Experience with 732 acute overdose patients admitted to an intensive care unit over six years

Risk factors for recurrence of suicide attempt via overdose: A prospective observational study

BACKGROUND

Although the prevalence of drug overdose has gradually increased worldwide, the risk factors associated with the recurrence of suicide attempts via drug overdose have not been well elucidated. In this study, we investigated the clinical course of patients with drug overdose and whether or not patients reattempted suicide via overdose, using telephone interviews, to evaluate the risk factors associated with overdose recurrence.

METHODS

This prospective observational study enrolled patients who attempted suicide by drug overdose and were transferred to a tertiary emergency hospital in Japan between January 1, 2015 and July 30, 2021. Recurrence of overdose within 1 year of admission for overdose was designated as the primary outcome. Multivariable logistic regression analysis was performed to assess the independent risk factors for the recurrence of overdose. Furthermore, we compared the difference in the recurrence interval between patients with and without cohabitants using the log-rank test.

RESULTS

A total of 94 patients were identified, and recurrence of overdose was observed in 28 patients (29.8%). The median recurrence interval was 6.0 months [IQR (interquartile range), 4.0-7.0 months]. The recurrence rate was significantly higher in patients with a history of schizophrenia than that in patients without a history of schizophrenia (58.3% vs 25.6%, p = 0.048), and significantly lower in patients with cohabitants than that in patients without cohabitants (22.6% vs 43.8%, p = 0.015). The presence of a cohabitant was significantly associated with a longer recurrence interval (p = 0.049). The effect of psychiatric intervention during hospitalization and psychiatric visits after discharge could not be found in this study.

CONCLUSIONS

A history of schizophrenia was an independent risk factor for the recurrence of overdose, and the presence of a cohabitant was significantly associated with a lower risk of recurrence. Large-scale, long-term studies are required to confirm the results of this study.

Alprazolam exposure during adolescence induces long-lasting dysregulation in reward sensitivity to morphine and second messenger signaling in the VTA-NAc pathway

Increased use of benzodiazepines in adolescents have been reported, with alprazolam (ALP) being the most abused. Drug abuse during adolescence can induce changes with lasting consequences. This study investigated the neurobiological consequences of ALP exposure during adolescence in C57BL/6J male mice. Mice received ALP (0, 0.5, 1.0 mg/kg) once/daily (postnatal day 35-49). Changes in responsiveness to morphine (2.5, 5.0 mg/kg), using the conditioned place preference paradigm, were assessed 24-h and 1-month after ALP exposure. In a separate experiment, mice received ALP (0, 0.5 mg/kg) and then sacrificed 24-h or 1-month after treatment to assess levels of extracellular signal regulated kinase 1/2 (ERK1/2) gene expression, protein phosphorylation, and downstream targets (CREB, AKT) within the ventral tegmental area (VTA) and nucleus accumbens (NAc). ALP-pretreated mice developed a strong preference to the compartment(s) paired with a subthreshold dose (2.5 mg/kg) of MOR short-term, and this effect was also present in the 1-month group. Adolescent ALP exposure resulted in dysregulation of ERK-signaling within the VTA-NAc pathway 24-h and 1-month after ALP exposure. Results indicate ALP exposure during adolescence potentiates the rewarding properties of MOR and induces persistent changes in ERK-signaling within the VTA-NAc pathway, a brain circuit highly implicated in the regulation of both drug reward and mood- related behaviors.

Impact of Lavender on Pain and Anxiety Levels Associated With Spine Procedures

Background: To reduce pain and anxiety associated with interventional pain procedures, sedation is often used, with benzodiazepines, opioids, and propofol the most commonly used classes of drugs for sedation. However, patient coherence and ability to communicate procedural pain and abnormal sensations help prevent adverse outcomes. Therefore, discovering alternative therapies to mitigate the anxiety and pain associated with these procedures and to minimize risk is important. The aim of our study was to investigate whether lavender has an effect on pain and anxiety associated with lumbar epidural steroid injections and lumbar medial branch blocks.

Methods: In this randomized controlled study, 54 subjects were randomly assigned to 1 of 3 intervention groups, and 46 patients were included in the final analysis: experimental lavender group (n=17), control almond oil group (n=15), and placebo sterile water group (n=14). Patients wore a mask infused with either lavender, almond oil, or water for 5 minutes prior to and during their procedure. Patients rated their anxiety using the State-Trait Anxiety Inventory prior to and after the procedure based on how they felt during the procedure. Patients rated their pain according to the numerical rating scale. Outcome measures were a comparison of pain among the 3 groups and a comparison of the change in anxiety before and after the procedure among the 3 groups.

Results: The lavender group demonstrated the highest mean change in anxiety scores (9.9) compared to almond oil (5.3) and water (3.6) preprocedurally vs postprocedurally. The lavender group also reported the lowest mean pain level (3.8) compared to almond oil (5.6) and water (5.6). However, none of the differences between groups showed statistical significance at the P<0.05 level.

Conclusion: Lavender may have a clinically beneficial effect on anxiety levels and pain reduction.

The management of the poisoned patient using a novel emergency department-based resuscitation and critical care unit (ResCCU)

OBJECTIVES

The Resuscitation & Critical Care Unit (ResCCU) is a novel ED-based ICU designed to provide early critical care services. This study sought to identify characteristics of poisoned patients treated in the ResCCU.

METHODS

We conducted a retrospective, single-center case study of poisoned patients over the age of 18 years old over a 16-month period. Patient demographics, drug concentrations, and severity of illness scores were extracted from electronic medical records. Patients were divided into two groups, those who required short term ICU level care (< 24 h) and prolonged ICU care (> 24 h).

RESULTS

A total of 58 ED visits with a tox-related illness were analyzed. There were 24 women (41%) and 34 men (59%). There were 42 patients (72%) who required short term ICU level care and 16 patients (28%) who required prolonged ICU care. In the short-term ICU group, 13 patients (31%) were discharged home directly from the ResCCU, 29 patients (69%) were sent to the inpatient floor, and 1 of the admitted floor patients expired. There were no patients admitted to the floor that required a step-up to the inpatient ICU. 56 patients (97%) were alive at post-admit day 7 and 28, and only 8 (14%) were re-admitted within 30 days.

