Dr Md Robed Amin Associate Professor of Medicine Dhaka Medical College 05122014 Poisoning gt600000 deathsyear in developing world Eddleston Q J Med 2000 DMC 2 nd cause of admissionAfter stroke More than 5000 case per annum since 2008 ID: 392013
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Slide1
Situation of Common Poisoning in Bangladesh
Dr Md Robed AminAssociate Professor of Medicine Dhaka Medical College
05.12.2014Slide2
Poisoning
>600,000 deaths/year in developing world, (Eddleston, Q J Med 2000)DMC- 2
nd cause of admission(After stroke), More than 5000 case per annum since 2008.
2
nd common cause of hospitalization and 9th
common cause of death(DGHS-Health bulletin-2011)Slide3
Prevalence of top 10 diseases/causes of admission In UHC
(DGHS health Bulletin 2014 p49-55) Male (n 762264) Female (n 894425)SerialDiseaseTotal%DiseaseTotal%
1
3
3
4
5
6
7
8
Serial
Disease
Number
%
Disease
Number
%
1
Diarrhoea
144742
18,99
Diarrhoea
142157
15.89
2
Assault
125895
16.52
Assault
99196
11.09
3
Peptic ulcer
52392
6.87
Peptic ulcer
61862
6.92
4
Pneumonia
52105
6.84
Pneumonia
34567
3.86
5
Enteric
26753
3.51
Enteric
26108
2.92
6
RTA
26455
3.47
Obstructive
labour
22897
2.56
7
Bronchial
Asthma
23446
3.08
Bronchial
Asthma
21499
2.40
8
Viral
19 188
2.52
Anaemia
20848
2.33
9
Poisoning
18697
2.45
Poisoning
19640
2.20
10
HTN
10374
1.36
Viral fever
18441
2.11Slide4
Top 10 diseases/causes of admission in upazila health complexes in 2012 and 2013
(DGHS health Bulletin 2014 p49-55) 2013 2012 Percentage trendsDiseaseRanking%Ranking %Ranking change
Diarrhoea1
16.32117.74
Assault2
13.59213.51Peptic ulcer36.903
6,43
Pneumonia
4
5.23
46.41Enteric53.1953.48Bronchial Asthma62.71
6
2.51
RTA72.3972.40Poisoning82.3192.23+1Viral92.3182.24-1Anemia101.79101.56Slide5
Prevalence of top diseases/causes of admission In District Hospital
Male Female SerialDiseaseTotal%DiseaseTotal%1
3
3
4
5
6
7
8
Serial
Disease
Number
%
DiseaseNumber%1Diarrhoea5895213.53Diarrhoea5319811.792Assault392269.00Assault238995.303RTA240845.53Peptic ulcer15994
3.544Pneumonia20819
4.78Pneumonia140743.12
5Peptic ulcer 141882
3.26Obstructive labour11571
2.566Bronchial asthma
123502.83Bronchial Asthma
111402.477viral
115592.65HTN
106872.378
Poisoning
9059
2.08
RTA
10397
2.30
9
HTN
8451
1.94
Viral
9923
2.20
10
CVD
8186
1.88
Anxiety/depression
9441
2.09
11
MI
8021
1.84
Poisoning
9338
2.07Slide6
Prevalence of top diseases/causes of admission In Primary, secondary and tertiary care
Male Female SerialDiseaseTotal%DiseaseTotal%1
3
3
4
5
6
7
8
Serial
Disease
Number
%
DiseaseNumber%1Diarrhoea21159114.47Diarrhoea20182712.942Assault18349812.55Assault1319878.463Pneumonia792615.42Peptic ulcer81157
5.204RTA70725
4.84Pneumonia537753.45
5Peptic ulcer 70642
4.83Obstructive labour38290
2.456Bronchial asthma
409012.80Bronchial Asthma
368822.267Enteric
fever370562.53Enteric
fever347752.23
8
Viral
fever
32677
2.24
Poisoning
33105
2.12
9
Poisoning
31014
2.12
RTA
32682
2.10
10
HTN
23307
1.59
Anemia
32675
2.09Slide7Slide8Slide9
Mortality report of DGHS (ICD based)in 451 public hospital
Name of disease Number PercentageDiseases of the circulatory system1620633.20Certain conditions originating in the
perinatal period
777915.93
Diseases of the respiratory system
678713.90Injury, poisoning, and certain other consequences of external causes
4521
9.26Slide10
Baseline Survey
Baseline survey: 6 months from Sep 2006 - Feb 2007 in 4 hospitals and 7 health centres: (Prof MA Faiz)4553 cases (28% pesticide)14.5% of admissions Mortality 4.1% (88% pesticide)Slide11
Place
PesticideSedativesKerosine
Snake bite
Cu-
Sul
phateMethanolPotka
fish
Others
Total
OP
CarmateOthers
Benzodiazepine
Other sedative
DMCH2792327601897
73
102
512
1
298
2318
CMCH
299
781
119
34
38
303
1
3
00
505
1390
Coxsbazar
90
0
4
4
1
7
0
0
0
0
13
119
Hathazari
UHC
26
0
1
3
5
1
16
0
0
0
74
126
Jenaida
445
3
6
8
17
13
1
1
4
0
39
537
Sitakund UHC
29
0
4
2
0
7
12
0
1
0
8
63
Total
1168
33
123
737
954
139
434
7
20
1
937
4553Slide12
Gender of patients
Name of poison/toxic substance
Pesticide
Sedative
Snake bite
KeroseneCuSul-phateMethanol
OP
Carba
mate
Others
BenzodiazepineOther
Male
666
16563918263156.9%
864
16
15.6%
26.5%
Female
502
1767
346
128
119
2.6%
53
3
4
12.7%
10.3%
Total
1291
28.3%
1675
36.8%
434
9.5%
139
3.0%
7
20
0.4%Slide13
Survey in Dhaka Medical College Hospital (DMCH)
20085932 total cases of poisoning in DMCH
2108/5929 (35%) female; 3821/5929 (65%) male
Median age was 25 years (IQR 19-35 years)
Overall mortality was 151/5932 (2.6%)Slide14
DMC survey95% sought initial - Government Hospital.
