Management of pharmaceutical and recreational drug poisoning

Progress on the Electrochemical Sensing of Illicit Drugs

Illicit drugs are harmful substances, threatening both health and safety of societies in all corners of the world. Several policies have been developed over time to deal with this illicit drug problem, including supply reduction and harm reduction policies. Both policies require on-site detection tools to succeed, i.e. sensors that can identify illicit drugs in samples at the point-of-care. Electrochemical sensors are highly suited for this task, due to their short analysis times, low cost, high accuracy, portability and orthogonality with current technologies. In this chapter, we evaluate the latest trend in electrochemical sensing of illicit drugs, with a focus on detection of illicit drugs in seizures and body fluids. Furthermore, we will also provide an outlook on the potential of electrochemistry in wearable sensors for this purpose.

Late-onset non-obstructive mesenteric ischemia (NOMI) resulting from delayed absorption of overdosed antihypertensive drugs: An autopsy case report

Non-obstructive mesenteric ischemia (NOMI) is caused by reduced blood flow to the intestines without physical occlusion in the mesenteric artery. Previous reports show that drug overdose occasionally induces late-onset NOMI; however, in most cases, the reason for the delayed onset is unclear. Here, we present an autopsy case of late-onset NOMI that was induced by a drug overdose. An 80-year-old man was admitted to the intensive care unit because of severe hypotension after an overdose of antihypertensive drugs. He received vasopressor therapy and continuous hemodiafiltration dialysis; however, gastrointestinal decontamination was not performed. He began to recover but developed acute mesenteric ischemia on the evening of day 4 and died on day 5. Autopsy showed discontinuous submucosal bleeding from the duodenum to the colon; there was no thrombus in the mesenteric artery, which led to a diagnosis of NOMI. In the stomach, there was 250 mL of reddish-brown fluid with a muddy brown substance. Histologic examination revealed ischemic necrosis in the small intestine. Quantitative analysis of serum collected during hospitalization revealed that nifedipine and cilostazol levels had peaked on day 3 of hospitalization. The formulation of nifedipine was a controlled-release tablet, and the low water solubility of cilostazol may have caused the tablets to adhere and remain in the stomach. Therefore, the drugs had been released into the blood stream several days after hospitalization, leading to delayed-onset NOMI. In cases of overdose, it is crucial to consider the formulation and properties of the involved drugs when determining medical treatment.

Psychoactive substance intoxication leading to general hospital admission in young and middle-aged people during and after the first lockdown

INTRODUCTION

Incidence of hospitalisations related to psychoactive substance (H-PS) intoxication has been strongly decreased during the coronavirus disease 2019 (COVID-19) pandemic especially in young adult and French region of Nouvelle-Aquitaine was mostly concerned. This study aimed to describe (i) the incidence of H-PS in Bordeaux teaching hospital during and after the first 2020 lockdown in adults aged 18-29 years or 30+ then (ii) their characteristics specifically associated with the pandemic period by comparing 2020 with 2017-2019 baseline period.

MATERIAL AND METHODS

This historical cohort study was conducted in adults admitted to the Bordeaux teaching hospital with main or associated diagnosis codes of intoxication with benzodiazepine, methadone, buprenorphine, codeine, morphine, heroin, cocaine, ecstasy and alcohol. Data were collected locally through the discharge database. Incidence and characteristics of H-PS were described according to patients' age, in 2020 before (01/01-16/03), during (17/03-10/05), and after the first lockdown (11/05-31/07).

RESULTS

Among the 5,824 stays included over the study period, PS most involved were alcohol and benzodiazepines. Compared to baseline, the decrease in H-PS's incidence was more important in young adults (-40%; nbaseline=450) in comparison to those aged 30+ (-18%; nbaseline=1,101) during the pandemic period, especially during the lockdown compared to 2017 (-59%; n2017=145 vs. -35%; n2017=166) with far decrease in alcohol and ecstasy intoxications. Seriousness of hospitalisation indications was increased regardless of age during the pandemic. Particularly in young adults, the proportion of suicides attempts increased during lockdown compared to the baseline period (almost 50% vs. 29%) and the period after lockdown was associated with 1.7 more-time road accident increased and 3 more-time fights compared with pre-lockdown period.

DISCUSSION/CONCLUSION

The period following lockdown should be considered at risk H-PS due to accident. Recreational use of alcohol and ecstasy could be a target for minimize serious consequences associated to PS use in young adult.

Comorbidity network analysis using graphical models for electronic health records

Importance

The comorbidity network represents multiple diseases and their relationships in a graph. Understanding comorbidity networks among critical care unit (CCU) patients can help doctors diagnose patients faster, minimize missed diagnoses, and potentially decrease morbidity and mortality.

