A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes

Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.

A Retrospective Cohort Study of Cobra Envenomation: Clinical Characteristics, Treatments, and Outcomes

This study investigated the clinical characteristics, treatments, and outcomes of envenomation involving cobra species in Thailand (Naja kaouthia, Naja siamensis, and Naja sumatrana). Data of patients who had been bitten by a cobra or inoculated via the eyes/skin in 2018-2021 were obtained from the Ramathibodi Poison Center. There were 1045 patients admitted during the 4-year study period (bite, n = 539; ocular/dermal inoculation, n = 506). Almost all patients with ocular/dermal inoculation had eye involvement and ocular injuries, but none had neurological effects. Most of the patients bitten by a cobra had local effects (69.0%) and neurological signs and symptoms (55.7%). The median interval between the bite and the onset of neurological symptoms was 1 h (range, 10 min to 24 h). Accordingly, patients should be observed closely in hospitals for at least 24 h after a bite. Intubation with ventilator support was required in 45.5% of patients and for a median duration of 1.1 days. Antivenom was administered in 63.5% of cases. There were nine deaths, most of which resulted from severe infection. Neurological effects and intubation were significantly more common after a monocled cobra bite than after a spitting cobra bite. The administration of antivenom with good supportive care, including the appropriate management of complications, especially wound infection, might decrease fatality.

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Purpose

This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting.

Patients and Methods

We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.

Results

In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.

Conclusion

Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

Malayan Pit Viper Envenomation and Treatment in Thailand

Introduction

The Malayan pit viper (MPV; Calloselasma rhodostoma) is a hematotoxic snake found in all regions of Thailand and many countries in Southeast Asia. Treatment of MPV envenomation varies among facilities due to their capabilities.

Materials and Methods

This study was a retrospective review of patients with MPV envenomation who were reported to the Ramathibodi Poison Center from 1 July 2016 to 30 June 2018.

Results

Of the 167 patients (median age, 40.5 years; range, 1.3–87.0 years) bitten by an MPV, the most common bite site was the foot (29.3%). Most patients reached the hospital within 1 hour of being bitten. One-hundred fifty-six patients (93.4%) had local effects from envenomation; 17 patients (10.2%) had severe local complications including necrotizing fasciitis (3.0%) and compartment syndrome (7.2%). Systemic effects such as hemorrhage and abnormal hemostasis occurred in 147 patients (88.0%). Additional effects included abnormal venous clotting time in 123 patients (73.7%), unclotted 20-minute whole blood clotting time in 57 patients (34.1%), low platelet counts (<50,000/µL) in 29 patients (17.4%), prolonged international normalized ratio (>1.2) in 51 patients (30.5%), and systemic bleeding in 14 patients (8.4%). The median onset of bleeding disorder was 6 hours. Monitoring for 24, 48, and 49 hours after bite enabled detection of systemic effects in 94.2%, 99.3%, and 100.0%, respectively. Three hundred fifteen courses of antivenin were administered to 144 patients (86.2%). All the patients who received antivenin recovered from bleeding disorder. Only 7.0% of antivenin doses were administered without Thai Red Cross indications. Allergic reactions from antivenin occurred in 34.7% of the 144 patients. One hundred thirty patients (77.8%) received antibiotics, and 32 patients (19.2%) required surgical management, including debridement and fasciotomy.

Conclusion

MPV envenomation results in local and systemic effects. Most systemic effects were abnormal clotting test results. Most patients reported onset of bleeding disorder within 48 hours.

Clinical effects and factors associated with adverse clinical outcomes of hymenopteran stings treated in a Thai Poison Centre: a retrospective cross-sectional study

OBJECTIVE

To describe clinical effects and outcomes of hymenopteran stings and to explore the non-laboratory factors associated with adverse clinical outcomes, a composite outcome including death, respiratory failure requiring intubation, acute kidney injury (AKI) requiring dialysis and hypotension requiring vasopressor use.

METHODS

A retrospective cross-sectional study was performed at the Ramathibodi Poison Center, a poison centre of a tertiary care hospital in Thailand. All cases of hymenopteran sting consultations from January 2015 to June 2019 were consecutively enrolled, and charts were reviewed. Demographics, initial clinical characteristics and outcomes were collected. Factors associated with adverse clinical outcome were explored.

