Dr M M Jahangir Alam Associate Professor Department of Medicine Sylhet M A G Osmani Medical College Poisoning is a medical emergency results in morbidity and mortality TESS of ID: 931155
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TRAVEL RELATED POISONING: BURDEN AND HEALTH EFFECTS
Dr
M
M
Jahangir
Alam
Associate Professor
Department of Medicine
Sylhet
M A G
Osmani
Medical College
Slide2Poisoning is a medical emergency, results
in
morbidity and mortalityTESS of the American Association of poison control center records more than 2 million exposures and more than 700 deaths annuallyPoisoning records around 300000 episodes and around 2000 death per year in Bangladesh
Introduction
Billal
Alam
et al,
Factors associated with travel related
poisoning
Slide3Mode and pattern of poisoning vary from region to region and country to countryRecent trends of poisoning favors travel related poisoning. Hospital registry of SOMCH revealed that 43.27% of total poisoning patients were admitted in medicine unit due to travel related poisoning
Introduction
Slide4Travel related poisoning is an emerging social and public health concern in
Bangladesh
Few years back it was observed to be introduced by Dhatura and allied compoundNow different benzodiazepines are used with different food items for this purpose
Poisoning is a man made incident, which can be preventable
Introduction
Slide5Bangladesh is one of the developing countries where basic data regarding travel related poisoning are not available as there is no remarkable study done in this
issue
On average, 1‑2 patients/day with induced poisoning on journey used to get admitted during festival timeSituation of Travel related
poisoning in Bangladesh
Bari et
al, Emerging
trend of commuter (Street) poisoning in Bangladesh:
4
years
(
2008- 2011) experience from Hospital
archive
Slide6Since 2008 to 2011, a total of 4435 cases of acute poisoning were admitted in the Medicine ward of Sylhet
M. A. G.
Osmani Medical College Hospital Of them commuter poisoning (1919; 43.27%) was the most commonly occurring type (p<0.05) both in male and female & this trend remained same in almost all study years Situation of Travel related poisoning in Bangladesh
Slide7Study year
Type of poisoning
Total
OPC
Commuter (unknown agents) poisoning
Sedative
Harpic
Rat-killer
Corrosive
Alcohol
Kerosene
Paracetamol
Snake bite
Others200820092010201126022333632143848745154312211313011786956567353345603125403291212116476695945156253550441022104111561216Total11401919482313173128442329301544435Percentage25.743.2710.877.063.92.890.990.520.650.683.47
Situation of induced poisoning in Bangladesh
Bari et al, Emerging trend of commuter (Street) poisoning in Bangladesh:
4 years (2008- 2011) experience from Hospital
archive
Slide8Most of the circumstances of travel related poisoning
occur within bus, bus stands, taxi,
tampoo, auto-rickshaw, train, launch, railway station, local marketsThe incidence of this type of induced poisoning in cities like Dhaka, Chittagong, Sylhet, Rajshahi, Khulna is increasing during festival time like Eid
ul fitr,
Eid
ul
azha
,
Durga
Puja,
etc
Mode and pattern of
travel related poisoning
Slide9The miscreants use tea, coffee, biscuit, 'dab water', cold drinks, fruit, fruit juice, betel nut, 'jhal
muri', etcSometimes they offer medication of low cost for some disease like skin disease, asthma, hemorrhoidsMode and pattern of travel related poisoning
Slide10Mode and pattern of travel related poisoning
Billal
Alam
et al, Factors associated with travel related poisoning
Slide11Mode and pattern of travel related poisoning
Billal
Alam
et al, Factors associated with travel related poisoning
Slide12Majority (70%) of people were made stuporus with dab water,
soft drinks and tea, betel leaf with nutSmaller percentage of victims is offered cream biscuits, fruit, fruit juiceThese agents are chosen as they are popular fast food, cheaper to buy and easily available
and widely accepted.
Mode and pattern of travel related poisoning
Slide13Majority of victim travels through bus. More incidence of induced poisoning occurred when they are returning home from office
Usually these patients are found unconscious on buses or other places of the public transport system, and are brought to hospital by
policeMode and pattern of travel related poisoning
Slide14Mode and pattern of travel related poisoning
Slide15There is exclusively male sex pre‑ponderance
in induced poisoning cases, male: female=
98:2=49:1Majority of the victims are at 21 to 30 years age groupMost of the victims had lost their valuables including money
Mode and pattern of travel related poisoning
Slide16Sometimes the people are robbed of their mobiles, wristwatches, wedding rings, credit‑cards, official documents
The miscreants act as small groups in different places taking it as a profession, making the people and police fool and rob their valuable in regular
basisMode and pattern of travel related poisoning
Slide17Mode and pattern of travel related poisoning
Slide18They may be linked with larger chain of miscreants and this needs to be identified by the law‑enforcing agencies of government to disrupt the chain and to protect the people of being robbed off during journey.
These patients are admitted throughout the year but interestingly more during summer possibly people are usually thirsty due to excessive hot weather and easily deceived with an offer of cold drink from other person (Hospital records)
Mode and pattern of travel related poisoning
Slide19The interesting aspect of change of pattern of poisoning happened in the nature of patients of unknown poisoning from
Datura
to sedative which can be differentiated by skin condition, pupil size, relatively calm patient with uneventful recovery.Majority of victims were unconscious within 30 minutes of time after ingestion of offered substance and remaining were unconscious within 60 minutes because hypnotics used were absorbed quickly from gut, acted rapidly on central nervous system and made the person stuporous.
Clinical Features and
Investigation
Slide20Clinical Features and Investigation
Slide21Patient are usually brought by police in a drowsy or stuporous
conditions. Systemic examination is usually normal with no focal neurological deficit.
Laboratory investigations including haemogram, liver & Kidney function tests, ECG examination are unremarkable in most casesClinical Features and Investigation
Slide22Full toxicological screening was performed for urine samples obtained from the 15 patients of May 2006, using an LC–TOF
MS
lorazepam was identified in all 15 cases but additional ingestion of diazepam five cases and nitrazepam (three cases) was also detected However, in eight cases with lorazepam only
Clinical Features and Investigation
M.M.A.
Majumder
, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008),
doi:10.1016/j.forsciint.2008.06.016
Slide23Clinical Features and Investigation
M.M.A.
Majumder
, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008), doi:10.1016/j.forsciint.2008.06.016
Slide24The patients are usually managed in a very busy admitting unit. Many patients are managed in hospital floor.
Few
patients had accompanying relatives with them. Hospital facilities, logistics and staff cannot cope with such number of admitted patients.Management
Slide25Young trainee doctors and nurses managed the patients with resource limitations
In the absence of a specific diagnosis, care of these patients has been limited to observation and supportive measures
eg- maintenance of nutrition, fluid replacement and nursing careManagement
Slide26Fortunately most of the patients are discharged within 24 hours after admission uneventfully.
Almost
all patients are given stomach wash as a part of management of general poisoning, which did not reveal any significant gastric aspirate colour.Usually almost all patients are recovered fully. Some of them absconded probably due to social and medico‑legal cause. Absence of mortality among suspected induced poisoning is reassuring for us
Management
Slide27Management
Slide28Management
Slide29The incidence of Travel related poisoning is increasing and pattern is changing day by day as urbanization is going on.
The
facility of chemical identification of the induced poisoning should be made available for more effective, specific treatment of the patients rather relying on supportive treatment onlyConclusion
Slide30Special measures should be taken by the hospital administration for urgent management of these unaccompanied victims.
Steps should be taken by law‑enforcing agencies to identify the offending agents and culprit by vigilance.
Advice should be given to the public not to take food items on the travel particularly from an unknown person.Social awareness for safe travel needs to be createdConclusion
Slide31A team of healthcare professionals including doctors, nurses, and paramedics is needed to build up.
A
separate day care room close to emergency department can be set up which can be utilized by all admitting adult medicine units If the people, the mass media, the police, the bus driver and conductors become alert, the incidence can be reduced. Recommendation
Slide32Much co-ordinate work is needed to tackle the situation such as: Community-based study to identify the problem on nationwide basis and uniform guidelines about treatment
Awareness of the public for its prevention, immediate first-aid measures and quick hospital
admissionRecommendation
Slide33Awareness of the doctors by giving adequate importance of poisoning in undergraduate curriculum as well as by continued medical education
Facilities for intensive care with artificial respiration, adequate drug supply and by improving diagnostic method of chemical
analysis
Slide34M.M.A.
Majumder
, et al., Criminal poisoning of commuters in Bangladesh,
Forensic Sci. Int. (2008), doi:10.1016/j.forsciint.2008.06.016
Slide35Majumder MMA, Basher A,
Faiz
MA, Kuch U, Pogoda W, Kauert GF, et al. Criminal poisoning of commuters in Bangladesh: prospective & retrospective study. Forensic Sci Int 2008 August 25; 180(1):10-16.
Sarker ZM, Khan RK. Acute poisoning– scenario at a district hospital. Bangladesh J Med 2002 July; 13(1):49-52.
Uddin
MJ,
Shahed
FH,
Bhowmik
SK, Rashid R,
Ghose
A,
Rahman
MR, et al. ‘Transport related poisoning’—an untapped public health problem. The Healer. 2002; 9: 40-42.
Rahman M, Rahman M, Chowdhury AH. Pattern of poisoning in Rangpur Medical College Hospital. Northern Med J 1994 January; 3(1): 15-18.Howlader MAR, Hossain MZ, Morshed MG, Begum H, Sardar MH, Uddin MZ, et al. changing trends of poisoning in Bangladesh. J Dhaka Med Coll 2011 April; 20(1): 51-56.Bari MS, Chakraborty SR, Alam MMJ, Qayyum JA, Hassan N, Chowdhury FR, Emerging trend of commuter (Street) poisoning in Bangladesh: 4 years (2008- 2011) experience from Hospital archiveAlam MB, Ahasan HAMN, Bari MS, Chowdhury FR, Factors associated with travel related poisoningReferences
Slide36THANK YOU