|Year : 2018 | Volume
| Issue : 2 | Page : 19-23
Analysis of emergency laboratory parameters of various poisonings in tertiary care teaching hospital
Raghu Kondle1, D Madhusudana2, P Shreevani3, G Vishwa Reddy4
1 Department of Emergency and Critical Care Medicine, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
2 Department of General Medicine, ACSR Government Medical College, Nellore, Andhra Pradesh, India
3 Department of Anaesthesia, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
4 Department of Emergency Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||21-Nov-2018|
Department of Emergency and Critical Care Medicine, Narayana Medical College and Hospital, Chintareddypalem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aim: India is predominantly an agricultural country; pesticides and insecticides are abundantly used during cultivation. The adult mortality rate due to mixed drug poisoning in rural south India is 0.97/1000 persons/year. Only 70%–80% of patients admitted to hospitals survive. The present study is undertaken to identifying the association of laboratory parameters with different poisoning etiologies which may help in predicting the need for ventilator support to reduce the mortality by timely entry into emergency department (ED). Materials and Methods: A prospective study on the mixed poisoning of 964 cases was done in the ED at Narayana Medical College Hospital, Nellore, Andhra Pradesh, for 8 years (from 2009 to Jan 2016). Clinical and laboratory data were recorded for all patients on admission (time 0) and 24 h later (time 24). The severity of patients graded according to the Glasgow Coma Scale (GCS) classification. Results: Among 964 patients, in the present study, the majority of the patients in the study group were males, and higher age group affected was 40–50 years. Agricultural farmers and rural residents were highly consumed pesticides. In the study, ingestion poisoning 95% had common occurrences than inhalation poisoning 5%. In severity categorization, we observed that 28.4% of patients were in mild condition, 55.6% in moderate, and 16% in severe. Mean, GCS scoring system was statistically significant between time 0 and time 24 in the survivors. Low GCS at admission was vulnerable for ventilator support. Cholinesterase activity was measured significantly depressed in the Grade 1, 2, and 3. Conclusions: The present study concludes that the need for ventilatory support in organophosphoros poisoning was significantly more in patients who consumed chlorpyrifos methyl parathion compounds, airway edema secondary to hair dye poisoning, presence of cholinergic crisis, GCS score of <6, and cardiovascular collapse secondary to aluminum poisoning.
Keywords: Acute physiology and chronic health evaluation score, cholinesterase, hair dye, organophosphorus, suicide
|How to cite this article:|
Kondle R, Madhusudana D, Shreevani P, Reddy G V. Analysis of emergency laboratory parameters of various poisonings in tertiary care teaching hospital. Saudi Crit Care J 2018;2:19-23
|How to cite this URL:|
Kondle R, Madhusudana D, Shreevani P, Reddy G V. Analysis of emergency laboratory parameters of various poisonings in tertiary care teaching hospital. Saudi Crit Care J [serial online] 2018 [cited 2018 Dec 10];2:19-23. Available from: http://www.sccj-sa.org/text.asp?2018/2/2/19/245942
| Introduction|| |
The World Health Organization (WHO) reports estimate poisoning as one of the most common causes of increased morbidity and mortality rate worldwide. Various agents such as pesticides and drugs have been used for intentional and accidental poisoning in different countries. The widespread use of organophosphorus compounds, hair dye, herbicides, and pharmaceutical compounds has increased incidence of its poisoning to the human kind by accidental or suicidal. In suicide, poisoning and hanging are the most common methods throughout the worldwide. Millions of people die each year due to poisoning. In the Indian scenario, pesticides are the most commonly used poisoning agents. Worldwide various agents such as agrochemicals, drugs, and environmental agents are used as poisoning agents.
Exposure to agrochemicals, medicines, and environmental agents is the major causes of poisoning. Distress due to loss in the business, failure in love or differences with the intimate partner, or failure to clear examination, emotional disturbances, and chronic diseases is the common reasons for intentional poisoning. Household products induced poisoning was seen more in children of age <5 years. A cross-sectional study was conducted among 542 randomly selected school-going adolescents (13–18 years), study provided information regarding the magnitude of the problem of depression and many modifiable risk factors for depression among school-going adolescents. 0.3 million people worldwide die every year due to various poisoning agents. High doses of analgesics, tranquilizers, and antidepressants are the commonly used agents for intentional poisoning in industrialized countries, and agricultural pesticides are used in the Asian region for suicide in the rural areas with a fatality range of 10%–20%., India is based major profession in the rural part farmers will stock the pesticides for weeds and pests. Due to the easy availability of the pesticides, they are commonly used by the individuals for suicide.
