Suicidal Ingestions Research Articles

Is EGD Needed in all Patients after Suicidal or Exploratory Caustic Ingestions?

Caustic ingestions are relatively uncommon, but remain a significant source of morbidity. Patients with caustic injury often undergo an urgent EGD, although it is not clear if an EGD is routinely needed in an asymptomatic patient. The study has two primary objectives; 1) to determine the utility of routine EGD in asymptomatic suicidal caustic ingestions; 2) to determine if asymptomatic unintentional acidic ingestions can be managed with observation alone, similar to basic ingestions. This retrospective study, which took place at 14 hospitals in three countries evaluated all patients who presented with a caustic ingestion between 2014-2020. The presence of symptoms and esophageal injury, demographic information, pH of ingested substance, reason for the ingestion, and outcome were recorded. 409 patients were identified; 203 (46.9%) were male. The median (IQR) age was 18 (4-31) years; overall range 10months to 78years. Suicidal ingestions accounted for 155 (37.9%) of cases. Dysphagia or dysphonia were more likely in those with significant esophageal injury compared to those without (59.3% vs. 12.6% respectively; OR 10.1; 95% CI 4.43-23.1). Among 27 patients with significant esophageal injury, 48% were found in suicidal patients, compared with 51.9% in non-suicidal patients (p = NS). On multivariate regression, there was no difference in the rate of significant esophageal injury among suicidal vs. non suicidal patients (aOR 1.55; p = 0.45, 95% CI 0.45-5.33). Most ingestions involved basic substances (332/409; 81.2%). Unknown or mixed ingestions accounted for 25 (6.11%) of the ingestions. Significant esophageal burns were found in 6/52 (11.5%) of acid ingestions, compared with 21/332 (6.3%) of basic ingestions. Of the 42 cases of acidic ingestions without dysphagia or odynophagia, 2 (4.8%; 0.58-16.1%) had significant esophageal burns, compared with 9 (3.2%; 95% CI 1.4-5.9%) of the 284 basic ingestions; p = 0.64). On multivariate logistic regression, patients with acidic ingestions were not more likely to experience a significant burn (aOR 1.7; p = 0.11, 95% CI 0.9-3.1) compared to those with basic ingestions. No patient with significant esophageal burns was asymptomatic. In this study, there was no statistical differences in the rates of significant burns between acidic and basic caustic ingestions. There were no significant esophageal injuries noted among asymptomatic patients.

Impact of social media “challenges” on poison center case volume for intentional ingestions among school-aged children: an observational study

Introduction Mental health problems among youth have escalated over the past decade, with increased rates of self-harm, including suicide attempts by ingestion. Social media use has been linked to youth mental health, including “challenges” urging youth to ingest substances for recreational and other purposes. We hypothesized that social media challenges for particular substances would temporally correspond with increased ingestions of these substances. Methods We identified peak Google Trends search times for social media ingestion challenges involving diphenhydramine, laundry pods, nutmeg, and cinnamon, and used data from America’s Poison Centers National Poison Data System to plot reported ingestions 3 months before and after peak searches in school-aged children. Results There were 2,169 individuals in the analysis. Diphenhydramine was the most frequently reported ingestion for misuse/abuse and suicidal purposes (n = 266 and 1,609, respectively). For all ingestions together, 45 percent (n = 979) had a moderate health effect, and 6.35 percent (n = 137) had a major health effect. Time of peak searches corresponded with increased ingestions for each substance. Discussion We found a temporal relationship between peak Google Trends searches for ingestion challenges and ingestions of that substance reported to United States poison centers. Compared to misuse/abuse ingestions, most suicidal ingestions peaked 1–2 months later, suggesting a public health opportunity for intervention. Limitations This retrospective observational study does not establish causal effect. All data are a result of self-reporting of the exposures, which may lead to a reporting bias. Google Trends is not the only search engine and likely underestimates the true incidence of social media posts. Conclusions Additional research is needed on the relationship between social media and youth mental health, particularly around “challenges” that place youths’ health at risk. There may be opportunities for intervention to decrease medical and mental health sequelae of these challenges.