Objective

The main objective of this study was to identify the comorbidity network among CCU patients using a novel application of a machine learning method (graphical modeling method). The second objective was to compare the machine learning method with a traditional pairwise method in simulation.

Method

This cross-sectional study used CCU patients' data from Medical Information Mart for the Intensive Care-3 (MIMIC-3) dataset, an electronic health record (EHR) of patients with CCU hospitalizations within Beth Israel Deaconess Hospital from 2001 to 2012. A machine learning method (graphical modeling method) was applied to identify the comorbidity network of 654 diagnosis categories among 46,511 patients.

Results

Out of the 654 diagnosis categories, the graphical modeling method identified a comorbidity network of 2,806 associations in 510 diagnosis categories. Two medical professionals reviewed the comorbidity network and confirmed that the associations were consistent with current medical understanding. Moreover, the strongest association in our network was between "poisoning by psychotropic agents" and "accidental poisoning by tranquilizers" (logOR 8.16), and the most connected diagnosis was "disorders of fluid, electrolyte, and acid-base balance" (63 associated diagnosis categories). Our method outperformed traditional pairwise comorbidity network methods in simulation studies. Some strongest associations between diagnosis categories were also identified, for example, "diagnoses of mitral and aortic valve" and "other rheumatic heart disease" (logOR: 5.15). Furthermore, our method identified diagnosis categories that were connected with most other diagnosis categories, for example, "disorders of fluid, electrolyte, and acid-base balance" was associated with 63 other diagnosis categories. Additionally, using a data-driven approach, our method partitioned the diagnosis categories into 14 modularity classes.

Conclusion and relevance

Our graphical modeling method inferred a logical comorbidity network whose associations were consistent with current medical understanding and outperformed traditional network methods in simulation. Our comorbidity network method can potentially assist CCU doctors in diagnosing patients faster and minimizing missed diagnoses.

General hospital admissions in young and middle-aged people who use psychoactive substances: Impact of Covid-19 lockdowns

BACKGROUNDS

The Covid-19 pandemic offered a unique opportunity to investigate trends in hospitalizations related to psychoactive substance intoxication, since the usual health burden of social use at parties and gatherings was likely to be decreased during lockdowns and curfew periods. Since young adults are the main users of psychoactive substances for experimental and recreational purposes, this study identified and compared hospitalization trends in young adults and adults over 30 years old.

METHODS

This national cohort study was conducted using the French hospital discharge database. An interrupted time-series analysis for the period between 2014 and 2020 was performed in two groups: young (age 18-29) and other adults (30+) to ascertain the trends in the monthly incidence of hospitalization related to psychoactive substance intoxication (opiates, cocaine, benzodiazepines, psychostimulants, alcohol and cannabis). Hospitalization characteristics during the first and second lockdown and the period between them were compared to the reference period (from 01/01/2014 to 29/02/2020).

RESULTS

Among 1,358,007 stays associated with psychoactive substance intoxication, 215,430 concerned young adults. Compared with adults 30+, hospitalization trends in young adults showed a greater decrease in the number of stays during lockdown, with a maximum decrease of -39% during the first lockdown (1,566 vs. 2,576; CI95%: 2,285-2,868) versus -20% (10,212 vs. 12,894; CI95%: 12,001-13,787) in the second lockdown. Presentations for alcohol intoxication decreased throughout the pandemic, particularly during the second lockdown, while admissions for benzodiazepine intoxication increased during both lockdowns. Admissions for cannabis intoxication increased throughout the entire period.

CONCLUSIONS

Lockdowns were associated with fewer hospitalizations related to psychoactive substance intoxication in both age groups, especially among young adults, which might reflect a decrease in social use. Recreational use might therefore be an important target for prevention and risk minimization.

New Trend in Toxicological Screening Using Volumetric Absorptive Microsampling (VAMS) and High-Resolution Mass Spectrometry (HR/MS) Combination

In toxicology, screenings are routinely performed using chromatographic methods coupled to detection systems such as high-resolution mass spectrometry (HR/MS). The increase in specificity and sensitivity of HRMS is responsible for the development of methods for alternative samples such as Volumetric Adsorptive Micro-Sampling. Whole blood overloaded with 90 drugs was sampled with 20 µL Mitra^TM to optimize the pre-analytical step as well as to determine the identification limits of drugs. Elution of chemicals was carried out in a solvent mixture through agitation and sonication. After dissolution, 10 μL was injected into the chromatographic system coupled to the Orbitrap^TM HR/MS. Compounds were confirmed against the laboratory library. The clinical feasibility was assessed in fifteen poisoned patients using the simultaneous sampling of plasma, whole blood and Mitra^TM. The optimized extraction procedure allowed us to confirm 87 compounds out of the 90 present in the spiked whole blood. Cannabis derivatives were not detected. For 82.2% of the investigated drugs, the identification limits were below 12.5 ng·mL^-1, with the extraction yields ranging from 80.6 to 108.7%. Regarding the patients' analysis, 98% of the compounds in plasma were detected in Mitra^TM compared to whole blood, with a satisfying concordance (R² = 0.827). Our novel screening approach opens new insights into different toxicologic fields appropriate for pediatrics, forensics or to perform mass screening.