RESULTS

One hundred and fourteen hymenopteran stings cases (wasp 48%, bee 33%, hornet 14% and carpenter bee 8.8%) were included (median age, 36.5 years (interquartile range 9-55); male 63%). The prevalence of adverse clinical outcomes was 12.3% (95%CI 6.88-12.8). At initial presentation, 100% of cases had local skin reactions, 11.4% were clinical anaphylaxis, and 8% had red urine. Adverse clinical outcomes included death (n = 10), respiratory failure requiring intubation (n = 9), AKI requiring dialysis (n = 6) and hypotension requiring vasopressor use (n = 2). None of the patients with carpenter bee or hornet stings developed adverse clinical outcomes. In univariable analysis, urticaria, wheezing, red urine, wasp sting and sting number > 10 were significantly associated with adverse clinical outcomes. In multivariable analysis, red urine (adjusted OR 11.1 (95% CI 1.57-216)), wheezing (adjusted OR 16.7 (95% CI 1.43-402)) and a number of stings > 10 (adjusted OR 21.5 (95% CI2.13-2557)) were significant.

CONCLUSIONS

Adverse clinical outcomes in hymenopteran stings were not uncommon among cases inquiring to a national Thai poison centre. At initial presentation, red urine, wheezing and a number stings >10 were significantly associated with adverse clinical outcomes. Larger epidemiologic studies are required to confirm these associations.

Toad Poisoning: Clinical Characteristics and Outcomes

Objective

This study was performed to describe the clinical characteristics and outcomes of patients with toad poisoning in Thailand.

Methods

We carried out a retrospective study of patients with toad poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012–2016).

Results

We studied 36 patients poisoned by toad toxin. The median age was 31 years. Most patients were male (66.7%) and had ingested toad meat (50%). The most common presentation was gastrointestinal (GI) symptoms with a median onset of 2 h after ingestion. Twelve patients presented with bradycardia; seven presented with shock and one with cardiac arrest. In the initial EKGs of all patients, the most common abnormality was sinus bradycardia.Two patients developed cardiac arrest early during management in the emergency room (within 15 minutes after ER arrival or within 4.5 h after ingestion). During admission, one patient developed sinus bradycardia, and two developed bradyarrhythmia; however, all three were stable. No tachyarrhythmias such as ventricular tachycardia were detected in any patient. Some patients (11.1%) presented with hyperkalemia. Serum digoxin was detected in five of seven patients tested, ranging from 0.43 to >8 ng/mL. Most patients (75%) were admitted to the hospital; the median duration of hospitalization was 2 d (range 0.5–5 d). The overall mortality rate was 8.3%, and all three patients that died ate toad meat and/or eggs and developed cardiac arrest. All patients received supportive with/without symptomatic care including GI decontamination, inotropic drugs, cardiac pacing, and management of hyperkalemia. One patient received intravenous calcium for hyperkalemia but did not develop dysrhythmia after calcium administration. One patient received digoxin-specific antibody fragments (DsFab), after which he clinically improved and was discharged.

Conclusion

Toad poisoning commonly caused GI symptoms and bradycardia. However, in severe cases, death occurred. Tachyarrhythmia was not observed. Supportive, symptomatic care might be the main therapies for this poisoning, especially if DsFab is not available.

Acute Imidacloprid Poisoning in Thailand

Introduction

Imidacloprid is the most commonly used neonicotinoid insecticide worldwide. Despite its reputation for safety, there is increasing evidence regarding its toxicity. This study characterized the clinical manifestations and outcomes of acute imidacloprid poisoning.

Methods

This was a retrospective study of patients with imidacloprid poisoning who were referred to the Ramathibodi Poison Center in Bangkok, Thailand between 2010 and 2018.

Results

A total of 163 patients with imidacloprid-only exposure were included. Most were exposed by ingestion (93.3%). The patients were predominantly male (55.8%), with a median age of 41.3 years. The common presenting features were gastrointestinal symptoms (63.8%) with no corrosive injuries and neurological effects (14.2%). The majority of medical outcomes was no (18.4%) to mild (76.1%) toxicity. One patient had symptoms mimicking cholinergic syndrome, three developed liver injury, and five died. Among the five deaths, two patients presented severe initial severity, and one presented moderate initial severity. Two of the patients who died initially presented only mild severity. The mortality rate was 3.1%. The estimated amount of ingestion, cardiovascular effects (especially tachycardia and cardiac arrest), central nervous system effects (especially coma), dyspnea, and diaphoresis were significantly associated with mortality. Patient management primarily included supportive and symptomatic care.

