Use Of Specific Antidotes Research Articles

Clinical Profile of Acute Poisoning Cases at a Tertiary Care Hospital in Kashmir, India: A Descriptive Cross Sectional Study

Acute poisoning from a variety of substances is common in every part of the world. The sooner the initial resuscitation, decontamination, and use of specific antidotes, the better the outcome. The main objective of this study was to describe the clinical profile and outcome of poisoning cases admitted to SKIMS Medical college, a tertiary care hospital located in central part of Jammu and Kashmir India. Descriptive cross sectional evaluations were conducted on all cases that were admitted to the hospital’s emergency room over a period of one year from March 2022 to February 2023. The following parameters were examined using data taken from hospital medical records: socioeconomic factors, substances consumed, routes of intake, clinical symptomatology and severity of poisoning.300 patients were included in the study with different poisonings of which 35% were males and 65% were females. The most common form of poisoning was due to pesticides followed by rodenticides and opioid intoxication respectively. Majority of the patients had suicidal intent followed by accidental ingestion reported mainly in children. Few patient required intensive care admissions rest all were managed in general ward depicting mild severity of poisoning in majority of the patients. Three patients were brought dead to hospital secondary to opoid overdose and one patient died in hospital who had pesticide ingestion complicated by ventilator associated pneumonia. The less mortality in this study was likely due to mild severity of poisoning, early gut lavage and easy access to hospital. The effects of poisoning on the human body are negative regardless of the agents or method used and this has an impact on the treatment and outcome. Due consideration must be given to clinical, toxicological and epidemiological profiles. Therefore precise and prompt diagnosis, adequate treatment and effective preventative efforts are required. This study highlighted the importance of awareness and for the establishment of poison information centre for the better management and prevention of all poisoning cases.

Acute Poisoning Cases Treated in Intensive Care Unit at Rural Tertiary Care centre

Background: Acute poisoning with various substance is common everywhere. Earlier initial resuscitation, gastric decontamination and use of specific antidotes, better is the outcome. The aim of the study was to characterize the poisoning cases admitted to the tertiary care teaching Hospital. Material and Methods: This is Prospective, observational, descriptive study was conducted to investigate the clinical characteristics and epidemiological patterns of acute poisoning admission into ICU of 137 cases. The inclusion criteria were: Either gender with Age > 13 years and chief complaint of acute poisoning included those who had undergone exposure to poison either by household or agricultural pesticides, stings bite, snake bite, industrial toxins, toxic plants, drug or miscellaneous products. Results: 137 of poisoned cases were enrolled in this study, the majority of poison cases were between 21-30 years accountable 60.6 % were male and gender ratio of the patients’ male: female was 1.53:1. The majority of all cases (61.3%) were due to suicidal poisoning. The exposure substances identified as most commonly encountered in the ICU included OPP (37.2%), Food Poisoning 15.3%, Alcohol intoxication, followed by overdose of drugs, (16.7%, 10.9%, respectively). Specific antidote 66.4% were given and Ventilator not received by 68.6% patients. Conclusions: The tertiary care hospitals of the Moinabad region, indicate that significant opportunities for reducing mortality are achieved by better medical management.

English

BACKGROUND Accidental and intentional poisoning are major preventable contributors to death and illness. According to World Health Organization (WHO) estimates, 0.3 million people die every year due to various poisoning agents. Earlier the initial resuscitation, gastric decontamination, and use of specific antidotes, better the outcome. In order to improve clinical management, proper planning and prevention is. This study was conducted in a tertiary care hospital to evaluate the pattern of acute poisoning cases in that region. METHODS This is a retrospective study conducted among 57 patients with poisoning admitted over a 2-year period. Data was collected from ICU registry and Medical Records Department, ESIC MH. RESULTS Females represented 59.6 % (n = 57). Most of our patients were in the age group 18 – 28 yrs. (35.08 %). Notably majority of the cases had consumed organophosphorus compounds (25 patients, 43.85 %) and tablets (22 patients, 38.60 %). Majority (22 patients, 38.59 %) stayed at ICU for less than three days; overall mortality from all poisoning was low (2 patients, 3.50 %). CONCLUSIONS Use of organophosphorus compound and tablets for intentional poisoning continues to be pervasive in India. Education on poison, counselling and strict pesticide and drugs regulation laws will reduce the incidence of this public health problem. KEYWORDS Organophosphorus Compound, Poisoning, Mortality

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique.

Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment. We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes. We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation. This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

Study of thrombin generation in three populations of patients on oral anticoagulants: Bleeding with reversion, haemorrhagic accidents without reversion or haemorrhagic accident

Bleeding under oral anticoagulant is a frequent reason for consultation in the emergency department. The aim of our study was to compare thrombin generation (TG) parameters in 3 populations under oral anticoagulant: severe bleeding patients who received procoagulant factors, patients with non-severe bleeding without reversion and anticoagulated patients without bleeding events. We conducted a prospective, single-center study of TG in patients under oral anticoagulant (VKA, Direct Oral Anticoagulants (DOACs): rivaroxaban, dabigatran, apixaban). The study was performed on platelet-poor plasma collected on arrival (V1) before reversal therapy, then 30 min (V2), 6 h (V3) and 24 h (V4) after reversal. A total of 307 patients were included in this study with 98 severe bleeding reversed, 95 patients with clinical relevant bleeding but non-reversed and 108 patients without bleeding. For V1, VKA patients with reversed bleeding had a significant decrease in the main TG parameters compared to patients without bleeding ( P = 0.017). Moreover at V1, the main parameters of TG were significantly decreased for VKA compared to DOACs ( P < 0.001) and between anti-IIa compared to anti-Xa ( P < 0.001). At visits V2, V3 and V4, reversal therapy restored a normocoagulable state for VKA patients with a significant increase in key TG parameters between V1 and V2-V3-V4 ( P < 0.001). For DOACs reversed by PCC or PCCactivated, a significant hypercoagulability state was demonstrated on the TG whereas a normal coagulation and no hypercoagulable state was found for those under dabigatran reversed by the idarucizumab. Patients on VKA regained a comparable coagulation state as healthy subjects after reversal therapy, whereas patients treated with DOACs and reversed with PCC or PCCa induced a hypercoagulable state. Probably, this hypercoagulable state could be minimized by reducing the doses of PCC or PCCa, or be circumvented by the use of specific antidotes.

Saline irrigation for the management of skin extravasation injury in neonates.

Extravasation injury, a complication commonly seen in the neonatal intensive care unit, can result in scarring with cosmetic and functional sequelae. A wide variety of treatments are available, including subcutaneous irrigation with saline (with or without hyaluronidase), liposuction, use of specific antidotes, topical applications, and normal wound care with dry or wet dressings. All such treatments aim to prevent or reduce the severity of complications. Primary objective To compare the efficacy and safety of saline irrigation or saline irrigation with prior hyaluronidase infiltration versus no intervention or normal wound care for tissue healing in neonates with extravasation injury. Secondary objectives To evaluate by subgroup analysis of controlled trials the influence of type of extravasate, timing of irrigation following extravasation, and postmenstrual age (PMA) of the neonate at the time of injury on outcomes and adverse effects.Specifically, we planned to perform subgroup analysis for the primary outcome, if appropriate, by examining:1. time to irrigation from identified extravasation injury (< 1 hour or ≥ 1 hour);2. type of extravasate (parenteral nutrition fluid or other fluids or medications);3. amount of saline used (< 500 mL or ≥ 500 mL); and4. PMA at injury (< 37 completed weeks or ≥ 37 completed weeks). We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 2 February 2017), Embase (1980 to 2 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 February 2017). We also searched clinical trial databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We used the Google Scholar search tool for reverse citations of relevant articles. Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing saline irrigation with or without hyaluronidase infiltration versus no intervention or normal wound care for the management of extravasation injury in neonates. Three review authors independently reviewed and identified articles for possible inclusion in this review. We used the GRADE approach to assess the quality of evidence. We found no eligible studies. Our search revealed 10 case reports or case series describing successful outcomes with different interventions for this condition. To date, no RCTs have examined the effects of saline irrigation with or without prior hyaluronidase infiltration for management of extravasation injury in neonates. Saline irrigation is frequently reported in the literature as an intervention for management of extravasation injury in neonates. Research should focus first on evaluating the efficacy and safety of this intervention through RCTs. It will also be important for investigators to determine effect size by examining the timing of the intervention, the nature of the infusate, and severity of injury at the time of intervention.

Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants.

Bleeding is the most common complication of all anticoagulants. Any bleeding patient on an anticoagulant should be risk-stratified based on hemodynamic instability, source of bleeding, and degree of blood loss. Although minor bleed may be managed with discontinuation of anticoagulant, major bleed may require transfusion of blood products and use of specific antidote. The residual effects of each anticoagulant may be monitored with distinct coagulation assay. Intravenous or oral vitamin K can reverse the effect of warfarin within 24 to 48 hours and is indicated for any bleeding, international normalized ratio of >10 or 4.5 to 10 in patients with other risk factors for bleeding. Fresh frozen plasma or prothrombin complex concentrate (PCC) may be necessary in major bleeding related to warfarin. Protamine sulfate reverses the effect of unfractionated heparin completely and of low-molecular-weight heparin (LMWH) partially. Idarucizumab has recently been approved in United States for dabigatran reversal, whereas andexanet alfa is expected to get approved in the near future for reversal of oral factor Xa inhibitors. The PCC may reverse the effect of rivaroxaban to some extent, but no data are available regarding reversal of apixaban and edoxaban. Aripazine has shown promising results to reverse the effects of LMWH, fondaparinux, and direct oral anticoagulants but is still in the developmental phase.

Treat anticoagulant-associated bleeding on the basis of bleeding severity and the availability of reversal agents

Bleeding is a serious complication associated with the use of both conventional and new anticoagulants in the prevention and treatment of thromboembolic complications. Although bleeding can often be managed with general measures, rapid reversal of the anticoagulant effect through the use of specific antidotes or other interventions is desirable in many cases.

Pattern of Poisoning Cases in a Tertiary Hospital in Bangladesh

Background: Poisoning with various substances is a global problem. It is one of the most important reasons for emergency admission in the hospital. The earlier the initial resuscitations, gastric decontamination and use of specific antidotes, the better is the outcome. Epidemiology of poisoning differs from region to region. This study was carried out to determine the pattern and severity of poisoning in a tertiary care hospital. Objective: To characterize the poisoning cases admitted in Enam Medical College Hospital. Materials and Methods: All cases admitted to the emergency department of Enam Medical College Hospital during the period of April to December, 2010 were evaluated retrospectively. We reviewed data obtained from the hospital medical records and included the following factors: demographic characteristics, etiology and outcome of the acutely poisoned patients. Total 84 poisoning cases were found and they were included in the study. Results: The overall case fatality rate was 3.5%. More detailed data from 2010 reveals that two-thirds of the patients were 20-30 years old, 53% male and 47% female. Organophosphorus was the most common cause (73.9%) followed by unknown poisoning (9.5%), sedative (5.9%), harpic (4.7%), aluminium phosphide (2.4%), savlon (1.2%), paracetamol (1.2%) and amitryptiline (1.2%). 90.5% cases were suicidal and 9.5% were homicidal. Conclusion: This study provides important information on the characteristics of the poisoning in this region. Community education about the danger of the drugs and reduction of exposure to pesticides are recommended. DOI: http://dx.doi.org/10.3329/jemc.v1i1.11133J Enam Med Col 2011; 1(1): 19-23

A study on poisoning cases in a tertiary care hospital.

