Pattern and outcome of poisoning at DHQ Hospital Rawalpindi Dr.Touseef Mehmood PGR Medicine

Case 1

A 30 years old male a brick Kiln workerPresented in DHQ ER with suicidal ingestion of one packet(30 grams)of Kala Pathar 6 hours ago.

Presenting complaints

Swollen neck and face Dyspnea Altered level of consciousness Passage of dark coloured urine Generalized body pains

…

Patient was in obvious distress with swollen neck and face;

Examination also revealed cyanosis both peripheral and central.

Vitals at the time of presentation

Pulse 110 bpm regular Bp 90/60 mmHg Temp 98.6Resp Rate 30 /min

Systemic examination

Altered mental status with GCS of 10/15

(confused speech and drowsiness)

On Auscultation of chest bilateral crepitations were audible

Abdominal examination tender epigastrium

Management The patient was immediately resuscitated

Airway and breathing maintained with intubation and oxygen inhalation

IV fluids and antibiotics given

Gastric lavage carried out with normal saline and charcoal

Patient’s haemodynamic status continued to deteriorate!

…Patient shifted to intensive care unit

Inotropic support started alongwith CVP guided fluids

Other supportive measures included steroids,soda bicarbonate and calcium gluconate.

Methylene blue and exchange transfusions

Investigations

Blood complete picture showed neutrophilic leucocytosis

ECG showed sinus tachycardia

Urinalysis showed brown coloured urine with WBC casts and albuminuria(+)

pH 7.32 7.35-7.45

pO2 116 83-108

pCO2 29.5 35-45

HCO3 14.9 21-28

ABGs

Test Result Unit Normal Range

ALT 270 U/L 43

Urea 25 mg/dl 12-45

Na 137 mmol/l 135-145

K 4 mmol/l 3.5-5

Cl 100 mmol/l 98-108

Chemistry

Test Result Unit Normal

ALT 547 U/L 43

Alkaline Phosphatse

312 U/L 65-360

Urea 16 mg/dl 12-45

Creatinine 1.2 mg/dl Upto 1.2

Uric Acid 5.4 mg/dl 2-7

Na 140 mmol/l 135-145

K 5.9 mmol/l 3.5-5

Cl 107 mmol/l 98-108

Chemistry

Despite all our utmost efforts;

unfortunate patient died after 6

hours stay at hospital.

Case 2

A 26 yrs old male working in a textile industry brought to ER with suicidal intake of ½ cup of solution which is used to remove tags of clothes(benzole solution).

.

Complaining of palpitations,apprehension,epigastric discomfort and repeated episodes of vomiting,shortness of breath

..

A toxic looking patient highly irritable,apprehensive and in respiratory distress

..Vitals

Pulse 110 bpm

B.P 100/60 mmHg

Temp. 98.6

Respiratory rate 36/min

Systemic examination was unremarkable other than bilateral ronchi in chest on auscultation and epigastric tenderness

Management

Patient resucitated with oxygen,back to back nebulization and IV fluids.

Gastric lavage carried out with normal saline and charcoal.

…

Patient shifted to intensive care unit for further investigations and management

…

Supportive care with

steroids,antibiotics,fluids,soda bicarb

and proton pump inhibitors continued.

Methylene blue was given at this stage.

Exchange transfusion carried out according to haematologist advice.

Progress

Dark coloured urine (day1)

Cyanosis (day2)

Ventilatory support (day2)

Central line (day2)

