Clinical Profile and Outcomes of Poisonings and Drug Overdose at King Saud Medical City

a A significant number of visits are due to poisonings and drug Poisonings is a major cause of the in and Ingestion of different poisons can or Poisoning can occur following ingestion, inhalational, or sometimes snuffing of drugs. it to poisoning or alcohol intoxication was recruited for this study. Methods: A study of all the patients that presented to our hospital from the period of January 2020 until September, 2020 was recruited for this horizontal study. Initial data was collected manually. An online Excel sheet was created, and the following parameters were collected; age, gender, and nationality, information regarding the ingested/inhaled substance, patients’ signs, and symptoms upon presentation to the Emergency room, and various laboratory tests. Patients were followed till they were in the hospital and finally disposed. Statistical analysis was then performed on the collected data. Results: Most of the patients (65.7%) were males. (69.4 %) were Saudi nationals with a mean age of 33-years. The most common presenting symptom is decreased level of consciousness (35 cases). Paracetamol overdose accounted for 12% of the cases, alcohol accounted for 10.2%. More than 50% of our patients had mixed drug poisoning or unidentifiable poison. The maximum reading for blood pressure was 221/149 mmHg among the benzodiazepine overdose group. The respiratory rate was within the normal limit in all patients. cMortaliyu was below 1%. Conclusion: Drug overdose is a common cause of emergency room visits and hospital admission. Paracetamol was the commonest cause of identifiable drug overdose, followed by Alcohol ingestion. But mixed poisoning involving multiple drugs were quite common these days. Outcome was generally good with just less than 1% mortality. direct activation of programmed cell-death to and the In a study evaluating the disturbances of and blood chemistry


INTRODUCTION Corresponding Author: Dr. Latif Ahmed Khan
snuffing of drugs or chemical but regardless of the method in which the poison was taking, it might lead to catastrophic outcomes. Substance misuse is an increasingly pressing issue, and hospital admissions due to such abuse has substantially increased. Although with the strong religious and constitutional sanctions against suicide, several cases of intentional drug overdose occasionally occur in Saudi Arabia.

METHODS
Being aware of the poisonimngs cases attending our hospital, we decided to take up this study. This study was conducted by the Interns of our department under the guidance of Principal investigator(PI). We obtained ethical approval from the local IRB committee,of King Saud Medical City. A horizontal study of all the patients that presented to King Saud Medical City, Emergency department, from the period of January 2020 until September 2020. Our inclusion criteria were the following: age more than 15 years, who ingested or inhaled chemical poisons/drugs or household material or a substance abuse. We also included patients with Alcohol intoxication, drug overdose weather prescribed or illegal drugs, either ingested or inhaled, intentionally or accidentally. We collected the data of 108 patients who were admitted to KSMC, either in the general ward or Intensive Care Unit. An online Excel sheet was devised , and the following parameters were added; demographic data (age, gender, and nationality), substance abused, patient's signs and symptoms upon presentation to the Emergency room, Glasgow Coma Scale (GCS), Vital signs, Venous Blood Gases (VBG), and the antidote used, if any. Laboratory tests such as Complete Blood counts(CBC)Liver function test (LFT), Coagulation profile, Kidney Function Test (KFT), fasting glucose, and status upon discharge, were calso recorded. The data were analyzed using SPSS 25.0 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Continuous variables Age, GCS, temperature, BP, Pulse, RR, SpO2, Ph, pCO2, pHCO3, Na+, K+, CL-, are presented as Mean along with spectrum. The parameters Urea, Cr, AST, ALT, WBC, PLT, HCT, PT, INR, PTT, Fasting Glucose are tested for its normality

