Drug overdoses with antimalarial agents: prescribing and dispensing errors.
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Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. Diagnosis of drug overdose by rapid reversal with naloxone.
A short-cut review was carried out to establish whether naloxone may have an awakening effect in patients who have not taken opiates, thereby clouding its use as a diagnostic manoeuvre. The clinical bottom line is that opioid antagonists are able to reverse symptoms such as altered consciousness in patients who have not taken an overdose of opiates. It is unclear in which conditions or circumstances this occurs.
Adult↗
Medical management of deliberate drug overdose: a neglected area for suicide prevention?
OBJECTIVES: Overdoses account for a quarter of all suicides in England. The number of people who survive the immediate effects of their overdose long enough to reach medical attention, but who subsequently die in hospital is unknown. The aim of this study was to determine the proportion of overdose suicides dying in hospital and describe their sociodemographic characteristics. METHOD: Cross sectional analysis of routinely collected Hospital Episode Statistics data for England (1997 to 1999) to identify hospital admissions for overdose among people aged 12+ and the outcome of these admissions. RESULTS: Between 1997 and 1999 there were 233 756 hospital admissions for overdose, 1149 (0.5%) of these ended in the death of the patient such deaths accounted for 28% [corrected] of all overdose suicides and 8% [corrected] of total suicides. The median time between admission and death was three days (interquartile range one to nine days). The most commonly identified drugs taken in fatal overdose were paracetamol compounds, benzodiazepines, and tricyclic/tetracyclic antidepressants. CONCLUSION: Around a quarter of all overdose suicide deaths occur subsequent to hospital admission. Further more detailed research is required to discover if better pre-admission and in-hospital medical management of those taking serious overdoses may prevent some of these deaths.
Acetaminophen↗
Calling emergency medical services during drug overdose: an examination of individual, social and setting correlates.
AIMS: The purpose of this study was to examine individual, social and setting correlates of calling the emergency number, 911, during an overdose. DESIGN: Cross-sectional survey. METHODS: A sample of 397 current or former drug users in Baltimore, MD, USA who reported having ever witnessed an overdose. FINDINGS: Participants reported calling an ambulance in 23% of the overdose cases. Results from multivariate logistic regression indicate that having ever overdosed and having four or more bystanders present independently decreased the likelihood of calling 911. Having ever witnessed a fatal overdose and having any female bystanders present increased the likelihood of calling 911. There was a significant interaction between fear of arrest and prior exposure to the police. Setting of the overdose (public versus private) was not associated with calling 911 after controlling for other factors. CONCLUSIONS: These findings suggest that in addition to personal characteristics of witnesses, social factors influence calling 911. Intervention at the social level may be a viable means to increase bystander helping behaviors.
Adult↗
Pharmaceutical drug overdose.
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Acetaminophen↗
A consideration not to be overlooked. Activated charcoal in acute drug overdoses.
Acute poisoning, accidental and incidental, is an everyday occurrence in most emergency departments. The mainstay of emergency therapy is to provide supportive care and limit further absorption of the toxic substance.
Charcoal↗
Effects of a drug overdose in a television drama on knowledge of specific dangers of self poisoning: population based surveys.
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Acetaminophen↗
Prolonged gastric emptying half-time and gastric hypomotility after drug overdose.
A prospective study was undertaken to determine if gastric motility and emptying are altered by the ingestion of overdoses of tricyclic antidepressants, acetaminophen, opioid-acetaminophen mixtures, carbamazepine or phenytoin. Gastric scintigraphy was used to measure gastric emptying half-time and assess gastric motility in 104 patients at initial presentation and again at follow-up (n = 85). Patients were imaged for 5 hours after being given 20 MBq of 99mTc tin colloid to drink. Drug serum levels were measured on all patients at initial presentation and at follow-up. We observed markedly prolonged gastric emptying half-times and severe hypomotility at initial presentation compared with follow-up in the vast majority of patients, except for a small group of patients with phenytoin poisoning. Twelve patients had gastric emptying half-times of over 300 minutes, a further 14 had half-times of over 200 minutes and 21 others had half-times of over 120 minutes. Poisoning is associated with hypomotility and a marked delay in gastric emptying that could influence the clinical course and patient management. These abnormalities may not be due to a direct effect of the ingested drug and factors such as stress may play a role.
Acetaminophen↗
Interaction between infusion equipment resulting in drug overdose in a critically ill patient.
