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Clinical study of acute poisoning: A retrospective study.

INTRODUCTION: Acute self-poisoning is a major public health issue around the world and in India. [1] According to World Health Organization (WHO) estimates in 2004, 346,000 people died worldwide from unintentional poisoning of which 91% occurred in developing countries. [2] Poisoning is the 4th most common cause of mortality in rural India. [1] The exact incidence of poisoning remain uncertain in India but 1 to 1.5 million cases occur every year of which 50,000 succumb to it. [1] Half of the poisoning is suicidal followed by one fourth of accidental and homicide. [1] It is common in 20 to 30 years age group and rare after 65 years with a predominant affection to male. [1] It has got predilection to literate, married and medium to low socioeconomic group. [1] Aluminium phosphide is the most common poisoning in rural area and OPP in other area. [1]

OBJECTIVES: The objectives of the study were to determine the common agents, clinical features and outcomes of acute poisoning.

MATERIALS AND METHODS: This is a retrospective study of patients of acute poisoning admitted through emergency in SRMS-IMS from Jan 2010 to Dec 2012. Data of the patients with acute, intentional, self-inflicting and suicidal poisoning of age more than 14 years were collected from medical records from record room. Complete history, clinical findings and investigations as in medical records were noted down. Identification of toxin was done by history, physical verification of toxin if available and by significant clinical signs.

RESULTS:

1) A total of 58 cases were included in the study admitted from January 2010 to December 2012.

2) Out of 58, 36 were males and 22 were females with M: F = 1.63:1. (Fig - 1).

3) They were in the age group of 16 to 65 years with a mean age of 25.79 and majority was in the age range of 16 to 25 years. (Table-1)

[FIGURE 1 OMITTED]

4) Poisoning cases occur throughout year with maximum prevalence in May and minimum in June (Table-2).

5) Organophosphorus was the most common poison followed by aluminium phosphide. Other poisons were insecticide (Miscellaneous), corrosive, rodenticide, opioids, alprazolam, sodium valproate and copper. In 6.89% cases poison was not identified. (Table - 3)

6) Vomiting was the most common symptoms followed by altered sensorium. 47 patients were normotensive and 11 were hypotensive at the time of admission. 12 patients were having abnormal liver function test and 4 patients were having abnormal renal function test. (Table-4)

7) Ventilatory support was required in 9(15.51%) patients.

8) 70.68% patients were discharged, 20.68% expired and 8.62% left against medical advice.(Table-5)

9) 32.75% consulted doctor within 4 hours whereas 27.58% in 5-12 hours and remaining 39.65% after 12 hours. (Table - 6)

10) 12 patients expired. Out of which 7 were males and 5 were females. They were commonly in 16-25 age groups. 41.66% availed medical services after 12 hours. 66.66% were hypotensive. 50.00% were having abnormal LFT. 25% were having abnormal RFT. 41.66% patients were given ventilator care. Aluminium phosphide was the most common toxin consumed by dead patients (Table - 7, 8, 9).

DISCUSSION: The study was conducted on 58 patients admitted in SRMS-IMS, Bhojipura, Bareilly. This was a retrospective observational study. In present study males were affected more commonly compared to females with M: F ratio 1.63: 1. Similar observation of more common affection of male was made by de Miguel-Bouzas JC et al (66%male affection). [3] Malangu N observed equal affection of male and female.M But in contrast to this many observed female preponderance like Mohammad Abdollahi et al.(1.8:1) [5] Exiara et al.(F: M = 1.56: 1) [6] Mert et al. (F:M = 1.26:1) [7] Islambulchilar M et al.(F:M = 1.2:1), [8] YC Chan et al. (F:M = 1.49:1) [9] and Afshari R et al.(F:M = 1.13:1). [10] Few authors like Baydin A et al. (F:M = 2:1) [11], Seydaoglu G et al.(F:M = 2.0:1) [12] and Tufekci IB et al (F:M = 2.68:1) [13] observed two times or more affections in females. Banerjee I et al. who conducted study in India also observed clear common affection in females. [14]

