AIMS:This study aimed to describe clinical features and outcomes of patients presenting to the emergency department with analytically confirmed methamphetamine intoxication, to determine the blood concentration of methamphetamine and to test its association with clinical findings. DESIGN:The Western Australian Illicit Substance Evaluation (WISE) study is a prospective observational cohort study. SETTING:Royal Perth Hospital Emergency Department, Perth, Australia, between 2016 and 2018. PARTICIPANTS:Patients suspected to be intoxicated with a stimulant, hallucinogenic or cannabinoid substance and who required intravenous access or blood tests as part of standard care. Those predominantly alcohol intoxicated, behaviourally disturbed or opioid intoxicated were excluded. The 431 participants with detectable methamphetamine (> 0.001 mg/l) included in this analysis had a mean age of 33.2 (9.4) years and 286/431 (66.4%) were male. MEASUREMENTS:Concentration was reported for methamphetamine and other illicit drugs detected. Univariate associations of symptoms and signs, and physiological and laboratory parameters with methamphetamine concentration were determined and used to develop a multivariable model. FINDINGS:The median concentration of methamphetamine was 0.12 mg/L [Q1,Q3: 0.05, 0.27]. Psychotic symptoms were seen in 265/431 (61.5%) patients and intravenous or intramuscular sedation was required in 280/431 (65.0%). Mean heart rate was elevated at 105.9 (21.5) beats per minute, but other mean or median physiological parameters were within normal limits. A multivariable model showed that methamphetamine concentration was 27% lower in males (P = 0.026), 60% higher in those with palpitations (P = 0.013), 62% higher in those with choreoathetoid movements (P = 0.002) and increased by 1% for each unit (μg/L) increment in creatinine (P = 0.001). CONCLUSIONS:In a cohort of emergency department patients with methamphetamine exposure, a multivariable model inferred a significant association between higher methamphetamine concentration and female sex, the presence of palpitations and choreoathetoid movements and creatinine concentration. The model showed no significant association with agitation, psychotic symptoms or other physiological or clinical parameters.

ObjectiveEarly antivenom administration is essential for effective treatment. We investigated the delays in antivenom administration. MethodsWe reviewed snakebites from the Australian Snakebite Project (2006-2021) given antivenom, presenting to hospital within 12 h. We extracted demographics, snake type, time of bite, hospital arrival, blood collection, antivenom treatment and hospital transfer. ResultsThere were 2,169 patients recruited to Australian Snakebite Project 1,132 patients received antivenom within 12 h of the bite, and 1,019 of these were envenomated: median age 41 years (IQR: 24-57 years); 738 (72%) males. A pressure bandage was applied in 950 (93%), a median of 15 min (IQR: 5-30 min) post-bite. Specific snakes were identified by venom assays in 855 patients (80%), including 328 brown snakes (32%), 173 tiger snakes (17%), 74 rough-scaled snakes (7%), 85 red-bellied black snakes (8%), 49 taipans (5%) and 26 death adders (3%). Seventy-seven patients (7%) received antivenom without envenomation. The median length of hospital stay was 41 h (IQR: 24-67 h). The median time to hospital was 60 min (IQR: 30-105 min), to first blood tests was 90 min (IQR: 59-154 min) and to antivenom was 235 min (IQR: 155-345 min). There was a median delay in blood tests of 20 min (IQR: 10-37 min) and a median delay to antivenom of 147 min (IQR: 84-249 min). Non-specific systemic symptoms occurred in 641 (63%) patients, which occurred a median of 24 min (IQR: 10-60 min) post-bite, which was at a median of 180 min (IQR: 106 to 275 min) prior to antivenom administration. Time to antivenom in the 314 transferred patients was similar to those not transferred. Time to antivenom was significantly shorter for 189 patients given antivenom prior to transfer, median 183 min (IQR: 110-270 min), compared to 130 patients given antivenom after transfer, median 363 min (IQR: 289-513 min; P <0.001). DiscussionAntivenom administration was delayed on average by 2.5 h after hospital presentation, despite three-quarters arriving in hospital within 3 h, the optimal time for antivenom administration. Patients requiring transfer received antivenom in a similar time, but earlier if administered prior to transfer, highlighting the possible benefits of pragmatic clinical decision-making prior to blood tests. ConclusionWe found the leading cause of delays to antivenom administration after patients arrive in hospital was waiting for blood results. Systemic symptoms occurred early in most cases and could be given greater weight in decisions about early antivenom.

