Intentional drug overdose (IDO) can lead to significant morbidity and can increased patient's risk of death. A study was recently performed to identify the predictors of death in a cohort of patient who intentionally overdose on drug(s).
National Self-Harm Registry and National Drug-Related Death Index were reviewed (between January 1st, 2007 and December 31st, 2014) to identify the study cohort.
Results
|
| Non fatal IDO | Fatal IDO |
| Number of cases | 63,831 | 364 |
| Incidence | 148.8/100,000 | 1.01/100,000 |
| Male | 42.0% | 55.2% |
| Age, years (median) | 35 | 44 |
| Multiple drug ingestion | 48.5% | 78.3% |
Risk of death
Conclusion
Many patients are treated in the emergency room for non-fatal opioid overdose. However, it is unknown what proportion of these patient population experience subsequent fatality after their ED visit.
A recent study investigated the 1-year mortality rate among Massachusetts ED patients who were treated and discharged from ED for non-fatal opioid overdose.
Results
Of those who died,
Manner of death
Place of death
Conclusion
Pharmacobezoars (clumps of medication/pills) formation has been demonstrated in few medications such as aspirin, and ferrous sulfate tablets. Their presence can alter management due to prolonged absorption and may cause GI obstruction.
Acetaminophen (APAP) is a commonly available over-the-counter medication that is often implicated in an acute overdose event. A recently published in-vitro study (using pig stomach) investigated whether APAP can form a pharmacobezoar.
APAP group/dosage
Positive control group
Negative control group
Results
Conclusion
Non-opioid medications such as gabapentin are frequently prescribed for the management of pain.
A retrospective study of the National Poison Data System (data collected by the U.S. Poison Centers) from 2013 – 2017 showed increasing trend of gabapentin exposure.
Gabapentin exposure increased between 2013 and 2017 by:
5 most commonly co-ingested substances with gabapentin
16.7% of the isolated gabapentin exposure required hospitalization.
Conclusion:
After many years of national shortage and FDA’s black box warning in 2001 (QT prolongation) droperidol is slowing becoming available.
In 2015, a prospective observational study was published involving ED patients who received droperidol for agitation (acute behavioral disturbance).
Method
Results
Four leading reason for ED presentation
Adverse events
Conclusion
As of November 20, 2019:
2290 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) from 49 states (except Alaska), District of Columbia and 2 U.S. territories.
Analysis of 29 bronchoalveolar lavage (BAL) fluid samples from EVALI patients submitted to CDC from 10 states showed:
*** Vitamin E acetate appears to be associated with EVALI but the investigation is continuing.***
Some research has suggested that oral vitamin E use has potential beneficial effects (i.e. anti-inflammatory/antioxidant) in the lung (e.g. asthma and allergic lung disease), cardiovascular disease and prostate cancer (Cook-Mills JM et al. 2013; Jiang Q et al. 2001)
Common uses of vitamin E
There is limited to no data on pulmonary effect of vitamin E from inhalation in the scientific literature.
Stay tuned for additional updates from CDC.
Metformin is one of the most commonly prescribed oral hypoglycemic agents. Metformin associated lactic acidosis (MALA) is uncommon but potentially life-threatening complication of metformin overdose.
Lactic acidosis occurs due to inhibition of mitochondrial glycerophosphate dehydrogenase, resulting in decreased conversion of lactic acid to pyruvate.
A small retrospective study (using Illinois Poison Center data) attempted to characterize the development of MALA after an acute overdose.
MALA was defined as
Results
40 cases of MALA identified between Jan. 2001 to Dec. 2014
Time to development of MALA (n=30)
Death: 1 (2.5%)
Conclusion
Droperidol has recently become available again in select U.S. institutions. It has been used as an antiemetic and to treat agitation prior to the FDA’s black box warning (for QT prolongation) and national shortage.
Recently, a retrospective study was conducted (Melbourne, Australia) in the use of droperidol in the management of cannabinoid hyperemesis syndrome (CHS).
Results
689 medical records were identified from January 2006 to December 2016.
76 cases met diagnostic criteria of CHS (below)
Droperidol group (DG) = 37; no droperidol group (NDG)= 39
Median length of stay:
Median time to discharge after final drug administration:
Frequency of droperidol (dose) used:
Metoclopramide and Ondansetron use in non-droperidol group was twice that of droperidol group
Conclusion
Patients with drug-induced cardiogenic shock [DIC] (e.g. overdose of CCB/BB, membrane stabilizing agents, etc.) are often managed with medical interventions such as vasopressors, bicarbonate infusion, high-dose insulin, lipid emulsion therapy. A fraction of these patients may be refractory to the standard medical therapy. VA-ECMO (venoarterial extracorporeal membrane oxygenation) has been utilized in such situation; yet clinical experience of using VA-ECMO in DIC is limited.
A recent retrospective study of the Extracorporeal Life Support Organization’s ECMO registry showed
Conclusion
The rate of suicide attempt has been increasing over the past decade. A recently published article investigated the temporal trend of suicide attempts in adolescent/young adult population (10 – 25 years old) from 2000 to 2018.