RESULTS
The study involved a total of 108 patients who came to emergency department (ED) of King Saud Medical City-Riyadh with drug overdose, chemical ingestion or alcohol intoxication. Vast majority of the patients, 71, (65.7%) were males and 69.4 % (n=75) were Saudi nationals with minimum age of 15 and maximum of 85 years and the mean age was 33 years.. Most of them were stable on arrival (74%) and one was a case of death on arrival (Table 1). Ages spectrum of different subgroups are represented in the figure 1, below  (3) published their surveillance report of poisoning From Alqaseem region and mentione that poisoning occurs both in children as well as adults. According to his report Insecticides were common cause of poisoning followed by paracetmol and analgecics. He also reported almost 50% mortality in insecticie poisoning.) Khan and Khan (4) reported from Corresponding Author: Dr. Latif Ahmed Khan Najran in 2003 and mentioned that 23% of the poisoning reported to Najran General Hospital were orgganophophorus poisoning and many of them were unstable at admission. They also mentioned about the local shamma poisong, a local herbal product.(4). Zainub et all reported from Almujmah,in 2014 region of saudi Arabia that although pharmaceutical drugs , stored at home were the common cause of poisoning in Children, but stings and envenimaton was the common in adults, especially those working in agricultural areas. (5) Bakhaider and his collegues, reported in 2015 that pharceutical drugs were the common cause in western Saudi Arabia. (6). More than 97% of their patients were saudi nationals and 54% were females and that probably reflects the type of patients eligible to get admission in their hospital. Sulaiman Alnasser from Qaseem region reported in 2017 that 56% of their patients were females and 46% had drug overdose and 23% had domestic products like chlorox poisoning. (7). Wahba and his team from Najran reported a retrospective study of 2017 to 2019 and reported that pharmacetical drugs and bleech was the common poison used by adult patients. (8) Sulaiman Alnasser while publishing his work from Makkah region from an official data had reported that 60% of the patients were males and most had accidental poisoning only.(9). Alzahrani et al reported that the poisoning in Jeddah region had a seasonal variation being highest in summer months (10) We had planned this study for five months, starting from january to May, 2020. But a Covid pandemic struck us and from April onwards the pandemic overwhelmed us. We were expecting atleast 200 patients over a period of 5 months, but we continued our study upto September and we got less patients. Our study included 108 patients who presented to the ER of KSMC. Majority of the patients were males with females accounting for 34.3% of the cases. Saudi Arabians accounted for 69.4% of the cases. A Similar study that was conducted in western region of Saudi Arabia provided the same results as in our study. However, in another study that was discussing patterns of drug overdose, it was shown that females were more than half and Saudis were even up to 97.7% . These differences might be due to geographic locations of the hospitals, the distribution of non-Saudi citizens in different cities, and hospitals' policies. Mean age of patients in our study was 33 years old which lies within the range of other similar studies (33-40y) (3-6). Other studies have shown a lower mean age which might be attributed to the inclusion of the children in the study. (6-7) Paracetamol was the most commonly ingested drug with presentation to the ER (12%) with alcohol being the second most common (10.2%) .Those results are supported by similar studies that were conducted in Saudi Arabia in which the most common ingested drug was paracetamol (9-10). However 50% of our patients had either a mixed poisoning or no single clearly defined agent was identified.Th drugs included ferrous sulphate tablets, folic acid, metformin tablet, glicliazide tablet, b-complex, anticonvulsants, carbamzepine, phenytoin, valproate, prednisolone and other commonly prescribe drugs Majority of patients were stable on presentation to the ER with 25% being unstable and 0.9% death on arrival. Also, 58% of patients were discharged home after 24 hours, 26% were admitted to the general ward, and 16% were admitted to the ICU. Patients presenting with poisoning due alcohol, paracetamol, benzodiazepines, organophosphate, and carbon monoxide had a higher percentage of ICU admission. Interestingly, we did not see patient with snake bites or other stings. We believe, it was mainly due to covid-19 that patients did not report to our hospital and then Riyadh city is the most urbanized city and people were staying mostly indoors during lockdown. Low Glasgow Coma Scale (GCS) is not a specific indicator of drug intoxication since in this study the average GCS was 13. Lower scales were associated with alcohol intoxication. However, the reduction in GCS in patients with alcohol intoxication was not clinically significant, therefore, it should not affect the diagnostic significance of GCS in patients with a traumatic head injury. In regards to vital signs, in our study, the highest reading of blood pressure was 221/149 which was reported in a patient with benzodiazepine (BZD) overdose. Isolated BZD overdose rarely causes significant derangement in vital signs, and the reported finding is most likely a result of drug coingestion or an underlying untreated or undiagnosed hypertension. . Also, tachycardia (defined as a heart rate above 100) was seen with the average heart rate of 105 per minute reading in this study. The most likely explanation for tachycardia in patients with drug overdose is the agitation and aggressiveness that most patients present with. Tachycardia could also be correlated with the type of drug intoxication since anticholinergic excess is the most associated with elevated heart rate due to vagal nerve blockage. On the other hand, bradycardia (defined as heart rate below 60) was commonly reported with paracetamol and BZD overdose. Paracetamolinduced cardiac toxicity without direct tissue injury could be the underlying mechanism for bradycardia especially in patients who developed hepatic failure. Furthermore, the average respiratory rate was within normal limits in this study indicating that respiratory derangement is not a strong factor to rule in drug intoxication. (11) In this study patients with alcohol intoxication had PCO2 values between 13 mmHg and 71.3 mmHg, this wide range of PCO2 could be attributed to the various stages of metabolic/respiratory abnormalities. In one of a study, patient admitted with alcoholism-related complications, the acid-base imbalance was reported in 43% of patients.
Metabolic acidosis was an important clinical finding in intoxicated patients. Five patients. In our study had the lowest value of HCO3 was 5.3 meq/L which was seen in a patient presenting with alcohol intoxication(12). Electrolyte disturbances were seen most in form of hypernatremia and hyperchloremia.(12) Alcohol can lead to direct mitochondrial injury and activation of programmed cell-death factors leading to cell apoptosis and release of enzymes and electrolytes to the extracellular compartment. In a study evaluating the disturbances of electrolytes and blood chemistry in acute alcohol intoxication hypernatremia and hyperchloremia were present in 41% and 21% respectively. In the other hand, Anemia (defined as < 13 g/dl in males and < 12 g/dl) was associated with alcohol intoxication. Moreover, Anemia in alcoholics is attributed to many underlying causes including nutritional deficiency (megaloblastic anemia), alcohol-induced liver disease, or direct alcohol toxic effect on the bone marrow. Other laboratory findings like elevated urea, elevated creatinine, and blood glucose are not specific and could be the result of dehydration and the general toxic effect of the overdosed drug.
Eventually, all but one of our patients were discharged home in stable conditions. Most of the cases did not receive a reversal agent (80%). Those who received were Paracetmol poisoning, Bezodiazepine overdose or those who had evidence of opiad overdose in mixed poisonongs. Supportive care is the cornerstone in managing patients with intoxication rather than counteracting the poison. Some antidotes usage could cause more harm than the actual intoxication, thus, its administration should be only in severe cases where its benefits are warranted and must be monitored carefully.

CONCLUSION
Poisoning is basically a heteregenous group of disorders and is difficult to present under single category. Riyadh being the capital city of the country and King Saud Medical City, the oldest and largest of the ministry of Health Hospitals, admits a diverse variety of patients. Paracetmol poisoning although the largest single group, still comprised of only 12 % of the total patients.These were usually young and predominantly female patients. Alcohol intoxication, is seen as second largest category, mainly young men, which we do not see in other cities of the kingdom. Similarly Aphemtamine overdose and Narcotoc overdose was also seen in our patients. These three were young but predominantly males. Organophophorus poising was seen mostly in expatriate farm workers. Combination of pharamceutical drugs, commonly prescription drugs, were more common. Antidote was used in 26% of the patients and mortality was less than 1%.