[Research progress in emergency assessment of acute poisoning].

Acute poisoning represents a prevalent critical illness jeopardizing patient survival. Early, precise assessment of the condition and subsequent appropriate therapeutic intervention are pivotal in enhancing treatment success rates. Currently, a standardized approach to evaluating the severity of acute poisoning is lacking. Various scoring systems, including Poisoning Severity Score (PSS) , Modified Early Warning Score (MEWS) , and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) , offer valuable insights into acute poisoning assessment. Nevertheless, the distinct attributes of each scoring system constrain their broad clinical utility. Confronted with the intricate clinical demands of acute poisoning, the adoption of staged and dynamic assessment strategies is imperative to ascertain the condition of acute poisoning patients with greater accuracy.

Demographics and Clinical Characteristics Assessment of Severe Acute Toxic Ingestions in Pediatric Patients: A Single-Center Study in Jilin Province of China.

OBJECTIVE: This study aimed to describe the demographic and clinical characteristics of severe acute toxic ingestions in children in Jilin Province and provide a reference for seeking effective measures to prevent poisoning accidents. METHODS: The clinical data of patients diagnosed with acute toxic ingestions and who presented with severe life-threatening symptoms or organ dysfunction at the Pediatric Intensive Care Unit of the First Hospital of Jilin University were retrospectively analyzed. Patients with incomplete clinical medical records, unclear toxic substance, and loss to follow-up within 6 months of discharge are excluded. We sorted out these children's demographic characteristics, types of poisoning, clinical manifestations, treatment process, and follow-up, etc. RESULTS: This study enrolled 141 cases with no significant differences in sex and region; adolescents accounted for 44.68%. The most common poisons were pesticides and insecticides for rural areas and internal medication for urban areas. With poisoning details as a grouping variable, there was no statistical difference between sex groupings (χ2 = 6.018, P = 0.198) and no difference between region groups (χ2 = 3.775, P = 0.289). However, there were statistical differences between age groups (χ2 = 28.22, P = 0.001). In this research, patients younger than 6 years are mainly unintentionally poisoned, whereas the suicide rate of the urban group (P < 0.05), adolescents (P < 0.01), and girls (P < 0.01) has increased significantly; moreover, the suicide group is more likely to take more overdose medication or pesticides and insecticides (P < 0.01). In addition, there was a statistical difference between suicide and length of intensive care unit stay (r = 0.268, P < 0.01). A total of 90.78% of the patients were successfully discharged after comprehensive treatment. Children aged younger than 12 years had good psychological and intellectual development during the follow-up period, whereas adolescents diagnosed with depression often required long-term psychological and medication intervention. CONCLUSIONS: This study identified poisoning details in different ages, regions, and sex of acute severe oral poisoning in children from Jilin Province. The results presentation of different prevention priorities should vary among children of different ages and emphasize adolescent suicide being a reality in Jilin Province. There is an urgent need for further culture-specific research in this area.

Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis.

BACKGROUND: Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. METHODS: Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. RESULTS: We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5). INTERPRETATION: Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.

Incidence of intoxication events and patient outcomes in Taiwan: A nationwide population-based observational study.

BACKGROUND: Intoxicated patients were frequently managed in the emergency departments (ED) with few studies at national level. The study aimed to reveal the incidence, outcomes of intoxications and trend in Taiwan. METHODS: Adults admitted to an ED due to an intoxication event between 2006 and 2013 were identified using the Taiwan National Health Insurance Research Database. The rate of intoxication and severe intoxication events, mortality rate, hospital length of stay (LOS), and daily medical costs of these patients were analyzed. Changes over time were analyzed using Joinpoint models. Multivariable generalized regressions with GEE were used to assess the effect of sex, age, and presence of prior psychiatric illness. RESULTS: A total of 20,371 ED admissions due to intoxication events were identified during the study period, and the incidence decreased with annual percentage change of 4.7% from 2006 to 2013. The mortality rate, hospital LOS, and daily medical costs were not decreased over time. Males and geriatric patients had more severe intoxication events, greater mortality rates, and greater daily medical costs. Patients with psychiatric illnesses had higher mortality rates and a longer hospital LOS, but lower daily medical expenses. CONCLUSION: From 2006 to 2013, there was a decline in the incidence of ED admission for intoxication events in Taiwan. Males, geriatric patients, and those with psychiatric illnesses had greater risks for severe intoxication and mortality.

