A retrospective study of paradigm and outcome of acute poisoning cases in a tertiary care teaching hospital in Southern India

INTRODUCTION

Acute poisoning is an important medical emergency. The nature of poisons used varies in different parts of the world and may vary even in different parts of the same region depending on the cultural diversity and socioeconomic factors. Management of these sick patients will greatly improve if the common causes of poisoning are properly defined.¹ Insecticide self-poisoning accounts for about one - third of the world’s suicides. The proportion of all suicides using insecticides differs from 4% in the European region to over 50% in the Western pacific region, but this proportion is not concordant with the volume of insecticides sold in each region; it is the pattern of insecticide use and the toxicity of the products, not the quantity used, that influences the likelihood that they will be used in acts of self-harm.² With the research in the industrial and agricultural field and advances in medical sciences, a large number of insecticides have become available, which on exposure may cause severe toxicity. Information available in India is limited, with regard to acute poisoning in adults, including hospitalized patients.^3-7 In general, and accidental poisoning is more common in children, whereas suicidal poisoning is more common in adults.³ It is very important to know the nature and severity of poisoning in order to take appropriate preventive and treatment measures. Studies of this nature will be a very important useful tool in planning and management of critically ill acute poisoning cases. In this context, our study was carried out with the intention to investigate the paradigm and outcome of acute poisoning cases in a tertiary care teaching hospital in Tamilnadu.

METHODS

This study is a retrospective study done at SRM Medical College Hospital and Research Centre, a tertiary care hospital in the Kancheepuram district of Tamil Nadu. Study period is 24 months extending from July 2013 to June 2015. All cases of acute poisoning admitted to the hospital were included in the study. Cases of snake envenomation, drug allergy and food poisoning were excluded. Data regarding age, sex, circumstances of poisoning, name of poison, time elapsed after intake, chemical type, duration of hospitalization; severity and outcome were collected in the structured proforma. Circumstantial evidences such as retained empty bottles and drugs were also collected from the patients. Patient blood, gastric aspirate, urine sample were collected and analyzed with a separate toxicological laboratory attached with the ICU complex. Data was analyzed using Epi info software package for windows.

RESULTS

Total of 169 cases of acute poisoning were admitted during the study period. Males constituted the majority with 102 cases (60.36%) and female cases were 67 (39.64%) (Table 1). Male: female ratio is 3:2. Most cases of acute poisoning presented in the age group between 10 and 30 years (60.95%) followed by 30 to 50 years age group (30.77%) and 50 to 70 years age group (8.28%) (Table 2).

A majority of the poisoning cases (27.2%) were due to organophosphorus compounds (OPC) followed by Oleander seed poisoning (16.6%), drugs (13.0%), corrosive poisoning (7.7%), rat killer poison (6.5%)), pyrethroid Poisoning (5.9%) and others (Table 3). Drugs consumed were acetaminophen, sedatives, anti-epileptics, antidepressants, anti-psychotics and beta blockers (Table 4).

Corrosives were acid poisoning and kerosene. Blood, urine and gastric aspirate samples were collected soon after admission to hospital and samples analyzed with separate toxicological laboratory attached to the ICU complex. Chemical analysis were positive in 36 cases (78.3%) of OPC, 20 cases (71.4%) of oleander seed, 20 cases (90.9%) of tablets poisoning, 10 cases (90.9%) of rat killer poisoning, 6 cases (75%) organocarbamate, 7 cases(70%) of pyrethroids. Other reports are shown in Table 3. Out of 46 patients of OPC poisoning, 34 (73.91%) showed signs of severe toxicity and respiratory paralysis and required ventilator support. Among 28 cases of oleander seed poisoning, 18 (64.28%) cases developed bradyarrthymias, 4 (14.28%) cases developed complete heart block that required temporary pacemaker. Out of 11 patients with rat killer poison, 9 (81.81%) developed coagulopathy and hepatotoxicity, whereas only 3 (13.63%) with drug poisoning had hepatotoxicity.

Renal failure requiring dialysis occurred in six cases among total of 169, of these 2 cases were due to rat killer poison, one due to abrus seed, one case due to mercuric chloride, one due to hair dye, one due to parquet poison. Total mortality was 5.32% (9 cases) (Table 4).

Out of 3 cases of parquet poison, 2 (66.66%) developed severe toxicity and died. Out of 3 cases of abrus seed poison, 1 (33.33 %) developed circulatory failure and expired. Among 3 cases of hair dye, 1 (33.33%) developed severe rhabdomyolysis, renal failure and expired, 1 case of oleander had expired due to complete heart block. Out of 11 cases of rat killer poisoning 2 (18.18%) had severe hepatotoxicity and expired. Out of 8 cases of carbamate poisoning one case (12.8%) expired. Only one case of aluminium poison admitted and expired due to circulatory failure. There was no mortality in organophosphate compounds despite the highest incidence in our study and there was also no mortality among organochlorine, pyrethroids, corrosives and drugs. Mortality rates due to parquet and abrus seeds were significantly high followed by rat killer poison, hair dye poison, oleander seed and carbamate. All the 9 expired cases were admitted more than 6 hours after ingestion of poison and there was no decontamination done outside the hospital. Patients admitted within 6 hours of ingestion had no mortality (Table 5).

