Central Annals of Public Health and Research

Cite this article: Raut A, Pawar A, Shaj K, Dave P (2017) Treatment Approaches for Management of Poisonings in India. Ann Public Health Res 4(4): 1068.

*Corresponding authorAsawari Raut, Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth Deemed University, Pune-411043, India, Tel: 8805058493; Email:

Submitted: 17 July 2017

Accepted: 28 August 2017

Published: 30 August 2017

Copyright© 2017 Raut et al.

OPEN ACCESS

Keywords•Intentional poisoning; Awareness; Poisoning

management; Inhalational poisoning

Research Article

Treatment Approaches for Management of Poisonings in IndiaAsawari Raut1*, Atmaram Pawar1, Kavya Shaj1, and Priti Dave2

1Department of Clinical Pharmacy, Bharati Vidyapeeth Deemed University, India2Department of Medicine, Bharati Vidyapeeth Deemed University, India

Abstract

Background: Poisoning is a common medical emergency needing prompt medical interventions. The study focuses on pattern of toxic agents, drug utilization, management and outcome in poisonings reported.

Methods: The cross sectional study was carried out on patients admitted to two urban hospitals in Pune, Maharashtra from January 2014 - March 2016.

Results: Total 1078 cases of poisoning were reported with male (57.1%) predominance. The cases reported ranged from 8 months to 72 years old in age with a mean (± SD) 37.8 ± 27.3. Intentional poisoning was more common (53%). Route of exposure was mostly Ingestion (72.5%) followed by Bite/Sting (26.4%), Inhalational (0.8%), Injection (0.1%) and Eye (0.1%). Household and agricultural agents (56.4%) were associated with most poisoning followed by Animal Bites and Stings (26.4%). The mortality reported was 9.7%. The management included Supportive treatment, Antidotes, and Enhanced Elimination Techniques. Supportive treatment was mainly with Gastro protective (94.3%) and Anti-Microbial (77.9%) agents. The antidote was used in 70.9% cases and mostly included Anti-Snake Venom (24.4%) followed by Atropine (21%) and Pralidoxime (18.1%). Enhanced Elimination Techniques included Gastric Lavage (76.3%), Nasogastric Aspiration (7.2%), Hemodialysis (0.1%), Activated Charcoal (4.5%) and Eye wash (0.1%).

Conclusion: The treatment approaches were based on parameters such as route of exposure, Toxic agent involved and age of the patient. The pharmacist can play a vital role in the recommendation of the rational management plan in Poisonings.

INTRODUCTIONAn estimated 193460 deaths occurred worldwide due to

poisoning as published by WHO of which a major proportion was from low and middle-income countries [1]. 110688 deaths due to poisoning were reported in India in 2012 according to a national report [2].

The outcome of poisonings is depended on the speed with which the patient is brought to medical care, understanding of the poison’s toxicity degree and the readiness of medical care [3]. The high mortality rate associated with poisoning is often related to a delay in diagnosis and/or improper management [4]. Globally, the management of the critically poisoned patient centers on careful supportive care and further maximized with appropriate decontamination, antidote administration, elimination enhancement and pharmaceutical interventions [5]. It hugely depends upon institutional protocols, healthcare facilities, and drugs. It is necessary for each medical setting to regularly evaluate and review drug utilization to rationalize drug use and enhance patients’ outcome [6]. Annual epidemiologic data on poisonings treated at each medical setting will also help to better handle and manage drug, antidote and other technical requirements [7].

Due to the paucity of information regarding poisoning cases in India, the introduction of new guidelines and updating current protocols needs knowledge of demographics and management of poisoning cases. To understand the interventions needed in the management of poisoning and define the role of health care professionals studies are needed to be conducted [8].

The study was conducted in Pune district in the state of Maharashtra in India. According to the most recent census in 2011, the total population was 9.4 million making it the 4th most populous district in India [9]. Pune has many industrial areas which provide easy accessibility of a large number of chemicals and pesticides resulting in the tremendous use of these agents for poisoning and the agricultural diversity has resulted in an increase of animal bites and stings and also accidental exposures to insecticides and pesticides. So far, this is the only study conducted in this area focusing on poisonings.

