Analysis of Data on Inhalation Poisoning using the Example of the Łuków County in the years 2015–2017

Aim: This article presents an original analysis of inhalation poisoning data using the example of the Łuków County in 2015-2017. The data was obtained from cases to which Emergency Medical Services were dispatched. Most of such exposures were accidental or caused by negligence. and could be avoided by applying appropriate prevention and safety rules. Introduction: Inhalation poisonings represent a small percentage of all poisonings. They are mainly associated with the heating season and carbon monoxide. The number of inhalation poisonings is much smaller than that of food poisonings, alcohol poisonings or drug overdoses but they also constitute a significant health risk for the public. Methodology: The study was based on an analysis of medical documentation of the emergency medical services station in Łuków. The research material was composed of the information contained in the dispatch documentation of EMS teams, i.e. ambulance call records and medical rescue records for events related to inhalation poisoning. The selection of events from all those that occurred during the audited period was made on the basis of: – information provided by the reporting person to the emergency number 999 or 112, – ICD-10 code in the medical emergency record, i.e. diagnosis of the cause of the illness or event. The analysed factors included age, sex, place of intoxication, seasonality and circadian variation of poisoning. The analysis also considered environmental conditions and the influence of stimulants. Results: In the analysed period there were 80 events related to inhalation poisoning. There were 89 people exposed in 80 events (65% – men, 35% – women). Over 90% were cases of accidental poisoning. 60% of the events occurred at 7 am – 7 pm and 40% of the events occurred at 7 pm – 7 am. Of all exposures, 90% were single poisonings and the remaining 10% were multiple. Most poisonings (78%) occurred at the place of residence. Among all the victims, 56% were hospitalized in the county hospital in Łuków, 38% of patients remained at home (including due to death –20% or lack of symptoms requiring hospital treatment – 18%), and almost 6% required immediate specialist treatment. Most incidents related to inhalation poisoning in the Łuków County occurred in rural areas – 56 out of 80. Most inhalation poisonings were caused by CO.


Introduction
Inhalation poisonings in the adult population, most of which are accidental, represent a significant threat to the health and life of people. Alongside trauma, they are the third major cause of death, frequent medical services intervention and hospitalisation in Poland [1]. Poison can enter the body through the digestive tract, respiratory system and, less frequently, through body cavities (nose, rectum, vagina). It can penetrate through the skin or be administered parenterally, intramuscularly, subcutaneously or intravenously. In the context of toxicology, the most significant pathways are by digestion and inhalation. Absorption by the respiratory tract is highly efficient due to the large surface area of this tract and the permeability of the air-blood barrier.
The respiratory pathway plays a significant role in occupational and accidental poisoning [2].
The most common, and also the best-known, medium of exposure is carbon monoxide, an odourless, colourless gas formed as a result of the incomplete combustion of carbon compounds where there is not enough oxygen in the combustion process.
When the room ventilation or flue liners are obstructed, during gas or solid-fuel heating, this gas concentrates inside rooms, which leads to dangerous poisoning [3].
However, cases of inhalation poisoning occur throughout the year and many of those are unrelated to the heating season or carbon monoxide. These are poisonings related to agriculture (during crop spraying, work with silage in silos [4]), deliberate spraying of gas or leaks in public places with large numbers of people present (school, workplace, mass event, such as a sporting occasion or concert). These causes are extremely rare in Poland, as well as in other European countries [5,6,7]. We should nione przyczyny występują niezwykle rzadko, z częstotliwością podobną do innych państw w Europie [5,6,7]. Należy też wspomnieć o dopalaczach, które występują w różnych formach, również wziewnej. W grupie zatruć celowych spowodowanych dopalaczami dominuje grupa wiekowa nastolatków -od 13 do 18 roku życia, a w niej zdecydowana większość to chłopcy [8,9,10,11]. 176 also mention designer drugs, which are available in a variety of forms, including inhaled. In the group of intentional self-poisonings caused by designer drugs, most involve teenagers from 13 to 18 years of age, the majority of which are boys [8,9,10,11]. This paper discusses the causes, frequency, location and seasonality of the inhalation poisonings which occurred in the Łuków County, i.e. the operating area of the Emergency Medical Services Station (SRM) in Łuków, over a period of three years.
The scale of the problem of inhalation poisoning is demonstrated on the basis of interventions made by emergency medical services (EMS) teams at SRM Łuków in the Lubelskie Province.
The research data was obtained from the medical documentation of the dispatch teams of SRM Łuków. The analysis covered selected parameters increasing the risk of poisoning, such as season, time of day, exposure site, age, sex and other factors, e.g. the influence of alcohol and the number of exposures resulting in death.

