Management Of Poisoning Research Articles

Accidental transdermal methanol poisoning presenting to a regional emergency department.

Learning Points:•Know and identify clinical presentations of toxic alcohols.•Understand the differential diagnosis of high anion gap metabolic acidosis.•Appreciate the importance of history and clinical findings in establishing methanol toxicity diagnoses, especially in centres where laboratory testing is unavailable.•Recognize the value of provincial poison centres in supporting emergency physicians in the diagnosis and management of poisonings and overdoses.

Stonefish (Synanceiea verrucosa) Envenomation in the Kingdom of Bahrain

Fishing, swimming, diving, and other water-based recreational activities are popular in the Kingdom of Bahrain and the Arabian Gulf. In this case report we describe a case of stonefish poisoning encountered by a 44-year-old fisherman on the coasts of Bahrain. Human envenomation is rare, and the Arabian Gulf is not the usual habitat of the stonefish. No accurate data is available on the incidence or international frequency of stonefish envenomation. This article describes the treatment and difficulties encountered with his management. We also review the proper management, medical guidelines, and care of stonefish poisoning. The patient presented with severe excruciating pain and edema of his upper limb. He was administered with intravenous analgesia for pain control and was admitted under surgical care for further management of impending compartment syndrome and underwent a fasciotomy. An antivenom for stonefish may be used, however is not available in Bahrain. He was discharged following treatment after 5 days of hospitalization. Although, stonefish is rare in our region, stonefish sightings have been reported in the Arabian Gulf. Management of stonefish and marine envenomation involves soaking the affected site in warm water to denature the venom, analgesia, and stonefish antivenom.

Experience of Indian emergency physicians in management of acute poisonings

Indian Emergency Departments (EDs) encounter a significant number of toxicologic cases each year, approximately half of which are attempts at deliberate self-harm. The objective of this study was to understand trends in the presentation and use of resources for the treatment of poisonings in the emergency department setting. Between September 2015 and May 2016, we administered an online survey to Indian emergency department (ED) physicians. We queried respondents about common poisonings, treatments, and educational resources, including use of Indian poison centers. A total of 152 individuals responded to the survey. Respondents living in the eastern (64% of respondents) and southern (57% of respondents) regions of India were most likely to report not having a poison center as compared to respondents from the north. Most physicians instead used hospital protocols, textbooks, or online resources to guide treatment and education efforts. Despite frequent presentations of potentially life-threatening ingestions, often EDs do not rely on extensive poison center consultation. Although India has a poison center hotline, most physicians in the south and east were unaware of this resource, suggesting an opportunity for better physician education.

Gruhadhuma in Agada Yogas: a review

Gruhadhuma is an ingredient mentioned in Ayurveda pharmaceutics in a group of drugs termed as panchamrittika. It is an ingredient that is used in various formulations in the treatment of vishas (poisons). Many formulations for the management of various poisons like snake bite, keetavisha (insect poisons), etc. have been explained in Ayurveda treatise that contains it as an ingredient. The agada yogas (formulations for poisonous bites) mentioned for the management of various poisons in bruhatrayee contain ingredients that are both herbal and mineral in origin. Formulations having gruhadhuma have been mentioned for oral administration, as nasya (nasal inhalation), anjana (collyrium), lepa (anointment), etc. A literary search through the treatises of Ayurveda has put a light on the various formulations containing it.
 Keywords: Agadayogas, Gruhadhuma, poisons, formulations

Role of ECMO in life threatening intoxication

Acute severe poisoning may lead to life threatening situation or death due to cardiovascular dysfunction or stunning, arrhythmia or cardiogenic shock. These substances include medications, substances used for addiction, house hold chemicals, industrial, plants and animal or vegetable toxicants. The poison profile varies in different parts of world; drugs with cardiotoxic potential are the common poisoning substances while pesticides and other house hold toxins are common in the other part of the world. Irrespective of the type of the poison, these patients are relatively young and usually healthy. Extracorporeal Life Support (ECLS) has become popular in the management of acute severe intoxication induced cardiogenic shock, arrhythmia or cardiac arrest as bridge therapy. The management of poisoning include further reduction of absorption or enhancing the elimination; antidote administration (if available); and supportive therapies including resuscitation. ECMO helps in maintaining adequate cardiac output and tissue perfusion and enhances the toxic substance metabolism. However most of the available literature is based on case reports, case series and retrospective cohort study. In spite of high mortality with severe poisoning and encouraging outcome with use of ECMO, it is underutilized modality across the world. The available literature shows a favourable outcome with ECMO in severely intoxicated patients with cardiovascular collapse, however, there are no clear guidelines for the time of initiation of ECMO on the basis of clinical, metabolic and echocardiographic parameters. Even prognostication prior to initiation of ECMO is difficult to predict. ELSO (Extracorporeal Life Support Organization) may support the global data collection on acute intoxication requiring ECMO, which may address some of these issues.

