increasing availability of next‐generation sequencing in a diagnostic setting, we expect that in more cases a genetic defect will be identified.
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Affiliation(s)
- N Kruijt
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - L R van den Bersselaar
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands.,Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - E J Kamsteeg
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - W Verbeeck
- Department of Pharmacology and Toxicology, Radboudumc, Nijmegen, The Netherlands.,Vincent van Gogh Institute for Psychiatry, Venlo, Venray, The Netherlands
| | - M M J Snoeck
- Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - D S Everaerd
- Department of Psychiatry, Radboudumc, Nijmegen, The Netherlands
| | - W F Abdo
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - D R M Jansen
- Department of Geriatrics, Radboudumc, Nijmegen, The Netherlands
| | - C E Erasmus
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands.,Department of Paediatrics, Radboudumc, Nijmegen, The Netherlands
| | - H Jungbluth
- Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK.,Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, UK.,Department of Paediatric Neurology, Neuromuscular Service, Guy's and St Thomas' Hospital NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - N C Voermans
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
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Verheij C, Rood PPM, Deelstra CK, Levendag MLL, Koch BCP, Polinder S, Schuit SCE, Haagsma JA. Emergency Department visits due to intoxications in a Dutch university hospital: Occurrence, characteristics and health care costs. PLoS One 2019; 14:e0226029. [PMID: 31856178 PMCID: PMC6922372 DOI: 10.1371/journal.pone.0226029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/19/2019] [Indexed: 11/19/2022] Open
Abstract
Background Intoxications with alcohol and drugs are common in the Emergency Department. This study aimed to describe the occurrence and characteristics of intoxications (alcohol, Drugs of Abuse (DOA), pharmaceutical and chemical) presented to the Emergency Department and the health care costs of these intoxications. Methods This was a retrospective medical record study of all patients (≥ 16 years) who presented to the Emergency Department of an inner-city academic hospital in the Netherlands due to single or multiple intoxication(s) as the primary or secondary reason in the year 2016. An intoxication was reported as present if the attending physician described the intoxication in the patient’s medical record. Results A total of 783 patients were included, accounting for 3.2% of the adult Emergency Department population (age ≥ 16 year). In 30% more than one substance was used. Intoxications with alcohol, Drugs of Abuse and pharmaceuticals was reported in respectively 62%, 29% and 21% of the intoxicated patients. The mean costs per patient presenting with an intoxication to the Emergency Department was € 1,490. The mean costs per patient were highest for pharmaceutical intoxications (€ 2,980), followed by Drugs of Abuse (€ 1,140) and alcohol (€ 1,070). Conclusions Intoxications among patients aged 16 years and older are frequently seen at the Emergency Department and are frequently caused by multiple substances. Alcohol is the most common intoxication. Substantial healthcare costs are involved. Therefore, this study suggests that further research into hazardous alcohol consumption and DOA abuse is warranted.
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Affiliation(s)
- C. Verheij
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- * E-mail:
| | - P. P. M. Rood
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C. K. Deelstra
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M. L. L. Levendag
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - B. C. P. Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S. Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S. C. E. Schuit
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J. A. Haagsma
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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6
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Grimsrud MM, Brekke M, Syse VL, Vallersnes OM. Acute poisoning related to the recreational use of prescription drugs: an observational study from Oslo, Norway. BMC Emerg Med 2019; 19:55. [PMID: 31615421 PMCID: PMC6794774 DOI: 10.1186/s12873-019-0271-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 09/24/2019] [Indexed: 12/19/2022] Open
Abstract
Background Recreational use of prescription drugs is widespread. We describe acute poisonings related to the recreational use of prescription drugs. Methods Retrospective observational study. We retrospectively registered all patients presenting from October 2013 through March 2015 at a primary care emergency outpatient clinic in Oslo, Norway, with an acute poisoning related to recreational drug use. We registered demographic data, toxic agents taken, clinical course and treatment. From this data set we extracted the 819/2218 (36.9%) cases involving one or more prescription drugs. Results Among the 819 included cases, 190 (23.2%) were female. Median age was 37 years. The drugs most commonly involved were benzodiazepines in 696 (85.0%) cases, methadone in 60 (7.3%), buprenorphine in 53 (6.5%), other opioids in 56 (6.8%), zopiclone/zolpidem in 26 (3.2%), and methylphenidate in 11 (1.3%). Prescription drugs were combined with other toxic agents in 659 (80.5%) cases; heroin in 351 (42.9%), ethanol in 232 (28.3%), amphetamine in 141 (17.2%), cannabis in 70 (8.5%), gamma-hydroxybutyrate (GHB) in 34 (4.2%), cocaine in 29 (3.5%), and other illegal drugs in 46 (5.6%). The patient was given naloxone in 133 (16.2%) cases, sedation in 15 (1.8%), and flumazenil in 3 (0.4%). In 157 (19.2%) cases, the patient was sent on to hospital. Conclusions One in three acute poisonings related to recreational drug use involved prescription drugs. Benzodiazepines were by far the most common class of drugs. Prescription drugs had mostly been taken in combination with illegal drugs or ethanol.
