Background: Poisoning contributes to significant morbidity and mortality worldwide, leading to significant hospital resource needs. Toxicology teams provide expert advice and impact management and length of stay for patients. Purpose: In May 2019, the Singhealth cluster toxicology service was started, providing its consult services to all hospitals in the cluster. An audit review of the patients referred to the service over a 2-year period is presented. (May 2019-April 2021). Research Design: A retrospective audit review of consultation records was performed. Study Sample: All patients referred to the Singhealth Cluster Toxicology Service. Data collection and analysis: Patient demographics, exposure patterns, clinical presentation, interventions received, and outcome were examined and presented. Information about resource use (length of stay, critical care utilisation), together with critical poisoning cases, cases placed on extracorporeal membrane oxygenation and fatalities are reviewed and presented briefly. Results: 911 records were analysed. Most were referred from the ED (87.2%), were male (50.7%), and were in the 20-29 age group (29.9%). Most were self-referred (84.3%) with oral ingestion (81.7%) being most common and majority attending for intentional (69.9%) and deliberate self-harm. The most common poison class was analgesics (20.4%), followed by sedatives and antidepressants. There were 509 hospital admissions, with 153 patients requiring HD/ICU admission. The median length of stay was 3 to 5 days respectively. A total of 9 deaths occurred, 3 of which were undoubtedly caused by poisoning. Conclusion: The Singhealth Toxicology Service provides valuable insight in the management of poisoned patients and plays a pivotal role in harm prevention and informing resource allocation.

Data on patients with poisoning requiring ICU (Intensive Care Unit) & HD (High Dependency) care in Singapore is inadequate. In this study, we describe the epidemiological, clinical characteristics, implicated agents, interventions, and outcomes of patients with toxic exposures admitted to HD & ICU. We conducted a retrospective and observational study. Hospital records of all cases referred to CGH Toxicology Service from 1 January 2015 to 31 December 2022 were reviewed. A total of 245 (9.6%) out of 2547 patients reviewed required HD or ICU care. 131 patients were admitted to ICU, while 114 patients were admitted to HD beds. Amongst those admitted to ICU, male to female ratio was approximately 60:40, and the commonest age group was 31-40 years old (19.9%), while deliberate self-harm poisoning accounted for 52.7 % of these cases. Benzodiazepines, anti-psychotics, anti-depressants, and opioids were most involved.The fatality rate was 3.2 %. Cardiotoxic drugs, anti-psychotics, and anti-depressants were associated with most fatalities. Benzodiazepines, anti-psychotics, anti-depressants, and opioids were the most associated with ICU admissions, while cardiotoxic drugs, anti-psychotics, and anti-depressants were associated most with mortalities.

Spin cycling (spinning) is an increasingly popular indoor sport both in Singapore and worldwide.We find a growing trend in cases of spin-induced rhabdomyolysis (SIR) among beginners of this sport presenting to our Emergency Department (ED), all requiring hospitalisation for further treatment.Spinning is an indoor cycling sport using a specialised stationary bicycle.It is often touted as an optimal aerobic sport, and a quick solution to increase one's metabolic rate and relieve stress.It is sometimes done in a group, with each session lasting 30-60 minutes.The intensity of cycling can be adjusted through cadence (i.e. the rate at which the cyclist pedals) and pedalling resistance.Exertional rhabdomyolysis is the breakdown of muscle that occurs after excessive or unaccustomed exercise.It is characterised by muscle pain, markedly elevated levels of serum muscle enzyme (e.g.creatine kinase) and myoglobinuria.We present a case series of 5 patients, all new to the sport, who developed exertional rhabdomyolysis after their spin session in March 2020.They presented to the ED of the Changi General Hospital, Singapore.This study was approved by the SingHealth Institutional Review Board (CIRB 2020/2475).Cases.The 5 patients' presenting history, clinical features, diagnostic workup, and medical management are as described.All patients were young adults in their 20s, non-smokers, with no significant comorbidities.Three of them did not exercise regularly (once per month), while 2 did aerobic exercises 3-4 times a week.Four were attending their first spin class, while 1 was attending her second class.In all the cases, the spin sessions were done as a group and in the presence of a class instructor.The spin duration for these patients was 45 minutes.The patients presented 2-4 days after their spin class.All had a common presenting complaint of bilateral thigh pain.Four also passed brown or dark urine, with the onset occurring 2-3 days after spinning.None of the patients had any intercurrent illnesses, or had any trauma.All 5 patients were given intravenous fluids and hospitalised.Peak serum creatine kinase (CK) levels for 1 patient remained at >100,000U/L for 3 days, while

