Introduction:
Intentional poisoning is one of the most important cause for mortality and morbidity worldwide with almost 0.3 million people dying annually[1]. Most commonly used poisons in India are pesticides, rodenticide poison, oleander seeds, tablet overdose, ant killer powder, mosquito repellents, kerosene, paraquat, chemicals and detergents[2]. The pattern of poisoning in a region and its outcome are affected by various factors. The availability and access to the poison, socio-economic status of an individual, cultural and religious influences determine the pattern of poisoning whereas the physical and chemical properties of the poison, quantity of poison consumed, mode of poisoning and individual characteristics like functional reserve of the individual or target organ, age and pre-existing diseases affect the outcome.
In India, agriculture and farmers being the majority, Insecticides and other agrochemical fertilizers are used to greater extent and poisoning with such compounds are much more common than other poisonous substances. The ease of their availability, low-cost and their extensive use might be the probable reasons why they are commonly consumed in intentional poisoning. The symptoms due to these poisons can range from mild to severe, sometimes even fatal. Psychiatric illness plays a major role in intentional poisoning. Various international and national studies have shown the raise of incidence of intentional poisoning cases.
In the practice of medical toxicology, an immediate attention to the assessment of Airway, Breathing, Circulation and decontamination plays an important role in addition to assessing and monitoring the overall status of the patients at regular intervals. The vital signs are essential part of evaluation of every patient and frequent monitoring of vitals are always necessary throughout the subsequent management of critically ill patients. Once the vitals are stabilised, the focus may switch to confirm the ingestion of toxin and specific management based on the toxidromes. An improved knowledge of the patterns of poisoning, their clinical course and outcomes can help to formulate better preventive and management strategies such as pesticide regulations laws, educational awareness, counselling and poison information centres[3,4]. These initiatives can lead to a significant reduction of morbidity and mortality due to poisoning. By and large, an overall comprehensive team approach is required to bring down morbidity and mortality in toxicological emergencies.
Materials and Methods
This is a prospective observational study of 250 patients admitted in a tertiary care hospital located at Trichy city, Tamil Nadu during July 2019 to December 2019 with alleged history of Intentional consumption of various poisons and overdose of drugs. A preinformed well written consent was obtained from relatives or patients. The demographic profile, socioeconomic status, timing of poisoning, lag time in reaching the health care facility, co-morbid illness, previous history of poisoning, and mode of poisoning were recorded. The details of resuscitative care and further treatment details, antidote details, duration of hospital stay and outcome were also noted.
Inclusion Criteria
- Age more than or equal to 18 years
- Patient who deliberately consumed poison with intention of self harm
Exclusion Criteria
- Age less than 18 years
- Accidental poisoning, snake bite poisoning, insect bite poisoning
- Brought dead patient or died before getting indoor treatment
Ethical Clearance: Approval was obtained from the Institutional Ethical Committee I.E.C.No. 33/2019
Sample Collection
In patients with alleged history of intentional consumption of poisons, after getting
consent from either patient or relatives, the following data were noted:
- Socioeconomic status
- Time of poisoning
- Type of poison
- Time of hospital arrival
- Lag time in reaching the hospital
- Any co-morbid illness
- Any previous history of poisoning
- Mode of poisoning
- First aid treatment details
- Door-to-needle time
- Requirement of antidote
- Duration of hospital stay
- Outcome
Statistical Analysis
After obtaining these datas , the results were transcribed into bar charts/
tabulations and statistical analysis was performed. Tests of significance were
used wherever required appropriately.
