Various symptoms manifest after organophosphate intoxication due to muscarinic, nicotinic, and central nervous system effects. Complications are common, and morbidity occurs due to respiratory center depression, cardiovascular complications, aspiration pneumonia, general weakness, and neurological symptoms. Some studies have reported a statistically significant association between organophosphate intoxication and deep vein thrombosis. However, cases of pulmonary thromboembolism (PTE) resulting from organophosphate poisoning are very rare. A 45-year-old male patient was transferred to our hospital after ingesting an unknown amount of an insecticide and receiving 6 L of gastric lavage at a local hospital. Other than nausea, no symptoms (e.g., dyspnea) were present, but a hemodynamic test showed an elevated lactic acid level, and metabolic acidosis worsened over time. Accordingly, we conducted initial treatment including continuous renal replacement therapy. After 7 hours, the poisoning analysis result was confirmed, and lambda-cyhalothrin and chlorpyrifos (0.441 µg/mL and 0.401 µg/mL, respectively) were detected. We introduced pralidoxime. Although no increase in pseudocholinesterase was found during hospitalization, continuous renal replacement therapy and pralidoxime were discontinued because the patient did not show symptoms of intermediate syndrome, including dyspnea and altered consciousness. The patient complained of abdominal pain on hospital day 8. Abdominal computed tomography was performed to evaluate the possibility of a corrosive injury to the stomach or esophagus, and we confirmed PTE. The D-dimer level was 1.96 mg/L (normal range, 0–0.55 mg/dL). A radiologic examination showed a PTE in the main pulmonary artery leading to the segmental pulmonary artery. After heparinization, the patient was discharged after being prescribed a vitamin K-independent oral anticoagulant. Through this case, we would like to emphasize the need for a thorough evaluation of clinical symptoms because atypical symptoms can occur after poisoning with organophosphate pesticides.
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.
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.
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.
Purpose: This study examined the clinical and epidemiological characteristics of intensive care unit (ICU) patients admitted or died in the emergency medical center with acute-poisoning to investigate the variables related to the prognosis. Methods: The data were collected from poisoning patients admitted or died in the emergency medical center of a general hospital located in Seoul, from January 2014 to February 2020. The subjects of this study were 190 patients. The medical records were screened retrospectively, and the clinical and epidemiological characteristics of the patients in the emergency room (ER) and ICU were examined to investigate the contributing factors that influence the poor prognosis. Results: The study analyzed 182 patients who survived after being admitted to the intensive care unit (ICU). The results are as follows. The mental change (87.4%) was the most common symptom. Sedative poisoning (49.5%) was the commonest cause. For most patients, pneumonia (26.9%) was the most common complication. Hypotension (23.7%), tachycardia (42.1%), fever (15.8%), seizures (10.5%), dyspnea (2.6%), high poisoning severity score (PSS), type of toxic material, mechanical ventilator application (39.5%), inotropes application (39.5%), and pneumonia (55.3%) were correlated the LOS over 5 days in the ICU. 8 patients died. In the case of death pesticides and carbon monoxide were the main toxic materials; tachycardia, bradycardia, and hypotension were the main symptoms, and a mechanical ventilator and inotropes were applied. Conclusion: Patients with unstable vital signs, high PSS, and non-pharmaceutical poisoning had a prolonged LOS in the ICU and a poor prognosis.
Purpose: The aims of the present study were twofold. First, the research investigated the effect of an individual's risk factors and the prevalence of psychotropic drugs on QTc prolongation, TdP (torsades de pointes), and death. Second, the study compared the risk scoring systems (the Mayo Pro-QT risk score and the Tisadale risk score) on QTc prolongation. Methods: The medical records of intoxicated patients who visited the emergency department between March 2010 and February 2019 were reviewed retrospectively. Among 733 patients, the present study included 426 psychotropic drug-intoxicated patients. The patients were categorized according to the QTc value. The known risk factors of QTc prolongation were examined, and the Mayo Pro-QT risk score and the Tisadale risk score were calculated. The analysis was performed using multiple logistic regression, Spearman correlation, and ROC (receiver operating characteristic). Results: The numbers in the mild to moderate group (male: 470≤QTc<500 ms, female: 480≤QTc<500 ms) and severe group (QTc≥500 ms or increase of QTc at least 60ms from baseline, both sex) were 68 and 95, respectively. TdP did not occur, and the only cause of death was aspiration pneumonia. The statically significant risk factors were multidrug intoxications of TCA (tricyclic antidepressant), atypical antipsychotics, an atypical antidepressant, panic disorder, and hypokalemia. The Tisadale risk score was larger than the Mayo Pro-QT risk score. Conclusion: Multiple psychotropic drugs intoxication (TCA, an atypical antidepressant, and atypical antipsychotics), panic disorder, and hypokalemia have been proven to be the main risk factors of QTc prolongation, which require enhanced attention. The present study showed that the Tisadale score had a stronger correlation and predictive accuracy for QTc prolongation than the Mayo Pro-QT score. As a result, the Tisadale risk score is a crucial assessment tool for psychotropic drug-intoxicated patients in a clinical setting.
Purpose: Atropine is an antidote used to relieve muscarinic symptoms in patients with organophosphate and carbamate poisoning. Nutritional support via the enteral nutrition (EN) route might be associated with improved clinical outcomes in critically ill patients. This study examined the administration of nutritional support in patients undergoing atropinization, including methods of supply, outcomes, and complications. Methods: A retrospective observational study was conducted in a tertiary care teaching hospital from 2010 to 2018. Forty-five patients, who were administered with atropine and on mechanical ventilation (MV) due to organophosphate or carbamate poisoning, were enrolled. Results: Nutritional support was initiated on the third day of hospitalization. Thirty-three patients (73.3%) were initially supported using parenteral nutrition (PN). During atropinization, 32 patients (71.1%) received nutritional support via EN (9) or PN (23). There was no obvious reason for not starting EN during atropinization (61.1%). Pneumonia was observed in both patient groups on EN and PN (p=0.049). Patients without nutritional support had a shorter MV duration (p=0.034) than patients with nutritional support. The methods of nutritional support during atropinization did not show differences in the number of hospital days (p=0.711), MV duration (p=0.933), duration of ICU stay (p=0.850), or recovery at discharge (p=0.197). Conclusion: Most patients undergoing atropinization were administered PN without obvious reasons to preclude EN. Nutritional support was not correlated with the treatment outcomes or pneumonia. From these results, it might be possible to choose EN in patients undergoing atropinization, but further studies will be necessary.
Citations
Citations to this article as recorded by
Enteral nutrition in mechanically ventilated patients after organophosphate poisoning Sang U Bark, Jeong Mi Moon, Byeng Jo Chun Journal of The Korean Society of Clinical Toxicology.2024; 22(1): 1. CrossRef
Purpose: Agent Orange (AO) is a herbicide and defoliant used by the United States and its military allies during the Vietnam War. Pneumonia is a common cause of death among Vietnam veterans in our hospital. There have been no previous studies researching any association between AO exposure and the prognosis for pneumonia. The primary objective of this study was to investigate associations between AO exposure and 30-day mortality due to pneumonia. The secondary objective was to examine the clinical factors associated with therapeutic outcomes in veterans with pneumonia, and to assess the prevalence of combined diseases in AO-exposed veterans. Methods: This study retrospectively included veteran patients diagnosed with pneumonia in the emergency department and hospitalized between February 2014 and March 2018. The enrolled patients were grouped according to their defoliant exposure history, and the clinical information of defoliant-exposed and non-defoliant-exposed groups were compared. Patients were divided according to 30-day mortality, and significant factors influencing mortality were evaluated by using univariate analysis and multivariate analysis. The final multivariate model revealed the effect of AO exposure on therapeutic outcomes of pneumonia. Results: A total of 1006 patients were analyzed. Of these, 276 patients had a history of AO exposure, whereas 730 patients had not been exposed. Factors positively associated with 30-day mortality were malignancy, respiratory rate, blood urea nitrogen, and albumin which was negatively associated with mortality. Conclusion: Exposure to defoliant is not associated with 30-day mortality in patients with pneumonia. However, veterans with defoliant exposure are associated with a high prevalence of diabetes mellitus, hypertension, cerebrovascular accident, malignancy, and chronic kidney disease.
