Prognostic value of lactate and qSOFA score in acute drug overdose patients in ED

박종학,조한진,송주현,김주영 대한응급의학회 2020 대한응급의학회 학술대회초록집 Vol.2020 No.2

Introduction There are currently no existing biomarkers or clinical risk scores proven to predict mortality in drug overdose patients. The initial lactate had excellent prognostic utility for the occurrence of both shock and fatality. However, the prognostic utility of lactate in the initial evaluation of drug overdose in the ED is controversial. We aimed to evaluate the prognostic value of lactate for adverse events in ED patients with an acute drug overdose. Moreover, we investigated whether the combination of lactate and qSOFA is a better prognostic predictor than lactate alone. Material & Method We conducted a retrospective analysis of a prospective observational suicide registry. Patients aged over 15 years who had acute drug overdose in the ED from January 1st, 2017 to December 31st, 2019 were enrolled. Using data from the suicide registry of our institution, we retrospectively retrieved data. The primary outcome was adverse events at any point during the ED or hospital stay. Adverse events were defined as follows: any vasopressors use, high-flow or ventilator care, AKI, toxic hepatitis, and severe rhabdomyolysis. Result During the study period, of patients screened, 531 were analyzed (mean age 40.4 years) and 62 had adverse events (11.7%). Mean lactate concentration (mmol/L) was 3.6 ± 2.6 for adverse event group and 2.3 ± 1.4 for non-adverse event group (p < 0.001). The AUC of lactate for the prediction of adverse events was 0.684 (95% CI: 0.569?0.726). The optimal lactate cut point for adverse events was 5.0 mmol/L (32.3% sensitivity, 93.0% specificity). The AUC of lactate with qSOFA score was 0.755 (95% CI: 0.686?0.825). The optimal cut-points of lactate with qSOFA were 1 point and 4.0 mmol/L, respectively (53.2% sensitivity, 85.7%). Multivariable analysis showed that lactate and qSOFA score were independent risk factors for adverse events of the acute drug overdose patients (aOR of lactate 1.32, 95%CI,1.14-1.52; aOR of qSOFA 2.60, 95%CI, 1.80-3.82). Conclusion This is the first study to assess the prognostic value of a combination of lactate concentration and qSOFA score in patients with an acute drug overdose. Our results suggest that lactate concentration can be a useful biomarker for clinical decision making in ED patients with an acute drug overdose. Moreover, a combination of lactate and qSOFA is had an excellent prognostic utility to predict adverse events for drug overdose patients than lactate alone.

Severe complications of tramadol overdose in Iran

Paria Habibollahi,Alireza Garjani,Samad Shams Vahdati,Seyyed-Reza Sadat-Ebrahimi,Neda Parnianfard 한국역학회 2019 Epidemiology and Health Vol.41 No.-

OBJECTIVES: Severe complications of tramadol overdose have been reported; however, few large-scale studies have investigated this issue. Therefore, this study aimed to explore the presentation and complications of tramadol overdose in patients admitted to an intoxication referral center in northwestern Iran. METHODS: Patients with tramadol overdose admitted to Sina Teaching Hospital in Tabriz, Iran during 2013-2017 were included. For each patient, the following data were collected: demographics, previous drug or medication overdose, whether the patient was in the process of quitting drug use, ingested dose of tramadol and co-ingestants, Glasgow Coma Scale (GCS) score, clinical symptoms at the time of admission, and admission characteristics. Serotonin toxicity was diagnosed in patients who fit the Hunter criteria. Multiple logistic regression was performed to identify variables associated with the incidence of severe complications of tramadol overdose. RESULTS: In total, 512 cases of tramadol overdose were evaluated, of which 359 patients were included, with a median age of 41 years (range, 16-69) and a median tramadol dose of 1,500 mg (range, 500-4,000). The most frequent complications associated with tramadol overdose were hypertension (38.4%), tachycardia (24.8%), and seizure (14.5%). No serotonin toxicity was detected in patients. Having a GCS score <15, having taken a tramadol dose of >1,000 mg, being in the process of quitting drug use, being 30-49 years old, and male sex were significantly related to the incidence of severe complications of tramadol overdose. CONCLUSIONS: Although seizure was prevalent among Iranian patients with tramadol poisoning, serotonin toxicity and cardiogenic shock were rare findings.

