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.
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.
Citations
Citations to this article as recorded by
Development of a Web Application for Simulating Plasma Drug Concentrations in Patients with Zolpidem Intoxication Hwa Jun Cha, Sungpil Han, Kwan Cheol Pak, Hyungsub Kim Pharmaceutics.2024; 16(5): 689. CrossRef
Purpose: This study sought to compare the characteristics of patients with pathogen-positive and negative cultures, and to investigate factors predicting pathogen-positive culture results in patients of acute poisoning with suspected aspiration. Methods: Consecutive patients with acute poisoning admitted to an intensive care unit between January 2016 and December 2018 were retrospectively studied. Respiratory specimens were collected from the enrolled patients at the time of the suspected aspiration. We compared the characteristics of patients with pathogen-positive and negative culture results and analyzed the causative pathogens. Results: Among the 526 patients, 325 showed no clinical features that could be attributed to aspiration, and 201 patients had clinical features suggestive of aspiration. Of these, 113 patients had pathogen-positive culture, 61 were negative, and the specimens of 27 patients contained poor-quality sputum. In univariate analysis, patients with a positive culture showed a longer time to culture from ingestion (p=0.01), faster heart rate (p=0.01), and higher partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) (p=0.02) than patients with negative culture. Multivariate analysis demonstrated that PaO2/FiO2 (adjusted odd ratio, 1.005; 95% confidence interval [CI], 1.002-1.008; p=0.005) was a significant risk factor for pathogen-positive culture. The area under the receiver operating characteristic curve of PaO2/FiO2 was 0.591 (95% CI, 0.510-0.669, p=0.05). Gram-negative pathogens (GNPs) were predominant and at least one GNP was observed in 84 (73.3%) patients among those with pathogen positive culture. Conclusion: We failed to find any clinical factors associated with positive culture results. Antibiotics that cover GNPs could be considered when deciding the initial antibiotic regimen at the time of suspected aspiration.
N-Acetylcysteine (NAC) is the standard antidote treatment for preventing hepatotoxicity caused by acetaminophen (AAP) poisoning. This review summarizes the recent evidence for the treatment of AAP poisoning. Several alternative intravenous regimens of NAC have been suggested to improve patient safety by reducing adverse drug reactions and medication errors. A two-bag NAC infusion regimen (200 mg/kg over 4 h, followed by 100 mg/kg over 16 h) is reported to have similar efficacy with significantly reduced adverse reactions compared to the traditional 3-bag regimen. Massive AAP poisoning due to high concentrations (more than 300-lines in the nomogram) needs to be managed with an increased maintenance dose of NAC. In addition to NAC, the combination therapy of hemodialysis and fomepizole is advocated for severe AAP poisoning cases. In the case of a patient presenting with an altered mental status, metabolic acidosis, elevated lactate, and an AAP concentration greater than 900 mg/L, hemodialysis is recommended even if NAC is used. Fomepizole decreases the generation of toxic metabolites by inhibiting CYP2E1 and may be considered an off-label use by experienced clinicians. Since the nomogram cannot be applied to sustained-release AAP formulations, all potentially toxic sustained-release AAP overdoses should receive a full course of NAC regimen. In case of ingesting less than the toxic dose, the AAP concentration is tested twice at an interval of 4 h or more; NAC should be administered if either value is above the 150-line of the nomogram.
Purpose: This study was undertaken to investigate how sedative-hypnotics affect the occurrence and severity of the patient's symptoms. In addition, we conducted a study to determine the type of patients who reacted severely and required hospitalization; patients were accordingly classified as hospitalized patients and patients discharged from the emergency room. Methods: From January 2017 to December 2019, we investigated the demographics, drug information, history, laboratory tests, and severity of patients who visited our emergency department and were diagnosed with benzodiazepine, zolpidem, and doxylamine succinate overdose. We further compared details of hospitalized patients and discharged patients. Results: Subjects who had overdosed and visited the ED included 120 for benzodiazepine, 147 for zolpidem, and 27 for doxylamine succinate. Comparisons between the three groups revealed differences in their early diagnosis, psychiatric history, and sleep disturbance. Differences between groups were also determined for mental state, poisoning history, treatment received in the intensive care unit, and intubation and ventilator support. In cases of benzodiazepine overdose, we obtained a high hospitalization rate (40.0%), admission to the intensive care unit (24.2%), and intubation rate (18.3%). Comparisons between hospitalized patients and discharged groups showed differences in transferred patients, early diagnosis, and mental state. Conclusion: Patients poisoned by sedative-hypnotics are increasing every year. In cases of benzodiazepine and zolpidem, the hospitalization rates were high, and benzodiazepine overdose resulted in hospitalization, intensive care unit admission, and pneumonia in a majority of cases. Therefore, active treatment and quick decisions in the emergency room are greatly required.
Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome is characterized by an altered mental status. The acute MRI lesions show abnormal restricted diffusion imaging bilaterally and symmetrically in the cerebellum, hippocampus, and basal nuclei. This syndrome is an unknown syndrome and is presumed to be mainly an opioidinduced toxidrome. Here, we present a case study wherein we show that it can also be caused by an antidepressant overdose.
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.
Purpose: The purpose of this study was to investigate the cause of acute fatal poisoning and the time of death by analyzing the National Emergency Department Information System (NEDIS) of South Korea. Methods: The NEDIS data from 2014 to 2018 excluding non-medical visits were used for this study. The patients with acute poisoning were extracted using diagnostic codes. The toxic substances were classified into pharmaceuticals, pesticides, gases, artificial poisonous substances, and natural toxic substances. Patients were classified according to the time of death, place of death, and region. In each case, the most causative substances of poisoning were identified. Results: There were 380,531 patients including poisoning-related diagnoses, of which 4,148 (1.1%) died, and the WHO age-standardized mortality rate was 4.8 per 100,000. Analysis of 2,702 death patients whose primary diagnosis was acute poisoning, the most common cause of poisoning death was pesticides (62%), followed by therapeutic drugs, gas, and artificial toxic substances. Herbicides were the most common pesticides at 64.5%. The proportion of mortality by time, hyperacute (<6 h) 27.9%, acute (6-24 h) 32.6%, subacute (1-7 d) 29.7%, and delayed period (>7 d) were 9.8%. Conclusion: This study suggests that the most common cause of poisoning death was pesticides, and 60% of deaths occurred within 24 hours. The 71% of mortality from pesticides occurred within 6-24 hours, but mortality from gas was mostly within 6 hours. According to the geographic region, the primary cause of poisoning death was varied to pesticides or pharmaceuticals.
Citations
Citations to this article as recorded by
A Novel Method for Medical Predictive Models in Small Data Using Out-of-Distribution Data and Transfer Learning Inyong Jeong, Yeongmin Kim, Nam-Jun Cho, Hyo-Wook Gil, Hwamin Lee Mathematics.2024; 12(2): 237. CrossRef
Factors Associated with Mortality in Elderly Patients Admitted to Intensive Care Unit due to Acute Drug Intoxication from Suicide Attempts Kyung-Eun Kim, Sun-Hee Moon, Chieun Song, Minjeong An Journal of Korean Critical Care Nursing.2024; 17(2): 1. CrossRef
Implementation of Regenerative Thermal Oxidation Device Based on High-Heating Device for Low-Emission Combustion Hoon-Min Park, Dal-Hwan Yoon, Joon-Seong Lee, Hyun-Min Jung, Dae-Hee Lee, Dong-Hwan Jeon, Tae-Yeung Lim Energies.2024; 17(20): 5182. CrossRef
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
Demographic characteristics of patients admitted to the emergency department for intoxication and a time series analysis during the COVID-19 period Bongmin Son, Nayoon Kang, Eunah Han, Gina Yu, Junho Cho, Jaiwoog Ko, Taeyoung Kong, Sung Phil Chung, Minhong Choa Journal of The Korean Society of Clinical Toxicology.2023; 21(2): 92. CrossRef
Machine Learning-Based Prediction Models of Acute Respiratory Failure in Patients with Acute Pesticide Poisoning Yeongmin Kim, Minsu Chae, Namjun Cho, Hyowook Gil, Hwamin Lee Mathematics.2022; 10(24): 4633. CrossRef
Purpose: Acetaminophen (APAP) is a widely available drug responsible for a large part of drug-induced hepatotoxicity in developed countries. Although acetaminophen overdose cases in Korea are being continuously reported, there are no reports related to the level of this drug in the patient's blood or of laboratory analysis at emergency departments (ED). This study sought to analyze the acetaminophen overdose cases at a toxicological laboratory and to survey APAP analysis services offered at select EDs. Methods: We analyzed the demographic and analytic data at a toxicological laboratory run by the National Emergency Medical Center (NMC) in 2019-2020. We surveyed the APAP laboratory service in the 38 regional emergency medical centers (EMCs) and 68 local EMCs near the toxicological laboratory. Results: We studied 175 acute poisoning cases (112 women) with positive blood APAP results (mean age 47.0±24.1 years). Suicide attempts comprised 40.0% of the cases and 30.3% APAP overdose events. In the univariate analysis, we observed that patients were significantly