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ISSN: 2161-0495
Journal of Clinical Toxicology

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Analyses of Etiologic and Sociodemografic Properties of the Intoxicated Cases in Van City and its Environs

Ahmet Cumhur Dulger1, Sevdegul Karadas2, Hayriye Gonullu2*, Enver Aytemiz3, Irfan Aydin2 and Imdat Dilek4

1Department of Gastroenterology, School of Medicine, Yuzuncu Yil University, Van, Turkey

2Department of Emergency Medicine, School of Medicine, Yuzuncu Yil University, Van, Turkey

3Department of Hematology, School of Medicine, Yuzuncu Yil University, Van, Turkey

4Department of Internal Medicine, School of Medicine, Yuzuncu Yil University, Van, Turkey

*Corresponding Author:
Hayriye Gonullu
Yuzuncu Yil Universitesi, Tip Fakultesi, Arastirma Hastanesi Acil Tip A.D. Maras Cad. 65300, Van, Turkey
Tel: 009 050 576 72 477
Fax: 009 043 221 68 352
E-mail: [email protected]

Received date: September 02, 2011; Accepted date: February 17, 2012; Published date: February 20, 2012

Citation: Dulger AC, Karadas S, Gonullu H, Aytemiz E, Aydin I, et al. (2012) Analyses of Etiologic and Sociodemografic Properties of the Intoxicated Cases in Van City and its Environs. J Clinic Toxicol 2:119. doi: 10.4172/2161-0495.1000119

Copyright: © 2012 Dulger AC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

The purpose of this retrospective hospital-based study was to evaluate clinical and epidemiologic characteristics of acute poisoning cases. All poisonings cases admitted to the emergency department of the Yuzuncu Yil University Training Hospital, Van, Turkey, between June 1999 and May 2005, were evaluated in the study. Etiologic and sociodemografic properties of the intoxicated cases were investigated.

There were males 32.6 % and females 67.3 % in the study. 74.6 % of the cases were suicidal and 25.4 % of them accidental. The highest suicidal attempts were seen in the age group 16-25 years and were mostly occurred during spring. The vast majority of the suicide attempters were also young females. Central nervous system drugs (21.8%), carbamates (17.1%), analgesics (10.3%) and organophosphorus components (10%) were most used agents among intoxicated patients. Half of the patients was treated and released from emergency department without hospitalization. Only 6.4% of the cases admitted to critical care. The percentage of the cases that need intensive care unit was highest in central nervous system drugs. Mortality rate was 1.6% and was mostly due to opioid and organophosphorus-related poisonings.

Based on the study it was suggested that there was a greater incidence of suicide attempts in younger females. Organophosphorus and carbamate containing chemicals are major causative agents for intoxications particularly in females.

Keywords

Poisoning; Emergency department; Organophosphorus poisoning

Introduction

Poisoning is described as the development of adverse events following exposure to chemicals as well as drugs. Human poisoning is just as important to the approach of today’s emergency cases as the introduction of new drugs itself. Despite efforts by clinicians to overturn the higher rate of poisoning- related mortality, cessation of human poisoning in the near term is unlikely [1,2].

The worldwide number of intoxicated cases has increased remarkably during the past century. The reported incidence of human poisoning has ranged from 0.7 and 9.3 poison exposures per 1000 population [3-5].

Intoxications mostly due to chemicals, analgesics, cosmetics and hydrocarbons and occur accidentally. Mortality rates are higher in patients with suicide attempts. Nonpharmaceutical agents such as pesticides are responsible for fatal poisoning particularly in rural areas as well as in developing countries [6].

The assessment of etiologic and demographic characteristics of intoxicated cases plays a major role in the clinical management of emergency cases as well as in epidemiologic research. Therefore, the purpose of the current retrospective study was to evaluate the etiologic and demographic characteristics of acute poisoning in patients who admitted to emergency department.

Methods

A great majority of the cases referring to emergency unit of our hospital emergency department (ED) in the period of between June 1999 and May 2005 were retrospectively examined. In this time scale the cases were composed of 321 males (32.6 %) and 661 females (67.3%).

Firstly, all cases were categorized as accidental or intentional. Various demographic (causative agents, age, sex, marital status, education level, inhabitation area, time to contact with emergency department) and clinical factors (underlying diseases, mortality rates, mortal agents and discharging time) were recorded by study group. Psychiatric consultation was also provided for all patients with intentional poisonings.

Causative agents were categorized into 10 groups: drugs, gases, food, corrosives, pesticides, organophosphorus (OP), alcohol, herbs, narcotics, or multiple drugs. The drugs except narcotics were also categorized into five subgroups: central nervous system (CNS) agents, cardiovascular system drugs, gastrointestinal system drugs, endocrine system drugs, antibiotics.

The results were also analyzed for six age groups: 1 ± 15 years, 15 ± 25 years, 25 ± 34 years, 34 ± 45 years, 45 ± 55 years, 55 ± 69 and over(>70 years). Statistical analyses were performed using the statistical package SPSS version 10.0. These values were evaluated by means of the Chi-squared test and one-way ANOVA. The Duncan test was used to compare values between the subgroups.

Results

The mean age of the total cases intoxicated w as 24.2 (range 1-90). 74.6% of the cases were understood to have suicidal purposes and 25.4% of them constituted accidental conditions. The drug intake aimed for suicide among females was 78% and 66.6% among males. The epidemiologic characteristics of poisoning cases are shown in figure 1,2 and tables 1,2. The monthly distribution of suicidal poisonings showed a peak in March (n=81 11%) and a deep point in December (n=45 6%). It was also seen that accidental poisonings were more prominent in May (n=36 14.5%) and had lower numbers in august (n=8 3.2%) (Figure 3).

Causative Agent Age groups
1-15 16-25 26-35 36-45 46-55 56-69 70< Total
n % n % n % n % n % N % n % n %
Physycoactive Drugs 5 9,62 156 23,96 46 25,99 5 9,62 1 3,45 1 7,14 0 ,00 214 21,84
Cardiovascular Drugs 0 ,00 14 2,15 2 1,13 0 ,00 1 3,45 0 ,00 0 ,00 17 1,73
Gastrointestinal Drugs 0 ,00 9 1,38 1 ,56 0 ,00 0 ,00 0 ,00 0 ,00 10 1,02
Antibiotics 0 ,00 11 1,69 1 ,56 2 3,85 1 3,45 0 ,00 0 ,00 15 1,53
Inhalation Agents 1 1,92 34 5,22 16 9,04 8 15,38 8 27,59 3 21,43 0 ,00 70 7,14
Endocrine System Drugs 0 ,00 8 1,23 1 ,56 1 1,92 0 ,00 0 ,00 0 ,00 10 1,02
Analgesics 0 ,00 74 11,37 22 12,43 5 9,62 0 ,00 0 ,00 0 ,00 101 10,31
Corrosives 38 73,08 29 4,45 6 3,39 2 3,85 0 ,00 3 21,43 0 ,00 78 7,96
Carbamates 1 1,92 119 18,28 30 16,95 8 15,38 8 27,59 1 7,14 1 20,00 168 17,14
Organicphosphorus 2 3,85 71 10,91 9 5,08 8 15,38 6 20,69 2 14,29 1 20,00 99 10,10
Opioids 0 ,00 3 ,46 11 6,21 1 1,92 1 3,45 0 ,00 0 ,00 16 1,63
Herbal Plants 1 1,92 8 1,23 8 4,52 3 5,77 0 ,00 2 14,29 2 40,00 24 2,45
Food 2 3,85 14 2,15 1 ,56 3 5,77 2 6,90 0 ,00 1 20,00 23 2,35
Multiple Drugs 2 3,85 87 13,36 22 12,43 6 11,54 1 3,45 2 14,29 0 ,00 120 12,24
Alcohol 0 ,00 14 2,15 1 ,56 0 ,00 0 ,00 0 ,00 0 ,00 15 1,53
Total 52 5,31 651 66,43 177 18,06 52 5,31 29 2,96 14 1,43 5 ,51 980 100,00

Table 1: Causative agents according to age groups.