CONCLUSIONS

Patients who were treated in the ED-based ICU for toxicology-related illnesses were frequently able to be either discharged home or admitted to a regular floor after their initial stabilization and treatment, and none that were sent to the floor required an ICU step-up.

Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes

The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients.

METHODS

A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité.

RESULTS

During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients.

CONCLUSIONS

Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.

Substance abuse-related admissions in a mixed Norwegian intensive care population

BACKGROUND

Alcohol and drug abuse are potentially modifiable risk factors for critical illness. The aims of this study were to describe patients with substance abuse-related admissions (abbreviated SARA) in a mixed intensive care (ICU) population in Oslo, and to compare these patients with patients with non-SARA.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population in Oslo, Norway. Data were collected consecutively using a questionnaire, medical records, and toxicology results. SARA included admissions due to acute or chronic complications of alcohol or drug abuse, as well as substance abuse-related injuries.

RESULTS

Of the 852 patients included, 168 (20%) had SARA; 102 (12%) alcohol-related and 66 (8%) drug-related. Male patients aged 18-39 had the highest proportion of SARA (47/97, 49%). Among the trauma patients, 69/182 (38%) were influenced by alcohol and drugs at the time of injury. Patients with SARA were significantly younger (median age 48 vs 66), had lower Charlson comorbidity index (mean 1.4 vs 2.5) and shorter length of stay (median days 2.4 vs 4.9), than non-SARA patients. Hospital mortality was similar when adjusting for age (OR 0.8, P = .27, non-SARA as reference).

CONCLUSION

Overall, one in five ICU admissions was associated with substance abuse. For male patients aged 18-39 this ratio was nearly half. More than one third of the trauma patients were influenced by alcohol or drugs at time of injury.

Risk factors for prolonged intensive care unit and hospital stay among patients with acute drug overdose in Japan

Aim

Hospital selection for patients with drug overdose (DOD) is a critical issue. In Tokyo, the 50‐tablet rule has been widely utilized by paramedics for triaging patients with DOD given that it shortens the triage time. However, studies have not investigated the utility of such a rule in local cities. The present study aimed to identify prognostic pre‐ and in‐hospital factors among patients with DOD and determine whether the 50‐tablet rule benefits local cities.

Methods

Clinical records of patients with DOD admitted at the University of Tsukuba Hospital (Tsukuba, Japan) between 2013 and 2017 were retrospectively reviewed.

Results

A total of 93 patients with DOD were enrolled in this study. Multivariate analysis showed that creatine kinase and C‐reactive protein values and the total number of ingested pills were in‐hospital risk factors that significantly prolonged intensive care unit (ICU) and hospital stay. Moreover, Glasgow Coma Scale score on admission and the total number of ingested pills were identified as significant pre‐hospital risk factors for prolonged ICU and hospital stay. Setting the total number of ingested pills to 50 tablets did not significantly influence ICU and hospital stay.

Conclusion

The total number of ingested pills and creatine kinase and C‐reactive protein values were identified as predictive factors for prolonged ICU and hospital stay in patients with DOD after admission. Moreover, pre‐hospital risk factors included Glasgow Coma Scale score and the total number of ingested pills. However, the 50‐tablet rule was determined to be a poor cut‐off value for patients with DOD. We presented a subset of our findings at the 46th annual meeting of the Japanese Society for Acute Medicine (Yokohama, Japan) on 20 November 2018.

Alcohol and Drug Abuse Resource Utilization in the ICU

Alcohol and drug abuse continue to be major causes of morbidity and mortality and have significant social and economic ramifications. Studies have shown that for every $1 spent on substance use disorder treatment, $4 are saved on healthcare costs. Characterizing the healthcare resource utilization of these patients may shed light on the burden of disease and opportunities for intervention. A retrospective chart review of all patients admitted to the ICU between July 1, 2017 and December 31, 2017 was completed. Variables regarding demographic and clinical characteristics as well as healthcare resource utilization were collected. Of 737 admissions to the ICU, 158 (21%) were due to acute or chronic complications of alcohol or drug abuse. Even though alcohol and drug users were significantly younger (average age 50 years) than the general ICU cohort (average age 66 years), resource utilization was similar between these patients. The median length of stay in the ICU was similar. The number of patients transferred to in-patient rehab was low (8%), and all of those were due to comorbid psychiatric illness. The total hospital charges for the alcohol and drug abuse cohort was over 7 million dollars for the 6 months observed. A significant number of patients had at least one ER visit (49%) during the previous year, and most of these had numerous visits. ICU resource utilization by patients with acute and chronic sequelae of drug or alcohol abuse disorders continues to be high. These patients utilize resources at rates similar to an older group with other disease processes. Patients are unlikely to receive intervention for their disorder unless they have a comorbid psychiatric illness. Patients admitted to the ICU with alcohol or drug-related illness were frequently seen in the ER or were admitted to the hospital in the year prior to ICU admission, providing opportunities for intervention.

The impact of the introduction of a toxicology service on the intensive care unit

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.

A Review of Alprazolam Use, Misuse, and Withdrawal

: Alprazolam is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder. Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness, whereas many primary care physicians continue to prescribe it for longer periods than recommended. Clinical research data has not fully shed light on its "abuse liability," yet it is one of the most frequently prescribed benzodiazepines. "Abuse liability" is the degree to which a psychoactive drug has properties that facilitate people misusing it, or becoming addicted to it, and is commonly used in the literature. We have replaced it in our manuscript with "misuse liability" as it reflects a more updated terminology consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In this paper, we have reviewed alprazolam's indications for use, its effect on pregnant women, misuse liability, withdrawal syndrome, pharmacodynamic properties, and suggest better clinical prescription practice of alprazolam by presenting an indepth theory of its clinical effects with use and withdrawal.