암로디핀 중독 환자의 임상양상

전영우 ( Young Woo Jeon ),김재연 ( Jae Yun Kim ),박재석 ( Jae Seok Park ),박재만 ( Jae Man Park ),길효욱 ( Hyo Wook Gil ),양종오 ( Jong Oh Yang ),이은영 ( Eun Young Lee ),홍세용 ( Sae Yong Hong ) 대한내과학회 2011 대한내과학회지 Vol.81 No.2

Background/Aims: Calcium channel blockers (CCBs) are anti-hypertensive medications that are used worldwide. CCB overdose has increased in proportion to the use of these drugs. Although amlodipine is the most widely used CCB, many physicians are not familiar with amlodipine overdose. We report the clinical outcome in patients with an intentional amlodipine overdose. Methods: We retrospectively reviewed the medical records of the patients who visited Soonchunhyang University Cheonan Hospital with an amlodipine overdose from January 2002 through December 2010. We recorded the initial vital signs, blood chemistry, electrocardiography, and estimated amount of amlodipine ingested. Results: Nine patients were enrolled, of whom two patients died. Both patients who died had ingested more than 200 mg/m2 of amlodipine, while all of the patients who ingested less than 200 mg/m2 of amlodipine survived. Three patients had blood sugar levels exceeding 200 mg/dL and two of these died despite high-dose insulin therapy in combination with glucose infusion (hyperinsulinemia/euglycemia therapy). Although three patients also took a glimepiride overdose, none had hypoglycemia. The amount of amlodipine ingested relative to the body surfaced area (BSA) was 197.1±92.3 mg/m2 in patients with an abnormal ECG and 58.5±27.1 mg/m2 in patients with a normal ECG. Conclusions: Amlodipine overdose can induce hyperglycemia, resulting in lethal cardiogenic shock owing to the decreased calcium influx, inappropriate energy production, and weakened inotropic effect. Therefore, amlodipine-induced hyperglycemia indicates a poor prognosis. (Korean J Med 2011;81:208-214)

항우울제 과량복용에 의한 심장 독성 증상과 치료

최경호,이경욱 대한정신약물학회 2008 대한정신약물학회지 Vol.19 No.6

The mortality and morbidity in tricyclic antidepressants (TCAs) overdose still remained high due to fatal cardiac toxicities despite their decreased prescriptions. Also, monoamine oxidase inhibitors (MAOIs) may show relatively high cardiac toxicities in excess or mixed overdoses. Selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants have been known to be safe in overdose until recently. However, many researchers have found that SSRIs and newer antidepressants also showed serious and fatal toxicities in case of excess or mixed overdoses. Citalopram or escitalopram overdoses showed a relatively high incidence of cardiac toxicity with a dose-dependent manner. Also, venlafaxine, bupropion and trazodone overdoses showed significant cardiac toxicities, although degrees of the toxicities are different each other. Especially, venlafaxine’s pattern and incidence of cardiac toxicities are the similar to those of TCAs. Mirtazapine and reboxetine show no significant toxicities in overdose although the present toxicological data are insufficient. To conclude, assessment of compliance, pharmacology education for patients and effective treatment may reduce the incidence and severity of toxicities in overdose. 치명적인 심장 독성으로 잘 알려진 TCA는 여전히 높 은 사망률과 이환율을 기록하고 있으며 넓은 치료용량범 위로 안전하다는 선택적 가역성 MAOI 역시 많은 양의 단일약물이나 복합약물 과량복용 상황에서 높은 비율로 심장 독성 증상을 보인다. SSRI 및 이후의 새로운 항우 울제들 역시 과량복용 상황에서 안전한 것으로 알려졌으 나, 많은 양의 단일약물이나 복합약물을 과량복용한 최근 의 사례 보고나 연구결과들에서 알 수 있는 바와 같이 심 각한 중독 증상과 심장 독성 증상을 보인다. 특히, citalopram, escitalopram은 정해진 용량을 초과하는 경우 높 은 비율의 심장 독성 증상을 보이며 venlafaxine, bupropion, trazodone도 용량의존성의 독성 증상과 심장 독 성 증상을 보인다. 특히, venlafaxine은 심각한 심장 독 성 증상의 발현 비율이 TCA와 거의 비슷하다고 한다. mirtazepine과 reboxetine은 과량복용 환자에 대한 독성 정 보가 충분하지 않지만 지금까지의 연구결과로 미루어 중 독 상황에서 심각한 중독 증상 및 심장 독성 증상을 보 이는 것 같지 않다. 따라서 항우울제를 처방할 경우 약물 순응도를 확인하고 적절한 약물 교육을 실시하며 효과적 으로 증상을 안정시킴으로써 약물 과량복용으로 인한 심 각한 부작용을 줄일 수 있을 것이다.

