Toxicological Intensive Care Unit Research Articles

The Predominant Microorganism During the COVID-19 Pandemic in the Toxicological Intensive Care Unit

Background: Although many studies have investigated the prevalence of hospital infections during the COVID-19 pandemic, the results are still challenging. Methods: In this routine data-based study, the medical records of 2213 poisoned patients admitted to the Toxicological Intensive Care Unit (TICU) of the Loghman Hakim Hospital from 2018 to 2022 were retrospectively reviewed. After the implementation of exclusion criteria, 220 patients were separated into the control and case groups. The information of the patients was extracted based on a preplanned form and analyzed with SPSS software, version 26. Results: Unlike the prepandemic period, when Staphylococcus aureus was the predominant pathogen, during the pandemic period, the predominant pathogen in tracheal culture was Acinetobacter spp., which increased from 11.3% in the prepandemic period to 14.9% during the COVID-19 pandemic. Moreover, coagulase-negative staphylococci in blood culture and Enterobacter spp. in tracheal culture both significantly decreased during the COVID-19 pandemic (P=0.035 and P=0.05, respectively), while Streptococcus viridans in the tracheal culture and Enterococcus in the urine culture both significantly increased (P=0.013). Conclusion: Although in the prepandemic period, S. aureus was usually the most common pathogen among poisoned patients in TICU, the predominant pathogen changed to Acinetobacter spp. during the COVID-19 pandemic period. Some hospital-acquired infections decreased and others increased in a different way between the two groups.

Evaluation of Emergency Service Admissions for Planning the Number of Intensive Care Beds in Hospitals

A significant portion of intensive care unit (ICU) admissions occur through the emergency department (ED). Since there are insufficient ICU beds, critically ill patients may have to be monitored and treated in ED for an extended period. In this study, we aimed to show the importance of the emergency department intensive care unit (EDICU) and that ED applications should be taken into account in determining the number of intensive care unit (ICU) beds in hospitals by analyzing the patients hospitalized in intensive care units from the ED. In this retrospective descriptive study, patients over 18 who applied to the ED of a tertiary hospital between July 1, 2018, and July 1, 2019, and were deemed suitable for ICU admission were included. In descriptive statistics, percentages were used in categorical data, and mean, and standard deviation were used in numerical data. Chi-square test was applied for categorical variables. Since the distribution within the groups was normal in the analysis of continuous variables, one-way analysis of variance (ANOVA) was used when more than two groups were compared. The student's t-test was used when two groups were compared. Of the 2783 patients who applied to the ED and were suitable for admission to the ICU, 1341 (48.2%) were admitted to the second-level ICU, and 1442 (51.8%) were admitted to the third-level ICU. 1140 (40.96%) patients were hospitalized in the EDICU and toxicology ICU within the ED. These units played an important role in facilitating the ED operation and reducing crowding. Patients admitted to the ICU were divided into three groups based on their length of stay. Of the patients, 2312 (%83.1) were hospitalized in the first 6 hours, 337 (%12.1) in 6-12 hours, and 205 (7.36%) in more than 12 hours. It was observed that the mortality rate increased significantly when hospitalization in the ICU was delayed (P=0.014). ED admissions should be considered when determining the number of ICU beds and step levels of hospitals. In addition, the presence of EDICU in tertiary care hospitals relieves the density of the emergency department and indirectly reduces the mortality rate.

Association of serum prolactin levels and thyroid hormones with poisoned patient outcome

Background: In acute and chronic phases of severe diseases, endocrine changes occur. Some hormones, such as prolactin (PRL) and thyroid hormones, were considered predictors of ICU patients' outcomes. The present study evaluates thyroid hormone profile, serum PRL level, and their relationship with ICU poisoned patients' mortality rate.Methods: This study included 140 inpatients in the Toxicology Intensive Care Unit (TICU) who enrolled in a prospective study of a single center and observational. After admission to the ICU, the researchers collected venous blood samples from all patients directly. Concurrently, the APACHE II score was calculated. The collected samples analysis was performed based on the entire triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH), and PRL level.Results: One hundred and forty subjects were studied, of which 109 (75.85%) were male with a mean age of 34.17 ± 14.01. One hundred and eighteen patients were survivors with a mean age of 33.29 ±13.76. In contrast, 22 patients with a mean age of 38.91 ±14.69 died. The model of PRL combined with APACHE II score (OR 1.17, 95% CI 1.06 to 1.28, P-value =0.001) was the best model for predicting post-ICU mortality in our study.Conclusions: This study’s results are consistent with the previous research, indicating a higher incidence of thyroid and PRL hormone changes in patients hospitalized in the ICU. It can be concluded that the presence of PRL based on the APACHE II score can lead us to be more precise in predicting the outcome of poisoning in hospitalized patients.