Epidemiological Characteristics, Spectrum of Upper Gastrointestinal Tract Injuries and Burden of Corrosive Intake Patients in A Tertiary Care Hospital in Islamabad

Objective: To investigate the epidemiology and spectrum of upper gastrointestinal (UGI) tract injuries, as well as to assess the burden of Corrosive intake patients who presented to an Islamabad tertiary care hospital.Study Design: Descriptive cross-sectional.Place and Duration of Study: The study was carried out at the Department of Gastroenterology of Pakistan Institute of Medical Sciences, Islamabad, Pakistan from January 2021 to December 2021.Materials and Methods: A retrospective descriptive study was carried out at the department of Gastroenterology using patient records. After taking a thorough history, patients were admitted in the hospital, which was followed by a physical examination, necessary investigations, and an initial emergency management. The study did not include any follow-up cases. Corrosive ingestion induced tissue damage was assessed via endoscopy using Zargar’s classification. The data was analyzed using SPSS version 26.Results: The total number of patients who were brought to emergency department with corrosive ingestion during one year were 74. There were 45 females (60.81%) and 29 male patients (39.19%). Age ranged from 13 to 60 years (mean 27.01 ± 18.91) with highest incidence in the age group of 21-30 years which was 44.59 % followed by 11-20 age Group (28.28 %). 41 patients were unmarried (55.41%), whereas 33 were married (44.59 %). Corrosive ingestion was most common in illiterate patients (44.59 %). 46 patients (62.16%) confessed that they ingested corrosive substance intentionally while 28 (37.84 %) claimed it happened due to accidental ingestion. Washroom cleaner was found to be the most commonly used corrosive Agent (90.54%). The most common sites that sustained corrosive injuries were the oropharynx and oesophagus, while the duodenum was found to be the least affected with normal endoscopic examination in the majority of the patients (51.35 %).Conclusion: In developing countries, corrosive ingestion is a major public health concern, with a high proportion of suicidal ingestions. It is particularly common in suicidal young people with easy access to washroom cleaners. The seriousness of this problem emphasises the importance of pursuing multidisciplinary solutions. In addition, strict action and stringent legislation by governing bodies are required in developing countries to limit adults' unrestricted access to hazardous corrosive elements.

Trends Over 2 Decades in Adolescent Suicidal and Recreational Ingestions of Over-the-Counter Coricidin Preparations.

The aim of this study was to assess national trends in recreational and suicidal ingestions of over-the-counter cough preparations that contain Coricidin. Using the American Association of Poison Control Center's National Poison Data System, we obtained data from 2004 to 2017 on patients aged 13 to 19 years with an ingestion of "Coricidin." We examined trends over time overall and ingestion intent (recreational vs suicidal) using linear regression. We compared patient characteristics, substances ingested, clinical effects and therapies, and outcomes by suicidal versus misuse or recreational intention. An initial search with the inclusion criteria found 19,213 calls that matched study inclusion criteria. On average, there was a yearly linear increase of 180.0 (95% confidence interval [CI], 136.6-223.3; P < 0.01) ingestions per year. Within suicide ingestions, there was an average yearly increase of 97.9 (95% CI, 66.9-128.9; P < 0.01) ingestions, and within misuse/recreational ingestions, there was an average yearly increase of 82.1 (95% CI, 60.3-103.9; P < 0.01) ingestions. The most common clinical effect was tachycardia, which occurred in 42.4% of ingestions. Altered mental status, mydriasis, and ataxia were all more common in misuse/recreational ingestions. Suicidal ingestions resulted in more hospital admissions and need for medical treatment. Recreational-use coded calls peaked in 2013, whereas calls coded for suicide attempts have continued to rise dramatically, with a 50% increase in the 14-year study period. Combination Coricidin products are a major source of morbidity in adolescents. Targeted preventive measures in primary care offices or larger-scale policy/legislative efforts may be helpful to address this.

