The Age Distribution of Illicit Agents Users.

 

Year	Country	Age	n	Substance	Reference
2021	US	40.0 ±11.4	1362	illegal drug	https://pubmed.ncbi.nlm.nih.gov/34831700/
2022	Taiwan	36.0 ±30.0	675	illicit drugs	https://pubmed.ncbi.nlm.nih.gov/35315299/
2020	Taiwan	34.5 ± 10.0	203	illicit substance	https://pubmed.ncbi.nlm.nih.gov/32037264/
2016	Switzerland	33	210	psychoactive substances	https://pubmed.ncbi.nlm.nih.gov/27228985/
2017	Switzerland	33	503	recreational drug toxicity	https://pubmed.ncbi.nlm.nih.gov/28264690/
2021	UK	31.2 (SD 10.0)	283	ketamine	https://pubmed.ncbi.nlm.nih.gov/34092131/
2021	Spain	31	17198	acute drug toxicity	https://pubmed.ncbi.nlm.nih.gov/33724118/
2016	Japan	30	589	novel psychoactive substances	https://pubmed.ncbi.nlm.nih.gov/27314752/
2016	Germany	26.9	13	gamma hydroxybutyrate	https://pubmed.ncbi.nlm.nih.gov/26395197/
2022	Taiwan	25.5	24	Nitrous Oxide	https://pubmed.ncbi.nlm.nih.gov/35324737/

 Edited by Yu-Jang Su   June 26, 2022. 

SSRI (selective serotonin reuptake inhibitor)

 SSRI (selective serotonin reuptake inhibitor) 血清素再吸收阻斷劑

SUBSTANCE

 

-          Newer and safer antidepressant compared to TCA [1].

-          Lower ADR than TCA.

 

 

Common name or Trade name 

 

-          Fluvoxamine、Paroxetine、Sertraline、Citalopram、Escitalopram、Fluoxetine。

 

 

Involving SYSTEM

 

-          Serotonin,  about 98% in extra-CNS [2]。

-          A long elimination half-life, with sustained biological activity due to active metabolites

-          In overdose, SSRI elimination times are further prolonged by the saturation of metabolic enzymes and by delayed absorption, especially for sustained-release preparations.

-          Electrolyte imbalance: hyponatremia, easily seen in the elderly [3].

-          Neural system: extra-pyramidal, hyperreflexia, Clonus, myoclonus [4].

-          Respiratory system: failure. Cough.

-          Gastrointestinal system: nausea, upset.

 

Presentation

 

-          Cause vomiting, mild CNS depression, or tremor.

-          Hyponatremia.

-          Unstable blood pressure. Arrhythmia. VT. Arrest, QRS QTc prolongation, Torsades de pointes [5].

-Bradycardia, hypotension: Fluvoxamine (Luvox)

- hyperreflexia, Clonus, myoclonus.

- Sweating, agitation.

- fever, coma, seizure (1.9%) [6].

 

Antidote and Treatment 

 

-          BLS, gastric lavage < 1 hr.  

-          Activated charcoal.

-          Not recommended for laxative.

-ACLS, inotropic agent.

-Nitroglycerin或Nitroprusside for hypertension。

-  magnesium sulfate 2 g IV over 2 min for Torsades de points

-  wide QRS: NaHCO3 1 to 2 mEq/kg IV push

- (benzodiazepine, BZD) for seizure.

- Serotonin antagonist:

     -Cyproheptadine (oral form; sedation) [7]. 12 mg, followed by 2 mg every 2 h if symptoms continue. 

- (Extrapyramidal signs): Diphenylhydramine 50mg bid。

 

Disposition

 

-          Suspicious: observe 6-8 hours with ECG monitoring, if no symptoms, then may be discharged.

-          Citalopram, need observe longer to 12hours, observe arrhythmia / convulsion [8].

 

REFERENCES

 

[1]. https://pubmed.ncbi.nlm.nih.gov/35206480/

[2]. https://pubmed.ncbi.nlm.nih.gov/19361459/

[3]. https://pubmed.ncbi.nlm.nih.gov/34483534/

[4]. https://pubmed.ncbi.nlm.nih.gov/23391344/

[5]. https://pubmed.ncbi.nlm.nih.gov/31845095/

[6]. https://pubmed.ncbi.nlm.nih.gov/30521236/

[7]. https://pubmed.ncbi.nlm.nih.gov/20833944/

[8]. https://pubmed.ncbi.nlm.nih.gov/33489987/

 

Edited by Yu-Jang Su                 May 26, 2022,  

                                                    June 21, 2026 revision.

Drug Overdose

 

Finding	Substance	Country	Reference
Top three types of substances were benzodiazepine (42.9%), mixed medications (32.1%), and acetaminophen (6.1%). Mean age: 39.2±18.3 years old Male intentional overdose patients were 8.1 years older than their female counterparts (45.3±19.5 vs. 37.2±17.5, respectively; P<0.05). Most intentional overdose cases occurred during the spring season (n=63, 32.1%), especially in male patients (n=28, 57.1%; P<0.001). Approximately 11.2% and 2% of the total patients were admitted to the Toxicology ward and intensive care units, respectively.	Overdose	Taiwan	[1]2022
Mean age of the cases was 23.1 +/- 7.3 years 84.1% of them were females. The risk factors were more significantly associated with males: chronic ethanol intake (p = 0.04), higher reported dose ingested (p = 0.01), higher latency time (p = 0.04) and longer hospital stay (p = 0.03).	Acetaminophen	Malaysia	[2]2010
Majority of cases were men (78%) Mean age was 37 years. (90%) were polydrug intoxications. Heroin was implicated in 67%. Residential address was the most  common place of death (67%). Women were 4 years older.	Drug-induced death	Norway	[3]2013
Suicide attempts occurred more frequently between May and November, and on Tuesdays.	overdose	Hong Kong	[4]2013
The mortality rate for overdose was 16.6 per 1000 PY for males and 13.74 per 1000 PY for females. In the multivariate regression analysis, the time from first ED overdose access (less than 1 year risk ratio [RR]: 7.07, 95% confidence interval [CI]: 5.32-9.39) was significantly associated with death by overdose. Males, subjects aged >30 years at presentation, patients who refused ED treatment, and those having previously contacted mental health services showed an increased mortality risk due to overdose.	overdose	Italy	[5]2016
Female sex (odds ratio [OR], 2.41); comorbid renal disease (OR, 4.22); untreated sleep apnea (OR, 32.32); receipt of long-acting oxycodone (OR, 4.76); and as-needed use of hydromorphone (OR, 2.73) were significant predictors of oversedation.	Overdose	United States	[6]2018

[1] https://www.spandidos-publications.com/10.3892/br.2022.1532

[2] https://pubmed.ncbi.nlm.nih.gov/20737523/

[3] https://pubmed.ncbi.nlm.nih.gov/23302498/

[4] https://pubmed.ncbi.nlm.nih.gov/24011683/

[5] https://pubmed.ncbi.nlm.nih.gov/26914353/

[6] https://pubmed.ncbi.nlm.nih.gov/30190295/

 Edited by Yu-Jang Su   April 21, 2022. 

 

Poisoning/ Intoxicated caused Skin discoloration

 

Substance	Skin	Year	Country	Reference
Carbon monoxide	cherry-red colour in the skin	1988	South Africa	Br J Dermatol. 1988 Jul;119(1):45-51. doi: 10.1111/j.1365-2133.1988.tb07099.x. PMID: 3408663.
Silver	darkly grayish "discolored" skin	2002	USA	Vet Hum Toxicol. 2002 Oct;44(5):291-2. PMID: 12361115.
dipyridamole (Persantin Depot) corresponding to 34 g	drug has a distinct yellowish colour	2003	Swedish	Lakartidningen. 2003 Dec 11;100(50):4194-5. Swedish. PMID: 14717009.
Rohypnol 1 film tablets (containing the coloring agent indigocarmine in its core)	bluish-turquoise coloration nostril and within the oral cavity	2004	German	Arch Kriminol. 2004 Sep-Oct;214(3-4):93-8. German. PMID: 15553282.
Cresol	black urine and dark skin	2010	Malyasia	Clin Toxicol (Phila). 2010 Nov;48(9):959-60. doi: 10.3109/15563650.2010.523830. Epub 2010 Oct 6. PMID: 20923396.
300 mg of vitamin B6 per day over 6 months	brown-coloured skin	2015	Kiel, Germany	Eur J Clin Nutr. 2015 Jul;69(7):862-3. doi: 10.1038/ejcn.2015.83. Epub 2015 Jun 3. PMID: 26039319.
2,3-dimercapto-1-propanesulfonic acid (DMPS)	Fixed drug eruption (ADR)* Annular, purple color plaque on penis	2019	Ankara , Turkey	Acta Clin Belg. 2019 Jun;74(3):200-202. doi: 10.1080/17843286.2018.1484983. Epub 2018 Jun 18. PMID: 29912651.
2,4-dinitrophenol (DNP) and clenbuterol	yellowish skin colour	2020	Paris, France.	Int J Legal Med. 2020 May;134(3):1003-1006. doi: 10.1007/s00414-020-02268-2.

l  * ADR= adverse reaction.

edited by Yu-Jang Su   March 2, 2022. 

 

Poisoning / Intoxicated related Intracranial Hemorrhage.