Hospital-treated deliberate self-poisoning in the older adult: Identifying specific clinical assessment needs.

BACKGROUND: Hospital-treated deliberate self-poisoning is common, with a median patient age of around 33 years. Clinicians are less familiar with assessing older adults with self-poisoning and little is known about their specific clinical requirements. OBJECTIVE: To identify clinically important factors in the older-age population by comparing older adults (65+ years) with middle-aged adults (45-64 years) during an index episode of hospital-treated deliberate self-poisoning. METHODS: A prospective, longitudinal, cohort study of people presenting to a regional referral centre for deliberate self-poisoning (Calvary Mater Newcastle, Australia) over a 10-year period (2003-2013). We compared older-aged adults with middle-aged adults on demographic, toxicological and psychiatric variables and modelled independent predictors of referral for psychiatric hospitalisation on discharge with logistic regression. RESULTS: There were (n = 157) older-aged and (n = 925) middle-aged adults. The older-aged group was similar to the middle-aged group in several ways: proportion living alone, reporting suicidal ideation/planning, prescribed antidepressant and antipsychotic drugs, and with a psychiatric diagnosis. However, the older-aged group were also different in several ways: greater proportion with cognitive impairment, higher medical morbidity, longer length of stay, and greater prescription and ingestion of benzodiazepines in the deliberate self-poisoning event. Older age was not a predictor of referral for psychiatric hospitalisation in the multivariate model. CONCLUSION: Older-aged patients treated for deliberate self-poisoning have a range of clinical needs including ones that are both similar to and different from middle-aged patients. Individual clinical assessment to identify these needs should be followed by targeted interventions, including reduced exposure to benzodiazepines.

The Global Educational Toxicology Toolkit (GETKIT): A 1-Day Course for Teaching Poisoning Essentials in Low- and Middle-Income Countries (LMIC): Course Development and Pilot Data Analysis.

INTRODUCTION: Worldwide an estimated one million deaths occur annually as a result of poisoning. Internationally there is a lack of toxicology training programs, especially in resource poor settings. We developed a one-day, interactive toxicology curriculum for healthcare practitioners in countries lacking clinical toxicology training and evaluated its feasibility and effectiveness for knowledge dissemination. METHODS: GETKIT was developed with 3 sections: didactics, hands on toxicology case lab, and technology clinic. The investigators, who are medical toxicologists,created 23 didactic lectures and 42 workshop cases. All materials were peer reviewed by 5 senior medical toxicologists for content validity. Participants atpilot sites were given pre-course, post-course, and 3-month follow-up tests and surveys. RESULTS: GETKIT was delivered internationally at 7 sites between November 2017 and April 2018. There were 186 total participants. One hundred and ten participants (59%) reported their hospital lacked a clinical toxicology service. The median post course score 12 (60%), IQR (6,14) was significantly higher compared to the pre-course score 9 (45%), IQR (6,11) (p < 0.0001). There was a significantly higher median 3-month post course score 13 (65%), IQR (8,14) vs. a median pre course score of 9 (45%), IQR (6,11) (p 0.0005). At 3-month follow up 86% of participants reported GETKIT had changed their clinical practice. CONCLUSIONS: An improvement in and retention of medical toxicology knowledge was demonstrated with the GETKIT course. It also conferred improvement in selfreportedpoisoning management practices in participants from low resource settings.

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.

[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. / Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial.

OBJECTIVE: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS: The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.

Adults with acute poisoning admitted to a university hospital in Belgium in 2017: cost analysis benchmarked with national data.