The healthcare costs of intoxicated patients who survive ICU admission are higher than non-intoxicated ICU patients: a retrospective study combining healthcare insurance data and data from a Dutch national quality registry

Background

The aim of this study was to describe the healthcare costs of intoxicated ICU patients in the year before and the year after ICU admission, and to compare their healthcare costs with non-intoxicated ICU patients and a population based control group.

Methods

We conducted a retrospective cohort study, combining a national health insurance claims database and a national quality registry database for ICUs. Claims data in the timeframe 2012 until 2014 were combined with the clinical data of patients who had been admitted to an ICU during 2013. Three study populations were compared and matched according to socioeconomic status, type of admission, age and gender: an “ICU population”, an “intoxication population” and a “control population” (who had never been on the ICU).

Results

2591 individual “intoxicated ICU patients” were compared to 2577 general “ICU patients” and 2591 patients from the “control population”. The median and interquartile ranges (IQR) healthcare costs per day alive for the “intoxicated ICU patients” were higher during the year before ICU admission (€20.3 (IQR €3.6–€76.4)) and the year after ICU admission (€23.9 (IQR €5.1–€82.4)) compared to the ICU population (€6.1 (IQR €0.9–€29.3) and €13.6 (IQR €3.3–€54.9) respectively) and a general control population (€1.1 (IQR €0.3–€4.6) and €1.1 (IQR €0.4–€4.9) respectively). The healthcare associated costs in intoxicated ICU patients were correlated with the number of chronic conditions present prior ICU admission (p < 0.0001).

Conclusions

Intoxicated patients admitted to the ICU had in the year before and after ICU admission much higher median healthcare costs per day alive compared to other ICU patients and a general population control group. Healthcare costs are greatly influenced by the number of psychiatric and other chronic conditions of these intoxicated patients.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0224-7) contains supplementary material, which is available to authorized users.

Clinical Predictors for Unsafe Direct Discharge Home Patients From Intensive Care Units

PURPOSE

To describe factors (demographics and clinical characteristics) that predict patients who are at an increased risk of adverse events or unplanned return visits to a health-care facility following discharge direct to home (DDH) from intensive care units (ICUs).

METHODS

Prospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between February 2016 and 2017 and were discharged directly home. Patients were followed for 8 weeks postdischarge. Univariable and multivariable logistic regression analyses were performed to identify factors associated with adverse events or unplanned return visits to a health-care facility following DDH from ICU.

RESULTS

A total of 129 DDH patients were enrolled and completed the 8-week follow-up. We identified 39 unplanned return visits (URVs). There was 0% mortality at 8 weeks postdischarge. Eight potential predictors of hospital URVs (P < .2) were identified in the univariable analysis: prior substance abuse (odds ratio [OR] of URV of 2.50 [95% confidence interval: 1.08-5.80], hepatitis (OR: 6.92 [1.68-28.48]), sepsis (OR: 11.03 [1.19-102.29]), admission nine equivalents of nursing manpower score (NEMS) <24 (OR: 2.28 [1.03-5.04], no fixed address (OR: 22.9 [1.2-437.3]), ICU length of stay (LOS) <2 days (OR: 2.95 [1.28-6.78]), home discharge within London, Ontario (OR: 2.44 [1.00-5.92]), and left against medical advice (AMA; OR: 6.06 [2.04-17.98]).

CONCLUSIONS

Our study identified 8 covariates that were potential predictors of URV: prior substance abuse, hepatitis, sepsis, admission NEMS <24, no fixed address, ICU LOS <2 days, home discharge within London, Ontario, and left AMA. The practice of direct discharges home from the ICU would benefit from adequately powered multicenter study in order to construct a clinical prediction model (that would require further testing and validation).

Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning

INTRODUCTION

Acute poisoning represents a major cause of morbidity and mortality, and many of these patients are admitted to the intensive care unit (ICU). However, little is known regarding ICU costs of acute poisoning.

METHODS

This was a retrospective matched database analysis of patients admitted to the ICU with acute poisoning from 2011 to 2014. It was performed in 2 ICUs within a single tertiary care hospital system. All patient information, outcomes, and costs were stored in the hospital data warehouse. Control patients were defined as randomly selected age-, sex-, severity index-, and comorbidity index-matched nonpoisoned ICU patients (1:4 matching ratio).

RESULTS

A total of 8452 critically ill patients were admitted during the study period, of whom 277 had a diagnosis of acute poisoning. The mean age was 44.5 years, and the most common xenobiotics implicated were sedative hypnotics (20.2%), antidepressants (15.2%), and opioids (10.5%). Of these, 73.6% of poisonings were deemed intentional. In-hospital mortality of poisoned patients was 5.1%, compared to 11.1% for control patients (P < .01). The median ICU length of stay (LOS) for poisoned patients was 3.0 days, compared with 4.0 days for control patients (P < .01). The mean total cost for poisoned patients was CAD$18 958. Control patients had a significantly higher mean total cost of CAD$60 628 (P < .01). The xenobiotics associated with the highest costs were acetaminophen (CAD$18 585), toxic alcohols (CAD$16 771), and opioids (CAD$12 967).

CONCLUSIONS

In our cohort, we confirmed the long-held belief that patients admitted to the ICU with a primary diagnosis of poisoning have a lower mortality rate, ICU LOS, and overall cost per ICU admission than nonpoisoned patients. However, poisoned patients still accrue significant daily costs, with the highest costs attributed to xenobiotics with known antidotes, such as acetaminophen, toxic alcohols, and opioids.

Suicidal Nonorganophosphate Poisoning in a Tertiary Hospital in South India: Nature, Prevalence, Risk Factors

BACKGROUND

People who deliberately ingest poisons commonly present to emergency departments of hospitals in India. However, there is a dearth of information on poisoning using nonorganophosphorus pesticides.

METHODS

This prospective, hospital-based study attempted to examine the nonorganophosphorus poisons used to attempt suicide. Data on sociodemographic characteristics of patients, site and source of poisons, co-ingested substances, premeditation, and reason for poisoning were collected. A multinomial logistic regression was performed to determine association between poison class and these exposure characteristics.