INTRODUCTION:Nitazenes are a group of potent synthetic opioids that have had increasing prominence as novel psychoactive drugs in the last 5 years. We describe emergency department nitazene-related presentations. METHODS:This is a prospective series of patients with analytically confirmed nitazene presentations identified by the Emerging Drugs Network of Australia and Emerging Drugs Network of Australia Victoria. Both studies' databases were searched between July 2020 and February 2024 with clinical data and blood nitazene concentrations abstracted. RESULTS:There were 32 presentations, 23 (72%) males, with a median age of 31 years (range 18-63 years). Only five (16%) intentionally ingested a nitazene, with most (12, 38%) believing they had taken alternative opioids. Co-exposures occurred in 31 (97%), mostly metamfetamine. Naloxone was administered in 23 (72%) presentations, with a median total dose of intravenous naloxone within 1 h post hospital presentation of 400 μg (interquartile range [IQR] 160-450 μg). Four (13%) received a naloxone infusion. Thirteen (41%) were admitted to the intensive care unit. The median length of stay was 17 h (IQR 7-39 h). Protonitazene was the commonest nitazene detected in 23 (72%) presentations with a median concentration of 2.0 μg/L (range 0.7-15 μg/L). The lowest concentration of protonitazene in a patient that received naloxone was 0.7 μg/L. DISCUSSION AND CONCLUSIONS:Most patients were unaware they were using nitazenes. Given their potency, this has important implications for harm, particularly in those not intentionally using opioids. Nitazene exposure was mostly unintentional. Naloxone use was common and standard dosing regimens appeared effective in most cases.

INTRODUCTION:Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS:This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS:GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS:Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

BACKGROUND:Chronic nitrous oxide (N2O) use causes inactivation of vitamin B12, resulting in neurological and psychiatric symptoms. This case series presents all N2O-related presentations to the emergency department at Royal Perth Hospital between June 2019 and June 2021, alongside the costs of these admissions. CASE PRESENTATION:Twenty-two patients were identified; 68% (n = 15) were male. The median age was 22.4 years (interquartile range [IQR], 20-30). Median daily number of N2O bulbs inhaled was 150 (IQR, 64-300) with a median duration of use of 9 months (IQR, 3-12). Presentations included ataxia, paraesthesia and falls (n = 18), urinary retention (n = 3) and psychotic symptoms (n = 2). Fourteen patients had severe symptoms prompting a magnetic resonance imaging of brain and spine, confirming 12 cases of subacute combined degeneration of the spinal cord. All patients had IMI vitamin B12 therapy, while 14 had oral methionine therapy. The median length of admission was 4 days (IQR 1-23 days). The median cost of admission per day for patients where costs were accessible (n = 7) was $2061 (IQR, $1903-$2860). DISCUSSION AND CONCLUSIONS:A case series of symptomatic chronic N2O use with severe neurological sequelae and significant costs associated per admission. Triangulation of emergency department and Ecstasy and Related Drugs Reporting System data helped prompt a swift public health response, including mandatory warning labels, limits to transaction amounts and legislative changes to the Medicines and Poisons Act to make it illegal for sale if there is a suspicion that it will be abused.

