Intentional drug overdose: predictors of clinical course in the intensive care unit

Clinical and Epidemiological Characteristics of Severe Acute Adult Poisoning Cases in Martinique: Implicated Toxic Exposures and Their Outcomes

The epidemiology of severe acute poisonings in the French overseas departments of the Americas remains poorly reported. The main objective of this study was to determine the epidemiology and characteristics of severe acutely poisoned adult patients.

METHODS

A retrospective descriptive study was conducted from 1 January 2000 to 31 December 2010 in severely poisoned patients presenting to the emergency department (ED) of the University Hospital of Martinique, and the general public hospitals of Lamentin and Trinité.

RESULTS

During the study period, 291 patients were admitted for severe poisoning, giving an incidence rate of 7.7 severe cases/100,000 inhabitants. The mean age was 46 ± 19 years and 166 (57%) were male. Psychiatric disorders were recorded in 143 (49.8%) patients. Simplified Acute Psychological Score (SAPS II) at admission was 39 ± 23 points and Poisoning Severity Score (PSS) was 2.7 ± 0.8 points. Death was recorded in 30 (10.3%) patients and hospital length of stay was 6 ± 7 days. The mode of intoxication was intentional self-poisoning in 87% of cases and drug overdose was recorded in 13% of cases. The toxic agent involved was a therapeutic drug in 58% and a chemical product in 52% of cases. The predominant clinical manifestations were respiratory failure (59%), hemodynamic failure (27%), neurologic failure (45%), gastrointestinal manifestations (27%), and renal failure (11%). Polypnea, shock, ventricular fibrillation or tachycardia, and gastro-intestinal disorders were the main symptoms associated with death. The main biological abnormalities associated with death in our patients were metabolic acidosis, hypokalemia, hyperlactatemia, hypocalcemia, renal injury, rhabdomyolysis, increased aspartate aminotransferases, and thrombocytopenia. Extracorporal membrane oxygenation (ECMO) was used in three patients and specific antidotes were used in 21% of patients.

CONCLUSIONS

Acute poisonings remain a major public health problem in Martinique with different epidemiological characteristics to those in mainland France, with a high incidence of poisoning by rural and household toxins.

Clinical and epidemiological characteristics of patients with acute drug intoxication admitted to ICU

Background: Drug overdose continues to be the most common cause of acute poisoning worldwide. There has been a substantial increase in drug overdose incidence and prevalence over the past decade, probably as a result of the emergence of new synthetic designer drugs. The purpose of this study is to describe the clinical and epidemiological characteristics of patients with acute drug intoxication admitted to the Intensive Care Unit (ICU).

Methods: A single center, prospective, observational study was conducted among all adult patients with clinical signs suggestive of acute drug intoxication admitted from the Emergency Department (ED) to ICU during a 6-month period (September to March).

Results: Sixty-five patients were admitted. Their median age was 49 years (mean 48.2, range 20–72), and the majority were male (48, 74%). Median Sequential Organ Failure Assessment (SOFA) score on admission to ICU was 6 (mean 6, range 0–13). Fifty-five patients (85%) had a positive urine and/or serum toxicology screen. Most commonly detected substances were: opiates (18, 33%), cocaine (13, 24%), methadone (12, 22%), benzodiazepines (10, 18%), and marijuana (9, 16%). In 16 patients (29%), >1 substance was isolated. Twenty-three patients (35%) had negative urine toxicology screen. Ethyl alcohol was detected in the serum of 23 patients (35%). Five patients (8%) expired in ICU.

Conclusion: Classic recreational drugs remain the most common substances involved in acute drug poisoning. More sensitive detection methods are warranted to identify new designer drugs of abuse such as synthetic cannabinoids.

Predicting the Need for Medical Intensive Care Monitoring in Drug-Overdosed Patients

Drug overdose (OD) is one of the most common single diagnoses admitted to medical intensive care units (MICUs). The diagnosis results in relatively little morbidity or mortality, suggesting a need to improve the methods utilized in deciding on MICU admission. Our objective in this study was to develop a quantitative system whereby the emergency room (ER) physician, with reasonable safety and ease, would be able to discriminate between the need for an ICU and a nonmonitored bed. We reviewed the charts of 216 consecutive MICU admissions for intentional OD involving 199 patients between the years 1995 and 1998. Clinical histories, vital signs, laboratory data inclusive of toxicologic analysis, and both APACHE II and Glasgow coma scores (GCS) were assessed from the ER and on transfer to the MICU 4–6 hours later. These scores, as well as individual components of the APACHE II score, were evaluated for significance. Of 216 admissions reviewed, 75 (35%) had MICU-requiring morbidity: intubation 61%, pneumonia 20%, arrhythmia or EKG changes 20%, and hypotension 3%. Mortality was 2.7%. The remaining admissions were for ICU monitoring due to lethargy, irritability, laboratory abnormalities, or simply based on the diagnosis of drug overdose. Urine examinations for drugs were positive in only 53%, with the most common agent identified being benzodiazepines (39%). Age, Apache II score, and GCS were significantly different between those patients who developed MICU-requiring morbidity and those who did not, as well as when comparing the morbidity with the mortality group. Receiver operator control (ROC) curves reveal that both the APACHE and GCS are excellent and equal predictors of morbidity, with a GCS of ≤ 12 having 88% sensitivity and 92% specificity in predicting MICU-requiring morbidity. We conclude that ER evaluation of GCS can be used to accurately assess and predict the need for MICU monitoring in drug overdose. OD patients with a persistent GCS of greater than 12 or who do not demonstrate any hemodynamic, infectious, or electrocardiographic complications in the ER do not require MICU admission.