RESULTS

Three hundred and forty-one cases of attempted suicide presented during the 6-month period (1.7% of all emergency room admissions). The majority was predominantly male and was young adults. Poisoning was the most common mode (91.7%), followed by hanging (7.3%) and self-injury (3, 0.9%). Pesticides (44.3%) including organophosphates (25.5%) were the predominant poisons, followed by pharmaceuticals (27.9%), caustics/chemicals (12.0%), and plant poisons (7.0%). One hundred and nine were available for prospective interview as the others who presented were not detained for prolonged observation the emergency department. Most patients who ingested such poisons were women, from rural backgrounds and were educated. The majority sourced the poisons from home, consumed poison at home, and mixed the poison with water; these attempts were impulsive and seemed to be in response to relationship conflicts. In the multivariate analysis, education (P = 0.08) and poison source (outside the home) were significant predictors of pesticide ingestion.

CONCLUSIONS

Suicidal poisoning results from a complex synthesis of socioeconomic and psychological factors; certain patterns of poisoning are likely to be more prevalent in demographic niche groups.

Characteristics and outcomes of patients with drug overdose requiring admission to Intensive Care Unit

OBJECTIVE

Approximately 20% of patients admitted to hospital with drug overdose will require intensive care unit (ICU) admission. An understanding of the characteristics of these patients may assist with their management and identify those patients at risk of multiple hospital presentations due to drug overdose. Our aim was to examine the characteristics of patients admitted to ICU following drug overdoses and identify the predictors of multiple hospital presentations due to drug overdose.

METHODS

Patients admitted to a metropolitan ICU over a three-year period following drug overdoses were identified using ICU patient databases, and their medical records.

RESULTS

There were 254 admissions due to drug overdoses. The majority of overdoses were intentional (82.7%) and included multiple agents (68.1%). Two-thirds of patients had psychiatric diagnosis, and 54% had documented history of substance use disorders. In-hospital mortality was 2.8%. Over half of patients admitted had documented history of prior hospital presentation due to overdoses. Personality disorder and schizophrenia were independent predictors of multiple hospital presentations due to overdoses.

CONCLUSION

Personality disorders or schizophrenia were independent predictors of patients with multiple overdose presentations. Preventative strategies focusing on these patients may reduce the incidence of their hospital presentations and ICU admissions.

Clinical and epidemiological characteristics of patients with acute drug intoxication admitted to ICU

Background: Drug overdose continues to be the most common cause of acute poisoning worldwide. There has been a substantial increase in drug overdose incidence and prevalence over the past decade, probably as a result of the emergence of new synthetic designer drugs. The purpose of this study is to describe the clinical and epidemiological characteristics of patients with acute drug intoxication admitted to the Intensive Care Unit (ICU).

Methods: A single center, prospective, observational study was conducted among all adult patients with clinical signs suggestive of acute drug intoxication admitted from the Emergency Department (ED) to ICU during a 6-month period (September to March).

Results: Sixty-five patients were admitted. Their median age was 49 years (mean 48.2, range 20–72), and the majority were male (48, 74%). Median Sequential Organ Failure Assessment (SOFA) score on admission to ICU was 6 (mean 6, range 0–13). Fifty-five patients (85%) had a positive urine and/or serum toxicology screen. Most commonly detected substances were: opiates (18, 33%), cocaine (13, 24%), methadone (12, 22%), benzodiazepines (10, 18%), and marijuana (9, 16%). In 16 patients (29%), >1 substance was isolated. Twenty-three patients (35%) had negative urine toxicology screen. Ethyl alcohol was detected in the serum of 23 patients (35%). Five patients (8%) expired in ICU.

Conclusion: Classic recreational drugs remain the most common substances involved in acute drug poisoning. More sensitive detection methods are warranted to identify new designer drugs of abuse such as synthetic cannabinoids.

Predicting the Need for Medical Intensive Care Monitoring in Drug-Overdosed Patients

Drug overdose (OD) is one of the most common single diagnoses admitted to medical intensive care units (MICUs). The diagnosis results in relatively little morbidity or mortality, suggesting a need to improve the methods utilized in deciding on MICU admission. Our objective in this study was to develop a quantitative system whereby the emergency room (ER) physician, with reasonable safety and ease, would be able to discriminate between the need for an ICU and a nonmonitored bed. We reviewed the charts of 216 consecutive MICU admissions for intentional OD involving 199 patients between the years 1995 and 1998. Clinical histories, vital signs, laboratory data inclusive of toxicologic analysis, and both APACHE II and Glasgow coma scores (GCS) were assessed from the ER and on transfer to the MICU 4–6 hours later. These scores, as well as individual components of the APACHE II score, were evaluated for significance. Of 216 admissions reviewed, 75 (35%) had MICU-requiring morbidity: intubation 61%, pneumonia 20%, arrhythmia or EKG changes 20%, and hypotension 3%. Mortality was 2.7%. The remaining admissions were for ICU monitoring due to lethargy, irritability, laboratory abnormalities, or simply based on the diagnosis of drug overdose. Urine examinations for drugs were positive in only 53%, with the most common agent identified being benzodiazepines (39%). Age, Apache II score, and GCS were significantly different between those patients who developed MICU-requiring morbidity and those who did not, as well as when comparing the morbidity with the mortality group. Receiver operator control (ROC) curves reveal that both the APACHE and GCS are excellent and equal predictors of morbidity, with a GCS of ≤ 12 having 88% sensitivity and 92% specificity in predicting MICU-requiring morbidity. We conclude that ER evaluation of GCS can be used to accurately assess and predict the need for MICU monitoring in drug overdose. OD patients with a persistent GCS of greater than 12 or who do not demonstrate any hemodynamic, infectious, or electrocardiographic complications in the ER do not require MICU admission.

Mortality and use of psychotropic medication in patients with stroke: a population-wide, register-based study

OBJECTIVES

The study sought to describe whether psychotropic medication may have long-term side effects in patients with stroke compared with controls.

SETTING

Use of national register data from healthcare services were identified from the Danish National Patient Registry in Denmark. Information about psychotropic medication use was obtained from the Danish Register of Medicinal Product Statistics.

