ABSTRACT

Aim:

This study aimed to evaluate studies on drug poisoning and emergency servics published in PubMed between January 2019 and January 2020.

Materials and Methods:

The literature review was carried out using the terms “drug poisoning and emergency medicine” in PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez) January 2019 and January 2020. All summaries defined in the searches were reviewed, and suitable studies were selected.

Results:

Eighty-five studies were identified in PubMed between January 2019 and January 2020. 28.24% (24) of these studies are retrospective, prospective, and cohort studies and meta-analyses. 56.47% (48) were original studies, of which 20.83% (20) were on narcotic poisoning (opioid, synthetic cannabinoids, cannabis, and heroin), 8.33% (4) were on overdose paracetamol poisoning, 8.33% (4) were on allergic reactions due to drug use, 6.25% (3) were on acute alcohol poisoning, and 56.25% were other original studies. Studies on treating intoxication complications were 15.29%.

Conclusion:

According to this annual evaluation, the most common studies on applications in emergency departments and poison centers were original articles on drug poisoning, 56.47%. Retrospective, prospective, and cohort studies and meta-analyses were 28.24%, and studies on the treatment of complications resulting from drug poisoning were 15.29%.

Keywords:

Drug poisonings, emergency service, clinical toxicology

Introduction

Poisoning is an important public health problem that causes a major portion of emergency department (ED) admissions and may cause serious consequences to health (1,2). The demographic characteristics of poisoning cases differ in terms of regions and socioeconomic factors (3).

Poisoning events are generally; the use of prescription or non-prescription medication initiated by the patient occurs due to iatrogenic administration of high doses of drugs, accidental exposure to chemicals, or deliberate intake of biological agents for suicide (4). Medicinal drugs are the most encountered (47-86%) agents in poisonings.

Among medicinal drugs, paracetamol, nonsteroidal anti‑inflammatory and antidepressants are mostly seen (5-7). Preventable adverse drug events (ADEs) are a common cause of ED visits, hospitalizations and death (8,9). ADEs cause or contribute to one in nine ED visits, and of deaths attributed to medical care, medications are the most common cause (10-13).

Our aim in this study is to evaluate the “drug poisonings and emergency service” studies published in Pubmed between 01.01.2019 and 01.01.2020.

Materials and Methods

The literature review was carried out using the terms “drug poisoning” and “emergency medicine” in PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez) between 01.01.2019 and 01.01.2020. All summaries defined in the studies were reviewed and suitable research selected for later review. Toxicity studies; applications to the University Hospital Adult Emergency Service, National, Regional Poison Centers and Poison Control Centers are selected. IBM SPSS version 20.0 program was used for statistical analysis.

Results

Eighty five studies were identified in Pubmed between 01.01.2019 and 01.01.2020 with the keywords “drug poisoning and emergency service”. 28.24% (24) of these studies are retrospective, prospective, cohort study, meta-analysis, 56.47% (48) original study and 15.29% treatment of complication (Table 1).

20.83% (10) of 48 original studies narcotic poisoning (opioid, synthetic cannabinoids, cannabis, heroin), 8.33% (4) overdose paracetamol poisoning, 8.33 (4) drug-related allergic reactions, 6.25% (3) acute alcohol poisoning, 56.25% (27) are other original studies (Table 2).

Some of the other original studies 56.25 % (27) “clinical toxicology of beta-blocker overdose in adults, acute deliberate salicylate toxicity, valproic acid toxicity, treatment of caffeine toxicity with metoprolol, central nervous system toxicity due to mefenamic acid, accidental mercury poisoning, the effects of amiodarone prophylaxis on cardiac dysrhythmia in acute aluminium phosphide poisoning, toxic epidermal necrolysis induced by allopurinol, deliberate self-poisoning with a lethal dose of pentobarbital, acute alcohol co-ingestion and hospital-treated deliberate self-poisoning” and similar cases.

15.29 (13) of 85 studies identified in Pubmed as a result of screening are studies to treat complications from poisoning. Some of those; antidote, intraveous lipid emulsion (ILE) therapy in fatal overdose cases, antidotal use of physostigmine for its treatment, the role and effect of brain computed tomography in drug treatment and guidance recommendations, Drug Compliance Check: To support drug surveillance clinical rules by applying advanced pharmacotherapy (Table 3).

Discussion

Drug poisoning can be either intentional or unintentional and occurs in both young adults and elderly people. Unintentional drug poisoning occurs more often than intentional drug poisoning. Whereas in young adults, the majority of drug poisoning cases is intentional (14-17).

In our study, 85 studies were identified in Pubmed. 28.24% (24) of these studies were retrospective, prospective, cohort studies, meta-analysis, 56.47% (48) original study, and 15.29% complication treatment studies. Some of those; emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. 48 hours cross-sectional study was carried out in 319 emergency medical service (EMS) and emergency services in France. Data from 703 patients (median age was 43 and men was 40%) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score and a higher rate of admission to an intensive care unit (18).

Over-the-counter analgesics are often used in suicide attempts. After the suicide attempt between 2009 and 2010 in Montreal, a cross-sectional study using the graphic examination of all individuals who applied to the emergency room of two adult general hospitals. Substances most frequently used were acetaminophen (30%), antidepressants (37%), anxiolytics (30%), opioids (10%), and anticonvulsants (9%) among prescription drugs, and cocaine (10%) among recreational drugs. Accessibility, toxicity and large amounts of unsupervised intake can be facilitators (19).

In a quantitative approach with data analysis of drug-related intoxication cases at the Poison Control Center University Hospital at Londrina State University in Brazil, the data were collected from the service notification records for the period 1985-2014. There was a trend for a higher proportion of cases of drug-related poisonings in males. Also, there was an increased trend towards cases involving analgesics/anti-inflammatories/immunosuppressants, antidepressants and antipsychotics (20).

Acetaminophen (APAP) poisoning, remains a leading cause of morbidity and mortality in developed countries. Time APAP is one of the most commonly used analgesics. The world can result in overdose hepatic injury and death antidotal treatment is delayed. For over 40 years, risk stratification decisions regarding antidotal treatment with N-acetylcysteine have been guided by the Rumack-Matthew nomogram (the nomogram). In a retrospective database analysis, changing nomogram risk zone classification with serial testing after acute acetaminophen overdose. Half of patients after acute APAP overdose cross nomogram risk areas, the current treatment threshold 150 mg/mL 4 hours after swallowing. Old age, male sex, independently of co-ingestants and final liver damage It is associated with a patient who moves to higher-risk areas (21).

Salicylate poisoning is a serious toxicologic problem with a complex pathophysiology. At the start of the session, teams received a 10-minute introduction to the activity. Upon entering a room in a simulated ED, teams had 15 minutes to complete a focused history and physical exam of the patient, interpret arterial blood gas and basic metabolic panel data, and administer treatment based on key findings and a presumptive diagnosis. This simulation exercise was successful in exposing students to the clinical presentation of salicylate toxicity and giving them the opportunity to apply and synthesize basic science knowledge during the scenario (22).

In a retrospective study examining the clinical toxicology of beta-blocker overdose, there was no significant difference in the severity of poisoning among beta-blockers in adults. No deaths were observed in case of overdose beta-blockers and single dose exposure. Other antihypertensives, sedatives or alcohol should be used with caution, and it is stated that death can develop (23).

In the systematic review incidence of mortality due to rebound toxicity in prehospital opioid overdose care: Mortality or serious adverse events in the included studies due to suspected rebound toxicity in patients treatment with naloxone was rare. There was very limited evidence available reporting on adverse events (24).

In retrospective study to assess the association of pregabalin misuse with use of other sedatives and with suicidal self-harm; to compare the characteristics of pregabalin misuse-related harms in people who misuse pregabalin according to whether or not they also used other sedatives. Rates of pregabalin misuse-related ambulance attendances have increased markedly over the past 6 years. Caution is required when prescribing pregabalin for people taking other sedatives. Limiting the dispensing of this drug may reduce the risks associated with its misuse (25).

Cyproheptadine is a serotonin and histamine antagonist that has been suggested as a treatment for serotonin syndrome. An 11‐year retrospective review of cyproheptadine use in serotonin syndrome cases reported to the California Poison Control System. The benefits of and indications for cyproheptadine are uncertain and questionable for the management of a serotonin syndrome. Future recommendations on its use should be based on diagnostic criteria, severity of symptoms and management in conjunction with other supportive measures (26).

