Management Of Poisoned Patients Research Articles

Paracetamol (acetaminophen) poisoning: The early years.

Paracetamol (acetaminophen) was marketed in the 1950s as a nonprescription analgesic/antipyretic without any preclinical toxicity studies. It became used increasingly for self-poisoning, particularly in the UK and was belatedly found to cause acute liver damage, which could be fatal. Management of poisoned patients was difficult as maximum abnormalities of liver function were delayed for 3days or more after an overdose. There was no treatment and the mechanism of hepatotoxicity was not known. The paracetamol half-life was prolonged with liver damage occurring when it exceeded 4h and the Rumack-Matthew nomogram was an important advance that allowed stratification of patients into separate zones of risk. It is used to guide prognosis and treatment and its predictive value could be increased by combining it with the paracetamol half-life. The problems of a sheep farmer in Australia in the early 1970s led to the discovery of the mechanism of paracetamol hepatotoxicity, and the first effective treatment of overdosage with intravenous (IV) cysteamine. This had unpleasant side effects and administration was difficult. N-acetylcysteine soon became the treatment of choice for paracetamol overdose and given early it was very effective when administered either IV or orally. N-acetylcysteine could cause anaphylactoid reactions, particularly early during IV administration when the concentrations were highest. Simpler and shorter regimes with slower initial rates of infusion have now been introduced with a reduced incidence of these adverse effects. In addition, there has been a move to use larger doses of N-acetylcysteine given over longer periods for patients who are more severely poisoned and those with risk factors. There has been much interest recently in the search for novel biomarkers such as microRNAs, procalcitonin and cyclophilin that promise to have greater specificity and sensitivity than transaminases. Paracetamol-protein adducts predict hepatotoxicity and are specific biomarkers of toxic paracetamol metabolite exposure. Another approach would be measurement of the plasma levels of cysteine and inorganic sulfate. It is 50 years since the first effective treatment for paracetamol poisoning and, apart from liver transplantation, there is still no effective treatment for patients who present late.

Electrocardiography and Drug Intoxication

Intoxication is the deterioration of body functions due to different toxic substances. Poisoning by drugs constitutes an important part of all poisonings. Symptoms such as altered consciousness, tachycardia/bradycardia, or hypertension/hypotension may be seen because the cardiovascular system is affected. Changes in clinical findings and ECG may be revealed according to the degree of heart involvement. Rapid recognition and effective intervention by the emergency physician are of great importance. This review considers the use of ECG in the management of poisoned patients. Systematic evaluation of the ECG in a patient followed up with poisoning is essential for details that may be overlooked. Velocity, rhythm, intervals, and segments, QRS, wave morphologies, durations, ischemic changes should be followed carefully.
 When performing rhythm analysis, clues to drug cardiotoxicity should be sought in unstable patients. Are there ectopic beats on the EKG? The answer to this question may carry important clues. Automaticity caused by sympathomimetics may underlie ectopic beats. This may be the first sign of a problem caused by acute coronary syndrome or electrolyte disturbances. Is the rhythm supraventricular? or ventricular? Is bradycardia with AV block? Or without AV block? Is tachycardia narrow complex? Or is it a large complex? Answers to questions such as: For life-threatening rhythms, ventricular tachycardia, ventricular fibrillation, and complete AV-block, the guidelines developed should be followed, and first intervention should be made. Agents that can cause tachycardia; are sympathomimetics (methamphetamine), anticholinergics (antidepressants, antipsychotics), class 1A and 1C antidysrhythmics, and TCA. Agents that can cause bradycardia; calcium channel / beta blockers / digoxin (AV block), opioids / ethanol, organophosphates, lithium. Prolonging the PR interval may indicate beta-adrenergic antagonism, calcium channel antagonism, or digoxin poisoning. Typical ECG of TCA poisoning shows sinus tachycardia with first-degree AV block, wide QRS complexes, and positive R' wave in aVR. The ECG should be taken and evaluated in patients presenting with poisoning within the first 10 minutes. Suppose the poisoning agent is an agent that influences the cardiovascular system. In that case, it should be kept in mind that continuous cardiac monitoring and control ECG evaluation should be performed in addition to the application of ECG.