METHODOLOGYStudy area

The study was conducted in Pune district of Maharashtra, which resides a total population of 9.4 million inhabitants with a male to female ratio of 1.1:1. It forms a part of the tropical monsoon land and therefore shows a significant seasonal variation in temperature and rainfall.

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The Pune city resides many multi specialty hospitals. The Government hospital, a 380 bedded multi specialty hospital, is located in Pimpri – Chinchwad which engulfs a wide area of surrounding suburban and industrial areas like Aundh, Bhosri, Nigdi and villages like Moshi, Chikli, Dehu, etc. The private teaching hospital is a 900 bedded hospital with hi-tech super specialties. It is located in inner suburbs of Pune which includes areas like Katraj, Ambegaon, Vadgaon, Parvati Hill, etc. These are the industrial and agricultural areas where a high number of chemical or pesticide poisoning can be observed.

Population and sampling

The study was cross-sectional and made use of retrospective and prospective extraction of data from records available at the government and private teaching hospitals respectively. All cases of poisoning available in the medical record departments were included in the study.

Data collection and extraction

The records were collected from Medical Record Department of the respective hospitals. The data collection period was from January 2014 to March 2016. The cases were reviewed for gender, age, route, and reason of poisoning and agents, management, and drug utilization.

RESULT

Demography of poisoning cases

During the study period of 28 months, 1078 cases of poisoning were reported to the emergency department of the hospitals, out of which 616 (57.1%) were male and 463 (42.9%) were Female. The cases reported ranged from 8 months to 72 years old in age with a mean (± SD) 37.8 ± 27.3. This suggestive that on an average 38 cases was reported per month which demands attention to the situation. The reason for poisoning was primarily Intentional (53%) than Accidental (44.1%) and Unknown (3%) and Route of exposure was mostly Ingestion (72.5%) followed by Bite/Sting (26.4%), Inhalational (0.8%), Injection (0.1%) and Eye (0.1%). The agents responsible were categorized as Household and Agricultural Agents (56.4%), Animal Bites and Stings (26.4%), Drugs (10.8%), Miscellaneous (3.6 %) and Unknown (2.8%). Few Intentional poisonings were a mix of above agents and some with alcohol as well. Length of Hospital Stay ranged from 1-15 days with a mean (± SD) 2.5 ± 1.2. Mortality reported was 9.7% and Symptoms Improved in most (77.6%) cases but 12.7% were DAMA (Discharged against Medical Advice) or Absconded [Table 1].

Treatment approaches in poisonings

The Management of admitted poisoning cases was done by Symptomatic treatment, Antidote, and Other Enhanced Elimination Techniques. Symptomatic Treatment were done with following drugs: Anti-Microbial (77.9%), Gastro protective (94.3%), Anti-allergic (52.7), Anti-Inflammatory (39.3), Anti-Hypertensive (54%), Antipsychotics (44.1%), Supplements (5.6%), Anticonvulsants (3.5%), and Hormones (2.2%). In Antibiotics, mostly administered were Cephalosporin’s (29%), Amoxicillin+Clavulanic Acid (25.7%) followed by Metronidazole (14.4%) (Figure 1). Other drugs Mannitol and Perinorm were

used as an adjunct for eliminating toxins and diazepam for alcohol withdrawal symptoms. Oxygen Inhalation was given to patients with Inhalational poisoning with insecticides and petroleum. Antidotes were used in 70.9% cases and included Anti-Snake Venom (24.4%), Atropine (21%), Pralidoxime (18.1%), Rabipur (3%), N-Acetylcysteine (1.4%), Neostigmine (3.2%). Other Enhanced Elimination Techniques were also used. These Included Gastric Lavage (76.3%), Nasogastric Aspiration (7.2%), Hemodialysis (0.1%), Activated Charcoal (4.5%) and Eye wash (0.1%) [Table 2].

