Asia Pacific Journal of Medical Toxicology
Volume:2 Issue: 3, Summer 2013

Poison Control Centre of Morocco (MPCC) plays a key role in promoting health. This study was aimed to demonstrate the role of the MPCC in improving public health and poisoning management. This was a retrospective study of poisoning cases reported to the MPCC between 1980 and 2011. The collected data included number of poisoning cases, profession of interlocutor who called the poison centre, time of poisoning (year), gender of poisoned patient, age of poisoned patient, toxic agent and intention of poisoning. Data were analyzed using Epi Info software. The activities of MPCC were evaluated by three indicators including structural indicators, process indicators and impact indicators Between 1980 and 2011, the MPCC received 401148 notifications which 73.1% of them involved scorpion stings and 26.9% were about other toxic agents. The main causes of poisoning, excluding scorpion stings, were pharmaceuticals (6.1%) followed by food (5.9%) and carbon monoxide (4.5%) poisoning. The MPCC devised five protocols through a consensual method and distributed to practitioners in hospitals around the country considering gastric emptying, management of PPD poisoning, management of scorpion stings, management of carbon monoxide poisoning and the management of snakebite. Gastric emptying decreased from 45% to 4% of cases during this period. A national strategy was set up for the management of scorpion stings leading to a decrease in mortality from 1.54% to 0.22%. During the period of more than two decades, the achievements of the MPCC have not been limited to providing toxicological information, but also activating a proper toxicovigilance system. In fact, a poison control centre is not a luxury structure. It is an integral part of every health system. Its impact on reducing morbidity and mortality is no longer discussed and its observatory role on poisonings should be strengthened.

Epidemic dropsy occurs due to ingestion of mustard oil contaminated with oil from Argemone mexicana, leading to edema and tenderness of the abdomen, upper and lower limbs. In this study, clinical profiles of patients presented with epidemic dropsy in north India are described. This was a prospective study of patients presented with epidemic dropsy to the emergency department of Nehru Hospital, during the period from March 2004 to December 2011. Inclusion criteria were patients presenting with tender bilateral pitting leg edema and dermal telangiectasia. Clinical and laboratory data of patients were entered into case record forms at the time of presentation until discharge from the hospital. Leg edema was the principal symptom in our series, and was in concurrence with current literature. Erythema has only been reported in 35-82% of published series, though it was present in all of our patients. Similarly, features such as diarrhea, hepatomegaly and anemia were more frequent in our cases compared to the literature. Furthermore, pancytopenia which was documented on peripheral blood counts in 54% of our cases has never been reported before. Epidemic dropsy should be considered in patients presenting with progressive erythema, edema, and tenderness of the limbs who had a history of consumption of mustard oil and confirmation of Argemone oil contamination according to laboratory tests.

Suicide is one of the leading factors of death worldwide. Hanging is one of the most common methods of suicide. This study was designed to evaluate post mortem toxicology laboratory findings of subjects with hanging death in northeast Iran. This study was carried out on reported cases with hanging death to Razavi Khorasan Province-General Office of Iranian Legal Medicine Organization during 2009 to 2011. In this study, toxicologic investigations were performed on urine samples using thin layer chromatography and gas chromatography mass spectrometry techniques. For cases which required confirmation, another sample was also obtained from blood or the vitreous. Autopsy and scene investigation findings were also studied and entered into a predesigned checklist. In total, 94 men (90.4%) and 10 women (9.6%) were studied. Suicide was proven in one hundred and one (97%) corpses and according to primary scene investigations and autopsy findings three (3%) cases were highly suspicious of non-suicidal events which eventually were clarified with the help of toxicology tests. No drug metabolites, substance or ethanol were noticed in 68 (65%) cases. Among 36 cases with discovered substances, morphine was the most common substance which was found in 27 (75%) cases. Ethanol and codeine came next and were reported in 9 (25%) and 8 (22%) cases, respectively. After plotting discovered substances against age groups, it was found that the presence of ethanol was significantly higher in younger individuals (P = 0.04). Although the nature of hanging death can be clarified by scene investigations, performing postmortem toxicology tests are also crucial to specify suicidal, homicidal or accidental background. In this study morphine was the main substance found in suicidal hanging cases. Hence, the abuse of opioids can be considered as one of the major risk factors of committing suicidal hanging in Iran.