Material and methods
The study involved data from three years of activity of SRM in Łuków, which is dispatched to 7-8 thousand interventions every year, which results in a three-year total of approx. 25 thousand calls. SRM Łuków is a unit subject to the County Hospital in Łuków. We obtained the Director's consent to access the documentation. The analysed data (regarding victims, EMS team call signs and composition, and cooperating services) are anonymous.
Dispatches based on data from the SRM Łuków Log, which lists every departure chronologically, were qualified to the study.
The Log also features the basic statistical, address and medical data, information on the dispatcher's decision regarding the urgency of departure and information on handling the patient. By analysing the information contained in the Log, we were able to select those interventions which fulfilled the criteria adopted for this paper. We qualified events for analysis on the basis of the following criteria: 1) reason for the call, i.e. data provided to the ECC dispatcher by the caller (e.g. chest pain, lower limb trauma, high body temperature, vomiting). We also searched for a num-

Results
The research material was composed of 80 ambulance call records of the EMS from 2015-2017.

Seasonal and monthly variability in the number of poisonings
In the analysed years the number of interventions connected with inhalation exposure remained at a similar level (26 .6 exposures per year on average). Figure

Exposure site
Most events in the analysed period occurred in rural areas (70%).
Several factors might be involved: -residents of rural areas are the majority of the county's population (the total population of the county's three towns is less than 40 thousand, which is illustrated in
Lokalizację zespołów wyjazdowych SRM Łuków obrazuje rycina3.  When the poisoning happened, the victims were at home, work, school or in an agricultural holding (which does not correspond to the statistics for the place of residence). This location was determined by their professional activity, education or everyday matters. Table 2 shows numbers of events by site of exposure.
The age of people exposed to poisoning We found that the age groups most exposed to poisoning

Causes of poisoning
In the analysis, we tried to determine the causes of poisoning and compared the findings with the later medical diagnosis.
The stated reason for the call is often different than actually found and determined by the EMS at the event site. The data provided during the call tend to be inaccurate, incoherent and chaotic, as the calls are often made by random individuals.  Tables 3   and 4 show the differences between the information contained in the EMS call and the medical diagnosis and their percentage share.
The most frequent reason for ambulance calls -unconscious -loss of consciousness -occurred in nine cases (table 3).
The most common diagnosis -R96 Death -was declared in eighteen of the analysed ambulance calls (    Table 3 item 1 and Table 4 item 1 highlights a frequent situation occurring when calling EMS. The person calling the ambulance sees a person lying on the ground who is not moving or responding to verbal prompts. As the caller did not witness the person falling and does not know how long the person has been lying, he or she reports that the person is unconscious. In eighteen cases patients were found dead on arrival by the EMS.     czają że jeśli wystąpi poważny pożar, to znajdujące się w środku osoby najprawdopodobniej zginą poprzez zatrucie wziewne, a nie z powodu bezpośredniego działania temperatury [20,21].
The analysed material contains 12 cases connected with fires in flats, houses or business premises, which occurred when people were inside. Three cases ended in the death of the person being inside and 9 events (involving 11 people) ended in inhalation poisoning or burns. These patients were taken to hospital and most of them were admitted to the nearest ED. Some patients required treatment in a specialised toxicology treatment centre or in a hyperbaric chamber. Oxygen therapy combined with the elevated pressure in the chamber accelerates the process of eliminating carbon monoxide from the body [23,24].
The studied material contained 18 cases of deaths of victims at the event site (Table 6), which constitute 20% of all victims. The causes of death could not be established at the EMS intervention stage, so it is difficult to confirm the statistics cited in the literature pointing that 51% of deaths in fires are caused by poisoning due to exposure to toxic combustion products [25].
EMS teams carry out a general examination of the body, which is not sufficient to determine the cause of death [26]. Autopsy reports were not included in the analysed material.

Most incidents related to inhalation poisoning in the
Łuków County occur in rural areas.
2. Carbon monoxide is the most common cause of inhalation-related incidents. more likely to die from inhalation poisoning than from the direct impact of temperature [20,21].