2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care

INTRODUCTION

Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel.

OBJECTIVES

We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel.

METHODS

We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing.

CONCLUSIONS

This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.

Biomedical Nanosystems for In Vivo Detoxification: From Passive Delivery Systems to Functional Nanodevices and Nanorobots

The problem of low efficiency of nanotherapeutic drugs challenges the creation of new alternative biomedical nanosystems known as robotic nanodevices. In addition to encapsulating properties, nanodevices can perform different biomedical functions, such as precision surgery, in vivo detection and imaging, biosensing, targeted delivery, and, more recently, detoxification of endogenous and xenobiotic compounds. Nanodevices for detoxification are aimed at removing toxic molecules from biological tissues, using a chemical- and/or enzyme-containing nanocarrier for the toxicant to diffuse inside the nanobody. This strategy is opposite to drug delivery systems that focus on encapsulating drugs and releasing them under the influence of external factors. The review describes various kinds of nanodevices intended for detoxification that differ by the type of poisoning treatment they provide, as well as the type of materials and toxicants. The final part of the review is devoted to enzyme nanosystems, an emerging area of research that provides fast and effective neutralization of toxins in vivo.

Acute poisoning in children: Etiology, structure, treatment tactics and outcomes

Introduction: Acute poisoning is often observed in children and can have serious consequences since it is characterized by rapid development of symptoms and obvious disfunction of vital organs.

Materials and methods: Retrospective analysis of the case histories of the children with acute poisoning admitted to Voronezh Regional Children’s Clinical Hospital No. 1 in 2016–2019 was carried out. Anamnesis, clinical and laboratory studies and effective treatment criteria were entered into electronic spreadsheets and served as the basis for a database on children’s poisoning.

Results and discussion: Analysis of 183 case histories of children with intoxication aged 4 months to 17 years old was performed. Distribution per age showed bimodal peaks at 1–2 years and 13–14 years. Poisoning was accidental in 96.2% of the cases, and 3.8% of the adolescents reported suicide cases. In the group of young children, acute drug poisoning is more frequent in girls (P < 0.05). In the older groups, there is no gender difference in frequency of poisoning cases.

Early call for medical help is typical for the adolescent age group. Correlation between time of help-seeking and children’s age is statistically significant (correlation coefficient r = 0.38, P < 0.05).

Conclusion: Study of poisoning issue in children will allow to carry out targeted preventive measures to reduce the number of poisoning cases, prevent their consequences and to determine the most rational modus operandi for medical personnel for effective and safe pharmacotherapy.

Graphical abstract

In pediatric practice, intoxication by poisons and drugs is among the most common reasons for seeking medical help and hospitalization in intensive care units. It is important to study and record dynamics, structure and frequency of acute poisoning with subsequent development of prevention and treatment methods.

Clinical Presentations and Predictors of In-Hospital Mortality in Illicit Drug Users in the New Psychoactive Substances (NPS) Endemic Era in Taiwan

Predictors of mortality in illicit drug users involving Novel Psychoactive Substances (NPS) and multiple substances have not been elucidated. We aimed to define predictors of mortality in the NPS endemic era’s illicit drug users to strengthen patient care in emergency treatment. This was a retrospective study. LC-MS/MS-confirmed positive illicit drug users who visited the emergency departments (ED) of six medical systems were enrolled. Demographic information, physical examinations, and laboratory data were abstracted for mortality analysis. There were 16 fatalities in 355 enrolled patients. The most frequently used illicit drugs were amphetamines, followed by opioids, cathinones, and ketamine. The most frequently detected cathinones among the 16 synthetic cathinones were eutylone, followed by mephedrone. The combined use of cathinones and ketamine was most commonly observed in our results. Univariate analysis revealed that the mortality patients were older, with deep coma, faster heart rate and respiratory rate, lower blood pressures and O2 room air saturation, more seizures, abnormal breath sounds, and had urine incontinence compared to the survivor patients. The mortality patients also had acute kidney injury, higher potassium, blood sugar, liver function test, and lactate level. The results of multiple logistic regression demonstrated that SBP < 90 mmHg, dyspnea, blood sugar > 140 mg/dl, and HCO3 < 20.6 mmHg were independent predictors of in-hospital mortality. Regardless of the pattern of the use of illicit drugs, the predictors allow for risk stratification and determining the optimal treatment.

