CTOX Annual report 2017emergpa.net/wp/wp-content/uploads/CTOX-Annual-report...A prospective observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine

2017 Annual Report

Clinical Toxicology Unit Princess Alexandra Hospital

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Table of Contents

Page

Executive Summary 4

Section 1: Service Data

Clinical Toxicology Unit Staffing Levels 6

Activities 6

Yearly Presentations CTOX 2015-2016 7

2016 Monthly CTOX Presentations 7

2016 BATS Consults 8

Presentations by Age and Gender 9

Patient Flow Management 10

Prescription Drug Presentations 11

Recreational Drug Presentations 12

Length of Stay 13

Section 2: Research and Educational Activities 2012-2016

Summary 14

Research – Publications 15

Research – Conference presentations 18

Research – Conference posters 20

Book Chapters/Sections 22

Reviews for Journals 23

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Executive Summary In 2017 the Clinical Toxicology Unit consolidated its progress since its introduction in 2014. Growth

was 5% over 2016 with 2246 patients admitted or consulted on. The local consultative service to

Metro South Health District (MSHD) hospitals which was established in 2016 also grew with 453

calls taken over the 2017 calendar year. These are very impressive results based on the unit’s

current funding. 2017 also saw the publication in Emergency Medicine Australasia of our efforts in

reducing length of stay since the unit’s inception (2014 & 2015). It is pleasing to see that the unit’s

performance based on Health Roundtable data in reducing length of stay continues to be

maintained in 2016 & 2017 and the unit continues to have one of the lowest lengths of stay with

over 500 bed days saved per year. The cost savings associated with this reduction in length of

stay are considerable. Depending on different government sources these savings amount to 1.1-

1.8 million dollars per year and the unit has the lowest relative cost for toxicology patients of all

hospitals contributing to the Health Roundtable at 37%. These results are outstanding and

represent the hard efforts of all those involved with the unit’s day-to-day activities.

In addition to the unit’s clinical work, teaching and research continue to feature prominently.

Monthly clinical meetings, which review clinical activity as well as case presentations, research

activity and journal club are well attended and provide a focus of ongoing review of the unit’s

activity. Morbidity and mortality cases are also an important component of these meetings and are

reviewed 6 monthly.

Funding is the unit’s biggest challenge long term. Despite the very impressive results to date, the

unit’s sustainability and ongoing viability is under threat if the unit cannot attract additional funding.

These are challenging times when it comes to hospital funding, and the competing interests of all

hospital services make financial decisions by hospital executive and management challenging and

difficult. We hope that our hard work and results to date over the last 4 years will ultimately be

rewarded.

Lastly but most importantly I have many people to thank. Since I have been on long term sick

leave Dr Katherine Isoardi has taken over the unit’s directorship and has done an outstanding job

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in continuing the unit’s responsibilities and in addition has grown the service we currently provide.

Thank you also to Dr Melanie Armitage who stepped in at late notice and to Dr Keith Harris who

commenced clinical toxicology training with us in 2018. Support from my emergency and general

medicine colleagues continues to be very much appreciated.

Dr Colin Page

MBChB FACEM MMedSci (Clin Epid)

Clinical Toxicologist

Director of Clinical Toxicology & Medical Director Queensland Poisons Information Centre

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Service Data

Clinical Toxicology Unit Staffing

Director Dr Colin Page

Staff Specialist Dr Katherine Isoardi (0.5 FTE)

Fellow Dr Melanie Armitage (0.5 FTE)

Registrar

ED (ACEM Advanced trainee) Dr Rebecca Bryant (Jan-July)

Dr Andrew Brier (Aug–Jan)

Ward (Clin Pharm Advanced trainee) Dr Chris Morris

Nursing

CNC ED Short Stay Ward Dale Mason

CNC Ward 5A Ian Ross

Office Manager Jillian Vernon

Administration Officer (0.5 FTE) Rebecca Knowles

Activities

• Daily ward rounds of toxicology patients throughout the hospital

• Brisbane Area Toxicology Service (BATS) consult

• QPIC toxicology consultant calls

• Database of unit’s activities (Filemaker relational database)

• Monthly unit meetings – continuing medical education

• 6 Monthly Morbidity and Mortality meetings

• Regular presentations at PAH ED teaching program

• Medical Grand Rounds

• Education sessions at other Brisbane ED’s – LCCH, Logan, Redlands, QEII

• QPIC Continuing Medical Education meetings

• TAPNA workshop facilitator

• ACEM Autumn Symposium facilitator

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Yearly CTOX Presentations

CTOX Presentations per Month

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BATS Consults per Month

BATS Consults

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Presentations by Age and Gender

Exposure intent

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Overall Patient Disposition

Most Common Prescription Drug Presentations

Prescription Drug Presentation by Class

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Recreational Drug Presentations

Other exposures

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Health Round Table Data: Average Length of Stay

Health Round Table Data: Relative Stay Index

Creationof TOXunit

Creationof TOXunit

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Research Activities

Summary

The unit has a number of research projects in 2017:

1. Shorter Acetylcysteine Regimen in Paracetamol Overdose Trial (SARPO)

A non-inferiority multi-centre RCT comparing short course to standard course N-acetyl

cysteine for the treatment of paracetamol overdose.

2. QAS sedation study

Prospective observational study examining the efficacy and safety of droperidol in

comparison to midazolam in the pre-hospital management of patients requiring sedation for

acute behavioural disturbance. This study was completed in 2017. Ongoing studies are

researching the use of droperidol in two age groups (65 years) in addition to

looking at the role of ketamine for failed sedation are currently underway.

3. Australian Toxicology Monitoring Study (ATOM)

Prospective observational study examining the pharmacokinetics and pharmacodynamics

of drugs in overdose.

APP Australian paracetamol project

VATS Valproate Toxicity

SPAM Sotalol, Propranolol, Atenolol, Metoprolol

METOX Metformin Toxicity Study

HIP Herbicide Intoxication & Pharmacokinetic study

DORA Digoxin Overdose & Response to Antibiotics

aPTT Anticoagulation Project Time and Treatment

SODA Sodium channel blocking drugs and bicarbonate therapy

MIA Methotrexate Intoxication & Antidotes

PGTP Pregabalin

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4. Australian Snakebite Project (ASP)

A prospective observational study of snake bite and snake envenomation in Australia with

laboratory confirmation of venom levels

5. Methamphetamine and Acute Kidney Injury Study (MAKI)

A prospective observational study determining if patients with an elevated creatinine in the

context of methamphetamine intoxication actually have acute kidney injury.

6. QPIC documentation and advice adherence Study

A prospective observational study examining the effect on advice adherence after timely

documentation in the patient’s electronic record

7. Retrospective case series

a. Amphetamine Presentations to a Toxicology Unit

b. Characterisation of Naloxone Use in a Toxicology Unit

c. Delirium in toxicological patients

8. Case reports with drug levels of rare toxic drugs in overdose

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Publications 2013-2017 Page CB, Ryan NM and Isbister GK. The safety of high-dose euglycaemia therapy in toxin-

induced cardiac toxicity. Clin Toxicol 2017 Oct 26:1-8. doi: 10.1080/15563650.2017.1391391

Chiew AL, Page CB, Clancy D, Mostafa A, Roberts MS and Isbister GK. 2-Methyl-4-

chlorophenoxyacetic acid (MCPA) and Bromoxynil herbicide ingestion. Clin Toxicol 2017 Oct

9: 1-4. Doi.1080/15563650.2017.1385790

Johnston CI, Ryan NM, Page CB, Buckley NA, Brown SG, O’Leary MA and Isbister GK. The

Australian Snakebite Project, 2005-2015 (ASP-20) Med J Aust 2017;207(3):119-125

Chiew AL, Isbister GK, Kirby KA, Page CB, Chan BSH and Buckley NA. Massive paracetamol

overdose: an observational study of the effect of activated charcoal and increased

acetylcysteine dose (ATOM-2). Clin Toxicol 2017; 55(10):1055-1065

Pillans PI, Page CB, Ilango S, Kashchuk A, Isbister GK. Poisoning in elderly Australians – A

prospective cohort study. Med J Aust 2017;206(4):164-169

Isoardi KZ, Armitage MA, Harris K, Page CB. Establishing a dedicated toxicology unit

reduces length of stay of poisoned patients and saves hospital bed days. Emerg Med

Australas 2017; 29(3):310-314.

