Management Of Poisoning Research Articles

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand.

Paracetamol is a common agent taken in deliberate self-poisoning and in accidental overdose in adults and children. Paracetamol poisoning is the commonest cause of severe acute liver injury. Since the publication of the previous guidelines in 2015, several studies have changed practice. A working group of experts in the area, with representation from all Poisons Information Centres of Australia and New Zealand, were brought together to produce an updated evidence-based guidance. The optimal management of most patients with paracetamol overdose is usually straightforward. Patients who present early should be given activated charcoal. Patients at risk of hepatotoxicity should receive intravenous acetylcysteine. The paracetamol nomogram is used to assess the need for treatment in acute immediate release paracetamol ingestions with a known time of ingestion. Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid ingestion in children, and repeated supratherapeutic ingestions. The new guidelines recommend a two-bag acetylcysteine infusion regimen (200mg/kg over 4h, then 100mg/kg over 16h). This has similar efficacy but significantly reduced adverse reactions compared with the previous three-bag regimen. Massive paracetamol overdoses that result in high paracetamol concentrations more than double the nomogram line should be managed with an increased dose of acetylcysteine. All potentially toxic modified release paracetamol ingestions (≥10g or ≥200mg/kg, whichever is less) should receive a full course of acetylcysteine. Patients ingesting ≥30g or ≥500mg/kg should receive increased doses of acetylcysteine.

Assessment of knowledge and practice of nurses on initial management of acute poisoning in Dessie referral hospital Amhara region, Ethiopia, 2018

IntroductionPoisoning is a major health problem worldwide, and it causes significant morbidity and mortality. It is estimated that 350,000 people died worldwide from unintentional poisoning. The purpose of this study is to assess nurses’ knowledge and practice on the initial management of acute poisoning among nurses in Dessie referral hospital, Amhara region, Ethiopia.MethodsHospital based cross sectional study was conducted from January 2018 to June 2018. Simple Random sampling technique was used to select the samples. Data was collected by using self-administered structured questioners. Data were cleansed, checked for completeness and entered into SPSS version 20 for analyses. Statistical measures of Central tendency, T-test and ANOVA were used in determining the association between independent and dependent variables.ResultsBased on the given 13 items to assess the general knowledge of nurses on poisoning, the score ranges from 2 to 9 with the range of 7 with the mean score of 7.48(SD-0. 0.839) for the entire respondents that was 57.5% for the given items that was less than 75% which was unsatisfactory level of knowledge. The mean score of general knowledge on poisoning was high among nurses who had training on initial management of poisoning than those nurses who had not the training.Conclusion and recommendationAll Dessie referral nurses that participated in this study had unsatisfactory general knowledge on poisoning, knowledge on initial management of acute poisoning and self-reported practice. The major implication of these study findings on the health system is the importance of ensuring support to nurses’ health care services for early detection and management of poisoning.

Progress in treatment of acute aluminum phosphide poisoning

Aluminum phosphide (ALP) is frequently used for grain conservation despite its high toxicity. In some developing countries increased utilization of ALP has resulted in increment of ALP-attributed poisoning numbers. The mortality of ALP poisoning is extremely high and no effective antidote is available so far. However, the astute survey of potential misconceptions in the course of acute toxicity has led some scientists to introduce novel therapeutic approaches. Meanwhile, some new antioxidants were discovered and expected to be used in the management of ALP poisoning. In addition, the progress in intensive care has promoted technologies such as CRRT, IABP and ECMO for the treatment of ALP poisoning with reported success in alleviating severe toxicity. Recent studies on the therapy of ALP poisoning are reviewed in this article.

Síndromes asociados a intoxicación por organofosforados: abordaje médico y fisioterapéutico en cuidado crítico