Effect of 4-methylpyrazole for Acetaminophen Hepatotoxicity in a Rat Model

Lee, Won-Jae,Oh, Dong-Rul,Park, Seung-Hyun,Park, Kyu-Nam,Rue, Eun-Young,Kim, Se-Kyung,Lee, Mi-Jin 가톨릭대학교 2000 Bulletin of The Catholic Research Institutes of Me Vol.28 No.-

Background : Hepatic necrosis after acetaminophen overdose results from the increased formation of a highly toxic intermediate (N-acetyl-p-benzoquinoneimine), produced by acetaminophen metabolism through the cytochrome P450 mixed function oxidase system. N-acetyl-p-benzoquinoneimine is normally detoxified by endogenous glutathione, but the increased production induced by an acetaminophen overdose may deplete glutathione store, allowing the intermediate to react with and to destroy hepatocytes. Methods & Materials : We estimated the hepatoprotective effects of 4-methylpyrazole (500mg/kg and 50mg/kg), inhibitor of cytochrome P450 isoenzyme, when given at two hours after single oral overdose of acetaminophen (2,000mg/kg) in rats. Results : As far as overall protective effect of 4-methylpyrazole on hepatic necrosis score concerned, seurm transaminase (AST, ALT) level were found to be decreased in 4-methylpyrazole-treated group compareded to untreated group after acetaminophen overdose. No consistent difference in hepatoprotective effect was demonstrated between rats with high does of 4-methylpyrazole (500mg/kg) and rats with lower dose of 4-methylpyrazole (50mg/kg). Conclusion : We concluded that oral administration of 4-methylpyrazole appeared to protect hepatoxicity effectively to acetaminophen overdose. (Journal of the Korean Society of Emergency Medicine 10(1):19-26, 1999)

디펜히드라민 중독환자의 심독성에 관한 연구

박성준 ( Sung Jun Park ),박종학 ( Jong Hak Park ),엄인경 ( In Kyung Um ),박경애 ( Kyung Ae Park ),김도현 ( Do Hyoun Kim ),김수진 ( Su Jin Kim ),이성우 ( Sung Woo Lee ),홍윤식 ( Yun Sik Hong ) 대한임상독성학회 2011 대한임상독성학회지 Vol.9 No.1