INTRODUCTION:Presentations related to illicit drugs are a feature of emergency department practice. Clinicians may form a belief that a patient is intoxicated with illicit drugs based on patient self-report, clinical features on presentation and the local prevalence of illicit drug use. But evidence of the accuracy of this assessment is lacking. The Western Australian Illicit Substance Evaluation (WISE) study enrolled patients believed by their treating clinician to be intoxicated with illicit drugs, and this analysis aims to evaluate the validity of this belief.METHODS:A blood sample was taken on patient arrival and details of patient history, examination and interventions were collected by clinical and research staff. Toxicological examination of biological samples used liquid chromatography-mass spectrometry techniques including Quadrupole Time of Flight screening and Triple Quadrupole targeted analyses.RESULTS:Of 632 study presentations, 518 had illicit drugs detected representing a positive predictive value of 0.82 (95% confidence interval 78.7, 84.9). Those with illicit drugs detected were significantly less likely to arrive by police transport (p = 0.010) or to have used alcohol (p < 0.001). They were significantly more likely to report illicit drug use (p < 0.001) and a much smaller proportion were admitted to a psychiatric ward (3.5% vs. 19.3%, p < 0.0001). Heart rate and systolic blood pressure were significantly higher in the illicit drug group (p = 0.004 and p = 0.003).DISCUSSION AND CONCLUSIONS:In this study, the positive predictive value of clinicians determining if their patient had taken illicit drugs was 0.82. Contemporaneous biochemical analysis in the clinical setting would increase this accuracy and inform patient care.

Introduction: Poppy seed tea is used for its opioid effects and contains multiple opium alkaloids, including morphine, codeine, papaverine, and thebaine. Animal studies indicate thebaine has strychnine-like properties, but there is limited literature describing human thebaine poisoning. We describe a cluster of acute thebaine poisoning in people ingesting tea made using poppy seeds with high thebaine content that entered the Australian food supply chain.Methods: This is an observational study of patients poisoned after drinking poppy seed tea. Cases were identified by three prospective toxicovigilance systems: the Emerging Drug Network of Australia collaboration, the New South Wales Prescription, Recreational and Illicit Substance Evaluation program, and the Emerging Drugs Network of Australia Victoria study. We report characteristics of clinical toxicity in cases with reported ingestion of poppy seed tea and analytical confirmation of thebaine exposure.Results: Forty cases presenting with multi-system toxicity following poppy seed tea ingestion were identified across seven Australian states/territories from November 2022 to January 2023. Blood testing in 23 cases confirmed high thebaine concentrations. All 23 were male (median age 35, range 16-71 years). All patients experienced muscle spasms. Rigidity was described in nine, convulsions in six, while rhabdomyolysis, acute kidney injury, and metabolic acidosis occurred in five patients. There were two cardiac arrests. The thebaine median admission blood concentration was 1.6 mg/L, with a range of 0.1-5.6 mg/L, and was the dominant opium alkaloid in all samples. Convulsions, acute kidney injury, metabolic acidosis, and cardiac arrest were associated with increasing median thebaine concentrations. Four patients were managed in the Intensive Care Unit, with two receiving continuous kidney replacement therapy (one also received intermittent haemodialysis) for kidney injury. There was one death.Conclusions: Thebaine toxicity, like strychnine poisoning, resulted in neuromuscular excitation characterized by muscle spasm, rigidity, and convulsions. Severe toxicity, including acute kidney injury, metabolic acidosis, and cardiac arrest, appears dose-dependent.

Objective The unprecedented rise in synthetic drugs, many containing unknown toxic agents, has made timely analytical diagnosis more difficult, and has reduced the confidence of clinicians providing ED management to this population of patients. This has also impacted the quality of evidence informing harm reduction responses. The Emerging Drugs Network of Australia (EDNA) brings together emergency physicians, toxicologists and forensic laboratories to establish a standardised ED toxicosurveillance system in Australia. Methods Blood analysis of intoxicated patients will be conducted by forensic laboratories to enable precise identification of the substances causing acute toxicity. This will be linked with clinical data collected at the time of ED presentation to enable analysis of the clinical effects and outcomes associated with different illicit and emerging drugs. Toxicological and clinical data collected across sentinel sites will align with a nationally endorsed minimum dataset. Results EDNA's collaborative network will establish a national system of surveillance and reporting of illicit and emerging drugs causing acute toxicity. Standardisation of data collection recorded in a national clinical registry will provide more robust data on epidemiology and associated harms. This will facilitate the translation of clinical and toxicological evidence into timely, appropriate harm reduction and policy. Conclusion Our work represents a collaborative response to calls for more sophisticated data on emerging drug trends in Australia. EDNA will improve coordination between clinicians and analytical services by way of its standardised approach to surveillance and reporting.

