Suspected stonefish envenomation in Queensland over eight years: a retrospective series.

INTRODUCTION: Stonefish envenomation results in localized severe pain and swelling and systemic features, including vomiting, arrhythmia, pulmonary oedema, and possibly death. There are limited data regarding the effectiveness of the available antivenom. The aim of this series is to characterize presentations of patients with suspected stonefish envenomation and investigate treatment, including antivenom. METHODS: This is a retrospective observational series of suspected stonefish envenomation as reported to the Queensland Poisons Information Centre or Princess Alexandra Hospital Clinical Toxicology Unit from July 2015 to January 2023. Patients were identified through the databases held by both the Centre and Unit, and data on clinical features and investigations were collected from the patient's electronic medical record. RESULTS: There were 87 suspected stonefish envenomations from July 2015 to January 2023. The median age was 26 (range: 5-69) years, and 69 (79 per cent) patients were male. Pain was reported in 85 (98 per cent) with a median peak pain score of 10 (range 4-12; three rated their pain greater than 10/10). A clear wound was documented in 64 (74 per cent), with local swelling in 63 (72 per cent). A foreign body was retained in eight (9 per cent) presentations. Systemic symptoms were rare, with vomiting in four (5 per cent) and dizziness in two (2 per cent) presentations. There were no instances of hypotension, arrhythmia, or pulmonary oedema. Hot water was administered in 72 (83 per cent) presentations. Oral analgesia was given in 55 (63 per cent). Parenteral analgesia was given in 53 (61 per cent), most commonly opioids. Local anaesthetic block was performed in 19 presentations (22 per cent), with effectiveness documented in 16/19 (84 per cent). Five patients received antivenom for intractable pain, and all received subsequent parenteral analgesia or local anaesthetic block. CONCLUSIONS: Stonefish envenomation is characterized by severe pain. Systemic symptoms were rare and not severe in this series. Local anaesthetic block appeared to be the most effective intervention for severe pain when performed. Antivenom appeared to be ineffective in managing pain.

Common calls to a poisons information centre by general practitioners.

BACKGROUND: Poisoning in the community is common and can occasionally result in serious outcomes, such as organ damage and death. Many cases of poisoning can be successfully managed in the primary care setting. OBJECTIVE: This article describes common calls the Queensland Poisons Information Centre (Qld PIC) receives from general practices and provides information on the management of poisoning in the community. DISCUSSION: Common calls to the Qld PIC from general practice include calls about exposure to paracetamol and household cleaning products, with ocular exposure to toxins common. Most cases of poisoning can be managed supportively. Decontamination, observation or antidote therapy may be required in some cases. Ocular exposure to poisons requires irrigation, examination and, occasionally, referral for specialist ophthalmological assessment. The PIC can help general practitioners (GPs) with risk assessment and management advice to ensure the best outcomes for their patients. GPs can contact the PIC on 13 11 26.

Plant poisonings in Australia: a retrospective series of calls to the Queensland Poisons Information Centre.

INTRODUCTION: There is little research to characterise plant poisoning in Australia. The aim of this project is to investigate plant exposures reported to a state poisons information centre. METHODS: This is a retrospective review of plant exposures reported to the Queensland Poison Information Centre (QPIC) between January 2019 and December 2021. Main outcome measures included patient demographics, plant exposure details, symptomatology, and management advice. RESULTS: QPIC received calls regarding 2766 plant exposures over the study period. Children aged 1-4 years were the commonest group exposed, accounting for 1295 (46.8%) exposures. The caller was usually a family member/caregiver (2036 [73.6%]) calling from home (2257 [81.6%]). Exposures were unintentional in 2722 (98.4%) cases, with the oral route being most common, occurring in 2264 (81.9%) cases.Plant groups most responsible for exposures included gastrointestinal irritants (536 [19.4%]), oxalates (522 [18.9%]), and non-toxic plants (442 [16.0%]). The plant involved was known in 2366 (85.5%) exposures, most commonly Euphorbiaceae (257 [9.3%]). Patients were asymptomatic (1644 [59.4%]) or had mild toxicity (1033 [37.3%]) in most exposures. Only 18 (0.6%) cases had moderate/severe toxicity, and this was most often due to recreational exposures by adults (9[0.3%]). Referral for medical review was advised in 407 (14.7%) cases, most commonly following exposures to Euphorbiaceae (140/407 [34.4%]), gastrointestinal irritants (52/407 [12.7%]), and oxalates (38/407 [9.3%]). CONCLUSIONS: The majority of plant exposures reported to QPIC are unintentional paediatric exposures. Most are asymptomatic or have mild toxicity. More severe toxicity is seen in adults with recreational plant exposures.

Unintentional paediatric iron poisoning: A retrospective case series.

OBJECTIVE: Iron poisoning is a historically important cause of paediatric morbidity and mortality. In recent decades, public health measures have considerably reduced paediatric iron exposures. We investigated unintentional paediatric iron poisoning in children with the aim of developing an assessment approach specific for this group. METHODS: This was a retrospective observational study of unintentional iron poisoning in children (<7 years old) referred to either a state-wide poisons information service or a tertiary clinical toxicology unit from 1 January 2015 to 16 February 2020. Patients were identified from prospective databases maintained by both services, and data were extracted from these in addition to the medical record. RESULTS: There were 54 children included in the study (29 [54%] male; median age 2 years (range 8 months to 4 years). The median suspected dose of elemental iron ingested was 72 mg/kg (IQR 41-140 mg/kg). Seventeen (31%) children were symptomatic. There were no cases of severe toxicity. Children symptomatic with gastrointestinal toxicity had a median suspected dose ingested of 60 mg/kg (IQR 38-150 mg/kg) that was similar to asymptomatic children (81 mg/kg [IQR 41-143 mg/kg], P = 0.809). The median peak iron concentration was 49 µmol/L (IQR 13.5-67.5 µmol/L, range 4-75 µmol/L). Symptomatic children had a significantly higher median peak serum iron concentration of 66 µmol/L (IQR 54-68 µmol/L) compared to 12 µmol/L (IQR 9-15 µmol/L) in asymptomatic children (P < 0.001). CONCLUSION: Unintentional paediatric iron poisoning is uncommon and largely benign. Suspected dose ingested is a poor predictor of toxicity. Targeting investigations and interventions to symptomatic children should reduce unnecessary assessment and management while still safely managing the exposure.

Documentation in the patient medical record was associated with improved adherence to Poisons Information Centres telephone advice.

Context: There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the management of poisoned patients. This study aimed to determine if contemporaneous documentation in the patient electronic medical record (EMR) improved adherence to Poisons Information Centre (PIC) advice.Methods: This was a prospective before and after observational study following the implementation of documented poisoning management advice by PIC staff into the patient's EMR. Advice adherence was assessed following a review of the patient medical records and designated to complete adherence, minor discrepancies not affecting patient care, major discrepancies affecting patient care and non-adherence. The primary outcome was the proportion of satisfactory (complete adherence/minor discrepancies) adherence. Secondary outcomes included the accuracy of documented telephone advice by the treating clinician, the number of case recalls and episodes of sub-optimal management.Results: A total of 980 cases (347 in the pre-intervention phase and 633 in the post-intervention phase) were included in the study, of which 350 had PIC EMR documentation performed. Documented call advice by the treating clinician was absent in 41 of 347 cases (11.8%) cases and inaccurate in 42 of 306 cases (13.7%). Following PIC documentation, satisfactory adherence improved from 304/347(87.6%) to 333/350(95.1%)(difference 7.5% [95% CI 3.1% to 11.9%]), with suboptimal management decreasing from 48/347(13.8%) to 14/350(4%)(difference - 9.8% [95% CI -5.5% to -14.4%]). Recalls were similar in both periods. The median time to enter advice into the EMR was 26 min (IQR: 14-45 min). The main reason for not documenting advice was that the PIC staff member was working a solo shift with a prohibitively heavy workload.Discussion: EMRs enable PICs to supplement verbal advice with written documentation, offering an opportunity to improve communication and enable better handover of clinical information.Conclusion: Documentation of advice by PIC staff in the patient medical record was associated with improved advice adherence and reduced sub-optimal management.

Health care cost savings from Australian Poisons Information Centre advice for low risk exposure calls: SNAPSHOT 2.

Introduction: To estimate cost savings from the Australian Poisons Information Centres (PIC) through reductions in unnecessary health resources following unintentional low toxicity poisonings.Methods: Two telephone surveys were conducted. The first to PIC callers over a one-week period about unintentional exposures where the callers' alternate course of action in the hypothetical situation in which the PIC did not exist was questioned. The second survey to determine the proportion of callers followed PIC advice. We estimated cost savings associated with instances where individuals acted on advice not to present to hospital, when they indicated they would have otherwise as well as savings from preventing unnecessarily utilisation of medical resources. Database records of unintentional poisonings from all Australian PICs for 2017 were used.Results: A total of 958 consecutive callers were surveyed. PIC advised 91% of callers to stay at home, remaining callers were referred to hospital (5%), to their GP (3%) or given other recommended management advice (1%). PIC advice was followed by 97.6% of callers. In PIC absence, 22% of callers who were advised to stay home would have presented to hospital (3% via ambulance), 8% would visit their General Practitioner (GP) and only 9% would stay at home. In 2017, PICs were called about 94,913 unintentional poisonings; and PICs generated at least $10.1 million in annual savings.Conclusion: In 2017, PICs provided at least a three-fold return on investment for every dollar invested, demonstrating that PICs are a highly cost effective service.

Button battery exposures in Australian children: a prospective observational study highlighting the role of poisons information centres.

CONTEXT: Button battery ingestion is a worldwide problem, with evidence of increasing harms and deaths in recent decades. Australian Poisons Information Centre (PIC) experience includes cases of treatment delay due to lack of healthcare professional recognition of risks, and/or lack of local resources. This study aims to characterise Australian button battery exposures, focusing on exposure circumstances, and preventable health system shortcomings. METHODS: A prospective observational study of button battery exposure calls to New South Wales PIC, November 2015-May 2017, using a follow-up survey to obtain outcome data and additional details. Survey data was combined with nationwide PIC data over the same period. RESULTS: Australian PICs were consulted on 578 exposures over the 19-month study period, including 506 paediatric cases. The median (IQR) age for the paediatric cases was 23 months (14-36 months). Where the source was identified, batteries came from toys in 26% of cases, with hearing aids, watches, and remote controls being other common sources. Children in outer regional, remote and very remote areas were overrepresented, and 15 cases were referred to a different hospital due to X-ray facilities being unavailable at their nearest hospital. We identified inconsistent triage from a range of first responders, and knowledge gaps regarding button battery dangers amongst some healthcare professionals. DISCUSSION: Button battery exposures are a common call to Australian PICs. This study highlights a potential role of education campaigns, professional guidelines, and child-resistant battery compartments in toys and household devices. PICs calling ahead to ensure X-ray availability/diversion to a different hospital likely reduced delays for this time-critical exposure. CONCLUSIONS: Button battery exposures continue to be a problem in Australia. Data collected by PICs can provide useful information for public health and product safety initiatives. A PIC-led protocol to direct initial medical management of button battery exposures could reduce delays and improve outcomes.

Patterns of poisoning exposure at different ages: the 2015 annual report of the Australian Poisons Information Centres.

OBJECTIVES: To characterise the types of calls received by Australian Poisons Information Centres (PICs) in Australia, and to analyse poisoning exposures by age group, circumstances of exposure, and the types of substances involved. Design, setting: Retrospective analysis of call records from all four Australian PICs (national coverage). MAIN OUTCOME MEASURES: Basic demographic information; exposure circumstances, substance types involved in each age group; recommendations for management (eg, stay at home, go to hospital). RESULTS: There were 204 906 calls to Australian PICs in 2015, 69.0% from the general public, 27.9% from health professionals; 16.2% of calls originated from hospitals. 170 469 calls (including re-calls about an exposure) related to 164 363 poison exposure events; 64.4% were unintentional, 18.1% were the consequences of medication error, and 10.7% involved deliberate self-poisoning. Most exposures were of 20-74-year-old adults (40.1%) or 1-4-year-old toddlers (36.0%). The PICs advised callers to stay at home for 67.4% of exposures, and to present to hospital for 10.9%. The most common substances involved in exposures overall were household cleaners (10.2%) and paracetamol-containing analgesics (7.3%). Exposures of infants and toddlers were most frequently to household cleaning substances (17.8%, 15.3% respectively) and personal care items (6.6%, 7.3%); callers were usually advised to stay at home (88.5%, 86.4%). Deliberate self-poisoning (49.1%) and hospital referral (23.9%) were most frequent for adolescents. Exposures of adults (20-74 years) frequently involved psychotropic pharmaceuticals (17.8%) or painkillers (15.1%). Exposures in adults over 74 were typically medication errors involving cardiovascular (23.6%), anticoagulant (4.6%), or antidiabetic (4.1%) medications. CONCLUSIONS: Poisoning is a significant public health problem throughout life, but the nature of the hazards differs markedly between age groups. PIC data could inform strategic public health interventions that target age-specific poisoning hazards.

Unintentional insecticide poisoning by age: an analysis of Queensland Poisons Information Centre calls.

OBJECTIVE: Data from the Queensland Poisons Information Centre (QPIC) was assessed to determine mechanisms of acute insecticide poisoning in young children (<5 years) and whether age affects insecticide-poisoning patterns. METHODS: Records of all insecticide-related calls placed to QPIC in 2014 were obtained. A stratified analysis of call patterns by age was conducted. RESULTS: Of 743 insecticide-related calls received by QPIC 364 (49.0%) were for young children. The number of calls peaked in children aged one. Ant and cockroach baits accounted for 39.0% of calls. Sprays, which were found to contain not only pyrethroids, pyrethrins and/or piperonly butoxide but also the organophosphate diazinon, accounted for 25.8% of calls. Mouthing or ingesting a pest-control product and consuming an item/insect after treatment were common mechanisms for children under the age of two. Topical exposure to sprays, via direct application, typically by the child or an older sibling, peaked in children aged two. In 12.3% of calls medical attention for the child was already sought or advised by QPIC. CONCLUSION: Normal behaviours associated with child development, particularly mouthing behaviours, explained the peak of exposure in one-year-olds. This finding should guide strategies to minimise poisonings in this vulnerable population.

A decade of Australian methotrexate dosing errors.

OBJECTIVE: Accidental daily dosing of methotrexate can result in life-threatening toxicity. We investigated methotrexate dosing errors reported to the National Coronial Information System (NCIS), the Therapeutic Goods Administration Database of Adverse Event Notifications (TGA DAEN) and Australian Poisons Information Centres (PICs). DESIGN AND SETTING: A retrospective review of coronial cases in the NCIS (2000-2014), and of reports to the TGA DAEN (2004-2014) and Australian PICs (2004-2015). Cases were included if dosing errors were accidental, with evidence of daily dosing on at least 3 consecutive days. MAIN OUTCOME MEASURES: Events per year, dose, consecutive days of methotrexate administration, reasons for the error, clinical features. RESULTS: Twenty-two deaths linked with methotrexate were identified in the NCIS, including seven cases in which erroneous daily dosing was documented. Methotrexate medication error was listed in ten cases in the DAEN, including two deaths. Australian PIC databases contained 92 cases, with a worrying increase seen during 2014-2015. Reasons for the errors included patient misunderstanding and incorrect packaging of dosette packs by pharmacists. The recorded clinical effects of daily dosage were consistent with those previously reported for methotrexate toxicity. CONCLUSION: Dosing errors with methotrexate can be lethal and continue to occur despite a number of safety initiatives in the past decade. Further strategies to reduce these preventable harms need to be implemented and evaluated. Recent suggestions include further changes in packet size, mandatory weekly dosing labelling on packaging, improving education, and including alerts in prescribing and dispensing software.