In present study age of affection ranges from 16 to 65 years with a mean age of 25.79 and majority were in the age group of 16 to 25 years. Similar finding was observed by Baydin A et al. with mean ages of female and male patients were 28.8+/-12.9 years and 35.1+/-15.4 years respectively, and majority of patients (46.9%) were between the ages of 16 and 25

years. [11] Cengiz M et al. observed a mean age of 26 +/- 9 years and the majority of the patients (56.9%) were 15-24 years of ages. [15] Mean age of affection in other studies were 35.6 [+ or -] 17.6 years by de Miguel-Bouzas JC et al., [3] 33 years (STD+/-18.10) by Burillo-Putze G et al. [16] and 37.1 for male and 33.4 for female by Exiara et al. [6] Seydaoglu G et al. observed mean age 29.3 +/- 13.2 for males and 23.8 +/- 9.6 for females. [12] Tufekci IB et al. observed mean age 27+/-12 years (age range 15-87) and the majority of the patients (73.94%) were below the age of 30 years. [13] Khan et al. observed poisoning more commonly in rural population (76.9%) and 46.35% patients were in 20-30 years age group. [17] So, in almost all study maximum prevalence of poisoning is in young adults.

In this study poisoning cases occur throughout year with maximum prevalence in May and minimum in June. Exiara T et al. observed peak incidence of poisoning in summer and June being the month with the highest incidence. [6] Baydin A had similar observation with peak incidence in the summer months (35.4%) [11] while Islambulchilar M et al. observed peak incidence of poisoning in spring (28%) and a bit lower incidence in summer (27.5%) [8] Tufekci IB et al. observed peak in summer (31.7%) and winter (30.9%) and lower numbers in spring (22.9%) and autumn (14.5%). [13] So, in various study poisoning occur uniformly throughout year with minor seasonal variation. The minor variation observed here might be associated with easy availability of toxin in particular season for agricultural or other commercial activities.

In this study 32.75% consulted doctor within 4 hours, 27.58% in 5-12 hours and remaining 39.65% after 12 hours whereas Mert et al. observed 67.7% of the cases presented to the emergency department within 3 hours of poisoning. [17] So, in my study 67.23% cases consulted doctor after 4 hours limiting the benefit of decontamination therapy, an important management option in poisoning cases.

We found organophosphorus as the most common poison followed by aluminium phosphide, insecticides (Miscellaneous), corrosive, rodenticide, opioids, alprazolam, sodium valproate and copper. In 6.89% cases poison was not identified. Khan et al. observed organophophorus in 63.9% cases followed by benzodiazepine in 6.8% cases. [17] Banerjee I et al. observed snakebite (31.90%) as the most common cause of poisoning followed by organophosphorus compounds (21.84%), rodenticide (16.49%), alcohol (13.80%), chemicals (9.04%), and drugs (2.3%). [14]

Mohammad Abdollahi et al. observed benzodiazepines (24.5%) as the most frequent, followed by antidepressants (20.5%) and analgesics (18%). Organophosphate insecticides were responsible for 57% of total pesticide poisoning cases. [5] de Miguel-Bouzas JC et al. observed drug abuse as the most common toxic agent and ethyl alcohol accounting for 61% of these cases [3] whereas

Baydin A et al. observed medicinal drugs to be the primary cause (60.5%) of poisoning and tricyclic antidepressants as the most frequent agents (36.3%). [11]

Cengiz M et al. also observed medical drugs overdose as the major cause of (51.2%) intoxication which includes benzodiazepines, antidepressants and analgesics which was followed by agricultural chemicals (37.2%). [15] Exiara et al. observed psychotropes as a leading cause of poisoning in patients with a psychiatric disease (74.1%) and analgesics in all the other patients groups (34.8%). [6] Seydaolu G et al. also observed psychoactive drugs as the most frequent cause of poisoning (59.0%) followed by pesticides (26.4%). [12] YC Chan et al. observed sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Pi Afshari R et al. observed pharmaceuticals agent (61.4%) as the commonest toxins followed by chemicals (22.8%), and natural toxins (16.6%). [10] Hence wide variations have been observed in type of toxin consumed by different population worldwide in various studies. But in my study pesticides are common toxins responsible for poisoning because of location of hospital in rural area and agriculture as a main occupation among patient consulting this hospital.

