Journal of The Korean Society of Clinical Toxicology

Byung Hak So

13 Articles

Predicting serum acetaminophen concentrations in acute poisoning for safe termination of N-acetylcysteine in a resource-limited environment: Dahae Kim, Kyungman Cha, Byung Hak So; J Korean Soc Clin Toxicol. 2023;21(2):128-134. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00013

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Abstract PDF: Purpose: The Prescott nomogram has been utilized to forecast hepatotoxicity from acute acetaminophen poisoning. In developing countries, emergency medical centers lack the resources to report acetaminophen concentrations; thus, the commencement and cessation of treatment are based on the reported dose. This study investigated risk factors that can predict acetaminophen detection after 15 hours for safe treatment termination.
Methods
Data were collected from an urban emergency medical center from 2010 to 2020. The study included patients ≥14 years of age with acute acetaminophen poisoning within 15 hours. The correlation between risk factors and detection of acetaminophen 15 hours after ingestion was evaluated using logistic regression, and the area under the curve (AUC) was calculated.
Results
In total, 181 patients were included in the primary analysis; the median dose was 150.9 mg/kg and 35 patients (19.3%) had acetaminophen detected 15 hours after ingestion. The dose per weight and the time to visit were significant predictors for acetaminophen detection after 15 hours (odds ratio, 1.020 and 1.030, respectively). The AUCs were 0.628 for a 135 mg/kg cut-off value and 0.658 for a cut-off 450 minutes, and that of the combined model was 0.714 (sensitivity: 45.7%, specificity: 91.8%).
Conclusion
Where acetaminophen concentrations are not reported during treatment following the UK guidelines, it is safe to start N-acetylcysteine immediately for patients who are ≥14 years old, visit within 15 hours after acute poisoning, and report having ingested ≥135 mg/kg. Additional N-acetylcysteine doses should be considered for patients visiting after 8 hours.

The 2022 Annual Report on Toxicology Surveillance and Severe Poisoning Cases at Emergency Departments in Korea: Eun Sun Lee, Su Jin Kim, Gyu Chong Cho, Mi Jin Lee, Byung Hak So, Kyung Su Kim, Juhyun Song, Sung Woo Lee; J Korean Soc Clin Toxicol. 2023;21(1):1-16. Published online June 30, 2023; DOI: https://doi.org/10.22537/jksct.2023.00007

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Abstract PDF Supplementary Material: Purpose: This study investigated the actual incidence of acute poisoning in Korea on a nationwide scale, with the aim of laying the groundwork for future initiatives in prevention, strategic antidote distribution, and the development of effective emergency treatment for acute poisoning.
Methods
The study analyzed data from 3,038 patients who presented to emergency departments with poisoning-related conditions from June 1, 2022 to December 31, 2022 at 10 sites in nine cities across the country. We extracted data on general characteristics of the poisoning cases, including demographic characteristics (age and gender), place of exposure, reason for poisoning, route of exposure, and the substance involved in the poisoning incident. Age-related patterns in reasons for poisoning, medical outcomes, frequent and primary poisoning substances, and deaths were also analyzed.
Results
The population analyzed in our study was predominantly female, with women constituting 54.74% of all cases. Among infants and children, non-intentional poisoning due to general accidents was the most common cause, accounting for 71.43% of cases. Conversely, suicidal poisoning was more prevalent among teenagers and adults over 20. Fifty-two patients died during the study period, with males comprising approximately two-thirds (67.31%) of these fatalities. Pesticides were the most common poisoning substance among those who died, accounting for 55.77% of such cases. Notably, a significant majority of the victims were elderly individuals aged 60 and above.
Conclusion
This study holds substantial significance, since it represents the first comprehensive investigation and analysis of the symptoms, treatment, and causes of death due to poisoning in Korea on a national scale. By substantially expanding the range and types of poisonous substances examined, we were able to more precisely identify the characteristics and clinical patterns of poisoning cases nationwide.