Case series of massive direct oral anticoagulant ingestion-Treatment and pharmacokinetics data

BACKGROUND

Direct oral anticoagulants (DOAC) are widely used due to favourable benefit/risk ratio. However, consequences of massive ingestion have been poorly investigated.

OBJECTIVES

We aimed to report outcome and pharmacokinetic parameters in patients who massively ingested DOACs.

METHODS

We conducted a 5-year cohort study including consecutive massive DOAC ingestion patients admitted to two critical care departments. Patients were managed in accordance with standards of care. We collected the main history, clinical, laboratory, management and outcome data. The time-course of plasma DOAC concentrations measured using specific assays was modelled.

RESULTS

Twelve patients (3F/9M; age, 55 years [41-63], median [25th-75th percentiles]) were included. Ingestions involved rivaroxaban (n = 7), apixaban (n = 3) and dabigatran (n = 2), with presumed doses of 9.4-fold [5.0-22.0] the full daily dose. Six patients received activated charcoal but no antidote nor blood-derived product. No bleeding was observed. One patient died due to refractory cardiogenic shock related to bisoprolol co-intoxication. Highest observed peak plasma concentrations were 1720 ng/ml (rivaroxaban), 750 ng/ml (apixaban) and 644 ng/ml (dabigatran). Times to reach DOAC concentration below 50 ng/ml were ~20-45 h (rivaroxaban), ~125 h (apixaban) and ~30-50 h (dabigatran). Elimination half-lives were 2.5-25.5 h (rivaroxaban), 22.0 and 36.5 h (apixaban), and 5.8 and 15.5 h (dabigatran), with substantial interindividual variability and prolongation in case of cardiovascular failure related to co-intoxicants. Charcoal administration, even if delayed, may have contributed to limit toxicity, possibly by reducing absorption and/or enteroenteric recycling.

CONCLUSION

No bleeding was observed in this series of massive DOAC ingestions despite elevated plasma concentrations. No patient required specific haemostatic agents. Charcoal administration should be considered to limit toxicity.

Whole-bowel irrigation in cases of poisoning: A retrospective multicentre study of feasibility, tolerability, and effectiveness

BACKGROUND

Whole-bowel irrigation (WBI) is a strategy of gastrointestinal decontamination, recommended by several European and American learned societies, which may be used in the management of the poisoned patients.

OBJECTIVES

The objectives of this study were to describe the feasibility and tolerability of this technique and to compare the clinical outcome of a group of poisoned patients treated with WBI versus that of an untreated group.

METHODS

This was a retrospective and observational study of data recorded by the Angers Poison Control Centre (PCC) between 2012 and 2018. All cases for which the PCC advised WBI were included. The association between outcomes (clinical deterioration after WBI advised by a PCC, length of hospitalisation), WBI treatment, and relevant associated risk factors was determined using univariate and multivariate logistic regression.

RESULTS

A total of 257 patients were included. One hundred forty-one patients were treated with WBI with clearly successful induction of diarrhoea in 47 cases (31%). WBI was not initiated in 89 patients. WBI was initiated but unsuccessful (no diarrhoea) in nine cases. The median age is 46 years (interquartile range: 32-55 years), with a sex ratio (M/F) of 1.3. A total of 27 of 150 patients (18%) who underwent WBI had adverse effects possibly linked to WBI, mainly vomiting (n=23). The patients with clinical deterioration (n=49) were irrigated significantly less often (95% confidence interval: 0.13-0.52; p<0.001). After adjustment for sex, age, time to implementation of WBI, type of substance ingested, and admission to intensive care, patients who were treated with WBI were less likely to deteriorate clinically than patients who were not treated with WBI (p<0.001).

CONCLUSION

Despite a low rate of completion of this procedure, WBI appeared to provide clinical benefits in patients treated in comparison of an untreated group and is associated with an acceptably low risk of direct complications.

Factors associated with prolonged intensive care stay among self-poisoned patients

CONTEXT

Since recovery or death is generally observed within a few days after intensive care unit (ICU) admission of self-poisoned patients in the developed countries, reasons for the prolonged ICU stay are of interest as they have been poorly investigated. We aimed to identify the characteristics, risk factors, outcome, and predictors of death in self-poisoned patients requiring prolonged ICU management.

METHODS

We conducted an eight-year single-center cohort study including all self-poisoned patients who stayed at least seven days in the ICU. Patients admitted with drug adverse events and chronic overdoses were excluded. Using multivariate analyses, we investigated risk factors for prolonged ICU stay in comparison with a group of similar size of self-poisoned patients with <7day-ICU stay and studied risk factors for death.

RESULTS

Among 2,963 poisoned patients admitted in the ICU during the study period, the number who stayed beyond seven days was small (398/2,963, 13.1%), including 239 self-poisoned patients (125 F/114M; age, 51 years [38-65] (median [25th-75th percentiles]); SAPSII, 56 [43-69]). Involved toxicants included psychotropic drugs (59%), cardiotoxicants (31%), opioids (15%) and street drugs (13%). When compared with patients who stayed <7days in the ICU, acute kidney injury (odds ratio (OR), 3.15; 95% confidence interval (1.36-7.39); p = .008), multiorgan failure (OR, 8.06 (3.43-19.9); p < .001), aspiration pneumonia (OR, 8.48 (4.28-17.3); p < .001), and delayed awakening related to the persistent toxicant effects, hypoxic encephalopathy and/or oversedation (OR, 8.64 (2.58-40.7); p = .002) were independently associated with prolonged ICU stay. In-hospital mortality rate was 9%. Cardiac arrest occurring in the prehospital setting and during the first hours of ICU management (OR, 27.31 (8.99-158.76); p < .001) and delayed awakening (OR, 14.94 (6.27-117.44); p < .001) were independently associated with increased risk of death, whereas exposure to psychotropic drugs (OR, 0.08 (0.02-0.36); p = .002) was independently associated with reduced risk of death.

CONCLUSION

Self-poisoned patients with prolonged ICU stay of ≥7days are characterized by concerning high rates of morbidities and poisoning-attributed complications. Acute kidney injury, multiorgan failure, aspiration pneumonia, and delayed awakening are associated with ICU stay prolongation. Cardiac arrest occurrence and delayed awakening are predictive of death. Further studies should focus on the role of early goal-directed therapy and patient-targeted sedation in reducing ICU length of stay among self-poisoned patients.

Comparison of clinical characteristics between meth/amphetamine and synthetic cathinone users presented to the emergency department

BACKGROUND

Synthetic cathinones (SC) are popular new psychoactive substances that produce sympathomimetic toxicity. Meth/amphetamine and SC have similar chemical structures and pharmacological effects. We aimed to compare the clinical characteristics between meth/amphetamine and SC users presenting to the emergency department (ED).

METHODS

This retrospective observational cohort study included patients who presented to six EDs from May 2017 to April 2021 with symptoms that related to recreational drug use and whose urine toxicology tests were positive only for meth/amphetamine or SC through liquid chromatography-tandem mass spectrometry.

RESULTS

There were 379 patients who tested positive only for meth/amphetamine (MA group), and 87 patients tested positive only for SC (SC groups). Patients in the MA group were older than those in the SC group (median (IQR); MA: 37.0 (30-43.7), SC: 25.0 (21.0-32.7), p < 0.001). There were no significant between-group differences in the sex distribution and initial chief complaints. Compared with the MA group, the SC group had more cases of tachycardia (≥ 135/min; MA: 29 (8.2%), SC:16 (19.0%), p = 0.0031) and hyperthermia (≥ 38 °C; MA: 31 (8.2%), SC:18 (20.7%), p = 0.001). Besides, the SC group had significantly higher levels of creatinine kinase (CK, IU/L; MA: 263 (115-601), SC: 497 (206-9216), p = 0.008) as well as a higher risk of rhabdomyolysis (CK > 1000; MA:32 (8.4%), SC: 16 (18.4%), p = 0.006) and severe rhabdomyolysis (CK > 10,000; MA:10 (2.6%), SC:10 (11.5%), p = 001). Multivariable logistic regression analyses indicated SC group in comparison with the MA group (adjusted odds ratio: 2.732, 95% confidence interval: 1. 250-5.972, p = 0.012) was an association with the risk of rhabdomyolysis.

CONCLUSION

Our findings demonstrate that tachycardia, hyperthermia, and rhabdomyolysis were more common among cathinone users than among meth/amphetamine users presented to EDs.

The performance of COBRA, a decision rule to predict the need for intensive care interventions in intentional drug overdose

BACKGROUND

COBRA was developed as a decision rule to predict which patients visiting the emergency department (ED) following intentional drug overdose will not require intensive care unit (ICU) interventions. COBRA uses parameters from five vital systems (cardiac conduction, oxygenation, blood pressure, respiration, and awareness) that are readily available in the ED. COBRA recommends against ICU admission when all these parameters are normal.

OBJECTIVE

The primary aim of this study was to determine the negative predictive value (NPV) of COBRA in predicting ICU interventions. Secondary outcomes were the sensitivity, specificity and positive predictive value (PPV), and the observation time required for a reliable prediction.

DESIGN

Observational cohort study.