Outcomes after toxic alcohol poisoning: a systematic review protocol

BackgroundToxic alcohols have been implicated in accidental ingestions and intentional exposures. Recognition of toxic alcohol poisoning is challenging. The main treatment modalities include antidotes with alcohol dehydrogenase inhibitors and dialysis. Current guidelines exist for both methanol and ethylene glycol intoxication. However, treatment consensus related to other toxic alcohols is limited. Furthermore, uncertainties regarding thresholds for when to initiate antidotes and dialysis persist. As a consequence, variations exist in the interventions utilized for management of all toxic alcohol poisonings. To our knowledge, no prior systematic review of clinical outcomes of toxic alcohols exists. The objective of this study is to summarize existing evidence on short- and long-term outcomes of patients following toxic alcohol poisonings, including methanol, ethylene glycol, isopropanol, propylene glycol, and diethylene glycol.MethodsA literature search in PubMed, MEDLINE, and EMBASE will be performed based on pre-determined criteria. There will be no restrictions on publication dates or languages. The search will be supplemented by manual scan of bibliographies of eligible studies and gray literature assessment. Observational studies and clinical trials will be included in this review. Once eligible studies have been selected based on pre-specified criteria, two investigators will extract relevant data independently and perform quality assessment per validated tools. A pooled analysis of mortality and short- and long-term secondary outcomes will be performed. Pre-specified subgroup analyses will be performed according to the type of toxic alcohol intoxication, mode of renal replacement therapy, and medical interventions received. A meta-analysis will be performed if three or more studies with similar populations, type of toxic alcohol poisoning, and outcome measures, as well as adequate quality, are identified. This review will be reported according to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement.DiscussionThis systematic review aims to synthesize current evidence in the short- and long-term outcomes of post-toxic alcohol poisoning. The results will enhance the understanding of patient morbidity and mortality after toxic alcohol poisoning, help inform uniform concrete management guideline development, identify gaps in the current state of knowledge, and provide evidence to help implement post-treatment follow-up.Systematic review registrationPROSPERO CRD42018101955

Detection of Cutting Agents in Drug-Positive Seized Exhibits within the United States.

The following report summarizes a study performed on seized drug exhibits collected in two U.S. states to evaluate the presence and identification of cutting agents. Aliquots of seized drug materials from Kentucky (n = 200) and Vermont (n = 315) were prepared using a dilute-and-shoot procedure. Initial analysis was performed using gas chromatography-mass spectrometry (GC-MS) followed by analysis using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF). Active compounds detected overall included caffeine (31.0%), quinine/quinidine (24.7%), levamisole (11.6%), acetaminophen, (8.2%) and procaine (8.2%). These compounds were found with several drugs of abuse, such as heroin, fentanyl, methamphetamine, and cocaine. This novel information about cutting agents used to dilute or alter drugs of abuse is important to criminal investigations and in the management of acute intoxications at health centers. However, common methodologies for analysis and standard reporting practices frequently do not include cutting agents, resulting in lacking or inadequate information regarding prevalence of these substances.

N-Acetylcysteine reverses silver nanoparticle intoxication in rats

The increasing use of silver nanoparticles (AgNPs) in consumer products raises the risk of human toxicity. Currently, there are no therapeutic options or established treatment protocols in cases of AgNPs intoxication. We demonstrated previously that thiol antioxidants compounds can reverse the cytotoxicity induced by AgNPs in Huh-7 hepatocarcinoma cells. Here, we investigated the use of N-acetylcysteine (NAC) against the systemic toxic effects of AgNPs (79.3 nm) in rats. Biochemical, histopathological, hematological, and oxidative parameters showed that a single intravenous injection of AgNPs (5 mg/kg b.w.) induced deleterious effects such as hepatotoxicity, potentially as a result of AgNPs accumulation in the liver. Treatment with a single intraperitoneal injection of NAC (1 g/kg b.w.) one hour after AgNPs exposure significantly attenuated all toxic effects evaluated and altered the bioaccumulation and release patterns of AgNPs in rats. The findings show that NAC may be a promising candidate for clinical management of AgNPs intoxication.

La crise des overdoses américaines : une menace pour la France ?

Since the 2000s, a concerning increase in opioid-analgesic-related overdoses and deaths has been reported in the United States. In contrast with opioid overdoses reported in the 80-90s mostly involving heroin, currently it is the misuse of opioid analgesics that is mainly responsible for opioid overdoses. This crisis is related to factors (not limited to the US) which occurred during the 90s and which have led to a broad prescription of opioids in non-cancer pain. In Europe and France, there is (but to a much lesser extent) an increase in strong opioid consumption and in opioid prescription related morbi-mortality. This situation, which can be described as “worrying” today, requires awareness among the French medical community, both upstream (rational prescription of opioids) and downstream (optimal management of opioid poisoning) from the opioid prescription.

An evaluation of the role of mixing techniques in the observed variation in acetylcysteine infusion concentrations.

Intravenous acetylcysteine is commonly prescribed as a course of three infusions for the management of paracetamol poisoning. Previous studies have demonstrated large variation in administered doses of intravenous acetylcysteine, which has been attributed to numerous factors, including inadequate mixing of infusion bags. The aim of this study was to determine whether the amount of mixing of infusion bags contributes significantly to this variation. Using acetylcysteine doses for a 60-69kg patient, we added the appropriate volume of acetylcysteine to 5% glucose and subsequently inverted the infusion bags 0-5 times to mix the solutions. Infusion bags were then run through using an infusion pump and acetylcysteine concentrations measured at the beginning and end of the infusions. We found no significant difference between the beginning and end concentrations of acetylcysteine regardless of whether bags were mixed or not; infusion 1 (150mgkg-1 ) showed beginning and end concentrations of 44.61 and 42.48mgml-1 respectively after 0 mixes, whilst beginning and end concentrations were 44.45 and 44.58mgml-1 respectively after five mixes. The same trend was observed for infusions 2 and 3. This confirmed that mixing does not play a substantial role in variation of drug concentrations; these are likely to be caused by an accumulation of small errors in infusion preparation.

Physiopathology and management of acetylsalicylic acid intoxication

Physiopathology and management of acetylsalicylic acid intoxication

Loperamide Abuse and Dependence: Clinical Features and Treatment Considerations

: Opioid use disorder and its associated mortality have become national epidemic problems. Different measures and regulations have been implemented to curb this trend, including stricter opioid prescribing practice. With the decreased access to prescription opioids, individuals with opioid use disorder have explored alternatives including loperamide, a peripheral opioid mu-receptor agonist. There are reports of increased loperamide misuse, dependence, and mortality rate in the past few years from poison control centers, medical examiners' offices, and clinical settings. Here, we report a case of loperamide use disorder, which led to the death of the patient. Associated clinical features and treatment of loperamide use disorder, including management of intoxication and withdrawal, and long-term maintenance therapy are discussed along with potential prescribing and sale regulations to manage this newly emerging substance use disorder.

Management of OPC and Carbamate Poisoning in Intensive Care Unit of Enam Medical College & Hospital, Savar, Dhaka

Background: Bangladesh is an agriculture-dependent country. Organophosphorus insecticides are widely used for the better outcome of cultivation. It is used for suicidal purpose due to its easy availability all over the country. Worldwide, acute pesticide poisoning is causing major health problems with high mortality in developing countries.Objective: The objective of our study was to establish that early management of acute poisoning with organophosphorus and carbamate in ICU along with ventilatory support in severe respiratory distress reduces the mortality rate.Materials and Methods: This study was conducted in the Department of Anesthesiology & ICU in Enam Medical College & Hospital, Savar, Dhaka from January 2013 to December 2015. Total 84 patients with acute poisoning cases were selected. The diagnosis was confirmed by the history of ingestion of insecticides, observing clinical signs and symptoms and presence of foul smelling of poisonous agent. Management included supportive care, intubation, artificial ventilation in selective cases, administration of antidotes as loading and maintenance dose for atropinization with atropine and pralidoxime, antibiotics, anti-ulcerant, anticonvulsant, inotropic support (in severe hypotension) along with other symptomatic treatment. After stabilization, decontamination was started with removal of contaminated clothes, thorough wash with soap and water, irrigation of eyes with water and normal saline. Gastric lavage was given within 2 to 3 hours of ingestion of poison.Results: Acute poisoning was observed more in male (60.71%) than in female (39.29%) and in age group of 21–40 years (60.71%). Suicidal attempt was present in 97.61% cases and causes of suicidal poisoning were familial disharmony (76.19%), financial loss (14.28%) and failure in examination (9.52%). Organophosphate group poison ingestion was in 77.38% cases and carbamate group poison in 21.43% and both agents in 1.19% cases. Ventilatory support was given in 48.80% cases and 78.05% patients were successfully extubated from mechanical ventilator. Mean duration of ventilatory support was 2–14 days. Out of 84 patients, 75 (89.28%) survived and 9 (10.72%) patients expired. Fifty two (61.91%) patients were discharged within 4–6 days, 16 (19.04%) within 2–3 days, and 7 (8.33%) patients were discharged within 7–14 days.Conclusion: Early ICU admission and appropriate management of patients after ingestion of poisonous agent results in reduced morbidity and mortality.J Enam Med Col 2018; 8(3): 144-152

Organophosphate poisoning and coenzyme Q10: an overview

Organophosphate (OP) poisoning can occur in acute and chronic forms. In developing countries, both forms are common, and represent a major cause of morbidity and mortality. In the UK, organophosphate poisoning is most likely to be encountered in chronic form, with sheep farmers the section of the population at greatest risk. The problem of poisoning in sheep farmers caused by exposure to organophosphate-based sheep dips has become increasingly apparent. Symptoms include fatigue, muscle pain and neurological problems. There is no specific treatment for this condition. OP toxicity is classically associated with inhibition of acetylcholinesterase enzymes involved in the process of neurotransmission. However, there is evidence that OP poisoning can also cause mitochondrial dysfunction, compromised cellular energy supply, oxidative stress and inflammation. Symptoms of sheep dip poisoning correspond with those known to result from depletion of coenzyme Q10 (CoQ10), a vitamin-like substance with a key role in cellular energy generation within mitochondria, as well as antioxidant and anti-inflammatory action. The authors have therefore reviewed evidence that oral supplementation with CoQ10 may provide effective symptomatic relief for farmers suffering from OP sheep dip poisoning. Evidence in support of the above is presented for: (a) OP-induced mitochondrial dysfunction; (b) beneficial effects of CoQ10 administration following OP exposure in relevant animal models; and (c) evidence from clinical studies in human subjects. The dosage of CoQ10 proposed (100 mg three times daily) is based on that required to raise blood levels to at least 3 μg/mL, which has been shown to be a requirement to effectively counter CoQ10 depletion in other disorders, particularly heart disease. It is important to note that a CoQ10 supplement with appropriate documented bioavailability should be used, since poor bioavailability may have been responsible for the failure of some previous studies. The safety of CoQ10 supplementation has been confirmed in more than 200 randomised controlled clinical trial studies on a wide range of disorders. In addition to the above, because of the increased risk of the use of OP compounds in terrorist-type poisoning incidents in the UK, a brief discussion on the management of acute OP poisoning is included.

Low-dose intravenous lipid emulsion as a safe treatment for lipophilic intoxications in five cats

The use of a low-dose infusion of intravenous lipid emulsion (ILE) in five young cats presented with acute neurotoxicity is reported. Suspected toxic compounds were permethrin (three, dermal), fipronil/eprinomectin/praziquantel (one,...

Successful management of acute bismuth intoxication complicated with acute renal failure, seizures and acute pancreatitis in a child

Bismuth salts, including bismuth subcitrate, are commonly used for gastrointestinal disorders. Overdose of bismuth salts can lead to renal failure. Seizures and pancreatitis have not been reported as complications of bismuth overdose and/or chelator treatment up-to-date. An 8-year-old girl was presented with history of taking 18 grams of bismuth subcitrate, headache, agitations and anuria. She was hypertensive and her serum creatinine was 6.5 mg/dL with the estimated glomerular filtration rate of 9.61 ml/min/1.73 m2. Antihypertensive drugs and hemodialysis were initiated. Fifteen hemodialysis sessions were performed during a month. At the sixth day of hospitalization dimercaptosuccinic acid (DMSA) treatment was initiated for chelating bismuth. Because of intense headache and seizures were observed after 7 days of DMSA therapy, DMSA was stopped and anticonvulsive drugs were given. Meanwhile pancreatitis was diagnosed based on ultrasound findings and increased serum lipase (maximum, 1363 IU/L) and amylase (maximum, 798 IU/L) levels. Following 10 days of anuria, polyuria developed. Clinical and laboratory findings of her returned to normal at the 35th day of hospitalization. In conclusion, seizures and pancreatitis may develop following chelator treatment for bismuth overdose. Chelation therapy should be used cautiously in bismuth intoxication.

