Patterns of poisoning and drug overdosage and their outcome among in-patients admitted to the emergency medicine department of a tertiary care hospital

Mortality of acute poisoning and its predictors in Ethiopia: A systematic review and meta-analysis

Introduction

Poison is defined as any chemical that has the potential to affect or harm human physiology due to its chemical activity. Poisoning is becoming a major preventable public health issue in many countries, including Ethiopia. There is a variation in acute poisoning mortality among the existing evidence in Ethiopia. This study aims to determine the pooled mortality rate from acute poisoning and its predictors in Ethiopia.

Methods

We searched available evidence of acute poisoning mortality in databases such as PubMed, Hinari, Cochrane, ScienceDirect, and other search engines. Using the Microsoft Excel data extraction form, three authors independently extracted all relevant data. The Higgins I2 test statistics were used to examine heterogeneity among included studies A random-effects model was used to analyze the pooled estimates and predictors in Stata MP version 17.

Results

We retrieved 2685 relevant records from different database sources, and after screening, 21 studies (17 published and 4 unpublished) were included. The pooled mortality rate for acute poisoning was 4.69(95 % CI: 3.69, 5.69 I2 = 94.7 %). The most common poisoning agents are organophosphate (29.9 %), household cleansing agents (17.5 %), and pharmaceuticals/medications (9.3 %). The majority of poisoning cases were intentional poisoning committed suicide. Poisoning cases in rural areas [RR: 3.98(95 % CI: 1.41, 11.25)] and delayed arrival times [RR: 2.90(95 % CI: 1.45, 5.84)] were identified predictors of mortality.

Conclusions

In this study, the pooled mortality from acute poisoning was 4.69 %. Poisoned cases from rural areas and delayed arrival times to the hospital were predictors of mortality. To prevent mortality, healthcare professionals should give special attention to rural residents and delayed arrival of poison cases. To control this avoidable death, poison control centers should be strengthened, and other preventive measures implemented at the national level.

Determinants of Poison-related Mortality in Tertiary Care Hospital, South India

Aims and background

Acute poisoning is one of the most common emergencies in India and around the world. Understanding the factors associated with mortality can aid us in devising appropriate preventive strategies to curtail deaths due to poisoning. Purpose of this study is to find various factors that determine the mortality among acute poisoning cases admitted in a tertiary care center.

Materials and methods

A retrospective hospital records-based study was conducted at Chengalpattu Medical College Hospital. The study included 2,123 cases of various poisoning cases admitted for a year from January to December 2022. Cases of bites, stings, drowning, and hanging were excluded. Information on sociodemographic profile, type of poison, time since ingestion and admission, and treatment outcome were collected using a structured pro forma.

Results

The mean age of the study population was 29.90 ± 14.98 years. Poisoning was found to be predominantly among males (56.42%) and residents of rural areas (58%). Insecticide consumption (27.0%) was the most common modality, followed by oleander poisoning (20%), corrosive poison (17%), rat poison (15%), tablet poison (13%), and other poisons. The overall case fatality rate (CFR) was 5.2%, with the highest CFR of 12.25% with insecticide poisoning. In multivariate analysis, Glasgow coma scale (GCS) score at admission is the only parameter showing a statistically significant association with mortality (adjusted odds-ratio 0.271(0.2-0.38, p-value < 0.01).

Conclusion

Acute poisoning primarily affects the young and economically productive population. In the south Indian population, pesticides are still the major contributor though corrosives are a major contributor among children. Mortality is still significant, and GCS status admission is the only predictor of mortality.

How to cite this article

Krishnasamy N, Narmadhalakshmi R, Parameshwari P, Jayalakshmi R, Lokesh R, Jayanthi R, et al. Determinants of Poison-related Mortality in Tertiary Care Hospital, South India. Indian J Crit Care Med 2024;28(4):329-335.

Uncovering the Hidden Burden of Pharmaceutical Poisoning in High-Income and Low-Middle-Income Countries: A Scoping Review

Pharmaceutical poisoning is a significant global public health concern, causing approximately 190,000 deaths annually. This scoping review aims to comprehensively map the available literature on pharmaceutical poisoning and compare patterns between high-income countries (HICs) and low-middle-income countries (LMICs). A systematic search was performed across the following databases: Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL. Studies included were from 1 January 2011 to 31 December 2020, in English, with full text available. Seventy-nine articles were included in the study; 21 were from LMICs and 58 were from HICs. Toxic exposure was largely intentional (77%) in LMICs and accidental (68%) in HICs. Drugs acting on the nervous system were responsible for 95% of toxicities worldwide with analgesics accounting for the largest subtherapeutic group in both LMICs (40%) and HICs (58%). Notable statistics were that HICs accounted for 99% of opioid overdoses, and LMICs accounted for 19% of anti-epileptic-induced toxicities. Overall, the medical outcomes due to poisonings were generally worse in LMICs. The review provides possible interventions to target specific geographic locations, based on the trends identified, to reduce the burden worldwide. Many gaps within the literature were recognised, calling for more robust analytical research.

