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JKSCT : Journal of The Korean Society of Clinical Toxicology

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Discrepancies and Validation of Ethanol Level Determination with Osmolar Gap Formula in Patients with Suspected Acute Poisoning
Haewon Jung, Mi Jin Lee, Jae Wan Cho, Jae Yun Ahn, Changho Kim
J Korean Soc Clin Toxicol. 2019;17(2):47-57.   Published online December 31, 2019
DOI: https://doi.org/10.22537/jksct.2019.17.2.47
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Purpose: Osmolar gap (OG) has been used for decades to screen for toxic alcohol levels. However, its reliability may vary due to several reasons. We validated the estimated ethanol concentration formula for patients with suspected poisoning and who visited the emergency department. We examined discrepancies in the ethanol level and patient characteristics by applying this formula when it was used to screen for intoxication due to toxic levels of alcohol. Methods: We retrospectively reviewed 153 emergency department cases to determine the measured levels of toxic ethanol ingestion and we calculated alcohol ingestion using a formula based on serum osmolality. Those patients who were subjected to simultaneous measurements of osmolality, sodium, urea, glucose, and ethanol were included in this study. Patients with exposure to other toxic alcohols (methanol, ethylene glycol, or isopropanol) or poisons that affect osmolality were excluded. OG (the measured-calculated serum osmolality) was used to determine the calculated ethanol concentration. Results: Among the 153 included cases, 114 had normal OGs (OG≤14 mOsm/kg), and 39 cases had elevated OGs (OG>14). The mean difference between the measured and estimated (calculated ethanol using OG) ethanol concentration was -9.8 mg/dL. The 95% limits of agreement were -121.1 and 101.5 mg/dL, and the correlation coefficient R was 0.7037. For the four subgroups stratified by comorbidities and poisoning, the correlation coefficients R were 0.692, 0.588, 0.835, and 0.412, respectively, and the mean differences in measurement between the measured and calculated ethanol levels were -2.4 mg/dL, -48.8 mg/dL, 9.4 mg/dL, and -4.7 mg/dL, respectively. The equation plots had wide limits of agreement. Conclusion: We found that there were some discrepancies between OGs and the calculated ethanol concentrations. Addition of a correction factor for unmeasured osmoles to the equation of the calculated serum osmolality would help mitigate these discrepancies.
Low Plasma Insulin Level Prolonged Hypoglycemia after High dose Insulin Lispro Injection
Jeong Ho Kang, Hyun Soo Park
J Korean Soc Clin Toxicol. 2016;14(2):151-154.   Published online December 31, 2016
DOI: https://doi.org/10.22537/jksct.2016.14.2.151
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Increased plasma insulin levels are often observed in exogenous insulin overdose patients. However, plasma insulin level may decrease with time. We report a case of low plasma insulin level hypoglycemia after insulin lispro overdose. The patient was a 37-year-old man with no previous medical history who suspected insulin lispro overdose. Upon arrival, his Glasgow coma scale was 3 points and his blood sugar level (BSL) was 24 mg/dl. We found five humalog-quick-pen (insulin lispro) in his bag. There was no elevation of glucose level, despite an initial 50 ml bolus of 50% glucose and 150 cc/hr of 10% dextrose continuous intravenous infusion. He also suffered from generalized tonic-clonic seizure, which was treated with lorazepam and phenytoin. We conducted endotracheal intubation, after which he was admitted to the intensive care unit (ICU). There were recurrent events of hypoglycemia below BSL<50 mg/dl after admission. We repeatedly infused 50 ml 50% glucose 10 times and administered 1 mg of glucagon two times. The plasma insulin level was 0.2 uU/ml on initial blood sampling and 0.2 uU/ml after 5 hours. After 13 hours, his BSL stabilized but his mental status had not recovered. Diffuse brain injury was observed upon magnetic resonance imaging (MRI) and severe diffuse cerebral dysfunction was found on electroencephalography (EEG). Despite 35 days of ICU care, he died from ventilator associated pneumonia.
Initial Blood Glucose Can Predict the Outcome of OP Poisoning
Sung Do Lee, Jeong Mi Moon, Byeong Jo Chun
J Korean Soc Clin Toxicol. 2015;13(2):55-61.   Published online December 31, 2015
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Purpose: Many studies have examined the mechanisms of impaired glucose homeostasis after organophosphate (OP) exposure, however no study has evaluated the clinical utility of blood glucose measurements in patients with OP poisoning. The current study was conducted to evaluate the initial glucose level at presentation and the glycemic variables during the first 3 days after admission as a predictor of mortality. Methods: This retrospective observational case series included 228 patients with a history of OP poisoning. Among other clinical data, information on the initial glucose level at presentation and mean glucose level, delta glucose level, and the presence of a hypoglycemic event during the first 3 days of admission, was collected. Results: Survivors had lower initial glucose levels at presentation and glucose variability during the first 3 days of admission compared to non-survivors. The frequency of hypoglycemic events was higher in non-survivors. In multivariate analysis, the initial glucose level (> 233 mg/dl) was an independent predictor of mortality, along with age. Conclusion: The initial glucose level at presentation can be helpful in prediction of mortality in cases of OP intoxication at bedside. The physician should pay attention to patients with a glucose level >233 mg/dl at presentation after ingestion of OP.
Acute Pancreatitis after Carbamate Poisoning
Joseph Park, Yong Won Kim, Se Hyun Oh, Yong Sung Cha, Kyoung Chul Cha, Oh Hyun Kim, Kang Hyun Lee, Sung Oh Hwang, Hyun Kim
J Korean Soc Clin Toxicol. 2014;12(2):77-84.   Published online December 31, 2014
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Purpose: Carbamate insecticides are potent cholinesterase inhibitors capable of causing severe cholinergic toxicity. Use of carbamate rather than organophosphate insecticides has been increasing. Compared with organophosphate poisoning, relatively few studies have investigated carbamate-associated acute pancreatitis. We investigated general characteristics and pancreatitis of carbamate poisoning and the predictors, among those readily assessed in the emergency department. Methods: We performed a retrospective review of consecutive patients, aged over 18 years, who were admitted between January 2008 and April 2012 to an emergency department (ED) of an academic tertiary care center for treatment of carbamate poisoning. Patients who exhibited poisoning by any other material, except alcohol, were excluded. After application of exclusion criteria, patients were divided according to carbamate-induced pancreatitis and non-pancreatitis groups. Results: A total of 41 patients were included in this study. Among these 41 patients, the prevalence of acute pancreatitis was 36.6% (15 patients). Initial blood chemistry tests showed a statistically higher glucose level in the pancreatitis group, compared with the non-pancreatitis group (222, IQR 189-284 vs. 137, IQR 122-175 mg/dL, P<0.05). Regarding clinical courses and outcomes, a significantly higher proportion of patients developed pneumonia [10 (66.7%) vs. 6 (23.1%), P<0.05] and had a longer hospital stay (7 days, IQR 6-12 vs. 5 days, IQR 2-11, P<0.05), but no difference in mortality, in the pancreatitis group vs. the non-pancreatitis group. In multivariate analysis, the initial glucose was showing significant association with the presentation of carbamate-induced acute pancreatitis (odds ratio 1.018, 95% confidence interval 1.001-1.035, P<0.05). Conclusion: Carbamate-induced acute pancreatitis is common, but not fatal. Initial serum glucose level is associated with acute pancreatitis.
Clinical Observation of Paraquat Poisoning
Kyung-Hong Jun, Myung-Soo Kang
J Korean Soc Clin Toxicol. 2009;7(1):1-9.   Published online June 30, 2009
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Purpose: Paraquat, a globally used herbicide, is highly toxic to human beings. Hence, we reviewed some cases of paraquat poisoning in Korea. Methods: We analyzed the clinical and laboratory findings of 50 patients poisoned with paraquat retrospectively. The patients were admitted to the department of internal medicine in the Eumseong KeumWang hospital from January 2008 to December 2008. Results: Among 50 cases of paraquat poisoning, 28 cases were male. Twenty-four cases (48%) were over 60 years old. Fourty-nine patients ingested paraquat on purpose as suicidal attempts, while 1 patient underwent accidental ingestion. Seven patients swallowed less than one mouthful of paraquat, of which 4 patients survived. Eleven patients swallowed two mouthfuls of paraquat, of which 8 patients survived. Thirty-two patients swallowed over three mouthfuls of paraquat and they all died. Thirty-one patients with leukocytosis died. Twenty-one patients with metabolic acidosis died. Increased levels of blood amylase and glucose were related to high mortality, and increased level of blood creatinine was related to severe mortality. Hemoperfusions were accomplished in 27 patients of paraquat poisoning, of which 12 patients survived. Conclusion: Paraquat is a highly toxic herbicide. When patients arrive at the hospital, laboratory findings, urine paraquat concentrations, arrival time, and the amount of paraquat consumed must be considered for treatment plan.
Severe Acidosis after Massive Metformin Overdose
Bo-In Kim, Jin-Hee Jung, Eun-Kyung Eo
J Korean Soc Clin Toxicol. 2008;6(1):42-44.   Published online June 30, 2008
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Metformin which is an oral hypoglycemic agents, acts by enhancing insulin sensitivity, decreasing hepatic glucose production and increasing peripheral utilization of glucose. Deliberate self poisoning with oral hypoglycemic agents is rare. The lactic acidosis associated with metformin toxicity is well described in the medical literature. Metformin overdose even in otherwise healthy patients may produce a profound and life threatening lactic acidosis. We report a case of massive metformin ingestion(75g) in a patient presenting with lactic acidosis and hypotension. She died 24h after presenting to our emergency department despite bicarbonate treatment and hemofiltration therapy.
A Fatal Case of Methylene Blue Threatment Failure in Methemoglobinemia
Ji-Yae Shim, Yun-Seok Seo, Jong-Oh Yang, Eun-Young Lee, Sae-Yong Hong, Hyo-Wook Gil
J Korean Soc Clin Toxicol. 2006;4(2):151-154.   Published online December 31, 2006
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Acute toxic methemoglobinemia is an infrequent complication of the use of various drugs. Severe methemoglobinemia is very often fatal. Methylene blue is an effective drug in the treatment of methemoglobinemia patients. However, failure to respond to methylene blue has been described in patients with sulfhemoglobinemia, chlorate poisoning, and glucose-6-phosphate dehydrogenase deficiency. It is even possible that hemolysis may occur due to methylene blue treatment itself. We encountered a case of a 71-year-old woman who developed methemoglobinemia caused by alprazolam intoxication. She presented with hemolytic anemia and did not respond to methylene blue. In spite of concerted N-acetylcysteine therapy, the hemolytic anemia became aggravated and the patient died eleven days after intoxication.
A Case of Acute Intoxication with Glyphosate and Oxyfluorfen Containing Powder Herbicide ($Daejangun^{(R)}$)
Seung Hee Lee, Kum Ho Yi, Sung-Soo Yoo, Heung-Keun Roh
J Korean Soc Clin Toxicol. 2005;3(2):110-113.   Published online December 31, 2005
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Glyphosate containing herbicides are an alternative to paraquat and have been widely used with increasing frequency in suicide attempts throughout Asia. It is an organophosphorus compound that is not a cholinesterase inhibitor. Daejangun powder consists of glyphosate ammonium, surfactant and another herbicide, oxyfluorfen. A 60-year-old man ingested about 300 g of Daejangun powder with 500 ml of water in a suicide attempt. He was brought to emergency room 6 hours after the ingestion and showed severe metabolic acidosis (pH 6.75), marked leukocytosis (WBC 35,800/$mm^3$), hypoglycemia (glucose 13 mg/dL) and increased liver enzymes (AST/ALT 1,683/418 IU/L). Later he developed aspiration pneumonia, acute renal failure and hyperchloremic acidosis. Upper gastrointestinal endoscopy which performed 5 days after the ingestion revealed corrosive injuries (grade 1) in both esophagus and stomach. However, intensive treatment with supportive measures improved the abnormal findings almost completely 4 weeks after the ingestion.

JKSCT : Journal of The Korean Society of Clinical Toxicology