10 Errores Graves en el Manejo del Paciente Intoxicado

Introduction: The patient with severe intoxication is a challenge for any physician due to the inherent acuity of the situation and the pitfalls encountered in terms of proper management, such as the identification of the toxic agent to neutralize, sometimes in circumstances where the history and physical examination will be incomplete. Objective: Identify common pitfalls interfering with key aspects of management of severely intoxicated patients and establish evidence-based recommendations on how to avoid these common issues. Method: The PUBMED/MEDLINE database was searched for papers related to pitfalls in the management of poisoned patients between 2001 and 2021, with the following keywords in title or abstract: “errors” and “diagnosis” and “management” and “poisoning” and “patient”. At the same time, articles from the author’s personal database were deliberately selected. Results: Seventeen papers from PUBMED/MEDLINE that met the selection criteria were selected and an additional 20 articles were included from the authors’ database. Conclusion: The most important characteristics of pitfalls concerning the treatment of severely intoxicated patients were identified and recommendations for key aspects of management and pitfall avoidance were formulated. Keywords: Critical ill patient, toxyndromes, antidote, poisoning.

Management of Poisoned Patients: Implementing a Blended Toxicology Curriculum for Emergency Medicine Residents.

Management of Poisoned Patients: Implementing a Blended Toxicology Curriculum for Emergency Medicine Residents.

The establishment of a medical toxicology consulting service for advancing care of poisoning and overdose in Qatar.

Objectives: The State of Qatar, in recent decades, underwent rapid, and substantial population growth. The country's emergency medicine (EM) needs are met by government-operated facilities of the Hamad Medical Corporation (HMC), which see virtually all acute-care cases in adults and children. In 2017, emergency departments (ED) established the Medical Toxicology Consulting Service (MTCS). This report aims to outline the MTCS's initial 100 cases’ experience and report salient findings that can help ongoing national strategies in meeting Qatar's medical toxicology needs. Methods: The study setting is Qatar, and the clinical base for the MTCS was the country's sole level I center, Hamad General Hospital. The MTCS group is composed of six physicians, all with advanced training in medical toxicology. The study group is composed of the first 100 consecutive cases of the MTCS registry. Registry entry was triggered by in-person consultation, telephone consultation, or identification of cases by daily MTCS rounder surveillance of the ED's electronic tracking board. Results: The MTCS institution identified a significant number of medical toxicology cases within the national hospital system. The trends of poisoning in this study showed a median age of 30 years (range 1–81 years, IQR 22–36 years). Fourteen patients were < 18 years old. The median interval between exposure and ED presentation was 2 hours, with a range of 15 minutes to 24 hours (IQR 1–3 hours). Most patients (71%, 95% CI, 51%–80%) were symptomatic because they were exposed. The MTCS recommended therapeutic intervention in over a third of cases (36%, 95% CI, 27%–46%). Decontamination procedures were ordered in 8% of cases (95% CI, 4%–15%) and specific therapies recommended in 13 cases (13%, 95% CI, 7%–21%). Conclusions: The study highlighted that the availability of experts in medical toxicology, such as with a poison center or toxicology consultation service, results in significant resource conservation in the management of poisoned patients.

Documentation in the patient medical record was associated with improved adherence to Poisons Information Centres telephone advice

Context: There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the management of poisoned patients. This study aimed to determine if contemporaneous documentation in the patient electronic medical record (EMR) improved adherence to Poisons Information Centre (PIC) advice.Methods: This was a prospective before and after observational study following the implementation of documented poisoning management advice by PIC staff into the patient’s EMR. Advice adherence was assessed following a review of the patient medical records and designated to complete adherence, minor discrepancies not affecting patient care, major discrepancies affecting patient care and non-adherence. The primary outcome was the proportion of satisfactory (complete adherence/minor discrepancies) adherence. Secondary outcomes included the accuracy of documented telephone advice by the treating clinician, the number of case recalls and episodes of sub-optimal management.Results: A total of 980 cases (347 in the pre-intervention phase and 633 in the post-intervention phase) were included in the study, of which 350 had PIC EMR documentation performed. Documented call advice by the treating clinician was absent in 41 of 347 cases (11.8%) cases and inaccurate in 42 of 306 cases (13.7%). Following PIC documentation, satisfactory adherence improved from 304/347(87.6%) to 333/350(95.1%)(difference 7.5% [95% CI 3.1% to 11.9%]), with suboptimal management decreasing from 48/347(13.8%) to 14/350(4%)(difference − 9.8% [95% CI −5.5% to −14.4%]). Recalls were similar in both periods. The median time to enter advice into the EMR was 26 min (IQR: 14–45 min). The main reason for not documenting advice was that the PIC staff member was working a solo shift with a prohibitively heavy workload.Discussion: EMRs enable PICs to supplement verbal advice with written documentation, offering an opportunity to improve communication and enable better handover of clinical information.Conclusion: Documentation of advice by PIC staff in the patient medical record was associated with improved advice adherence and reduced sub-optimal management.

