The epidemiology of poisoning in emergency department in Türkiye

Abstract

Aim Poisoning has a high potential mortality and morbidity. In order to prevent poisonings and reduce the risk of mortality and morbidity, it is necessary to determine the poisoning profile. Along with changes in medicine, technology and sociocultural life, the poisoning profile also changes over time. It is essential to keep up-to-date information on the subject in order to control poisoning. Methods Poisoning cases admitted to the emergency department between 2016 and 2020 were retrospectively reviewed. Patients aged 18 years and older were included in the study. Patients younger than 18 years of age and those with missing data were excluded from the study. Demographic, etiological and clinical features of poisonings were analyzed. Results A total of 774 subjects with a mean age of 39.1±15.4 were included in the study. Of these subjects, 472 (61%) were male. The most common mechanism of poisoning was intentional exposures (n=418, 54%). It was known which substance 737 (95.2%) patients were exposed to, and a total of 1030 substances that caused poisoning were identified. Medications (n=579, 56.2%) were the first among the exposed substances, and antidepressants (n=152, %26.3) were the first among the medications. Poisoning with alcohol and its derivatives (n=282, 27.4%) was in the second place. The rate of hospitalization in the inpatient service was 50.8% (n = 393), intensive care unit was 13.8% (n = 107) and the mortality rate was 4.4% (n = 34). The statistical significance between unintentional poisonings, the subjects who used antidote and the subjects who underwent hemodialysis and mortality was high (p values, respectively: P < .001, P < .001, P < .001). Conclusion This study is one of the that contain up-to-date information in large case series in the field of toxicology. Poisonings were most often caused by intentional exposure. Among the substances that cause poisoning, medications, alcohol and its derivatives are in the first two places. Hospitalization, ICU admission and mortality rates are high in poisonings, which creates a serious economic and social burden for the health system.

Keywords

Introduction

Poisoning constitutes an important disease group in the emergency department (ED) with high potential mortality and morbidity.¹ The rate of admission to the ED with poisoning varies between 0.27% and 1.4% in Turkey.^2,3 This rate has been reported as 0.64% in United States,⁴ between 0.39% and 5% in European countries,^5,6 and 0.82% in Taiwan.⁷ Between 5% and 14% of intensive care unit (ICU) admissions are due to poisoning.⁸
The cause of poisoning can be clearly identified in some cases, but sometimes it is very difficult to diagnose.¹ The causes and forms of poisoning can vary between countries, as well as between different geographical regions of the same country.⁹ Determining the poisoning profile in a country or a particular region is crucial for identifying risks, taking necessary precautions, and managing cases.³ In addition, the profile of poisoning may change over time with the effect of new treatment methods in modern medicine, advances technology, sociocultural changes. It is essential to record the cases and keep the relevant information up-to-date for the prevention and better management of poisonings.²
In this study, it was aimed to determine the demographic, etiological and clinical characteristics of acute poisoning cases admitted to the ED.