OBJECTIVES

We aimed to evaluate all-cause mortality in relation to the use of benzodiazepines, antidepressants and antipsychotics in patients with stroke and matched controls.

PARTICIPANTS

Patients with a diagnosis of stroke and either no drug use or preindex use of psychotropic medication (n=49,968) and compared with control subjects (n=86,100) matched on age, gender, marital status and community location.

PRIMARY OUTCOME MEASURE

All-cause mortality.

RESULTS

All-cause mortality was higher in patients with previous stroke compared with control subjects. Mortality HRs were increased for participants prescribed serotonergic antidepressant drugs (HR=1.699 (SD=0.030), p=0.001 in patients; HR=1.908 (0.022), p<0.001 in controls, respectively), tricyclic antidepressants (HR=1.365 (0.045), p<0.001; HR=1.733 (0.022), p<0.001), benzodiazepines (HR=1.643 (0.040), p<0.001; HR=1.776 (0.053), p<0.001), benzodiazepine-like drugs (HR=1.776 (0.021), p<0.001; HR=1.547 (0.025), p<0.001), first-generation antipsychotics (HR=2.001 (0.076), p<0.001; HR=3.361 (0.159), p<0.001) and second-generation antipsychotics (HR=1.645 (0.070), p<0.001; HR=2.555 (0.086), p<0.001), compared with no drug use. Interaction analysis suggested statistically significantly higher mortality HRs for most classes of psychotropic drugs in controls compared with patients with stroke.

CONCLUSIONS

All-cause mortality was higher in patients with stroke and controls treated with benzodiazepines, antidepressants and antipsychotics than in their untreated counterparts. Our findings suggest that care should be taken in the use and prescription of such drugs, and that they should be used in conjunction with adequate clinical controls.

Increased all-cause mortality with use of psychotropic medication in dementia patients and controls: A population-based register study

We aimed to evaluate all-cause mortality of middle-aged and elderly subjects diagnosed with dementia and treated with psychotropic drugs as compared with controls subjects. Using data from the Danish National Patient Registry, n=26,821 adults with a diagnosis of dementia were included. They were compared with 44,286 control subjects with a minimum follow-up of four years and matched on age, gender, marital status, and community location. Information about psychotropic medication use (benzodiazepines, antidepressants, antipsychotics) was obtained from the Danish Medicinal Product Statistics. All-cause mortality was higher in patients with dementia as compared to control subjects. Mortality hazard ratios were increased for subjects prescribed serotonergic antidepressant drugs (respectively, HR=1.355 (SD=0.023), P=0.001 in patients; HR=1.808 (0.033), P<0.001 in controls), tricyclic antidepressants (HR=1.004 (0.046), P=0.925; HR=1.406 (0.061), P<0.001), benzodiazepines (HR=1.131 (0.039), P=0.060); HR=1.362 (0.028), P<0.001), benzodiazepine-like drugs (HR=1.108 (0.031), P=0.078; HR=1.564 (0.037, P<0.001), first-generation antipsychotics (HR=1.183 (0.074), P=0.022; HR=2.026 (0.114), P<0.001), and second-generation antipsychotics (HR=1.380 (0.042), P<0.001; HR=1.785 (0.088), P<0.001), as compared with no drug use. Interaction analysis suggested statistically significantly higher mortality hazard ratios for most classes of psychotropic drugs in controls than in dementia patients. We found that use of psychotropic drugs is associated with increased all-cause mortality in both patients with dementia and control subjects. Thus, the frequently reported increased mortality with antipsychotic drugs in dementia is not restricted to subjects with impaired cognition and is not restricted to only one class of psychotropic drugs.

Acute drug overdose: clinical profile, etiologic spectrum and determinants of duration of intensive medical treatment

OBJECTIVES

Acute drug overdosing is an important cause of organ dysfunction and metabolic derangements and the patients often require intensive care. This study aims to determine the clinical pattern of severe drug overdose as well as the factors influencing the duration of intensive care

METHODS

The clinical characteristics and course of consecutive adult patients admitted with a diagnosis of acute drug poisoning in the ICU of a tertiary hospital in Oman from January 2007 to December 2008 were reviewed retrospectively from the electronic case records.

RESULTS

Acute drug poisoning (n=29) constituted 3.9% of admissions to the ICU. Mean age was 29.38±7.9 years. They were brought in by their relatives (72%) or the state services (24%). Accidental poisoning was noted in 21 patients (72%) and suicidal overdosing in 6 (21%). The commonest drug was an opioid (65.5%). Glasgow Coma Scale score of ≤8 was recorded in 18 (62.1%). Sixty two percent of patients required mechanical ventilation. The prominent complications were hypotension in 9 (31%), pulmonary in 19 (65.5%), hepatic in 18 (62.1%) and renal in 12 (41.4%) patients. The major electrolytes abnormalities were low bicarbonate in 11 (37.9%), hyponatremia in 5 (17.2%) and hypokalemia in 4 (13.8%). Patients stayed in the ICU for 1 to 20 days (median-2 days). Factors associated with a longer ICU stay included hypotension upon arrival (p=0.048) and the need for mechanical ventilation on the first (p=0.001) and second (p=0.001) days of hospitalization. There was no mortality.

CONCLUSION

Early and prompt intensive medical therapy in acute drug poisoning can favorably influence the outcome. In addition, the presence of hypotension and requirement of mechanical ventilation on the first two days of hospitalization were responsible for prolonged ICU stay.

Treatment of four psychiatric emergencies in the intensive care unit

OBJECTIVES

To review the diagnosis and management of four selected psychiatric emergencies in the intensive care unit: agitated delirium, neuroleptic malignant syndrome, serotonin syndrome, and psychiatric medication overdose.

DATA SOURCES

Review of relevant medical literature.