Management in different patient population

The usage pattern of Antidote and the Enhanced Elimination Techniques were observed in different patient population; Pediatric, Adult, and Geriatric for different toxic agents. In 276 cases of Pediatrics aged 0-18 years, Antidotes were given in 135 (48.9%), Gastric Lavage in 156 (56.5%), Nasogastric Aspiration in 12 (4.3%), Activated Charcoal in 24 (8.7%) and Eye Wash in 1 (0.4%). In 760 cases of Adults aged 19-55 years, Antidotes were given in 600 (78.9%), Gastric Lavage in 648 (85.3%), Nasogastric Aspiration in 66 (8.7%), Hemodialysis in 1 (0.1%), Activated Charcoal in 24 (3.2%). Finally, in 42 cases of Geriatric above age 55 years, Antidotes were given in 30 (71.4%) and Gastric Lavage in 18 (42.9%) [Table 3, Figure 2].

Treatment approach according to toxic agents

The treatment was recorded toxic agent wise. For Household and Agricultural agents, Atropine or Pralidoxime along with gastric lavage and/or nasogastric aspiration and/or activated

Table 1: Characteristics of Poisoning cases observed.Characteristics Number of casesDemographic Male 616Female 462Age (Mean ± SD) 37.8 ± 27.3Route Ingestion 782Injection 1Inhalational 9Bite/Sting 285Eye 1Reason Intentional 571Accidental 475Unknown 32Length of Hospital Stay (Mean ± SD) 2.5 ± 1.6Outcome Symptoms improved 836DAMA 137Death 105Agents Household and Agricultural 608Animal Bites and Stings 285Drugs 116Miscellaneous 39Unknown 30

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0

5

10

15

20

25

30

35

Perc

enta

ge o

f Pos

onin

g ca

ses

Anti Microbial Agent

Amoxicillin+Clavulanic

Ampicillin

Tetracycline

Doxycycline

Ciprofloxacin

Cotrimoxazole

Gentamicin

Metronidazole

Cephalosporins

Norfloxacin

Fluconazole

Figure 1 Usage Pattern of Anti microbial agent used for poison Management.

1 10 100 1000

Antidote

Gastric lavage

Nasogastric Aspiration

Hemodialysis

Charcoal hemoperfusion

Eye wash

AntidoteGastric lavageNasogastric AspirationHemodialysisCharcoal

hemoperfusionEye wash

Pediatric 135156120241Adult 600648661240Geriatric 30180000

Figure 2 Poisoning treatments in different patient population.

charcoal was done. Atropine was given IV with doses ranging from 0.1mg-2g, STAT or 1 to maximum 4 hourly in 24 hours. A close monitoring Heart Rate with target to keep below 100 beats/minute. Pralidoxime was given IV, Dose ranging from 500mg-2g with Normal Saline STAT or 2-8 hourly for 24 hours. Maintenance given in some cases was 500mg-1g with Normal Saline as Slow Infusion. For Animal Bites and Stings especially snake bite, ASV, and Rabipur for Dog bite were given. ASV was given as Test dose, 2-10 vials and in some cases as IV Infusion with Normal Saline or Dextrose Saline. Tetanus toxoid was given in unknown bites. For drugs, especially acetaminophen, N-Acetyl cysteine and/or gastric lavage were given. N-acetylcysteine effervescent tablets were given 500mg with water. For some Miscellaneous and unknown, Atropine was given. Oxygen Inhalation was given for inhalational exposure by insecticides and petroleum. Eye wash was done in eye exposure of household agent. All poisonings were also provided supportive treatment [Table 4, Table 5].

DISCUSSIONPoisoning cases brought to Emergency Departments are very

common in India and the study shows that on an average 38 cases are reported per month and this is due to easy availability of toxic agents, occupational exposures mainly ones involved in agriculture and no awareness particularly in rural areas [10]. In this study, a male predominance was observed which the similar pattern is observed by other studies in India [11-13]. This trend may be due to increased occupational hazard and exposure of men to stress being the earning members compared to women. In this study, most of the cases were between 19-55 years of age similar to the trend in other Indian studies and may be due to domestic, educational and employment related stress [12-14].The most common reason behind poisoning was intentional which was observed in 57.1% of cases [15].