INTRODUCTION:The often unknown nature of acute drug intoxication, especially with illicit drugs and emerging novel psychoactive substances, can present a significant challenge for emergency clinicians. Less experienced clinicians are particularly vulnerable to the diagnostic dilemmas of complex toxicology emergencies. We sought to better understand the confidence of junior doctors in assessing and managing toxicological emergencies across two emergency departments in Perth, Australia.METHODS:An online survey was conducted between August 2020 and February 2021. Self-rated confidence was measured on a five-point Likert Scale across 10 statements. Two open-ended questions were included to capture perceived barriers and facilitators impacting clinical confidence. Quantitative data were analysed using descriptive methods and Fisher's exact test. Free-text responses were analysed using content analysis.RESULTS:A total of 104 surveys were completed (19.2% interns, 40.4% resident medical officers and 40.4% registrars). Self-rated confidence varied across statements and by staff type. The lowest confidence rating was for managing a patient who had overdosed from an unknown substance (31.7%) and the highest rating for referring a patient to psychiatry following deliberate self-poisoning (86.6%). Confidence increased with greater clinical experience for all statements. Qualitative analysis revealed perceptions of clinical preparedness, complexity of patients and a safe and supportive culture as key factors impacting confidence.DISCUSSION AND CONCLUSIONS:Overcoming perceived deficits in knowledge and clinical experience were key to building confidence. Our findings highlight the need for improved access to toxicology-specific curricula and training, and strategies to ensure adequate supervision from senior clinicians.

OBJECTIVE:To assess the accuracy and marginal value of quantitative D-dimer testing for diagnosing venom-induced consumption coagulopathy (VICC) in people bitten by Australian snakes.DESIGN, SETTING:Analysis of data for suspected and confirmed cases of snakebite collected prospectively by the Australian Snakebite Project, 2005-2019, from 200 hospitals across Australia.PARTICIPANTS:1363 patients for whom D-dimer was quantitatively assessed within 24 hours of suspected or confirmed snakebite.MAIN OUTCOME MEASURES:Diagnostic performance of quantitative D-dimer testing for detecting systemic envenoming with VICC (area under the receiver operating characteristic curve, AUC); optimal D-dimer cut-off value (maximum sum of sensitivity and specificity).RESULTS:D-dimer values exceeded 2.5 mg/L within three hours of the bite for 95% of patients who developed VICC, and were lower than 2.5 mg/L for 95% of non-envenomed patients up to six hours after snakebite. The AUC for diagnosing envenoming with VICC on the basis of quantitative D-dimer testing within six hours of snakebite was 0.97 (95% CI, 0.96-0.98; 944 patients). Diagnostic performance increased during the first three hours after snakebite; for quantitative D-dimer testing at 2-6 hours, the AUC was 0.99 (95% CI, 0.99-1.0); with a cut-off of 2.5 mg/L, sensitivity was 97.1% (95% CI, 95.0-98.3%) and specificity 99.0% (95% CI, 97.6-99.6%) for VICC. For 36 patients with normal international normalised ratio (INR) and activated partial thromboplastin time (aPTT) values 2-6 hours after snakebite, the AUC was 0.97 (95% CI, 0.93-1.0); with a cut-off of 1.4 mg/L, sensitivity was 94% (95% CI, 82-99%) and specificity 96% (95% CI, 94-97%). In all but one of 84 patients who developed VICC-related acute kidney injury, D-dimer values exceeded 4 mg/L within 24 hours of the bite.CONCLUSION:D-dimer concentrations assessed 2-6 hours after snakebite, with a cut-off value of 2.5 mg/L, could be useful for diagnosing envenoming with VICC.