Introducción: el artículo reporta un caso clínico de intento suicida de un paciente con síndrome intermedio a causa de intoxicación por organofosforados. Para ello se analizó la historia clínica, los exámenes complementarios y el estudio electromiográfico, y se realizó revisión no sistemática de la literatura. Presentación del caso: se describe un caso diagnosticado en la unidad de cuidado intensivo, el cual presentó trastornos neuromotores, requerimiento de soporte ventilatorio con destete difícil y extubación fallida, así como el tratamiento médico y fisioterapéutico instaurado. Dentro del manejo de la intoxicación por organofosforados se incluye la descontaminación del tóxico, administración de atropina y pralidoxima, diagnóstico oportuno del síndrome intermedio y la prescripción de ejercicio terapéutico. El paciente recibió manejo interdisciplinario, logrando liberación de su condición crítica, pero con persistencia de debilidad muscular proximal; sin embargo, con el ejercicio alcanzó recuperación funcional de sus actividades básicas cotidianas. Conclusión: el panorama mundial de las intoxicaciones por sustancias químicas muestra que son causa de morbilidad y discapacidad importante. Los organofosforados son los plaguicidas más frecuentemente involucrados. Los síntomas y signos clínicos de este tipo de intoxicaciones se clasifican en manifestaciones colinérgicas, el síndrome intermedio y la neuropatía retardada.

Treatment of lead and arsenic poisoning in anuric patients \u2013 a case report and narrative review of the literature

BackgroundHeavy metal poisoning can cause debilitating illness if left untreated, and its management in anuric patients poses challenges. Literature with which to guide clinical practice in this area is rather scattered.Case presentationWe present a case of symptomatic lead and arsenic poisoning from use of Ayurvedic medicine in a 28-year-old man with end-stage kidney disease on chronic hemodialysis. We describe his treatment course with chelating agents and extracorporeal blood purification, and review the relevant literature to provide general guidance.ConclusionCumulative clinical experience assists in identifying preferred chelators and modalities of extracorporeal blood purification when managing such patients. However, a larger body of real-world or clinical trial evidence is necessary to inform evidence-based guidelines for the management of heavy metal poisoning in anuric patients.

Analytical aspects and management of copper poisoning- A review

Analytical aspects and management of copper poisoning- A review

In this October issue

The World Health Assembly (the decision-making arm of the World Health Organization) recently released this resolution, urging all countries to assess and develop their emergency care systems so as to improve care for the acutely ill and injured. Australian and New Zealand emergency care stakeholders have an important role to play. In an important editorial, we discuss the resolution in detail and what it means for the Indo-Pacific region and ACEM. [Correction added on 23 October 2019 after first online publication: the World Health Assembly Resolution number has been changed from 72.31 to 72.16.] Complaints about IT systems are common in ED. ED data are important for both primary (clinical) and secondary uses (remuneration, operational, strategic and research). Rapid turnover of patients and frequent task interruption means that emergency physicians can spend more time entering data than on patient care. We publish a paper that audits current data quality from ED systems in NSW. A linked editorial comments on the implications of these findings. Clinical research produces evidence regarding the efficacy or effectiveness of a diagnostic tool or treatment strategy, and this informs clinical decision-making. Clinicians, especially in the ED, are familiar with increasing service demands and limited resources and make daily decisions balancing risk and benefit, where providing care for one patient delays care for another. Health economics is the application of economic principles to the distribution of scarce resources for healthcare to improve patient outcomes. The latest paper in our popular Acute Geriatrics series reports on the challenge of diagnosing urinary tract infections in the elderly. Misdiagnosis is common. How valuable is dipstick testing? The AANZDEM/EURODEM study compared treatment and outcomes between patients treated for asthma in Europe and Southeast Asia/Australasia and compliance with international guidelines. A total of 584 patients were identified from a total of 112 EDs in both regions. Inhaled beta-agonists were given in 86% of cases, systemic corticosteroids in 66%, oxygen in 44% and antibiotics in 20%. Compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is suboptimal. There is also overuse of antibiotics. Non-fatal injuries sustained from animal–vehicle collisions are a globally under-recognised road safety issue, with limited data on these crash types. An analysis of major trauma cases in Victoria between 2007 and 2016 demonstrated that 152 major trauma patients were admitted to Victorian trauma-receiving hospitals because of vehicle collisions with animals. In 2016, the World Health Organization introduced a Trauma Care checklist, which outlines steps to follow after the primary and secondary surveys and before the team leaves the patient. The checklist, whilst likely to be successful in reducing errors of omission related to hospital admission, is limited in its ability to reduce errors that occur in the initial 30 min of reception – when most of the life-saving decisions are made. An alternative option is discussed. Septic shock and severe bacterial infections benefit from antibiotics administered as soon as possible. Many hospitals have sepsis campaigns and sepsis pathways that focus on giving broad-spectrum antibiotics to patients with potential sepsis. Loosening of the definitions, clinically dichotomised cut-offs and pressure to treat might cause more harm than good. An author of a letter to the editor says that the evidence for early antibiotics is weaker than the strength of current recommendations. In the second article of our occasional series, an experienced clinician reflects on the ‘Scandinavian’ approach to barbiturate poisoning and its impact on the management of toxicological poisoning. Everything we do today is built on the pioneering work of those who came before us.

