Clinical toxicology of beta-blocker overdose in adults.

Beta-blocker overdose is potentially harmful due to the strong blood pressure-lowering and heart rate-lowering effects. However, conflicting data exist as to their differential toxicity, single-substance exposures and the effect of co-exposure with additional antihypertensive medication. For this, a 10-year retrospective, explorative analysis of the Mainz Poison Center/Germany database with regard to circumstances of beta-blocker exposure, doses, symptoms and treatment was carried out. Analyses were restricted to adult patients with single-substance exposures and co-exposures with one additional antihypertensive substance. Written follow-up information was obtained in half the cases. A total of 2967 cases were analysed, of which 697 were single-substance exposures. Metoprolol was most frequently reported followed by bisoprolol, atenolol, propranolol and sotalol. Metoprolol showed a linear dose-symptom relationship, whereas propranolol and sotalol seemed to have a threshold dose beyond which symptoms aggravated. Symptoms did not differ substantially, except for more seizures being reported with propranolol, and more CNS depression/vomiting with sotalol. Activated charcoal was used in 38%, gastric lavage in 11%, temporary pacemaker in 3%, glucagon in 1%, intubation for respiratory insufficiency and cardiopulmonary resuscitation in 1% and 0.5%. All patients recovered. In 174 co-exposure cases, the distribution of poisoning severity and rate of worsening of symptoms was comparable with single-substance exposures except one patient deceased after bisoprolol and verapamil co-exposure. In adults with beta-blocker overdose, no significant differences in poisoning severity among beta-blockers were detected, and no fatalities were observed with single-substance exposures. Co-exposures with other antihypertensives, sedatives or alcohol should be carefully attended to as fatalities might occur.

Analysis of Gastric Lavage Reported to a Statewide Poison Control System.

BACKGROUND: As decontamination trends have evolved, gastric lavage (GL) has become a rare procedure. The current information regarding use, outcomes, and complications of GL could help refine indications for this invasive procedure. OBJECTIVES: We sought to determine case type, location, and complications of GL cases reported to a statewide poison control system. METHODS: This is a retrospective review of the California Poison Control System (CPCS) records from 2009 to 2012. Specific substances ingested, results and complications of GL, referring hospital ZIP codes, and outcomes were examined. RESULTS: Nine hundred twenty-three patients who underwent GL were included in the final analysis, ranging in age from 9 months to 88 years. There were 381 single and 540 multiple substance ingestions, with pill fragment return in 27%. Five hundred thirty-six GLs were performed with CPCS recommendation, while 387 were performed without. Complications were reported for 20 cases. There were 5 deaths, all after multiple ingestions. Among survivors, 37% were released from the emergency department, 13% were admitted to hospital wards, and 48% were admitted to intensive care units. The most commonly ingested substances were nontricyclic antidepressant psychotropics (n = 313), benzodiazepines (n = 233), acetaminophen (n = 191), nonsteroidal anti-inflammatory drugs (n = 107), diphenhydramine (n = 70), tricyclic antidepressants (n = 45), aspirin (n = 45), lithium (n = 36), and antifreeze (n = 10). The geographic distribution was clustered near regions of high population density, with a few exceptions. CONCLUSIONS: Toxic agents for which GL was performed reflected a broad spectrum of potential hazards, some of which are not life-threatening or have effective treatments. Continuing emergency physician and poison center staff education is required to assist in patient selection.

Pesticide poisoning in Palestine: a retrospective analysis of calls received by Poison Control and Drug Information Center from 2006-2010.