Objective: Aims were to (1) analyse the direct cost charged by a university hospital to the government and the patient in case of an admission for acute poisoning, (2) identify the factors associated with the cost, and (3) compare the cost in the hospital studied with national data from the government.Methods: Patient records and invoices of all poisoning-related episodes of patients 14 years or older admitted to the Emergency Department (ED) of Ghent University Hospital (GUH) in 2017 were analysed. A generalised linear model with gamma loglink was applied to assess the variables associated with the cost. Our GUH data collected in 2017 were compared with national data 2016 for all Belgian hospitals on the one hand, and for the subgroup of GUH 2016 data on the other hand. To do this, we used data provided by the Technical Unit of the Federal Public Service Health, containing All Patient Refined Diagnosis Related Groups 812 (poisoning by medicinal agents) and 816 (toxic effects by non-medicinal substances).Results: The total direct cost for the treatment of 1,175 poisoned patients amounted to $1,830,870. Median direct cost per patient was $512 per episode, with $199 for ambulatory patients, $1,575 for patients admitted to the ED-observation-unit, $3,398 for hospitalised patients and $4,859 for patients treated in the intensive care unit. Factors associated with the cost were gender, degree of severity, type of hospitalisation, intentionality, and involvement of ethanol, paracetamol, antidepressants or amphetamines. Median hospitalisation cost per admission in GUH for medicinal agents was 70.5% higher than the cost reported in national hospitalisation data. Median cost per admission in case of non-medicinal agents was 54.5% higher than the national median 2016.Conclusion: The type of hospitalisation has a high impact on the cost, a.o. primarily due to the length of hospital stay, with accommodation accounting for a large proportion of the costs. It is important to benchmark individual hospital data with (inter)national data to evaluate its own cost management in the context of continuous improvement.

Study of Caregivers Regarding Pediatric Poisoning.

The overall objective was to characterize action by caregivers when a potential poison exposure occurs and identify barriers to poison control center (PCC) utilization. A prospective survey of caregivers of pediatric patients who presented to an emergency department for a potential poison exposure was completed by each study participant. A total of 371 surveys were completed between August 2016 and August 2017. The majority of patients were 3 years or younger. Caucasians were more likely to have heard of the PCC, had the toll-free number available, and had previously called compared with other races and ethnicities. Caregivers with some government insurance were more likely to think that PCCs report child poisoning calls to authorities. Education efforts of nationwide PCCs focus on awareness of the PCC as well as poison prevention strategies. Understanding barriers to utilization of PCC and populations who are more likely to underutilize the PCC can help direct education efforts.

Burden of poisoning on a critical care unit in southern India.

Background: Poisoning inflicts a considerable economic cost on the health sector. Few cases of poisoning may require intensive management in a critical care unit and thus add to the financial burden. In this study, our primary objective was to analyse the financial burden of poisoning on critical care facilities and the secondary objective was to analyse the critical care needs and treatment outcomes of patients with poisoning. Methods: We did this retrospective study of patients admitted with poisoning in the critical care unit of Government Medical College Hospital, Thiruvananthapuram, Kerala (12- bedded critical care unit of 2500-bedded medical college hospital) from January 2011 to December 2013. Patients <13 years of age were excluded. Cost was estimated using the hospital expenditure data. Results: A total of 118 patients, comprising 2.5% of the total critical care unit admissions, were included in the study. The average cost of providing critical care for cases of poisoning was ₹367 333 per annum. Organophosphorus poison was the most common agent (33.9%) with the highest cost per admission of approximately ₹1 8 500. The highest number of deaths was due to phosphide poisoning with a case fatality rate of 83%. Conclusions: Poisoning imposes a considerable burden on the limited critical care services. Organophosphorus was the most common substance consumed for poisoning and it led to the highest expenditure per admission.

Inpatient toxicology services improve resource utilization for intoxicated patients: a systematic review.

AIMS: Presentations of intoxicated patients to hospital are frequent and increasing. We aimed to review the existing evidence that the presence of inpatient clinical toxicology services reduces use of resources without impacting on the care of these patients. METHODS: We conducted a literature search using the Cochrane Library, PubMed, and Embase for articles that measured length of stay (and other outcomes) for the target population, with toxicology services as an intervention. The articles were reviewed with respect to the ROBINS-I tool. RESULTS: Seven relevant articles were identified. Six of these studies demonstrated reduced hospital length of stay for intoxicated patients in hospitals with inpatient toxicology services. None of the articles demonstrated a detriment in morbidity or mortality. There were also improvements in other resource-related outcomes. CONCLUSIONS: The presence of inpatient toxicology services appears to improve resource utilization, in reduction of length of stay, as well as a number of other related outcomes. It does this without compromising on patient morbidity or mortality. Thus, it should be considered as a potential model of care for future toxicology services, especially with current trends of increasing demand for service efficiency.

Efficient diagnosis and treatment of acute paracetamol poisoning: cost-effectiveness analysis of approaches based on a hospital toxicovigilance program. / Eficiencia en el diagnóstico y tratamiento de la intoxicación aguda por paracetamol: análisis de costeefectividad a través de un programa de toxicovigilancia activa hospitalario.

OBJECTIVES: To evaluate 5 diagnostic-therapeutic strategies for suspected acute paracetamol poisoning in terms of cost-effectiveness in a tertiary university hospital with an active, validated poisoning surveillance program (SAT-HULP). MATERIAL AND METHODS: Cost-effectiveness analysis of the 5 diagnostic-therapeutic alternatives considered when attending patients with suspected paracetamol poisoning. The alternatives were chosen by means of a decision tree. We studied patients detected by the SAT-HULP program between April 1, 2011, and January 31, 2015. The diagnostic-therapeutic alternatives were as follows: 1) systematic treatment of all patients with N-acetylcysteine (NAC), 2) NAC treatment according to the reported dose; 3) NAC treatment according to a Rümack-Matthew nomogram; 4) NAC treatment according to urine test results confirmed by a blood test, and 5) treatment according to elimination half-life calculation. Probability data were obtained from the SAT-HULP program and validation studies corresponding to the diagnostic tests. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The approaches that were most cost-effective were those guided by reported doses and nomograms. The incremental cost-effectiveness of treatment according to reported dose was €5985.37. The sensitivity analysis showed that the model was highly dependent on variations in the main variables; the probabilistic sensitivity analysis indicated an incremental cost-effectiveness of €25 111.06 (SD, €1 534 420.16; range, €42 136.03-€92 358.75) between the first approach (treat all cases) and last (calculate elimination half-life); half-life calculation was the more efficient. CONCLUSION: Treating according to nomogram was the most efficient diagnostic-therapeutic approach to treating paracetamol poisoning in our hospital. However, when the prevalence of paracetamol poisoning is higher and uncertainty is greater, it would be more efficient to treat based on calculating the half-life.

OBJETIVO: Evaluar la eficiencia de cinco estrategias diagnóstico-terapéuticas posibles ante la sospecha de intoxicación aguda (IA) por paracetamol (PCT) a través de un análisis coste-efectividad, según la perspectiva del financiador en un hospital universitario terciario dotado de un programa de toxicovigilancia activa validado (SAT-HULP). METODO: Estudio de análisis de coste-efectividad (ACE) de cinco alternativas diagnóstico-terapéuticas consideradas en el abordaje de los pacientes atendidos en el servicio de urgencias hospitalario (SUH) con intoxicación por PCT mediante un modelo de árbol de decisión. La población estudiada fueron los pacientes atendidos en un SUH detectados por el SAT-HULP, entre el 1/04/2011 y el 31/01/2015. Las alternativas diagnóstico-terapéuticas consideradas fueron: 1) administración sistemática de Nacetilcisteína; 2) administración del tratamiento según la dosis confirmada; 3) tratamiento según el nomograma de Rümack- Matthew; 4) tratamiento según test de orina confirmado con posterior test en sangre; y 5) tratamiento según el cálculo de la semivida. Los datos correspondientes a probabilidades fueron obtenidos del programa SAT-HULP y publicaciones sobre la validación de las pruebas diagnósticas. Se realizaron análisis de sensibilidad determinístico y probabilístico. RESULTADOS: Las opciones "Tratar según dosis comunicada" y "Tratar según el nomograma" son las que muestran mejor coste-efectividad. Al compararlas, la razón coste-efectividad incremental es de 5.985,37 € para la primera. El análisis de sensibilidad mostró una importante dependencia del modelo a la variación de las variables principales. En el análisis de sensibilidad probabilístico la estrategia "Tratar a todos los casos" respecto a "Cálculo de semivida" obtuvo una razón coste-efectividad incremental de unos 25.111,06 € (DE: 1.534.420,16; intervalo: ­42.136,03 a 92.358,75), resultando esta última la más eficiente. CONCLUSIONES: La estrategia "Tratar según el nomograma" es la alternativa más eficiente en el diagnóstico y tratamiento de la intoxicacióna aguda por Paracetamol en nuestro medio, no así para un escenario de mayor prevalencia e incertidumbre, donde la opción "Cálculo de semivida" se muestra como la más eficiente.