Adolescent Ingestions: Various Reasons and Medications.

1. David C. Sheridan, MD, MCR* 2. Adrienne Hughes, MD*,† 3. B. Zane Horowitz, MD*,† 1. *Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 2. †Oregon Poison Center, Portland, OR 1. There have been increases in both suicidal and recreational adolescent ingestions over time. 2. Knowledge of these common ingestions is important to properly diagnose, treat, and refer to emergent care as needed. 3. Pediatricians and emergency physicians should be familiar with these ingestions to develop preventive efforts. After completing this article, readers should be able to: 1. Explain the national trends for adolescent suicidal ingestions and recreational abuse. 2. Become familiar with ingestions of prescription drugs, over-the-counter medications, and recreational drugs of abuse. 3. Describe the potential serious clinical complications and treatment options for these ingestions. Adolescents generally do not unintentionally ingest pharmaceutical agents, as seen in the younger pediatric population. The main reasons for adolescent ingestions generally fall into 2 categories: suicidal/self-harm and recreational abuse. These 2 categories are very important and carry different levels of morbidity and mortality. The agents ingested may be unique and require different clinical management and preventive strategies. Suicidal ingestions alone now account for more than 1 million annual emergency department visits, making this a very timely and important review article. (1) Adolescent suicidality and suicide attempts are growing in number, now accounting for more than 1.12 million emergency department visits per year. (1) The reasons for this are multifactorial, with ingestions a common part of a suicide plan or attempt. One recent study evaluated national trends in suicidal ingestions over the most recent decade using the National Poison Center System, a database that consists of all calls to poison centers in the United States. (2) This study found that there were approximately 400,000 calls for “intentional-suspected suicide.” More importantly, calls about adolescent ingestions accounted for more than 80% of all intentional ingestion calls during the study period. The top 5 agents ingested included over-the-counter (OTC) medications of acetaminophen, ibuprofen, and antihistamines, as well as the prescription psychiatric …

Despair in the time of COVID: A look at suicidal ingestions reported to the California Poison Control System during the pandemic.

BackgroundDespite concern that the global pandemic will worsen depression and suicide rates, there remain little data on its actual effect. The purpose of this study was to determine the effect of the COVID‐19 pandemic on suicidal ingestions reported to the California Poison Control System (CPCS).MethodsThis was a cross‐sectional comparison of suicidal ingestions reported to the CPCS during the 2020 COVID‐19 pandemic compared to suicidal ingestions reported during the same period in 2018 and 2019.ResultsThe CPCS received 19,607 call for suicidal ingestions during the study periods, of which 13,800 were in the pre‐COVID era (2018 and 2019) and 5,807 were in the COVID era. The median (IQR) number of suicidal ingestions per month decreased from 2,286 (2,240–2,364) to 1,940 (1,855–2,045; p = 0.02). This decrease was consistent and significant across all age groups except those age 70 or older. Ingestions without adverse events decreased by 101 cases/month (95% confidence interval [CI] = 136.8 to 65; p = 0.0003), minor outcomes decreased by 156.6 cases/month (95% CI = 226.2 to 87.1; p = 0.001), and moderate outcomes decreased by 96 cases/month (95% CI = 143.9 to 48.1; p = 0.00021). Major outcomes decreased from 793 (4.99%) cases in the pre‐COVID era to 315 (4.60%) cases in the COVID era (risk ratio = 0.92, 95% CI = 0.81 to 1.05). The number of deaths decreased by 3.7 cases/month (95% CI = –8.3 to 0.92, p = 0.10).ConclusionsDespite concern for worsening suicidality, calls regarding suicidal ingestions to the nation's largest poison control center decreased during the COVID era compared to the pre‐COVID era. This study provides evidence that the pandemic's effects on modern society remain difficult to predict. Further effort is needed to understand how pandemic will affect American's mental health.