Materials and Methods

2.1. Study Design and SettingsThis study was carried out in the adult ED of a tertiary health institution affiliated with the university in the city center of Izmir, with a population of 4.4 million, located in the west of Turkey. Poisoning cases admitted to the adult ED, which has an admissions of approximately 60,000 yellow and red coded patients (excluding trauma) annually, during the 5-year period between ‘January 1, 2016-December 31, 2020’ were analyzed retrospectively. Approval for the study was obtained from the Izmir Katip Çelebi University Non-Interventional Clinical Research Ethics Committee (Date 18.02.2021 and Decision No 0044).2.2. Study PopulationAmong the patients who presented to the ED, patients aged 18 years and older who had at least one of all the diagnostic codes containing the word “poisoning” (F10-19, T36-61, T96, X40-49, Y10-19, Y91) according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) were included in the study. A total of 774 subjects were included in the study. Patients younger than 18 years of age and patients with missing data will be excluded from the study.2.3. Data Collection and ProcessingFrom the medical records of the subjects, age, gender, place of residence (province, district, countryside), time of admission to the hospital (hour, month and year), mechanism of poisoning (intentional, unintentional, adverse reaction and other) and type or name of the exposed substance, the number of exposed substances (single, two, more than two, unknown), the status of receiving counseling from a The National Poison Information Center (NPIC), the use and name of antidote, the need for hemodialysis, the hospitalization status, mortality and cost information were obtained. Subjects were divided into six groups according to age groups as 18-24, 25-34, 35-44, 45-54, 55-64 and ≥65. The time of admission to the hospital was grouped according to the year, month and time of the day of admission. The hours of the admission day are divided into daytime (08:00-15:59), evening (16:00-23:59) and night (00:00-07:59). The factors that cause poisoning are divided into 8 main groups as medications, recreational drugs, alcohol and its derivatives, gases, pesticides, bite/sting by animals, others (foods, corrosives, etc.) and unknown. Medications are divided into subgroups. These subgroups are psychotropic drugs, antidepressants, psychostimulant drugs, anticonvulsant drugs, analgesic and myorelaxant drugs, cardiovascular system drugs, gastrointestinal system drugs, antibiotics, antivirals and antifungals, vitamins, antihistamines, and others. (antidiabetics, hormones, herbal products, etc.) The cost of the subjects was calculated based on the Social Security Institution invoice.2.4. Outcome MeasuresIn this study, it was aimed to determine the most common causes of poisoning and the antidotes used in the ED. In addition, factors related to mortality and total costs of subjects were also calculated.2.5. Data AnalysisIBM SPSS Statistics 23 (SPSS Inc., Chicago, USA) program was used for data analysis. Descriptive statistics were expressed with frequency, percentage, mean and standard deviation values. The suitability of the data to the normal distribution was evaluated using the Shapiro-Wilk test, skewness-kurtosis values, and Q-Q plots. In the comparison of two independent groups, Independent Samples t-Test was used for data conforming to normal distribution. The chi-square test was used to compare two or more categorical groups. Values with p value less than 0.05 were considered significant. All statistics were performed at 95% confidence interval.

Results

In the 5-year period, in which approximately 300.000 yellow and red coded patients (excluding trauma) were admitted, the number of patients who presented to the ED due to poisoning was 774. Of these subjects, 472 (61%) were male. The mean age of the subjects who presented was calculated as 39.1 ± 15.4, the mean age of men as 42.7 ± 14.8, and the mean age of women as 33.5 ± 14.7. Based on age groups, the highest number of subjects are between the ages of 25-34 (n=172, 22.2%) (Table 1). Most of the subjects are living in the city center (n=621, %80.2). Most of the subjects presented during the daytime, between 08:00 and 15:59 (n=319, 41.2%). The highest number of presentations were made in 2018 (n=174, 22.1%), the least in 2020 (n=108, 14.0%). The months with the highest number of presentations are October (n=80, 10.3%), June (n=76, 9.8%) and February (n=74, 9.6%) (Graph 1). The most common mechanism of poisoning was intentional exposure (n=418, 54%). A total of 1030 exposed substances causing poisoning were detected in 737 (95.2%) of 774 subjects. The cause of poisoning in 37 (4.8%) subjects was unknown. Of the subjects, 167 (21.6%) were poisoned with more than one substance and 71 (9.2%) were poisoned with more than two substances (Table 2). Poisonings occurred mostly with medications (n=579, 56.2%), and among medications, antidepressants (26.3%) and analgesic – myorelaxant drugs (n=134, 23.1%) were the most common ones. Poisoning with alcohol and its derivatives (n=282, 27.4%) was the most common following medications (Table 2). Among all poisonings, the most common cause was sucidal attempts (n=407, 52.6%). When the number of suicide attempts by months was analyzed, no significant difference was found (P = .285). NPIC was called for 469 (60.6%) of the subjects and counseling service was obtained. In total, specific antidotes were used 161 times for 127 (16.4%) subjects, and hemodialysis was applied to 87 (11.2%) subjects. The most commonly used specific antidotes were ethyl alcohol (n=46, 28.6%), oxygen (n=22, 13.7%) and fomepizole (n=21, 13.0%) . The number of subjects treated in the ICU was 107 (13.8%), the number of subjects treated in the service was 393 (50.8%). The mean length of stay in the hospital (including the observation period in the ED) was 5.9 ± 9.9 days, and the average cost per subject was calculated as approximately 1762.6 ± 4787.6 TL. Mortality due to poisoning occured in 34 (4.4%) of the subjects (Table 3). A statistically significant relationship was found between unintentional poisoning and mortality, one of the poisoning mechanisms (P < .001). The statistical significance between the subjects who used antidote and the subjects who underwent hemodialysis and mortality was high (p values, respectively: P < .001, P < .001). In the mortality group, the mean age (44.4 ± 17.3) was found to be statistically significantly higher than the others (33.8 ± 15.3) (P = .004) (Table 3), but no statistical significance was found when looking at the age groups (P = .210). No statistically significant was found between gender, poisoning time, exposure to more than one substance, duration of hospitalization and mortality (p values, respectively: P = .240, P = .603, P = .886, P = .487).

