The Characteristics of Cases presenting because of Poisoning at Akdeniz University Medical Faculty between 2017 and 2018

According to WHO reports, intoxication is one of the most frequent reason of morbidity and mortality in all over the world. The aim of this study was to determine the frequency and demographic characteristics of cases presenting with a history of poisoning, to create an awareness in all healthcare personnel and primarily physicians of evaluation in respect of forensic medicine, and to remind all staff of precautions to be taken with the consideration of the frequency and severity of the poisonings. Approval for the study was granted by the Clinical Research Ethics Committee of Akdeniz University Medical Faculty (decision no: 36, dated:16.01.2019). A retrospective screening of data was made by entering all the ICD-10 codes that could be related to poisoning into the Mia-Med Hospital Information Management System, which is used in our hospital. The codes used were the ranges of A03-A09, F10-F19, J60-J70, L23-L25, T36-T65, T96-97, X40-X49, X60-X69, X85-X90, Y10-Y19, Y40-Y57, Y64-Y65, Y90-Y91 and all subgroups, and J92, J95, K52, L27, P04, R78, R82, R83, T88, W36, W56, X09, X20, X22, X29, Z57, Z72, Z81, Z86 and subgroups. A total of 1972 cases were identified who presented at Akdeniz University Medical Faculty Hospital between 01 January 2017 and 31 December 2018 with a history of poisoning. A record was made of demographic data, time of poisoning (season, month, day, time), the agent of intoxication, origin, how taken into the body, forensic case notification, treatment method and duration, disability/mortality frequency, and costs. All the cases of poisoning, evaluated or not evaluated as forensic cases on presentation at the Emergency Department, were evaluated in medicolegal terms according to the parameters defined in the Republic of Turkey Penal Code Injury Guide, taking into consideration the information in the patient files and the treatments applied. The cases that presented because of poisoning comprised 54,4% (n=1072) males and 45,6% (n=900) females. Most cases (32,2%, n=635) were in the 20-29 years age group. The poisonings occurred most often in the summer (n=562, 28,5%), in the month of August (n=209, 10,6%), on a Tuesday (n=302, 15,3%) and between 18:00-23:59 (n=656, 33,3%). The origins were determined to be accidental in 1592 (80,7%) cases, a suicide attempt in 379 (19,2%), and criminal (intentional) in 1 (0,1%) case. In both genders, the origin was mostly accidental (males, n=947, 88,3%; females, n=645, 71,7%). The majority of the suicide attempts of poisoning were female (n=255, 67,3%), and of the accidental poisonings, 59,5% (n=947) were male. The cases of suicide and accidental origin were determined to be mostly in the 20-29 years age group (suicide, n=134, 35,4%; accidental, n=501, 31,5%). Ingestion of the poison was determined to be via the oral route in 85,9% (n=1693) and by inhalation in 9,3% (n=184) of cases. Poisoning was determined to have been mostly from food (n=723, 36,7%) followed by drugs (n=519, 26,3%). Of the drug intoxication cases, 62,6% (n=285) were female, and of the cases with ethyl alcohol poisoning, 79,8% (n=154) were male. The vast majority of those who had taken sedatives or stimulants were male (86,1%, n=118). Drug origin poisoning was determined in the 1-6 years age group at the rate of 29,0% (n=132). Non-drug and food poisoning cases were determined to be mostly in the 20-29 years age group (non-drug, n=188, 26,6%; food, n=309, 42,7%). Of the cases of drug poisoning, a single drug had been taken by 61,4% (n=319) and multiple drugs by 38,6% (n=200). The 3 most commonly taken single drugs were analgesic group drugs (NSAID, n=35, 11,0%, paracetamol, n=29, 91%), antidepressant group drugs (SSRI, n=24, 7,5%, TCA, n=8, 2,5%, other antidepressants, n=16, 5,0%), and anti-epileptics (n=31, 9,7%). Suicide attempts were determined to be the most common form of drug-origin poisonings (61,5%, n=280). All of the cases of food, corrosive substance and carbon monoxide poisoning were accidental, as were the majority of cases of poisoning by sedatives or stimulants (98,2%, n=111), ethyl alcohol (94,3%, n=182), and pesticides (59,0%, n=23). Ethyl alcohol values were measured as maximum 100-150mg/dL in females (n=12, 16,0%) and maximum 200-250 mg/dL in males (n=28, 14,4%). A history of heroin intake was determined in 46 (33,6%) cases and cannabis use in 36 (26,3%) cases. Of the cases of pesticide poisoning, insecticides were most frequent at the rate of 57,5% (n=27), and within this group, the most frequent were organophosphate and carbamate poisonings (n=14, 29,8%). Of the pesticide poisoning cases, 59% (n=23) were determined to be accidental. When the "other agents" group, seen at the lower rate of 2,8% (n=56), was evaluated, 25% were determined to be solvents and 17,7% were hydrocarbons. A history of psychiatric disease was determined in 6,9% (n=135) of cases. Of these, 60% (n=81) were cases of attempted suicide and 40% (n=54) were accidental in origin, and the agent used was drugs in 57,8% (n=78) and a non-drug agent in 30.4%. Suicide attempt was determined in 46,1% (n=12) of the cases who were pregnant or had suspected pregnancy (n=26). The Glasgow Coma Score at the time of presentation at the hospital was 13-15 in 97,4% (n=1920) of cases, 3-8 in 1,5% (n=30), and 9-12 in 1,1% (n=22). Of the total cases, 21,3% (n=420) had consulted a poison information centre. Consultation had been requested from the relevant departments by 33,4% (n=658) of cases. The departments most frequently consulted were Psychiatry (57,2%), Internal Medicine (51,7%) and Anaesthesia (17,1%). Cases aged <18 years referred to the Paediatric and Adolescent Mental Health and Diseases Department were determined to be 86,2% (n=25) female with origin of suicide attempt. Cases aged >18 years who were referred to the Mental Health and Diseases Department were determined to be 66,4% (n=211) females with origin of suicide attempt. In cases of attempted suicide, psychiatric support is important for both genders and therefore, a psychiatric interview is just as appropriate for males as females. Symptomatic treatment and observation was applied to 76% (n=1503) of the cases, with nasogastric lavage applied together with active charcoal treatment in 148 (7,4%) cases. Hospitalisation for treatment was required by 18,1% (n=356) of cases. Treatment was applied in the Emergency Department to 79,5% (n=1569) and in the Internal Medicine Department to 7,7% (n=157) of cases. The patients admitted to a ward or the Intensive Care Unit were determind to have received treatment for mean 3,71 days (range, 1-36 days). Mortality developed in 3 (0,2%) cases and 1 (0,1%) case was dead on arrival. Of the cases hospitalised for treatment, length of hospital stay was 2-7 days in 81,7% (n=291) and 8-15 days in 7,9% (n=28). The total treatment costs of all the patients was 475109 TL, which was calculated to be mean 24092 TL per patient (minimum 15 TL - maximum 25293 TL). Of all the poisoning cases presenting at the Emergency Department, 52,7% (n=1039) were determined to be forensic cases. The poisoning was determined to be non-life-threatening in 87,2% (n=1720) of the cases and lifethreatening in 12,8% (n=252). None of the food poisoning cases (n=723) were evaluated as forensic cases. Of the drug intoxication cases, 326/343 (95%) that were not life-threatening, and 102/112 (91,1%) that were life-threatening were evaluated as forensic cases. Of the corrosive substance poisoning cases, 137/191 (71,7%) nonlife-threatening cases and all 4 (100%) life-threatening cases of accidental origin were evaluated as forensic cases. Of the pesticide poisoning cases, 30/33 (90,9%) non-life-threatening cases and all 6 (100%) life-threatening cases were evaluated as forensic cases. Of the poisoning cases presenting with multiple agent intake, 56/59 (95%) non-lifethreatening cases and 27/28 (96%) life-threatening cases were evaluated as forensic cases. Physicians were determined to be more likely to report forensic cases when the patient presented with life-threatening intake of drugs, pesticides, corrosive substance and multiple substances, and they tended not to report other forensic cases. In 85,4% (n=1684) of cases, severe of the intoxication was determined to be mild enough that it could be resolved with a simple medical intervention (SMI). Of the drug poisoning cases, 318/334 (95,2%) that could be resolved with SMI and 110/121 (90,9%) that could not be resolved with SMI were evaluated as forensic cases. Of the corrosive substance cases, 132/186 (71,0%) that could be resolved with SMI and all 9 (100%) that could not be resolved with SMI were evaluated as forensic cases. Of the pesticide cases, 28/31 (90,3%) that could be resolved with SMI and all 8 (100%) that could not be resolved with SMI were evaluated as forensic cases. Of the cases of poisoning with multiple agent intake, 54/57 (94,7%) that could be resolved with SMI and 29/30 (96,7%) that could not be resolved with SMI were evaluated as forensic cases. When it was considered that a total of 23% (n=454) of cases were aged <18 years (food poisoning: n=46, 2,3%; non-food: n=408, 20,7%) and the origin of the poisoning was accidental in 90,3% (n=410) of these cases below the age of 18 years, there can be seen to be a need for specific precautions to be taken for this age group. To reduce cases of poisoning to a minimum, and reduce morbidity and mortality rates, there is a need for preventative steps and precautions to be taken, primarily family and community education not to sell drugs without a prescription, not to take or give any medication in the dark, to correctly dispose of all out-of-date medications, to only buy drugs in child-proof packaging, to store all drugs and toxic substances in a locked cupboard, to keep chemicals in the home away from food, to store cleaning materials, pesticides and other chemicals in their original packaging outside the kitchen, to ensure that tops and lids are securely closed and containers are not left open, to not leave cleaning products within the reach of children, such as on the floor, under the sink or a low counter, to consume food knowledgably, to ensure the good establishment of an air circulation system where bottled gas, natural gas or coal/wood-burning stoves are used and to check this before going to bed at night, to pay special attention and provide immediate psychiatric support for individuals with suicidal tendencies, to take precautions against air pollution in factories producing chemicals, to provide appropriate training for all workers in all factories, to provide health and safety equipment, to develop systems to supervise substance use and prevent the purchase of illegal substances, and to provide addiction rehabilitation. It would also be useful to create awareness of the subject of poisoning using written and visual publications. In respect of forensic medicine, all types of poisoning cases must reported officially, and to prevent loss of patient rights and unnecessary injustice, physicians and other healthcare personnel should receive in-service training on forensic medicine subjects related to poisoning, and it would be useful to closely follow changes in basic regulations and management.