Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 13  |  Issue : 2  |  Page : 71--75

A retrospective analysis of acute organophosphorus poisoning cases admitted to the tertiary care teaching hospital in South India


M Rajesh Kumar1, GP Vignan Kumar2, P Ramesh Babu1, S Satish Kumar3, BV Subrahmanyam4, M Veeraprasad5, P Rammohan6, M Srinivas3, Amit Agrawal7,  
1 Department of Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Pulmonary Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
3 Department of Emergency Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
4 Department of Forensic Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
5 Department of Hospital Administration, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
6 Department of Pharmacology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
7 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Correspondence Address:
M Rajesh Kumar
Department of Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India

Abstract

Objectives: We have herein reported our experience with the pattern of presentation of cases of acute organophosphorus (OP) poisoning cases in a tertiary care hospital. Materials and Methods: This retrospective study evaluated the hospital records of patients with acute OP poisoning. In a pre-structured proforma, data regarding age, sex, time elapsed after intake, circumstances of poisoning, duration of hospitalization, severity, complications, and outcome of the patients were recorded. The data were presented as mean ± standard deviation, entered in the open office datasheet, and analyzed with PSPP software. Results: A total 101 patients were included in the study. Young adult males were more commonly involved than females (M:F 2.5:1). The mean age of the patients was 28 years (range 2-72 years, SD ± 14.3 years). Mean time to receive treatment was 5.2 ± 7.4 (range 1-48 h). About 45.5% patients received first aid before coming to the hospital. The reason was suicide in 88.1% cases and accident in 12 (11.9%, all children). Seventy-nine patients received pralidoxime (PAM) and the mean duration was 1.7 ± 1.1 (range 1-4 days). Atropine was given in all patients. Mean duration was 5.1 ± 3.1 (range 1–19 days). Mean hospital stay was 7.5 ± 4.7 days (range 1–26 days). Mortality was 9.9% in the present series. Conclusion: Although the present study contribute substantial information regarding the epidemiology and outcome of acute OP poisoning in a tertiary care teaching hospital at a district level, its relatively small sample size and the retrospective record-based nature are the major limitations of the present study. There is a further need for prospective studies to understand the underlying socio-economic factors responsible for acute OP poisoning in our population, and, accordingly, address the problems to reduce the incidence of acute OP poisoning cases.



How to cite this article:
Kumar M R, Vignan Kumar G P, Babu P R, Kumar S S, Subrahmanyam B V, Veeraprasad M, Rammohan P, Srinivas M, Agrawal A. A retrospective analysis of acute organophosphorus poisoning cases admitted to the tertiary care teaching hospital in South India.Ann Afr Med 2014;13:71-75


How to cite this URL:
Kumar M R, Vignan Kumar G P, Babu P R, Kumar S S, Subrahmanyam B V, Veeraprasad M, Rammohan P, Srinivas M, Agrawal A. A retrospective analysis of acute organophosphorus poisoning cases admitted to the tertiary care teaching hospital in South India. Ann Afr Med [serial online] 2014 [cited 2019 Dec 5 ];13:71-75
Available from: http://www.annalsafrmed.org/text.asp?2014/13/2/71/129876


Full Text

 Introduction



Organophosphorous (OP) compounds (the anticholinesterases) are used as insecticides, pesticides, herbicides, and chemical warfare agents. [1],[2],[3],[4] OP compound's easy availability is responsible for increasing incidences of pesticide poisoning and it being a major cause of morbidity/mortality that poses public health problem in developing countries, including India. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] World Health Organization (WHO) and several other studies have estimated that OP pesticides were responsible for majority of self-attempted deaths in the developing world. [2],[4],[5],[6],[12],[13],[14],[22],[23] In this study, we have reported our experience with the pattern of presentation of cases of acute OP poisoning cases in a tertiary care hospital.

 Materials and Methods



This retrospective study was conducted in a tertiary care teaching hospital in Andhra Pradesh, India. Hospital records of patients with acute OP poisoning from the year 2008 to 2012 were reviewed. In a pre-structured proforma, data regarding age, sex, time elapsed after intake, circumstances of poisoning, duration of hospitalization, severity, complications, and outcome of the patients were recorded along with the details of general physical examination, systemic examination, laboratory investigations, and management offered. Mild intoxications were defined by symptoms of miosis, rhinorrhea, lacrimation, and mild abdominal pain without difficulties in respiration and without disturbances of consciousness. Moderate cases were defined as having aggravation of the latter symptoms with additional complaints of the respiratory and gastrointestinal systems. Severe cases were defined as having, in addition to the previous symptoms, loss of consciousness, convulsions, or respiratory depression. Ethical clearance was obtained from the ethical review committee, Narayana Medical College and Hospital. Patients included in the study followed a standard treatment guideline of organophosphate poisoning in our hospital. All the patients were given gastric lavage and their skin was thoroughly cleansed with water at the time of admission. Activated charcoal was administered in a selected group of patients. Atropine and pralidoxime (PAM) were administered in accordance with the protocol of the hospital. Injection PAM was given patients at a dose of 1–2 g intravenous (IV) bolus, followed by 500 mg/h (IV) for 3 days. Injection atropine 1–2 mg IV stat. was administered, followed by 5–10 mg/h according to the clinical condition. All the patients were closely monitored with ECG, SpO 2 . ABG (define), and chest X-ray as per the requirement. Patients were ventilated when there was an evidence of respiratory failure. Injection glycopyrrolate was given to patients who had excessive bronchial secretions. Weaning from mechanical ventilation was as per the standard protocol. Data were presented as mean ± standard deviation, entered in the open office datasheet, and analyzed with PSPP software. To analyze the variables multivariate linear regression and multivariate logistic regression analysis (as appropriate) were used. A p-value of less than 0.05 was considered statistically significant.

