Journal of The Korean Society of Clinical Toxicology

Clinical and Epidemiological Characteristics of Severe Poisoning Patients and Analysis of Prognostic Factors: Young Yun Jung, Chul Min Ha, Sung Tae Jung, Hyoung Ju Lee; J Korean Soc Clin Toxicol. 2020;18(2):94-101. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.94

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Abstract PDF: 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.

A Study of Predicting the Severity Following Glufosinate Ammonium Containing Herbicide Poisoning Experienced in Single Emergency Medical Institution: Doo Sung Lee, Kyoung Ho Choi; J Korean Soc Clin Toxicol. 2019;17(1):7-13. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.7

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Abstract PDF: Purpose: Owing to the increased agricultural use of the herbicide glufosinate ammonium (GLA), the incidence of GLA poisoning has recently increased. Therefore, we investigated the possible predictive factors associated with severe complications following GLA poisoning. Methods: A retrospective analysis of medical records was conducted based on 76 patients who had visited our regional emergency medical center with GLA poisoning from 2006 to 2017. Severe complications were defined as respiratory failure requiring intubation, systolic blood pressure less than 90 mmHg, Glasgow Coma Scale (GCS) less than 8, and presence of seizure. Results: Age, ingested amount and ingested amount per weight were significantly greater in the severe group (p<0.001). PSS grade 2 or higher was more common in the severe group (p<0.001), and In addition, the APACHE II score was significantly higher in the severe group (p<0.001), as were the SOFA scores (p=0.002). Serum ammonia levels were significantly higher in the severe group (p=0.007), while MDRD-GFR was smaller in the severe group (p=0.002). The spot urine protein levels were significantly higher in the severe group (p=0.005), as was the urine protein to creatinine ratio (p=0.001). Upon multivariate analysis, the amount ingested per weight and PSS grade 2 or higher were identified as significant predictors. Conclusion: Our study showed that MDRD-GFR was significantly lower in the severe group after GLA poisoning. PSS grade 2 or higher and ingested amount per weight may be useful to evaluate the severity of complications after GLA poisoning.

Survival after Cardiac Arrest due to Acute Methamphetamine Poisoning: A Case Report: You Ho Mun, Jung Ho Kim; J Korean Soc Clin Toxicol. 2018;16(2):176-180. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.176

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Abstract PDF: Drug abuse and its related problems are increasing continuously in Korea. One of the most frequently abused drugs is methamphetamine, but there are few medical report in Korea. This is the first report of the identification of methamphetamine in the blood of a patient who had a return of spontaneous circulation after cardiac arrest and survived discharge. A 33-year-old male arrived at the emergency department presenting with chest pain and dyspnea. He had ingested methamphetamine and alcohol approximately 7 hours before arrival. One hour after arrival, he had seizure followed by cardiac arrest. Spontaneous circulation was recovered after 4 minutes of CPR. An analysis of the National Forensic Service identified plasma methamphetamine with an estimated average concentration of plasma methamphetamine at the time of arrival of 0.6 mg/L, a lethal dose. He had rhabdomyolysis and acute kidney injury but survived after continuous renal replacement therapy. Since then, he has suffered chronic kidney disease, and he is being followed up at the out-patient department. In Korea, although drug abuse is still uncommon, it is on the increase. Therefore, emergency physicians should be aware of the clinical characteristics of methamphetamine poisoning.

Relationship between Serum Neuron Specific Enolase Level and Seizure in Patients with Acute Glufosinate Ammonium Poisoning: Gyo Jin An, Yoonsuk Lee, Yong Sung Chan, Hyun Kim; J Korean Soc Clin Toxicol. 2018;16(1):49-56. Published online June 30, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.1.49

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Abstract PDF: Purpose: Glufosinate ammonium poisoning can cause seizures, even after a symptom-free period. This study was conducted to evaluate the relationship between serum neuron specific enolase (NSE) level and the occurrence of seizures in patients with acute glufosinate ammonium poisoning. Methods: For this retrospective observational study, data from patients diagnosed with acute glufosinate ammonium poisoning were collected between January 2016 and June 2016. Serum NSE was measured within 2 hours of arrival at the emergency department. The patients were divided into a seizure group and a non-seizure group. Results: The seizure group included eight of the 15 total patients (53.3%). The serum NSE level was significantly higher in the seizure group than in the non-seizure group ($32.4{pm}11.9ng/mL$ vs. $19.5{pm}5ng/mL$, p=0.019). The amount of glufosinate ingested and initial and peak serum ammonia levels were significantly higher in the seizure group than in the non-seizure group. There was no significant difference in the area under the curve of the serum NSE level or the initial and peak serum ammonia levels in terms of predicting the occurrence of seizures. Conclusion: In acute glufosinate poisoning, initial serum NSE levels may help in prediction of seizures.