A critically ill septic patient on haemofiltration for acute renal failure suffered sudden circulatory and respiratory collapse. The cause of the collapse was traced to an interaction between mechanical devices (syringe driver infusion pumps and haemofiltration equipment) connected to two central venous catheters.
Acute Kidney Injury↗
Poisoning and drug overdose.
Poisoning is a common cause for intensive care unit admission for both children and adults, and most poisoning victims are effectively treated using standard decontamination measures and supportive care. For a small number of poisons, acceleration of toxin removal with hemodialysis or hemofiltration is indicated. Similarly, specific antidotes are indicated in a few selected circumstances. Rarely, patients may benefit from more aggressive supportive techniques such as cardiopulmonary bypass.
Adult↗
Medical management of adolescent drug overdoses.
This article outlines the current clinical approach to poisonings in the adolescent age group. Management issues are presented for several specific substances frequently abused by this population. The purpose of such a review is to stimulate self-education in the practitioner. A secondary goal is to promote awareness of the various manifestations of substance abuse problems to facilitate recognition and referral. Adolescence is often a critical point for effective intervention and prevention on the road from use to addiction. Long-term survival may depend more on substance use rehabilitation than on the initial medical management.
Adolescent↗
Suspected central nervous system toxicity from inadvertent nonsteroidal antiinflammatory drug overdose.
This case illustrates a severe adverse reaction of the central nervous system involving a moderate overdose of diclofenac sodium along with therapeutic dosages of indomethacin and ibuprofen. Our patient became disoriented, hallucinated, lost consciousness, and suffered respiratory arrest after ingesting five diclofenac tablets (375 mg total), two ibuprofen tablets (400 mg total), and one indomethacin capsule (75 mg). Aggressive supportive therapy was instituted and the patient improved. She was awake, alert, and extubated in less than 24 hours with no serious sequelae.
Anti-Inflammatory Agents, Non-Steroidal↗
Phytonadione therapy in a multiple-drug overdose involving warfarin.
We cared for a patient who ingested an unknown amount of acetaminophen with zopiclone and warfarin. The only liver function test that was abnormal was an increased international normalized ratio (INR), which remained elevated despite treatment with subcutaneous phytonadione and a prolonged infusion of N-acetylcysteine. An interaction between acetaminophen and warfarin may have decreased the hepatic metabolism of warfarin. The patient received numerous antibiotics that may have contributed to the increased INR. The prolonged elevation of INR also may have been due to infrequent administration of phytonadione.
Acetaminophen↗
Multiple drug overdose in a kidney transplant patient.
Development of depression in patients with organ transplants is accompanied by an increased incidence of suicide attempts. A 60-year-old man with chronic polycystic renal disease underwent a kidney transplant 2 years previously. Six months prior to admission, the patient had been medicated for depression. This course was complicated by noncompliance and worsening family problems. One morning, the patient was found unconscious, along with a suicide note and empty bottles of cyclosporine (CsA), imipramine (IP), meticorten, azathioprine, oxazepam, alprazolam, and fluoxetin, approximately 24 h after the presumed intake of these agents. Initial plasma IP level was 2260 ng/ml, whole blood total cyclosporine (T-CsA) concentration was 1,800 ng/ml and that of specific cyclosporine (Sp-CsA), 714 ng/ml. Urine toxic screening was positive also for benzodiazepines metabolites. IP and CsA blood levels were measured daily. Five days after overdose, the IP concentration was 232 ng/ml, that of T-CsA 401 ng/ml, and that of Sp-CsA 96 ng/ml. Compared to subjects on therapeutic doses, a significant prolongation of the half-life, t 1/2, was observed for both IP (t1/2, 43.4 h) and Sp-CsA (t1/2, 70.1 h). In the present case, prolonged elevated IP plasma levels were not associated with cardiovascular complications. On the 5th hospital day, after the patient had apparently recovered from the intoxication, he jumped from the 8th floor to his death.
Chromatography, Thin Layer↗
Segmental analysis for cocaine and metabolites by HPLC in hair of suspected drug overdose cases.
Hair samples of eight postmortem cases were analyzed in segments of 1 to 3 cm for cocaine, benzoylecgonine and cocaethylene. Samples were prepared for analysis by digestion in 0.1 M HCl and subsequent extraction with mixed-mode solid-phase extraction columns. Measurement was made by reversed-phase, narrow-bore HPLC and fluorescence detection using two laboratory-made internal standards. The concentrations were in the region of 0.29-316 ng/mg of hair for cocaine, 0.43-141 ng/mg of hair for benzoylecgonine and 0.93-1.83 ng/mg of hair for cocaethylene. All eight investigated cases had cocaine-positive segments. In six of the cases, all segments were positive, suggesting regular cocaine use and two showed in-between negative segments indicating an interruption or a change of the abuse intensity. The results showed a second, remarkable observation, i.e. enormous concentration differences (factor >150) for both cocaine and benzoylecgonine between the different subjects. Furthermore, interindividual cocaine/benzoylecgonine ratios ranged from 0.02 to 8.43. We believe these observations could in part be attributed to both some of the still existing limitations in the analytical approach(es), especially the mandatory hair washing steps, and in our still too limited knowledge of the hair incorporation processes. Nevertheless, in some cases, segmental analysis proved to be an important tool to distinguish, together with postmortem examination, deadly chronic abuse from single acute drug overdosage.
Chromatography, High Pressure Liquid↗
Chlormezanone plasma and blood levels in patients after single and repeated oral doses and after suicidal drug overdose.
Chlormezanone plasma concentrations were determined in 5 volunteers (group 1) after a single oral dose of 200 mg of chlormezanone with high performance liquid chromatography. A plasma elimination half-life of 23 +/- 2.3 h was calculated. The mean peak chlormezanone plasma level was 1.86 +/- 0.2 micrograms/ml, 1 h after ingestion. Additionally, chlormezanone plasma levels were determined after repeated oral doses of chlormezanone recommended for treatment of muscular spasms due to degenerative skeletal disease. After 5 days of repeated daily doses of 3 x 200 mg (group 2; 12 patients) or 3 x 400 mg (group 3; 10 patients) of chlormezanone, mean predose chlormezanone plasma levels were 12.0 +/- 2.0 micrograms/ml (group 2) and 22.7 +/- 4.0 micrograms/ml (group 3), respectively. Comparable plasma concentrations were determined after 10 days of repeated doses of 3 x 200 mg or 3 x 400 mg of chlormezanone in 3 patients from each of these 2 groups. In 7 patients of group 3, chlormezanone had to be discontinued on the 5th day due to increasing muscular weakness, ataxia and exercise-inducible tachycardia. After a loading dose of 800 mg and repeated doses of 3 x 200 mg chlormezanone to 5 patients (group 4), plasma levels of 6.5 +/- 2.1 micrograms/ml, 8.9 +/- 2.2 micrograms/ml, 12.7 +/- 2.0 micrograms/ml, and 10.4 +/- 2.4 micrograms/ml were determined after 2, 8, 16, and 36 h, respectively. Trace amounts of a degradation product of the acid-labile chlormezanone could be detected in plasma besides the unchanged drug after administration of repeated oral doses.(ABSTRACT TRUNCATED AT 250 WORDS)
Acetaminophen↗
Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study.
OBJECTIVES: To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning. DESIGN: Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods. SETTING: 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data. SUBJECTS: 4403 self poisoning patients; questionnaires completed for 1047. MAIN OUTCOME MEASURES: Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers. RESULTS: Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%). CONCLUSIONS: Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.
Acetaminophen↗
Identification of anhydroecgonine ethyl ester in the urine of a drug overdose victim.
Toxicological evaluation of postmortem urine collected from a 41-year-old deceased white male detected anhydroecgonine ethyl ester (ethylecgonidine, AEEE), a transesterification product of smoked cocaine co-abused with ethanol. A solid phase extraction (SPE) method was used to extract cocaine, AEEE, and related metabolites from urine. SPE on a 1 mL urine sample from the decedent followed by GC-MS detected AEEE. Other metabolites identified by GC-MS included cocaine, cocaethylene, and anhydroecgonine methyl ester (AEME). To determine whether some or all of the AEEE was artifactually produced in the heated GC injector port, an alternative LC-MS method was developed. LC/MS following SPE found at least 50 ng/mL of AEEE in the extract. The mass fragmentation (MS/MS and MS3) of AEEE detected in the urine was compared to spectra of authentic, synthesized compound. AEEE is a potential additional forensic marker for the co-abuse of smoked cocaine and ethanol.
Adult↗