Management of pharmaceutical and recreational drug poisoning.

BACKGROUND: Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS: A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS: The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS: The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

Daily volume of cases in emergency call centers: construction and validation of a predictive model.

BACKGROUND: Variations in the activity of emergency dispatch centers are an obstacle to the rationalization of resource allocation. Many explanatory factors are well known, available in advance and could predict the volume of emergency cases. Our objective was to develop and evaluate the performance of a predictive model of daily call center activity. METHODS: A retrospective survey was conducted on all cases from 2005 to 2011 in a large medical emergency call center (1,296,153 cases). A generalized additive model of daily cases was calibrated on data from 2005 to 2008 (1461 days, development sample) and applied to the prediction of days from 2009 to 2011 (1095 days, validation sample). Seventeen calendar and epidemiological variables and a periodic function for seasonality were included in the model. RESULTS: The average number of cases per day was 507 (95% confidence interval: 500 to 514) (range, 286 to 1251). Factors significantly associated with increased case volume were the annual increase, weekend days, public holidays, regional incidence of influenza in the previous week and regional incidence of gastroenteritis in the previous week. The adjusted R for the model was 0.89 in the calibration sample. The model predicted the actual number of cases within ± 100 for 90.5% of the days, with an average error of -13 cases (95% CI: -17 to 8). CONCLUSIONS: A large proportion of the variability of the medical emergency call center's case volume can be predicted using readily available covariates.

Impact of an emergency medical dispatch system on survival from out-of-hospital cardiac arrest: a population-based study.

BACKGROUND: In countries where a single public emergency telephone number is not in operation, different emergency telephone numbers corresponding to multiple dispatch centres (police, fire, emergency medical service) may create confusion for the population about the most appropriate service to call. In particular, out-of-hospital cardiac arrest (OHCA) requires a prompt and effective response. We compare two different dispatch systems on OHCA patient survival at 30 days in a national system with multiple emergency telephone numbers. METHODS: We conducted an observational retrospective study of 6871 patients aged 18 years or older with presumed OHCA of cardiac origin between 2005 and 2013 in three counties of the Northern French Alps region. One county had a single dispatch centre combining medical and fire emergencies, and two had multiple dispatch centres. Propensity score matching analyses were performed to compare patient survival at 30 days. RESULTS: A total of 2257 emergency calls for OHCA were managed by a single dispatch centre and 4614 by a multiple dispatch centre. A single dispatch centre was associated with an increase in survival (adjusted odds ratio [OR] for all patients: 1.7; 95 % confidence interval [CI] = 1.3-2.2; p <0.001; adjusted OR for propensity-matched patients: 2.0; 95 % CI = 1.2-3.4; p = 0.012). CONCLUSIONS: A single dispatch centre was associated with a markedly improved increase of survival among OHCA patients at 30 days in a system with several emergency telephone numbers.

Noninvasive End Tidal CO2 Is Unhelpful in the Prediction of Complications in Deliberate Drug Poisoning.

STUDY OBJECTIVE: We study the performance of capnometry in the detection of early complications after deliberate drug poisoning. METHODS: This was a prospective cohort study of self-poisoned adult patients who presented at an emergency department (ED) between April 20, 2012, and May 6, 2014. Patients who ingested at least 1 neurologic or respiratory depressant drug were included. The primary outcome was the predictive value of an end tidal CO2 (etco2) measurement greater than or equal to 50 mm Hg for the detection of early complications defined a priori by hypoxia requiring oxygen greater than or equal to 3 L/min, bradypnea less than or equal to 10 breaths/min, or ICU admission after intubation or antidote administration because of unresponsiveness to pain or respiratory arrest. Consciousness scales and clinical data were recorded at admission and every 30 minutes. Noninvasive etco2 was continuously measured for 2 hours after inclusion unless the patient was admitted to the ICU. Patients and physicians were blinded to etco2 values. RESULTS: Two hundred one patients were included, 35 of whom exhibited at least 1 complication. An etco2 measurement greater than or equal to 50 mm Hg predicted the onset of a complication, with a sensitivity of 46% (95% confidence interval [CI] 29% to 63%) and a specificity of 80% (95% CI 73% to 86%), leading to a positive predictive value of 33% (95% CI 20% to 48%) and a negative predictive value of 88% (95% CI 81% to 92%). etco2 was less able to predict complications than the Glasgow Coma Scale score at inclusion. CONCLUSION: Capnometry in isolation does not provide adequate prediction of early complications in self-poisoned patients referred to the ED. A dynamic minute-by-minute assessment of etco2 could be more predictive.

