salicylates and Drug-Overdose

Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence- and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning.. The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations.. Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D).. Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.

Topics: Delphi Technique; Drug Overdose; Humans; Practice Guidelines as Topic; Renal Dialysis; Salicylates

Salicylates are widely used and are easily available as over-the-counter medications; thus, they can be readily abused. Although acute toxicity can be readily diagnosed if an ingestion history is provided, both acute and chronic salicylate toxicity often goes unrecognized, with high mortality when the patient is not treated properly. Salicylates should be considered in the differential diagnosis of an adult patient with acid-base abnormalities of uncertain cause, especially when there are concurrent neurologic symptoms. Patients with salicylate toxicity are treated with alkaline diuresis and sometimes dialysis. The prognosis depends on prompt recognition and treatment. Delayed diagnosis results in increased morbidity and mortality, particularly in the elderly.

Topics: Drug Overdose; Humans; Male; Middle Aged; Salicylates

Salicylate toxicity continues to be encountered commonly in emergency medicine. This article portrays the signs and symptoms of salicylate toxicity, reviews the erratic absorption and elimination kinetics, describes the devastating physiologic effects of overdose, and illustrates the potentially subtle manifestations of chronic aspirin toxicity.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Drug Overdose; Emergency Service, Hospital; Humans; Renal Dialysis; Resuscitation; Salicylates

Although aspirin (acetylsalicylic acid) has become widely available without prescription, cases of self-poisoning due to overdose of salicylates are quite uncommon, with a low reported mortality. However, severe poisoning with these preparations is life threatening. Besides the aspirin, there are other sources of salicylate poisoning, such as an excessive application of topical agents, ingestion of salicylate containing ointments, use of keratolytic agents or agents containing methyl salicylate (e.g. oil of wintergreen). Most of these preparations are liquid, highly concentrated and lipid soluble, and, therefore, they are able to provoke a severe, rapid salicylate poisoning. On the basis of clinical and metabolic features or salicylate concentration in plasma it is very important to diagnose severe poisoning with salicylates in time and prescribe an adequate treatment. In the present review article various aspects of salicylate poisoning and its treatment are discussed: epidemiology, pharmacokinetics and pharmacodynamics of salicylates, clinical manifestations of their toxicity, management, enhanced elimination and prognosis.

Topics: Acute Disease; Adult; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Child; Child, Preschool; Diagnosis, Differential; Drug Interactions; Drug Overdose; Fixatives; Humans; Ointments; Poisoning; Prognosis; Pulmonary Edema; Salicylates; Time Factors

The treatment of poisoned patients is still largely defined by history, clinical assessment and interpretation of ancillary investigations. Measurement of drug concentrations is clinically important for relatively few compounds. Most measurements form an adjunct to and should not be considered a substitute for clinical assessment. Drug concentrations are particularly important for those compounds where the concentration is predictive of serious toxicity in an otherwise asymptomatic patient.

Topics: Acetaminophen; Anticonvulsants; Digoxin; Drug Monitoring; Drug Overdose; Ethanol; Ethylene Glycol; Humans; Iron; Lithium; Methanol; Paraquat; Prognosis; Salicylates; Theophylline

Salicylate poisoning continues to be an important cause of drug related mortality. The zero order kinetics of salicylates at high doses is responsible in part for cases of iatrogenic poisoning. Serum levels tend to correlate with severity of poisoning in acute overdose cases only. Clinical manifestations include involvement of nervous system, hepatic and pulmonary systems along with metabolic disturbances. Measures at enhancing elimination and reducing absorption, while providing supportive care form the basis of management.

Topics: Absorption; Adult; Aged; Child; Drug Overdose; Humans; Poisoning; Salicylates; Sorption Detoxification

Paracetamol and salicylate are commonly taken in acute overdose. Clinicians have a low threshold for excluding the presence of these two drugs, by ordering laboratory tests in any patient suspected of ingesting an overdose or with an altered mental state.. To test the effectiveness of a new point of care test that qualitatively detects paracetamol and salicylate in blood and to examine the potential time saved by its use.. Prospective multicentre trial.. The new test was compared with laboratory analysis in a routine blood sample taken from patients presenting to emergency departments with suspected overdose.. The test had sensitivities of 98.5% and 88.5%, and specificities of 74.7% and 92%, for paracetamol and salicylate, respectively, at cut-off levels of 25 mg/l and 100 mg/l, respectively The point of care test results were available 2 h before the laboratory result.. This point-of-care test could be used to rule out an overdose with either of these two drugs, and could thus lead to earlier clinical decisions for suspected overdose patients. Recommendations have been made following this trial that the cut-off value for paracetamol should be reduced from 25 mg/l to 12.5 mg/l in order to increase its usefulness. To prevent the test being misread, we also suggest that each device should be embossed to remind users that the presence of a line indicates there is no drug present.

Topics: Acetaminophen; Adult; Blood Chemical Analysis; Drug Overdose; Female; Humans; Male; Point-of-Care Systems; Prospective Studies; Salicylates; Sensitivity and Specificity; Time Factors

Ferric chloride (FC) and Trinder reagent (TR) have both been used to identify salicylates (ASA) in the urine of patients presenting with possible drug overdose. The authors sought to compare the sensitivities and specificities of these two reagents in detecting ASA in the urine of patients presenting to an emergency department (ED) with suspected drug overdose.. Patients were eligible for inclusion in this study if they presented to the ED with either suspected overdose or unexplained metabolic acidosis. One milliliter of the patient's urine was added to 1 mL of each of the two reagents. A positive test was defined as any darkening of the color of the reagent. Each patient had a quantitative serum ASA measured.. Twenty of 180 patients (11%) had quantitative serum ASA levels above 5 mg/dL. Both reagents were 100% sensitive in identifying these patients. The specificity of FC was 71% compared with 73% for TR. The two reagents gave similar results in 91% of cases.. Both FC and TR are reliable in detecting ASA in the urine of patients presenting with suspected drug overdose. A negative result with either test eliminates the need for a quantitative serum ASA level. Because FC has a longer shelf life than TR, it is the more practical reagent for use in the ED.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Chlorides; Confidence Intervals; Drug Overdose; Emergency Service, Hospital; False Positive Reactions; Female; Ferric Compounds; Humans; Indicators and Reagents; Male; Middle Aged; Predictive Value of Tests; Prospective Studies; Salicylates; Sensitivity and Specificity

Management of patients with salicylate toxicity frequently requires urine alkalinization to enhance excretion of salicylate. One strategy for determining when to stop urine alkalinization is to wait for two consecutive serum salicylate concentrations to be less than 300 mg/L (2.17 mmol/L) and declining. When alkalinization of the urine ceases, a rebound in serum salicylate concentration can occur from tissue redistribution or delayed gastrointestinal absorption. Whether this can lead to rebound toxicity is not well understood.. This was a single-center, retrospective review of cases with a primary ingestion of acetylsalicylic acid reported to the local poison center over a five-year period. Cases were excluded if the product was not listed as the primary ingestion or if there was no serum salicylate concentration documented after discontinuation of intravenous sodium bicarbonate infusion. The primary outcome was the incidence of serum salicylate rebound to a concentration greater than 300 mg/L (2.17 mmol/L) after discontinuation of intravenous sodium bicarbonate infusion.. A total of 377 cases were included. Of these, eight (2.1%) had a serum salicylate concentration increase (rebound) after stopping the sodium bicarbonate infusion. All these cases were acute ingestions. Five of the eight cases had rebound serum salicylate concentrations that were greater than 300 mg/L (2.17 mmol/L). Of these five patients, only one reported recurrent symptoms (tinnitus). Prior to stopping urinary alkalinization, the last or the last two serum salicylate concentrations were less than 300 mg/L (2.17 mmol/L) in three and two cases, respectively.. In patients with salicylate toxicity, the incidence of rebound in serum salicylate concentration after cessation of urine alkalinization, is low. Even if serum salicylate rebounds to supratherapeutic concentrations, symptoms are often absent or mild. Routine repeat serum salicylate concentrations after urine alkalinization is stopped may be unnecessary unless symptoms recrudesce.