Poisoning patients’ clinical features according to the blood level of propranolol: Sungheon Kim, Byung Hak So, Hyung Min Kim, Kyeong Man Cha, Hwan Song, Won Jung Jeong; J Korean Soc Clin Toxicol. 2023;21(1):56-63. Published online June 30, 2023; DOI: https://doi.org/10.22537/jksct.2023.00010

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Abstract PDF: Purpose: Propranolol is widely prescribed to psychiatric patients to control adrenergic symptoms. However, propranolol poisoning can be fatal due to cardiovascular complications. We analyzed associations between blood levels of propranolol and patients’ clinical features, with the aim of predicting progression to severe complications.
Methods
Data were collected from patients aged 18 years or older who presented to the emergency department with propranolol poisoning between January 2016 and May 2022. We retrospectively analyzed their medical records and compared blood levels of propranolol between those who had cardiovascular complications and those who did not.
Results
Two hundred patients were included in this study. The blood levels of propranolol were significantly higher in patients with hypotension, bradycardia, and prolonged QT intervals, with median values of 247.0 ng/mL (interquartile range [IQR], 56.5–333.8 ng/mL), 275.8 ng/mL (IQR, 154.3–486.4 ng/mL), and 159.0 ng/mL (IQR, 33.9–310.8 ng/mL), respectively. In the predictive analysis of cardiovascular complications using a receiver operating characteristic curve, the area under the curve was 0.729 with a cut-off value of 72.40 ng/mL (sensitivity, 0.667; specificity, 0.819). In addition, the correlation coefficient between blood levels and the amount of drug described during the history-taking at the time of presentation was 0.634, which was found to have a significantly higher relationship.
Conclusion
Because blood levels of propranolol can be used as predictors of exacerbation in patients with propranolol poisoning, patients with blood levels above 72.40 ng/dL require careful treatment and observation from their initial presentation at the emergency department.

Comparison of medical history based diagnosis and urine test using ultra-performance liquid chromatography-tandem mass spectrometry in drug overdose: Ja-Young Lee, Kyungman Cha, Won Jung Jeong, Hyung Min Kim, Byung Hak So; J Korean Soc Clin Toxicol. 2022;20(1):1-7. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.1

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Abstract PDF: Purpose: In patients with acute drug overdose, identification of drugs ingested is crucial to make a precise diagnosis. In most cases, the diagnoses are made on the medical history and physical examination findings. This study was undertaken to determine the concordance of diagnosis made on the basis of patient history by comparing it with urine toxicology analysis. Methods: This was a retrospective study of drug intoxicated patients over 18 years old who presented to the emergency center from 2017 to 2019. Specimens from urine were tested using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-TMS). The test results were compared with information obtained from patients. Diagnostic concordances for drug detection in intoxicated patients were calculated. Logistic regression analysis was used to examine the association between clinical characteristics and diagnostic discrepancy. Results: Totally, 370 patients were included in the analysis. Overall, 66 types of drugs were detected by UPLC-TMS. The drugs detected most frequently were zolpidem (104, 27.8%), citalopram (70, 18.7%), and paracetamol (66, 17.6%). The mean diagnostic concordance of patients was 52.7%. There were statistically significant diagnostic discrepancies in patients with underlying depression and patients intoxicated with multiple types of drugs. Conclusion: In ED patients with acute drug overdose, the diagnoses made on history alone were often inaccurate. It is essential to perform urine toxicology tests such as UPLC-TMS as a confirmatory instrument to improve accuracy in evaluating patients with drug intoxication.

Effect of ETCO2 monitoring of poisoning patients with decreased mental state in ED: Yong Hee Kwon, Byung Hak So, Won Jung Jeong; J Korean Soc Clin Toxicol. 2021;19(1):44-50. Published online June 30, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.1.44

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Abstract PDF: Purpose: This study aimed to analyse the effect of End-Tidal Carbon Dioxide (ETCO2) monitoring on patients who had been poisoned and presented in the emergency department with decreased consciousness. Methods: The data of patients over 18 years old presenting with poisoning from 2016 to 2020 was collected from the emergency department. We retrospectively analyzed their medical records, and defined patients with a Glasgow Coma Scale (GCS) score of 9 or less as having decreased consciousness. We divided the patients into two groups, one with ETCO2 monitoring and the other without, and the difference between the two groups was compared. Results: 168 patients participated in this study and 83 (49.4%) of them belonged to the ETCO2 monitoring group. In this group, the interval between arterial blood tests was statistically significantly longer and the rate of intubation was lower. In addition, in the monitoring group, the incidence of pneumonia and the rate of poor prognosis was not significantly higher. Conclusion: Although ETCO2 monitoring does not directly affect the prognosis of poisoned patients with decreased consciousness, it should be actively done as it can help to adequately treat patients while avoiding invasive techniques or unnecessary intubation.

Severity Predictors of Elderly Poisoning Patients Admitted to an Emergency Medical Center: Chang Yong Park, Kyung Man Cha, Byung Hak So, Won Jung Jeong; J Korean Soc Clin Toxicol. 2019;17(2):94-101. Published online December 31, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.2.94

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Purpose: This study examined the clinical characteristics of severe elderly poisoning patients to determine the factors that can prevent them. Methods: Data were collected from patients over 65 years of age presenting to the emergency center with poisoning from 2013 to 2018. Their medical records were analyzed retrospectively, and patients with a poisoning severity score of three or more were defined as the severe poisoning group. The risk factors were evaluated by univariate and multivariate analysis. Results: This study analyzed 292 patients, of whom 37 (12.7%) belonged to the severe poisoning group. The severe poisoning group showed a significantly higher association with pesticide poisoning and intentional suicide attempts. Loneliness and somatization were the cause of the suicidal ideas. No significant differences in age, sex, drinking, ingestion time, poisonous materials other than pesticides, and neuropsychological consultation were observed between the two groups. Conclusion: The severe elderly poisoning patients were the result of intentional poisoning for suicide. Loneliness and somatization were the most influential causes of suicidal poisoning. Therefore, psychiatric screening and frequent medical treatment for elderly people are required to prevent severe poisoning in elderly patients.

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The 2022 Annual Report on Toxicology Surveillance and Severe Poisoning Cases at Emergency Departments in Korea
Eun Sun Lee, Su Jin Kim, Gyu Chong Cho, Mi Jin Lee, Byung Hak So, Kyung Su Kim, Juhyun Song, Sung Woo Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 1. CrossRef

Risk Factors of Delirium in ICU Patients with Acute Poisoning: Hee Yeon Kim, Kyung Man Cha, Byung Hak So; J Korean Soc Clin Toxicol. 2019;17(1):14-20. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.14

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Abstract PDF: Purpose: This study estimated the incidence of delirium and associated risk factors and outcomes in ICU patients with acute poisoning. Methods: Data were collected from ICU patients over 18 years of age that were admitted via the emergency center after presenting with poisoning from 2010 to 2015. Delirium was assessed retrospectively using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors were evaluated by univariate and multivariate analysis. Results: A total of 199 patients participated in this study and 68 (34.2%) were diagnosed with delirium based on the ICDSC score. The delirium group showed a significantly higher association with prolonged length of stay in the hospital and ICU in comparison with the non-delirium group. The delirium group was associated with greater use of physical restraint. A statistically greater number of patients with pharmaceutical substance poisoning developed delirium over a short period of time than those with non-pharmaceutical substance poisoning. There was no significant difference between the two groups with respect to age, sex, past history, GCS score, vital signs, application of ventilator care and renal replacement therapy. Conclusion: The finding that the delirium group had a greater length of stay in both the hospital and the ICU is consistent with the results of previous worldwide studies of the effects of delirium on the prognosis of patients who were admitted to the ICU, suggesting the possibility for domestic application. Additionally, use of physical restraint was positively related to the incidence of delirium. Thus, interventions for minimizing the use of physical restraints and considering alternatives are needed.

Evaluation of Cut-off Values in Acute Acetaminophen Intoxication Following the Revised Guideline of the United Kingdom: Sung Jin Park, Kyungman Cha, Byung Hak So, Hyung Min Kim, Won Jung Jeoung; J Korean Soc Clin Toxicol. 2018;16(2):68-74. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.68

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Abstract PDF: Purpose: In 2012, a revised guideline for acute acetaminophen overdose was proposed in the UK, recommending that the treatment threshold should be lowered to 100 mcg/ml at 4 hours after ingestion without risk stratification of hepatotoxicity. However, the poison centers in some developing countries do not have laboratory resources to provide serum drug levels in time. The primary aim of the study is to evaluate the cut-off value of reported dose per kilogram to determine when N-acetylcysteine treatment is warranted under the revised guideline. Methods: Data were collected retrospectively from the toxicology registry of an urban emergency medical center between 1st January 2010 and 30th June 2017. Inclusion criteria were single acute overdose of more than 75 mg/kg in 15 hours from ingestion and over 14 years of age. Subgroups were created by 25 mg/kg increments of reported dose, then sensitivity, specificity, positive predictive value and negative predictive value were calculated for the cut-off values of 100 mg/kg, 125 mg/kg, 150 mg/kg and 175 mg/kg for toxic serum level over '100-treatment line'. Results: A total of 99 patients were enrolled in the study; 24 patients showed toxic serum levels (24.2%). Zero of 17 patients with an ingestion dose under 100 mg/kg showed toxic level (0%), and 0 of 15 under 125 mg/kg (0%), 2 of 14 under 150 mg/kg (14.3%), and 4 of 12 under 175 mg/kg (33.3%) had toxic levels. The higher the ingested dose per kilogram of weight, the higher the frequency of the toxic serum concentration on the first test (${chi}^2$ test for trend, ${chi}^2=22.66$, p-value<0.001) and the sensitivity of each value was 100%, 100%, 92% and 76%. Conclusion: In acute single acetaminophen intoxication, the ingestion dose of 100 mg/kg of weight will be useful in determining the need for the N-acetylcysteine antidote in the indigent laboratory environment.

Risk Factors for Aspiration Pneumonia in Acute Benzodiazepine Overdose: Won Sik Chung, Kyung Man Cha, Hyung Min Kim, Won Jung Jeong, Byung Hak So; J Korean Soc Clin Toxicol. 2016;14(1):26-32. Published online June 30, 2016

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Abstract PDF: Purpose: Aspiration pneumonia is an important complication of drug intoxication with decreased mental status. The purpose of the study is to investigate the risk factors of aspiration pneumonia in the patients of benzodiazepine overdose with or without co-ingestion of other drugs. Methods: A retrospective chart review of patients who visited the emergency department between January 2012 and December 2014 was conducted. Demographic data, time from ingestion to visit, initial vital signs, symptoms, mental status, medical history, laboratory results, chest radiological findings and co-ingested medications were recorded. Multiple logistic analyses were performed to verify the association between variables and the development of aspiration pneumonia. Results: A total of 249 patients presented to the emergency department with benzodiazepine overdose. Aspiration pneumonia had developed in 24 patients (9.6%). Univariate analysis revealed time from ingestion to visit was longer, Glasgow coma scale score was lower, hypoxia was presented, leukocytosis was shown, types of ingested drugs was high, less activated charcoal was applied and tricyclic antidepressants was taken in patients that developed aspiration pneumonia. Time from ingestion to visit (odds ratio (OR) 1.121, 95% confidence interval (CI), 1.057-1.189, p=0.000), GCS score (OR 0.724. 95% CI, 0.624-0.839, p=0.000), oxygen saturation (OR 0.895, 95% CI, 0.835-0.959, p=0.002), and co-ingestion of TCA (OR 4.595, 95% CI, 1.169-18.063, p=0.029) were identified as risk factors of morbidity of aspiration pneumonia upon multiple logistic regression analysis. Conclusion: Time from ingestion to visit, low GCS score, low oxygen saturation and co-ingestion of TCA were risk factors of the development of aspiration pneumonia in benzodiazepine overdose patients.

Analysis of Clinical Characteristics by Gender in Children and Adolescents with Intentional Poisoning at Emergency Department: Yun Jae Kim, Byung Hak So, Hyung Min Kim, Won Jung Jeong, Kyeong Man Cha, Seong Wook Kim; J Korean Soc Clin Toxicol. 2014;12(2):63-69. Published online December 31, 2014

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Abstract PDF: Purpose: The aim of this study is to investigate the difference between male and female in some clinically meaningful aspects and to prevent intentional poisoning in children and adolescents. Methods: Retrograde medical records review of patients who visited the emergency department of two secondary hospitals for drug ingestion from March 2010 through March 2013 was performed. Unintentional ingestion or ingestion by others was excluded. Results: A total of 138 cases were reported, male 25.4% (n=35), female 74.6% (n=103). The reason for poisoning was intentional in 132 cases (95.7%) and misuse in six cases (4.3%). In female patients, non-prescription drugs was the most common cause of intentional poisoning (68.9%). Male patients tend to use life substances for intentional poisoning more frequently (20.0%) than female (3.9%). Seven male patients and 12 female patients had previous psychiatric history and 34.3% of male and 41.7% of female were consulted to the psychiatric department. Conclusion: Female adolescents are more likely to ingest drugs intentionally for suicide attempt than males of comparable ages. The drugs they ingested were, in many cases, obtained with ease from the drug store nearby and, remarkably, most of the drugs they obtained in that way were acetaminophen-containing. This suggests that some guidelines or control in the pharmacy that restrict children or adolescents from obtaining potentially or possibly life-threatening drugs might be necessary. In addition, education regarding drugs is thought to be necessary in school for teenagers as they tend to misuse them with incorrect acknowledgement.

