Florian Eyer

Background: A Glasgow Coma Scale (GCS) ≤ 8 is frequently used to guide prehospital intubation, but its generalizability to acutely poisoned patients is uncertain. We compared outcomes of poisoned patients with GCS ≤ 8 managed with or without prehospital intubation. Methods: We retrospectively included poisoned patients with a GCS ≤ 8 found as helpless persons in public settings and admitted to a tertiary toxicology center. Patients were grouped by prehospital intubation status. Clinical characteristics, management, and outcomes were analyzed using nonparametric and categorical tests, the analyses were exploratory due to the limited sample size. Results: Among 84 patients, 10 (11.9%) were intubated prehospitally, and 74 (88.1%) were not. Median GCS was lower in intubated patients (3 vs. 7). Aspiration pneumonitis in non-intubated patients was rare (6.8%) and did not differ significantly between groups. Vasopressor therapy within 24 h was required in one of 74 (1.4%) non-intubated patients and two of 10 (20.0%) intubated patients. Antidotes were frequently administered, especially in non-intubated patients, predominantly in the prehospital setting. Two non-intubated patients (2.7%) required delayed mechanical ventilation. No deaths occurred. Conclusions: Non-intubated patients showed favorable outcomes with low complication rates and infrequent delayed intubations, while antidotes were frequently administered in both the prehospital and in-hospital settings. These results suggest that GCS alone may be insufficient to guide airway management in poisoning, supporting an individualized, clinically guided approach.

Recreational drugs affect the cardiovascular system through distinct mechanisms; however, data regarding their cardiovascular impact in the emergency department setting is limited. This study aimed to assess the incidence of cardiovascular effects following recreational drug use in presentations to the emergency department, identify the main drug groups involved, and compare cases with and without cardiovascular effects. Data were extracted from the European Drug Emergency Network (Euro-DEN Plus) dataset from October 2013 to December 2021. Recreational drugs were categorised into ten main drug groups: opioids, cocaine, crack cocaine, cannabis, 3,4-methylenedioxymethamfetamine, amfetamine-type stimulants, gamma-hydroxybutyrate and gamma-butyrolactone, hallucinogens, benzodiazepines, and ketamine. Among 59,571 presentations, 13,905 (23.3%) involved cardiovascular effects. Cocaine (OR 3.19, 95% CI 2.99-3.39) and 3,4 methylenedioxymethamphetamine (OR 1.18, 95% CI 1.13-1.23) showed the strongest associations with cardiovascular features, including chest pain, palpitations, hypertension, and arrhythmias. Opioids (OR 0.35, 95% CI 0.31-0.38) and benzodiazepines (OR 0.38, 95% CI 0.32-0.44) were associated with less frequent cardiovascular features. Patients with cardiovascular features exhibited higher median values for temperature, heart rate, blood pressure, and respiratory rate (p <0.001). Cardiovascular features were associated with an increased risk of intubation (OR 1.91, 95% CI 1.70-2.15), critical care admission (OR 2.18, 95% CI 2.00-2.38), and mortality (OR 15.8, 95% CI 7.36-33.9). Cardiovascular effects were common in acute recreational drug toxicity. Cocaine and amfetamine-type stimulants increased the risk of chest pain and arrhythmias, with chest pain being a key indicator of acute coronary syndrome. Cardiovascular effects were more frequently observed with cocaine than with crack cocaine. Cannabis was positively associated with palpitations but not arrhythmias. Gamma-hydroxybutyrate and gamma-butyrolactone, opioids, and benzodiazepines were linked to hypotension. The presence of cardiovascular effects was associated with worse outcomes, underscoring the need for thorough cardiac assessment. Cardiovascular effects were present in almost a quarter of emergency department presentations with acute recreational drug toxicity, particularly involving cocaine and 3,4 methylenedioxymethamphetamine.

Aim: This report presents a series of 16 patients who were admitted to the emergency department following confirmed intake of the potent synthetic cannabinoid ADB‐CHMINACA. Methods: The cases are drawn from a prospective observational study following the recreational use of synthetic cannabinoids. The clinical and analytical data were combined and submitted to a Poison Centre. The severity of poisoning was evaluated on the basis of clinical data, including follow‐up information. The present analysis was conducted exclusively on patients with analytically confirmed intake of ADB‐CHMINACA and treatment in emergency departments for acute adverse effects. Cases with additional relevant serum concentrations of other drugs of abuse that suggested relevant interactions were excluded. Results: Common clinical manifestations included panic attacks, tachycardia, agitation, vomiting and seizures. Most of the patients experienced these symptoms within minutes after inhaling this new psychoactive substance. Serum concentrations of ADB‐CHMINACA varied widely and ranged from 0.2–31 ng/mL, without a clear correlation between severity of the poisoning and drug concentration. Severity of poisoning was moderate to severe, but all patients recovered. Notably, 1 of the patients developed a posterior reversible encephalopathy syndrome, a rare but serious neurological complication characterised by usually transient symptoms like headaches, seizures and altered mental state, often accompanied by brain oedema. In this case, the patient recovered after 4 days. Conclusion: Clinical presentations exhibited by patients with analytically confirmed intake of ADB‐CHMINACA showed similarities to previous reports; neuropsychiatric and cardiovascular symptoms were most prominent. Notable distinctions include the prevalence of panic attacks and trembling.

