Jenny J. Lu

The general approach to the poisoned patient

The poisoned patient can present many challenges to the healthcare practitioner. An organized and thoughtful approach to the poisoned patient is necessary. Understanding the nuances of a toxicological history and physical examination can aid in the management of these patients. Supportive care with attention to the body systems at risk from the poisoning is the mainstay of therapy. Consultation with a medical toxicologist or regional poison control center can positively impact diagnosis, management, and disposition of poisoned patients.

Computerized N-acetylcysteine physician order entry by template protocol for acetaminophen toxicity

Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in treating acetaminophen poisoning. An 18-month retrospective review of computerized inpatient pharmacy records for NAC use was performed. All patients who received NAC for the treatment of acetaminophen poisoning were included. Each record was analyzed to determine the form of NAC given and whether an administration error occurred. In the 82 cases of acetaminophen poisoning in which NAC was given, no medication administration errors were identified. Oral NAC was given in 31 (38%) cases; intravenous NAC was given in 51 (62%) cases. In this retrospective analysis of N-acetylcysteine administration using computerized physician order entry and order sets, no medication administration errors occurred. CPOE is an effective tool in safely executing complicated protocols in an inpatient setting.

A complicated hospitalization following dilute ammonium chloride ingestion

IntroductionUnintentional ingestions of dilute (<7.5%) cleaning solutions containing ammonium chloride typically do not cause serious harm. We present a case of an intentional ingestion of a dilute ammonium chloride solution resulting in significant morbidity.Case ReportA 60-year-old woman with bipolar disorder presented one hour after an intentional ingestion of approximately 15 fluid ounces (500 mL) of an algae and odor humidifier treatment containing a total of 2.25% ethyl ammonium chloride. Initial complaints included nausea with a single episode of nonbilious, nonbloody emesis, mild shortness of breath, and chest and epigastric pain. Physical exam was remarkable for bilateral wheezing and epigastric tenderness. An emergent endoscopy demonstrated a Grade 2b caustic injury in the esophagus and a Grade 3b injury in the stomach. Due to persistent cough, copious oral secretions, and worsening hoarseness, the patient was intubated and admitted to the ICU. Her course was complicated by mild hypotension, nonanion gap metabolic acidosis, and oliguria treated successfully with intravenous (IV) fluids. She also developed bilateral pneumonias later in the hospital course. Bedside bronchoscopy showed laryngeal edema and mucosal injury to the segmental level. The patient underwent tracheostomy on hospital day 6. An upper GI swallow study revealed poor esophageal motility in the mid- to lower third of the esophagus. The patient gradually tolerated oral fluids and on hospital day 20 had her tracheostomy tube removed. The patient was subsequently transferred to the psychiatric ward on hospital day 22.ConclusionIntentional ingestions of dilute ammonium chloride solutions can cause serious injury to the gastrointestinal tract and pulmonary systems, which can result in a complicated and prolonged hospitalization.

The association of hemodialysis and survival in intubated salicylate-poisoned patients

Introduction Salicylate poisonings are common due to their multiple uses and wide availability. The variation of presenting symptoms contributes to inconsistent treatments in the emergency department. Patients with severe salicylate overdose require a high minute ventilation. Early in the course of an overdose, a patient will require hyperventilation. If they become too fatigued to compensate, mechanical ventilation may be needed. It can be impossible to recreate such a high minute ventilation with mechanical ventilation. This places patients at a high risk for decompensation and death. Hemodialysis is an effective elimination technique for salicylate overdose and should be considered early. Methods All salicylate cases reported to the Illinois Poison Center were reviewed from 2003–2014. All intubated patients with a salicylate level > 50 mg/dl were included for analysis. Survival was compared to measured serum salicylate level and the administration of hemodialysis. Results 56 Cases were identified with an overall survival rate of 73.2% in patients with a serum salicylate level > 50 mg/dl. When patients did not receive hemodialysis, a peak salicylate level > 50 mg/dl had a 56% survival rate and 0% survival when the level was > 80 mg/dl. In the patients who received hemodialysis, a peak salicylate level > 50 mg/dl had a 83.9% survival rate and 83.3% survival when the level was > 80 mg/dl. Conclusion Survival was decreased in these patients if hemodialysis was not performed. Mortality increases with the measured serum salicylate level. Timely hemodialysis for intubated salicylate overdose patients decreases mortality.