Topics: Aspirin; Drug Overdose; Humans; Incidence; Salicylates; Sodium Bicarbonate

Screening preadmission psychiatric patients for acetaminophen or salicylate overdose is unnecessary in the absence of specific clinical concern for medication ingestion.. This was a multicenter retrospective cohort study of 3 Veteran's Administration emergency departments that medically evaluate patients prior to psychiatric admission. During the 10-year study period, these departments followed screening protocols that required the measurement of acetaminophen and salicylate levels on every patient prior to psychiatric admission. We examined all the acetaminophen and salicylate assays performed to see if any that were sent for screening led to a diagnosis of overdose and/or the administration of antidotal therapy.. A total of 33,439 combined acetaminophen and salicylate assays were sent on 10,482 unique patients over approximately 17,000 patient encounters. An estimated 29,000 assays were sent for screening purposes only-87% (95% confidence interval [CI] 85% to 89%) of salicylate assays and 85% (95% CI 83% to 87%) of acetaminophen assays. We identified 43 patients with elevated acetaminophen levels and 11 with elevated salicylate levels. Among these patients, only 6 in total had their levels drawn for screening purposes only, with no history of suspected ingestion; in all but 1 patient, the levels were only slightly above the reference range. None of the patients with elevated levels identified by screening had clinical toxicity or received antidotal therapy.. Over a 10-year period, 3 Veteran's Administration emergency departments performed psychiatric preadmission screening protocols with acetaminophen and salicylate assays approximately 17,000 times without diagnosing a single case of toxicity. Our results suggest that this practice is unnecessary and wasteful.

Topics: Acetaminophen; Adolescent; Adult; Aged; Diagnostic Tests, Routine; Drug Overdose; Emergency Service, Hospital; Hospitals, Veterans; Humans; Illinois; Male; Mental Disorders; Middle Aged; Patient Admission; Retrospective Studies; Salicylates; Unnecessary Procedures; Wisconsin

Topics: Aged; Drug Overdose; Female; Humans; Insecticides; Oils, Volatile; Plant Extracts; Salicylates; Suicide, Attempted

Salicylates are usually rapidly absorbed and quickly measurable in serum. An undetectable serum salicylate concentration ([ASA]) may occur early after ingestion and may be interpreted as evidence of non-exposure and not repeated. Although cases of delayed salicylate detection are reported rarely, the risk factors associated with this phenomenon are not known.. What factors are associated with an early undetectable [ASA] in salicylate poisoning?. Records from a single regional poison center were searched from 2002 to 2016 for cases of salicylate toxicity treated with bicarbonate and [ASA] > 30 mg/dL. Cases were excluded if initial [ASA] was obtained >4 h after presentation. Case information, serial [ASA], and outcomes were recorded and compared between groups.. A total of 313 records met all criteria with 11 initially undetectable [ASA] (3.5%) and 302 detectable [ASA] (96.5%). Time of first [ASA] occurred sooner in the undetectable [ASA] group (89 vs. 137 min, p = 0.011) while time to peak [ASA] was longer (640 vs. 321 min, p < .001). The longest interval between ingestion and undetectable [ASA] was 225 min. Peak [ASA] and reported mean ingested dose were similar in both groups (45 vs. 50 mg/dL, p = NS; 19.7 g vs. 32.9 g, p = NS). Coingestion of agents that delay gastric emptying were similar in both groups (18% [2/11] vs. 25% [76/302], p = NS, chi-square). Hemodialysis was performed in 9% (1/11) of undetectable [ASA] patients and 5.6% (17/302) of detectable [ASA] patients (p = NS, chi-square). A single death occurred in the entire cohort in a patient with an initially detectable [ASA].. In this series, a small but significant proportion (3.5%) of patients who developed [ASA] > 30 mg/dL had an initially undetectable [ASA]. Those with an undetectable [ASA] were measured earlier after ingestion with a longer time to peak [ASA]. However, neither coingestion of agents prolonging gastric emptying nor reported dose ingested was different between groups. Formulation was infrequently recorded but one undetectable [ASA] did ingest a non-enteric coated product. Limitations include the small number of patients with undetectable [ASA], use of single poison center data and partial data on co-ingestants and aspirin formulation.. [ASA] may be undetectable early after an overdose and need for serial [ASA] in the evaluation of salicylate ingestion should be further explored. Additional research is needed to determine any causative factors and the optimal timing of [ASA] measurements.

Topics: Adolescent; Adult; Drug Overdose; Female; Humans; Male; Retrospective Studies; Salicylates; Young Adult

The threshold salicylate concentration commonly recommended to initiate extracorporeal elimination, in the absence of significant end-organ toxicity, is 100 mg/dL. Unfortunately, the grade of evidence to support this decision is low. Our primary aim is to describe highest reported salicylate concentrations in patients who died from acute salicylate ingestions. Our secondary aim is to determine if age or coingestants varied with highest reported salicylate concentration.. We analyzed acute salicylate fatalities reported to the National Poison Data System (NPDS) between 1 January 1986 and 31 December 2014. Included were patients who died during the index hospitalization and for which acute salicylate toxicity was the primary cause of death. We used descriptive statistics with standard deviations (SD) or 95% confidence intervals (CI) where appropriate. We created a general linear model that evaluated the association of age and coingestions with salicylate concentrations. We divided the patients into age quartiles to assess a possible interaction between age and salicylate concentration.. We identified 602 acute salicylate fatalities that fit inclusion criteria. The mean peak reported fatal salicylate concentration across all age groups was 99.19 mg/dL (± 50.2 mg/dL). The median peak fatal salicylate concentration was 97.0 mg/dL. The oldest quartile had a lower mean concentration (age >57 years; 90.4 mg/dL) than the youngest quartile (age <30 years; 111.6 mg/dL, mean difference 21.2 mg/dL, 95%CI 6.1-36.3). Fatalities with a coingestant had a lower mean concentration of 91.5 mg/dL compared to 104.8 mg/dL among those ingesting salicylates alone (mean difference 13.4 mg/dL, 95%CI 21.4-5.3). Increasing age and the presence of any coingestions were negatively associated with fatal concentrations (estimates; 95%CI 0.41; 0.61-0.021 and -14.43; 22.45-6.42, respectively). When opioids were a coingestant, mean concentration was 72.8 (mean difference 32.1 95%CI 23.1-41.1).. Using the current recommended hemodialysis threshold of 100 mg/dL, more than half of the patients would be deprived of this critical life-saving therapy. Additionally, increasing age and ingestion of other substances, especially opioids, are associated with lower peak fatal salicylate concentrations. A prospective, randomized controlled trial considering salicylate concentrations and other clinical factors may provide further guidance for hemodialysis.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Dose-Response Relationship, Drug; Drug Overdose; Female; Humans; Infant; Male; Middle Aged; Poison Control Centers; Prospective Studies; Salicylates; United States; Young Adult

2,4-Dinitrophenol (DNP) is a known uncoupler of oxidative phosphorylation that clinically leads to hyperthermia, tachycardia, tachypnea, and metabolic acidosis. Intentional overdoses of DNP are often fatal. We present an analytically confirmed fatal case of DNP overdose with a falsely positive elevated salicylate concentration. We further explored this cross reactivity of DNP with two salicylate assays.. Clinically relevant serial dilutions of DNP were prepared in drug-free serum and analyzed using two different colorimetric NADH/NAD-based analytical methodologies.. The enzymatic salicylate assay demonstrated a reproducible false elevation of salicylate starting at a DNP level of 100 mg/L while the EMIT-based methodology was without any such interference at the maximum concentration tested (150 mg/L).. DNP cross reacts with some salicylate assays. This knowledge is important for providers, as there are significant variations in the management of DNP versus salicylate toxicity.