 

Date	Country	Age	Gender	Substance	hemorrhage
2019	China	44	Female	Bromadiolone, often called a super-warfarin	SAH [1]
2018	France	47	Man	Ticagrelor	ICH [2]
2018	Japan		Male	Cocaine	SAH [3]
2017	China	Neonatus	Male	Bromadiolone, often called a super-warfarin	severe SDH, bilateral IVH  and SAH [4]
2017	Iran	70	Male	Methanol	expanding hemorrhagic transformation in previous hypodensities.[5]
2017	Canada		Female	Diethylene glycol (DEG)	right basal ganglia hemorrhage[6]
2016	Saudi Arabia	47	Man	Methanol	basal ganglia; putamen, IVH, SAH[7]
2015	Korea			Methanol	IVH [8]
2006	Turkey	35	Male	Methanol	ICH[9]
2005	France	50	Male	Ethylene glycol	Bipallidal haemorrhage[10]
1995	Brazil			Methanol	Bilateral putaminal hemorrhage[11]
1988	Canada			Methanol	13.5% ICH [12]

  The table does not contain trauma, secondary causes, and substance leading to intracranial hemorrhage with unclear, unexplained mechanisms. SAH =  subarachnoid hemorrhage; ICH = intracranial hemorrhage; IVH = intra-ventricular hemorrhage.

 

References

 

1.      Zuo W, Zhang X, Chang JB, Ma WB, Wei JJ. Bromadiolone poisoning leading to subarachnoid haemorrhage: A case report and review of the literature. J Clin Pharm Ther. 2019 Dec;44(6):958-962. doi: 10.1111/jcpt.13005. Epub 2019 Sep 26. PMID: 31556967.

2.      Willeman T, Marlu R, Böhle H, Francony G, Jourdil JF, Fonrose X, Stanke-Labesque F. Lethal cerebral hemorrhage after ticagrelor intoxication: a specific antidote is urgently needed. Clin Toxicol (Phila). 2018 Dec;56(12):1200-1203. doi: 10.1080/15563650.2018.1480026. Epub 2018 Jun 11. PMID: 29889575.

3.      Takayama M, Waters B, Fujii H, Hara K, Kashiwagi M, Matsusue A, Ikematsu N, Kubo SI. Subarachnoid hemorrhage in a Japanese cocaine abuser: Cocaine-related sudden death. Leg Med (Tokyo). 2018 May;32:43-47. doi: 10.1016/j.legalmed.2018.02.008. Epub 2018 Mar 2. PMID: 29518652.

4.      Ma M, Zhang M, Tang X, Li Z. Massive neonatal intracranial hemorrhage caused by bromadiolone: A case report. Medicine (Baltimore). 2017 Nov;96(45):e8506. doi: 10.1097/MD.0000000000008506. PMID: 29137047; PMCID: PMC5690740.

5.      Hassanian-Moghaddam H, Bahrami-Motlagh H, Zamani N, Fazeli SA, Behnam B. Intracranial Hemorrhage in Methanol Toxicity: Challenging the Probable Heparin Effect during Hemodialysis. J Res Pharm Pract. 2017 Jul-Sep;6(3):186-189. doi: 10.4103/jrpp.JRPP_17_39. PMID: 29026846; PMCID: PMC5632941.

6.      Gupta A, Diaz FJ, Lal A, Sung L, Aaron CK. Basal Ganglion Hemorrhage as Delayed Complication of Diethylene Glycol Ingestion. Am J Forensic Med Pathol. 2017 Mar;38(1):39-42. doi: 10.1097/PAF.0000000000000295. PMID: 28085681.

7.      Aisa TM, Ballut OM. Methanol intoxication with cerebral hemorrhage. Neurosciences (Riyadh). 2016 Jul;21(3):275-7. doi: 10.17712/nsj.2016.3.20150592. PMID: 27356664; PMCID: PMC5107299.

8.      Lee SM, Moon JM, Chun BJ, Song KH. Unusual intracranial hemorrhage in severe methanol intoxication. Am J Emerg Med. 2015 Nov;33(11):1717.e1-2. doi: 10.1016/j.ajem.2015.03.031. Epub 2015 Mar 18. PMID: 25892398.

9.      Sebe A, Satar S, Uzun B, Topal M, Yesilagac H, Avci A. Intracranial hemorrhage associated with methanol intoxication. Mt Sinai J Med. 2006 Dec;73(8):1120-2. PMID: 17285208.

10.  Caparros-Lefebvre D, Policard J, Sengler C, Benabdallah E, Colombani S, Rigal M. Bipallidal haemorrhage after ethylene glycol intoxication. Neuroradiology. 2005 Feb;47(2):105-7. doi: 10.1007/s00234-005-1347-y. Epub 2005 Feb 16. PMID: 15714272.

11.  Giudicissi Filho M, Holanda CV, Nader NA, Gomes SR, Bertolucci PH. Bilateral putaminal hemorrhage related to methanol poisoning: a complication of hemodialysis? Case report. Arq Neuropsiquiatr. 1995 Sep;53(3-A):485-7. doi: 10.1590/s0004-282x1995000300020. PMID: 8540827.

12.  Phang PT, Passerini L, Mielke B, Berendt R, King EG. Brain hemorrhage associated with methanol poisoning. Crit Care Med. 1988 Feb;16(2):137-40. doi: 10.1097/00003246-198802000-00008. PMID: 3342624.

edited by Yu-Jang Su                 Feb, 14, 2022