Team Emergency Assessment Measure (TEAM) for the assessment of non-technical skills during resuscitation: Validation of the French version.

AIM: Evaluation of team performances during medical simulation must rely on validated and reproducible tools. Our aim was to build and validate a French version of the Team Emergency Assessment Measure (TEAM) score, which was developed for the assessment of team performance and non-technical skills during resuscitation. METHODS: A forward and backward translation of the initial TEAM score was made, with the agreement and the final validation by the original author. Ten medical teams were recruited and performed a standardized cardiac arrest simulation scenario. Teams were videotaped and nine raters evaluate non-technical skills for each team thanks to the French TEAM Score. Psychometric properties of the score were then evaluated. RESULTS: French TEAM score showed an excellent reliability with a Cronbach coefficient of 0.95. Mean correlation coefficient between each item and the global score range was 0.78. The inter-rater reliability measured by intraclass correlation coefficient of the global score was 0.93. Finally, expert teams had higher French TEAM score than intermediate and novice teams. CONCLUSION: The French TEAM score shows good psychometric properties to evaluate team performance during cardiac arrest simulation. Its utilization could help in the assessment of non-technical skills during simulation.

Outcome after severe accidental hypothermia in the French Alps: A 10-year review.

OBJECTIVE: To describe the factors associated with outcome after accidental deep hypothermia. METHODS: We conducted a retrospective cohort study on patients with accidental hypothermia (core temperature <28 °C) admitted to a Level I emergency room over a 10-year period. RESULTS: Forty-eight patients were included with a median temperature of 26 °C (range, 16.3-28 °C) on admission. The etiology of hypothermia was exposure to a cold environment (n = 27), avalanche (n = 13) or immersion in cold water (n = 8). Mean age was 47 ± 22 years, and 58% were males. Thirty-two patients had a cardiac arrest (CA): 15 patients presented unwitnessed cardiac arrest (UCA) and 17 patients presented rescue collapse (RC). Extracorporeal life support (ECLS) was implemented in 21 patients with refractory cardiac arrest and in two patients with hemodynamic instability. Overall mortality was 50%. For cardiac arrest patients, only three out of 15 patients with UCA survived at day 28, whereas eight out of 17 patients with RC survived. The cerebral performance category score was 4 for all the survivors of UCA and 1 [range, 1-2] for survivors of RC. Patients with poor outcome presented more UCA, a lower pH, a higher serum potassium, creatinine, serum sodium or lactate level as well as more severe coagulation disorders. CONCLUSION: Cardiac arrest related to rescue collapse was associated with favorable outcome. On-scene rescue collapse should prompt prolonged resuscitation and ECLS rewarming in all CA patients with deep hypothermia. Conversely, unwitnessed cardiac arrest was associated with unfavorable outcome and will likely not benefit from ECLS.

More than half the families of mobile intensive care unit patients experience inadequate communication with physicians.

PURPOSE: This study aimed to assess comprehension by family members of the patient's severity in the prehospital setting. METHOD: We conducted a cross-sectional study in four mobile intensive care units (ICUs, medicalized ambulances) in France from June to October 2012. Nurses collected data on patients, patient's relatives, and mobile ICU physicians. For each patient, one relative and one physician independently rated the patient's severity using a simplified version of the Clinical Classification of Out-of-Hospital Emergency Patients scale (CCMS). Relatives were also asked to assess their interview with the physician. The primary outcome was agreement between the relative's and physician's ratings of the patient's severity. RESULTS: Data were available for 184 patients, their relatives, and mobile ICU physicians. Full and partial agreement between relatives and physicians regarding the patient's severity was found for 79 (43%) and 121 (66%) cases, respectively [weighted kappa = 0.32 (95% confidence interval, CI, 0.23-0.42)]. Relatives overestimated the patient's severity assessed by the physician [6 (5-8) vs. 4 (3-7), p <0 .001]. The interview lasted 5 min (range 5-10) with the physician talking 80% (range 70-90) of that time. Overall, 171 (93%) and 169 (92%) relatives reported adequate interview time and use of understandable words by physicians. In multivariable analysis, the characteristics independently associated with increased odds of disagreement included (1) the relative not having a diploma (OR 4.88; 95% CI 1.27-18.70) and (2) greater patient severity (OR 6.64; 95% CI 1.29-16.71). CONCLUSION: More than half of family members reported inadequate comprehension of information on the patient's severity as communicated by mobile ICU physicians.

Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study.

AIM: Supraglottic devices are thought to allow efficient ventilation and continuous chest compressions during cardiac arrest. Therefore, the use of supraglottic devices could increase the chest compression fraction (CCF), a critical determinant of patient survival. The aim of this study was to assess the CCF in out-of-hospital cardiac arrest (OHCA) patients ventilated with a supraglottic device. METHODS: We conducted an open prospective multicenter study with temporal clusters. OHCA patients treated by emergency nurses received either intermittent chest compressions with bag-valve mask ventilations (30:2 rhythm; BVM group); or continuous chest compressions with asynchronous ventilations by laryngeal tube (LT group). The primary endpoint was the CCF assessed using an accelerometer connected to the defibrillator. We also investigated the ease of use of the laryngeal tube. RESULTS: Eighty-two patients were included (41 in each group); 68% were male and the median age was 68 (54-80) years. Patients and cardiac arrest characteristics did not differ between groups. The CCF was 75% (68-79%) in the LT group and 59% (51-68%) in the BVM group (p<0.01). LT insertion failed in nine out of 40 cases (23%). The median time of LT insertion was 26s (11-56 s). CCF was significantly lower when LT insertion failed (58% (48-74%) vs. 76% (72-80%) when LT insertion succeeded; p=0.01). CONCLUSION: The use of the LT during OHCA increases the CCF when compared to standard BVM ventilation. However, the impact of LT use on mortality remains unclear.

Intentional drug poisoning care in a physician-manned emergency medical service.

OBJECTIVES: Severely poisoned patients can benefit from intensive and specific treatments. Emergency medical services (EMS) may therefore play a crucial role by matching prehospital care and hospital referral to the severity of poisoned patients. Our aim was to investigate EMS accuracy in this condition. METHODS: A 3-year retrospective study was conducted in a university hospital. Emergency telephone calls about adult patients with intentional drug poisoning (IDP) were included. In daily practice, an emergency physician answers such telephone calls and dispatches either first responders or a mobile intensive care unit (MICU). According to on-scene evaluation, patients are referred to the emergency department (ED) or to an intensive care unit (ICU). We therefore calculated global EMS accuracy according to patients' actual medical needs. We further evaluated the performance of dispatch and hospital referral decision. We also performed a regression analysis to identify factors of inappropriate dispatch. RESULTS: A total of 2,227 patients were studied. Median age was 41 years old (range 30-49) and 63% were women. Dispatch was appropriate for 1,937 (87%) patients. Sensitivity and specificity of dispatch decision were 0.43 and 0.93, respectively. Decision of patients' referral to an appropriate hospital facility had a sensitivity of 0.67 and a specificity of 0.98. Toxicological data, age, and Glasgow coma scale were significantly associated with inappropriate EMS decisions. CONCLUSIONS: A physician-operated EMS is an accurate system to provide prehospital care to IDP patients. However, dispatch physicians should pay attention, especially to toxicological anamnesis, to anticipate proper patient care.

Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial.