In our study vomiting was the most common symptoms in 30 cases followed by altered sensorium in 9, diarrhoea in 3, abdominal pain in 2 and dyspnoea in 1. Normal blood pressure was observed in 47 patients and 11 were having hypotension at the time of admission. 12 patients were having abnormal liver function test and 4 patients were having abnormal renal function test. Ventilatory support was required in 9(15.51%) patients. So, symptoms were normally gastrointestinal and mild in majority of patients. Exiara T et al. observed good general condition of patient on arrival and serious symptoms (e.g. unconsciousness, insufficient ventilation necessitating intubation, aspiration, convulsions or hypotension) occurred in 15% of cases. [6] Banerjee I et al. observed the mean GCS (Glasgow Coma Scale) score of the poisoned patients at presentation was 6.85 [+ or -] 1.62.P4]

In this study 70.68% patients were discharged, 20.68% expired and 8.62% left against medical advice. Out of 12 patients expired 7 were males and 5 were females and were in 16-25 age groups. 41.66% availed medical services after 12 hours. 66.66% were hypotensive. 50.00% were having abnormal liver function test and 25% were having abnormal renal function test. 41.66% patients were given ventilator care. Aluminium phosphide was the most common toxin consumed by dead patients. Banerjee I et al. reported death in 16.24% patients. [14] Cengiz M et al. found death in 5.8% cases, [15] Mert et al. in 2.6% cases, [7] Baydin A et al. in 1.85% cases [11] Exiara T in 0.9 % patients [6] and Burillo-Putze G et al. in 0.2% cases, [16] Islambulchila M observed death in 2.3% of cases and found common cause of death was due to pesticides [l8] Khan et al. observed death in 3.4% cases. [17] Death observed by western worker was low as compared to ours.

In this study, aluminium phosphide poisoning occurred in 16 cases (27.58%) and was responsible for 6 deaths (50.00% of total cases and 37.5% of aluminium phosphide cases). Singh S et al. conducted a study on 195 patient of aluminium phosphide poisoning with mortality in 115 patients [18] Chugh SN et al. conducted a study on 418 patients with aluminium phosphide poisoning and observed 77.2% patient mortality. [19] Katira R et al. conducted a study on 90 patients of aluminium phosphide poisoning with a mortality rate of 63.3%. [20]

In my study organophosphorus poisoning was the most common poisoning contributing 20 cases (34.48%) but is responsible for 1 death (8.33%). Hrabetz H et al. conducted a study on 33 patients with OPP with moderate to severe poisoning and observed recovery in 28 patients and death in 5 patients. [21] Banerjee I et al. observed death in 5.78% cases. [22] Yurumez Y et al. conducted a study on 220 patients of OPP and observed twenty patients (9.1%) died due to sudden respiratory and cardiac arrest (45%), respiratory failure (25%), CNS depression (5%) and septic shock (25%). [23]

Higher number of total death in my study is related to higher prevalence of pesticide poisoning especially significant number of patients consuming aluminium phosphide and delay in consulting hospital.

CONCLUSION: Acute poisoning is an important preventable public health problem commonly affecting young population. Poison etiology is highly variable in different countries. Overall mortality is low besides high mortality with aluminum phosphide.

ABBREVIATION:

WHO - World Health Organization.

OPP - Organophosphorus Poisoning.

LAMA - Left Against Medical Advice.

GCS - Glasgow Coma Scale.

RFT - Renal Function Test.

LFT - Liver Function Test.

DOI:10.14260/jemds/2014/3803

REFERENCES:

[1.] Singh NP, Kaur G. Poisoning-Basic Consideration and epidemiology. API Text book of Medicine, Editor -in-Chief YP Munjal. Jaypee Brother Medical Publishers (P) Ltd. 2; 1990-1992.

[2.] World Health Organisation. International Programme on Chemical Safety. Poisoning prevention and management. Available from: http://www.who.int/ipcs/poisons/en/.

[3.] de Miguel-Bouzas JC, Castro-Tubio E, Bermejo-Barrera AM, Fernandez-Gomez P, Estevez-Nunez JC, Tabernero-Duque MJ. Epidemiological study of acute poisoning cases treated at Galician hospital between 2005 and 2008. Adicciones. 2012; 24 (3): 239-46.

[4.] Malangu N. Characteristics of acute poisoning at two referral hospitals in Francistown and Gaborone SA Fam Pract 2008; 50 (3): 67.

[5.] Mohammad Abdollahi, Naser Jalali, Omid Sabzevari, Ruhollah Hoseini and Tlaat Ghanea. A Restrospective Study of Poisoning in Tehran.1997, 35(4); 387-393.

[6.] Exiara T, Mavrakanas TA, Papazoglou L, Papazoglou D, Christakidis D, Maltezos E. A prospective study of acute poisoning in a sample of Greek patients. Cent Eur J Public Health. 2009 Sep; 17 (3): 158-60. [6]

[7.] Mert E, Bilgin NG. Demographical, aetiological and clinical characteristics of poisoning in Mersin, Turkey. Hum Exp Toxicol.2006 Apr; 25 (4): 217-23.

