Assessment and Management of Toxidromes in the Critical Care Unit

Rasimas, Joseph J.; Sinclair, Courtney M.

doi:10.1016/j.ccc.2017.03.002

Cited by 30 publications

(35 citation statements)

References 78 publications

(75 reference statements)

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“…Rationale No published study of sufficient quality has provided conclusive evidence for the contribution of PCC and expert centres to the improvement of the management of patients with pharmaceutical or recreational drug poisoning, whether in terms of toxin identification or expected morbidity and mortality. Note that, in terms of identification of the suspected toxin: (1) due to the detailed knowledge of clinical toxicology (toxidromes), these expert centres can help to identify the class of toxins consumed [29]; (2) as in other countries [30], the dedicated and trained pharmacists of PCCs are able to identify medication tablets marketed in France 24 h a day, 7 days a week; and (3) PCC/expert centres work in collaboration with laboratories able to identify the possible presence of a toxic substance (tablet or liquid) within a package. In terms of morbidity and mortality, it should be noted that: (1) consultation of a PCC could reduce the length of hospital stay (probably by recommending earlier discharge from hospital than that envisaged in the absence of PCC opinion) [31][32][33]; and (2) PCC/expert centres can rapidly guide clinicians concerning the indications for antidotes, toxin elimination methods and the indications for exceptional techniques (ECMO).…”

Section: Question 14: In a Patient With Pharmaceutical Or Recreationmentioning

confidence: 99%

Management of pharmaceutical and recreational drug poisoning

Mégarbane

Oberlin

Alvarez

et al. 2020

Ann. Intensive Care

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Background Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. Methods A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d’Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. Results The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. Conclusions The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

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Section: Question 14: In a Patient With Pharmaceutical Or Recreationmentioning

confidence: 99%

Management of pharmaceutical and recreational drug poisoning

Mégarbane

Oberlin

Alvarez

et al. 2020

Ann. Intensive Care

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“…Сьогодні провідними токсикологічними школами США та країн Європейського Союзу переглядаються рекомендації з клінічної практики щодо гострих отруєнь наркотичними та психотропними речовинами (НПР) із метою визначення тих, що можуть бути покладені в основу нових діагностичних підходів з оцінки пацієнта та протоколів лікування. Пошук нових підходів знаходить відображення в сучасній науковій літературі [4][5][6][7][8].…”

Section: вступunclassified

Diagnosis of acute poisoning by addictive and psychotropic substances based on the toxidrome

Kurdil

2021

ЕМ

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Background. Poisoning by addictive and psychotropic substances is one of the main reasons for the admission of patients to emergency departments in most countries of the world. The purpose of this study was to investigate the current structure of toxic syndromes in patients with acute poisoning and to analyze existing approaches to the diagnosis of addictive and psychotropic substance poisoning based on the syndromic approach. Materials and methods. Medical data of 2987 patients treated with the diagnosis: “Acute drug poisoning” (ICD-10: T40.0-T40.3) in the Kyiv Toxicological Center were studied. Laboratory studies of addictive and psychotropic substances in the biological environment were performed using immunochromatographic analysis (rapid tests) and chromate-mass spectrometry (device Aligent 6850/5973N, column HP-5MS). Statistical analysis was performed using the program Statistica 12.6 (Windows 10/7). Results. According to the Center for Mental Health and Monitoring of Drugs and Alcohol of the Ministry of Health of Ukraine in 2018, the most common substances that result in abuse were: alcohol — 14.6 %, cannabis — 2.8 %, opioids — 2.1 %, sedative agents — 1.1 %, solvents — 0.9 %, amphetamine-type stimulants — 0.2 %, cocaine — 0.1 %, and hallucinogens — 0.1 %. The range of substances that caused severe poisoning in adults in 2016–2020 represented by: ethanol — 29.2 %, opioids — 42.3 %, cannabinoids — 8.4 %, sedative agents and hypnotics — 9.5 %, cocaine, and stimulants, inclu-ding caffeine — 7.4 %, hallucinogens — 5.5 %, solvents — 2.1 %. The following toxidromes were diagnosed: sedative in 46.3 % of patients, opioid — 37.6 %, sympathomimetic — 17.7 %, anticholinergic — 9.5 %, serotonin — 0.4 %, and syndrome of inappropriate diuretic hormone secretion (SIADH) — 0.2 %. During the study period, the number of combined poisonings increased 1.8 times (from 20.5 to 37.1 %), and among the combinations of addictive and psychotropic substances, the most common are methadone + ethanol, methadone + benzodiazepines, methadone + amphetamine, opioids + cocaine + ethanol, opioids + cannabis, as well as other combinations involving methamphetamine, hallucinogens, analgesics. Clinical diagnosis of combined poisonings is difficult, miosis may be absent in tramadol and meperidine poisoning, in cases of combined use of opioids and stimulants, or extremely severe cases, when the patient shows signs of deep post-hypoxic encephalopathy. Modern synthetic opioids (fentanyl and buprenorphine analogues) significantly outweigh the toxic effects of heroin, so there is a fairly common approach to using higher initial doses of naloxone in the treatment of such overdoses. However, approaches to the use of naloxone differ in various scientific sources. The practical experience in the Kyiv Toxicological Center proves that treatment can be started with standard doses of naloxone and quickly increased in the absence of side effects (agitation, convulsions, pulmonary edema). Given the fact that modern test systems are aimed at finding a small range of narcotic and psychotropic substances and do not determine their concentration, considerable attention should be paid to clinical diagnosis based on the definition of pathological symptoms and syndromes. Since the main target for narcotic and psychotropic substances is the nervous system, the identification of biomarkers of its dysfunction at different levels is key in the diagnosis of poisoning. Based on certain biomarkers, an understanding of the existing toxic syndrome (toxidrome) is formed. Today, opioids play a key role in morbidity and mortality from drug poisoning in Ukraine. A threatening trend in recent years is the increase in the proportion of combined poisonings by opioids and other substances, which complicates the determination of the toxidrome. It is important to note that the “fashion” for the use of combinations of narcotic drugs and psychotropic substances among drug users is constantly changing, so doctors try to regularly update information on available drugs and psychotropic substances in the region, which are popular among consumers and characteristic manifestations of poisoning. The universal approach ABCDE should be used in cases where there are no specific tests for toxic substances, and because more than a third of positive tests show the presence of two or more xenobiotics. Conclusions. Identification of toxidrome is important from the standpoint of diagnosis and treatment of acute poisoning. Many researchers note that its importance exceeds the value of rapid tests to determine the toxic substance, and the patient’s vital signs and careful examination are the best clues for choosing treatment tactics. In cases of combined poisoning with drugs or psychotropic substances, or in situations where it is not possible to conduct rapid testing of the patient’s urine for toxic substances, it is necessary to approach the use of antidotes (naloxone) with caution. It is important to remember that the object of medical intervention in any poisoning is the patient, not the toxin or the results of laboratory tests, which do not always correctly indicate the poison. Pharmacological interventions in the treatment of a patient with acute addictive or psychotropic substance poisoning should be aimed at correcting the underlying pathological syndrome (if possible), taking into account not to exacerbate its manifestations, but rather to minimize its severity and duration.

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“…Several drugs such as acetaminophen, anesthetics and some cardiotoxins, β-adrenergic blockers, calcium channel blockers, digitalis glycosides, iron, isoniazid, methotrexate, neuroleptics, sulfonylureas, insulin, tricyclic antidepressants (and related compounds with sodium channel blocking properties), valproic acid, anticoagulants could be the cause of toxidromes [7,8].…”

Section: Editorial Open Accessmentioning

confidence: 99%

Toxidromes and multimorbidity: Do we need more case reports?

Greco¹,

Alfredo²,

Fabbian³

2021

J Case Rep Images Med

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One of the most frequent causes of accidental death is poisoning, and it is frequently ascribed to pharmaceutical agents. Already Paracelsus, in the 16th century, stated that the difference between remedy and medicine was the dose ("All things are poison, and nothing is without poison; the dosage alone makes it so a thing is not a poison"). However, some drugs could become dangerous even at therapeutic dose, depending on patient's clinical conditions and on the interactions with different molecules."Drug abuse" is a common medical condition involving a high percentage of the world population. It was estimated that a quarter of a billion people, or around 5% of the global adult population, used drugs at least once in 2015 [1]. The most abused substances are alcohol, opioids, cannabinoids, sedative-hypnotics, cocaine, and many other stimulants such as caffeine, hallucinogens, tobacco, and volatile solvents. Not all these substances are equally harmful and many of them have different "harm ratings" to users themselves and/or to third persons [2].The term "drug abuse" is still of common use, even if it is no longer considered a medical diagnosis in both the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and the World Health Organization's International Statistical Classification of Diseases (ICD), the most used diagnostic tools in the world. The DSM-5, released in 2013, revisited the terminology, and both the terms "substance abuse" and "substance dependence" were merged into the bigger

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Assessment and Management of Toxidromes in the Critical Care Unit

Cited by 30 publications

References 78 publications

Management of pharmaceutical and recreational drug poisoning

Management of pharmaceutical and recreational drug poisoning

Diagnosis of acute poisoning by addictive and psychotropic substances based on the toxidrome

Toxidromes and multimorbidity: Do we need more case reports?

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