In a another retrospective cohort study acute alcohol ingestion and when the effect of self-harm was examined in patients treated intentionally with self-poisoning. There was no significant relationship between the coingestion of alcohol in an index DSP and subsequent repeated or suicide (27).

Little is known about the relative harms of edible and inhalable cannabis products. In an observational study examining acute diseases associated with cannabis use by exposure route, visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected (28).

In this retrospective analysis of all cases of human exposures (intentional abuse, accidental and unknown circumstances, and suicide attempts) for the period 2002-2016. Poisoning due to substance abuse has changed significantly during the last few years. Therefore, developments of substance abuse reported to the Poisons Information Centre Erfurt were investigated and compared to other circumstances of human exposures during the last 15 years. Clinical significance of substance abuse is shown by the fact that it resulted more often in moderate and severe symptoms than suicide attempts (29).

A cross-sectional observational study examining drug treatment deficiencies as a reason for admission to the intensive care unit in a university hospital. The frequency of drug therapeutic failures in our study was similar to that described in the literature; being the most common cause the inappropriate drug use, particularly for drugs with complex kinetics, such as antiepileptic drugs (30).

Pharmacogenetic relationship between NAT2 gene polymorphisms and hepatotoxicity from isoniazid: in meta-analysis study. Genetic variants of the NAT2 gene, plays an important role in hepatotoxicity from isoniazid. Thus, NAT2 genotyping, understanding of drug-enzyme metabolic capacity and helping early predisposition isoniazid-induced hepatotoxicity (31).

Urinary Drug Screening in Acute Drug Poisoning: A Prospective Cross-Sectional Study. In the treatment of patients suspected of acute drug poisoning, the patient’s urine is usually performed. In Japan, using common screening kits at the point of care. They evaluated which kit was appropriate. In acute drug poisoning screening, the results are more useful compared to serum drug analysis results (32).

In a retrospective study, the examination of patient characteristics associated with taking home naloxone to an intensive, urban emergency room. Naloxane (THN) kits may be recommended for patients with an overdose of opioids. ED staff use illegal opioids or use a serious overdose because you can potentially benefit from THN, but may miss others who are at high risk for the future, overdose. Hospital EDs, all eligible people Patients at risk of overdose can access THN (33).

In the observational retrospective cohort study, the electronic medical record data of geriatric patients and the safety of parenteral ketorolac use for analgesia management in geriatric ED patients were examined. The respiratory side effects of the central nervous system and opioids have been investigated with a varying approach to optimal ED pain management with opioids in the geriatric population outbreak (34).

In this study physiostigmine and non-antidote treatment have been prospectively investigated in antimuscarinic therapy. Poison centers usually manage patients with antimuscarinic delirium. However, the discussion It surrounds the antidotal use of physostigmine for its treatment. This study provides further evidence of both the safety and efficacy of physostigmine in the treatment of antimuscarinic delirium (35).

Investigation of ILE therapy in fatal overdose cases in an observational study. Within the Association of Poison Control Centers National Poison Data System, hundreds of cases exist in which ILE therapy was given and death occurred. In many of these cases, ILE was given prior to cardiovascular collapse. Although there is some suggestion of transient improvement in a small subset of cases, adverse effects are also reported. When taken in totality, the number of published cases of failed lipid emulsion therapy outnumbers the published instances of ILE success. Given all the uncertainty generated by case reports, the evaluation of the role and efficacy of ILE therapy in non-local anesthetic poisoning needs robust controlled clinical trials (36).

In the study examining the development and characteristics of the Overdose Cohort in British Columbia Canada, hospitalization, doctor visits, poison center and ambulance overdose cases, emergency visits and forensic data were recorded. It is available from multiple sources. 10,456 people were overdosed by 14,292 from January 1, 2015 to November 30, 2016. In ambulance records, only 28% of overdose events were found in multiple data sets of the highest cases (32%). Compared to fatal overdoses, non-fatal events more frequently included women, young individuals (20 to 29 years old) and those 60 or older. 78% of illicit drug deaths had no associated ambulance response. In the year before the first overdose, 60% of individuals had at least one ED visit, 31% had at least one hospital visit, 80% had at least one doctor visit, and 87% had at least one visit in a community pharmacy. It was observed that he filled the prescription (37).

