Clinical Toxicology最新文献

Introduction: Improper use of botulinum neurotoxin may result in poisoning. This study aimed to investigate the causes, characteristics, and risk factors of iatrogenic botulism incidents in China.

Methods: Patients diagnosed with iatrogenic botulism who presented to the emergency department of the Second Hospital of Hebei Medical University between June and July 2024 were included. We assessed baseline demographics, clinical symptoms, disease grade, and botulinum toxin type A-related variables. Multivariate regression analysis was used to identify independent risk factors influencing the 30-day prognosis.

Results: A total of 195 patients were included in the study, with a median age of 38 years (IQR: 33-47 years) and a male-to-female ratio of 1:38. Blurred vision was the most common early feature (82.1%), followed by dizziness and ptosis (75.9%), fatigue (65.1%), and dysarthria (63.1%). The most frequently observed complications were acute gastroenteritis (9.7%), followed by aspiration pneumonia (7.2%). Fifty-one patients experienced severe poisoning with early ocular, facial, limb muscle, and respiratory muscle involvement. Thirty-two patients (16.4%) required mechanical ventilation. The median latent period was 3 days (IQR: 2-4 days), with a median interval of 7 h (IQR: 4-10 h) observed between symptom onset and antitoxin administration. The median duration of hospitalization was 6 days (IQR: 4-8 days). Adverse reactions to the antitoxin included serum sickness in 11 patients and allergic reactions in 20 patients. Based on the presence or absence of clinical signs 30 days post-discharge, we categorized the cohort into good and poor prognostic groups; 87 patients (44.6%) had a poor prognosis. Independent risk factors for a poor prognosis included a latent period ≤3 days, increased time from onset of features to antitoxin treatment, longer hospital duration, disease severity, and need for mechanical ventilation.

Discussion: Iatrogenic botulism frequently leads to severe outcomes due to delayed diagnosis and intervention. We identified a disease severity grading system alongside additional risk factors to predict patient prognosis.

Conclusion: Our study underscores the critical importance of early recognition and timely treatment of iatrogenic botulism. Clinicians should implement prompt treatment to mitigate disease progression.

Introduction: Consensus guidelines for out-of-hospital assessment and triage of paracetamol (acetaminophen) exposure were published in 2006. Changes in the healthcare system, paracetamol ingestion trends, and availability of paracetamol-containing products necessitate an update to these guidelines. Updated guidelines were created for out-of-hospital management of paracetamol exposure in the United States and Canada.

Methods: A modified Delphi consensus methodology was used to create a decision framework to evaluate clinical aspects of care related to paracetamol overdose in the out-of-hospital setting. Twenty-one panelists were selected by four clinical toxicology societies (America's Poison Centers®, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association for Poison Centres and Clinical Toxicology) to participate as panelists. Guidelines were collected from most poison centers in the United States and Canada, and systematic collection and review of medical literature was conducted.

Results: The panel developed a guideline for out-of-hospital management of paracetamol exposure that encompasses acute and repeated supratherapeutic ingestion patterns. Acute ingestion is defined as any ingestion presenting within 24 h of initial ingestion, regardless of ingestion pattern. Repeated supratherapeutic ingestion is defined as an exposure that occurs over a period of 24 h or more. This guideline emphasizes the importance of obtaining accurate history. When ingestion history is determined as accurate, dosage and ingestion pattern are used to decide treatment referral. It is recommended that patients be referred to the emergency department if their ingestion amount is: (1) ≥200 mg/kg or 10 g (whichever is less) within 24 h; (2) ≥150 mg/kg/24 h or 6 g/day (whichever is less) within 48 h; (3) ≥100 mg/kg/24 h or 4 g/day (whichever is less) for more than 48 h.

Discussion: The need for standardizing the out-of-hospital assessment and triage of paracetamol exposure is pressing. Despite the availability of acetylcysteine, some patients develop fatal liver failure due to missed diagnoses and delays in treatment. Failure to recognize cases requiring acetylcysteine is associated with significant morbidity and mortality.

Conclusion: This consensus statement provides evidence-based guidance for out-of-hospital management of paracetamol ingestion to standardize healthcare facility referral criteria for paracetamol exposed patients.

Introduction: Metformin is a biguanide medication thought to contribute to increased insulin sensitivity. It does not induce insulin release or act via insulin receptors, so it is not considered a common cause of hypoglycemia, even in overdose. However, massive metformin overdoses may be associated with severe hypoglycemia as well as hypothermia.