Suicidal attempt -43.8%Family disharmony -37.7% stupifying agent (38.2%).Mortality: 105 OP death among 151 herbal medicine-25%, then OP poisoning-16%., methanol poisoning-11% and copper sulfate poisoning (9%).Slide15
Major risk factor for mortality
rural residence, hindu religion, illiterate, farmer, suicide attempt, deliberate self harm, GCS<9, BP<80/60, HR>100/<60 and abnormal pupils esp constricted or pinpoint.Slide16
Types of Poison - DeathsSlide17
Types of Poison - 1
All
Survivors
Deaths
Mortality
Unknown
2061
(36%)
2050
(37%)
11 (
7%)
1%
Benzodiazepine / other sedative714(12%)710(13%)4 (3%)
1%
Organophosphate
/ Carbamate
672
(12%)567
(10%)
105 (70%)
16%
Rat killer
382
(7%)
379
(7%)
3
(2%)
1%
Snake bite / puffer fish / insect bite / sting
370
(6%)
366
(7%)
4
(3%)
1%
Other medication
360
(6%)
360
(6%)
0
(0%)
0%
"Street"
331
(6%)
330
(6%)
1
(1%)
0%
Household cleaning chemical
183
(3%)
183
(3%)
0
(0%)
0%
Kerosine
167
(3%)
166
(3%)
1
(1%)
1%
Other pesticide / insecticide
164
(3%)
162
(3%)
2
(1%)
1%
Slide18
Types of Poison - 2
All
Survivors
Deaths
Mortality
Other chemical / acid
97
(2%)
90
(2%)
7
(5%)
7%
Tricyclic
/other antidepressant
76
(1%)
76
(1%)
0
(0%)
0%
Ethanol
52
(1%)
48
(1%)
4
(3%)
8%
Methanol
38
(1%)
34
(1%)
4
(3%)
11%
Paracetamol
32
(1%)
32
(1%)
0
(0%)
0%
Copper sulphate
23
(0%)
21
(0%)
2
(1%)
9%
Herbal medicine
12
(0%)
9
(0%)
3
(2%)
25%
Datura
plant
12
(0%)
12
(0%)
0
(0%)
0%
Illicit drugs
7
(0%)
7
(0%)
0
(0%)
0%
Miscellaneous
179
(3%)
179
(3%)
0
(0%)
0%
Total
5746
5595
151
3%
Slide19
Predicting Mortality
Class of PredictorSubstance
OPC
Non-OPC
Factor
OR
P
Factor
OR
P
Clinical
Low GCS (<11)
22.7
<0.0001
Low systolic BP (<80)
54.5<0.0001
Low GCS (<11)
49.7
<0.0001
(Area under ROC curve = 0.81)
(Area under ROC curve = 0.87)
Clinical and non-clinical
Non-
muslim
4.1
0.003
Economic loss
44.03
<0.0001
Constricted pupils
2.8
0.045
Failure to pass exam
10.86
0.031
Low GCS (<11)
1.4
<0.0001
Low GCS (<11)
1.65
<0.0001
Low systolic BP (<80)
1.04
<0.0001
(Area under ROC curve = 0.87)
(Area under ROC curve = 0.97)
Multivariate analysisSlide20
Pesticide Poisoning
Pesticide poisoning- 39.1% (CI 37.6-40.6%) OPCs- 89.8% (Malathion was the commonest pesticide used, followed by carbamates) rodenticides- 4.3% carbamates - 4.0% unknown compounds - 1.6% pyrethroids - 0.3% Mortality -72.6% (CI 68.0-76.8) 0.7 deaths per 100,000 population was due to pesticide poisoningAnalysis of Recent Situation of Pesticide Poisoning in Bangladesh: Is There a Proper Estimate?..Gourob
DewanAPJMT 3;2 http://apjmt.mums.ac.ir June 2014Slide21
Complication of Pesticides
atropine toxicity (15.6%)intermediate syndrome (13.6%),acute cholinergic crisis (13.3%) respiratory failure (7.9%),arrhythmia (2.6%) and aspiration pneumonia/hypoxic encephalopathy (1.8%)mortality rate - 5.1% (CI 4.6-5.6) (all poisoning)72.6% (CI 68.0-76.8) were due to pesticidesOPC- 8.9% (CI 7.7-10.4) Carbamates-, 1.4% (CI 0.2-7.7) Rodenticide -3.0% (CI 0.8-10.4) Analysis of Recent Situation of Pesticide Poisoning in Bangladesh: Is There a Proper Estimate?..Gourob DewanAPJMT 3;2 http://apjmt.mums.ac.ir June 2014Slide22Slide23
Estimated
doses of different Benzodiazepine were used by miscreantsSlide24
Household poisoning4.5 % of poisoning cases in Tertiary care hospital.
