Management Of Acute Poisoning Research Articles

WITHDRAWN: Emergency management of acute poisoning

WITHDRAWN: Emergency management of acute poisoning

The Impact of Emergency Medicine Ward in Acute Intoxication Management

Background The Emergency Medicine Ward (EMW) was established in Caritas Medical Centre (CMC) in November 2007 under the management of emergency physicians. With the support from the psychiatric team and medical social workers, it provided effective management for intoxicated patients as an alternative to traditional inpatient service. Objective The aim of this study was to evaluate the impact of the EMW in the management of acute intoxication. Method A retrospective comparative study with data retrieved from all admitted intoxicated and suspected intoxicated patients was carried out over two separate half-year periods in 2007 and 2008, before and after the establishment of the EMW. Data on patient demographics, reason of exposure, substance involved, treatment, psychiatric service offered, clinical outcome, hospital length of stay (LOS) and 28-day hospital re-admission were compared. Results A total of 316 intoxicated patients were admitted to CMC with 165 in the 2007 group and 151 in the 2008 group. Both groups shared similar basic epidemiological data. There was a marked reduction in hospital LOS from 80.1 hours to 45.9 hours (p<0.01), a markedly increased proportion of patients receiving psychiatric service from 47.9% to 71.5% (p<0.01) and a significant decline in the access time of psychiatric assessment from 27.4 hours to 10.6 hours (p<0.05). There were no statistically significant difference in treatment, patient clinical outcome and 28-day hospital re-admission. Conclusions The establishment of EMW achieved a significant reduction in hospital LOS of intoxicated patients without jeopardizing patient outcome. The results also illustrate that EMW can provide a good platform for the integration of psychiatric service for these patients.

The Impact of an Emergency Department Toxicology Team in the Management of Acute Intoxication

Objective To evaluate the impact of the recently established Emergency Department (ED) Toxicology Team of Queen Mary Hospital (QMH) in the management of acute intoxication. Method A descriptive comparative study with retrospective data collection from all intoxicated and suspected intoxicated patients over two separate half-year periods in 2001 and 2006, before and after the establishment of the ED Toxicology Team in July 2005. Data on reasons of intoxication, drugs and substances involved, ED treatments, patient disposition, length of stay in ED, length of stay in hospital, patient outcome, and 30-day ED re-attendance and hospital re-admission were collected and examined. Results A total of 333 intoxicated patients were included in the study, 171 in 2001 and 162 in 2006. The basic epidemiological data were similar in both groups. There was a marked reduction in hospital admissions from 89.5% to 40.7% (P<0.01) and significant decline in average length of hospital stay from 46.8 hours to 29.2 hours (P<0.05). There was no statistically significant difference in patient outcome, 30-day ED re-attendance and hospital re-admission. Conclusion Our findings showed that the establishment of the ED Toxicology Team in QMH achieved significant reductions in hospital admissions and the length of stay in hospital in the management of patients with acute intoxication without jeopardising patient outcome. The results illustrate that the new model has a beneficial role in reducing cost and alleviating stress on hospital bed availability, therefore it can be recognised as a cost-effective means of management of acute intoxication.

