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- A case of various clinical aspects associated with cardiotoxicity after glufosinate poisoning
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Seon Tae Kim
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J Korean Soc Clin Toxicol. 2021;19(2):133-138. Published online December 31, 2021
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DOI: https://doi.org/10.22537/jksct.2021.19.2.133
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Abstract
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- Glufosinate-containing herbicides is a non-selective herbicide commonly used worldwide. As the use of them increased gradually since paraquat was banned in 2012, the number of suicides by their ingestion is also increasing continuously. Complications of glufosinate-containing herbicide poisoning include various central nervous system (CNS) toxicities such as convulsions, loss of consciousness, memory impairment, and respiratory depression, which may be accompanied by hemodynamic changes such as bradycardia and hypotension. However, it is very rare that arrhythmias other than bradycardia occurred and Takotsubo cardiomyopathy was combined due to cardiotoxicity. A 71-year-old female patient was transferred to our hospital after ingesting 500 mL of glufosinate-containing herbicide and receiving 5 L of gastric lavage at a local hospital. A few hours later, she presented stuporous mentality, respiratory depression, and convulsions, and was accompanied by hypotension and bradycardia. On the second day of admission, electrocardiogram (ECG) showed bradycardia and QTc prolongation with hemodynamic Instability. Accordingly, we conducted the early treatment with continuous renal replacement therapy (CRRT) and the application of temporary cardiac pacemaker. An echocardiogram demonstrated decreased ejection fraction (EF) and Takotsubo cardiomyopathy on the third day of admission. Then, she was discharged safely with conservative treatment. At the follow-up after 1 year, Takotsubo cardiomyopathy, EF and QTc prolongation were recovered on echocardiogram and ECG. Because cardiac toxicity after glufosinate-containing herbicide poisoning may cause life-threatening consequences, caution is required while treating the patient. Therefore, if electrocardiogram changes are seen in the elderly with a large amount of glufosinate herbicide ingestion, additional cardiac function test through echocardiography should be concerned, and early treatment through CRRT or artificial cardiac pacing should be considered.
- QTc Prolongation due to Psychotropic Drugs Intoxication and Its Risk Assessment
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Kwan Ho Park, Hoon Pyo Hong, Jong Seok Lee, Ki Young Jeong, Seok Hun Ko, Sung Kyu Kim, Han Sung Choi
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J Korean Soc Clin Toxicol. 2020;18(2):66-77. Published online December 31, 2020
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DOI: https://doi.org/10.22537/jksct.2020.18.2.66
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Abstract
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- 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.
- Application of Poisoning aBIG score for Prediction of Fatal Severity in Acute Adult Intoxications
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Michael Sung Choe, Jae Yun Ahn, In Gu Kang, Mi Jin Lee
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J Korean Soc Clin Toxicol. 2014;12(1):14-21. Published online June 30, 2014
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- Purpose: The objective of this study was to develop a new scoring tool that is comprehensively applicable and predicts fatality within 24 h of intoxication. Methods: This was a cohort study conducted in two emergency medical centers from 2011 to 2012. We identified factors associated with severe/fatality. Through a discriminant analysis, we devised the aBIG (age, Base deficit, Infection, and Glasgow coma scale) score. To compare the ability of aBIG to predict intoxication severity with that of previous scoring systems such as APACHE II, MODS, SAPS IIe, and SOFA, we determined the receiver operating characteristic curves of each variable in predicting severe-to-fatal toxicity. Results: Compared with the mild/moderate toxicity group (n=211), the severe/fatal group (n=143) had higher incidences of metabolic acidosis, infection, serious mental change, QTc prolongation and hepato-renal failure. Age, base deficit, infection-WBC count, and Glasgow Coma Scale were independently associated with severe/fatal poisoning. These variables were combined into the poisoning "aBIG" score [$0.28{ imes}$Age group+$0.38{ imes}WBC$ count/$10^3+0.52{ imes}$Base deficit+$0.64{ imes}$(15-GCS)], which were each calculated to have an area under the curve of 0.904 (95% confidence interval: 0.868-0.933). The aBIG poisoning score had an equivalent level of severity predictability as APACHE II and a superior than MODS, SOFA, and SAPS IIe. Conclusion: We developed a simplified scoring system using the four variables of age, base deficit, infected leukocytosis, and GCS. The poisoning aBIG score was a simple method that could be performed rapidly on admission to evaluate severity of illness and predict fatal severity in patients with acute intoxications.
