Treatment Of Poisoned Patients Research Articles

Study on the trend of nutritional biochemical indexes in patients with paraquat poisoning

Objective To observe the nutritional biochemical indicators of paraquat poisoning patients, analyze and compare the nutritional status of patients and understand the changing trend of each indicator. Methods A total of 104 patients with acute paraquat poisoning who were admitted to the emergency department of the Second Hospital of Hebei Medical University from December 2015 to December 2017 were enrolled, and divided into the cure group (patients who survived >30 days) and the death group. Nutritional biochemical indicators including serum protein (ALB, PA, TP) and serum lipids (TCh, TG, LDL) were selected for dynamic observation. The observation time points were set as follows: immediate treatment of poisoned patients (day 1 on admission), on day 4, 7, 10, 13 and 16 after admission, and on day 30 after follow-up. The nutritional biochemical indicators of the two groups on day 1 and 4 were statistically analyzed and compared by t test. The nutritional status of the patients in the cure group was analyzed, and the Repeated Measures Anova was performed to understand the trend of each indicator over time. Results In the cure group, the TP level decreased from (73.34±5.75)g/L on day 1 to (51.95±6.05)g/L on day 4, t=20.34, P<0.01; and the TCh level decreased from (4.37±0.98)mmol/L on day 1 to (3.03±1.01)mmol/L on day 4, t=7.56, P<0.01. In the death group, the TP level decreased from (72.25±8.80)g/L on day 1 to (49.07±5.48)g/L on day 4, t=12.38, P<0.01, and the TCh level decreased from (4.38±0.88)mmol/L on day 1 to (2.51±1.07) mmol/L on day 4, t=7.94, P<0.01. Compared with the cure group, serum levels of ALB, TP and TCh in the death group decreased greater from day 1 to day 4 (all P<0.05). In addition, dynamic observation of the indicators in the cure group within 16 days after admission showed that, after treatment, the levels of ALB and TP recovered slowly and were still lower than normal . While the levels of PA and lipid rose rapidly after 10 days of admission. Conclusions Paraquat poisoning seriously affects the nutritional status of patients, and the serum protein levels decline significantly and can not be recovered easily. Therefore, sufficient attention should be paid to the treatment, and timely and appropriate nutritional support should be provided. Key words: Paraquat poisoning; Nutritional status; Protein; Lipids

Intravenous lipid emulsion therapy in calcium channel blocker and beta-blocker poisoning

Background Intravenous lipid emulsion (ILE) therapy is recommended for the treatment of poisoned patients with cardiovascular collapse secondary to lipophilic drug poisoning, e.g., beta blockers (BB) and calcium channel blockers (CCB).

Case reports of extracorporeal treatments in poisoning: historical trends.

There are currently limited data on the trends in case reporting of poisoned patients undergoing enhanced elimination with an extracorporeal treatment (ECTR). The present manuscript specifically reviews the longitudinal trends of reports according to technique, poison, and country of publication. To identify case reports of ECTR use in the management of poisoning, multiple databases were searched. There were no limitations on language and year of publication. All case reports describing individual patients undergoing ECTR with the intent of enhancing the elimination of a poison were included in the analysis. Since 1913, 2908 reports were identified. There were an increasing number of published reports with time except for a slight decrease during the 1990s. Hemodialysis was by far the most commonly used ECTR in poisoning, followed by hemoperfusion. The number of reported peritoneal dialyses decreased steadily since 1980s. Methanol, ethylene glycol, lithium, and salicylates remained among the most commonly reported poisons in every decade. The large majority of publications originated from either Europe or North America, and more specifically from the United States, Germany, the United Kingdom, and China. Despite the emerging apparition of new techniques, hemodialysis remains to this day the favoured ECTR in the treatment of poisoned patients.

