Acute of mortality even exceeding road traffic accidents

Acute intoxication with pharmaceutical
products or other chemical substances is a common presentation to emergency
department ranging from milder form to life threatening cardiovascular or
respiratory dysfunction.(1) Conventional supportive therapy and specific
antidotes administration are usually effective but may not be sufficient in
cases of cardiovascular  collapse due to
life threatening overdoses. Children are usually the victim of accidental
overdoses and symptoms are usually apparent immediately while adult intoxication
is usually deliberate and present late to emergency department. (2)

Poisoning
associated deaths both due to accidental ingestion and ingestion for self harm
has increased in last few years. More than 5000 poisoned patients are attending
Emergency Departments every day across the United States and unintentional poisoning
is a significant cause of mortality even exceeding road traffic accidents as a
cause of death in younger & middle age group. The poisoning victims are usually
younger but intoxicant varies across the world (3, 4)

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ECMO
has been used successfully in children with respiratory and cardiopulmonary
failure. However, its use in adults remained limited until recently when CSAR
trials other reports showed a favourable outcome during H1N1 pandemic. (5)
The use of ECMO has increased more than 4 fold in last decade.(6) Extracorporeal membrane oxygenation (ECMO)
supports the failing heart and/or lung functions unresponsive to conventional management
until a specific end-point has been achieved.(7) It is often
considered as a bridge therapy, buying time until definitive therapy has been
instituted. For example, a deteriorating patient with a myocardial infarction
& cardiogenic shock can be shifted for (percutaneous coronary intervention)
PCI or a patient with a massive pulmonary embolus can undergo thrombectomy with
ECMO support.

 The
main cause of death in patients with acute poisoning is failure of various
vital organs. Intubation and mechanical ventilation has shown dramatic
improvement in survival of sedative-induced respiratory failure, which was the
leading cause of death in Western world. Similarly, toxin induced acute renal
failure has successfully been managed with renal replacement therapy. Even
liver transplant in drug induced fulminant liver failure is reported in selected
cases. However, the use of mechanical circulatory support in cardiac failure due
to acute intoxication still a matter of debate.(8) ECMO helps in maintaining tissue perfusion
and oxygenation in acutely intoxicated patient until the drug or toxin is
eliminated by the body’s natural metabolism and excretory processes or possibly
renal replacement therapy may be instituted to enhance the elimination.

 

Once
a toxin enters the systemic circulation and distributed in the tissues, the
cardiovascular collapse may require temporary support of circulatory function.  This helps in hepatic detoxification over time
(9) while providing reliable tissue perfusion and allowing
sufficient antidote circulation(10) The various modalities such as
continuous cardiopulmonary resuscitation (CPR; manual or with a mechanical
device), Intra aortic balloon (IAB) counterpulsation, and cardiopulmonary
bypass (CPB) has been used. (11)

The
miniaturization of circuit, safe application of ECMO due to advancement of
technology & better outcome has allowed critical care specialists and emergency
physicians to explore newer indications for use of ECMO in ICU. However ECMO
has not been established as rescue modality in acutely intoxicated patients with
cardiovascular collapse or cardiac arrest. Even the ELSO (Extracorporeal Life
Support Organization) guidelines and registry data does not address the use of
ECMO in acute intoxication. This review focus on the mortality associated with
acute intoxication, difference in toxicology profile across the globe,
available literature on use of ECLS (Extra Corporeal Life Support) and
discusses the current practices.