Methods: Four patients who had hypoglycemia after metformin overdoses are presented. None had access to other diabetic medications or a known diagnosis of diabetes mellitus.

Results: Severe hypoglycemia (blood glucose concentration <2.2 mmol/L [<39.6 mg/dL]) in all patients was diagnosed on presentation or within 9 h of initial presentation. Peak serum lactate concentrations were observed after hypoglycemia in each patient. Three patients developed hypothermia. Three patients received extracorporeal therapy; hemodialysis (one), continuous kidney replacement therapy (one), both modalities (one). One patient died. The remainder were discharged home within 2-6 days of presentation.

Discussion: The complex mechanisms of metformin may explain the observed progression of manifestations following large metformin overdoses.

Conclusion: Large metformin ingestions exceeding 60 g can be associated with critically low serum glucose concentrations concurrently with or preceding increases in serum lactate concentrations. Hypothermia may also occur. Further study is needed to determine the exact mechanisms and true incidence of this manifestation, which may be underrecognized.

Introduction: "Snake" fireworks are a type of pyrotechnic device that, when ignited, burn and transform into a friable, snake-like structure. The inclusion of barium salts produces a green flame. Ingestion of these fireworks poses a risk of barium toxicity, which may result in hypokalemia, weakness, dysrhythmias, and respiratory distress.

Methods: We evaluated firework-related cases at a single poison center between 2009 and 2023 and extracted those pertaining to snake fireworks. Cases were eligible for analysis if oral exposure was suspected or confirmed. Cases were excluded if there was no oral exposure, the missing firework was located after the initial call, or there was no longitudinal follow up after a suspected or witnessed exposure (that is, premature case closure). Pertinent details related to the exposure or those associated with barium toxicity were extracted and evaluated in a descriptive fashion.

Results: Sixty-four cases met inclusion criteria. No deaths, dysrhythmias, weakness, or respiratory compromise were reported. All six children (9.3%) who were symptomatic had gastrointestinal complaints at initial contact with our poison center. Only two symptomatic patients had hypokalemia with the minimum serum potassium concentrations falling to 3.4 mmol/L and 2.1 mmol/L. Four additional patients developed mild hypokalemia (lowest 3.0 mmol/L) but no symptoms. The maximal latency after exposure until nadir potassium concentration was 8 h.

Discussion: Oral exposures to snake fireworks occasionally resulted in mild symptomatic toxicity. The presence of symptoms did not appear to predict whether hypokalemia would develop. In the instances in which hypokalemia was present, or there was a notable downtrend in the serum potassium concentration, the repletion of potassium usually did not correlate with the extent of rebound.

Conclusion: In our case series, most children who had oral exposure to snake fireworks in an exploratory setting did not develop symptoms. Although severe toxicity reassuringly did not occur in our review, evaluation and monitoring are nevertheless prudent for symptomatic children.

Introduction: Lamotrigine overdose is not typically associated with severe toxicity. However, both severe toxicity and serotonin toxicity is occasionally reported following large ingestions. We aimed to investigate the clinical effects of lamotrigine overdose.

Methods: This was a prospective observational study from July 2020-March 2024. Patients >14 years-old with acute lamotrigine overdose (≥2 g ingestion) were recruited from the Australian Toxicology Monitoring study or identified from three toxicology units. Data extracted included clinical features, lamotrigine concentrations, management, and outcomes.

Results: Fifty-four patients were included, median age 29 years (IQR: 21-42 years), 37 (69%) were female. The median ingested dose was 4.8 g (IQR: 3.2-6.3 g) and 41 patients (76%) co-ingested other substances. The median maximum lamotrigine concentration was 18.5 mg/L (IQR: 12.4-25.0 mg/L) at a median time of 4.3 h (IQR: 3.2-10.8 h) post-ingestion. Clinical effects and their management included sedation in 44 (81%) with 29 patients (54%) endotracheally intubated, tachycardia in 39 (72%), hypotension in 21 (39%) with 15 (28%) receiving inotropes, and seizures in 11 (20%). Serotonin toxicity occurred in 23 (43%) patients with four having severe toxicity characterised by temperature >38.5 °C and/or rigidity treated with muscle paralysis. Higher peak lamotrigine concentrations were correlated with severe outcomes such as endotracheal intubation for coma (P <0.0001), patients with hypotension receiving inotropes (P = 0.0269) and patients developing seizures (P = 0.0002). Patients who co-ingested another serotonin agent (some in therapeutic doses) had a higher incidence of developing serotonin toxicity (22/33 [67%]) versus those who had not (1/21 [5%]); P <0.0001).