Stress ulcer prophylaxis in critically ill poisoned patients

Letter to the editor Management of critically ill patients in the intensive care unit (ICU) is an important issue in medicine [1,2]. These patients may have clinically important bleeding, which is associated with an increased mortality rate. Mechanical ventilation may also increase the risk of bleeding in the upper gastrointestinal system. Sucralfate, histamine-2receptor antagonists, and proton pumps inhibitors (PPIs) are widely used for stress ulcer prophylaxis in critically ill adults [3]. Available data shows that PPIs are safe and efficacious for increasing intragastric pH in critically ill patients [4]. Since the superiority of the PPIs over histamine-2-receptor antagonists or sucralfate is not yet proved, they should only be used as an alternative to these agents. Poisoned patients may need to be admitted in ICU because of their critical condition. Poisoning with fatal agents such as aluminum phosphide, paraquat, organophosphate, or massive pharmaceutical drug overdoses usually needs ICU care and sometimes mechanical ventilation [5,6]. A question is therefore arisen: which of these agents is better to be used for ulcer prophylaxis in poisoned patients? Affection of the cytochrome P450 (CYP) by toxins or pharmaceutical drugs is an important point in answering this question. Generally, most of the toxicants have a liver metabolism [7]. The number of the known P450 enzyme inducers or inhibitors exceeds 1000, but P450 3A4 is the most frequent CYP in the human liver and is known to metabolize the majority of drugs whose biotransformation is known [8]. So, inhibition or induction of CYP may increase or decrease the final metabolites of the toxicants and may have a value in the treatment of poisoned patients in the ICU.

The availability of toxicological analyses for poisoned patients in Ireland

Background. The National Poisons Information Service and the Association of Clinical Biochemists in the United Kingdom published guidelines on laboratory analyses for poisoned patients in 2002. In 2003, U.S. guidelines were prepared by an expert panel of analytical toxicologists and emergency department (ED) physicians. Some professional associations in different countries quote these guidelines but there are no data to support adherence to these recommendations in the medical literature. Objective. To analyze the availability of 15 quantitative laboratory analyses, specifically relating to the management of the poisoned patient, in Ireland. Methods. A questionnaire relating to the provision of toxicological analyses was compiled and distributed to 39 acute care hospital laboratories in Ireland. The availability of 15 quantitative analyses (carbamazepine, carboxyhemoglobin, digoxin, ethanol, ethylene glycol, iron, lithium, methemoglobin, methanol, paracetamol, paraquat, phenobarbital, salicylate, theophylline, and valproic acid), specifically relating to the management of the poisoned patient, was analyzed. The reporting units for these analyses were also collected. The acute care hospitals were sorted into groups according to their number of ED attendances: A) <20,000, B) 20,000–30,000, C) 30,000–40,000, D) 40,000–50,000, and E) >50,000 based on ED activity data for 2008. The median number of assays provided by each hospital group was calculated. Results. The response rate was 100%, allowing complete national data to be ascertained. Hospital laboratories provided a more comprehensive testing service when ED attendances exceeded 30,000 per annum. Sixteen hospital laboratories (41.0%) performed at least 10 of the 15 toxicological investigations. The most widely available assay was paracetamol (74.4%, n = 29) and the least widely available assays were methanol, ethylene glycol, and paraquat (2.6%, n = 1). Only one hospital laboratory provided all 15 analyses. Hospital laboratories in groups A and B carried out a median number of 3/15 assays (range 0–8) and 4/15 assays (range 0–10), respectively. Hospital laboratories where ED attendances exceeded 30,000 per annum carried out a median number of 11/15 toxicological assays (range 1–15). There was a lack of consistency in the reporting units with both molar and mass units used. Conclusion. There is wide availability of toxicological analyses among hospital laboratories in Ireland. Most analyses were provided with 24-h availability. Hospitals with ED attendances in excess of 30,000 provided a more comprehensive laboratory service with respect to the number of analyses performed. The lack of consistency with units used by Irish hospital laboratories could present challenges with the reporting and interpretation of quantitative results. This study could be carried out in other countries to establish what analyses are available for the treatment of poisoned patients.

Analytical role in clinical toxicology: impact on the diagnosis and treatment of poisoned patients1

AbstractAcute poisoning is a medical emergency situation and requires urgent but adequate medical intervention. The outcome depends on accurate primary care, the correct identification of poison(s) and adequate therapeutic decisions. The present paper reviews the literature concerning the role of analytical toxicology in emergency medicine with particular focus on the last few years. This study is mainly based on a PubMed search: “clinical toxicology review (urine, serum)”. Many acutely poisoned patients are treated with no laboratory support other than general clinical chemistry, haemostaseology and haematology. Emergency toxicological analyses that could influence immediate patient management, if offered on the basis of 24-h availability, are most often restricted to ethanol, oximetry and drugs of abuse in urine. Despite paracetamol (acetaminophen) being the top entry on all hit lists of poison control centres worldwide with few exceptions, the availability of its determination in blood on an urgent basis is not standard even at hospitals with large accident and emergency departments. Therefore, recommendations regarding the assays and methods that should be provided locally and at regional centres were provided for the US and UK, and should be adapted for Germany. Emergency toxicological analyses that could influence immediate patient management are relatively few in number and are remarkably similar worldwide. Recommendations for the US and UK are compared in the present paper together with suggestions for Germany. The first group of these assays should be provided locally by larger hospitals with emergency and intensive care units with a turnaround time (TAT) of &lt;1 h. Other assays (second group) and a systematic toxicological analysis that can help improve patient management after a period of primary stabilisation of vital functions and general supportive therapy can be provided from regional centres with a TAT of 4 h. The need for such centres and the repertoire of tests and methods that should be available will be adapted and discussed. It is well known that comprehensive toxicological analysis incorporating various methods can identify much more substances than are clinically suspected. At the same time, this information might have no clinical utility owing to the time required for sampling, transportation, analysis and reporting, or because the toxicological report might be inconsequential. This has contributed to a range of clinical opinions and practices, from a minimalist approach to a “shotgun” approach of broad-based laboratory testing. The present review should help to understand and discuss the pros and cons of both approaches.

Diploma in Medical Toxicology

Credit: TONY CRADDOCK/SPL FURTHER INFORMATION Ms Sue Coleman, Department of Pharmacology, Therapeutics and Toxicology, Cardiff University, Cardiff, Wales tel: 029 2074 6698; www.cardiff.ac.uk/nursing/medicine/pharmacology/ttc/pge/diptox/) Anyone concerned with the treatment of poisoned patients, such as emergency physicians and occupational physicians. Doctors, nurses, pharmacists, and poisons information officers will also find it useful. I did it during my first year as a registrar in emergency medicine in 2005-6. To broaden my knowledge of clinical toxicology. …

Therapeutic drug monitoring in drug overdose.

The treatment of poisoned patients is still largely defined by history, clinical assessment and interpretation of ancillary investigations. Measurement of drug concentrations is clinically important for relatively few compounds. Most measurements form an adjunct to and should not be considered a substitute for clinical assessment. Drug concentrations are particularly important for those compounds where the concentration is predictive of serious toxicity in an otherwise asymptomatic patient.

Therapeutic drug monitoring in drug overdose

The treatment of poisoned patients is still largely defined by history, clinical assessment and interpretation of ancillary investigations. Measurement of drug concentrations is clinically important for relatively few compounds. Most measurements form an adjunct to and should not be considered a substitute for clinical assessment. Drug concentrations are particularly important for those compounds where the concentration is predictive of serious toxicity in an otherwise asymptomatic patient.

Therapeutic drug monitoring in drug overdose.

The treatment of poisoned patients is still largely defined by history, clinical assessment and interpretation of ancillary investigations. Measurement of drug concentrations is clinically important for relatively few compounds. Most measurements form an adjunct to and should not be considered a substitute for clinical assessment. Drug concentrations are particularly important for those compounds where the concentration is predictive of serious toxicity in an otherwise asymptomatic patient.