Plasma procalcitonin may be an early predictor of liver injury in acetaminophen poisoning: A prospective cohort study.

Background and AimsAcetaminophen is a common cause of poisoning and liver injury worldwide; however, patient stratification is suboptimal. We aimed to assess the contribution of admission plasma procalcitonin concentration (PCT) to better identify acetaminophen‐poisoned patients likely to develop liver injury.MethodsWe conducted a prospective observational cohort study including all acetaminophen‐poisoned patients requiring N‐acetylcysteine admitted in a toxicological intensive care unit between 2012 and 2017. Multivariate analysis was performed using a Cox regression model to investigate factors associated with liver injury, defined as an increase in alanine aminotransferase (ALT) >100 IU/L.ResultsOne hundred seventeen patients (age, 32 years (21–53), median [25th–75th percentiles]) were included after self‐ingesting 16 g (9–30) acetaminophen and received N‐acetylcysteine infusion administered within a median 6 h‐delay (4–12) from exposure. Co‐ingestions were reported in 77% of patients. Rumack–Matthew nomogram was non‐interpretable in 47% cases. Liver injury occurred in 38 patients (32%) with a median peak ALT of 2020 IU/L (577–4248). In liver injury patients, admission PCT was significantly increased in comparison to patients without liver injury (21.5 ng/ml (3.2–44.9) versus 0.1 ng/ml (0–0.4), respectively, p < 0.01). The increase in PCT preceded the increase in ALT by 33 h (10–74). In a multivariate analysis, PCT > 1 ng/ml was significantly associated with liver injury (hazard ratio, 7.2 [95% confidence interval, 2.3–22.6; p < 0.001]). PCT (area under the receiver‐operating characteristics curve, 0.91 [95%CI: 0.84–0.97]) predicted liver injury with sensitivity, specificity, negative, and positive predictive values of 0.92, 0.84, 0.96, and 0.73, respectively.ConclusionPCT on admission is associated with liver injury in acetaminophen poisoning. PCT might be used as a predictive tool of liver injury to improve clinical decision‐making.

Sepsis Criteria and Revision in Toxicological Intensive Care Unit

Background: Sepsis is one of the significant causes of mortality in hospitalized patients. This cross-sectional study was performed to determine the frequency of positive blood culture and assess sepsis criteria based on Third International Consensus Definitions (related to Sequential Organ Failure Assessment score) and clinical and paraclinical findings (i.e., on-admission leukocytosis, increased lactate level, and fever) in poisoned patients admitted to the Toxicological Intensive Care Unit (TICU). Methods: Medical records of a total of 2000 poisoned patients admitted to the TICU of Loghman Hakim Hospital from 2016 to 2018 were assessed. Among them, 189 cases (9.45%) with suspected sepsis were considered eligible to be enrolled in the study. Results: Of 189 cases, 146 (77.24%) had possible signs and symptoms of sepsis as well as SOFA score higher than two with positive blood culture in 81 cases (55%). The Mean±SD serum level of lactate was 25.97±16.32 on admission. The most common pathogen detected in blood culture was coagulase-negative Staphylococci in 35 (24.0%) out of 146 cases. Glasgow Coma Scale (GCS) less than 12, age older than 50 years, and bilirubin more than 1.2 mg/dL were found as independent predictors of sepsis on multivariate analysis. Conclusion: Based on our findings, it is proposed that the sepsis definition should not be restricted to the guidelines. The patients’ poisoning background and presence of many confounding factors, including poisoning-induced on-admission increased lactate levels, leukocytosis, and disturbed arterial blood gas provide a critical decision-making situation to confirm sepsis according to guidelines.