SETTINGS AND PARTICIPANTS

Patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function were included, and data necessary to complete the decision rule was collected. The attending physician in the ED made the actual admission decision, on the basis of clinical judgement. COBRA was measured 0, 3 and 6 h after arrival at the ED.

OUTCOME MEASURES

Need for ICU interventions (treatment of convulsion; defibrillation; mechanical or noninvasive ventilation; intravenous administration of vasopressive agents, antiarrhythmics, atropine, calcium, magnesium or sedation; continuous hemofiltration or administration of antagonist/antidote and fluid resuscitation).

MAIN RESULTS

Of 230 new cases (144 unique patients), 59 were immediately referred to the psychiatric services and/or sent home by the attending physician, 27 went to a regular ward, and 144 were admitted to the ICU. Of these 144 cases, 40 required one or more ICU interventions. By the time the first parameters were collected, the NPV of COBRA was 95.6%. After 3 h of observation, NPV was 100%, while sensitivity, specificity and PPV were 100, 61.1 and 35.1%, respectively. None of these values improved by prolonging the observation time to 6 h.

CONCLUSION

In patients with a reported intentional overdose with drugs having potential acute effects on neurological, circulatory or ventilatory function, the COBRA decision rule showed good performances in predicting the need for intensive care interventions, with a NPV of 100% after 3 h of observation.

L-carnitine does not improve valproic acid poisoning management: a cohort study with toxicokinetics and concentration/effect relationships

Background

Valproic acid (VPA) poisoning is responsible for life-threatening neurological and metabolic impairments. Despite only low-level evidence of effectiveness, L-carnitine has been used for years to prevent or reverse VPA-related toxicity. We aimed to evaluate the effects of L-carnitine used to treat acute VPA poisoning on the time-course of plasma VPA concentrations and VPA-related toxicity. We designed a single-center cohort study including all VPA-poisoned patients admitted to the intensive care unit. We studied VPA toxicokinetics using a nonlinear mixed-effects model-based population approach and modeled individual plasma VPA/blood lactate concentration relationships. Then, we evaluated L-carnitine-attributed effects by comparing VPA elimination half-lives and time-courses of blood lactate levels and organ dysfunction [assessed by the Sequential Organ Failure Assessment (SOFA) score] between matched L-carnitine-treated and non-treated patients using a multivariate analysis including a propensity score.

Results

Sixty-nine VPA-poisoned patients (40F/29 M; age, 41 years [32–47]) (median [25th–75th percentiles]; SOFA score, 4 [1–6]) were included. The presumed VPA ingested dose was 15 g [10–32]. Plasma VPA concentration on admission was 231 mg/L [147–415]. The most common manifestations were coma (70%), hyperlactatemia (3.9 mmol/L [2.7–4.9]) and hyperammonemia (127 mmol/L [92–159]). VPA toxicokinetics well fitted a one-compartment linear model with a mean elimination half-life of 22.9 h (coefficient of variation, 28.1%). Plasma VPA (C)/blood lactate concentration (E) relationships were well described by an exponential growth equation [\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$E={E}_{0}\times {e}^{k\cdot C}$$\end{document}E=E0×ek·C; with baseline E₀ = 1.3 mmol/L (43.9%) and rate constant of the effect, k = 0.003 L/mg (59.5%)]. Based on a multivariate analysis, peak blood lactate concentration was the only factor independently associated with L-carnitine administration (odds ratio, 1.9, 95% confidence interval, 1.2–2.8; P = 0.004). We found no significant contribution of L-carnitine to enhancing VPA elimination, accelerating blood lactate level normalization and/or preventing organ dysfunction.

Conclusions

VPA poisoning results in severe toxicity. While L-carnitine does not contribute to enhancing VPA clearance, its impact on accelerating blood lactate level normalization and/or preventing organ dysfunction remains uncertain. Investigating VPA toxicokinetics and concentration/effect relationships may help understanding how to improve VPA-poisoned patient management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00984-z.

[The patient with intentional drug or alcohol intoxication in the emergency room]

The intoxicated patient is a frequent situation in the emergency department (ED). Assessment and monitoring of somatic risk must be a priority, especially if there is any doubt about the treatments ingested. The risk of suicide, assessed on the patient's arrival, can lead to increased monitoring. Because of the strong interaction between serious psychiatric pathologies and drug intoxication, a psychiatric assessment should be systematically carried out. This is done at a distance from the intoxication, when the patient's condition allows it. In the case of alcohol intoxication associated with psychiatric symptoms or complaints, the assessment should be carried out after a period of sobering up, defined between the ED and psychiatry teams.