Household and agricultural agents were associated with most intentional poisoning due to easy availability of these agents and inadequate knowledge to support their safe residential use [16]. Studies have shown that pesticide is the most common toxic agent involved in poisoning [15,17,18]. Animal bites and stings were the most common cause of accidental poisoning which

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Table 2: Treatment Methods for poisoning cases.Treatment Cases Number (Percentage)SymptomaticAnti-microbial agent 840 77.90%Gastroprotective agent 1017 94.30%Anti-allergic 568 52.70%Anti-inflammatory 424 39.30%Anticonvulsants 38 3.50%Hormones 24 2.20%Anti-hypertensive 582 54.00%Anti-psychotics 475 44.10%Supplements 60 5.60%Alcohol withdrawal 235 21.80%Enhance Elimination 8 0.70%Oxygen Inhalation 9 0.80%Tetanus toxoid 24 2.20%AntidoteASV 263 24.40%Atropine 226 21.00%Pralidoxime 195 18.10%Rabipur 32 3.00%N-Acetylcysteine 15 1.40%Neostigmine 34 3.20%Other Enhanced EliminationGastric lavage 822 76.30%Nasogastric Aspiration 78 7.20%Hemodialysis 1 0.10%Charcoal hemoperfusion 48 4.50%Eye wash 1 0.10%

Table 3: Management of Toxic Agents in Different Patient Population.

Management of Poisoning

Pediatric/Adult/Geriatric [Cases (Number)]

TotalToxic AgentsHousehold and Agricultural Drugs Animal Bites and

Stings Miscellaneous Unknown

Antidote 57/315/18 3/39/0 75/228/12 - 0/18/0 765

Gastric lavage 105/528/15 21/87/3 - 12/12/2000 18,21,0 822

Nasogastric Aspiration 12/24/2000 0/42/0 - - - 78

Hemodialysis - 0/1/0 - - - 1

Activated Charcoal 3/14/2000 3/10/2000 - 18/0/0 - 48

Eye wash 1/0/0 - - - - 1Pediatric : 0 - 18 yearsAdult: 19-55 yearsGeriatric: 56 +

was contrary to findings of the studies conducted in South India where most accidental poisonings was due to household poisons [19-20]. This may be due to the difference in geography and occupation. The Length of Stay recorded in this study was 2.4 ± 1.2 days which is much lesser than an Indian study which showed 5.4 ± 3.8 days [21]. Moreover, in the present study the mortality was 9.7% of patients which is lesser than other studies in India which showed in range of 10-20% [21,22]. This may be due to number of factors such as nature of poison, dose consumed, level of available medical facilities and time interval between intake of poison and provision of medical help. The lesser mortality and

length of stay might also be indicative of better management strategies which were observed in this study [Table 6].

The management strategies in the present study included Symptomatic Treatment, Antidote, and other Enhanced Elimination Techniques. Symptomatic Treatment with Supportive care played a vital role in managing acute poisonings. The Symptomatic Treatment mainly involved usage of gastroprotective agents like PPIs, H2 Blockers, Antacids, Antiemetic as well as laxatives which were observed in other studies too [21,22]. Antimicrobials were prescribed to 77.9% patients and most used were cephalosporins, followed by penicillin and Metronidazole.

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Table 4: Treatment for specific Toxic Agents.

Toxic Agent Antidote Enhanced Elimination techniques Supportive Treatment

Household and Agricultural

Gastroprotective agents, Anti-allergic, Anti-microbial, Anti-inflammatory

Insecticides and Atropine and Pralidoxime

Gastric Lavage, Nasogastric Aspiration and Activated CharcoalPesticides

Corrosive agents Atropine Gastric Lavage, Nasogastric Aspiration

Animal Bites and Stings

Anti-Inflammatory, Anti-microbial agent, Anti-allergic, Gastroprotective ,

Snake Bite ASV

Scorpion Bite

Dog Bite Rabipur

Insect Sting

Unknown Bite

Drugs N Acetyl cysteine Gastric Lavage Anti-allergic, Anti-inflammatory, Gastroprotective agents

Miscellaneous and Unknown Atropine Gastric Lavage Gastroprotective agents, Anti-allergic, Anti-microbial, Anti-inflammatory

Table 5: Dosing of Antidotes given in poisonings.