Risk Factors of Hospital-acquired Thrombocytopenia in Toxicological Intensive Care Unit

Background: Platelet count is a readily available biomarker predicting disease severity and risk of mortality in the intensive care units (ICU). This study aims to describe the frequency, to assess the risk factors, and to evaluate the impact of thrombocytopenia on patient outcomes in a Toxicological ICU (TICU).Methods: In this prospective observational Cohort study, we enrolled 184 patients admitted to our TICU from October 1st, 2019, to August 23rd, 2020. Mild/moderate and severe thrombocytopenia were defined as at least one platelet counts less than 150×103/μL and 50×103/μL during the ICU stay, respectively.Results: Of 184 enrolled patients, 45.7% had mild to moderate thrombocytopenia and 5.4% had severe thrombocytopenia. Old age (OR: 1.042, 95%CI: 1.01-1.075, P=0.01), male gender (OR: 4.348, 95%CI: 1.33-14.22, P=0.015), increased international normalized ratio (INR) levels (OR: 3.72, 95%CI: 1.15-112, P=0.028), and administration of some medications including heparin (OR: 3.553, 95%CI: 1.11-11.36, P=0.033), antihypertensive drugs (OR: 2.841, 95%CI: 1.081-7.471, P=0.034), linezolid (OR: 13.46, 95%CI: 4.75-38.13, P&lt;0.001), erythromycin (OR: 19.58, 95%CI: 3.23-118.86, P=0.001), and colistin (OR: 10.29, 95% CI 1.44-73.69, P=0.02) were the risk factors of hospital-acquired thrombocytopenia. The outcomes of patients with normal platelet count were significantly better than those who developed thrombocytopenia (P&lt;0.001).Conclusion: We found that thrombocytopenia could develop in almost 50% of patients admitted to TICU, which is associated with poor prognosis. Additionally, the platelet counts should be closely monitored to administer some medications (heparin, antihypertensive drug, and linezolid), especially in old patients.

Outbreak of hypervirulent Klebsiella pneumoniae harbouring blaVIM-2 among mechanically-ventilated drug-poisoning patients with high mortality rate in Iran.

Carbapenem-resistant Klebsiella pneumoniae infections are associated with increased rates of treatment failure and death. Several studies have reported isolates with a combined hypervirulent and antimicrobial-resistant phenotype. In this study, the molecular characteristics of hypervirulent K. pneumoniae (hvKP) isolated from mechanically-ventilated patients admitted to a toxicological intensive care unit (ICU) in Tehran, Iran, were examined. String test, antimicrobial susceptibility testing, virulence factors analysis and plasmid replicon typing were performed. The clonal relatedness of the isolates was analysed by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). hvKP accounted for 9.4% (5/53) of K. pneumoniae isolated from ventilator-associated pneumonia among patients admitted to the ICU with acute drug poisoning. The mortality rate was 7.5% (4/53) among K. pneumoniae-infected patients. All fatal K. pneumoniae were hvKP isolates, were resistant to imipenem and harboured an aacA7, blaVIM-2 and dhfrI cassette arrangement in a class 1 integron. The isolates were shown to be ST23 (Pasteur scheme) and exhibited similar PFGE patterns. Plasmid analysis revealed a class 1 integron harbouring blaVIM-2 located on an ca. 45-kb IncN plasmid. Here we describe the emergence of VIM-2-producing hvKP serotype K1/ST23 in an outbreak with high mortality in a hospital toxicological ICU. It appears that we must alert and prepare the hospital's surveillance system for the appearance, expansion and clinical importance of new K. pneumoniae clones associated with high antimicrobial resistance and robust virulence capabilities.

Structural Analysis of Patients with Severe Acute Alcoholic Poisoning Admitted to the Toxicological Intensive Care Unit in 2012—2016

Based on the analysis of 17,735 patients, an increase in the incidence of alcohol intoxication was found. The most vulnerable groups include adolescents aged 13—17 and women of reproductive age. Increased ethanol concentration in the blood in patients with combined opioid poisoning does not always worsen the severity of the coma.