Purpose: This study was designed to analyze the contributing factors, as well as the incidence and nature of the cardiac toxicity, in patients presenting with diphenhydramine overdose. Methods: We retrospectively reviewed the medical records of the intoxicated patients who presented to the ED of Korea University Anam Hospital from January 2008 to December 2010. Those patients who visited due to a diphenhydramine overdose were selected and the following features were recorded for analysis: the general characteristics, vital signs, the amount of ingested diphenhydramine, the time interval from ingestion to presentation, the coingested drugs (if any), the toxicities and the ECG findings. Cardiac toxicity, while defined mainly in terms of the temporary ECG changes such as QTc prolongation, right axis deviation, QRS widening, high degree AV block and ischemic changes, also encompassed cardiogenic shock, which is a clinical finding. Results: A total of eighteen patients were enrolled. Of the eighteen patients, eight had ingested diphenhydramine only, while ten had ingested other drugs in addition to diphenhydramine. The most commonly observed toxicity following diphenhydramine overdose included cardiac toxicity (78%). Cardiac toxicity was observed in all the patients who presented to the emergency department 2 hours after ingestion. The patients with QTc prolongation turned out to have ingested significantly larger amounts of diphenhydramine. Conclusion: QTc prolongation and right axis deviation were common findings for the patients with a diphenhydramine overdose. QTc prolongation was more likely to occur with ingesting larger amounts of diphenhydramine. Close monitoring is mandatory for patients who have ingested large amounts of diphenhydramine to prevent such potentially lethal cardiac toxicity.

약물중독 후 흡인성 폐렴의 발생에 미치는 인자에 대한 고찰

김동희,오주석,경연영,최세민,오영민,최경호,박규남,Kim, Dong-Hee,Oh, Joo-Suk,Kyoung, Yeon-Young,Choi, Se-Min,Oh, Young-Min,Choi, Kyoung-Ho,Park, Kyu-Nam 대한임상독성학회 2009 대한임상독성학회지 Vol.7 No.2

Purpose: It is known that aspiration pneumonitis is associated with high mortality and morbidity following overdose. However, until now, few domestic studies on this subject have been conducted. The main aim of this study is to investigate the risk factors associated with aspiration pneumonitis in intubated patients following overdose. Methods: Among 654 adult overdosed patients who visited our institution from Jan. 2006 to June 2008, we enrolled 70 intubated patients within 24 hours after their overdose, and we reviewed the medical records to collect the data. This data was processed by univariate analysis, followed by multiple logistic regression analysis. P values <0.05 were deemed statistically significant. Results: In our study, a high incidence of pneumonitis was seen in the patients with an older age, a lower GCS and a high poisoning severity score or a high comorbidity score (p<0.05). Compared with the non-pneumonitis group, the pneumonitis group had a higher incidence of intubation (6% vs 61.8%, respectively, p<0.05). The main cause of intubation was a decreased mentality (68.6%). Older age, a high comorbidity score, irrigation without airway protection, relative hypoxemia and hyperkalemia were the risk factors of aspiration pneumonitis in the intubated overdosed patients (p<0.05). Among these factors, age, a high potassium level and airway protection might be significant predictors of aspiration penumonitis (p<0.05). Conclusion: Older age, a high potassium level and irrigation without proper airway protection may be the significant factors that can predict aspiration pneumonitis in patients who are intubated within 24 hours after overdose, although the further investigations on this are needed.

Serial Monitoring of Lead aVR in Patients with Prolonged Unconsciousness Following Tricyclic Antidepressant Overdose

최경호,이경욱 대한신경정신의학회 2008 PSYCHIATRY INVESTIGATION Vol.5 No.4

Severe cardiac and neurologic toxicities of tricyclic antidepressant (TCA) overdose have been reported since the introduction of TCAs in 1950s. Despite the decreased numbers of TCA overdoses, the mortality and morbidity rates of TCA overdose have remained constantly high. Clinical manifestations of TCA overdose are characterized by unconsciousness and specific electrocardiography (ECG) abnormalities such as prolongation of the PR and QTc intervals, widening of the QRS duration, and an increased R wave and R/S ratio in lead aVR. We report a case with unusually prolonged unconsciousness without initial stem reflexes for 7 days and multiple ECG abnormalities following TCA overdose. It is suggested that the serial monitoring of R wave and R/S ratio in lead aVR might be informative in predicting recovery from toxicity following TCA overdose.

