Effect of the UK's revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment

AIMS: In September 2012 the UK’s Commission on Human Medicines (CHM) recommended changes in the management of paracetamol poisoning: use of a single ‘100 mg l(−1)’ nomogram treatment line, ceasing risk assessment, treating all staggered/uncertain ingestions and increasing the duration of the initial acetylcysteine (NAC) infusion from 15 to 60 min. We evaluated the effect of this on presentation, admission, treatment, adverse reactions and costs of paracetamol poisoning. METHODS: Data were prospectively collected from adult patients presenting to three large UK hospitals from 3 September 2011 to 3 September 2013 (year before and after change). Infusion duration effect on vomiting and anaphylactoid reactions was examined in one centre. A cost analysis from an NHS perspective was performed for 90 000 patients/annum with paracetamol overdose. RESULTS: There were increases in the numbers presenting to hospital (before 1703, after 1854; increase 8.9% [95% CI 1.9, 16.2], P = 0.011); admitted (1060/1703 [62.2%] vs. 1285/1854 [69.3%]; increase 7.1% [4.0, 10.2], P < 0.001) and proportion treated (626/1703 [36.8%] vs. 926/1854 [50.0%]; increase: 13.2% [95% CI 10.0, 16.4], P < 0.001). Increasing initial NAC infusion did not change the proportion of treated patients developing adverse reactions (15 min 87/323 [26.9%], 60 min 145/514 [28.2%]; increase: 1.3% [95% CI –4.9, 7.5], P = 0.682). Across the UK the estimated cost impact is £8.3 million (6.4 million–10.2 million) annually, with a cost-per-life saved of £17.4 million (13.4 million–21.5 million). CONCLUSIONS: The changes introduced by the CHM in September 2012 have increased the numbers of patients admitted to hospital and treated with acetylcysteine without reducing adverse reactions. A safety and cost-benefit review of the CHM guidance is warranted, including novel treatment protocols and biomarkers in the assessment of poisoning

Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial:a randomised controlled trial

Copyright © 2014 Bateman et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd. All rights reserved. The trial was funded by Chief Scientist Office, Scotland (award CZB/4/722).Peer reviewedPublisher PD

Late onset dystonia following risperidone overdose [Abstract]

Objective: Risperidone overdose is generally associated with mild and predictable clinical effects, including sedation, tachycardia and dystonia, which are usually resolved within 24 hours of ingestion. We report the management of a case of risperidone overdose in a 28 year old woman who remained asymptomatic for almost 60 hours post-ingestion before the sudden onset of an acute dystonic reaction of the tongue and throat.  Case report: The patient presented following the sudden onset of extremely distressing spasm and swelling of her tongue, neck and side of face, two and a half days after an alleged overdose with 90 mg of a friend's risperidone. She was dyspnoeic and could not speak. Examination was unremarkable except for an acute dystonia of her tongue and throat, noisy breathing without true stridor, and sinus tachycardia (HR 150). Neurological examination was normal except for the dystonia. Coagulation, renal and liver function test results were within normal limits. Procyclidine was given as an intravenous bolus of 10 mg. The patient described a reduction in the swelling and spasm of her tongue and throat within 30 minutes of treatment. Serum risperidone concentration at the time of presentation was below the limit of detection for the assay and the concentration of the active metabolite, 9-OH risperidone, was 31 μg/L, which is within the normal range of 10 - 90 μg/L for patients taking risperidone therapeutically. Her heart rate settled following resolution of the dystonia and she was discharged the same day.  Conclusion:  This case report confirms that dystonic reactions can occur some days after an otherwise asymptomatic overdose of risperidone, even in the absence of elevated blood concentrations of the parent drug or its metabolite. Although dystonic reactions are not usually life-threatening, the localisation in this case of the dystonia in the mouth and throat led to severe distress that was treated effectively with procyclidine

Flumazenil use in benzodiazepine overdose in the UK: a retrospective survey of NPIS data [Abstract]

Flumazenil is an effective benzodiazepine (BDZ) antagonist, but its usefulness in managing BDZ overdose (OD) is limited by its potential to precipitate seizure. The approach of UK clinicians to the use of flumazenil has not been systematically studied or reported so far. Complicated cases of poisoning in the UK are referred to the National Poisons Information Service (NPIS) for advice. Details of enquiries to the NPIS are recorded in the UK poisons information database (UKPID). Using UKPID, we present data on 2 years of UK experience with the use of flumazenil in the management of BDZ OD. Between 2007 and 2009 there were 4,504 enquiries to the NPIS relating to overdoses involving BDZ. Sixty-five of these patients were definitely administered flumazenil (60 prior to enquiry and 5 others on toxicologists’ recommendation), including many patients who had also ingested proconvulsant drugs. Of 40 patients for whom information on response to flumazenil was available, 32 demonstrated rapid improvement in GCS/airway/breathing and 8 demonstrated no benefit. One patient developed brief convulsions after a second dose of flumazenil after an ineffective first dose in one mixed OD involving BDZ and a proconvulsant drug (seizure rate 1.5%). The only other adverse reaction recorded was one case of agitation following flumazenil administration. The indications for flumazenil use were not clear in a significant proportion of cases. Seizures also occurred in 0.25% of BDZ OD patients in the absence of flumazenil therapy (due to coingestion of proconvulsant drugs). There is evidence of uncertainty/disagreement about the use of flumazenil in relation to: indications for use, safety in a mixed OD or when there is a past history of seizures, dose escalation after partial response or no response, and role in lateonset compromise of airway/breathing. Further research should aim to address these issues through a systematic review of the use of flumazenil in BDZ OD, and through a well designed prospective study using standardised data collection and better follow-up for NPIS enquiries

Carbon Monoxide Poisoning: Saving Lives, Advancing Treatment

Carbon monoxide (CO) poisoning is a serious public health issue. In England and Wales alone, every year some 4,000 attendances to emergency departments (EDs) are the result of accidental CO poisoning. Statistics show that CO kills more than 30 people a year and leads to around 200 hospital admissions, but these figures are likely to be a gross underestimate. Consequently, treating accidental CO poisoning may actually be costing much more than the estimated £178 million per annum. Healthcare professionals have a vital role to play in preventing, diagnosing and treating patients exposed to CO. However, these professionals face a number of barriers to action: gaps in knowledge, limited awareness, and a lack of co-ordination within and between the healthcare sectors. These barriers need to be removed if we are to reduce significantly the number of accidental deaths and unnecessary injuries caused by CO poisoning, and to improve patient management and recovery. This report has been prepared by members of COMed, the healthcare professionals’ sub-group of the APPCOG Stakeholder Forum. It presents a number of hard-hitting essays that review current knowledge and practice on the diagnosis and management of CO poisoning in the healthcare system. It identifies gaps in knowledge and practice, and makes recommendations to close those gaps so that diagnosis, patient management and recovery can be improved. The findings presented in this report led members of the sub-group to conclude that: A lack of awareness amongst healthcare professionals of CO poisoning as a cause of illness is very likely to be impacting adversely on public health outcomes. Much remains to be discovered and explained about the link between low level chronic CO exposure and long-term effects on an individual’s health - for example, its impact on diseases of the cardiovascular and neurological system and whether CO is a casual factor of disease or involved in disease processes not previously associated with exposure to CO. Action is required throughout the healthcare profession, as well as by the Government, its Agencies, and Academia, to help protect the public from accidental CO poisoning