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

In the aftermath of the Great East Japan Earthquake, most of the areas in Yamagata prefecture experienced a serious power failure lasting for approximately 24 hours. A number of households were subsequently poisoned with carbon monoxide (CO) due to various causes. In this study, we conducted a survey of CO poisoning during the disaster. A questionnaire regarding CO poisoning associated with the disaster was sent to 37 emergency hospitals in Yamagata prefecture. A total of 51 patients were treated for unintentional CO poisoning in 7 hospitals (hyperbaric oxygen chambers were present in 3 of the hospitals). The patients (18 men, 33 women) ranged in age from 0 to 90 years. The source of CO exposure was charcoal briquettes (23 cases; 45%), gasoline-powered electric generators (18 cases; 35%), electric generators together with oil stoves (8 cases; 16%), oil stoves (1 cases; 2%), and automobile exhaust (1 cases; 2%). Blood carboxyhemoglobin levels ranged from 0.5% to 41.6% in 49 cases. Of these, 41 patients were treated by normobaric oxygen therapy, while one was intubated for artificial respiration. Additionally, 5 patients (10%) were treated by hyperbaric oxygen therapy, and 3 patients (6%) experienced delayed neuropsychiatric sequelae. CO sources included gasoline-powered electric generators and charcoal briquettes during the disaster. Storm-related CO poisoning is well recognized as a disaster-associated accident in the United States, but not in Japan. We emphasize that public education is needed to make people aware of the dangers of CO poisoning after a disaster. In addition, a pulse CO-oximeter should be set up in hospitals.

Initiating a National Poisoning Information Centre (PIC) in Estonia took about 12 years of challenging work on research, training and attracting governmental support and funding. In this study we described the establishment process and the profile of phone calls in the first year which the PIC started to be available full time (24h/day 7days/week). This was a descriptive retrospective study. Relevant documents from 2000-2012 were reviewed. The documents were categorized into 5 main issues against establishment of PIC. Data of all inquiries related to toxic agent exposures regarding patient’s demographic, intention of poisoning and type of toxic substances in 2012 were collected. The data were reported with frequency and percentage. During establishment process, 386 documents including governmental regulations and contracts, memorandums from meetings, professional e-mails, newspaper articles, interviews, annual reports and program sheets of other poison centres and conference presentations were collected. Funding was provided form PHARE and BTox projects (2000-2003), and government of Estonia (2004-2012). Educational programs were held to train specialists in clinical toxicology and poisoning information to direct the PIC. The active phase of establishment started in 2004; however, the services of PIC became available at the beginning of 2008. In 2012, total number of calls was 1118. 20% of calls were related to general questions about pharmaceuticals and non-toxic agents. 894 calls were related to acute poisoning cases. Most of them (87.9%) were due to accidental poisoning. The most common types of substances responsible for poisoning were pharmaceutical products (30.2%), household products (29.5%) and plant toxins (11.1%). To establish a stable PIC, it is crucial to have a wide range data backbone, clear support and direct funding from the government, assistance from collaborative PICs, active international/domestic collaboration and experienced committed specialists in clinical toxicology. A well-established PIC improves public health surveillance and reduces health-care costs. These effects should be investigated in future studies about the National PIC of Estonia.

Poisoning is one of the main causes of visits to emergency departments and hospitals in Iran. Drug and Poison Information Centers (DPIC) are reliable sources to guide poisoned patients and provide information about pharmaceutical agents. This study was designed to analyze recorded phone calls to Iran DPICs during 2011-2012. This was a retrospective study on phone calls to DPIC in Tehran between January 2011 and November 2012. Data including demographic features, type of poison (in case of poisoning) and intention of poisoning were collected by reviewing the reported phone calls to central division of Iran DPICs in Tehran. It was found that 98.5% of the phone calls were inquiries about pharmaceutical products and only 1.5% of them were associated with poisoning. 49% of poisonings reported from the DPICs in 2011was intentional, while this rate increased to 67% in 2012. Regarding toxic agents responsible for poisonings, pharmaceuticals were the most common consisting of 68.6% and 70.9% of cases in 2011 and 2012, respectively. Pharmaceutical products are the main causes of poisonings in Iran. Public education on safety and storage issues and also strict terms of sale should be implemented. In addition, the majority of poisonings occurred intentionally while the rate showed an increasing trend. Predisposing factors of this high rate should be studied.

Poisoning incidents, in both children and adolescents, are known to occur in New Zealand but little is known about the agents implicated. All the calls received over the ten years between 2000 and 2009, by the National Poison Centre in New Zealand, were retrospectively reviewed. Calls related to cases involving those less than 19 years were included. The data were analyzed according to age and gender of cases, the toxic agent implicated in the poisoning and the year of the incident. Most poisonings occurred in children less than five years of age (86%), with these being further concentrated in children aged one to two years (57%). The most frequently implicated agents were therapeutic agents (39%) and then household products (36%). In adolescents, an increase in drug misuse or abuse was seen from 12 years old – with those aged 13 and 18 years being most frequently exposed to agents with psychotropic properties. This study showed that accidental (and intentional) ingestion is still an issue for children and adolescents in New Zealand. Specific strategies are needed to be targeted to the 1) products implicated in a high number of poisonings and 2) to children at the different ages.