DATA SYNTHESIS

Standardized screening for delirium should be routine. Agitated delirium should be managed with an antipsychotic and, possibly, dexmedetomidine in treatment-refractory cases. Delirium management should also include ensuring a calming environment and adequate pain control, minimizing benzodiazepines and anticholinergics, normalizing the sleep-wake cycle, providing sensory aids as required, and providing early physical and occupational therapy. Neuroleptic malignant syndrome should be treated by discontinuing dopamine blockers, providing supportive therapy, and possibly administering medications (benzodiazepines, dopamine agonists, and/or dantrolene) or electroconvulsive therapy, if indicated. Serotonin syndrome should be treated by discontinuing all serotonergic agents, providing supportive therapy, controlling agitation with benzodiazepines, and possibly administering serotonin2A antagonists. It is often unnecessary to restart psychiatric medications upon which a patient has overdosed in the intensive care unit, though withdrawal syndromes should be prevented, and communication with outpatient prescribers is vital.

CONCLUSIONS

Understanding the diagnosis and appropriate management of these four psychiatric emergencies is important to provide safe and effective care in the intensive care unit.

Reactivity of commercial benzodiazepine immunoassays to phenazepam

Phenazepam is a long acting benzodiazepine that is not controlled in Canada, the United States or many European countries. The abuse of phenazepam has gained recent attention due to the number of hospitalizations and fatalities resulting from overdose. The compound is relatively potent with recommended doses of 0.5-1.0 mg, or 1/10th the recommended dose of diazepam, and is easy to obtain locally or from international suppliers via the internet. Increased risk of phenazepam overdose is attributed to its potency and the forms in which it is supplied. Individuals without scales or balances are prone to estimate dose amounts of powder visually, which can result in significant errors. The detection of phenazepam has been described using various methods including GC, GC/MS and LC/MS, but no data regarding the sensitivity of commercially available immunoassays exist. In this study, phenazepam-spiked urine samples were analyzed using five commercial instruments and two point of care devices. The concentrations of phenazepam required for detection ranged from 140-462 ng/mL, which is comparable to those of other benzodiazepines. Laboratorians and clinicians should be confident that phenazepam will be detected via most commercial drugs of abuse screens in patients after significant ingestion.

Comparison of emergency hospital admissions for drug poisoning and major diseases: a retrospective observational study using a nationwide administrative discharge database

OBJECTIVE

To compare the clinical and procedural characteristics of emergency hospital admissions for drug poisoning and major diseases.

DESIGN

Retrospective observational study.

SETTING

Discharged patients from 855 acute care hospitals from 1 July to 31 December in 2008 in Japan.

RESULTS

There were a total of 1 157 893 emergency hospital admissions. Among the top 100 causes, drug poisoning was ranked higher in terms of the percentage of patients using ambulance services (74.1%; second) and tertiary emergency medical services (37.8%; first). Despite higher utilisation of emergency care resources, drug poisoning ranked lower in terms of the median length of stay (2 days; 100th), percentage of requirement for surgical procedures (1.7%; 91st) and inhospital mortality ratio (0.3%; 74th).

CONCLUSIONS

Drug poisoning is unique among the top 100 causes of emergency admissions. Our findings suggest that drug poisoning imposes a greater burden on emergency care resources but has a less severe clinical course than other causes of admissions. Future research should focus on strategies to reduce the burden of drug poisoning on emergency medical systems.

Profile and outcome of patients with acute toxicity admitted in intensive care unit: Experiences from a major corporate hospital in urban India

Background and Aim:

There is scarcity of data from the Indian subcontinent regarding the profile and outcome of patients presenting with acute poisoning admitted to intensive care units (ICU). We undertook this retrospective analysis to assess the course and outcome of such patients admitted in an ICU of a tertiary care private hospital.

Methods:

We analyzed data from 138 patients admitted to ICU with acute poisoning between July 2006 and March 2009. Data regarding type of poisoning, time of presentation, reason for ICU admission, ICU course and outcome were obtained.

Results:

Seventy (50.7%) patients were males and majority (47.8%) of admissions were from age group 21 to 30 years. The most common agents were benzodiazepines, 41/138 (29.7%), followed by alcohol, 34/138 (24.63%) and opioids, 10/138 (7.2%). Thirty-two (23%) consumed two or more agents. Commonest mode of toxicity was suicidal (78.3%) and the route of exposure was mainly oral (97.8%). The highest incidence of toxicity was due to drugs (46.3%) followed by household agents (13%). Organ failure was present in 67 patients (48.5%). During their ICU course, dialysis was required in four, inotropic support in 14 and ventilator support in 13 patients. ICU mortality was 3/138 (2.8%). All deaths were due to aluminium phosphide poisoning.

Conclusions:

The present data give an insight into epidemiology of poisoning and represents a trend in urban India. The spectrum differs as we cater to urban middle and upper class. There is an increasing variety and complexity of toxins, with substance abuse attributing to significant number of cases.

Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention?

BACKGROUND

Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning.

AIM

To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received.

DESIGN

National population-based descriptive study and confidential inquiry.

METHODS

Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroner's verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome.

RESULTS

We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patient's death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive.

CONCLUSION

In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.

Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China

In order to obtain up-to-date information on the pattern of severe acute poisoning and the characteristics and outcomes of these patients, 265 consecutive patients admitted to an intensive care unit in Hong Kong for acute poisoning from January 2000 to May 2008 were studied retrospectively. Benzodiazepine (25.3%), alcohol (23%), tricyclic antidepressant (17.4%), and carbon monoxide (15.1%) were the four commonest poisons encountered. Impaired consciousness was common and intubation was required in 67.9% of admissions, with a median duration of mechanical ventilation of less than 1 day. The overall mortality was 3.0%. Among the 257 survivors, the median lengths of stay in the intensive care unit and acute hospital (excluding days spent in psychiatric ward and convalescent hospital) were less than 1 day and 3 days, respectively. Factors associated with a longer length of stay included age of 65 or older, presence of comorbidity, Acute Physiology and Chronic Health Evaluation II score of 25 or greater, and development of shock, rhabdomyolysis, and aspiration pneumonia, while alcohol intoxication was associated with a shorter stay. This is the largest study of its kind in the Chinese population and provided information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of the patients concerned.

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.

General characteristics of hospitalized patients after deliberate self-poisoning and risk factors for intensive care admission

BACKGROUND

Deliberate self-poisoning (DSP) is recognized as a major health problem worldwide with significant morbidity. After DSP, a substantial number of patients require intensive care unit (ICU) care, but little is known about how these patients differ from patients admitted to a general medical ward.

