Hours Of Ingestion Research Articles

Drug overdose — reducing the load

To review available information about various methods for reducing gastrointestinal absorption of a poison or drug. Articles on overdose and accidental poisoning generated by the Australian Medlars Service and concentrating on the period between 1985 and 1990 were surveyed. Earlier studies were included if relevant. English language articles with an emphasis on studies using objective methods to measure individual and comparative efficacy of gastrointestinal decontamination techniques were selected. A total of 65 articles were reviewed. Gastric emptying procedures (gastric lavage or emesis caused by syrup of ipecac) are only effective if performed within one hour of drug ingestion. Gastric lavage is superior to syrup of ipecac. Oral administration of activated charcoal is more effective than either gastric emptying procedure, and is recommended for most cases of poisoning. Cathartics (sorbitol) can be used with activated charcoal. Whole bowel lavage with polyethylene glycol is indicated in selected cases of potentially lethal overdose where the toxic substance cannot be absorbed by charcoal and has passed the pylorus. Children--syrup of ipecac can be given at home to children older than 12 months. Most children who reach hospital can be treated by charcoal alone. ADULTS--Most patients are managed with supportive care and, in the absence of contraindications, a single dose of activated charcoal if seen within four hours of ingestion of the poison or drug. Gastric lavage is used if the patient presents within one hour of ingestion and has clinical features of toxicity.

The rise in the total iron-binding capacity after iron overdose

To determine if and to what extent the total iron-binding capacity (TIBC) would increase following an iron overload, and to identify specific iron-binding proteins that might be responsible for the increased TIBC. A prospective laboratory investigation. A certified regional poison control center. Six healthy adult male volunteers. All volunteers ingested 20 mg/kg of elemental iron. Blood samples were drawn at hourly intervals for eight hours and analyzed for serum iron, TIBC, transferrin, ferritin, lactoferrin, glucose, bicarbonate, and WBC. Within two hours of ingestion, subjects developed symptoms of toxicity, including nausea, lightheadedness, vomiting, severe crampy abdominal pain, and voluminous diarrhea. The TIBC was statistically significantly increased at all points measured from one to six hours. Despite rising above 300 micrograms/dL in five of six subjects, the serum iron never exceeded the TIBC in any subject. Transferrin and ferritin did not increase to account for the increased TIBC. The lactoferrin levels did increase, but they did not correlate with significant increases in the TIBC. Twenty mg/kg of elemental iron caused clinical toxicity in this study, and after iron overload the colorimetric TIBC increased by unknown mechanisms.

Screening for drug poisoning

Since most patients presenting with a drug overdose do so within 2 hours of ingestion of the drug, the specimen of choice for a drug screen is the gastric contents. Under these circumstances, the concentration is likely to be relatively large and the drugs not yet metabolised. Where the overdose has occurred several hours prior to the patient's examination, urine could be the preferred specimen, or for those laboratories equipped with mass spectroscopy, a blood sample could suffice. Using techniques such as U.V. spectroscopy, thin layer chromatography and gas chromatography, the identity of most drugs can be established absolutely within 2 hours. The exact analytical approach must depend on the nature of the compounds swallowed, if this is known. Once the identity of the offending agent is established, quantitation in blood can be used to indicate the severity of the poisoning provided there is a means of meaningfully interpreting this data.

Acute Poisoning with a Glyphosate-Surfactant Herbicide ('Roundup'): A Review of 93 Cases

Between 1 January 1980, and 30 September 1989, 93 cases of exposure to herbicides containing glyphosphate and surfactant ('Roundup') were treated at Changhua Christian Hospital. The average amount of the 41% solution of glyphosate herbicide ingested by non-survivors was 184 +/- 70 ml (range 85-200 ml), but much larger amounts (500 ml) were reported to have been ingested by some patients and only resulted in mild to moderate symptomatology. Accidental exposure was asymptomatic after dermal contact with spray (six cases), while mild oral discomfort occurred after accidental ingestion (13 cases). Intentional ingestion (80 cases) resulted in erosion of the gastrointestinal tract (66%), seen as sore throat (43%), dysphagia (31%), and gastrointestinal haemorrhage (8%). Other organs were affected less often (non-specific leucocytosis 65%, lung 23%, liver 19%, cardiovascular 18%, kidney 14%, and CNS 12%). There were seven deaths, all of which occurred within hours of ingestion, two before the patient arrived at the hospital. Deaths following ingestion of 'Roundup' alone were due to a syndrome that involved hypotension, unresponsive to intravenous fluids or vasopressor drugs, and sometimes pulmonary oedema, in the presence of normal central venous pressure.

