Traditional Chinese medicine poisoning in the emergency departments in Hong Kong: Trend, clinical presentation and predictors for poor outcome

doi:10.5847/wjem.j.1920-8642.2021.02.010

Abstract

Rex Pui Kin Lam, Eric Ho Yin Lau, Wai Lam Yip, Joe Kai Shing Leung, Matthew Sik Hon Tsui. Traditional Chinese medicine poisoning in the emergency departments in Hong Kong: Trend, clinical presentation and predictors for poor outcome[J]. World Journal of Emergency Medicine, 2021, 12(2): 143-150.

Figures/Tables 4

Table 1

Clinical presentations of TCM-related toxicities and comparison of patients with any CHM or PCM exposure, n (%)

Variables	Total (n=123)	Involving any CHM (n=80)	Involving any PCM (n=45)	P-value
Acute toxicity	96 (78.0)	55 (69.6)	41 (91.1)	0.006^a
Nature of poisoning				<0.001^a
Accidental	14 (11.4)	1 (1.3)	13 (28.9)
Adverse drug reaction	86 (69.9)	78 (97.5)	10 (22.2)
Intentional	23 (18.7)	1 (1.3)	22 (48.9)
Major toxic herbal ingredients involved
Aconitine	18 (14.6)	18 (22.5)	0 (0)	0.001^a
Atropine/hyoscyamine/scopolamine	3 (2.4)	3 (3.8)	0 (0)	NS^b
Cardiac glycosides	4 (3.3)	2 (2.5)	2 (4.4)	NS^b
Psoralen/isopsoralen	10 (8.1)	9 (11.3)	2 (4.4)	NS^b
Sophora alkaloids	9 (7.3)	9 (11.3)	0 (0)	0.026^b
Methyl salicylate	16 (13.0)	0 (0)	16 (35.6)	<0.001^a
Anthraquinones	13 (10.6)	12 (15.0)	3 (6.7)	NS^a
Co-ingestion of Western medicine	14 (11.4)	1 (1.3)	13 (28.9)	<0.001^a
Time from exposure to symptom onset				<0.001^a
<1 hour	13 (10.6)	8 (10.0)	5 (11.1)
≥1-4 hours	45 (36.6)	32 (40.0)	13 (28.9)
>4-24 hours	13 (10.6)	12 (15.0)	1 (2.2)
>24 hours	11 (8.9)	11 (13.8)	0 (0)
Not applicable (no symptom)	8 (6.5)	1 (1.3)	7 (15.6)
Unknown	33 (26.8)	16 (20.0)	19 (42.2)
Time from exposure to ED presentation				<0.001^a
<1 hour	6 (4.9)	1 (1.3)	5 (11.1)
≥1-4 hours	44 (35.8)	21 (26.3)	23 (51.1)
>4-24 hours	32 (26.0)	24 (30.0)	8 (17.8)
>24 hours	28 (22.8)	25 (31.3)	3 (6.7)
Unknown	13 (10.6)	9 (11.3)	6 (13.3)
Triage categories				<0.001^a
1 (critical)	11 (8.9)	4 (5.0)	7 (15.6)
2 (emergent)	12 (9.8)	5 (6.3)	7 (15.6)
3 (urgent)	65 (52.8)	37 (46.3)	30 (66.7)
4 (semi-urgent)	35 (28.5)	34 (42.5)	1 (2.2)
5 (non-urgent)	0 (0)	0 (0)	0 (0)
PSS, median (IQR)	1.0 ( 1.0-2.0)	2.0 (1.0-2.0)	1.0 (1.0-2.0)	0.002^c
Treatments
Gastric lavage	2 (1.6)	0 (0)	2 (4.4)	NS^b
Activated charcoal	21 (17.0)	3 (3.8)	18 (40.0)	<0.001^a
Antidote	7 (5.7)	2 (2.5)	5 (11.1)	NS^b
Electrical therapy	4 (3.2)	3 (3.8)	1 (2.2)	NS^b
Antiarrhythmic agent	7 (5.7)	7 (8.8)	0 (0)	0.049^b
Inotropic support	4 (3.2)	4 (5.0)	0 (0)	NS^b
Intubation and mechanical ventilation	7 (5.7)	3 (3.8)	4 (8.9)	NS^b
Renal replacement therapy	4 (3.3)	1 (1.3)	3 (6.7)	NS^b
Observation ward/emergency medicine ward admission	59 (48.0)	39 (48.8)	20 (44.4)	NS^a
General ward admission	36 (29.3)	23 (28.7)	15 (33.3)	NS^a
ICU admission	15 (12.2)	8 (10.0)	7 (15.6)	NS^a
Median ED length of stay, hours	1.8 (1.0-2.6)	2.0 (1.2-3.1)	1.2 (0.7-2.5)	0.004
Median length of hospitalization, hours, median (IQR)	26.7 (16.9-76.2)	33.1 (17.6-90.9)	23.2 (14.4-71.3 )	NS
Median length of ICU stay, hours, median (IQR)	30.8 (19.1-73.3)	32.8 (19.4-81.4)	30.4 (10.0-73.3)	NS
Episode death	1 (0.8)	0 (0)	1 (2.2)	NS^b
Poor outcome	16 (13.0)	8 (10.0)	8 (17.8)	NS^a

Table 1

Figure 1.

Table 2

The Poison Severity Score (PSS) and distribution of most severe symptomatology in different organ systems of ten selected toxic herbal ingredients

Herbal ingredients involved	Median PSS (IQR)	Organ system where the most severe symptomatology occurred	Commonest clinical features (n, %)	Intervention provided (n, %)
Aconitine	2.0 (1.8-3.0)	Cardiovascular system	Limb numbness (13, 72.2), perioral numbness (12, 66.7), dizziness (12, 66.7), ventricular ectopics (7, 38.9), ventricular tachycardia (6, 33.3), vomiting (6, 33.3)	IV fluid (12, 66.7), administration of amiodarone (7, 38.9), administration of magnesium (4, 22.2), use of inotrope (4, 22.2), intubation (3, 16.7), synchronized cardioversion (3, 16.7), defibrillation (2, 11.1), activated charcoal (2, 11.1), CPR (1, 5.6)
Atropine/hyoscyamine/ scopolamine	1.0 (1.0-1.5)	Nervous system	Anticholinergic toxidrome (3, 100), dizziness (3, 100)	IV fluid (1, 33.3)
Cardiac glycosides	1.0 (1.0-2.5)	Cardiovascular system	Vomiting (3, 75.0), abdominal pain (2, 50.0), dizziness (2, 50.0), sinus bradycardia (1, 25.0)	IV fluid (1, 25.0), activated charcoal (1, 25.0), administration of DigiFab (1, 25.0)
Psoralen/isopsoralen	2.0 (2.0-2.5)	Liver/kidney	Tea-colour urine (8, 88.9), malaise (8, 88.9), jaundice (4, 44.4), peak ALT > 1,000 IU/L (4, 44.4), renal impairment (1, 11.1)	IV fluid (1, 11.1), haemodialysis (1, 11.1)
Sophora alkaloids	1.0 (1.0-1.0)	Nervous system	Dizziness (8, 88.9), vomiting (5, 55.6), palpitation (4, 44.4), limb weakness (3, 33.3), diarrhoea (3, 33.3)	IV fluid (3, 33.3)
Methyl salicylate	1.0 (0.3-3.0)	Nervous system	Dizziness (5, 31.3), vomiting (5, 31.3), abdominal pain (5, 31.3), decrease in sensorium (4, 25.0), metabolic acidosis (2, 12.5), hypokalaemia (2, 12.5)	IV fluid (14, 87.5), activated charcoal (12, 75.0), urine alkalinization (5, 31.3), intubation (4, 25.0), haemodialysis (3, 18.8), gastric lavage (2, 12.5), defibrillation (1, 6.3), CPR (1, 6.3)
Anthraquinones	2.0 (1.5-2.5)	Liver/kidney	Tea-colour urine (9, 69.2), peak ALT > 1,000 IU/L (8, 61.5), jaundice (7, 53.8), malaise (6, 46.2), poor oral intake (5, 38.5)	IV fluid (1, 7.7)

Table 2

Table 3

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Variables	Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Exposure to aconitine	6.79 (2.11-21.83)^*	27.42 (2.55-295.31)^*
Exposure to methyl salicylate	8.47 (2.55-28.14)^**	24.17 (2.09-279.69)^*
High triage category (category 1 or 2)	12.10 (3.75-38.69)^**	7.33 (1.32-40.61)^*
Triage systolic BP	0.96 (0.94-0.99)^*
Triage Glasgow Coma Scale	0.71 (0.41-1.23)
Time from exposure to ED presentation <1 hour	Ref
Time from exposure to ED presentation ≥1-4 hours	0.59 (0.09-3.70)
Time from exposure to ED presentation >4-24 hours	0.13 (0.01-1.23)
Time from exposure to ED presentation >24 hours	0.07 (0.01-1.02)