Drug intoxication in children: A retrospective study at the University Hospital of Casablanca

Background: The drug intoxication is increasingly a serious problem in pediatrics across the world due to their frequency and management difficulties. In Morocco, the number of studies concerning this subject is few which were made to this day at only some hospitals. Objective: The aim of this study is to review the prevalence, severity, the different etiologies, the clinical, and therapeutic aspects, also the possible preventive ways of these underestimated poisonings in Morocco. Materials and Methods: It is a retrospective study using 216 cases of drug intoxication who came to the pediatric ward II of the University Hospital of Casablanca. Results: All the age groups under 15 years old were hit with two frequency peaks at 3 years and 15 years. In most cases, it was an accidental poisoning, though some suicidal ingestions were also noted, especially in teenagers. In over half of cases, the causal drug was neurotropic (benzodiazepines and antipsychotics). The clinic was dominated by neurological signs: Consciousness disorder, behavioral disorders, or seizures. Treatment varies depending on the delay between the incident and the case management and was limited to symptomatic treatment or detoxification measures were required: Spillway treatment or an antidote. Poison Control Center was consulted in all cases. Conclusion: Accidental drug intoxication in children is a public health issue. Legislation and means of prevention must be determined and clarified to confront this problem. Studies on this issue would be appreciated to delimit the real epidemiological and clinical profile of these intoxications.

Profile of acute poisoning cases and their outcome in a teaching hospital of north India.

Objectives:Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED).Methods:This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained.Results:Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006].Conclusion:Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level.

Suicidal bupropion ingestions in adolescents: increased morbidity compared with other antidepressants

Objective: Bupropion is often categorized as a newer generation antidepressant and assessed with serotonin reuptake inhibitors as a lower risk than older tricyclic antidepressants (TCAs). The objective of this study was to compare outcomes in adolescent suicide from ingestions between bupropion and TCA medications.Study design: An analysis of the National Poison Data System for exposures coded “suspected suicide” in adolescents (age: 13–19) was undertaken for the years 2013–2016 and included TCAs or bupropion. We compared clinical effects, therapies and medical outcomes.Results: Over the four-year period there were 2253 bupropion and 1496 TCA adolescent suspected suicide calls. There was a significant linear increase in bupropion ingestions over the four years. Across all years, there were on average 189.2 (95% CI: 58.1–320.4; p = .01) more ingestions of bupropion than TCA. When comparing bupropion to a TCA, ingestions of bupropion were significantly more likely to be accompanied by seizure (30.7% vs 3.9%; p < .01), to be admitted (74.8% vs 61.6%; p < .01) and medical outcomes to be coded as a major outcome (19.3% vs 10.0%; p < .01). The number of cases with death or major clinical outcome for both increased over the four-year period. Ingestions of bupropion were less likely to have hypotension (2.7% vs 8.0%; p < .01) and less likely to be intubated (5.6% vs 16.4%; p < .01) as compared to ingestions of TCA.Conclusions: Adolescents who overdose on a single medication in a suicide attempt with bupropion have a statistically significant higher incidence of major outcomes and seizures. The risks of bupropion as a potential means of suicidal gesture by overdose must be considered, and weighed against its benefits and side effect profile when choosing an appropriate agent for the treatment of depression in adolescents.

A Large Case Series of Acute Pediatric Methotrexate Ingestions: Significant Clinical Effects Are Rare.