METHODS

From January 2001 to December 2002, all adult patients admitted to Soroka University Hospital after DSP were identified by ICD-9 coded diagnoses. Demographic data, previous psychiatric illness, laboratory tests, medication used in the DSP, presenting syndromes, treatment, and time elapsed after ingestion until emergency department presentation were obtained retrospectively from the patients' charts.

RESULTS

Out of a total of 217 patients, 34 (15.7%) were admitted to the ICU. Their mean age was 35.9 years and 65.4% of the patients were female. In multivariate analysis, the risk factors for ICU admission were suicide attempt with an antihypertensive medication (OR=12.2, 95% CI 2.3-65.8), coma on presentation (OR=15.8, 95% CI 4.9-50.7), and arrival at the emergency department less than 2 h after ingestion as compared to arrival after 2 h (OR=8.4, 95% CI 2.6-26.7). Previous psychiatric disease had no impact on ICU admission, and a recurrent attempt was protective of ICU admission.

CONCLUSIONS

We have shown that ingestion of antihypertensive medication, coma upon presentation, and emergency department admission less than 2 h after ingestion are predictive of ICU admission after a deliberate overdose with medication. These variables may help emergency department physicians to identify high-risk patients more quickly and, thereby, to improve patient care.

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

OBJECTIVE

To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.

DESIGN

Retrospective cohort study.

SETTING

Medical ICU of an academic tertiary care hospital.

PATIENTS

A total of 273 consecutive overdose admissions.

MEASUREMENTS AND RESULTS

Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10(9)/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors.

CONCLUSIONS

Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.

The hospital management of fatal self-poisoning in industrialized countries: an opportunity for suicide prevention?

Suicide by self-poisoning is a prevalent cause of death worldwide. A substantial proportion of individuals who poison themselves come into contact with medical services before they die. Our focus in the current study was the medical management of drug self-poisoning in industrialized countries and its possible contribution to suicide prevention. We reviewed the literature to determine the proportion of self-poisoning suicides who reach hospital alive, the sociodemographic and clinical characteristics of in-hospital overdose deaths, the in-hospital management this group of patients receives, and whether there are specific aspects of pre-hospital care and in-hospital management that have the potential to improve survival. Between 11% and 28% of individuals who died following deliberate ingestion of drugs reached hospital alive. The substances which were most frequently implicated in death were paracetamol (acetaminophen) and paracetamol compounds, tricyclic antidepressants, and benzodiazepines. Most patients received fairly intensive treatment, yet death may have been preventable in a small proportion of cases. Only one intervention (the administration of acetylcysteine) was shown to reduce mortality and this was in a highly selected group of patients (those who had ingested paracetamol and developed fulminant hepatic failure). It is possible that other interventions such as better airway management, the prompt administration of activated charcoal, and improved pre-hospital care may improve outcomes but their potential contribution to suicide prevention needs to be investigated in future studies.

Self-poisoning suicides in England: a multicentre study

BACKGROUND

Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die.

AIM

To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital.

DESIGN

Retrospective audit.

METHODS

We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001.

RESULTS

Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose.

DISCUSSION

Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.

Admissions to intensive care units from emergency departments: a descriptive study

OBJECTIVES

To describe the case mix, activity, and outcome for admissions to intensive care units (ICUs) from emergency departments (EDs).

DESIGN

An observational study using data from a high quality clinical database, the Case Mix Programme Database, of intensive care admissions, coordinated at the Intensive Care National Audit & Research Centre (ICNARC).

SETTING

91 adult ICUs in England, Wales, and Northern Ireland, 1996-99.

SUBJECTS

46,587 intensive care admissions.

MAIN OUTCOME MEASURES

Ultimate hospital mortality.

RESULTS

Admissions from EDs constituted 26% of total admissions to ICU, 77% of which were direct admissions to ICU from EDs. Direct admissions from EDs, indirect admissions from EDs, and non-ED admissions presented to ICU with different conditions and severity of illness. Indirect admissions from EDs presented in the ICU with the more severe case mix (older age, more acute severity of illness, more likely to have a chronic illness) compared with direct admissions to ICU from EDs. Compared with ICU admissions not originating in EDs, unit and hospital mortality were higher for admissions from EDs, with indirect admissions experiencing the highest hospital (46.4%) mortality. For ICU survivors, indirect admissions stayed longest in the ICU.

CONCLUSIONS

A large proportion of admissions to ICU (26%) originate in EDs, and differ from those not originating in EDs in terms of both case mix and outcome. Additionally, those admitted directly to ICU from EDs differ from those admitted indirectly via a ward. The observed differences in outcome between different admission routes require further investigation and explanation.

Medical management of deliberate drug overdose: a neglected area for suicide prevention?

OBJECTIVES

Overdoses account for a quarter of all suicides in England. The number of people who survive the immediate effects of their overdose long enough to reach medical attention, but who subsequently die in hospital is unknown. The aim of this study was to determine the proportion of overdose suicides dying in hospital and describe their sociodemographic characteristics.

METHOD

Cross sectional analysis of routinely collected Hospital Episode Statistics data for England (1997 to 1999) to identify hospital admissions for overdose among people aged 12+ and the outcome of these admissions.

RESULTS

Between 1997 and 1999 there were 233 756 hospital admissions for overdose, 1149 (0.5%) of these ended in the death of the patient such deaths accounted for 28% [corrected] of all overdose suicides and 8% [corrected] of total suicides. The median time between admission and death was three days (interquartile range one to nine days). The most commonly identified drugs taken in fatal overdose were paracetamol compounds, benzodiazepines, and tricyclic/tetracyclic antidepressants.

CONCLUSION

Around a quarter of all overdose suicide deaths occur subsequent to hospital admission. Further more detailed research is required to discover if better pre-admission and in-hospital medical management of those taking serious overdoses may prevent some of these deaths.

Alprazolam is relatively more toxic than other benzodiazepines in overdose

AIMS

To describe alprazolam poisoning and the relative toxicity of alprazolam compared with other benzodiazepines.