Detoxification Therapy in Critical States of Toxic Etiology

Objective: to improve the results of detoxification therapy for acute exogenous intoxications. Materials and methods. More than 20 thousand patients with intoxication caused by psychopharmacological agents, organic phosphorus compounds, chlorinated hydrocarbons, and other poisons, in whose treatment enhanced natural detoxification methods, as well as artificial detoxification methods and antidote therapy were used, were examined. Results. Complex detoxification should include efferent methods (hemosorption, hemo- and peritoneal dialysis and intestinal lavage, as well as physiohemotherapy (magnetic, laser, and ultraviolet) and chemohemotherapy with sodium hypochlorite) and should be composed of 2 basic stages: 1) to reduce for a short space of time (1—2 h) the blood poison level to the life-safe one (below the lethal or critical one) that promotes elimination of severe hemostatic disorders, wherein the leading role is played by efferent methods and chemohemotherapy and 2) to terminate a detoxifying process within 1—2 days, which is predominantly associated with the effect of physiohemotherapy as a potent stimulant of natural detoxification and which is achieved just via further stabilization of homeostatic disorders. In the somatogenic stage, detoxification is continued through the program use of physiochemical hemotheraupetic methods and drugs. Conclusion. Introduction of the above principle of complex detoxification performed by a certain algorithm contributes to the higher rate of freeing the blood and urine from exo- and endogenous toxicants by 1.4-12 times and to the significant (more than 2-fold) mortality reduction achieved in an intensive care unit, Moscow City Center of Acute Intoxication Management.

Part 10.2: Toxicology in ECC

Poisoning is an infrequent cause of cardiac arrest in older patients, but it is a leading cause of cardiac arrest in victims <40 years of age.1–4 When a patient with poisoning is in cardiac arrest or near-arrest, immediate support of airway, breathing, and circulation is essential. Urgent consultation with a medical toxicologist or certified regional poison center is recommended5,6 because standard guidelines for emergency cardiovascular care may not be optimal in the management of acute poisoning and overdose. This section presents recommendations for the care of the patient with a toxicologic problem. Some recommendations are evidence-based, but most toxicology research in this area consists primarily of small case series (LOE 5), case reports, and animal studies (LOE 6). Hence many of these recommendations are based on expert consensus, and further research is needed to validate them. Clinicians may see a patient with a history of ingestion of an unknown substance. In such cases the clinician must be familiar with common toxidromes and their therapies. To assist during such encounters, Table 1 lists drug-induced cardiovascular emergencies or altered vital signs, potential therapies to consider, and interventions that should be used with caution. View this table: TABLE 1. Drug-Induced Cardiovascular Emergencies or Altered Vital Signs * :Therapies to Consider † and Contraindicated Interventions Clinicians may also encounter patients with a history of known ingestion. Then the clinician must anticipate the complications from that substance and be prepared to treat them. Table 2 lists potentially cardiotoxic drugs, signs of toxicity, and therapy to consider. View this table: TABLE 2. Potentially Cardiotoxic Drugs: Cardiopulmonary Signs * of Toxicity and Therapy to Consider † ### Airway and Respiratory Management Poisoned patients may deteriorate rapidly. Providers must assess and frequently reassess airway, breathing, and circulation and support them as needed. Although consultation with a poison control center or toxicologist may be needed to identify a …

A Study of Drug Radiopacity by Plain Radiography

Plain abdominal X‐ray (AXR) may be helpful in the management of acute poisoning in the emergency department if the drugs involved are radiopaque. There are varying radiopacity among different medications and even for the same medication from different manufacturers. Therefore, we performed this study to detect local drug radiopacity in Hong Kong. A total of 430 drugs under the formulary of the United Christian Hospital were tested by standard AXR (75 kV, 23 mA) in a specially designed box which corresponded to the soft tissue density of the abdomen. Two different radiologists classified the drug radiopacity into three grades. Eight drugs (1.9%) were graded as definitely radiopaque (ranitidine bismuth citrate, tripotassium dicitratobismuthate, Drixoral SR, amiodarone, ferrous sulphate, sodium chloride, calcium carbonate, and Cafertamin). Another 129 drugs (30.0%) were slightly radiopaque, including slow release drugs, neuroleptics, antacids, ionic salts, beta‐blockers, tricyclic antidepressants, antibiotics and others. The remaining 293 drugs were undetectable. As a significant number of drugs (31.9%) were detectable by plain AXR in vitro and some of them were potentially lethal, we should consider AXR as an adjunct in managing a suspected poisoned patient. Further study may be needed to evaluate these drugs' radiopacity in vivo with respect to the dosage and time of ingestion to assess its clinical application.