Significant adverse effects after acute pediatric methotrexate (MTX) exposures have been limited to parenteral exposures. Treatment recommendations for pediatric MTX exposures do not differentiate between routes of exposure. We report the incidence of significant clinical effects and drug-specific treatments reported in a large series of acute, pediatric MTX ingestions. Poison center records of all MTX ingestions by patients younger than 17 years during 2000 to 2005 were collected from 6 poison centers. The cases included all MTX ingestions including those with additional substances. One trained reviewer, blinded to the study purpose, used a standardized data collection form to extract study data. Missing or conflicting data were reconciled with predetermined process. Forty-seven cases were documented for 6 years, 42 (89%) of which were unintentional. Thirty-six percent (17/47) were male. The mean age for the unintentional ingestions was 3.7 years (range, 20 days-17 y; median, 2 y). Five cases (11%) were intentional suicidal ingestions in teenagers. The mean dose in acute, unintentional ingestions (AUIs) in all children and in children younger than 6 years was the same, 8 mg (range, 2.5-17.5 mg). Eleven patients (23%) had follow-up greater than 12 hours. No patient with an AUI developed MTX-induced sedation, hepatotoxicity, renal insufficiency, seizures, or bone marrow suppression. Three patients with an AUI received folinic acid, but no patients in this group received sodium bicarbonate or hemodialysis. One patient with an intentional suicidal exposure developed hepatotoxicity, but the patient also ingested a toxic dose of acetaminophen and valproate. Hemodialysis was performed once on this patient. No patient died. Acute pediatric MTX ingestion is uncommon. Methotrexate-induced seizure, renal failure, hepatic injury, and sedation were not documented in our series. Supportive care and observation only should be considered the mainstay of treatment of pediatric AUIs. Prospective verification of our findings is warranted.

On-Year Study on Pattern of Acute Pharmaceutical and Chemical Poisoning Cases Admitted to a Tertiary Care Hospital in Thrissur, India

Background: Identification of regional pattern of poisoning is essential for health care authorities for proper planning on prevention programs and optimized management of antidote stockpiles. This study was designed to evaluate one-year epidemiologic pattern of acute poisoning cases treated at a tertiary care hospital in Thrissur, India. Methods: In this retrospective cross sectional study, medical records of patients with the diagnosis of acute pharmaceutical and chemical poisoning admitted to Jubilee Mission Hospital (JMH), during 1st October 2012 to 30th September 2013 were reviewed. Results: During the study period, 168 poisoned patients (59.5% women) were treated at emergency department of JMH. Married patients outnumbered unmarried ones (55.4% vs. 44.6%). The highest number of patients aged 21 to 30 years (31.5%) followed by patients with 11-20 years of age (17.3%). Most of the poisonings occurred following suicidal ideation (72.6%). Familial disharmony (14.3%) was the most common reason behind suicidal ingestions, followed by mental disorders (11.3%). Drug poisoning made up the largest proportion of poisoning-related admissions (43.5%) followed by pesticide poisoning (37.5%). Among poisoning with pharmaceutical agents, most cases were due to paracetamol (13.7%) followed by anti-psychotics and sedatives (5.4%). In pesticide poisonings, the most common classes ingested by the patients were rodenticides and organophosphates. The most common household items ingested by the patients were petroleum products. The average length of hospital stay was 5.5 days. Seven patients (4.2%) died, of which 4 were due to organophosphates followed by 2 due to carbamates and one due to rodenticide ingestion. Conclusion: Pharmaceutical and pesticide products were identified as the main cause of poisoning. This finding warrants educational programs for adequate safety measures on storage and use of these substances.

Admissions for drug-related problems at the Emergency Department of a University Hospital in the Kingdom of Saudi Arabia.