Oral ingestion of paraphenylenediamine (PPD) main toxic component of permanent hair dye causes severe angioedema of the upper airway accompanied by a swollen, dry, hard, and protruding tongue and requires emergency airway management. PPD intoxication also results in multisystem involvement causing rhabdomyolysis and acute kidney injury, flaccid paralysis, severe gastrointestinal manifestations, cardiotoxicity, and arrhythmias. Propylene glycol and resorcinol are other potentially nephrotoxic agents of hair dye poisoning.
The objective of this retrospective study was to study the risk factors, laboratory parameters, and their correlation with the outcome of the patients with organophosphate (OP) intoxication attempted to commit suicide.
| Materials and Methods|| |
This study was conducted from May 2009 to May 2016 in Narayana Hospital, a superspecialty teaching institution belonging to the rural area at Nellore in the State of Andhra Pradesh, in southern India. Retrospective studies of 964 poisoning cases were recorded during the period at Emergency Department, Narayana Medical College Hospital, Nellore, Andhra Pradesh. The data were collected in relation to demographic details (age, sex, marital, and socioeconomic status) volume consumed; time to reach the hospital, clinical features, and laboratory findings. A Performa was prepared to study the various investigational parameters of liver function test and renal function test and electrolytes. A detailed history had been taken from the patient attender or patient's family member. Tracheotomy was done for severe cervicofacial edema when definitive airway securing was difficult. Demographic, clinical, radiological, and laboratory data were reviewed wherever necessary during intensive care unit (ICU) stay.
Investigations include serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), blood urea, serum creatinine, serum electrolytes, and cholinesterase. Patients who intended to commit suicide with OP agents are graded according to clinical findings in relation to Bardin classification. In addition to general supportive measures (i.e., decontamination of the whole body, gastric lavage, administration of cathartics, and activated charcoal), a standard therapy method with atropine and pralidoxime was administered to the patients. All the patients were stabilized in the emergency room and shifted to ICU for further management; during their hospital stay, clinical outcome was also noted.
The initial emergency laboratory parameters, serum cholinesterase (SChE, method with S-butyrylthiocholine iodide. Cholinesterase catalyzes the hydrolysis of S-butyrylthiocholine iodide to thiocholine iodide and butyrate. Thiocholine iodide reacts with 5,5'-dithiobis-2-nitrobenzoate and forms the yellow-colored product 5-mercapto-2-nitrobenzoate. The rate of formation of this product is directly proportional to the catalytic cholinesterase activity. It is determined by measuring the increase in absorbance at 480 nm. Mean values were level 1 – 1728 U/L and Level 2 – 9545 U/L, CV within run: 1.0% (Level 1) and 0.99% (Level 2), and CV between run: 2.2% (Level 1) and 1.8% (Level 2). Analytical sensitivity: 4.5 U/L, creatinine, urea, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels were determined by autoanalyzer.
Data were represented as mean ± standard deviation (SD). Chi-square test or Fisher's exact test was used for comparison of proportions. For continuous variables, mean, median, and SD were calculated and compared by Student's t-test or nonparametric tests.
| Results|| |
Among 964 patients, 58% were male and 42% were female. Mean age of the studied patients was 32 ± 12.4 years. In total 964 cases, 96 cases were seen in <20 age group, 217 cases seen in 20–30 age group, 241 cases seen in 30–40 age group, 271 cases seen in 40–50 age group, and 139 cases were seen in ≥50 age group. 559 (58%) were male and 404 (42%) were female were recorded [Table 1].
In our study, poisoning by ingestion route had is maximum 95% than inhalation route 5%. Of 964 cases, chemical poisoning observed in 6%, hair dye poisoning observed in 22.5%, pesticide poisoning observed in 30%, insecticide poisoning observed in 3.3%, tablet overdose observed in 3.2%, and rodenticide poisoning observed in 3.1%. Of 537 cases, suicidal cases registered were 76% and accidental cases registered were 24% [Table 2].