Low Plasma Insulin Level Prolonged Hypoglycemia after High dose Insulin Lispro Injection: Jeong Ho Kang, Hyun Soo Park; J Korean Soc Clin Toxicol. 2016;14(2):151-154. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.151

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Abstract PDF: 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.

Clinical Analysis of Acute Endosulfan Poisoning: Single Center Experience: So Eun Kim, Su Ik Kim, Jae Baek Lee, Young Ho Jin, Tae Oh Jeong, Si On Jo, Jae Chol Yoon; J Korean Soc Clin Toxicol. 2015;13(2):71-77. Published online December 31, 2015

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Abstract PDF: Purpose: Acute endosulfan poisoning is rare but causes significant morbidity and mortality. The aim of our study is to describe complications and features of seizure and determine factors associated with mortality in acute endosulfan poisoning. Methods: Twenty-eight adult patients with acute endosulfan poisoning admitted to our emergency department during a 15-year period were studied retrospectively. The clinical features of seizure, use of antiepileptic drugs during seizure, and hospital courses were evaluated. Clinical factors between survived group and non-survived group were compared for identification of factors associated with mortality. Results: Of the 28 patients with endosulfan poisoning, 4 patients (14.3%) died and 15 (53.6%) patients developed generalized tonic-clonic seizure. Thirteen patients (46.4%) and 5 patients (17.9%) progressed to status epilepticus (SE) and refractory status epilepticus (RSE), respectively. SE and RSE were associated with mortality. Almost all significant complications including shock, acute renal failure, hepatic toxicity, rhabdomyolysis, and cardiac injury developed in SE and RSE patients. Conclusion: SE and RSE were important contributors to death in endosulfan poisoning. Emergency physicians treating endosulfan poisoning should make an effort not to progress seizure following endosulfan poisoning to SE and RSE using a rapid and aggressive antiepileptic drug.

A Case of Seizures after Zolpidem Withdrawal: Hyung Jun Moon, Jung Won Lee, Byeong Dae Yoo; J Korean Soc Clin Toxicol. 2013;11(2):127-129. Published online December 31, 2013

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Abstract PDF: The imidazopyridine, zolpidem, a non-benzodiazepine hypnotic drug, is widely-prescribed for insomnia. It is regarded as a good alternative to benzodiazepine because of the reduced possibility for abuse and development of dependence. However, more recently, due to the reduced possibility for abuse and development of dependence, it is regarded as a good alternative to benzodiazepine. adverse effects of zolpidem have been recognized. The objective of this report is to provide information on the potential for occurrence of benzodiazepine-like withdrawal seizure in patients who chronically take zolpidem continually. We present and discuss a case of seizure after sudden interruption of the protracted use of an abusively high dose of zolpidem. Zolpidem may not be the ideal drug for longterm pharmacotherapeutic management of insomnia. Clinicians should administer zolpidem at a low-dose for a short period of time for prevention of drug abuse and dependence and the potential for occurrence of benzodiazepine- like withdrawal seizure.

A Case of Central Nervous System (CNS) Toxicity in Acute Organophosphate Intoxication: Jae Sung Lee, Jin Hui Paik, Sung Hyun Yun, Ji Hye Kim, Seung Baik Han, Jun Sig Kim, Hyun Min Jung; J Korean Soc Clin Toxicol. 2013;11(1):31-35. Published online June 30, 2013

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Abstract PDF: Acute organophosphate intoxication is important because of its high morbidity and mortality. The mortality is still high despite the use of atropine as specific antidotal therapy and oximes for reactivation of acetylcholinesterase. Inhibition of acetylcholinesterase by organophosphate can cause acute parasympathetic system dysfunction, muscle weakness, seizure, coma, and respiratory failure. Acute alteration in conscious state or a coma, which may occur following organophosphate intoxication, is an indication of severe intoxication and poorer prognosis. This acute decline in conscious state often reverses when the cholinergic crisis settles; however, it may be prolonged in some patients. We report on a case of a 60-year-old male who showed prolonged decline in conscious state due to of Central Nervous System (CNS) toxicity after a suicide attempt with organophosphate.