Background: Drug-induced psychosis (DIP) represents a complex clinical challenge, particularly among younger substance-using populations. Recent epidemiological data indicate increasing DIP prevalence and decreasing age at first presentation, underscoring its growing clinical and public health relevance. While DIP arises in the context of substance use, distinguishing transient episodes from emerging primary psychotic disorders remains difficult, and data on demographic and clinical variations are limited. Methods: We conducted a descriptive cohort study of 340 patients diagnosed with DIP (ICD-10: F1X.5) between 2010 and 2020 at two university hospitals in Germany. We collected data from all eligible cases (n = 170) from a toxicology department (Technical University of Munich, TUM), and from the same number of cases from a psychiatry department (Ludwig-Maximilians-Universität in Munich, LMU). Variables assessed included sociodemographic data, psychiatric symptoms, substance use (self-report and toxicology), comorbidities, and family history. Analyses included descriptive statistics, chi-square or Fisher’s exact tests, and Mann–Whitney U tests to examine group differences, and Cohen’s Kappa coefficients to quantify agreement between self-reported and toxicologically confirmed substance use. Results: The cohort was predominantly male (77.4%) with a median age of 27 years. Migration background was present in 27.6%, with admissions peaking in 2015–2018. Psychotic symptoms were dominated by perceptual disturbances (62.3%) and thought disorder (76.3%). Women exhibited higher rates of tactile hallucinations, suicidal ideation, and depression (all p < 0.05) and tended to have higher serum ethanol levels. Daily substance use was common (69.0%), with polysubstance use exceeding 75%. Cannabis and stimulants predominated in younger patients, while opiates, sedatives, and ethanol were more frequent in older groups. Self-reported substance use showed fair to good agreement with toxicological findings, with the highest concordance for opiates and lower agreement for sedatives and ethanol. Conclusion: DIP showed clear gender- and age-related differences in psychotic symptom profiles and clinical presentation, alongside high rates of daily and polysubstance use, young male predominance, and migration-related patterns. These findings underscore the need for early, individualized, and demographically informed interventions.