Relative Efficacy of Long-Acting Stimulants on Children With Attention Deficit-Hyperactivity Disorder: A Comparison of Standard Methylphenidate, Sustained-Release Methylphenidate, Sustained-Release Dextroamphetamine, and Pemoline

Twenty-two children with attention deficit-hyperactivity disorder underwent a double-blind, placebo-controlled, crossover evaluation of the efficacy of standard methylphenidate twice a day and comparable doses every morning of a sustained-release preparation of methylphenidate (SR-20 Ritalin), a sustained-release form of dextroamphetamine (Dexedrine Spansule), and pemoline. The children were participating in a summer treatment program in which they engaged in recreational and classroom activities. Dependent measures include evaluations of social behavior during group recreational activities, classroom performance, and performance on a continuous performance task. Results revealed generally equivalent and beneficial effects of all four medications. Dexedrine Spansule and pemoline tended to produce the most consistent effects and were recommended for 10 of the 15 children who were responders to medication. The continuous performance task results showed that all four medications had an effect within 2 hours of ingestion, and the effects lasted for 9 hours. The implications of these results for the use of long-acting stimulant medication in children with attention deficit-hyperactivity disorder are discussed.

Swallowed button batteries: is there a consensus on management?

The optimum management of ingested button batteries was ascertained by postal questionnaire sent to 608 members of the endoscopic and paediatric sections of the British Society of Gastroenterology. Some 312 returns were suitable for analysis: 36.2% of the respondents were not concerned about ingested button batteries and gave no treatment, 6.4% used medical treatment, 48.4% removed them under certain circumstances, and 9% did not know how to manage the problem. Emetics and H2 antagonists or antacids were often used for batteries in the oesophagus, stomach, and duodenum and laxatives were commonly prescribed for batteries in the small and large bowel. Of the 48.4% who felt batteries should be removed under certain circumstances, 78%, 72%, and 48% extracted them from the oesophagus, stomach, and duodenum respectively within 24 hours of ingestion. The main reason for operative removal from the small and large bowel was failure of the battery to progress. Current management is therefore variable. Heavy metal poisoning may be occurring more frequently than is suggested in the published reports.

Nonsteroidal anti-inflammatory drugs and coma: A case report of fenoprofen overdose

We present the case of a 17-year-old girl who ingested 24 to 36 g fenoprofen as a suicidal gesture. She presented with coma, hypotension, metabolic acidosis, and respiratory depression within four hours of ingestion. The most common adverse effects of the nonsteroidal anti-inflammatory drugs occur in both therapeutic and toxic doses and include gastrointestinal upset, blood dyscrasias, and analgesic nephropathy. The propionic acid derivatives of nonsteroidal anti-inflammatory drugs, including fenoprofen and ibuprofen, are rarely associated with severe toxic effects. This is the first report of pure fenoprofen overdose presenting as coma and metabolic acidosis.

Methanol poisoning: factors associated with neurologic complications.

Hospital records of thirty patients with methanol poisoning were studied. Neurologic manifestations at presentation including coma, seizures and decreased visual acuity were seen in nineteen patients. The mean blood pH at presentation was significantly lower in the patients with these neurologic signs and symptoms than in the eleven patients without them (p less than 0.05). Methanol levels at presentation tended to be higher in patients with neurologic manifestations at presentation and these patients tended to present later after methanol ingestion than those patients without neurologic manifestations. Fifteen patients with methanol poisoning developed serious neurologic sequelae or died. The mean blood pH was significantly lower in this patient group than in those who survived without neurologic sequelae (p less than 0.05). Methanol levels at presentation were not different in the patients who developed neurologic sequelae or died as compared to those who did not. The time from ingestion of methanol to presentation at the hospital was however significantly longer in those patients who developed neurologic sequelae or died (p less than 0.05). Initiation of treatment within eight hours of ingestion of methanol was associated with a better clinical outcome.

Acute Thyroxine Ingestion in Pediatric Patients

During a 1-year period, 15 cases of acute thyroxine (T4) overdose with documented serum T4 concentrations were studied. All patients were less than 5 years of age and 80% were boys. All were examined within 1 to 6 hours of ingestion and all were asymptomatic. Estimated dose ingested in 10 patients ranged from 1.5 to 8.8 mg (0.1 to 0.73 mg/kg). Three patients with initial T4 serum concentrations greater than 75 micrograms/dL manifested signs of toxicity within 12 to 48 hours (fever, tachycardia, hypertension, and/or agitation) that resolved within 24 to 60 hours. The mean elimination half-life of T4 in 7 patients with multiple serum concentrations was 2.8 +/- 0.4 days, whereas the mean elimination half-life of triiodothyronine was 6 +/- 1.7 days. It was concluded that (1) the majority of acute pediatric T4 overdoses are not severe and may be managed on an outpatient basis, (2) the absence of early clinical manifestations does not preclude delayed onset of toxicity that may be better predicted by initial T4 concentrations, and (3) the elimination half-life of T4 is shorter and the elimination half-life of tri-iodothyronine is longer than with therapeutic doses.

Pediatric Coin Ingestion

It has been recommended that all children with a history of coin ingestion immediately undergo roentgenography to locate the coin, regardless of symptoms. We performed a prospective evaluation of these ingestions to determine the risk of asymptomatic esophageal impaction and the need for routine roentgenography. One hundred sixty-two children (mean +/- SD age, 3.6 +/- 2.1 years) were evaluated. All were referred for immediate roentgenography after ingestion and followed up daily by telephone for 5 days. Sixty-six patients (41%) did comply and 96 (59%) did not comply with the roentgenogram recommendation. A coin was visualized in the esophagus of 13 patients (20%); 11 were symptomatic and 2 were asymptomatic at the time of ingestion. Symptomatic patients had a 42% risk of a coin later being located in the esophagus compared with a 5% risk for asymptomatic patients. The asymptomatic patients with lodged coins passed them without difficulty after the administration of oral fluids. Nineteen percent of the patients who did not undergo roentgenography were symptomatic and all became asymptomatic within 24 hours of ingestion. There was no difference in morbidity between the group that underwent roentgenography and the group that did not undergo roentgenography at 5 days after ingestion. Children who are asymptomatic at the time of coin ingestion may not need routine roentgenography if they can tolerate oral fluids and telephone follow-up is available.

Toddler Eats Clonidine Patch and Nearly Quits Smoking for Life

To the Editor.— Clonidine has recently been advocated as an aid in smoking cessation.1,2Should it prove useful, it is likely that childhood ingestions of clonidine, already common, would increase. We recently treated a child with a toxic reaction due to ingestion of clonidine from a transdermal patch prescribed for smoking cessation. Report of a Case. — A 2-year-old child presented to the emergency department with a history of progressive lethargy over several hours. Examination revealed a heart rate of 75 beats per minute, blood pressure of 90/50 mm Hg, 2-mm pupils, and gasping respirations. The child responded to pain only by withdrawal; she did not open her eyes or speak. Her parents denied exposure to prescription medicines or heart medicines and, when asked specifically, denied exposure to clonidine. Routine urine toxicology screens by chromatography were negative on two samples taken within five hours of ingestion. The child was

The generation of acetonemia/acetonuria following ingestion of a subtoxic dose of isopropyl alcohol

A subtoxic dose of isopropyl alcohol was ingested by three subjects to evaluate the time to and extent of acetone generation and to explore its detection in the urine. Maximal serum isopropyl alcohol concentrations were observed by 30 minutes after ingestion of approximately 1 oz 70% isopropyl alcohol (0.4 mL/kg), but maximal serum acetone concentrations were not recorded until at least four hours postingestion. Urine tested positive (small) for acetone within three hours of ingestion using Acetest urine testing tablets (Ames Labs, Elkhart, IN). It was concluded that acetonemia occurs early after ingestion of isopropyl alcohol and increases as serum isopropyl alcohol concentrations decline. In addition, acetonuria may be qualitatively measured by three hours postingestion with rapid urine screening tests and may remain positive for 24 hours.

The influence of ruminant digestion on the germination ofPennisetum clandestinumhochst. ex chiov1

Approximately half of the viable Pennisetum clandestinum seed fed to sheep was found to be viable after passing through the digestive system. 82% of the viable seed was excreted within 28 hours of ingestion with no viable seed being excreted after 52 hours after ingestion. These results have important implications for the dispersion of this species.Keywords: digestion; dispersion; germination; ingestion; kikuyu; pennisetum clandestinum; seed; sheep; south africa

Early evaluation and therapy for caustic esophageal injury

Forty-one patients with caustic ingestion were reviewed. Eighty-three percent were children, all of whom suffered accidental injury. Liquid drain cleaner was the agent in 57 percent and was responsible for all esophageal burns. Symptoms and physical findings were unreliable in predicting the extent of injury. Endoscopy was performed in most patients within 36 hours of ingestion and accurately estimated the risk of subsequent esophageal stricture formation. Steroid administration had no influence on the development of strictures. Esophageal strictures developed in 22 percent of the patients. One-third were successfully managed by periodic dilation, whereas the remaining two-thirds required esophagectomy and reconstruction. Early endoscopic evaluation was the best means of assessing the degree of injury after caustic ingestion. Routine steroid administration had no apparent clinical benefit.

Addendum: nitrates (25 July, p.58)

We unintentionally omitted to mention Imdur (Astra), another sustained-release formulation of isosorbide mononitrate which releases most of the dose within 16–18 hours of ingestion.

Treatment of phenytoin toxicity with repeated doses of activated charcoal

A 38-year-old woman ingested at least 10 g of phenytoin and was managed using repeated doses of oral activated charcoal. The peak serum concentration of 52 micrograms/mL was reached within 42.5 hours of ingestion. Signs and symptoms of phenytoin toxicity had disappeared four days after ingestion. The serum phenytoin concentration was in the therapeutic range six days after ingestion. The clinical course of this patient was shorter than those of other conventionally treated patients with phenytoin overdoses. Multiple-dose activated charcoal may have a role in the treatment of phenytoin overdoses by limiting the amount of gastrointestinal absorption and by enhancing elimination.

Severe Toxic Reactions and Death Following the Ingestion of Diethyltoluamide-Containing Insect Repellents

N,N-diethyl-m-toluamide (DEET) is the most commonly used mosquito repellent. This report describes five cases of toxic reactions after ingestion of insect repellents containing DEET. Each patient ingested large amounts of concentrated (47.5% to 95%) products. Their common symptoms and signs were coma, seizures, and hypotension occurring within one hour of ingestion. Two patients died; three survivors had no sequelae. The two patients who died had serum DEET levels of 0.88 mmol/L (16.8 mg/dL) and 1.25 mmol/L (24 mg/dL). It is concluded that the ingestion of DEET can produce severe toxic reactions of rapid onset that may be fatal in some instances.

