AIM OF ASHTII STANDARDIZED TERMINOLOGY LITERATURE REVIEW OF CLINICAL EFFECTS

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1 Clinical Effect Profiles (CEPs) for chemical agents of concern Role of Syndromic surveillance and Rare Symptoms Pelclova D 1, Kennedy K 2, Edwards N 2, Tizzard Z 2, McParland M 2, Sutton N 2, Desel H 3, Schaper A 3, Ochsenfahrt G 3, Mathieu Nolf M 4, Nisse P 4, Linke JC 4, Orford R 5, Duarte Davidson R 5, Wyke S 5, Zakharov S 1 1 General Faculty Hospital, Charles University in Prague, Czech Republic 2 Medical Toxicology Unit, Guy s and St Thomas NHS Foundation Trust, London, UK 3 GIZ Nord Poisons Centre, University Medical Centre, Goettingen, Germany 4 Centre Hospitalier Universitaire de Lille, France 5 Health Protection Agency, International Research and Development Group, Oxford, UK. AIM OF ASHTII develop a Rapid Alert System for Chemical Health Threats (RAS CHEM) enable a rapid exchange of information on potential public health threats improve national response strategies to real or potential chemical incidents for the benefit of all EU Member States Toxicological Information Centres Poison Information Centres STANDARDIZED TERMINOLOGY RAS CHEM to operate successfully in an interdisciplinary multi language environment needs a standardised terminology to describe clinical effects associated with exposure to chemical agents LITERATURE REVIEW OF CLINICAL EFFECTS AIMS of Workpackage 6 performed on chemical agents identified as high risk and likely to causes severe health effects to identify a comprehensive range of the clinical effects, features and symptoms of poisoning OPTIMALLY ALL SYMPTOMS OF POISONINGS

2 SEARCH IN GOOGLE Number 1 DATABASE LISTED IN THE GOOGLE SEARCH TOXNET toxicology database created by the U.S. Environmental Protection Agency (EPA) Set of databases on toxicology, hazardous chemicals, environmental health, and toxic releases. TOXNET: Toxicology Data Network Fact Sheet FROM TOXNET TO TOXSEEK DATABASE INTENDED FOR EXTENSIVE SEARCH TOXSEEK ToxSeek free meta search engine developed by the Division of Specialized Information Services at the National Library of Medicine. enables simultaneous searching of many different information resources on the World Wide Web. ASHTII, EAPCCT Dubrovnik 2012 Meta sources to provide detailed (quantified) information NEED FOR DATA: Current and regularly updated, peer reviewed, referenced, and easily accessible MICROMEDEX Healthcare Series Main Keyword Search: Search Drug, Toxicology, Disease, and Labs databases for: POISINDEX Search summary documents only. INCHEM Find all keywords that: Exactly Match End in an asterisk (diab*, aceta*) for Begin With search Toxbase Begin With ASHTII, Oxford March 2009 CHOICE OF AGENTS RESULTS Development of Generic Scenarios, Alerting System and Training Modules Relating to Release of Chemicals by Terrorists (GSCT Project ) important industrial chemicals in Sweden, chemical warfare agents, pesticides historical poisonings Poisons centre experience to expand the list (ethylene glycol, methanol, nitrates,..) typical poisonings, agents capable of testing the system CLINICAL EFFECTS PROFILES (CEPs) produced for 118 chemical agents included in RAS CHEM to be accessed easily by both the poisons centres and public health authorities. Medical Toxicology Unit, Guy s and St Thomas NHS Foundation Trust, London, UK Katherine Kennedy, Nick Edwards, Zoe Tizzard, Maeve McParland, Nick Sutton

3 STRUCTURE OF CEPs STRUCTURE OF CEPs Agent Time course Effects Initial (Severe) Sequelae Organ Blood Cardio-vascular system GI-tract Kidney Liver Metabolic balance Muscular system Nervous system Respiratory system Skin Structure of CEPs REFERENCING Agent Time course Organ Symptom Reference Acetylene Effects Acetylene Effects Cardio-vascular system Respiratory system Heart rate increased Respiratory rate increased Poisindex Poisindex Ammonia Effects Respiratory system Dyspnoea Poisindex Ammonia Sequelae Respiratory system COPD Poisindex Group CEPs RARE SYMPTOMS ORGANIC PHOSPHORUS Sarin Soman Sulphur mustard Tabun Terbufos VX CYANIDES Cyanogen chloride Hydrogen cyanide Potassium cyanide PETROLEUM DISTILLATES Black oil Crude oil Diesel Kerosene To capture all symptoms with the potential to point on a specific agent, CEPs were cross checked for missing terms from the initial literature review.

4 Additional literature search RARE SYMPTOMS Brent J (et al.): Critical care toxicology 2005 Diagnosis of Poisonings p , Index p Dart RC (ed.) Medical Toxicology 2004 Initial diagnosis and treatment of the poisoned patient p , Index p Moeshlin S: Klinik und Therapie der Vergiftungen. 1986, 7 th ed. Leitsymptome der Vergiftungen p Additional 200 terms not previously identified during the literature review were added to the list of clinical effects To substitute a toxicologist with a long experience LaDou J: Current Occupational & Environmental Medicine: 4 th ed Additional 15 CEPs of agents with rare symptoms Rare Symptoms 1 Rare Symptoms 2 Agent Organ Symptom AMIODARON Skin Skin discoloration (blue-grey-purple) Coloured halos (rings around lights) Visual acuity lost Corneal deposits CADMIUM GI-Tract Tooth discoloration (yellow) Kidney Fanconi syndrome CARBAMAZEPINE Doll s eye reflexes lost Roving eyes movements Strabismus Ophthalmoplegia Kidney Tubular nephropathy LITHIUM Nervous system Lip smacking Nervous system Tongue dystonia MERCURY Skin Acrodynia MYDOCALM Nervous system Myoclonus Agent Organ Symptom OPIATES + OPIOIDS Skin Track marks Pinpoint pupils PHENOTHIAZINES Nervous system Torticollis Nervous system Bruxism Oculogyric crisis TOLUENE Color vision impaired Nervous system Cognitive impairment Nervous system Intellectual quotient impaired Nervous system Visual potentials impaired Nervous system Cerebral atrophy TRICYCLIC Doll s eye reflexes lost ANTIDEPRESSANTS Roving eyes movements Strabismus Ophthalmoplegia VINYL CHLORIDE Cardio-vascular Raynaud s disease Number of symptoms in new CEPs ANTACIDS 41 SULFONAMIDES 44 CARBAMAZEPINE 75 CADMIUM 94 LITHIUM 98 SULFONYLUREA 102 TRICYCLIC ANTIDEPRESSANTS 103 METFORMIN 111 CONCLUSIONS CEPS COVER ABOUT 1200 SYMPTOMS OF POISONINGS enable 1) search based on symptoms from the complex symptomatology of most probable agents 2) and search for unusual and rare symptoms

5 CONCLUSIONS Thank you Project partners: Health Protection Agency, UK Guy s and St. Thomas NHS Foundation Trust, UK Universitätsmedizin Göttingen Giz Nord Poisons Centre, Germany Centre Hospitalier Universitaire de Lille, France Health Emergency Situations Centre, Lithuania colleagues from TIC in Prague, Czech Republic S Zakharov, T Navratil, S Vlckova EAPCCT, collaborating TICs EU project number