It was found that 88.75% (150) of cases were of intentional poisoning for suicidal attempt and 11.25% (19) of cases had accidental poisoning (Table 6). All the patients (5.32%) who expired were secondary to suicidal intention. Median hospital stay was 6 days. 54 patients (31.95%) stayed in the hospital for more than 5 days (Table 7).

98 cases (57.98%) underwent psychiatric workup and were given psychiatric counseling and drug therapy. Depression was seen in 35 (36.84 %) patients secondary to failure in social, academic, and financial areas and crisis in interpersonal adjustment. Other contributory factors were chronic alcohol dependence, financial stress and bipolar disorder.

DISCUSSION

In our study, insecticides followed by oleander seed poison were the two common types of poisoning. A study from Pondicherry revealed a rapidly increasing trend in the incidence of Organophosphorus poisoning over a period of 3 years.⁸ Other studies also showed that Organophosphorus are the commonly used poisonous compound.^4,7 In contrast, some other studies showed that majority of poisoning admissions were due to drugs.^3,9 A study from the All India Institute of Medical Sciences, Delhi, showed that drugs (19%) and pesticides (13%) are the most common agents out of a total of 728 poisoning cases. Out of this pesticide group, organocarbamate (47%) group followed by Organophosphorus (44%) and organochlorine agents.³ This difference in the types of poisoning seen within India may be due to the difference in the patterns of use and availability of insecticides. In this study, most cases of acute poisoning presented in the age group between 10 and 30 years (60.95%), similar findings were seen in other studies.^3-5 Males to female ratio of 3:2. The incidence of poisoning among males might be due cultural patterns and change in the lifestyle. In this study, the overall mortality was found to be 5.32 %. It is known from this study that on psychiatric assessment; most of the suicidal cases were associated with reactive depression. High degree of stress in financial, academic and social sectors as well as failure to achieve the targets on professional, education and socioeconomic leading to limited alternatives were the contributory factors in taking self-inflicted harms. Majority of the patients (88.75%) consumed the poison with suicidal intent as compared with (11.25%) of the patients exposed accidentally. A study reported from Kathmandu showed that 97% of the poisoning cases admitted in a hospital were due to suicidal attempt and study did not include snake bite cases as our study.¹⁰ In contrast, another study done at Delhi reported that nearly half (47%) of poisoning were accidental (1-70 age group).⁶ But the study had included pediatric cases, unlike in our study in which we excluded pediatric cases. It is found in our study that time interval lapse has a significant effect on the total outcome. All the expired cases were admitted to hospital after 8 hours of ingestion of poison. All the cases admitted less than 2 hours of ingestion of poison survived despite of heavy consumption. The first aid support like administration of gastrointestinal lavage, dose schedule of various antidotes such as atropine, Pralidoxime, activated charcoal given had considerable impact on the outcome. Patients who did not receive first aid support were probably brought to the hospital directly as they may have been closer to this hospital, and hence administered appropriate treatment earlier compared to others. It is found in our study that time lapse has a significant bearing on the total outcome. This is in comparison with other studies.^11,12

CONCLUSION

Overall, our study has managed to contribute substantial additional information regarding the epidemiology, paradigm and outcome of poisoning in a tertiary care teaching hospital at a district level. Poisoning is more common in young adolescent males. The overall mortality is significantly high, mainly contributed by self-poisoning with parquet and oleander seed in our study. Timely transport and early intervention of all critically ill acute poisoning cases is required to prevent the high mortality among poison victims.

Poison prevention protocols can be implemented at various levels as follows:

• 1. Strict implementation of insecticide act, so that import, manufacture, transport, sale, distribution and use of insecticides can be under the supervision of the government.
• 2. Controlling access to dangerous insecticide and follow secure storage practice.
• 3. Poison information centre should be initiated in each district. It will benefit people in timely diagnosis and treatment.
• 4. Primary health centre should be upgraded to provide immediate effective treatment to acute poisoning cases.
• 5. Peoples with psychosocial problems should be identified and should be referred for psychiatric counseling.
• 6. Health education should be started at school and college level about poisoning and its preventive measures.
• 7. Strict implementation of anti-dowry law, women empowerment and marriage counseling and will help women in decreasing the stress in married life and decrease in the incidence of poisoning among housewives.

ACKNOWLEDGEMENTS

We would like to thank our Dean, Medical Superintendent, and Head of the Department of Medicine and Dr. Mohammad Gani V.M.S. MD, Professor, Department of General medicine, for providing his support for the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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