Management of pharmaceutical and recreational drug poisoning

Bruno Mégarbane; Mathieu Oberlin; Jean-Claude Alvarez; Frederic Balen; Sébastien Beaune; Régis Bédry; Anthony Chauvin; Isabelle Claudet; Vincent Danel; Guillaume Debaty; Arnaud Delahaye; Nicolas Deye; Jean-Michel Gaulier; Francis Grossenbacher; Philippe Hantson; Frédéric Jacobs; Karim Jaffal; Magali Labadie; Laurence Labat; Jérôme Langrand; Frédéric Lapostolle; Philippe Le Conte; Maxime Maignan; Patrick Nisse; Philippe Sauder; Christine Tournoud; Dominique Vodovar; Sebastian Voicu; Pierre-Géraud Claret; Charles Cerf

doi:10.1186/s13613-020-00762-9

Management of pharmaceutical and recreational drug poisoning

Ann Intensive Care. 2020 Nov 23;10(1):157. doi: 10.1186/s13613-020-00762-9.

Authors

Bruno Mégarbane¹, Mathieu Oberlin², Jean-Claude Alvarez³, Frederic Balen⁴, Sébastien Beaune⁵, Régis Bédry⁶, Anthony Chauvin⁷, Isabelle Claudet⁸, Vincent Danel⁹, Guillaume Debaty¹⁰, Arnaud Delahaye¹¹, Nicolas Deye¹², Jean-Michel Gaulier¹³, Francis Grossenbacher¹⁴, Philippe Hantson¹⁵, Frédéric Jacobs¹⁶, Karim Jaffal¹⁷, Magali Labadie¹⁸, Laurence Labat¹⁹, Jérôme Langrand²⁰, Frédéric Lapostolle²¹, Philippe Le Conte²², Maxime Maignan²³, Patrick Nisse²⁴, Philippe Sauder²⁵, Christine Tournoud²⁶, Dominique Vodovar²⁰, Sebastian Voicu¹⁷, Pierre-Géraud Claret²⁷, Charles Cerf²⁸

Affiliations

¹ Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010, France. [email protected].
² Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France.
³ Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France.
⁴ Emergency Department, Toulouse University Hospital, Toulouse, France.
⁵ Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France.
⁶ Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France.
⁷ Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France.
⁸ Pediatric Emergency Department Children's Hospital CHU Toulouse, Toulouse, France.
⁹ Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France.
¹⁰ 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France.
¹¹ Intensive Care Unit, Rodez Hospital, Rodez, France.
¹² Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France.
¹³ Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L'Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France.
¹⁴ Emergency Department, Reims University Hospital, Reims, France.
¹⁵ Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium.
¹⁶ Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France.
¹⁷ Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010, France.
¹⁸ Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France.
¹⁹ Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France.
²⁰ Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France.
²¹ SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France.
²² Department of Emergency Medicine, University Hospital of Nantes, Nantes, France.
²³ Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France.
²⁴ Poison Control Centre, University Hospital of Lille, Lille, France.
²⁵ Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France.
²⁶ Poison Control Centre, University Hospital of Nancy, Nancy, France.
²⁷ Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France.
²⁸ Intensive Care Unit, Foch Hospital, Suresnes, France.

Abstract

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.

Keywords: Antidote; Guidelines; Intoxication; Pharmaceutical drug; Poisoning; Recreational drug.

Publication types

Review