16 Cases of Anti-obesity Drug Intoxication Experienced in 4 Emergency Departments: Sung Hoon Han, Byung Hak So, Won Joong Jung, Hyung Min Kim; J Korean Soc Clin Toxicol. 2012;10(2):111-117. Published online December 31, 2012

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Abstract PDF: Purpose: In Korea, few studies have examined the acute toxicity of anti-obesity drugs. The purpose of this study is to analyze the general characteristics and clinical aspect of acute anti-obesity drug intoxication. Methods: We retrospectively investigated patients admitted to the emergency department after anti-obesity drug intoxication between March, 2004 and February, 2012. The medical records of these patients were reviewed for demographic data, toxicologic history, time elapsed to presentation, clinical symptoms and signs, treatment, and outcome. Results: There were a total of 18 anti-obesity intoxication cases during the study period; of 16 which were included in our study. The purchasing route of the anti-obesity drug was mainly through a doctor's prescription (68.8%), however, some were obtained through the internet and the pharmacies. The mean time to The most commonly ingested antiobesity drug was sibutramine (31.3%) and many of the cases (62.5%) were multi-drug ingestions. The most common clinical manifestations were gastrointestinal symptoms (94%), but, CNS symptoms (75%) and cardiovascular symptoms (75%) were almost equally present. 13 patients (81%) were discharged after clearance of toxic symptoms and signs with a mean observational period of 7.0 hours. 3 patients were admitted for observation and treatment; of which 1 patient died due to fatal complications. Conclusion: Most anti-obesity intoxications show mild toxicity and a nonfatal clinical course. However, the recent trend toward prescribing psychostimulant anti-obesity medication, which can be fatal after an acute overdose, calls physicians' attention to treating of anti-obesity intoxications.

Death after Ingestion of MCPP -A Case Report-: Byung Hak So, Won Jae Lee, Byoung Yong Shim, Hoon-Kyo Kim, Chi Hong Kim; J Korean Soc Clin Toxicol. 2005;3(1):45-47. Published online June 30, 2005

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Abstract PDF: MCPP (2-(2-methyl-4-chlorophenoxy)propionic acid; mecoprop), a hormonal weedkiller has been widely used. Although chronic exposure is generally considered to be mildly toxic to man, acute intoxication can be severe and should thus be taken seriously. We report the case of a patient who died after ingestion of MCPP. A 64-year-old man ingested about 400 ml of $50\%$ MCPP solution. He was stuporous and had an inadequate respiration. He had an hypotension which did not respond to vasopressors and died about twelve hours after ingestion.

Clinical Analysis of Rhabdomyolysis Complicated with Drug Intoxications: Mi Jin Lee, Hyung Min Kim, Young Min Kim, Won Jae Lee, Byung Hak So, Se Kyung Kim; J Korean Soc Clin Toxicol. 2003;1(1):27-33. Published online June 30, 2003

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Abstract PDF: Purpose: According as the accessibility about drugs becomes various, the occurrence of drug intoxication is increasing. Since report that doxylamine causes rhabdomyolysis often, drug-induced rhabdomyolysis is one of the most important complications in patients with drug intoxication. Acute renal failure (ARF)'s availability is important to the management in rhabdomyolysis, but report about rhabdomyolysis or ARF occurrence for whole intoxicated drugs is lacking up to now. Methods: This research did to 61 patient who had rhabdomyolysis of drug intoxication. First, object patients were divided into two gruops: doxylamine-ingested (Group I) vs non-doxylamine ingested (Group II). And then we analyzed on the early patient's clinical events and laboratory data. We used ROC curve to recognize'the early clinical factors that could forecast ARF appearance among these patients in addition. Results: Almost rhabdomyolysis was happened by doxylamine in drug intoxication ($55.7\%$). However, as compared to group II, group I showed better clinical course, lesser ARF occurrence and hemodialysis requirement. In group II, time was longer in hospital reaching from intoxication, the ARF occurrence rate was higher ($52.6\%$). Analyzing the ROC curve to useful initial factors, they were creatinine, uric acid and interval time from ingestion to hospital. These cut-off values were 1.44 mg/dL, 6.8 mg/dL and 5 hrs. Sensitivity for ARF estimate was $100\%$, specificity $69-98\%$. Conclusion: Compared to group II, Doxylamine-ingested group showed good clinical course. Creatinine, uric acid, interval time from ingestion to hospital aided in ARF estimate in drug-induced rhabdomyolysis.

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