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Abstract
Experience of a central London unit dedicated to the care of patients following parasuicide between 1984 and 1988 is reviewed. There were 1160 admissions, which accounted for 11% of all acute adult medical admissions. The female to male ratio was 1.3, with a peak rate for females below 25 years and for males between 20 and 35. Unemployment was found to be a risk factor for parasuicide in men. Benzodiazepines were the most frequently used drug in parasuicide (35%), followed by paracetamol (13%) and aspirin (9%).
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Affiliation(s)
- G N Fuller
- Department of Clinical Pharmacology and Therapeutics, Charing Cross and Westminster Medical School, St Stephen's Hospital, London
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2
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Daveluy A, Géniaux H, Baumevieille M, Létinier L, Matta MN, Lazès-Charmetant A, Haramburu F, Guéroult P. Parachuting psychoactive substances: Pharmacokinetic clues for harm reduction. Addict Behav 2018; 78:173-177. [PMID: 29175294 DOI: 10.1016/j.addbeh.2017.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/10/2017] [Accepted: 11/12/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Parachuting, also called bombing, is a way to ingest psychoactive substances wrapped into cigarette paper, toilet paper, etc. There is little data describing parachuting in terms of substances use, context of use and, most importantly, the motivations for using such wrappers, although some authors hypothesized that parachute could be used for pharmacokinetic reason. However, inconsistently, some authors report that parachutes are used for sustained-release whereas others report that users are looking for an immediate effect. RESEARCH DESIGN AND METHODS Considering parachute as a "home-made" dosage form, we have applied the dissolution testing to characterize the dissolution performance of a substance wrapped into a parachute and to characterize whether a parachute represents an immediate-release form or not. RESULTS This in-vitro study provides the first pharmacokinetic data for drugs wrapped in parachutes. It shows that parachute acts as sustained-release form when made with a cigarette paper wrapper, but as immediate release form in the presence of alcohol or if wrapped with toilet paper. CONCLUSIONS An important message to harm reduction is that users must be aware that a parachute can have unexpected pharmacokinetics and have to avoid taking another parachute in the absence of an immediate-effect to avoid overdose.
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Affiliation(s)
- Amélie Daveluy
- Centre d'addictovigilance, Service de pharmacologie médicale, CHU Bordeaux, F-33000 Bordeaux, France; Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team, Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Hélène Géniaux
- Centre d'addictovigilance, Service de pharmacologie médicale, CHU Bordeaux, F-33000 Bordeaux, France
| | - Marie Baumevieille
- Centre d'addictovigilance, Service de pharmacologie médicale, CHU Bordeaux, F-33000 Bordeaux, France; Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team, Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France; Laboratoire de droit et économie pharmaceutiques, Univ. Bordeaux, F-33000 Bordeaux, France
| | - Louis Létinier
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team, Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Marie-Noëlle Matta
- Laboratoire de technologies pharmaceutiques industrielles (LTPIB), Univ. Bordeaux, F-33000 Bordeaux, France
| | - Aurélie Lazès-Charmetant
- Comité d'étude et d'information sur la drogue et les addictions (CEID-Addictions), F-33000 Bordeaux, France
| | - Françoise Haramburu
- Centre d'addictovigilance, Service de pharmacologie médicale, CHU Bordeaux, F-33000 Bordeaux, France; Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team, Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France
| | - Pascale Guéroult
- Laboratoire de technologies pharmaceutiques industrielles (LTPIB), Univ. Bordeaux, F-33000 Bordeaux, France
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Shenai N, Shulman J, Gopalan P, Cheng E, Cerimele JM. Fetal Outcomes in Intentional Over-the-Counter Medication Overdoses in Pregnancy. Psychosomatics 2017; 59:400-404. [PMID: 29277425 DOI: 10.1016/j.psym.2017.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Neeta Shenai
- University of Pittsburgh Medical Center, Psychiatry, Pittsburgh, PA.
| | | | - Priya Gopalan
- University of Pittsburgh Medical Center, Psychiatry, Pittsburgh, PA
| | - Edith Cheng
- University of Washington, Obstetrics & Gynecology, Seattle, WA
| | - Joseph M Cerimele
- University of Washington School of Medicine, Psychiatry and Behavioral Sciences, Seattle, WA
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4
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Basavarajaiah S, Sigston P, Budack K. Severe Salicylate Poisoning Treated Conservatively. J R Soc Med 2017; 97:587-8. [PMID: 15574860 PMCID: PMC1079675 DOI: 10.1177/014107680409701211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sandeep Basavarajaiah
- Department of General Medicine, Kent and Sussex Hospital, Tunbridge Wells TN4 9AT, UK.
