Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance

Objective: Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. Methods: This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturatio

A fatal case of polyoxyethylated-<i>p</i>-nonylphenol surfactant (Wetter 600) ingestion

A fatal case of polyoxyethylated-p-nonylphenol surfactant (Wetter 600) ingestio

Neurotoxicity in chronic lithium poisoning

Background: Lithium-induced neurotoxicity typically occurs with chronic accumulation rather than following acute overdose. There is little emphasis in the literature on the protracted nature of lithium neurotoxicity long after the lithium concentration returns to the therapeutic range. Aims: To characterise lithium neurotoxicity, with a view of increasing awareness of this important phenomenon. METHODS: This is a retrospective observational study of patients presenting with lithium-induced neurotoxicity over a 5-year period to a clinical toxicology unit. Patients were identified through the unit's database, and clinical notes were analysed. Results: There were 22 patients, with a median age of 65 (range: 36-89) years. Six patients (27%) had previous lithium toxicity, and nine (41%) were regularly prescribed medications that impair lithium excretion. The median lithium concentration on presentation was 2.2 mmol/L, taking a median of 3 days to return to the therapeutic range. Reversible acute kidney injury was observed in 21 patients (95%) on presentation. The median length of stay was 13 (range: 3-95) days due mostly to delayed neurological recovery. Confusion was the predominant symptom, present in 21 (95%) patients, followed by tremors (18(82%)) and ataxia (16(73%)). Multiple investigations were performed to exclude delirium differentials, including 11 computed tomography (CT) and five magnetic resonance imaging (MRI) brain scans, all unremarkable. Conclusions: Lithium neurotoxicity has a prolonged course. Its severity correlates poorly with lithium concentrations, which normalise quickly. Most poisonings occur in elderly patients with acute kidney injury. Prolonged delirium often prompts multiple unnecessary investigations. Rationalisation of lithium therapy is important in elderly patients

Establishing a dedicated toxicology unit reduces length of stay of poisoned patients and saves hospital bed days

Objective: This study evaluates the effect on the average length of stay (LOS), relative stay index (RSI), bed days and costs saved following the establishment of a dedicated clinical toxicology unit in an Australian tertiary referral hospital. Methods: This retrospective descriptive study uses Health Roundtable and other state and federal data to compare the average LOS, RSI, estimated bed days and costs saved by patients admitted with a diagnosis-related group (DRG) of X62 (Poisoning/Toxic Effects of Drugs and Other Substances), over the 4 year period 2012–2015. This period corresponds to before and after the introduction of the clinical toxicology unit in February 2014 at the Princess Alexandra Hospital, a tertiary referral teaching hospital in Brisbane, Queensland, Australia. Results: There was a reduction in the average LOS and RSI from 2.1 days and 122% in 2012 to 0.9 days and 52% in 2015, respectively. This reduction correlates with a reduction in 1350 bed days and a saving of $2.25 million over the 2 year period 2014–2015 since the clinical toxicology unit was established. Conclusion: The reduction in average LOS is similar to results previously published by two Australian toxicology units over 15 years ago. Despite changes in healthcare delivery since this time, these results continue to support the efficiency and associated cost saving of a dedicated toxicology unit in managing poisoned patients

Methamphetamine intoxication and acute kidney injury: a prospective observational case series

