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Ned Tijdschr Geneeskd 2018;162:D1574

St Antonius Ziekenhuis, afd. Klinische Farmacie, Nieuwegein.

- A new guideline: 'Intoxication: initial approach in the hospital' will be published this year. This guideline sets out the latest insights on gastrointestinal decontamination in intoxication; the advice is summarized in a flowchart.- The advice is to generally administer activated charcoal, unless there are indications that the toxin will not bind to activated charcoal or that the amount of toxin that the patient has ingested is too great; in these cases gastric lavage can be considered. Read More

Pediatr Emerg Care 2017 Jul 11. Epub 2017 Jul 11.

From the *Department of State Health Services, Austin, TX.

Objectives: There is concern that ingestion of superabsorbent polymer toys, which can absorb large amounts of fluid and increase greatly in volume, may pose a risk if swallowed by children.The intent of this study was to characterize pediatric Orbeez ingestions reported to a statewide poison center system.

Methods: Cases were Orbeez ingestions among patients 19 years or younger reported to Texas poison centers during January 2011 to June 2016. Read More

Clin Toxicol (Phila) 2018 Jan 26;56(1):69-73. Epub 2017 Jun 26.

c Department of Internal Medicine, Gastroenterology Unit , Ospedale dell'Angelo and Ospedale SS Giovanni e Paolo , Venice , Italy.

Background: Ingestion of elemental mercury (Hg0) is considered non-toxic. After massive ingestion, local intestinal complications may develop: retention within appendix is quite frequent but treatment is debated. We describe a case of intentional ingestion of Hg0 requiring multi-step decontamination and prophylactic appendectomy. Read More

Wilderness Environ Med 2017 Sep 17;28(3):246-248. Epub 2017 Jun 17.

Department of Emergency Medicine, Lehigh Valley Hospital/USF Morsani College of Medicine, Allentown, Pennsylvania. Electronic address:

For individuals who work outdoors in the winter or play winter sports, chemical hand warmers are becoming increasingly more commonplace because of their convenience and effectiveness. A 32-year-old woman with a history of chronic pain and bipolar disorder presented to the emergency department complaining of a "warm sensation" in her mouth and epigastrium after reportedly ingesting the partial contents of a chemical hand warmer packet containing between 5 and 8 g of elemental iron. She had been complaining of abdominal pain for approximately 1 month and was prescribed unknown antibiotics the previous day. Read More

J Med Toxicol 2016 12 13;12(4):391-395. Epub 2016 Jun 13.

Institute of Analytical Chemistry and Food Chemistry, Graz University of Technology, Graz, Austria.

Introduction: Whole bowel irrigation (WBI) is a management option for overdose of medications poorly adsorbed to activated charcoal, with modified release properties, or for body packers. Polyethylene glycol (PEG) is a mixture of ethylene oxide polymers of varying molecular weight. PEG with an average molecular weight of 3350 g/mol is used for WBI. Read More

Br J Clin Pharmacol 2016 Mar 30;81(3):453-61. Epub 2015 Oct 30.

Monash Health Clinical Toxicology and Addiction Medicine Service, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.

Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Read More

Pediatr Emerg Care 2015 Aug;31(8):605-7

From the Children's Mercy Hospital and Clinics, Kansas City, MO.

Foreign body ingestion is a common pediatric complaint. Two case reports describe intestinal obstruction in children from an ingestion of a single superabsorbent water ball, requiring surgical removal. We describe nonsurgical management of an asymptomatic child who ingested approximately 100 superabsorbent water beads. Read More

Turk J Med Sci 2015 ;45(2):404-8

Background/aim: Even though polyethylene glycol-electrolyte lavage (PEG-EL)-based regimes have become the gold standard in recent years, to finish drinking 4 L of PEG-EL solution can be difficult. The quality of sennoside-based bowel-cleansing regimes used in Turkey has been known for some time. Therefore, we aimed to investigate the efficacy of both bowel-cleansing regimes. Read More

Lakartidningen 2014 Sep 17-23;111(38):1576-7

A 20-year-old woman was found semiconscious on the floor in a pool of black diarrhea with an empty 100 jar of ferrous sulphate beside her (100 mg Fe2+/tablet), 160 mg/kg. She was brought to the hospital an estimated 4 hours after ingestion and presented with irritability and a fluctuating CNS depression. Her blood pressure was 190/85 mmHg and pulse 130 bpm. Read More

J Med Toxicol 2015 Sep;11(3):309-16

Department of Internal Medicine, Tulane University Medical Center, New Orleans, LA, USA,

Prisoners have a high prevalence of substance misuse and abuse, but few studies have examined symptomatic exposures among incarcerated populations. We sought to further characterize the nature of these exposures among this population using the California Poison Control System data. Keyword searches identified inmate cases in 2011-2013 for patients 20+ years old exposed to a single substance and taken to hospital from jail, prison, or police custody. Read More

Clin Toxicol (Phila) 2015 Jan 16;53(1):5-12. Epub 2014 Dec 16.

European Association of Poisons Centres and Clinical Toxicologists , Brussels , Belgium.

Context: A position paper on the use of whole bowel irrigation (WBI) was first published in 1997 by the American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) and updated in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data and recommendations.

Methods: A systematic review of the literature from January 2003 to February 28, 2013 was conducted using multiple online databases for articles concerning WBI for gastrointestinal decontamination. Read More

Toxicol Rep 2014 22;1:209-213. Epub 2014 May 22.

Residente de Toxicología Hospital Angeles Lomas, Vialidad de la Barranca No. 14, Colonia Valle de las Palmas, Huixquilucan, Estado de México CP 52787, Mexico.

Background: Reported cases of potassium overdoses have shown that this condition could generate several morbidities, mainly related to cardiac dysrhythmias even with fatal outcomes in some cases. Potassium salts in extended release tablets could form pharmacobezoars if a large amount is ingested. In relation to the above, when the patient has a pharmacobezoar, clinical findings may be delayed and may persist. Read More

J Emerg Med 2014 Mar 7;46(3):351-4. Epub 2013 Oct 7.

Department of Emergency Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia.

Background: Hyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence.

Objective: This case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose. Read More

Clin Toxicol (Phila) 2013 Nov 18;51(9):846-9. Epub 2013 Sep 18.

Department of Emergency Medicine, Iwate Medical University, School of Medicine , Morioka, Iwate , Japan.

Context: In acute glufosinate poisoning, sudden respiratory arrest and convulsion can occur after a latent period of 4-60 h. There is still no factor that accurately predicts the occurrence of these symptoms.

Objective: To elucidate the predictors of severe effects following acute glufosinate poisoning. Read More

Ann Coloproctol 2013 Aug 29;29(4):160-6. Epub 2013 Aug 29.

Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea.

Purpose: The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery.

Methods: A questionnaire was mailed to 129 colorectal specialists. Read More

Clin Toxicol (Phila) 2013 May 9;51(4):243-8. Epub 2013 Apr 9.

CHU Angers, Pôle Médecines Intensives et spécialisées, Centre antipoison et Toxicovigilance, Angers, France.

Objective: The objective of this study was to evaluate the effects of early digestive tract decontamination on the severity of acute-on-chronic lithium poisoning (acute poisoning in patients under long-term therapy).

Materials And Methods: This was an observational and retrospective study of acute-on-chronic lithium overdoses recorded by the Angers Poisons and Toxicovigilance Centre between February 2006 and September 2010. The cases of overdose were divided into two groups: those undergoing early decontamination (by sodium polystyrene sulphonate and/or whole bowel irrigation) and those in whom decontamination was delayed (> 12 h) or not performed. Read More

Clin Toxicol (Phila) 2013 Mar 13;51(3):134-9. Epub 2013 Feb 13.

European Association of Poison Centres and Clinical Toxicologists.

Context: An update of the first position paper on ipecac syrup from 1997 was published by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data.

Methods: A systematic review of the literature from the year 2003 forward. Read More

Clin Toxicol (Phila) 2012 Jun;50(5):414-7

University of California-San Diego, Toxicology, San Diego, CA 92103, USA.

