الفهرس 
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Abstract
Cardiovascular therapeutic agents poisoning is the second most common cause of death after analgesics, accounting for more than 10% of all poisoning fatalities .The most common cardiovascular drugs involved in acute toxicity areBeta Blockers (BBs), Calcium Channel Blockers (CCBs) and digitalis. According to the 2019 annual report of the Poison Control Center of Ain Shams University Hospitals, Cardiovascular therapeutic agents toxicity represented 6.7% of all poisoned cases.There is a great variability in the disposition of the poisoned patients with cardiovascular therapeutic agents between poison control centers depending on the presence oftriage guidelines, the compliance to these guidelines and the current poison control center practice. Decidingfor how long to observe after suspected ingestion of cardiovascular therapeutic agents can be perplexing because most of these drugs are formulated as modified release products, so many poison control centers automatically recommend a 24 hour admission for observation
There is a wide range of approaches regarding disposition of poisoned patients by cardiovascular therapeutic agents, so this suggest lack of a clear evidence based standard of care.
The aim of this study is to compare the triage method for disposition of the poisoned patients with cardiovascular therapeutic agents in the Poison Control Center of Ain Shams University Hospitals with the American Association of Poison Control Centers in order to improve the health care outcome.
The current study was a comparative cross sectional study, performed in thePoison Control Center of Ain Shams University Hospitals(PCC-ASUH). Thestudy involved all patients presented to the PCC-ASUH with a history of acute poisoning after ingestion of cardiovascular therapeutic agents, in a period from January to December2019,the exclusion criteria included chronic poisoning andco-ingestion of multi cardio-depressant drugs e.g. (beta blockers, calcium channel blockers, anti arrhythmics, central acting sympatholytics).
The study consists of two groups,First group: Retrospective(in which the data of 406 patient acutely poisoned with cardiovascular therapeutic agents had been collected from electronic database and medical records of PCC-ASUH in a 7 month period from 1/1/2019 to 31/7/2019).The decision regarding disposition in this groupwas based on PSS and local Poison Control Center protocols thatrecommended patients with suicidal exposure should be admitted to the ICU due to hospital requirements to admit all suicidal patients by cardiovascular therapeutic agents to the ICU in order for them to be closely monitored.
Second group: Prospective observational group in which the data of 399 acutely poisoned patient with cardiovascular therapeutic agents had been collected in a five months period following the retrospective study, from 1/8/2019 to 31/12/2019. Assessment of patients was done using The American Association ofPoison Control Centers (AAPCC) Guidelines.
Disposition of patients was assessed and comparison between the retrospective group and prospective group done by different statistical analysis as Chi Square, sensitivity, and specificity to determine the effect on patients disposition and outcome.
Comparing the results of retrospective and prospective studies to determine the effect on disposition and outcome for each drug group
Demographic &Clinical data: The mean age of all patients was (20.6 ± 13.8) years. As regard the gender of the patients, the majority (82%) of patients were females; while (18%) were males, with only of the total patients (1.1%) having previous CVS disease, and (1.2%) were on cardio-depressant drug.
Drug ingestion data: Retrospective group (52.22%) of patients have ingestedtoxic dose, But only (11.33%) experienced manifestations. Prospective group (44.11%) of patients have ingested toxic dose, But only (5.51%) experienced manifestations. Regarding type of drug ingestion, In retrospective group (59.11%) ingested BBs drugs, (23.4%) of patients ingested anti-HTN drugs, (11.82%) ingested Digoxin, and (5.67%) ingested CCBs drugs. In prospective group (50.38%) ingested BBs drugs, (33.08%) of patients ingested anti-HTN drugs, (11.28%) ingested CCBs drugs and (5.26%) ingested Digoxin.
Management and outcome data: The median time of presentation to ER is 2 hours in both groups. Regarding disposition of patients, Retrospective group: (37.20%) observed in ER then discharged to home, (36.70%) of patients admitted to ICU, (17.73%) referred to another toxicology center, and (8.37%) admitted to inpatient unit, with (7.88%) of patients had abnormal investigations, (5.91%) required treatment and(0.49%) mortality rate.Prospective group: (57.39%) observed in ER then discharged to home, (27.82%) admitted to inpatient unit, (11.78%) of patients admitted to ICU, and (3.01%) referred to another toxicology center, with (1.5%) of patients had abnormal investigations, (1.75%) required treatment and (0.00%) mortality rate.