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia

and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Jan

20:1-6. doi: 10.1080/15563650.2016.1277234. [Epub ahead of print]

Page CB, Mostafa A, Saiao A, Grice JE, Roberts MS, Isbister GK. Cardiovascular toxicity with

levetiracetam overdose. Clin Toxicol. 2016 Feb;54(2):152-4.

Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-

Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med.

2016;67(5):581-87.

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Page CB, Kruger PS, Dimeski G, Walsham J. Severe Toxicity with Guanidine Thiocyanate

Ingestion. J Clin Toxicol 2016;6(5)325

Armitage MA, Woolfield KI, Page CB. Serotonin toxicity caused by the interaction of fentanyl

and serotonergic medications. Emerg Med Australas. 2016 Feb;28(1):119-120

Isbister GK, Downes MA, McNamara K, Berling I, Whyte IM, Page CB. A prospective

observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine

in paracetamol poisoning. Clin Toxicol. 2016;54(2):120-126.

Bateman DN, Page CB. Antidotes to coumarins, isoniazid, methotrexate and thyroxine, toxins

that work via metabolic processes. Brit J Clin Pharamacol. 2016 Mar;81(3):437-445.

Isbister GK, Page CB. Brown snake envenoming: Why are we left in the dark? Clin Toxicol

2015 Nov;53(9):925

Calver L. Page CB, Downes M, Chan B, Kinnear F, Wheatley L, Spain D and Isbister GK. The

Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the

Emergency Department. Ann Emerg Med 2015 Vol. 66, Issue 3, p230–238.e1

Letter to above – in reply Isbister GK, Calver L, Downes MA, Page CB. Ann Emerg Med. 2016

Jan;67(1):146-7.

Calver L, Drinkwater V, Gupta R, Page CB & Isbister GK. Droperidol v. haloperidol for

sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J

Psychiatry. 2015 Mar;206(3):223-8.

Isbister GK, Maduwage K & Page CB. Antivenom cross neutralisation in a suspected Asian pit

viper envenoming causing severe coagulopathy. Toxicon 2014;90:286-90

Williams MM, Taylor PJ, Page CB & Martin JH. Clinical research in synthetic cannabinoids —

do we need a national approach. Med J Aust 2014; 201(6): 1-3

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Isbister GK, Page CB, Buckley NA, Fatovich Dm. Pascu O, MacDonald SPJ, Calver LA &

Brown SGA. Randomized Controlled Trial of Intravenous Antivenom Versus Placebo for

Latrodectism: The Second Redback Antivenom Evaluation (RAVE-II) Study. Ann Emerg Med

2014, Vol. 64, Issue 6, p620–628.e2

Letter to above – in reply Geoffrey K. Isbister, Colin B. Page, Nicholas A. Buckley, Daniel M.

Fatovich, Simon G.A. Brown. Ann Emerg Med, Vol. 65, Issue 1, p124–125

Dimeski G, Jones B, Pillans P, Page C, Brown NN. Digoxin overdose - an accurate method for

determining free digoxin concentrations on general chemistry analysers post DigiFab

treatment. Clin Chem Lab Med. 2014 Feb 24.

Isbister GK, Buckley NA, Page CB et al. Snakebite in Australia: a practical approach to

diagnosis and treatment. Med J Aust 2013;199(11): 763-8

Isbister GK, Buckley NA, Page CB et al. A randomized controlled trial of fresh frozen plasma

for treating venom-induced consumption coagulopathy in cases of Australian snakebite (ASP-

18). J Thromb Haemost 2013 Jul; 11: 1310-18

Isbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment of

QT interval in clinical practice. Brit J Clin Pharamacol 2013 Jul;76(1) 48-57

Parker SD, De Gioannis A & Page C. Chronic promethazine misuse and the possibility of

dependence: a brief review of antihistamine abuse and dependence. J Subst Use 2013;18(3):

238-41

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Conference Presentations 2013-2017 Page CB, Parker LE, Rashford SJ, Bosley E, Isoardi KZ, Williamson FE and Isbister GK. A

Prospective Observational Study of Midazolam and Droperidol for Prehospital Acute Behavioural

Disturbance. Paramedics Australasia International Conference Melbourne November 2017.