BACKGROUND AND OBJECTIVE: The agricultural industry is the largest economic sector in Palestine and is characterized by extensive and unregulated use of pesticides. The objective of this study was to analyze phone calls received by the Poison Control and Drug Information Center (PCDIC) in Palestine regarding pesticide poisoning. METHODS: All phone calls regarding pesticide poisoning received by the PCDIC from 2006 to 2010 were descriptively analyzed. Statistical Package for Social Sciences (SPSS version 16) was used in statistical analysis and to create figures. RESULTS: A total of 290 calls regarding pesticide poisoning were received during the study period. Most calls (83.8%) were made by physicians. The average age of reported cases was 19.6 ± 15 years. Pesticide poisoning occurred mostly in males (56.9%). Pesticide poisoning was most common (75, 25.9%) in the age category of 20-29.9 years. The majority (51.7%) of the cases were deliberate self-harm while the remaining was accidental exposure. The majority of phone calls (250, 86.2%) described oral exposure to pesticides. Approximately one third (32.9%) of the cases had symptoms consistent with organophosphate poisoning. Gastric lavage (31.7%) was the major decontamination method used, while charcoal was only utilized in 1.4% of the cases. Follow up was performed in 45.5% of the cases, two patients died after hospital admission while the remaining had positive outcome. CONCLUSION: Pesticide poisoning is a major health problem in Palestine, and the PCDIC has a clear mission to help in recommending therapy and gathering information.

Trends in emergency department use of gastric lavage for poisoning events in the United States, 1993-2003.

OBJECTIVE: To determine current trends in the use of gastric decontamination for the emergency department (ED) treatment of overdose patients. METHODS: In the National Health Ambulatory Medical Care Survey (NHAMCS), a weighted sampling of U.S. EDs, overdose-related visits were examined using ICD-9 CM E codes and NHAMCS' "reason-for-visit" classification. RESULTS: From 1993 to 2003 there were an estimated 11.68 million ED-treated poisoning events. Some 13.7% of those treated were lavaged. Rates fell significantly, from an annual average of 18.7% of cases during 1993-97 to 10.3% during 1998-2003 (p < 0.001). Controlling for year, urgency, and admission status in multivariate logistic modeling, lavage was significantly and positively associated with private insurance payor status, younger age (<30), female gender, white race, 8 PM-8 AM presentation, and intentional rather than unintentional overdose. CONCLUSION: ED use of gastric lavage in poisoned patients has decreased significantly over the past decade but varies by demographic and non-clinical factors.

Quality improvement process in the adherence to gastric decontamination guidelines for poison exposures as recommended by a poison control center.

PURPOSE: Adherence to new guidelines for the use of ipecac syrup, gastric lavage, cathartics, and activated charcoal by a poison control center was studied with a quality improvement framework. METHODS: The rates of gastric decontamination were monitored through an electronic case record system. In February 2002, a revised guideline that narrowed the use of gastric decontamination was implemented with a performance improvement process. The rates of recommendation and utilization during 12 months following implementation of the new guidelines were compared with those during 12 previous months. RESULTS: Recommendations for the use of ipecac syrup declined from 1.50% to 0.02% (OR; 95% CI = 0.02; 0.01, 0.03), single-dose-activated charcoal declined from 5.39% to 1.38% (0.25; 0.22, 0.28), gastric lavage declined from 4.19% to 0.22% (0.05; 0.04, 0.06), and a cathartic declined from 1.48% to 0.13% (0.08; 0.06, 0.12). Declines in utilization were also significant (P < .001) for all forms of gastric decontamination. The proportions of patients managed at the scene of the poisoning were unchanged (1.04; 0.99, 1.09) before (67.64%) and after (68.50%) the new guidelines as were those for referral to a health care facility (20.57% and 21.42%, respectively, 1.05; 1.00, 1.11). CONCLUSION: Recommendations on gastric decontamination can be effectively modified with no detriment to patient outcome.

Predictors of outcome in children with hydrocarbon poisoning receiving intensive care.

The retrospective study included 48 children between 8.5 months--10 years, admitted to the PICU of an urban, tertiary care, teaching hospital in northern India from January 1995 to December 2001. Eighteen (38%) patients were hypoxemic on arrival, of which 8 (45%) required mechanical ventilation. Compared to the non-hypoxemic children, the hypoxemic patients were more likely to have received gastric lavage before arrival to our center (Odds Ratio 23.2, 95% CI 2.4 - 560.7) and had higher frequency of severe respiratory distress and leucocytosis (Odds Ratio 8.0, 95% CI 1.79 -38.6). On multiple regression analysis, we could not identify any particular variable that could predict hypoxemia. Secondary pneumonia developed in 16 (33.3%), with the duration of PICU stay being longer in these patients as against those who did not (144 hours vs 72 hours, p <0.05). Two (4.2%) children died and one suffered hypoxic sequelae. Prior lavage, hypoxemia at admission, need for ventilation, secondary sepsis and ventilator related complications were associated with poor outcome.

Organización y disponibilidad de recursos para la asistencia toxicológica en los servicios de urgencias de los hospitales españoles / Organisation and resources availability for toxicological care at the emergency outpatient clinics of the Spanish hospitals

Introducción: La mayoría de los intoxicados agudos acaban siendo asistidos en los Servicios de Urgencias Hospitalarios (SUH), constituyendo este ámbito adecuado para evaluar el tipo de organización, los recursos y la asistencia prestada a estos enfermos. Método: Se envió una encuesta por correo a los SUH de 176 hospitales españoles, la cual constaba de siete apartados: características del hospital, disponibilidad de analítica toxicológica urgente las 24 horas, disponibilidad de un botiquín toxicológico, formación específica de postgrado/continuada, investigación clínica, información toxicológica y calidad asistencial (método preferente de descontaminación digestiva e intervalo eficaz para su aplicación en 3 situaciones clínicas). Resultados: El índice de respuestas fue del 43,7%. El 54,5% de los SUH usaban un test en orina para el diagnóstico analítico rápido. La disponibilidad de analítica cuantitativa de los parámetros útiles para el tratamiento fue del 61,9% en hospitales de nivel III. Sólo el 31,4% de las sustancias del botiquín toxicológico estaban disponibles en el 100% de los hospitales. Los quelantes eran accesibles en el 60% y compuestos de aplicación inmediata variaban según el nivel del Hospital entre el 63 y el 90%. El 72,5% de los médicos habían asistido a algún curso de postgrado, el 25,6% había publicado algún trabajo toxicológico y el 59,5% alguna comunicación a un congreso. Disponían de protocolos de intoxicaciones el 87%. El 94,8% de los centros utilizaban como fuente de información el Servicio de Información Toxicológica ubicado en Madrid. El 86,7% de los SUH señalaron al lavado gástrico como método preferente de descontaminación digestiva. Los intervalos de descontaminación correctamente contestados oscilaron entre el 18,7 y el 38,7%. Conclusiones: Es necesario realizar un consenso sobre analítica toxicológica, dotación mínima de antídotos y tiempo en que deben estar disponibles ambos, en función del nivel asistencial del hospital. También debe valorarse la implantación de programas específicos de formación de postgrado/reciclaje, y la redacción y difusión de guías por parte de las Sociedades Científicas, para evitar actitudes rutinarias en el tratamiento del intoxicado agudo (AU)

Background: Most cases of acute intoxication are finally referred to the Hospital Emergency Outpatient Clinics (HEOC), and this is the adequate environment for assessing the type of organisation, the resources and the care provided to these patients. Methods: A questionnaire was mailed to the HEOCs of 176 Spanish hospitals; the questionnaire encompassed seven areas: characteristics of the hospital, 24-hour availability of emergency toxicologic analysis services, availability of a toxicologic “ready-use box”, soecific postgraduate/continuing training of the personnel, clinical research, toxicologic information and quality of care. Results: The response index was 43.7%. Fifty-four point five per cent of the HEOCs used an urine test for rapid toxicologic diagnosis. Availability of quantitative analysis of parameters useful in therapy was 61.9% at level- III hospitals. Only 31.4% of the substances prescribed for the toxicologic “ready-use box” were immediately available in 100% of the hospitals. Chelating agents were accessible in 60%, and immediate-use compounds availability varied between 63% and 90% in the various hospitals. Seventy-two point five per cent of the physicians had attended some postgraduate course; 25.6% had already published some paper on toxicologic subjects, and 59.5% had presented communications at Meeting. Intoxication management protocols were available in 87%; in 94.8% of the Centres the source for emergency information was the Toxicologic Information Service in Madrid. Eighty-six point seven per cent of the HEOCs named gastric lavage as the preferred method for digestive tract decontamination. The questions regarding the decontamination intervals were correctly answered in 18.7% to 38.7% of the cases. Conclusions: A consensus must be reached regarding toxicologic analyses, minimum antidote availability and the period for availability of both. Furthermore, the implementation of specific postgraduate training/recycling programmes and the Guidelines of Scientific Societies should be considered (AU)