Can we do better with paracetamol poisoning in rural Asia? – A model based approach to reduce cost of management of paracetamol poisoning in Sri Lanka

Can we do better with paracetamol poisoning in rural Asia? – A model based approach to reduce cost of management of paracetamol poisoning in Sri Lanka

Acute Poisonings at a Regional Referral Hospital in Western Kenya.

The emergency department (ED) of the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) handles many cases of poisoning. However, there is scant information on the factors, agents, and outcomes of poisoning at the hospital. The aim of this work was to determine the factors, agents, and outcomes of poisoning at JOOTRH. Records of patients who presented to JOOTRH with symptoms of poisoning between January 2011 and December 2016 were retrieved. Data on age, gender, offending agents, time, and season of exposure were collected. Information on the route of exposure, motive, and clinical symptoms of poisoning was also included. Other information included the laboratory evaluation, first aid measures, period of hospitalization, and outcome of poisoning. Mean, standard deviation, frequencies and bar graphs were used to describe the demographic factors of the study population. Multivariate logistic regression was used to determine the strength of association between risk factors and outcome of poisoning among patients. The level of significance for inferential analysis was set at 5%. There were 385 cases of poisoning: 57.9% (223/385) were male, 31.9% (123/385) were 13–24 years of age, and 83.9% (323/385) of exposures were in Kisumu County. The peak time of exposure was 6:00–00:00, and 23.6% (91/385) presented 1–4 h after exposure. About 62.9% (242/385) of the cases were due to accidental poisoning. Snakebites and organophosphates (OPPs) contributed to 33.0% (127/385) and 22.1% (85/385) of all cases, respectively. About 62.1% (239/385) of exposures were oral, and 63.9% (246/385) of all cases occurred in the rainy season. Additionally, 49.2% (60/122) of intentional poisoning was due to family disputes, and 16.1% (10/62) of pre-hospital first aid involved the use of tourniquets and herbal medicine. About 28.6% (110/385) of the victims were subjected to laboratory evaluation and 83.9% (323/385) were hospitalized for between 1–5 days. Other results indicated that 80.0% (308/385) responded well to therapy, while 7.3% (28/385) died, 68% (19/28) of whom were male. Furthermore, 39.3% (11/28) of the deaths were related to OPPs. Our findings suggest that the earlier the victims of poisoning get to the hospital, the more likely they are to survive after treatment is initiated. Similarly, victims of poisoning due to parental negligence are more likely to survive after treatment compared to other causes of poisoning, including family disputes, love affairs, snakebites, and psychiatric disorders. The management of JOOTRH should consider allocating resources to support the development of poison management and control.

Hyperbaric Oxygen Therapy and Acute Carbon Monoxide Poisoning

Carbon monoxide poisoning is the most commonly seen cause of poisoning in the emergency room (ER). The high affinity between carbon monoxide andhemoglobin and their complex biological characteristics greatly increase the risks of cardiac, nervous, muscular, and kidney diseases. In severe cases, patients may lose consciousness or die in just a few minutes. In recent years, hyperbaric oxygen therapy has been applied extensively in patients with severe conditions such as carbon monoxide poisoning and cerebral hypoxia. Hyperbaric oxygen accelerates the decomposition of carbon monoxide in hemoprotein. Therefore, treating patients with similar conditions in the ER with hyperbaric oxygen as soon as possible will improve their cognitive disorder and postpone their neuropsychological sequelae. ER nurses typically play a decisive role in saving patients with carbon monoxide poisoning. This research scrutinizes a case analysis of using hyperbaric oxygen to treat carbon monoxide poisoning and offers general rules for the use of hyperbaric oxygen. Further, the research elaborates from the perspective of ER nursing staffs the management and care of acute carbon monoxide poisoning and hyperbaric oxygen therapy nursing care. The aim of this research is to offer references for members of the ER nursing team and to enable this team to provide accurate and effective medical measures to patients during the "golden hours" of nursing care. Achieving this will help ensure that patients receive comprehensive nursing and care, thus reducing the harm suffered by patients and increasing the rate of survival.

Acute copper sulphate poisoning

Abstract Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical spectrum of the copper sulphate intoxicated patient is variable and often complex ranging from intravascular hemolysis, jaundice and renal failure. The treatment although is mainly supportive but recognition of severe cases like methemoglobinemia, renal failure needs early intervention. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is performed.