Background and Aim:Medication Errors can result in drug-related problems (DRPs). Insight into the frequency, type, and severity of DRPs could help reduce their incidence. The aim of the present study was to estimate the prevalence of admissions as a result of DRPs at the Emergency Department (ED) of a university hospital in the Kingdom of Saudi Arabia.Materials and Methods:Files of suspected cases of DRPs reporting to ED in the year 2012 were scrutinized. Suspicion arose from the hospital record system based on Diagnosis Code Numbers (ICD-9-CM, Professional 2010) and from triggers, such as some drugs, laboratory tests, and signs and symptoms pointing to DRPs.Results:Of 5574 admissions, 253 (4.5%) were DRPs and were categorized as: Overdose toxicity and side effects of drugs 50 (19.8%), drug-interactions 29 (11.5%), accidental and suicidal drug ingestions 26 (10.3%), drug abuse 18 (7.1%), drug allergy 10 (4%), super-infections 8 (3.2%), and noncompliance to treatment 112 (44.3%). About 70% of DRPs were preventable; 67 (26.5%) required hospital admission for 7-102 days and 10 (4%) died.Conclusions:Noncompliance to treatment, overdose toxicity, drug interactions, and drug abuse are important causes of hospital admissions as a result of DRPs. Awareness of prescribers to the problem and their education would help to prevent them and improve patient care.

Acute methotrexate ingestions in adults: a report of serious clinical effects and treatments.

Objective. Limited reported data have reports effects after acute ingestion of methotrexate. Treatment recommendations do not differentiate between exposure routes. Our objective was to determine the frequency of significant toxicity effects and use of therapy after methotrexate ingestion in adults. Methods. We performed a retrospective study on adult cases reported to 6 poison centers over 6 years (2000–2005) which exceed 180,000 exposures/year. Variables collected included demographics, dosages ingested, coingestions, clinical effects, and therapies with outcomes. Results. Sixty-three patients examined over the 6-year period met inclusion criteria. No patient in the series received dialysis or died. The mean dose ingested for all patients was 24 mg (range 2.5–100 mg) and the mean dose for suicidal ingestions was 47.5 mg (12.5–100 mg). The most common clinical effects were abdominal pain, oral irritation, throat irritation, nausea, dizziness, and headache. Nine patients received folinic acid and 3 patients received sodium bicarbonate. No patient developed renal failure, bone marrow suppression, seizure, or coma. No patient died or received dialysis. Conclusion. In our series of patients from 6 poison centers over six years, 63 cases of acute adult methotrexate ingestions were reported. Methotrexate toxicity from ingestion in adults was uncommon and rarely toxic.

Gastrocele Complicates the Course of Non‐operated Severe Caustic Injuries: Operative Strategies

For selected cases of severe caustic injuries, evidence favors conservative management, consisting of radiographic and clinical observation without emergency surgery. However, this approach can lead to the development of gastric distension caused by combined esophageal and antral strictures, called gastrocele. This study assessed the safety of a two-stage surgical treatment for gastrocele. Patients treated in our department between 2004 and 2010 for caustic injury who did not receive emergency surgery and subsequently developed gastrocele were retrospectively analysed. Demographic information, symptoms, and ingestion history were documented. Surgical management included partial gastrectomy and postponed esophageal stricture treatment. Outcome measures included postoperative morbidity and mortality. Eight nonoperated patients with severe caustic injury from suicidal ingestions of caustic substances were found to have developed gastrocoele. They presented with mostly endoscopic stage IIIb esophageal and gastric injuries. All patients had clinical symptoms of vomiting and abdominal tenderness at day 8 after caustic ingestion. Antrectomy and esophageal stricture treatment were performed at an average of 2 and 8 months, respectively, after caustic ingestion. There were no postoperative deaths, and the long-term survival rate was 83 %. Gastrocele should be suspected in patients with stage III gastric and esophageal injuries who have been treated by conservative management and are still vomiting more than 1 week postingestion. A two-staged surgical strategy of antrectomy followed by a postponed esophageal stricture treatment was found to be safe and effective for these patients.

