Deliberate self-poisoning and harm: A meticulous quest of methods in vogue

Background:

Deliberate self-poisoning and harm (DSPH) is an unabating problem with a wide variation in the methods used across the world. Hence, this study was conducted to understand the current spectrum of methods used for DSPH by patients in our geographic locality and catchment area with special emphasis on newer compounds and drugs used.

Methods:

This retrospective study included patients presenting with DSPH to the emergency department (ED) between January 2017 and December 2018.

Results:

This study included 1802 patients, with a mean age of 32 ± 12.7 years. Of the patients, 85% were in the young to middle age group (16–45 years). Agrochemicals (n = 604, 33.5%), drugs (n = 498, 27.6%), plant toxins (n = 150, 8.3%) and rodenticides (n = 145, 8%) were the predominantly used compounds. The major emergency resuscitation procedures required in the ED were intubation (n = 321, 18%), vasopressor support (n = 73, 4%) and cardiopulmonary resuscitation (n = 27, 1.4%). A quarter (23.2%) was discharged stable from the ED, whereas a further 56.5% were discharged stable after hospital admission. The in-hospital mortality rate was 3% (n = 47). Multivariate logistic regression analysis showed rodenticides (odds ratio (OR): 22.32; 95% confidence interval (CI): 8.05–61.88; P = 0.005) and plant poisons (OR: 23.92; 95% CI: 8.95–63.94; P = 0.005) to be the independent predictors of mortality.

Conclusion:

DSPH is prevalent in the highly productive young age group. Agrochemical ingestion and drug overdose are the most common methods used, whereas rodenticide and plant poisoning are associated with significant mortality.

Ten-year profile of acute poisoning patients presenting to an Accident and Emergency Department requiring intensive care in a regional hospital of Hong Kong

Background:

Hong Kong Poison Information Centre publishes annual reports on all poisoning cases received by the Centre in that year since 2006. However, there is little data about acute poisoning cases requiring intensive care unit admissions in Hong Kong.

Objective:

To report and analyze the 10-year poisoning data of acute poisoning patients presenting to an Accident and Emergency Department requiring intensive care in a regional hospital of Hong Kong.

Methods:

This was a retrospective study on patients presented from January 2007 to December 2016. These cases were retrieved from Clinical Data Analysis and Reporting System of the Hospital Authority, Hong Kong. Clinical data of these cases were then retrieved from patients’ electronic records.

Results:

A total of 270 cases were analyzed during the period. There were 152 (56.3%) male patients and 118 (43.7%) female patients. The middle aged group (age 30–39 and age 40–49) constitutes nearly half (48.6%) of all these admissions. Around 50% of them had history of psychiatric illness. Nearly 40% of them were known substance abusers. Majority of the patients (66.7%) were admitted directly from Accident and Emergency Department. The commonest cause was suspected self-harm (56.3%). When ethanol (13%) was excluded, the five commonest types of poisons were benzodiazepine (26.3%), opioids (20.7%), zopiclone (18.5%), carbon monoxide poisoning (13%), and household products (10.7%). Twenty-seven patients (10%) had decontamination done in Accident and Emergency Department or Emergency Medicine Ward. 112 patients (41.5%) were given one or more antidotes in Accident and Emergency Department and Emergency Medicine Ward. Altered mental status was the most frequently found complications (72.2%) in these patients. 76 patients (28.1%) required endotracheal intubation in Accident and Emergency Department. The length of stay in Intensive Care Unit ranged from 1 to 7 days with an average of 2.1 days. There were 25 deaths (9.3%) and 31 patients with major effects (11.5%).

Conclusion:

An estimate of 9.4% of acute poisoning patients presenting to Accident and Emergency Department might need Intensive Care Unit care at certain stage of their hospital stay. Benzodiazepine, opioids, zopiclone, carbon monoxide poisoning, and ethanol were the top five poisons in our series from 2007 to 2016. The mortality rate (9.3%) was high in our series given that there were more substance abusers.

