Predictive Factors of Mortality in Acute Amphetamine Type Stimulants Poisoning; a Review of 226 Cases.

INTRODUCTION: Amphetamine type stimulants (ATS) such as amphetamine and methamphetamine (MA) are one of the most important causes of poisoning in the world. In this study we aimed to define the predictive factors of mortality in acute ATS poisoning patients. METHODS: This is a retrospective cross-sectional study on all cases with acute ATS poisoning who were referred to a referral center for poisoning, Tehran, Iran, from April 2011 to March 2014. Using patients' medical records, demographic data, route of exposure, type and amount of ATS, the cause of poisoning, clinical presentations, and electrocardiogram (ECG) and laboratory findings, as well as patient's outcomes were collected and analyzed regarding the independent predictive factors of mortality. RESULTS: 226 cases with the mean age of 32.9 ± 10.9 years were studied (77% male). MA was the most abused ATS (97.4%) and the most frequent route of exposure was oral (55.3%). The mortality rate was 5.4%. There was a significant association between agitation (p = 0.002), seizure (p = 0.001), loss of consciousness (p < 0.001), creatine phosphokinase level (p = 0.002), serum pH (p = 0.002), serum HCO3 (p = 0.02), and PCO2 (p = 0.01) with mortality. However, serum HCO3 [OR=1.27 (95% CI: 1.07-1.50); p value=0.005], PCO2 [OR=0.89 (95% CI: 0.84-0.96); p value=0.002], and loss of consciousness [OR=0.019 (95% CI: 0.003-0.106); p value=0.000] were the only independent predictive factors of mortality. CONCLUSION: PCO2 ≥ 51 mmHg, serum bicarbonate ≤ 22.6 mEq/L, and loss of consciousness on admission could be considered as prognostic factors of mortality in acute ATS poisoning cases presenting to emergency department.

Severe camphor poisoning, a seven-year observational study.

In a retrospective case series from 2007 to 2014, we searched for any accidental/intentional, and recreational cases of pure camphor poisoning through hospital records. Epidemiological data, as well as factors correlated with seizure, were evaluated. Thirty cases including 29 males were recruited with a median age of 18 years (range; 0.2-87). Patient's reported ingestion rate of camphor was 1.5-15 grams. Almost all of the patients (96.7%) were conscious on arrival time and the ingestion to the presentation time ratio was 7±5h. It was observed that in a majority of the cases (53.4%), decreasing libido was the main intent of Camphor ingestion. Nausea and vomiting occurred in 22 (73.3%) cases and tonic-clonic seizure was seen in 12 (40%) patients. Mean presentation time was significantly longer in patients who experienced seizure (9.1±6.1h vs. 5.2±2.8h, p=0.05). No correlation was found between the amount of ingested camphor (grams or mg/kg) and vital signs along with the bio-chemistry results. Not only did all of our cases survive but also they exclusively received supportive care.

Can duration of hemodialysis be estimated based on the on-arrival laboratory tests and clinical manifestations in methanol-poisoned patients?

PURPOSE: We aimed to evaluate the efficacy of Lachance formula and more readily available clinical or laboratory factors (other than serum methanol level) in prediction of the needed time for hemodialysis in methanol-poisoned patients. METHODS: In a retrospective study, all methanol-poisoned patients referred to us between March 2008 and March 2016 were enrolled. The patients' demographic characteristics, on-arrival vital signs, signs/symptoms, and laboratory tests were evaluated for factors that could prognosticate the dialysis duration. RESULTS: Of 72 patients enrolled, 54 underwent hemodialysis once (group 1) and 18 needed more than one session of hemodialysis (group 2). All were treated by ethanol, bicarbonate, and leucovorin. Lachance formula overestimated the patients in higher methanol levels and underestimated them in lower methanol levels. It properly predicted the needed time for hemodialysis when the methanol level was between 15 and 25 mg/dL. Groups 1 and 2 were different in terms of their ingested alcohol dose (P = 0.001), creatinine (P = 0.02), dyspnea on presentation (P = 0.002), and the place they had been dialyzed (P = 0.013). Dialysis duration significantly correlated with dyspnea on presentation (P = 0.028) and ingested alcohol dose (P = 0.02). After performance of logistic regression analysis, only creatinine was statistically significantly different between the two groups (P = 0.02). Median creatinine levels were 1.3 [1, 6] (0.8-2.7) and 1.4 [1.35, 2.1] (0.8-6.5) in the patients who were dialyzed once and twice, respectively. CONCLUSIONS: As a conclusion, creatinine is possibly a readily available test that can predict the appropriate time needed for hemodialysis in methanol-poisoned patients.