Human Exposures to Pesticides in the United States

ABSTRACT Pesticides are used in most homes, businesses, and farms to control a variety of pests, including insects, weeds, fungi, rodents, and even microbial organisms. Inappropriate use of pesticides can lead to adverse effects to humans and the environment. This study provides updated information on the magnitude of adverse pesticide exposures in the United States. Data on pesticide exposure were obtained from calls to poison control centers (PCCs) reported by the American Association of Poison Control Centers. Estimates of emergency department visits, hospitalizations, and health care costs were reported by the Agency for Healthcare Research and Quality (AHRQ), and deaths from pesticide poisonings reported by the Centers for Disease Control and Prevention (CDC) WONDER (Wide-ranging Online Data for Epidemiologic Research). An average of 23 deaths occur each year with pesticides as the underlying cause of death, most due to suicidal ingestions. An average of 130,136 calls to poison control centers were reported from 2006 to 2010, with an average of 20,116 cases (17.8%) treated in health care facilities annually. AHQR reported an annual average of 7385 emergency room visits during 2006 to 2008, and 1419 annual hospitalizations during 2005 to 2009. Excluding cost from lost work time, hospital physician fees, and pesticide-induced cancers, the annual national cost associated with pesticide exposures was estimated as nearly $200 million USD based on data from emergency department visits, hospitalizations, and for deaths. Pesticide exposures remain a significant public health issue. Health care providers, cooperative extension agents, and pesticide manufactures can help prevent exposures by increasing education of parents and workers, encourage use of less toxic agents, and encourage the practice of integrated pest management.

Neonicotinoid insecticides: an emerging cause of acute pesticide poisoning

Introduction. Neonicotinoids are a relatively new class of insecticides. They exhibit agonistic effects at postsynaptic nicotinic receptors in insects and are believed to have low toxicity in humans. Methods. We conducted a retrospective analysis of all neonicotinoid exposures reported to the Taiwan National Poison Center to better understand the toxicity profile of neonicotinoid insecticides. Results. A total of 70 patients were analyzed. Most exposures involved suicidal ingestions of imidacloprid alone. Clinical manifestations of neonicotinoid insecticide toxicity bear some resemblance to those of acute nicotine poisoning. Although most exposures were of mild-to-moderate severity, eight patients developed major effects and two died. Aspiration pneumonia and respiratory failure were the main cause of severe toxicity. Conclusion. Significant toxicity of neonicotinoids can occur following large amount of oral ingestion. Poisoned patients may present with cholinergic syndrome, and judicious use of atropine seems justified. Symptomatic treatment, especially ventilator support, remains most important in clinical management.

Suicidal antidepressant overdoses: A comparative analysis by antidepressant type

The safety of antidepressants following overdose is critical because of the high risk of suicide attempts in depressed patients. This study was conducted to decrease the fatality rate of antidepressant overdoses by providing data to shift prescribing toward safer antidepressants. US poison control data for 2000-2004 were analyzed by 25 antidepressant types. Medical outcome differences were quantified using a hazard index (number of major or fatal outcomes per 1000 reported antidepressant ingestions). Of 82,802 suicidal single-agent ingestions of identifiable antidepressants approved for use in the US, cases occurred predominantly in females and peaked in teens. Fatal cases peaked at 40 to 49 years of age. Suicidal ingestions of the SSRIs, SNRIs, and other antidepressants peaked in teens, lithium in the twenties, tricyclics and tetracyclics in the thirties, and MAO inhibitors in the forties. There were 40 major or fatal outcomes per 1000 cases. Weighted by antidepressant type, the mean hazard index for the 25 antidepressants was 79 (range: 0 to 292). Amoxapine (292), maprotiline (211), and desipramine (187) had the highest hazard indices. The tricyclic antidepressants, MAO inhibitors, maprotiline, and bupropion were in the more severe half of antidepressants, ranked by hazard index. All SSRIs had low hazard indices. Hazard index and exposure frequency were inversely correlated (R = -0.423, p = 0.035), while hazard index and use of critical care were positively correlated for the 25 antidepressant types (R = 0.797, p < 0.001). Clinical effect profiles for each antidepressant type are presented. Suicidal overdose severity varied considerably by antidepressant type. Prescribing decisions should be informed by regularly updated comparative overdose severity data.

