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The profile evolution of acute severe poisoning in Spain
ToxicologyLetters, 6465 (1992) 725-727 0 1992 Elsevier Science Publishers B.V., All rights reserved 03784274/‘92/$5.00
725
The profile evolution of acute severe poisoning in Spain S. Nogub, L. Marruecos, J. Nolla, J. Monte%, A. Ferrer and E. Civeira Hospital Clinic (Barcelona) and Toxicology Group of the Spanish Intensive Care Society Key words: Acute poisoning; Intoxication; Intensive care units
SUMMARY About 5% of the patients admitted to emergency departments with poisonings are seriously ill and need admission to intensive car units (ICUs). This paper presents the result of three multicentric studies carried out in Spain during the last ten years. A study was made of 6 ICUs in 1980,41 in 1987 and 15 in 1990 with a total of 596 patients. The average age (36) remained stable throughout, but the number of female cases decreased each time. The most frequent cause (79%) was attempted suicide. The products used most frequently were therapeutic drugs (82,71 and 58%) followed by drugs of abuse, and then agricultural, household and industrial products. We observed a progressive decrease in barbiturates (54,15 and 2%) and an increase in benzodiazepines and cyclic antidepressants. Therapeutic methods used were mostly gastric lavage (64%), activated charcoal (35%), forced diuresis (43%), extracorporeal therapy (11%) and antidotes. The mortality rate fluctuated between 6.4 and 9.1%, being significantly higher with poisoning by non-therapeutic drugs. In conclusion, the most common poisoning admitted to our ICUs was by psychoactive drugs in suicide attempts. We observed the under-use of activated charcoal and an excessive usage of kidney and extracorporeal methods. The prognosis was worse for poisonings with non-therapeutic drugs.
INTRODUCTION
Upon commencing work in the intensive care unit (ICU) at Hospital Clinic Barcelona in 1980, we became interested by the number of severe poisoning cases that were admitted to our ICU. We therefore decided to undertake an epidemiological investigation in various ICUs throughout Spain which would allow us to observe the development of such cases during the last IO years. Correspondence to: S. Noguk, Intensive Care Unit (AVI), Hospital Clinic i Provincial, Villarroel 170,08036 Barcelona, Spain.
726 PATIENTS AND METHODS
The study was carried out in different ICUs in Spain. All patients were over 14 years and were admitted with severe poisonings. We received permission to investigate 6 ICUs in 1980,41 in 1987 and 15 in 1990, giving a total of 596 cases of poisoning. All of the units observed were general ICUs - no hospital in Spain has a separate unit for severe poisoning. The variables used in the investigation were: incidence, sex, age, reason and type of poisoning, why the patient was admitted to the ICU, the treatment used and the development of patient. RESULTS
Our first finding was surprising. We noted a gradual decrease in the number of poisonings admitted to ICUs. In 1980,7 out of every 100 cases of poisoning that arrived at emergency departments needed to be admitted to the ICU. However, by 1990 this figure had decreased to just 2%. Another interesting observation was that in 1980 6 out of every 100 patients admitted to ICUs were toxic cases, but by 1990 this figure had decreased to only 2 cases in every 100. The average age of the toxic cases has remained stable at around 36 years throughout the 10 years of the study. However, the number of female cases has decreased considerably, from 60% in 1980 to 17% in 1990. The main cause of the severe poisoning cases was attempted suicide. However, the number of such cases has now decreased and poisoning by accident and overdoses are increasing. The main substances used in severe poisonings are pharmaceutical drugs although their use is diminishing. The use of other substances such as domestic, agricultural and industrial products, illicit drugs, and plant and animal poisons has increased in the last IO years. There have been several notable changes in the use of pharmaceutical drugs used in the last 10 years, e.g. a dramatic decrease in barbiturates, and an increase in benzodiazepines, cyclic antidepressants and phenothizines. Severe poisoning by salicilates and paracetamol still continue to pose a small problem in Spain. Among non-pharmaceutical drugs, the use of domestic products containing caustic is quite significant, particulary hydrogen chloride. Next are heroin overdoses, insecticides (in particular organophosphate), carbon monoxide and herbicides, especially paraquat. The three main reasons for admitting these patients into ICUs have remained the same and are often related: deep coma, lung problems and hypotension or shock.