Topics: 2,4-Dinitrophenol; Autopsy; Colorimetry; Cross Reactions; Drug Overdose; False Positive Reactions; Fatal Outcome; Humans; Male; Salicylates; Suicide; Young Adult

Salicylate poisoning is a serious toxicologic problem with a complex pathophysiology that requires prompt diagnosis and action for a favorable outcome. A simulated experience in the evaluation and management of an aspirin-overdose patient allows learners to construct a differential diagnosis from an array of symptoms and signs, analyze a mixed acid-base disturbance, and explore the multistep management of this disorder.. This simulation exercise was designed for second-year medical students. At the start of the session, teams received a 10-minute introduction to the activity. Upon entering a room in a simulated Emergency Department, teams had 15 minutes to complete a focused history and physical exam of the patient, interpret arterial blood gas and basic metabolic panel data, and administer treatment based on key findings and a presumptive diagnosis. The scenario was followed by a 90-minute facilitated debriefing session. An alternative 45-minute debriefing guideline is also included.. Students voluntarily completed a 13-question, 5-point Likert-scale survey about the educational exercise immediately following the session. They evaluated the preparatory materials and briefing, the simulation scenario, the usefulness of the debriefing, and their confidence in their understanding of salicylate poisoning following the session. Students reported a favorable response to the overall experience and the debriefing, as well as an increase in confidence following the session.. This simulation exercise was successful in exposing students to the clinical presentation of salicylate toxicity and giving them the opportunity to apply and synthesize basic science knowledge during the scenario.

Topics: Drug Overdose; Educational Measurement; Emergency Service, Hospital; Humans; Michigan; Patient Simulation; Poison Control Centers; Salicylates; Suicide; Surveys and Questionnaires; Teaching

Chronic salicylate toxicity is an uncommon, potentially life-threatening poisoning that requires high clinical suspicion in order to make the diagnosis. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an elevated anion gap metabolic acidosis with respiratory alkalosis, and initiate treatment for this toxicity.. The simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. For interns, a team of two learners comanaged the case; for senior learners, the case was managed solo. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, and initiate specific treatments. The simulation was followed by a 15-minute facilitated debrief session that included an overview of key learning points and learner performance based on an evaluation checklist.. Residents completed a postparticipation questionnaire consisting of six questions rated on a 5-point Likert scale. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap.. This simulation exercise was effective in showing residents the uncommon presentation of chronic salicylate toxicity. Learners reported increased confidence in recognizing and managing this ingestion. The simulation experience closed an identified education gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.

Topics: Child; Drug Overdose; Emergency Medicine; Humans; Male; Pediatric Emergency Medicine; Problem-Based Learning; Salicylates; Simulation Training; Surveys and Questionnaires

Salicylate poisonings are common due to their multiple uses and wide availability. The variation of presenting symptoms contributes to inconsistent treatments in the emergency department. Patients with severe salicylate overdose require a high minute ventilation. Early in the course of an overdose, a patient will require hyperventilation. If they become too fatigued to compensate, mechanical ventilation may be needed. It can be impossible to recreate such a high minute ventilation with mechanical ventilation. This places patients at a high risk for decompensation and death. Hemodialysis is an effective elimination technique for salicylate overdose and should be considered early.. All salicylate cases reported to the Illinois Poison Center were reviewed from 2003-2014. All intubated patients with a salicylate level >50mg/dl were included for analysis. Survival was compared to measured serum salicylate level and the administration of hemodialysis.. 56 Cases were identified with an overall survival rate of 73.2% in patients with a serum salicylate level >50mg/dl. When patients did not receive hemodialysis, a peak salicylate level >50mg/dl had a 56% survival rate and 0% survival when the level was >80mg/dl. In the patients who received hemodialysis, a peak salicylate level >50mg/dl had a 83.9% survival rate and 83.3% survival when the level was >80mg/dl.. Survival was decreased in these patients if hemodialysis was not performed. Mortality increases with the measured serum salicylate level. Timely hemodialysis for intubated salicylate overdose patients decreases mortality.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Drug Overdose; Emergency Service, Hospital; Humans; Illinois; Renal Dialysis; Respiration, Artificial; Retrospective Studies; Salicylates; Survival Rate

Topics: Drug Overdose; Humans; Risk Factors; Salicylates

Topics: Drug Overdose; Humans; Risk Factors; Salicylates

Topics: Drug Overdose; Humans; Intubation; Salicylates

Topics: Drug Overdose; Humans; Intubation; Salicylates

We report the case of a 17-year-old girl with a 126-mg/kg nonenteric coated aspirin ingestion with nontoxic salicylate concentrations at 1.5 and 3.9 hours postingestion, who developed tinnitus and vomiting an estimated 8 hours postingestion, and who was subsequently found to have a toxic salicylate concentration at 22.7 hours postingestion. This case, as well as previous cases of delayed aspirin therapy, may prompt providers to consider educating patients and their care providers regarding the need to return for further testing if symptoms, such as vomiting or tinnitus, develop after an aspirin ingestion.

Topics: Adolescent; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Drug Overdose; Female; Humans; Salicylates; Time Factors

Salicylate poisoning remains a significant public health threat with more than 20,000 exposures reported annually in the United States.. We aimed to establish early predictors of severe in-hospital outcomes in Emergency Department patients presenting with acute salicylate poisoning.. This was a secondary data analysis of adult salicylate overdoses from a prospective cohort study of acute drug overdoses at two urban university teaching hospitals from 2009 to 2013. Patients were included based on confirmed salicylate ingestion and enrolled consecutively. Demographics, clinical parameters, treatment and disposition were collected from the medical record. Severe outcome was defined as a composite occurrence of acidemia (pH <7.3 or bicarbonate <16 mEq/L), hemodialysis, and/or death.. Out of 1997 overdoses screened, 48 patients met inclusion/exclusion criteria. Patient characteristics were 43.8% male, median age 32 (range 18-87), mean initial salicylate concentration 28.1 mg/dL (SD 26.6), and 20.8% classified as severe outcome. Univariate analysis indicated that age, respiratory rate, lactate, coma, and the presence of co-ingestions were significantly associated with severe outcome, while initial salicylate concentration alone had no association. However, when adjusted for salicylate concentration, only age (OR 1.13; 95% CI 1.02-1.26) and respiratory rate (OR 1.29; 95% CI 1.02-1.63) were independent predictors. Additionally, lactate showed excellent test characteristics to predict severe outcome, with an optimal cutpoint of 2.25 mmol/L (78% sensitivity, 67% specificity).. In adult Emergency Department patients with acute salicylate poisoning, independent predictors of severe outcome were older age and increased respiratory rate, as well as initial serum lactate, while initial salicylate concentration alone was not predictive.

Topics: Acidosis; Acute Disease; Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Cohort Studies; Drug Overdose; Emergency Service, Hospital; Female; Hospitals, University; Humans; Male; Middle Aged; Prospective Studies; Renal Dialysis; Risk Factors; Salicylates; Sensitivity and Specificity; Severity of Illness Index; Young Adult

There are limited data on modern intermittent hemodialysis (IHD) efficacy on salicylate elimination from topical poisoning.. A 54-year-old male sought treatment for dyspnea but was then diagnosed with salicylate toxicity from topical application of Dencorub Extra Strength Heat Gel® for 1 week. Each tube contained 100 g with 26 % methylsalicylate (26 g). Laboratory workup was remarkable for an elevated anion gap of 30 and salicylate concentration of 78.7 mg/dL [5.7 mmol/L (N < 0.4 mmol/L)]. Treatment with urinary alkalinization was followed by hemodialysis for 5 h. Extraction ratios were 0.44 with clearance rates of 78.5 mL/min. Salicylate concentrations fell rapidly following initiation of hemodialysis with no rebound observed.. Modern high flux IHD is an effective method of removing salicylates in the treatment of chronic topical poisoning.

Topics: Administration, Cutaneous; Antirheumatic Agents; Drug Overdose; Humans; Male; Middle Aged; Renal Dialysis; Respiration Disorders; Salicylates; Treatment Outcome

Topics: Anti-Inflammatory Agents, Non-Steroidal; Child; Drug Overdose; Humans; Nonprescription Drugs; Salicylates

Salicylate absorption following overdose of aspirin (ASA) tablet formulations can be prolonged for greater than 24 h. Accordingly, serial serum concentrations are typically recommended to guide treatment. However, there are little published data on absorption following ingestion of powder ASA formulations, and it is not known if delayed ASA absorption occurs following overdose of powder formulations. The objective of this study is to compare the absorption characteristics of powder and tablet formulations of ASA in patients reported to a single poison center.. Electronic records from an accredited poison center were searched for single substance acute or acute on chronic ingestions of ASA in powder form between 1 January 2002 and 31 January 2014. An identical search for ingestions of ASA tablet products between 1 January 2012 and 31 December 2013 was undertaken as the comparator group. Other inclusion criteria were age >12 years, documented time of ingestion, treatment in a health care facility within nine hours of ingestion and at least two detectable serum salicylate concentrations.. 16 of 25 powder and 22 of 49 tablet cases met inclusion criteria for analysis. Repeat serum salicylate concentrations following ingestion of tablets increased or insignificantly changed in 11 of 22 (50%) cases, and median serum salicylate concentrations in followed cases remained elevated for up to 12 h in some cases. In comparison, serum salicylate concentrations following powder ingestions declined in 15 of 16 (94%) cases. One patient, who ingested a powder product, underwent hemodialysis pursuant to an initial serum salicylate concentration of 96 mg/dL.. In contrast to persistent concentrations following overdose of tablets, the majority of serum salicylate concentrations declined following ingestion of powder formulations. In this small study population, these findings suggest that prolonged absorption is unlikely following ingestions of ASA powders.

Topics: Adolescent; Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Drug Overdose; Female; Humans; Male; Middle Aged; Poison Control Centers; Powders; Renal Dialysis; Retrospective Studies; Salicylates; Tablets; Time Factors; Young Adult

Topics: Anti-Inflammatory Agents, Non-Steroidal; Clinical Decision-Making; Combined Modality Therapy; Drug Overdose; Humans; Salicylates; Societies, Medical; Toxicology; United States; Workforce

Topics: Acid-Base Equilibrium; Anti-Inflammatory Agents, Non-Steroidal; Drug Overdose; Female; Humans; Middle Aged; Salicylates

Topics: Acid-Base Equilibrium; Acidosis; Adolescent; Drug Overdose; Female; Humans; Salicylates

Suspected ingestions are a common chief complaint to the emergency department although the majority of ingestions by children are insignificant.. Assess the utility of screening laboratory tests and Electrocardiograms (ECGs) in unintentional asymptomatic pediatric poisonings.. Retrospective chart review at a tertiary care children's hospital and a regional poison center of patients less than 12 years of age using ICD-9 codes from January 2005 through December 2008. Laboratory or ECG results requiring intervention and/or direct treatment, a non-RPC subspecialty consultation, and/or prolonged Emergency Department stay was considered changed management.. Five hundred ninety five suspected ingestions met our criteria. The median age was 2.6 years (IQR 1.6, 3.0 years) and 56% were male. One laboratory test or ECG was obtained in 233 patients (39%). Of 24 screening ECGs, 32 complete blood counts and 34 blood gases, none were clinically significant. Fifty-two patients received screening metabolic panels, 3 were abnormal and 2 changed management (anion gap metabolic acidosis with unsuspected salicylate ingestions). None of the 127 (21%) screening acetaminophen levels changed management. Two of sixty-five (13%) screening salicylate levels changed management. Three screening urine toxicology tests on patients with altered mental status were positive without ingestion history. No patient under the age of 12 years with normal vital signs and normal mental status had positive screening tests.. Screening laboratory tests and ECGs were of limited utility and rarely changed management despite being ordered in a significant number of patients. Screening tests are rarely indicated in unintentional overdoses in children who are asymptomatic.

Topics: Acetaminophen; Asymptomatic Diseases; Blood Cell Count; Blood Chemical Analysis; Child; Child, Preschool; Clinical Enzyme Tests; Drug Overdose; Electrocardiography; Emergency Service, Hospital; Female; Humans; Infant; Male; Poisoning; Retrospective Studies; Salicylates; Urinalysis

Salicylate poisoning classically results in an increased anion gap metabolic acidosis. We discuss a case of normal anion gap metabolic acidosis despite elevated serum salicylate concentration. This diagnostic dilemma stemmed from aberrant reading of salicylate ions by analyzer electrodes as chloride ions leading to falsely negative anion gap. On review, this phenomenon is found to be possible with a number of commonly used analyzers. In emergency department settings, high level of clinical suspicion for salicylate poisoning should be maintained, and metabolic acidosis with normal anion gap should not be used to rule out salicylate overdose. This can prevent significant avoidable morbidity and mortality.

Topics: Acid-Base Equilibrium; Acidosis; Adult; Chlorides; Drug Overdose; Emergency Service, Hospital; Humans; Male; Salicylates

Salicylates are common exposures. We report an unusual case of salicylate ingestion, as salsalate, with resolution of symptoms and return of salicylate levels to non-toxic values, with a subsequent, unexpected recrudescence to toxic levels requiring reinstitution of therapy. A 31-year-old man ingested unknown amounts of salsalate, hydroxyzine, and a benzodiazepine. He was intubated and treated with IV sodium bicarbonate and two doses of oral activated charcoal. Eight hours after presentation, his serum salicylate concentration peaked at 55 mg/dL, and then decreased to a nadir of 5.6 mg/dL 38 h after presentation, coinciding with return of GI motility. Several hours later salicylate concentrations began to rise, peaking 67 h after presentation at 61.7 mg/dL. He was treated with sodium bicarbonate and charcoal, which resulted in decreased serum salicylate to therapeutic levels. Salicylate ingestions are known to exhibit unusual toxicokinetics and absorption in overdose; however, this is the first case we are aware of that shows a return to toxic concentrations after apparent resolution of toxicity. Recrudescence of salicylate concentrations to a degree that would dictate reinstitution of therapy for overdose is unusual and may warrant prolonged monitoring of serum salicylate concentrations in salsalate ingestions.