METHODS

A database of consecutive poisoning admissions to a regional toxicology service was searched to identify consecutive benzodiazepine deliberate self poisonings, which were coded as alprazolam, diazepam or other benzodiazepine. Major outcomes used were length of stay (LOS), intensive care (ICU) admission, coma (GCS < 9), flumazenil administration and requirement for mechanical ventilation. Prescription data were obtained for benzodiazepines for the study period.

RESULTS

There were 2063 single benzodiazepine overdose admissions: 131 alprazolam overdoses, 823 diazepam overdoses and 1109 other benzodiazepine overdoses. The median LOS for alprazolam overdoses was 19 h which was 1.27 (95% CI 1.04, 1.54) times longer compared with other benzodiazepines by multiple linear regression. For patients with alprazolam overdoses, 22% were admitted to ICU which was 2.06 (95% CI 1.27, 3.33) times more likely compared with other benzodiazepines after multivariate analysis adjusting for age, dose, gender, time to ingestion and co-ingested drugs. Flumazenil was administered to 14% of alprazolam patients and 16% were ventilated, which was significantly more than for other benzodiazepine overdoses (8% and 11%, respectively). Twelve percent of alprazolam overdoses had a GCS < 9 compared with 10% for other benzodiazepines. From benzodiazepine prescription data, total alprazolam prescriptions in Australia increased from 0.13 million in 1992 to 0.41 million in 2001. Eighty five percent of prescriptions were for panic disorder, anxiety, depression or mixed anxiety/depression.

CONCLUSIONS

Alprazolam was significantly more toxic than other benzodiazepines. The increased prescription of alprazolam to groups with an increased risk of deliberate self poisoning is concerning and needs review.

Street drug abuse leading to critical illness

Critical care physicians are frequently confronted with intoxicated patients who have used street drugs. In the last decade there has been an upward trend in the use of these substances, particularly amongst adolescents and young adults in large urban areas. In excess quantities all street drugs can lead to critical illness. Early and appropriate medical attention by emergency medicine physicians and intensivists can improve outcomes. In this review article we intend to familiarize critical care physicians with the most common street drugs such as amphetamines, ecstasy, cocaine, gamma hydroxybutyrate, opioids, and phencyclidine.

Pattern and risk factors for intentional drug overdose in Saudi Arabia

BACKGROUND

Attempted suicide by intentional drug overdose is an understudied subject in Saudi Arabia. Saudi Arabia is an Islamic country where suicide or attempted suicide is strictly prohibited. Despite the strong religious and constitutional sanctions against suicide, cases of intentional drug overdose occasionally occur. Our study represents the first attempt to better understand and characterize this sensitive topic.

METHODS

Using a retrospective chart review of patients aged 12 years and over with a diagnosis of intentional drug overdose between 1997 and 1999, we studied the demographic characteristics, the risk factors, the most commonly used drugs, and the resulting morbidities and mortalities of study subjects.

RESULTS

Most of the patients were young (mean age 22 years, SD 4.6, range 15 to 40 years), and most were Saudi nationals (n = 76; 96%). Eighty percent of the patients were women. The occurrence of intentional drug overdose peaked during the month of September (that is, 20% of total cases). Previous suicide attempts, family conflicts, and psychiatric disorders represented significant risk factors. Single-agent overdose occurred in 30% of the patients, and most of the drugs used were prescribed medications (53%). Acetaminophen represented the most common drug (30%). While some patients required prolonged hospital stay or admission to the intensive care unit, no mortalities occurred.

CONCLUSIONS

Intentional drug overdose is a relatively uncommon reason for hospital admission in Saudi Arabia. This study identifies certain risk factors relevant to the Saudi community and raises awareness about intentional drug overdose.

Single-dose oral activated charcoal in the treatment of the self-poisoned patient: a prospective, randomized, controlled trial

Oral activated charcoal (OAC) is a universally accepted treatment of the overdose patient. Although the benefits of OAC have been suggested, there are no conclusive clinical data indicating that OAC affects outcome in overdose patients. This study was a prospective, randomized, controlled trial to determine the effects of OAC treatment in the self-poisoned adult patient. Adult patients presenting to the emergency department (ED) with a history of oral overdose were assigned to treatment with OAC (50 g) or supportive care only on an even-odd day protocol. Patients did not undergo gastric evacuation procedures in the ED. The outcome measures were clinical deterioration, length of stay in the ED or hospital, and complication rate. Over a 24-month period, 1479 patients were entered into the study. There were no significant differences in outcome parameters between the OAC treatment group and controls when comparing the length of intubation time, length of hospital stay, and the complication rates associated with the overdose. There was a higher incidence of vomiting and longer length of ED stay associated with OAC treatment. The results of this study indicated that oral drug overdose patients do not require gastric evacuation or charcoal administration. OAC provided no additional benefit to supportive care alone, was associated with a higher incidence of vomiting and a longer length of ED stay, and did not improve clinical outcome.

Impact of a toxicology service on a metropolitan teaching hospital

OBJECTIVE

To evaluate the impact of a toxicology service on a major metropolitan teaching hospital.

METHOD

A descriptive comparative study of all patients presenting with poisoning or suspected poisoning 12 months before and after the commencement of a toxicology service. Data on length of stay in the emergency department, disposition, length of stay of admitted patients and substance(s) involved were examined.

RESULTS

A total of 1,316 poisoned patients were studied. There was a statistically significant increase in self-poisonings from 612 to 704 (P = 0.002) and in the number of admissions from 113 to 192 (P < 0.05). There was no significant change in emergency department length of stay. The average length of stay for patients admitted under the care of the toxicology service decreased, especially for complicated patients.

CONCLUSION

In the first 12 months of operation the toxicology service treated more patients than the 12-month period prior to commencement, achieving a decrease in average length of stay for those patients admitted to the service. The emergency department length of stay was not altered. We surmise that by decreasing average length of stay for the patients under the care of the toxicology service, the net increase in the general pool of unoccupied beds improves bed access for all emergency department patients.