Conclusion

Most patients with imidacloprid poisoning developed only mild toxicity. The mortality rate was low, but a few patients with mild initial severity died. Patients who ingest a large amount or show these warning signs including cardiovascular effects, central nervous system effects, dyspnea, and diaphoresis at the initial presentation should be considered for close observation and monitoring.

Myotoxic Mushroom Poisoning in Thailand: Clinical Characteristics and Outcomes

Purpose

To describe the clinical characteristics and outcomes of myotoxic mushroom poisoning in Thailand.

Patients and Methods

We performed a retrospective cohort study of cases of myotoxic mushroom poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012-2016).

Results

Forty-one cases were included. Most (53.7%) were male with the average age of 49 years. In three cases, the mushrooms were identified as Russula species by an experienced mycologist. Common presenting symptoms were gastrointestinal (GI) symptoms and myalgia. The median onset of GI symptoms and symptoms suggesting rhabdomyolysis after consuming mushrooms was 2 hours (0.17-24 hours) and 24-48 hours (2-120 hours), respectively. Eight patients who ate the mushrooms together with other patients with rhabdomyolysis had GI symptoms but did not develop rhabdomyolysis. For patients with rhabdomyolysis, acute kidney injury (AKI) and hyperkalaemia occurred in 51.5% and 33.3% of cases, respectively. Median initial and maximum creatine phosphokinase (CPK) levels in patients with rhabdomyolysis were 31,145 and 47,861 U/L, respectively. Fifteen of 17 patients who were investigated for troponin levels had elevated troponin. Three patients had a low ejection fraction. Most patients (95.1%) were admitted to hospital, with a median stay of 5 days. The mortality rate was 26.8%. Treatments included intravenous fluid, urine alkalinization, haemodialysis and peritoneal dialysis. Among patients with rhabdomyolysis, AKI, hyperkalaemia during hospitalisation, maximum CPK level, maximum creatinine level and initial and maximum potassium levels were the factors found to be significantly different between patients who died and those who survived.

Conclusion

Myotoxic mushroom poisoning had a high mortality rate. Most patients had early or delayed onset of clinical symptoms after mushroom ingestion. Some patients developed severe cardiovascular effects. Early detection, close monitoring (especially serum potassium, creatinine, CPK and cardiac effect) and good supportive care were the main treatment modalities.

Poisoning of glutaraldehyde-containing products: clinical characteristics and outcomes

OBJECTIVE

This study describes the clinical characteristics, outcomes, and factors at presentation associated with death of cases poisoned by glutaraldehyde (GA)-containing products.

METHODS

We performed a 5-year retrospective cohort study (July 2013-June 2018) using data from the Ramathibodi Poison Center.

RESULTS

There were 244 cases included in this study. Most were men with a median age of 37 years. The GA-containing products were mainly used as farm disinfectants (99.2%), with a median concentration of 15%. Most products (76.2%) contained co-formulants such as cationic detergents and formaldehyde.Most circumstances were accidental (56.9%). The others were suicide attempts by ingestion, except one patient who intentionally injected GA subcutaneously. The most common route of exposure was ingestion (95.0%). Local symptoms in areas of exposure were common. Ingestion resulted in more severe local effects than other routes, and corrosive effects occurred in 23 cases (9.4%). Systemic signs and symptoms occurred in 149 patients (61.1%). Systemic effects included abnormal vital signs, desaturation, altered mental status, hypo/hypernatremia, hypokalemia, low bicarbonate/metabolic acidosis, acute kidney injury (AKI), hepatitis, and rhabdomyolysis. Systemic effects mostly resulted from ingestion. Most patients had mild severity, received only supportive treatment, and fully recovered. The median length of hospital stay was 2 days. The one case of subcutaneous injection developed both local and systemic effects but survived. The mortality rate was 3.7%. Multivariate analysis indicated that either neurological symptoms or AKI at presentation were associated with death.

CONCLUSIONS

In our study, patients were exposed to GA-containing products that were mainly used as farm disinfectants and were generally co-formulated with other substances. Poisoning with these products commonly resulted in mild local irritative symptoms. However, some cases developed corrosive symptoms, systemic effects, or even died. As neurological symptoms or AKI could prognosticate deaths; physicians should look for these factors in patients with GA exposure at presentation for close monitoring and aggressive treatment.