Prognostic value of cortisol and thyroid function tests in poisoned patients admitted to toxicology ICU

Prognostic value of cortisol and thyroid function tests (TFTs) has previously been evaluated in medical ICUs. We aimed to evaluate prognostic efficacy of cortisol and TFTs in critically ill poisoned patients admitted to toxicology intensive care unit (ICU). In a prospective study of consecutively enrolled subjects admitted to the toxicology ICU, lab analyses included TFTs (total T3 and T4 as well as TSH) and cortisol levels drawn between 8 am-10 am during period of the first 24 hours post-ingestion/exposure. Simplified Acute Physiology Score II (SAPS II) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were recorded. All scores were compared to detect the best prognostic factor. Type of poisoning was also included. In 200 patients evaluated, 129 were male and mean age was 31 years. In general, SAPS II, T4, and cortisol could prognosticate death. After regression analysis, only cortisol had such efficacy (P=0.04; OR=1.06; 95%CI=1.05-1.08; cut-off=42 µg/dL; sensitivity=70%; specificity=82%). Between aluminium phosphide (ALP)- and non ALP-poisoned patients, level of consciousness, mean arterial pressure, and cortisol level could prognosticate death in ALP poisoning (all Ps<0.001 in both uni and multivariate analyses). Median (interquartile range; IQR) GCS was 7 (6, 10) and 15 (8, 15) in non-ALP and ALP-poisoned patients (P<0.003). SAPS II and APACHE II could not prognosticate death at all. Cortisol best prognosticated outcomes for subjects admitted to the toxicology ICU. Its level is higher in ALP-poisoned patients probably due to the higher stress while they remain conscious till the final stages of toxicity and are aware of deterioration of their clinical condition or may be due to their significantly lower blood pressures.

The Overestimation of Vancomycin-Associated Nephrotoxicity: The Effect of Rhabdomyolysis and Nephrotoxicants at a Referral Poison Center, Tehran, Iran

Background: Vancomycin is a first-line therapy for infections due to Methicillin-Resistant Staphylococcus aureus (MRSA). Nephro- toxicity subsequent to vancomycin administration has been discussed in many previous researches. Objectives: The present study aimed to determine the nephrotoxic potential of vancomycin among ventilator-associated pneumo- nia (VAP) poisoned patients after restricting the eect of risk factors such as rhabdomyolysis and other nephrotoxicants. Methods: This two-year cross-sectional retrospective study was conducted among VAP patients, who received vancomycin at the toxicological intensive care unit of Loghman Hakim hospital of Iran from 2013 to 2015. Baseline and laboratory data of eligible patients were extracted from medical records. Nephrotoxicity was defined based on the risk, injury, failure, loss, and end state (RIFLE) criteria. Results: One hundred and fifty-four VAP patients' profiles were reviewed, of whom 110 were eligible. The median age was 33.50 (12 to 94) years and 73.6% were male. The median time interval between poisoning and admission was four (0 to 48) hours. The most common cause of poisoning was opioids (33%). Ten patients developed new-onset nephrotoxic event, including four in risk, four in injury and two in failure class. Median vancomycin treatment time until a nephrotoxic event was three days. There was no significant dierence between those who developed nephrotoxicity compared to those who did not except median vancomycin trough level (14.5 in nephrotoxic versus 13.7 in non-nephrotoxic, P = 0.007). Conclusions: The result of this study indicated that nephrotoxicity rate among patients treated with vancomycin is under the influence of the poisoning by nephrotoxicants. Higher vancomycin trough level was associated with increasing nephrotoxicity rate.

Survey on Hypothermia and Hyperthermia in Poisoned Patients in a Unique Referral Hospital, Tehran, Iran.

BackgroundBody temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia.ObjectivesOur previous study’s findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins.Materials and MethodsA cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16.ResultsData were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively.ConclusionsBody temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

Central Nervous System Depressants Poisoning and Ventilator Associated Pneumonia: An Underrated Risk Factor at the Toxicological Intensive Care Unit.