COW'S MILK SPECIFIC ANTIBODIES, SERUM IMMUNOGLOBULINS COMPLEMENT FRACTIONS, LYMPHOCYTE SUBSETS AND STIMULATION OF LYMPHOCYTES IN COW'S MILK ALLERGY

A cow's milk (CM) challenge test was done to 34 children aged from 3 to 51 months suspected to have CM allergy. Nineteen of them had clinical relapse during the CM challenge: 16 (84 %} showed cutaneous, 4 (21 %} gastrointestinal and 6 {32 %) respiratory manifestations. Fourteen showed immediate reaction within an hour of ingestion or skin contact with CM, in five the reaction took place later. Before and during the challenge test we measured serum levels of immnunoglobulins G, A, M and E, complement fractions 3 and 4, of class specific cow's milk antibodies, numbers of lymphocyte subsets and the stimulation of lymphocytes in whole blood by photohemaagglutinin, concanavalin A and betalactoglobulin. Of the 19 patients with positive CM challenge, 11 (61 %) showed increased levels of CM specific IgE antibodies, and of the remaining 8, betalactoglobulin stimulation was positive in 5, in half the helper/suppressor ratio increased during the challenge and 3 had decreased serum level of C3. None of the laboratory methods used could alone discriminate between children who reacted to CM in challenge and who did not. The combination of increased level of CM specific IgE with decreased serum IgG and C3 gave the sensitivity of 83 % and specificity of 55 % to predict clinical reaction.

Non-narcotic analgesics. Problems of overdosage.

The first cases of fulminant hepatic failure due to paracetamol poisoning were reported in 1966, and in the United Kingdom this condition is now responsible for more cases of acute hepatic failure than any other cause. Adults account for the majority of serious and fatal cases of paracetamol poisoning and it is extremely rare for young children to ingest sufficient paracetamol to cause more than minimal liver damage. A single measurement of the plasma paracetamol concentration is an accurate predictor of liver damage provided that it is taken not earlier than 4 hours after ingestion of the overdose. Peak disturbance of liver function occurs 2 to 4 days after the overdose, often accompanied by mild jaundice, after which recovery is usually rapid and complete. In a few patients, fulminant hepatic failure, manifested by increasing jaundice and encephalopathy, may develop by the third to fifth day. Acute renal failure may complicate paracetamol poisoning, often in the context of severe liver damage. Renal failure, which is often non-oliguric, typically becomes apparent 24 to 72 hours after overdosage. The treatment of paracetamol intoxication should include gastric lavage, which has been shown to be of value for up to 6 hours after ingestion of a paracetamol overdose. Further general treatment may include parenteral fluid replacement and a prophylactic infusion of dextrose (5-10%) in patients at risk of hepatic failure. Specific protective agents in those patients at risk of paracetamol-induced liver damage include N-acetylcysteine and methionine which are most effective if given within 8 to 10 hours of ingestion of the overdose. Hepatic and renal failure should be managed conventionally. In recent years in the United Kingdom there has been a gradual decline in the number of hospital admissions and the number of deaths from aspirin poisoning. Salicylates in overdose directly stimulate the respiratory centre and so cause a respiratory alkalosis. Metabolic acidosis occurs in severe poisoning because of impairment of the oxidative metabolism of energy substrates. At very high salicylate concentrations respiratory depression may occur, possibly associated with neuroglycopenia, adding respiratory acidosis to the worsening metabolic acidosis. In addition to a mixed acid-base disturbance, hypokalaemia and hypoglycaemia may be present. Nausea and vomiting increase the fluid deficit. If dehydration is sufficiently severe, decreasing cardiac output may hasten development of lactic acidosis and acute renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of acutely poisoned patients without gastric emptying

During an 18-month period, 592 acute oral drug overdose patients were studied prospectively in a controlled, randomized fashion to determine the efficacy of gastric emptying procedures in altering clinical outcome. Patients presenting on even-numbered days had no gastric emptying procedures performed, and they were compared to patients presenting on odd-numbered days who received either syrup of ipecac or gastric lavage. Patients were carefully followed for evidence of subsequent clinical improvement or deterioration after initial management. Syrup of ipecac did not significantly alter the clinical outcome of patients who were awake and alert on presentation to the emergency department (ED). Gastric lavage in obtunded patients led to a more satisfactory clinical outcome (P less than .05) only if performed within one hour of ingestion. Gastric emptying procedures in the ED for initial treatment of drug overdose are generally not of benefit unless gastric lavage is performed within one hour of ingestion in obtunded patients.