Novel psychoactive substances (NPSs) are a new generation of designer drugs that are quickly replacing the traditionally abused street drugs. Since their development, the number of molecules in NPSs and their variants have expanded exponentially. Little is known locally about the toxic effects of the exposure of these NPSs. We report two cases of accidental ingestion of methyl (2S)-2-{[1-(5-fluoropentyl)-1H-indole-3-arbonyl]amino}-3,3-dimethylbutanoate (5-fluoro-MDMB-PICA), a recent NPS. They were drinking the liquid in a winter melon tea bottle, and one patient had a seizure episode directly after ingestion. Both patients were managed supportively and discharged after a brief hospitalization period. Presentation to the emergency departments (EDs) following exposure to NPSs may become more common. Knowledge about the impact of NPS exposure and their clinical effects is lacking amongst emergency physicians in Singapore, and this case report serves as a potential resource for physicians.

Introduction Emergency department observation units (EDOU) have been shown to be effective in decreasing hospitalization rates and length of stay (LOS) for various conditions. However, cost savings and efficacy in the management of poisoning in EDOU have not been widely studied. The objective of our study is to compare the costs and effectiveness of managing paracetamol poisoned patients in the EDOU with those treated in the inpatient wards. Methods We conducted a historical controlled observational study comparing paracetamol-poisoned patients (who received at least 21 hours of IV N-acetylcysteine [NAC]) admitted to the EDOU during 2013-2014 with similar patients admitted to inpatient ward during 2011, 2013-2014. Results We found 136 patients admitted to the inpatient ward and 95 to our EDOU due to paracetamol poisoning but only 78 and 39 patients respectively fulfilled the inclusion criteria. Between the EDOU and inpatient ward groups, we found similar demographics, poisoning presentation, treatment, and adverse event profiles. There were no fatalities and only two patients (one from each group) developed hepatotoxicity. The "medical" length of stay was 31.9 hours shorter in the EDOU group compared to the inpatient ward group (23.3 versus 55.2 hours). EDOU patients have statistically significant savings (comparing bill size) of S$784 per patient. Conclusions Admission to the EDOU resulted in significant cost savings and 58% decreased LOS when compared to inpatient wards. The EDOU is a cost-effective and safe alternative for the management of selected paracetamol poisonings requiring NAC. Further studies would be needed to verify these results.

INTRODUCTION Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. METHODS A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. RESULTS A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. CONCLUSION The quality improvement initiative resulted in a reduction in median DIN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.

Objectives: A toxicology team providing round-the-clock consultations for poisoning was established in Changi General Hospital in November 2014. This study aims to describe the epidemiology of patients referred to this service in 2015. Methods: A retrospective electronic and paper records review of all patients referred to the toxicology service from January to December 2015 was performed for demographics, poisoning, clinical, and outcome data. The cases were graded for poisoning severity score (PSS), likelihood of poisoning exposure and relative contribution to fatality for death cases. Results: A total of 306 cases were referred to this service in 2015. The median age was 34 years with majority being females (54%). The most common cause of poisoning was deliberate self-harm (62%) and the most common route of poisoning was oral (85%). Analgesics (21%) and sedatives (19%) were the most common poisoning classes. Six per cent of patients received decontamination and 17% received antidotes. The likelihood of poisoning exposure was probable to definite certainty for 85% of the cases. Mild poisoning (PSS 0–1) constituted 76% of the cohort, while 22% had moderate to severe poisoning (PSS 2–3). Out of the five fatalities, three were exposure-related fatalities contributing to a fatality rate of 1%. Fifty-four per cent of patients were admitted to the emergency department observation unit, 17% to general inpatient wards and 9% to either intensive care unit or high dependency wards. Conclusions: Although most poisoning cases resulted in mild clinical effects, a small but significant number of severe acuity cases occurred in this cohort.

Introduction: The mainstay of treatment for significant envenoming from snakebites is antivenom. However, there is insufficient data regarding the safety of antivenom used in Hong Kong. We describe the incidence of hypersensitivity reactions from antivenom use and review the frequency and reasons for intensive care unit (ICU) admission. Methods: The Hong Kong Poisons Information Centre database was reviewed. All patients given snake antivenom between 2008 and 2015 were included. Patient demographics, species of snake involved, details of antivenom used, treatment location, use of pre-treatment, reasons for ICU admission (where applicable) and details of early and late antivenom reactions were extracted. Results: There were 191 patients who received snake antivenom. Most (93%) were treated with either the green pit viper antivenom from Thailand or the Agkistrodon halys antivenom from China. The incidences of early hypersensitivity reactions to green pit viper antivenom and Agkistrodon Halys antivenom were 4.7% and 1.4%, respectively. Most patients (69%) were managed in the ED observation ward or general ward. There were 59 patients managed in ICU, most (90%) of whom were admitted for close monitoring during antivenom administration. There were no cases of significant morbidity from antivenom administration. Eight patients (5.6%) had features suggestive of mild serum sickness. Conclusions: The incidence of immediate hypersensitivity reaction to antivenom commonly used in Hong Kong is low. Majority of patients were managed safely in the emergency department observation ward or general ward. Serum sickness appears to be uncommon and possible cases presented with mild features.

