D. N. Bateman

Comparative Toxicity of Citalopram and the Newer Antidepressants After Overdose

Objective: To compare the toxicity of citalopram, venlafaxine, mirtazapine, and nefazadone after overdose. Methods: Two‐year retrospective review of consecutive patients admitted to the toxicology unit of Edinburgh Royal Infirmary. Outcome measure included physiological variables, ECG recordings, peak creatine kinase, development of arrhythmias, seizure, tremor or agitation, and the need for admission to a critical care facility. Results: A total of 225 patients were studied. Venlafaxine was associated with a significantly higher pulse rate (p < 0.0001) and tremor (p = 0.007) than other antidepressants. Citalopram was associated with a significantly longer QT interval on ECG recording (p < 0.0001) but mean QTc durations were not significantly different between all drugs studied. No arrhythmias were recorded. Only venlafaxine and citalopram caused seizures and were associated with the need for admission to Intensive Care, but there was no significant difference between them. Conclusions: Mirtazapine and nefazadone appear safe in overdose and were associated with minimal features of neurological or cardiovascular toxicity. Citalopram is more likely to cause QT prolongation but other features of cardiovascular toxicity were uncommon. Both citalopram and venlafaxine are proconvulsants. Venlafaxine also causes more frequent features of the serotonin syndrome.

Laboratory analyses for poisoned patients: joint position paper

To enable consistency of investigation and the establishment of best practice standards, consensus guidelines have been formulated jointly by the UK National Poisons Information Service (NPIS) and the Association of Clinical Biochemists (ACB). The types of laboratory investigation required for poisoned patients were categorized as either (a) essential common laboratory investigations or (b) specific toxicological assays, and also as either (i) common or (ii) specialist or infrequent. Tests in categories (a) and (bi) are expected to be available 24 h per day, with a maximum turnaround time of 2 h. For the specialist assays, i.e. category (bii), availability and turnaround times have been specified individually. The basis for selection of these times has been clinical utility. The adoption of these guidelines, along with the use of the NPIS online poisons information resource TOXBASE (www.spib.axl.co.uk), will enable the poisoned patient to receive appropriate, best practice investigations according to their clinical needs and will avoid the use of unnecessary investigations.

National toxicovigilance for pesticide exposures resulting in health care contact – An example from the UK's National Poisons Information Service

Abstract Background. Although there are extensive systems in place for pharmacovigilance, similar systems for detecting adverse health effects relating to pesticide exposure are rare. In 2004, the National Poisons Information Service (NPIS) pesticide surveillance study was implemented to identify cases requiring health care contact in the UK. This report describes the epidemiology of pesticide exposures reported to poison centres in the UK over a 9-year period. Methods. Data on exposures were gathered through monitoring access to the NPISs online clinical toxicology database TOXBASE® and through monitoring calls to the four NPIS units (Edinburgh, Cardiff, Newcastle and Birmingham). Severity was judged by both caller and NPIS staff. Results. During the 9 years, 34,092 enquiries concerning pesticides were recorded; 7,804 cases of pesticide exposure were derived from these enquiries. Exposures were predominantly unintentional and acute (6,789; 87.0%); 217 (2.8%) and 755 (9.7%) were chronic unintentional and acute deliberate self-harm exposures, respectively. The majority of cases occurred in children, especially the 0–4 year age group The minimum incidence of pesticide exposure requiring health care contact was 2.0 cases/100,000 population per year. Reported numbers were 6- to 25-fold greater than those picked up through other UK pesticide toxicovigilance schemes. There were 81 cases of severe toxicity and 38 cases of fatal exposure. Deliberate self-harm accounted for 62.3% of severe cases and 79% of deaths. Aluminium phosphide, paraquat, diquat and glyphosate were responsible for most severe and fatal cases. Conclusions. The data gathered from this pesticide surveillance study indicate that poison centre resources can usefully monitor pesticide exposures resulting in health care contact in the UK. The NPIS may usefully be one component of the UKs response to European legislation requiring surveillance of complications resulting from pesticide use.

UK childhood exposures to pesticides 2004–2007: a TOXBASE toxicovigilance study

Objective: There are no systematic methods for toxicovigilance of non-medicinal products in the UK. This is particularly relevant for pesticides, where there is significant public concern about potential adverse effects. This study describes a prospective toxicovigilance scheme based on follow-up of enquiries to the National Poisons Information Service (NPIS) through its online poisons information system TOXBASE. These enquiries reflect acute exposures and the patterns of acute illness that result. Results: A total of 10u2009061 pesticide-related enquiries were identified. After follow-up, data were gathered on 2364 suspected exposures, of which 1162 involved children. After exclusions, 1147 exposures are reported here. No deaths were reported and only 37 children were admitted to hospital. The majority were considered to have either minimal or no features (925, 80.6%). Symptoms for 38 children were unknown. Symptoms reported in the other 184 children included nausea or vomiting (58), eye irritation, pain or conjunctivitis (29), skin irritation (28), abdominal pain (24), mouth or throat irritation (18) and diarrhoea (15). Where age was recorded, 60.5% (680) of children involved in suspected pesticide exposures were aged 2 years or less. The most common scenario for acute accidental exposure to pesticide in children was exposure after application (329, 28.7%) or due to poor storage (228, 19.9%). Conclusions: Areas of potential concern identified included storage, access of young children to “laid” baits and pesticides, and exposures as a result of medication errors, with liquid head lice preparations being confused with other medicines. Use of NPIS systems provides a potentially useful method of toxicovigilance.

Guidelines for laboratory analyses for poisoned patients in the United Kingdom.

To enable consistency of investigation and the establishment of best practice standards, consensus guidelines were formulated previously by the UK National Poisons Information Service and the Association for Clinical Biochemistry. These joint guidelines have now been updated to reflect current best practice. The types of laboratory investigation required for poisoned patients are categorized as either (a) essential common laboratory investigations or (b) specific toxicological assays, and also as either (i) common or (ii) specialist or infrequent. Tests in categories (a) and (bi) should be available 24 hours per day, with a maximum turnaround time of 2u2009h. For the specialist assays, i.e. category (bii), availability and turnaround times have been specified individually. The basis for selection of these times has been clinical utility. The adoption of these guidelines, along with the use of the National Poisons Information Service (0844 8920111) and its online poisons information resource TOXBASE® (www.toxbase.org) enable the poisoned patient to receive appropriate, ‘best practice’ investigations according to their clinical needs and will avoid unnecessary investigations.

Systematic differences between healthcare professionals and poison information staff in the severity scoring of pesticide exposures

Context. Severity scores are used in triage and for data comparison in cases of poisoning. Exposure severity scores have not been generally validated and their utilization by healthcare staff other than specialists in poison information (SPIs) is untested. Objective. To compare the poisoning severity grading allocated in pesticide exposure cases by healthcare professional enquirers and poison information staff. Methods. Pesticide exposures reported to the U.K. National Poisons Information Service (NPIS) systems in a prospective study were graded for severity by healthcare professional enquirers and NPIS SPIs who used established poisons severity-grading algorithms. The scores were compared in children and adults, for the two professional groupings, both overall and for separate pesticides. Results. Overall SPIs graded severity resulting from pesticide exposure at a lower level than the enquirer. For children, enquirer mean severity score was 1.62 (95% confidence interval (CI) 1.57–1.66) and SPIs mean severity score was 1.16 (95% CI 1.13–1.19) (p < 0.001). For adults, enquirer mean severity score was 1.91 (95% CI 1.84–1.97) and SPIs mean severity score was 1.74 (95% CI 1.69–1.79) (p < 0.001). Importantly, the differences in the scores between the two professional groups were greater in children [+0.46 (95% CI 0.41–0.51)] than in adults [+0.17 (95% CI 0.11–0.24)] (p < 0.001). Findings for individual pesticides were less consistent but in general showed similar trends. The exception was glyphosate for which severity grading by poison information staff was higher for children [SPIs 1.68 (95% CI 1.38–1.96) than the enquirers 1.26 (95% CI 1.08–1.44), p < 0.02]. Conclusions. Our findings suggest inherent differences in the perception of pesticide toxicity between healthcare professionals and SPIs. There was also a difference in the scoring approach depending on the pesticide involved. Additional investigations are required to define the role and accuracy of severity scoring in different types of poisoning and the applicability to different types of severity assessors.