Discussion

Poisoning is a universal public health problem that especially threatens the young population. It constitutes an important patient group among critically ill patients admitted to the ED. This study is one of the rare studies that contain up-to-date information in large case series in the field of toxicology in Turkey.^2,3 The prevalence of poisoning cases admitted to the ED varies according to countries, regions, cities and hospitals.^2-7 In the present study, this rate was found to be 0.25% and it is similar to studies conducted in recent years.^3,5 In many studies conducted in Turkey and in the world, it has been reported that poisoning cases are more common in women.^2-5 The number of studies reporting that male subjects are in the majority is less.¹⁰ In this study, the majority of subjects (61%) were male. Similar to other studies in the literature, the majority of subjects (63.7%) are adults between the ages of 18-45.^2-5 It has been reported in previous studies that hospital admissions are most common in the hours before midnight.^3,5 In this study, the highest number of admissions was during the daytime hours between 08:00 and 15:59 (n=319, 41.2%). Looking at the number of cases by year, it is seen that the least number of cases is in 2020. This may be related to the significant decrease in the number of patients admitted to the hospital in the first period of the Covid-19 pandemic. Among all poisoning cases, the most reported case as the cause of poisoning was suicidal attempt.^3,5 and in this study, the rate of suicidal attempt was found to be 52.6%. When the number of suicide attempts by months was analyzed, no significant difference was found (P = .285). Subjects poisoned more than one exposed substance were 21.6% of all subjects. Poisonings occurred mostly with medications (56.2%). Among the medications, poisoning with antidepressants and analgesic-myorelaxant drugs take place in the first two ranks. Similar results were reported in two studies conducted with large patient groups in Turkey.^2,3 Although poisoning with alcohol and its derivatives (27.4%) and recreational drugs (5.6%) was found to be quite high compared to these two studies,^2,3 it is similar to many studies conducted abroad.^1,5,11,12 Intoxication with alcohol and its derivatives and drugs is 3-7 times more common in male than in female.¹³ In our study, male gender was detected more frequently. We think that this is due to the differences in the causes of poisoning. In addition to supportive treatment for poisonings, specific antidote treatments were administered to eligible subjects. Ethyl alcohol and fomepizole were at the top of the list of the most commonly used antidotes, similar to the high incidence of poisoning with alcohol and its derivatives. Poison counseling centers are institutions that provide regional or country-wide services for poisoning. Doctors called NPIC in the study for 60.6% of the subjects and received consultancy service. This issue is one of the important points emphasized by the authors. We recommend calling poison control centers in all cases in order to contribute to obtaining more accurate and reliable data on a national scale and to get information about current treatment approaches. A significant amount of the subjects admitted to the ICU consists of cases of poisoning. Mortality rates of 0.09-2.8% have been reported in previous studies.^2,12,14 In this study, the rate of hospitalization was 50.8%, the rate of admission to the ICU was 13.8%, and the mortality rate was 4.4%. When another study with similar hospitalization and ICU admission rates is examined, it is seen that the mortality rate was higher in this study.⁵ This may be explained by the higher number of subjects (11.2%) who underwent hemodialysis compared to other studies.⁹ Extracorporeal treatments such as hemodialysis are usually the treatment options used in high-dose or fatal toxicity situations where other treatment methods do not benefit.¹⁵ When the factors that may be associated with mortality are evaluated, the significance of the mortality rate in unintentional poisonings is higher than in other groups. (P < .001). This may be due to the inability to control the amount of the agent exposed in unintentional poisonings. The mortality rate was also statistically significant in subjects given specific antidote therapy and subjects underwent hemodialysis (p values, respectively: P < .001, P < .001). We think that this situation is related to high dose exposure. The length and cost of hospital stay were also calculated. The mean hospital stay of the subjects was 5.9 ± 9.9 days and the average cost to the healthcare system was calculated as 1762.6 ± 4787.6 TL. The psychosocial burden and losses caused by these cases on subjects, their relatives and healthcare workers are out of the scope of this study.