Performance of an emergency department observation unit protocol in reducing length of stay for acetaminophen overdose: a retrospective study

IntroductionAcetaminophen is one of the most common causes of poisoning among developed countries. The emergency department observation unit (EDOU) has been increasingly used in the management of various conditions to reduce hospitalisation but its efficacy in not well studied in management of poisoned patients. In this study, we aim to study the effectiveness of our EDOU in the management of acetaminophen overdosed patients.ResultsMedical records of patients admitted from the emergency department from 2012 to 2016 for acetaminophen overdose were reviewed. One hundred ninety-five patients presenting with acetaminophen overdose were admitted to the EDOU while 184 were admitted to the general ward. Of these, 27 patients admitted to EDOU did not meet the admission criteria for it while 71 patients who met EDOU criteria were admitted to the ward instead. For patients who fulfilled EDOU admission criteria, median length of stay for EDOU patients was 23 h (IQR 19–24) while that for those admitted to the ward was 66 h (IQR 62.5–88.3).ConclusionThe EDOU is a safe alternative to hospitalisation for patients presenting with acetaminophen poisoning. It is also associated with a shorter length of stay for such patients. Further studies need to be done to assess the cost-effectiveness of EDOU for management of patients presenting with acetaminophen overdose.

Specific Poisons in Pakistan: A Mini Review

Poisoning either results from intentional or unintentional exposures, recreational drug use, and therapeutic use of drugs or other agents. Although mortality and serious morbidity in poisonings are uncommon, patients requiring hospitalization often require intensive care. The appropriate management of poisoned patients should improve outcome and decrease complications. Some specific poisons in Pakistan are pesticides, hydrocarbons, iron, insecticides, benzodiazepines, organophosphates etc.

Antidotes supply in emergency from Pavia Poison Control Centre

Objective: Antidotes can play a critical role in the management of poisoned patients. Nevertheless, the inadequate availability of antidotes is a known problem in Italian Emergency Departments (EDs) [1]. In Italy, one of the planned Poison Centre functions is monitoring antidotes demand and managing the antidotes stockpile to ensure their prompt availability in the emergency setting. The antidotes supply by the Pavia Poison Control Centre (PCC) to the Emergency Departments of the National Health System is evaluated. Methods: A retrospective analysis of antidote supply in emergency from PCC from 1 January 2007 to 31 December 2012 was conducted. Antidotes for human poisonings are examined for type, amount e destination. Antidotes mobilization for treatment of animals or preventive stocking (hospitals, industries, other settings) were excluded. Results: 151 cases (20 different antidotes) of supply in emergency were registered; 39 mobilizations were related to fomepizole 1.5 g (min/max, 1-9 vials), 15 calcium gluconate gel (3-21 tubes), 15 N-acetylcysteine (6-50 vials), 12 ViperFab-antivenom (2-6 vials), 12 digoxin immune Fab (2-12 vials), 10 glucagon (30-100 vials), 7 pralidoxime (60-400 vials), 7 succimer (15-180 capsules),5 physotigmine (1-20 vials), 4 Ca-EDTA (1-20 vials), 4 hydroxocobalamin (2-3 kit), 4 penicillamine (100-200 capsules), 4 activated charcoal (3-10 bottles), 4 ethanol (30-50 vials), 2 PEG 400 (2 bottles), 2 sodium thiosulfate (50-100 vials), 2 L-carnitine (15-20 vials), 1 atropine (50 vials), 1 cyproheptadine (2 vials), 1 pyridoxine (18 vials). In 45% of cases, antidotes were provided for immediate administration (availability in 30 minutes). The antidote was supplied in other Italian regions in 47% of cases. Most antidotes were mobilized for ethylene glycol/methanol, hydrofluoric acid, alpha-amanitin, digoxin, viper and beta-blockers poisonings. Conclusion: Antidote stockpiles of Italian EDs are often lacking and sometimes insufficient for a single patient treatment. Forty-five percent of the emergency supply activity involved antidotes that should be available in EDs within 30 minutes, and 20% regarded antidotes not registered in Italy. Mobilizations involved only 29% of Pavia-PCC stockpile: it must be considered that in the analyzed period, there was no request of antidote for industrial accident/mass intoxication or for rare intoxications. Moreover in some cases the PCC moved antidotes from other hospital stockpiles identified through the 'national antidotes data-base' (www.cavpavia.it). This data-base, available since 2006, represents a unique operating system that permits the management and optimization of all the national hospital stockpiles of antidotes. The results point out the critical role of Pavia-PCC in early mobilization of antidotes for timely management of acutely poisoned patients in Italy.

The Use of Gastric Lavage in India for Poisoned Patients

Background: According to current international standards, gastric lavage (GL) should not be employed routinely, if ever, in the management of poisoned patients. Several clinical studies have demonstrated that the risks outweigh the benefits of this procedure. The utility of GL decreases as a function of time and is minimally effective more than one hour after toxin ingestion. Nonetheless, observational experience suggests that this procedure is still widely practiced in response to toxic ingestion in India. This study aims to quantify the prevalence and scope of gastric lavage use among healthcare providers in India. Methods: A convenience sample of 81 acute care hospital-based health providers practicing throughout India were anonymously surveyed at the 12 th Annual Conference of the Society for Emergency Medicine in Ahmedabad, India, November 2010. The survey included questions on the frequency and scope of GL use. Results: 68 respondents (86%) claim that they use GL in treating at least 50% of their poisoned patients. 55 (70%) claim that they would use GL more than 1 hour after the ingestion of a poison, and 19 (24%) claim they would use it up to 6 hours after ingestion. 78 respondents (96%) claim they would not use lavage to treat ingestion of caustic or corrosive substances; however, substantially fewer respondents claim they would not use lavage in cases of hydrocarbons (31, 38%), large objects (22,27%), or sharp objects (47,58%). Conclusion: Despite extensive evidence demonstrating little benefit and significant risk of GL in the management of poisoned patients, it is still practiced in India. Further research should explore why this practice is still common when less risky and more effective, evidence-based alternatives are available.

Features of Neurotoxicity on Brain CT of Acutely Intoxicated Unconscious Patients

Diagnostic imaging is a valuable device in clinical management of poisoned patients presenting to emergency units in a comatose state. Some toxic agents have adverse effects on the central nervous system (CNS). Non-contrast computed tomography (CT) of the brain, as an available diagnostic method with a high resolution, can provide useful information about structural disturbances of unconscious patients with suspected drug or chemical intoxication. The authors would describe various presentations of toxic substances detected on the brain CT scans of ten patients with acute intoxication. While non-specific, CT findings of low-attenuation lesions in the basal ganglia, infarctions in young patients, or diffuse edema should raise suspicion for poisoning or overdose.

Interpretation of clinical guidelines for poisoned patients: positive and negative effects of standard phrases used in TOXBASE

Electronic information sources are increasingly relied upon for clinical management advice. TOXBASE is a standardised online resource that offers clinical advice on the management of poisoned patients and is the first point of contact between clinicians and the National Poisons Information Service in the United Kingdom. Advice is delivered using a series of standard phrases. The present study examined how healthcare professionals interpret the phrases and studied their impact on clinical decision-making. A structured prospective written questionnaire was offered to healthcare staff in the Lothian region, and an electronic questionnaire issued to TOXBASE users across the United Kingdom. Participants were asked to respond to a variety of scenarios representing acutely poisoned patients. Clinical management advice was offered via TOXBASE using a variety of standard phrases, and participants were asked to express the likelihood that they would then administer gut decontamination treatment. There were 70 respondents to written questionnaires, and 119 respondents to the electronic version. Phrases that included didactic instructions, for example 'give', 'contraindicated', 'do' and 'perform' were associated with strongly positive or strongly negative responses. In contrast, advice that consisted of open phrases such as 'consider', 'benefit uncertain', and 'few data' were associated with inconsistent responses. Didactic words and phrases are associated with more consistent interpretation and response than open-ended words and phrases. The choice of words and phrases used in electronic systems can have an independent impact on clinical decision-making and require further consideration.

Gut decontamination of acutely poisoned patients: what do doctors really know about it?

There are consensus guidelines on the appropriate use of gut decontamination in the management of poisoned patients. This study demonstrates that few doctors have read these guidelines and that they...

Position Paper: Single-Dose Activated Charcoal

Single-dose activated charcoal therapy involves the oral administration or instillation by nasogastric tube of an aqueous preparation of activated charcoal after the ingestion of a poison. Volunteer studies demonstrate that the effectiveness of activated charcoal decreases with time. Data using at least 50 g of activated charcoal, showed a mean reduction in absorption of 47.3%, 40.07%, 16.5% and 21.13%, when activated charcoal was administered at 30 minutes, 60 minutes, 120 minutes and 180 minutes, respectively, after dosing. There are no satisfactorily designed clinical studies assessing benefit from single-dose activated charcoal to guide the use of this therapy. Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to one hour previously. Although volunteer studies demonstrate that the reduction of drug absorption decreases to values of questionable clinical importance when charcoal is administered at times greater than one hour, the potential for benefit after one hour cannot be excluded. There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated. A review of the literature since the preparation of the 1997 Single-dose Activated Charcoal Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement.