127
We grouped the treatment received by these patients into two main groups. The first is non-specific or general treatment, and the second is specific or antitoxic treatment. The first comprises a series of different treatments used on general cases admitted to the ICU. Those mostly used are tracheal intubation, artificial ventilation and vasopressor drugs like dopamine or dobutamine. Of course, the treatment is related to the reasons for admittance (i.e. deep coma, lung problems and cardiocirculatory collapse). Of the second treatment group (specific treatment), gastric lavage is most often used. We also observed a relative but progressive increase in the use of activated charcoal, cathartics, extracorporeal therapy and antidotes, and a decrease in forced diuresis. Despite the considerable reduction in the use of forced diuresis, it still continues to be used excessively. In the IO years of the study and for the 600 severe poisonings, only 10 different antidotes have been used. The most frequent is physostigmine which is being used less, followed by naloxone, atropine and oximes, n-acetyl-cysteine, oxygen and finally flumazenil which has quickly become the most commonly-used antidote. The mortality rate did not reach 10% in any of the 10 years. The most significant data obtained on the mortality rate groups the intoxications into two categories: pharmaceutical and non-pharmaceutical drugs. Pharmaceutical drug poisoning had a mortality rate between 0 and 3.6%, and non-pharmaceutical drugs between 19 and 28%; these results are statistically very significant. The most common substances used in poison-re1ate.d deaths are benzodiazepines, cyclic antidepressants and barbiturates among the pharmaceutical drugs, and in the non-pharmaceutical category, household caustic products, insecticides, herbicides and heroin. CONCLUSIONS
The number of severe poisonings admitted to ICUs has decreased in the last 10 years in both absolute and relative terms. The main reason for this decrease is the drop in the number of self-poisonings in women. The most common reason for admission is deep coma and respiratory complications. The use of activated charcoal and cathartics is increasing whereas forced diuresis, though still used excessively, is decreasing. The 600 severely poisoned cases required only 10 different antidotes. The tendency to use physostigmine has now decreased whereas flumazenil is being used more frequently. The mortality rate among the 600 cases is low but is very much higher among poisonings from non-pharmaceutical drugs.
725
The profile evolution of acute severe poisoning in Spain S. Nogub, L. Marruecos, J. Nolla, J. Monte%, A. Ferrer and E. Civeira Hospital Clinic (Barcelona) and Toxicology Group of the Spanish Intensive Care Society Key words: Acute poisoning; Intoxication; Intensive care units
SUMMARY About 5% of the patients admitted to emergency departments with poisonings are seriously ill and need admission to intensive car units (ICUs). This paper presents the result of three multicentric studies carried out in Spain during the last ten years. A study was made of 6 ICUs in 1980,41 in 1987 and 15 in 1990 with a total of 596 patients. The average age (36) remained stable throughout, but the number of female cases decreased each time. The most frequent cause (79%) was attempted suicide. The products used most frequently were therapeutic drugs (82,71 and 58%) followed by drugs of abuse, and then agricultural, household and industrial products. We observed a progressive decrease in barbiturates (54,15 and 2%) and an increase in benzodiazepines and cyclic antidepressants. Therapeutic methods used were mostly gastric lavage (64%), activated charcoal (35%), forced diuresis (43%), extracorporeal therapy (11%) and antidotes. The mortality rate fluctuated between 6.4 and 9.1%, being significantly higher with poisoning by non-therapeutic drugs. In conclusion, the most common poisoning admitted to our ICUs was by psychoactive drugs in suicide attempts. We observed the under-use of activated charcoal and an excessive usage of kidney and extracorporeal methods. The prognosis was worse for poisonings with non-therapeutic drugs.
INTRODUCTION
Upon commencing work in the intensive care unit (ICU) at Hospital Clinic Barcelona in 1980, we became interested by the number of severe poisoning cases that were admitted to our ICU. We therefore decided to undertake an epidemiological investigation in various ICUs throughout Spain which would allow us to observe the development of such cases during the last IO years. Correspondence to: S. Noguk, Intensive Care Unit (AVI), Hospital Clinic i Provincial, Villarroel 170,08036 Barcelona, Spain.