Green pit viper bite is an important cause of morbidity in Bangladesh. The objective of this study was to investigate the characteristics and clinical presentations of green pit viper bite in Bangladesh. This prospective observational study was done in the department of Medicine in Chittagong Medical College Hospital, Bangladesh. A total of 40 patients with history of green pit viper bite presented with local swelling and hematological abnormality were enrolled. Clinical and demographic features of patients were entered into a checklist. A careful assessment of grading of swelling and a 20 minute whole blood clotting test was done for every patient. Patients’ age ranged from 10 to 65 years with majority in 11 to 40 years group. Most bites occurred during daytime while the patients were busy in plantation, gardening and cultivation. Most of the patients received one or more harmful traditional treatments such as multiple tight ligatures (90%). The most common clinical manifestation was local swelling found in 100% of patients followed by incoagulable blood (65%), lymphadenitis (62.5%) and fang marks (60%). All patients received supportive treatments and were rehabilitated. Widely practiced traditional treatments must be discouraged and community education for the people should be arranged for first aid treatments and quick transfer to the nearest hospital. Young and working people should take precautions during agricultural activities. The national guideline for management of snakebite should be encouraged to practice everywhere in Bangladesh.

Poisoning with non-barbiturate anti-epileptics (carbamazepine, sodium valproate and phenytoin) shows a growing trend. The objective of this study was to investigate clinical manifestations of poisoned patients with these medications. This prospective study was conducted in the Shiraz Shoushtari Hospital during a two-year period from 2010 to 2012. Poisoning was confirmed according to patient’s history and clinical examinations. Patients who consumed other anti-epileptics and those who consumed other medications (except anti-epileptics) were excluded from the study. Using the AVPU scale, level of consciousness was graded. Clinical manifestations and demographic features of patients were entered into a predesigned checklist. In total, 200 patients were studied, of which 36% were men. The mean (SD) age of patients was 26.2 (11.7). The most common overdosed medication was sodium valproate, followed by carbamazepine and phenytoin. Decreased consciousness was seen in 34.5% of patients. Sixty-three patients (31.5%) had metabolic acidosis, 15 patients (7.5%) had respiratory alkalosis and 4 patients (2%) had mixed acid-base disorders. Hypercalcemia was the most common electrolyte disorder (49%). Eighty-four patients (42%) had developed seizure. The highest proportion of seizure occurred in patients with multiple drug overdose (100%) followed by phenytoin overdose (60%), carbamazepine overdose (42%) and sodium valproate overdose (33%). This is the first study that shows high rates of seizure in patients poisoned with antiepileptic medications. Due to the growing trend of poisoning with these medications, it is necessary to take appropriate preventive measures include restriction on sale of these medications in pharmacies, psychiatric counseling for the patients and medication safety training to the patients.

The effective therapeutic dose of pralidoxime methylsulphate for organophosphate (OP) poisoning is necessary to be clarified. This study was designed to comparatively assess the blood level of pralidoxime (BPL) and clinical outcomes in OP poisoned patients treated with intermittent dosing and patients treated with continuous infusion. This was a prospective, open labelled, cross-sectional, nonrandomized observational study which was done from 2009 to 2012 in a tertiary care hospital in Manipal, India. A high-performance liquid chromatography (HPLC) method with prominence diode array (PDA) detector was developed to measure BPL. Patients were categorized into study and control groups. Patients in study group were divided into 3 subgroups as they were treated with (a) intermittent pralidoxime dosing (1 g/q8h) or (b) continuous pralidoxime infusion (500 mg/h) or (c) continuous pralidoxime infusion (1 g/h). Patients who were not treated with pralidoxime were considered as the control group. The level of acetylcholinesterase (AChE) was measured before and pralidoxime therapy. The developed HPLC method was linear over the range of 0.5-50 µg/mL and the correlation coefficient was found to be greater than 0.99. The median (IQR) of BPL in intermittent dosing (4.63 (5.26)) was comparatively lower than patients treated with continuous infusion. The highest BPL was maintained in 1 g/h group with median (IQR) serum level of 38.86 (16.75). The reactivation rate of AChE was higher in continuous infusion groups compared to intermittent dosing. Comparison of AChE before and after pralidoxime therapy showed that higher BPL was associated with greater reactivation of AChE. HPLC can be used as alternative method for measurement of pralidoxime level in blood. Continuous infusion of pralidoxime maintained a steady higher blood concentration compared to intermittent dosing with vast fluctuations. The reactivation rate of AChE was higher in continuous infusion compared to intermittent dosing. Hence, continuous infusion of pralidoxime can more rapidly recover the OP poisoned patients with less morbidity.