Agent Antidote Dosing Recommended Study

OP and Carbamate Poisoning

Atropine IV: 0.03-0.05 mg/kg q10-20min PRN to effect; then q1-4hr for at least 24 hours

IV: 0.1mg-2g, STAT or1-4 hourly for 1 day*Monitor Heart Rate(Keep < 100)

Pralidoxime

IV loading dose followed by continuous infusion: 20-50 mg/kg/dose (not to exceed 2 g/dose) infused IV over 15-30 minutesMaintenance: 10-20 mg/kg/hr IV continuos infusion

IV: 500mg-2g with Normal Saline ,STAT or 2-8 hourly.

Maintenance: 500mg-1g slow infusion

Snake Bite ASV ASV Test Dose: Initial Dose 8-10 vials IV Infusion: 5-10 ml/kg body weight (2ml/min)

ASV Test Dose: 2-10 vialsIV Infusion: 2-10 vials with Normal OR Dextrose Saline.

Acetaminophen N-Acetyl Cysteine PO: 500mg-2.5g PO: 500mg stat

Similar Usage was found in other Indian studies [21,22]. Though there is no evidence of anti microbial therapy benefit in poisoning trials [23,24], improvement in symptoms were observed in patients with Cellulitis post-Snake Bite in the study. Anti allergic agents like Avil, Phenergan, and Hydrocortisone were preferred in 52.7% patients. Anti Inflammatory and Anti Spasmodic Buscopan and Dexamethasone were given in 39.3% patients, Iron and Calcium supplementation were also given in 5.6% patients. Anti Psychotics (44.1%) were introduced or continued in patients who attempted self-poisoning. Adrenaline and Anti-Hypertensive’s were used on patients with cardiac co morbidities. Anticonvulsants Carbazepine and Phenytoin were given to ones with k/c/o seizure disorders. Mannitol and Perinorm were also given in poisonings to enhance the elimination to avoid neurotoxicity. Dopamine was used in patients who were severe and progressed to Cardiogenic Shock. As many cases had mixed the toxins with alcohol and some were a chronic alcoholic, Diazepam was given to manage the withdrawal symptoms.

In the study, Antidotes ASV (dose range1-10vial), Atropine (dose range: 0.1mg-2mg), Pralidoxime (dose range: 500mg-2g) were used widely. Rabipur was preferred in dog bites and unknown bites sometimes. The dosing of Antidotes given in study

subjects was compliant with dosing recommendation given in drug databases [25,26]. The study found the considerably good use of Enhanced elimination techniques along with pharmacotherapy which was not the case in Indian studies. Gastric Lavage was considered in 76.3% and Nasogastric Aspiration in 7.2% cases. Even lesser popular Hemodialysis (0.1%) and Activated Charcoal (4.5%) was attempted in our study settings.

Toxic Agent wise approach was also studied. The first class of Household and Agricultural agents could be further categorized into two; Pesticides and Corrosives. In cases of Pesticides and Insecticides, Antidotes Atropine and Pralidoxime were used and Gastric lavage was done with Potassium Permanganate or Normal Saline or Plain Water. Activated Charcoal alone or with Gastric Lavage was also considered. Nasogastric Aspiration was also included with or without Gastric Lavage. Whereas in case of Corrosive substances, Antidote given was Atropine and for acute poisonings, gastric lavage with or without nasogastric aspiration was also done. Some poisonings were a mixture of both insecticides and Corrosives. As such cases were acute, above approaches were considered. In our study, there were 9 cases of inhalational poisonings by insecticides and petroleum. These were managed by Atropine and Oxygen Inhalation along

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Table 6: Classification of toxic agents according to ICD-10 2017.Type of Poison ICD-10 CODE No. of casesHousehold & Agricultural Agents OPP and Carbamate T60.0 162Other Insecticides T60.2 34Rodenticides T60.4 35Other pesticides T60.8,9 3Kerosene T52.0 24Phenol and Related Agents T54.0 42Corrosives Acids and Alkali T54.1/2/3/9 13

