Document Type : Original Article
Authors
- Manal Hassan Abdel El-Aziz 1
- Riham Ali Abdelhafeez Elkassass 1
- Hanaa Saeed Elhoshy 2
- Nourhan Mohamed Saeed 1
1 Department of forensic medicine and clinical toxicology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of medical education, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Abstract
Background: Paracetamol poisoning is a common cause of drug-induced liver injury, especially due to its widespread availability. This study evaluates the frequency, clinical presentation, severity, and treatment outcomes of acute paracetamol toxicity cases at Alexandria Poison Control Center (APC) over six months.
Methods: This prospective study included 75 patients admitted to the APC with acute paracetamol overdose between July and December 2023. Data collected included demographics, exposure history, clinical examination findings, laboratory results, treatment protocols, and outcomes. Poison Severity Score (PSS) was used to assess toxicity severity. Statistical analyses examined associations between clinical and laboratory variables and patient outcomes.
Results: Of the patients, 74.7% were female, and 61.3% were adults. Suicide attempts accounted for 76% of cases. Clinical symptoms were predominantly gastrointestinal, with 48% reporting vomiting and 37.3% experiencing abdominal pain. The majority(72%) of cases were classified as minor toxicity based on PSS, while 8% were moderate, and only 1.3% were severe. Most patients were presented within 24 hours, with a mean hospital stay of 1.27 days. Liver enzyme elevation and INR correlated with prolonged hospital stay and higher PSS scores. All patients received N-acetylcysteine (NAC), with recovery observed in all cases and no fatalities.
Conclusion: Prompt administration of NAC, based on estimated toxic dose, proved effective in managing paracetamol toxicity, with all patients achieving full recovery. The study highlights the need for early intervention and underscores the role of demographic and social factors in overdose patterns. These findings support current treatment protocol and emphasize the need for preventive strategies, especially addressing intentional overdose.
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Main Subjects
- Graham GG, Davies MJ, Day RO, Mohamudally A, Scott KF. The modern pharmacology of paracetamol: therapeutic actions, mechanism of action, metabolism, toxicity and recent pharmacological findings. Inflammopharmacology. 2013;21(3):201-32. doi:10.1007/s10787-013-0172-x.
- Ahmed L, Omer R. Population analysis and UV-Vis spectra of dopamine molecule using Gaussian 09. J Phys Chem Funct Mater. 2020;3(1):48-58.
- Chidiac AS, Buckley NA, Noghrehchi F, Cairns R. Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease. Expert Opin Drug Metab Toxicol. 2023;19(4):297-317. doi:10.1080/17425255.2023.2223959.
- Cole JB, Oakland CL, Lee SC, Considine KA, Rudis MI, Swanson AL, et al. Is two better than three? A systematic review of two-bag intravenous N-acetylcysteine regimens for acetaminophen poisoning. West J Emerg Med. 2023;24(6):1131-45. doi:10.5811/westjem.59099.
- Saeed NM, Ghanem M, Alhoshy HA, Atef M. A five-year study on the profile of acute poisoning cases admitted to Poison Center, Alexandria, Egypt. Asia Pac J Med Toxicol. 2023;12(1):42.
- Abdel Shaheed C, Ferreira GE, Dmitritchenko A, McLachlan AJ, Day RO, Saragiotto B, et al. The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews. Med J Aust. 2021;214(7):324-31. doi:10.5694/mja2.50992.
- Mostafa EMA, Tawfik AM, Abd-Elrahman KM. Egyptian perspectives on potential risk of paracetamol/acetaminophen-induced toxicities: lessons learnt during COVID-19 pandemic. Toxicol Rep. 2022;9:541-8. doi:10.1016/j.toxrep.2022.03.035.
- Beltrán-Olazábal A, Martínez-Galán P, Castejón-Moreno R, García-Moreno ME, García-Muro C, Esteban-Zubero E. Management of acetaminophen toxicity, a review. Iberoam J Med. 2019;1(1):22-8. doi:10.5281/zenodo.3470262.
- Ramesha KN, Rao KB, Kumar GS. Pattern and outcome of acute poisoning cases in a tertiary care hospital in Karnataka, India. Indian J Crit Care Med. 2009;13(3):152-5. doi:10.4103/0972-5229.58541.
- Çalışkan F, Akça G, Çalışkan B, Akça Ü. Clinical use of the poisoning severity score in acute pediatric poisoning. J Exp Clin Med. 2021;38(4):565-70.
- Zaaqoq A, Gamaluddin H, El-Taftazani E, Al-Sayed G, Ahmed S. Poisoning severity score as a predictor of cardiotoxicity induced by anticholinesterase pesticides, digoxin and beta blockers. Ain Shams J Forensic Med Clin Toxicol. 2012;19(1):53-66. doi:10.21608/ajfm.2012.19482.
- Kotz S, Balakrishnan N, Read CB, Vidakovic B, Johnson NL. Encyclopedia of statistical sciences. Vol. 1. New York: John Wiley & Sons; 2005.
- Kirkpatrick LA, Feeney BC. A simple guide to IBM SPSS: for version 22.0. Philadelphia: Delmar Learning; 2014.
- Zaid A, Rinno T, Jaradat N, Jodeh S, Khammash S. Interchangeability between paracetamol tablets marketed in Palestine: is there a quality reason for a higher price? East Mediterr Health J. 2013;19(6):542-6.
