Prolonged coma resulting from massive levothyroxine overdose and the utility of N-terminal prohormone brain natriuretic peptide (NT-proBNP).

Introduction: Levothyroxine overdose rarely results in systemic toxicity. We report a case of intentional levothyroxine overdose with a delayed onset coma and delirium lasting two weeks.

Case Summary: A 72-year-old female ingested 12 mg levothyroxine.

Patterns of poisoning exposure at different ages: the 2015 annual report of the Australian Poisons Information Centres.

Objectives: To characterise the types of calls received by Australian Poisons Information Centres (PICs) in Australia, and to analyse poisoning exposures by age group, circumstances of exposure, and the types of substances involved. Design, setting: Retrospective analysis of call records from all four Australian PICs (national coverage).

Main Outcome Measures: Basic demographic information; exposure circumstances, substance types involved in each age group; recommendations for management (eg, stay at home, go to hospital).

Increasing rates of quetiapine overdose, misuse, and mortality in Victoria, Australia.

Background: Quetiapine is misused due to its anxiolytic and hedonic effects and has been associated with deliberate self-harm. This study analyzed quetiapine-related calls to the Victorian Poisons Information Centre (VPIC), coronial data from Victorian Institute of Forensic Medicine (VIFM) and prescribed data from the Pharmaceutical Benefits Scheme (PBS) to determine current trends in overdose, misuse and mortality.

Methods: This was a retrospective review of multiple databases.

'Massive' metformin overdose.

Massive metformin overdose can cause metabolic acidosis with hyperlactatemia. A 55-year-old woman presented 5 h after multidrug overdose, including 132 g extended-release metformin. Continuous venovenous haemodiafiltration (CVVHDF) and noradrenaline were commenced due to metabolic acidosis (pH 7.

Accuracy of the paracetamol-aminotransferase product to predict hepatotoxicity in paracetamol overdose treated with a 2-bag acetylcysteine regimen.

Introduction: Paracetamol concentration is a highly accurate risk predictor for hepatotoxicity following overdose with known time of ingestion. However, the paracetamol-aminotransferase multiplication product can be used as a risk predictor independent of timing or ingestion type. Validated in patients treated with the traditional, "three-bag" intravenous acetylcysteine regimen, we evaluated the accuracy of the multiplication product in paracetamol overdose treated with a two-bag acetylcysteine regimen.

Pharmacokinetic modelling of modified acetylcysteine infusion regimens used in the treatment of paracetamol poisoning.

Purpose: Paracetamol overdose is common and is treated with acetylcysteine to prevent the development of hepatotoxicity. N-acetyl-p-benzoquinone imine (NAPQI) is the toxic metabolite of paracetamol overdose. We aimed to assess the expected acetylcysteine concentration time profiles following delivery of modified acetylcysteine regimens proposed for those at high and low risk of hepatotoxicity.

Impact of online toxicology training on health professionals: the Global Educational Toxicology Uniting Project (GETUP).

Objective: The Global Educational Toxicology Uniting Project (GETUP), supported by the American College of Medical Toxicology, links countries with and without toxicology services via distance education with the aim to improve education. Due to the lack of toxicology services in some countries there is a knowledge gap in the management of poisonings. We describe our experience with the worldwide delivery of an online introductory toxicology curriculum to emergency doctors and other health professionals treating poisoned patients.

Risk prediction of hepatotoxicity in paracetamol poisoning.

Context: Paracetamol (acetaminophen) poisoning is the most common cause of acute liver failure in the developed world. A paracetamol treatment nomogram has been used for over four decades to help determine whether patients will develop hepatotoxicity without acetylcysteine treatment, and thus indicates those needing treatment. Despite this, a small proportion of patients still develop hepatotoxicity.

Accuracy of the paracetamol-aminotransferase multiplication product to predict hepatotoxicity in modified-release paracetamol overdose.

Context: The paracetamol-aminotransferase multiplication product (APAP × ALT) is a risk predictor of hepatotoxicity that is somewhat independent of time and type of ingestion. However, its accuracy following ingestion of modified-release formulations is not known, as the product has been derived and validated after immediate-release paracetamol overdoses.

Objective: The aim of this retrospective cohort study was to evaluate the accuracy of the multiplication product to predict hepatotoxicity in a cohort of patients with modified-release paracetamol overdose.

Outcomes from massive paracetamol overdose: a retrospective observational study.

Linked Article: This article is commented on by Bateman DN and Dear JW. Should we treat very large paracetamol overdose differently? Br J Clin Pharmacol 2017; 83: 1163-5. https://doi.

Workplace chemical and toxin exposures reported to a Poisons Information Centre: a diverse range causing variable morbidity.

Objective: The aim of this study is to determine the period prevalence, nature and causes of workplace chemical and toxin exposures reported to the Victorian Poisons Information Centre (VPIC).

Patients And Methods: All cases classified as 'workplace: acute' when entered into the VPIC database (June 2005-December 2013) were analysed. Data were collected on patient sex, the nature of the chemical or toxin, route of exposure and season.

Severe Hypertension and Bradycardia Secondary to Midodrine Overdose.

The objective of this case is to describe the pharmacokinetics and toxicity of midodrine in overdose. A 20 year old female ingested up to 350 mg midodrine while recovering in hospital from another overdose. She developed vomiting and severe hypertension (blood pressure [BP], 210/100 mmHg).

A decade of Australian methotrexate dosing errors.

Objective: Accidental daily dosing of methotrexate can result in life-threatening toxicity. We investigated methotrexate dosing errors reported to the National Coronial Information System (NCIS), the Therapeutic Goods Administration Database of Adverse Event Notifications (TGA DAEN) and Australian Poisons Information Centres (PICs).

Design And Setting: A retrospective review of coronial cases in the NCIS (2000-2014), and of reports to the TGA DAEN (2004-2014) and Australian PICs (2004-2015).

Accuracy of QT interval measurement on electrocardiographs displayed on electronic 'smart' devices.

Objective: The objective of the study was to compare QT intervals measured on the original bedside electrocardiographs (ECG), facsimile, iPhone, iPad and 17 inch computer monitor.

Methods: This was a prospective, observational study conducted within a tertiary referral metropolitan ED. Thirteen doctors measured the QT intervals of 15 non-identifiable, routinely recorded ECGs using randomly allocated modalities over five sessions.

Simplification of the standard three-bag intravenous acetylcysteine regimen for paracetamol poisoning results in a lower incidence of adverse drug reactions.

Context: Adverse reactions to intravenous (IV) acetylcysteine treatment in paracetamol overdose, are common. Previous studies suggest the incidence and severity of non-allergic anaphylactic reactions (NAARs) are influenced by the rate of acetylcysteine infusion.

Objective: We compared the incidence of adverse drug events of a two-bag IV acetylcysteine regimen with that of the traditional three-bag regimen.

High-visibility warning labels on paracetamol-containing products do not prevent supratherapeutic ingestion in a simulated scenario.

Context: In Australia, legislation requires medication containing paracetamol display warning of co-administration with other paracetamol products, and safe maximum daily dosing (4 g). Labelling style, size and visibility differ, potentially leading possible supratherapeutic misadventure.

Objective: We studied the likelihood of participants exceeding the recommended dose of paracetamol using products with standard packaging versus products labelled with one of two additional warning labels.