Antiseptics and Disinfectants Classify based on composition 50

Specific inorganic substance T57.8 1Other organic solvents T52.8 2Alcohol T51 36Soap and detergent T55 1Aluminium Phosphide T57.1 2Organochlorine T53 6Herbicides-Paraquat T60.3 35DrugsAntibiotic T36 2Anti infectives and antiparasitic T37 10

Hormones and Synthetic substitutes T38 1

Non opioid analgesics and antipyretics T39 20

Anti epileptic, Sedative Hypnotics T42 8

Psychotropic T43 5Hematological, Antiallergic T45 3Cardiac Stimulant glycoside T46.0 2Gastroprotective agents T47 2Vaccines and unknown medication T50 10

Topical lotion T49 1Respiratory T48.5 3Animal Bite & StingsSnake T63.0 126Scorpion T63.2 7Bee/Wasp T63.4 39Unknown bite T63.9 33Dog bite, Rat bite 52MiscellaneousFood Poisoning Fish T64 4Lizard in Food T62.8 5Stale food contaminated T64 19Parts of plants T62.2 6Poisoning by antidote, Chelating agent T50.6 9

Fumes/Gases Vapors T65 4Unknown T65.9 18

with Symptomatic Treatment. A pediatric case of accidental eye exposure to insecticide was managed by eye wash.

The second class of Animal Bite and Stings type of Poisonings could be further classified as Snake Bites, Scorpion Bites, Dog

Bites, Insect Stings and Unknown Bites. Snake Bite Treatment approach was according to The Snake Bite Treatment Guideline by AIIMS, Delhi with Anti-Snake Venom for mild to severe envenomation. Neostigmine was given along with ASV for neurotoxic snake bites. ASV related anaphylaxis reaction was also seen in 15 patients who were treated with epinephrine. Scorpion Bite Management was Symptomatic with Gastroprotective, Anti inflammatory and sometimes cardio protective agents. Dog Bite was treated with Rabipur Vaccination. Insect Stings and Unknown Bites were treated symptomatically. Unknown Bites which were Severe and showed similar symptoms to Snake Bites were administered ASV. The Third class of Drug poisonings was mainly due to Antibiotics, NSAIDs, Acetaminophen, and mix of various medications. The treatment was mainly Symptomatic. N-Acetylcysteine was used for Acetaminophen toxicity. Gastric Lavage is also considered along with symptomatic treatment. In our study, Hemodialysis was performed on a patient with severe Carbamazepine overdose. For other classes of Miscellaneous and Unknown poisonings, the approach was mainly symptomatic. Gastric lavage was also done.

The overall treatment strategy focused on lesser absorption and faster elimination of toxins. Also, the treatment approaches were based on parameters such as route of exposure, Toxic agent involved and age of the patient. This demands the need for a proper guideline for the management of poisonings in all tertiary care settings in India. Well equipped settings can not only reduce hospital stay but can play a vital role in lowering mortality. Expert training is needed for managing particularly poisoning patients in the country with such huge population and poison exposure rates. As poisoning management can be described as the use of chemicals to tackle harmful chemical effects, choice of drugs plays a vital role. Pharmacists can help in the recommendation of the treatment plan and rational drug use in these cases which can help in effective management with economic benefits to patients [17]. Apart from this, the pharmacist can assist in history taking and assessment as well patient and community education.

The limitation was that Poor maintenance of records was frequently observed in the government setting and Cases referred from other hospitals lacked detailed patient history. Very few studies on poisoning targeted cases have been done in the country with over 1.2 billion population. More studies should be encouraged in different hospital settings and geographical areas to study the pattern of poisoning, its morbidity, and mortality. A long term prospective study is needed in case of poisoning for understanding the clinical pattern and management techniques which can help in intervention for a better outcome. An urgent need to implement preventative and intervention strategies to combat suicide needs national emphasis and awareness measures.

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Raut A, Pawar A, Shaj K, Dave P (2017) Treatment Approaches for Management of Poisonings in India. Ann Public Health Res 4(4): 1068.

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