- Alqahtani SS, Banji D, Banji OJF. Assessment of paracetamol usage practices and perceptions among caregivers for children post-COVID-19 in Saudi Arabia: a cross-sectional analysis. Healthcare. 2024;12(10):1047. doi:10.3390/healthcare12101047.
- World Health Organization, Pan American Health Organization. Poison control center. Geneva: WHO/PAHO; 2021.
- Mohd Zain Z, Fathelrahman AI, Ab Rahman AF. Characteristics and outcomes of paracetamol poisoning cases at a general hospital in Northern Malaysia. Singapore Med J. 2006;47(2):134-7.
- Sanhueza-Aroca T, Verdugo-Silva S, Olate-Fica E, Rivas L, Müller-Ramírez C. Acetaminophen poisonings in Chilean healthcare settings: a 20-year story that does not end. Nepal J Epidemiol. 2021;11(4):1086-94. doi:10.3126/nje.v11i4.38919.
- Friðriksdóttir ÞA, Jónsdóttir F, Snook CP, Líndal H, Björnsson ES. Paracetamol poisoning: a population-based study from Iceland. Scand J Gastroenterol. 2021;56(7):832-9. doi:10.1080/00365521.2021.1921254.
- Abdel Rasheed EMA, Elmahdy N, Shalaby E, Karoube HS, Badawy SM. A study of pharmaceutical drugs poisoning cases admitted to the National Poisoning Center, Kasralainy Teaching Hospital in Cairo. Euras J Emerg Med. 2020;19(1):10-6.
- Chefirat B, Zergui A, Rahmani C, Belmessabih MN, Rezk-Kallah H. Acute paracetamol poisonings received at the Oran University Hospital. Toxicol Rep. 2020;7:1172-7. doi:10.1016/j.toxrep.2020.08.025.
- Aqeel T, Shabbir A, Basharat H, Bukhari M, Mobin S, Shahid H, et al. Prevalence of self-medication among urban and rural population of Islamabad, Pakistan. Trop J Pharm Res. 2014;13(4):627-33. doi:10.4314/tjpr.v13i4.22.
- Kenko Nkontcheu DB, Ngwe-Bell MU, Ngameni Tchamadeu N. Five year (2013–2017) trends in poisoning among patients of the Buea Regional Hospital, South-West Region (Cameroon). Braz J Biol Sci. 2020;7(16):209-16. doi:10.21472/bjbs(2020)071607.
- Noshad H, Sadreddini S, Etemadi J. Acetaminophen self-poisoning: suicidal and accidental. Iran J Psychiatry Behav Sci. 2010;4(2):47-52.
- Gyamlani GG, Parikh CR. Acetaminophen toxicity: suicidal vs. accidental. Crit Care. 2002;6(2):155-9. doi:10.1186/cc1475.
- Buckley N, Calear A, Christensen H. Independent expert report on the risks of intentional self-poisoning with paracetamol. Therapeutic Goods Administration (TGA). 2022. Available from: https://www.tga.gov.au/how-we-regulate/ingredients-and-scheduling-medicines-and-chemicals/poisons-standard-and-scheduling-medicines-and-chemicals/scheduling/independent-expert-report-risks-intentional-self-poisoning-paracetamol.
- Çelik A, Şaşmaz Mİ. Evaluation and comparison of patients poisoned with acetaminophen and nonsteroidal anti-inflammatory drugs. East J Med. 2019;24(3):314-9.
- Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW. Association between gastrointestinal manifestations following acetaminophen poisoning and outcome in 291 acetaminophen poisoning patients. Pharmacoepidemiol Drug Saf. 2010;19(5):511-7. doi:10.1002/pds.1940.
- Popiolek I, Hydzik P, Jagielski P, Zrodlowska M, Mystek K, Porebski G. Risk factors for hepatotoxicity due to paracetamol overdose in adults. Medicina (Kaunas). 2021;57(8):752. doi:10.3390/medicina57080752.
- Hegazy R, Almalki W, Kamel H, Fatani S. Metabolic acidosis vs. transaminases level in diagnosis and predicting prognosis of acetaminophen poisoning. Int J Pharma Bio Sci. 2012;3(3):830-9.
- Rubin JB, Hameed B, Gottfried M, Lee WM, Sarkar M. Acetaminophen-induced acute liver failure is more common and more severe in women. Clin Gastroenterol Hepatol. 2018;16(6):936-46. doi:10.1016/j.cgh.2017.11.042.
- Buckley N, Eddleston M. Paracetamol (acetaminophen) poisoning. BMJ Clin Evid. 2007;2007:2101.
- Zyoud SH, Awang R, Sulaiman SA, Al-Jabi SW. An analysis of the length of hospital stay after acetaminophen overdose. Hum Exp Toxicol. 2011;30(7):550-9. doi:10.1177/0960327110377647.
- Abushanab D, Gasim M, Devi D, Elbdairy M, Elqasass H, Ahmed N, et al. Patterns and outcomes of paracetamol poisoning management in Hamad Medical Corporation, Qatar: a retrospective cohort study. Medicine (Baltimore). 2023;102(5):e34872. doi:10.1097/MD.0000000000034872.
- Craig DG, Bates CM, Davidson JS, Martin KG, Hayes PC, Simpson KJ. Overdose pattern and outcome in paracetamol-induced acute severe hepatotoxicity. Br J Clin Pharmacol. 2011;71(2):273-82. doi:10.1111/j.1365-2125.2010.03819.x.
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