Chan BSH, Chiew AL, Page CB, O'Leary M, Isbister GK and Buckley NA. Acute digoxin

overdose and response to antibody (DORA study). EAPCCT Basel May 2017.

Chiew AL, Isbister GK, Page CB, Chan BSH, Buckley NA. Modified release paracetamol

overdose: a prospective observational study. EAPCCT Basel May 2017.

Ayles S, Finch C, Isoardi KZ and Page CB. Amphetamine Presentations to a Toxicology Unit:

Management and Complications. TAPNA Melbourne April 2017.

Page CB, Ryan NM, Isoardi GK. The use and safety of high dose insulin euglycaemia in toxin

induced cardiac toxicity. TAPNA, Melbourne April 2017.

Chan BS, Chiew A, Page C, O’Leary M, Isbister G, Buckley NA. Acute Digoxin Overdose and

Response to Antibody (DORA study). TAPNA, Melbourne April 2017.

Chan BS, Chiew A, Page C, Abdalla A, Buckley NA, Roberts M, Isbister G. Dihydropyridine

CCB Toxicity (DTP) and the renin angiotensin axis. TAPNA, Melbourne April 2017.

Chiew AL, Isbister GK, Page CB, Chan BSH, Buckley NA. Modified release paracetamol

overdose: a prospective observational study. TAPNA, Melbourne April 2017.

Wylie C, Heffernan A, Brown J, Cairns R Lynch AM, Robinson J, Page C. Electronic cigarettes

– smoking cessation tool or potential poison. TAPNA, Melbourne April 2017.

Isoardi KZ, Armitage M, Harris K, Page CB. Establishing a dedicated toxicology unit reduces

length of stay of poisoned patients and saves hospital bed days. TAPNA Brisbane May 2016.

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Page CB, Isoardi KZ, Armitage M, Rosek T, Roberts M, Isbister GK. Severe Toxicity with

Triclopyr Overdose – A Case Report. TAPNA Brisbane May 2016.

Downes MA, Berling IL, Page CB, Whyte IM, Isbister GK. Use of an electronic device based

database to measure the telephone consultation workload of a regional toxicology service in

Australia. TAPNA Brisbane May 2016.

Chiew AL, Isbister GK, Page CB, Buckley NA. Management of massive paracetamol

overdose. An observational study. TAPNA Brisbane May 2016.

Ryan N, Page CB, Isbister GK. The incidence of pregabalin overdose has increased but

clinical effects are primarily associated with the coingestants. TAPNA Brisbane May 2016.

Chiew AL, Isbister GK, Page CB, Buckley NA. Massive Paracetamol Overdose: An

Observational Study. EAPCCT Madrid May 2016

Vlad I, Page C, Brown J & Cairns R. Jungle Juice or When Oxygen Does not Turn Blue into

Red. TAPNA 2015

Page C. Toxicology Knicks Knacks. The new NAC. A novel infusion protocol for the

administration of N-acetyl cysteine. Autumn Symposium (Queensland ACEM) May 2014

Chiew A & Page C. Just another paracetamol overdose. TAPNA 2014

McNamara KP, Sellors K, Isbister GK, Whyte IM, Page C, Downes M. Death following

recreational use of alpha-pyrrolidinopentophenone (alpha PVP): A case of excited delirium

syndrome. TAPNA May 2013

McNamara KP, Isbister GK, Whyte IM, Page CB, Downes M. Sustained release paracetamol

toxicity: A case of kinetics. TAPNA May 2013

Dean D, Wylie C & Page C. A bite to remember. A case report of a snakebite envenoming.

TAPNA May 2013.

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Conference Posters 2013 – 2017

Chan BSH, Chiew AL, Page CB, Isbister GK, Buckley NA. Dihydropyridine calcium channel

blocker toxicity and the renin angiotensin axis. EAPCCT Basel May 2017.