Severity of cases: By application of poisoning severity score retrospectively most of poisoned cases (61.82%) were none to mild (24.38%), while moderate cases were (12.32%) and severe cases were (0.99%), with fatality (0.49%). BBs overdose: most of cases (62.5%) were none, (35%) were mild, (2.08%) were moderate, and (0.42%) were severe, with no fatality. CCBs overdose: most of cases (43.48%) were moderate, (26.08%) were mild, (13.04%) were none, and (8.7%) were severe, with (8.7%) fatal cases. Digoxin overdose: most of cases (72.92%) were moderate, (18.75%) were mild (6.25%) were none, and (2.08%) were sever, with no fatality. Anti-HTN overdose: (100%) were none, with no fatality.
ROC curve analysis to predict cardiotoxicity by PSS: By using ROC-curve analysis, PSS for BB, CCB, and Anti-HTN showed non-significant predictive values in discrimination of patients with cardio-toxicity from patients without (p > 0.05). PSS for Digoxin predicted patients with cardio-toxicity, with good (85%) accuracy, sensitivity= 72% and specificity= 97.5% (p <0.01).
American Association of Poison Control Centers (AAPCCs) Guidelines: All 7 factors showed significant values in differentiating toxicity positive from toxicity negative patients. By using ROC-curve analysis, AAPCC guidelines predicted patients with cardio-toxicity, with excellent (93%) accuracy, sensitivity(99.4%) and specificity (87.6%) (p <0.01). The value of Sensitivity, Specificity, positive predictive value, and negative predictive value were calculated as 99.4%, 87.6%, 86%, 99.5% respectively. The false negative case was shown only in one case.
Comparative study: Comparing the results of retrospective and prospective studies to determine the effect on disposition and outcome for each drug group.
The 805 patients were classified into 2 groups: Retrospective (N=406); in which the disposition decision depended on PSS and local poison control center protocol of management. Prospective (N=399); in which the disposition decision determined by application of AAPCCs guidelines. Retrospective group: (37.20%) observed in ER then discharged to home, (36.70%) of patients admitted to ICU, (17.73%) referred to another toxicology center, and (8.37%) admitted to inpatient unit, with (7.88%) of patients had abnormal investigations, (5.91%) required treatment and(0.49%) mortality. Prospective group: (57.39%) observed in ER then discharged to home, (27.82%) admitted to inpatient unit, (11.78%) of patients admitted to ICU, and (3.01%) referred to another toxicology center, with (1.5%) of patients had abnormal investigations, (1.75%) required treatment and (0.00%) mortality.
BBs; ICU admission was high (41.25%) and Inpatient admission was low(14.16%) in retrospective group but prospectively after application of AAPCC guidelines ICU admission decreased (11.94%) and Inpatient admission (40.79%), and observation (45.77%)increased with decreased referral of patients(1.49%).With a high significant difference between both retrospective and prospective groups as regard patients disposition after application of AAPCC guidelines.
CCBs ; ICU admission was high (60.86%)with no Inpatient admission (0.00%) in retrospective group. But prospectively after application of AAPCC guidelines ICU admission decreased (17.77%) and Inpatient admission increased (64.44%).With a high significant difference between both retrospective and prospective groups as regard patients disposition after application of AAPCC guidelines.
Digoxin; ICU admission was high (75%) in retrospective group and decreased (71.42%) after AAPCC guidelines application.With a high significant difference between both retrospective and prospective groups as regard patients disposition after application of AAPCC guidelines.
Anti-HTN; no difference with the application of PSS and AAPCC guidelines between the two studied groups, where all the poisoned patients with Anti-HTN only need observation in emergency room with no deterioration.
This study showed that after application of the AAPCCs guidelines in the prospective group, ICU admission decreased from (36.70%)to (11.78%), With sensitivity (99.4%), negative predictive value (99.5%), Specificity (87.6%), positive predictive value (86%). All the forementioned data was compared with retrospective group where application of PSSand local management protocol did not show that apparent decrease in the percentage of usage of ICU beds. It means that this AAPCC triage method is able to reduce the unnecessary admissions of poisoned patients with cardiovascular therapeutic agents through increasing the percent of observed patients in ER and reducing the cost of ICU admission together with decreasing the need for referral to other health care facility which might pose a risk on the patient.