Methods
Results
Top 5 substance involved in suicide attempt
Agents associated with serious medical outcome (after 2011)
Conclusion
E-cigarette (vaping) use has become increasingly popular over the past 10 years, especially among adolescents. Intentional exposure (i.e. ingestion in self harm) of nicotine (e-cigarette liquid) can be life threatening where it can produce mixture of stimulatory (early), cholinergic toxicity and muscle paralysis/respiratory failure by blocking the neuromuscular junction. However, the severity of clinical toxicity in unintentional exposure can vary widely depending on the dose/route/circumstance of their exposure.
A recently published study investigated the characteristics of e-cigarette liquid exposure between Jan 1, 2010 to Dec 31, 2018 using the National Poison Data System
Result
Top 4 clinical/demographic characteristics are listed below.
Age group:
Route of exposure
Level of care:
Clinical effects - overall
In <5 years group
Conclusion
Cannabinoid hyperemesis syndrome [CHS] (i.e. cyclic/recurrent nausea, vomiting and abdominal pain) is associated with long-term and frequent use of marijuana. Patients with CHS often report temporary relief of symptoms with hot water/shower exposure. Emergency room providers may encounter a growing number of patients with CHS with increasing legalization of marijuana-containing products.
Topical capsaicin has been gaining interest as a potential adjunct to the conventional management of patients with CHS (e.g. antiemetics, opioids, benzodiazepines and antipsychotics).
A small retrospective study was performed involving 43 patients who had multiple visits, and were treated with and without capsaicin. The primary outcome was the ED length of stay (LOS).
Results
Conclusion
Breath analyzers are commonly used by law enforcment officers to test for alcohol intoxication. Breath analyzer uses ethanol partition ratio between blood:breath of 1:2100 = 1 gm of ethanol in 2100 mL of breath/air.
Mouth wash products are frequently used for oral hygiene, and at times, to "mask" odor of substances. These products are readily available in any grocery stores or pharmacy and contain upto 26.9% ethanol (e.g. Listerine) (18.9% - Scope; 14.0% - Cepacol).
Recently, a small study using healthy volunteers (n=11) was published to investigate the impact of limited ethanol exposure (mouth wash and ethanol vapor) on the breath-alcohol concentration (BrAC).
Method
Results
Blood: No or very low levels of ethanol (0.002 mg/g) were detected in blood at all collection time for both exposures.
BrAC - first collection -- seconds after exposure
Mean time to negative BrAC level (Swedish statutory limit of 0.1 mg/L = 0.01 mg/dL in air) (FYI: US limit = 80 mg/dL)
Conclusion
Numerous different household products can potentially be misused/abused. One such product is whipped cream charger/propellant that contains nitrous oxide.
Acute toxicity produce dose dependent response
Chronic toxicity causes myeloneuropathy (demyelination of the dorsal and lateral columns of the spinal cord) due to vitamin B12 deficiency
Management
Center for Disease Control and Prevention (CDC) recently issued alerts regarding cases of pulmonary illnesses that may be linked to "vaping" (in 15 states with 149 possible cases). These cases are still under investigation but all cases reported vaping weeks/months prior to hospitalization.
Most cases involve young adults who have been using THC-containing products
Common complaints included
Imaging studies:
Clinical course
What to do:
Direct hepatotoxicity from a drug is predictable and dose-dependent.
Most commonly implicated agents include:
On the contrary, idiosyncratic prescription drug-induce liver injury is rare, unpredictable and not related to dose.
Most commonly implicated agents are:
Bottom line:
Hematologic toxicity (coagulopathy/bleeding) can occur with pit viper envenomation. Copperhead is the most commonly implicated pit viper envenomation in the U.S. However, the prevalence of hematologic toxicity from copperhead envenomation is variable, possibly due to regional variation in venom potency and species misidentification.
An observation study was performing using multi-center (Virginia Commonweath university, University of Virginia Medical Center and Eastern Virginia Medical medical center) electronic hospital/medical records (Jan 1, 2006 to Dec 31, 2016) of suspected copperhead bites. Authors state that copperhead snakes are "nearly exclusively endemic" to the VCU and UVA medical center region.
Results:
388 patients were identified but 244 met inclusion/exclusion criteria.
Hematologic toxicity: 14%
Conclusion
In a small sample of copperhead envenomation in Virginia, “subtle” hematologic abnormalities were observed but clinically significant hematologic toxicity was not observed (i.e. bleeding)
Pulmonary complications - aspiration, pulmonary edema, etc. are frequently reported in both heroin intoxication and in reversal of opioid overdose with naloxone.
Suspected opioid overdose victims (N=1831) who received naloxone from EMS providers were studied retrospectively. Pulmonary complications were defined as pulmonary edema, aspiration pneumonia and aspiration pneumonitis.
Results
Conclusion
Higher out of hospital naloxone administration is associated with increased odds of developing pulmonary complications
“Push dose pressors” – administration of small doses of vasopressors in the emergency room has become a common practice. A recently published study investigated the incidence of human error and adverse hemodynamic events.
Push dose pressors were defined as:
Adverse hemodynamic event was defined as:
249 out of 1522 patients were identified and analyzed from Jan 2010 to November 2017
Adverse event
Errors
Conclusion
Cyanide poisoning, while uncommon, is frequently fatal. Current antidotes include methemoglobinemia inducers (nitrites), sulfur donators (thiosulfate), and hydroxocobalamin. Each has risks and benefits that must be considered. Three new potential antidotes, including sodium tetrathionate, have recently been evaluated in swine models.
Intramuscular sodium tetrathionate1
Advantages:
Bottom line: