Abstract
BackgroundPoisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.MethodsA committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d’Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.ResultsThe SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.ConclusionsThe experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
Highlights
Poisoning is one of the leading causes of admission to the emergency department and intensive care unit
Intensive Care (2020) 10:157 occurred over the last decade, the US opioid overdose crisis and the exponential growth of new synthetic recreational drugs called "new psychoactive substances" (NPS)
The concept of antidote was considered from a restrictive point of view, limited to drugs that have been clearly established to act on toxicokinetics or toxicodynamics, allowing improvement of the poisoned patient’s functional or vital prognosis
Summary
These guidelines are the result of the work conducted by an SRLF and SFMU joint expert committee. Rationale The clinical features of voluntary or accidental pharmaceutical or recreational drug poisoning are the result of a large number of factors, including the intrinsic properties of the toxin, the dose, the formulation, the mode of exposure, co-ingestion of other toxins, and the patient’s prior health status [120] Despite this wide range of factors, the mortality of poisoned patients admitted to the ER or ICU is low as a result of the efficacy of life support treatments that play a much larger role than antidotes or enhanced elimination techniques (including haemodialysis). These techniques are associated with technical difficulties, high cost, limited availability and sometimes significant iatrogenic effects [125, 130] All of these findings suggest that, except in the context of a study protocol, an extracorporeal treatment other than haemodialysis should not be used to enhance elimination of toxins in patients with medication or recreational drug poisoning. Recommendations for the management of calcium-channel blocker poisoning consider that VAECMO can be used in cases of refractory shock in expert centres [72]
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