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5
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Kitamoto T. [Sodium bicarbonate]. Chudoku Kenkyu 2016; 29:41-44. [PMID: 27255025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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6
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7
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Inoue Y. [Blood concentration useful in the diagnosis and treatment of poisoning]. Chudoku Kenkyu 2014; 27:47-53. [PMID: 24724362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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8
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Tominaga A. [Transition of acetylsalicylic acid serum concentration in a case of overdose]. Chudoku Kenkyu 2013; 26:314-315. [PMID: 24483012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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9
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Schou M, Svennum V. [Acute salicylate poisoning may cause non-cardiogenic pulmonary edema]. Lakartidningen 2012; 109:700-701. [PMID: 22530469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michael Schou
- Anestesiavdelning V, Odense Universitetshospital (OUH), Svendborg Sygehus, Danmark.
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10
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Nogué-Xarau S, Dueñas-Laita A. Salicylate poisoning. Nefrologia 2012; 32:252-253. [PMID: 22466272 DOI: 10.3265/nefrologia.pre2011.dec.11299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2011] [Indexed: 05/31/2023] Open
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Donald K, Hall S, Seaton C, Tanyanyiwa D. Is non-therapeutic aspirin use in children a problem in South Africa? S Afr Med J 2011; 101:823-828. [PMID: 22272965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 08/29/2011] [Accepted: 08/30/2011] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Aspirin should not be used in children except for specific therapeutic reasons. We report on a severely ill infant who had ingested aspirin contained in a traditional medicine and review 21 other patients with pre-admission non-therapeutic salicylate exposure. OBJECTIVES AND METHODS We reviewed laboratory, clinical and poisons unit records to determine how many children were admitted to our hospital over an 18-month period with evidence of salicylate ingestion not prescribed for therapeutic reasons. We determined the source of the salicylate, elapsed time between ingestion and laboratory assay, morbidity and mortality and final diagnosis. RESULTS Twenty-one children meeting our criteria, including 9 under 6 months of age, were admitted during this period. The most prevalent source of salicylate was over-the-counter (OTC) aspirin, but some had reportedly only been given traditional medicines. Nineteen were seriously ill, 4 died and 3 had severe brain injury. Two, initially diagnosed with Reye's syndrome, probably had inherited metabolic disorders. Only 2 patients had salicylate levels that at the time of measurement are normally considered toxic; however, the literature suggests that lower levels may exacerbate illness severity in young children. CONCLUSIONS We found inappropriate use of OTC aspirin in children that requires explanation. There may be policy implications for the content and presentation of patient information; the incorporation of pharmaceuticals in traditional medicines merits further study. Salicylate toxicity should be considered in children with unexplained metabolic acidosis out of keeping with the severity of their acute illness.
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Affiliation(s)
- Kirsten Donald
- Department of Paediatrics, School of Child and Adolescent Health, Red Cross War Memorial Children’s Hospital, Cape Town
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12
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Höjer J, Karlson-Stiber C. [Chronic salicylate poisoning can give rise to pronounced metabolic alkalosis]. Lakartidningen 2010; 107:2896-2897. [PMID: 21197787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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13
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Karsbøl JD, Jørgensen HL, Dalhoff K. [Low mortality following salicylic poisoning]. Ugeskr Laeger 2010; 172:2541-2546. [PMID: 20836965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
INTRODUCTION The objective of the study was to identify possible prognostic factors in patients with salicylic poisoning. MATERIAL AND METHODS A chart review on 53 patients with salicylic poisoning was performed. Clinical and biochemical data were registered for all patients with a serum level of salicylic acid higher than or equal to 2 mmol/l in the 2004-2008 period. The patients were divided into groups according to the outcome of the poisoning. A complicated outcome was defined as: hospital stay > 48 hours, dialysis, persisting complications at discharge or death. RESULTS In the group with complicated outcome, chronic poisoning (43% versus 13%, p = 0.02) and medical diseases (24% versus 9%, p = 0.07) were more prevalent and the proportion of elderly (55 years versus 38 years, p = 0.003) and alcoholics (48% vs. 25%, p = 0.09) were higher. The mortality was low, with only one fatality among the acutely poisoned and none among the chronically poisoned. Neurological symptoms (somnolence and confusion) were the only symptoms which differed significantly between the two groups (67% versus 28%, p = 0.006), as well as being the only variable independently emerging as a risk factor in the multivariate logistic regression analysis with an odds ratio of 6.6 (95% confidence interval: 1.5-28.9) for a complicated outcome. A significantly lower level of bicarbonate was seen in the group with complicated outcome. Among the other biochemical data, only haemoglobin and certain liver enzymes differed between the two groups, probably due to pre-existing differences. CONCLUSION Mortality after salicylic poisoning is low. Chronic poisonings, old age or concurrent medical diseases are associated with a complicated outcome. If neurological symptoms or low standard-HCO3- are present, the prognosis is poor.