Ranitidine overdose in paediatric patients [Abstract]

Objective: To survey the availability of antidotes in nacute hospitals in the United Kingdom following the npublication of joint College of Emergency Medicine nand National Poisons Information Service guidelines non antidote stocking in 2008. Methods: A questionnaire nwas sent to the Chief Pharmacist in 224 hospitals nwith emergency departments in the UK in July 2010 nrequesting information on the availability of 28 antidotes ncategorised in 3 groups: available immediately n(category A), available within 1 hour (category B) and navailable supra-regionally (category C). Results: Completed nquestionnaires were received from 196 (87.5%) nof the 224 hospitals by the survey completion date of n31st January 2011. In the category A list of antidotes, ncommonly used antidotes such as acetylcysteine, activated ncharcoal, naloxone, fl umazenil were available for nimmediate use in more than 90% of hospitals surveyed nbut the availability of cyanide antidotes was much nlower. Dicobalt edetate, currently recommended as the nantidote of choice for severe confi rmed cyanide poisoning, nwas available immediately in 144 (74%) and was nnot stocked in 29 (15%) hospitals. Hydroxocobalamin, nsodium nitrite and sodium thiosulphate were available nfor immediate use in 21%, 57% and 66% of hospitals nrespectively. In the category B list, dantrolene, desferrioxamine nand phytomenadione (vitamin K) were navailable for use within 1 hour in more than 90% of nhospitals but there was poor availability of cyproheptadine n(45%), viper venom antiserum (45%), pralidoxime n(30%) and antidotes used for the treatment of ntoxic alcohol poisoning, with intravenous ethanol being navailable within 1 hour in 72%, oral ethanol in 28% and nfomepizole in 18% of hospitals. Antidotes which are nrarely used and recommended for supra-regional stocking nwere stocked in few hospitals, ranging from 4% for nDMSA and DMPS, 20% for botulinum antitoxin and n25% for sodium calcium edetate. Conclusion: Commonly nindicated antidotes are widely available but nthere is inconsistent stocking of less commonly used nantidotes, for example those used to treat poisoning nwith organophosphorus insecticides, cyanide and toxic nalcohols. This is of concern because these agents are nfrequently associated with severe morbidity and mortality nand the timely use of an appropriate antidote may nbe life-saving in these situations.Objective: The indications for, and availability of, nlaboratory assays required for the effective management nof the poisoned patient are described. Methods: nCurrently recommended assays, their indications and ntheir availability were reviewed within the United nKingdom by the National Poisons Information Service nand the Association for Clinical Biochemistry. Results: nLaboratory assays for toxins and/or their metabolites nare a very important part of the management of patients nwith potentially serious poisoning. However, there is nevidence that laboratory toxicological investigations are noverused by medical staff. There is also evidence that the navailability of these investigations varies between hospitals, nparticularly when required outside normal working nhours. This may present problems in management. nIndications for laboratory assays include: confi rmation nof the diagnosis of poisoning when this is in doubt; to ninfl uence patient management, (e.g. the need for further ninvestigations, antidotes, haemodialysis or other extracorporeal nmethods of elimination, or to stop treatment) nand to plan the re-institution of chronic therapy. They nare also of use in the diagnosis of brain death, in assessing nthe suitability of potential organ donors and for nmedico-legal or forensic reasons. In addition to supportive ninvestigations which are widely available (e.g. urea nand electrolytes, glucose, calcium, magnesium, creatine nkinase, liver function tests, clotting studies, anion gap, nosmolarity, blood gas analysis), specialist assays should nbe available at hospitals admitting acutely poisoned npatients. These specifi c assays may be divided into two ngroups. Group 1 should be available on a 24 hour basis nin all hospitals that admit patients with acute poisoning n(Table 1). Group 2 includes those assays that are important nin patient management but which are infrequently nneeded (Table 1). For these, arrangements need to be in nplace so that the assays can be obtained from specialist nlaboratories if they are not available on site. This may ninvolve an arrangement with a supra-regional specialist ntoxicology laboratory or a subregional centre. It is nthe responsibility of each individual hospital to ensure nthat appropriate arrangements are in place and that staff ncan follow these arrangements when the need arises, nincluding outside normal working hours. Laboratory nstaff should have contact details readily available for nspecialist laboratories providing these assays, together nwith information on how samples should be collected nand transported. Clinical staff should discuss the use of ngroup two assays with a local clinical biochemist and nconsider seeking advice from a Poisons Information nCentre. In a national survey of major hospitals in the nUnited Kingdom, most Group 1 assays were available at all times. However, this was not the case for Group n2 assays. In this group assays for pharmaceuticals were nmore readily available than other assays: in particular, nthe availability of assays for cholinesterase, cyanide and nheavy metals was poor. It is essential to be aware of the ntype of sample required and the units in which results nare specifi ed. A consensus meeting held by the Association nfor Clinical Biochemists agreed that concentrations nfor drugs should be reported in mass units per litre with nthe exception of iron, lithium, methotrexate and thyroxine. nTo avoid confusion it is recommended that, with the nexception of these four agents, laboratories that report in nmolar units should also provide the result in mass units nand should be encouraged for patient safety reasons to nadopt the recommended use of mass units. Reference: n1. National Poisons Information Service; Association of nClinical Biochemists. Laboratory analyses for poisoned npatients: joint position paper. Ann Clin Biochem 2002; n39:328 – 39.Objective: ‘ Steatoda nobilis ’ , commonly known as nthe false black widow spider, is an immigrant spider noriginating from the Canary Islands. Closely related to nthe black widow species but lacking its distinctive red nspot, this spider was fi rst reported in the UK in 1879. nIt has since become acclimatised along the south coast nof England although National Poisons Information nService (NPIS) call records indicate that it has been nwitnessed as far north as Yorkshire. While the spider is nnot considered aggressive, it possesses large venomous nfangs that can instigate ‘ instant ’ severe pain, described nas being worse than a wasp sting. Methods: A case nstudy is reported and enquiries to NPIS concerning nfalse black widow spider bites between August 2007 nand August 2011 were analysed with regard to location nand features. Case report: A 41-year-old male npresented to the accident and emergency department ntwo days after being bitten on the calf by a spider nsubsequently identifi ed as ‘ Steatoda nobilis ’ . He was ntreated prophylactically with co-amoxiclav. The skin naround the bite was warm and discoloured with acute nswelling at the puncture site. NPIS advised that apart nfrom appropriate analgesia further treatment was nunlikely to be required and that localised features from nthe envenomation would subside with time. Other than nmild cellulitis in the calf and a raised CRP (31 mg/L), nthis patient exhibited no systemic complications and nwas discharged the same day. Results: NPIS received n21 enquiries involving ‘ Steatoda nobilis ’ throughout nthe study period. The majority of enquiries were from nsouthern England with a few as far north as Yorkshire nand Suffolk. Localised oedema was the most signifi cant nfeature along with hypoaesthesia, paraesthesia and nskin rash. Systemic features such as tachycardia, chest ntightness, vomiting, anxiety with increased sweating nand fever were also reported in fi ve cases. Conclusion: nIt has been reported that ‘ Steatoda nobilis ’ bites may nbe neurotoxic and affect the parasympathetic nervous nsystem. 1 Nevertheless, NPIS experience suggests that nthese bites, although sometimes medically signifi cant, ncan be managed successfully with supportive care and nanalgesia. Reference: 1. Warrell DA, Shaheen J, Hillyard nPD, et al. Neurotoxic envenoming by an immigrant nspider (Steatoda Nobilis) in southern England. Toxicon n1991; 29:1263 – 5.Objective: Prescription stimulant abuse is on the rise in nthe United States (US). Abuse in other countries is not nwell studied. The objective of this study is to characterize nhuman exposures to specifi c prescription stimulants nreported to poison centres from multiple countries over na four year study period. Methods: Human exposures nto methylphenidate and amfetamines reported to npoison centres from 2007 – 2010 were obtained using na standardized data template with written defi nitions. nRates are reported as number of exposures reported to npoison centre per 100,000 population. Results: Seven ncountries participated; Australia, Germany (G o ttingen), nItaly, Netherlands, Switzerland, United Kingdom n(UK) and US. All centres manage calls from health ncare providers. Australia, Italy, Germany, Switzerland nand US manage calls from the public as well. Methylphenidate: nFive of 7 countries reported an increase nduring the study period (range 17 – 137%; Table 1). The UK reported a decrease of 28%. Amfetamine: US nreported the highest rate and surpassed second ranked nNetherlands by almost 4-fold. While US, Netherlands nand Australia reported increased amfetamine rates n(range 18 – 221%), the remaining countries suggesting na downward trend from 8 to 45%. There are no nprescription amphetamines available in Switzerland. nConclusions: Methylphenidate exposures per person nincreased in the majority of participating countries. nAmfetamine exposures were less commonly reported nto participating non-US centres, which indicated less nthan 50% change during the study period. While these ndata illustrate rates over time within each country, one ncannot compare rates between countries due to variation nof data collection methods (some centres accept ncalls from the public, some do not). Additional data is nrequired on reporting bias, drug availability, drug supply nsource, and perhaps cultural differences that may ncontribute to these fi ndings.Objective: Ambulance paramedics, often the fi rst point nof contact with poisoned patients, need to make rapid nassessments and instigate appropriate emergency treatment nplans. To do so effectively they require speedy naccess to relevant information. This outreach programme nwas established to ensure that all ambulance npersonnel in Wales and South West England are familiar nwith the full range of resources offered by The National nPoisons Information Service (NPIS). Methods: All nambulance stations in Wales and the South West (173) nwere contacted by letter and/or telephone and provided nwith the following information: 1. General information nabout NPIS and a request that all ambulance crews be nmade aware of the NPIS 24/7 poisons enquiry telephone nnumber. 