Hypo and hyperglycemia among tramadol overdose patients in Loghman Hakim Hospital, Tehran, Iran.

Tramadol is a synthetic and centrally active analgesic. Hypoglycemia as another possible major side effect among abusers has not been known well. Our objective is evaluation of the Blood Glucose Level (BGL) among tramadol-overdosed patients. This prospective cross-sectional study was performed from Feb to June 2013; BGL was measured at the time of admission, 8 and 12 hours later. All patients with hypoglycemia received infusion of 0.5-1 gr/kg of hypertonic dextrose and their BGL was checked every hour until normal BGL. Patients' demographic, clinical and paraclinical data were collected. Totally, 128 patients with a mean (SD) age of 24.5 (6.9) years were recruited; 127 (99.2%) were male. Seizure occurred in 59.4% cases. Mean ± SD admission BGL was 94.88 ± 21.5mg/dL. Fourteen patients experienced hypoglycemia within 12 hours period. Hyperglycemia was experienced in 8 patients (6.25%) on admission day. There was no significant relation between the dose of tramadol and BGL. In conclusion, hypoglycemia must be considered as an important side effect of tramadol-overdose. It is suggested that serial BGL monitoring in cases of Tramadol-overdose should be done for early recognition of hypoglycemia and its timely management. Also hyperglycemia may be revealed.

Acute adult and adolescent poisoning in Tehran, Iran; the epidemiologic trend between 2006 and 2011.

BACKGROUND: The aim of this study was to determine the frequency of each poisoning and its related death in our center as a sample of Tehran in six consecutive years (2006 to 2011). METHODS: All poisoned children and adults referring to Loghman-Hakim hospital poison center and hospitalized in the study period were enrolled and evaluated. RESULTS: In 108,265 patients, the most common causes of poisoning were anti-epileptics and sedative-hypnotics (22.3%). The most common causes of death were pesticides (24.84%) and narcotics (24.75%). In drugs of abuse, opium was more prevalent in the early period of the study but was replaced by methadone later. CONCLUSION: It seems that national policies for drug control and prevention of suicide have not been efficient enough. We expect to see Iran in the first 50 countries with regard to suicide and to maintain the first place in narcotic abuse if enough attention is not provided.

Suicide epidemiology and characteristics among young Iranians at poison ward, Loghman-Hakim Hospital (1997-2007).

BACKGROUND: Suicide is a critical public health problem. In developing countries, the highest suicide rate is found in young adults with remarkable increasing rate. In this study, we have evaluated the epidemiology and characteristics of 8-16-year-old individuals who attempted suicideand were hospitalized in Loghman-Hakim Hospital, Tehran, Iran from 1997 to 2007. METHODS: A total of 6414 hospitalized patients, ages 8-16, who attempted suicide and were residents of Loghman-Hakim Hospital were investigated. We performed a retrospective chart review to study the characteristics of cases in a 10-year period by review of psychiatric and medical records. RESULTS: Out of 6414 patients, 22.6% were males, 5978 patients were 12-16 years old and the rest were aged 8-12 years. During the 10-year period, suicides showed a rising trend among adults, while in children no significant increase was detected. Communicative disorders were the most common underlying risk factors, particularly in females. One patient out of five cases had psychiatric disorders, of which adjustment disorders were the most predominant. A remarkable peak in suicides was observed in May and July, while winter had the highest suicide rate among seasons. CONCLUSIONS: Suicide due to drug overdose is higher in females than males in young population. This increasing trend is a psychiatric concern and should be resolved by improving mental and public health.

Temperature changes among organophosphate poisoned patients, Tehran- Iran.

BACKGROUND: Acute poisoning with organophosphorus compounds (OPs) is a major global clinical problem in the developing countries. There have been many animal studies and few human surveys on the effects of organophosphorus pesticide (OP) poisoning on thermoregulation. The aim of this prospective study was to document the pattern of tympanic temperature changes among OP poisoned patients throughout the length of their hospital stay. METHODS: 60 patients with diagnose of organophosphate poisoning were included in this study. Questioner was filled out by trained nurses including demographic, clinical and paraclinical data. Tympanic temperature and Pulse rate data of the cases were collected on five- occasions after admission. RESULTS: There were 41 (68.3%) male and 19 (31.7%) female, with a mean age of 34.4 ±19.4 years (range 13-89 years). Forty five patients had intentional poisoning for suicidal attempt. At the time of entry, the mean tympanic temperature, pulse rate, respiratory rate and blood pressure (systolic and diastolic) of the OP poisoned patients were respectively 37.1+/-0.6°C (36.0- 39.5), 91+/-18 (55-145), 18+/-5.6 (8-44), 116+/-20 mm Hg (70-170) and 75+/-11.6 mm Hg (40-110). 41.7% of the cases had serum butyryl cholinesterase activities (BChE) ≥ 50% normal (≥1600 mU/ml). Our patients had normal temperature at the time entry (mean = 37.1). Tympanic temperature decreasing below 36°C was not detected among the patients during the study period. A rise in mean tympanic temperature was found after atropine administration. CONCLUSION: Our study showed hypothermia was not considerable factor among organophosphate poisoned patients, although more studies with similar situations in tropical countries are needed.