Acute poisoning with various substance is common everywhere. The earlier the initial resuscitations, gastric decontamination and use of specific antidotes, the better the outcome. The aim of this study was to characterize the poisoning cases admitted to the tertiary care hospital, Warangal district, Andhra Pradesh, Southern India. All cases admitted to the emergency department of the hospital between the months of January and December, 2007, were evaluated retrospectively. We reviewed data obtained from the hospital medical records and included the following factors: socio-demographic characteristics, agents and route of intake and time of admission of the poisoned patients. During the outbreak in 2007, 2,226 patients were admitted to the hospital with different poisonings; the overall case fatality rate was 8.3% (n = 186). More detailed data from 2007 reveals that two-third of the patients were 21–30 years old, 5.12% (n = 114) were male and 3.23% (n = 72) were female, who had intentionally poisoned themselves. In summary, the tertiary care hospitals of the Telangana region, Warangal, indicate that significant opportunities for reducing mortality are achieved by better medical management and further sales restrictions on the most toxic pesticides. This study highlighted the lacunae in the services of tertiary care hospitals and the need to establish a poison information center for the better management and prevention of poisoning cases.

Drugs and pharmaceuticals: management of intoxication and antidotes.

The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life suppport — airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, l-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.

Doctors’ knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity

Background:Specific antidotes (eg, naloxone, flumazenil, cyproheptadine and benzodiazepines) are available for the management of certain recreational drug-induced toxicities. Some controversies surround the use of some of these antidotes, especially flumazenil...

Management of Body Packers in the Emergency Department

Body packing of illicit drugs is one of the means of drug trafficking. Asymptomatic suspects may be brought in by law-enforcement officers for body search of possible drug packing inside the body. Symptomatic body packers may present with gastrointestinal obstruction or toxicity of the leaking drugs inside the packets. Management strategies are largely determined by the modes of presentation. Asymptomatic persons must be persuaded with every effort for consent to the body cavity search as well as treatment for the safe passage of any packed drugs to avoid possible complications and medico-legal sequelae. Abdominal X-rays and computed tomography can be helpful in confirming the presence of drug packets and in identifying possible packet leakage. Gastrointestinal decontamination, whole bowel irrigation, use of specific antidote as well as operative intervention may be indicated. Emergency physicians must be conversant with the medical and legal aspects of the management of these body packers.

The use of specific antidotes as a response to bleeding complications during anticoagulant therapy for venous thromboembolism

When a bleeding complication occurs during therapy with heparin or vitamin K antagonists, there is an option to give a specific antidote. Several new anticoagulants have been developed that are likely to have some risk of bleeding complications, for which no specific antidotes are available. Interestingly, it is unknown how often the use of an antidote is necessary in clinical practice. We investigated 1877 patients treated for venous thromboembolism included in three large clinical trials, of which 181 (9.6%) had a total of 225 adjudicated bleeding episodes; 46 hemorrhages being designated as major. Some form of antidote was given to 26 (14.4%) patients with a hemorrhage. Of the patients with at least one major hemorrhage, 19 (41.3%) received an antidote. Vitamin K was given to 23 (1.2%) patients, one (0.05%) patient received protamin sulfate and seven (0.4%) patients received fresh frozen plasma. The use of antidotes was comparable for initial and long-term treatment. Antidotes were statistically significantly more frequently given in Canada as compared to other participating countries. Vitamin K was more frequently given in case of a higher international normalized ratio value. Although antidotes against anticoagulant treatment are widely available, our analysis shows that in only a very small number of patients a direct, or slow-acting antidote to reverse the anticoagulant effect was used.

Goldfrank's Toxicologic Emergencies

This fifth edition is a timely and welcome one because of recent management changes in the treatment of acute poisoning. The routine use of syrup of ipecac as the primary household emetic has been supplanted by immediately calling the Poison Control Center, which may then recommend ipecac or, more likely, other measures and actions. General management of poisoning and overdoses is more important than the use of specific antidotes. Nevertheless, important antidotes or antagonists are still useful and recommended for special situations. Each chapter ends with an in-depth discussion of the relevant antidotes for the particular type of poison. I particularly enjoyed the historical account of the birth of the Poison Control Center concept and movement, since I was a member of the first Accident Prevention Committee of the American Academy of Pediatrics when it made the survey of its 3000 members in 1952 seeking the most prevalent childhood accident.