Topics: Adult; Antacids; Anti-Inflammatory Agents, Non-Steroidal; Antidotes; Benzodiazepines; Charcoal; Depressive Disorder; Drug Overdose; Humans; Hydroxyzine; Hypnotics and Sedatives; Male; Recurrence; Salicylates; Sodium Bicarbonate; Stress Disorders, Post-Traumatic; Suicide, Attempted

Poisoning with weak analgesics is a major public health problem because of easy accessibility of the compounds; however, few studies have investigated their influence on subsequent suicide in the context of subjects' psychiatric status and other factors.. This nested case-control study was based on the entire Danish population including all 21,169 suicide cases and 423,128 matched population controls. Data on hospital admissions for poisoning and confounding factors were retrieved from national medical and administrative registries. Conditional logistic regression was used to compute relative risk.. A prior hospital admission for poisoning with weak non-opioid analgesics significantly increased the risk of subsequent suicide [crude incidence rate ratio (IRR) 24.7, 95% confidence interval (CI) 22.1-27.6], and the effect of paracetamol poisoning was substantially stronger than that of poisoning with salicylates or non-steroidal anti-inflammatory drugs (NSAIDs). This association could not be explained by confounding from socio-economic or psychiatric factors. The elevated risk was extremely high during the first week following the overdose (adjusted IRR 738.9, 95% CI 173.9-3139.1), then declined over time but still remained significantly high 3 years later (adjusted IRR 4.2, 95% CI 3.5-5.0). Moreover, a history of weak analgesic poisoning significantly interacted with a person's psychiatric history, increasing the risk for subsequent suicide substantially more for persons with no history of psychiatric hospitalization than did it for those with such a history.. A history of non-fatal poisoning with weak analgesics is a strong predictor for subsequent suicide. These results emphasize the importance of intensive psychiatric care of patients following overdose.

Topics: Acetaminophen; Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Case-Control Studies; Cause of Death; Cross-Sectional Studies; Denmark; Drug Overdose; Humans; Incidence; Longitudinal Studies; Patient Admission; Recurrence; Registries; Risk; Salicylates; Suicide; Suicide, Attempted

Topics: Acidosis; Aged; Confusion; Consciousness Disorders; Critical Care; Diagnostic Errors; Drug Overdose; Fatal Outcome; France; Humans; Salicylates; Schizophrenia

Topics: Anti-Inflammatory Agents, Non-Steroidal; Antidiarrheals; Child; Diarrhea; Drug Administration Schedule; Drug Dosage Calculations; Drug Overdose; Humans; Periodicals as Topic; Practice Guidelines as Topic; Reye Syndrome; Risk; Salicylates; Travel

To determine whether it is necessary to routinely measure serum salicylate levels in addition to serum paracetamol levels in alert overdose patients who deny ingestion of that substance.. Prospective observational study of overdose patients attending an urban emergency department.. A total of 171 patients attended with an alleged overdose. Thirty-seven patients were excluded; 24 patients had a reduced conscious level (Glasgow Coma Scale <15), nine patients could not recall the time of overdose and four patients had a staggered overdose. In all, 47.0% (63/134) claimed to have taken paracetamol and 5.2% (7/134) claimed to have taken salicylate. No patient who denied taking paracetamol or salicylate subsequently tested positive for them. In all, 51.5% (69/134) of patients reported that they had taken alcohol at the time of their overdose.. Given the relatively low clinical risk and evident symptoms and signs from salicylate overdose, routine testing may not be required for fully conscious asymptomatic patients who deny taking it. The risks of delayed toxicity and lack of initial symptoms in those ingesting paracetamol suggests that continued routine testing is necessary.

Topics: Acetaminophen; Drug Overdose; Emergency Service, Hospital; Humans; Poisoning; Prospective Studies; Salicylates

Topics: Aged; Anti-Inflammatory Agents, Non-Steroidal; Delirium; Drug Overdose; Emergency Service, Hospital; Fatigue; Female; Humans; Muscle Weakness; Neuropsychological Tests; Renal Dialysis; Salicylates; Tinnitus

Acetylic acid, such as aspirin, is one of the most commonly used medication in Western societies. Aspirin overdosage causes ototoxic side effects in some patients, such as bilateral mild to moderate sensorineural hearing loss and tinnitus. Recent literature describes, that salicylates act as competitive inhibitors of Cl- anions at the anion-binding site of prestin, the motor protein of the outer hair cell. This molecular mechanism correlates well with the clinical audiological mainstays of aspirin-induced hearing loss, dose dependency, cochlear site of hearing loss and reversibility. We report about a young man with an acute moderate aspirin intoxication resulting in asymmetric hearing loss of 50 dB HL and tinnitus for five days. Otoacoustic emissions were absent on the first day of intoxication but could be measured again on the fifth day after the intoxication. As the ototoxic side effects resolve with in two or three days, no specific treatment is necessary for ototoxicity. Medical treatment of acute or chronic aspirin intoxications aims to decrease further drug absorption by gastrointestinal decontamination and to accelerate elimination by alkaline diuresis. Only in severe intoxications hemodialysis may be considered to treat neurologic, pulmonal, renal or cardial complications.

Topics: Adaptation, Physiological; Adult; Aspirin; Drug Overdose; Hearing Loss; Humans; Male; Otoacoustic Emissions, Spontaneous; Salicylates; Tinnitus

To raise clinicians' awareness of chronic (therapeutic) salicylate poisoning as a common cause of admission in paediatric patients presenting to hospital with respiratory distress (a clinical manifestation of metabolic acidosis) and a history of 'over the counter' treatment with salicylate (Aspirin). We present two complex cases and provide a review of the literature on pathogenesis, clinical presentation and management of salicylate poisoning. A complete history of the illness, including questions on drug use, is vital in assessing the cause of metabolic acidosis in children. Due to the limited options available in managing such patients in many developing countries, emphasis should be placed on prevention of poisoning by educating the community and health care providers.

Topics: Child, Preschool; Drug Overdose; Fatal Outcome; Fever; Humans; Male; Nonprescription Drugs; Salicylates; Treatment Outcome

Topics: Acidosis; Adult; Alkalosis, Respiratory; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Charcoal; Child; Drug Overdose; Humans; Salicylates; Sorption Detoxification

Topics: Drug Industry; Drug Overdose; Gastric Lavage; Humans; Periodicals as Topic; Renal Dialysis; Salicylates

All pharmaceutical drugs have the potential to be misused or wrongly administered, which can result in toxic amounts of drug being ingested. To help you keep up-to-date with the latest data on outcomes and management of overdoses, both accidental and intentional, we have selected the following case reports recently published in the international medical literature and summarised in Reactions Weekly. Any claim of first report has been verified by a search of the Adisbase (a proprietary database of Adis International) and Medline. In addition, the World Health Organization (WHO) Adverse Drug Reaction database is also searched. This database, maintained by the Uppsala Monitoring Centre in Sweden, is the largest and most comprehensive adverse drug reaction source in the world, with information obtained from the National Centres of over 70 affiliate countries.

