Central Annals of Public Health and Research

Research Article *Corresponding author

Asawari Raut, Department of Clinical Pharmacy, Poona

Treatment Approaches for College of Pharmacy, Bharati Vidyapeeth Deemed

University, Pune-411043, India, Tel: 8805058493; Email:

Management of Poisonings in Submitted: 17 July 2017

Accepted: 28 August 2017

India Published: 30 August 2017

Copyright
© 2017 Raut et al.
Asawari Raut1*, Atmaram Pawar1, Kavya Shaj1, and Priti Dave2
1 OPEN ACCESS
Department of Clinical Pharmacy, Bharati Vidyapeeth Deemed University, India
2
Department of Medicine, Bharati Vidyapeeth Deemed University, India
Keywords
• Intentional poisoning; Awareness; Poisoning
management; Inhalational poisoning

Abstract
Background: Poisoning is a common medical emergency needing prompt medical interventions. The study focuses on pattern of toxic agents, drug
utilization, management and outcome in poisonings reported.
Methods: The cross sectional study was carried out on patients admitted to two urban hospitals in Pune, Maharashtra from January 2014 - March 2016.
Results: Total 1078 cases of poisoning were reported with male (57.1%) predominance. The cases reported ranged from 8 months to 72 years old in
age with a mean (± SD) 37.8 ± 27.3. Intentional poisoning was more common (53%). Route of exposure was mostly Ingestion (72.5%) followed by Bite/
Sting (26.4%), Inhalational (0.8%), Injection (0.1%) and Eye (0.1%). Household and agricultural agents (56.4%) were associated with most poisoning followed
by Animal Bites and Stings (26.4%). The mortality reported was 9.7%. The management included Supportive treatment, Antidotes, and Enhanced Elimination
Techniques. Supportive treatment was mainly with Gastro protective (94.3%) and Anti-Microbial (77.9%) agents. The antidote was used in 70.9% cases and
mostly included Anti-Snake Venom (24.4%) followed by Atropine (21%) and Pralidoxime (18.1%). Enhanced Elimination Techniques included Gastric Lavage
(76.3%), Nasogastric Aspiration (7.2%), Hemodialysis (0.1%), Activated Charcoal (4.5%) and Eye wash (0.1%).
Conclusion: The treatment approaches were based on parameters such as route of exposure, Toxic agent involved and age of the patient. The pharmacist
can play a vital role in the recommendation of the rational management plan in Poisonings.

INTRODUCTION Due to the paucity of information regarding poisoning cases

An estimated 193460 deaths occurred worldwide due to
poisoning as published by WHO of which a major proportion was
from low and middle-income countries [1]. 110688 deaths due to
poisoning were reported in India in 2012 according to a national
report [2].
The outcome of poisonings is depended on the speed with
which the patient is brought to medical care, understanding of
the poison’s toxicity degree and the readiness of medical care
[3]. The high mortality rate associated with poisoning is often
related to a delay in diagnosis and/or improper management
[4]. Globally, the management of the critically poisoned patient
centers on careful supportive care and further maximized
with appropriate decontamination, antidote administration,
elimination enhancement and pharmaceutical interventions
[5]. It hugely depends upon institutional protocols, healthcare
facilities, and drugs. It is necessary for each medical setting to
regularly evaluate and review drug utilization to rationalize drug
use and enhance patients’ outcome [6]. Annual epidemiologic
data on poisonings treated at each medical setting will also help
to better handle and manage drug, antidote and other technical
requirements [7].
in India, the introduction of new guidelines and updating current
protocols needs knowledge of demographics and management
of poisoning cases. To understand the interventions needed in
the management of poisoning and define the role of health care
professionals studies are needed to be conducted [8].
The study was conducted in Pune district in the state of
Maharashtra in India. According to the most recent census in
2011, the total population was 9.4 million making it the 4th most
populous district in India [9]. Pune has many industrial areas
which provide easy accessibility of a large number of chemicals
and pesticides resulting in the tremendous use of these agents
for poisoning and the agricultural diversity has resulted in an
increase of animal bites and stings and also accidental exposures
to insecticides and pesticides. So far, this is the only study
conducted in this area focusing on poisonings.
METHODOLOGY
Study area
The study was conducted in Pune district of Maharashtra,
which resides a total population of 9.4 million inhabitants with
a male to female ratio of 1.1:1. It forms a part of the tropical
monsoon land and therefore shows a significant seasonal
variation in temperature and rainfall.

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The Pune city resides many multi specialty hospitals. The Table 1: Characteristics of Poisoning cases observed.
Government hospital, a 380 bedded multi specialty hospital, Characteristics Number of cases
is located in Pimpri – Chinchwad which engulfs a wide area of Demographic
surrounding suburban and industrial areas like Aundh, Bhosri, Male 616
Nigdi and villages like Moshi, Chikli, Dehu, etc. The private Female 462
teaching hospital is a 900 bedded hospital with hi-tech super Age (Mean ± SD) 37.8 ± 27.3
specialties. It is located in inner suburbs of Pune which includes Route
areas like Katraj, Ambegaon, Vadgaon, Parvati Hill, etc. These
Ingestion 782
are the industrial and agricultural areas where a high number of
Injection 1
chemical or pesticide poisoning can be observed.
Inhalational 9
Population and sampling Bite/Sting 285
Eye 1
The study was cross-sectional and made use of retrospective
Reason
and prospective extraction of data from records available at the
Intentional 571
government and private teaching hospitals respectively. All cases
Accidental 475
of poisoning available in the medical record departments were
Unknown 32
included in the study.
Length of Hospital Stay (Mean ± SD) 2.5 ± 1.6
Data collection and extraction Outcome
Symptoms improved 836
The records were collected from Medical Record Department
DAMA 137
of the respective hospitals. The data collection period was from
Death 105
January 2014 to March 2016. The cases were reviewed for gender,
age, route, and reason of poisoning and agents, management, and Agents
drug utilization. Household and Agricultural 608
Animal Bites and Stings 285
RESULT Drugs 116
Miscellaneous 39
Demography of poisoning cases
Unknown 30
During the study period of 28 months, 1078 cases of poisoning
were reported to the emergency department of the hospitals, out used as an adjunct for eliminating toxins and diazepam for
of which 616 (57.1%) were male and 463 (42.9%) were Female. alcohol withdrawal symptoms. Oxygen Inhalation was given
The cases reported ranged from 8 months to 72 years old in age to patients with Inhalational poisoning with insecticides and
with a mean (± SD) 37.8 ± 27.3. This suggestive that on an average petroleum. Antidotes were used in 70.9% cases and included
38 cases was reported per month which demands attention to Anti-Snake Venom (24.4%), Atropine (21%), Pralidoxime
the situation. The reason for poisoning was primarily Intentional (18.1%), Rabipur (3%), N-Acetylcysteine (1.4%), Neostigmine
(53%) than Accidental (44.1%) and Unknown (3%) and Route of (3.2%). Other Enhanced Elimination Techniques were also used.
exposure was mostly Ingestion (72.5%) followed by Bite/Sting These Included Gastric Lavage (76.3%), Nasogastric Aspiration
(26.4%), Inhalational (0.8%), Injection (0.1%) and Eye (0.1%). (7.2%), Hemodialysis (0.1%), Activated Charcoal (4.5%) and Eye
The agents responsible were categorized as Household and wash (0.1%) [Table 2].
Agricultural Agents (56.4%), Animal Bites and Stings (26.4%),
Drugs (10.8%), Miscellaneous (3.6 %) and Unknown (2.8%). Management in different patient population
Few Intentional poisonings were a mix of above agents and some The usage pattern of Antidote and the Enhanced Elimination
with alcohol as well. Length of Hospital Stay ranged from 1-15 Techniques were observed in different patient population;
days with a mean (± SD) 2.5 ± 1.2. Mortality reported was 9.7% Pediatric, Adult, and Geriatric for different toxic agents. In 276
and Symptoms Improved in most (77.6%) cases but 12.7% were cases of Pediatrics aged 0-18 years, Antidotes were given in 135
DAMA (Discharged against Medical Advice) or Absconded [Table (48.9%), Gastric Lavage in 156 (56.5%), Nasogastric Aspiration
1]. in 12 (4.3%), Activated Charcoal in 24 (8.7%) and Eye Wash in 1
Treatment approaches in poisonings (0.4%). In 760 cases of Adults aged 19-55 years, Antidotes were
given in 600 (78.9%), Gastric Lavage in 648 (85.3%), Nasogastric
The Management of admitted poisoning cases was done Aspiration in 66 (8.7%), Hemodialysis in 1 (0.1%), Activated
by Symptomatic treatment, Antidote, and Other Enhanced Charcoal in 24 (3.2%). Finally, in 42 cases of Geriatric above age
Elimination Techniques. Symptomatic Treatment were done 55 years, Antidotes were given in 30 (71.4%) and Gastric Lavage
with following drugs: Anti-Microbial (77.9%), Gastro protective in 18 (42.9%) [Table 3, Figure 2].
(94.3%), Anti-allergic (52.7), Anti-Inflammatory (39.3), Anti-
Hypertensive (54%), Antipsychotics (44.1%), Supplements Treatment approach according to toxic agents
(5.6%), Anticonvulsants (3.5%), and Hormones (2.2%). In The treatment was recorded toxic agent wise. For Household
Antibiotics, mostly administered were Cephalosporin’s (29%), and Agricultural agents, Atropine or Pralidoxime along with
Amoxicillin+Clavulanic Acid (25.7%) followed by Metronidazole gastric lavage and/or nasogastric aspiration and/or activated
(14.4%) (Figure 1). Other drugs Mannitol and Perinorm were