The Impact of an Emergency Department Toxicology Team in the Management of Acute Intoxication

Objective

To evaluate the impact of the recently established Emergency Department (ED) Toxicology Team of Queen Mary Hospital (QMH) in the management of acute intoxication.

Method

A descriptive comparative study with retrospective data collection from all intoxicated and suspected intoxicated patients over two separate half-year periods in 2001 and 2006, before and after the establishment of the ED Toxicology Team in July 2005. Data on reasons of intoxication, drugs and substances involved, ED treatments, patient disposition, length of stay in ED, length of stay in hospital, patient outcome, and 30-day ED re-attendance and hospital re-admission were collected and examined.

Results

A total of 333 intoxicated patients were included in the study, 171 in 2001 and 162 in 2006. The basic epidemiological data were similar in both groups. There was a marked reduction in hospital admissions from 89.5% to 40.7% (P<0.01) and significant decline in average length of hospital stay from 46.8 hours to 29.2 hours (P<0.05). There was no statistically significant difference in patient outcome, 30-day ED re-attendance and hospital re-admission.

Conclusion

Our findings showed that the establishment of the ED Toxicology Team in QMH achieved significant reductions in hospital admissions and the length of stay in hospital in the management of patients with acute intoxication without jeopardising patient outcome. The results illustrate that the new model has a beneficial role in reducing cost and alleviating stress on hospital bed availability, therefore it can be recognised as a cost-effective means of management of acute intoxication.

Hong Kong Poison Information Centre: Annual Report 2007

Objective

To report the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2007.

Methods

From 1st January 2007 to 31st December 2007, all poisoning cases received by HKPIC were retrieved from its database (DATOX) for analysis.

Results

2842 poisoned cases were analyzed. There were 1199 male and 1610 female patients and more than two-thirds of the cases were between 20 and 59 years old. Common causes of exposure were suicidal attempt, accident and abusive use. Non-benzodiazepine sedative-hypnotic, household products and paracetamol were common poisons exposed. The majority of the patients were managed conservatively, with 8.4% and 6.4% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; less than 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes.

Conclusions

This 2007 annual report provided updated epidemiological information on the poisoning pattern in Hong Kong and highlighted some changes in comparison to the situation in 2006.

Emergency Medicine Ward as a Step down Unit for Selected Poisoned Patients after Intensive Care Unit Management: A Pilot Study

Introduction

Starting from the 1st July 2009, poisoned patients who fulfilled the emergency medicine ward (EMW) admission criteria were transferred to the EMW for subsequent care after intensive care unit (ICU) management. This study was undertaken to review the impact of such a strategy on the length of stay (ALOS).

Study design

This was a retrospective study on consecutive poisoned patients discharged from the ICU from the 1st July 2009 to 31st December 2010. Poisoned patients from the 1st January 2008 to 30th June 2009, who were discharged to the general medical ward or to other specialty wards were used as historical controls for comparison.

Method

Medical records of eligible cases were reviewed and data were collected using a standardized data collection form. Disease severity during the ICU stay was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The median ALOS and APACHE II scores of the 2 groups were compared.

Results

A total of 32 poisoned patients were transferred from the ICU to EMW during the study period, in which 28 patients were included as the study group. For the historical control group, 19 patients were identified for comparison. The study group had a significantly shorter median length of stay in the ICU (21.3 h vs. 36.0 h, p=0.013) and a significantly shorter median ALOS (28.8 h vs. 52.5 h, p=0.002) compared to the historical control group. All patients discharged to the EMW survived with no ICU re-admission.

Conclusion

The strategy of using the EMW as a step-down unit for selected poisoning cases after ICU discharge is feasible, safe and effective.

The Impact of Emergency Medicine Ward in Acute Intoxication Management

Background

The Emergency Medicine Ward (EMW) was established in Caritas Medical Centre (CMC) in November 2007 under the management of emergency physicians. With the support from the psychiatric team and medical social workers, it provided effective management for intoxicated patients as an alternative to traditional inpatient service.

Objective

The aim of this study was to evaluate the impact of the EMW in the management of acute intoxication.