- Cardiac Toxicity Following a Diphenhydramine Overdose
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Sung-Jun Park, Jong-Hak Park, In-Kyung Um, Kyung-Ae Park, Do-Hyoun Kim, Su-Jin Kim, Sung-Woo Lee, Yun-Sik Hong
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J Korean Soc Clin Toxicol. 2011;9(1):20-25. Published online June 30, 2011
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- Purpose: This study was designed to analyze the contributing factors, as well as the incidence and nature of the cardiac toxicity, in patients presenting with diphenhydramine overdose. Methods: We retrospectively reviewed the medical records of the intoxicated patients who presented to the ED of Korea University Anam Hospital from January 2008 to December 2010. Those patients who visited due to a diphenhydramine overdose were selected and the following features were recorded for analysis: the general characteristics, vital signs, the amount of ingested diphenhydramine, the time interval from ingestion to presentation, the coingested drugs (if any), the toxicities and the ECG findings. Cardiac toxicity, while defined mainly in terms of the temporary ECG changes such as QTc prolongation, right axis deviation, QRS widening, high degree AV block and ischemic changes, also encompassed cardiogenic shock, which is a clinical finding. Results: A total of eighteen patients were enrolled. Of the eighteen patients, eight had ingested diphenhydramine only, while ten had ingested other drugs in addition to diphenhydramine. The most commonly observed toxicity following diphenhydramine overdose included cardiac toxicity (78%). Cardiac toxicity was observed in all the patients who presented to the emergency department 2 hours after ingestion. The patients with QTc prolongation turned out to have ingested significantly larger amounts of diphenhydramine. Conclusion: QTc prolongation and right axis deviation were common findings for the patients with a diphenhydramine overdose. QTc prolongation was more likely to occur with ingesting larger amounts of diphenhydramine. Close monitoring is mandatory for patients who have ingested large amounts of diphenhydramine to prevent such potentially lethal cardiac toxicity.
- Comparative Analysis of Overdose with Common Sleep-aid Medications - Doxylamine vs Diphenhydramine -
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Hyun-Sik Ryu, Mi-Jin Lee, Seong-Soo Park, Won-Joon Jeong, Hyun-Jin Kim
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J Korean Soc Clin Toxicol. 2010;8(2):79-87. Published online December 31, 2010
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- Purpose: The previous studies on $H_1$ antihistamine overdose have generally been limited to cases of acute doxylamine succinate (DS) poisoning, yet there have been some studies on diphenhydramine (DPH) overdosing. But many clinicians consider the two drugs to be very similar and to have similar ingredients. The purpose of this study was to clarify the toxicologic characteristics and clinical outcomes between DS and DPH poisoning/overdose. Methods: We reviewed the medical and intensive care records of the patients with acute DS or DPH poisoning and who admitted to our emergency department from January 2008 and April 2010. We collected patient information regarding the features of the poisoning and the clinical and demographic characteristics. The patients were assessed for the clinical outcomes, the GCS, the PSS (Poisoning Severity Score) and the SOFA (Sequential Organ Failure Assessment). Results: Fifty seven patients (45 cases of DS poisoning and 12 cases of DPH poisoning) were enrolled. Compared with the DS group, the DPH group had higher incidences of intubation, serious mental change, QTc prolongation and ECG conduction abnormality (p=0.041, <0.001, 0.014 and 0.044, respectively). The DPH group had a higher PSS and a longer ICU stay. The peak CPK time and the CPK normalization time were longer for the patients with rhabdomyolysis due to DS poisoning. Conclusion: Two common $H_1$ antihistamines, doxylamine and diphenhydramine, are in the same ethanolamine-structural class, but the toxico-clinical outcomes are different according to many aspects. Therefore, clinicians could take a careful approach for the differential diagnosis and management between DS and DPH poisoning.
- Cardiovascular Manifestations of Acute Organophosphate and Carbamate Poisoning
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Sam-Beom Lee, Jung-Ho Kim, Byung-Soo Do
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J Korean Soc Clin Toxicol. 2004;2(1):7-11. Published online June 30, 2004
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- Purpose: We would evaluate the cardiovascular manifestations of the patients with acute organophosphate and carbamate poisoning in the emergency department. Methods: This was retrospectively studied with the review of patient's charts, included total 38 patients were admitted during the past two years in the emergency department of Yeungnam university hospital with the diagnosis of organophosphate or carbamate poisoning. Results: Cardiovascular complications were variously developed in many patients. Electrocardiographic findings were as follows; 4 ($10.5\%$) cardiac arrhythmias included 1 cardiac arrest caused by ventricular fibrillation, 14 ($36.8\%$) sinus tachycardias, 3 ($7.9\%$) sinus bradycardias, and 17 ($44.7\%$) normal sinus rhythms. Conduction disturbances were 23 ($60.5\%$) like as prolonged QTc, 4 ($10.5\%$) ST-T changes, 2 (5.3%) first degree AV block, and 3 ($7.9\%$) right bundle branch block were shown. Other cardiovascular complications were 22 ($57.9\%$) hypertensives, 4 ($10.5\%$) hypotensives, 15 ($39.5\%$) tachycardias, 2 ($5.3\%$) bradycardias, 18 ($47.4\%$) hypoxemics, 12 ($31.6\%$) metabolic acidosis, and 9 ($23.7\%$) pulmonary edemas. Sixteen patients ($42.1\%$) needed ventilatory support because of respiratory paralysis. No patients died in hospital and 36 ($94.7\%$) patients were alive-discharged. Conclusion: Cardiovascular complications are variously in patients with acute organophosphate and carbamate poisoning. Especially, some findings included ventricular arrhythmias, QTc prolongation, hypoxemia, acidosis, and blood pressure changes are known as major precipitating factors to increase the mortality. So, intensive support and aggressive treatment are needed in patients shown various cardiovascular manifestations in the emergency department.