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35
Amoxicillin+Clavulanic
30 Ampicillin

Percentage of Posoning cases

25 Tetracycline
Doxycycline
20 Ciprofloxacin
Cotrimoxazole
15
Gentamicin
10 Metronidazole
Cephalosporins
5
Norfloxacin
0 Fluconazole
Anti Microbial Agent

Figure 1 Usage Pattern of Anti microbial agent used for poison Management.

1 10 100 1000

Antidote

Gastric lavage

Nasogastric Aspiration

Hemodialysis

Charcoal hemoperfusion

Eye wash

Charcoal Nasogastric
Eye wash Hemodialysis Gastric lavage Antidote
hemoperfusion Aspiration
Pediatric 1 24 0 12 156 135
Adult 0 24 1 66 648 600
Geriatric 0 0 0 0 18 30

Figure 2 Poisoning treatments in different patient population.

charcoal was done. Atropine was given IV with doses ranging
from 0.1mg-2g, STAT or 1 to maximum 4 hourly in 24 hours. A
close monitoring Heart Rate with target to keep below 100 beats/
minute. Pralidoxime was given IV, Dose ranging from 500mg-2g
with Normal Saline STAT or 2-8 hourly for 24 hours. Maintenance
given in some cases was 500mg-1g with Normal Saline as Slow
Infusion. For Animal Bites and Stings especially snake bite, ASV,
and Rabipur for Dog bite were given. ASV was given as Test dose,
2-10 vials and in some cases as IV Infusion with Normal Saline
or Dextrose Saline. Tetanus toxoid was given in unknown bites.
For drugs, especially acetaminophen, N-Acetyl cysteine and/or
gastric lavage were given. N-acetylcysteine effervescent tablets
were given 500mg with water. For some Miscellaneous and
unknown, Atropine was given. Oxygen Inhalation was given for
inhalational exposure by insecticides and petroleum. Eye wash
was done in eye exposure of household agent. All poisonings
were also provided supportive treatment [Table 4, Table 5].
DISCUSSION
Poisoning cases brought to Emergency Departments are very
common in India and the study shows that on an average 38
cases are reported per month and this is due to easy availability
of toxic agents, occupational exposures mainly ones involved in
agriculture and no awareness particularly in rural areas [10]. In
this study, a male predominance was observed which the similar
pattern is observed by other studies in India [11-13]. This trend
may be due to increased occupational hazard and exposure of
men to stress being the earning members compared to women.
In this study, most of the cases were between 19-55 years of age
similar to the trend in other Indian studies and may be due to
domestic, educational and employment related stress [12-14].
The most common reason behind poisoning was intentional
which was observed in 57.1% of cases [15].
Household and agricultural agents were associated with most
intentional poisoning due to easy availability of these agents and
inadequate knowledge to support their safe residential use [16].
Studies have shown that pesticide is the most common toxic
agent involved in poisoning [15,17,18]. Animal bites and stings
were the most common cause of accidental poisoning which

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Table 2: Treatment Methods for poisoning cases.

Treatment Cases Number (Percentage)
Symptomatic
Anti-microbial agent 840 77.90%
Gastroprotective agent 1017 94.30%
Anti-allergic 568 52.70%
Anti-inflammatory 424 39.30%
Anticonvulsants 38 3.50%
Hormones 24 2.20%
Anti-hypertensive 582 54.00%
Anti-psychotics 475 44.10%
Supplements 60 5.60%
Alcohol withdrawal 235 21.80%
Enhance Elimination 8 0.70%
Oxygen Inhalation 9 0.80%
Tetanus toxoid 24 2.20%
Antidote
ASV 263 24.40%
Atropine 226 21.00%
Pralidoxime 195 18.10%
Rabipur 32 3.00%
N-Acetylcysteine 15 1.40%
Neostigmine 34 3.20%
Other Enhanced Elimination
Gastric lavage 822 76.30%
Nasogastric Aspiration 78 7.20%
Hemodialysis 1 0.10%
Charcoal hemoperfusion 48 4.50%
Eye wash 1 0.10%

Table 3: Management of Toxic Agents in Different Patient Population.

Pediatric/Adult/Geriatric [Cases (Number)]
Management of Toxic Agents
Total
Poisoning Household and Animal Bites and
Drugs Miscellaneous Unknown
Agricultural Stings
Antidote 57/315/18 3/39/0 75/228/12 - 0/18/0 765
Gastric lavage 105/528/15 21/87/3 - 12/12/2000 18,21,0 822
Nasogastric Aspiration 12/24/2000 0/42/0 - - - 78
Hemodialysis - 0/1/0 - - - 1
Activated Charcoal 3/14/2000 3/10/2000 - 18/0/0 - 48
Eye wash 1/0/0 - - - - 1
Pediatric : 0 - 18 years
Adult: 19-55 years
Geriatric: 56 +

was contrary to findings of the studies conducted in South India
where most accidental poisonings was due to household poisons
[19-20]. This may be due to the difference in geography and
occupation. The Length of Stay recorded in this study was 2.4 ±
1.2 days which is much lesser than an Indian study which showed
5.4 ± 3.8 days [21]. Moreover, in the present study the mortality
was 9.7% of patients which is lesser than other studies in India
which showed in range of 10-20% [21,22]. This may be due to
number of factors such as nature of poison, dose consumed, level
of available medical facilities and time interval between intake of
poison and provision of medical help. The lesser mortality and
length of stay might also be indicative of better management
strategies which were observed in this study [Table 6].
The management strategies in the present study included
Symptomatic Treatment, Antidote, and other Enhanced
Elimination Techniques. Symptomatic Treatment with Supportive
care played a vital role in managing acute poisonings. The
Symptomatic Treatment mainly involved usage of gastroprotective
agents like PPIs, H2 Blockers, Antacids, Antiemetic as well as
laxatives which were observed in other studies too [21,22].
Antimicrobials were prescribed to 77.9% patients and most used
were cephalosporins, followed by penicillin and Metronidazole.

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Table 4: Treatment for specific Toxic Agents.

Toxic Agent Antidote Enhanced Elimination techniques Supportive Treatment
Household and Agricultural
Insecticides and Atropine and Gastric Lavage, Nasogastric Aspiration and Gastroprotective agents, Anti-allergic,
Pesticides Pralidoxime Activated Charcoal Anti-microbial, Anti-inflammatory

Corrosive agents Atropine Gastric Lavage, Nasogastric Aspiration

Animal Bites and Stings
Snake Bite ASV
Scorpion Bite Anti-Inflammatory, Anti-microbial
Dog Bite Rabipur agent, Anti-allergic, Gastroprotective ,

Insect Sting
Unknown Bite
Anti-allergic, Anti-inflammatory,
Drugs N Acetyl cysteine Gastric Lavage
Gastroprotective agents
Gastroprotective agents, Anti-allergic,
Miscellaneous and Unknown Atropine Gastric Lavage
Anti-microbial, Anti-inflammatory

Table 5: Dosing of Antidotes given in poisonings.

Dosing
Agent Antidote
Recommended Study
IV: 0.1mg-2g, STAT or
IV: 0.03-0.05 mg/kg q10-20min PRN to effect; then q1- 1-4 hourly for 1 day
Atropine
4hr for at least 24 hours *Monitor Heart Rate
OP and Carbamate (Keep < 100)
Poisoning IV loading dose followed by continuous infusion: 20-50 IV: 500mg-2g with Normal Saline ,
mg/kg/dose (not to exceed 2 g/dose) infused IV over STAT or 2-8 hourly.
Pralidoxime
15-30 minutes
Maintenance: 10-20 mg/kg/hr IV continuos infusion Maintenance: 500mg-1g slow infusion
ASV Test Dose: 2-10 vials
ASV Test Dose: Initial Dose 8-10 vials
Snake Bite ASV IV Infusion: 2-10 vials with Normal OR
IV Infusion: 5-10 ml/kg body weight (2ml/min)
Dextrose Saline.
Acetaminophen
N-Acetyl Cysteine PO: 500mg-2.5g PO: 500mg stat

Similar Usage was found in other Indian studies [21,22]. Though
there is no evidence of anti microbial therapy benefit in poisoning
trials [23,24], improvement in symptoms were observed in
patients with Cellulitis post-Snake Bite in the study. Anti allergic
agents like Avil, Phenergan, and Hydrocortisone were preferred
in 52.7% patients. Anti Inflammatory and Anti Spasmodic
Buscopan and Dexamethasone were given in 39.3% patients,
Iron and Calcium supplementation were also given in 5.6%
patients. Anti Psychotics (44.1%) were introduced or continued
in patients who attempted self-poisoning. Adrenaline and Anti-
Hypertensive’s were used on patients with cardiac co morbidities.
Anticonvulsants Carbazepine and Phenytoin were given to ones
with k/c/o seizure disorders. Mannitol and Perinorm were
also given in poisonings to enhance the elimination to avoid
neurotoxicity. Dopamine was used in patients who were severe
and progressed to Cardiogenic Shock. As many cases had mixed
the toxins with alcohol and some were a chronic alcoholic,
Diazepam was given to manage the withdrawal symptoms.
In the study, Antidotes ASV (dose range1-10vial), Atropine
(dose range: 0.1mg-2mg), Pralidoxime (dose range: 500mg-
2g) were used widely. Rabipur was preferred in dog bites and
unknown bites sometimes. The dosing of Antidotes given in study
subjects was compliant with dosing recommendation given in drug
databases [25,26]. The study found the considerably good use of
Enhanced elimination techniques along with pharmacotherapy
which was not the case in Indian studies. Gastric Lavage was
considered in 76.3% and Nasogastric Aspiration in 7.2% cases.
Even lesser popular Hemodialysis (0.1%) and Activated Charcoal
(4.5%) was attempted in our study settings.
Toxic Agent wise approach was also studied. The first class of
Household and Agricultural agents could be further categorized
into two; Pesticides and Corrosives. In cases of Pesticides and
Insecticides, Antidotes Atropine and Pralidoxime were used
and Gastric lavage was done with Potassium Permanganate or
Normal Saline or Plain Water. Activated Charcoal alone or with
Gastric Lavage was also considered. Nasogastric Aspiration
was also included with or without Gastric Lavage. Whereas in
case of Corrosive substances, Antidote given was Atropine and
for acute poisonings, gastric lavage with or without nasogastric
aspiration was also done. Some poisonings were a mixture of
both insecticides and Corrosives. As such cases were acute,
above approaches were considered. In our study, there were 9
cases of inhalational poisonings by insecticides and petroleum.
These were managed by Atropine and Oxygen Inhalation along

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Table 6: Classification of toxic agents according to ICD-10 2017. Bites, Insect Stings and Unknown Bites. Snake Bite Treatment
Type of Poison ICD-10 CODE No. of cases approach was according to The Snake Bite Treatment Guideline
Household & Agricultural Agents by AIIMS, Delhi with Anti-Snake Venom for mild to severe
OPP and Carbamate T60.0 162 envenomation. Neostigmine was given along with ASV for
Other Insecticides T60.2 34 neurotoxic snake bites. ASV related anaphylaxis reaction was also
Rodenticides T60.4 35
seen in 15 patients who were treated with epinephrine. Scorpion
Bite Management was Symptomatic with Gastroprotective, Anti
Other pesticides T60.8,9 3
inflammatory and sometimes cardio protective agents. Dog
Kerosene T52.0 24
Bite was treated with Rabipur Vaccination. Insect Stings and
Phenol and Related Agents T54.0 42
Unknown Bites were treated symptomatically. Unknown Bites
Corrosives Acids and Alkali T54.1/2/3/9 13
which were Severe and showed similar symptoms to Snake Bites
Classify based on
Antiseptics and Disinfectants 50 were administered ASV. The Third class of Drug poisonings was
composition
mainly due to Antibiotics, NSAIDs, Acetaminophen, and mix of
Specific inorganic substance T57.8 1
various medications. The treatment was mainly Symptomatic.
Other organic solvents T52.8 2
N-Acetylcysteine was used for Acetaminophen toxicity. Gastric
Alcohol T51 36
Lavage is also considered along with symptomatic treatment. In
Soap and detergent T55 1
our study, Hemodialysis was performed on a patient with severe
Aluminium Phosphide T57.1 2
Carbamazepine overdose. For other classes of Miscellaneous and
Organochlorine T53 6 Unknown poisonings, the approach was mainly symptomatic.
Herbicides-Paraquat T60.3 35 Gastric lavage was also done.
Drugs
Antibiotic T36 2 The overall treatment strategy focused on lesser absorption
Anti infectives and and faster elimination of toxins. Also, the treatment approaches
T37 10 were based on parameters such as route of exposure, Toxic agent
antiparasitic
Hormones and Synthetic involved and age of the patient. This demands the need for a
T38 1 proper guideline for the management of poisonings in all tertiary
substitutes
Non opioid analgesics and care settings in India. Well equipped settings can not only reduce
T39 20
antipyretics hospital stay but can play a vital role in lowering mortality. Expert
Anti epileptic, Sedative training is needed for managing particularly poisoning patients
T42 8
Hypnotics in the country with such huge population and poison exposure
Psychotropic T43 5 rates. As poisoning management can be described as the use
Hematological, Antiallergic T45 3 of chemicals to tackle harmful chemical effects, choice of drugs
Cardiac Stimulant glycoside T46.0 2 plays a vital role. Pharmacists can help in the recommendation of
Gastroprotective agents T47 2 the treatment plan and rational drug use in these cases which can
Vaccines and unknown help in effective management with economic benefits to patients
T50 10
medication [17]. Apart from this, the pharmacist can assist in history taking
Topical lotion T49 1 and assessment as well patient and community education.
Respiratory T48.5 3
The limitation was that Poor maintenance of records was
Animal Bite & Stings
frequently observed in the government setting and Cases referred
Snake T63.0 126 from other hospitals lacked detailed patient history. Very few
Scorpion T63.2 7 studies on poisoning targeted cases have been done in the
Bee/Wasp T63.4 39 country with over 1.2 billion population. More studies should be
Unknown bite T63.9 33 encouraged in different hospital settings and geographical areas
Dog bite, Rat bite 52 to study the pattern of poisoning, its morbidity, and mortality. A
Miscellaneous long term prospective study is needed in case of poisoning for
Food Poisoning Fish T64 4 understanding the clinical pattern and management techniques
Lizard in Food T62.8 5 which can help in intervention for a better outcome. An urgent
Stale food contaminated T64 19 need to implement preventative and intervention strategies
Parts of plants T62.2 6 to combat suicide needs national emphasis and awareness
Poisoning by antidote, measures.
T50.6 9
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Cite this article
Raut A, Pawar A, Shaj K, Dave P (2017) Treatment Approaches for Management of Poisonings in India. Ann Public Health Res 4(4): 1068.
Ann Public Health Res 4(4): 1068 (2017)
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