Background:Ventilator-Associated Pneumonia (VAP) is the main cause of nosocomial infection at intensive care units (ICUs), which causes high mortality and morbidity.Objectives:The objective of the present survey was to identify the VAP risk and prognostic factors among poisoned patients, who were admitted to the toxicological ICU (TICU), especially central nervous system (CNS) depressants due to their prevalence and importance.Patients and Methods:A case-control study was conducted at the Loghman Hakim hospital between March 2013 and March 2014. Among 300 poisoned patients with mechanical ventilator ≥ 48 hours, 150 patients, who had developed microbiologically-confirmed VAP were considered as the VAP group and 150 without VAP were defined as the control group. The following data were collected; age, gender, type of poisoning, glasgow coma score, Acute physiology and chronic health evaluation (APACHE) II score, length of hospital stay, previous antibiotic use, microbial culture of the trachea, body temperature, leukocyte count, and patients’ outcome. Based on the type of poisoning, patients were divided into three groups including: opioid, CNS depressants and others. All data were expressed as means (SD) for continuous variables and frequencies for categorical variables. Logistic regression was used to determine the relationship between risk factors and VAP.Results:The mean age of the patients was 33.9 ± 14.3 years. The probable VAP incidence and mortality were 22% and 18.6%, respectively. The rate of CNS depressant versus opioid use (odds ratio, 3.74; P < 0.027), APACHE II (odds ratio, 1.28; P < 0.000) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent risk factors for VAP. While, the APACHE II score (odds ratio, 1.12; P < 0.044) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent predictors of VAP mortality among these patients. The most common microorganisms in VAP cases were Methicillin-Resistant Staphylococcus aureus (MRSA) and Acinetobacter sp. (56.7% and 12.7%, respectively).Conclusions:Central nervous system depressant was an important risk factor for VAP among poisoned patients. Hypoventilation due to CNS depression can lead to VAP. The APACHE II and length of hospital stay were shown as independent predictors of VAP and mortality among these patients.

Neurological Sequels and Their Causes in Patients Hospitalized in the Toxicology Intensive Care Unit of Bahraloo Hospital, Tehran, Iran

Background: The occurrence of neurologic complications in the intensive care units (ICUs) is one of the major risks in management of patients. These sequels may be caused by structural or metabolic disorders. The same phenomenon can be seen in the toxicology ICUs, although the toxicological effects of drugs and poisons may also cause the neurological complications. Objectives: This study aimed to determine the frequency of neurological sequels and their causes in patients hospitalized in the toxicology ICUs. Patients and Methods: In this descriptive study, the data of patients admitted in toxicology ICU of Baharloo Hospital, Tehran, Iran, were investigated during a 2-year period (2010 ‒ 2011) and the patients with neurological sequels, based on neurological examination or brain computed tomography (CT) scan findings, were included. Data recorded in questionnaires were analyzed by means of SPSS software, with a significance level at P < 0.05. Results: Out of 1571 patients admitted in toxicology ICU during this period, 56 patients (3.56%), with the mean ± SD age of 36 ± 13.01 years, were included. The most common finding in neurological examination was the Babinski sign (67.9%). Ischemic encephalopathy with brain edema was the most common finding on the brain CT scans of these patients (33.9%). The mortality rate was 58.9% (33 out of 56). Thirteen patients (23.2%) were discharged with vegetative state. The most common cause of neurological sequel, in this study, was hypoxia (64.3%) Conclusions: This study, for the first time in Iran, investigated the frequency and cause of neurological sequels in toxicology ICUs. The findings can improve the prophylaxis and diagnostic programs for the patients in this field.

Retrospective Investigation of Intoxication Cases That Require Mechanical Ventilation

Aim: Intoxication cases are hospitalized in intensive care units not for intervention but for close observation and monitoring. Endotracheal intubation and mechanical ventilation may sometimes be required. Materials and Methods: In total, 2118 intoxication cases have been hospitalized in our toxicology intensive care unit sequentially between March 2011 and March 2013. Of these patients, 23 cases that required endotracheal intubation and mechanical ventilation were included in this retrospective study; data was obtained by screening the patient files. Results: Twenty-three cases (1.1%) required mechanical ventilation, and only 7 cases (0.33%) died. The most common reasons for requiring mechanical ventilation were unconsciousness and respiratory failure. During hospitalization, they were attached to mechanical ventilator for a mean of 4.17 days. While the mean duration of mechanical ventilation of patients with organophosphate intoxication was 6.92 days, the other non-organophosphate intoxication group was 1.18 days. There is significant statistical difference between two groups (p<0.01). We compared the organophosphate intoxication group with other non-organophosphate intoxication group for Glasgow Coma Scale, arterial blood gas, C-reactive protein, and pro-calcitonin and troponin levels at initial admission. Pro-calcitonin levels were significantly high in the organophosphate group. Conclusion: Intoxication cases that require mechanical ventilation can differ from classical intoxication epidemiology for age and sex. Organophosphate intoxications are one of the intoxication types that require mechanical ventilation and have the highest mortality. (JAEM 2015; 14: 2-7)

Intoxication due to Papaver rhoeas (Corn Poppy): Five Case Reports.

Introduction. In this paper, we aimed to present five Papaver rhoeas intoxication cases, which is very rare in the literature. Case 1. A 35-year-old female patient was admitted to our emergency room with the complaints of nausea, restlessness, and dyspnea developing 3 hours after eating Papaver rhoeas. On physical examination, her general condition was moderate; she was conscious and the vital findings were normal. The pupils were myotic. She was transferred to the toxicology intensive care unit as she experienced a generalized tonic clonic seizure lasting for three minutes. Case 2. A 41-year-old female patient was brought to our emergency room by 112 ambulance as she had contractions in her arms and legs, unconsciousness, and foam coming from her mouth two hours after Papaver rhoeas ingestion. On physical examination, she was confused, the pupils were myotic, and she was tachycardic. Arterial blood gases analysis revealed lactic acidosis. Case 3. A 38-year-old female patient was admitted to our emergency room with complaints of nausea and vomiting two hours after ingestion of Papaver rhoeas. Her physical examination and tests were normal. Case 4. A 34-year-old male patient was admitted to our emergency room with complaints of numbness and loss of power in his arms and legs one hour after Papaver rhoeas ingestion. He was hospitalized at the toxicology intensive care unit for follow-up and treatment. Dyspnea and bradycardia developed on the follow-up. The oxygen saturation without oxygen support was 90%. ECG revealed sinus bradycardia. The cardiac enzymes did not increase. Case 5. A 42-year-old female patient was brought to our emergency room by 112 ambulance with contractions in her arms and legs and unconsciousness two hours after Papaver rhoeas ingestion. On her physical examination, she was confused and the pupils were myotic. Arterial blood gases analysis revealed lactic acidosis. Conclusion. All patients were followed up for a few days and then discharged from the hospital with recovery. Unconscious consumption of Papaver rhoeas leads to a clinical condition resembling morphine intoxication, CNS depression, and epileptic seizures.

Coexistence of prion disease and benzodiazepine intoxication – Case report

Case report A 26 year-old female presented for deliberate ingestion of 200 mg benzodiazepine associated with 500 mg metoprololum and she was admitted in our Toxicology Intensive Care Unit one hour following the ingestion. Clinical evaluation showed a conscious patient, mildly agitated, with stable vital signs and unusual hyperosmia. She also had a history of about 10 months of psychiatric symptoms like mood disorders, memory loss and insomnia treated as depression. The interview emphasized multiple study visits in the United Kingdom and occasional intravenous abuse and substances dependence. Her urine benzodiazepine level was positive according to fluorescence polarization immunoassay method and the toxicological screening was negative for other drugs. Ten hours after ingestion she developed impressive opisthotonus and deep coma that required mechanical ventilation. Regarding the high suspicion of tetanus due to her intravenous drug administration, the infectious disease evaluation indicated anti-tetanus serum therapy. Brain tomography (CT) was in normal ranges. The cerebrospinal fluid (CSF) had a clear aspect and was normotensive, without biochemical abnormalities. After 48 hours of nonresponsive evolution a new brain CT scan identified massive cerebral edema. Brain magnetic resonance imaging (MRI) showed hyperintensities on T2 sequences in basal ganglia bilaterally along with diffusion restriction in the same areas, being suggestive of progressive multifocal leukoencephalopathy. Considering these aspects we performed PCR for the detection of JC virus, which was negative. A prion disease was highly suspected and 14-3-3 protein immunoassay on CSF was positive. After 2 months spent in the Critical Care Unit, the patient died through multiple organ dysfunctions.