Background and objectives The effects of methamphetamine intoxication on the kidney are not well reported. We aimed to investigate acute kidney injury (AKI) associated with methamphetamine intoxication, in particular its severity, duration and association with rhabdomyolysis. Design setting, participants, and measurements This is a prospective observational series of methamphetamine intoxicated patients presenting to an Emergency Department. Patients self‐reporting recent methamphetamine use, with a positive urine drug screen and an elevated creatinine, were eligible for the study. Urinary neutrophil gelatinase‐associated lipocalin (NGAL) was measured, and serum creatinine, creatine kinase and cystatin C concentrations were performed on arrival and at several time points until discharge from hospital. Demographic and clinical data were obtained from the medical records. Results There were 634 presentations with methamphetamine intoxication over a 10‐month period, with 73/595(12%) cases having an elevated serum creatinine concentration on arrival. 50 presentations in 48 patients were included in the study. Most patients (85%) were male with a median age of 32 years. The median serum creatinine concentration on presentation was 125 μmol/L (IQR:113‐135μmol/L) with 45(90%) presentations meeting diagnostic criteria for AKI. Concurrent rhabdomyolysis occurred in 22(44%) presentations with a median CK of 2695 U/L (IQR:1598–5060 U/L). Cystatin C was elevated (> 0.98 mg/L) in 18 cases. An elevated NGAL concentration (>150μg/L) was present in five (10%) cases. No patients required dialysis. The median length of stay was 19 hours (IQR 14‐24hours). Conclusions AKI is common in methamphetamine intoxication. The kidney injury is relatively mild and short‐lived, resolving with crystalloid therapy

Duloxetine overdose causes sympathomimetic and serotonin toxicity without major complications

Objective: Duloxetine is a commonly used antidepressant that is a serotonin and norepinephrine reuptake inhibitor. We aimed to investigate the frequency and severity of clinical effects following duloxetine overdose. Methods: We undertook a retrospective review of duloxetine overdoses (>120 mg) admitted to two tertiary toxicology units between March 2007 and May 2021. Demographic information, details of ingestion (dose, co-ingestants), clinical effects, investigations (ECG parameters including QT interval), complications (coma [GCS < 9], serotonin toxicity, seizures and cardiovascular effects), length of stay [LOS] and intensive care unit [ICU] admission were extracted from a clinical database. Results: There were 241 duloxetine overdoses (>120 mg), median age 37 years (interquartile range [IQR]: 25–48 years) and there were 156 females (65%). The median dose was 735 mg (IQR: 405–1200 mg). In 177 patients, other medications were co-ingested, most commonly alcohol, paracetamol, quetiapine, diazepam, ibuprofen, pregabalin and oxycodone. These patients were more likely to be admitted to ICU (12 [7%] vs. none; p = 0.040), develop coma (16 [9%] vs. none; p = 0.008) and hypotension [systolic BP 140 mmHg) in 29 (45%). One patient had persistent sympathomimetic toxicity, and one had hypotension after droperidol. Two patients of 63 with an ECG recorded had an abnormal QT: one QT 500 ms, HR 46 bpm, which resolved over 3.5 h and a second with tachycardia (QT 360 ms, HR 119 bpm). None of the 64 patients had an arrhythmia. Conclusion: Duloxetine overdose most commonly caused sympathomimetic effects and serotonin toxicity, consistent with its pharmacology, and did not result in coma, arrhythmias or intensive care admission, when taken alone in overdose

Epidemiology and survival outcomes of out-of-hospital cardiac arrest following volatile substance use in Queensland, Australia

Introduction: The deliberate inhalation of volatile substances for their psychotropic properties is a recognised public health issue that can precipitate sudden death. This study aimed to describe the epidemiological characteristics and survival outcomes of patients with out-of-hospital cardiac arrests following volatile substance use.Methods: We conducted a retrospective cohort analysis of all out-of-hospital cardiac arrest attended by the Queensland Ambulance Service over a ten-year period (2012-2021). Incidents were extracted from the Queensland Ambulance Service cardiac arrest registry, which collects clinical information using the Utstein-style guidelines and linked hospital data.Results: During the study period, 52,102 out-of-hospital cardiac arrests were attended, with 22 (0.04%) occurring following volatile substance use. The incidence rate was 0.04 per 100,000 population, with no temporal trends identified. The most commonly used product was deodorant cans (19/22), followed by butane canisters (2/22), and nitrous oxide canisters (1/22). The median age of patients was 15 years (interquartile range 13–23), with 14/22 male and 8/22 Indigenous Australians. Overall, 16/22 patients received a resuscitation attempt by paramedics. Of these, 12/16 were bystander witnessed, 10/16 presented in an initial shockable rhythm, and 9/16 received bystander chest compressions. The rates of event survival, survival to hospital discharge, and survival with good neurological outcome (Cerebral Performance Category 1–2) were 69% (11/16, 95% CI 41–89%), 38% (6/16, 95% CI 15–65%) and 31% (5/16, 11–59%), respectively. Eight patients in the paramedic-treated cohort that used hydrocarbon-based products were administered epinephrine during resuscitation. Of these, none subsequently survived to hospital discharge. In contrast, all six patients that did not receive epinephrine survived to hospital discharge, with 5/6 having a good neurological outcome.Conclusion: Out-of-hospital cardiac arrest following volatile substance use is rare and associated with relatively favourable survival rates. Patients were predominately aged in their adolescence with Indigenous Australians disproportionately represented