2. Information relating to TOXBASE ® , the primary ntoxicology database of the NPIS, and an encouragement nto each station to apply for free registration. n(Telephone number and website information were also nprovided in the form of stickers and postcards for ease nof dissemination and availability to individual crews) 3. nNPIS (Cardiff) offers free hands-on training for ambulance npersonnel in the effi cient use of TOXBASE ® . nConsultant clinical toxicologists are also available to nprovide training in the basic management of poisoned npatients including recognition of toxidromes and signs nand symptoms relating to the severity of poisoning; ntraining courses often being structured to the specifi c nrequirements of individual cohorts. Results: Since the noutreach programme began, TOXBASE ® registrations nfrom ambulance stations have increased 31% in Wales nand 44% in the South West. There has also been a very npositive response to the offer of specialist training; noverall 217 ambulance personnel have received training nfrom poisons information specialists and clinical toxicologists non the effi cient use of TOXBASE ® and other naspects of poisoning in 13 separate training sessions. nSix specialist training sessions have also been held for n42 members of the South West England Hazardous nArea Response Team (HART). Conclusion: Specialised ntraining greatly enhances the confi dence of paramedics nwhen dealing with poisoned patients. In cases where nthere remains uncertainty regarding the potential toxicity nof agents, access to TOXBASE ® or the poisons nenquiry line provides invaluable reassurance and markedly nreduces the costs associated with unnecessary ntransport and accident and emergency admission.Objective: To investigate the circumstances and etiology nof ranitidine overdose in patients aged under n3 years old reported to the UK National Poisons Information nService (NPIS) between November 2008 and October n2011. Disproportionately high levels of therapeutic nerror have been noted during calls to NPIS centres. The ncauses of this are investigated. Methods: Using data nextracted from UKPID, a centralised NPIS telephone nenquiry database, we reviewed the number and nature nof incidents involving ranitidine from November 2008 nto October 2011. Results: 244 calls were made to the nNPIS between 01/11/2008 and 31/10/2011 regarding npoisoning with ranitidine alone. One hundred and ninety- nsix incidents (80.3%) involved children aged under n3 and 205 (84.0%) involved children aged under 5; by ncontrast, in the fi nancial year 2010 – 2011, only 28.8% of nall calls made to the NPIS involved children aged under n5 (p � 0.0001). In those patients aged under 3, 86.7% n(170/196) of ranitidine overdoses were due to therapeutic nerror, compared to 7.0% of all calls for the same nage group taken in the same time period (p � 0.0001). nOf those patients who overdosed as a result of therapeutic nerror, 146 (85.9%) ingested ranitidine syrup, nand 43 of these patients (29.5%) were given a 10 times noverdose of 75 mg/5 mL syrup. Medical intervention nwas required in 19.4% (38/196) of all patients under n3, most commonly investigations (16/38 or 42.1% of patients). 11/196 patients (5.6%) were referred to A&E nand 12/196 patients (6.1%) were referred to their GP. n85.2% (167/196) patients were asymptomatic; 10.2% n(20/196) patients had minor features, and 1 patient n(0.5%) had moderate features (multiple episodes of nvomiting and diarrhoea). Conclusion: Ranitidine overdose nis a common enquiry to the NPIS. Although usually nasymptomatic these cases often required some sort nof medical intervention. Cases frequently involved paediatric npatients. Overdose commonly occurred due to nadministration of 10x the prescribed dose of ranitidine nsyrup, suggesting a preventable dosing error by carers. nAlthough the consequences of ranitidine overdose are nusually benign, these results suggest that formulation nchanges could reduce risk and prevent unnecessary npresentations to health professionals.bearing on the assigned triage category. The existence of poisons information centres (PIC) within a healthcare system has signifi cant implications on emergency triage presentations. 5 The ability to fi lter the majority of trivial and minor exposures with out-of-hospital management selects higher acuity patients for ED presentation. PICs also play a key role in ambulance triage at the scene as well as in ambulance control systems that decide on transportation of potentially poisoned patients. ED triage offi cers may also choose to contact a PIC during or at the completion of triage in order to modify risk stratifi cation. Experienced triage offi cers are able to appropriately triage poisoned patients with symptoms and signs, particularly those involving agents that cause reduced level of consciousness or coma. Diffi culties in triage are more common with the well-looking patient whose toxidrome has yet to develop or does not manifest in altered sensorium, gastrointestinal upset or dyspnoea. Common triage pitfalls include ingestions of cardiac medications, heavy metals, oral hypoglycaemic agents, unusual chemicals, sustained-release preparations and paediatric patients. 6,7 Emergency triage systems, in their current form, do not necessarily take into account a risk assessment of the potential toxicity of the agent ingested. As such, they may fail to predict precipitous clinical deterioration in a minority of cases. Furthermore, failure to recognise potentially severe complications of specifi c agents, such as calcium channel blockers, may delay early life-saving interventional strategies. The triage offi cer has an additional role in instituting decontamination, if appropriate. Conclusion: Emergency triage of the poisoned patient is a crucial decision point in their medical management – ultimately, it can mean the difference between life and death. Several emergency triage systems are utilised around the world, each with its own limitations in risk assessment. The existence of poisons information centres within a healthcare system has signifi cant bearing on ED presentations of poisoning and envenomation. There are uncommon and dangerous toxicological presentations that require an astute and experienced triage offi cer to recognise the potential for life-threatening toxicity. References: 1. Australasian College for Emergency Medicine. The Australasian Triage Scale. www.acem.org.au [accessed 23 Jan 2012]. 2. Mackway-Jones K, Marsden J, Windle J, eds. Emergency Triage. Manchester Triage Group. 2nd ed. Oxford, England: Blackwell Publishing. BMJ Books, 2005. 3. Grouse AI, Bishop RO, Bannon AM. The Manchester Triage System provides good reliability in an Australian emergency department. Emerg Med J 2009; 26:484 –6. 4. Commonwealth of Australia. Emergency Triage Education Kit, 2009. www.health. gov.au [accessed 23 Jan 2012]. 5. Benson BE, Smith CA, McKinney PE, et al. Do poison center triage guidelines affect healthcare facility referrals? J Toxicol Clin Toxicol 2001; 39:433 – 8. 6. Bartlett D. Tricky toxic presentations at triage. J Emerg Nurs 2005; 31:403 – 4. 7. Wolf L. Considerations in triage for the intoxicated patient. J Emerg Nurs 2008; 34:272 – 3. The Role of the ECG in Risk Assessment of the 2. Poisoned Patient Manini AF. Division of Medical Toxicology, Department of Emergency Medicine, Mount Sinai School of Medicine, Elmhurst Hospital Centre, New York, US Background: Poisoning is the leading cause of cardiac arrest in patients under 40 years of age 1 and the second-leading cause of injury-related fatality across all age groups in the US 2 . The ECG represents a rapidly available clinical tool that can help clinicians manage poisoned patients. Specifi c myocardial effects of cardiotoxic drugs have well-described electrocardiographic manifestations. The objectives of this review are: (a) to summarize specifi c toxic effects on the myocardium that can cause characteristic ECG changes; (b) to review the approach to the ECG in acutely poisoned patients and ECG-toxidrome pearls; and (c) to integrate ECG interpretation with management decisions in the poisoned patient. Discussion: Clinicians should adopt a systematic approach to ECG interpretation for poisoned patients that includes analysis of rhythm, intervals (QRS, QT, etc), and ischemic changes (ST and T wave changes). Common patterns of ECG manifestations may serve as pearls to aid clinicians in diagnosis and management of poisoning. In the setting of poisoning, drug classes that cause characteristic ECG manifestations include ion channel antagonists (sodium, potassium, calcium), cardioactive steroids (sodium-potassium ATPase), and beta adrenergic antagonists. Recent data suggests that initial ECG interpretation may predict in-hospital prognosis for patients with undifferentiated poisonings in the emergency department. 3 Poisoned patients suffering from cardiac arrest should be treated according to Advanced Cardiac Life Support (ACLS) guidelines with consideration of toxicology-specifi c antidotes as adjunctive therapy. 4 Conclusion: In medical toxicology, the ECG plays an important role in the evaluation of the poisoned patient to identify or exclude cardiotoxicity, as well as to take fundamental initial steps in initial management. A sound understanding of ECG interpretation and the characteristics of cardiotoxicity is necessary to establish a basis for the utility of the ECG in drug overdose. A systematic approach to the ECG in poisoned patients based on patterns of cardiotoxicity may help clinicians identify management strategies to ameliorate cardiotoxicity. References: 1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation C lin ic al T ox ic ol og y D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y U ni ve rs ity o f Z ue ri ch o n 04 /3 0/ 12 Fo r pe rs on al u se o nl y.

Antidote stocking in acute hospitals in the United Kingdom [Abstract]

Objective: To survey the availability of antidotes in nacute hospitals in the United Kingdom following the npublication of joint College of Emergency Medicine nand National Poisons Information Service guidelines non antidote stocking in 2008. Methods: A questionnaire nwas sent to the Chief Pharmacist in 224 hospitals nwith emergency departments in the UK in July 2010 nrequesting information on the availability of 28 antidotes ncategorised in 3 groups: available immediately n(category A), available within 1 hour (category B) and navailable supra-regionally (category C). Results: Completed nquestionnaires were received from 196 (87.5%) nof the 224 hospitals by the survey completion date of n31st January 2011. In the category A list of antidotes, ncommonly used antidotes such as acetylcysteine, activated ncharcoal, naloxone, fl umazenil were available for nimmediate use in more than 90% of hospitals surveyed nbut the availability of cyanide antidotes was much nlower. Dicobalt edetate, currently recommended as the nantidote of choice for severe confi rmed cyanide poisoning, nwas available immediately in 144 (74%) and was nnot stocked in 29 (15%) hospitals. Hydroxocobalamin, nsodium nitrite and sodium thiosulphate were available nfor immediate use in 21%, 57% and 66% of hospitals nrespectively. In the category B list, dantrolene, desferrioxamine nand phytomenadione (vitamin K) were navailable for use within 1 hour in more than 90% of nhospitals but there was poor availability of cyproheptadine n(45%), viper venom antiserum (45%), pralidoxime n(30%) and antidotes used for the treatment of ntoxic alcohol poisoning, with intravenous ethanol being navailable within 1 hour in 72%, oral ethanol in 28% and nfomepizole in 18% of hospitals. Antidotes which are nrarely used and recommended for supra-regional stocking nwere stocked in few hospitals, ranging from 4% for nDMSA and DMPS, 20% for botulinum antitoxin and n25% for sodium calcium edetate. Conclusion: Commonly nindicated antidotes are widely available but nthere is inconsistent stocking of less commonly used nantidotes, for example those used to treat poisoning nwith organophosphorus insecticides, cyanide and toxic nalcohols. This is of concern because these agents are nfrequently associated with severe morbidity and mortality nand the timely use of an appropriate antidote may nbe life-saving in these situations.Objective: The indications for, and availability of, nlaboratory assays required for the effective management nof the poisoned patient are described. Methods: nCurrently recommended assays, their indications and ntheir availability were reviewed within the United nKingdom by the National Poisons Information Service nand the Association for Clinical Biochemistry. Results: nLaboratory assays for toxins and/or their metabolites nare a very important part of the management of patients nwith potentially serious poisoning. However, there is nevidence that laboratory toxicological investigations are noverused by medical staff. There is also evidence that the navailability of these investigations varies between hospitals, nparticularly when required outside normal working nhours. This may present problems in management. nIndications for laboratory assays include: confi rmation nof the diagnosis of poisoning when this is in doubt; to ninfl uence patient management, (e.g. the need for further ninvestigations, antidotes, haemodialysis or other extracorporeal nmethods of elimination, or to stop treatment) nand to plan the re-institution of chronic therapy. They nare also of use in the diagnosis of brain death, in assessing nthe suitability of potential organ donors and for nmedico-legal or forensic reasons. In addition to supportive ninvestigations which are widely available (e.g. urea nand electrolytes, glucose, calcium, magnesium, creatine nkinase, liver function tests, clotting studies, anion gap, nosmolarity, blood gas analysis), specialist assays should nbe available at hospitals admitting acutely poisoned npatients. These specifi c assays may be divided into two ngroups. Group 1 should be available on a 24 hour basis nin all hospitals that admit patients with acute poisoning n(Table 1). Group 2 includes those assays that are important nin patient management but which are infrequently nneeded (Table 1). For these, arrangements need to be in nplace so that the assays can be obtained from specialist nlaboratories if they are not available on site. This may ninvolve an arrangement with a supra-regional specialist ntoxicology laboratory or a subregional centre. It is nthe responsibility of each individual hospital to ensure nthat appropriate arrangements are in place and that staff ncan follow these arrangements when the need arises, nincluding outside normal working hours. Laboratory nstaff should have contact details readily available for nspecialist laboratories providing these assays, together nwith information on how samples should be collected nand transported. Clinical staff should discuss the use of ngroup two assays with a local clinical biochemist and nconsider seeking advice from a Poisons Information nCentre. In a national survey of major hospitals in the nUnited Kingdom, most Group 1 assays were available at all times. However, this was not the case for Group n2 assays. In this group assays for pharmaceuticals were nmore readily available than other assays: in particular, nthe availability of assays for cholinesterase, cyanide and nheavy metals was poor. It is essential to be aware of the ntype of sample required and the units in which results nare specifi ed. A consensus meeting held by the Association nfor Clinical Biochemists agreed that concentrations nfor drugs should be reported in mass units per litre with nthe exception of iron, lithium, methotrexate and thyroxine. nTo avoid confusion it is recommended that, with the nexception of these four agents, laboratories that report in nmolar units should also provide the result in mass units nand should be encouraged for patient safety reasons to nadopt the recommended use of mass units. Reference: n1. National Poisons Information Service; Association of nClinical Biochemists. Laboratory analyses for poisoned npatients: joint position paper. Ann Clin Biochem 2002; n39:328 – 39.Objective: ‘ Steatoda nobilis ’ , commonly known as nthe false black widow spider, is an immigrant spider noriginating from the Canary Islands. Closely related to nthe black widow species but lacking its distinctive red nspot, this spider was fi rst reported in the UK in 1879. nIt has since become acclimatised along the south coast nof England although National Poisons Information nService (NPIS) call records indicate that it has been nwitnessed as far north as Yorkshire. While the spider is nnot considered aggressive, it possesses large venomous nfangs that can instigate ‘ instant ’ severe pain, described nas being worse than a wasp sting. Methods: A case nstudy is reported and enquiries to NPIS concerning nfalse black widow spider bites between August 2007 nand