726 PATIENTS AND METHODS
The study was carried out in different ICUs in Spain. All patients were over 14 years and were admitted with severe poisonings. We received permission to investigate 6 ICUs in 1980,41 in 1987 and 15 in 1990, giving a total of 596 cases of poisoning. All of the units observed were general ICUs - no hospital in Spain has a separate unit for severe poisoning. The variables used in the investigation were: incidence, sex, age, reason and type of poisoning, why the patient was admitted to the ICU, the treatment used and the development of patient. RESULTS
Our first finding was surprising. We noted a gradual decrease in the number of poisonings admitted to ICUs. In 1980,7 out of every 100 cases of poisoning that arrived at emergency departments needed to be admitted to the ICU. However, by 1990 this figure had decreased to just 2%. Another interesting observation was that in 1980 6 out of every 100 patients admitted to ICUs were toxic cases, but by 1990 this figure had decreased to only 2 cases in every 100. The average age of the toxic cases has remained stable at around 36 years throughout the 10 years of the study. However, the number of female cases has decreased considerably, from 60% in 1980 to 17% in 1990. The main cause of the severe poisoning cases was attempted suicide. However, the number of such cases has now decreased and poisoning by accident and overdoses are increasing. The main substances used in severe poisonings are pharmaceutical drugs although their use is diminishing. The use of other substances such as domestic, agricultural and industrial products, illicit drugs, and plant and animal poisons has increased in the last IO years. There have been several notable changes in the use of pharmaceutical drugs used in the last 10 years, e.g. a dramatic decrease in barbiturates, and an increase in benzodiazepines, cyclic antidepressants and phenothizines. Severe poisoning by salicilates and paracetamol still continue to pose a small problem in Spain. Among non-pharmaceutical drugs, the use of domestic products containing caustic is quite significant, particulary hydrogen chloride. Next are heroin overdoses, insecticides (in particular organophosphate), carbon monoxide and herbicides, especially paraquat. The three main reasons for admitting these patients into ICUs have remained the same and are often related: deep coma, lung problems and hypotension or shock.
127
We grouped the treatment received by these patients into two main groups. The first is non-specific or general treatment, and the second is specific or antitoxic treatment. The first comprises a series of different treatments used on general cases admitted to the ICU. Those mostly used are tracheal intubation, artificial ventilation and vasopressor drugs like dopamine or dobutamine. Of course, the treatment is related to the reasons for admittance (i.e. deep coma, lung problems and cardiocirculatory collapse). Of the second treatment group (specific treatment), gastric lavage is most often used. We also observed a relative but progressive increase in the use of activated charcoal, cathartics, extracorporeal therapy and antidotes, and a decrease in forced diuresis. Despite the considerable reduction in the use of forced diuresis, it still continues to be used excessively. In the IO years of the study and for the 600 severe poisonings, only 10 different antidotes have been used. The most frequent is physostigmine which is being used less, followed by naloxone, atropine and oximes, n-acetyl-cysteine, oxygen and finally flumazenil which has quickly become the most commonly-used antidote. The mortality rate did not reach 10% in any of the 10 years. The most significant data obtained on the mortality rate groups the intoxications into two categories: pharmaceutical and non-pharmaceutical drugs. Pharmaceutical drug poisoning had a mortality rate between 0 and 3.6%, and non-pharmaceutical drugs between 19 and 28%; these results are statistically very significant. The most common substances used in poison-re1ate.d deaths are benzodiazepines, cyclic antidepressants and barbiturates among the pharmaceutical drugs, and in the non-pharmaceutical category, household caustic products, insecticides, herbicides and heroin. CONCLUSIONS
The number of severe poisonings admitted to ICUs has decreased in the last 10 years in both absolute and relative terms. The main reason for this decrease is the drop in the number of self-poisonings in women. The most common reason for admission is deep coma and respiratory complications. The use of activated charcoal and cathartics is increasing whereas forced diuresis, though still used excessively, is decreasing. The 600 severely poisoned cases required only 10 different antidotes. The tendency to use physostigmine has now decreased whereas flumazenil is being used more frequently. The mortality rate among the 600 cases is low but is very much higher among poisonings from non-pharmaceutical drugs.