Results:
Most of our study population were middle aged individuals around 20.8% (n=52) in 31-40 age groups. Males were more in numbers in the study group comprising about 53.2% (n=133). Majority of our study population around 46.8% (n=117) belonged to upper lower class according to Modified Kuppusamy scale whereas only about 6% (n=15) belonged to upper middle class. Out of 250 patients, OPC poison was the most widely used compound (26%, n=65) followed by rodenticide poison (rat killer paste/ powder). Tablet overdose namely antiepileptics, paracetamol, sedative-hypnotics and antipsychotic drugs comprised about 16.4% (n=41). Majority of our study population were hypertensives (32.8%, n=20) followed by coronary artery disease patients (29.5%, n=18). There were about four psychiatric patients and three pregnant women in our study group. Those psychiatric patients were three depression and one schizophrenia patient. Most of our patients (90.8%, n=227) presented within 2 hours of consumption of poison to our hospital. Remaining 9.2% (n=23) presented late to the hospital due to remote area far away from health care facility, lack of transportation facility, late identification of consumption of poison and getting treated in nearby health centre for first aid. One patient was diagnosed late as poisoning patient as the patient revealed the history of rodenticide poison consumption only after two days of admission. For all the other patients, treatment including first aid was started within 5 minutes of arrival from the casualty. About 71.2% (n=178) patients were successfully discharged and about 23.6% (n=59) expired due to various poisoning. Thirteen patients were either discharged at request or went against medical advice from our hospital, but their outcome was followed up through phone calls. Most of the patients were directly brought to our hospital before getting any first aid treatment at nearby hospitals (70.4%, n=176). Few were managed with stomach wash, antidotes and other supportive measures before referral to our hospital. Only 8 patients had previous history of poisoning.
| Table 1: Characteristics and outcome of study participants |
| Variable |
Number (n) |
Percentage (%) |
| Gender |
| Male |
133 |
53.2% |
Female |
117 |
46.8% |
Age (in years) |
18-20 |
19 |
7.6% |
21-30 |
47 |
18.8% |
31-40 |
52 |
20.8% |
41-50 |
49 |
19.6% |
51-60 |
42 |
16.8% |
>60 |
41 |
16.4% |
Comorbid conditions |
Diabetes mellitus |
16 |
26.2% |
Hypertension |
20 |
32.8% |
Coronary artery disease |
18 |
29.5% |
Pregnancy |
3 |
4.9% |
Psychiatric disorders |
4 |
6.6% |
Socioeconomic status |
Upper middle |
15 |
6.0 % |
Lower middle |
73 |
29.2% |
Upper lower |
117 |
46.8% |
Lower |
45 |
18.0% |
Type of poison |
Rat Killer Paste/Powder |
59 |
23.6% |
OPC |
65 |
26.0% |
Oleander Seeds |
45 |
18.0% |
Tablet overdose |
41 |
16.4% |
Mosquito Repellent |
30 |
12.0% |
Paraquat |
10 |
4.0% |
Survivors |
178 |
71.2% |
Non-survivors |
59 |
23.6% |
AMA/At request |
13 |
5.2% |
Most common age group to consume poison was 31-40 years with highest mortality among the same age group (28.8%, n=15) but this was not statistically significant. Many deaths occurred among male patients (n=32) due to various poisoning but there was no statistical difference between gender and death. The death among upper lower socio-economic class was higher (32%, n=117) followed by lower class (31%, n=45). These correlations were merely due to more number of admitted patients belonged to upper lower class and hence statistically not found to be significant.
| Table 2: Variables between survivors and non-survivors |
Variable |
Non-survivors (n) |
Survivors (n) |
P value |
| Gender |
| Male (n=133) |
32 |
101 |
|
Female (n=117) |
27 |
90 |
0.855 |
Age (in years) |
0.687 |
18-20 (n=19) |
4 |
15 |
21-30 (n=47) |
7 |
40 |
31-40 (n=52) |
15 |
37 |
41-50 (n=49) |
13 |
36 |
51-60 (n=42) |
10 |
32 |
>60 (n=41) |
10 |
31 |
Comorbid conditions |
0.187 |
Diabetes mellitus (n=16) |
3 |
13 |
Hypertension (n=20) |
8 |
11 |
Coronary artery disease (n=18) |
6 |
12 |
Pregnancy (n=3) |
0 |
3 |
Psychiatric disorders (n=4) |
2 |
2 |
Out of 250 patients of our study population, 59 patients succumbed to poisoning in spite of best intensive care. Mortality was highest with OPC poison (55%, n=36). About 20% (n=12) deaths were observed in Rat killer poisoning. Statistical significance was obtained with comparing different poisons and its outcomes. About 60 patients having co-morbid illness admitted with poison consumption amidst whom 31% (n=19) died. Hypertensive patients were more in numbers in our study group and they were the group with higher mortality (66%, n=8). No antenatal death occurred in our study.
Table 3: Association of type of poison and its outcome |
Type of Poison |
Non-survivors
n=59 |
Survivors
n=191 |
P value |
Rat Killer Paste/Powder [n=59 (23.6%)] |
12 |
47 |
<0.0001 |
Organophosphorus compounds [n=65 (26%)] |
36 |
29 |
Oleander seed [n=45 (18%)] |
5 |
40 |
Tablet overdose [n=41 (16.4%)] |
2 |
39 |
Mosquito repellent [n=30 (12%)] |
0 |
30 |
Paraquat [n=10 (4%)] |
4 |
6 |
Out of 4 psychiatric patients admitted, 2 died of poisoning and both were males who consumed OPC poison. About 9.2% patients (n=23) arrived late to the hospital due to various reasons like lack of transportation facilities, late referral from hospitals or unawareness of patient's poison consumption by patients' attenders. Out of this, 39.1% (n=9) died and it outnumbered the percentage of deaths among patients who came early to hospitals (22%). Only one patient presented with delayed manifestations and hence treated late. It was a case of rat killer paste poisoning and patient died after 4 days of hospital stay. First aid treatment was given to 74 patients got from elsewhere before they were received in our hospital out of which only 22 died accounting to 37.2%. Remaining 62.8% patients did not receive any first aid treatment from other hospitals. 3.2% (n=8) of patients had a previous history of poisoning among whom only one died.
| Table 4 : Comparison of outcome with time of arrival, early treatment, prior first aid and previous history of poisoning |
Variables |
Non-survivors |
Survivors |
P value |
Time of arrival |
Within 2 hrs of consumption
n=227 |
50 |
177 |
0.066 |
More than 2 hrs of consumption
n=23 |
9 |
14 |
Interval between arrival and treatment |
Within 5 mins of arrival
n=249 |
58 |
191 |
0.071 |
More than 5 mins
n=1 |
1 |
0 |
| First aid given before referral to our hospital |
| Yes (n=74) |
22 |
52 |
|
No (n=176) |
37 |
139 |
0.139 |
| Previous history of poisoning |
| Yes (n=8) |
1 |
7 |
|
No (n=242) |
58 |
184 |
0.452 |
| Table 5: Duration of hospital stay of various poisonings |
|
n |
Mean |
Std. Deviation |
P value |
Rodenticide |
59 |
6.14 |
1.88 |
<0.0001 |
OPC |
65 |
5.28 |
2.57 |
Oleander seed |
45 |
3.91 |
1.14 |
Tablets |
41 |
3.68 |
0.99 |
Mosquito repellent |
30 |
2.90 |
0.96 |
Paraquat |
10 |
7.80 |
2.53 |
Total |
250 |
4.79 |
2.21 |
| Table 6 : Association of psychiatric disorders with various poisonings |
|
Type of poison |
P valuel |
Rat killer paste/ powder
n=59 |
OPC
n=65 |
Oleander seeds
n=45 |
Tablets
n=41 |
Mosquito repellent
n=30 |
Paraquat
n=10 |
|
Psychiatric |
No
n=246 |
59 |
63 |
44 |
40 |
30 |
10 |
0.763 |
Yes
n=4 |
0 |
2 |
1 |
1 |
0 |
0 |
Discussion
As the study was done in a Tertiary level care hospital, many poison cases from peripheral hospital in and around the city who require intensive care were referred to our hospital. In this study of 250 patients, variety of intentional poisoning such as OPC, Rodenticide, Paraquat, Mosquito Repellent, Oleander seeds, Tablet overdose were included.
Most of our study population took poisons through oral route. Satvika Reddy et al[5] study also showed 81.2% of their study population consumed poisons orally. Most commonly used poison in our study was OPC[6] followed by Rodenticide poison. Hemani Ahuja et al[7] study was also correlating with our study with OPC as most widely used poison in India (32.8%). Extensive use of pesticide and easy availability would be the reason for using OPC as the common poison. Majority of our study population were young, in the age group of 31-40 years, accounting for 20.8%. Being most active and vulnerable to stress like work tension, loss of jobs, unemployment and marital issues could be the cause of more suicidal tendencies in this age group. A study by Anthony L et al[8] also showed incidence of poison is higher in similar age group (20-40 years).
Typically, males predominated in our study group (53.2%). The deaths due to poisons were also higher in males compared to females (24%). About 46.8% of study population belonged to Upper Lower class according to Modified Kuppusamy scale. Hypertension was the most common co-morbidity among the study population (32.8%) followed by Coronary Artery Disease (29.5%). There were about 6% of psychiatric patients in the study group which is an important factor in intentional poisoning. About 3.2% of our patients had previous history of poisoning. Undiagnosed or untreated psychiatric disorders, lack of family support and lack of psychiatric counselling could have attributed to repeated suicidal attempts. Of the patients, 90.8% were brought to our hospital within 2 hours of poison consumption. Remaining patients had delay in getting hospitalized which would be due to remote areas where transportation facilities are not readily available. In our study, overall mortality was 23.6% and 71.2% got discharged in good health and 1.2% went Against Medical Advice.
Comparison of outcome with the various patterns and socio-demographic factors of poisoning: Most of the deaths occurred in the middle age group (31-40 years). Comparison of death with gender was not significant statistically proving that both groups are comparable. Death was more common in Upper Lower class accounting to 24% as the maximum numbers of poisons were also in this class group. Most lethal poison causing death was OPC (55%) followed by Rat killer paste. Mosquito repellent was the least toxic poison with no mortality among 30 patients. Many studies also showed similar results with OPC leading the first place in mortality. Dewan A et al[9] found out that OPC had more mortality of 32% among their study population. A study by Maharani and Vijayakumari[10] showed Rodenticide was highly toxic causing death (35.2%). Regarding co-morbidities, hypertensive patients had a mortality of 42.1% among 19 patients followed by Coronary Artery Disease. More mortality was seen in patients who presented late after the consumption of poison (39.1% among 23 patients who were brought after 2 hours of consumption) than within 2 hours of consumption (22% out of 227 patients). About 74 among 250 patients got first aid treatment like stomach wash, specific antidotes from some other hospitals or clinics before coming to our hospital. Out of this, 29% patients died and remaining majority were rescued timely. Paraquat poisoning had the longest hospital stay with a mean of 7.80 ± 2.53 days followed by Rat killer paste poison with a mean of 6.14 ± 1.88 days. Least duration of hospital stay was for Mosquito repellent with mean duration of approximately 3 days.
Limitations: Personal habits of patients like alcoholism, smoking, other substance abuse were not taken into account and amount of poison couldn't be calculated accurately which all might have influenced the outcome.
Conclusion
The management of the medical ailments have improved dramatically over the past few decades due to advancement in diagnostic methods and appropriate treatment. This has led to prolonged survival of patients with good quality of life. In spite of these medical progression, intentional poisoning remains to be one of the major burden worldwide especially in developing countries like India, causing significant mortality and morbidity. Many young budding individuals lose their precious lives because of poisoning due to their family circumstances. Counselling and education at various levels right from school period may allow them to behave maturely and boldly in such occasions. Learning about the patterns and socio-demographic profile of poisoning patients in a tertiary care hospital helps in identifying the lacunae in prevailing setup and thereby paving way for better strategies to decrease the mortality.
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