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Affiliation(s)
- Marit Mæhle Grimsrud
- Faculty of Medicine, University of Oslo, Oslo, Norway.,The Norwegian PSC Research Center, Oslo University Hospital, Oslo, Norway
| | - Mette Brekke
- General Practice Research Unit, University of Oslo, Oslo, Norway
| | - Victoria Lykke Syse
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Oslo Accident and Emergency Outpatient Clinic, Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway
| | - Odd Martin Vallersnes
- Oslo Accident and Emergency Outpatient Clinic, Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway. .,Department of General Practice, University of Oslo, Oslo, Norway.
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7
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Descamps AMK, Vandijck DM, Buylaert WA, Mostin MA, Paepe PD. Characteristics and costs in adults with acute poisoning admitted to the emergency department of a university hospital in Belgium. PLoS One 2019; 14:e0223479. [PMID: 31584988 PMCID: PMC6777762 DOI: 10.1371/journal.pone.0223479] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 09/23/2019] [Indexed: 11/21/2022] Open
Abstract
Objective The aims of this study were to assess the characteristics of all acute poisoning admissions among adult emergency department (ED) patients, to identify factors associated with admission and to calculate direct medical cost. Methods Data of 2017 (1st January to 31st December) were collected and analyzed retrospectively using patients’ medical records and hospital invoices. Factors associated with type of hospitalization were identified using appropriate statistics. Results A total of 1,214 hospital admissions were included, accounting for 3.6% of all ED admissions. Men (62.2%) and the age group 21–40 years (43.0%) accounted for the largest proportion. Substances most commonly involved were ethanol (52.9%), benzodiazepines (9.7%), cocaine (4.9%), cannabis (4.6%), antidepressants (4.6%) and psychostimulants (4.6%). A total of 4,561 treatment acts were recorded, most commonly monitoring of vital signs (63.6%) and medication and/or intravenous drip administration (62.9%). Patients were discharged home after having received care in the emergency department (ED-amb) in 54.5% of admissions, were admitted to the emergency-department-24-hours-observation unit (ED-24h) or were hospitalized (Hosp) in 24.6% and 20.9% of admissions, respectively. Factors found to be associated with hospitalization type were age, hour of admission, victim location, degree of severity, use of antidotes, involvement of antidepressants, antipsychotics, psychostimulants, benzodiazepines and ethanol. Total cost was €1,512,346 with an average of €1,287 per admission. Conclusion Poisonings entail a considerable percentage of patients admitted to an ED and financial burden. In particular, ethanol poisonings account for the largest proportion of all ED admissions. Comparison of our figures with other data is hampered by the heterogeneity in inclusion criteria. Availability of a uniform template would facilitate comparison and allow better monitoring policies for prevention and cost reduction.