Illicit drugs are involved in 7% of emergency department (ED) presentations, however the identification and measurement of blood concentrations is unavailable to the emergency physician [1]. Relying on clinical impressions can be inaccurate affecting further diagnostic evaluation and treatment in these patients. An approach based on the Western Australian Illicit Substance Evaluation (WISE) study developed at our hospital, overcomes this through the collection, storage and analysis of blood samples using Liquid Chromatography-Quadrupole-Mass Spectrometry [2]. If a clinician suspects that a patient has taken an illicit drug, then a blood sample can be collected. Knowledge of the causative agent in the clinical context may allow management to be tailored, particularly in life threatening ingestions and clusters (defined as aggregation of cases close in time and place) of poisoning. A cluster of patients with suspected 3, 4-methylenedioxymethamphetamine (MDMA) poisoning illustrates the value of blood testing to detect or exclude illicit drugs as a cause of the patient’s presentation. A cluster of six patients presented with suspected illicit drug intoxication to the ED of Royal Perth Hospital over 4 h in 2019. Many patients exhibited agitated delirium, sweating, tachycardia, dilated pupils, and abnormal movements suggestive of sympathomimetic toxicity. All patients received symptomatic care for sympathomimetic toxicity including IV fluids and benzodiazepines. Blood samples were sent to WA ChemCentre Forensic Laboratories for analysis against a database of approximately 500 illicit and novel psychoactive compounds. Results were available within 29 h of sample receipt (Table 1). MDMA was detected in four patients, with median plasma MDMA concentrations 0.29mg/L (IQR, 0.10–0.57). In those patients all were discharged from hospital by 24 h. However one of these patients ( ) presented with status epilepticus requiring intubation and admission to ICU that was attributed to MDMA intoxication. This assumption was refuted at 29 h when no illicit drugs were detected in her blood analysis thus prompting ongoing investigations (MRI brain, EEG, lumbar puncture, vasculitic and autoimmune screens), looking for alternate causes for their seizure disorder. There is currently limited information relating MDMA plasma concentrations to clinical effects in recreational users. The Australian National Coronial Information System reports a median MDMA concentration of 0.45mg/L between 2001 and 2018 and was significantly higher amongst females than males (0.70 vs. 0.42mg/L). Deaths attributed solely to MDMA toxicity had higher blood MDMA concentration than deaths attributed to multiple drugs (1.20 vs. 0.43mg/L) [3]. The patients in this cluster had median plasma MDMA concentrations of 0.29mg/L. This cluster highlights that despite similar patient presentations in close proximity in location and time, the inference of these associations can lead to medical bias. Blood collection, storage and analysis helps refine clinical decisions and management. In the most severely unwell patient, the absence of illicit drugs on analysis changed the direction of clinical management. While results currently take 24 h, advances in analysis and wider availability of assays for illicit substances have the potential to improve the timeliness of clinical care and reduce clinical bias. This cluster also noted that plasma MDMA concentrations were at median levels as previously reported in coronial literature.

Calcium channel blockers (CCB) overdose can result in cardiogenic shock and that high dose insulin euglycaemic therapy (HIET) is increasingly used to treat CCB poisoning. This case illustrates the risk of severe hypokalaemia resulting from HIET for calcium channel blocker poisoning.

Emergency Medicine AustralasiaVolume 32, Issue 5 p. 901-901 Letter to the Editor Comparison of illicit drug-related presentations to the emergency department: Pre-COVID versus COVID Clara Marais, Clara Marais Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this authorJessamine Soderstrom, Jessamine Soderstrom Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this authorDaniel Fatovich, Daniel Fatovich daniel.fatovich@health.wa.gov.au orcid.org/0000-0001-9414-6905 Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this author Clara Marais, Clara Marais Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this authorJessamine Soderstrom, Jessamine Soderstrom Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this authorDaniel Fatovich, Daniel Fatovich daniel.fatovich@health.wa.gov.au orcid.org/0000-0001-9414-6905 Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, AustraliaSearch for more papers by this author First published: 04 August 2020 https://doi.org/10.1111/1742-6723.13597Citations: 5 Clara Marais, BSc, BA, MBBS. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume32, Issue5October 2020Pages 901-901 RelatedInformation