<p>Clinical Characteristics of <em>Acalypha indica</em> Poisoning</p>

Background

Patients and Methods

Results

Discussion

Conclusion

Hematotoxic Manifestations and Management of Green Pit Viper Bites in Thailand

Introduction

Green pit vipers (GPV) are widely distributed throughout Thailand and are responsible for significant morbidity. The primary objective of this study was to characterize clinical presentations and treatment methods for GPV bites. The secondary objective was to demonstrate the earliest and latest onset of hematotoxicity.

Methods

GPV bites reported to the Ramathibodi Poison Center between July 1, 2016, and June 30, 2018, were analyzed.

Results

There were 288 GPV cases within the study period. Patients were predominantly male (62.8%), and the median age was 40 years (interquartile range (IQR) 22.8–58). Median time from envenomation to hospital presentation was 1 hour (IQR 0.5–2). Patients were primarily bitten on the finger (27.4%). Most patients reported swelling (90.3%). Necrosis and compartment syndrome occurred in 13 and 9 cases, respectively. Systemic effects occurred in 190 cases (65.9%), with median onset 15 hours (IQR 6–28.3) post-bite. Venous clotting time (VCT) showed the highest percentage of abnormalities. Systemic bleeding occurred in 13 cases (4.5%). Monitoring patients for 24, 48, and 72 hours after bites detected 62.7%, 85.9%, and 96.5% of cases with systemic effects, respectively. In total, 184 patients (62.5%) were treated, sometimes repeatedly, with antivenoms (285 courses, 949 vials). The most common indication was prolonged VCT (144 courses, 50.5%). Recurrent systemic effects after antivenom occurred in 11 cases (6.1% of patients received antivenom). No recurrence presented as systemic bleeding. Adverse reactions to antivenom were reported in 44 courses (15.4% of 285 courses), being anaphylaxis in 19 courses (6.7%). Other treatments included antibiotics (192 cases, 66.7%), surgical intervention (10, 34.7%), and blood components (4, 1.4%).

Conclusion

Most GPV bites result in envenomation. The most frequent local effect is mild swelling. Systemic bleeding is uncommon. The current recommendation of a 3-day follow-up can detect up to 96% of patients who may require antivenom. No severe morbidity or mortality is reported. Antivenoms are primarily indicated by prolonged VCT. Side effects of antivenom are minimal.

Utility of Thrombin Time in Management of Patients with Green Pit Vipers Bite

Objectives:

GGreen pit vipers (GPV) envenomation causes consumptive coagulopathy mainly by thrombin-like enzymes. Fibrinogen levels are generally investigated to help evaluate systemic envenomation. However, tests of fibrinogen levels may not be available in every hospital. This study aimed to determine the sensitivity, specificity and accuracy for a range of various coagulation tests (20 minute whole blood clotting test (20WBCT), prothrombin time, international normalized ratio and thrombin time (TT)), comparing to the two gold standards performed in patients with GPV bite.

Methods:

This was the pilot study which we retrospectively reviewed fibrinogen level results including the hospital records of 24 GPV (Trimeresurus albolabris or macrops) bite patients visiting Ramathibodi Hospital, Thailand during 2013–2017 with 65 results of fibrinogen levels. The fibrinogen levels <164 and <100 mg/dL were used as the standard cut-off points or gold standards as the abnormal low and critical levels, respectively.

Results:

Most were male. All had local effects. For fibrinogen levels <164 and <100 mg/dL, prolonged TT had the highest sensitivity of 57.1% and 82.4%; the negative predictive value of 74.5% and 93.6%; the accuracy of 81.0% and 92.1%; and the area under a receiver operating characteristic curve of 0.762 and 0.873, respectively. For fibrinogen levels <164, unclotted 20WBCT and prolonged TT had the highest specificity and positive predictive value of 100% all. For fibrinogen levels <100, unclotted 20WBCT had the highest specificity and positive predictive value of 100% both, while prolonged TT had the specificity and positive predictive value of 95.7% and 87.5%, respectively. One patient developed isolated thrombocytopenia without hypofibrinogenemia and coagulopathy.

Conclusions:

Among four coagulation tests, TT was the most sensitive and accurate test to indicate hypofibrinogenemia in GPV bite patients. In case of unavailable fibrinogen levels thrombin time might be investigated to help evaluate patients’ fibrinogen status. Isolated thrombocytopenia could occur in GPV envenomation.

Clinical outcome of paraquat poisoning during pregnancy

Objectives: We aimed to describe clinical characteristics and outcomes of paraquat poisoning in pregnant patients, their fetuses, and newborns. Methods: We performed a retrospective study of pregnant patients who were exposed to paraquat, from the Ramathibodi Poison Center Toxic Exposure Surveillance System, during a 5-year period. Results: Thirty-six patients, representing every trimester, were included. All experienced oral exposure with a mean age of 22.7 years and mean gestational age (GA) of 23.1 weeks. Most had gastrointestinal symptoms and signs. Systemic effects, which mainly comprised of acute kidney injury (AKI), were found in 13 patients (36.1%); obstetric complications were noted in five patients (13.9%). Medical treatment included intravenous dexamethasone and cyclophosphamide. Some patients received hemodialysis and endotracheal intubation. Nine patients delivered during hospitalization; four newborns (maternal GAs of 30-36 weeks with systemic effects) died after delivery. One patient with GA 26 weeks delivered and died, but her newborn survived. Mortality rates of pregnant patients and their offspring delivered in-hospital were 25% and 44.4%, respectively; all deaths occurred in patients with systemic toxicity. The median length of hospital stay was 6 days. Notably, AKI, hepatotoxicity, and maximum white blood cell count significantly differed between dead and surviving patients. We followed-up 15 surviving patients who were discharged before delivery to assess delivery outcomes. All 15 patients and newborns survived without reports of congenital anomalies. Conclusions: Paraquat poisoning during pregnancy caused high fatalities in pregnant patients, fetuses, and newborns who were delivered during hospitalization, especially among patients with systemic effects. The GA of the pregnancy affected fetal outcomes, both in utero and at birth. Selective, appropriate management is warranted and might be guided by poisoning severity and the GA of the pregnancy.

Krait envenomation in Thailand

Purpose

Three species in the genus Bungarus inhabit Thailand. Among these, Bungarus candidus (Malayan krait) is the most common and deadliest. Currently, the clinical manifestations of patients envenomed by kraits, especially Bungarus fasciatus (banded krait), have not been thoroughly investigated. This study was performed to elucidate the clinical manifestations and outcomes of patients bitten by kraits in Thailand.

Materials and methods

The data of krait envenomation cases that occurred during a 9-year period were obtained from the Ramathibodi Poison Center Toxic Exposure Surveillance System and retrospectively analyzed.

Results

In total, 78 cases of krait envenomation were included. Most patients were male (59.0%) and the median age was 28 years. All had minimal local effects. The median duration from the bite to the onset of neurological manifestations was 3 hours (range, 0.5–8 hours). Besides neurological effects, the patients also developed high blood pressure (67.4%), tachycardia (61.7%), hypokalemia (55.3%), and hyponatremia (17.6%). Severe hyponatremia (<120 mEq/L) was noted in four pediatric patients. Other clinical manifestations were bradycardia, abdominal pain, and rhabdomyolysis. The mortality rate was 6.4%, and all deaths occurred from B. candidus bites. Eighty-six percent of patients received antivenom. Most patients (75.6%) were intubated and underwent assisted ventilation for a median of 6 days (range, 1–37 days). The median length of hospital stay was 7 days. Some patients developed complications during hospitalization; the most common was pneumonia. These in-hospital complications were significantly associated with death.

Conclusion

Although krait bites caused only minimal local effects, the mortality rate was still high, particularly from Malayan krait bites. Besides neurological effects, other clinical manifestations were high blood pressure, tachycardia, hypokalemia, and hyponatremia. Thus, vital signs and electrolytes should be frequently and closely monitored in these patients. Apart from antivenom treatment, adequate supportive care including management of complications might help to decrease the mortality rate.

Clinical characteristics and outcome of toxicity from Amanita mushroom poisoning

Objective

To describe and analyze the clinical characteristics and outcome of amatoxin poisoning cases.

Methods

We performed a retrospective cohort study of amatoxin poisoning cases from Ramathibodi Poison Center Toxic Exposure Surveillance System, from May 2013 to August 2015.