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Affiliation(s)
- Anne-Marie K. Descamps
- Antigifcentrum/Centre Antipoisons, Brussels, Belgium
- Department of Public Health of Ghent University, Ghent, Belgium
- Department of Medicine and Health Sciences of Hasselt University, Diepenbeek, Belgium
- * E-mail: anne-marie.descamps@poisoncentre,
| | - Dominique M. Vandijck
- Department of Public Health of Ghent University, Ghent, Belgium
- Department of Medicine and Health Sciences of Hasselt University, Diepenbeek, Belgium
| | - Walter A. Buylaert
- Department of Emergency Medicine of Ghent University Hospital, Ghent, Belgium
| | | | - Peter De Paepe
- Department of Emergency Medicine of Ghent University Hospital, Ghent, Belgium
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8
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Hondebrink L, Rietjens SJ, Donker DW, Hunault CC, van den Hengel-Koot I, Verputten PM, de Vries I, Kaasjager KAH, Dekker D, de Lange DW. A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study. Eur J Intern Med 2019; 66:41-47. [PMID: 31113710 DOI: 10.1016/j.ejim.2019.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/13/2019] [Accepted: 05/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission. METHODS For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect. RESULTS We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%). CONCLUSIONS The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.
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Affiliation(s)
- Laura Hondebrink
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma van den Hengel-Koot
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Pauline M Verputten
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Irma de Vries
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Douwe Dekker
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Internal Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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Choi KM, Chan CK, Lau FL. Toxicology Training Unit in Emergency Department Reduces Admission to other Specialties and Hospital Length of Stay. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the outcome of intoxicated patients presented to Accident and Emergency Department (AED) in Hong Kong with Toxicology Training Unit accreditation and AED without toxicology team. Method A retrospective observational study with data collection from all intoxicated cases reported through Pre-hospital Activated Charcoal Programme, a protocol driven poisoning reporting system, from 1/7/2011 to 30/6/2013 (2 years). Data on basic demographic data (e.g. sex, age), receiving AED, admission rate to other specialty, length of stay in hospital exclude psychiatry ward admission and clinical outcome were collected and analysed. Five AEDs with Toxicology Training Unit (study group) and 7 AEDs without toxicology team (control group) were included. Results A total of 329 intoxicated cases were included in this study. The basic epidemiological data were similar in both groups. There was a significantly lower in hospital admissions in study group (16.9%) than in control group (69.3%; p<0.001) and significant shorter median of hospital stay of 22.1 hours (interquartile range [IQR] 12.8-43.5 hours) in study group compare to 42.7 hours (IQR 20.4-76.1 hours) in control group (p<0.001). Conclusion Our findings show that the establishment of the toxicology training unit can achieve significant reduction in admissions to other specialty and the length of stay in hospital in the management of patients with acute intoxication.
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Measuring inhibition of monoamine reuptake transporters by new psychoactive substances (NPS) in real-time using a high-throughput, fluorescence-based assay. Toxicol In Vitro 2017; 45:60-71. [PMID: 28506818 DOI: 10.1016/j.tiv.2017.05.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/03/2017] [Accepted: 05/11/2017] [Indexed: 12/12/2022]
Abstract
The prevalence and use of new psychoactive substances (NPS) is increasing and currently over 600 NPS exist. Many illicit drugs and NPS increase brain monoamine levels by inhibition and/or reversal of monoamine reuptake transporters (DAT, NET and SERT). This is often investigated using labor-intensive, radiometric endpoint measurements. We investigated the applicability of a novel and innovative assay that is based on a fluorescent monoamine mimicking substrate. DAT, NET or SERT-expressing human embryonic kidney (HEK293) cells were exposed to common drugs (cocaine, dl-amphetamine or MDMA), NPS (4-fluoroamphetamine, PMMA, α-PVP, 5-APB, 2C-B, 25B-NBOMe, 25I-NBOMe or methoxetamine) or the antidepressant fluoxetine. We demonstrate that this fluorescent microplate reader-based assay detects inhibition of different transporters by various drugs and discriminates between drugs. Most IC50 values were in line with previous results from radiometric assays and within estimated human brain concentrations. However, phenethylamines showed higher IC50 values on hSERT, possibly due to experimental differences. Compared to radiometric assays, this high-throughput fluorescent assay is uncomplicated, can measure at physiological conditions, requires no specific facilities and allows for kinetic measurements, enabling detection of transient effects. This assay is therefore a good alternative for radiometric assays to investigate effects of illicit drugs and NPS on monoamine reuptake transporters.