[Gastric lavage, hemodialysis and specific antidotes in acutely poisoned patients treated at the Specialist Hospital in Biala Podlaska (1993, 2001 and 2002)]. / Plukanie zoladka, hemodializa i specyficzne odtrutki u pacjentów leczonych z powodu ostrych zatruc w Wojewódzkim Szpitalu Specjalistycznym w Bialej Podlaskiej w latach 1993, 2001 i 2002.

Gut decontamination, the methods of extracorporeal elimination of poisons and antidote use are the specific measures in clinical toxicology. Statistically they are not often used in intoxicated patients. It is not known, in how many cases of poisoning treated outside toxicological units are they applied. Approximately 110 poisoned patients were hospitalised each year in the Specialist Hospital in Biala Podlaska in years 1993, 2001 and 2002. Gastric lavage was performed in about 50 percent of those cases, especially often in children up till third year of life and in the cases of poisoning with medical drugs. The Gut Decontamination Position Statement of AACT and EAPCCT, published in 1997, had no significant impact on use of decontamination procedures in our hospital. Haemodialyses were performed in 3-5% of poisoned patients. All those patients were poisoned with ethylene glycol or methanol. Only 4 specific antidotes were used in years 1993, 2001 and 2002. The most commonly used antidote was ethanol, despite its level is not measured in our laboratory. Recommendations for gut decontamination should be widely popularised. The use of activated charcoal may be in many cases more suitable as a gastric lavage. Safe and effective use of ethanol as an antidote in a hospital requires its measuring in own laboratory.

Intoxicaciones pediátricas atendidas en el Hospital Clínico de Santiago de Compostela (1993-1996) / Cases of pediatric poisoning treated at the clinical hospital of Santiago de Compostela (1993-1996)

Se estudiaron 193 intoxicaciones pediátricas atendidas en el Hospital Clínico de Santiago de Compostela desde enero de 1993 a diciembre de 1996, ambos inclusive. Se observó un ligero predominio del sexo masculino (54,4 por ciento), siendo la edad media de 5,57+/-5,00 años. La incidencia fue máxima en el intervalo de 0-4 años (116 casos) y los tóxicos más frecuentemente implicados fueron los medicamentos (106 casos), con un lugar preferente para los analgésicos (40 por ciento), seguidos de las benzodiacepinas (30 por ciento). Los lunes y los miércoles fueron los días de la semana en donde se dió un mayor número de intoxicaciones, no encontrándose diferencias significativas entre los doce meses del año. El 72 por ciento de los pacientes presentaban clínica al ingreso, siendo mayoritaria en el grupo de 10-14 años, con predominio de las manifestaciones neurológicas. Entre todos los tratamientos aplicados destacó el lavado gástrico (84 casos) y, aunque 135 pacientes tuvieron que ser ingresados, la evolución clínica fue siempre favorable. En el 47 por ciento de la población estudiada se detectaron todos o parte de los tóxicos sospechados y en el 26 por ciento se encontraron otros tóxicos. De los niveles plasmáticos calculados, 77 resultaron subtóxicos y 52 tóxicos, relacionándose los primeros con intoxicaciones por fármacos y los segundos con sobredosis por drogas de abuso (AU)

Pemoline ingestion in children: a report of five cases and review of the literature.