Results

There were 30 consultations with a total of 55 poisoning cases. Most cases were male and from the north-east region. Hepatitis, acute kidney injury, jaundice, and coagulopathy accounted for 74%, 46.3%, 44.7%, and 52.8% of the cases, respectively. Almost all of the patients were admitted to the hospital, and the median duration of hospital stay was found to be 4 days. Mortality rate was found to be 27.3%. Most patients (73%) received the treatment including multiple-dose activated charcoal (67.5%), intravenous N-acetylcysteine (87.5%), and benzylpenicillin (45%). In 60% of the cases, the treatment was initiated within 24 h after eating mushrooms. Exchange transfusion and liver transplantation were performed in one severe case. However, this patient died eventually. Because intravenous silybinin is not available in Thailand during the study period, 8 patients received oral silymarin instead. All 8 patients had hepatitis and were treated with high dosage of oral silymarin (5 patients with 4.48 g/day, 2 patients with 1.68 g/day, and 1 patient with 1.4 g/day) for a couple of days. One of these patients died as she received treatment very late; she was treated with silymarin at 1.68 g/day dosage. Thus, the fatality in oral silymarin treatment group was 12.5%. We performed the analysis between the dead and survival groups. We found that in hepatitis, initial and maximum serum aspartate transaminase, initial and maximum serum alanine transaminase, and acute kidney injury were significantly different between the two groups.

Conclusion

Amanita mushroom poisoning caused high fatalities. Serum transaminase and creatinine were the factors associated with death. Treatment with oral high dose silymarin should be investigated further as one of the principal therapies in amatoxin poisoning.

Cyanide poisoning in Thailand before and after establishment of the National Antidote Project

CONTEXT

Antidote shortage is a global problem. In Thailand, the National Antidote Project (NAP) has operated since November 2010 to manage the national antidote stockpile, educate the healthcare providers on appropriate antidote use, and evaluate antidote usage.

OBJECTIVE

To evaluate the effect of NAP implementation on mortality rate and antidote use in cyanide poisoning cases arising from ingestion of cyanide or cyanogenic glycoside.

METHODS

This is a retrospective cohort of poisoning cases involving cyanide or cyanogenic glycoside ingestion reported to Ramathibodi Poison Center from 1 January 2007 to 31 December 2015. Mortality rate, antidote use, and appropriateness of antidote use (defined as correct indication, proper dosing regimen, and administration within 90 min) before and after NAP implementation were compared. Association between parameters and fatal outcomes was analyzed.

RESULTS

A total of 343 cases involving cyanide or cyanogenic glycoside ingestion were reported to Ramathibodi Poison Center. There were 213 cases (62.1%) during NAP (Project group) and 130 cases (37.9%) pre-NAP implementation (Before group). Implementation of NAP led to increased antidote use (39.9% in Project group versus 24.6% in Before group) and a higher rate of appropriate antidote use (74.1% in Project group versus 50.0% in Before group). All 30 deaths were presented with initial severe symptoms. Cyanide chemical source and self-harm intent were associated with death (OR: 12.919, 95% CI: 4.863-39.761 and OR: 10.747, 95% CI: 3.884-28.514, respectively). No difference in overall mortality rate (13 [10.0%] deaths before versus 17 [8.0%] deaths after NAP) was found. In subgroup analysis of 80 cases with initial severe symptoms, NAP and appropriate antidote use reduced mortality (OR: 0.327, 95% CI: 0.106-0.997 and OR: 0.024, 95% CI: 0.004-0.122, respectively). In the multivariate analysis of the cases with initial severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of death (OR: 0.122, 95% CI: 0.023-0.633 and OR: 0.034, 95% CI: 0.007-0.167, respectively), adjusted for intent of exposure, cyanide source, age, and sex.

CONCLUSIONS

After NAP implementation, both antidote use and appropriate antidote use increased. In cases presenting with severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of mortality.

Clinical characteristics of zinc phosphide poisoning in Thailand

Objective

The objectives of this study were to describe the clinical characteristics and outcomes of poisoning by zinc phosphide, a common rodenticide in Thailand, and to evaluate whether these outcomes can be prognosticated by the clinical presentation.

Materials and methods

A 3-year retrospective cohort study was performed using data from the Ramathibodi Poison Center Toxic Exposure Surveillance System.

Results

In total, 455 poisonings were identified. Most were males (60.5%) and from the central region of Thailand (71.0%). The mean age was 39.91±19.15 years. The most common route of exposure was oral (99.3%). Most patients showed normal vital signs, oxygen saturation, and consciousness at the first presentation. The three most common clinical presentations were gastrointestinal (GI; 68.8%), cardiovascular (22.0%), and respiratory (13.8%) signs and symptoms. Most patients had normal blood chemistry laboratory results and chest X-ray findings at presentation. The median hospital stay was 2 days, and the mortality rate was 7%. Approximately 70% of patients underwent GI decontamination, including gastric lavage and a single dose of activated charcoal. In all, 31 patients were intubated and required ventilator support. Inotropic drugs were given to 4.2% of patients. Four moribund patients also received hyperinsulinemia–euglycemia therapy and intravenous hydrocortisone; however, all died. Patients who survived and died showed significant differences in age, duration from taking zinc phosphide to hospital presentation, abnormal vital signs at presentation (tachycardia, low blood pressure, and tachypnea), acidosis, hypernatremia, hyperkalemia, in-hospital acute kidney injury, in-hospital hypoglycemia, endotracheal tube intubation, and inotropic requirement during hospitalization (P<0.05).