[8.] Islambulchilar M, Islambulchilar Z, Kargar-Maher MH. Acute adult poisoning cases admitted to a university hospital in Tabriz, Iran. Hum Exp Toxicol. 2009 Apr; 28 (4): 185-90.

[9.] YC Chan, HT Fung, CK Lee, SH Tsui, HK Ngan, MY Sy ML Tse, CW Kam, GCK Wong, HK Tong, ACH Lit, TW Wong, FL Lau. A prospective epidemiological study of acute poisoning in Hong Kong. Hong Kong j. emerg. med. Vol. 12 (3) Jul 2005. Hong Kong Journal of Emergency Medicine.

[10.] Afshari R, Majdzadeh R, Balali-Mood M. Pattern of acute poisonings in Mashhad, Iran 1993-2000.J Toxicol Clin Toxicol. 2004; 42 (7): 965-75.

[11.] Baydin A, Yardan T, Aygun D, Doganay Z, Nargis C, Incealtin O. Retrospective evaluation of emergency service patients with poisoning: a 3-year study. Adv Ther. 2005 Nov-Dec; 22 (6): 650-8.

[12.] Seydaoglu G, Satar S, Alparslan N. Frequency and mortality risk factors of acute adult poisoning in Adana, Turkey, 1997-2002. Mt Sinai J Med. 2005 Nov; 72 (6): 393-401.

[13.] Tufekci IB, Curgunlu A, Sirin F. Characteristics of acute poisoning cases admitted to a university hospital in Istanbul. Hum Exp Toxicol. 2004 Jul; 23 (7): 347-51.

[14.] Banerjee I, Tripathi SK, Roy AS. Clinico-epidemiological profile of poisoned patients in emergency department: A two and half year's single hospital experience. Int J Crit IIIn Inj Sci. 2014 Jan; 4 (1): 14-7. Doi: 10.4103/2229-5151.

[15.] Cengiz M, Baysal Z, Ganidagli S, Altindag A. Characteristics of poisoning cases in adult intensive care unit in Sanliurfa, Turkey. Saudi Med J. 2006 Apr; 27 (4) 497-502.

[16.] Burillo-Putze G, Munne P, Duenas A, Pinillos MA, Naveiro JM, Cobo J, Alonso J. National multicentre study of acute intoxication in emergency departments of spain. Eur J Emerg Med. 2003 Jun; 10 (2): 101-4.

[17.] Khan NA, Rahman A, Sumon SM, Haque MF, Hasan I, Sutradhar SR, Barman TK, Rahman S, Ferdous I, Miah AH, Alam MK, Debnath CR, Islam MZ, Miah of. Pattern of poisoning in a tertiary level hospital. Mymensingh Med J. 2013 Apr; 22 (2); 241-7.

[18.] Singh S, Singh D, Wig N, Jit I, Sharma BK. Aluminium phosphide ingestion-a clinic-pathologic study. J Toxicol Clin Toxicol. 1996; 34 (6): 703-6.

[19.] Chug SN, Dushyant, Ram S, Arora B, Malhotra KC. Incidence & outcome of aluminum phosphide poisoning in a hospital study. Indian J Med Res. 1991 Jun; 94: 232-5.

[20.] Katira R, Elhence GP, Mehrotra ML, Srivastva SS, Mitra A, Agarwala R, Ram A. A study of aluminum phosphide poisoning with special reference to electrocardiographic changes. J Assoc Physicians India. 1990 Jul; 38 (7): 471-3.

[21.] Hrabetz H, Thiermann H, Felgenhauer H, Zilker T, Haller B, Nahrig J, SaugeIB, Eyer F. Organophosphate poisoning in the developed world - a single centre experience from here to the millennium. Chem Biol Interact. 2013 Dec5; 206 (3): 561-8.doi: 10.1016/j.cbi.2013.05.003. Epub 2013 May 17.

[22.] Banerjee I, Tripathi S, Roy AS. Clinico-epidemiological characteristics of patients presenting with organophorus poisoning. N Am J Med Si. 2012 Mar; 4 (3): 147-50. Doi: 10.4103/1947-2714. 93884.

