A DISSERTATION ON PROSPECTIVE STUDY OF CLINICAL PROFILE AND OUTCOME OF CHILDREN PRESENTING WITH POISONING IN GOVT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM Submitted to THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY, CHENNAI In partial fulfillment of the regulations for the award of M. D. DEGREE IN PAEDIATRICS BRANCH VII GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE, SALEM APRIL 2017 Government Mohan Kumaramangalam Medical College Hospital DECLARATION BY THE CANDIDATE I hereby declare that this dissertation titled “PROSPECTIVE STUDY OF CLINICAL PROFILE AND OUTCOME OF CHILDREN PRESENTING WITH POISONING IN GMKMCH, SALEM” is a bonafide and genuine research work carried out by me under the guidance of DR.T. S. SUNDARARAJAN, M.D,D.C.H , Professor, Department of Paediatrics , Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India. Place : Salem Signature of the Candidate Date : DR.M. S.BALAMURUGAN Government Mohan Kumaramangalam Medical College Hospital CERTIFICATE BY THE GUIDE This is to certify that this dissertation “PROSPECTIVE STUDY OF CLINICAL PROFILE AND OUTCOME OF CHILDREN PRESENTING WITH POISONING IN GMKMCH, SALEM” is a bonafide work done by Dr.M.S.BALAMURUGAN in partial fulfillment of the requirement for the degree of M. D. in PAEDIATRICS, examination to be held in 2017. Signature of the Guide Dr. T.S.SUNDARARAJAN,M.D.,D.C.H., Place: Salem Professor & Head of the Department, . Date : Department of peadiatrics Government Mohan Kumaramangalam \ Medical College Salem,Tamil Nadu,India . Government Mohan Kumaramangalam Medical College Hospital ENDORSEMENT BY THE HEAD OF DEPARTMENT This is to certify that this dissertation titled “ PROSPECTIVE STUDY OF CLINICAL PROFILE AND OUTCOME OF CHILDREN PRESENTING WITH POISONING IN GMKMCH, SALEM” is a bonafide work done by Dr.M.S.BALAMURUGAN under overall guidance and supervision of Dr. T.S.SUNDARARAJAN,M.D,D.C.H., Professor and Head, Department of paediatrics, Government Mohan Kumaramangalam Medical College Hospital, in partial fulfillment of the requirement for the degree of M. D. in Paediatrics, examination to be held in 2017. Seal & Signature of the of the H.O.D Dr. T.S.SUNDARARAJAN,M.D.,D.C.H., Professor & Head of the Department, Department of Paediatrics, Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India. Government Mohan Kumaramangalam Medical College Hospital ENDORSEMENT BY THE DEAN OF THE INSTITUTION This is to certify that this dissertation titled“PROSPECTIVE STUDY OF CLINICAL PROFILE AND OUTCOME OF CHILDREN PRESENTING WITH POISONING IN GMKMCH, SALEM” is a bonafide work done by Dr.M.S.BALAMURUGAN under the guidance and supervision of Dr.T. S. SUNDARARAJAN, M.D, D.C.H., Professor and Head, Department of Paediatrics, Government Mohan Kumaramangalam Medical College Hospital, in partial fulfillment of the requirement for the degree of M. D. in Paediatrics, examination to be held in 2017. Seal & Signature of the of the Dean Prof. Dr.P.KANAGARAJ, M.D., Dean Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India. Government Mohan Kumaramangalam Medical College Hospital COPYRIGHT I hereby declare that THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY, CHENNAI, TamilNadu, India, shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose. Place: Salem Signature of the Candidate Date : DR.M. S.BALAMURUGAN © THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY, CHENNAI, Tamil Nadu, India Acknowledgement I feel greatly indebted to Prof.Dr.P.KANAGARAJ, M.D., Dean, Govt. Mohan Kumaramangalam Medical College, for permitting me to undertake this study. I would like to express my humble gratitude and sincere thanks to Prof. Dr.T.S.SUNDARARAJAN,M.D,D.C.H, Head of the Department of Pediatrics, Govt. Mohan Kumaramangalam Medical College and Hospital, Salem for his excellent guidance and encouragement during this study. I sincerely thank our Associate Professors Dr. D.SAMPATH KUMAR M.D., D.C.H for their invaluable guidance to complete this dissertation. I am thankful to Dr. P. SAMPATH KUMAR, M.D., DCH, Assistant Professor of Paediatrics for his guidance and help for completion of this dissertation in time. I am grateful to Dr. S.GOPINATHAN, M.D,D.C.H., Asst. Professor of Pediatrics for showing special interest in my work and for his valuable advice. I am thankful to all my Assistant Professors Dr. P. KANIMOZHI M.D, D.C.H., Dr.K. SURESH KANNAN, M.D., Dr.P.VASUMATHY, M.D., Dr. V. NARMADHA, M.D., Dr.M.NIRMALA, M.D. DCH, Dr.V.ANUREKHA,M.D., Dr.AMUDHADEVI,M.D., Dr.V.BALAJI,M.D., Dr. R. SASIVARADHAN,M.D, Dr.A.LOGESH ANAND, M.D, Dr.P. KUMAR,M.D.,D.C.H., Department of Pediatrics, for their valuable suggestions. I thank all my PG colleagues, friends and staff members of the department of Pediatrics who helped me a lot in completing this dissertation successfully. I extend my hearfelt thanks to all my family members for their support rendered during my study. Last but not the least; I bow my head in reverence to all our patients who formed the back bone of this study without whom this would not have been possible. LIST OF ABBREVIATIONS ABG ARTERIAL BLOOD GAS AChE ACETYL CHOLINEESTERASE AgNO3 SILVER NITRATE AgCl2 SILVER CHLORIDE ARDS ACTE RESPIRATORY DISTRESS SYNDROME APTT ACTIVATED PARTIAL THROMBOPLASTIN TIME AST ASPARTATE AMINOTRANSFERASE ALT ALAINE TRANSAMINASE CCL4 CARBON TETRACHLORIDE BT BLEEDING TIME CBC COMPLETE BLOOD HEMOGRAM CUSO4 COPPER SULPHATE CT CLOTTING TIME CO CORBONMONAXIDE CO2 CORBONDIOXIDE CNS CENTARL NERVOUS SYSTEM CVS CARDIOVASCULAR SYSTEM ECG ECLECTRO CARDIOGRAPHY FFP FRESH FROZEN PLASMA ET ENDOTRACHEAL GABA GAMMA AMINO BUTYRIC ACID G6PD GLUCOSE 6 PHOSPHATASE DEFICIENCY HCL HYDROCHLORIC ACID IM INTRAMUSCULAR IMS INTERMEDIATE SYNDROME INR INTERNATIONAL NORMALIZED RATIO IV INTRA VENOUS LFT LIVER FUNCTION TEST MODS MULI ORGAN DYSFUNCTION SYNDROME NAHCO3 SODA BICARBONATE NICU NEWBORN INTENSIVE CARE UNIT OPC ORGANO PHOPHOROUS COMPOUND OG ROUTE ORO GASTRIC ROUTE PAM PRALIDOXIME PCV PACKED CELL VOLUME PEGLEC POLYETHYLENE GLYCOL PT PROTHROMBIN TIME PICU PAEDIATRIC INTENSIVE CARE UNIT RFT RENAL FUNCTION TEST RS RESPIRATORY SYSTEM SC SUBCUTANEOUS SSU SECONDS SAYBOLT UNIVERSAL WBI WHOLE BOWEL IRRIGATION TABLE OF CONTENTS PAGE SI.NO TITLE NUMBER 1 1 INTRODUCTION 3 2 AIM AND OBJECTIVES 4 3 REVIEW OF LITERATURE 58 4 MATERIALS AND METHODS 61 5 OBSERVATION AND RESULTS 88 6 DISCUSSION 95 7 CONCLUSION 96 8 SUMMARY ANNEXURES (I)BIBLIOGRAPHY (II)STUDY PROFORMA (III)PARENT CONSENT FORM (IV)MASTER CHART LIST OF TABLES S.NO Title Page no 1 Poisons syndromes 18 2 Mini toxidromes 20 Screening laboratory clues in toxicological 3 22 diagnosis 4 Specific antidotes for poison 30 5 Additional antidotes 34 6 Age distribution of poisoning 61 7 Sex wise distribution of poisoning 63 8 Educational status of parents 63 9 Socioeconomic status 64 10 Type of poisoning 65 11 Agent of poisoning 67 12 Mode of poisoning 69 13 Route of poisoning 70 14 Pre referral treatment 72 15 Duration between poisoning and presentation 74 16 Mode of presentation 75 17 Duration of hospital stay 77 18 Duration of ICU stay and antidote used 79 19 Outcome of this study 79 20 Outcome in relation to age 81 21 Outcome according to duration and presentation 81 22 Outcome in relation to clinical features 82 23 Outcome in relation to ICU stay 84 24 Outcome in relation to antidote used 84 25 Outcome in relation to duration of hospital stay 86 LIST OF FIGURE Page S.NO Title No 1 Pie chart showing age distribution 62 2 Pie chart showing sex distribution 62 3 Bar diagram showing type of poisoning 66 Bar diagram showing agent of poison in relation to 4 socio economic status 68 5 Bar diagram showing mode of poisoning 71 6 Bar diagram showing route of poisoning 71 7 Bar diagram showing pre referral treatment 73 Bar diagram showing duration between poisoning and 8 73 presentation 9 Pie chart showing mode of presentation of poisoning 76 10 Bar diagram showing duration of hospital stay 78 Bar diagram showing outcome of poisoning in relation 11 80 to age Bar diagram showing correlation of outcome with 12 83 duration between poisoning and presentation Bar diagram showing correlation of outcome with 13 83 clinical feature Bar diagram showing correlation of outcome with ICU 14 85 stay Bar diagram showing correlation of outcome with 15 antidote used 85 Bar diagram showing correlation of outcome with 16 duration of hospital stay 87 ABSTRACT ABSTRACT Background: Child hood poisoning covers the entire gamut from accidental ingestion in toddlers and preschool children to intentional over dosage in adolescents.. Aims and Objectives: Our study is aimed at finding out the clinic- epidemiological profile of poisoning regarding age, sex, type of poison, manner of poisoning, common clinical features, duration between poisoning and presentation to hospital , duration of hospital stay ,to find out the different agents involved , duration of ICU stay, pre referral treatment and treatment given and evaluating the outcome of those children admitted with Poisoning in NICU,PICU and paediatric ward at GMKMCH, Salem Materials and methods: All children below 12 years of age admitted during the one year study period with a history of poisoning were included. Animal bites, snake and scorpion envenomation, chronic poisoning, drug allergy were excluded. All children were examined, investigated and treated according to hospital policy .Outcome of poisoning were recorded. Results: There were 143 cases of children with poisoning admitted. Accidental poisoning constituted 88.1% cases (n126),7.7% (n11) were suicidal and the remaining 4.2%(n6) were homicidal .In most of the cases poisoning was due to hydrocarbons followed by pesticides. kerosene oil was the most common substance followed by OPC. The higher incidence of poisoning was found in lower middle socio economic class 65.7%(n136) an analysis of the outcome showed that 95.1% were discharged home and death in 4.9% (n7) cases.