The Clinical Features and Risk Factors of Seizure After Doxylamine Intoxication: Beom-Soo Song, Ki-Man Lee, Sun-Wook Kim, Je-Sung You, Tae-Nyung Chung, Yoo-Seok Park, Sung-Phil Jung, Hong-Du Goo, In-Cheol Park; J Korean Soc Clin Toxicol. 2010;8(2):88-96. Published online December 31, 2010

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Abstract PDF: Purpose: Doxylamine is antihistamine drug that is used as a hypnotic. It is also used for suicidal attempts because it can be easily purchased at the pharmacy without a prescription. There were many articles about the complications after doxylamine intoxication such as a rhabdomyolysis, but only a few articles have reported on seizure. We reviewed the cases of doxylamine intoxication with seizure that were treated in the emergency department. Methods: We reviewed the medical records of the patients who were over 15 years old and who were intoxicated by doxylamine at 3 emergency medical centers from January 2006 to June 2010. We reviewed the patients' age, gender, the dose of doxylamine ingested, if gastrointestinal decontamination was done, the time from intoxication to hospital arrival, the seizure history, treatment of seizure, the electroencephalography (EEG) results, the brain computed tomography (CT) results and the blood test results. Results: There were 168 patients who were intoxicated by doxylamine during the study period. Twelve patients had a seizure episode. The differences between the patients who developed seizure and the patients who did not were the dose and the serum levels of sodium and creatinine. The only clinically meaningful difference was the amount of doxylamine. The amount of doxylamine ingested (>29 mg/kg) predicted the development of seizure with a sensitivity of 75% and a specificity of 92% on the ROC curve. One patient among the seizure patients expired in the emergency department. Conclusion: In case of doxylamine intoxicated patients, there is close relationship between seizure and ingested amount, so close observation needs to be done for the patients who ingest too much because doxylamine can cause death. Further prospective studies are needed for doxylamine intoxicated patients with a seizure episode.

A Lethal Case of Aute Zipeprol Poisoning Occurring in a Drug Addicted Old Woman: Doo-Hwan Lee, Sang-Cheon Choi, Jung-Hwan Ahn, Young-Shin Cho, Gi-Woon Kim, Young-Gi Min, Yoon-Seok Jung; J Korean Soc Clin Toxicol. 2009;7(2):172-175. Published online December 31, 2009

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Abstract PDF: Zipeprol dihydrochloride is a non-opioid mucolytic, antitussive agent and it is frequently prescribed for respiratory symptoms such as cough and sputum. The main pharmacologic mechanisms of zipeprol are inhibition of superior laryngeal nerve stimulation and direct antagonism for stimulation of the bronchial receptors, which might have an effect for the drug's mucolytic action. Many cases of drug abuse with zipeprol have occurred world-wide due to the hallucinogenic effect of the drug. In Korea, zipeprol was reported to be the most commonly abused drug among young people for the 1990s. Zipeprol associated death was first reported since 1991 and 69 cases of death related to zipeprol abuse were further reported during 8 years (between 1991 and 1998). In addition to the hallucinogenic effect, dyspnea, extrapyramidal symptoms, seizure, cerebral edema have been reported as the signs and symptoms of toxic zipeprol overdose. However, zipeprol abuse is not common for old age people and non drug abusers. We report here on a fatal case of acute zipeprol poisoning in an eighty five year old drug addicted woman.

Effect of Seizure on Prognosis in Acute Endosulfan Intoxication: Byung-Gon Han, Jun-Ho Lee, Kyung-Woo Lee; J Korean Soc Clin Toxicol. 2009;7(2):77-82. Published online December 31, 2009

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Abstract PDF: Purpose: In highly doses, endosulfan lowers the seizure threshold and elicits central nervous system stimulation, which can result in seizures, respiratory failure, and death. Management of seizure control is essential for survival and prognosis of intoxicated patients. This study assessed whether seizure time was an independent predictor mortality in patients with endosulfan poisoning. Methods: This retrospective study enrolled patients with endosulfan poisoning presenting to Masan Samsung Hospital and Gyeongsang National University Hospital from January 2003 to December 2008. The data were collected from clinical records and laboratory files. Using a multivariate logistic analysis, data on the total population was retrospectively analyzed for association with mortality. Results: Of the 24 patients with endosulfan poisoning, nineteen (79.1%) experienced seizure. The patients in the seizure group showed significantly lower Glasgow coma scale score, base excess, bicarbonate, and significant existence of mechanical ventilation, as compared to the non seizure group (n=5). Seizure, Glasgow coma scale score, systolic blood pressure, bicarbonate level, need for respiratory support, pulse rate, respiratory rate, pH, base excess, and seizure time were associated with mortality. The fatality rate of endosulfan poisoning was 54.1% with higher mortality among patients experiencing. Longer seizure time was associated with higher mortality. Conclusion: Seizure time can be a significant independent predictor of mortality in patients with acute endosulfan poisoning. Physicians should aggressively treat for seizure control in patients with acute endosulfan poisoning.