Changing trends in the profile of rodenticide poisoning

Background

Deliberate self-poisoning (DSP) is one of the leading causes of mortality and morbidity, with rodenticides being common compounds used by many victims. However, comprehensive data regarding the spectrum and outcome of rodenticide poisoning is scant.

Method

This retrospective study was conducted in the Emergency Department (ED) of a large tertiary care hospital in South India between January 2017 and December 2018. All patients with deliberate consumption of rodenticides were included in the analysis.

Results

During the study period, 1802 patients presented with DSP, among which 145 (8%) consumed rodenticide compounds. The mean (SD) age was 27.9 (10.7) years. Young adults (16-30 years) comprised 73% (106/145) of the study population. The majority (87%) were triaged as priority 2, while 10% were triaged as priority 1. Common rodenticide compounds consumed were yellow phosphorous (57%: 82/145), coumarins (12%: 17/145), zinc phosphide (19%: 27/145), and aluminum phosphide (1%: 1/145). A significant proportion of patients (18.6%) were under the influence of alcohol. Among the 73 males, 25 (34.2%) gave a history of co-consumption of alcohol. There was a history of previous DSP attempts in 6%. The majority (68%) of the patients were discharged alive from the hospital, and the in-hospital mortality rate was 9%. Age >30 years (adjusted OR: 2.2; 95% CI: 1.00-5.05; p value: 0.04) was an independent predictor of poor outcome.

Conclusion

Rodenticide compound consumption for DSP is prevalent in young adults and is associated with significant mortality, especially with yellow phosphorous poisoning. The current trend in our country of the increasing use of highly fatal phosphorous compounds over the innocuous coumarin derivatives is a cause of grave concern.

Acute poisoning among children and adolescents: a narrative review

Background: Acute poisoning is a frequent emergency and a significant health concern in the pediatric population. The pattern of acute intoxication differs between countries and within each country. Poisoning depends on many factors. It can be divided into two categories (accidental and intentional), and each one has its own characteristics. Aim of the study: This study aimed to analyze and discuss the overall patterns of accidental and intentional poisoning among children and adolescents. Material and methods: A systematic literature search was conducted using Google Scholar, Elsevier, and the PubMed database. The following keywords were used: “acute poisoning”, “pediatric poisoning”, “intentional poisonings”, “unintentional poisonings”, and “suicide attempts”. Results: A total of 38 articles were included in the review. Half had been published in the last five years. The analysis focused on the characteristics of the materials and methods, results, and conclusions sections of each study. Conclusions: Unintentional poisonings dominate among younger children, with a slight male predominance. They usually occur at home and occasionally lead to severe harm or even death. The most common causes of intoxication in this population are medications and household products. The majority of poisonings among adolescents are intentional suicide attempts. Among older children, over-the-counter analgesics are the most common cause of acute poisoning. Accidental poisoning can be avoided by providing preventive educational programs to guardians and replacing potentially toxic household products with safer ones. The prevention of intentional poisoning should be based on a community support system and behavioral programs. Healthcare professionals should be familiar with poisoning and be aware of the different patterns of intoxication according to age and gender.

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review

BACKGROUND

Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years.

METHODS

We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study.

RESULTS

We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths.

CONCLUSION

Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.

Probabilistic model to predict the outcome in acute suicidal chemical poisoning cases from age and gender of patient and type of chemical poison consumed

Background: Acute chemical poisoning is a significant global health problem. Chemical poisons include agrochemical, household and industrial poison subtypes. The present study used a probabilistic model based on age, gender and type of poison consumed by the patient to predict the outcome in acute suicidal poisoning cases. Material and methods: A prospective observational study was conducted at emergency department of SMS Hospital, Jaipur, India, from January 2019 to February 2020. Patients over 15 years of age with poisoning severity score 2 or above were included in the study. Probabilistic model was used to predict the outcome measured in terms of cure, death and left against medical advice (LAMA) using Minitab 14. Results: Poisoning cases were 0.32 % of all emergency presentations. Out of them, 857 (59.6 %) had consumed chemical poison. Their mean age was 32 years and men to women ratio was 1.22. Agrochemical subtype was most common followed by household and industrial poisoning. Analysis by Probabilistic model showed that person between 30-60 years is more likely to be cured and chances of death and LAMA are highest in age group 60-75. Gender-wise, men have higher possibility for recovery. Besides, a person has highest chances of recovery in case of household poisons; death is most common in industrial poisons and LAMA in agrochemical poisons. Conclusion: The study concluded that in poisoning, patients' basic information like age, gender, type of poison consumed can be used to identify high death probability and LAMA risk patients. It will assist in designing and monitoring the most effective strategies for them.

The systemic inflammatory response syndrome in acute antipsychotic poisoning

The purpose of this study was to investigate the mutual effect of systemic inflammatory response syndrome (SIRS) accompanied with fibrinolysis, endotoxemia, and coagulation in severe cases of antipsychotic poisoning. A total of 199 patients were examined, of which 71 were men and 128 were women. The age of the patients was from 22 to 63 years, (45.3 ± 6.1 years on average). According to the results of the course of therapy, the patients were divided into two groups. In the blood plasma, the content of C-reactive protein, fibrinogen and its proteolysis products (oligopeptides, D-dimers), interleukin-6 were determined. In the first 1 to 3 days, in group 1, the level of interleukin-6 decreased and approached the normal level (P ≤ .05). The opposite trend continued throughout the observation of patients from group 2-their levels of interleukin-6 increased day by day (P ≤ .05). The concentration of D-dimer already in 1 day after admission to intensive care in patients from group 2 exceeded the norm by 14 times (P ≤ .05). The level of D-dimer correlated with the level of oligopeptides in blood plasma upon admission, as well as for 3 and 5 days after admission to intensive care: 0.36, 0.76 at P ≤ .05, 0.94 at P ≤ .01, respectively. Similar correlations were obtained for the content of oligopeptides in urine and the level of D-dimer: 0.55, 0.85 at P ≤ .05, 0.93 at P ≤ .01. In this regard, the most pronounced correlation is that between the SIRS score, plasma D-dimer level, and the plasma level of the D-dimer derivatives, oligopeptides.

A Study of the Pattern of Admissions to the Accident and Emergency (A&E) Department of a Tertiary Care Hospital in Sri Lanka

Introduction

The latest national healthcare reform policies of Sri Lanka include the development of accident and emergency (A&E) departments in all major hospitals. Provincial General Hospital Kurunegala (PGHK) is a home to the first established A&E department in Sri Lanka. PGHK provides services to a population of 2.4 million spread out in the North Western Province and part of the Sabaragamuwa Province. This study was carried out to identify the pattern of all admissions to the A&E department of PGHK.

Methods

The prospective observational study was carried out from July 1, 2016, to June 30, 2017 (one year) to identify the pattern of admissions to the A&E department.

Results

There were 49,213 admissions to PGHK's A&E department during the study period. The average number of admissions was 135 (±17.9) per day. The percentage of deaths in the A&E department was 0.21%. The mean age of admitted patients was 46.7 (±21.7) years. A further 62% of admitted patients were males. The number of medical, surgical, paediatric, and gynaecological and obstetrical admissions was 55%, 42%, 3.5%, and 0.22%, respectively. Among the common emergency medical presentations, 34% were chest pain, 11% patients presented with unilateral weakness and/or slurring of speech, 10% covered dyspnoea, and 9% complained of dizziness/giddiness. Among emergency surgical presentations, 83% were trauma due to accidents, of which 27% were road-traffic-related accidents (RTAs). Discussion. The A&E department of PGHK provides services to a significantly high number of health emergencies every day. The majority of these admissions was due to chest pain and trauma related to accidents. The lower recorded number of paediatric and gynaecological and obstetrical emergencies presented to the A&E department is a result of a government policy mandating the admission of these types of patients directly to their respective wards. Further infrastructure development, staff recruitment, and training have to be planned and implemented to address the significantly high number of admissions to the A&E Department of PGHK.