QT Dispersion and Prognostication of the Outcome in Acute Cardiotoxicities: A Comparison with SAPS II and APACHE II Scoring Systems

We aimed to evaluate the efficacy of QT dispersion (QTD) in determining the outcome of the patients poisoned by cardiotoxic medications and toxins. Patients who referred to our emergency department (ED) due to acute toxicity with any cardiotoxic medication or toxin and were admitted to medical toxicology intensive care unit (MTICU) were enrolled into the study. A questionnaire containing the demographic characteristics, vital signs, laboratory tests, electrocardiographic (ECG) parameters of the first ECG taken on MTICU or ED admission, simplified acute physiology score (SAPS), and acute physiology and chronic health evaluation (APACHE) score was filled for every single patient. QTD was manually calculated. The patients were divided into two groups of survivors and non-survivors and compared. Although QTD was not significantly different between the survivors and non-survivors (P = 0.8), SAPS II and APACHE II score were so. SAPS and APACHE had the highest sensitivity and specificity in determining the patients' mortality, respectively. SAPS had the highest sensitivity, and QTD had the highest specificity in predicting the later development of the complications. SAPS II and APACHE II scoring systems are the best systems for prognostication of death in patients with acute cardiotoxic medication-induced poisonings. QTD can be successfully used for the prediction of complications.

Polypharmacy in the elderly from the clinical toxicologist perspective

Polypharmacy is closely associated with multimorbidity in the elderly and can lead to problems and drug interactions. This study assessed polypharmacy in the elderly, tracking inquiries to the Poison Information Centre Nuremberg (PICN) and patients needing toxicological intensive care therapy. From 2006-2009, all PICN inquiries involving individuals > 70years were tracked, as were cases at the Toxicological Intensive Care Unit (T-ICU) regarding adverse drug reactions (ADRs) and drug poisoning. Of 11,683 PICN calls about pharmaceuticals, 175 (1.5%) were from people > 70years; 156 (4.8%) of 3,272 T-ICU patients were > 70years. Calls about psychopharmaceuticals (46.9%) and analgesics (25.7%) were most frequent. Among the T-ICU patients, psychopharmaceuticals like sedatives and hypnotics were frequently involved (20.5%), as were tricyclic antidepressants (17.9%) and analgesics (29.5%). Ethanol was co-ingested by 18.3%. Population-specific poison prevention strategies are needed to reduce toxic exposures. Such strategies could include pharmacist intervention, improved prescriber communication and education regarding the geriatric population, and computerized drug databases.

Early laryngeal injury and complications because of endotracheal intubation in acutely poisoned patients: a prospective observational study

Objective. Tracheal intubation may represent a life-saving supportive measure in many acutely poisoned patients. Although considered as a safe procedure, intubation may rapidly damage laryngeal mucosa. The incidence and nature of short-duration intubation-associated laryngeal injuries are unknown in the population of poisoned patients. Methods. We designed a prospective clinical investigation to study intubation-related laryngeal complications in poisonings. All consecutive intubated poisoned patients admitted over a 20-month period in our toxicological intensive care unit in a teaching hospital were included in this study. Daily clinical observation and laryngeal fiberscopic evaluation were performed to assess intubation-related laryngeal complications. Results. We included 266 consecutive poisoned patients who had been intubated [116M/150F; age 41 years (31–53); median (25–75% percentiles); simplified acute physiology score II 43 (32–51); intubation time 24 h (13–52)]. Intubation was mainly performed at the scene (69%) and depended on the level of coma (89%). Complications included postextubation laryngeal dyspnea (9%) requiring mandatory reintubation (2%). Laryngoscopy was performed in 209 patients (79%) within 24 h after extubation. Eighty percent of patients presented significant initial laryngeal lesions. Stepwise logistic regression showed that two variables were predictive of injuries: female gender (odds ratio: 2.6; 95% confidence interval: 1.3–5.3) and intubation time ≥72 h (odds ratio: 6.4; confidence interval: 1.5–27.6). Overall, injuries were independent of age, severity of illness, coma level, vital signs, intoxicants, and intubation modalities. The most severe injuries were significantly associated with intubation time (p < 0.001) and simplified acute physiology score II (p = 0.04). Within 24 h following extubation, persistent dysphonia (p < 0.0001), dysphagia (p < 0.0001), or pharyngeal pain (p = 0.02) were predictive of laryngeal injury. Conclusions. Despite short-duration intubation, poisoned patients are at high risk of initial laryngeal injury.