Roberts DM and Page CB. Gastrointestinal toxicity and acute kidney injury following ingestion

of suspected Amanita ochrophylla. EAPCCT Basel May 2017.

Roberts DM, Xu T and Page CB. Effect of extracorporeal treatments in a patient with

prolonged phenytoin toxicity. EAPCCT Basel May 2017.

Chiew AL, Page CB, Clancey D, Mostafa A, Roberts MS, Isbister GK. Bin-Die ingestion: Too

hot to handle. TAPNA, Melbourne April 2017.

Page CB, Ryan NM, Isbister GK. The Use and Safety of High Dose Insulin Euglycaemia

Therapy in Toxin Induced Cardiac Toxicity. TAPNA, Melbourne April 2017.

Isbister GK, Heppell S. Page CB, Ryan N. Adult clonidine overdose: prolonged bradycardia

and CNS depression but not severe toxicity. TAPNA Brisbane May 2016.

Roberts D, Xu, Tina, Page CB. Effect of extracorporeal treatments in a patient with prolonged

phenytoin toxicity. TAPNA Brisbane May 2016.

Logan H, Dean D, Soderstrom J, Page CB. Baby Bottle blues. A Case Report of Ethylene

Glycol Poisoning. TAPNA Brisbane May 2016.

Page CB, Kruger PS, Dimeski G, Walsham J. Severe Toxicity with Guanidine Thiocyanate

Ingestion. EAPCCT Madrid May 2016

Page CB, Isoardi KZ, Armitage MC, Rosek T, Roberts M, Isbister GK. Severe Toxicity with

Triclopyr Overdose – A Case Report. EAPCCT Madrid May 2016

Page CB, Ryan NM, Isbister GK. The Use and Safety of High Dose Insulin Euglycaemia

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Therapy in Toxin Induced Cardiac Toxicity. EAPCCT Madrid May 2016

Isbister GK, Page CB, Ryan N. Changing epidemiology and severity of opioid poisoning: from

street drugs to prescription medications. NACCT Boston September 2016

Isbister G, Downes M, McNamara K, Berling I, Whyte I, Page C. A novel infusion protocol for

the administration of acetylcysteine. EAPCCT Malta May 2015

Page CB, Mostafa A, Saiao A, Grice J, Roberts M, Isbister GK. Cardiovascular Toxicity with

Levetiracetam Overdose. EAPCCT Malta May 2015

Isbister GK, Buckley NA, Page CB, Brown SGA. A multicentre cohort study of snake

envenoming defines clinical syndromes and influences clinical practice?. EAPCTT Malta May

2015

Page C, Berling I & Isbister G. Rate dependent bundle branch block in drug overdose a case

report. TAPNA 2014.

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Book Chapters/Sections

Therapeutic Guidelines Toxicology (3rd edition expert panel) 2017

QAS Clinical Procedure Manual - Toxicology section 2016

PAH prescribing guidelines – toxicology section 2011 & 2016

Oxford textbook of Critical Care 4th ed 2016. Poisoning – Beta Blockers and Calcium

channel Blockers. Co-authored with Geoff Isbister.

Queensland Health and Royal Flying Doctor Service (Queensland Section), Primary Clinical

Care Manual 9th edition 2015 (& 8th edition 2013, 7th edition 2011). Poisoning and drug

emergencies and toxinology chapters. Co-authored with Carol Wylie – Manager Queensland

Poisons Information Centre.

RBH prescribing guidelines – toxicology section 2011 & 2013

Section Editor – Toxicology – Emergency Medicine Australasia (2013-present)

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Reviews for Journals

Annals of Pharmacotherapy

Human & Experimental Toxicology

Journal of Clinical Psychopharmacology

Emergency Medicine Australasia

Emergency Medicine Journal

General Hospital Psychiatry

Medical Journal of Australia

Australian Prescriber

Neuropsychiatric Disease and Treatment

CNS Drugs

European Journal of Emergency Medicine

Journal of the Neurological Sciences

Documents

CTOX Annual report 2017emergpa.net/wp/wp-content/uploads/CTOX-Annual-report...A prospective observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine