Australian clinical toxicology investigators collaboration randomized trial of different loading infusion rates of N-acetylcysteine [6]

Adverse reactions to N-acetylcysteine are reported in 6% to 23% of patients who are administered the antidote for treatment of paracetamol poisoning.1 Because paracetamol is the most common pharmaceutical product taken in overdose in many countries, it is essential that attempts be made to prevent or minimize adverse effects caused by N-acetylcysteine. We congratulate Kerr et al2 on their attempt to address this important issue

Severe hypokalaemic metabolic alkalosis following ingestion of gaviscon

Uncommon metabolic abnormalities in the emergency department could be a result of drug overdose due to uncommon agents. Case report. A 35-year-old male presented to the emergency department with a Glasgow Coma Scale (GCS) of 3/15 and a normal pulse rate and blood pressure. Subsequent questioning after recovery revealed he had ingested 2 L of Gaviscon® over the preceding 48 hours. He had normal haematology, liver, and renal function during admission. The electrocardiogram showed T wave inversion in the inferior leads on admission. Arterial blood gas on air was: pH 7.54, HCO3 50 mmol/L (50 meq/L), Chloride 66 mmol/L, anion gap was 19, pO2 11 kPa (82.5 mmHg), and pCO2 8 kPa (60 mmHg). Serum sodium was 127 mmol/L and serum potassium was 1.6 mmol/L. His GCS improved within one hour of admission with supportive care, and his serum potassium and bicarbonate improved within 24 hours. He subsequently made a full recovery. Discussion. Bicarbonate ingestion in the form of Gaviscon® and vomiting made this patient alkalotic, and simple supportive care provided effective management with a complete recovery. Conclusion. This case illustrates how a severe metabolic alkalosis can result from a significant ingestion of Gaviscon®, and that such presentations can give rise to diagnostic dilemm

Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: A prospective observational study

Objective: To examine the clinical safety of hyperinsulinaemia/ euglycaemia therapy (HIET) in calcium channel blocker (CCB) poisoning. Design: A prospective observational study examining biochemical and clinical outcomes of a HIET protocol administered under local poisons centre guidance. Setting: Critical care settings. Patients: Seven patients with significant CCB toxicity [systolic blood pressure (BP) \u3c 90 mmHg] treated with HIET. Interventions: HIET was commenced after correction of any pre-existing hypoglycaemia ([blood glucose]\u3c 65 mg/dl) or hypokalaemia ([K+] \u3c 3.5 mmol/l). A quantity of 50 ml of 50% intravenous dextrose was followed by a loading dose (1 unit/kg) of intravenous short-acting insulin and an insulin maintenance infusion (0.5–2.0 units/kg/h). Euglycaemia was maintained using 5–10% dextrose infusions. Potassium was maintained within low normal range (3.8–4.0 mmol/l). Measurements and results: Six patients survived. All patients received fluids, calcium, and conventional inotropes. Three patients (who all ingested diltiazem) received an insulin-loading dose; all experienced a significant sustained rise in systolic BP (\u3e 10 mmHg) during the first hour of HIET. Systolic BP did not increase significantly in four patients who did not receive insulin loading. Single episodes of non-clinically significant biochemical hypoglycaemia and hypokalaemia were recorded in one and two patients respectively. Hypoglycaemia was not recorded in any patient administered HIET during the 24 h following CCB ingestion. Conclusions: HIET used to treat CCB-induced cardiovascular toxicity is a safe intervention when administered in a critical care setting. Maximal HIET efficacy may be obtained when HIET is administered in conjunction with conventional therapy relatively early in the course of severe CCB poisoning when insulin resistance is high

Improvement in the management of acutely poisoned patients using an electronic database, prospective audit and targeted educational intervention

Problem: The need to improve the clinical assessment and management of acutely poisoned patients presenting to an NHS hospital emergency department (ED). Design: Creation of an electronic clinical toxicology database to prospectively collect all aspects of clinical information on poisoned-patient presentations. Systematic analysis of collated information to identify shortfalls in patient assessment and management. Bimonthly audit meetings, and design and implementation of educational interventions to address identified shortfalls. Ongoing audit to demonstrate continued improvement in patient care. Background and setting: ED in tertiary-level inner-city London teaching hospital. Study conducted by staff from the ED and clinical toxicology service. Key measures for improvement: Demonstration of overall reduction in the incidence of predefined shortfalls in patient assessment and management during 12-month study period. Strategies for improvement: Targeted educational lectures and case-based clinical scenarios addressing identified deficiencies in the knowledge required to effectively manage poisoned patients. Weekly case-based anonymised feedback report sent electronically to staff involved in caring for poisoned patients. Effects of change: Implementation of targeted teaching of ED staff and regular electronic distribution of teaching cases. Between the first and second 6 months of the study, there was a significant increase in the proportion of presentations for which clinical management was graded as ‘‘good’’ (77.6% to 89.4%, p≺0.0001) and a significant reduction in the proportion of ‘‘major’’ (9.9% to 5.8%,p=0.012) and ‘‘minor’’ (12.6% to 4.8%, p≺0.0001) shortfalls. Lessons learnt: Systematic collection of clinical information, using a dedicated electronic database and subsequent review and audit of collated data by interested clinicians, enabled design and implementation of targeted educational interventions to address shortfalls in patient management. This process has led to significant improvements in the clinical care of acutely poisoned patients presenting to the ED