Background: Emergency physicians must be updated about the variations in poisoning pattern during Covid19 pandemic. Limited data exist on the incidence and characteristics of patients presenting with poisoning in Indian Emergency Departments (ED) during the COVID 19 pandemic. Hence, we aimed to explore the impact of Covid19 pandemic on poisoning cases presenting to the ED.Methods: This cross-sectional retrospective study was conducted on poisoning patients presenting to ED during the pandemic period (April 1-October 30, 2020 (period 2)), and a matching period before the pandemic (September 1,2019 to March 31, 2020 (period 1)). The rate of prevalence and clinical profile were compared between period 1 and 2 using appropriate statistical test.Results: A total of 111 (periods 1 = 57, and periods 2 = 54) cases were analysed. Poisoning prevalence rates had slightly increased by 2.7% before the pandemic (51.33%) in comparison to during the pandemic (48.6%) period (p=0.3). Females were predominant in both periods, and the mean age of 32.5 years. The predominant (57%) patient age group was 15-34 years. 36.9% (n=41) patients consumed multiple poisons, 19.8% (n=22) consumed paracetamol, and 14.4% (n=16) patients consumed psychiatric medications. Before lockdown, 27.02% (n=30) patients presented within 3 hours ingestion, and 21.6% (n=24) presented after 3 hours ingestion (p=0.12). A significant delay in arrival of poisoning cases during lockdown (p= 0.12) with increased hospital admission (p=0.03) was observed. A psychiatric disorder was observed in 36.03% cases. Majority of the cases were admitted in the ICU, and 0.9%(n=1) death was recorded.Conclusions: This is the first Indian study that describes the incidence of poisoning cases and their pattern during the COVID 19pandemic period, study revealed that increased mental health crisis in low resource settings in rural Kerala affects predominantly young population. Study implies the importance of priming the mental health care professionals to initiate their mental health screening programmes.

Background: In acute and chronic phases of severe diseases, endocrine changes occur. Some hormones, such as prolactin (PRL) and thyroid hormones, were considered predictors of ICU patients' outcomes. The present study evaluates thyroid hormone profile, serum PRL level, and their relationship with ICU poisoned patients' mortality rate.Methods: This study included 140 inpatients in the Toxicology Intensive Care Unit (TICU) who enrolled in a prospective study of a single center and observational. After admission to the ICU, the researchers collected venous blood samples from all patients directly. Concurrently, the APACHE II score was calculated. The collected samples analysis was performed based on the entire triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH), and PRL level.Results: One hundred and forty subjects were studied, of which 109 (75.85%) were male with a mean age of 34.17 ± 14.01. One hundred and eighteen patients were survivors with a mean age of 33.29 ±13.76. In contrast, 22 patients with a mean age of 38.91 ±14.69 died. The model of PRL combined with APACHE II score (OR 1.17, 95% CI 1.06 to 1.28, P-value =0.001) was the best model for predicting post-ICU mortality in our study.Conclusions: This study’s results are consistent with the previous research, indicating a higher incidence of thyroid and PRL hormone changes in patients hospitalized in the ICU. It can be concluded that the presence of PRL based on the APACHE II score can lead us to be more precise in predicting the outcome of poisoning in hospitalized patients.

Background: Hexaconazole is a category 3/4 of poison as per the W.H.O Expert Group on Pesticide Residues. Hexaconazole is used to control infection by fungi in paddy and other crops. Apart from destroying the target species, it can also cause damage to humans. There have been discrete reports of instances of human poisoning due to hexaconazole. Methodology: A patient record-based cross-sectional study was carried out in Konaseema Institute of Medical Science & Research Foundation, Amalapuram, Andhra Pradesh, India during a period from March 2014 to April 2020 on 26 confirmed cases of hexaconazole poisoning. The clinic-demographic data, hematological, and biochemical parameters at the time of admission and at 72 hrs as well as the outcome were recorded and analyzed using descriptive statistics and paired t test. Result: The prevalence of hexaconazole poisoning was 4.79% of all poisoning cases. The major clinical presentation was gastrointestinal symptoms with vomiting being commonest. There was no significant change in the biochemical and hematological parameters. The mean duration of hospitalization was 4.93+1.39 days. The recovery rate was 100% without any major sequel. Conclusion: Poisoning due to hexaconazole is uncommon in comparison to poisoning by other pesticides in the agricultural community. The clinical manifestations of hexaconazole poisoning indicated that it is of non-serious nature and its recovery was without any sequel.

Acute poisoning is a common cause of emergency department visits in childhood and can increase children’s morbidity and mortality. Since the causes of child poisoning in different parts of Iran may differ due to cultural differences, this study was conducted to evaluate the most common causes of poisoning in Yazd. This retrospective cross-sectional study is based on the medical records of children less than 18 years of age admitted to the pediatric emergency department at Shahid Sadoughi Hospital in Yazd during 2018. The collected data included demographic information, the cause, and the outcome of acute poisoning. Out of 105 cases, 61.9% were boys. The highest poisoning rates were in the age group of 1 to 4 years (55.2%). In 50% of the participants, the family size was five or more, and 91% had Iranian nationality. Drugs were identified as the most common causes of poisoning (51.4%), and opioid analgesics were the most frequent drugs. The most common complaint at the time of referral in patients was the loss of consciousness (33%). The mean hospital stay was 56 hours, and no death was reported. According to the findings of this study in Yazd, the probability of accidental poisoning in boys under four years and due to different types of drugs, especially opioids, was higher than others. It seems that increasing parents’ awareness about keeping drugs used by family members in a safe place and out of children’s reach is essential in preventing poisoning.

Abstract Background: Ayurveda is one of the traditional medical practices that is originated from India where it is still widely practiced. This study is an attempt to determine the concentration of 6 selected metals, namely chromium, cobalt, nickel, arsenic, mercury, and lead in 19 samples of Ayurvedic herbal medicines and 7 Sindoor powders sent by physicians for analysis. Methods: In this study, ICP-MS as direct analysis of a 1 in 100 dilution of the tested materials was employed which gives an estimate of the solubility of the metal constituents of the materials tested in 0.5% nitric acid. Results: The highest individual metal values found per gram in the tested materials were: chromium 3.2 microgram/g, cobalt 3.1microgram/g, arsenic 2811 microgram/g, mercury 1320 microgram/g, and lead 8329 microgram/g. Assuming only a 1 g intake/day of any single material tested, lead content exceeded in 10/26 (38%) of the preparations above the ANSI 173 oral permitted daily limit (PDE). Likewise, mercury and arsenic contents exceeded the oral PDE in 6/26 (23%). Some of these folk medicines had high levels of more than one element in it. The lead content in 3 of the 7 Sindoor powders surpassed the guideline. However, the nickel content did not exceed the PDE in the 19 samples tested. Conclusions: Our data shows that, many of Ayurvedic medicine preparations tested still contain toxic amounts of arsenic, mercury, and lead. Sindoor powder which is traditionally and religiously used by many Indian women at their forehead also contains heavy metals like lead. All these materials can pose serious health risks to their users

Background: A WHO report included snake envenomation in the list of most important Neglected Tropical Diseases (NTD) and 95% of these cases were reported within developing countries. The reason behind this given importance is the high morbidity and mortality rates of snake envenomation as well as the challenges in availability and affordability of anti-snake venom [1]. Vasculotoxic snake bites has a myriad of manifestations ranging from local complications like necrosis and cellulitis to systemic complications such as coagulopathy, acute renal failure, acute respiratory failure, and hemolysis. Case Presentation: We report a case of a young male patient who was bitten by a Russell viper snake and developed cellulitis and blackish discolorations of the local site. The patient developed altered sensorium and subsequent loss of consciousness with a CT scan of the brain showing intra-parenchymal and subarachnoid hemorrhage. The coagulation profile demonstrated disseminated intravascular coagulation. He was treated for the above complications with polyvalent anti-snake venom, fresh frozen plasma, and cryoprecipitate units. Three days later, the patient developed breathlessness and hemoptysis with a drop in haemoglobin level with bilateral parenchymal infiltrates and left lower lobe consolidation indicative of diffuse alveolar hemorrhage with acute respiratory distress syndrome. On the fifth day, the patient reduced urine output with raised serum and creatinine levels. The patient’s clinical status rapidly worsened despite mechanical ventilatory and inotropic support and unfortunately succumbed to death on the 7th day of admission. Conclusion: Although there are case reports of snake bite induced isolated organ involvement, little is known about multi-organ dysfunction due to snake envenomation. The widespread multi-systemic involvement of snake envenomation resulting in fatal intracranial hemorrhage, acute lung, and kidney injury in our patient has been illustrated in this case report.

Background: Oxidative stress (OS), oxidative DNA damage and inflammatory response induced by chronic exposure to volatile organic compounds and heavy metals (HM) have been implicated in multiple organ dysfunction. The liver enzymes (alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma glutamyl transferase (GGT)), biomarkers of OS (nitric oxide (NO), glutathione (GSH), total antioxidant capacity (TAC), total plasma peroxides (TPP), malondialdehyde (MDA)) oxidative stress index (OSI)), oxidative DNA damage (8-hydroxy-2-deoxyguanosine (8-OHdG)), and inflammation marker (tumor necrosis factor alpha (TNF-α)); heavy metals (cadmium (Cd), lead (Pb)) and urine hippuric acid (uHA) levels were assessed in automobile workers. Methods: Fifty automobile workers and 50 controls aged 18-60 years were enrolled into this study. The MDA, GSH, NO, TAC, TPP, ALT, ALP and GGT were estimated by colorimetry, 8-OHdG and TNF-α by enzyme linked immunosorbent assay, Cd, Pb by atomic absorption spectrophotometry and uHA by high performance liquid chromatography. Data were analyzed using t-test and correlation analysis at p <0.05. Results: Automobile workers had significantly higher liver enzymes, lipid peroxidation, oxidative stress, oxidative DNA damage, nitric oxide, HM, uHA and lower total antioxidants relative to controls. Heavy metals were positively associated with MDA, TPP and OSI; TPP with duration of exposure; ALP with number of working hours; and liver enzymes with OSI only in automobile workers. Conclusion: Association of exposure to toluene and heavy metals with increased liver enzymes activity, lipid peroxidation, oxidative stress, oxidative DNA damage, and depressed antioxidants in automobile workers suggest increased risk of hepatotoxicity and hepatocellular carcinogenesis.