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de Bree GJ, Butterhoff-Terlingen MH, Vermeer EHJ, Treskes M, van der Linden PD, Ruys TA. [Analysis of the intoxicated patient: pitfalls]. Ned Tijdschr Geneeskd 2010; 154:A1605. [PMID: 20482922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A 39-year-old man was admitted to the ICU after having taken 96 tablets of 500 mg acetylsalicylic acid. Although a high plasma concentration (1040 mg/l) was found, underestimation and misinterpretation of clinical signs and symptoms with decreasing salicylate plasma concentrations led to haemodialysis being postponed. One day after admission the patient suddenly died of cardiovascular collapse due to severe salicylate toxicity. Doctors should be aware that underestimating the severity of salicylate intoxication is a common and dangerous pitfall. Another patient, a 60-year-old woman, was suspected of suffering from toxic alcohol intoxication. She had marked hyperlactaemia (17 mmol/l), which could not be explained from a clinical perspective. However, ethanol was administered intravenously while awaiting the toxic alcohol test results (ethylene glycol: 1300 mg/l). The hyperlactaemia was artificial and caused by an interaction between glycolic acid and lactate on a point-of-care analyser. Doctors should consider artificial hyperlactaemia in patients with ethylene glycol intoxication. The patient recovered.
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Christensen LA, Schmidt EB. Perforated peptic ulcer--a complication in acute salicylate intoxication. Acta Med Scand 2009; 222:191-2. [PMID: 3673672 DOI: 10.1111/j.0954-6820.1987.tb10658.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A patient with perforated peptic ulcer following acute salicylate intoxication is presented. The patient had reversible renal failure requiring dialysis therapy, but no abdominal symptoms were noticed until six days after arrival. At this time haematemesis and melaena were observed. Symptoms and objective findings were vague, but further investigations revealed a perforated prepyloric ulcer, which was successfully treated with cimetidine, The delay from intoxication to symptoms has previously been described and might be due to the analgetic properties of salicylates.
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Affiliation(s)
- L A Christensen
- Department of Internal Medicine and Nephrology, Aalborg Hospital, Denmark
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Quintero Parra N, Wurgaft Kirberg A, Orellana Araya Y, Arellano Lorca J, Rojas Wettig L, Pefaur Penna J. [Haemodialysis management for salicylate intoxication]. Nefrologia 2009; 29:182-183. [PMID: 19396334 DOI: 10.3265/nefrologia.2009.29.2.4824.en.full] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
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17
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Affiliation(s)
- T Nishizawa
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Ihama Y, Ageda S, Fuke C, Miyazaki T. [Autopsy case of aspirin intoxication: distribution of salicylic acid and salicyluric acid in body fluid and organs]. Chudoku Kenkyu 2007; 20:375-380. [PMID: 18044220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
A 52 year-old woman ingested approximately 300 tablets (325 mg) of aspirin in a suicide attempt. We analyzed the concentrations of salicylic acid (SA) and salicyluric acid (SUA) in body fluids and organs using a modified previous high-performance liquid chromatographic method. The concentrations of SA in heart and femoral blood were 1.1 mg/mL and 1.3 mg/mL, respectively; the results were far higher than the lethal level. The concentration of SA was 0.3-0.4 mg/g in brain, 0.9-1.4 mg/g in lung, 0.6-0.8 mg/g in liver and 0.9 mg/mL in kidney.
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Affiliation(s)
- Yoko Ihama
- Department of Legal Medicine, School of Medicine, University of the Ryukyus, Okinawa
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Tsimihodimos V, Psychogios N, Kakaidi V, Bairaktari E, Elisaf M. Salicylate-Induced Proximal Tubular Dysfunction. Am J Kidney Dis 2007; 50:463-7. [PMID: 17720526 DOI: 10.1053/j.ajkd.2007.03.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Accepted: 03/27/2007] [Indexed: 11/11/2022]
Abstract
We describe the case of a 17-year-old girl who was admitted to our clinic for drug poisoning. Twelve hours after the ingestion of 25 tablets of aspirin (12.5 g of acetylsalicylic acid), the patient had a generalized proximal tubular dysfunction characterized by glucosuria (in the face of normal serum glucose levels), proteinuria, and uric acid wasting. Further characterization of the tubular dysfunction using high-resolution proton nuclear magnetic resonance spectroscopy of the urine showed a pattern consistent with proximal tubular injury. An important characteristic of the salicylate-induced proximal tubular dysfunction in our patient was its rapid reversibility. A trend toward normalization of fractional excretion values of electrolytes was observed 2 days after ingestion. Determination of serum and urine metabolites and spectroscopy of urine 15 days later showed no evidence of tubular dysfunction. The mechanisms potentially implicated in the pathogenesis of salicylate-induced Fanconi syndrome are discussed and a brief review of the relevant literature is provided.
