Journal of The Korean Society of Clinical Toxicology

Original Articles

Patterns of self-harm/suicide attempters who visited emergency department over the past 10 years and changes in poisoning as a major method (2011–2020): Kyu Hyun Pai, Sung Woo Lee, Su Jin Kim, Kap Su Han, Juhyun Song, Sijin Lee, Ji Hwan Park, Jeijoon Song; J Korean Soc Clin Toxicol. 2023;21(2):69-80. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00019

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Purpose: Suicide ranks among the top causes of death among youth in South Korea. This study aimed to identify the characteristics of suicidal individuals treated at emergency departments between 2011 and 2020.
Methods
A retrospective analysis was conducted using data from January 2011 to December 2020 in the Injury Surveillance Cohort, a prospective registry. Patients’ sex, age, mortality, methods of self-harm, and previous suicide attempts were analyzed. The methods of self-harm were categorized into falls, asphyxiation, blunt injuries, penetrating injuries, poisoning, and others. Sub-groups with and without poisoning were compared.
Results
The proportion of self-harm/suicide attempts increased from 2.3% (2011) to 5.0% (2020). The mortality rate decreased from 10.8% (2011) to 6.3% (2020). Poisoning was the most common method (61.7%). Mortality rates ranged from 42.0% for asphyxiation to 0.2% for blunt injuries. Individuals in their 20s showed a marked increase in suicide/self-harm attempts, especially in the last three years. A large proportion of decedents in their 70s or older (52.6%) used poisoning as a method of suicide. The percentage of individuals with two or more previous attempts rose from 7.1% (2011) to 19.7% (2020). The death rates by poisoning decreased from 7.7% (2011) to 2.5% (2020).
Conclusion
Our findings underscore the urgent need for targeted interventions and suicide prevention policies. Managing and reducing suicide and self-harm in emergency settings will require a focus on poisoning, the 10–29 age group, and the elderly. This paper will be valuable for future policies aiming to reduce the societal burden of suicide and self-harm.

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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

Comparison of hyperbaric oxygen therapy pressures for acute carbon monoxide poisoning: Jeong Yun Kim, Jihye Lim, Sung Hwa Kim, Sang Il Han, Yong Sung Cha; J Korean Soc Clin Toxicol. 2023;21(2):117-127. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00012

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Abstract PDF: Purpose: No consensus currently exists regarding the maximal pressure of hyperbaric oxygen (HBO₂) therapy performed within 24 hours of acute carbon monoxide (CO) poisoning. This study aimed to evaluate the difference in therapeutic effects according to the first HBO₂ pressure (3.0 atmospheres absolute [ATA] vs. 2.8 ATA).
Methods
We used prospectively collected registry data on CO poisoning at a tertiary academic hospital in the Republic of Korea. Adult patients with acute CO poisoning treated with HBO₂ within 24 hours after arrival at the emergency department and without the use of additional HBO₂ after 24 hours between January 2007 and February 2022 were included. Data from 595 patients were analyzed using propensity score matching (PSM). Patients with mild (non-intubated) and severe (intubated) poisoning were also compared. Neurocognitive outcomes at 1 month after CO poisoning were evaluated using the Global Deterioration Scale combined with neurological impairment.
Results
After PSM, the neurocognitive outcomes at 1-month post-CO exposure were not significantly different between the 2.8 ATA (110 patients) and 3.0 ATA (55 patients) groups (p=1.000). Similarly, there was also no significant difference in outcomes in a subgroup analysis according to poisoning severity in matched patients (165 patients) (mild [non-intubated]: p=0.053; severe [intubated]: p=1.000).
Conclusion
Neurocognitive sequelae at 1 month were not significantly different between HBO₂ therapy pressures of 2.8 ATA and 3.0 ATA in patients with acute CO poisoning. In addition, the 1-month neurocognitive sequelae did not differ significantly between intubated and non-intubated patients.

Association between defoliant exposure and survival to discharge after out-of-hospital cardiac arrest: Dong Wook Kim, Yu Chan Kye, Jung Youp Lee, Eui Gi Jung, Dong Sung Kim, Hyun Jung Choi, Young Lee; J Korean Soc Clin Toxicol. 2021;19(1):38-43. Published online June 30, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.1.38

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Abstract PDF: Purpose: We investigated the association between defoliant exposure and survival to discharge after out-of-hospital cardiac arrest. Methods: This is a retrospective case-control study based on the cardiopulmonary resuscitation (CPR) registry. The electronic medical records of out-of-hospital cardiac arrest victims from 6/9/2008 to 12/31/2016 were analyzed statistically. The case patients group had a history of defoliant exposure while the control group did not. Among the 401 victims studied, a total of 110 patients were male out-of-hospital cardiac arrest patients. Baseline characteristics and the parameters involved in cardiac arrest were analyzed and compared between the two groups after propensity score matching. The primary outcome was survival to discharge, and secondary outcomes were sustained return of spontaneous circulation (ROSC) and survival to admission. Results: After propensity score matching a total of 50 patients (case=25, control=25) were analyzed. Primary outcome (survival to discharge) was not significantly different between case and control groups [(OR, 1.759; 95% C.I., 0.491-6.309) and (OR, 1.842; 95% C.I., 0.515-6.593), respectively]. In the subgroup analysis, there were also no significant differences between the control group and subgroups in primary and secondary outcomes according to defoliant exposure severity. Conclusion: There is no statistically significant association between defoliant exposure and survival of out-of-hospital cardiac arrest.