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11
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van den Oever HLA, van Dam M, van 't Riet E, Jansman FGA. Clinical parameters that predict the need for medium or intensive care admission in intentional drug overdose patients: A retrospective cohort study. J Crit Care 2016; 37:156-161. [PMID: 27744235 DOI: 10.1016/j.jcrc.2016.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 08/04/2016] [Accepted: 09/21/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Many patients with intentional drug overdose (IDO) are admitted to a medium (MC) or intensive care unit (IC) without ever requiring MC/IC related interventions. The objective of this study was to develop a decision tool, using parameters readily available in the emergency room (ER) for patients with an IDO, to identify patients requiring admission to a monitoring unit. METHODS Retrospective cohort study among cases of IDO with drugs having potentially acute effects on neurological, circulatory or ventilatory function, admitted to the MC/IC unit between 2007 and 2013. A decision tool was developed, using 6 criteria, representing intubation, breathing, oxygenation, cardiac conduction, blood pressure, and consciousness. Cases were labeled as 'high acuity' if one or more criteria were present. RESULTS Among 255 cases of IDO that met the inclusion criteria, 197 were identified as "high acuity". Only 70 of 255 cases underwent one or more MC/IC related interventions, of which 67 were identified as 'high acuity by the decision tool (sensitivity 95.7%). CONCLUSION In a population of patients with intentional drug overdose with agents having potentially acute effect on vital functions, 95.7% of MC/IC interventions could be predicted by clinical assessment, supplemented with electrocardiogram and blood gas analysis, in the ER.
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Affiliation(s)
- Huub L A van den Oever
- Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Mirja van Dam
- Intensive Care Unit, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Esther van 't Riet
- Teaching Hospital Deventer, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands; Department of Pharmacotherapy, -Epidemiology and -Economics, University Groningen, Antonius Deusinglaan 1, 9713AV, Groningen, The Netherlands.
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Toxicodynetics: A new discipline in clinical toxicology. ANNALES PHARMACEUTIQUES FRANÇAISES 2016; 74:173-89. [PMID: 27107462 DOI: 10.1016/j.pharma.2016.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Regarding the different disciplines that encompass the pharmacology and the toxicology, none is specifically dedicated to the description and analysis of the time-course of relevant toxic effects both in experimental and clinical studies. The lack of a discipline devoted to this major field in toxicology results in misconception and even in errors by clinicians. MATERIAL AND METHODS Review of the basic different disciplines that encompass pharmacology toxicology and comparing with the description of the time-course of effects in conditions in which toxicological analysis was not performed or with limited analytical evidence. RESULTS Review of the literature clearly shows how misleading is the current extrapolation of toxicokinetic data to the description of the time-course of toxic effects. CONCLUSION A new discipline entitled toxicodynetics should be developed aiming at a more systematic description of the time-course of effects in acute human and experimental poisonings. Toxicodynetics might help emergency physicians in risk assessment when facing a poisoning and contribute to a better assessment of quality control of data collected by poison control centres. Toxicodynetics would also allow a quantitative approach to the clinical effects resulting from drug-drug interaction.
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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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Maignan M, Pommier P, Clot S, Saviuc P, Debaty G, Briot R, Carpentier F, Danel V. Deliberate drug poisoning with slight symptoms on admission: are there predictive factors for intensive care unit referral? A three-year retrospective study. Basic Clin Pharmacol Toxicol 2013; 114:281-7. [PMID: 23998644 DOI: 10.1111/bcpt.12132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/19/2013] [Indexed: 11/26/2022]
Abstract
Deliberate drug poisoning leads to 1% of emergency department (ED) admissions. Even if most patients do not exhibit any significant complication, 5% need to be referred to an intensive care unit (ICU). Emergency physicians should distinguish between low- and high-acuity poisoned patients at an early stage to avoid excess morbidity. Our aim was to identify ICU transfer factors in deliberately self-poisoned patients without life-threatening symptoms on admission. We performed a 3-year retrospective observational study in a university hospital. Patients over 18 years of age with a diagnosis of deliberate drug poisoning were included. Clinical and toxicological data were analysed with univariate tests between groups (ED stay versus ICU transfer). Factors associated with ICU admission were then included in a logistic regression analysis. Two thousand five hundred and sixty-five patients were included. 63.2% were women, and median age was 40 (28-49). 142 patients (5.5%) were transferred to ICU. Cardiac drugs [adjusted OR (aOR) = 19.81; 95% confidence interval (95% CI): 7.93-49.50], neuroleptics (aOR = 2.78; 95% CI: 1.55-4.97) and meprobamate (aOR = 2.71; 95% CI: 1.27-5.81) ingestions were significantly linked to ICU admission. A presumed toxic dose ingestion (aOR = 2.27; 95% CI: 1.28-4.02), number of ingested tablets (aOR = 1.01; 95% CI: 1.01-1.02 for each tablet) and delay between ingestion and ED arrival <2 hr (aOR = 2.85; 95%CI: 1.62-5.03) were also factors for ICU referral. The Glasgow Coma Scale was the only clinical feature associated with ICU admission (aOR = 1.57; 95% CI: 1.44-1.70 for each point loss). These results suggest that emergency physicians should pay particular attention to toxicological data on ED admission to distinguish between low- and high-acuity self-poisoned patients.
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Affiliation(s)
- Maxime Maignan
- Emergency Department and Mobile Intensive Care Unit, CHU Michallon, Grenoble, France; UJFGrenoble1/CNRS/TIMC-IMAG UMR 5525/PRETA Team, Grenoble, France
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Krayeva YV, Brusin KM, Bushuev AV, Kondrashov DL, Sentsov VG, Hovda KE. Pre-hospital management and outcome of acute poisonings by ambulances in Yekaterinburg, Russia. Clin Toxicol (Phila) 2013; 51:752-60. [DOI: 10.3109/15563650.2013.827707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lund C, Drottning P, Stiksrud B, Vahabi J, Lyngra M, Ekeberg I, Jacobsen D, Hovda KE. A one-year observational study of all hospitalized acute poisonings in Oslo: complications, treatment and sequelae. Scand J Trauma Resusc Emerg Med 2012; 20:49. [PMID: 22828054 PMCID: PMC3413541 DOI: 10.1186/1757-7241-20-49] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/24/2012] [Indexed: 11/17/2022] Open
Abstract
Objectives Changes in poisoning trends may affect both complications and outcomes in patients with acute poisoning. This study reports the treatments given and the frequency of complications, also related to treatment, mortality and sequelae related to various toxic agents. Methods All acute poisonings in adults (≥16 years) admitted to the five hospitals in Oslo were included consecutively during one year (2008 to 2009) in an observational cross-sectional multicenter study. A standardized form was completed by the treating physician, which covered the study aims. Results There were 1065 admissions in 912 patients. The median length of hospital stay was one day, and 49% were observed in an intensive care unit (ICU). Active treatment was given to 83%, and consisted of supportive therapy (70%), antidote(s) (38%), activated charcoal (16%) and gastric lavage (9%). The most commonly used antidotes were flumazenil (19%), naloxone (17%) and N-acetylcysteine (11%). The rate of treatment-related complications was 2.4% (21/884). Neither flumazenil, naloxone, nor the combination, was associated with convulsions or other complications. Among those receiving N-acetylcysteine, 5% (6/120) developed allergic reactions, one of which mandated discontinuation of treatment. Nineteen percent presented in a coma. Complications developed in 30%, compared with 18% in a 2003 study, mainly respiratory depression (12%), prolonged QTc interval (6%) and hypotension (5%). Eight patients died (0.8%) and five (0.5%) survived with permanent sequelae, mainly anoxic brain damage. Discussion Few patients stayed more than two days. The use of the ICU was liberal, considering that only one out of five presented in a coma. Antidotes were frequently given diagnostically. Although N-acetylcysteine induced allergic reactions, most were mild and treatment discontinuation was only necessary once. The frequency of complications had almost doubled in five years, although the poisoning pattern was largely unchanged. However, few patients developed permanent sequelae.
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Affiliation(s)
- Cathrine Lund
- Department of Acute Medicine, Oslo University Hospital Ullevaal, Kirkeveien 166, Oslo (0407), Norway
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