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Affiliation(s)
- Vasilis Tsimihodimos
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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20
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Abstract
Salicylate toxicity continues to be encountered commonly in emergency medicine. This article portrays the signs and symptoms of salicylate toxicity, reviews the erratic absorption and elimination kinetics, describes the devastating physiologic effects of overdose, and illustrates the potentially subtle manifestations of chronic aspirin toxicity.
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Affiliation(s)
- Gerald F O'Malley
- Division of Toxicology, Albert Einstein Medical Center, Philadelphia, PA 19141, USA.
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21
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Abstract
Acquired tracheo-oesophageal fistula is a devastating condition, usually occurring as a late manifestation of oesophageal or other thoracic malignancies. In these cases palliation by placement of an oesophageal stent is the preferred option, but management of a large non-malignant fistula is more complex. In many patients in whom primary repair of the defects is not possible oesophagectomy may be seen as the best treatment. We present a case of a large tracheo-oesophageal fistula repaired with a gastric antral patch oesophagoplasty and intercostal muscle flap.
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Affiliation(s)
- Michael L Talbot
- Department of Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.
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22
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Abstract
BACKGROUND Paracetamol (acetaminophen) poisoning is the leading cause of acute liver failure in Great Britain and the United States. Successful interventions to reduced harm from paracetamol poisoning are needed. To achieve this, the government of the United Kingdom introduced legislation in 1998 limiting the pack size of paracetamol sold in shops. Several studies have reported recent decreases in fatal poisonings involving paracetamol. We use interrupted time-series analysis to evaluate whether the recent fall in the number of paracetamol deaths is different to trends in fatal poisoning involving aspirin, paracetamol compounds, antidepressants, or nondrug poisoning suicide. METHODS AND FINDINGS We calculated directly age-standardised mortality rates for paracetamol poisoning in England and Wales from 1993 to 2004. We used an ordinary least-squares regression model divided into pre- and postintervention segments at 1999. The model included a term for autocorrelation within the time series. We tested for changes in the level and slope between the pre- and postintervention segments. To assess whether observed changes in the time series were unique to paracetamol, we compared against poisoning deaths involving compound paracetamol (not covered by the regulations), aspirin, antidepressants, and nonpoisoning suicide deaths. We did this comparison by calculating a ratio of each comparison series with paracetamol and applying a segmented regression model to the ratios. No change in the ratio level or slope indicated no difference compared to the control series. There were about 2,200 deaths involving paracetamol. The age-standardised mortality rate rose from 8.1 per million in 1993 to 8.8 per million in 1997, subsequently falling to about 5.3 per million in 2004. After the regulations were introduced, deaths dropped by 2.69 per million (p = 0.003). Trends in the age-standardised mortality rate for paracetamol compounds, aspirin, and antidepressants were broadly similar to paracetamol, increasing until 1997 and then declining. Nondrug poisoning suicide also declined during the study period, but was highest in 1993. The segmented regression models showed that the age-standardised mortality rate for compound paracetamol dropped less after the regulations (p = 0.012) but declined more rapidly afterward (p = 0.031). However, age-standardised rates for aspirin and antidepressants fell in a similar way to paracetamol after the regulations. Nondrug poisoning suicide declined at a similar rate to paracetamol after the regulations were introduced. CONCLUSIONS Introduction of regulations to limit availability of paracetamol coincided with a decrease in paracetamol-poisoning mortality. However, fatal poisoning involving aspirin, antidepressants, and to a lesser degree, paracetamol compounds, also showed similar trends. This raises the question whether the decline in paracetamol deaths was due to the regulations or was part of a wider trend in decreasing drug-poisoning mortality. We found little evidence to support the hypothesis that the 1998 regulations limiting pack size resulted in a greater reduction in poisoning deaths involving paracetamol than occurred for other drugs or nondrug poisoning suicide.
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Affiliation(s)
- Oliver W Morgan
- Department of Primary Care and Social Medicine, Imperial College London, United Kingdom.
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23
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Abstract
The authors discuss a new study that examined the change in deaths attributed to paracetamol poisoning in England and Wales in the six years before and after a legislated reduction in the maximum pack size.
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Affiliation(s)
- Nicholas A Buckley
- Department of Clinical Pharmacology and Toxicology, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.
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Wollersen H, Preuss J, Thierauf A, Musshoff F, Madea B. [Suicide with acetylsalicylic acid]. Arch Kriminol 2007; 219:115-23. [PMID: 17539592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The authors report on a suicide of a 41-year-old man with acetylsalicylic acid. According to his own statement the man had taken about 200 tablets of Aspirin (65 g acetylsalicylic acid) and initially showed no symptoms of intoxication. 4-5 hours after ingestion he vomited twice, but clear intoxication symptoms like convulsions and cardiac arrhythmia occurred not earlier than 11 hours after ingestion. Resuscitation by the emergency physician was not successful. The chemical-toxicological analysis (HPLC-DAD) of blood samples taken in the hospital approximately 12 h after ingestion showed salicylate in concentrations of 475 mg/L to 557 mg/L. The post-mortem concentrations of salicylate were within the lethal-toxic range, i.e. 762 mg/L in heart blood and 215 mg/L in femoral blood. All tested organs contained equally lethal salicylate levels (e.g. 503 mg/L in the liver and 251 mg/L in the brain).