younger, with fewer underlying medical diseases. There were a higher number of APAP overdose events, more favorable initial mental status, more toxic quantity intake in the above treatment line group (p<0.05), In multivariate analysis, the toxic amount intake was significantly more frequent in the above treatment line group (p<0.01). Hospital APAP analysis services were available in six EMCs (3/38 regional and 3/68 local). The hospital blood APAP level reporting intervals were shorter than outside-hospital laboratory services (p<0.01, regional 7.0±3.0 vs. 40.6±27.5, local 5.3±3.1 vs. 57.9±45.1 hours). The NMC toxicological laboratory reporting interval was shorter than the other outside-hospital laboratories (p<0.01, regional 5.7±0.6 vs. 50.2±22.7 local 7.5±3.0 vs. 70.5±41.5 hours). Conclusion: Over the treatment line group, toxic amount intake was significantly more frequent. Only six of 106 EMCs have their own APAP analysis service in their hospitals.
Purpose: The annual statistics for poisoning are reported based on the data from poison control centers in many advanced countries. In 2016 a study was conducted to analyze the 2016 Korea Poisoning status. This study was conducted to make a better annual report for poisoning statistics in Korea from a 2017-2018 national representative database. Methods: This study was a retrospective analysis of poisoning patients based on the data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2017-2018. Bite or sting injuries were not included. Results: A total of 17714 patients presented to 23 EDs because of poisoning. Adults above 20 years old age accounted for 84.6% of the population, while the proportion of intentional poisoning was 60.8%. The poisoning substance presented in the ED were therapeutic drugs (51.2%), gas (20.3%), pesticides (16.4%), and artificial substances (11.4%). Overall, 35% of patients were admitted for further treatment. The mortality was 2.4% (422 cases), and the most common fatal substances in order were carbon monoxide, other herbicides, and paraquat. Conclusion: This study showed the 2017-2018 status of poisoning in Korea. The prognosis is different from the cause of poisoning and the initial mental state of the patient. Therefore, appropriate methods for preventing poisoning and therapeutic plans in specific situations are needed.
Citations
Citations to this article as recorded by
응급실 기반 중독 심층 실태조사 1차년도 결과 보고 성우 이, 수진 김, 규종 조, 미진 이, 병학 소, 경수 김, 주현 송 Public Health Weekly Report.2024; 17(14): 535. CrossRef
Factors influencing repeated suicide attempts among suicide attempters who visited the emergency room due to acute drug intoxication: a retrospective study In Ah Yun, Mi Yang Jeon Journal of Korean Biological Nursing Science.2024; 26(3): 228. CrossRef
Status and trends of medical expenditures for poisoning patients Eung Nam Kim, Soyoung Jeon, Hye Sun Lee, Sung Phil Chung Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 24. CrossRef
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
Prioritising Risk Factors for Prescription Drug Overdose among Older Adults in South Korea: A Multi-Method Study Eun-Hae Lee, Ju-Ok Park, Joon-Pil Cho, Choung-Ah Lee International Journal of Environmental Research and Public Health.2021; 18(11): 5948. CrossRef
Pharmaceutical agents are the most common causes of poisoning in Korea. Calcium channel blockers (CCBs) are commonly used in Korea for the management of hypertension and other cardiovascular diseases, but are associated with a risk of mortality due to overdose. Due to the frequent fatalities associated with CCB overdose, it is essential that the emergency physician is capable of identifying CCB intoxication, and has the knowledge to manage CCB overdose. This article reviews the existing clinical guidelines, retrospective studies, and systematic reviews on the emergency management of CCB overdose. The following are the varied treatments of CCB overdose currently administered. 1) For asymptomatic patients: observation with enough time and decontamination, if indicated. 2) For symptomatic patients: infusion of calcium salt, high dose insulin therapy, and vasopressor (norepinephrine) or atropine for bradycardia. 3) For patients refractory to the first line therapy or with refractory shock or impending arrest: lipid emulsion therapy and extracorporeal membrane oxygenation. 4) As adjunct therapy: phosphodiesterase inhibitors, glucagon, methylene blue, pacemaker for AV block. Small CCB ingestion is known to be fatal for pediatric patients. Hence, close observation for sufficient time is required.
Purpose: Non-benzodiazepine hypnotic drugs (including zolpidem) are associated with an increased risk of suicide and suicidal ideation. Considering the wide usage of zolpidem, this drug should be considered a possible etiology for stupor or coma in any patient exposed to this drug. However, there are no reports on zolpidem blood levels in emergency department patients in Korea. We therefore reviewed the analyzed data of a toxicology laboratory at one university affiliated hospital. Methods: The sex, age, chief symptoms, suspiciousness of poisoning, and presumption of poison were analyzed from January 2018 to June 2019. The detection frequency and level of zolpidem in the patient blood were compared to the mental changes presented, which is the main consequence of zolpidem. Results: A total of 229 toxicological analyses, requested to a toxicological laboratory at one university affiliated hospital, were reviewed. Among 229 patients, the mean age was 54.3±20.7 years old with 113 women and 116 men. 8.7% of patients have psychiatric illness and 39.7% were poisoned intentionally. The chief symptoms detected were: mental change 55.0%, gastrointestinal 14.4%, cardiovascular 10.5%, focal neurological 7.4%, respiratory 3.5%, none 8.7%, and unknown 0.4%. A request for detailed reports revealed that causative poisons were specified only in 20.1% cases. Zolpidem was detected in 22.3% cases (51/229), with median blood level 1.26 mg/L (interquartile 0.1, 5.06 mg/L) and urine 0.90 mg/L (interquartile 0.11, 5.6 mg/L). Furthermore, zolpidem was more frequently detected in toxicology analysis of patients where mental change was the primary symptom, as compared to other symptoms (32.5% vs. 9.7%, p<0.01). Conclusion: This study reported the blood level of zolpidem in suspected poisoning patients admitted to the emergency department.
Procalcitonin (PCT) is commonly employed in medical practice as a diagnostic biomarker of bacterial infection and also as a monitoring biomarker for antimicrobial therapy. There have been a few published reports concerning elevated PCT levels in people with acute liver injury caused by an overdose of acetaminophen. We report here on a case of PCT elevation in an adolescent with acute acetaminophen poisoning without any bacterial infection or liver injury. A 15-year-old girl had deliberately ingested 20 tablets of 650 mg acetaminophen (13 g) and she presented to our emergency department. The PCT level on admission was elevated to 65.64 ng/mL (reference range: 0-0.5 ng/mL). Her PCT level on the second day peaked up to 100 ng/mL and then it gradually decreased. There was no evidence of liver injury or infection on the computed tomography examination and other lab tests. The patient regained her good health and was discharged on the sixth day of hospitalization.
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.
An overdose of antihypertensive agents, such calcium channel blockers (CCBs) and angiotensin II receptor blocker (ARBs), and the antihyperglycemic agent, metformin, leads to hypotension and lactic acidosis, respectively. A 40-year-old hypertensive and diabetic man with hyperlipidemia and a weight of 110 kg presented to the emergency room with vomiting, dizziness, and hypotension following an attempted drug overdose suicide with combined CCBs, ARBs, 3-hydroxy-3-methylglutaryl-coemzyme A reductase inhibitors, and metformins. A conventional medical treatment initially administered proved ineffective. The treatment was then changed to simultaneous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), which was effective. This shows that simultaneous ECMO and CRRT can be an effective treatment protocol in cases of ineffective conventional medical therapy for hypotension and lactic acidosis due to an overdose of antihypertensive agents and metformin, respectively.