August 2011 were analysed with regard to location nand features. Case report: A 41-year-old male npresented to the accident and emergency department ntwo days after being bitten on the calf by a spider nsubsequently identifi ed as ‘ Steatoda nobilis ’ . He was ntreated prophylactically with co-amoxiclav. The skin naround the bite was warm and discoloured with acute nswelling at the puncture site. NPIS advised that apart nfrom appropriate analgesia further treatment was nunlikely to be required and that localised features from nthe envenomation would subside with time. Other than nmild cellulitis in the calf and a raised CRP (31 mg/L), nthis patient exhibited no systemic complications and nwas discharged the same day. Results: NPIS received n21 enquiries involving ‘ Steatoda nobilis ’ throughout nthe study period. The majority of enquiries were from nsouthern England with a few as far north as Yorkshire nand Suffolk. Localised oedema was the most signifi cant nfeature along with hypoaesthesia, paraesthesia and nskin rash. Systemic features such as tachycardia, chest ntightness, vomiting, anxiety with increased sweating nand fever were also reported in fi ve cases. Conclusion: nIt has been reported that ‘ Steatoda nobilis ’ bites may nbe neurotoxic and affect the parasympathetic nervous nsystem. 1 Nevertheless, NPIS experience suggests that nthese bites, although sometimes medically signifi cant, ncan be managed successfully with supportive care and nanalgesia. Reference: 1. Warrell DA, Shaheen J, Hillyard nPD, et al. Neurotoxic envenoming by an immigrant nspider (Steatoda Nobilis) in southern England. Toxicon n1991; 29:1263 – 5.Objective: Prescription stimulant abuse is on the rise in nthe United States (US). Abuse in other countries is not nwell studied. The objective of this study is to characterize nhuman exposures to specifi c prescription stimulants nreported to poison centres from multiple countries over na four year study period. Methods: Human exposures nto methylphenidate and amfetamines reported to npoison centres from 2007 – 2010 were obtained using na standardized data template with written defi nitions. nRates are reported as number of exposures reported to npoison centre per 100,000 population. Results: Seven ncountries participated; Australia, Germany (G o ttingen), nItaly, Netherlands, Switzerland, United Kingdom n(UK) and US. All centres manage calls from health ncare providers. Australia, Italy, Germany, Switzerland nand US manage calls from the public as well. Methylphenidate: nFive of 7 countries reported an increase nduring the study period (range 17 – 137%; Table 1). The UK reported a decrease of 28%. Amfetamine: US nreported the highest rate and surpassed second ranked nNetherlands by almost 4-fold. While US, Netherlands nand Australia reported increased amfetamine rates n(range 18 – 221%), the remaining countries suggesting na downward trend from 8 to 45%. There are no nprescription amphetamines available in Switzerland. nConclusions: Methylphenidate exposures per person nincreased in the majority of participating countries. nAmfetamine exposures were less commonly reported nto participating non-US centres, which indicated less nthan 50% change during the study period. While these ndata illustrate rates over time within each country, one ncannot compare rates between countries due to variation nof data collection methods (some centres accept ncalls from the public, some do not). Additional data is nrequired on reporting bias, drug availability, drug supply nsource, and perhaps cultural differences that may ncontribute to these fi ndings.Objective: Ambulance paramedics, often the fi rst point nof contact with poisoned patients, need to make rapid nassessments and instigate appropriate emergency treatment nplans. To do so effectively they require speedy naccess to relevant information. This outreach programme nwas established to ensure that all ambulance npersonnel in Wales and South West England are familiar nwith the full range of resources offered by The National nPoisons Information Service (NPIS). Methods: All nambulance stations in Wales and the South West (173) nwere contacted by letter and/or telephone and provided nwith the following information: 1. General information nabout NPIS and a request that all ambulance crews be nmade aware of the NPIS 24/7 poisons enquiry telephone nnumber. 2. Information relating to TOXBASE ® , the primary ntoxicology database of the NPIS, and an encouragement nto each station to apply for free registration. n(Telephone number and website information were also nprovided in the form of stickers and postcards for ease nof dissemination and availability to individual crews) 3. nNPIS (Cardiff) offers free hands-on training for ambulance npersonnel in the effi cient use of TOXBASE ® . nConsultant clinical toxicologists are also available to nprovide training in the basic management of poisoned npatients including recognition of toxidromes and signs nand symptoms relating to the severity of poisoning; ntraining courses often being structured to the specifi c nrequirements of individual cohorts. Results: Since the noutreach programme began, TOXBASE ® registrations nfrom ambulance stations have increased 31% in Wales nand 44% in the South West. There has also been a very npositive response to the offer of specialist training; noverall 217 ambulance personnel have received training nfrom poisons information specialists and clinical toxicologists non the effi cient use of TOXBASE ® and other naspects of poisoning in 13 separate training sessions. nSix specialist training sessions have also been held for n42 members of the South West England Hazardous nArea Response Team (HART). Conclusion: Specialised ntraining greatly enhances the confi dence of paramedics nwhen dealing with poisoned patients. In cases where nthere remains uncertainty regarding the potential toxicity nof agents, access to TOXBASE ® or the poisons nenquiry line provides invaluable reassurance and markedly nreduces the costs associated with unnecessary ntransport and accident and emergency admission.Objective: To investigate the circumstances and etiology nof ranitidine overdose in patients aged under n3 years old reported to the UK National Poisons Information nService (NPIS) between November 2008 and October n2011. Disproportionately high levels of therapeutic nerror have been noted during calls to NPIS centres. The ncauses of this are investigated. Methods: Using data nextracted from UKPID, a centralised NPIS telephone nenquiry database, we reviewed the number and nature nof incidents involving ranitidine from November 2008 nto October 2011. Results: 244 calls were made to the nNPIS between 01/11/2008 and 31/10/2011 regarding npoisoning with ranitidine alone. One hundred and ninety- nsix incidents (80.3%) involved children aged under n3 and 205 (84.0%) involved children aged under 5; by ncontrast, in the fi nancial year 2010 – 2011, only 28.8% of nall calls made to the NPIS involved children aged under n5 (p � 0.0001). In those patients aged under 3, 86.7% n(170/196) of ranitidine overdoses were due to therapeutic nerror, compared to 7.0% of all calls for the same nage group taken in the same time period (p � 0.0001). nOf those patients who overdosed as a result of therapeutic nerror, 146 (85.9%) ingested ranitidine syrup, nand 43 of these patients (29.5%) were given a 10 times noverdose of 75 mg/5 mL syrup. Medical intervention nwas required in 19.4% (38/196) of all patients under n3, most commonly investigations (16/38 or 42.1% of patients). 