Method

A retrospective comparative study with data retrieved from all admitted intoxicated and suspected intoxicated patients was carried out over two separate half-year periods in 2007 and 2008, before and after the establishment of the EMW. Data on patient demographics, reason of exposure, substance involved, treatment, psychiatric service offered, clinical outcome, hospital length of stay (LOS) and 28-day hospital re-admission were compared.

Results

A total of 316 intoxicated patients were admitted to CMC with 165 in the 2007 group and 151 in the 2008 group. Both groups shared similar basic epidemiological data. There was a marked reduction in hospital LOS from 80.1 hours to 45.9 hours (p<0.01), a markedly increased proportion of patients receiving psychiatric service from 47.9% to 71.5% (p<0.01) and a significant decline in the access time of psychiatric assessment from 27.4 hours to 10.6 hours (p<0.05). There were no statistically significant difference in treatment, patient clinical outcome and 28-day hospital re-admission.

Conclusions

The establishment of EMW achieved a significant reduction in hospital LOS of intoxicated patients without jeopardizing patient outcome. The results also illustrate that EMW can provide a good platform for the integration of psychiatric service for these patients.

Cost Benefits of the Drug and Poison Information Centre in Preventing Unnecessary Hospitalisation: The Singapore Experience

Background

The Drug and Poison Information Centre (DPIC) in Singapore was piloted as a new service in April 2004. This study evaluated the cost benefits of its interventions in the first two years of its operation.

Method

A two-year retrospective review of DPIC call records was performed and the following outcome measures were noted: (A) proportion of patients who were managed onsite and hence did not need to attend the emergency department (ED); and (B) proportion of patients who were managed in the ED without the need for admission. Cost savings were calculated based on admission costs for patients with poisoning, including other out-of-hospital costs. This amounted to savings of S$1390 and S$1170 for patients who fulfilled outcome measures A and B respectively. Savings for the hospital was S$1477 per case. The cost of operating the DPIC over the same period was S$507,922.

Results

There were 831 calls on acute toxic exposures over the study period. Of these, 115 and 405 patients fulfilled outcome measure A and B respectively with consequent cost savings of S$159,850 (115 x S$1390 per patient), and S$473,850 (405 x S$1170 per patient). The hospitals saved S$768,040 (520 x S$1477) from prevented admissions. Excluding operating cost, this gave net savings of S$893,818 over the two years from DPIC interventions.

Conclusion

The cost savings from DPIC services is evident from this study. This translates to more effective use of limited healthcare resources.

Should N-Acetylcysteine be Administered Orally or Intravenously for the Treatment of Paracetamol Overdose?

Introduction

Paracetamol is the most commonly used drug in deliberate poisoning. N-acetylcysteine is the standard antidote for significant acute paracetamol overdose, but the route of administration varies between countries. This review aimed to find and appraise those comparative studies which would help answer the following question: in patients who have taken an overdose of paracetamol requiring antidote, is there any difference between intravenous and oral N-acetylcysteine in mortality, hepatotoxicity, adverse drug reactions or cost?

Methods

A literature search was conducted using Medline and other databases. Relevant papers were identified and appraised.

Results

One animal study and seven comparative clinical studies were identified and appraised. The quality of the evidence was generally poor, and there was no clear difference in outcomes between the two routes of administration.

Conclusions

Without evidence of advantage for one route over the other, routine practice should not be changed. However, after 30 years experience, both routes appear to be effective and safe, and in countries where intravenous administration is the standard, it would be reasonable to consider the oral route as an alternative when intravenous access is problematic. There is a need for prospective, randomised trials to determine the relative effectiveness, safety and cost of intravenous and oral formulations of N-acetylcysteine.

Pattern of acute poisoning at two urban referral hospitals in Lusaka, Zambia

BACKGROUND

Poisoning remains an important public health problem contributing significantly to the global burden of disease. Evidence on the exact burden and pattern of acute poisoning in Zambia is limited. We aimed to characterise acute poisoning with regard to demographic and epidemiologic factors of cases reported at the University Teaching Hospital and Levy Mwanawasa General Hospital; two large referral hospitals in Lusaka, Zambia.