Conclusion

Preventable adverse drug events is an important public health problem that causes a major portion of hospital adult emergency service, national, regional poison centers and poison control centers admissions and may cause serious consequences to health.

Ethics

Ethics Committee Approval: Ethics committe approval is not obtained for studies conducted by examining the studies published in Pubmed.

Informed Consent: Informed consent is not made in studies using pubmed data.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: İ.H.H., N.G., Design: İ.H.H., N.G., Data Collection or Processing: İ.H.H., N.G., Analysis or Interpretation: İ.H.H., N.G., Literature Search: İ.H.H., N.G., Writing: İ.H.H., N.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

Sungur S, Bilge U, Acar N, Unluoglu I. Retrospective evaluation of adult poisoning cases admitted to emergency department of a University Hospital in Turkey. Niger J Clin Pract. 2018;21:1023-8.

Lund C, Vallersnes OM, Jacobsen D, Ekeberg O, Hovda KE. Outpatient treatment of acute poisonings in Oslo: poisoning pattern, factors associated with hospitalization, and mortality. Scand J Trauma Resusc Emerg Med.
2012;20:1.

Greene S. General Management of Poisoned Patients. In Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D. Meckler, David M. Cline (Eds) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th edition; Mc. Graw- Hill, USA 2016.

Vale A, Bradberry S. Poisoning: Introduction - Medicine 2016;44:75.

Dal O, Kavak H, Akay S, Ünlüer EE, Aksay E. Retrospective evaluation of poisoning patients in the emergency department. Çağdaş Tıp Derg. 2013;3:22-7.

Baydin A, Yardan T, Aygun D, Doganay Z, Nargis C, Incealtin O. Retrospective evaluation of emergency service patients with poisoning: a 3-year study. Adv Ther. 2005;22:650-8.

Ozcan N. Summary of the National Poison Information Center 2008 Annual Report. Turk Hij Den Biyol Derg. 2009;66:29-58.

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678-86.

Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America Washington DC: National Academy Press, 2000.

Forster AJ, Asmis TR, Clark HD, Al Saied G, Code CC, Caughey SC, et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004;170:1235-40.

Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-84.

Zed PJ, Abu-Laban RB, Balen RM, Loewen PS, Hohl CM, Brubacher JR, et al. Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study. CMAJ. 2008;178:1563-9.

Hohl CM, Yu E, Hunte GS, Brubacher JR, Hosseini F, Argent CP, et al. Clinical decision rules to improve the detection of adverse drug events in emergency department patients. Acad Emerg Med. 2012;19:640-9.

Haoka T, Sakata N, Okamoto H, Oshiro A, Shimizu T, Naito Y, et al. Intentional or unintentional drug poisoning in elderly people: retrospective observational study in a tertiary care hospital in Japan. Acute Med Surg. 2019;6:252-8.

Hirata K, Matsumoto Y, Tomioka J, Kurokawa A, Matsumoto M, Murata M. Acute drug poisoning at critical care departments in Japan. Jpn J Hosp Pharm. 1998;24: 340-8.

Sugimura T, Muraishi M, Ariyoshi K. Present status of acute medication intoxication in elderly. JJAAM. 2015;26:702-26.

Kroner BA, Scott RB, Waring ER, Zanga JR. Poisoning in the elderly: characterization of exposures reported to a poison control center. J Am Geriatr Soc. 1993;41:842-6.

Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, et al. Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France. Intern Emerg Med. 2019;14:981-8.

Mikhail A, Tanoli O, Légaré G, Dubé PA, Habel Y, Lesage A, et al. Over-the-Counter Drugs and Other Substances Used in Attempted Suicide Presented to Emergency Departments in Montreal, Canada. Crisis. 2019;40:166-75.

Mathias TL, Guidoni CM, Girotto E. Trends of drug-related poisoning cases attended to at a poison control center. Rev Bras Epidemiol. 2019;22:e190018.