11/196 patients (5.6%) were referred to A&E nand 12/196 patients (6.1%) were referred to their GP. n85.2% (167/196) patients were asymptomatic; 10.2% n(20/196) patients had minor features, and 1 patient n(0.5%) had moderate features (multiple episodes of nvomiting and diarrhoea). Conclusion: Ranitidine overdose nis a common enquiry to the NPIS. Although usually nasymptomatic these cases often required some sort nof medical intervention. Cases frequently involved paediatric npatients. Overdose commonly occurred due to nadministration of 10x the prescribed dose of ranitidine nsyrup, suggesting a preventable dosing error by carers. nAlthough the consequences of ranitidine overdose are nusually benign, these results suggest that formulation nchanges could reduce risk and prevent unnecessary npresentations to health professionals.bearing on the assigned triage category. The existence of poisons information centres (PIC) within a healthcare system has signifi cant implications on emergency triage presentations. 5 The ability to fi lter the majority of trivial and minor exposures with out-of-hospital management selects higher acuity patients for ED presentation. PICs also play a key role in ambulance triage at the scene as well as in ambulance control systems that decide on transportation of potentially poisoned patients. ED triage offi cers may also choose to contact a PIC during or at the completion of triage in order to modify risk stratifi cation. Experienced triage offi cers are able to appropriately triage poisoned patients with symptoms and signs, particularly those involving agents that cause reduced level of consciousness or coma. Diffi culties in triage are more common with the well-looking patient whose toxidrome has yet to develop or does not manifest in altered sensorium, gastrointestinal upset or dyspnoea. Common triage pitfalls include ingestions of cardiac medications, heavy metals, oral hypoglycaemic agents, unusual chemicals, sustained-release preparations and paediatric patients. 6,7 Emergency triage systems, in their current form, do not necessarily take into account a risk assessment of the potential toxicity of the agent ingested. As such, they may fail to predict precipitous clinical deterioration in a minority of cases. Furthermore, failure to recognise potentially severe complications of specifi c agents, such as calcium channel blockers, may delay early life-saving interventional strategies. The triage offi cer has an additional role in instituting decontamination, if appropriate. Conclusion: Emergency triage of the poisoned patient is a crucial decision point in their medical management – ultimately, it can mean the difference between life and death. Several emergency triage systems are utilised around the world, each with its own limitations in risk assessment. The existence of poisons information centres within a healthcare system has signifi cant bearing on ED presentations of poisoning and envenomation. There are uncommon and dangerous toxicological presentations that require an astute and experienced triage offi cer to recognise the potential for life-threatening toxicity. References: 1. Australasian College for Emergency Medicine. The Australasian Triage Scale. www.acem.org.au [accessed 23 Jan 2012]. 2. Mackway-Jones K, Marsden J, Windle J, eds. Emergency Triage. Manchester Triage Group. 2nd ed. Oxford, England: Blackwell Publishing. BMJ Books, 2005. 3. Grouse AI, Bishop RO, Bannon AM. The Manchester Triage System provides good reliability in an Australian emergency department. Emerg Med J 2009; 26:484 –6. 4. Commonwealth of Australia. Emergency Triage Education Kit, 2009. www.health. gov.au [accessed 23 Jan 2012]. 5. Benson BE, Smith CA, McKinney PE, et al. Do poison center triage guidelines affect healthcare facility referrals? J Toxicol Clin Toxicol 2001; 39:433 – 8. 6. Bartlett D. Tricky toxic presentations at triage. J Emerg Nurs 2005; 31:403 – 4. 7. Wolf L. Considerations in triage for the intoxicated patient. J Emerg Nurs 2008; 34:272 – 3. The Role of the ECG in Risk Assessment of the 2. Poisoned Patient Manini AF. Division of Medical Toxicology, Department of Emergency Medicine, Mount Sinai School of Medicine, Elmhurst Hospital Centre, New York, US Background: Poisoning is the leading cause of cardiac arrest in patients under 40 years of age 1 and the second-leading cause of injury-related fatality across all age groups in the US 2 . The ECG represents a rapidly available clinical tool that can help clinicians manage poisoned patients. Specifi c myocardial effects of cardiotoxic drugs have well-described electrocardiographic manifestations. The objectives of this review are: (a) to summarize specifi c toxic effects on the myocardium that can cause characteristic ECG changes; (b) to review the approach to the ECG in acutely poisoned patients and ECG-toxidrome pearls; and (c) to integrate ECG interpretation with management decisions in the poisoned patient. Discussion: Clinicians should adopt a systematic approach to ECG interpretation for poisoned patients that includes analysis of rhythm, intervals (QRS, QT, etc), and ischemic changes (ST and T wave changes). Common patterns of ECG manifestations may serve as pearls to aid clinicians in diagnosis and management of poisoning. In the setting of poisoning, drug classes that cause characteristic ECG manifestations include ion channel antagonists (sodium, potassium, calcium), cardioactive steroids (sodium-potassium ATPase), and beta adrenergic antagonists. Recent data suggests that initial ECG interpretation may predict in-hospital prognosis for patients with undifferentiated poisonings in the emergency department. 3 Poisoned patients suffering from cardiac arrest should be treated according to Advanced Cardiac Life Support (ACLS) guidelines with consideration of toxicology-specifi c antidotes as adjunctive therapy. 4 Conclusion: In medical toxicology, the ECG plays an important role in the evaluation of the poisoned patient to identify or exclude cardiotoxicity, as well as to take fundamental initial steps in initial management. A sound understanding of ECG interpretation and the characteristics of cardiotoxicity is necessary to establish a basis for the utility of the ECG in drug overdose. A systematic approach to the ECG in poisoned patients based on patterns of cardiotoxicity may help clinicians identify management strategies to ameliorate cardiotoxicity. References: 1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation C lin ic al T ox ic ol og y D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y U ni ve rs ity o f Z ue ri ch o n 04 /3 0/ 12 Fo r pe rs on al u se o nl y.