Conclusion

Zinc phosphide poisoning causes fatalities. Most patients have mild symptoms, and GI symptoms are the most common. Patients who present with abnormal vital signs or electrolytes might have more severe poisoning and should be closely monitored and aggressively treated. All patients should be observed in the hospital for 2 days and followed up for cardiovascular and respiratory symptoms, electrolyte balances, kidney function, and blood glucose.

Hematuria, an unusual systemic toxicity, in formic acid ingestion: a case report

Background

Acid ingestion can cause severe injuries of the upper gastrointestinal tract and the respiratory tract. Besides hydrofluoric acid and selenious acid, systemic toxicities of acid ingestion can occasionally occur. However, hematuria is a rare systemic toxicity reported in caustic poisoning.

Objectives

To describe a case of a one-year-old girl who accidentally ingested liquid formic acid.

Methods

This patient had severe local corrosive effects including a compromised upper respiratory tract and developed gross hematuria during the hospital admission.

Results

Hematuria could be a consequence of acid ingestion.

Conclusions

Significant hematuria can be a systemic effect of acid ingestion, but in this case was self-limiting

PLANT POISONING IN THAILAND: A 10-YEAR ANALYSIS FROM RAMATHIBODI POISON CENTER

Plant poisoning is not uncommon in Thailand. The objective of this study was to determine the incidence, type, clinical manifestations, severity and outcomes of plant poisoned patients in Thailand over a 10-year period. We retrospectively reviewed data from the Ramathibodi Poison Center Toxic Exposure Surveillance System for 2001-2010. A total of 2,901 poisonous plant exposure cases were identified, comprising 3.1% of the 92,392 poison cases recorded during the study period. This was the fifth most common type of poisoning recorded. Children aged < 13 years comprised the largest percent (69.8%) of the cases. The major type of exposure was unintentional ingestion. Ninety-nine types of poisonous plants were recorded as the causative agents among 99.1%of the cases. Gastrointestinal symptoms were reported in 72.0% of cases with Jatropha curcas (physic nut) comprising 54.1% of these. Most patients had only minor signs and symptoms. The mortality rate among the total plant poisoning cases was 0.9%, with 26 deaths. Thirteen deaths occurred in children aged < 13 years. The greatest number of fatalities were due to ingestion of Manihot esculenta (cassava), primarily due to multi-system organ failure. Children aged < 13 years are at the greatest risk for plant poisoning in Thailand; mostly unintentional. Most cases were minor and the mortality rate was low. Jatropha curcas was the most common cause of poisoning and Manihot esculenta was the most common cause of death. Public education is important to minimize these poisonings.

OCCUPATIONAL CARBAMATE POISONING IN THAILAND

Carbamate insecticide is a leading cause of poisoning in Thailand. The objective of this study was to characterize the clinical manifestations and modes of occupational exposure in carbamate poisoning cases. We retrospectively studied all the cases of carbamate poisoning due to occupational exposure recorded in the Ramathibodi Poison Center Toxic Exposure Surveillance system during 2005 to 2010. Demographic data, clinical manifestations and severity were analyzed statistically. During the study period, 3,183 cases were identified, of which 170 (5.3%) were deemed to be due to occupational exposure. Ninety-six cases (56.5%) and 35 cases (20.6%) were poisoned by carbofuran and methomyl, respectively. Carbofuran is sold as a 3% grain and applied by sowing; methomyl is sold as a liquid and is applied by spraying. The majority of poisoned patients did not wear personal protective equipment (PPE) while applying the carbamates. The clinical manifestations of occupational carbofuran poisoning recorded were nausea and vomiting (82.3%), headaches (56.3%) and miosis (19.8%). The clinical manifestations of methomyl poisoning were nausea and vomiting (74.3%), headaches (57.1%) and palpitations (11.4%). Most patients in both groups had mild symptoms. Only one case in each group required endotracheal intubation and mechanical ventilation support. There were no deaths and the lengths of hospitalization ranged from 2 hours to 2 days. Occupational carbamate poisoning cases in our series were mostly mild and the patients recovered quickly. There were only rare cases of serious symptoms. Lack of knowledge and inadequate PPE were the major factors contributing to occupational poisoning. Educating agricultural workers about correct precautions and pesticide use could minimize this type of poisoning.