Difficulties In Managing Methemoglobinemia

Acute poisoning with nitrobenzene causing significant methemoglobinemia is a rare yet life-threatening emergen-cy. A 20-year-old, female presented to Emergency in altered sensorium with a history of consumption of a bioor-ganic formulation. On examination she was cyanosed restless and agitated with SpO2 of 70% on room air. Blood samples drawn for ABG was chocolate brown colour on blotting paper. ABG showed metabolic acidosis with a satu-ration of 80%. Methylene blue 50mg in IV saline was given over 5 mins and oral ascorbic acid. She improved slowly after the 9th day with SpO2 of 92% on room air. She was discharged on the 17th day on oral iron, ascorbic acid, and breathing exercises. Early aggressive management of severe poisoning, strongly suspected on clinical grounds may change the outcome of the patient. Key-words: Nitrobenzene, methemoglobinemia, methylene blue, pulse oximetry

Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup

Intentional or unintentional ingestions among children and adolescents are common. There are a number of ingestions amenable to renal replacement therapy (RRT). We systematically searched PubMed/Medline, Embase, and Cochrane databases for literature regarding drugs/intoxicants and treatment with RRT in pediatric populations. Two experts from the PCRRT (Pediatric Continuous Renal Replacement Therapy) workgroup assessed titles, abstracts, and full-text articles for extraction of data. The data from the literature search was shared with the PCRRT workgroup and two expert toxicologists, and expert panel recommendations were developed. We have presented the recommendations concerning the use of RRTs for treatment of intoxications with toxic alcohols, lithium, vancomycin, theophylline, barbiturates, metformin, carbamazepine, methotrexate, phenytoin, acetaminophen, salicylates, valproic acid, and aminoglycosides.

Severe ARDS Complicating an Acute Intentional Cresol Poisoning

Cresol is a phenol derivative used as a disinfectant that may cause gastrointestinal corrosive injury, central nervous system, cardiovascular disturbances, renal, and hepatic injury following intoxication. We present a case of a female patient who was admitted to the emergency department after ingesting an unknown amount of cresol; she was admitted with tachypnea, shortness of breath with low oxygen level in the blood. She did not develop hepatic or renal dysfunction. The gastrointestinal endoscopy was performed and showed esophagus and gastric erosins only. The patient was sedated and ventilated for 7 days. After receiving supportive intensive care, the patient recovered and was sent for psychiatric evaluation. Cresol intoxication can be fatal, and cause a respiratory failure with an acute respiratory distress syndrome (ARDS), hepatic, and renal injury. This shows the importance of intensive care in the management of cresol poisoning.

A pilot clinical study of the neuromuscular blocker rocuronium to reduce the duration of ventilation after organophosphorus insecticide poisoning

Background: A common manifestation of organophosphorus insecticide self-poisoning is prolonged respiratory failure due to neuromuscular junction dysfunction and likely nicotinic receptor overstimulation. We aimed at collecting preliminary data on whether addition of the competitive nicotinic antagonist rocuronium to standard early therapy might be clinically feasible and associated with reduced duration of ventilation.Methods: A pilot three-arm dose–response phase II trial was set up to compare bolus doses of rocuronium bromide titrated to produce initial >95% or 50% inhibition of neuromuscular function, measured using acceleromyography, plus standard treatment, versus standard treatment alone. After attaining inhibition, patients receiving bolus rocuronium then received rocuronium infusions for a maximum of 120 h. Primary outcome was duration of intubation; secondary outcome was case fatality. Plasma butyrylcholinesterase activity was measured throughout the inpatient stay. Blood was analysed to confirm the organophosphorus insecticide ingested.Results: Forty-five patients were randomised to receive: rocuronium to initially attain 95% inhibition (Roc>95, n = 15), rocuronium to initially attain 50% inhibition (Roc50, n = 14), or no rocuronium (control, n = 16). The most commonly ingested pesticide was profenofos (29/45, 64.4%). Butyrylcholinesterase activity remained severely inhibited for the duration of the study for most patients. Case fatality was 9/45 (20%) and similar across study arms: control 3/16 (18.8%), Roc50 4/14 (28.6%) and Roc>95 2/15 (13.3%) (p = .5842). When excluding patients who died, median [IQR] duration of intubation was significantly longer in the Roc50 (259.5 [176–385] h) and Roc>95 (226.8 [186–355] h) groups compared to controls (88.5 [47–160] h, p = .0162 and p = .0016, respectively).Conclusions: In this pilot dose–response study, we found no evidence that rocuronium in addition to standard therapy reduced the duration of intubation. It is possible that it worsened neuromuscular junction function. Further clinical research, including testing of shorter duration regimens, needs to be performed before nicotinic antagonists can be used in the clinical management of OP poisoning.