Topics: Acetaminophen; Adolescent; Adult; Aged; Amlodipine; Child, Preschool; Diphenhydramine; Dizocilpine Maleate; Drug Overdose; Female; Humans; International Normalized Ratio; Lithium; Male; Middle Aged; Paroxetine; Salicylates; Valproic Acid; Warfarin

The Compendium of Pharmaceuticals and Specialties (CPS) is a collection of monographs written by pharmaceutical companies and published by the Canadian Pharmacists Association. The CPS is widely available and is consulted frequently by Canadian physicians. We examined overdose management advice contained in the CPS to see whether it reflects current standards.. We restricted our review to 10 classes of medication for which an overdose is frequently fatal: acetaminophen, beta-blockers, calcium-channel blockers, digoxin, lithium, opioids, salicylates, tricyclic antidepressants, theophylline and valproic acid. A panel of 3 toxicologists arrived at a consensus on indicated, contraindicated and futile interventions for each of these classes of drug. Monographs were then rated for their inclusion of essential interventions as excellent (listed all interventions and unique supportive care issues and gave correct and complete indications), good (listed the key interventions and gave correct and complete indications), fair (listed the key indications but failed to give proper indications) or poor (failed to list the key interventions). Monographs were also rated on how well they warned against contraindicated interventions as excellent (did not advocate any futile or contraindicated treatments and warned against contraindicated treatments), good (did not advocate any futile or contraindicated treatments), fair (did not advocate any contraindicated treatments but did list some simple futile treatments) or poor (advocated contraindicated or complicated futile treatments, such as unnecessary hemodialysis). We also considered whether the monograph would allow a clinician to manage an overdose, whether it served to refresh one's memory and whether it was simply misleading or dangerous.. We reviewed 119 monographs, of which 25 (21%) were adequate to allow a clinician to manage an overdose. Another 25 monographs were not adequate to allow a clinician to manage an overdose but would serve to refresh the memory regarding key management points. Sixty monographs (50%) contained misleading or dangerous advice. Nine monographs (8%) did not fall into any of these categories. In terms of listing essential interventions, 61 monographs (51%) were poor, 35 (29%) were fair, 22 (18%) were good, and 1 (1%) was excellent. For warning against contraindicated interventions, 57 monographs (48%) were poor, 9 (8%) were fair, 51 (43%) were good, and 2 (2%) were excellent.. Overdose management advice in the CPS is inadequate in most cases and is misleading or dangerous in half of the monographs examined. These sections should be omitted or rewritten to reflect current standards of care. Physicians should refer to authoritative sources (e.g., current toxicology texts, computerized databases or local poison control centres) for poisoning management advice.

Topics: Drug Industry; Drug Overdose; Gastric Lavage; Humans; Periodicals as Topic; Renal Dialysis; Salicylates

Topics: Acetaminophen; Antidepressive Agents, Tricyclic; Barbiturates; Diagnosis, Differential; Drug Overdose; Humans; Salicylates; Tranquilizing Agents

To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter.. Before and after study.. UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999.. People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates.. Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates.. Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change.. Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.

Topics: Acetaminophen; Analgesics, Non-Narcotic; Anti-Inflammatory Agents, Non-Steroidal; Drug Overdose; Drug Packaging; Humans; Liver; Liver Function Tests; Liver Transplantation; Morbidity; Salicylates; Suicide, Attempted; United Kingdom

Rates of deliberate self-poisoning have increased in recent years. While over-the-counter availability and prescribing patterns may influence trends in substances used in overdose, these may also be related to clinical characteristics of patients. We investigate trends in substances used for self-poisoning and the influence of age, gender, suicidal intent and repetition status on the substances used.. Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends and patterns of self-poisoning between 1985 and 1997.. There were substantial increases in self-poisoning with paracetamol and antidepressants. While the increase in antidepressant self-poisoning closely paralleled local prescribing figures during 1995-97, SSRI antidepressant overdoses occurred somewhat more often than expected compared with tricyclic overdoses. Paracetamol overdoses were more common in first-timers and young people, whereas overdoses of antidepressants and tranquillizers were more common in repeaters and older people. Self-poisoning with gas and non-ingestible poisons was associated with high suicidal intent.. There have been marked changes in the substances used for self-poisoning, which seem primarily to reflect availability, as do the influences of age and repeater status on choice of substances used. Degree of suicidal intent may also influence choice of method of self-poisoning.

Topics: Acetaminophen; Adolescent; Adult; Age Distribution; Analgesics, Non-Narcotic; Antidepressive Agents; Drug Overdose; Female; Humans; Male; Middle Aged; Poisoning; Recurrence; Retrospective Studies; Salicylates; Self-Injurious Behavior; Sex Distribution; Suicide, Attempted; Tranquilizing Agents; United Kingdom

Topics: Adult; Cochlea; Drug Overdose; Female; Humans; Otoacoustic Emissions, Spontaneous; Salicylates; Severity of Illness Index; Tinnitus

Salicylate intoxication is frequently overlooked as a cause of noncardiogenic pulmonary edema and altered mental status in adult patients. We describe a 42-year-old woman who presented with two episodes of recurrent noncardiogenic pulmonary edema requiring intubation. The first admission to hospital triggered an extensive initial workup that did not indicate a cause for the pulmonary edema. At the second presentation, recognition of the clinical syndrome in the emergency department led to the correct diagnosis of salicylate intoxication. The patient was successfully treated with hemodialysis and urinary alkalinization, leading to rapid resolution of pulmonary edema and extubation. Several aspects of the clinical presentation suggest that the patient suffers from chronic salicylism, probably complicated by episodic superimposed acute intoxication, a condition often misdiagnosed or diagnosed late in the course of disease, contributing to substantial morbidity and mortality in these patients. Maintenance of a high index of suspicion and rapid institution of appropriate therapy including hemodialysis once the diagnosis is established is an important determinant of outcome in this serious but underdiagnosed disorder.

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Drug Overdose; Female; Humans; Pulmonary Edema; Renal Dialysis; Salicylates

Topics: Adult; Anti-Inflammatory Agents, Non-Steroidal; Diagnosis, Differential; Diflunisal; Drug Overdose; Humans; Male; Salicylates

Topics: Adolescent; Adult; Diagnosis, Differential; Diagnostic Errors; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Salicylates; Severity of Illness Index; Suicide, Attempted

An 81-year-old woman with unintentional salicylate intoxication presented with features of sepsis, abdominal pain, and tenderness. Laparotomy was performed to rule out acute cholecystitis. Anesthesia was complicated by severe hypercarbia despite hyperventilation, and progressive cardiovascular and neurologic deterioration postoperatively. The adverse neurologic, respiratory, and hepatic effects of abdominal surgery and general anesthesia probably potentiated salicylate toxicity and increased patient morbidity. Anesthesiologists should be aware of the protean manifestations of salicylate poisoning and consider it as a cause of "medical abdomen."

Topics: Abdominal Pain; Aged; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Drug Overdose; Female; Humans; Salicylates; Sepsis

Topics: Aged; Drug Overdose; Drugs, Chinese Herbal; Fatal Outcome; Female; Humans; Salicylates

Drug screens were performed for 434 adult patients who presented to the Parkland Memorial Hospital Emergency Department with suspected acute drug overdose. The screening consisted of analysis of urine by automated high performance liquid chromatography (REMEDi) in combination with qualitative EMIT immunoassays. Selected patients also had ethanol measured in blood, salicylate and acetaminophen measured in serum, and urine specimens analyzed qualitatively for cannabinoids. Most patients (83.4%), regardless of age, race, or gender, had evidence of consumption of at least one drug. The drugs detected most often were ethanol (30.0%) and cocaine (23.7%). At least one of the nine most common drugs-of-abuse (amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, ethanol, opiates, opioids, and phencyclidine) was detected in 64.5% of the specimens, and combinations of these drugs were present in 45.4%. For most drugs, age, gender, ethnicity, time of day, day of week, and indication for screening could not be used to predict the drug screen result.