Gamma-butyrolactone and 1,4-butanediol: abused analogues of gamma-hydroxybutyrate.

gamma-Hydroxybutyrate (GHB) is a GABA-active CNS depressant, commonly used as a drug of abuse. In the early 1990s, the US Drug Enforcement Administration (DEA) warned against the use of GHB and restricted its sale. This diminished availability of GHB caused a shift toward GHB analogues such as gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD) as precursors and surrogates. Both GBL and 1,4-BD are metabolically converted to GHB. Furthermore, GBL is commonly used as a starting material for chemical conversion to GHB. As such, the clinical presentation and management of GBL and 1,4-BD intoxication shares a great deal of common ground with that for GHB. This similarity exists not only for acute intoxication but also for withdrawal in those patients with a history of extended high-dose abuse. This review examines the history of GHB analogue abuse as well as the clinical presentation and management of acute intoxication and withdrawal associated with abuse of these compounds.

Activated charcoal: the untold story

Introduction. To identify the prevalence and appropriateness of prescribing activated charcoal in the management of acute poisoning and to document patient compliance with treatment. Methods. A prospective study was conducted, between October 1998 and September 1999, on patients attending our accident and emergency department, with a history of overdose. Overdoses were classified as potentially toxic or non-toxic according to the history and/or information received from the National Poisons Information Service. Results. Two hundred and seventy five patients presented following overdose; 17% within one hour, 102 were prescribed charcoal (37.1%) but of these, 40 (39%) refused it, and of the 62 patients (61%) who accepted charcoal only 15 (24.2%) took all that was prescribed. Patients were 5.4 times more likely to take charcoal if they had taken a potentially toxic overdose. Of those who presented within one hour and were judged to have taken a potentially toxic overdose, only three patients took the full-prescribed amount. Conclusion. We report a substantially greater proportion of patients (39%) refusing charcoal than previously reported (9.9%). The widespread availability of TOXBASE© should help redress this discrepancy.

Assessment and management of acute poisoning by petroleum products.

Petroleum products are highly complex chemical mixtures consisting predominantly of hydrocarbons. Their composition varies with source and intended use of the product. Virtually all are blended products that come into contact with man in a wide range of circumstances. Their toxicity for man is generally low and the use of additives rarely affects the toxicity of the final product. Because products are blended to meet performance, and not chemical specifications, their composition varies significantly. Management of toxicity benefits from simplified guidelines that consider the product by its type. Management in most cases is symptomatic, but the doctor needs to be aware of the potential for development of sequelae such as aspiration pneumonia and central nervous system (CNS) depression. Local and systemic effects of exposure to hydrocarbons are reviewed, as are immediate assessment and recommended management of acute exposure to petroleum products. Because of the large scope of this subject, this paper limits itself to acute toxicity of petroleum products encountered inthe public domain. It does not address topics such as chronic toxicity, solvent abuse, petrochemicals, or pesticides.

Assessment and classification of patients with psychiatric and substance abuse syndromes. 1989.

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical by potbeses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.

Past, present, and future role of ipecac syrup.

Historically, ipecac syrup has played a principal role in the management of acute poisonings and overdoses. Presently, its role largely has been relegated to prompt decontamination of acute childhood poisonings for which emesis is not contraindicated. However, even this specific and limited role has undergone rigorous re-evaluation, and many toxicologists have discouraged against its use in any circumstance. This article reviews the history, scientific literature, and public health implications of ipecac syrup that support its present clinical application.

Acute poisoning in children

OBJECTIVES: To review the literature, covering the most important aspects of management of acute poisoning.METHODS: The most relevant articles on the management of acute poisoning were selected.RESULTS: Acute poisoning is an important matter of public health, particularly for the child. Medicaments are the main responsible agents followed closely by accidents with poisonous animals and household chemical products, pesticides and industrial products. The management of the poisoned patient must proceed through the following sequential stages: initial clinical evaluation and stabilization of the patient, when life-threatening situations are identified and treated; recognition of the toxic syndrome and identification of the causal agent, when the careful analysis of the signs and symptoms help choosing the diagnostic tests; decontamination, with the careful use of the available methods; administration of antidotes, which are small in number and should never delay the other phases; enhancing the elimination of the absorbed toxic, which requires knowledge of the kinetics of the toxic substance; and supportive treatment.CONCLUSIONS: The recognition of the toxic syndrome and knowledge of the phases of management are basic conditions for the success of treatment.

Hallucinogens

Substances that produce hallucinations have been used for thousands of years. It is said that the Oracle of Delphi inhaled carbon dioxide emanating from a rock fissure to alter consciousness. Cannabis and certain mushrooms were used at the time of the Vedas. Hallucinogenic drugs first captured the American public's attention and concern in the early to mid-1960s during the age of psychedelic experience and "flower children." Over the past 20 years the aura surrounding hallucinogens has changed so greatly that today they are sometimes considered to be just another class of drugs used inappropriately by adolescents. However, the use of hallucinogens by adolescents is much more widespread than many pediatricians may realize. Approximately 14% of adolescents have used hallucinogens. Annual surveys of high school seniors indicate that approximately 10% have used hallucinogens, with 2% to 3% having used them in the past month. Specifically, 1.8% have used lysergic acid diethylamide (LSD) and 1.4% have used phencyclidine (PCP) within the past 30 days. Studies suggest that PCP is the only drug for which use by adolescents has been increasing in recent years. The purpose of this article is to review the major physiologic and behavioral consequences of hallucinogen abuse, the presentation and management of acute intoxication and withdrawal, and the association between maternal use of hallucinogens and fetal abnormalities or neonatal withdrawal syndromes.

Commentary: Management of Acute Poisoning

Commentary: Management of Acute Poisoning

Poisoning Due to Class IA Antiarrhythmic Drugs Quinidine, Procainamide and Disopyramide

Quinidine, procainamide and disopyramide are antiarrhythmic drugs in the class 1A category. These drugs have a low toxic to therapeutic ratio, and their use is associated with a number of serious adverse effects during long term therapy and life-threatening sequelae following acute overdose. Class 1A agents inhibit the fast inward sodium current and decrease the maximum rate of rise and amplitude of the cardiac action potential. Prolonged Q-T interval and, to a lesser extent, QRS duration may be observed at therapeutic concentrations of quinidine. With increasing plasma concentrations, progressive depression of automaticity and conduction velocity occur. 'Quinidine syncope' (a transient loss of consciousness due to paroxysmal ventricular tachycardia, frequently of the torsade de pointes type) occurs with therapeutic dosing, often in the first few days of therapy. Extracardiac adverse effects of quinidine include potentially intolerable gastrointestinal effects and hypersensitivity reactions such as fever, rash, blood dyscrasias and hepatitis. Procainamide produces electrophysiological changes that are similar to those of quinidine, although Q-T interval prolongation with the former is less pronounced at therapeutic concentrations. Hypersensitivity reactions including fever, rash and (more seriously) agranulocytosis are associated with procainamide, and a frequent adverse effect requiring cessation of therapy is the development of systemic lupus erythematosus. Of the 3 drugs, disopyramide has the most pronounced negative inotropic effects, which are especially significant in patients with pre-existing left ventricular dysfunction. As with quinidine, unexpected 'disopyramide syncope' at therapeutic concentrations has been described. Anticholinergic side effects are common with this drug and may require cessation of therapy. Disopyramide therapy may unpredictably induce severe hypoglycaemia. Severe intoxication with the class 1A agents may result from acute accidental or intentional overdose, or from accumulation of the drugs during long term therapy. Acute overdose can result in severe disturbances of cardiac conduction and hypotension, frequently accompanied by central nervous system toxicity. Decreased renal function can cause significant accumulation of procainamide and its active metabolite acecainide (N-acetyl-procainamide), resulting in severe intoxication. Mild to moderate renal dysfunction is less likely to lead to quinidine or disopyramide intoxication, unless renal failure is severe or concurrent hepatic dysfunction is present. Management of acute intoxication with class 1A drugs includes gut decontamination with provision of respiratory support and treatment of seizures as needed. Hypertonic sodium bicarbonate, by antagonising the inhibitory effect of quinidine on sodium conductance, may reverse many or all manifestations of cardiovascular toxicity.(ABSTRACT TRUNCATED AT 400 WORDS)

Office management of acute pediatric poisonings.

Over the past five years, the role of the office practitioner in diagnosis and management of acute poisoning has developed into an important first line of defense in preventing serious morbidity and mortality associated with these exposures. The prime role of the practitioner is to accurately identify and quantify a poisoning exposure, to institute appropriate initial stabilization and management, and to recognize individuals who require further treatment and transfer to hospital settings. Beyond the obvious importance of initial stabilization of severely poisoned patients, the most important step in approaching the acute overdose is to identify what was taken, how much was taken, and when it was taken. To ensure appropriate treatment, the practitioner must use all the resources possible to obtain accurate identification and quantification of these exposures. Nontoxic exposures judged by the product (see Table 5) or by the quantity ingested (see Table 4) may safely be discharged with follow-up care. With toxic exposures, all attempts must focus on terminating the exposure by gastrointestinal decontamination with oral poisonings, adequate aeration with inhalational poisonings, and copious washing with topical and/or ocular exposures. The skillful approach of the office practitioner will provide the most effective initial management of the poisoned child. Appropriate referral to an emergency department for further evaluation and treatment may then be considered.

Antagonism of ethanol-induced depressant effects by 4-aminopyridine in the central nervous system of the rat

Intraperitoneal injection of ethanol (2 g/kg) produced significant motor impairment in rats, as measured by performance on the tilting plane. Administration of 3 mg/kg 4-aminopyridine (4-AP) antagonized the depressant effect of ethanol on motor performance. Using slices of hippocampus, in vitro, 4-aminopyridine (10–100 μM) also antagonized the ethanol-indueed depressant effect on orthodromically-elicited population spikes in the CA1 pyramidal cell layer. This antagonism appears to result from the ability of 4-aminopyridine to enhance release of transmitter in both excitatory and inhibitory neurones. Due to a number of unwanted side effects, further evaluation of 4-aminopyridine and its analogues needs to be done before it can be considered useful in the management of acute intoxication with ethanol.

Cathartics and laxatives. Do they still have a place in management of the poisoned patient?

Continued use of cathartics in the management of acute poisoning appears, in our view, to be appropriate.The availability of a number of agents offers options based on the patient and the drug ingested. Whole bowel irrigation is appearing as another potentially useful means of catharsis. Further research is clearly needed to define efficacy, particularly in the face of abnormalities of bowel function, a very common situation in toxic ingestions. These offer exciting avenues for further investigation.

Treatment of Acute Drug Emergencies

Drug and alcohol problems are increasingly important factors in emergency health services. Unless recognized and treated early, substance abuse will likely lead to repeated medical, psychiatric, and surgical emergencies. Each emergency room must develop procedures for detecting substance abuse. Emergency room personnel must also acquire clinical skills and knowledge for the early diagnosis of substance abuse. Acute medical management of emergencies associated with alcohol and drug abuse must be promulgated, since many nurses and physicians have limited knowledge regarding the management of acute intoxication, overdose, withdrawal conditions, and complications from alcohol and drug abuse.

Book Review: Poisoning Diagnosis and Treatment, Diagnosis and Management of Acute Poisoning, Clinical Management of Poisoning and Drug Overdose

Book Review: Poisoning Diagnosis and Treatment, Diagnosis and Management of Acute Poisoning, Clinical Management of Poisoning and Drug Overdose