The impact of bittering agents on suicidal ingestions of antifreeze

Background. Legislation requiring the addition of bittering agents to antifreeze enables assessment of the impact on frequency, volume and severity of suicidal antifreeze ingestions. Methods. U.S. poison control data were analyzed comparing 130 suicidal antifreeze ingestions occurring in two states after enactment of bittering requirements with 3,493 cases occurring in states (or at times) where bittering was not required. Results. The frequency of suicidal antifreeze ingestions was unchanged after implementation of bittering. The volume implicated, medical outcome distribution, and use of antidotes, hemodialysis, intubation, or critical care, showed no significant difference between bittered and non-bittered groups. Bittering was not a significant contributor (positively or negatively) in predicting lethal or life-threatening medical outcomes. Conclusion. The addition of bittering agents to antifreeze for the purpose of limiting the frequency or severity of suicidal ingestions could not be justified using U.S. poison control data.

Acetaminophen safety and hepatotoxicity – where do we go from here?

Acetaminophen has been widely used for > 50 years in the treatment of pain and fever and provides for the safe and effective relief of these symptoms. In a small minority of patients, however, acetaminophen is responsible for life-threatening liver injury and accounts for up to 50% of all adult cases of acute liver failure in the US. Although approximately two-thirds of adult overdoses are associated with suicide attempts, many are inadvertent, often due to the use of multiple acetaminophen formulations over many days. Additionally, some individuals appear to experience acetaminophen toxicity at ‘therapeutic’ doses of < 4 g/day, for reasons unknown. In pediatric populations, the overwhelming majority of acetaminophen overdoses are due to unintentional overdoses, except for the predominance of suicidal ingestions in the teenage population. This article seeks to review the mechanism and metabolism of acetaminophen and the features of toxicity in adults, pediatric and special populations. Additionally, expert opinion is presented herein to aid in reducing the frequency and severity of liver injury from acetaminophen.

Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status

Is universal screening of acetaminophen (APAP) and salicylate (SAL) necessary in patients with a suicidal ingestion or an altered mental status and suspected ingestion? This descriptive, retrospective chart review in an emergency department in a large urban county hospital examined all patients who presented with a history of suicidal ingestion or an altered mental status with a strong suspicion of ingestion from January 1992 through October 1993. APAP and SAL serum levels were measured in 1,820 patients, and charts of patients with APAP serum levels of >1 μg/mL or SAL serum levels of >1 mg/dL were reviewed. The patient's history of ingesting APAP or SAL was recorded, as well as the clinician's interpretation of that level. Sixteen charts were not available. APAP levels of >1 μg/mL were found in 175 (9.6%) patients, 120 (6.5%) of whom were APAP history-positive and 55 (3%) APAP history-negative. None of the APAP history-negative group required therapy with N-acetylcysteine. Eight (0.3%) of the APAP history-negative group had potentially toxic levels of >50 μg/mL. SAL levels of >1 mg/dL were found in 155 (8.5%) patients, 44 (2.5%) of whom were SAL history-positive and 111 (6%) SAL history-negative. Three patients were SAL history-negative but had a significant chronic SAL intoxication. All these patients presented with an altered mental status and had an anion gap of >20 mEq/L. Universal screening found that 0.3% of suicidal ingestions had a potentially toxic APAP intoxication not suggested by history. This incidence of infrequent but potentially life:threatening overdose should prompt clinicians to screen all of their patients with a suspected ingestion. Salicylate screening found that 0.16% of suicidal ingestions had a toxic SAL intoxication not suggested by history, although such intoxication should be suggested by an elevated anion gap and an altered mental status. Since this less severe intoxication is less frequent and usually suggested by commonly obtained laboratory data, universal screening is not indicated, but a more selective approach to screening could be taken.