Introduction Paracetamol is a common agent taken in deliberate self-poisoning and in accidental overdose in adults and children. Paracetamol poisoning is the commonest cause of severe acute liver injury. Since the publication of the previous guidelines in 2015, several studies have changed practice. A working group of experts in the area, with representation from all Poisons Information Centres of Australia and New Zealand, were brought together to produce an updated evidence-based guidance. Main recommendations (unchanged from previous guidelines) The optimal management of most patients with paracetamol overdose is usually straightforward. Patients who present early should be given activated charcoal. Patients at risk of hepatotoxicity should receive intravenous acetylcysteine. The paracetamol nomogram is used to assess the need for treatment in acute immediate release paracetamol ingestions with a known time of ingestion. Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid ingestion in children, and repeated supratherapeutic ingestions. Major changes in management in the guidelines The new guidelines recommend a two-bag acetylcysteine infusion regimen (200 mg/kg over 4 h, then 100 mg/kg over 16 h). This has similar efficacy but significantly reduced adverse reactions compared with the previous three-bag regimen. Massive paracetamol overdoses that result in high paracetamol concentrations more than double the nomogram line should be managed with an increased dose of acetylcysteine. All potentially toxic modified release paracetamol ingestions (>= 10 g or >= 200 mg/kg, whichever is less) should receive a full course of acetylcysteine. Patients ingesting >= 30 g or >= 500 mg/kg should receive increased doses of acetylcysteine.

OBJECTIVE:An ever-increasing number of novel psychoactive substances are being detected worldwide. These emerging drugs have been demonstrated to cause toxicity in clusters, and deaths have been reported. We urgently need to learn more about their effects. We report the protocol for the Western Australian Illicit Substance Evaluation (WISE) study, a research project investigating illicit drug use in the ED.METHODS:Patients can be enrolled if the treating clinician strongly suspects they are currently intoxicated with a stimulant, hallucinogenic or cannabinoid drug; and an i.v. cannula or blood tests are required for routine clinical care. Patients are enrolled under a waiver of consent. A single additional blood tube is collected, de-identified and frozen on site. A temporary link between patient identification number and study identification number is retained for up to 10 business days post-hospital discharge to allow for clinical data collection, before this is destroyed and the patients become permanently de-identified. Samples are transported for external liquid chromatography-mass spectrometry analysis in batches once de-identified.RESULTS:The key outcome will be identification of any psychoactive drugs present in the blood sample, together with their respective concentration. This will be linked to the clinical effects, as well as being compared with the substance the patient believed they had taken.CONCLUSION:We consider the novel approach outlined forms a template for an early warning system for emerging drugs of concern, while also providing vital and comprehensive information on current drugs of abuse, their clinical effects and their impact on the health system.

Isoniazid is a rare overdose that causes seizures and there is limited evidence to guide treatment. We report a 20-year-old female migrant who presented with recurrent seizures after ingesting 25 g of isoniazid. She was treated with activated charcoal, repeated doses of midazolam for the seizures, and given multiple doses of pyridoxine (14 mg), limited by availability. She was admitted to intensive care, and 5.5 hours post-ingestion, she was commenced on continuous veno-venous hemodiafiltration (CVVHDF). She was extubated after 24 hours and CVVHDF was ceased 6 hours later (30 hours post-overdose). Her renal function remained normal and her initial lactate was the highest at 2.3. She made a full recovery. Five plasma samples were collected before, during, and after CVVHDF, and isoniazid was quantified with liquid chromatography-tandem mass spectrometry. A pharmacokinetic analysis of time-isoniazid concentration data was fitted to a two-compartment model with first-order input (with fixed ka ) with the effect of CVVHDF modeled as a time-dependent covariate. This suggested that there was initially good clearance with CVVHDF (4 times endogenous clearance), which rapidly declined within hours.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT:• Paracetamol is commonly used in deliberate self poisoning (DSP) and this requires blood sampling to refine risk assessment. If saliva concentrations agreed with plasma concentrations, then this could support the development of non-invasive testing. Our pilot work supports this hypothesis, but was largely confined to nontoxic concentrations.WHAT THIS STUDY ADDS:• We found agreement between the indications for treatment of paracetamol DSP based on plasma and saliva paracetamol concentrations. Saliva may hold promise as a non-invasive method to risk stratify paracetamol poisoning.AIMS:Paracetamol is commonly used in deliberate self poisoning (DSP) and requires blood sampling to refine risk assessment. We aimed to test the agreement between plasma and saliva paracetamol concentrations in the toxic range in DSP.METHODS:Contemporaneous paired plasma and saliva paracetamol concentrations were measured. Saliva was collected using a Sarstedt Salivette® device and the concentration was measured using a colorimetric method.RESULTS:Fifty-six patients (44, 78% female) median age 26 years (IQR 20-41) were enrolled. The median reported paracetamol ingestion was 10 g (IQR 6-14). Specimens were collected at a median of 4 h (IQR 4-5.3) post ingestion. The median plasma and saliva paracetamol concentrations were 29 mg l(-1) (IQR 8-110) and 38 mg l(-1) (IQR 10-105) respectively [mean difference 8 mg l(-1) , 95% confidence interval (CI) 2, 14]. Lin's concordance correlation was 0.97 (95% CI 0.96, 0.98). There were 15 patients who were treated with N-acetylcysteine. Their median reported paracetamol ingestion was 14 g (IQR 10-23) and samples were collected at a median of 4 h post ingestion. The median plasma and saliva paracetamol concentrations were 167 mg l(-1) (IQR 110-200) and 170 mg l(-1) (IQR 103-210) respectively (mean difference 15 mg l(-1) , 95% CI -4, 35). Lin's concordance correlation was 0.94 (95% CI 0.88, 0.99). No patient needing treatment would have been missed using saliva concentrations only.CONCLUSIONS:The agreement between the indications for treatment of paracetamol DSP based on plasma and saliva paracetamol concentrations extends into the toxic range, but with slightly lower agreement. Saliva may hold promise as a non-invasive method to risk stratify paracetamol poisoning.