독시라민 음독후 합병된 횡문근융해증 환자의 임상적 고찰

김세경,최세민,이원재,이미진,오동렬 대한응급의학회 2000 대한응급의학회지 Vol.11 No.1

Background. Doxylamine succinate(DS) is an antihistamine commonly used as an over-the-counter medication to relieve insomnia and frequently involved in overdoses. Its overdoses are dominated by anticholinergic effect. Recently it was revealed that DS had a direct effect on muscle, while its exact mechanism is not clear yet. We evaluated the patients with rhabdomyolysis induced by DS overdose for patients disposition bases upon clinical decision, especially by creatinine phosphokinase(CPK). Methods. We reviewed retrospectively the medical records of patients admitted by DS overdose from Jan. 1998 to Oct. 1999. Seventy and nine cases of DS overdose were evaluated with respect to age and sex distribution, amount ingested, clinical symptomatology, time from ingestion to visit, pattern of CPK, amount of bicarbonate used as therapy, complication and prognosis, especially in patients complicated rhabdomyolysis. Results. Rhabdomyolysis, diagnosed as more than 1,000I.U/L of CPK, has been noted in 25(31.6%) of 79 cases of DS overdose visited to our emergency department(ED). In patients diagnosed rhabdomyolysis, the number of man was 10 cases(40%) and the number aged between 20 and 40 years was 22 cases(88%). The average time from DS ingestion to ED visit was 459 minutes. The amount of DS ingested was 500-5,000mg(mean, 1,980mg). 13(52%) cases ingested less than 2,250mg of DS. The initial levels of CPK(range, 48-14900I.U/L; normal range, 26-200I.U/L) after admitting to our emergency department were normal in 15 cases(60%) of rhabdomyolysis patients. The range of peak CPK levels after ingestion was 607 to 412,500I.U/L(mean, 33,550I.U/L). Its peak time was 6 to 96 hours(mean, 28.96 hours). In 14 cases(67%) of 21 visiting within 24 hours after ingestion, peak time of CPK ranged 12 to 24 hours after ingestion. The amount of bicarbonate used as therapy of rhabdomyolysis ranged 100 to 2,740mEq(mean, 656mEq) and all patients was discharged after improvement without other complication including acute renal failure. Conclusions. Although patients ingested less than 2,250mg of DS, emergency physicians should observe them more than 24 hours after DS ingestion with CPK follow-up after gastric irrigation and charcoal administration.

쥐모형에서 아세트아미노펜 간독성에 대한 4-메칠피라졸의 효과

이원재,오동렬,박승현,박규남,유은영,김세경,이미진 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.1

Background : Hepatic necrosis after acetaminophen overdose results from the increased formation of a highly toxic intermediatic(N-acetyl-p-benzoquinoneimine), produced by acetaminophen metabolism through the cytochrome P450 mixed function oxidase system. N-acetyl-p-benzoquinoneimine is normally detoxified by endogenous glutathione, but the increased production induced by an acetaminophen overdose may depletc glutathione stores, allowing the inter mediate to react with and to destroy hepatocytes. Method & Material : We have estimated the hepatoprotecitve effects of 4-methylpyrazole(500㎎/㎏ and 50㎎/㎏), inhibitor of cytochrone P450 isoenzyme, when given at two hours after single oral overdose of acetaminophen(2,000㎎/㎏) in rats. Results : As far as overall protective effect of 4-methylpyrazole on hepatic necrosis score concerned, serum transaminase(AST, ALT) level were found to be decreased in 4-methylpyrazole-treated group compared to untreated group after acetaminophen overdose, No consistent difference in hepatoprotective effect was demonstrated between rats with high dose of 4-methylpyrazole (500㎎/㎏) and rats with lower dose of 4-methylpyrazole(50㎎/㎏). Conclusion : We concluded that oral administration of 4-methylpyrazole apperas to protect hepatotoxicity effectively to acetaminophen overdose.