Day1 Day2 Day3 Day4

Blood Pressure

125/80 130/90 155/90 70 systolic

SaO2 87% 77% 68% 65%

GCS 15/15 8/15 5/15 3/15

Out Put 700ml

Investigations

Blood complete picture

RBS 136 mg /dl

ECG sinus tachycardia

Parameter

ResultDay1

ResultDay2

Result Day4

Unit Reference Range

WBCs 15.1 18.3 27.2 109 per liter

4-11x109 per liter

Neutrophils

82% 88% 93% 54-62

Hb 13.6 11.6 10.2 g/dl 13.5-17.5 g/dl

Plt 215 188 129 109 per liter

150-450 x 109 per liter

Urinalysis showed brown coloured urine

Colour Brown

Turbidity +ve

pH 6.5

Sediment +ve

Sp gravity 1.025

Urobilinogen Normal

Pus cells 4-5

RBCs 1-2

Crystals 0-1

Casts WBC

Albumin +ve

Glucose Nil

Day1 Day4

pH 7.36 7.3 7.35-7.45

pCO2 36.5 32.5 35-45

pO2 80 78 83-108

HCO3 23.5 18.5 21-28

ABGs

Test ResultDay1

Result Day2

Result Day3

Result Day4

Unit Normal

ALT 45 75 105 123 U/L 43

Alkaline Phosphatse

312 346 378 U/L 65-360

Urea 43 86 106 116 mg/dl 12-45

Creatinine

1.8 2.1 2.3 mg/dl Upto 1.2

Uric Acid 6.8 6.9 7.1 mg/dl 2-7

Na 137 140 142 140 mmol/l 135-145

K 4 4.3 4 4.5 mmol/l 3.5-5

Cl 100 103 107 105 mmol/l 98-108

Chemistry

Patient developing multiorgan failure…

..

But patient failed to maintain vitals and ultimately went into cardiorespiratory arrest and could not be revived..

He died after 4 days stay at hospital

Case 3

A 26 years old presented in ER with suicidal ingestion of 2 tablets of wheatpill(aluminium phosphide)1 and a half hour ago.

..

Complaining of multiple episodes of vomiting..

..

A young anxious looking female with vitals of

Bp 110/70

Pulse 86/bpm

T 98.6 F

R/R 18/min

Systemic examination was unremarkable..

Investigations

Blood complete picture

RBS 128 mg /dl

ECG

Parameter Result Unit Reference Range

WBCs 11.6 109 per liter 4-11x109 per liter

Neutrophils 79.8% 54-62

Hb 12.7 g/dl 13.5-17.5 g/dl

Plt 179 109 per liter 150-450 x 109 per liter

pH 7.34 7.35-7.45

pCO2 29.5 35-45

pO2 116 83-108

HCO3 17.9 21-28

ABGs

Colour Yellow

Turbidity +ve

pH 6.2

Sediment +ve

Sp gravity 1.025

Urobilinogen Normal

Pus cells 6-7

RBCs 1-2

Crystals 0-1

Casts Nil

Albumin -ve

Glucose Nil

Urine analysis

Test Result Unit Normal

ALT 42 U/L 43

Alkaline Phosphatse

326 U/L 65-360

Urea 35 mg/dl 12-45

Creatinine 1.1 mg/dl Upto 1.2

CKMB 25 IU/L Upto 25

Na 140 mmol/l 135-145

K 4.1 mmol/l 3.5-5

Cl 107 mmol/l 98-108

Chemistry

.. Gastric lavage carried out with 1lit of edible

oil and charcoal.

Supportive management done with iv fluids,magnesium sulphate,calcium gluconate

steroids,antibiotics and PPIs.

Continuous cardiac monitoring done. ECG&ABGs 12 hourly Amiodarone Strict vitals monitoring and input output

charting done.

..

Standard protocol treatment continued for 4 days during hospital stay.

Stay remained uneventful and patient discharged in a healthy state and

referred to psychiatry department.

Case 4

A 22 years old female presented with suicidal ingestion of 2 teaspoonfull of rat killing granules;2 hours before presentation to Emergency department.

..

Presented with complains of

frothing,

shivering,

urinary and fecal incontinence,

multiple episodes of vomiting and

abdominal cramps.

..