Treatment of self-poisoning at a tertiary-level hospital in Bangladesh: cost to patients and government.

OBJECTIVES: Approximately 10 000 people die from suicide annually in Bangladesh, many from pesticide poisoning. We aimed to estimate financial costs to patients and health services of treating patients with self-poisoning. METHODS: Data on direct costs to families, sources of funds for treatment and family wealth were collected prospectively over a one-month period in 2016 at the tertiary Chittagong Medical College Hospital, Bangladesh. Aggregate operational costs to the government were calculated using annual budget, bed occupancy and length-of-stay data. RESULTS: Agrochemicals were the most common substances ingested (58.8%). Median duration of stay and of illness was 2 and 5 days, respectively. Median total cost to patients was conservatively estimated at US$ 98.40, highest in agrochemical poisoning (US$ 179.50), with the greatest cost due to medicines and equipment. Misdiagnosis as organophosphorus poisoning in 17.0% of agrochemical cases resulted in increased cost to patients. Only 51.9% of patients had indicators of wealth; 78.1% borrowed money to cover costs. Conservatively estimated median healthcare costs (US$ 21.30 per patient) were markedly lower than costs to patients. CONCLUSIONS: Cost to patients of treating a case of agrochemical poisoning was approximately three times the cost of one month's essential items basket. Incorrect diagnosis at admission costs families substantial sums of money and increased length of stay; it costs the national government an estimated US$ 80 428.80 annually. Widespread access to a list of pesticides used in self-poisoning plus greater focus on training doctors to better manage different forms of agrochemical poisoning should reduce the financial burden to patients and healthcare systems.

Treatment of Gabapentin Toxicity With Peritoneal Dialysis: Assessment of Gabapentin Clearance.

Gabapentin is almost exclusively cleared by the kidney and thus presents challenges in patients with kidney failure. Gabapentin is known to be effectively cleared by hemodialysis, but the efficiency of clearance by peritoneal dialysis (PD) has not been previously described. We report a case of gabapentin toxicity in a patient on long-term PD who was treated with continuous automated cycling PD. We find that continuous PD provides significant clearance of gabapentin. With 2-L exchanges every 2 hours, we document an apparent elimination half-life of 41.33 hours, which is substantially shorter than the reported elimination half-life of 132 hours in the absence of kidney function. Further, our patient's symptoms of gabapentin toxicity gradually improved and had fully resolved after about 36 hours of dialysis. Gabapentin clearance by PD was estimated at 94% of urea clearance. We conclude that intensive PD provides gabapentin clearance that approximates that of urea and is an effective but slow method to treat gabapentin overdose and toxicity.

Resource Utilization in Emergency Department Patients with Known or Suspected Poisoning.