The Clinical Toxicology Recommendations Collaborative was established by three international clinical toxicology societies and tasked to produce recommendations on the management of poisonings. The Activated Charcoal in Clinical Toxicology Workgroup (the Workgroup) was formed to provide recommendations on the administration of activated charcoal for gastrointestinal decontamination and enhanced elimination in poisoning. Based on a systematic review of the literature, 43 poisons or poison categories were selected for appraisal. Voting statements were drafted using a predetermined format. Strength of consensus was measured using the Disagreement Index as defined by the RAND/University of California at Los Angeles Appropriateness Method. A two-round modified Delphi method was used to reach expert consensus. The Workgroup concluded that there is no role for activated charcoal in poisoning from arsenic, caesium, copper, ethanol, methanol, ethylene glycol, iron, lead, lithium, and metformin. Activated charcoal is appropriate after ingestion of antidysrhythmics (types I and III not discussed specifically), beta-adrenergic antagonists, bupropion, calcium-channel blockers, carbamazepine, cardiac glycosides, chloroquine, cocaine, colchicine, cyanide, dapsone, diphenhydramine, disopyramide, factor Xa inhibitors, ibuprofen, isoniazid, lamotrigine, methotrexate, moclobemide, opioids, organophosphorus insecticides, paracetamol (acetaminophen), paraquat, phenobarbital, phenytoin, quinidine and quinine, salicylates, selective serotonin reuptake inhibitors, sulfonylureas, thallium, theophylline, tricyclic antidepressants, valproic acid, venlafaxine, and warfarin. An additional dose of activated charcoal to complete gastrointestinal decontamination is appropriate after ingestion of carbamazepine, paracetamol, paraquat, phenobarbital, salicylates, thallium, theophylline, valproic acid and verapamil. The maximum time post-ingestion for which activated charcoal administration is recommended differs for each poison and different formulations. According to an individualized risk assessment, activated charcoal is appropriate up to 6 h post-ingestion for many poisons. If ongoing absorption is suspected, which may occur, for example, with pharmacobezoar formation, certain modified-release preparations, or when drug burden exceeds the limits of solubility, then activated charcoal can be administered beyond 6 h post-ingestion for gastrointestinal decontamination. Multiple-dose activated charcoal for enhanced elimination is appropriate in poisoning with carbamazepine, cardiac glycosides, colchicine, dapsone, phenobarbital, phenytoin, thallium and theophylline. Before deciding to perform endotracheal intubation to assist with the administration of activated charcoal, every clinician needs to weigh the potential complications and adverse effects of this procedure against the toxicity expected to be prevented by the administration of activated charcoal. This is a challenging decision, and a local poison centre and/or a bedside toxicology consultation can assist with this decision. Endotracheal intubation is not a benign procedure and is associated with a high rate of various adverse events, such as new haemodynamic instability, severe hypoxaemia, and cardiac arrest, which seem more common in children. In three studies that evaluated the risks of endotracheal intubation in over 2,200 poisoned patients, the rates of hypotension were between 1.5% and 11.8%, desaturation between 3.4% and 7.1%, and cardiac arrest in 0.4%. The risk of aspiration following administration of activated charcoal after endotracheal intubation is reported to be low (1-4%). Therefore, the decision to endotracheally intubate a patient to administer activated charcoal needs to carefully assess the patient's other comorbidities and the expected toxicity of the ingestion, which needs to be clinically significant to outweigh the risk of endotracheal intubation. Endotracheal intubation may also be considered if another treatment, such as haemodialysis or extracorporeal circulation, might be required or for transportation to another institution for ongoing clinical care. In these situations, for which endotracheal intubation has been performed for another indication, the risk-benefit will change in favour of activated charcoal administration. The following good practice statements were adopted to address the use of endotracheal intubation to facilitate the administration of activated charcoal.Endotracheal intubation should not be performed solely for the purpose of administration of activated charcoal in patients not anticipated to develop clinically significant complications of poisoning.In patients in whom endotracheal intubation is clinically indicated (e.g., compromised or unprotected airway, respiratory failure, significantly diminished level of consciousness, refractory seizures, hemodynamic instability), insertion of a nasogastric or orogastric tube is reasonable to facilitate gastrointestinal decontamination with activated charcoal.In patients with a clinically significant risk of developing life-threatening toxicity, endotracheal intubation is reasonable to safely facilitate gastrointestinal decontamination, especially if other treatment options are nonexistent or unavailable.Use of nasogastric or orogastric tube insertion without endotracheal intubation to facilitate the administration of activated charcoal: The following good practice statement was adopted: Nasogastric or orogastric tube insertion without endotracheal intubation should not be performed solely for the purpose of administration of AC. The decision to use activated charcoal is complex and depends primarily on the nature of the poison(s), the time since ingestion, the severity of the symptoms present at the time of decision or expected based on the dose ingested or patient comorbidities, and the availability of antidotes or other treatments. Although the existing level of evidence is primarily of low or very low quality, clinical decisions are still necessary. The Workgroup recommends the administration of a single-dose of activated charcoal beyond the traditional 1 h post-ingestion time point in selected poisons and introduces the concept of an additional dose of activated charcoal to prevent further absorption of poisons that may remain in the gastrointestinal tract for prolonged periods of time. Multiple-dose activated charcoal is also recommended to enhance elimination in selected clinical scenarios.

Aspiration-induced lung injury complicates acute poisoning due to impaired airway reflexes. This study aims to identify risk factors for aspiration-induced lung injury in acutely poisoned patients and evaluate the predictive value of the CRB-65 score, a tool for assessing the severity of community-acquired pneumonia in poisoning. We performed a retrospective review of patients presenting with acute poisoning due to recreational drug use at one hospital between January 2019 and June 2021. Clinical data, laboratory findings, and radiological reports were analyzed. Logistic regression analysis was performed to identify independent risk factors. Additionally, the CRB-65 score was assessed for its ability to predict aspiration-induced lung injury in poisoned patients. Of 497 cases included, 34 patients (6.8%) diagnosed with aspiration-induced lung injury. The logistic regression model identified fever (OR 39.4, 95% CI: 3.0-522.3), dysrhythmia (OR 20.5, 95% CI: 1.4-290.5), respiratory insufficiency (OR 18.7, 95% CI: 2.9-119.4), sedation (OR 4.6, 95% CI: 1.5-14.3), long-term medication (OR 4.5, 95% CI: 1.3-15.9), and neuroleptic administration (OR 4.1, 95% CI: 1.3-13.7) as independent predictors. Aspiration-induced lung injury was also associated with confusion (P .001) and lower Glasgow Coma Scale scores (P .001). The CRB-65 score demonstrated a high negative predictive value (96.6%) but low specificity (46.1%). The observed incidence was lower than in comparable studies, likely due to varying diagnostic criteria, as no standardized definition exists. A negative CRB-65 score may help rule out aspiration-induced lung injury, but it is insufficient as a standalone diagnostic tool. In acutely poisoned patients, aspiration-induced lung injury is associated with impaired consciousness, cardiovascular instability, and administration of neuroleptics or sedatives. While the CRB-65 score can help exclude aspiration-induced lung injury in low-risk patients, further diagnostic tools such as clinical examination, laboratory testing, and imaging remain necessary for confirmation.