Position Paper: Gastric Lavage

Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnormalities, and aspiration pneumonitis. Contraindications include loss of protective airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition. A review of the 1997 Gastric Lavage Position Statement revealed no new evidence that would require a revision of the conclusions of the Statement.

Rational use of toxicology testing in children

The majority of all patients with poison exposures in the United States are children. The evaluation and management of poisoned patients may be aided by the use of laboratory assays, ranging from basic assessments not uniquely indicated for the poisoned patient to highly sophisticated laboratory tests with very specific indications. Literature concerning poisoning in pregnant patients is evaluated and recommendations regarding the utility of pregnancy testing in poisoned females are discussed. Recent studies evaluating the use of toxicology testing in pediatrics have concluded that the use of comprehensive toxicology screening in pediatric patients is costly and does not affect the medical management of most poisoned patients. The utility of focused quantitative serum assays to determine serum levels of particular poisons is reviewed. Toxicology tests used for detection of drugs of abuse, with a particular focus on the capabilities and limitations of such tests, are discussed. The potential pitfalls that occur when toxicology tests are obtained indiscriminately, are misapplied, or are misunderstood are analyzed. Hair sampling as nonemergent toxicology testing for drugs of abuse is discussed.

A dedicated district poisons treatment unit: response to the College guidance on the management of deliberate self-harm

Aims and methodAn examination of the activities of a district-wide dedicated admission unit for poisoned patients in Cardiff, Wales, between 1987 and 1997. Number of admission episodes, gender, drugs taken. intent, psychiatric diagnosis and disposal were recorded.ResultsAlthough the number of admission episodes almost doubled over the 10–year period, the median length of stay fell by almost half.Clinical implicationsThe results suggest that a dedicated unit is a cost-effective model for the management of poisoned patients.

Summary of American academy of clinical toxicology and european association of poison centres and clinical toxicologists position: Statements on gut decontamination

The Position Statements on gastrointestinal decontamination were produced by the American Academy of Clinical Toxicology and the European Association over a 4-year period using agreed methodology. The Statements conclude that as the effect of syrup of ipecac diminishes with time and as there are no clinical studies to prove that ipecac improves the outcome of poisoned patients, its routine administration in the Emergency Department should be abandoned. It should be considered only if it can be administered within 60 minutes of drug ingestion to an alert conscious patient who has ingested a potentially toxic amount of a poison; even then clinical benefit has not been confirmed in controlled studies. Gastric lavage should not be employed routinely in the management of poisoned patients. There is no certain evidence that its use improves clinical outcome and it may cause significant morbidity. Gastric lavage should not be considered unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion; even then clinical benefit has not been confirmed in control studies. Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. On the basis of volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within 1 hour. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour. There is no evidence that the administration of activated charcoal improves clinical outcome. On the basis of available data there are no definite indications for the use of cathartics in the management of the poisoned patient. In addition, there are no established indications for the use of whole bowel irrigation. On the basis of experimental studies, WBI is an option for potentially toxic ingestions of sustained release or enteric-coated drugs. WBI is of theoretical value in the management of patients who have ingested substantial amounts of iron and for the removal of ingested packets of elicit drugs.

Practical management of the poisoned patient.

Clinical toxicology is undergoing a change in its previously perceived unscientific image. As in other medical disciplines, there is an effort to ensure that its treatments are evidence based. A successful outcome seems likely not only to rationalize the management of poisoned patients but to simplify it.

Position Statement: Ipecac Syrup

In preparing this Position Statement, all relevant scientific literature was identified and reviewed critically by acknowledged experts using agreed criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not usually considered. A draft Position Statement was then produced and subjected to detailed peer review by an international group of clinical toxicologists chosen by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists. The Position Statement went through multiple drafts before being approved by the boards of the two societies and being endorsed by other societies. The Position Statement includes a summary statement for ease of use and is supported by detailed documentation which describes the scientific evidence on which the Statement is based. Syrup of ipecac should not be administered routinely in the management of poisoned patients. In experimental studies the amount of marker removed by ipecac was highly variable and diminished with time. There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients and its routine administration in the emergency department should be abandoned. There are insufficient data to support or exclude ipecac administration soon after poison ingestion. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. Ipecac should not be administered to a patient who has a decreased level or impending loss of consciousness or who has ingested a corrosive substance or hydrocarbon with high aspiration potential.