Childhood Drug and Non-Drug Poisoning in Nigeria: An Economic Appraisal.

Background:The dearth of information on the economic cost of childhood poisoning in sub-Saharan Africa necessitated this study.Objective:This study has investigated the prevalence of childhood drug and non-drug poisoning, treatment modalities and economic costs in Nigeria.Method:A retrospective study of childhood drug and non-drug poisoning cases from January 2007 to June 2014 in the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria was carried out. Medical records were analysed for demographic and aetiological characteristics of poisoned children (0–14 years of age), as well as fiscal impact of poisoning cases.Findings:Of the 100 poisoned patients, 46% were male and 54% female, with female/male ratio of 1.17:1. Most of the children were under five years of age. Paracetamol, amitriptyline, chlorpromazine, ferrous sulphate, kerosene, organophosphates, carbon monoxide, snake bite, alcohol and rodenticides were involved in the poisoning. The average cost of poison management per patient was about $168, which is high given the economic status of Nigeria.Conclusion:Childhood poisoning is still a significant cause of morbidity among children in Nigeria and accounts for an appreciable amount of health spending, therefore preventive strategies should be considered.

Lithium Poisoning Update in Diagnosis and Treatment

Introduction: Lithium has been used over time in the treatment of psychiatric pathologies, mainly the bipolar spectrum, however, the narrow therapeutic range generates a high incidence of poisoning by this metal, with a very heterogeneous clinical presentation of toxicity which will depend on two factors: the time of evolution, if it is acute or chronic, and the serum levels, ranging from gastrointestinal symptoms to severe neurological compromise. As of today, there is no specific antidote for lithium, so intermittent hemodialysis is the strategy of choice for the intoxicated patient. Objectives: To describe the available and relevant literature on the management of Lithium poisoning. Methodology: A search was performed with the MeSH terms "Lithium, Renal Dialysis, Poisoning, Toxicity, Acute kidney injury" in the ClinicalKey, PubMed and Ovid databases search engines, finding 156 results, of which 47 were used to develop this manuscript. Conclusions: Lithium poisoning is frequent due to its narrow therapeutic margin, so serum lithium levels should be monitored in patients medicated with it. Today there is no specific antidote, so renal replacement therapy is the best therapeutic option for lithium poisoning, demonstrating high efficiency, especially in cases of marked neurotoxicity. It is necessary to assess the need to initiate timely management in order to achieve a rapid clearance of the drug and decrease the rate of complications and mortality.

Synthesis and biological evaluation of Piroxicam derivative as a lead chelator

Abstract Lead as a potent environmental and occupational pollutant, exerts its toxic effect mainly through oxidative stress induction. Currently, chelation therapy is the only medical management of metal intoxications in clinic, but its administration is associated with various side effects as well. In this study the protective effect of synthetized Piroxicam derivative was evaluated against lead toxicity in vitro. First the chelating activity of Piroxicam derivative was studied through Jobs method and 13C{1H} NMR spectroscopy. Then the cytoprotective effect of Piroxicam derivative (10, 20, 50, 100 and 200 μg/mL) was evaluated and compared with that of EDTA (30 μg/mL) in the presence of lead nitrate (30 μg/mL). The EC50 value of Piroxicam derivative was calculated as well. Finally, the chelation efficacy and antioxidant effects of Piroxicam derivative in EC50 and 2EC50 values was assessed and compared with that of EDTA. Results showed that Piroxicam derivative chelates lead ion as much as EDTA. Moreover, Piroxicam derivative prevented lead-induced cells death more effectively than EDTA which is may due to its potent innate antioxidant activity. In conclusion, the synthetized Piroxicam derivative with possessing potent chelating activity as well as potent antioxidant activity, could be considered as potential drug target in management of toxic metals poisoning.