Comparison of different scores as predictors of mechanical ventilation in drug overdose patients

The decision of intubation and mechanical ventilation in poisoned patients with impaired consciousness can be a difficult task. The present study aimed to evaluate the power of Glasgow Coma Scale (GCS), acute physiology and chronic health evaluation (APACHE II), rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS) at admission in predicting the need of intubation and mechanical ventilation in drug overdose patients with disturbed consciousness level (DCL). This prospective observational study was conducted on 104 poisoned patients who were admitted to Tanta Toxicological Unit with a DCL. Four scoring systems (GCS, APACHE II, RAPS and REMS) were recorded for all patients on admission. Discrimination was evaluated using receiver operating characteristics curve and calculating the area under the curve (AUC). Twenty-four cases required mechanical ventilation. The mechanically ventilated patients had significantly lower value of GCS and higher values of APACHE II, REMS and RAPS than other group ( p < 0.001). Although the APACHE II score has the best AUC value (0.796) in predicting mechanical ventilation, there was no statistically significant difference between the four scores. GCS > 8 had 100% negative predictive value, while REMS > 8 had 100% positive predictive value.

Homeward bound: an analysis of patients discharged home from an oncologic intensive care unit

PURPOSE

The objectives of our study were to evaluate the characteristics and outcomes of patients discharged home directly from an oncologic intensive care unit (ICU) and their 30-day hospital readmission patterns.

MATERIALS AND METHODS

We retrospectively reviewed ICU discharges over 3 years (2008-2010) and identified patients who were discharged directly home. Demographic, clinical, ICU discharge, and 30-day hospital readmission and mortality rates were analyzed.

RESULTS

Ninety-five patients (3.6%) were discharged home directly from the ICU (average annual rate of 3.9%). ICU diagnoses primarily included respiratory insufficiency, sepsis, cardiac syndromes, and gastrointestinal bleeding. Home discharge occurred most commonly between Thursday and Saturday. Five (5.3%) patients, including 2 hospice patients, died within 30 days of ICU home discharge. Thirty (31.6%) patients were readmitted within 30 days of discharge. The unplanned 30-day readmission rate was 23.2% (22/95) with a median time to hospital readmission of 13 (8-18) days. Most (64%) of the unplanned readmissions were related to the initial ICU admission.

CONCLUSIONS

Home discharge of ICU patients at our institution is infrequent but consistent. Almost one third of these patients were readmitted to the hospital within 30 days. Enhancements to the ICU home discharge process may be required to ensure optimal post-ICU care.

Glasgow coma scale and its components on admission: are they valuable prognostic tools in acute mixed drug poisoning?

Introduction. The verbal, eye, and motor components of Glasgow coma scale (GCS) may be influenced by poisoned patients' behavior in an attempted suicide. So, the values of admission GCS and its components for outcomes prediction in mixed drugs poisoning were investigated. Materials and Methods. A followup study data was performed on patients with mixed drugs poisoning. Outcomes were recorded as without complications and with complications. Discrimination was evaluated by calculating the area under the receiver operating characteristic curves (AUC). Results. There was a significant difference between the mean value of each component of GCS as well as the total GCS between patients with and without complication. Discrimination was best for GCS (AUC: 0.933 ± 0.020) and verbal (0.932 ± 0.021), followed by motor (0.911 ± 0.025), then eye (0.89 ± 0.028). Conclusions. Admission GCS and its components seem to be valuable in outcome prediction of patients with mixed drug poisoning.

The Functional Outcome and Recovery of Patients Admitted to an Intensive Care Unit following Drug Overdose: A Follow-Up Study

Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described.

All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status.

During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80.

Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.

Neurointensive care management of raised intracranial pressure caused by severe valproic acid intoxication

INTRODUCTION

We describe the neurointensive care (NIC) management of a patient with severe cerebral swelling and raised intracranial pressure (ICP) after severe sodium valproic acid (VPA) intoxication. A previously healthy 25-year old male with mild tonic-clonic epilepsy was found unconscious with serum VPA levels >10,000 micromol/l. The patient deteriorated to Glasgow Motor Scale score (GMS) 2 and a CT scan showed signs of raised ICP. Early ICP was elevated, >50 mm Hg, and continuous EEG monitoring showed isoelectric readings.