Effect of activated charcoal in reducing paracetamol absorption at a supra-therapeutic dose

BACKGROUND

Activated charcoal (AC) is recommended for treatment of acute poisoning, thereby decreasing gastrointestinal tract absorption. AC from different sources may have different adsorptive capacity. The AC that is available in Thailand has not been proven yet for its efficacy The authors simulated paracetamol overdose model for the present study.

OBJECTIVE

To assess the efficacy of AC that is available in Thailand in decreasing absorption of paracetamol at supratherapeutic dose.

MATERIAL AND METHOD

This was a two-arm, prospective, crossover study. Washout period was 1 week Twelve healthy male volunteers participated. All volunteers were randomly assigned to either sequence of control-experiment (CE) or EC. The participants ingested 60 mg/Kg of paracetamol at Time=0. At Time = 0.25 hour, they ingested 50 g of AC as slurry with 250 ml of water when they were assigned as E, but drank 250 mL of water when were assigned as C. Blood samples were serially collected for determination of paracetamol concentration and calculating pharmacokinetic parameters, area under the time-concentration curve (AUC (0, infinity)).

RESULTS

Means of the AUC (0, infinity) were 313.7 +/- 29.8 and 184.8 +/- 91.6 mg-h/ L in the control and experimental arm, respectively It was statistically different (p = 0.01).

CONCLUSION

The tested AC was found to be able to reduce the absorption of the supratherapeutic dose of paracetamol.

Human poisoning in Thailand: The Ramathibodi Poison Center's experience (2001–2004)

OBJECTIVE

To identify poisoning and toxic exposure pattern, severity, and clinical outcome in Thailand during 2001 to 2004.

METHOD

This is a prospective study. All inquiries were registered, followed up, and verified. Interlocutors, poisons, patients' profiles, severity, and medical outcome after exposure or poisoning were analyzed.

RESULTS

A total 14,428 events was suspected as human poisoning or exposure. After follow-up and verification, 98.9% were confirmed as poisoning or poison exposure. These involved 15,016 patients and accounted for 6.0 per 100,000 populations per year. The vast majority of calls (92.4%) were from physicians. Pesticides, household products, and pharmaceutical products were the most common poisons involved in human exposure, which were 41.5%, 19.5%, and 18.9%, respectively. Patients aged 0-6 years, teenagers and adults with 20-29 years of age had the highest rates of exposure, which were 33.0, 24.5, and 10.5 exposures per 100,000 per year, respectively. Unintentional accidental exposure is the major reason of exposure in children, but intentional suicide was the main reason of exposure in teenagers and adults. The death rate of all exposure was 5.5%. Pesticides cause more severe clinical course and the highest death rate (10.0%).

CONCLUSION

Features of poisoning in Thailand were different from those in Western countries. Pesticide poisoning was the major problem in Thailand. Intentional suicide was the major circumstance of poison exposure in adults, but accidental exposure was the major reason of exposure in children.

Comparative bioavailability of paracetamol

Prescribing brand name versus generic drugs continues to be a controversial issue. The harmful effects of nonequivalence result from either too little or too much drug reaching the patient which will cause either failure of treatment or adverse drug reactions. On the other hand, if physicians prescribe higher priced original drugs instead of therapeutically equivalent lower cost generic drugs to their patients, the patients then have to pay for the added cost. This study was designed to compare the bioavailability of paracetamol of a generic versus original drug. The original brand (Tylenol, Cilag) which was assigned as the reference standard against another generic formulation (Sara, Thai Nakorn Patana). Ten healthy male volunteers aged 20 to 45 years participated in this study. The study was conducted as a cross-over experimental design. The dose was 2 tablets of 500 mg. In conclusion, based on the concentration-time curve and pharmacokinetic analysis there were no statistically significant differences between T1/2 absorption and Cmax. Although AUC of Sara was marginally statistically greater than Tylenol, this magnitude of difference probably has no clinical significance. All these parameters are within the accepted 20 per cent difference, indicating these products are bioequivalent.