Discussion: Severe toxicity was associated with higher peak lamotrigine concentrations. Serotonin toxicity was common in those who were exposed to another serotonergic agent.

Conclusion: Coma, seizures and hypotension following lamotrigine overdose appeared to be concentration dependent. Serotonin toxicity occurred in those who co-ingested another serotonergic agent and was unrelated to lamotrigine concentration.

Introduction: This study primarily aimed to assess the ability to detect major cardiac events using the history, electrocardiogram, age, risk factors and troponin (HEART) pathway, modified cocaine HEART score, and HEART score among patients with cocaine-associated chest pain.

Methods: This single-centre retrospective study included consecutive patients with cocaine-associated chest pain admitted between January 2016 and December 2022 who were age and sex-matched in a 1:2 ratio to patients with chest pain not associated with cocaine use. The primary outcome was the percentage of major adverse cardiovascular events within 30 days.

Results: In total, 1,412 patients were included, with 1,653 presentations, of whom 551 presented with cocaine-associated chest pain and were ≥18 years old. Most presentations involved male patients (84%). Major adverse cardiovascular events occurred in 139 presentations: 50 (9.1%) among patients with cocaine-associated chest pain and 89 (8.1%) among patients with non-cocaine-associated chest pain. The number of low-risk presentations of cocaine-associated chest pain patients was 409 (74.2%), 345 (62.6%) and 394 (71.5%) according to the HEART score, modified cocaine HEART score and HEART pathway, respectively. The HEART pathway had the lowest percentage of observed major adverse cardiac events in low-risk patients (0%; 95% CI: 0-0.9%), followed by the modified cocaine HEART score (0.3%; 95% CI: 0.007-1.6%) and the HEART score (0.7%; 95% CI: 0.2-2.1%). Sensitivity, negative predictive value, and area under the curves were very similar between the three scores.

Discussion: The occurrence of missed major adverse cardiovascular events in low-risk patients was below 0.7% (95% CI: 0.2%-2.1%) in all three risk stratification scores. The HEART pathway was the safest risk stratification tool with a sensitivity and negative predictive value of 100%. Nevertheless the differences with the other risk stratification scores were non-significant.

Conclusions: All three risk stratification scores performed well in a low-risk population with cocaine-associated chest pain, with a percentage of 0.7% of patients with a missed major adverse cardiovascular event.

Introduction: Hemodialysis has an essential role in the treatment of certain poisoned patients, both by enhancing the elimination of select poisons and correcting underlying fluid, electrolyte, and acid-base disturbances. We sought to identify barriers to the performance of hemodialysis when it was recommended by our poison center.

Methods: Data from a single United States poison center were retrospectively queried for adult patients for whom the poison center recommended intermittent hemodialysis for poison removal. The primary outcome was the performance of intermittent hemodialysis within 12 h of the poison center recommendation, which we defined as timely hemodialysis. Univariable and multivariable logistic regressions were performed to assess the effect of the following variables on this outcome: age group, patient sex, time of day of the recommendation, day of week of the recommendation, year of the recommendation, hospital location, and poison category.

Results: A total of 535 patient encounters were analyzed. The majority (73.5%) of patients had intermittent hemodialysis performed within 12 h of when it was recommended. The multivariable analyses showed that the odds of receiving recommended intermittent hemodialysis within 12 h were significantly lower when the recommendation was made during the nighttime (OR: 0.660; 95% CI: 0.442-0.987) compared to daytime and during the weekend (OR: 0.605; 95% CI: 0.398-0.918) compared to weekdays.

Discussion: Intermittent hemodialysis is resource-intensive and requires specialized equipment and personnel, which is likely less available outside of regular business hours. This study is limited by its retrospective nature and may not be generalizable to other poison centers.

Conclusion: Patients for whom our poison center recommended intermittent hemodialysis during non-weekday times had lower odds of receiving timely hemodialysis. Hospital administrators and healthcare providers should be aware of this potential treatment obstacle for poisoned patients and identify the specific barriers involved in order to facilitate timely hemodialysis.