Vitals showed bradycardia

Bp 100/70

Pulse 58/min

T 98.6F

r/r 22/min

..Systemic examination revealed

Bilateral crepitations in chest on auscultation

GCS 9/15 and pinpoint pupils

Hyperactive Bowel sounds

Rest of the examination was unremarkable

Management

Airway maintained and oxygen administered

Deep throat suctioning carried out.Fluids given.Gastrointestinal decontamination

done with normal saline and charcoal.

…

Specific antidotes pralidoxime and atropine given per protocol.

Investigations

Blood complete picture

RBS 119 mg /dl

ECG

Parameter Result Unit Reference Range

WBCs 12.1 109 per liter 4-11x109 per liter

Neutrophils 82.8% 54-62

Hb 13.1 g/dl 13.5-17.5 g/dl

Plt 198 109 per liter 150-450 x 109 per liter

pH 7.42 7.35-7.45

pCO2 33.7 35-45

pO2 82 83-108

HCO3 23.6 21-28

ABGs

Colour Yellow

Turbidity -ve

pH 6.9

Sediment -ve

Sp gravity 1.025

Urobilinogen Normal

Pus cells 4-5

RBCs 3-4

Crystals 0-1

Casts Nil

Albumin -ve

Glucose Nil

Urine analysis

Test Result Unit Normal Range

ALT 41 U/L 43

Urea 39 mg/dl 12-45

Na 139 mmol/l 135-145

K 3.95 mmol/l 3.5-5

Cl 103.5 mmol/l 98-108

Chemistry

Test Result Unit Normal

ALT 42 U/L 43

Alkaline Phosphatse

278 U/L 65-360

Urea 35 mg/dl 12-45

Creatinine 1.0 mg/dl Upto 1.2

Na 140 mmol/l 135-145

K 4.1 mmol/l 3.5-5

Cl 107 mmol/l 98-108

PT 15 sec 13

aPTT 28 sec 27

Chemistry

…

Standard therapy continued for 3 days.

Patient improved and recovery was uneventful.

Dischrged after 3 days stay in a stable state and referred for psychiatric

evaluation.

Cases of poisoning received by DHQ

Rawalpindi in 3 months from JAN

till march 2015

Cases of Poisoning seen at ER in 3 Months

Acid/corrosive 31

Wheat pill 35

Organophosphate/Rat pill 104

Opioid 3

Benzodi-azepine 25

Mixed 11Kalapathar 1

Kerosine oil 1

Paracetamol 6

NSAIDs 7

Unknown 25

Poisoning 239

Cases of Poisoning seen at ER in 3 Months

12%14%

42%

1%

10%4%

0.4%

0.4%2%

3%

10%Total Cases 239

Acid/corrosive 31Wheat pill 35Organophosphate/Rat pill 104Opioid 3Benzodiazepine 25Mixed 11Kalapathar 1Kerosine oil 1Paracetamol 6NSAIDs 7Unknown 25

Cases of Poisoning seen at ER in 3 Months

Acid/corrosive 3113%

Wheat pill 3514%

Organophosphate/Rat pill 10442%

Opioid 31%

Benzodi-azepine 25

10%

Mixed 115%

Kalapathar 10.4%

Kerosine oil 10.4%

Paracetamol 6

2%NSAIDs 7

3%

Unknown 2510%

Total Cases 239

Mortality of Poisoning patients in 3 months

Wheat pill 6

Organophosphate2

Unknown 3

Opioid 1

Kalapathar 1

Others 1Deaths due to poisoning 14

Mortalty of Poisoning patients in 3 months

Total Cases239

Deaths 146%

Deaths due to poisoning

Mortalty of Poisoning patients in 3 months

Total Cases104

Deaths 22%

Mortality of organophosphate poisoning

Mortalty of Poisoning patients in 3 months

Total Case

s35

Deaths 617%

Mortality wheat pill poisoning

Mortalty of Poisoning patients in 3 months

Total Cases 25

Deaths 312%

Mortality unknown poisoning

Mortalty of Poisoning patients in 3 months

Total Cases

3

Deaths 133%

Mortality opioid poisoning