Poisoning with suicidal intention was observed to be the major cause 80%, while other reasons attributed were occupational 9%, accidental 7%, homicidal 2%, and unknown 3% reasons.
Liver function test
In organophosphorous poisoning, SGOT observed to be increased in 70% of cases and alkaline phosphatase (ALP) levels observed as high in 52% of cases. In total cases who consumed hair dye, SGOT observed increased in 70% of cases and SGPT was raised in 40% of cases, ALP levels were raised in 40% of cases.
Cholinesterase activity was measured significantly depressed in the Grade 1, 2, and 3. In organophosphorus poisoning, the mean ± SD of cholinesterase (U/L) levels 3695.65 ± 2025.21 observed in 61%, whereas 795.5 ± 396.52 observed in 39% [Table 3].
Renal function test
In organophosphorus poisoning cases, serum creatinine levels observed normal in 85% of cases, blood urea in 90% of cases, and uric acid in 80% of cases, whereas in hair dye ingestion cases, serum creatinine levels were normal in 60% and normal blood urea in 40%.
International normalized ratio/activated partial thromboplastin time levels
In organophosphorus poisoning cases, international normalized ratio levels were normal in 68% of cases, and activated partial thromboplastin time (APTT) levels were within the normal range in 80%. In hair dye poisoning cases, PT levels were normal in 60% of cases, and APTT levels were within the normal in 60% of cases.
Glasgow Coma Scale scoring
Low Glasgow Coma Scale (GCS) at admission was vulnerable for ventilator support. GCS scoring was performed in the 964 patients, 16%, 55.6%, and 16% were with mild, moderate, and severe score, respectively. 23, 210, and 110 cases kept under ventilation [Table 4].
|Table 4: Percentage of patients showing Glasgow Coma Scale score and ventilation support|
Click here to view
A total of 87% patients improved after treatment while 5% of the patients were discharged with severe morbidity, and mortality rate was 8%. Majority deaths are seen in organophosphorus compound poisons secondary to intermediate syndrome, pneumonia and septicemia and sudden cardiac arrest.
| Discussion|| |
The current study involved total 964 cases, in which highest number of patients belongs to age group 40–50 years and belonged to the rural areas. Whereas, other studies show various age groups such as 21–30 and middle age. A wide range of age groups of both genders was found exposed and victims to poisoning, with male predominance. A similar trend was reported by studies conducted in all regions of India and countries such as Sri Lanka and Uganda. This trend may be due to increased occupational hazard and exposure of men to stress as they are the only earning members of a large family.
Most commonly used route for poisoning exposure was oral followed by inhalation and dermal exposure. In our study, it was found that the substances most commonly used for self-poisoning were agricultural pesticides followed by hair dye poison. Previous studies have also shown that pesticide is the most common toxic agent involved in poisoning.,
Animal bites and stings were the most common cause of accidental poisoning which was contrary to findings of the studies conducted in South India where most accidental poisoning was due to household poisons. This may be due to the difference in geography and occupation. In our study, snake bite poisoning observed in 16% of total poisoning cases.
The symptomatology of organophosphorus insecticides is that they irreversibly inhibit both cholinesterase and pseudocholinesterase activity. Subsequent accumulation of acetylcholine at synapse causes an initial overstimulation followed by exhaustion and disruption of neurotransmission in both central and peripheral nervous systems. In our study, cholinesterase levels observed as 3695.65 ± 2025.21 U/L. SChE levels were estimated only at the time of admission. Daily estimation of PCE levels would have been more informative in foretelling the prognosis or severity of poisoning and to monitor the effectiveness of either therapy. The study was not randomized rather a case control; this too limits our findings.