A Case of Seizure in Diphenhydramine Overdose: Jung-Soo Park, Hoon Kim, Suk-Woo Lee; J Korean Soc Clin Toxicol. 2009;7(1):23-25. Published online June 30, 2009

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Abstract PDF: A 21-year-old woman ingested 1,250 mg of diphenhydramine in a single overdose. Diphenhydramine, a rare ingredient in over-the-counter medication, is used to treat insomnia in Korea. Toxicity is usually limited to anticholinergic symptoms. The standard approach to therapy for the treatment of diphenhydramine overdose is supportive care, including physostigmines and sodium bicarbonates. Here, we review the literature and for the first time report a case of acute diphenhydramine overdosage in Korea, complicated with seizures.

A Case of Fatal Arrhythmia after Propafenone Overdose: Yeon-Young Kyong, Kyoung-Ho Choi; J Korean Soc Clin Toxicol. 2008;6(2):123-129. Published online December 31, 2008

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Abstract PDF: A 36-year-old female was transferred to our emergency medical center with decreased mental status after a 6.0 g propafenone overdose because of domestic disturbance. She had no previous history of epilepsy, diabetes mellitus, hypertension or psychiatric illness. Before presenting to our center, gastrointestinal decontamination, charcoal administration, and endotracheal intubation due to bradycardia and generalized seizure had been performed. Soon after hospital arrival, at 5 h after ingestion, she collapsed into shock and fatal arrhythmia. We successfully resuscitated the patient with amiodarone, sodium bicarbonate, a large volume of normal saline, calcium, and ventilator care. At 23 h after ingestion, she was fully recovered and had no subjective signs or symptoms. To our knowledge, this is the first case report of intentional propafenone overdose in Korea, which we report with reviews of the previous literature.

Rhabdomyolysis after Lamotrigine Poisoning: A Case report: Gun-Bea Kim, Hong-Du Gu; J Korean Soc Clin Toxicol. 2008;6(2):142-145. Published online December 31, 2008

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Abstract PDF: Lamotrigine is a newer anti-epileptic drug for adjunctive treatment of refractory epilepsy, partial seizures, generalized tonic-clonic seizures, and bipolar disorder. Lamotrigine overdose causes serious central nervous and cardiovascular problems, but reports are uncommon. Few lamotrigine overdoses have been described because anti-epileptic drug use is limited and usually used with combination of other anti-epileptic drugs. In addition, most patients visit emergency departments with multi-drug overdoses, so few cases of lamotrigine poisoning alone exist. We had a female patient visit our emergency department a couple of hours after a lamotrigine overdose treated with intravenous hydration and urine alkalization by NaHCO3. She recovered successfully without any evidence of renal injury. However, she developed profound rhabdomyolysis, a previously unreported complication of this medication. We suggest that serial creatine kinase levels should be measured after lamotrigine poisoning.

Two Cases of Phytolacca Americana Intoxication with Confusion and Abdominal Cramping: Yang-Weon Kim, Yoo-Sang Yoon, Mi-Ran Kim, Sang-Hoon Park, Jun-Cheol Choi; J Korean Soc Clin Toxicol. 2008;6(2):146-148. Published online December 31, 2008

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Abstract PDF: Phytolacca americana poisoning is a benign plant intoxication that causes gastrointestinal symptoms, including abdominal cramps, vomiting, diarrhea, and gastrointestinal bleeding. Other signs and symptoms include diaphoresis, salivation, visual disturbance, and seizures or mental changes. We report two cases of patients who experienced confusion and abdominal pain, vomiting, and hematemesis after oral ingestion of pokeweed. A 60-year-old female with confusion and a 67-year-old female with abdominal pain, vomiting, and diarrhea were admitted to the emergency department after pokeweed poisoning. After supportive treatment of hydration and gastrointestinal medication, the two patients showed full recovery within 24 h and were discharged from the hospital.

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