Topics: Acetaminophen; Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Alcoholic Intoxication; Amphetamines; Analgesics, Non-Narcotic; Barbiturates; Cannabinoids; Chromatography, High Pressure Liquid; Cocaine; Drug Overdose; Enzyme Multiplied Immunoassay Technique; Ethanol; Female; Forecasting; Hallucinogens; Humans; Male; Middle Aged; Narcotics; Phencyclidine; Poisoning; Retrospective Studies; Salicylates; Substance-Related Disorders

Is universal screening of acetaminophen (APAP) and salicylate (SAL) necessary in patients with a suicidal ingestion or an altered mental status and suspected ingestion? This descriptive, retrospective chart review in an emergency department in a large urban county hospital examined all patients who presented with a history of suicidal ingestion or an altered mental status with a strong suspicion of ingestion from January 1992 through October 1993. APAP and SAL serum levels were measured in 1,820 patients, and charts of patients with APAP serum levels of > 1 microgram/mL or SAL serum levels of > 1 mg/dL were reviewed. The patient's history of ingesting APAP or SAL was recorded, as well as the clinician's interpretation of that level. Sixteen charts were not available. APAP levels of > 1 microgram/mL were found in 175 (9.6%) patients, 120 (6.5%) of whom were APAP history-positive and 55 (3%) APAP history-negative. None of the APAP history-negative group required therapy with N-acetylcysteine. Eight (0.3%) of the APAP history-negative group had potentially toxic levels of > 50 micrograms/mL. SAL levels of > 1 mg/dL were found in 155 (8.5%) patients, 44 (2.5%) of whom were SAL history-positive and 111 (6%) SAL history-negative. Three patients were SAL history-negative but had a significant chronic SAL intoxication. All these patients presented with an altered mental status and had an anion gap of > 20 mEq/L. Universal screening found that 0.3% of suicidal ingestions had a potentially toxic APAP intoxication not suggested by history. This incidence of infrequent but potentially life: threatening overdose should prompt clinicians to screen all of their patients with a suspected ingestion. Salicylate screening found that 0.16% of suicidal ingestions had a toxic SAL intoxication not suggested by history, although such intoxication should be suggested by an elevated anion gap and an altered mental status. Since this less severe intoxication is less frequent and usually suggested by commonly obtained laboratory data, universal screening is not indicated, but a more selective approach to screening could be taken.

Topics: Acetaminophen; Acid-Base Equilibrium; Adult; Aged; Analgesics, Non-Narcotic; Cognition Disorders; Drug Overdose; Female; Humans; Liver Function Tests; Male; Medical History Taking; Middle Aged; Poisoning; Retrospective Studies; Salicylates; Suicide, Attempted

In a 7-year-old boy, ichthyosis vulgaris was treated with a 10% ointment for application over a large area of the body surface. In this way, the child received 400 g salicylic acid (0.6 g/kg body weight per day) percutaneously over a period of 4 weeks. The patient was referred to hospital by the family doctor: he was in a deep somnolent state, apparently caused by hyperventilation following wheezing, vomiting, tinnitus and vertigo. Salicylate intoxication was suspected because of metabolic acidosis, an anion gap and respiratory overcompensation. The diagnosis was confirmed by a serum salicylate level of 985 micrograms/ml (therapeutic level 150-300 micrograms/ml). Following forced diuresis and alkalization with sodium bicarbonate, haemodialysis was unnecessary. As the salicylate level declined to values within the therapeutic range, the patient started to recover consciousness, waking on the 4th day. By day 6 there were still obvious neurological deficiencies. Fecal incontinence, bilateral ptosis and intermittent diverging strabismus on the right persisted for some weeks. It was 6 months before complete neurological resolution was achieved. The pathogenesis of salicylate toxicity and the need for safer therapies for ichthyosis vulgaris are discussed.

Topics: Acid-Base Equilibrium; Administration, Topical; Child; Critical Care; Dose-Response Relationship, Drug; Drug Overdose; Humans; Ichthyosis Vulgaris; Keratolytic Agents; Male; Renal Dialysis; Salicylates; Salicylic Acid; Skin Absorption

As part of a pilot project establishing a porcine model for aspirin overdose, the percentage protein binding of acetylsalicylate (ASA) and salicylate (SA) in porcine and human sera was evaluated in vitro over a range of concentrations. Serum from 2 pigs and 4 humans were spiked with ASA concentrations of 0.5-100 mg/dL and SA concentrations of 1-120 mg/dL. Protein binding for each concentration of ASA and SA was determined using radiolabeled drug and ultrafiltration with the Centrifree micropartition system. The percentage protein binding for ASA in pig and human sera were similarly low (< 50%) for all concentrations evaluated. Percentage protein binding for SA for pig and human sera were high (approximately 90% and 80%) at low therapeutic concentrations, but then declined to approximately 30% at higher toxic concentrations (120 mg/dL). The protein binding of ASA and SA over a range of concentrations was similar for porcine and human sera.

Topics: Animals; Anti-Arrhythmia Agents; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Blood Proteins; Drug Overdose; Esterases; Humans; In Vitro Techniques; Isotope Labeling; Pilot Projects; Protein Binding; Salicylates; Salicylic Acid; Serum Albumin; Swine; Ultrafiltration

Detailed toxicological studies were undertaken on two suicides by amitriptyline overdose, one with salicylate also. In the first case, 10 initial blood samples taken 21 h after body discovery and an estimated 28 1/2 h after overdose had drug concentration (mg/L) ranges of 2.5-12 for amitriptyline (AM), 0.7-3.1 for nortriptyline (NOR), and 81-244 for salicylate (SAL). Ten blood samples taken 42 h later showed corresponding ranges of 1-39 AM, 0.6-7.0 NOR, and 86-310 SAL. Sample haemoglobin concentrations (range, 8.7-23.5 g/dl) did not correlate with drug concentrations. Postmortem increase in pulmonary vein AM concentration occurred more rapidly than in the pulmonary artery, likely reflecting relative ease of diffusion across the vessel walls from lung (AM, 60 mg/kg). In nine tissue samples, drug concentrations (mg/kg) were highest in the liver: AM, 301; and SAL, 670. Considerable drug residue was present in gastric contents, duodenal contents, and seven sequential small bowel contents. In both cases, sanguineous putrefactive pleural fluid showed higher AM concentrations on the left than on the right (2.0 vs 1.4 and 23 vs 16), likely reflecting diffusion from gastric drug residue. The detailed case data illustrate the intensity and complexity of postmortem drug diffusion from reservoirs in solid organs, such as the lungs, and unabsorbed gastric residue, into the blood and putrefactive fluids.

Topics: Adult; Amitriptyline; Body Fluids; Chromatography, High Pressure Liquid; Drug Overdose; Humans; Male; Nortriptyline; Postmortem Changes; Salicylates; Suicide

Traditional medicine is practised to some degree in all cultures. Many different types of herbal preparations and "oils" are widely used in Malaysia, too. We report a case of acute salicylism due to accidental ingestion of one brand of such oils. Compulsory labelling of traditional drugs with their chemical ingredients is suggested for proper and timely management of such cases.

Topics: Blood Chemical Analysis; Drug Overdose; Epilepsy, Tonic-Clonic; Humans; Infant; Malaysia; Male; Medicine, Traditional; Metabolic Clearance Rate; Salicylates

Topics: Drug Overdose; Emergencies; Female; Humans; Middle Aged; Salicylates; Salicylic Acid; Treatment Refusal

The authors describe a therapeutically well managed case of severe salicylate intoxication in a patient with psoriasis who treated himself with 40 percent salicylic ointment applied to approximately 41 percent of his body surface. Nineteen hours after the application of salicylic acid, his blood level of the agent was 6.04 mmol/liter. The patient underwent hemodialysis and was discharged after fourteen days in good general health.