Purpose: To evaluate the association between neutrophil-to-lymphocyte ratio (NLR) and occurrence of aspiration pneumonia in drug intoxication (DI) patients in the emergency department (ED) and to evaluate the relationship between NLR and length of hospital admission/intensive care unit (ICU) admission Methods: A total of 466 patients diagnosed with DI in the ED from January 2016 to December 2017 were included in the analysis. The clinical and laboratory results, including NLR, were evaluated as variables. NLR was calculated as the absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of DI, data on the development of aspiration pneumonia were obtained. Also, we evaluated the relationship between NLR and length of hospital admission and between NLR and length of ICU admission. Statistically, multivariate logistic regression analyses, receiver-operating characteristic (ROC) curve analysis, and Pearson's correlation (${
ho}$) were performed. Results: Among the 466 DI patients, 86 (18.5%) developed aspiration pneumonia. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting aspiration pneumonia (odds ratio, 1.7; p=0.001). NLR showed excellent predictive performance for aspiration pneumonia (areas under the ROC curves, 0.815; cut-off value, 3.47; p<0.001) with a sensitivity of 86.0% and a specificity of 72.6%. No correlations between NLR and length of hospital admission (${
ho}=0.195$) and between NLR and length of ICU admission (${
ho}=0.092$) were observed. Conclusion: The NLR is a simple and effective marker for predicting the occurrence of aspiration pneumonia in DI patients. Emergency physicians should be alert for aspiration pneumonia in DI patients with high NLR value (>3.47).
Purpose: The number of glyphosate and glufosinate intoxication cases are increasing in Korea. This study was undertaken is to compare the clinical manifestations of poisoning by these two herbicides and to document severities and clinical outcomes. Methods: We retrospectively evaluated cases of glyphosate or glufosinate intoxication among patients that visited our emergency department between January 1, 2013, and December 31, 2017. Incidences of intoxications were analyzed over this five year period, and underlying diseases, transportation, mental state, shock occurrence, inotropics, gastric lavage, charcoal administration, intubation and ventilator therapy, and hemodialysis were investigated. In addition, we included transfer to the intensive care unit, incidences of pneumonia and of other complications, death, and hopeless discharge. Results: There were 119 cases of glyphosate intoxication and 42 of glufosinate intoxication. Levels of consciousness were lower for glufosinate and vasopressor usage was higher due to a high shock rate (p=0.019). In addition, many patients were referred to the ICU for intubation and ventilation. The incidences of pneumonia and of other complications were significantly higher for glufosinate. Conclusion: Overall glufosinate intoxication was found to be more severe than glyphosate intoxication as determined by complication and ICU admission rates.
Purpose: Extremely hazardous pesticides are classified as World Health Organization (WHO) hazard class Ia. However, data describing the clinical course of WHO class Ia OP (organophosphate) poisonings in humans are very scarce. Here, we compare the clinical features of patients who ingested hazard class Ia OPs. Methods: This retrospective observational case study included 75 patients with a history of ingesting ethyl p-nitrophenol thio-benzene phosphonate (EPN), phosphamidon, or terbufos. The patients were divided according to the chemical formulation of the ingested OP. Data regarding mortality and the development of complications were collected and compared among groups. Results: There were no differences in the baseline characteristics and severity scores at presentation between the three groups. No fatalities were observed in the terbufos group. The fatality rates in the EPN and phosphamidon groups were 11.8% and 28.6%, respectively. Patients poisoned with EPN developed respiratory failure later than those poisoned with phosphamidon and also tended to require longer mechanical ventilatory support than phosphamidon patients. The main cause of death was pneumonia in the EPN group and hypotensive shock in the phosphamidon group. Death occurred later in the EPN group than in the phosphamidon group. Conclusion: Even though all three drugs are classified as WHO class Ia OPs (extremely hazardous pesticides), their clinical courses and the related causes of death in humans varied. Their treatment protocols and predicted outcomes should therefore also be different based on the chemical formulation of the OP.