PURPOSE: Mild therapeutic hypothermia (TH) is recommended as soon as possible after the return of spontaneous circulation to improve outcomes after out-of-hospital cardiac arrest (OHCA). Preclinical data suggest that the benefit of TH could be increased if treatment is started during cardiac arrest. We aimed to study the impact of intra-arrest therapeutic hypothermia (IATH) on neurological injury and inflammation following OHCA. METHODS: We conducted a 1:1 randomized, multicenter study in three prehospital emergency medical services and four critical care units in France. OHCA patients, irrespective of the initial rhythm, received either an infusion of cold saline and external cooling during cardiac arrest (IATH group) or TH started after hospital admission (hospital-cooling group). The primary endpoint was neuron-specific enolase (NSE) serum concentrations at 24 h. Secondary endpoints included IL-6, IL-8, and IL-10 concentrations, and clinical outcome. RESULTS: Of the 245 patients included, 123 were analyzed in the IATH group and 122 in the hospital-cooling group. IATH decreased time to reach temperature ≤ 34 °C by 75 min (95% CI: 4; 269). The rate of patients admitted alive to hospital was not different between groups [IATH n = 41 (33%) vs. hospital cooling n = 36 (30%); p = 0.51]. Levels of NSE and inflammatory biomarkers were not different between groups [median NSE at 24 h: IATH 96.7 µg/l (IQR: 49.9-142.8) vs. hospital cooling 97.6 µg/l (IQR: 74.3-142.4), p = 0.64]. No difference in survival and cerebral performance were found at 1 month. CONCLUSIONS: IATH did not affect biological markers of inflammation or brain damage or clinical outcome.

Severity of deliberate acute baclofen poisoning: a nonconcurrent cohort study.

Interest in high-dose baclofen treatment for alcohol dependence has increased over the past few years. In the meantime, the rate of acute baclofen poisoning has increased and life-threatening cases have been reported. Thus, severity of acute poisoning could lessen the benefit of baclofen treatment. Our aim was to evaluate the severity of acute baclofen poisoning independently of confounders and to assess whether severity is correlated with the reported ingested dose. We prospectively included consecutive patients with acute and deliberate baclofen overdose and compared them with gender and age-matched patients from a retrospective cohort of common acute medicine self-poisoning. The primary end-point was the adjusted risk ratio of mechanical ventilation. We also analysed the lengths of mechanical ventilation and risks of aspiration pneumonitis and convulsions. We finally examined the correlation between the supposed reported ingested dose and the severity of poisoning. Fourteen baclofen-poisoned patients were included and matched to 56 poisoned patients. Median age was 45 y/o (40-58), and men comprised 43% of patients. In logistic regression, the adjusted risk ratio of mechanical ventilation was 7.9 (1.4-43.5; p=0.02) for baclofen-treated patients. Aspiration pneumonitis was more frequent in baclofen-treated patients (29% versus 2%; p=0.005), and the length of mechanical ventilation was significantly correlated with the reported ingested dose of baclofen (Spearman coefficients: 0.48; p<0.001). Our results show that acute baclofen poisoning is more severe than other acute medicine overdoses, and severity seems to be correlated with the ingested dose of baclofen. These results raise some questions about the safety of high-dose baclofen treatment for alcohol dependence.

Deliberate drug poisoning with slight symptoms on admission: are there predictive factors for intensive care unit referral? A three-year retrospective study.

Deliberate drug poisoning leads to 1% of emergency department (ED) admissions. Even if most patients do not exhibit any significant complication, 5% need to be referred to an intensive care unit (ICU). Emergency physicians should distinguish between low- and high-acuity poisoned patients at an early stage to avoid excess morbidity. Our aim was to identify ICU transfer factors in deliberately self-poisoned patients without life-threatening symptoms on admission. We performed a 3-year retrospective observational study in a university hospital. Patients over 18 years of age with a diagnosis of deliberate drug poisoning were included. Clinical and toxicological data were analysed with univariate tests between groups (ED stay versus ICU transfer). Factors associated with ICU admission were then included in a logistic regression analysis. Two thousand five hundred and sixty-five patients were included. 63.2% were women, and median age was 40 (28-49). 142 patients (5.5%) were transferred to ICU. Cardiac drugs [adjusted OR (aOR) = 19.81; 95% confidence interval (95% CI): 7.93-49.50], neuroleptics (aOR = 2.78; 95% CI: 1.55-4.97) and meprobamate (aOR = 2.71; 95% CI: 1.27-5.81) ingestions were significantly linked to ICU admission. A presumed toxic dose ingestion (aOR = 2.27; 95% CI: 1.28-4.02), number of ingested tablets (aOR = 1.01; 95% CI: 1.01-1.02 for each tablet) and delay between ingestion and ED arrival <2 hr (aOR = 2.85; 95%CI: 1.62-5.03) were also factors for ICU referral. The Glasgow Coma Scale was the only clinical feature associated with ICU admission (aOR = 1.57; 95% CI: 1.44-1.70 for each point loss). These results suggest that emergency physicians should pay particular attention to toxicological data on ED admission to distinguish between low- and high-acuity self-poisoned patients.