Topics: Administration, Cutaneous; Adult; Drug Overdose; Humans; Male; Medication Errors; Ointments; Psoriasis; Renal Dialysis; Salicylates

Acute salicylate poisoning with enteric-coated aspirin may result from accidental ingestion, a suicide attempt, or a complication of long-term therapy. Because absorption of enteric-coated aspirin is delayed, use of the Done nomogram to determine toxicity may lead to underestimating the severity of the poisoning. Treatment options include induction of emesis or diuresis, gastric lavage, administration of activated charcoal, and surgery.

Topics: Adolescent; Drug Overdose; Emergencies; Female; Humans; Salicylates; Tablets, Enteric-Coated; Time Factors

1. The metabolism of aspirin was investigated in 45 patients who had taken self-administered overdose of aspirin and were treated with fluids only, glycine, N-glycylglycine by mouth, or by sodium bicarbonate i.v. 2. The major metabolite recovered in the urine of patients treated with oral fluids, glycine or N-glycylglycine was salicyluric acid, which accounted for means of 51%, 47% and 38% of the total, respectively; salicylic acid comprised 19%, 29% and 29%. In contrast, salicylic acid (42%) was the major urinary metabolite recovered from patients treated with sodium bicarbonate. 3. Plasma glycine concentrations in healthy volunteers who had taken no aspirin remained constant through the day and were not affected by a therapeutic dose (500 mg) of aspirin. Plasma glycine was consistently lower in patients with aspirin overdose than in these healthy volunteers, suggesting depletion of available glycine. 4. Orally administered glycine and N-glycylglycine increased plasma glycine. While the fraction of total salicylate recovered as salicyluric acid was not altered, the maximum rate of excretion of salicyluric acid was higher in patients who received glycine than in the control group; there was no significant difference in the maximum rate of excretion of salicyluric acid between the group that received glycine and the group that received N-glycylglycine. 5. The data suggest that exogenous glycine increases the rate of formation of salicyluric acid in salicylate overdose.

Topics: Administration, Oral; Adult; Aged; Aspirin; Drug Overdose; Female; Glycine; Glycylglycine; Hippurates; Humans; Male; Middle Aged; Salicylates; Salicylic Acid

Data were collected on 176 consecutive cases of drug overdose evaluated in an emergency department. Quantitative serum toxic screening (TS) was performed for 164 (93%) of these patients; positive results were noted for 133 patients (81%). Six classes of drugs (ethanol, benzodiazepines, salicylates, acetaminophen, barbiturates, and tricyclic antidepressants) were responsible for nearly 70% of all drug detections and were associated with 80% of all admissions in this patient sample. Only two patients (1%) had drug-specific treatment initiated because of TS results. In 12 patients (7%), TS confirmed substances for which specific treatments had been initiated on clinical grounds. Four patients (2%) had drug-specific treatment discontinued because of TS results. Thirty-two patients (19%) were admitted to a medical service; however, only seven patients (4%) were admitted primarily because of TS results. All other patients were admitted because of clinical abnormalities that required inpatient care. It is concluded that only a few drugs are responsible for most drug overdoses. Moreover, TS results rarely change the treatment or disposition of overdose patients; these decisions are typically based on clinical parameters.

Topics: Acetaminophen; Alcoholic Intoxication; Antidepressive Agents, Tricyclic; Barbiturates; Blood Chemical Analysis; Diazepam; Drug Overdose; Emergencies; Humans; Retrospective Studies; Salicylates

During the period 1978-1986, annual sales of paracetamol in Denmark increased from 1 million defined daily doses (DDD) (3 g) to 47 million DDD, while the number of admissions and deaths from overdose increased from 26 to 202 and from 1 to 3-4, respectively. The corresponding figures for salicylates are a decrease in sales from 113 to 94 million DDD, an increase in admissions from 282 to 595, and an increase in deaths from 5 to 22. From 1 January 1984 paracetamol became available on an over-the-counter basis. The figures for 1983 and 1984 were an increase in sales from 14 to 28 million DDD, an increase in admissions from 114 to 198, and an increase in deaths from 0 to 4. The number of deaths from opioid overdose remained constant at a value of about fifty during this period, the mortality per dose being about 20-fold higher than for paracetamol and salicylates. Dextropropoxyphene-related deaths increased twofold to 121 in 1986, with unchanged sales figures. A campaign launched by the National Board of Health resulted in a reduction in the number of deaths from dextropropoxyphene to 66 in 1987. The main effect of over-the-counter release of paracetamol was a dramatic increase in sales, without the epidemic of deaths observed a decade ago in the UK. It is suggested that the higher mortality of paracetamol poisonings in the UK compared to Denmark is related to the dextropropoxyphene content of the combination product, which is not available in Denmark. From an epidemiological toxicological viewpoint such combinations are not justified.

Topics: Acetaminophen; Analgesics; Denmark; Dextropropoxyphene; Drug Overdose; Drug Utilization; Hospitalization; Humans; Narcotics; Nonprescription Drugs; Salicylates; Suicide

Topics: Autopsy; Drug Overdose; Female; Humans; Iatrogenic Disease; Infant; Salicylates; Salicylic Acid

The clinical features, plasma salicylate concentrations, acid-base abnormalities and other biochemical findings are presented for 97 patients who either died from acute salicylate overdosage or survived maximum recorded plasma salicylate concentrations of 700 mg/l or greater. These patients comprised 4 per cent of 2204 cases of salicylate poisoning admitted during the period 1975 to 1985 inclusive. Seven patients died (overall mortality 0.3 per cent); they were significantly older than the survivors, the mortality being as high as 33 per cent in patients over the age of 70 years. Delayed presentation, coma, hyperpyrexia, pulmonary oedema and acidaemia were more common in the fatal cases. Failure to hyperventilate appropriately may contribute to the development of acidaemia. The prognosis of acute salicylate poisoning cannot be determined from the plasma concentration of the drug alone. Clinical features, particularly impaired consciousness, and the arterial hydrogen ion concentration must be taken into consideration. Haemodialysis is the treatment of choice for severe salicylate intoxication and should be used more liberally than it is at present.

Topics: Adult; Aged; Aged, 80 and over; Drug Overdose; Female; Humans; Male; Middle Aged; Mortality; Prognosis; Renal Dialysis; Salicylates; Salicylic Acid

To evaluate the validity of the Done nomogram in the management of acute adult salicylate intoxications, a retrospective review of cases at our institution was performed. The degree of severity (ie, asymptomatic, mild, moderate, or severe) as determined by plotting the serum concentration and time on the nomogram for 55 acute salicylate intoxications was compared with the degree of severity decided on by three experienced emergency physicians who based their decision on the clinical presentation of the cases and the original criteria devised by Done for each category of severity. Discordant classifications between the nomogram and the physicians provided a basis on which a predictive index for the nomogram and various subsets of cases could be determined. The calculated predictive index for the nomogram was 0.42, with the highest predictive index of 0.79 in the mild salicylate category. The nomogram tends to overpredict the severity of intoxication in the moderate and severe categories. There was no significant difference between predictive indexes of mixed versus nonmixed or enteric-coated acetylsalicylic acid versus plain acetylsalicylic acid cases, although the nomogram had a higher predictive index when used for concentrations drawn six to 12 hours after ingestion (P less than .01, Fisher's exact test). Decisions on management of an acute salicylate overdose should be based on clinical presentation and good judgment as well as the serum salicylate concentration in relation to the time of ingestion.

Topics: Adult; Drug Overdose; Evaluation Studies as Topic; Humans; Male; Predictive Value of Tests; Retrospective Studies; Salicylates; Severity of Illness Index; Time Factors

Topics: Cardiovascular System; Drug Overdose; Humans; Salicylates

Topics: Aspirin; Child; Drug Overdose; Humans; Infant; Poisoning; Salicylates