METHODS

The patient was treated with an ICP-guided protocol including mild hyperventilation, normovolemia, head elevation and intermittent doses of mannitol. Due to refractory elevations of ICP, high-dose pentobarbital infusion was initiated, and ICP gradually normalised.

RESULTS

There were several systemic complications including coagulopathy, hypocalcemia and pancreatitis. The patient remained in a depressed level of consciousness for 2 months but gradually recovered, showing a good recovery with minor subjective cognitive deficits by 6 months.

CONCLUSION

We conclude that NIC may be an important treatment option in cases of severe intoxication causing cerebral swelling.

The hospital management of fatal self-poisoning in industrialized countries: an opportunity for suicide prevention?

Suicide by self-poisoning is a prevalent cause of death worldwide. A substantial proportion of individuals who poison themselves come into contact with medical services before they die. Our focus in the current study was the medical management of drug self-poisoning in industrialized countries and its possible contribution to suicide prevention. We reviewed the literature to determine the proportion of self-poisoning suicides who reach hospital alive, the sociodemographic and clinical characteristics of in-hospital overdose deaths, the in-hospital management this group of patients receives, and whether there are specific aspects of pre-hospital care and in-hospital management that have the potential to improve survival. Between 11% and 28% of individuals who died following deliberate ingestion of drugs reached hospital alive. The substances which were most frequently implicated in death were paracetamol (acetaminophen) and paracetamol compounds, tricyclic antidepressants, and benzodiazepines. Most patients received fairly intensive treatment, yet death may have been preventable in a small proportion of cases. Only one intervention (the administration of acetylcysteine) was shown to reduce mortality and this was in a highly selected group of patients (those who had ingested paracetamol and developed fulminant hepatic failure). It is possible that other interventions such as better airway management, the prompt administration of activated charcoal, and improved pre-hospital care may improve outcomes but their potential contribution to suicide prevention needs to be investigated in future studies.

Prognostic impact of psychoactive substances use during hospitalization for intentional drug overdose

OBJECTIVE

To assess whether current use of psychoactive substance(s) is a prognostic factor during hospitalization for intentional drug overdose (IDO).

METHOD

Current intoxication with psychoactive substance(s) [cannabis, opiate, buprenorphine, amphetamine/ecstasy, cocaine, lysergic acid diethylamide (LSD)] was identified using toxicological urinalysis in 671 patients with IDO. An IDO was a priori defined as serious if associated with one of the following events: death, hospitalization in intensive care unit longer than 48 h, respiratory support, use of vasopressive drugs, cardiac massage or dialysis.

RESULTS

Subjects positive for toxicological assays were twice as likely to present with serious IDO (OR = 1.9, 95% CI: 1.3-2.8, P = 0.001), independently from a large range of confounding factors. The risk of serious IDO was especially marked in subjects using LSD, buprenorphine or opiates.

CONCLUSION

Systematic investigation of substance use could be important to adapt medical management of subjects with IDO in general hospital, but also in primary care and psychiatric settings.

ED utilization of computed tomography in a poisoned population

The objective of this prospective, analytic study was to identify predictors and describe the demographic and clinical correlates of head computed tomography (CT) evaluation in patients with poisoning or drug overdose and altered mental status. Forty-three patients that were evaluated by head CT and 109 that were not evaluated by head CT were entered into the study at a poison control center. None of the 43 scanned patients had any acute findings on head CT. A logistic regression model yielded 4 predictors that were statistically associated with the ordering of a head CT scan: Glasgow Coma Scale (GCS) < or = 8 (odds ratio [OR]: 2.3; 95% confidence interval [CI] 1.03-5.7); age > or = 41 years (OR 5.3; 95% CI 2.2-13); use of drugs or abuse by history (OR 2.8; 95% CI 1.04-7.6); and witnessed seizure activity (OR 4.8; 95% CI 1.3-17.9). We also tested 2 additional models to identify predictors of hospital admission, 1 with and 1 without CT scan included as a covariate. In the first model, only GCS </=8 was a significant predictor of admission (OR 10.7; 95% CI 2.4-47.2). When the use of head CT was added to the second model, it also emerged as an independent explanatory predictor of admission (OR 4.8; CI 95% 1.2-20.4) in addition to GCS (OR 10.1; 95% CI 2.2-45.4). In this pilot study, patients presenting to the emergency department (ED) with suspected poisoning or drug overdose were found to have a low likelihood of abnormal findings on head CT scan. Those among whom CT scans were obtained were more likely to be admitted to the hospital from the ED, despite negative findings.