[23.] Yurumez Y, Durukan P, Yavuz y, Ikizceli I, Avsarogullari L, Ozkan S, Akdur O, Ozdemir C. Acute organophosphate poisoning in university hospital emergency room patients. Intern Med. 2007; 46 (13); 965-9. Epub 2007 Jul 2.

Praveen Kumar (1), Kalpana Chandra (2), Amit Varshney (3)

AUTHORS:

(1.) Praveen Kumar

(2.) Kalpana Chandra

(3.) Amit Varshney

PARTICULARS OF CONTRIBUTORS:

(1.) Associate Professor, Department of General Medicine, SRMS-IMS, Bhojipura, Bareilly.

(2.) Associate Professor, Department of Pathology, SRMS-IMS, Bhojipura, Bareilly.

(3.) Junior Resident, Department of Medicine, SRMS-IMS, Bhojipura, Bareilly.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Praveen Kumar, Associate Professor, Department of Medicine, A-1, Doctor's Residence, Shri Ram Murti Smark Institute of Medical Sciences, Bhojipura, Bareilly, Uttar Pradesh-243202. Email: praveen_kmr_23 @yahoo.co.in

Date of Submission: 28/10/2014.

Date of Peer Review: 29/10/2014.

Date of Acceptance: 07/11/2014.

Date of Publishing: 11/11/2014.

Praveen Kumar (1), Kalpana Chandra (2), Amit Varshney (3)
Table 1: AGE WISE DISTRIBUTION

Age range    Frequency

16-25       34 (58.62%)
26-35       18 (31.03%)
36-45        4 (6.89%)
46-55        1 (1.72%)
56-65        1 (1.72%)

TABLE 2: MONTH WISE DISTRIBUTION OF CASES

Month       Frequency

January     7(12.06%)
February    7(12.06%)
March        3(5.17%)
April       8((13.79%)
May         11(18.96%)
June          0(0 %)
July         4(6.89%)
August      9(15.51%)
September    5(8.62%)
October      1(1.72%)
November     2(3.44%)
December     1(1.72%)

TABLE 3: VARIOUS TOXINS RESPONSIBLE FOR POISONING

Poison                        Frequency

Organophosphorus              20(34.48%)
Aluminium phosphide           16(27.58%)
Insecticide (Miscellaneous)   6(10.34%)
Corrosive                      5(8.62%)
Rodenticide                    3(5.17%)
Opioid                         1(1.72%)
Alprazolam                     1(1.72%)
Sodium valproate               1(1.72%)
Copper                         1(1.72%)
Unknown                        4(6.89%)

TABLE 4: CLINICAL FEATURES AND ABNORMAL LABORATORY PARAMETERS

S. N.             Symptom                       Frequency

1                 Vomiting                          30
2            Altered sensorium                      9
3                Diarrhoea                          3
4              Abdominal pain                       2
5                 Dyspnoea                          1
6               Normotensive                        47
7               Hypotensive                         11
8       Abnormal renal function test                4
9       Abnormal liver function test   12 (Commonly high SGOT/SGPT)

TABLE 5: OUTCOME

S. N.   Out come     Variable

1       Discharge   41(70.68%)
2         Death     12(20.68%)
3         LAMA       5(8.62%)

TABLE 6: TIME LAG IN AVAILING MEDICAL CARE

S. N.    Time lag    Frequency

1        <4 hours    19(32.75%)
2       5-12 hours   16(27.58%)
3          >12       23(39.65%)

TABLE 7: AGE VARIABLE IN DEAD PATIENTS

S.N.   Age range   Frequency

1        16-25     7 (58.33%)
2        26-35     2 (16.66%)
3        36-45      3 (25%)

TABLE 8: TIME LAG IN AVAILING MEDICAL FACILITIES
IN DEAD PATIENTS

S. N.   Time lag   Frequency

1          <4      2(16.66%)
2         5-12     3(25.00%)
3         >12      5((41.66%)

TABLE 9: TOXIN USED BY DEAD PATIENTS

S. N.             Poison             Frequency

1          Aluminium phosphide       6(50.00%)
2               Corrosive            1(8.33%)
3                  OPP               1(8.33%)
4       Insecticide(Miscellaneous)   1(8.33%)
5                 Copper             1(8.33%)
6              Rodenticide           1(8.33%)
7                Unknown             1(8.33%)
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Title Annotation:ORIGINAL ARTICLE
Author:Kumar, Praveen; Chandra, Kalpana; Varshney, Amit
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Nov 13, 2014
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