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.

Changes in Toxicological Characteristics after Sales of Nonprescription Drugs in Convenience Stores: Chang Yeong Kim, Eui Jung Lee, Sung Woo Lee, Su Jin Kim, Kap Su Han; J Korean Soc Clin Toxicol. 2018;16(1):42-48. Published online June 30, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.1.42

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Abstract PDF: Purpose: On November 15, 2012, sales of OTC (Over-The-Counter) drugs began at convenience stores, which changed the accessibility of some drugs. As a result, the exposure and access patterns of these drugs could have changed. In this study, we reviewed the changes in the characteristics of drug poisoning patients because of the reposition of nonprescription drugs according to the revised Pharmaceutical Affairs Act. Methods: A retrospective study was conducted to evaluate changes in characteristics of drug poisoning patients between 2008 and 2016. A registry was developed by an emergency medical center in a local tertiary teaching hospital, and patients who visited the center were enrolled in this registry. We compared two periods, from 2008 to 2012 (Pre OTC) and from 2013 to 2016 (Post OTC), for type of intoxicant, time from poisoning to visiting the emergency center, intention, psychiatric history, previous suicidal attempt, alcohol status, and emergency room outcomes. The primary outcome was the number of patients who took acetaminophen and NSAIDs (nonsteroidal anti-inflammatory drugs). Secondary outcomes were ICU admission rate, mortality rate, and number of patients who visited the ER when the pharmacy was closed after taking acetaminophen and NSAIDs (nonsteroidal anti-inflammatory drugs). Results: Among 1,564 patients, 945 and 619 patients visited the emergency room during pre and post OTC periods. The number of patients with acetaminophen and NSAIDs poisoning decreased from 9.2% to 6.1% (p=0.016). The ICU admission rate and mortality rate in the emergency room did not show significant results in the relevant patient groups, and so was the number of patients visiting ER when the pharmacy was closed taking acetaminophen and NSAIDs. Conclusion: Despite the sales of nonprescription drugs at convenience stores, the number of acetaminophen and NSAIDs poisoning patients decreased.

Analysis of Poisoning Patients Using 2016 ED Based Injury in-depth Surveillance Data: Sung Phil Chung, Mi Jin Lee, Hyunggoo Kang, Bum Jin Oh, Hyun Kim, Yang Weon Kim, Byeong Jo Chun, Kyung Hwan Kim; J Korean Soc Clin Toxicol. 2017;15(2):86-93. Published online December 31, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.2.86

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Abstract PDF: Purpose: Some advanced countries have reported annual statistics for poisoning based on data from poison control centers. This study was conducted to propose a baseline format and statistics of poisoning in Korea from a national representative database. Methods: This study was a retrospective analysis of poisoning patients based on data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2016. Bite or sting injuries were not included. Variables related to poisoning were summarized using a similar format as the National Poison Data System in the United States. Results: A total of 7,820 poisoning patients presented to 23 EDs. Adults ${geq}20$ years accounted for 84% of the population, while the proportion of intentional poisoning was 59.4%. The most common poisoning substances were therapeutic drugs (45%), gas (21%), pesticides (15%), and artificial toxic substances (13%). Overall, 34.5% of patients were admitted for further treatment. The mortality was 3.2% (248 cases), and the most common causative substances were carbon monoxide, glyphosate, and paraquat, in order. Conclusion: This study showed the recent status of poisoning in Korea. However, a comprehensive poisoning registry based on poison control centers may be required to provide more accurate national statistics in the future.

