Journal of The Korean Society of Clinical Toxicology

Volume 18(1); June 2020

Treatments of Calcium Channel Blocker Overdose: Sung Woo Lee; J Korean Soc Clin Toxicol. 2020;18(1):1-10. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.1

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Abstract PDF: Pharmaceutical agents are the most common causes of poisoning in Korea. Calcium channel blockers (CCBs) are commonly used in Korea for the management of hypertension and other cardiovascular diseases, but are associated with a risk of mortality due to overdose. Due to the frequent fatalities associated with CCB overdose, it is essential that the emergency physician is capable of identifying CCB intoxication, and has the knowledge to manage CCB overdose. This article reviews the existing clinical guidelines, retrospective studies, and systematic reviews on the emergency management of CCB overdose. The following are the varied treatments of CCB overdose currently administered. 1) For asymptomatic patients: observation with enough time and decontamination, if indicated. 2) For symptomatic patients: infusion of calcium salt, high dose insulin therapy, and vasopressor (norepinephrine) or atropine for bradycardia. 3) For patients refractory to the first line therapy or with refractory shock or impending arrest: lipid emulsion therapy and extracorporeal membrane oxygenation. 4) As adjunct therapy: phosphodiesterase inhibitors, glucagon, methylene blue, pacemaker for AV block. Small CCB ingestion is known to be fatal for pediatric patients. Hence, close observation for sufficient time is required.

Errors of Death Certificate for Poisoning Related Death: Chan Hyeok Park, Sun Hyu Kim; J Korean Soc Clin Toxicol. 2020;18(1):11-17. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.11

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Abstract PDF: Purpose: This study examines errors in death certificates (DCs) issued to cases of poisoning. Methods: DCs issued in poisoning cases were retrospectively reviewed. Errors in the DC were classified as major and minor errors, and were evaluated in accordance with their impact on the process of selecting the cause of death (COD). Results: A total of 79 DCs were evaluated; 43 (54.4%) DCs were issued in the emergency department (ED), and 36 (45.6%) DCs were issued outside the ED. The average major and minor errors per DC were determined to be 0.4 and 3.3, respectively. Moreover, an average of 3.0 errors were discovered in DCs issued at the ED, and 4.4 errors in DCs issued outside the ED. The most common major errors were incorrect manner of death (11.4%, 9/79), followed by unacceptable COD (7.6%, 6/79), and the mode of dying as an underlying COD (5.1%, 4/79). The common minor errors most frequently encountered were incorrect time interval (86.1%, 68/79), followed by incorrect other significant conditions (73.4%, 58/79), and no record for date of onset (62.0%, 49/79). Conclusion: Our results indicate that the total numbers of major errors, minor errors and cases of misjudged cause of death were greater in DCs issued outside the ED than in DCs issued at the ED. The most frequently quoted major error of DCs related to poisoning was determined to be the incorrect manner of death.

Associations between Early Hyperoxia and Long Term Neurologic Outcome in Acute Carbon Monoxide Poisoning: Ju Chan Kim, Byeong Jo Chun, Jeong Mi Moon, Young Soo Cho; J Korean Soc Clin Toxicol. 2020;18(1):18-25. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.18

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Abstract PDF: Purpose: We studied the impact of arterial oxygen tension (PaO2) on the long term neurologic outcome in patients with acute carbon monoxide poisoning. Methods: The study population included 311 patients who presented to emergency department with acute CO poisoning from January 2015 to January 2018. These patients underwent arterial blood gas testing at the time of presentation. The baseline demographic, clinical, laboratory, and clinical outcome data were recorded. The primary outcome of interest was the long term neurologic status. Results: The normoxia group was significantly older and it had a higher incidence of diffusion weighted MRI abnormality, and this group needed multiple HBO sessions compared to the group with moderate or severe hyperoxia. Also, the incidence of altered mentality at discharge was higher in the normoxia group than that of the moderate hyperoxia group. The incidence of a poor long term neurologic outcome was 11.3%. The incidence of a poor long term neurologic outcome decreased as the PaO2 increased. The PaO2 was significantly lower in patients with a poor long term neurologic outcome than that of the patients with a good outcome 198 (165.2 to 231.1) mmHg in the good outcome group vs. 154 (119-162) mmHg in poor outcome, p<0.001). In multivariate logistic regression analysis, PaO2 was selected as an independent factor of the poor long-term neurologic outcome (OR 0.981 (95% CI: 0.968 to 0.995)) Conclusion: Higher PaO2 was independently associated with a lower incidence of a poor long-term neurologic outcome.

The Effects of Agent Orange in Patient with Pneumonia: Dong Sung Kim, Jungyoup Lee, Yu Chan Kye, Euigi Jung, Ki Young Jeong; J Korean Soc Clin Toxicol. 2020;18(1):26-33. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.26

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Abstract PDF: Purpose: Agent Orange (AO) is a herbicide and defoliant used by the United States and its military allies during the Vietnam War. Pneumonia is a common cause of death among Vietnam veterans in our hospital. There have been no previous studies researching any association between AO exposure and the prognosis for pneumonia. The primary objective of this study was to investigate associations between AO exposure and 30-day mortality due to pneumonia. The secondary objective was to examine the clinical factors associated with therapeutic outcomes in veterans with pneumonia, and to assess the prevalence of combined diseases in AO-exposed veterans. Methods: This study retrospectively included veteran patients diagnosed with pneumonia in the emergency department and hospitalized between February 2014 and March 2018. The enrolled patients were grouped according to their defoliant exposure history, and the clinical information of defoliant-exposed and non-defoliant-exposed groups were compared. Patients were divided according to 30-day mortality, and significant factors influencing mortality were evaluated by using univariate analysis and multivariate analysis. The final multivariate model revealed the effect of AO exposure on therapeutic outcomes of pneumonia. Results: A total of 1006 patients were analyzed. Of these, 276 patients had a history of AO exposure, whereas 730 patients had not been exposed. Factors positively associated with 30-day mortality were malignancy, respiratory rate, blood urea nitrogen, and albumin which was negatively associated with mortality. Conclusion: Exposure to defoliant is not associated with 30-day mortality in patients with pneumonia. However, veterans with defoliant exposure are associated with a high prevalence of diabetes mellitus, hypertension, cerebrovascular accident, malignancy, and chronic kidney disease.

The Risk Factors of Acute Cardiovascular and Neurological Toxicity in Acute CO Poisoning Patients and Epidemiologic Features of Exposure Routes: Jinsoo Park, Seunglyul Shin, Youngho Seo, Hyunmin Jung; J Korean Soc Clin Toxicol. 2020;18(1):34-41. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.34

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Abstract PDF: Purpose: This study evaluated aggressive hyperbaric oxygen therapy (HBOT) by understanding various exposure routes of acute carbon monoxide (CO) poisoning, the risk factors causing acute cardiovascular, and neurological toxicity caused by poisoning. Methods: A retrospective study was conducted based on the medical records of 417 acute CO poisoning patients who visited the emergency care unit from March 2017 to August 2019. The exposure routes, HBOT performance, age, sex, medical history (hypertension, diabetes mellitus, ischemic heart disease, heart failure), intentionality, loss of consciousness (LOC), intake with alcohol or sedatives, and initial test results (carboxyhemoglobin (COHb), troponin-I, electrocardiography, echocardiography, brain MRI) were examined. Comparative analysis of the clinical information was conducted between the groups that showed acute cardiovascular toxicity and neurological toxicity, and groups that did not. Results: Among 417 patients diagnosed with acute CO poisoning, 201 cases (48.2%) were intentional, and charcoal briquette was the most common route (169 patients (40.5%)). Two hundred sixteen cases (51.8%) were accidental, and fire was the most common route (135 patients (32.4%)). The exposure route was more diverse with accidental poisoning. Three hundred ninety-nine patients were studied for acute cardiovascular toxicity, and 62 patients (15.5%) were confirmed to be positive. The result was statistically significant in intentionality, LOC, combined sedatives, initial COHb, HTN, and IHD. One hundred two patients were studied for acute neurological toxicity, which was observed in 26 patients (25.5%). The result was statistically significant in age and LOC. Conclusion: Active HBOT should be performed to minimize damage to the major organs by identifying the various exposure routes of CO poisoning, risk factors for acute cardiovascular toxicity (intentionality, LOC, combined sedatives, initial COHb, HTN, IHD), and the risk factors for acute neurological toxicity (age, LOC).

Respiratory Failure following Tetramine poisoning after Ingestion of Sea Snail: A Case Report: Joo Hwan Lee, Jin Wook Park, Seong Jun Hong, Jae-Cheon Jeon, Sang-Chan Jin; J Korean Soc Clin Toxicol. 2020;18(1):42-46. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.42

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Abstract PDF: Tetramine toxicity due to sea snail ingestion is generally mild and has a good prognosis. Tetramine toxicity acts on the acetylcholine receptor, affecting the neuromuscular junction and autonomic nervous system. A 78-year-old female patient visited the emergency room with vomiting and dyspnea after eating sea snails. At the time of admission, the vital signs recorded were 140/80 mmHg-105/min-24/min-36.5℃, and 90% oxygen saturation. Arterial blood test revealed hypercapnia (pCO2 58.2 mmHg) and respiratory acidosis (pH 7.213, HCO3- 22.5 mmol/L), whereas other blood tests showed no specific findings. Due to decreased consciousness and hypoxia, endotracheal intubation and mechanical ventilation were administered to the patient. Successful weaning was accomplished after 12 hrs, and the patient was discharged without any further complications. Although tetramine toxicity rarely results in acute respiratory failure due to paralysis of the respiratory muscle, caution is required whilst treating the patient.

A Case of Ischemic Stroke in Young Patient Associated with Marijuana Use: Sue Young Ha, Dong-Wan Kang, Seung-Hoon Lee; J Korean Soc Clin Toxicol. 2020;18(1):47-50. Published online June 30, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.1.47

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Abstract PDF: A 21-year-old female patient complaining of hemiparesis was diagnosed with right middle cerebral artery infarction. No risk factor was found, despite an extensive young-age stroke work-up, except her history of marijuana use. The patient had smoked marijuana for treating depression for more than five years. Magnetic resonance angiography showed multifocal intra- and extracranial stenoses, suggesting cannabinoid-induced vasculopathy. Since the use of illicit drugs has increased nationwide, physicians should consider it as a possible cause of a stroke due to an unknown etiology.

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