Toxicity of household products in the UK [Abstract]

Background: Based on a Federal Institute for RiskAssessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill lighters and kerosene. Based on their typical lowviscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intraalveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wallthickness 15 mm) was half-filled with fluorocarbon(FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor,connected to a high-sensitivity Pico-ammeter. Results:The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen.This could explain the severe asphyxia and deathd ocumented in BfR cases. Conclusion: The ASC experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations.The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Background: Based on a Federal Institute for Risk Assessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill-lighters and kerosene. Based on their typical low viscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intra-alveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wall thickness 15 mm) was half-filled with fluorocarbon (FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor, connected to a high-sensitivity Pico-ammeter. Results: The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15 fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen. This could explain the severe asphyxia and death documented in BfR cases. Conclusion: The ASC-experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations. The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Abstracts of the 2011 International Congress of the Europeans of the 2011 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 24–27 May 2011, Dubrovnik, Croatia 1. GHB and its Analogues Knudsen K. Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital,Background: The Federal Institute for Risk Assessment (BfR) Documentation and Assessment Centre for Poisonings (BfR-Doc Centre) is part of the German toxicological network. German Physicians and Poison Centres (PCs) report human data of poisonings to the BfR. Every case is assessed on the chemical product involved with the distinct formula provided by BfR product database, which contains notifications of the German industry. Data on human poisonings is condensed in a harmonized and standardized data file for analysis. In addition cases of special toxicological and scientific interest (e.g. rare poisonings, high-/low-dose exposures, cases with unexpected clinical course, substances of special interest etc) are prepared for standardized case reports. For better retrieval of human toxicological data a bilingual case report database has been implemented. Methods: The cases are documented in a standardized form (accident/situation of poisoning/age/gender/symptoms/signs/exposure data/clinical course/assessment/remarks), indicated by the substance/product involved and supplemented with important references. After co-checks for correctness, completeness and readability, the German text is translated into English and transferred to the database. In addition, selected case reports from literature were transferred as pdf-files to the same database. Results: Since July 2002 more than 500 cases have been selected, prepared and processed with additional data for case reports. The case reports were written down in uniform documents, provided with keywords and additional information, finally assigned to index words. Starting in 2004, the documents were recorded in a prototype database driven by MS-Access, from 2006 onwards the case record database was transferred to an Informix 9.2 database in web-browser technology. At present, the BfR-case database has been provided with additional staff. The BfR is in consultation with specialists in data protection to ask whether the BfR case record database can to be opened in the future for specialists. Conclusion: In the assessment of poisonings and for e-learning there is a great interest in case reports. The BfR intends in future to offer its case reports on poisoning via its Internet portal for subject-specific access.Objective: Information relating to interference in certain biochemistry analyses is readily available in the scientific literature, yet the UK National Poisons Information Service (NPIS) still regularly receives enquiries from clinicians struggling to interpret unexpected results. We report three recent cases that serve to illustrate how erroneous laboratory results can confuse the clinical picture and even lead to misdiagnosis in cases of poisoning. n nCase series: 1. A 19-year old male presented at hospital claiming a deliberate ingestion of methanol. He appeared clinically well but had a markedly raised serum creatinine - 766u2009µmol/L. He had been admitted 10 days previously with a paracetamol overdose and it was assumed that the elevated creatinine was a consequence of this and his methanol story was disregarded. An NPIS specialist advised that nitromethane in model engine fuel is known to give falsely high results with certain (Jaffe) creatinine assays. This was confirmed and antidotal treatment was commenced for methanol ingestion. 2. A 35-year old male was admitted with acidosis (pH 6.8) and a raised serum lactate concentration of 24u2009mmol/L. A preliminary diagnosis of cyanide poisoning was made and antidote considered. An NPIS specialist advised that certain Point of Care blood gas analysers have been reported to provide falsely elevated blood lactate concentrations when ethylene glycol metabolites are present. Blood lactate was measured on a different instrument and shown to be within normal limits. Antidotal therapy was commenced for ethylene glycol ingestion - a diagnosis subsequently confirmed by blood ethylene glycol measurement and a markedly raised osmolar gap. 3. A 3-year old girl was admitted with a 3-day history of vomiting. She was obtunded, acidotic (pH 6.9) and had a serum salicylate concentration of 50u2009mg/L, although there was no history of aspirin ingestion. Supportive treatment was initiated and a search at home for possible sources of salicylic acid made. A suggestion by NPIS to the clinician that metabolic disorders such as Maple Syrup Urine Disease can cause acidosis and give false positive salicylate results was later confirmed to be the case. n nConclusion: The possibility of assay interference should be considered when the figures don’t fit the facts.Objective: To ascertain the toxicity of current UK household products. Methods: Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service collected prospectively 5939 telephone enquiries relating to household products, approximately 12% of all telephone enquiries. n nResults: The majority of enquiries (65.5%) concerned children five years of age or less and were received predominantly from hospitals (32.1%), general practitioners (29.8%) and NHS Direct/NHS 24 (28.5%). The majority of exposures occurred at home (97.6%); most exposures were accidental (93.6%). Liquid detergent capsules were most commonly involved (nu200a=u200a647) followed by bleach (nu200a=u200a473), multipurpose cleaners (nu200a=u200a408), descalers (nu200a=u200a397) and disinfectant/antiseptic/sanitiser liquids (nu200a=u200a270). Intentional exposures were more likely to involve bleaches, multipurpose cleaners and disinfectant/antiseptic/sanitiser liquids. Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burn (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score was known at the time of the enquiry. The majority of patients (70.5%) were asymptomatic, 28.0% had developed minor features, 75 patients had developed moderate features and nine patients had developed serious features (PSS 3). Five of these nine patients made a complete recovery, though two developed severe complications and two others died from poisoning with drain cleaner and PVC solvent cleaner; the outcome in two is unknown. n nConclusions: Household product exposures are common in the UK, in other parts of Europe1 and in the US2, though they rarely result in severe sequelae.Background: Besides house and road accidents, in accidental poisoning in children within the house itself, kerosene poisoning is a major problem. In particular in developing countries, where kerosene is still used daily on a large scale for different purposes such as cooking, lightning and for rural medicine. Over the past 15 years, data from Egypt to Sri Lanka have shown that risk. Kerosene accounts for about 60% of pediatric poisonings in Kenya and South Africa. Methods: Analysis of available information and literature in order to: 1. find the main causes for accidental kerosene ingestion and 2. prepare a framework for the prevention of accidental kerosene ingestion in children from developing countries. To obtain a deeper view about the most recent or current scenarios in different parts of the developing world several International Program on Chemical Safety (IPCS) offices and Poison Centers in South-East Asia and the African region were contacted. Results: Kerosene was found as the most common cause of accidental poisoning in children among household poisonings. Mortality was found to be low, but morbidity was high. Children aged 1-3 years were most likely to be involved in accidental kerosene poisoning. Improper storage of kerosene was detected as the main contributory factor for these accidents. Kerosene was found to be stored in jars, bottles or containers previously used for beverages and juices and these were in easy access of children and mistaken by children for something to drink. Conclusion: Accidental kerosene ingestion is a public health issue in the developing world, because children are innocent and parents are not aware and careful enough about storage of kerosene. There is a need for education and increased awareness regarding the poisonous effects of kerosene. Active interventions such as campaigns in schools and local hospitals, performing dramas on the street especially in rural areas, should educate people about safe storage practices. Also they could be provided with safety information (flyer, stickers, symbols etc) and printed information on the back of the pay receipt each time they buy kerosene. Illegal and unsafe kerosene sale has to be stressed.