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Abstract
Extracorporeal elimination of drugs and toxins is a critical component in the management of poisonings, though specific techniques and indications remain a matter of debate. Conventional hemodialysis is frequently the treatment of choice because of its widespread availability and proven effectiveness for certain drugs and toxins. With the increased availability of continuous renal replacement therapy (CRRT) modalities, there is yet another therapeutic option, but one that has yet to find a definitive role in this field. The continuous nature of these therapies is attractive for the management of acute renal failure, but the relatively slower clearance rates as compared to conventional hemodialysis is a distinct drawback in patients with acute xenobiotic-induced toxicity. There are abundant case reports as well as a few small case series in the medical literature documenting the use of CRRT, but specific techniques and the clinical outcomes vary considerably. Therefore one cannot draw definitive conclusions regarding benefit. Some patients, particularly those who are hemodynamically unstable and are not candidates for conventional hemodialysis, may warrant a trial of CRRT. However, at the present time, routine use for the treatment of poisoning is not supported. Controlled trials to better clarify its role would be beneficial, though such studies would be extremely difficult to conduct in this field. We believe that the intelligent application of extracorporeal modalities requires a thorough knowledge of drug pharmacokinetics, of the techniques utilized, and a skeptical analysis of the available literature.
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Affiliation(s)
- Jeffrey W Goodman
- Nephrology Section, New York Harbor VA Medical Center, New York, New York 10010, USA
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Rauschka H, Aboul-Enein F, Bauer J, Nobis H, Lassmann H, Schmidbauer M. Acute cerebral white matter damage in lethal salicylate intoxication. Neurotoxicology 2007; 28:33-7. [PMID: 16930716 DOI: 10.1016/j.neuro.2006.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Revised: 06/17/2006] [Accepted: 06/30/2006] [Indexed: 10/24/2022]
Abstract
A 34-year-old oligophrenic woman was admitted in comatose state with marked tachypnea. History revealed the oral ingestion of a large amount of acetylsalicylate to attenuate ear pain within the preceding 3 days. Laboratory investigations showed a toxic concentration of serum salicylate (668 mg/l, toxic range above 200 mg/l) and metabolic acidosis. Oxygenation, blood pressure, electrocardiography, echocardiography and CT of thorax and brain were normal. The patient was intubated, fluid and bicarbonate was given intravenously. Six hours after admission asystolia refractory to resuscitation led to death. Autopsy showed venous congestion of the brain, cardiac dilatation and pulmonary edema. Brain histopathology showed myelin disintegration and caspase-3 activation in glial cells, whereas, grey matter changes were sparse. Acute white matter damage is suggested to be the substrate of cerebral dysfunction in salicylate intoxication and possible mechanisms are discussed.
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Affiliation(s)
- Helmut Rauschka
- Department of Neurology, Hospital Hietzing, and Department of Neuroimmunology, Brain Research Institute, Medical University Vienna, Austria.
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Mégarbane B, Baud F. [Acute poisoning: general management and main causes]. Rev Prat 2006; 56:1603-13. [PMID: 17139875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Bruno Mégarbane
- Service réanimation médicale et toxicologique, hôpital Lariboisière, 75010 Paris.
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Pharmaceutical drug overdose. Treat Guidel Med Lett 2006; 4:61-6. [PMID: 16929234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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Tan SY. Issues in medical malpractice II. Hawaii Med J 2006; 65:241-2. [PMID: 17004625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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30
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[Metabolic acidosis]. Nihon Naika Gakkai Zasshi 2006; 95:853-8. [PMID: 16774060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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31
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Reingardiene D, Lazauskas R. [Acute salicylate poisoning]. Medicina (Kaunas) 2006; 42:79-83. [PMID: 16467617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Although aspirin (acetylsalicylic acid) has become widely available without prescription, cases of self-poisoning due to overdose of salicylates are quite uncommon, with a low reported mortality. However, severe poisoning with these preparations is life threatening. Besides the aspirin, there are other sources of salicylate poisoning, such as an excessive application of topical agents, ingestion of salicylate containing ointments, use of keratolytic agents or agents containing methyl salicylate (e.g. oil of wintergreen). Most of these preparations are liquid, highly concentrated and lipid soluble, and, therefore, they are able to provoke a severe, rapid salicylate poisoning. On the basis of clinical and metabolic features or salicylate concentration in plasma it is very important to diagnose severe poisoning with salicylates in time and prescribe an adequate treatment. In the present review article various aspects of salicylate poisoning and its treatment are discussed: epidemiology, pharmacokinetics and pharmacodynamics of salicylates, clinical manifestations of their toxicity, management, enhanced elimination and prognosis.