Dog Bite - An Ayurvedic Approach

Ayurveda is an ancient science that balanced state of these 3 doshas, Vata, Pitta, Kapha is a life & imbalanced state of doshases is called disease.
 Ras, Rata, Mansa, Meda, Asthi, Majja, Shukra these are 7 dhatus. All 7 dhatu’s Sar is known as Oaj. Oaj qualities is totally differ from poison. Oaj & poison qualities are opposite from each other.
 Dog Bite is known as Aalarkvisha by Ayurvedic means. In the majority of cases Dog bite becomes Rabies or Hydrophobia due to delay in wound, poison management & wound unproper hygiene care.

Oxidative and histopathological alterations after sub-acute exposure of diisopropyl phosphorofluoridate in mice: Beneficial effect of N‑acetylcysteine

AimsProtective efficacy of N‑acetylcysteine (NAC) was assessed against sub-acute diisopropyl phosphorofluoridate (DFP) poisoning in mice. Main methodsMice were allocated into nine groups of six each: vehicle control; DFP (0.125 LD50 ≈ 0.483 mg/kg bwt, s.c.); DFP + Atropine (ATR, 10 mg/kg bwt, i.p., 0 min); DFP + Pralidoxime (2-PAM, 30 mg/kg bwt, i.m., 0 min); DFP + NAC (150 mg/kg bwt, i.p., −60 min); DFP + ATR + NAC; DFP + 2-PAM + NAC; DFP + ATR + 2-PAM; and DFP + ATR + 2-PAM + NAC. Animals received various treatments for 21 d daily. Plasma butyrylcholinesterase (BChE) was measured after 7, 14 and 21 d of exposure. Brain acetylcholinesterase (AChE) and reduced glutathione (GSH), malondialdehyde (MDA), glutathione peroxidase (GPx), glutathione reductase (GR), catalase (CAT), and superoxide dismutase (SOD) were measured (brain, liver and kidney) after 21 d of exposure. Histopathology, immunohistochemistry, and Western blot for inducible nitric oxide synthase (iNOS) and c-fos were also performed. Key findingsDFP significantly reduced BChE and AChE levels. Diminished GSH, CAT, SOD (brain and liver), GPx, GR, and elevated MDA (Brain) levels were also observed. DFP caused notable histopathology (brain, liver and kidney) and over expression of iNOS, and c-fos proteins (brain). NAC enhanced the protective efficacy of ATR and 2-PAM in most parameters, without any appreciable protection in iNOS and c-fos expression. SignificanceNAC as an adjunct with ATR and 2-PAM, exhibited marked beneficial effects against sub-acute DFP poisoning, indicating its possible implications in the management of OP poisoning.

A systemic review of vegetable poisoning and challenges in management

A systemic review of vegetable poisoning and challenges in management - IJFMTS- Print ISSN No: - 2581-9844 Online ISSN No:- 2456-9615 Article DOI No:- 10.18231/j.ijfmts.2019.002, IP International Journal of Forensic Medicine and Toxicological Sciences-IP Int J Forensic Med Toxicol Sci

Pattern of Poisoning, Management and Antidote Availability in St. Paulo’s Specialized Hospital Addis Ababa, Ethiopia

Poisoning is the contact with a substance that results in toxicity. It can be deliberate or accidental. Antidotes are substances opposing the harmful effect of poisons and are cornerstones in the management of poisoning. Availability of antidotes highly affects the effective poisoning management. To assess the poisoning management in relation to an antidote availability. A retrospective study was used to assess the practice of poisoning management and antidote availability in St. Paulo’s specialized hospital. Females are among the majority of acutely poisoned patients (50.6%) and most of the patients are in the younger age groups (32.4%). The most common type of poison is sodium hypochlorite (Berekina) (45.2%) which the most common source is household materials (48.6%). Intentional self-harm (95.4) was the common circumstance of poisoning and majority of patients improved (74.6%) after management. Low number of antidotes were available and gastric lavage and fluid resuscitation were the common management options in the absence of antidotes (61.4%) and (33%) respectively. Even though the recommended items of antidote were not available, the management pattern is good based on the outcome. It is recommended to have sufficient items of antidotes to improve the overall management practice of poisoning and the hospital organization should take the responsibility in preparing list of antidotes that should be available in the hospital and formulating guideline for poisoning management should also be considered. Keywords: poison, antidote, sodium hypochlorite, gastric lavage Cite this Article Kebebe D, Gobena M, Seelam RK. Pattern of poisoning management and antidote availability in st. Paulo’s specialized hospital Addis Ababa, Ethiopia. Research and Reviews: Journal of Toxicology. 2015; 5(3): 8–12p.