Overdoses and Substance Toxicity in Patients Admitted to Intensive Care Units in a Midwestern U.S. City

Toxic exposures with serious outcomes have increased over the last decade. Limited data exists on the pattern and outcomes of overdose-exposure patients requiring intensive care unit (ICU) admission. The primary objective of this study was to characterize the causes, treatments, and outcomes of toxic exposures in a mid-sized Midwestern health system. The secondary objective was to report cumulative economic costs associated with these patients. Data were obtained from medical records of patients 18 years or older with a diagnosis code of overdose admitted to the ICU at 2 teaching hospitals between August 1, 2012, and July 31, 2014. There were 470 (10%) of the 4,495 total ICU admissions that met inclusion criteria during the study period. Average patient age was 39 (SD = 14.2) years, with 64% females. Intentional overdose exposure was the cause of 87% of admissions. The majority (70%) of exposures involved multiple pharmacological agents, including ethanol. Most patients did not require therapeutic maneuvers, nor used decontamination methods. Primary substance classes included analgesics, benzodiazepines, ethanol, selective serotonin reuptake inhibitor antidepressants, and methamphetamine. Two hundred sixty-five (56%) patients were ICU to direct home discharges, whereas 198 (42%) were transferred to a lower level of care. The mortality rate in the sample was 1%. Average hospital charges per admission were $20,375 and average ICU charges were $5,284, which summed to more than $2 million in total charges. Causes, treatments, and outcomes of toxic exposures admitted to the ICU in a mid-sized Midwestern city reveal a potential ICU burden. Financial health care costs associated with these toxic exposures were substantial. Greater public health efforts are needed to attempt to minimize preventable admissions and better understand antecedents.

Acute Poisonings Admitted to a Tertiary Level Intensive Care Unit in Northern India: Patient Profile and Outcomes

BACKGROUND

Poisoning is becoming a real health care burden for developing countries like India. An improved knowledge of the patterns of poisonings, as well as the clinical course and outcomes of these cases can help to formulate better preventive and management strategies.

AIM

To study the demographic and clinical profiles of patients admitted to the ICU with acute poisoning and to study the factors that predict their mortality.

MATERIALS AND METHODS

Retrospective two years (September 1, 2010 to August 31, 2012) study of all consecutive patients admitted to the Intensive Care Unit (ICU) with acute poisoning at a tertiary care hospital in Northern India.

RESULTS

Out of the 67 patients admitted to the ICU during the study period, the majority were young (median age 29 years) males (69%) who had consumed poison intentionally. Pesticides were the most commonly employed poison, notably organophosphorus compounds (22 patients, 32.8%) and aluminium phosphide (14 patients, 20.9%). While the overall mortality from all poisonings was low (18%), aluminium phosphide was highly toxic, with a mortality rate of 35%. The factors at ICU admission that were found to be associated with a significant risk of death were, high APACHE II and SOFA scores (p =0.0001 and p=0.006, respectively), as well as the need for mechanical ventilation and drugs for vasoactive support (p=0.012 and p= 0.0001, respectively).

CONCLUSION

Use of pesticides for intentional poisoning continues to be rampant in Northern India, with many patients presenting in a critical condition to tertiary level hospitals. Pesticide regulations laws, educational awareness, counseling and poison information centers will help to curtail this public health problem.

Nonmedical use of sedatives in urban Bengaluru

BACKGROUND

Nonmedical sedative use is emerging as a serious problem in India. However, there is paucity of literature on the patterns of use in the population.

AIM

The aim of the present analysis was to explore sedative use patterns in an urban metropolis.

MATERIALS AND METHODS

Data for the present analysis come from the parent study on nonmedical prescription drug use in Bengaluru, India. Participants (n = 717) were recruited using a mall-intercept approach, wherein they were intercepted in five randomly selected shopping malls, and administered an interview on their use of prescription drugs.

RESULTS

Past 12-month nonmedical sedative use was reported by 12%, benzodiazepines being the commonest. Reasons cited for nonmedical use included "sleeplessness, pain relief, stress." A majority (73%) reported sedative use "in ways other than as prescribed," compared to "use without prescription" (27%). All prescriptions were issued by general physicians in private hospitals. About 11% among those who used "in ways other than as prescribed," and 100% of nonprescribed users, reported irregular use (skipping doses/stopping/restarting). Among those who used "in ways other than prescribed," pharmacy stores were the source of obtaining the sedatives. Among "nonprescribed users," family/friends were the main source. Three-percent reported using sedatives and alcohol together in the same use episode. In multivariate logistic regression analyses, nonmedical sedative use was significantly associated with graduation-level education or above (adjusted odds ratio [aOR]: 2.53, 95% confidence interval [CI]: 1.30-4.91), and married status (aOR: 2.32, 95% CI: 1.04-5.18).

CONCLUSIONS

Findings underscore the need for considering various contextual factors in tailoring preventive interventions for reducing nonmedical sedative use.