[Emergency medical assessment of the patient with psychiatric conditions]

The evaluation by the emergency doctor of the patient presenting with a psychiatric symptom before being taken care of by the psychiatric team is described by the term medical clearance. There is little work on the performance of complementary examinations on these patients. A retrospective multicentre study conducted at the Metz-Thionville regional hospital (57) shows that at least one complementary examination was carried out in 61% of hospitalised patients, compared with 28% of non-hospitalised patients. For 2.4% of patients, the final diagnosis was organic.

Drug and Chemical Poisoning Patterns in Makkah Region, Saudi Arabia

This research reveals that drugs and chemicals poisoning have been reported to have severe and fetal side effects on health provided by doctors in statistics and periodical records. This work aimed to explore the interaction among drug and chemical poisoning patterns concerning risk factors, especially gender, age, exposure circumstances, and outcomes in the Makkah region. A retrospective analysis was of clinical drug and chemical poisoning cases (2014-2015). The data were retrieved from the Department of Environmental and Occupational Health, Ministry of Health, Makkah, Saudi Arabia. The Saudi Arabia Ministry of Health received 1216 reports of drug and chemical poisoning during 2014-2015 in Makkah. This study has found that, the most affected gender was that of males (65%). The most affected age category with drug poisoning was over 15 years old (67%), but under 5 years for chemical poisoning (60%). The majority of drug poisoning cases are unknown drugs (42%), which accidental poisoning was a minority compared with other drug causes (27%). Chemical poisoning accidents were the majority causes of the recorded cases (63%). We reported healthy recovered without complications for most patients from drug and chemical poisoning (85-95%). Antidotes were administered in only (5%) of cases, and fatalities were reported (0.5% of cases). We have shown a flagrant increase in the number of people poisoned by drugs and chemical agents during 2015. Increases poisoning cases involved both genders and all studied age categories, especially males over 15 years up to 25 (drugs) and < 5 years (chemicals). Most cases were accidental (chemicals) and reported healthy recovery for most patients.

A Supramolecular Antidote to Macromolecular Toxins Prepared through Coassembly of Macrocyclic Amphiphiles

Poisoning is a leading cause of admission to medical emergency departments and intensive care units. Supramolecular detoxification, which involves injecting supramolecular receptors that bind with toxins to suppress their biological activity, is an emerging strategy for poisoning treatment; it has few requirements and a broad application scope. However, it is still a formidable challenge to design supramolecular therapeutic materials as an antidote to macromolecular toxins, because the large size, flexible conformation, and presence of multiple and diverse binding sites of biomacromolecules hinder their recognition. Herein, a supramolecular antidote to macromolecular toxins is developed through the coassembly of macrocyclic amphiphiles, relying on heteromultivalent recognition between the coassembled components and toxic macromolecules. The coassembly of amphiphilic cyclodextrin and calixarene strongly and selectively captures melittin, a toxin studied herein; this imparts various therapeutic effects such as inhibiting the interactions of melittin with cell membranes, alleviating melittin cytotoxicity and hemolytic toxicity, reducing the mortality rate of melittin-poisoned mice, and mitigating damage to major organs. The use of the proposed antidote overcomes the limitation of supramolecular detoxification applicability to only small-molecular toxins. The antidote can also detoxify other macromolecular toxins as long as selective and strong binding is achieved because of the coassembling tunability.

Interaction of Energy Drinks with Prescription Medication and Drugs of Abuse

In recent years, the consumption of energy drinks (EDs) has become increasingly popular, especially among adolescents. Caffeine, a psychostimulant, is the main compound of EDs which also contain other substances with pharmacological effects. This review aims to compile current evidence concerning the potential interactions between EDs, medicines, and drugs of abuse as they are frequently consumed in combination. The substances involved are mainly substrates, inductors or inhibitors of CYP1A2, psychostimulants, alcohol and other depressant drugs. Furthermore, intoxications reported with EDs and other substances have also been screened to describe acute toxicity. The results of our review show that the consumption of both EDs alone and in combination is not as safe as previously thought. Health professionals and consumers need to be aware of the potential interactions of these drinks as well as the absence of long-term safety data.

Does the ICU Requirement Score allow the poisoned patient to be safely managed without admission to the intensive care unit? - a validation cohort study

BACKGROUND

The Intensive care unit (ICU) Requirement Score (IRS) has been defined as identifying poisoned patients on hospital admission who do not require ICU referral, in an effort to reduce health expenses. However, this score has been poorly validated. We aimed to evaluate the IRS in a large cohort of poisoned patients.

METHODS

We performed a single-center retrospective cohort study. IRS was calculated using clinical parameters obtained on admission including age, systolic blood pressure, heart rate, Glasgow coma score, intoxication type, co-morbidities (i.e., arrhythmia, cirrhosis, and respiratory insufficiency), and the combination of the intoxication with another reason for ICU admission. We evaluated the ability of IRS < 6 determined on admission to predict the lack of need for ICU treatment, defined as the need for mechanical ventilation, vasopressors, and/or renal replacement therapy in the first 24 h post-admission and/or death during the hospital stay. This score was compared to the usual prognostic scores, i.e., SAPS II and III, SOFA score, and PSS.

RESULTS

During the 10-year study period, 2,514 poisoned patients were admitted, 1,011 excluded as requiring ICU treatment on admission, and 1,503 included. Among these patients, 232 met the endpoint whereas only 23/510 patients with IRS < 6 (4.5%) presented the endpoint and one patient died. The area under the curve of the IRS ROC curve was 0.736 (95% confidence interval (CI), 0.702-0.770). The negative predictive value of IRS < 6 was 95% (95% CI, 93-97), sensitivity 89% (95% CI, 85-93), specificity 38% (95% CI, 36-41), and positive predictive value 21% (95% CI, 18-24). IRS performance was similar to those of the other tested scores, which are however not readily available on admission.

CONCLUSION

Our data demonstrate the excellent negative predictive value of the IRS, allowing the exclusion of ICU requirements for poisoned patients with IRS < 6. IRS usefulness should be confirmed based on a prospective multicenter cohort study before extensive routine use.

Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences

De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.

Massive suicidal ingestion of caffeine: a case report with investigation of the cardiovascular effect/concentration relationships

BACKGROUND

Caffeine poisoning may cause life-threatening arrhythmias and hemodynamic failure. We aimed to investigate the toxicokinetics (TK), toxicodynamics (TD) and TK/TD relationships of caffeine in a case of poisoning.

CASE REPORT

A 47-year-old male ingested pure anhydrous caffeine powder (70 g) in a suicide attempt. He developed agitation, tachycardia, and two episodes of ventricular fibrillation treated with defibrillation and tracheal intubation. He was successfully managed using intravenous infusions of esmolol and norepinephrine.

METHODS

We modelled the time-course of plasma caffeine concentration (TK study using online liquid chromatography-tandem mass spectrometry), the time-course of blood lactate concentration and infusion rates of esmolol and norepinephrine (TD studies) and the TK/TD relationships.

RESULTS

Caffeine TK was of first-order peaking at 258 mg/L with an elimination half-life of 46.2 h and clearance of 2.2 L/h. Caffeine-related effects on blood lactate (peak, 10 mmol/L at 1.25 h postingestion) were described by a Bateman-type equation (formation rate, 0.05 mmol/mg.h; elimination rate, 0.9 mmol/mg.h). Esmolol and norepinephrine infusion rates to reverse caffeine-related cardiovascular effects (peaks at 51-h postingestion) fitted well with a sigmoidal E_max model (EC₅₀, 180.0 and 225.9 mg/L, respectively; Hill coefficient, 10.0).

CONCLUSION

Massive caffeine ingestion is characterized by prolonged caffeine elimination. TK/TD relationships are helpful to quantify caffeine-related catecholaminergic effects.

The prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children's Hospital, Cape Town, South Africa

Background

Paediatric poisoning is a common presentation to emergency departments worldwide. There is a paucity of data on the role of liquid chromatography-tandem mass spectrometry (LC-MS/MS), in the management of paediatric poisoning in low-and middle-income countries (LMICs). In high-income countries, most studies are retrospective, and few include children.

Objective

The study describes the prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa.

Methods

Children admitted with suspected poisoning between 1 January 2017 and 31 December 2017, were recruited. All patients had a urine and/or blood sample sent for LC-MS/MS toxicology. Data collected included demographic data, clinical features, investigations, management, outcome and social interventions.

Results

One hundred fifty-two children, with median age of 39 (IQR 25–61) months were enrolled of which 128 (84%) were poisoning cases. Of the 128 poisoning cases, 88 (69%) presented with a history of ingesting a known substance, 16 (12%) an unknown substance and 24 (19%) were cases of occult poisoning. LC-MS/MS was able to identify a substance in 92% of the cases of occult poisoning. In those who had presented with a seemingly known substance, LC-MS/MS found a different substance in 15 cases. LC-MS/MS was also able to detect multiple drugs in 40 patients. Of the poisoning cases, six (5%) cases were attempted homicide cases and 5 (4%) cases were attempted suicide cases. No children died. Individualized social interventions were instituted in poisoning cases. Emergency placement safety reasons was required in 6 children.

Conclusion

When the limitations are known, LC-MS/MS is useful in identifying cases of occult poisoning, identifying patients who have ingested multiple substances and/or an unknown substance and when targeted towards child protection. As LC-MS/MS is an expensive test, it should be used judiciously in LMICs.