Conclusion

Poisoning especially threaten the young population. Hospitalization, ICU admission and mortality rates are high in poisonings, which creates a serious economic and social burden for the health system. The data obtained during present study can provide important and up to date information about the characteristics of poisoning cases seen in this region, and can guide the preventative actions for cases of poisoning. There is a need for more extensive and detailed studies across the country in order to better understand poisonings and raise awareness on this issue.

Declarations

References

1. Lam SM, Lau AC, Yan WW. Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China. Hum Exp Toxicol. 2010;29(9):757-765. doi:10.1177/0960327110361753
   Article · PubMed · Google Scholar
2. Avsarogullari L, Senol V, Akdur O, Akin A, Durukan P, Ozkan S. Characteristics of acute adult poisonings in a university hospital emergency department in central Turkey: a three-year analysis. J Pak Med Assoc. 2012;62(2):129-133.
   PubMed · Google Scholar
3. Zöhre E, Ayrik C, Bozkurt S, et al. Retrospective analysis of poisoning cases admitted to the emergency department. Arch Iran Med. 2015;18:117-122.
   PubMed · Google Scholar
4. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th annual report. Clin Toxicol (Phila). 2020;58(12):1360-1541. doi:10.1080/15563650.2020.1834219
   Article · PubMed · Google Scholar
5. Kristinsson J, Palsson R, Gudjonsdottir GA, Blondal M, Gudmundsson S, Snook CP. Acute poisonings in Iceland: a prospective nationwide study. Clin Toxicol (Phila). 2008;46(2):126-132. doi:10.1080/15563650701438268
   Article · PubMed · Google Scholar
6. Schaper A, Ebbecke M. Intox, detox, antidotes: evidence-based diagnosis and treatment of acute intoxications. Eur J Intern Med. 2017;45:66-70. doi:10.1016/j.ejim.2017.10.019
   Article · PubMed · Google Scholar
7. Chen CK, Chan YL, Su TH. Incidence of intoxication events and patient outcomes in Taiwan: a nationwide population-based observational study. PLoS One. 2020;15(12):e0244438. doi:10.1371/journal.pone.0244438
   Article · PubMed · Google Scholar
8. Irwin RS, Rippe JM, eds. Irwin and Rippe's Intensive Care Medicine. 6th ed. Tulunay M, Cuhruk H, eds; Turkish translation. Güneş Tıp Kitabevleri; 2014:1433.
   PubMed · Google Scholar
9. Koylu R, Dundar ZD, Koylu O, et al. The experiences in a toxicology unit: a review of 623 cases. J Clin Med Res. 2014;6(1):59-65.
   PubMed · Google Scholar
10. Bjornaas MA, Hovda KE, Mikalsen H, et al. Clinical vs laboratory identification of drugs of abuse in patients admitted for acute poisoning. Clin Toxicol (Phila). 2006;44(2):127-134. doi:10.1080/15563650500514384
    Article · PubMed · Google Scholar
11. Singh O, Javeri Y, Juneja D, Gupta M, Singh G, Dang R. Profile and outcome of patients with acute toxicity admitted in intensive care unit: experiences from a major corporate hospital in urban India. Indian J Anaesth. 2011;55(4):370-374. doi:10.4103/0019-5049.84860
    Article · PubMed · Google Scholar
12. Lund C, Teige B, Drottning P, et al. A one-year observational study of all hospitalized and fatal acute poisonings in Oslo: epidemiology, intention and follow-up. BMC Public Health. 2012;12:858. doi:10.1186/1471-2458-12-858
    Article · PubMed · Google Scholar
13. Fiscella K, Noonan M, Leonard SH, et al. Drug- and alcohol-associated deaths in US jails. J Correct Health Care. 2020;26(2):183-193. doi:10.1177/1078345820917356
    Article · PubMed · Google Scholar
14. Goksu S, Yildirim C, Kocoglu H, Tutak A, Oner U. Characteristics of acute adult poisoning in Gaziantep, Turkey. J Toxicol Clin Toxicol. 2002;40:833-837. doi:10.1081/clt-120016953
    Article · PubMed · Google Scholar
15. Ouellet G, Bouchard J, Ghannoum M, Decker BS. Available extracorporeal treatments for poisoning: overview and limitations. Semin Dial. 2014;27(4):342-349. doi:10.1111/sdi.12238
    Article · PubMed · Google Scholar

Tables

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions