Is routine screening for Aspirin deliberate self-poisoning ...€¦ · CEREBRAL OEDEMA 31(100%)...
Transcript of Is routine screening for Aspirin deliberate self-poisoning ...€¦ · CEREBRAL OEDEMA 31(100%)...
ROUTINE SCREENING FOR ASPIRIN IN DELIBERATE SELF
POISONING?Nic Ionmhain, U. ¹, Kavanagh, K. ¹, Griffin, E. ², Rokovac, A. ¹, Crowley, V. ¹, Shields, D ¹.
¹St James’s Hospital Dublin ²National Self-Harm Registry Ireland, National Suicide Research Foundation
INTRODUCTION
• Acute salicylate ingestion is a well-recognised overdose with significantpotential toxicity and fatality with aknown toxidrome
• Many Irish and UK hospitals stillperform routine salicylate assays indeliberate self-poisoning (DSP)screening (no longer standard practicein Australia) despite research evidenceover the past 20 years of its limitedutility
• Toxbase.org advises that clinical historyof ingestion, evidence of salicylism,coma or metabolic derangementshould guide its screening use
AIMS AND METHODS• Aims:
• To establish the relative national and local (SJH) frequency of DSPattendances to Emergency Departments (ED) and to investigate theproportion ingesting salicylate or paracetamol containing compounds
• To assess the cost-effectiveness of routine screening salicylate-assays
in DSP at a local level, by reviewing the number of assays from
June 2010 to April 2014
• Method: Retrospective observational cross sectional cohort study
• National statistics were obtained from the National Self-Harm RegistryIreland
• For local data, the SJH Biochemistry Department’s Telepath databaseidentified all salicylate levels performed by patient number and date of
assay.All cases with levels >5mg/dL underwent chart review for
• (1) Clinical and biochemical evidence of salicylate poisoning
• (2) Requirement for treatment of salicylate ingestion
• (3) Reported ingestion of salicylate-containing compounds
RESULTSFEATURES OF SALICYLATE
TOXICITY (n = 31)
(1 notes not available)
YES NO UNKNOWN /
NOT
DOCUMENTED
TINNITUS 31 (100%)
DEAFNESS 31 (100%)
VERTIGO 31 (100%)
VOMITING 6 (19.4%) 25 (80.6%)
AGITATION 31 (100%)
TACHYPNOEA 31 (100%)
FEVER 1(SEPTIC)
(3.2%)
27 (87.1%) 3 (9.7%)
CEREBRAL OEDEMA 31(100%)
METABOLIC ACIDOSIS 2 (SEIZURE)
(6.5%)
16 (51.5%) 13 (42%)
RESP ALKALOSIS 19 (61.3%) 12 (38.7%)
SEIZURE 2 (6.5%) 29 (93.5%)
DECEASED 31 (100%)
31658
9728 (30.7%)
975 (3.1%)2016 620 (30.8%) 52 (2.58%)
0
5000
10000
15000
20000
25000
30000
35000
All deliberate selfpoisoning attendances
All self poisoningsinvolving Paracetamol
ingestion
All self poisoningsinvolving Salicylate
ingestions
National (n=31658)
St James's Hospital(n=2016)
Total Valid Tests Total Cases
2998 2782
Positive Tests 46 (1.5%) 32 (1.2%)
Negative Tests 2959 (98.5)% 2750 (98.8%)
National Registry of Deliberate Self–Harm June 2010- April 2014
Total tests performed in SJH June 2010-April 2014
Clinical and Metabolic Features of Salicylate Toxicity
Reported Salicylate ingestion on history 23 (74%)
Peak Level 38mg /dL
Average / Median level across all cases 16.3mg/dL / 15.5mg/dL
Required treatment Nil
Admissions due to salicylate ingestion None
Additional Data
DISCUSSION AND LIMITATIONS• DISCUSSION
• DSP involving salicylates is rare on a national and local level. Routine screening ofall poisonings is unlikely to yield many positive results. Reasons for this areunclear, perhaps related to packaging restrictions ¹ or decreased use of aspirin as ahousehold analgesic
• 2782 attendances underwent routine biochemical screening for salicylate ingestionwith no evidence of toxidrome. No assays were in the toxic levels and no caserequired treatment or admission secondary to salicylate ingestion
• Our data and methods are in keeping with prior publications over the past 20 yearswhich describe salicylate ingestion as a rare overdose with limited costeffectiveness of routine screening in the awake asymptomatic patient and the highsensitivity of history and clinical symptoms for ingestion. (Wood et al 2005 ²,Graham et al 2006³, Sporer et al 1996 ⁴. )
• Routine salicylate assays cost €2.50 / test. This demonstrates a cost saving of€7,495 over the course of the study period excluding additional laboratory costs– staff, equipment etc.
• LIMITATIONS
• This study is limited by its retrospective nature involving chart review and relianceon accurate documentation and history
CONCLUSION• Salicylate ingestion nationally in Ireland and locally (St James’s Hospital) is rare
• Unlike paracetamol ingestion, it has a recognised clinical toxidrome
• Routine biochemical screening in all cases of deliberate self poisoning for salicylateingestion is unlikely to be cost-effective or clinically beneficial in the awake,asymptomatic patient
• Indications to consider performing a salicylate level should include – history ofingestion, evidence of a toxidrome, coma or metabolic derangement consistentwith a suspicion of salicylate poisoning (as per Toxbase guidelines)
• References– ¹ Hawton et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ. 2001 May
19;322(7296):1203-7.– ² Wood et al. Measuring plasma salicylate concentrations in all patients with drug overdose or altered consciousness: is it necessary? Emerg Med J. 2005 Jun;22(6):401-3. – ³ Graham et al. Paracetamol and salicylate testing: routinely required for all overdose patients? Eur J Emerg Med 2006 Feb;13(1):26-8.– ⁴ Sporer et al. Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. Am J Emerg Med 1996 Sep;14(5):443-6
• Contact: Dr Una Nic Ionmhain [email protected]