The Incidence, Associated Factors and Clinical Impact of Hyperamylasemia in Self-poisoning Patients: Min Gu Seo, Sang Hoon Oh, Jee Yong Lim, Han Joon Kim, Se Min Choi; J Korean Soc Clin Toxicol. 2016;14(2):83-91. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.83

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Abstract PDF: Purpose: This study was conducted to investigate the incidence, associated factors and clinical impact of hyperamylasemia in self-poisoning patients. Methods: This study was based on a toxicology case registry of patients treated from 2009 to 2013 at a tertiary care university hospital. We retrospectively investigated the demographics, clinical variables, laboratory variables and intoxicants. Hyperamylasemia was defined as an elevation in serum amylase level to above the upper normal limit within 24 hours after admission. We analyzed the predisposing factors and clinical outcomes of patients in the hyperamylasemia group. Results: Hyperamylasemia was identified in 49 (13.3%) of the 369 patients. Using multivariate logistic regression, the odds ratios for HA were 3.384 (95% confidence interval, 1.142-8.013, p=0.014), 3.261 (95% confidence interval, 1.163-9.143, p=0.025) and 0.351 (95% confidence interval, 0.154-0.802, p=0.013) for pesticides, multi-drug use and sedatives, respectively. In the hyperamylasemia group, the peak amylase levels during 72 hours were correlated with the peak lipase levels (r=0.469, p=0.002) and peak aspartate aminotransferase levels (r=0.352, p=0.013). Finally, none of these patients had confirmed acute pancreatitis. Conclusion: Hyperamylasemia occurred rarely in these self-poisoning patients, and pesticide and multi-drug use were independent predictors of hyperamylasemia. Peak amylase levels were correlated with the peak lipase and aspartate aminotransferase levels.

The Clinical Characteristics for Emergency Endotracheal Intubation in Acute Drug Intoxication: Eol Han, Hyun Soo Chung, Yoo Seok Park, Je Sung You, Youngseon Joo, Taeyoung Kong, Incheol Park, Sung phil Chung; J Korean Soc Clin Toxicol. 2015;13(1):11-18. Published online June 30, 2015

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Abstract PDF: Purpose: The aim of this study was to compare the clinical characteristics in emergency endotracheal intubation between patients with acute drug intoxication and medical disease. Methods: Data for airway registry collected in two emergency departments (ED) between April 2006 and March 2010 were reviewed retrospectively. The airway registry data included patient's demographic information and variables such as Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, complications of intubation, and clinical outcomes after intubation. Results: A total of 1480 patients were enrolled; 62 patients were classified as belonging to the intubation group after the drug intoxication group. No significant differences in Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, and complications after intubation were observed between patients with acute drug intoxication and medical disease. However, significant difference was observed for indication of emergency endotracheal intubation. While emergency endotracheal intubations were usually performed in medical patients because of failure of airway patency, they were performed in intoxicated patients with the goal of preventing serious complications. Conclusion: Anatomical structures related to endotracheal intubation, the process and clinical outcome of intoxicated patients are not significantly different from those for medical patients.

The Factors Affecting the Registration Rates for Emergency Department Based Post-suicidal Care Program: Junchul Lee, Hyung Goo Kang, Changsun Kim, Jaehoon Oh, Taeho Lim, Dong Hyun Ahn, Jung Im Lee, Min Hee Park, Kyung Hee Kim; J Korean Soc Clin Toxicol. 2015;13(1):25-32. Published online June 30, 2015

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Abstract PDF: Purpose: The aim of this study was to investigate the independent factors associated with the registration rate for the community-based post suicidal care program in the emergency department (ED). Methods: This prospective observational study was conducted between March and December 2013 at the academic ED at the tertiary urban hospital. During the study period, the pre-designed registry was recorded. The variables examined included the following: patients' demographic data (Sex, age, address, type of insurance, marital status, level of education, and history of previous psychiatric disease), suicide-related data (suicidal methods, combined drink of alcohol and number of previous attempts), and management-related data (disposition at ED, physician's training level, etc.). Univariated and multivariated logistic regression analyses were performed for identification of factors affecting the registration rate for the community-based post suicidal care program. Results: A total of 163 suicides were included during the study period. Of these, 33 (20.2%) patients were registered in the post-suicide care program. Factors including a patient's address (OR: 14.92, 95% CI: 3.606-61.711), immediate intervention by psychiatric healthcare center (OR: 5.05, CI: 1.688-15.134), admissions in hospital (OR: 3.69, CI: 1.286-10.605), and history of previous psychiatric disease (OR: 3.52, CI: 1.216-10.201) showed significant association with registration for the program. Conclusion: The community-based post-suicidal care program, which is available 24 hours a day, should be operated in each district in order to increase the registration rate. Emergency physicians should actively consider the inpatient treatment program for suicidal patients and strongly recommend registration to the program, particularly for patients without previous history of psychiatric disease.