Aluminum phosphide (AlP) poisoning is one of the most life threatening emergencies. In this study, demographic characteristics, clinical profiles and outcomes of a series of patients presented with AlP poisoning in north Iran are described. The study was a retrospective descriptive medical chart review of AlP poisoned patients who were admitted to internal ward of Imam Khomeini hospital, Sari, Iran, from July 1st 2011 to July 1st 2012. Collected data included gender, age, intention of poisoning, amount of AlP ingested, clinical manifestations at admission, therapeutic interventions, laboratory tests and outcome. During the one-year period, 8 patients which were all men with mean (SD) age of 40.5 (22.5) years were admitted with AlP (rice tablet) poisoning. The most common signs and symptoms at admission were nausea and vomiting (100%), metabolic acidosis (100%) and hemodynamic instability (87.5%). All cases were poisoned as a result of suicidal attempt leading to 5 (62.5.6%) deaths. Compared with the patients who survived, those who died had taken higher doses of AlP, developed hepatic dysfunction in higher rates and had severer metabolic acidosis. All patients were admitted to intensive care unit and received gastric washing with sodium bicarbonate, followed by activated charcoal therapy and intravenous calcium gluconate for decontamination purposes. The median (IQR) of length of hospital stay was 2 (1-4) days. AlP is a low-cost highly-toxic rodenticide. It is easily available and used as a toxic compound for suicide in the Asia region. There has been no effective antidote available for treatment of AlP poisoned patients; thus, symptomatic management should be taken into consideration as soon as possible.

High-Dose Insulin Euglycemic Therapy (HIET) and Lipid Rescue Therapy (LRT) are new alternative treatments for acute poisoning with calcium channel blockers. In this report a severely poisoned patient with verapamil and furosemide who was successfully treated with these two treatments is presented. Case report: A 27-year-old woman was brought to “Mother Theresa” Clinical Center in Skopje with a history of consumption of 24 grams (100 pills) sustained-release verapamil and 4 grams (10 pills) furosemide. She was alert and oriented with 60/35 mmHg blood pressure (BP), her respiratory rate was 25 breaths/min and heart rate was 40 beats/min with first degree atrioventricular (AV) block on electrocardiogram (ECG). In the first 90 minutes, she received activated charcoal, 1 liter of 0.9% saline, 60 mL of calcium chloride (CaCl2), 40 mg potassium and subsequently dopamine and 100 mg noradrenaline. However, there was no significant improvement in her hemodynamic status (BP = 70/50 mmHg) and she developed second degree AV block. Temporary pace maker was implanted. In the next one hour, the patient had stable vital signs, when she again became hypotensive (BP = 60/35 mmHg) with prolonged QRS complex (20 msec). During this period she was treated with epinephrine (9mg), atropine (2mg), isoprenalin, bicarbonate, CaCl2 and intravenous fluid. Unsuccessful conventional treatments indicated administration of HIET and LRT. Three hours later, the BP was normalized (110/75mm) and 36 hours later, all ECG disturbances disappeared. She left the Clinic without any sequels, four days later. LRT in addition to HIET are effective treatments for CCB overdose. LRT can be considered as a standard treatment for CCB overdose. Nevertheless, further investigations are necessary to establish the real value of these treatments.