Blood levels of methemoglobin in patients with aluminum phosphide poisoning and its correlation with patient's outcome.

Although methemoglobinemia following aluminum phosphide (AlP) intoxication has been reported, probable effect of blood level of methemoglobin (Met-Hb) on outcome of AlP-poisoned patients has not yet been investigated. This study aimed to evaluate blood levels of methemoglobin in patients with AP intoxication and its correlation with patient's outcome. This prospective study was carried out at the Loghman-Hakim poison hospital from April 2009 to August 2009. All patients aged >12 years who had ingested AlP and were admitted at the hospital were enrolled in the study. Using the co-oximetry, blood Met-Hb level was measured at the time of admission and 24 h later if the patient survived. Forty-eight patients with AlP intoxication including 24 males were evaluated. Mean age of the patients was 25.5±9.5 years. There was significant association between blood level of Met-Hb at the time of admission and mortality (2.4%±7.1% in survivors versus 15.2%±13.5% in non-survivors, P<0.001). The same association was found at the 2nd day of admission (2.9%±8.2% in survivors versus 26.5%±9.9% in non-survivors, P=0.02). The present study found an association between blood level of Met-Hb and mortality in patients with AlP intoxication. Effect of administration of vitamin C and methylene blue on outcome of patients with AlP intoxication should be investigated in future studies.

Pattern of acute poisoning in Tehran-Iran in 2003.

To characterize the poisoning cases admitted to the Loghman-Hakim Hospital Poison Center (a teaching reference hospital of poisoning) in Tehran, Iran. All admitted acutely poisoned patients from January to December 2003 were evaluated retrospectively. Information of socio-demographic characteristics, agents and cause of poisoning, and the mortality rate were collected from medical records of the hospital. During this period, 24 179 cases were referred to the emergency department that 10 206 of them were admitted. Of the admitted cases, 51% were male and 49% female. The majority (38%) of cases were in the age range of 21-30 years. Most (79%) of poisonings were intentional and 21% were unintentional. The most important agents of acute poisoning were drugs (69.13%) especially sedative-hypnotics followed by opioids (12.34%) and pesticides especially organophosphates (OPs) (6.21%). The mortality rate was 1.3% (318 patients). Death was mostly occurred by opioids (41.54%), followed by drugs (28%) and pesticides especially OPs (12%). The prevention and treatment of poisoning due to opioids, pesticides specially OPs and sedative-hypnotics drugs should merit high priority in the health care of the indigenous population of Tehran.

A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning.

ABSTRACT Body packers are people who illegally carry drugs, mostly cocaine as well as opium and/or heroin, concealed within their bodies. The packets are inserted in the mouth, rectum, or vagina in order to get across borders without being detected. In this presentation we report a case of an opium body packer and review the available scientific literature by focusing on mechanisms of toxicity and treatment approach. The patient was a 35-year-old man who had lethargy, respiratory depression, tachycardia, normal blood pressure, hyperthermia, and pinpoint pupils on presentation. No past medical history was obtained and the only positive history was his travel from Afghanistan 2 days earlier, which he had given to emergency personnel before arriving at our hospital. Complete blood cells and kidney and liver tests were all in normal range. In the emergency department, the patient was treated with oxygen, naloxone, and hypertonic glucose. One dose of activated charcoal (1 g/kg) was administered orally. After intravenous injection of naloxone (4 mg), the lethargy, respiratory depression, and miosis were resolved. The patient was admitted to the intensive care unit and 90 min after admission, the patient redeveloped respiratory distress and lost consciousness. He was intubated and mechanically ventilated due to the suspicious of body packing. Plain abdominal x-ray showed multiple packets throughout the gastrointestinal tract; 81 packets were removed by surgery and three of them were left due to leaking. After removing the packets, the patient was treated conservatively. He suffered a pulmonary infection (aspiration pneumonia) and he regained consciousness after 4 days. Upon recovery the patient was seen by a psychiatrist prior to going to prison. Surgery is recommended for body packers who have significant signs or symptoms.

Evaluation of oxidative stress and genotoxicity in organophosphorus insecticide formulators.

The aim of this study was to evaluate genotoxicity and oxidative stress in workers who formulate organophosphorus (OP) pesticides. In this survey, blood leukocytes and erythrocytes of a group of 21 pesticide formulating workers and an equal number of control subjects were examined for genotoxicity and oxidative stress parameters. The mean comet tail length and mean comet length were used to measure DNA damage. Lipid peroxidation level, catalase, superoxide dismutase (SOD) and glutathione peroxidase activities in erythrocytes were analysed as biomarkers of oxidative stress. In addition, the acetylcholinesterase activity was measured as a biomarker of toxicity. The average duration of employment of workers in the factory was 97 months. Results indicated that chronic exposure (multiple-dose, greater than or equal to 6 months duration) to OP pesticides was associated with increased activities of catalase, SOD and glutathione peroxidase in erythrocytes. The level of lipid peroxidation and acetylcholinesterase activity did not show any significant differences between the two groups. The results also indicated that chronic exposure to OP pesticides was associated with increased DNA damage. It is concluded that human chronic exposure to OP pesticides may result in stimulated antioxidant enzymes and increased DNA damage in the absence of depressed acetylcholinesterase levels. Routine genotoxicity monitoring concomitant to acetylcholinesterase activity in workers occupationally exposed to OP insecticides is suggested.

Successful treatment of acute aluminium phosphide poisoning: possible benefit of coconut oil.

Aluminium phosphide is used to control rodents and pests in grain storage facilities. It produces phosphine gas, which is a mitochondrial poison. Unfortunately, there is no known antidote for aluminium phosphide intoxication, but our recent experience with a case showed that rapid prevention of absorption by coconut oil might be helpful. In the present case, we used the same protocol in a 28-year-old man who had ingested a lethal amount (12 g) of aluminium phosphide with suicidal intent and was admitted to hospital approximately 6 hours postingestion. The patient had signs and symptoms of severe toxicity, and his clinical course included metabolic acidosis and liver dysfunction. Treatment consisted of gastric lavage with potassium permanganate solution, oral administration of charcoal and sorbitol suspension, intravenous administration of sodium bicarbonate, magnesium sulphate and calcium gluconate, and oral administration of sodium bicarbonate and coconut oil. Conservative and supportive therapy in the Intensive Care Unit was also provided. The patient survived following rapid treatment and supportive care. It is concluded that coconut oil has a positive clinical significance and can be added to the treatment protocol of acute aluminium phosphide poisoning in humans.

Benefits of magnesium sulfate in the management of acute human poisoning by organophosphorus insecticides.

Organophosphorus chemicals (OPs) are the pesticides most often involved in serious human poisoning. Treatment of intoxication with OPs conventionally involves atropine for reduction of muscarinic signs and oximes that increase the rate of hydrolysis of the phosphorylated enzyme acetylcholinesterase (AChE). Although atropine and oximes (pralidoxime or obidoxime) are traditionally used in the management of such poisoning, their efficacy remains a major issue of debate; thus, the goal of this prospective clinical trial was to elaborate the value of magnesium sulfate (MgSO4) in the management and outcome of OP insecticide poisoning. This unicenter, randomized, single-blind trial study was conducted on patients who were acutely poisoned with OPs and admitted to the Poisoning Center of Loghman-Hakim Hospital in Tehran, Iran. In a systematic sampling, every fourth eligible patient was chosen to undergo MgSO4 treatment. Magnesium sulfate was administered at dose of 4 g/day i.v. continued for only the first 24 hours after admission. The mean daily oxime requirement and the mean daily atropine requirement were not statistically significant between two treated groups. The mortality rate and hospitalization days of patients who received MgSO4 treatment were significantly lower than those who had not received MgSO4 (P < 0.01). It is concluded that administration of MgSO4, in a dose of 4 g/day concurrent to conventional therapy, in OP acute human poisoning is beneficial by reducing the hospitalization days and rate of mortality.

Successful treatment of acetaminophen overdose associated with hepatic failure.

Acetaminophen is the most widely used antipyretic and analgesic drug in the world. Acetaminophen poisoning and the following hepatic failure are not rare and are the most common indications of liver transplantation in the USA and Europe. In this case report, the patient was a 25-year old woman with hepatic failure who was brought to Loghman-Hakim Poison Centre 24 hours after attempted suicide with 100 tablets of acetaminophen, 325 mg. She was treated with N-acetylcysteine (NAC) and discharged from the hospital 12 days after admission and followed up for 1 month. In conclusion, acetaminophen poisoning should be considered in the differential diagnoses of hepatic failure. In acetaminophen-induced hepatic damage the administration of NAC must always be considered even after 24 hours of overdose.