Extracorporeal techniques in the treatment of poisoned patients: In Reply

Extracorporeal techniques in the treatment of poisoned patients: <i>In Reply</i>

Extracorporeal techniques in the treatment of poisoned patients

The role of haemodialysis, haemoperfusion and haemofiltration in the management of poisoned patients is reviewed in light of 15 years' clinical experience. During haemodialysis, blood is pumped across a semipermeable membrane (dialysis) through which the compound diffuses and, during haemoperfusion, through a cartridge that contains activated charcoal to which the compound is adsorbed. During haemofiltration, the constituents of blood that have a relative molecular mass which is below the cut-off point of the hollow fibre membrane (usually less than 40,000) are extracted. Haemofiltration is indicated particularly for aminoglycoside toxicity. The clearance by these three procedures depends on the physicochemical characteristics and kinetics of the toxic compound. In general, if a compound is adsorbed by charcoal, the clearance by haemoperfusion will be higher than that achieved by haemodialysis. Similarly, if a compound is amenable to removal by haemodialysis, its clearance will be greater than that achieved by haemofiltration. The indications for extracorporeal elimination depend on the clinical severity and complications of the overdose, the characteristics of the individual patient and the nature, dose and plasma concentrations of the toxic substance. It is generally accepted that extracorporeal elimination is worthwhile if it increases total body clearance by 30% or more. It has little or no value for intoxication caused by chloroquine, flecainide, methotrexate, paraquat, quinine, and tricyclic antidepressants. The complications of extracorporeal elimination which are encountered most frequently are: hypotension; blood loss; haematomas; metabolic disequilibria; mechanical problems such as air embolism; and, in the case of haemoperfusion, hypocalcaemia, thrombocytopenia and leukopenia. In practice, the compounds for which extracorporeal elimination is used most frequently are the alcohols, lithium and salicylate (haemodialysis) and theophylline (haemofiltration).

An Approach to the Management of the Poisoned Patient

Our systematic approach to the evaluation and treatment of the acutely poisoned patient involves establishing an accurate diagnosis and prognosis that often may be based on quantitation of the blood concentration of the toxic substance. The major feature of this approach is the proper selection of treatment(s) for the poisoned patient, ie, decontamination and supportive care and, in some cases, antidotal therapy and/or active removal of the toxic substance. Invasive, expensive methods of active removal (eg, hemodialysis or hemoperfusion) are generally recommended only if specific criteria are satisfied. Noninvasive, inexpensive methods of active removal (eg, manipulation of urinary pH or the oral administration of multiple doses of activated charcoal) may have significant utility in the treatment of poisoned patients not requiring invasive methods. This systematic approach to the poisoned patient should lead to an effective use of treatment modalities with minimal risks and optimal clinical results.

Gas chromatographic screening for drugs and metabolites in plasma and urine.

There is an increasing need for sensitive and specific methods for toxicological screening. Development of a dual-column gas chromatography system for the screening of drugs and metabolites in the plasma of poisoned patients is described. The system has been evaluated using plasma from a well-documented series of patients presenting with overdose, and results obtained have been compared with results of specific assays for the groups of drugs encountered. The method has been found to be of value in the treatment of poisoned patients despite its apparent insensitivity to certain more polar drug metabolites such as nortriptyline and desmethyldiazepam.

Analysis of haemoperfusion columns for evaluation of treatment of phenobarbital overdosage.

A simple procedure for the extraction of phenobarbital from charcoal haemoperfusion columns is presented. This method enables to evaluate the efficacy of treatment of poisoned patients with haemoperfusion. The applicability of this procedure is tested with four columns which were used in the treatment of two patients with severe phenobarbital intoxication. When an appropriate internal standard and solvent are used, this method is applicable for any drug.