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Affiliation(s)
- Dagmara Reingardiene
- Clinic of Intensive Care, Kaunas University of Medicine, Eiveniu 2, 50009 Kaunas, Lithuania
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32
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Matsumoto Y. [A pharmacokinetic analysis in a patient with acute drug poisoning]. Chudoku Kenkyu 2005; 18:309-15. [PMID: 16318388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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33
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Abstract
A short cut review was carried out to establish whether gastric lavage was better than activated charcoal alone at reducing toxicity after aspirin or other non-steroidal anti-inflammatory drug (NSAID) overdose. Altogether 72 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. A further relevant paper was found on scanning the references of papers identified. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
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Affiliation(s)
- Stewart Teece
- Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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34
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Onouchi T, Horiuchi T, Kinouchi T. [Salicylic acid, aspirin]. Nihon Rinsho 2004; 62 Suppl 12:392-4. [PMID: 15658346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Tsuneko Onouchi
- Laboratory for Collaborative Research, Teikyo University School of Medicine, Ichihara Hospital
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35
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Müller GJ. Aspirin, other salicylates and non-steroidal anti-inflammatory agents. SADJ 2004; 59:283. [PMID: 15537029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- G J Müller
- Tygerberg Poison Information Centre, PO Box 19063, Tygerberg, 7505.
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36
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Rivera W, Kleinschmidt KC, Velez LI, Shepherd G, Keyes DC. Delayed Salicylate Toxicity at 35 Hours Without Early Manifestations Following a Single Salicylate Ingestion. Ann Pharmacother 2004; 38:1186-8. [PMID: 15173556 DOI: 10.1345/aph.1d575] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To report a case of delayed toxicity following a single ingestion of aspirin, where the initial concentrations were nearly undetectable and the patient was completely asymptomatic for the first 35 hours. CASE SUMMARY: A 14-year-old white female was evaluated after a single ingestion of 120 tablets of aspirin 81 mg/tablet hours before arrival to the emergency department. She denied nausea, abdominal pain, tinnitus, or shortness of breath. She received one dose of activated charcoal. The first salicylate concentration (4 h after ingestion) was 1 mg/dL. At 35 hours, the patient became symptomatic (dizziness, tinnitus, epigastric discomfort). Her salicylate concentration at that time was 46 mg/dL. A second dose of activated charcoal was administered, and intravenous bicarbonate with potassium was started as a continuous infusion for 30 hours. DISCUSSION: While delayed salicylate toxicity is well reported in the literature, no report was found regarding concentrations increasing to toxicity 35 hours after ingestion. The delayed aspirin absorption may be due to salicylate-induced pylorospasm or the formation of pharmacobezoars. CONCLUSIONS: In cases with known salicylate ingestion, it is important to follow salicylate concentrations every 4 hours until they are steadily decreasing according to a 4-hour half-life and the patient shows no symptoms of salicylate intoxication.
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Affiliation(s)
- Wilfredo Rivera
- Section of Toxicology, University of Texas Southwestern (UTSW) Emergency Medicine, Dallas, TX 75390-8579, USA.
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37
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Abstract
Thyroid dysfunction is one of the serious consequences of an overdose of acetaminophen, aspirin, or nonsteroidal antiinflammatory drugs. The management of such consequences remains a medical challenge. A variety of thyroid abnormalities are common in clinical practice and can, in many cases, be accurately diagnosed and managed by the primary care physician. This case study covers an aspirin overdose causing thyroid storm that was treated successfully with hemodialysis.
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Affiliation(s)
- Ahmet Sebe
- Cukurova University School of Medicine, Department of Emergency Medicine, Balcali, Adana, Turkey
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38
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Ishizawa F, Kirihara M, Ishiwata T, Yashiki M, Namera A, Nishida M, Kimura K. [Development of salicylic acid detector tube]. Chudoku Kenkyu 2004; 17:149-54. [PMID: 15266849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
A detector tube was successfully devised for the screening of salicylic acid in urine. It, named "salicylic acid detector tube", consists of glass tube in which silica gel coated with 5% (w/w) of ferric chloride is enclosed. A pipette rubber cap was attached to an end of the tube, and another end was inserted into urine sample. The sample was then introduced into the tube, the color of the reagent immediately turned purple under the condition of more than 50 microg/ml of salicylic acid in urine. This device was useful for the emergency screening of salicylic acid in acute poisoning cases with aspirin.