Background: Traditionally whole bowel irrigation (WBI) has been advocated for ingestions involving substances not bound with activated charcoal as well as extended release and enteric coated medications. Other than isolated case reports, little exists in the literature regarding the use of WBI in poisoned pediatric patients. The purpose of this study is to better understand the use of WBI in pediatric patients. Read More

CJEM 2012 May;14(3):193-7

Departmens of Medicine, Dalhousie University, Halifax, NS.

Tricyclic antidepressant (TCA) overdose is a leading cause of death among intentional overdoses. Intravenous lipid emulsion therapy is an emerging antidote for local anesthetic toxicity, and there is animal evidence that lipid therapy may be efficacious in TCA overdose. Furthermore, case reports in humans have described the use of lipid therapy to reverse the toxicity of other lipophilic drugs. Read More

Gastroenterology 2012 Mar 7;142(3):490-6. Epub 2011 Dec 7.

Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland.

Background & Aims: Treatment of recurrent Clostridium difficile infection (CDI) with antibiotics leads to recurrences in up to 50% of patients. We investigated the efficacy of fecal transplantation in treatment of recurrent CDI.

Methods: We reviewed records from 70 patients with recurrent CDI who had undergone fecal transplantation. Read More

Emerg Med Australas 2011 Dec;23(6):769-72

New South Wales Poisons, The Children's Hospital at Westmead, New South Wales, Australia.

Potassium chloride poisoning can be potentially life-threatening, particularly in massive ingestions of sustained-release preparations. Profound hyperkalaemia, developing over several hours, can lead to cardiac arrhythmias and death. This case series reports three episodes of sustained-release potassium chloride poisoning in two individuals requiring whole bowel irrigation or haemodialysis. Read More

Int J Emerg Med 2011 Oct 12;4:65. Epub 2011 Oct 12.

Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, California, USA.

Objective: To define the role of gastrointestinal (GI) decontamination of the poisoned patient.

Data Sources: A computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources.

Study Selection And Data Extraction: Clinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient. Read More

Case Rep Med 2011 12;2011:495938. Epub 2011 May 12.

Department of Pharmacy Services, University Health System, 4502 Medical Drive, San Antonio, TX 78229, USA.

Purpose. Fentanyl is available as a transdermal system for the treatment of chronic pain in opioid-tolerant patients; however, it carries a black box warning due to both the potency of the product and the potential for abuse. In this report, we describe a case of transbuccal and gastrointestinal ingestion of fentanyl patches and the management of such ingestion. Read More

Br J Clin Pharmacol 2011 Jul;72(1):125-32

School of Pharmacy, University of Otago, Dunedin, New Zealand.

Aims: To investigate the relationship between decontamination procedures and seizure events caused by venlafaxine overdose and to estimate the time at which 90% of patients would have had their first seizure in the presence and absence of decontamination.

Methods: Data were collected from 319 patients who took an overdose of venlafaxine on 436 occasions. Seizures occurred on 24 of 436 occasions (5%). Read More

EXS 2010 ;100:397-460

New York City Poison Control Center, New York University School of Medicine, New York, USA.

The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life support--airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Read More

Can J Surg 2009 Oct;52(5):417-21

Department of Surgery, Charing Cross Hospital, Fulham Palace Road, London, UK.

Background: International smuggling of cocaine by internal concealment is a serious and growing problem. People who engage in this practice are commonly referred to as body packers or mules. The most serious risks associated with body packing include intestinal obstruction and death from cocaine intoxication. Read More

Clin Pharmacol Ther 2009 Oct 15;86(4):403-10. Epub 2009 Jul 15.

School of Pharmacy, University of Otago, Dunedin, New Zealand.

The aim of this work was to investigate the pharmacokinetics (PK) of venlafaxine in overdose and the effects of single-dose activated charcoal (SDAC) and whole-bowel irrigation (WBI), alone or in combination, as methods of decontamination. The data included 339 concentration-time points from 76 venlafaxine overdose events (median dose 2,625 (150-13,500 mg)); 69 were slow-release doses. SDAC, WBI, a combination of both, or no decontamination were administered to patients as decided by the treating clinician. Read More

Ther Umsch 2009 May;66(5):331-4

Schweizerisches Toxikologisches Informationszentrum, Zürich.

In acute poisoning the maintenance or reconstitution of vital functions is the first and most critical action. All subsequent therapies and the prognosis depend on the identification of the causative agent and on information about substance-specific toxicity. Despite incomplete evidence the concept of harm reduction by decreased absorption of the toxicants and by shortening the course of illness is consistent with toxicokinetic-dynamic principles and is therefore still used by clinical toxicologists. Read More

BMJ Case Rep 2009 8;2009. Epub 2009 May 8.

Pediatric Intensive Care Unit, Odense University Hospital, Odense, Denmark.

An 18-month-old previous healthy girl who had ingested 442 mg elemental iron/kg was admitted to a paediatric intensive care unit. The child was treated with gastric lavage, whole bowel irrigation and intravenous deferoxamine. After 2 h of standard therapy serum iron had risen threefold to 1362 µg/dl (244 µmol/l). Read More

Clin Toxicol (Phila) 2008 Dec;46(10):1102-3

J Med Toxicol 2008 Sep;4(3):170-2

Department of Emergency Medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA.

Background: Lithium toxicity is associated with electrocardiogram (ECG) changes, but changes suggestive of an ST segment elevation myocardial infarction have not been reported.

Case Report: A 46-year-old incarcerated man suffering from diabetes, hypertension, and schizoaffective/bipolar disorder was treated with lithium 1,200 mg twice daily. Two days prior to presentation the patient became confused, ataxic, and anorexic in jail. Read More

J Emerg Med 2010 Feb 9;38(2):171-4. Epub 2008 Jul 9.

The Toxikon Consortium at Cook County Hospital, Chicago, Illinois 60612, USA.

Sustained-release calcium channel blocker (CCB SR) overdoses are potentially life-threatening ingestions. These patients may not become hemodynamically unstable until many hours after ingestion. On theoretical grounds, some have suggested that whole bowel irrigation (WBI) with polyethylene glycol electrolyte lavage solution may be of value in the management of these cases. Read More

Clin Toxicol (Phila) 2008 Nov;46(9):919

Arch Dis Child 2008 Apr;93(4):321-2

Pediatric Intensive Care Unit, Afdeling V, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C., Denmark.

An 18-month-old previous healthy girl who had ingested 442 mg elemental iron/kg was admitted to a paediatric intensive care unit. The child was treated with gastric lavage, whole bowel irrigation and intravenous deferoxamine. After 2 h of standard therapy serum iron had risen threefold to 1362 microg/dl (244 micromol/l). Read More

Pediatr Emerg Care 2008 Mar;24(3):176-86; quiz 187-9

Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH 45429, USA.

Gastrointestinal decontamination has been a historically accepted modality in the emergency management of oral intoxicants. Theoretically, gastric and whole-bowel emptying procedures hinder absorption, remove toxic substances, prevent clinical deterioration, and hasten recovery. This article presents a current overview of gastrointestinal decontamination. Read More

Acute Med 2008 ;7(1):39-42

Imperial College Healthcare NHS Trust Department of Medicine Praed Street London W2 1NY Tel: 07941346678.

A 54 year gentleman was admitted to hospital within four hours of taking an overdose of modified release felodipine tablets, with a total dose of approximately 250 mg. The initial management comprised fluid resuscitation, calcium chloride and glucagon. He remained hypotensive and was commenced on hyperinsulinaemia-euglycaemic therapy. Read More

J Med Toxicol 2005 Dec;1(1):18-22

Departments of Clinical Toxicology, Prince of Wales Hospital and Westmead Hospital, Sydney, Australia.

Introduction: Effective whole bowel irrigation may be difficult in the presence of drug-induced ileus. Neostigmine, which inhibits the enzymatic degradation of acetylcholine, has been suggested to improve drug-induced ileus. We present two poisoning cases in which neostigmine was used to facilitate gut decontamination complicated by ileus. Read More

Chudoku Kenkyu 2007 Oct;20(4):358-60

Pediatr Emerg Care 2007 Nov;23(11):846

Clin Pharmacokinet 2007 ;46(11):897-939

South Asian Clinical Toxicology Research Collaboration, Medical School, Australian National University, Canberra, Australia.

Pharmacokinetic and pharmacodynamic principles should be regarded in the assessment and proper management of patients exposed to a poison. Clinicians must apply these principles to make rational clinical decisions regarding the significance of the poisoning (risk assessment) and to formulate an appropriate management plan. However, pharmacokinetic processes and parameters may be changed in the patient with acute poisoning. Read More

Pediatr Emerg Care 2007 Apr;23(4):234-7

Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA.

Bupropion, an atypical antidepressant commonly used for depression and smoking cessation, is well known to cause seizures in both therapeutic use and overdose, but cardiac effects have been reported as minimal, usually sinus tachycardia. We describe an ingestion of bupropion estimated to be greater than 2 g by a 3-year-old boy that resulted in seizures. The child was decontaminated with whole bowel irrigation (WBI), and he experienced aspiration of polyethylene glycol and electrolyte solution used for the WBI. Read More

Basic Clin Pharmacol Toxicol 2006 Nov;99(5):358-9

New York City Poison Control Center, Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.

Ingestion of strontium ferrite is previously unreported. We document absorption of strontium without acute toxicity. A 22 year-old schizophrenic man was brought to hospital after he was witnessed to pulverize and ingest flexible adhesive magnets, which later were identified as strontium ferrite. Read More

Clin Toxicol (Phila) 2006 ;44(4):379-82

Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland 97239, and Eugene Emergency Physicians at Sacred Heart Hospital, Eugene, Oregon, USA.

Background: Methamphetamine is an illicit stimulant that is typically smoked, insufflated, or injected. We report an unusual method of ingesting methamphetamine called "parachuting" and its implications for the treatment of "body stuffers."

Case Report: A 25-year-old man wrapped methamphetamine into a plastic baggie and ingested it in an attempt to "parachute. Read More

Pharmacotherapy 2006 Mar;26(3):403-9

College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73190, USA.

Percy Medicine is a nonprescription gastrointestinal suspension containing bismuth subsalicylate as the active ingredient (1050 mg/10-ml dose). A 3-month-old infant with colic developed salicylate toxicity requiring hospitalization in the pediatric intensive care unit (PICU) as a result of continued administration of this medicine. Bismuth subsalicylate has an aspirin equivalency conversion factor of 0. Read More

Clin Toxicol (Phila) 2006 ;44(1):77-80

Emergency Department, Guys and St. Thomas' NHS Trust, London, UK.

Background: Tricyclic antidepressant poisoning is often associated with significant cardiovascular and central nervous system toxicity. Effective treatment includes the use of appropriate gastric decontamination techniques, the administration of sodium bicarbonate, and meticulous supportive care. Tricylcic antidepressant toxicity typically lasts 24-48 hours following a significant overdose. Read More

Ned Tijdschr Geneeskd 2005 Dec;149(53):2964-8

Nationaal Vergiftigingen Informatie Centrum van het Rijksinstituut voor Volksgezondheid en Milieu en het Universitair Medisch Centrum Utrecht (UMCU), Postbus 1, 3720 BA Bilthoven.

New guidelines on gastrointestinal decontamination in overdose situations have been published. In cases of serious and potentially life-threatening intoxication, gastric lavage can be performed up to 1 hour after ingestion. It should not be considered as routine treatment. Read More

J Pediatr (Rio J) 2005 Nov;81(5 Suppl):S212-22

Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP.

Objective: To review the literature on acute toxic exposure in children, excluding envenomations.

Sources Of Data: MEDLINE review (emphasis on the past decade), including the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists position statements and position papers (peer-reviewed information based on scientific evidence and broad consensus) on gastrointestinal decontamination, multiple-dose activated charcoal and urine alkalinization.

Summary Of The Findings: Acute toxic exposure in children is a common event, mainly in children under six years of age. Read More