The authors describe five pediatric cases of excessive pemoline ingestion. Based on their experience compared with previously reported cases in the literature, they describe the clinical presentation and rational treatment recommendations for acute pemoline ingestion. Overall, patients experienced a relatively benign clinical course following pemoline ingestion. Symptoms of pemoline ingestion appear to be primarily an accentuation of the drug's pharmacological effects on the central nervous and cardiovascular systems with sinus tachycardia, hypertension, hyperactivity, choreoathetoid movements, and hallucinations being most commonly observed. These findings are consistent with previously reported cases. Possible rhabdomyolysis manifested by evaluation of serum CPK was also observed in 3 of 4 patients in whom this laboratory parameter was measured and appears to be a common finding in acute pemoline poisoning. After acute ingestion, symptoms occurred within 6 hours, lasting up to 48 hours in all patients. Gastric lavage and/or activated charcoal would be effective decontamination measures, whereas ipecac-induced emesis should be avoided after massive ingestion due to the possibility of seizures. Aggressive use of a benzodiazepine appears a reasonable first choice to treat associated involuntary movements, tremor, hyperactivity, irritability, and agitation. Phenothiazines or butyrophenones may also be used especially for serious life-threatening symptoms, including hypertensive crisis and severe hyperthermia, although these serious complications of stimulant overdose have not been reported after pemoline ingestion. If a patient should experience pemoline-induced hypertensive crisis, individual dose titration of labetalol or sodium nitroprusside would appear reasonable pharmacologic approaches for rapid stabilization of blood pressure.

Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose?

STUDY OBJECTIVE: Because the ability of gastrointestinal decontamination to alter drug absorption varies inversely with time, we compared the time from arrival in the emergency department to gastrointestinal decontamination (gastric lavage or activated charcoal) for patients transported by ambulance with patients transported by other means after overdose. METHODS: A retrospective chart review was conducted in an academic university ED with an annual volume of 56,000 visits. Consecutive cases of oral overdose treated by gastrointestinal decontamination between December 1, 1995, and May 31, 1996, were identified from International Classification of Diseases, ninth revision, billing codes. ED charts were reviewed to determine the patient's age, sex, mode of transportation, disposition, and time interval to gastrointestinal decontamination with either gastric lavage or activated charcoal. RESULTS: Two hundred eighty-one patient visits were identified. Complete data were available for 173 visits. Six patients were excluded because the diagnosis of overdose was not made on presentation, leaving 167 cases for analysis. The median age for all patients was 27 years; 95 (57%) were female. Overdose patients were transported by ambulance in 105 (67%) cases. Admission rates were similar for patients transported by ambulance and those who arrived by other means. The median interval from arrival to any gastrointestinal decontamination (lavage or charcoal) for patients transported by ambulance was shorter than patients who arrived by other means at 55 and 73 minutes, respectively (95% confidence interval for difference 2.5 to 30.5 minutes, P =.03). Subgroup analysis showed this difference was largely the result of gastric lavage. CONCLUSION: Overdose patients transported by ambulance have a shorter time interval from ED arrival to gastrointestinal decontamination than patients arriving by other means. This difference was largely related to more rapid gastric lavage.

Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population.

STUDY OBJECTIVE: To determine the extent of drug removal by emesis at different times after the ingestion of a toxic substance. DESIGN: Multicenter retrospective chart review. METHODS: Using the American Association of Poison Control Centers' aggregate data base, children who had ingested acetaminophen and who were referred to a health care facility by one of 11 poison centers during a two-year period were identified. Charts of these patients were reviewed to determine the quantity ingested per kilogram of body weight, method of decontamination used, the timing of decontamination, and the serum acetaminophen concentration obtained four hours after ingestion. RESULT: Charts of 455 patients met all requirements for inclusion. When emesis occurred within one-half hour after ingestion, mean serum acetaminophen concentration drawn four hours after ingestion was approximately half that in a control group that received no decontamination. Emesis had less impact when it was delayed further and had no demonstrable impact when it occurred more than 90 minutes after ingestion. CONCLUSION: Many factors must be considered when deciding if and by what method a given patient should receive decontamination. When delayed gastric emptying is not expected, emesis can at best decrease a toxic burden by half if it occurs early. Medical care givers must continue to scrutinize management practice to ensure that syrup of ipecac is given only in situations in which it is likely to make a difference in outcome and in which it is the most effective agent to achieve this goal.