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Affiliation(s)
- Fujio Ishizawa
- Scientific Criminal Investigation Laboratory, Ibaraki-prefectural Police Headquarters
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39
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Abstract
Acetylic acid, such as aspirin, is one of the most commonly used medication in Western societies. Aspirin overdosage causes ototoxic side effects in some patients, such as bilateral mild to moderate sensorineural hearing loss and tinnitus. Recent literature describes, that salicylates act as competitive inhibitors of Cl- anions at the anion-binding site of prestin, the motor protein of the outer hair cell. This molecular mechanism correlates well with the clinical audiological mainstays of aspirin-induced hearing loss, dose dependency, cochlear site of hearing loss and reversibility. We report about a young man with an acute moderate aspirin intoxication resulting in asymmetric hearing loss of 50 dB HL and tinnitus for five days. Otoacoustic emissions were absent on the first day of intoxication but could be measured again on the fifth day after the intoxication. As the ototoxic side effects resolve with in two or three days, no specific treatment is necessary for ototoxicity. Medical treatment of acute or chronic aspirin intoxications aims to decrease further drug absorption by gastrointestinal decontamination and to accelerate elimination by alkaline diuresis. Only in severe intoxications hemodialysis may be considered to treat neurologic, pulmonal, renal or cardial complications.
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Affiliation(s)
- H Wecker
- HNO-Klinik der Universität Witten/Herdecke, Katholisches Krankenhaus Hagen gGmbH.
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40
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Hender EA, Raftos J. The effect of recalling paracetamol on hospital admissions for poisoning. Med J Aust 2003; 179:222; author reply 223. [PMID: 13678047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
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41
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Peña-Alonso YR, Montoya-Cabrera MA, Bustos-Córdoba E, Marroquín-Yáñez L, Olivar-López V. Aspirin intoxication in a child associated with myocardial necrosis: is this a drug-related lesion? Pediatr Dev Pathol 2003; 6:342-7. [PMID: 14692648 DOI: 10.1007/s10024-001-0127-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 5-year-old girl with a mild upper airways infection was admitted to the hospital because of sudden vomiting and drowsiness that evolved to stupor; she was dehydrated, hypotensive, and tachypneic; laboratory tests revealed noncompensated lactic acidosis. She also had hypoglycemia followed by hyperglycemia, and progressive bradycardia leading to reversible cardiac arrest. Her clinical condition complicated by sinus bradycardia, ventricular tachycardia, third-degree atrioventricular blockage and lethal asystole. At the final stage of her illness, the serum salicylate concentration was 383.8 mcg/mL. Based on this single data, a retrospective toxicological analysis estimated a theoretical peak level of serum salicylate of approximately 1570 mcg/mL (therapeutic range, 20-250 mcg/mL) although the real amount of aspirin that this child ingested is difficult to calculate because aspirin is a drug that shows a so-called zero order kinetics. At autopsy, the most striking finding was multiple foci of coagulative necrosis involving the entire thickness of the myocardium with scant inflammatory infiltrate composed mainly of macrophages and polymorphonuclear leukocytes. The morphologic characteristics of the myocardial lesion in addition to salicylate blood levels suggests the possibility of an adverse drug reaction of the type acute toxic myocarditis.
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Affiliation(s)
- Y Rocío Peña-Alonso
- Department of Pathology, Hospital Infantil de México Federico Gómez, Dr. Márques 162, México, D.F., CP 06720, México.
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42
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Sharma AN, Hexdall AH, Chang EK, Nelson LS, Hoffman RS. Diphenhydramine-induced wide complex dysrhythmia responds to treatment with sodium bicarbonate. Am J Emerg Med 2003; 21:212-5. [PMID: 12811715 DOI: 10.1016/s0735-6757(02)42248-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Diphenhydramine, a common ingredient in over-the-counter medications, is often taken in overdose. Toxicity is usually limited to anticholinergic symptoms. However, because diphenhydramine also exhibits type IA sodium channel blockade, cardiac toxicity is also possible. Although it would be expected that, like other type IA toxicities, diphenhydramine-induced cardiotoxicity could be responsive to hypertonic sodium bicarbonate, this finding is largely unappreciated. We describe 3 cases of diphenhydramine-induced cardiac toxicity that were responsive to bicarbonate.
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Affiliation(s)
- Adhi N Sharma
- New York City Poison Control Center, New York, NY, USA.
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43
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Affiliation(s)
- Allison A Muller
- The Poison Control Center, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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44
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45
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Affiliation(s)
- Glyn Volans
- National Poisons Information Service (London Centre), Medical Toxicology Unit, Guy's and St Thomas' Hospital, London.