Sulfur mustard (SM) as a chemical warfare agent, increases permeability of bronchial vessels and damages airway epithelium. SM exposure causes debilitating respiratory complications. This study was designed to evaluate clinical respiratory manifestations, and to compare chest X ray (CXR) and high resolution computed tomography (HRCT) scan of chest in SM exposed patients with respiratory complaints. All patients with history of SM exposure who visited Imam Reza Specialized Clinic of Respiratory Diseases from September 2001 to March 2011 were included. Patients with other comorbidities which affect respiratory system were excluded. CXR and chest HRCT scan were performed on the same day and were repeated after 5 years. Clinical and radiologic findings were collected and were compared with each other. In total, 62 male patients with mean age of 53 (6.9, 41-65) were studied. Dyspnea (61 cases; 100%), dry cough (40 cases; 66%), hemoptysis (21 cases; 35%) and productive cough (20 cases; 33%) were the most common respiratory manifestations. Pulmonary infiltration (51; 83%), pleural thickening (25; 40%) and emphysema (16; 26%) were the most common findings on CXR. According to HRCT scan, pulmonary infiltration (53; 85%), bronchiolitis obliterans (38; 61%) and pleural thickening (36; 58%) were the most common findings (Table 2). Repeated radiologic assessments after 5 years showed a few additional findings in HRCT scan, while in about one fifth of CXRs, new pathologic findings were found. Patients with SM exposure experience debilitating respiratory disorders in long term. Repeating CXR in patients who present with subjective symptoms may show new findings; however, repeating HRCT scan is probably not necessary.

To study the pattern of acute chemical and pharmaceutical poisoning in Ahmadabad, Gujarat, India. This was a prospective study of patients with chemical and pharmaceutical poisoning who were admitted to the emergency department of Civil Hospital Ahmadabad, from 1st October 2006 to 30th September 2007. Socio-demographic details, intention of poisoning, type of poison, duration of hospitalization and outcome were recorded in a data checklist. In total, 366 cases were studied over one year. Of these, 70.8% were male. The majority (45.08%) of cases had 21 to 30 years of age. 71.6% of cases lived in rural area and 28.4% of cases lived in urban area. The most common type of poison was pesticides in 33.9% of cases, followed by household chemicals in 26.8% of cases. In 74.6% of cases, intention of poisoning was self-harm. Case fatality rate among the patients was 18.6% while this index in patients poisoned with household chemicals was the highest (19.9%) followed by pesticides (17.7%). The prevention and treatment of poisoning with pesticides and household chemicals should merit high priority in the health care of Gujarat population. A specific concern should be raised toward pesticides availability and terms of sale. A national concern should be raised toward providing more laboratory and diagnostic facilities in hospitals in India.

Low molecular weight heparin (LMWH) is used for the treatment and prevention of coagulative disorders. Few patients receiving therapeutic doses of LMWH develop major hemorrhage. Currently there are few reports in the literature on acute overdose on adults. In this study, clinical profile, treatment and outcome of 21 patients who acutely overdosed enoxaparin are described. A retrospective chart review of California Poison Control System (CPCS) database: Visual Dot Lab during 1997 to 2007 was obtained. All patients with a definite reported overdose of subcutaneous injection of LMWH were included. In total, 21 patients who were all exposed to enoxaparin were studied. The reasons for overdose included medical miscalculation (3 cases, all infants), intentional misuse (2 patients), accidental overdose (7 cases), suicidal attempt (7 cases) and unknown in 2 patients. 7 cases were documented to have overdosed more than 2 times the therapeutic dose. The overdose ranged from 50 mg to 1300mg (0.1-80 times the therapeutic range). No patients were documented to experience bleeding or have thrombocytopenia although complete follow-up was only available for 11 patients. Reassurance was given to patients with less than 0.14 times the therapeutic dose. The 2 patients who received protamine were overdosed with more than 2.5 times the therapeutic dose of enoxaparin. Most patients had no complications and were not treated with protamine. This study suggests that a large dosage of LMWH is unlikely to result in any life threatening complications, though further studies are needed to certainly conclude about this. The use of protamine in LMWH overdose seems to remain controversial.

Peripheral nervous injury and neuromuscular complications from methamphetamine abuse has not been reported. The mechanism is not yet identified. Eight patients with lower extremity weakness following methamphetamine abuse were reported during December 2009 to May 2010. Patients presented with lower extremity weakness. All patients were co-abusers of methamphetamine and opioids. Other clinical manifestations comprised of distal paresthesia of the lower extremities with progression to proximal portions, with minimal sensory involvement in the distal of the lower extremities. Electrodiagnostic findings were consistent with lumbosacral Radiculopathy. Vital signs were unremarkable and all laboratory tests were within normal limits. Follow-up examination after three months showed improvement of weakness in 3 patients. For patients with a history of illicit drug abuse and acute neuromuscular weakness, methamphetamine or heroin toxicity should be taken into account. Hence, urine morphine and amphetamine/ methamphetamine tests should be performed and serum lead and thallium levels should be evaluated. In addition, rhabdomyolysis and myoglobinuria should be worked up.