[Recommendations for the prescription, implementation and interpretation of medical examinations in biology in the context of severe poisoning]. / Recommandations pour la prescription, la réalisation et l'interprétation des examens de biologie médicale dans le cadre des intoxications graves.

A multidisciplinary working group named "Toxicology and clinical biology" and whose members belong to the French Society of Clinical Biology (SFBC), Critical Care Medicine Society of French Language (SRLF), the French Society of Medical Emergency (SFMU), the French Society of Analytical Toxicology (SFTA), the Society of Clinical Toxicology (STC), and the National College of Biochemistry (CNBH) updated the professional practice recommendations published in 2003. These recommendations aimed the biologists who are not specialized in toxicology and more largely all the health professionals involved the management of severely poisoned patients. Among the data published in the initial edition, only the major table dealing with severe poisonings was updated, as all other supplements remained valid. The current revised table details poisonings due to fifty-five different xenobiotics and presents their main clinical features, useful biomarkers of toxicity, methods of identification or assays available in the emergent setting with their respective relevance and recommended delays to obtain their result. Assessments with a good agreement among the working group members regarding all laboratory issues for poisoning management are presented. A table updates the list of the main currently useful antidotes. A section on the value and place of toxicology screening was added.

[Acute acetaminophen overdose]. / Intoxication aiguë par le paracétamol.

Acute ingestion of acetaminophen can induce a dose-dependent hepatotoxicity and lead to death. The management of acute acetaminophen poisoning at the early stage is well codified. A reported amount of ingestion > 200 mg/kg in a child, > 150 mg/kg in an adult (125 mg/kg if risk factors are present) require hospitalisation. Activated charcoal is administered within 1-2 hours of ingestion. AST/ALT levels are measured on admission, 12 hours after, and according to outcome every 12-24 h. N-acetylcysteine (NAC) administration within 8-10 hours protects against acetaminophen-induced hepatotoxicity. The two protocols of NAC administration, intravenous and oral, have a comparable effectiveness. NAC is indicated if the serum acetaminophen level drawn 4 hours after ingestion and plotted on the nomograme falls above the "200 mg/L-4 hours" line. Nomograme is not usable with repeated acute ingestion or repeated supratherapeutic doses; presence of risk factors (enzymatic induction, malnutrition, chronic alcoholism) must be taken into account ("100 mg/L - 4 hours" line). Outcome is favorable with respect to these conditions.

Poisoning by lavandin extract in a 18-month-old boy.

An 18-month-old boy ingested a small amount of homemade lavandin extract. The child developed a central nervous system depression and a confused state three hours after ingestion. The electroencephalogram showed fast rhythm disorders consistent with a toxic etiology. The outcome was favorable. Poisoning was confirmed by headspace-gas chromatography-mass spectrometry. Linalyl acetate, linalyl formate, and acetone were identified in pure lavandin extract and in the child's blood and urine. We report the only case of lavandin extract poisoning confirmed by toxicological analysis.

New syndromes in mushroom poisoning.

Several new mushroom poisoning syndromes have been described since the early 1990s. In these syndromes, the onset of symptoms generally occurs >6 hours after ingestion. Treatment is mainly supportive. The syndrome induced by Amanita smithiana/proxima consists of acute tubulopathy, which appears earlier and does not have the same poor prognosis as the orellanine-induced syndrome. It has been described since 1992 in the US and Canada with A. smithiana; in France, Spain and Italy with A. proxima; and in Japan with A. pseudoporphyria. The responsible toxin is probably 2-amino-4,5-hexadienoic acid. The erythromelalgia syndrome has been described as early as the late 19th century in Japan and South Korea with Clitocybe acromelalga, and since 1996 in France and then Italy with C. amoenolens. Responsible toxins are probably acromelic acids identified in both species. Several cases of massive rhabdomyolysis have been reported since 1993 in France and 2001 in Poland after ingestion of large amounts of an edible and, until then, valuable species called Tricholoma equestre. These cases of rhabdomyolysis are associated with respiratory and cardiac (myocarditis) complications leading to death. Rhabdomyolysis with an apparently different mechanism was described in Taiwan in 2001 with Russula subnigricans. Finally, cases of encephalopathy were observed twice after ingestion of Hapalopilus rutilans in Germany in 1992 and Pleurocybella porrigens in Japan in 2004, where a convulsive encephalopathy outbreak was reported in patients with history of chronic renal failure.