Objective: To determine if increased liver stiffness (ILS) is a risk factor for patients with alcohol withdrawal to develop severe alcohol withdrawal symptoms (SAWS) like delirium tremens (DT) or withdrawal seizures (WS). Method: Prospective inclusion of 394 patients undergoing withdrawal treatment between 2013-2021. Laboratory exams, history, physical examination, abdominal sonography with elastography and FibroScan® measurements were performed. Primary endpoint was SAWS defined as DT and/or WS. Patients with > 12.5 kPa stiffness in FibroScan® and > 1.75 m/s in Acoustic Radiation Force Impulse Imaging were considered ILS, patients with both measurements below the respective cut-off were ILS negative. Univariate analysis with receiver operating characteristic curve analysis and multivariate analysis were performed. Results: 78 patients (19.8%) had ILS. Of these, 28 patients developed complications despite treatment. SAWS correlated significantly with patients with ILS. Further significant correlations were emergency hospital admission, Alcohol Withdrawal Scale ≥ 5, lower potassium, elevated bilirubin, increased Gamma-GT, thrombocytopenia, previous WS, and previous DT. In multivariate binary regression analysis, odds ratio for SAWS was 5.4 for emergency admission, 3.5 for previous DT and 2.2 for ILS, even if the significance level for the last parameter was missed. Conclusions: Patients with ILS have an increased risk of developing SAWS, as well as patients with emergency admission and previous DT among other markers. Treatment in an appropriately equipped facility is recommended for patients with this risk profile which can be measured easily by a general practitioner or in an emergency department.

Neue psychoaktive Substanzen (NPS), auch als „Designerdrogen“ bekannt, stellen eine zunehmend komplexe Herausforderung für das Gesundheitswesen dar. Unter diesem Begriff werden psychoaktive Substanzen zusammengefasst, die sowohl als Sedativa als auch als Stimulanzien, Entaktogene oder Halluzinogene wirken. Diese Substanzen ahmen durch chemische Modifikation die Wirkung von illegalen Substanzen nach, entgehen aber oftmals gesetzlichen Regelungen. Article published online: 05 March 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Background: Patients with recreational drug and ethanol poisoning often present with reduced consciousness, coma, or disorientation. It is often unclear if there was recent head trauma. Algorithms to perform cranial computed tomography (cCT) like the Canadian CT Head Rule (CCHR), the National Emergency X-Radiography Utilization Study Head CT Decision Instrument (NEXUS DI), or the New Orleans Criteria (NOC) exist for patients with head trauma. It is unclear whether these algorithms can be applied to this patient collective. Methods: This is a retrospective data analysis of patients admitted to our emergency department with drug or ethanol poisoning in 2019. Minors < 16 years were excluded. The primary outcome was fracture/bleeding in cCT, the secondary outcome was neurosurgical intervention. These results were calculated: 1. Sensitivity and negative predictive value (NPV) of the CCHR, NEXUS DI, and NOC. 2. Uni- and multivariate analysis of risk factors for critical findings. 3. The Munich cCT Rule sensitivity and NPV. Results: A total of 420 patients were included. cCT was performed in 120 patients. Eight patients had fracture/bleeding in cCT, two required neurosurgical intervention. The number of patients at risk, sensitivity, and NPV for critical cCT findings were as follows: CCHR 57/25%/98.3%, NEXUS DI 239/100%/100%, NOC 420/100%/100%. The sensitivity and NPV for neurosurgical intervention were as follows: CCHR 50%/99.7%, NEXUS DI 100%/100%, NOC 100%/100%. In univariate analysis, these findings correlated significantly with the following critical findings: accident, injury, injury above clavicle, head wound, anisocoria, ethanol in serum > 2 g/L, hypotension, drug ingestion, GCS < 8, focal neurological deficit, age > 60, and cerebellar symptoms. Via chi-square recursive partitioning analysis, we created the Munich cCT Rule which is positive for intoxicated patients if both an accident and an ethanol level > 2 g/L are present. This identified 70 patients at risk. It excluded fracture/bleeding and neurosurgical intervention with a sensitivity and NPV of 100%. Conclusions: Fracture/bleeding in cCT in intoxicated patients is rare. Performing unnecessary cCTs should be avoided. The Munich cCT Rule for patients with recreational drug and ethanol poisoning may help rule out critical findings and is superior to the NEXUS DI and NOC. It also has a 100% sensitivity which the CCHR (25%) is lacking.