Background: Snake and scorpion envenomation is a common public health problem in many regions of the world. Life-threatening emergencies may occur in patients with snake and scorpion envenomation; therefore, these patients may be required intensive care unit (ICU) follow-up. Our objective was to present the demographic and clinical characteristics, treatment modalities and short term outcomes of patients with snake and scorpion envenomation who followed up in our tertiary hospital ICU. Methods: Patient records were retrospectively searched and snake or scorpion envenomation patients with ICU stay were identified with relevant keywords and ICD-10 codes between January 2010 and September 2019. All cases with ICU stay were included for study analysis, regardless of patient age. Scorpion and snake envenomation managed in outpatient clinic were excluded from our data. Poisoning severity score (PSS) system was used to present signs and symptoms and PSS was calculated. Primary and critical care treatment modalities were identified and analyzed. Results: Forty patients (25 with snake bites [62.5%] and 15 with scorpion sting [37.5%]) were included in this retrospective study. Local and systemic effects have been reported in 33 (82.5%) and in 27 patients (67.5%), respectively. Majority of patients suffered from pain or disturbances in sensory neural, hematological, cardiovascular or metabolic systems. Median PSS was 2 (0-4) and median length of stay in ICU was 2 days (1-12). Mortality rate was 2.5%. Antivenom immunoglobulins (n=32, %80.0), systemic antibacterial agents (n=24, 60%), and paracetamol (n=21, 52.5%) were the most common systemically administered treatments. Surgical interventions were performed in 4 patients (10%) Conclusions: We reported that snake and scorpion envenomation were mostly admitted to the ICU with local and/or systemic symptoms for advanced monitoring and observation. Although life treating emergencies and mortality was uncommon in our study, we think that these patients should be closely followed up in ICU.

Introduction: Clonidine is among the drugs that are in a list of ‘one pill can kill’ drugs. We are reporting a child with clonidine toxicity with classical manifestations who recovered completely. Case Report: A 3 year and 2 months old ADHD girl presented with drowsiness for 30 minutes. Her mother gave the history of accidental consumption of 3/4th clonidine 100 mcg tablet 45 minutes prior. On the examination, the child was drowsy with Glasgow Coma Score (GCS) 12/15. Her heart rate was 82 /minute with low volume pulse, respiratory rate 22 /minute, systolic blood pressure was 80 mm of Hg, and diastolic BP was not recordable. Immediately normal saline bolus was administered and her pulse volume improved and BP was 94/60 mm of Hg. After an hour, GCS was 9/15 and the respiration was shallow. After 4 hours, her sensorium improved (GCS 15/15). By 6 hours of ingestion, the child showed complete recovery. Discussion: Most of the clonidine poisoning children were younger than 6 years according to the NSWPIC database. Among them, 60% developed symptoms, most commonly lethargy (80%), bradycardia (17%), hypotension (15%), and respiratory depression (5%). Symptoms usually develop within 30-60 minutes and resolve within 24-48 hours. In our case, classical symptoms like drowsiness, hypotension, meiosis occurred within 30 minutes of ingestion and her consciousness deteriorated along with shallow respiration by the next 2 hours. By 6 hours of ingestion, the child showed complete recovery. Conclusion: While prescribing clonidine caution should be exercised regarding the side-effects. When calculating the dose, extra vigilance should be ensured and drug needs to be kept out of the reach of children.

Background: There is limited data on refined opium extract (Shireh) abuse, especially the magnitude of its complications and its mortality rates. To bridge such a gap, in this study, we aimed to investigate the frequency of pure refined opium extract poisoning and its consequences in a sample of our patients. Methods:This retrospective study was conducted on all the patients presented to our center with pure refined opium extract poisoning. Patients’ demographics, clinical and laboratory data, and outcome were collected during a ten-year period between 2006 and 2016. The included patients were divided into two groups: those who remained conscious and those who developed loss of consciousness. However, they were compared subsequently. Results:A total of 227 patients were evaluated. Most (75.8 %) of them were male. Mean age was 38.26±25.91 years. We found a significant correlation between educational (.038), marital (<.001), and occupational status (<.001) and age-gender groups of the patients. The mean amount of refined opium extract consumed was 4400 mg which had significant correlation with hospitalization period (<.001) and on-arrival rhabdomyolysis (<.001). We also found a correlation in vomiting (<.001), dizziness (.015), respiratory distress (.001), and apnea (<.001) between the two groups. The mean hospitalization period was 2.3 days and the mortality rate was 1.76%. Conclusion: Naloxone therapy use effective in most cases of pure poisoning with refined opium extract. There were four deaths incidences three of which happened due to cardiopulmonary arrest following body packing. Further studies in this type of poisoning are recommended.