Comparison between Emergency Patient Poisoning Cases and the Tox-Info System Database: Hyun-Jong Kim, Yang-Weon Kim, Hyun Kim, Chang-Bae Park, Byung-Hak So, Kyeong-Ryong Lee, Kyung-Woo Lee, Kyung-Won Lee, Sung-Woo Lee, Jang-Young Lee, Gyu-Chong Cho, Jun-Ho Cho, Sung-Phil Chung; J Korean Soc Clin Toxicol. 2012;10(1):8-14. Published online June 30, 2012

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Abstract PDF: Purpose: The Tox-Info system is a poisonous substance information database developed by the Korean National Institute of Food and Drug Safety Evaluation. The aim of this study was to estimate the coverage effectiveness of the Tox-Info system by comparing the toxic substances included in the database with the distribution of the toxic substances implicated in the cases of intoxicated patients presenting to emergency departments. The secondary aim of the study was to propose any additional substances that should be added to the database. Methods: We retrospectively reviewed the medical records of patients suffering with toxic exposure who had visited any of 12 selected emergency departments in Korea from January 2010 to December 2011. The identified toxic substances were classified into groups including prescription drugs, agricultural chemicals, household products, animals or plants, herbal drugs, and others. We calculated the coverage rate of the Tox-Info database relative to the number of intoxication cases and the type of toxic substances involved. Results: A total of 5,840 intoxicated patient records were collected. Their mean age was $46.6{pm}20.5$ years and 56.2% were female. Of the total intoxication cases, 87.8% of the identified toxic substances were included in the Tox-Info database, while only 41.6% of all of the types of identified toxic substances were included. Broken down by category, 122 prescription drugs, 15 agricultural chemicals, 12 household products, 14 animals or plants and 2 herbal drugs involved in poisoning cases were not included in the Tox-info database. Conclusion: This study demonstrated the clinical usefulness of the Tox-Info system. While 87.8% of the substances involved in the cases were included in the Tox-Info database, the database should be continuously updated in order to include even the most uncommon toxic substances.

Resuscitation Outcomes and Clinical Characteristics of Out-of-Hospital Drug Induced Cardiac Arrest: Yun Kwon Kim, Hyun Kim, Ho Kyong Won, Kwon Il Lee, Sung Bum Oh, Joong Bum Moon, Kang Hyun Lee, Sung Oh Hwang; J Korean Soc Clin Toxicol. 2005;3(2):93-98. Published online December 31, 2005

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Abstract PDF: Purpose: This study was to investigate the resuscitation outcomes and the clinical characteristics of non-traumatic drug-induced out-of-hospital cardiac arrest by analyzing data from a single institution's registry. Method: We conducted a retrospective study of 795 patients who came to the emergency department with non-traumatic drug-induced out-of-hospital cardiac arrest during the period $1991{~}2004$. Only patients over 18 years of age were included. Clinical characteristics. variables associated with cardiac arrest, and data during resuscitation were obtained from our cardiac arrest database. Patients were divided into two groups: drug-induced cardiac arrest (drug group, n=33), and non drug-induced cardiac arrest (non-drug group, n=762). Results: Spontaneous circulation was restored in 23 ($72{\%}$) patients in the drug group and in 314 ($45{\%}$) patients in the non-drug group ($x^2=0.020$). The patients who discharged alive number were 46 ($6{\%}$) in the non-drug group and 0 ($0{\%}$) in the drug group ($x^2=0.005$). The witnessed arrest, the epinephrine doses, and total defibrillation energy were not different between two groups. Conclusion: The return of spontaneous circulation rate was higher in the drug group than the non-drug group. However the drug group was lower survival discharge rate than in the non-drug group.

Effects of Alcohol in Intoxicated Patients: Hyun Kim, Ho Kyong Won, Ho Jung Kim, Seo Young Lee, Kang Hyun Lee, Sung Oh Hwang; J Korean Soc Clin Toxicol. 2004;2(2):96-100. Published online December 31, 2004

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Abstract PDF: Purpose: This study was to investigate the effects of ethanol in ingested patients by analyzing data from a single institution's registry, Methods: We conducted a prospective study of 50 patients who has ingested drugs with/without ethanol came to emergency department from January 2004 to May 2004. Only patients over 18 years of age were included. Clinical characteristics, general and specific treatment, laboratory finding, complication, and clinical outcomes were obtained from protocol. Patients were divided into two groups: drug ingested with alcohol (ethanol group, n=18), and ingested without alcohol (non-ethanol group, n=32). Results: The age, the amout of ingestion, the time to treatment, the systolic blood pressure, the diastolic blood pressure and the shock duration were not different between two groups. The AST level with the ethanol group was higher than with the non-ethanol group ($230.94pm518.88$ U/L vs $43.22pm63.39$ U/L, p=0.002). The ALT level with the ethanol group was higher than with the non-ethanol group ($97.06pm152.98$ U/L vs $32.75pm43.10$ U/L, p=0.001). The lactic acid level with the ethanol group was higher than with the non-ethanol group ($7.40pm6.33$ mmol/L vs $3.77pm3.10$ mmol/L, p=0.001). The hospital stay duration and the admission rate were not different between two groups. Conlusions: The ethanol increased the levels of serum AST, ALT and lactic acid in intoxicated patients. But the ethanol dose not increase admission rate and duration of admission stay in intoxicated patients.

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