INTRODUCTION: Previous work has shown poisoning-related emergency department (ED) visits are increasing, and these visits are resource-intensive. Little is known, however, about how resource utilization for patients with known or suspected poisoning differs from that of general ED patients. METHODS: We reviewed 4 years of operational data at a single ED. We identified visits due to known or suspected poisoning (index cases), and paired them with time-matched controls. In the primary analysis, we compared the groups with respect to a broad array of resource utilization characteristics. In a secondary analysis, we performed the same comparison after excluding patients ultimately transferred to a psychiatric facility. RESULTS: There were 405 index cases and 802 controls in the primary analysis, and 374 index cases and 741 controls in the secondary analysis. In the primary/secondary analyses, patients with known or suspected poisoning had longer ED lengths of stay in minutes (370 vs. 232/295 vs. 234), higher rates of laboratory results per patient (40.4 vs. 26.8/39.6 vs. 26.8), greater administration of intravenous medications and fluids per patient (2.0 vs. 1.6/2.1 vs. 1.6), higher rates of transfer to a psychiatric facility (7.7 vs. 0.2%/not applicable), and higher rates of both admission (40.2 vs. 32.8/43.6 vs. 33.1%) and admission to an advanced care bed (21.5 vs. 7.6/23.3 vs. 7.8%). Patients with known or suspected poisoning had lower rates of imaging per patient, for both plain radiographs (0.4 vs. 0.5/0.4 vs. 0.5) and advanced imaging studies (0.3 vs. 0.5/0.4 vs. 0.5). CONCLUSIONS: ED patients with known or suspected poisoning are more resource intensive than general ED patients. These results may have implications for both resource allocation (particularly for departments that might see a high volume of such patients) and ED operations management.

Assessment and Management of Toxidromes in the Critical Care Unit.

The most important diagnostic factor in uncovering a toxic etiology for delirium or critical illness is the clinician's openness to the possibility of its existence. Therefore, a consulting psychiatrist, already prepared to perform the detail-oriented work of sorting out behavioral manifestations of disease, can be a vital asset at the bedside if also attuned to the role of purposeful, accidental, and iatrogenic exposures in the intensive care unit. This article summarizes the presentation, evaluation, and treatment of toxidromes relevant to the work of acute psychosomatic medicine.

Availability and cost of extracorporeal treatments for poisonings and other emergency indications: a worldwide survey.

BACKGROUND: Extracorporeal treatments (ECTRs) are used for different conditions, including replacement of organ function and poisoning. Current recommendations for ECTRs in various poisonings suggest that intermittent haemodialysis (IHD) is the most efficient technique. However, the practicality of these recommendations is poorly defined in view of limited information on availability and cost worldwide. METHODS: A survey invitation to an Internet-based questionnaire was emailed between January 2014 and March 2015 to members of international societies to determine the availability, time to initiation and cost of ECTRs (including filters, dialysate, catheter, anticoagulant and nursing/physician salary). The median cost ratio of every ECTR compared with IHD performed in the same institution were presented. RESULTS: The view rate was estimated at 28.1% (2532/9000), the participation rate was 40.1% (1015/2532) and the completion rate was 16.0% (162/1015). Respondents originated from 89 countries, and nearly three-fourths practiced in a tertiary care centre. A total of 162 respondents provided sufficient data for in-depth analysis. IHD was the most available acute ECTR (96.9%), followed by therapeutic plasma exchange (TPE; 68.3%), continuous renal replacement therapy (CRRT; 62.9%), peritoneal dialysis (PD; 44.8%), haemoperfusion (HP; 30.9%) and liver support devices (LSDs; 14.7%). IHD, CRRT and HP were the shortest to initiate (median = 60 min). The median cost ratios of each ECTR compared with IHD were 1.7 for CRRT and HP, 2.8 for TPE, 6.5 for LSDs and 1.4 for PD (P < 0.001 for all). The median cost ratio of a 4-h IHD treatment compared with 1 day in the intensive care unit was 0.6 (P = 0.2). CONCLUSIONS: IHD appears to be the most widely available ECTR worldwide and is at least 30% less expensive than other ECTRs. The superior efficacy of IHD for enhanced elimination, added to its lower cost and wider availability, strengthens its preference as the ECTR of choice in most cases of acute poisoning. KEYWORDS: costing, CRRT, EXTRIP, hemodialysis, hemoperfusion.