Increased plasma insulin levels are often observed in exogenous insulin overdose patients. However, plasma insulin level may decrease with time. We report a case of low plasma insulin level hypoglycemia after insulin lispro overdose. The patient was a 37-year-old man with no previous medical history who suspected insulin lispro overdose. Upon arrival, his Glasgow coma scale was 3 points and his blood sugar level (BSL) was 24 mg/dl. We found five humalog-quick-pen (insulin lispro) in his bag. There was no elevation of glucose level, despite an initial 50 ml bolus of 50% glucose and 150 cc/hr of 10% dextrose continuous intravenous infusion. He also suffered from generalized tonic-clonic seizure, which was treated with lorazepam and phenytoin. We conducted endotracheal intubation, after which he was admitted to the intensive care unit (ICU). There were recurrent events of hypoglycemia below BSL<50 mg/dl after admission. We repeatedly infused 50 ml 50% glucose 10 times and administered 1 mg of glucagon two times. The plasma insulin level was 0.2 uU/ml on initial blood sampling and 0.2 uU/ml after 5 hours. After 13 hours, his BSL stabilized but his mental status had not recovered. Diffuse brain injury was observed upon magnetic resonance imaging (MRI) and severe diffuse cerebral dysfunction was found on electroencephalography (EEG). Despite 35 days of ICU care, he died from ventilator associated pneumonia.
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.
Purpose: Drug overdose is easily found in the emergency department (ED). Sedative-hypnotics overdose causes the aspiration pneumonia in patients with decreased mental status. The purpose of this study was to investigate the risk factors of aspiration pneumonia in patients poisoned with sedative-hypnotics. Methods: One hundred seventy eight patients who were poisoned with sedative-hypnotics and who visited ED between 2009 and 2015 were included. This study was conducted retrospectively, with collection of data by review of medical records. We collected the data concerning the characteristics of patients and classified them into two groups based on the development of aspiration pneumonia. Logistic regression analysis was performed to investigate the factors for the development of aspiration pneumonia. Results: Thirty five patients had an aspiration pneumonia during their hospital stay in 178 patients. The age, amount of ingestion, Glasgow Coma Scale (GCS) score at admission, a history of hypertension and diabetes mellitus, and the hypotension at admission were significantly different between two groups in univariate analysis. The age, amount of ingestion and GCS score at admission were associated with the development of aspiration pneumonia in the multivariate logistic regression analysis (OR 1.028 (95%CI, 1.002-1.056, p=0.037), 1.026 (95%CI, 1.004-1.043, p=0.001), 0.737 (95%CI, 0.683-0.915, p=0.002)). All patients with aspiration pneumonia were discharged without a sequelae. Conclusion: The development of aspiration pneumonia in the patients of sedative-hypnotics overdose is associated with old age, amount of drug ingestion, and GCS score at admission.
Benzoylureas are chemical compounds best known for their use as insecticides. Diflubenzuron is one of the more commonly used benzoylurea pesticides. Others include chlorfluazuron, flufenoxuron, hexaflumuron, and triflumuron. They act as insect growth regulators by inhibiting synthesis of chitin in the body of the insect. They have low toxicity in mammals because mammals have no chitin. Chlorfluazuron insecticides, which are mixed with solvent naphatha, are commonly used. Thus we assume that in the presented case mental change outcome of poisoning was connected with toxic effects of solvent naphtha rather than with chlorfluazuron action. Components of solvent naphtha, particularly trimethylbenzenes, exert strong irritant action on the gastric mucosa and are very well absorbed from the gastrointestinal tract. We report on a 67-year-old man with stuporous mentality after intentional ingestion of approximately 200 ml of liquid chlorfluazuron in a suicide attempt. He was discharged after conservative treatments including gastric irrigation, charcoal, mechanical ventilation, hydration, and antibiotics for aspiration pneumonia without complications.