This study investigated the clinical characteristics, treatments, and outcomes of envenomation involving cobra species in Thailand (Naja kaouthia, Naja siamensis, and Naja sumatrana). Data of patients who had been bitten by a cobra or inoculated via the eyes/skin in 2018–2021 were obtained from the Ramathibodi Poison Center. There were 1045 patients admitted during the 4-year study period (bite, n = 539; ocular/dermal inoculation, n = 506). Almost all patients with ocular/dermal inoculation had eye involvement and ocular injuries, but none had neurological effects. Most of the patients bitten by a cobra had local effects (69.0%) and neurological signs and symptoms (55.7%). The median interval between the bite and the onset of neurological symptoms was 1 h (range, 10 min to 24 h). Accordingly, patients should be observed closely in hospitals for at least 24 h after a bite. Intubation with ventilator support was required in 45.5% of patients and for a median duration of 1.1 days. Antivenom was administered in 63.5% of cases. There were nine deaths, most of which resulted from severe infection. Neurological effects and intubation were significantly more common after a monocled cobra bite than after a spitting cobra bite. The administration of antivenom with good supportive care, including the appropriate management of complications, especially wound infection, might decrease fatality.

Ethephon (2-chloroethylphosphonic acid) is a generally used plant growth regulator, but the data on its toxic effects, especially in humans, are very limited. This study was conducted to describe the clinical characteristics, management, and outcomes of patients exposed to products containing ethephon. We performed an 8-year retrospective study using data from the Ramathibodi Poison Center database (2013–2020), which included 252 patients. Most patients were male, with a median age of 32 years. Almost all patients were exposed through ingestion, mainly in unintentional circumstances. The clinical presentations included local effects, gastrointestinal (GI), neurological, and respiratory symptoms. Some patients required hospital admission; specifically, seven patients received inotropic drugs, and six were intubated with ventilator support. Most patients had either no or only minor clinical effects. However, six patients experienced moderate/severe effects, and two patients died. Age, intentional exposure, and the presence of initial neurological symptoms could prognosticate moderate to fatal outcomes. In conclusion, exposure to ethephon predominantly resulted in no or minor effects, and GI symptoms were the most common clinical manifestation. The cholinergic toxic syndrome was not frequently observed. The mortality rate was very low. Patients presenting with factors associated with worse outcomes should be monitored closely for clinical deterioration and appropriately managed.

Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011–2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E–I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15–65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.

The current data regarding poisoning associated with ingestion of fungus-infected cicada nymphs are limited. We performed a retrospective cohort study of patients who ingested fungus-infected cicada nymphs and were referred to the Ramathibodi Poison Center for consultation from June 2010 to June 2022. Thirty-nine patients were included for analysis. Most were men (53.8%). Mean age was 40.2 ± 15.0 years. All nymphs were ingested as a health/food supplement. Thirty-one patients (79.5%) reported gastrointestinal symptoms. Median time from ingestion to symptom onset was 5 h. Twenty-nine patients (74.4%) reported neurological symptoms, including tremor, myoclonus, muscle rigidity, nystagmus/ocular clonus, drowsiness, dysarthria, seizure, and confusion. Some complained of dizziness, urinary retention, and jaw stiffness. Most patients (94.9%) were admitted to the hospital. Median hospital stay was 3 days. Ibotenic acid was detected in the blood and urine samples of one patient. All received supportive care. Four patients developed infectious complications. No deaths occurred. Consuming fungus-infected cicada nymphs may cause poisoning in humans. Gastrointestinal and neurological symptoms were common. Ibotenic acid might be the underlying cause. The main treatment is supportive care and appropriate management of complications. Education of the general public is advocated to prevent the incidence of this type of poisoning.

Emamectin benzoate (Emamectin) is a broad-spectrum insecticide. Current data regarding emamectin poisoning in humans are very limited. We performed a 10-year retrospective cross-sectional study (2011–2020) using data from the Ramathibodi Poison Center database to examine the clinical characteristics and outcomes in patients exposed to emamectin. Eighty-eight patients were included. Most of the patients were male (72.7%) and exposure was frequently oral (86.4%) and intentional (67.0%).Their mean age was 42.8 years. The clinical presentations included gastrointestinal tract symptoms (62.5%), neurological symptoms (27.3%) including seizures, respiratory symptoms (6.8%), and local effects (12.5%). At presentation, the majority of patients exhibited normal consciousness and vital signs. Eleven patients showed no obvious clinical effects. Initially, 15 patients had metabolic acidosis and 11 had hypokalemia. Overall, 46 and 52 patients were administered gastric lavage and activated charcoal, respectively. Most patients (78.4%) were hospitalized, with a median hospital stay of 40 h, and generally received supportive treatment. Eight patients were intubated for ventilator support and one received inotropic drugs. Most patients (90.9%) showed no or minor outcomes; however, two patients died. The presence of Glasgow Coma Scale (GCS) <15 differed significantly (p < 0.001) between patients with no or minor outcomes (n = 80) and those with moderate or fatal outcomes (n = 8). In conclusion, emamectin poisoning mainly caused no or minor clinical effects. A low GCS at presentation was associated with worse outcomes. Therefore, patients who present with low GCS should be closely observed, monitored, and properly managed during hospitalization.

Local anesthetic systemic toxicity is a rare but potentially life-threatening complication of local anesthetic use. This study aimed to describe the characteristics of patients with local anesthetic systemic toxicity and to identify initial clinical prognostic factors. A retrospective cohort study of patients diagnosed with local anesthetic systemic toxicity from January 2013 to December 2022 was conducted using data from the Ramathibodi Poison Center Toxic Exposure Surveillance System, Thailand. One hundred and forty-three patients were included, with a median age of 41.5 years (IQR: 27.0-56.0 years). Lidocaine was the most commonly implicated local anesthetic (89.5%). The most frequent routes of administration were local infiltration (59.4%) and intravenous (15.4%). Neurological symptoms (perioral numbness, seizures, or coma) were the most common initial presentations (78.3%), followed by cardiovascular symptoms (43.4%), including chest pain, palpitations, hypotension, and cardiac arrest; cardiac arrest occurred in 10.5% of cases. Intravenous lipid emulsion therapy was administered in 12.6% of patients, and the median time from symptom onset to administration was 63 min (IQR: 48-90 min). Adverse effects of intravenous lipid emulsion (acute respiratory distress syndrome and fat overload syndrome) occurred in two of 18 (11.1% [95% CI:3.4-26%]) recipients. A multivariate analysis identified intravenous administration of local anesthetic (OR: 5.59; 95% CI: 1.53-20.33), the initial presence of coma (OR: 12.0; 95% CI: 2.96-48.60), hypotension (OR: 5.23; 95% CI: 1.34-20.29), and cardiac arrest (OR: 210; 95% CI: 22-1,919) as independent predictors of mortality. Seizures were the most frequent initial neurological presentation in our study, followed by cardiovascular features, particularly hypotension and palpitations, which is consistent with previous reports of local anesthetic systemic toxicity. In our study, the presence of hypotension, coma, and cardiac arrest at presentation and intravenous administration of local anesthetic was strongly associated with severe outcomes and increased mortality. Although intravenous lipid emulsion therapy has shown clinical efficacy, delayed access to this treatment remains a considerable barrier, particularly in rural or resource-limited settings.