Forecasting the course of occupational chronic fl uorine intoxication by means of univariate analysis

Relevance. In contemporary occupational pathology, diagnosis of occupational fluorosis is based on locomotory apparatus disorder such as fluorine osteopathy. Other significant consequences of negative effects of fluorine compounds are deactivation of enzymatic systems, metabolic disorders — that results in pathologic involvement of many organs and systems (hepato-biliary, cardiovascular, respiratory, nervous, endocrine, gastrointestinal). Topical issue is search of a complex of factors influencing development of the occupational disease, to optimize management of occupational fluorine intoxication risk.Objective. To determine spectrum of factors that promote development of occupational fl uorine intoxication in workers exposed to inorganic fl uorine compounds, for forecasting the disease outcome and selecting main trends of preventive measures.Materials and methods.Single-factor analysis methods helped to carry retrospective cohort study of occupational fl uorine intoxication development in 201 workers of aluminum production in Ural region. Th e study covered infl uence of main occupational factors and somatic health parameter s on occupational fl uorosis development.Results.Findings are reliable infl uence of age (k=0.532, p<0.001), length of service in hazardous work conditions (p<0.001), hydrofl uoride level (p<0.001) and constant magnetic fi eld (p=0.005). Besides that, analysis of immune and metabolic state of the workers revealed signifi cant infl uence of disordered lipid, carbohydrate, purine metabolism, altered immune parameters on occupational fl uorosis development. Other evidence was reliable dependence between concomitant cardiovascular diseases and period of occupational chronic fl uorine intoxication development.Conclusion.Using single-factor analysis helped to determine wide spectrum of factors associated with the workers’ health state and work conditions, that signifi cantly infl uence development of fl uorine intoxication. Th e authors proved that period of occupational chronic fl uorine intoxication is notably infl uenced by occupational factors (length of service, hydrofl uoride level, fl uorine load degree, magnetic fi eld) and somatic state characteristics as age, parameters of carbohydrate, lipid, purine metabolism, status of cardiovascular, excretory systems, kidneys and gastrointestinal tract functions.

Endoscopic removal of a gastric pharmacobezoar induced by clomipramine, lorazepam, and domperidone overdose: a case report

IntroductionGastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects. Certain medications, such as sustained-release forms, contain cellulose derivatives that may contribute to the adhesion between pills and lead to the creation of an aggregate resulting in a pharmacobezoar. Case reports are rare, and official guidelines are needed to help medical teams choose proper treatment options.Case presentationOur patient was a 40-year-old Caucasian woman with borderline personality disorder and active suicidal thoughts who was found unconscious after a massive drug consumption of slow-release clomipramine, lorazepam, and domperidone. On her arrival in the emergency room, endotracheal intubation was preformed to protect her airway, and a chest x-ray revealed multiple coffee grain-sized opaque masses in the stomach. She was treated with activated charcoal followed by two endoscopic gastric decontaminations 12 h apart in order to extract a massive gastric pharmacobezoar by manual removal of the tablets.ConclusionThis case demonstrates that in the case of a massive drug consumption, a pharmacobezoar should be suspected, particularly when cellulose-coated pills are ingested. Severe poisoning due to delayed drug release from the gastric aggregate is a potential complication. Detection by x-ray is crucial, and treatment is centered on removal of the aggregate. The technique of decontamination varies among experts, and no formal recommendations exist to date. It seems reasonable that endoscopic evaluation should be performed in order to determine the appropriate technique of decontamination. Care should be patient-oriented and take into account the clinical presentation and any organ failure, and it should not be determined solely by the suspected medication ingested. Thus, serum levels are not sufficient to guide management of tricyclic antidepressant intoxication.