The Toxicity of Liquid Detergent Capsules (Fabric Cleaning Liquid Tablets) [Abstract]

Background: Based on a Federal Institute for RiskAssessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill lighters and kerosene. Based on their typical lowviscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intraalveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wallthickness 15 mm) was half-filled with fluorocarbon(FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor,connected to a high-sensitivity Pico-ammeter. Results:The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen.This could explain the severe asphyxia and deathd ocumented in BfR cases. Conclusion: The ASC experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations.The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Background: Based on a Federal Institute for Risk Assessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill-lighters and kerosene. Based on their typical low viscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intra-alveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wall thickness 15 mm) was half-filled with fluorocarbon (FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor, connected to a high-sensitivity Pico-ammeter. Results: The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15 fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen. This could explain the severe asphyxia and death documented in BfR cases. Conclusion: The ASC-experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations. The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Abstracts of the 2011 International Congress of the Europeans of the 2011 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 24–27 May 2011, Dubrovnik, Croatia 1. GHB and its Analogues Knudsen K. Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital,Background: The Federal Institute for Risk Assessment (BfR) Documentation and Assessment Centre for Poisonings (BfR-Doc Centre) is part of the German toxicological network. German Physicians and Poison Centres (PCs) report human data of poisonings to the BfR. Every case is assessed on the chemical product involved with the distinct formula provided by BfR product database, which contains notifications of the German industry. Data on human poisonings is condensed in a harmonized and standardized data file for analysis. In addition cases of special toxicological and scientific interest (e.g. rare poisonings, high-/low-dose exposures, cases with unexpected clinical course, substances of special interest etc) are prepared for standardized case reports. For better retrieval of human toxicological data a bilingual case report database has been implemented. Methods: The cases are documented in a standardized form (accident/situation of poisoning/age/gender/symptoms/signs/exposure data/clinical course/assessment/remarks), indicated by the substance/product involved and supplemented with important references. After co-checks for correctness, completeness and readability, the German text is translated into English and transferred to the database. In addition, selected case reports from literature were transferred as pdf-files to the same database. Results: Since July 2002 more than 500 cases have been selected, prepared and processed with additional data for case reports. The case reports were written down in uniform documents, provided with keywords and additional information, finally assigned to index words. Starting in 2004, the documents were recorded in a prototype database driven by MS-Access, from 2006 onwards the case record database was transferred to an Informix 9.2 database in web-browser technology. At present, the BfR-case database has been provided with additional staff. The BfR is in consultation with specialists in data protection to ask whether the BfR case record database can to be opened in the future for specialists. Conclusion: In the assessment of poisonings and for e-learning there is a great interest in case reports. The BfR intends in future to offer its case reports on poisoning via its Internet portal for subject-specific access.Objective: Information relating to interference in certain biochemistry analyses is readily available in the scientific literature, yet the UK National Poisons Information Service (NPIS) still regularly receives enquiries from clinicians struggling to interpret unexpected results. We report three recent cases that serve to illustrate how erroneous laboratory results can confuse the clinical picture and even lead to misdiagnosis in cases of poisoning. n nCase series: 1. A 19-year old male presented at hospital claiming a deliberate ingestion of methanol. He appeared clinically well but had a markedly raised serum creatinine - 766u2009µmol/L. He had been admitted 10 days previously with a paracetamol overdose and it was assumed that the elevated creatinine was a consequence of this and his methanol story was disregarded. An NPIS specialist advised that nitromethane in model engine fuel is known to give falsely high results with certain (Jaffe) creatinine assays. This was confirmed and antidotal treatment was commenced for methanol ingestion. 2. A 35-year old male was admitted with acidosis (pH 6.8) and a raised serum lactate concentration of 24u2009mmol/L. A preliminary diagnosis of cyanide poisoning was made and antidote considered. An NPIS specialist advised that certain Point of Care blood gas analysers have been reported to provide falsely elevated blood lactate concentrations when ethylene glycol metabolites are present. Blood lactate was measured on a different instrument and shown to be within normal limits. Antidotal therapy was commenced for ethylene glycol ingestion - a diagnosis subsequently confirmed by blood ethylene glycol measurement and a markedly raised osmolar gap. 3. A 3-year old girl was admitted with a 3-day history of vomiting. She was obtunded, acidotic (pH 6.9) and had a serum salicylate concentration of 50u2009mg/L, although there was no history of aspirin ingestion. Supportive treatment was initiated and a search at home for possible sources of salicylic acid made. A suggestion by NPIS to the clinician that metabolic disorders such as Maple Syrup Urine Disease can cause acidosis and give false positive salicylate results was later confirmed to be the case. n nConclusion: The possibility of assay interference should be considered when the figures don’t fit the facts.Objective: To ascertain the toxicity of current UK household products. Methods: Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service collected prospectively 5939 telephone enquiries relating to household products, approximately 12% of all telephone enquiries. n nResults: The majority of enquiries (65.5%) concerned children five years of age or less and were received predominantly from hospitals (32.1%), general practitioners (29.8%) and NHS Direct/NHS 24 (28.5%). The majority of exposures occurred at home (97.6%); most exposures were accidental (93.6%). Liquid detergent capsules were most commonly involved (nu200a=u200a647) followed by bleach (nu200a=u200a473), multipurpose cleaners (nu200a=u200a408), descalers (nu200a=u200a397) and disinfectant/antiseptic/sanitiser liquids (nu200a=u200a270). Intentional exposures were more likely to involve bleaches, multipurpose cleaners and disinfectant/antiseptic/sanitiser liquids. Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burn (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score was known at the time of the enquiry. The majority of patients (70.5%) were asymptomatic, 28.0% had developed minor features, 75 patients had developed moderate features and nine patients had developed serious features (PSS 3). Five of these nine patients made a complete recovery, though two developed severe complications and two others died from poisoning with drain cleaner and PVC solvent cleaner; the outcome in two is unknown. n nConclusions: Household product exposures are common in the UK, in other parts of Europe1 and in the US2, though they rarely result in severe sequelae.Background: Besides house and road accidents, in accidental poisoning in children within the house itself, kerosene poisoning is a major problem. In particular in developing countries, where kerosene is still used daily on a large scale for different purposes such as cooking, lightning and for rural medicine. Over the past 15 years, data from Egypt to Sri Lanka have shown that risk. Kerosene accounts for about 60% of pediatric poisonings in Kenya and South Africa. Methods: Analysis of available information and literature in order to: 1. find the main causes for accidental kerosene ingestion and 2. prepare a framework for the prevention of accidental kerosene ingestion in children from developing countries. To obtain a deeper view about the most recent or current scenarios in different parts of the developing world several International Program on Chemical Safety (IPCS) offices and Poison Centers in South-East Asia and the African region were contacted. Results: Kerosene was found as the most common cause of accidental poisoning in children among household poisonings. Mortality was found to be low, but morbidity was high. Children aged 1-3 years were most likely to be involved in accidental kerosene poisoning. Improper storage of kerosene was detected as the main contributory factor for these accidents. Kerosene was found to be stored in jars, bottles or containers previously used for beverages and juices and these were in easy access of children and mistaken by children for something to drink. Conclusion: Accidental kerosene ingestion is a public health issue in the developing world, because children are innocent and parents are not aware and careful enough about storage of kerosene. There is a need for education and increased awareness regarding the poisonous effects of kerosene. Active interventions such as campaigns in schools and local hospitals, performing dramas on the street especially in rural areas, should educate people about safe storage practices. Also they could be provided with safety information (flyer, stickers, symbols etc) and printed information on the back of the pay receipt each time they buy kerosene. Illegal and unsafe kerosene sale has to be stressed.