Objective The Royal Perth Hospital (RPH; Perth, Australia) has been the receiving facility for burns patients in two separate disasters. In 2002, RPH received 28 severely injured burns patients after the Bali bombing, and in 2009 RPH received 23 significantly burnt patients as a result of an explosion on board a foreign vessel in the remote Ashmore Reef Islands (840?km west of Darwin). The aim of this paper is to identify the interventions developed following the Bali bombing in 2002 and review their effectiveness of their implementation in the subsequent burns disaster. Methods A comparative case study analysis using a standardised approach was used to describe context with debrief reports and ED photographs from both disasters used for evaluation. Results The implementation of regular ED disaster response planning and training, early Code Brown notification of the entire hospital with regular updates, early clearing of inpatient beds, use of Short Message Service to communicate regularly with ED staff, control of the public and media access to the ED, visual identification of staff within the ED, early panendoscopy to ascertain intubation needs, and senior clinical decision makers in all areas of the ED were all acknowledged as effective based on the debrief reports. There was a reduction in ED length of stay (150 to 55?min) and no deaths occurred; however, quantitative analysis can only be suggestive rather than a direct measure of improvement given the likelihood of other system changes. Conclusion There were a number of lessons observed from the Bali experience in 2002 that have led to improvements in practice and lessons learned.

Introduction: Little is known about patient perceptions of the lethality of their overdose. Our aim was to compare patient perceptions with the risk assessment of clinical toxicologists.Methods: A prospective observational study of overdose patients presenting to a tertiary hospital. Eligible patients were surveyed once they were medically fit for psychiatric evaluation. Descriptive data were collected, including the Pierce Suicide Intent Scale (SIS). In response to 'how dangerous did you think this overdose was when you took the tablets?' patients marked a 10 cm VAS, with 0 = would be harmless, 10 = certain to cause death. A panel of clinical toxicologists independently made a risk assessment on a 10 cm VAS, with 0 = non-toxic ingestion and 10 = uniform lethality even with full medical intervention.Results: Of 202 patients enrolled, 118 (58.4%, 95% CI 51-65) were female; median age 33 years (interquartile range [IQR] 24-42). One hundred and three (51%, 95% CI 44-58) stated it was their intention to kill themselves and 44 (21.8%, 95% CI 16-28) wrote a suicide note. They most commonly used their own prescription medications (141, 69.8%, 95% CI 63-76). The median patient visual analog scale (VAS) was 5.8 (IQR 2.3-8.3) and median toxicology VAS was 1.4 (IQR 0.6-2.8); this difference was statistically significant (P < 0.0001). The correlation between the patient visual analog scale (VAS) and Pierce SIS (median 8.5/25 [IQR 4-12]) was strong (r = 0.73, P < 0.0001).Conclusions: Patient perceptions of the lethality of their overdose are correlated with their suicidal intent as measured on the Pierce SIS, with a significant mismatch between patient perceptions and the toxicological risk assessment.