Methamphetamine presentations to an emergency department: management and complications

Objective: There is little recent published data characterising methamphetamine intoxication. The present study aims to describe the clinical effects, management, complications and disposition of patients with methamphetamine exposure. Methods: This is a retrospective review of patients presenting with methamphetamine intoxication to an ED in 2016. All presentations were extracted from a relational database and each medical record reviewed. Demographics, clinical features, complications and disposition were extracted. Results: There were 378 presentations of 329 patients (234 men [71%]), median age 31 years (range 16–68 years). The most common clinical effect was acute behavioural disturbance, occurring in 295 (78%) presentations. This was successfully managed with oral sedation alone in 180 (61%) patients, with the remainder receiving parenteral sedation. Other effects included tachycardia in 212 (56%), hypertension in 160 (42%) and hyperthermia in 17 (5%) presentations. No anti-hypertensives were given. One patient was actively cooled. Complications included 21 (30%) presentations with rhabdomyolysis and 41 (13%) presentations with acute kidney injury. There were two seizures, three intracranial bleeds and one myocardial infarction. The majority (317 [84%]) of patients were managed solely within the ED. The median length of stay was 14 h. There were 41 (11%) mental health admissions. Two deaths occurred: one following an out-of-hospital cardiac arrest and the other a subarachnoid haemorrhage. Conclusion: The main toxicity seen with methamphetamines is acute behavioural disturbance, which is managed well with sedation. Complications, apart from rhabdomyolysis and acute kidney injury, are rare. Most patients are managed within the ED and discharged home

A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance

Study objective: Although uncommon, children (= 2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturatio

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning

Objective: Naloxone is an established antidote for the treatment of heroin poisoning; however, dosing regimens vary widely, with a current trend towards small titrated intravenous dosing. This study aims to characterise naloxone use in the treatment of patients presenting with suspected heroin poisoning. Methods: This was a retrospective review of poisoned patients presenting to a clinical toxicology unit in Brisbane from January 2015 to December 2017. Patient demographics, clinical effects, naloxone dosing, observation periods and complications were extracted from the patient's medical records. Results: There were 117 presentations accounted for by 108 patients. Prehospital naloxone was provided to 57 (49%) patients, 46 of which received a standardised 1.6 mg i.m. dose. The remaining 60 (51%) patients received their first naloxone in hospital, with 58 (97%) receiving this by titrated i.v. doses. A subsequent naloxone infusion was required significantly more often in those treated with i.v. titrated naloxone compared to i.m. dose (27/69 [39%] vs 5/48 [10%], P = 0.0006). The need for parenteral sedation to manage acute behavioural disturbance following naloxone provision was rare (3/117 [3%]). Conclusions: In this retrospective observational study, a single large i.m. dose of naloxone reversed the toxicity of suspected heroin overdose in the majority of patients. In addition, patients were less likely to require repeated intermittent doses or naloxone infusion than those treated solely with i.v. naloxone. Further comparison in a prospective study is warranted to validate these observations in confirmed heroin overdose. Requirement for sedation secondary to acute behavioural disturbance was rare regardless of the route