Causative Agent Inhabitation area
Village Town City Unknown Total
n % N % n % n % n %
Physycoactive Drugs 30 13.27 59 20.49 125 26.88 0 0.00 214 21.84
Cardiovascular Drugs 1 .44 4 1.39 12 2.58 0 0.00 17 1.73
Gastrointestinal Drugs 2 .88 4 1.39 4 0.86 0 0.00 10 1.02
Antibiotics 2 .88 3 1.04 10 2.15 0 0.00 15 1.53
Inhalation Agents 10 4.42 21 7.29 39 8.39 0 0.00 70 7.14
Endocrine System Drugs 0 .00 4 1.39 6 1.29 0 0.00 10 1.02
Analgesics 16 7.08 31 10.76 54 11.61 0 0.00 101 10.31
Corrosives 15 6.64 13 4.51 49 10.54 1 100.00 78 7.96
Carbamates 73 32.30 64 22.22 31 6.67 0 0.00 168 17.14
Organicphosphorus 48 21.24 30 10.42 21 4.52 0 0.00 99 10.10
Opioids 2 .88 5 1.74 9 1.94 0 0.00 16 1.63
Herbal Plants 12 5.31 8 2.78 4 .86 0 0.00 24 2.45
Food 3 1.33 8 2.78 12 2.58 0 0.00 23 2.35
Multiple Drugs 12 5.31 31 10.76 77 16.56 0 0.00 120 12.24
Alcohol 0 .00 3 1.04 12 2.58 0 0.00 15 1.53
Total 226 23.06 288 29.39 465 47.45 1 0.10 980 100.00

Table 2: Causative agents according to inhabitation area.

clinical-toxicology-intoxication-age-groups

Figure 1: Causes of intoxication according to age groups.

clinical-toxicology-Ages-intoxication-cases

Figure 2: Ages of intoxication cases according to gender.

clinical-toxicology-Causes-intoxication

Figure 3: Causes of intoxication according to months.

The most frequently determined intoxication substances were CNS drugs (21.8%), carbamates (17.1%), analgesics (10.3%) and organophosphorus components (10%). Whereas the accidents comprised inhalation 27.8%, corrosive substances 19.7%, carbamates 18.1%, analgesics 13.4% and organicphosphorus 10%, suicidal poisonings consisted of CNS drugs 28.3%, pesticides 18.1%, analgesics 13.4% and organophosphorus 10%. A single agent was responsible for 88% of all drugs poisoning, while multiple agents were noted in 12% of the cases (Table 3).

Causative Agent Gender
Male Female Total
Causes of poisoning Causes of poisoning Causes of poisoning
Accidentally Suicide Accidentally Suicide Accidentally Suicide
n % n % n % n % n % n %
Physycoactive Drugs 2 1.87 46 21.50 5 3.55 161 31.14 7 2.82 207 21.8
Cardiovascular Drugs 0 0.00 5 2.34 0 0.00 12 2.32 0 0.00 17 1.7
Gastrointestinal Drugs 0 0.00 2 0.93 0 0.00 8 1.55 0 0.00 10 1.0
Antibiotics 0 0.00 6 2.80 0 0.00 9 1.74 0 0.00 15 1.5
Inhalation Agents 27 25.23 0 0.00 42 29.79 1 0.19 69 27.82 1 7.1
Endocrine System Drugs 0 0.00 1 0.47 0 0.00 9 1.74 0 0.00 10 1.0
Analgesics 0 0.00 38 17.76 3 2.13 60 11.61 3 1.21 98 10.3
Corrosives 36 33.64 11 5.14 13 9.22 18 3.48 49 19.76 29 8.0
Carbamates 7 6.54 37 17.29 28 19.86 96 18.57 35 14.11 133 17.1
Organicphosphorus 7 6.54 17 7.94 18 12.77 56 10.83 25 10.08 73 10.1
Opioids 0 0.00 16 7.48 0 0.00 0 0.00 0 0.00 16 1.6
Herbal Plants 11 10.28 0 0.00 13 9.22 0 0.00 24 9.68 0 2.4
Food 6 5.61 0 0.00 17 12.06 0 0.00 23 9.27 0 2.3
Multiple Drugs 1 0.93 31 14.49 2 1.42 86 16.63 3 1.21 117 12.2
Alcohol 10 9.35 4 1.87 0 0.00 1 0.19 10 4.03 5 1.5
Total 107 33.00 214 67.00 141 21.40 517 78.60 248 25.30 731 100.0

Table 3: Gender of cases and causes of poisoning according to causative agents.

66.5% of the intoxicated cases were between 16-25 age groups, whereas first intervention on a third of the cases was performed in our emergency department. Two-thirds of them had first intervention in the clinics where they came. Time of contact with ED was significantly shorter in female OP related-suicide attempters than males (p<0.01) (Table 4).

Causative Agent Time to contact to the emergency department (hours)
Male Female Total F P
͞X SD ͞X SD ͞X SD    
Physycoactive Drugs 2.67 2.05 2.95 2.53 2.88 2.43 0.489 0.485
Cardiovascular Drugs 1.80 .84 3.58 3.12 3.06 2.75 1.535 0.234
Gastrointestinal Drugs 1.50 .71 5.75 6.73 4.90 6.21 0.727 0.419
Antibiotics 3.67 1.97 2.44 1.24 2.93 1.62 2.215 0.160
Inhalation Agents 3.37 1.67 2.37 1.79 2.76 1.80 5.447 0.023*
Endocrine System Drugs 8.00 1.80 2.33 1.41 2.90 2.23 14.450 0.005**
Analgesics 2.13 1.72 3.15 3.47 2.77 2.97 2.852 0.094
Corrosives 2.83 3.58 2.44 1.43 2.67 2.92 0.339 0.562
Carbamates 4.02 6.44 2.69 3.30 3.04 4.36 3.071 0.082
Organicphosphorus 3.61 2.86 2.05 1.22 2.42 1.85 14.156 0.000**
Opioids 3.19 2.23 0.00 0.00 3.19 2.23    
Herbal Plants 2.36 2.01 7.69 13.57 5.25 10.26 1.653 0.212
Food 3.17 1.83 9.71 28.47 8.00 24.47 0.307 0.586
Multiple Drugs 2.89 3.34 2.50 1.92 2.60 2.37 0.635 0.427
Alcohol 3.07 1.54 1.00 0.00 2.93 1.58 1.683 0.217

Table 4: Anova analysis for time to contact to the emergency department according to causative agents and gender.

Poisonings with organophosphorus 13.9%, pesticides 11.9% and herbal plants 4.1% among the cases who were first intervened in our emergency department were referred to our hospital from rural areas. While accidents were frequently observed between 1-15 and over 70 ages; suicides were observed between 16-25 age group. Those cases living in the villages were most frequently poisoned with pesticides and organic phosphorus, whereas those living in urban areas were found to have a (remove) relatively lower rates of poisoning with this substances. The most frequent poisoning in Van city center and its environs were found to be with CNS drugs. 80% of poisonings with herbal plants constituted those living in villages and towns. Accidents were made most frequently due to inhalation, corrosive substances, pesticides and organophosphorus.

75% of the intoxicated cases consisted of those who were illiterates and primary school graduates. 50 % of the patients were discharged from the hospital, 50% were hospitalized, and 6.4 % were sent to intensive care unit (ICU). Whereas hospitalization rate in the intensive care unit was 6.4% and the higher number of the intensive care patients was seen to be poisoned with CNS drugs (46.8%) (Figure 4).

clinical-toxicology-intoxication-education-levels

Figure 4: Causes of intoxication according to education levels.

Psychiatric illness was diagnosed in a total of 6.3% of the intoxicated cases. Mortality rate in the total cases was 1.6% and the highest mortality was seen in opioid and organophosphorus poisonings.

Discussion

Alongside the medical advancements surrounding the human health, at both preclinical and clinical levels, it is clear that the poisoning cases have become more complex. Another important issue in the field of poisoning is that recommendations and guidelines for optimum treatment are currently based on observational data. Poisoning cases also continue to occur frequently, and the consequences can be lifetreating. Prompt recognition and treatment of severely intoxicated patients may result in preservation of human life. Therefore, the data obtained from this study is crucial to evaluate the poisoning pattern of patients who were admitted to ED.

In the current study, poisoning cases accounted for 3.6 % of all admissions to the ED. In Turkey, the rate of poisoning-related ED visits ranges from 0.7 to 5% of ED visits annually. Our findings were consistent with previous national reports as well as world data [4,7].

The vast majority of poisoned victims in developing countries has been found as young females [3,4,7]. We found that, 2/3 cases were women and young female patients between the ages of 16 and 25 years had a higher rate of intentional poisoning. Marital status was not different in both genders.

The ED visit rate for intentional poisoning also differs by region. The rate is reported as substantially higher in the eastern part of Turkey than in the West [3]. These data suggested that the increasing suicide trend in younger females may be continuing in the eastern part of Turkey. This phenomenon may be due to accelerated social turmoil particularly in rural areas of the country and contributes substantially to the suicide burden in female gender. There were also similar observations of a high incidence of suicide attempts in rural areas in Iran [8].

Epidemiological studies of human poisoning indicated profound variations in seasonal distribution. But, most of these reports have been showed an association between spring months and suicide attempts [9]. The results of our study showed that 11% of the suicide poisonings occurred in March; it was similar with recent published reports and it may be due to long-lasting negative effect of eastern winter season on human behavior in our region.

In our study, majority of the cases referred to our ED from another hospital. It suggested that, cases with mild poisoning were considered as heavy and most of satellite hospitals had lack of trained specialists as well as medical equipment.

Interestingly, a shorter time to contact with ED was found closest with female cases with OP poisoning (p<0.01). This finding is also consistent with a previous report which suggests that the shorter ED admission time correlates with female gender [10]. It also suggests that the relatives of female cases with OP poisoning were more vigilant than those of males.

Unintentional (accidental) poisonings were mostly seen in patients older than 70 years of age and younger than 15 years old. Furthermore, corrosive agents were the most common toxins seen in pediatric cases. Results were consistent with data previously reported in the literature [11,12]. Based on this result, it may speculate that keeping corrosive agents out of reach of children may be life-saving. The number of serious accidents, including fatal outcomes may prevent keeping corrosive agents out of children’s reach.

According to a recent report from Turkey, the majority of intoxicated patients are used analgesics for suicide attempts [4]. Interestingly, this study found that physicoactive drugs including CNS drugs were the leading cause of intentional poisonings, whereas analgesics was determined as third cause of intoxications. This phenomenon may be due to unprohibited sales of these drugs in our region.

Organophosphate and carbamate poisoning are generally used as global pesticides. The heavy toxicity of these agents was found to be due to their irreversible inactivation of acetyl cholinesterase, which resulted in devastating effects [13,14]. In Turkey, pesticides account for 7% to 12% of emergency admissions due to poisoning [3,15].

In the current study, the poisoning with pesticides was found higher than other agents. We also found that, time of arrival to the emergency department was significantly shorter among female suicide attempters who poisoned with OP than males. This finding suggests that, male patients with organophosphorus poisoning were more constant in their suicide purposes.

Our data also supports the literature and suggest that pesticiderelated poisonings is a common cause of emergency admissions. This is, probably due to Van region which is an agricultural area. More complete nationwide registration should clarify this.

Van is a city of roughly 400.000 inhabitants, and situated around the higher mountains of the eastern part of Turkey. The lowest average temperature is around subzero Celsius during winter. Carbon monoxide (CO) is emitted whenever flammable materials are burned. Breathing high levels of the CO may cause severe illness or death due to respiratory failure. CO poisoning generally occur during autumn and winter [16].

In our study, inhalation of gases (mostly carbon monoxide) was found as leading cause of accidental poisonings. It was possible that cold temperature with higher altitude, using gas-powered generators without CO detector and the lack of availabity of infrastructure were probably responsible for this situation.

A Turkish study showed that, low educated patients were more likely to be prone to suicide attempts than patients who had high education levels [17]. Significant correlation was found between education level and suicide attempt. ED visit rates of intoxicated patients were higher among the low education level. Our data was in accordance with previous reports from Turkey.

The percentage of patients who admitted to critical care was 6.4%. This rate has been reported as high as 27% in Western world [9]. In our country, the rate of patients who need intensive care was reported as 13 .3%. In our study, the lower rate of intensive care unit admission was probably due to mild to moderate poisoning pattern in poisoning cases.

In this study, personal psychiatric illness was diagnosed in a total of 6.3% of the poisoning cases. The rate of psychiatric illness among suicide attempters was found significantly much lower in our region than other parts of Turkey [17].

Approximately half of the cases were discharged from the emergency department. The lower percentage of hospitalized patients shows us that most of the cases were mild. This data was compatible with published reports from Turkey [4].

Published studies from Turkey, mortality rate were reported as 1% to 2% among poisoning cases [12-18]. In the present study, mortality rate was found as 1.6%, which was compatible for Turkish data.

Poisoning with pesticides, especially those containing organophosphorus, has been associated with increased risk of mortality [19]. In the current study, mortality was found significantly correlated with opioid and organophosphorus poisonings. Our data was also similar with recent reports published from Turkey [20].

Conclusion

Many younger females living in rural areas have chronic social problems that challenge their future and it was observed that the female cases between 16-25 age group in our region was more likely to commit suicide with agricultural substances most frequently. Due to the fact that, our study was conducted on a hospital bases, our findings were in coherence with the worlds and our region’s poisoning characteristics though it may not reflect results of general population.

However, if would be much more tempting to say that further studies to based on multiple centers and means and modes should be conducted in order to have an adequate understanding of precise epidemiologic and clinic findings and data.

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