METHODS

This was a cross-sectional study involving retrospective collection of data on all poisoning cases recorded in hospital records from 1 January to 31 December 2012. A pretested data collection form was used to extract demographic and other data such as poisonous agents used, circumstance of poisoning, route and outcome of poisoning. All analyses were performed in STATA (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP).

RESULTS

A total of 873 poisoning cases were reviewed with almost similar proportions of males (52 %) and females (49 %). Poisoning cases were highest in the 0-12 years age category (36 %) followed by the 20-30 years age category (31 %). Accidental poisoning characterised most (65 %) cases in children aged < 13 years. The common route of exposure to poisonous agents was ingestion. Overall, the mortality rate was 2.6 per 100 cases, the majority of deaths were observed in men (78 %). Poisonous agents associated with most cases were pesticides (57 %) and pharmaceuticals (13 %).

CONCLUSIONS

The high risk of accidental poisoning observed in children calls for special health education on chemical safety, tailored for mothers and caregivers to prevent chemical exposure in this important age group whose access to toxic agents is mainly in homes or their immediate environment. The results also call for additional regulatory controls on pesticides and pharmaceuticals, which were the most common toxic agents.

Changing epidemiologic patterns of deliberate self poisoning in a rural district of Sri Lanka

Background

Acute poisoning is a major public health issue in many parts of the world. The epidemiology and the mortality rate is higher in low and middle income countries, including Sri Lanka. The aim of this study was to provide details about the epidemiology of acute poisoning in a rural Sri Lankan district and to identify the changing patterns and epidemiology of poisoning.

Methods

A prospective study was conducted from September 2008 to January 2010 in all hospitals with inpatient facilities in Anuradhapura district of North Central Province of Sri Lanka. Acute poisoning data was extracted from patient charts. Selected data were compared to the data collected from a 2005 study in 28 hospitals.

Results

There were 3813 poisoned patients admitted to the hospitals in the Anuradhapura district over 17 months. The annual population incidence was 447 poisoning cases per 100,000 population. The total number of male and female patients was approximately similar, but the age distribution differed by gender. There was a very high incidence of poisoning in females aged 15–19, with an estimated cumulative incidence of 6% over these five years. Although, pesticides are still the most common type of poison, medicinal drug poisonings are now 21% of the total and have increased 1.6 fold since 2005.

Conclusions

Acute poisoning remains a major public health problem in rural Sri Lanka and pesticide poisoning remains the most important poison. However, cases of medicinal drug poisoning have recently dramatically increased. Youth in these rural communities remain very vulnerable to acute poisoning and the problem is so common that school-based primary prevention programs may be worthwhile.

Lalith Senarathna, Shaluka F Jayamanna, Patrick J Kelly, Nick A Buckley,michael J Dibley, Andrew H Dawson. These authors contributed equally to this work.

Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China

In order to obtain up-to-date information on the pattern of severe acute poisoning and the characteristics and outcomes of these patients, 265 consecutive patients admitted to an intensive care unit in Hong Kong for acute poisoning from January 2000 to May 2008 were studied retrospectively. Benzodiazepine (25.3%), alcohol (23%), tricyclic antidepressant (17.4%), and carbon monoxide (15.1%) were the four commonest poisons encountered. Impaired consciousness was common and intubation was required in 67.9% of admissions, with a median duration of mechanical ventilation of less than 1 day. The overall mortality was 3.0%. Among the 257 survivors, the median lengths of stay in the intensive care unit and acute hospital (excluding days spent in psychiatric ward and convalescent hospital) were less than 1 day and 3 days, respectively. Factors associated with a longer length of stay included age of 65 or older, presence of comorbidity, Acute Physiology and Chronic Health Evaluation II score of 25 or greater, and development of shock, rhabdomyolysis, and aspiration pneumonia, while alcohol intoxication was associated with a shorter stay. This is the largest study of its kind in the Chinese population and provided information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of the patients concerned.