Journal of The Korean Society of Clinical Toxicology

Volume 12(2); 2014

L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication: A Systematic Review: Byung Keun Yang, Jae Eun Ku, Young Seon Joo, Je Sung You, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2014;12(2):39-45. Published online December 31, 2014

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Abstract PDF: Purpose: The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication Methods: PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. Results: Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs 11 days) in case of delayed extracorporeal therapy. Conclusion: Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.

The Clinical Features and Prognostic Factors in Adults with Acute Etrodotoxin Poisoning Caused by Ingesting Puffer Fish: Yong Soo Jo, Byeong Jo Chun, Jeong Mi Moon, Hyun Ho Ryu, Yong Hun Jung, Sung Min Lee, Kyung Hwan Song, Jin Ho Ryu; J Korean Soc Clin Toxicol. 2014;12(2):46-53. Published online December 31, 2014

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Abstract PDF: Purpose: We conducted this study in order to determine clinical features and prognostic factors in adults with acute tetrodotoxin (TTX) poisoning caused by ingestion of puffer fish. Methods: In this retrospective study, 107 patients were diagnosed with TTX poisoning. The subjects were divided into two groups according to duration of treatment; Group I, patients were discharged within 48 hours (n=76, 71.0%), Group II patients were discharged after more than 48 hours (n=31, 29.0%). Group II was subsequently divided into two subgroups [IIa (n=12, 11.2%), IIb (n=19, 17.8%)] according to the need for mechanical ventilation support. Results: In multivariable logistic regression analysis, the predictors of the need for treatment over 48 hours were dizziness (odds ratio [OR], 4.72; 95% confidence intervals [CI], 1.59-12.83), time interval between onset of symptom and ingestion (OR, 0.56; 95% CI, 0.16-0.97), $PaCO_2$<35 mmHg (OR, 8.37; 95% CI, 2.37-23.59). In addition, predictors of the need for mechanical ventilation were a time interval between onset of symptoms and ingestion (OR, 0.54; 95% CI, 0.11-0.96) and $PaCO_2$<35 mmHg (OR, 5.65; 95% CI, 1.96-18.66). Conclusion: Overall, dizziness, time interval between onset of symptoms and ingestion, ${Delta}DBP$ and $PaCO_2$<35 mmHg predict the need for treatment over 48 hours, time interval between onset of symptoms and ingestion and $PaCO_2$<35 mmHg predict the need for mechanical ventilation support after acute TTX poisoning.

Comparison of Prescription Patterns and Clinical Features according to Clinical Departments in Sedative-hypnotic Intoxication: Do Min Kim, Won Bin Park, Yong Su Lim, Jin Joo Kim, Jae Ho Jang, Jee Yong Jang, Hyuk Jun Yang, Geun Lee; J Korean Soc Clin Toxicol. 2014;12(2):54-62. Published online December 31, 2014

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Abstract PDF: Purpose: The purpose of this study was to compare prescription patterns and clinical features according to clinical departments in sedative-hypnotic intoxication. Methods: This was a retrospective study of histories, substances of poisoning, acquisition routes, clinical courses, and outcomes of patients treated for acute intoxication in a single emergency medical center from January, 2011 to December, 2013. Results: A total of 769 patients were treated for acute intoxication, 281 patients ingested sedative hypnotics during the study period. Among 281 patients, 155 patients were prescribed by psychiatric department and 80 patients were prescribed by non-psychiatric department. Benzodiazepines were more likely to be prescribed by psychiatrists, and zolpidem was preferred by non-psychiatrists (p<0.001). Non-psychiatrists were more likely to prescribe short acting benzodiazepines than psychiatrists (p<0.001). However, there was no statistically significant difference in the clinical outcomes, including prevalence of admission to ICU, ventilator care, and length of stay in ICU. In patients prescribed by non-psychiatrists, there were more patients prescribed without psychiatric diagnosis and diagnosed as major depression disorder after hospitalization. Conclusion: To promote rational prescribing of sedative hypnotics, proper psychiatric evaluation should be performed before prescribing, and educational programs including the contents of interactions and side effects of sedative hypnotics are needed.

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.