Background A significant proportion of patients with toxic exposures presenting to the ED require admission. However, most will improve within 24 hours, and so could potentially be managed in a short-stay observation unit. We describe the management and outcomes of these patients in a 23-hour ED observation unit (EDOU). Methods A retrospective chart review of all patients with toxic exposures admitted to the EDOU in Singapore between 1 April 2013 and 31 March 2015 was performed. Patient demographics, exposure patterns, clinical presentation and interventions received were abstracted. The poisoning severity score (PSS) was retrospectively determined. Outcomes were length of stay and disposition. Results A total of 286 patients were analysed, of which 78.0% had intentional self-poisoning, 12.2% had bites/stings and 9.8% had unintentional or occupational toxic exposures. Analgesics (29.4%), sedatives (12.3%) and antidepressants (6.8%) were the most common drugs encountered. The majority of patients had a mild (68.9%) or moderate (15.4%) PSS, but 4.2% were graded as severe. Most patients with deliberate self-poisoning were reviewed by psychiatry (88.8%) and social services (74.9%). Most patients (92.0%) were medically cleared during their stay in EDOU, including all 12 with a severe PSS. Of these, 200 (69.9%) were discharged and 63 (22.0%) were transferred directly to a psychiatric unit. The median length of stay in the EDOU was 18 hours (IQR 13–23). Conclusion Most patients admitted to the EDOU were successfully managed and medically cleared within 23 hours, including those with a severe PSS. The EDOU appears to be a suitable alternative to inpatient admission for selected patients.

Although snakebites are uncommon, there are several species of medically important venomous snakes native to Singapore. We present a case of envenoming by the shore pit viper (Trimeresurus purpureomaculatus) that showed clinical improvement when treated with the Indian (Haffkine) polyvalent antivenom. A 40-year-old man was bitten on his right hand by a snake, which was identified through photos and his description to be a shore pit viper, which is native to the local mangrove area. Severe swelling and pain developed immediately after the bite, which progressed up the arm. Because of the progression of local swelling, antivenom was started. He was given a total of 6 vials (60 mL) of polyvalent antivenom, with the first vial started 3 hours after the bite. He showed clinical improvement within 24 hours. His subsequent recovery was uneventful, with no other complications as a result of envenomation or antivenom use. Severe envenoming by the shore pit viper can lead to marked local effects such as extensive swelling and tissue necrosis. Antivenom is indicated in the presence of severe local envenomation. Antivenom against the shore pit viper is however not available locally. The Indian (Haffkine) polyvalent antivenom contains antibodies against 4 common venomous snakes in India, namely the Indian cobra, common krait, Russell's viper, and sawscaled viper. The improvement seen in this patient suggests possible cross-neutralizing activity of the Indian vipers' antivenom against the local shore pit viper venom. Further in vivo and in vitro studies should be performed to verify this clinical case.

Objective.-We describe the epidemiology and clinical features of scorpion stings presenting to an emergency department in Singapore, including that of the venomous species Isometrus maculatus. A management approach to scorpion stings is proposed.Methods.-A retrospective study was done for patients from 2004 to 2009. Cases were identified by searching through emergency department records with ICD code E905, inpatient records, and the hospital toxicology service records. Identification of species was assisted by the Venom and Toxin research program at the National University of Singapore.Results.-A total of 13 cases of scorpion stings were identified. Eleven stings occurred locally, and the remaining 2 stings occurred in neighboring countries. The most common presenting symptoms were pain (92%), numbness (31%), and weakness (23%) confined to the region of the sting. The most common clinical signs recorded were redness (77%), tenderness (77%), and swelling (46%). Only 2 patients had significant alterations of vital signs: 1 had hypertension and the other had hypotension from anaphylaxis. Three patients experienced complications (abscess formation, anaphylaxis, cellulitis) requiring inpatient management. There were no fatalities, and all patients made a good recovery. Three cases were identified to be stings from I maculatus. These cases occurred locally, and mainly had clinical features of pain, redness, and mild regional numbness.Conclusions.-Scorpion stings are uncommon presentations to the emergency department. Most stings cause local reactions that can be managed with supportive treatment. Stings by I maculatus were observed to cause mild, self-limiting effects.