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46
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Kisely SR, Lawrence D, Preston NJ. The effect of recalling paracetamol on hospital admissions for poisoning in Western Australia. Med J Aust 2003; 178:72-4. [PMID: 12526726 DOI: 10.5694/j.1326-5377.2003.tb05067.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2002] [Accepted: 09/23/2002] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the effect of two recalls of paracetamol products on rates of intentional and unintentional overdoses of paracetamol in all age groups, as well as any effect on poisoning by other agents. DESIGN A before-and-after epidemiological study using data from the Western Australian Health Services Research Linked Database, which records all admissions to public and private hospitals throughout the State. MAIN OUTCOME MEASURES Hospital admissions in Western Australia for poisonings with all agents, including paracetamol and other over-the-counter analgesics. RESULTS There were 11 752 admissions for poisoning from 1996 to 2001. Paracetamol was the primary poisoning agent in 2266 (19.3%) admissions, aspirin in 120 (1%) and ibuprofen in 277 (2%). There was a significant decrease in the admission rate for paracetamol poisoning when sales were restricted in 2000 (rate ratio, 0.82; 95% CI, 0.68-0.99) compared with the same period in other years. There was no increase in poisoning with other agents at this time. However, admissions for paracetamol overdose also showed a large random variation that tended to obscure any effect. CONCLUSIONS Our study highlights the need to control for random as well as seasonal fluctuations in admission rates, and for restrictions on paracetamol sales to last for several months across all retail outlets. Limiting access to paracetamol may reduce paracetamol poisonings without a coincident increase in the use of other agents
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Affiliation(s)
- Stephen R Kisely
- University Department of Psychiatry at Fremantle Hospital, University of Western Australia, Fremantle, WA.
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47
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Hori Y, Iwasaki Y, Komiyayama Y, Yashiki M, Kuroki Y. [Practical analysis of toxic substances useful for clinical toxicology. 5--Salicylate salts]. Chudoku Kenkyu 2003; 16:93-8. [PMID: 12712551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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48
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Affiliation(s)
- M Riordan
- Department of Pediatrics, Yale University Medical School, USA
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49
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Juurlink DN, Szalai JP, McGuigan MA. Discrepant advice from poison centres and their medical directors. Can J Clin Pharmacol 2002; 9:101-5. [PMID: 12172589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE To characterize the recommendations of the medical directors of North American poison information centres for gastrointestinal decontamination of a hypothetical poisoned patient, and to examine the extent to which those recommendations agree with the advice previously issued by their poison information centres for the same scenario. METHODS The medical directors of 72 poison centres in the United States and Canada were contacted and invited to participate in a survey. Each participant was asked to provide specific advice for gastrointestinal decontamination of a hypothetical patient presenting 1 h after a potentially life-threatening ingestion (32.5 g) of enteric-coated acetylsalicylic acid. The directors were then presented with the recommendation their poison centres had previously issued for the same overdose scenario. The main outcome measures were perceived agreement with their own centre's recommendation and director-centre concordance for each method of gastrointestinal decontamination. RESULTS Sixty-seven of 72 (93%) medical directors participated in the survey. They issued 30 different management suggestions for our hypothetical patient, and were in full agreement with their own centres 27% of the time. Concordance was moderate for recommendations on syrup of ipecac (k=0.468, P<0.001), and fair for whole bowel irrigation (k=0.348, P=0.005) and the use of sorbitol with activated charcoal (k=0.305, P=0.005). Concordance was poorest for advice on gastric lavage (k=0.093, P=0.445) and multidose charcoal (k=0.039, P=0.745). CONCLUSIONS The medical directors of North American poison centres offer widely varying advice on gastrointestinal decontamination for a hypothetical patient who is acutely poisoned with enteric-coated acetylsalicylic acid. Their advice was often different from that previously issued by their respective centres.
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Affiliation(s)
- David N Juurlink
- Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada.
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50
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Abstract
OBJECTIVE To evaluate the effectiveness of child-resistant packaging in reducing the mortality rate from the unintentional ingestion of aspirin for children younger than 5 years. DESIGN Estimates of the annual aspirin-related mortality rate for children younger than 5 years in the United States were developed for the 1958-1990 study period. A multivariate negative binomial regression model was then used to estimate the independent effect of the packaging requirements on the child mortality rate during the postintervention period. The analysis controlled for changes in the per capita use of aspirin, long-term safety trends, and other extraneous and potentially confounding factors that may have affected the aspirin-related child mortality rate. MAIN OUTCOME MEASURE Estimated percentage reduction in the child mortality rate associated with the use of child-resistant packaging. RESULTS After controlling for covariates, the use of child-resistant packaging was associated with a 34% reduction in the aspirin-related child mortality rate. This mortality rate reduction equates to the prevention of about 90 child deaths during the 1973-1990 postregulatory study period. CONCLUSIONS Child-resistant packaging has been effective in reducing aspirin-related child poisonings. However, because its effectiveness is only partial, further poison prevention strategies should be developed and instituted.
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Affiliation(s)
- Gregory B Rodgers
- Directorate for Economic Analysis, US Consumer Product Safety Commission, Washington, DC 20207, USA.
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