Bleaches, cleaners-commonly consumesMorbidity issue?/stricturePredominantly young groups Slide25
Miss M, 20 years, admitted with the history of ingestion of
Tab. Tryptin 10 mg (amytriptylin
)
40 in number and repeat the attempt after recovery with 60 tab.
She recovered with ICU support and intensive HCO3 therapy on both occasion.
Amitriptiline poisoningSlide26
ECGSlide27
Substance Abuse (methamphetamine,
YABA)A-25-year-old Upazilla level officer working in an Upazilla bordering with Myanmar presented with acute
confussional state in a private facility having no H/O fever, during workup developed generalized tonic
clonic convulsion. Key findings; and investigations gave no clue to diagnosis. Subsequent information from attendants and confirmed by the patient: H/O of multiple substance abuse including amphetamine (‘
Yaba’).Slide28
Unknown Herbal PoisoningSlide29
Herbal Poisoning
Three young friends end up there experiments admitted through ER of a public MCH, following an attempt of gratification by using a cocktail of ?safe herbal concoction (photo of cocktail) having features of GI toxicity and cardiac abnormalities (ECG finding). One of them died, one could be resuscitated, the other left the hospital by their own.Slide30
ECG Showed Ventricular TachycardiaSlide31
Aluminium
Phosphide PoisoningSlide32
Aluminum
Phosphide Increasing trends in Comilla, Bogura.
In DMC 4 yrs (2008-2011) 43 cases and 37 death.Mortality-50%-80%
Fatal case series observed in 2008 in DMC ( 7 death within 3 months).Slide33
Aluminium
Phosphide ‘Kari’ or ‘Gas’ TabFirst known fatal case of AP poisoning case in Bangladesh: Cardiac, renal, hepatic involvement, hypernatremia
, acidosis, haemolysis, thrombocytopenia; Died 8 days after ingestion of single
pellete.
DMCH (29/08/2004);Slide34
Methanol Poisoning
A 35-year-old previously healthy business executive admitted in an ICU with coma, respiratory distress and features of anion gap acidosis having HO social drinking followed by death of a mate and serious disability in the case with permanent blindness. J MEDICINE 2010; 11 : 212-213
Non contrast axial CT scan of the Head showing bilateral symmetrical
hypodense shadows in theregions
of putamen.Slide35
Methanol Poisoning-fatal Case Series
In DMC-2008- 8 cases within 4 monthsUnconsciousness, blindness and metabolic acidosis were characteristics features.None of the patient received antidote or specific supportive measures. Slide36
Large numbers of patients with
neurotoxic poisoning admitted All with history of puffer fish consumption Caused by shipment of fish (41 kg) from Bay of Bengal Exported to Kuliarchar fish depot in Kishoreganj District
From there distributed to all affected areas
April 2008
Narsingdi & Kishoreganj Districts (1)
Port of originSlide37
Laboratory investigations (2)
Patient samples, Natore DistrictTTX (ng/ml)
Sample No. (1–38)
Tetrodotoxin concentration in the blood of patients
ELISA
Fatal outcomeSlide38Slide39
Stomach wash roomSlide40Slide41
Comment
Recommendations of BANTROPTOX (2010 and 2013) is yet to be taken into consideration Is development of treatment guidelines and few training enough to tackle the huge burden of cases of poisoning.Frequent newspaper reports of seizure of ‘Yaba
’, ‘Phensedyl’, ‘snake venom’, ‘travel related poisoning of commuters’ are interesting but requires multifaceted serious interventions.Slide42
Comment
Alum phosphide,Methanol and Copper sulphate are raisingScientific diagnosis of poisoning is yet to be made available in public facilities.Available investigations during management and follow up are not considered in most of the cases of poisoning. Slide43
Acknowledgement
Prof MA FaizDr.
Gourab Dewan
Dr.
Ariful basher