Mutsaers A, Green JP, Sivilotti MLA, Yarema MC, Tucker D, Johnson DW, et al. Changing nomogram risk zone classification with serial testing after acute acetaminophen overdose: a retrospective database analysis. Clin Toxicol (Phila). 2019;57:380-6.

Lammers RL, Sheakley ML, Hendren S. A Simulated Case of Acute Salicylate Toxicity From an Intentional Overdose. MedEdPORTAL. 2018;14:10678.

Lauterbach M. Clinical toxicology of beta-blocker overdose in adults. Basic Clin Pharmacol Toxicol. 2019;125:178-86.

Greene JA, Deveau BJ, Dol JS, Butler MB. Incidence of mortality due to rebound toxicity after ‘treat and release’ practices in prehospital opioid overdose care: a systematic review. Emerg Med J. 2019;36:219-24.

Crossin R, Scott D, Arunogiri S, Smith K, Dietze PM, Lubman DI. Pregabalin misuse-related ambulance attendances in Victoria, 2012-2017: characteristics of patients and attendances. Med J Aust. 2019;210:75-9.

Nguyen H, Pan A, Smollin C, Cantrell LF, Kearney T. An 11-year retrospective review of cyproheptadine use in serotonin syndrome cases reported to the California Poison Control System. J Clin Pharm Ther. 2019;44:327-34.

Borruso LD, Buckley NA, Kirby KA, Carter G, Pilgrim JL, Chitty KM. Acute Alcohol Co-Ingestion and Hospital-Treated Deliberate Self-Poisoning: Is There an Effect on Subsequent Self-Harm? Suicide Life Threat Behav. 201949:293-302.

Monte AA, Shelton SK, Mills E, Saben J, Hopkinson A, Sonn B, et al. Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study. Ann Intern Med. 2019;170:531-7.

Gollmann M, Frimlova G, Just S, Liebetrau G, Prasa D, Stürzebecher A, et al. Substanzmissbrauch – Entwicklung des Vergiftungsgeschehens im Einzugsbereich des Giftnotrufes Erfurt 2002–2016 [Substance Abuse Poisoning Reported to the Poisons Information Centre Erfurt from 2002 to 2016]. Gesundheitswesen. 2019;81:397-404.

Ruiz-Garzon JA, Rojas-Velandia CA, Calderon-Ospina CA. Drug Therapeutic Failures as a Cause of Admission to an Intensive Care Unit at a University Hospital. J Res Pharm Pract. 2019;8:168-72.

Khan S, Mandal RK, Elasbali AM, Dar SA, Jawed A, Wahid M, et al. Pharmacogenetic association between NAT2 gene polymorphisms and isoniazid induced hepatotoxicity: trial sequence meta-analysis as evidence. Biosci Rep. 2019;39:BSR20180845.

Fujikawa A, Ohde S, Otani N, Ishimatsu S. Triage DOA® versus INSTANT-VIEW M-1® in Urinary Drug Screening for Acute Drug Poisoning: A Prospective Cross-sectional Study. Intern Med. 2019;58:2627-32.

O’Brien DC, Dabbs D, Dong K, Veugelers PJ, Hyshka E. Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review. BMC Health Serv Res. 2019;19:632.

Anderson GL, Mattson AE, Brown CS, Cabrera D, Mara KC, Bellolio MF. Safety of parenteral ketorolac use for analgesia in geriatric emergency department patients. Am J Emerg Med. 2020;38:727-30.

Boley SP, Olives TD, Bangh SA, Fahrner S, Cole JB. Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center. Clin Toxicol (Phila). 2019;57:50-5.

Smolinske S, Hoffman RS, Villeneuve E, Hoegberg LCG, Gosselin S. Utilization of lipid emulsion therapy in fatal overdose cases: an observational study. Clin Toxicol (Phila). 2019;57:197-202.

MacDougall L, Smolina K, Otterstatter M, Zhao B, Chong M, Godfrey D, et al. Development and characteristics of the Provincial Overdose Cohort in British Columbia, Canada. PLoS One. 2019;14:e0210129.

Anual Evaluation of “Drug Poisonings, Emergency Service” Studies Published in Pubmed 01.01.2019-01.01.2020