In our study, there was a normal observation in liver function and blood clotting parameters in more number of poisoning cases. Whereas, Patel et al. study in workers engaged in OP insecticide production, and Hernández et al. in the year 2006 study in 106 agriculture workers showed that there were changes in liver functional markers and other biochemical parameters, such as markers of nephrotoxicity (urea and creatinine). Their results revealed an association of pesticide exposure with changes in AST (increased activity) and amino oxidase (decreased activity) as well as with changes in serum creatinine and phosphorus (lower and higher levels, respectively). These results provide support for a very slight impairment of the liver function, but overall, these findings are consistent with no clinically significant hepatotoxicity.,
In our study, cases that required ventilatory support were cholinergic crisis secondary to organophosphorus poisoning, airway edema secondary to hair dye poisoning, and clinically evaluated and were intubated and put on ventilatory support accordingly. In the present study, fasciculations were present in maximum number of patients, followed by cholinergic crisis, intermediate syndrome. Our observations are in agreement with earlier studies by Tripathi. GCS scoring was performed in all 964 patients; showed significant association between GCS score and need for ventilatory support. In our study, patients with moderate score were maximum in number. The present study concludes that the need for ventilatory support in organophosphorus poisoning was significantly more, presence of cardiovascular collapse, and low level of sensorium at the time of admission (i.e., GCS score of <6).
| Conclusions|| |
Incidences of intentional poisoning are rising day by day due to social, emotional, and professional stress. Most commonly used agents for intentional poisoning are pesticides, hair dye, tablet overdose, and according to availability to the people. The findings of the study conclude that intentional poisoning was more in male adults and in female adolescent group. The mortality and morbidity due to poisoning can be reduced by conducting educational programs in the rural areas and providing counseling services and poison information services to the needy people. Awareness and education among the population about safety from hazardous chemicals at household and occupational level are a strong indication to prevent accidental poisoning. Maximum cases reported with time lag of 1–3 h suggest the need for awareness about first aid in emergency situation at primary health-care level. Burden of poisoning and animal bite cases brought to emergency room demands strategies for identification and rational management providing optimal outcomes. Cases referred from other hospitals lacked detailed patient history.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hempstead K. Manner of death and circumstances in fatal poisonings: Evidence from New Jersey. Inj Prev 2006;12 Suppl 2:ii44-8.
Chowdhary AN, Banerjee S, Brahma A, Biswas MK. Pesticide poisoning in nonfatal, deliberate self-harm: A public health issue. Indian J Psychiatry 2007;49:117-20.
] [Full text]
Singh MM, Gupta M, Grover S. Prevalence & factors associated with depression among schoolgoing adolescents in Chandigarh, North India. Indian J Med Res 2017;146:205-15.
] [Full text]
Thundiyil JG, Stober J, Besbelli N, Pronczuk J. Acute pesticide poisoning: A proposed classification tool. Bull World Health Organ 2008;86:205-9.
McClure GM. Suicide in children and adolescents in England and wales 1970-1998. Br J Psychiatry 2001;178:469-74.
Marecek J. Culture, gender, and suicidal behavior in Sri Lanka. Suicide Life Threat Behav 1998;28:69-81.
Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, et al.
Suicides in young people in rural Southern India. Lancet 2004;363:1117-8.
Abdelraheema M, Hamdoukb M, Zijlstra EE. Paraphenylenediamine (Hair Dye) poisoning in children. Arab J Nephrol Transplant 2010;3:39-43.
Asawari R, Atmaram P, Bhagwan K, Priti D, Kavya S, Jabeen GA. Toxicological pattern of poisoning in urban hospitals of Western India. J Young Pharm 2017;9:315-20.
Banerjee I, Tripathi SK, Roy AS, Sengupta P. Pesticide use pattern among farmers in a rural district of West Bengal, India. J Nat Sci Biol Med 2014;5:313-6.
Jesslin J, Adepu R, Churi S. Assessment of prevalence and mortality incidences due to poisoning in a South Indian tertiary care teaching hospital. Indian J Pharm Sci 2010;72:587-91.
] [Full text]
Shakuntala YG. Analysis of organophosphorus poisoning, at tertiary care hospital: A report. J Evid Based Med Healthc 2015;2:421-30.
Patel AB, Shivgotra VK, Bhatnagar VK. Biochemical indices in workers engaged in production and formulation of organophosphate insecticides. Internet J Toxicol 2008;5:1-4.
Hernández AF, Amparo Gómez M, Pérez V, García-Lario JV, Pena G, Gil F, et al.
Influence of exposure to pesticides on serum components and enzyme activities of cytotoxicity among intensive agriculture farmers. Environ Res 2006;102:70-6.
Tripathi S. Prognostic value of Glasgow coma scale, poisoning severity score and serum acetylcholinesterase levels in organophosphorus poisoning. J Evol Med Dent Sci 2014;3:3415-22.
[Table 1], [Table 2], [Table 3], [Table 4]