 Results



A total of 101 patients were included in this study. Young adult males were more commonly involved than females (M:F of 2.5:1) [Figure 1]. The mean age was 28.0 years (range 2-72 years, SD ± 14.4 years). Mean time to receive treatment was 5.2 ± 7.4 (range 1-48 h). By occupation, non-farmers were 56.4% and farmers were 43.6%. About 45.5% patients received first aid before coming to the hospital, while 54.5% did not receive the same. The reason to consume OPC was suicide in 88.1% cases and accident in 12 (11.9%, all children). About 42.6% patients were conscious at the time of presentation, 39.6% were drowsy, and 17.8% patients were unconscious at the time of presentation. In most of the patients, the temperature was normal (98%), only 2 patients had mild fever. About 47.5% patients had normally reactive pupils at the time of presentation, 44.6% patients had pinpoint pupils at the time of presentation, and 7.9% patients had dilated and non-reacting pupils. Nine patients had a history of convulsions. 13.9% had features of aspiration at the time of presentation, 55.4% had tachycardia at the time of presentation (pulse rate >100). Seventy-nine patients received PAM and the mean duration was 1.72 ± 1.08 (range 1-4 days). Atropine was given in all cases. Mean duration was 5.14 ± 3.12 (range 1–19 days). Also, 34.7% patients required mechanical ventilation; dialysis was needed in 2 patients with increase in serum creatinine. Mean hospital stay was 7.53 ± 4.68 days (range 1–26 days) and mortality was in 9.9% in the present series.{Figure 1}

 Discussion



In this study, as in most other studies, male dominated females (M:F ratio range 0.1-6.1), [24],[25],[26],[27],[28] and young adults (2 nd to 4 th decade) were victims of OP self-poisoning. [18],[19],[20],[24],[25],[29] In contrast, in accordance with the literature, accidental poisoning was more common in children. [26] Acute pesticides exposure can be accident or suicide, occupational, bystander exposure, or exposure because of consumption of food items containing pesticide residues. [30],[31] The commonest incidence of OP poisoning was suicidal attempt, [2],[5],[12],[15],[26],[28],[32],[33],[34],[35] as in this study. Accidental exposure is more common in children and female homemakers. [17],[24],[26],[36],[37] Although we did not study these differences in details, it has been proposed that high proportion of poisoning among males might be due to change in the lifestyle and cultural patterns, [38] reactive depression, and high degree of stress in academic, financial, and social sectors. [17],[39],[40] Careful resuscitation with appropriate use of antidotes, followed by good supportive care and observation is helpful in achieving good outcome. [12] In the present series, most of the patients could receive first aid within hours of poisoning as timely transport and intervention of all critically poisoning cases were recognized to prevent the high mortality. [17] In accordance with the previous findings, there was no significant difference in the mortality of the patients who received first aid and those who did not. [17] Treatment of all patients was based on the well-established principles and included decontamination and gastric lavage, antidotal therapy with atropine and oximes, and supportive therapy with benzodia-zepines and mechanical ventilation. [11],[30],[31],[41],[42]

Duration of the hospital stay varied according to the severity of clinical condition and could range from 1 day (mild cases) to 14 days (severe cases), [26] it may be longer in patients who need prolonged duration of mechanical ventilation. [43],[44],[45] In comparison to the western literature, [46],[47] OP poisoning has high mortality in resource poor settings and the causes of this high mortality are multifactorial and include the high toxicity of locally available poisons, difficulties in transporting patients, the paucity of health care, and the lack of facilities and antidotes. [13],[14],[42],[48] The mortality in the present series was comparable to that in the literature where it has been reported to be 10–20%. [13],[19],[49] The explanation for this high mortality include intentional poisoning [16],[26] and availability of highly toxic OP pesticides (WHO Class I toxicity). [50],[51] In developing countries, with the widespread use of OP pesticides by farmers, it will be very difficult to reduce mortality by primary prevention. [15] Clinical OP poisoning recognition is very important, as pesticide poisoning is associated with a high fatality rate. [52] The possible steps to reduce the incidence of OP poisoning-related mortality include immediate shifting of the victim to a well-equipped and well-staffed hospital, careful resuscitation improvement in medical management, and provision of antidotes, intensive care beds, awareness, and education. [5],[14],[15]

 Conclusion



OP poisoning is a medical emergency that needs rapid diagnosis and treatment. Early recognition, careful monitoring, and appropriate management will decrease the complication and the mortality rate. Although the present study contribute substantial information regarding the epidemiology and outcome of acute OP poisoning in a tertiary care teaching hospital at a district level, relatively small sample size and the retrospective record-based nature are the major limitations of the present study. There is a further need for prospective studies to understand underlying socio-economic factors responsible for OPC poisoning in our population and, accordingly, address the problems to reduce the incidence of OPC poisoning cases.

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