[Childhood poisoning: data from the French Poison Control and Toxicovigilance Centres (2002)]. / Intoxications de l'enfant: données des centres antipoison et de toxicovigilance (CAP-TV) français (2002).

MATERIALS AND METHODS: Data for 2002 from a number of French poison control centres were analysed in terms of several age groups; 87 678 possible or established poisoning cases were counted, including 49 355 cases in the 0- to 18-year age group. RESULTS: The 0- to 3-year age group accounted for 71.7% of cases of childhood poisoning. Accidental poisoning was predominant up to 12 years, while from 13 to 18 years poisoning was essentially deliberate. The principal route of exposure was oral and involved liquids for babies and solid products for older children. The toxic agents most often implicated were pharmaceuticals and domestic products. The place of poisoning was mainly the home. A 'no-risk' evaluation was performed, and varied between 41.6% before the age of 3 years to 18.0% for the 13- to 18-year age group. The oldest children were more often managed in medical facilities. DISCUSSION: Fortunately, most of these poisoning cases were not serious (death rate: 0.026%). The poison control centres' information system is continuing to expand: it will allow an improvement in medical health monitoring associated with poisoning.

Watching symptoms and illnesses through the eyes of Multiple Correspondence Analysis: a case study in toxicology.

The goal of the reported research was the design of a computerized tool aimed at aiding an emergency specialist, in a toxicological emergency unit, to quickly identify, at the admission time, the various poisons ingested by a comatose patient. This medical decision making problem has been proved to be computationally intractable since a lot of patient cases sharing the same clinical table have different diagnoses in terms of psychotropes combinations. The paper explores the idea that the outcome of Multiple Correspondence Analysis (MCA), a mathematical data analysis method, can be thought of as visual and analytical aids for the physician facing this decision problem. We argue that the expert's clinical reasoning can be enhanced by the factorial maps and some computerized results provided by MCA. Using a learning database of 505 diagnosed cases, we realized a whole decision aiding system called TOXSYMEDIA. A test-base of 97 patients was used to partially assess the system. The method and resulting tool revealed to be appreciable to early inform the physician about the possible combination of ingested psychotropes.

Carbon monoxide poisoning monitoring network: a five-year experience of household poisonings in two French regions.

BACKGROUND: In France, the epidemiological situation of acute carbon monoxide (CO) poisoning is only partially known. The purpose of this study was to assess the epidemiological situation of household poisonings in two French regions where a regional toxicovigilance network was active. METHODS: During five years, we studied, by means of a standardized data collection form, cases of acute CO poisoning admitted to regional hospitals and notified by hospital physicians. RESULTS: From 1997 to 2001, 1,458 people were involved in 489 places. Household poisonings represented the first circumstance of CO poisoning with 811 people involved in 293 places. So, analysis was performed only for household poisonings. The mean age was 33.3 years. Twenty patients died (2.6%), 16 patients were in coma (2.1%), and 11 patients had an initial isolated loss of consciousness (14.4%). Responsible appliances in household poisonings were identified in 84% of places. The appliances most often involved were vented heating systems (46.4%), mobile heaters (13.2%), and thermal motors (8.7%). In 63% of the 293 places, investigation showed that poisoning occurred because of a faulty installation. Vented gas heaters and mobile heaters were responsible for half of the severe household CO poisonings. CONCLUSION: In the countries of Rhône-Alpes and Auvergne, most of household CO poisonings are no longer caused by waterheaters but by gas heating systems. Poisonings caused by mobile heaters more frequently led to coma and death and thermal motors played a large part in moderate poisonings. These recently emerging trends justify the efforts focused on ongoing monitoring and the introduction of preventive measures.