Comparing the Possible Complications of Endoscopy Dependent on Time in Caustic Poisoned Patients: Jin Geul Choi, Oh Hyun Kim, Hyun Kim, Dong Keon Lee, Jin Go, Tae Hoon Kim, Kyoung Chul Cha, Kang Hyun Lee, Sung Oh Hwang, Yong Sung Cha; J Korean Soc Clin Toxicol. 2014;12(2):70-76. Published online December 31, 2014

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Abstract PDF: Purpose: Endoscopy has been recommended as a primary procedure for determining the extent of damage and prognosis in patients with caustic ingestions. Endoscopy within the first 24 hours has been suggested, however, such immediate endoscopy is not always possible. Therefore, we wanted to determine complications and possible delayed sequelae after the endoscopy performed dependent on time, including less than 24 hours and more than 24 hours, after ingestion of relatively high toxic caustic agents. Methods: From January 2005 to May 2013, 105 consecutive patients were diagnosed with caustic poisoning in the emergency department of the Wonju Severance Christian Hospital. Out of 95 patients who underwent endoscopy, while excluding 49 patients who ingested sodium hypochlorite and 15 patients due to insufficient data, 41 patients were ultimately included. We compared general characteristics, complications related to endoscopy, late sequelae, total admission length, and mortality between two groups. Results: Twenty eight patients (68.3%) were diagnosed with acid ingestion. Median endoscopy time was 17.8 (IQR 9.7-36.9) hours and performed in 16 patients (39%) after 24 hours. There were no complications, such as perforation and bleeding in either endoscopy within 24 hours group or endoscopy after 24 hours group. In addition, no difference in ingested materials, endoscopy grade, or late sequelae was observed between endoscopy within 24 hours group and endoscopy after 24 hours group. Conclusion: No difference in complications and late sequelae was observed between endoscopy within 24 hours group and endoscopy after 24 hours group when endoscopy was performed based on a clinician's assessment.

Acute Pancreatitis after Carbamate Poisoning: Joseph Park, Yong Won Kim, Se Hyun Oh, Yong Sung Cha, Kyoung Chul Cha, Oh Hyun Kim, Kang Hyun Lee, Sung Oh Hwang, Hyun Kim; J Korean Soc Clin Toxicol. 2014;12(2):77-84. Published online December 31, 2014

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Abstract PDF: Purpose: Carbamate insecticides are potent cholinesterase inhibitors capable of causing severe cholinergic toxicity. Use of carbamate rather than organophosphate insecticides has been increasing. Compared with organophosphate poisoning, relatively few studies have investigated carbamate-associated acute pancreatitis. We investigated general characteristics and pancreatitis of carbamate poisoning and the predictors, among those readily assessed in the emergency department. Methods: We performed a retrospective review of consecutive patients, aged over 18 years, who were admitted between January 2008 and April 2012 to an emergency department (ED) of an academic tertiary care center for treatment of carbamate poisoning. Patients who exhibited poisoning by any other material, except alcohol, were excluded. After application of exclusion criteria, patients were divided according to carbamate-induced pancreatitis and non-pancreatitis groups. Results: A total of 41 patients were included in this study. Among these 41 patients, the prevalence of acute pancreatitis was 36.6% (15 patients). Initial blood chemistry tests showed a statistically higher glucose level in the pancreatitis group, compared with the non-pancreatitis group (222, IQR 189-284 vs. 137, IQR 122-175 mg/dL, P<0.05). Regarding clinical courses and outcomes, a significantly higher proportion of patients developed pneumonia [10 (66.7%) vs. 6 (23.1%), P<0.05] and had a longer hospital stay (7 days, IQR 6-12 vs. 5 days, IQR 2-11, P<0.05), but no difference in mortality, in the pancreatitis group vs. the non-pancreatitis group. In multivariate analysis, the initial glucose was showing significant association with the presentation of carbamate-induced acute pancreatitis (odds ratio 1.018, 95% confidence interval 1.001-1.035, P<0.05). Conclusion: Carbamate-induced acute pancreatitis is common, but not fatal. Initial serum glucose level is associated with acute pancreatitis.

A Case Report of Spider Bite by Tarantula: Do Young Kim, Seung Baek Han, Ji Hye Kim, Jin Hue Baek, Hyun Min Jung, Hyung Min Lee, Ah Jin Kim; J Korean Soc Clin Toxicol. 2014;12(2):85-87. Published online December 31, 2014

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Abstract PDF: A total of 631 species of spiders have been reported in Korea. However, there are no spiders with noxious venom such as Latrodectus sp. Because of this, to date, no serious medical problems due to spider bites have been reported in Korea, and only two cases of spider bite were officially reported. However, as the number of earning spiders from other countries is increased, the number of cases of spider bite has also shown a recent increase. A 17-year-old man presented with numbness of both extremities after being bitten by a spider which he had as a pet. The spider is called an Indian ornamental tree spider (Poecilotheria regalis sp.), one kind of tarantula species. Herein, we report on a case of a spider bite by a tarantula.

Fatal Brain Injury in Pyrethroid Poisoned Patient: Case Report: Woo Jin Jung, Yong Sung Cha, Dong Keon Lee, Hyun Kim; J Korean Soc Clin Toxicol. 2014;12(2):88-91. Published online December 31, 2014

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Abstract PDF: Pyrethroids have been widely using insecticides. Although generally regarded as less toxic to mammals including humans, we report one fatal case of pyrethroid poisoning with severe brain injury.

Dabigatran Toxicity Secondary to Acute Kidney Injury: Hyoung Ho Moon, Seung Eun Lee, Dong Jun Oh, Hee Bum Jo, Ki Hwan Kwon, Yoon Jin Kim, Kyung Soo Kim, Sung Joon Shin; J Korean Soc Clin Toxicol. 2014;12(2):92-96. Published online December 31, 2014

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Abstract PDF: Dabigatran is the first oral direct thrombin inhibitor approved by the US Food and Drug Administration (FDA) for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Because dabigatran is excreted mainly by the kidneys, serum levels of dabigatran can be elevated to a supratherapeutic range in patients with renal failure, predisposing to emergent bleeding. We describe the case of a 66-year-old man taking dabigatran 150 mg twice daily for atrial fibrillation and cerebral infarction who presented with hematochezia and disseminated intravascular coagulation. Laboratory evaluation showed a hemoglobin level of 6.3 g/dL, platelets of $138,000/mm^3$, activated partial thromboplastin time (aPTT) of 10 s, and an international normalized ratio (INR) of 8.17. Colonoscopy showed a bleeding anal fissure. Hemostasis was provided by hemoclips and packed red blood cells and fresh frozen plasma were transfused. Since then, there was no further hematochezia, however, bleeding including oral mucosal bleeding, hematuria, and intravenous site bleeding persisted. At presentation, his serum creatinine was 4.96 mg/dL (baseline creatinine, 0.9 mg/dL). Dabigatran toxicity secondary to acute kidney injury was presumed. Because acute kidney injury of unknown cause was progressing after admission, he was treated with hemodialysis. Fresh frozen plasma transfusion was provided with hemodialysis. At 15 days from admission, there was no further bleeding, and laboratory values, including hemoglobin, partial thromboplastin time, and prothrombin time were normalized. He was discharged without bleeding. After 2 months, he undergoes dialysis three times per week and no recurrence of bleeding has been observed.

A Case of Successful Resuscitation of 10,150 J Shocks and Therapeutic Hypothermia on Aconitine-induced Cardiovascular Collapse: Hyung Jun Moon, Jung Won Lee, Ki Hwan Kim, Dong Kil Jeong, Jong Ho Kim, Young Ki Kim, Hyun Jung Lee; J Korean Soc Clin Toxicol. 2014;12(2):97-101. Published online December 31, 2014

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Abstract PDF: Aconitine, found in the Aconitum species, is highly extremely toxic, and has been known to cause fatal cardiac arrhythmias and cardiovascular collapse. Although several reports have described treatment of aconitine intoxication, management strategy for the patient in a hemodynamically compromised state who experienced cardiopulmonary collapse is unknown. We report here on a case of a successful cardiopulmonary resuscitation and therapeutic hypothermia in an aconitine-induced cardiovascular collapsed patient. A 73-year-old male who presented with nausea, vomiting, chest discomfort, and drowsy mental state after eating an herbal decoction made from aconite roots was admitted to the emergency department. He showed hemodynamic compromise with monomorphic ventricular tachycardia resistant to amiodarone and lidocaine. After 3 minutes on admission, he collapsed, and cardiopulmonary resuscitation was initiated. We treated him with repeated cardioversion/defibrillation of 51 times, 10,150 joules and cardiopulmonary resuscitation of 12 times, 69 minutes for 14 hours and therapeutic hypothermia for 36 hours. He recovered fully in 7 days.

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